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REPUBLIC OF KENYA
MINISTRY OF HEALTH
© NTLD-Program 2014
All rights reserved.
TABLE OF CONTENTS
Foreword ............................................................................................................................................................... iAcknowledgements ............................................................................................................................................. iiAcronyms .............................................................................................................................................................. iiiExecutive Summary ............................................................................................................................................. viVision and Targets ................................................................................................................................................ vii
CHAPTER 1: Rationale for and Methodology of NSP Development .................................................................... 11.1. Rationale for 3-Year Plan .................................................................................................................... 11.2. Methodology ......................................................................................................................................... 1
CHAPTER 2: Background ...................................................................................................................................... 22.1. Country Profile ...................................................................................................................................... 2
2.1.1. Geography and Demographics ............................................................................................ 32.1.2. Political Structure and Policy Context ............................................................................... 32.1.3. Economic Development Agenda ........................................................................................ 3
2.2. Health Profile ......................................................................................................................................... 32.2.1. Health Status of the Population ........................................................................................... 32.2.2. Health Sector Strategy and Health Policy ........................................................................... 52.2.3. Health Financing ..................................................................................................................... 52.2.4 HIV/AIDS Policy and Financing Context ............................................................................... 6
.2.3. Epidemiology of TB, Leprosy and Lung Diseases ................................................................................. 7 2.3.1. Tuberculosis ............................................................................................................................. 7
2.3.2. HIV/AIDS .................................................................................................................................. 92.3.3. Socio- economic Burden of TB ................................................................................................. 92.3.4. Progress and Trends in Control of TB and Leprosy .............................................................. 102.3.5. Summary Findings of the Mid-Term Review 2014 ............................................................... 11
CHAPTER 3: Operational structure of the NTLD Program .......................................................................................... 15 3.1. Roles and Responsibilities ....................................................................................................... 15 3.2. Intra- and Inter-Ministry Partnerships ..................................................................................... 16
CHAPTER 4: 2015-2017 National Strategic Plan .................................................................................................... 17 4.1. Goals and Objectives of the NSP .............................................................................................. 17 4.2. Impact and Outcome Targets .................................................................................................... 17 4.3. HSSP Outcome 1: Eliminate Communicable Diseases ............................................................ 19
4.3.1. Strategy 1: Devolve implementation of activities and budgets ............................ 19 4.3.2. Strategy 2: Identify and treat all cases (find the missing cases) ............................ 21
4.3.2.1. Core DOTS .................................................................................................... 21 4.3.2.2. Programmatic Management of Drug-Resistant TB .................................. 38 4.3.2.3. Pediatric TB ................................................................................................... 46 4.3.2.4. Leprosy .......................................................................................................... 56
4.3.3. Strategy 3: Engage all care providers (PPM) ............................................................. 63 4.3.4. Strategy 4: Promote and strengthen community engagement ............................... 69 4.3.5. Strategy 5: Enhance the multi-sectoral response to TB/HIV ................................... 77 4.3.6. Strategy 6: Accelerate appropriate diagnosis ........................................................... 87 4.3.7. Strategy 7: Ensure stable & quality supply of drugs, diagnostic tests & commodities 100 4.3.8. Strategy 8: Enhance evidence-based programme monitoring and implementation 106
4.3.9. Strategy 9. Create an enabling environment .......................................................................... 117 4.3.9.1. Policy .............................................................................................................................. 117 4.3.9.2. Advocacy and Communications .................................................................................. 119 4.3.9.3. Human Rights and Gender ............................................................................................ 124 4.3.9.4. Social Protection ............................................................................................................ 129
4.4. HSSP Outcome 2: Halt/Reverse Non-Communicable Diseases ............................................................... 134 4.4.1. Strategy 10: Expand the utilization of the Practical Approach to Lung Health (PAL) ................ 134
4.5. HSSP Outcome 3: Minimize Risk Factor Exposure ..................................................................................... 140 4.5.1. Strategy 11: Prevent transmission and disease: IPC, IPT and contact tracing ............................. 140
CHAPTER 5: Resource Implications of the NSP .......................................................................................................................... 144
ANNEXESAnnex 1: NSP Writing Team .......................................................................................................................................................... 149
Annex 2: Stakeholder Meeting Participants ................................................................................................................................ 150
TABLE OF CONTENTS
FOREWORD
The Kenya National Strategic Plan on Tuberculosis, Leprosy and Lung Diseases 2015 – 2018, marks a milestone in our nation’s response to these diseases.
This national strategic plan has been birthed through a robust country dialogue, which brought together various stakeholders, including the national and county governments, bilateral and multilateral development partners, non-governmental organizations, civil society organizations, tertiary medical training institutions and key affected population representatives, among others.
The strategic plan is based on epidemiological analysis of the burden of these diseases and information gleaned from the program review. The plan is aligned to the Kenya Health Sector Strategic and Investment Plan 2013 - 2017 and the global post – 2015 plan. It promotes strategic interventions unique for each county, and which have the greatest impact for case notification, childhood tuberculosis, drug resistant tuberculosis, leprosy and lung diseases. For the first time, priority interventions related to key affected populations, gender and human rights are covered.
On the same note, we must endeavor to put together our synergistic efforts and pull in the same direction so as to deliver on Chapter IV Article 43 I (a) of the Kenyan Constitution that envisages access to the highest attainable standard of health to our people.
Dr Nicholas Muraguri, Director of Medical ServicesMinistry of Health, Government of Kenya
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The 2015-2018 National Strategic Plan (NSP) for the Control of Tuberculosis, Leprosy and Lung Diseases represents the leadership and commitment of the Ministry of Health, Kenya. The team wishes to acknowledge the leadership of the National Tuberculosis, Leprosy and Lung Diseases Program (NTLD Program). Additionally, the writing team benefitted from the extensive knowledge and expertise of Ministry of Health staff and partners at all levels of the health system.
The planning secretariat included Dr Joseph Sitienei, Head, Division of Communicable Disease Prevention and Control, MoH; Dr Jackson Kioko, Head, NTLD Program; Dr Enos Masini (NTLD Program); Dr Samuel Kinyanjui, Chief of Party, Centre for Health Solutions (CHS); Dr Brenda Mungai, Deputy Chief of Party, CHS; Dr Kadondi Kasera, CHS; Dr Maurice Maina, U.S. Agency for International Development (USAID); Dr Herman Weyenga, U.S. Centers for Disease Control and Prevention (CDC); Dr Joel Kang’angi, World Health Organization (WHO)/Kenya; and Dr Jane Ong’ang’o, Kenya Medical Research Institute (KEMRI).
The full list of the writing team is included as Annex 1.
The staff of various units and departments within the Ministry of Health, county and sub-county officials, as well as bilateral and multilateral donors and agencies, and non-governmental and civil society organizations made, valuable contributions.
ACKNOWLEDGEMENTS
Dr Jackson Kioko, Head, Department of Preventive and Promotive HealthMinistry of Health, Government of Kenya
We also wish to make special mention of the following long-term partners of the NTLD Program: National HIV/AIDS and STI Control Programme (NASCOP), WHO, USAID, Centre for Health Solutions - Kenya (CHS), Amref Health Africa, Management Sciences for Health (MSH), Programme for Appropriate Technologies in Health (PATH), Kenya Association for the Prevention of Tuberculosis and Lung Disease (KAPTLD), Kenyatta National Hospital (KNH), Kenya AIDS NGOs Consortium (KANCO), KEMRI, CDC, International Organization for Migration (IOM), Japanese Agency for Cooperation (JICA), Tuberculosis Advocacy Consortium (TAC), and the World Bank.
This multi-sectoral and partnership approach ensured that the NSP represents the collective best thinking of a broad range of stakeholders. A full list is available as Annex 2.
The writing team wishes to thank Macalester College in the United States, and Professor Christy Hanson for her leadership in the NSP development. The Ministry also wishes to thank students and staff, including Omar Mansour, Riccardo Maddalozzo, Asad Zaidi, Chloe Schumaker and Karla Nagy for their support in conducting background literature reviews, data analysis, geographic mapping, and document formatting.
The Ministry of Health is grateful for generous financial support from USAID, through CHS and the Global Fund, which enabled the numerous stakeholder meetings and workshops for the writing team.
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ACSM Advocacy, Communication, and Social MobilizationADR Adverse Drug ReactionAFB Acid-Fast BacilliAFRO African Regional Office (of the World Health Organization)AIDS Acquired Immune Deficiency SyndromeAMREF African Medical and Research FoundationARI Acute Respiratory Infection ART Anti-Retroviral TherapyBOLD Burden of Lung Disease BSC Bio-Safety CabinetBSR Blinded Slide RecheckingC+ Culture PositiveC- Culture NegativeCAP Community Acquired PneumoniacART Combined Anti-Retroviral TherapyCBO Community-Based OrganizationCBHIS Community-Based Health Information SystemCCT Conditional Cash TransferCDC United States Centers for Disease ControlCDR Case Detection RateCHEW Community Health Extension WorkersCHU Community Health Program CHS Centre for Health Solutions - KenyaCHSU Community Health Service UnitsCME Continuing Medical EducationCNR Case Notification RateCoEs Centers of ExcellenceCOPD Chronically Obstructive Pulmonary DiseaseCPT Cotrimoxazole Preventive TherapyCR Cure RateCQIs Continuous Quality ImprovementsCSO Civil Society OrganizationCSR Corporate Social ResponsibilityCTBC Community Tuberculosis Care CTLC County TB and Leprosy CoordinatorCU Central ProgramCXR Chest X RayDALY Disability-Adjusted Life YearDCDPC Division of Communicable Disease Prevention and ControlDOT Directly Observed TreatmentDOTS Directly Observed Treatment, Short-CourseDQA Data Quality Assessment DRS Drug Resistance SurveillanceDR-TB Drug Resistant TuberculosisDSSM Direct Sputum Smear MicroscopyDST Drug Susceptibility TestingDTLC District TB Lab CoordinatorDMLT District Medical Laboratory TechnologistEQA External Quality AssessmentETR Electronic TB RegistryFBC Full Blood CountFBO Faith-Based Organizations
ACRONYMSiii
FIND Foundation for Innovative New DiagnosticsFDC Fixed Dose CombinationFM Fluorescence MicroscopyGDF Global Drug FacilityGF Global Fund to Fight AIDS, Tuberculosis, and MalariaGLC Green Light CommitteeGoK Government of KenyaH IsoniazidHC Health CenterHCP Health Care ProviderHCW Health Care WorkersHISP Health Insurance Subsidy ProgrammeHIV Human Immunodeficiency VirusHMIS Health Management Information SystemHSSF Health Sector Services FundHTC HIV Testing And Counseling IC Infection ControlICC Inter-Agency Coordinating CommitteeICF Intensified Case FindingICT Information, Communication and Technology IEC Information, Education, and CommunicationIOM International Organization for MigrationINH IsoniazidIPC Infection Prevention and Control IPT Isoniazid Preventive TherapyISAAC International Studies of Asthma and Allergic Disease in Childhood ISTC International Standards on TB CareIT Information TechnologyJICA Japanese Agency for Cooperation KAD Kenya Association of DermatologistsKDVO Kenya Dermato-Venereology OfficerKAIS Kenya AIDS Indicator SurveyKANCO Kenya AIDS NGOs Consortium KAP Knowledge, Attitude And PracticesKAPTLD Kenyan Association for the Prevention of Tuberculosis and Lung DiseasesKCOA Kenya Clinical Officers Association KEMRI Kenyan Medical Research InstituteKEMSA Kenya Medical Supplies AgencyKHPF Kenya Health Policy FrameworkKMA Kenya Medical Association KNCV Koninklijke Nederlandse Chemische Vereniging (Royal Netherlands Tuberculosis Foundation)KPA Kenya Pediatric AssociationLED Light-Emitting Diode Microscopes LFT Liver Function TestLMIS Laboratory Management Information SystemM&E Monitoring and EvaluationMB Multi-Bacillary LeprosyMC Microscopy CenterMCH Maternal and Child HealthMDG Millennium Development GoalMDR-TB Multi-drug Resistant TuberculosisMNCH Maternal, New Born and Child HealthMOH Ministry of HealthMOP Manual Of ProceduresMOPC Medical Outpatient ClinicMSF Medecins Sans FrontieresMSH Management Sciences For HealthMTB Mycobacterium TuberculosisMTEF Medium Term Expenditure FrameworkMTR Mid-Term ReviewNACC National AIDS Control CouncilNASCOP National AIDS and Sexually Transmitted Infections Control ProgrammeNCC National Coordinating Committee
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NGO Non-Governmental OrganizationNHA National Health AccountsNHSSP National Health Sector Strategic PlanNHIF National Hospital Insurance FundNSR No Smear ResultNTLD Program National Leprosy, Tuberculosis and Lung Disease ProgramNTRL National TB Reference LaboratoryNPS/NTPS National TB Prevalence SurveyOOP Out-Of-PocketOR Operational Research PAL Practical Approach To Lung HealthPATH Program for Appropriate Technologies in HealthPBG Performance-Based GrantPCR Polymerase Chain Reaction PHC Primary Health Care PHO Physician Hospital OrganizationPLHIV People Living With HIVPMDT Programmatic Management of Drug-resistant TuberculosisPMTCT Prevention of Mother-To-Child Transmission of HIVPNK Pharmaceutical Society of KenyaPP Private PractitionersPPB Pharmacy and Poisons Board PPE Personal Preventive EquipmentPPM Public-Private Mix DOTSPSM Procurement and Supply Management PPR Policy Planning and Research PT Proficiency Testing QA Quality AssuranceQAS Quality Assurance SystemQC Quality ControlQMRL Queensland Mycobacterium Reference LaboratoryQMS Quality Management System R RifampicinRCC Regional Coordinating CommitteeS+ Smear PositiveS- Smear NegativeSCTLC Sub-County TB and Leprosy Coordinator SHA System Of Health Account SOP Standard Operating ProceduresSRL Supranational Reference LaboratorySTI Sexually Transmitted InfectionsTA Technical AssistanceTAG Tuberculosis Action GroupTAT Turn-Around TimeTB TuberculosisTB/HIV TB Disease and HIV InfectionTIBU Treatment Information from Basic ProgramTOT Training of Trainers TSH Thyroid Stimulating HormoneTSR Treatment Success RateTST Tuberculin Skin TestTWG Technical Working GroupUEC Urea, Electrolytes, CreatinineUSAID United States Agency for International DevelopmentWHO World Health OrganizationZN Ziehl-Neelsen
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The Government of Kenya has a vision to reduce the burden of lung disease in Kenya and render Kenya free of TB and leprosy. Towards this aim, the National Tuberculosis, Leprosy and Lung Disease Program (NTLD Program) has been implementing activities within the framework of a five-year (2011-2015) national strategy. TB is a major cause of morbidity, with nearly 90,000 cases notified in 2013. It is the 4th leading cause of death in the country.
Kenya is globally recognized as a pathfinder for TB and leprosy control. Within Africa, Kenya was the first country to achieve World Health Organization (WHO) targets for case detection and treatment success of new smear-positive pulmonary TB cases. Treatment success continues to be a hallmark of the NTLD Program, with rates among new smear-positive cases averaging over 88% among HIV-negative patients, 82% among PLHIV, and approximately 68% among those being treated for MDR-TB. The country has been a leader in rolling out TB/HIV collaborative activities. In 2013, over 93% of patients with TB disease were tested for HIV. About 98% of those with TB and HIV co-infection (TB/HIV) received cotrimoxazole preventive therapy (CPT), and 83% started on anti-retroviral therapy (ART).
In line with the constitution, devolution of government functions and resources to 47 newly created counties is swiftly changing the mode of operations in the health sector, including the management of TB, leprosy and lung disease. The health sector, previously characterized by central-level planning and supply-side financing, is shifting to devolved planning and demand-side financing modalities, including national health insurance, conditional and performance-based grants, and equity-enhancing allocations of national resources.
Devolution presents opportunities for local prioritization and adaptation of TB and leprosy control activities that are targeted and patient-centered. Translating the cascade model of technical excellence and assistance into the new structure is ongoing and will require additional human resources and new skill sets, given the expanded number of administrative units and new requirements for planning capacity at county level. The NSP describes how the gains of the past five years will be sustained under this new system of governance.
With an already declining rate of TB case notification, it is time to build on the Program’s solid foundation with a stronger focus on the prevention of transmission. The Health Sector Policy calls for a 62% decline in deaths due to communicable diseases by 2018. To build towards achieving this goal, the NTLD Program will: a) implement quality enhancements; b) re-align the program’s operations to the new governance structure, ensuring unified commitment from both national and county levels; and c) rapidly introduce/expand prevention efforts, including reducing diagnostic delays to diminish transmission.
This four-year National Strategic Plan (NSP) for TB, leprosy and lung disease represents a transition to: a) program implementation through the newly established 47 counties; and b) intentional acceleration of declining incidence. The NSP is based on robust evidence generated by the national case-based electronic data system, Tuberculosis Information from Basic Units (TIBU) as well as results of small-scale pilot projects and operational research. The NSP intentionally capitalizes on well-performing counties as mentors and training hubs for others, while also scaling up high impact pilot projects. It describes a county-tailored approach to the prioritization of technical assistance and programmatic enhancements addressing particular challenges of each county and sub-population.
EXECUTIVE SUMMARYvi
Figure 1: Strategic Plan Vision, Goals, Impact Targets and Strategic Objectives
KENYA NATIONAL STRATEGIC PLAN FOR TB, LEPROSY AND LUNG HEALTH 2015-2018
Vision To reduce the burden of lung disease in Kenya and render Kenya free of Tuberculosis and Leprosy
Goal To accelerate the reduction of TB, Leprosy and lung disease burden through provision of people-centered, universally accessible, acceptable and affordable quality services in Kenya
Impact Targets
By 2018: 1. Reduce the incidence of TB by 5%, compared to 2014
1.1 Reduce the prevalence of MDR-TB among new patients by 15% 1.2 Reduce the incidence of TB among PLHIV by 60%
2. Reduce mortality due to TB by 3% 3. Reduce the proportion of affected families who face catastrophic costs due to TB,
Leprosy and lung diseases 4. Reduce by 50%, the proportion of cases with grade 2 disability due to leprosy 5. Reduce mortality due to chronic lung diseases e.g. COPD, asthma
Strategic Objectives
1. Sustain the gains in the context of a newly devolved health system
2. Intensify efforts to find “missing” cases
3. Reduce transmission
4. Prevent active disease and morbidity
5. Enhance the quality of care for chronic lung diseases
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CHAPTER 1
RATIONALE AND METHODOLOGY OF NSP DEVELOPMENT1.1. Rationale for Planning Period
The current Health Sector Strategic Plan covers 2013-2017. To align this NSP with the national planning cycles, it will cover four years, running from 2015 to mid 2018. Subsequent NSPs will be aligned to the country’s medium term plans.
1.2. MethodologyThe development of the NSP started in earnest with the NTLD Program carrying out an epidemiological assessment and impact evaluation with technical assistance from WHO Kenya and CDC. The Epidemiological Assessment and Impact Evaluation Report 2014, served as a critical background document for the mid-term review (MTR) of the 2011 - 2015 NSP, which took place in March 2014. The findings from both the assessment and review were shared widely.
As part of the country’s dialogue spirit, two stakeholder meetings were convened under the leadership of the NTLD Program that brought together the national government, county governments, donors, technical partners, civil society organizations, non – governmental organizations, medical institutions of higher learning, medical research institutes, key populations, private health providers and medical insurance companies.
To support the writing of the document, a drafting team was drawn from the participants of the stakeholder meetings. This drafting team was diverse in both composition and sector representation. The stakeholder meetings were held interchangeably with drafting retreats. The first stakeholder meeting fed into the first drafting retreat that led to a sub–zero NSP draft. The second stakeholder meeting was held to share and further develop the sub –zero NSP draft. Subsequently, the final drafting retreat was held to incorporate the feedback from the second stakeholder meeting.
This entire process ultimately gave birth to the country’s prioritized needs with county–specific interventions. Consensus was reached on the goal, the impact and outcome targets, and the strategic objectives for the 2015 – 2018 NSP. A costing plan, operational plan, and monitoring and evaluation plan were developed at the conclusion of the drafting. The final draft was shared electronically with all the stakeholders and feedback incorporated by the NSP development secretariat.
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CHAPTER 2
BACKGROUND
2.1. Country Profile
2.1.1. Geography and Demographics
Kenya is located in the African Great Lakes region, in the Eastern part of the continent. It has a total surface area of 581,309 km2 (or 224,445 sq mi) and it borders Tanzania to the south, Uganda to the west, South Sudan to the northwest, Ethiopia to the north and Somalia to the northeast.
According to July 2013 estimates, Kenya has a total population of 44 million1, making it the seventh most populated country in Africa. The population increased by 14% between 2009 and 2013, based on the most recent census. The total fertility rate in 2012 was 4.46. This was a decline from 4.54 in 2011, but an increase from 3.66 children per woman of childbearing age reported in 2000. Kenya’s population is thus rapidly growing. World Bank projections predict that it could increase further to 85 million by 2050. Reflecting this rapid surge, Kenya’s population is young, with UN statistics reporting that 42.2% of the population is below the age of 15. According to the World Health Organization (WHO), life expectancy is 58.1 for men and 61.4 for women, making an average life expectancy at birth of 59.7 years.
Kenya’s population is mostly rural, with only 24% of Kenyans living in urban settlements2. The main urban area being the capital city of Nairobi, which hosts over three million people. The country has experienced sustained economic growth, with GDP per capita increasing from US$404 in 2000 to US$943 in 2012. Nonetheless, Kenya continues to have chronically high levels of poverty. The World Bank poverty estimates range between 34 to 42% indicating that a huge part of the Kenyan population was living below the poverty line in 2013. Estimates suggest that 72.2% of adults are literate, but there are significant inequities and age distribution3. Encouragingly, literacy is higher (82.4%) among people aged 15-243. Kenya is a demographically and linguistically diverse country with 42 different ethnic tribes and 69 languages4.
_________________________________________________________________________________________________________________________________1 CIA Factbook2 WHO3 UNESCO4 Ethnologue
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2.1.3. Economic development agenda
Kenya’s Medium Term Expenditure Framework (MTEF) 2012/2013 – 2015/2016 aims to facilitate “an effective and efficient use of Government resources”, considering that internal reviews of performance noted an ineffective management of public spending. The MTEF has three specific goals:
1. Maintain aggregate fiscal discipline by ensuring that policy changes are consistent with fiscal norms and program objectives
2. Increase efficiency in resource allocation3. Promote efficient delivery of services.
2.2. Health Profile
2.2.1. Health status of the population
The principal causes of deaths and of Disability-Adjusted Life-Years (DALYs) reported by the Kenyan Government Review of the Health Policy Framework 1994 - 2010 are listed in Table 1 below.
The main risk factors to health in Kenya include unsafe sex, suboptimal breastfeeding, alcohol and tobacco use, obesity and physical inactivity, amongst others. Such factors, particularly tobacco use and unsafe sex, are asscociated with TB/HIV co-infection and contribute to the burden of lung diseases, and are considered in this NSP.
Available evidence suggests a reduction in unsafe sexual practices, though the HIV incidence remains high in selected counties. This is attributed to steady improvements in knowledge and attitudes of communities regarding sexually transmitted infections and conditions.
Breastfeeding practices have also changed, with exclusive breastfeeding for up to five (5) months showing significant improvements.
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2.1.2. Political structure and policy context
Kenya’s Vision 2030, the country’s development blueprint, was finalized in 2007. It aims to achieve “a globally competitive and prosperous Kenya with a high quality of life by 2030.” The key role that health plays in maintaining the healthy and skilled workforce needed to drive the economy made health one of the key components of the vision’s social pillar.
To align with Vision 2030, the health sector defined priority reforms as well as flagship projects and programs, including restructuring of the sector’s leadership and governance mechanisms; improving procurement and availability of essential medicines and medical supplies; modernizing health information systems; accelerating health facility infrastructure development to improve access; development of human resource for health; strengthening of equitable financing mechanisms; and establishment of social health insurance.
The new Constitution, adopted in 2010, replaced a governance structure of eight provinces with 47 newly created counties. Kenya adopted a bicameral legislature composed of Senate (Upper house) and The National Assembly (Lower House). The senate was re-established with the 2010 Constitution. It has 47 members elected directly by the counties with powers to represent the interests of counties, participate in law making and determine budgeting allocation and has powers of impeachment over President, Deputy President, County Governor and Deputy Governor. The National Assembly, on the other hand, has 349 members; 290 elected from constituencies, 47 women elected from the counties and 12 nominated members.
In line with the new Constitution, the devolution of government functions and resources to the 47 counties is swiftly changing the mode of operations for the health sector including the management of TB, leprosy and lung disease. The health sector, previously characterized by central-level planning and supply-side financing, is shifting to devolved planning and demand-side financing modalities including national health insurance, conditional and performance-based grants, and equity-enhancing allocations of national resources.
Cause of Death
Rank Disease % of deaths
1 HIV/AIDS 29.3
2 Conditions arising during perinatal period
9.0
3 Lower respiratory infections 8.1
4 Tuberculosis 6.3
5 Diarrheal diseases 6.0
6 Malaria 5.8
7 Cerebrovascular disease 3.3
8 Ischemic Heart Disease 2.8
9 Road traffic accidents 1.9
10 Violence 1.6
Source: Kenya Health Policy (2012-2030)
Table 1: Principal causes of deaths and of DALYs
Cause of DALYs
Rank Disease % of DALYs
1 HIV/AIDS 24.2
2 Conditions arising during perinatal period
10.7
3 Malaria 7.2
4 Lower respiratory infections 7.1
5 Diarrheal diseases 6.0
6 Tuberculosis 4.8
7 Road traffic accidents 2.0
8 Congenital anomalies 1.7
9 Violence 1.6
10 Unipolar depressive disorders 1.5
Tobacco use remains high, particularly among productive populations in urban areas and among males. Evidence shows that one in five males aged 18 – 29 years and one in two males aged 40 – 49 years are using tobacco products. Tobacco use has been associated with chronic obstructive lung disease, recurrent UTIs, malignancies, including lung cancer and increased risk of developing active TB disease.
Obesity appears to be on the rise, with an increasing population of Kenyans being overweight. It is anticipated that this will fuel an increase in diabetes, a known co-morbidity for TB. It is estimated that 25% of all persons in Kenya are overweight or obese, with the prevalence being highest among women in their mid to late 40s and in urban areas.
A 2007 Household Health Expenditures and Utilization Survey reports that more than half of outpatient visits (57%) occur in government facilities, while private and mission facilities account for 24%, and traditional healers for about 1%. Chemists are the first visit for around 15% of patients. Approximately 38% of people who did not seek care cited financial concerns/constraints as the reason. Gender was also an important determinant of outpatient services utilization, with women making for 1.3 times as many visits per capita as males (2.9 vs. 2.3).
The 2007 Survey also highlighted a major improvement in access to outpatient services, with the poor more likely to seek outpatient medical attention than their wealthier counterparts. Urban dwellers reported seeking inpatient services more than their rural counterparts (38/1,000 vs. 24/1,000). Unlike outpatient care, inpatient services were strongly correlated with wealth index, with individuals in the richest quintile twice as likely to use inpatient care compared to those in the lowest one, a trend that remained largely unchanged since 2003.
Lastly, while 75% of the richest household and 55% of the poorest had money to cover immediate inpatient services, 14% still reported having to either borrow or sell property to be able to comply with the payments, suggesting the importance of pursuing social protection programs.
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2.2.2. Health sector strategy and health policy
The Kenya Health Policy Framework (KHPF) was the basis for the health development agenda in Kenya from 1994-2012. The framework emphasized “quality health care that is acceptable, affordable and accessible to all.”
The implementation of this framework was divided into two five-year strategic plans: the National Health Sector Strategic Plan (NHSSP I, 1999-2004), and the National Health Sector Strategic Plan II (NHSSP II, 2005-2010).
The Kenya Health Policy 2012 – 2030 aims at attaining the highest possible health standards in a manner responsive to the population needs.
The policy aims to achieve this goal through supporting provision of equitable, affordable and quality health and related services at the highest attainable standards to all Kenyans. It also aims at attaining a level and distribution of health that is commensurate with a middle-income country through attainment of specific health impact targets. The policy directions in the Kenya Health Policy are structured around Six Service Delivery outcomes and Seven System investment orientations.
Consistent with the Health Policy, the National Health Sector Strategic Plan III (NHSSP III, 2012-2017) is currently being implemented. NHSSP III has the following policy objectives that relate to the control of TB, leprosy and improvement of lung health; all of which are aligned with the realization of the Health Sector Vision:
1. Eliminate communicable conditions: This is to be achieved through reducing the burden of communicable diseases, until they are not of major public health concern.
2. Halt, and reverse the rising burden of non-communicable conditions: This is to be achieved by ensuring clear strategies for implementation to address all the identified non-communicable conditions in the country.
3. Provide essential health care: These shall be medical services that are affordable, equitable, accessible and responsive to client needs.
4. Minimize exposure to health risk factors: This aims at strengthening the health promoting interventions, which address risk factors to health, plus facilitating use of products and services that lead to healthy behavior in the population.
5. Strengthen collaboration with other sectors: This aims at adopting a ‘Health in all Policies’ approach, which ensures the Health Sector interacts with and influences design, implementation and monitoring processes in all health related sector actions. In addition, it is critical that other sectors of government and non-state actors reach populations for prevention, screening, communication, and treatment follow-up.
2.2.3. Health financing
Overall, expenditures for the health sector are estimated at US$40 having increased from US$17 per capita. This is due to increased government and donor resources, with the proportion of household expenditures reducing as a proportion of the total expenditures. The health expenditure as a proportion of the GDP and the general government expenditure stagnated during the same period.
Out of pocket spending is highest in the wealthier provinces of the country. Financial risk protection has steadily increased with an estimated 17% of the total population benefiting from the same. Evidence from the National Health Accounts 2010 demonstrated improvements in allocation efficiencies, with more services being provided using the same amounts of resources in real terms. However, resources are increasingly being directed to management functions as opposed to service delivery.
Looking at actual expenditures, limited real improvements in human resources for health and infrastructure were noted during the previous policy period. There have been limited improvements in human resource for health and infrastructure despite an increase in investment in the two areas in the 2005-2010 period. This is a reflection of the stagnation of real resources for health. Improvements in real terms are only notable in the last two (2) years of the policy period (2009 and 2010).
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_______________________________________________________________________________________________________________________________5 Taken directly from “The Kenya AIDS Epidemic – Update 2012” – National AIDS Control Council
2.2.4 HIV/AIDS policy and financing context5
Kenya’s response to HIV is guided by a strategic plan that aims to harmonize and align the HIV-related activities of diverse partners and stakeholders. Coordinated by the National AIDS Control Council (NACC), HIV response builds on the robust engagement of civil society and people living with HIV. The National AIDS and STI Control Programme (NASCOP) within the Ministry of Health, administers the bulk of HIV-related services in Kenya. The country has developed a series of performance indicators to drive progress and promote accountability in the response.
Declaring HIV a national disaster in 1999, the Government established the National AIDS Control Council (NACC) within the Office of the President to coordinate national response to the epidemic. An important step in establishing a rights-based framework for effective action on HIV occurred in September 2003, when the Government approved legislation making it illegal to engage in employment discrimination on the basis of a person’s HIV status. The law also prohibited insurers from withholding services to people living with HIV or from imposing discriminatory premiums on HIV-infected individuals.
In 2006, Kenya enacted the HIV and AIDS Prevention and Control Act. The law formally protects the rights of people living with HIV, prohibits mandatory HIV testing, and authorizes various measures to mitigate the epidemic’s impact. It also prohibits discrimination on the basis of one’s HIV status and disallows insurers from withholding services to people living with HIV. Although this law does not specifically address vulnerable populations, other laws, such as the Sexual Offence Act and the Children’s Act, provide explicit protection to women, children and young people. Formal policies and guidelines have been developed to support program planning and implementation with respect to specific aspects of HIV response. These normative frameworks aim to ensure that Kenya’s HIV response is firmly grounded in available evidence.
Financing for HIV programs in Kenya rose roughly seven-fold from 2000–2001 to 2008–2009. However, the continuing global financial and economic downturn threatens future HIV funding. The U.S. Government, the single largest source of HIV funding in Kenya, is capping its financial support for HIV programs in the country. In response to the uncertainty of future international HIV assistance, Kenya has embarked on a national effort to mobilize new sources of financing, with particular focus on increasing domestic funding for HIV. The Government of Kenya has already taken steps to increase domestic support for HIV programmes, with domestic HIV outlays nearly doubling between 2006–2007 and 2008–2009.
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2.3. Epidemiology of TB, HIV, Leprosy and Lung Diseases
2.3.1. TuberculosisFrom the TB Epidemiological and Impact Analysis Report of 2014, various trends were noted and these have been highlighted in this section.
Analysis of the trends in estimates of TB incidence (Figure 2) suggests a consistent decline in new TB cases over time. The decline in TB cases started in 2005 following the decline in TB/HIV cases, which started in 2004. Furthermore, after a peak in 2006, the TB prevalence declined and thereafter plateaued from 2009 (Figure 3). TB mortality estimates suggest an increase in TB deaths in 2011-2012 (Figure 4). However, the wide confidence intervals indicate considerable uncertainty in the estimates, suggesting the need for other more direct methods to measure prevalence and mortality.
Figure 4: Trends in TB Mortality
Data on TB prevalence and mortality are sparse. Kenya has not conducted a national TB prevalence survey in the recent past (the last TB prevalence survey was conducted in 1956), but the NTLD Program is planning to carry out a prevalence survey in 2015.
There is currently no national level vital registration system with standard ICD-10 coding in place. Less than half of deaths are recorded, and approximately 10% of deaths receive an ICD code. Results from a prevalence survey and vital registration systems would provide data on the current status of the TB burden and the effectiveness of TB control interventions.
The TB case notification showed an upward trend from 2003 to 2007, when it peaked with 116,000 cases. Thereafter, it has steadily declined, reaching an all time low of 89,000 in 2013 (Figure 5)6. This may be explained by better TB and HIV control efforts, as well as the recent introduction of the electronic case based surveillance. An inventory study would, however, be necessary to confirm this sharp decline.
Figure 5: Trends in TB Related Deaths among PLWHIV
Figure 2: Trends in TB Incidence Figure 3: Trends in TB Prevalence
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TB case notification patterns vary across reporting zones. A majority of zones experienced gradual decline in notified cases from 2007-2012 (e.g. Western, Nyanza South, Nairobi South). On the contrary, a few zones showed an increase. They included Rift Valley South and North Eastern, especially those harbouring refugee groups. Some zones like Nyanza North and Nairobi North had variable case notification reporting. These stark differences are likely evidence of data management problems.
Males had higher TB case notification rates than females among all age groups, except for children (0-15 years) and young adults (15-24 years). Adults aged 35 - 44 years had the highest CNR with the rates of TB among males being 30% greater than that of females.
The NTLD Program has continued to successfully screen about 93% of all notified TB cases for HIV. The current prevalence of HIV among notified TB cases is about 37%. The HIV prevalence among notified TB cases is also 37%7 but varies by region. Zones with higher HIV prevalence are associated with higher co-infection rates. Prisons contributed to about 1% of the notified TB cases in 2013. Surveillance for DR-TB among retreatment cases has led to increased reporting with 290 cases notified in 2013. Refugees constituted 28% of the MDR-TB cases detected in 2013.
The relative numbers of new bacteriologically confirmed (smear positive) cases and extra pulmonary TB cases have remained fairly consistent over time. From 2003 to 2012 the proportion of new cases that were bacteriologically confirmed ranged from 37.3 – 43.0%, while the proportion of new extra pulmonary cases increased gradually since 2003, but maintained a narrower range: 15.1% to 18.2%.
For the past five years, the proportion of retreatment cases has remained just below 10% of all notified TB cases. (Figure 14). Data on TB in other high-risk populations and in patients with underlying comorbidities is not readily available from TIBU.
_______________________________________________________________________________________________________________________________6 & 7 NTLD Program Annual Report 2013
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Figure 6: Trends in Notified TB Cases in Kenya (2003-2013)
2.3.2. HIV/AIDS
In 2014, the Kenya AIDS Indicator Survey was published. This section highlights some of the findings of the report.
According to the UNAIDS Global Report 2013, Kenya is ranked 4th in the world in terms of HIV prevalence, with an estimated 1,600,000 people living with HIV in the country.
Kenya’s HIV prevalence has declined from 7.2% in the general population in 2007 to 5.6% in 2014 (KAIS 2014 Report). Women have consistently been more affected by HIV than men. Currently 6.9% of women in Kenya are living with HIV (down from 8.5% in 2007) compared to 4.4% of men (down from 5.5% in 2007). Women with secondary education reported having higher infection rates (7.4%) compared to those with no primary education at all (4%). A similar pattern is observed in men with 2.4% among those with no primary education and 4.4% in those with secondary education. However, the prevalence is highest at 4.8% among men who completed primary education.
HIV is not evenly spread throughout the country, with the Eastern North (2.1%) and North Eastern (0.5%) having significantly lower prevalence compared to other parts, particularly the West.
Nyanza region reported a prevalence of 15.1%, increasing slightly from 14.9% in 2007. Nyanza was also one of the only two regions that experienced an increase, although limited, in the prevalence, together with Central region where the prevalence rose from 3.6% to 3.8%. The rest of the country has witnessed a considerable decline in HIV prevalence, especially the Coast region (from 8.1% to 4.3%) and Nairobi (from 8.8% to 4.9%).
HIV prevalence was higher among urban dwellers compared to rural dwellers, being 6.5% and 5.1% respectively. About 8% of urban females were HIV infected compared to 6.2% of rural females, and 5.1% of urban males were living with HIV compared to 3.9% or rural men.
Marital status also shaped different patterns of the disease, particularly negatively affecting widowed men and women with an infection rate of about 20% (M: 19.2% and F: 20.3%), ten times higher than among individuals who never married or cohabited (1.8%).
Among HIV infected adults, 58% were eligible for anti-retroviral therapy (ART). They had a CD4+ cell count equal to, or below 350 or in stage III or IV and with co-infections. Among those eligible, 63% reported using ART and 78% of them also reported achieving viral suppression. About 11.9% of all HIV infected persons reported having a history of TB.
2.3.3. Socioeconomic burden of TB
Tuberculosis is known to have a strong association with poverty8. Patients and households affected by TB are likely to be caught in a ‘medical poverty trap’ – a situation where treatment expenditures increase as income levels decrease.
In one study, the median total cost incurred as a result of TB infection in Kenya was KSH 22,753 (US$ 350), a figure that was roughly equivalent to a quarter of the median household income measured before the onset of the illness. Most patients must borrow money or sell assets to meet the expenses they face due to illness. Indirect costs, primarily in the form of loss or reduction of income, account for about 85% of the economic burden Kenyan individuals and households affected by TB incur, with median indirect costs amounting to an estimated KSH 19,123 (US$ 294). Significant decreases in productivity are reported as a result of TB illness. During treatment, direct costs are incurred when patients have to travel to get medication or for follow-up sputum tests. Food, accommodation, and drug administration also contribute to direct costs. Costs due to Direct Observation of Treatment (DOT) are rarely incurred as most patients receive DOT from their family members. As a result of the high prevalence of HIV/TB co-infection, many TB patients must also cover expenses brought about by their HIV+ status9.
Over half of the TB patients are malnourished to some degree at the onset of treatment, with 17% being severely malnourished and a further 22% being moderately malnourished10.
The TB control strategies outlined in this NSP take into consideration these socioeconomic determinants and aim to cushion patients from the negative impact.
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8 WHO Addressing Poverty in TB Control Guidelines 20059 Mauch, V., Woods, N., Kirubi, B., Kipruto, H., Sitienei, J., & Klinkenberg, E. (2011). Assessing access barriers to tuberculosis care with the tool to Estimate Patients’ Costs: pilot results from two districts in Kenya. BMC Public Health, 11(1), 43.10 http://digitalcommons.calpoly.edu/cgi/viewcontent.cgi?article=1009&context=fsn_fac
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2.3.4. Progress and trends in control of TB and leprosy
Kenya is one of the 22 high burden TB countries that together account for more than 80% of the world’s TB cases. WHO estimated that there were 120,000 new cases of TB in Kenya in 2012. The estimated 9,500 (5,400-15,000) deaths due to TB make it the fourth leading cause of mortality in the country. Since 2006, a gradual decline in case notification has persisted, suggesting that incidence may be declining following years of high treatment success, currently at over 88%. Case detection has been enhanced through community engagement, inclusion of the private sector, intensified case finding, pro-poor enablers such as nutritional support, TB/HIV collaborative activities, and an increased focus on identifying TB in children.
HIV/AIDS continues to be an important driver of the TB epidemic in Kenya, with approximately 37% of patients with TB also living with HIV (TB/HIV). TB-related deaths among people living with HIV have declined from a high of 12% in 2004 to 5% in 2012, as access to anti-retroviral therapy (ART) and cotrimoxazole preventive therapy (CPT) have increased. Approximately 74% of TB patients co-infected with HIV were initiated on HAART in 2012. Nearly all (98%) HIV infected TB patients were initiated on CPT in the same year (NTLD Program Annual Report 2013).
Programmatic Management of Drug-Resistant TB (PMDT) was initiated in 2007. In 2013, 254 cases of multi-drug resistant TB (MDR-TB) were identified and started on treatment compared to 60 in 2007. Twenty eight percent of notified MDR-TB cases occurred among refugees residing in Kenya. The Kenyan Government made an important humanitarian and public health decision to manage these cases with the resources and infrastructure of the Ministry of Health. WHO currently estimates that there are 2,750 cases of MDR-TB in the country. A drug-resistance survey is ongoing to define the estimates of prevalence of DR-TB in the country.
The number of new leprosy cases detected in the country has declined from 6,000 in 1989 to 139 cases notified in 2013. The health system currently manages grade 1 or 2 disabilities in 48% of the cases notified.
Sustained political commitment for TB has been fundamental to the success of the NTLD Program. Among the performance indicators of the new HSSP is TB treatment success rate, with a goal of reaching 90%. In addition to the government’s commitment, the NTLD Program has nurtured strong partnerships at national and county levels, with donors, international and national NGOs, CSOs, and technical partners through its inter-agency coordinating committees (ICCs). For two consecutive fiscal years of 2013/14 and 2014/15, the National Treasury devolved all funds for TB control to the counties, including commodity procurement funds.
Kenya will remain a legacy in sub-Saharan Africa for being the first country to reach WHO targets for both TB case detection and treatment success. The NTLD Program has successfully managed a high quality program through a cascade of TB and leprosy coordinators at decentralized levels. A network of trained and skilled health workers has consistently enabled the rapid uptake of new policies and technologies, while also providing the platform for supportive supervision to address operational challenges on a systematic basis. The full integration of TB and leprosy service provision into the primary care system has enabled mentorship and decentralized touch points for coordination with community based organizations and care providers.
Kenya maintains a policy of evidence-based strategy development and program implementation. Having the first real-time electronic case-based surveillance system is evidence of the desire for data for action. New approaches, such as the engagement of all care providers and collaborative TB/HIV activities have been successfully scaled up rapidly in Kenya due to the cascade system and the use of evidence of their effectiveness to achieve buy-in at all levels.
Leprosy has also been controlled successfully through the cascade system, and within the primary health care network. Kenya is now in the post-elimination phase of leprosy control.
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2.3.5. Summary of findings from mid-term review 2014
A mid-term review for the just concluded Strategic Plan 2011-2015 was conducted in March 2014 to review progress and give a way forward especially in the changing health context and the new constitutional dispensation. The key findings of this review are highlighted in this section.
Tuberculosis
Treatment success continues to be a hallmark of the NTLD Program, with rates among new smear-positive cases averaging over 88% among HIV-negative patients, 82% among PLHIV, and approximately 68% among those being treated for MDR-TB.
In TB/HIV collaborative activities, over 93% of patients with TB were tested for HIV in 2012. Some 98% of TB/HIV co-infected patients received CPT and 74% were started on ART. The review found that in 75% of facilities visited, TB and HIV services were offered in the same room for patients with TB/HIV. The uptake of TB screening among PLHIV has improved, with 83% screened for TB at their last visit, across the sites visited.
Kenya was one of the first countries in the region to embrace systematic involvement of private providers in TB control, through its Public-Private Mix (PPM) model. In 2012, over 10% of notified cases were reported from the private sector. Kenya was one of the first countries in the region to introduce a nationwide case-based electronic recording system for monitoring program activities known as TIBU. Community engagement in TB control has been facilitated by the roll-out of a national strategy, with an increasing number of civil society organizations and local partners involved. Information, education and communication materials for TB have been developed and disseminated countrywide.
Activities to increase case detection and improve the care of children with TB have also been intensified. Guidelines, on-the-job tools and capacity building activities have been developed. All pediatric formulations of recommended medicines were available in many of the facilities visited. Currently, 11.4% of TB cases notified are in children.
These inaugural and sustained successes have led to what appears to be a steady decline, since 2006, in the case notification rate (CNR), which may resemble a decline in the incidence of TB (Figure 7).
The review acknowledged the presence of three pillars that seem to support the success of the NTLD Program. These include:
1. Sustained government commitment: The government’s financial contribution to TB has increased gradually over the past decade and now accounts for approximately 28% of all spending on TB control in the country. The country has maintained government funding for commodities and a strong staffing structure that extended from the central level to the primary health care system, a key indicator of commitment. Stock-outs of anti-TB medicines at facility level were rarely reported. The review team commended the Government of Kenya on its humanitarian and important public health decision to treat MDR-TB cases among refugees residing in Kenya.
Figure 7: Declining Case Notification Rate suggests decline in TB incidence
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2. Evidence-based Innovation: The NTLD Program has historically adopted innovations in TB control, such as PPM, community-based care and TB/HIV collaborative activities. The Program continues to pilot and scale up new innovations like the nationwide roll-out of TIBU, an electronic case-based recording system. It will enable real-time evaluation of program performance, including early identification of emerging challenges at any level of the health system.
The adoption and rollout of new diagnostic technologies is noteworthy. The country currently has 70 GeneXpert MDR/RIF machines, 5 culture laboratories and 150 LED microscopes; operating within a network of 1,860 AFB microscopy sites (1:25,000 population). Scale-up of GeneXpert represents a tremendous opportunity to rapidly and accurately diagnose and treat TB in people living with HIV and among children, as well as to identify drug resistance.
3. Strong Partnerships: Under solid stewardship by the national government, the NTLD Program benefits from long-standing partnerships with its development and technical partners, especially USAID, Global Fund, WHO, CDC, KNCV, World Bank, GDF, and FIND. In addition, it has been able to mobilize and ensure collaboration with community-based organizations (CBOs), non-governmental organizations (NGOs), Stop TB Partnership, and the private sector. Its sustained engagement with partners through the Inter-Agency Coordinating Committee (ICC) and its five component working groups are to be applauded.
Leprosy Leprosy control is fully integrated in the primary health care network. Kenya’s successful efforts in leprosy control have placed the country in the post-elimination phase.
Figure 8: Declining Notification of Leprosy
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Main Challenges
The NTLD Program is well positioned to emerge as a flagship program within the new health sector strategy, and to contribute to the sector-wide target of a 62% reduction in deaths due to communicable diseases by 2018. To do so, the review team identified challenges relating to:
a) Preventing transmission and diseaseb) finding all TB and leprosy patientsc) ensuring that all TB and leprosy patients are curedd) securing an enabling environment for quality TB control.
Preventing Transmission and Disease
The NTLD Program has excelled in establishing a solid foundation for the control of TB and leprosy disease through the primary health care network. While enhancing the quality of these operations, the NTLD Program can also move into the next era of TB control with an enhanced focus on preventing transmission and disease. Specifically, the team observed limited use of Isoniazid Preventive Therapy (IPT) among PLHIV, and among child contacts of people diagnosed with TB. Infection control (IC) practices were found to be inconsistent, and generally sub-optimal in many health facilities serving patients with TB.
Finding all TB and Leprosy Cases
a) Diagnostic Network: Four broad challenges to timely diagnosis of TB were identified. The first concerns the introduction of new diagnostic technologies. The review noted the absence of an up-to-date strategic plan that articulates the levels of placement and purpose of new technologies. In some cases, the new technologies may replace antique and error-prone methods. For example, the use of GeneXpert as the first diagnostic tool for TB in PLHIV is not yet routine. The second relates to the limited access, high out of pocket cost, inferior quality and challenges with interpretation of radiographs for TB diagnosis. Third, while the coverage of external quality assurance of AFB sputum microscopy was reported as 85%, the review team found inadequate quality testing practices and a lack of timely feedback of results to inform good practice. Mentorship and technical assistance to laboratory technicians was found to be irregular. Financial and geographic barriers to high-quality diagnostic services, especially for children and vulnerable populations, was identified as a main challenge.
b) TB/HIV Collaborative Activities: HIV testing among patients with TB was routinely conducted and monitored. The recording of TB screening among people living with HIV was done but it was not consistently reported through standardized data capture systems. Limited access to diagnostics beyond smear microscopy was noted as a major barrier to clinicians screening for TB among PLHIV.
c) Intensified Case Finding (ICF) activities among contacts of TB and MDR-TB patients remains limited. Barriers to ICF were noted, including the costs of transport, food and radiography.
d) Childhood TB: There remains limited access to diagnostics for childhood TB, especially quality chest radiographs, TST and Xpert. Fee-based testing presents a financial barrier for many families. The team found poor integration between maternal and child health (MCH) clinics, pediatric clinics, emergency rooms and TB service providers. Health care providers at all levels of the health system showed a low index of suspicion for pediatric TB and were not aware of new treatment guidelines.
e) PMDT: Drug resistance testing is limited mostly to retreatment patients, potentially missing cases with primary resistance.
f) Leprosy: The review noted a low index of suspicion for leprosy among health care workers, even in endemic areas.
Ensuring that All Patients are Cured
a) Monitoring and Evaluation: Monitoring, supervision, quality control and evaluation of program activities were sub-optimal at all levels of the system. This deficit was most severe in the diagnostic network. The gaps appeared to be largely associated with a lack of clarity at county-level about the availability of funding for supervision, following devolution. The TIBU system may support more routine monitoring, but it is not yet utilized optimally and there are still challenges in data quality. Capacity to utilize the TIBU – generated local data for decision-making was inadequate.
b) Care for patients with MDR-TB: While the treatment outcomes for PMDT have improved every year since 2008, social and nutritional support for patients remain inconsistent. At the county level, there are limited isolation facilities, absence of functional PMDT clinical teams, and insufficient pharmacovigilance. The high burden of MDR-TB among refugees presents a public health challenge, particularly given the political sensitivities inherent in working with this population.
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c) Community-based care: There were no systematic linkages between providers of community based care and health facilities. This left some community care providers without the needed mentorship and support required to deliver quality care.
d) Social determinants of TB: The World Bank estimates that Kenya’s poverty rate in 2013 was between 34% and 42%. While this is down from 47% in 2005, the social determinants of TB cannot be overlooked. In the Kenyan Demographic and Health Survey of 2009, financial barriers were a primary cause of delayed seeking of health care. The review team identified financial barriers stemming from the following areas: transportation costs, fee-based diagnostic tests, and lack of nutritional and financial support during intensive phase of TB treatment. Malnutrition is known to negatively affect treatment outcomes. The NTLD Program estimated that 17% of notified TB cases were severely malnourished and a further 21% moderately malnourished.
e) Public-private mix: While evidence has suggested that nearly half of care seeking for TB and other lung health issues is done through the private sector, only 10.5% of TB cases were notified by the private sector in 2012. Further scale-up is needed for collaborative public-private mix interventions, which may require a nationwide application of the International Standards of TB Care, particularly through the private providers.
Sustaining government commitment and stewardship in a devolved system
The review acknowledged the potential for devolution to promote patient-centered care by enabling county and sub-county adaptations to relevant service delivery. However, the team also recognized risks that would need to be mitigated to ensure that the successes of a cohesive national program were sustained through the prioritization of TB and consideration of leprosy by all 47 counties.
Key challenges will include:
a) Ensuring a stable and quality assured drug supply: Limited capacity for commodity management was found at all levels of the system. There is no clear process for the procurement of drugs within the new framework despite the counties having the funds for commodity purchase. This needs to be clarified further and adapted with the growing capacity of county governments. A normal procurement cycle can take 6-9 months.
b) Closing the financing gap for TB control: The MTR estimated that the NTLD Program would face a financing gap of nearly US$200 million over the next five years, which represents half of its required funding. Data from the National Health Accounts (NHA) suggested that while TB accounted for over 6% of deaths and nearly 5% of DALYs in the country, it received only 1% of total health expenditures for priority areas. This is in contrast to malaria’s contribution to nearly 6% of deaths and 7% of DALYs, but in receipt of 25% of total health expenditures for priority areas.
c) Ensuring sustained priority for TB prevention and control at central and county levels: TB is not fully considered within the health sector strategy (e.g. the only indicator for TB is treatment success rate), and is not an integral part of the essential health package that has formed the basis for emerging/expanding demand-side, performance-based and social support financing schemes. For example, the direct facility cash transfer program called the Health Sector Services Fund (HSSF) or the health insurance for poor families called the Health Insurance Subsidy Programme (HISP) does not include TB prevention and control services. At county level, health plans were not available for review as they were still being developed, but the inclusion of TB and leprosy activities was not guaranteed.
d) Re-profiling the functions and staff of the central program to support new roles: The functions of the NTLD Program have expanded to include: a) high-level policy formulation to include TB in emerging health system strategies, plans, and demand-side financing modalities including national health insurance and social protection programs; b) coordination of a comprehensive program through guidance/support to 47 counties; and c) continued technical leadership. This places more demand on the NTLD Program staff even as devolution continues. Additional skills, particularly related to economics and statistics are required.
e) Building the capacity of counties and renewing a comprehensive national program: Planning and budget tools to support county-level planning for TB and leprosy control activities, including drug quantification estimates are essential. Counties were unaware of the new funding structures for TB or leprosy control, including supervision and, therefore, activities were not optimal.
f) Shifting epidemiology of TB: The epidemiological profile of TB is bound to change in future due to the potential to detect drug resistance, as well as the improved capacity to detect TB in children and PLHIV, the cross border movement for TB services and the ageing epidemic. There is need to build the capacity of county-level planners to recognize these trends locally and to support relevant activities.
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3.1 Roles and ResponsibilitiesTo achieve the country’s aspirations envisioned in this strategic plan, strong and responsive organizational structures are required to guide the implmentation and monitoring of the Program activities. The exisiting structures, which may evolve with devolution, are anchored on the Constituion of Kenya 2010.
The constitution created two distinct (National and County) Governments that are mutually interdependent with a new level of management and structures that support health services at the County level. The country now has 47 Counties that enjoy relative autonomy in the management of health services. The National Government is made up of three arms: executive, including the Ministry responsible for health, the legislature and judiciary.
The Constitution mandates the National Government with development of Policies, Capacity Building and Technical Assistance to the Counties among other tasks, while empowering the County Governments to be responsible for county health services. These structures are further strengthened by the Kenya Health Policy 2012 - 2030 that provides the framework for seamless implementation of activities. The health service delivery has been reorganized into four tiers of care within which TB, leprosy and lung diseases control programs fit. These are:
• Tier 1: Community Level – as defined in the Kenya Essential Package of Health (KEPH)• Tier 2: Primary Care Level – that provides basic outpatient services• Tier 3: County Level – that provides primary referral services• Tier 4: National Level – that provides secondary and specialized services
The National Leprosy, TB and Lung Disease Program is under the Division of Communicable Disease Prevention and Control in the Directorate of Preventive and Promotive Health Services of the Ministry of Health. Presently, this Program, popularly called Central Program, is made up of technical staff distributed across four sections: Prevention and Health Promotion, Care Services, Policy, Planning and Research (PPR) and Administration and Finance. The Program is linked to the County level through 47 County TB and Leprosy Coordinators (CTLCs), who provide technical and implementation support to 153 Sub-County TB and Leprosy Coordinators (SCTLC).
The overall development of the technical aspects of TB control, including policies, is mandated to the NTLD Program under the umbrella of the Ministry of Health. The NTLD Program has the additional role of setting standards (including providing technical specifications), identifying and mobilizing resources.
The recent increase in global attention to tuberculosis has encouraged local and international partners to support TB control activities in the country. This has created challenges in the coordination of the response of control activities and alignment to the National strategies and policies. The TB Inter Agency Coordination Committee (TB-ICC), initially created to meet the requirements of Global Fund to Fight AIDS, TB and Malaria has shaped the role of all major players in TB control, as membership is all-inclusive. This committee has Technical Working Groups (TWG) that respond to policy matters at scheduled quarterly meetings to deliberate on all issues pertaining to TB control in Kenya.
The Technical Working Groups of the TB ICC include National TB/HIV steering Committee, Laboratory, M&E, MDR-TB, Commodity, ACSM, Community and Gender, Special Groups, PPM and Lung Health. These technical working groups draw membership from both technical and development partners, including affected communities. Some of these working groups have been cascaded to lower levels and hold meetings in stakeholders’ forums where critical issues of implementation and challenges are discussed and addressed.
CHAPTER 3
OPERATIONAL STRUCTURE OF THE NTLD PROGRAM
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3.2. Intra- and Inter-Ministry PartnershipsTuberculosis, Leprosy and Lung diseases prevention, detection, diagnosis, treatment, care and control will benefit from a multidisciplinary approach that identifies and utilizes the varying core competencies of diverse stakeholders, including their complementary resources - human and/or financial, access to presumptive and confirmed patients and their communities, and skills. While a fully multi-sectoral approach to the control of these diseases has not yet been achieved, its appeal is even greater in the context of devolution as a broad array of local stakeholders can optimize the ability to identify local solutions to the contextual nuances of the diseases. To achieve this, thorough mapping of needs and resources at county and sub-county level will be needed. A multipronged approach to working with and through other health and non-health actors, both in the public and private sectors, will be explored for each of the thematic areas covered in this NSP.
a) Public Sector: Inter- and Intra-Ministry collaborations and partnerships
In order to address the diverse social determinants and drivers of TB, leprosy and lung diseases at National and County levels, the NTLD Program will strengthen collaborations and partnerships with relevant departments/sectors within the Ministry of Health, e.g. HIV/AIDS, NHIF, KEMSA, NCDs, etc. In the same breadth, partnerships and collaborations across the Government Ministries/Sectors, which are non-health, will be sought for purposes of resource mobilization, efficiency in resource allocation (e.g. building TB screening into workplace settings), relevant policy formulation and enforcement, establishing forums and platforms for sustained health promotion and education, just to name a few. Such sectors would include but are not limited to:
1. Ministry of Devolution and Planning – for leadership, governance and resource mapping, mobilization and allocation2. The National Treasury – for resource mobilization and allocation3. Ministry of Labor, Social Security and Services - e.g. Workplace health/wellness policies and interventions; resource
allocation for both public and private sectors4. Ministry of Education – for health promotion and education5. Ministry of Defense – for cross border TB6. Ministry Foreign Affairs - for resource mapping, mobilization and allocation7. Ministry of Information, Communication and Technology – for integrating health through ICT8. Ministry of Sports, Culture and the Arts – for health promotion and education9. Ministry of Land, Housing and Urban development – for disease control10. Ministry of EAC Affairs, Commerce and Tourism – for resource mobilization and disease control11. Ministry of Mining – for control of TB and Lung Disease; workplace and labor policies implementation12. Ministry of Interior and Coordination of National Government – for internal migrants and refugees
b) Private Sector: Health and Non Health Actors
The NTLD Program will actively engage the private for-profit and non-profit health actors, at both national and county levels, to support interventions covered within the plan, either directly or indirectly. This will enable systematic application of the relevant standards of care in TB, leprosy and lung health.
Partnering with the private non-health actors may enable new avenues for resource mobilization, enhanced advocacy for the implementation of health policies, among other areas of involvement. If well engaged and sensitized, this sector may contribute substantially towards health through integrating/mainstreaming health in their core business, offer support through their core competencies, or even contribute towards health resources in kind or in cash. Examples exist in Kenya of innovative corporate partners supporting health care, but commonly at a small scale or through corporate social responsibility (CSR) programs.
The Stop TB Partnership in Kenya has been revitalized to spearhead the multi-sectoral approach for purposes of building synergy from the diverse competencies, through an advocacy and resource mobilization platform.
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4.1. NSP Goals and Objectives Within the context of a newly devolved health system, the goal of the 2015-2018 NSP is to accelerate the reduction of TB, leprosy and lung disease burden through provision of people-centered, universally accessible, acceptable and affordable quality services in Kenya.
Specific objectives include:a) Sustain the gains made over the past decade, in the context of a newly devolved health systemb) Intensify efforts to find the “missing” cases of TB, leprosy and lung disease; c) Reduce transmission of TB and leprosy;d) Prevent active disease and morbidity; e) Enhance the quality of care for chronic diseases
4.2. Impact and Outcome TargetsThe NSP seeks to achieve the following by 2018:
CHAPTER 4
2015-2018 NATIONAL STRATEGIC PLAN
IMPACT AND KEY OUTCOME INDICATORS
Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014
Outcomes
1. Increase case notification of new cases to 85% of estimated prevalence
2. Ensure treatment success of at least 90% among all drug – susceptible forms of TB
Impact 1.1. Reduce the prevalence of MDR-TB among new patients by 15% by 2018, compared to 2014
Outcomes
1. Increase case notification of MDR-TB to at least 75% of estimated prevalence (Baseline TBD: DR Survey)
2. Increase treatment success rate to at least 80% among all cases of DR-TB
Impact 1.2. Reduce the incidence of TB among PLHIV by 60% by 2018 compared to 2014
Outcomes
1. Increase treatment success rate to 85% among all HIV-infected TB patients
2. Reduce case fatality among HIV-infected TB patients to <5%
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IMPACT AND KEY OUTCOME INDICATORS
Impact 2: Reduce mortality due to TB by 3% by 2018, compared to 2014
Outcomes
1. Ensure treatment success of at least 90% among all DS forms of TB
2. Reduce case fatality among HIV-infected TB patients to <5%
Impact 3: Reduce the proportion of affected families who face catastrophic costs due to TB, leprosy & other lung diseases by 2018 (baseline TBD)
Outcomes
1. Increase to at least 60% the proportion of eligible TB and leprosy patients who access nutritional support or other transport, or financial subsidies
2. Reduce out-of-pocket expenditures attributed to TB care seeking
Impact 4: Reduce by 50% the proportion of cases with grade 2 morbidity due to leprosy by 2018
Outcomes
1. Increase to 90% the proportion of leprosy patients notified prior to grade 2 morbidity
Impact 5: Reduce morbidity due to chronic lung diseases (e.g. COPD, asthma)
Outcomes
1. Reduce the average number of annual acute episodes for children with asthma by 15% in areas with established asthma clinics
2. Increase to 80% the proportion of controlled asthma patients
Table 2: NSP Impact and Key Outcome Indicators
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4.3. Eliminate Communicable Diseases
4.3.1 Devolve implementation of activities and budgets
1. Situational Analysis (SWOT)
Sustained political commitment to TB has been fundamental to the past success of the NTLD Program.
In addition to the government’s commitment, the NTLD Program has nurtured strong partnerships at national and decentralized levels. International and national NGOs, CSOs, technical and development partners have been engaged to benefit the plan.
The NTLD Program has successfully managed a high quality program through a cascade of TB and leprosy coordinators at decentralized levels; i.e. provincial and district level prior to devolution. The network of trained and skilled health workers has consistently enabled the rapid uptake of new policies and technologies, while also providing the platform for supportive supervision to address operational challenges on a systematic basis. The full integration of TB and leprosy service provision into the primary care system enabled mentorship and decentralized touch points for coordination with community based organizations and care providers.
Devolution presents opportunities for local prioritization and adaptation of TB and leprosy control, and support for targeted and patient-centered care. Since fiscal year 2013, all government funds for TB control have devolved to the counties, including funds for commodity procurement. In accordance with the Constitution, all devolved funds were bundled and no line item for health, or TB, was specified.
Translating the cascade model of technical excellence and assistance into the new structure is ongoing and will require additional human resources and new skill sets, given the expanded number of administrative units and new requirements for planning capacity at county level.
2. Strategic Direction(s) for 2015-2018
The priority in this period is to ensure a smooth transition to the county-based system of governance. Specifically, the NTLD Program, NTRL and county health offices will collaborate to ensure that a comprehensive national program is maintained within the devolved context. At a minimum, joint annual work plans between the Central Program and each county will be needed to yield a national plan built on county priorities.
3. Proposed Approaches
Establish Inter-Governmental Agreements between the NTLD Program and NTRL and each county
a) Articulate and document the devolution of responsibilities for all TB activities: i.e. considering all dimensions of program implementation and detailing which will be completed by central, county and sub-county levels (NTLD Program Operations Manual 2014)
b) Define financial and human resource commitments, including technical assistance and possibly commodity management support from central program(s).
Bolster county-level capacity for planning for TB, leprosy and lung health
a) Ensure the county and sub-county structure can support all designated activities: e.g. identify a TB and leprosy focal point for each level, take inventory and address any capacity building needs; and develop on-the-job tools and disseminate existing guidance to promote national standards.
b) Support and monitor the inclusion of TB and leprosy within county health plansi) Develop a template(s) for planning and budgeting of TB control activities, including commodity requirements, for use at county level.
ii) Annual joint work planning between the NTLD Program and each county, ensuring TB and leprosy are appropriately represented in health plans. Detailed technical assistance plans will be included in each county
19
plan. Commodity estimates, based on past utilization, will be completed annually for inclusion in county health plans. The NTLD Program will monitor expenditures on TB through the NHA sub-account and via expenditure tracking from Treasury to facilities
iii) Stakeholder mapping will be completed at all levels, and annual planning meetings held to engage stakeholders in county planning
Establish County-based centres of excellence, based on strong performance, for: a) PMDTb) Pediatric TBc) TB/HIVd) Diagnostic services e) PPMf) PALg) Community engagementh) Leprosy
Incentivize counties to serve as models and enable county-to-county technical assistance.
Develop and implement a technical assistance and quality assurance plan through a cascade from central to community levels
Given that many of the county and sub-county staff are new, capacity building will be required for TB and leprosy focal point persons in the counties. The nature of technical assistance from central to county level must be expanded to build capacity for planning, advocacy, budgeting, quality assurance of labs and facilities, and data monitoring.
Ensure county ownership and designated funding of supportive supervision to sub-counties, health facilities, laboratories and community-based treatment partners. Ensure implementation of technical standards including updated SOPs for new diagnostic technologies, and treatment protocols for management of TB e.g. pediatric and drug-resistant TB. Revise the tools available to guide county-level staff in their supervision of more decentralized levels, based on the new county structure.
Specific activities include:
a) Creation of on-the-job tools to serve as reference to key policy and implementation principles. As the infrastructure to support electronic data management, potential for web- based refresher training may be optimized to address the ongoing training needs that result from high staff turnover.
b) Promote the establishment of inter-agency coordinating committees to assist with planning, budgeting, implementing and monitoring activities. The ICCs include all partners, such as the private sector, MCH programme, CSOs and communities, at county and sub-county levels.
c) Establish and disseminate technical standards to guide delivery of services at County level and create buy-in for their implementation and monitoring.
d) Re-profile the staff of the central program to ensure in-house capacity for: i) high-level policy formulation to include TB in emerging health system strategies, plans, and demand-side financing modalities including national health insurance and social protection programmes; ii) coordination of health system structures for comprehensive program implementation to 47 counties; and iii) continued technical leadership. Additional skills, particularly related to economics and statistics, are required at the Program level.
20
4.3.2 Identify and treat all cases (find
the missing cases)
4.3.2.1. Core DOTS
1. Situational Analysis
TB incidence has shown a declining trend as illustrated in Figure 9. It is estimated that nearly 80% of new TB cases were notified in 2013. Map 1 and Figure 12 reflect case notification rates by county, showing the wide inter-country variance of case notification. It is not known if the variance reflects true epidemiological differences, but it can certainly be assumed that cases are missed in all counties to varying degrees.
During the last five years, the program has maintained a national treatment success rate above 85% as shown in Figure 10. Map 2 reflects cases that are lost to follow up, also known as ‘out-of-control.’ Figure 11 shows treatment success rates by county, similarly highlighting the variance in programmatic performance across the country.
Considering the well-documented relationship between poverty and TB, areas of lower case notification and high poverty density may provide hints as to the location of some of the 20% of cases that are undetected. Figure 12 shows markedly lower case notification rates in some counties that have high rates of poverty prevalence i.e. percentage of households that are below the poverty line. Nationwide, approximately 45% of households are estimated to live below the poverty line.
Figure 9: TB Incidence
Figure 10: Treatment Success for Notified Cases
Map 1: Case Notification Rates, 2013
4.3.
2.1.
Cor
e D
OTS
21
Map 2: Lost to Follow Up Rate, 2012
4.3.2.1. Core DO
TS
Figure 11: Overall Case Notification and Treatment Success Rates by County, 2012
22
The NTLD Program is planning a national prevalence survey to be completed during 2014-2015, which will provide more evidence regarding at-risk groups that are under-served by the current network of providers. Until the prevalence survey is completed, data from the national M&E system and operational research studies must guide the Program’s priority setting.
Based on existing evidence from within Kenya and other neighboring countries, the following high-risk groups are recognized as hosting disproportionately high rates of TB and/or being underserved by health services:
a) Urban slums: While the incidence of TB in slum areas throughout Kenya is not known, slums are considered a high-risk setting given the ease of transmission due to overcrowding and financial, geographical and social barriers to care. A pilot project launched under TB-REACH in 2010 to provide affordable and accessible services in Kibera, an urban slum near Nairobi, has increased case notifications by 10%.
b) Health care workers: In Kenyatta National Hospital, a study showed that the rate of TB among health care workers was three times higher than in the surrounding community. In 2011, the notification rate was the equivalent of 772/100,000. Only 75% of cases among health care workers during 2006-2011 successfully completed treatment.
c) Mobile/migrant populations: Kenya is host/home to diverse migrant populations. Ethnic conflict, cattle raids, and climate change have driven internal movement and displacement. Labor-related movement between plantations across rural areas is common. Social determinants arising from migration, such as living in cramped settlements, and income and food instability, increase the risk of TB. Access to continuous care is constrained by many of the social dimensions of migration1.
d) Refugees: Kenya absorbs migrants and refugees from Sudan, Somalia, Ethiopia, Tanzania and Uganda. While WHO estimates the incidence rate of TB to be similar in countries from which many of the refugees in Kenya originate, refugees currently account for 30% of all of the MDR-TB cases notified in the country.
e) Prisoners: TB case notification rates in two large prisons in Kenya, Meru and Embu, were 941 and 4,714/100,000 respectively in 2012. These rates are 4-10 times higher than in the surrounding population. It is estimated that similarly disproportionately high rates occur in other prison settings.
_______________________________________________________________________________________________________________________________1 International Organization for Migration, 2011: An Analysis of Migration Health in Kenya
4.3.
2.1.
Cor
e D
OTS
Figure 12: Case Notification Rate by Prevalence of Poverty, by County
23
f) Uniformed service personnel: Long recognized as a high-risk group for HIV infection in Kenya, this cadre of government personnel is relatively at higher risk for TB.
g) People living with HIV: A study2 suggested that the incidence of TB is 8 times higher among PLHIV in Kenya.
h) Contacts of TB patients: Limited evidence is available from country-level practice regarding the benefits of contact tracing. However, the WHO global recommendation in favor of screening of close contacts of active TB patients is based on five cross-sectional studies showing that contact tracing contributed 2-19% of all cases, and two randomized control trials showing a 15% reduction in incidence and 22% reduction in prevalence due to contact tracing3.
i) Diabetics: While less recognized than its relationship with HIV, TB is 2.5 times more likely to strike in people with diabetes. The International Diabetes Federation predicts the prevalence of diabetes in sub-Saharan Africa to rise by 98.1% between 2010 and 20304.
j) Moderately and severely malnourished individuals: The importance of nutrition for patient recovery has been documented in several studies as a key intervention to improve treatment outcomes and an incentive to promote treatment adherence. Almost 20% of all TB patients were severely malnourished in 2013; i.e. BMI<16. More than a quarter (27.4%) of severely malnourished patients did not receive any form of nutritional support.
The NTLD Program has established policies, strategies and guidelines that are in line with international recommendations and lessons learned from Kenya. The operationalization of national norms occurs through service delivery that is fully integrated into the public health network. Dedicated TB and leprosy coordinators assigned at devolved levels provide supportive supervision to sub-counties and health facilities.
Structured quality assurance for diagnosis and treatment, as well as case-based monitoring and evaluation provide the foundation for ensuring the quality of the program. Currently, one TB treatment or follow-up center serves fewer than 15,000 people. However, despite efforts to build capacity for TB prevention, detection and care at all levels of the health system, it is estimated that fewer than 40% of dispensaries are able to provide TB treatment.
2. Strategic Direction(s) for 2015-2018
The priorities for this period are to:
a) Ensure treatment success rate of at least 90% nationally among all drug-susceptible (DS) forms of TB.
b) Reach marginalized, high-risk and under-served populations, closing the case detection gap
c) Incorporate TB into existing and emerging social protection schemes, including nutritional support platforms.
_______________________________________________________________________________________________________________________________2 Comparison of Trends in Tuberculosis Incidence among Adults Living with HIV and Adults without HIV – Kenya, 1998–2012Courtney M. Yuen1, Herman O. Weyenga2, Andrea A. Kim3, Timothy Malika2, Hellen Muttai3, Abraham Katana3, Lucy Nganga3, Kevin P. Cain3*, Kevin M. De Cock33 Feasibility, yield, and cost of active tuberculosis case finding linked to a mobile HIV service in Cape Town, South Africa: a cross-sectional study.Kranzer1, Lawn SD, Meyer-Rath G, Vassall A, Raditlhalo E, Govindasamy D, van Schaik N, Wood R, Bekker LG., 20124 International Diabetes Federation. IDF Diabetes Atlas, 5th edn. Brussels, Belgium: International Diabetes Federation, 2011. http://www.idf.org/diabetesatlas
STRATEGIC OBJECTIVES
4.3.2.1. Core DO
TS
24
3. Proposed Approaches
The proposed approaches reflect activities that will be needed nationwide to sustain a cohesive national program, in addition to targeted approaches that address specific epidemiological and programme performance contexts.
Sustain quality programme implementation
At the heart of this NSP is the acknowledgement that the NTLD Program has achieved important milestones in terms of case notification and treatment success. The factors contributing to these successes must be sustained nationwide while aligning to the newly devolved governance structure.
Among the key arrangements to be sustained are:
a) Human resource capacity, in sufficient numbers and adequately trained and supported to fully implement the activities of this NSP.
Specifically:
i. TB and leprosy dedicated staff at national, county and sub-county levels: This concerns the continued availability of TB and leprosy dedicated staff with technical expertise to guide implementation across the system.
ii. Technical assistance to counties to ensure technical excellence and the appropriate application or adaptation of national guidelines will reflect specific needs/gaps in counties (Tables 3- 4). Regular technical assistance from the central program or more devolved centers of excellence to individual counties is anticipated on a quarterly basis.
iii. Supportive supervision to systematically extend capacity building and knowledge sharing from the county to sub-county, health facility and community levels. Supportive supervision is planned in a cascade manner, on a monthly basis.
iv. Training and professional development tailored to the specific epidemiological and program performance contexts of each county, sub-county and facility type. Innovative formats for cost-efficient continuing education, such as web-based training, android applications and other on-the-job tools will be developed.
v. International technical assistance to enable continuous innovation and evidence-based program evolution that is enhanced by learning from other countries and experts.
b) Normative functions, guidelines and tools
The normative role of the central program has not changed with the devolution of other responsibility to counties. Gradual updating of all guidelines to align with implementation through the newly devolved system will be required.
i. Guidelines: Guidelines will be updated as new technical standards emerge internationally and/or where local evidence drives a policy shift.
ii. Training tools: Updated planning, budgeting and technical training tools will be required to support devolution and the roll-out of new approaches
iii. Information Technology (IT): Pilot testing and roll-out of new IT solutions to enhance patient-centered care, such as SMS treatment reminders, are planned
iv. Data management system: Continued enhancement of TIBU is detailed in the M&E section
c) Coordination forums
The 2014 mid-term review cited the strength of programme coordination internally and with partners as central to its success. Among the forums to be sustained with regular meetings and follow-up activities are the:
i. Technical working groupsii. Inter-agency coordinating committeeiii. Stop TB Partnershipiv. Data dissemination forums.
d) Stable supply of commodities including drugs, laboratory supplies and equipment, vehicles, and stationery, as described in the commodities section of this NSP.
Target activities to increase case notifications and treatment success
This NSP aims to reduce the disparities between counties in terms of case detection and treatment success, elevating and sustaining programmatic performance at a high level within each county. It is expected that treatment success will reach at least 90% in all counties, and all counties will make targeted efforts to increase case notification.
An assessment of the county-specific epidemiological and programme performance contexts is provided in Table 3
4.3.
2.1.
Cor
e D
OTS
25
and Figure 12. Based on each county’s context, intensified effort will be given to scaling up proven interventions as described below:
a) Package 1: TB Case Notification Rate <175/100,000
16 counties have case notification rates at or below 175/100,000.
While it is recognized that incidence may be lower in these counties, ensuring that capacity exists to detect and diagnose cases is a priority.
In these counties, intensified effort will be given to:
i. Build capacity of health workers and laboratory technicians to identify and diagnose TB
ii. Employ active case finding, with county-based tailoring of the modalities and target groups
iii. Strengthen implementation and monitoring of systematic TB screening at health facility, in-patient wards and community levels, with improved documentation of presumptive TB cases and linkages to diagnostic and care sites
iv. Engage all care providers with an emphasis on systematic screening for TB and reporting of presumptive and active cases, through private, NGO, CSO, MCH and HIV-specialty care facilities
v. Expand communication efforts in communities to stimulate care seeking
vi. Ensure the availability of referral networks for sputum samples and patient care
vii. Intensify technical assistance and supportive supervision from Centers of Excellence or the NTLD Program
4.3.2.1. Core DO
TS
Evidence for Targeting
Case Notifications
• 16 counties have low TB case notification (<175/100,000)
• 10 counties have relatively high TB caseloads (around or above 250/100,000)
• Case notification rates are loosely, yet inversely related to the prevalence of poverty in counties, suggesting missing cases among the poor
Treatment Successes
• 27 counties have treatment success rates below 88%
Defaulters
• Three counties; Nairobi, Meru and Mombasa account for 27% of all cases notified, but 36% of cases of treatment default
• 9 counties have default rates >7%
Box 1b) Package 2: TB Case Notification Rate 175-250/ 100,000
There are 22 counties with case notification rates between 175 – 250/100,000. In these counties, assessment of the sub-county epidemiology and programme performance will shape the focus of intensified case finding or other tailored approaches. Capacity in these counties should be sufficient to deploy active contact tracing, especially among child contacts of active TB cases and PLHIV.
c) Package 3: Case Notification Rate >250/100,000
There are nine (9) counties with case notification rates near or above 250/100,000. These counties may host successful models of case finding and human resource expertise that can be shared in other counties. Center(s) of Excellence within these counties will be established to serve as referral points, and to host HCWs and TB and leprosy coordinators from other counties for on-site mentorship, training and technical assistance.
These counties may also host particularly high incidence among sub-populations. Intensified efforts to reach high-risk groups will be supported. Contact tracing will be further enhanced.
d) Package 4: Treatment success <88%
In 27 counties, treatment success rates in 2012 were below the national target of 88%. In these counties, intensified efforts will be mobilized for:
i. Defaulter tracingii. Strengthen access to critical enablers i.e. nutrition support and other social protections iii. Improved health education for patients, including innovations in the use of technology platforms for communicating
with patientsiv. Building CHEW capacity to oversee family-based and community volunteer-supported DOTv. Strengthen referral networks to bring care closer to patients.
e) Package 5: Poverty prevalence > 45%
There are 26 counties in which >45% of households live below the poverty line. The poorest TB patients face particular socio-economic barriers to care that will be addressed through:
i. Strengthening access to social protections, especially nutritional support, transport vouchers, and health insurance.
26
ii. Strengthening referral networks, such as sputum collection points to connect to laboratories, to bring care closer to patients
iii. Prioritize the engagement of communities
County-specific needs to be addressed are summarized in the following table:
County-Specific Contexts
COUNTY Low CNR (< 175/ 100,000)
Mid CNR ( 1 7 5 - 2 5 0 / 100,000)
Low treatment success (< 88%)
High poverty prevalence (> 45%)
>40% of TB patients with BMI < 18
High HIV prevalence in general population (>5%)
HIV prevalence 2.5-5%
Low community case notification ( < 9% of total)
Low pediatric case notification (<8% of total)
Baringo X X X X X X X
Bomet X X X X X
Bungoma X X X X X X
Busia X X X X
Embu X X X X
Garissa X X X X
Homa Bay X X X
Isiolo X X X X X
Kajiado X X X X X
Kakamega X X X X X
Keiyo-Marakwet X X X X X
Kericho X X X X
Kiambu X X X X X
Kilifi X X X X X
Kirinyaga X X X X X
Kisii X X X X X X
Kisumu X X X X
Kitui X X X X X X X
Kwale X X X X X X
Laikipia X X X X X X X
Lamu X X X
Machakos X X X X X X X
Makueni X X X X X X
Mandera X X X X
Marsabit X X X X X
Meru X X X X X X
Migori X X X X
Mombasa X X X
Murang'a X X X X X X
Nairobi X X X X
Nakuru X X X X X
Nandi X X X X X X
Narok X X X X X
Nyamira X X X
Nyandarua X X X X X X
Nyeri X X X X X
Samburu X X X X X X
Siaya X X X X X
Taita Taveta X X X X X X
Tana River X X X X X X
Tharaka X X
Trans Nzoia X X X X X
Turkana X X X X X
Uasin Gishu X X X X
4.3.
2.1.
Cor
e D
OTS
27
Expand special initiatives to reach most at-risk
The most at-risk populations defined above warrant targeted approaches. Successful pilots will be scaled-up and new approaches introduced with attention to monitoring the impact on case notification and treatment outcomes. The table below summarizes the approaches by high-risk group:
High-Risk Group Approaches
Health care workers Implement infection control plans in all government health facilities
Conduct annual screening for HCWs as part of a revised workplace-based policy on TB control
Assess and respond to socio-economic barriers to treatment initiation and treatment completion
Prisoners
Implement screening upon entry to prisons
Enhance infection control practices
Introduce diagnostic and DOT capacity on-site
Develop health education tools for prisoners and prison staff
Develop referral mechanisms for prisoners who are transferred or released
Mobile populations Integrate TB screening and control activities within service delivery platforms reaching these populations; e.g. MCH mobile outreach, HIV activities along transport corridors
Refugees Enhance infection control capacity within camps
Ensure diagnostic and DOT capacity, including Rif-resistance identification (Xpert), on-site
Uniformed service Introduce diagnostic and DOT capacity on-site
Update the workplace-based policy to allow 1 month of paid leave for new cases
Intensify contact tracing
Urban slums Intensify community engagement and outreach
Increase the engagement of non-state providers already present in the slums or reaching slum dwellers, including employers
Expand the availability of diagnostic sites and/or referral networks, including sputum collection points, to bring services closer to patients
Expand eligibility of social protection programs to include TB patients
Diabetics Pilot systematic screening for TB among all diabetics followed by hospitals and other providers (Year 1); and screen TB patients for diabetes (Year 3)
Table 4: Approaches by High-Risk Group
COUNTY Low CNR (< 175/ 100,000)
Mid CNR ( 1 7 5 - 2 5 0 / 100,000)
Low treatment success (< 88%)
High poverty prevalence (> 45%)
>40% of TB patients with BMI < 18
High HIV prevalence in general population (>5%)
HIV prevalence 2.5-5%
Low community case notification ( < 9% of total)
Low pediatric case notification (<8% of total)
Vihiga X X X X
Wajir X X X X
West Pokot X X X X X
Table 3: County Specific Contexts
4.3.2.1. Core DO
TS
28
Contribution to NSP Impacts Outcomes (Core DOTS)
Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014
Increase case notification (in each county) of new cases to 85% of estimated prevalence
Impact 1.2: Reduce the incidence of TB among PLHIV by 60% by 2018, compared to 2014
Increase the treatment success rate among HIV-infected TB patients to 85%
Impact 2: Reduce mortality due to TB by 3% by 2018, compared to 2014
Ensure treatment success rate (in each county) of at least 90% among all DS forms of TB
Impact 3: Reduce the proportion of affected families who face catastrophic costs due to TB, leprosy & other lung diseases, by 2018 (baseline TBD)
Increase to 100% the proportion of severely and moderately malnourished people with TB who access appropriate nutritional support
Table 5: Impact and Outcome Indicators for Core DOTS
4.3.
2.1.
Cor
e D
OTS
29
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st
aff,
50
cl
inic
al
offi
cers
an
d
115
labo
rato
ry
tech
nolo
gist
s
175
Num
ber
of
staf
f su
ppor
ted
to
unde
rtak
e pr
ofes
sion
al c
ours
es a
t th
e K
enya
Sch
ool o
f G
over
nem
ent
Supp
ort
sta
ff f
rom
NTL
D P
rogr
am a
nd c
ount
ies
to
unde
rtak
e pr
offe
sion
al c
ours
es a
t K
enya
Sch
ool
of
Gov
ernm
ent
Supp
ort
sta
ff f
rom
NTL
D P
rogr
am
and
coun
ties
to
un
dert
ake
prof
fesi
onal
co
urse
s at
K
enya
Sc
hool
of
Gov
ernm
ent
60Su
ppor
t s
taff
fro
m N
TLD
Pr
ogra
m
and
coun
ties
to
un
dert
ake
prof
fesi
onal
co
urse
s at
Ken
ya S
choo
l of
G
over
nmen
t
60Su
ppor
t s
taff
fro
m N
TLD
Pr
ogra
m
and
coun
ties
to
un
dert
ake
prof
fesi
onal
co
urse
s at
Ken
ya S
choo
l of
Gov
ernm
ent
60Su
ppor
t s
taff
fro
m N
TLD
Pr
ogra
m
and
coun
ties
to
un
dert
ake
prof
fesi
onal
co
urse
s at
Ken
ya S
choo
l of
Gov
ernm
ent
60
Num
ber
of s
taff
sup
port
ed t
o at
tend
in
tern
atio
nal c
ours
es
Supp
ort
staf
f fr
om N
TLD
and
cou
ntie
s to
att
end
inte
rnat
iona
l cou
rses
Supp
ort
staf
f fr
om N
TLD
Pro
gram
an
d co
unti
es t
o at
tend
inte
rnat
iona
l co
urse
s
6Su
ppor
t st
aff
from
N
TLD
Pr
ogra
m
and
coun
ties
to
at
tend
in
tern
atio
nal
cour
ses
6Su
ppor
t st
aff
from
N
TLD
Pr
ogra
m
and
coun
ties
to
at
tend
in
tern
atio
nal
cour
ses
6Su
ppor
t st
aff
from
N
TLD
Pr
ogra
m
and
coun
ties
to
at
tend
in
tern
atio
nal
cour
ses
6
Num
ber
of a
udit
ors
trai
ned
on IS
OTr
ain
inte
rnal
aud
itor
s on
ISO
Trai
n in
tern
al a
udit
ors
on IS
O5
Trai
n in
tern
al
audi
tors
on
IS
O5
Trai
n in
tern
al a
udit
ors
on
ISO
5
Num
ber
of l
ead
audi
tors
tra
ined
on
ISO
Trai
n le
ad a
udit
ors
on IS
OTr
ain
lead
aud
itor
s on
ISO
2Tr
ain
ISO
lead
aud
itor
s2
Num
ber
of
NTL
D
Prog
ram
st
aff
sens
itiz
ed o
n IS
OSe
nsit
ize
NTL
D P
rogr
am s
taff
on
ISO
Sens
itiz
e N
TLD
Pro
gram
sta
ff o
n IS
O40
Sens
itiz
e N
TLD
Pr
ogra
m
staf
f on
ISO
40
ISO
ce
rtif
icat
ion
reta
ined
by
N
TLD
Pr
ogra
mM
eet
ISO
cer
tifi
cati
on r
equi
rem
ents
for
ret
enti
on
incl
udin
g fe
esA
nnua
l ISO
fee
s1
Ann
ual I
SO f
ees
1A
nnua
l ISO
fee
s1
Ann
ual I
SO f
ees
1
Num
ber
of C
TLC
s or
ient
ed a
nnua
llyCo
nduc
t IS
O o
rien
tati
on t
rain
ing
for
CTL
Cs
Cond
uct
ISO
orie
ntat
ion
trai
ning
fo
r C
TLC
s30
Cond
uct
ISO
orie
ntat
ion
trai
ning
for
CTL
Cs
30Co
nduc
t IS
O
or
ient
atio
n tr
aini
ng f
or C
TLC
s30
Cond
uct
ISO
orie
ntat
ion
trai
ning
for
CTL
Cs
30
1.2
Nor
mat
ive
Func
tion
s, G
uide
lines
and
Too
ls
4.3.2.1. Core DO
TS
Core
DO
TS O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Perc
enta
ge o
f 'r
etre
atm
ent'
pat
ient
s st
arte
d on
cat
egor
y 2
reg
imen
D
evel
op a
pol
icy
for
pha
sing
out
TB
Cat
egor
y II
regi
men
TWG
to
phas
e ou
t C
AT
II re
gim
en1
Dis
sem
inat
ion
of g
uide
lines
and
sen
siti
zati
on10
0%D
isse
min
atio
n of
ne
w
guid
elin
es o
n ph
asin
g ou
t of
C
AT
II re
gim
en
80%
Pati
ents
re
ceiv
ing
CA
T II
regi
men
60%
Pati
ents
re
ceiv
ing
CA
T II
regi
men
40%
Num
ber
of
trai
ning
ne
eds
asse
ssm
ents
co
nduc
ted
and
diss
emin
ated
Trai
ning
nee
ds a
sses
smen
t (T
NA
) to
ide
ntif
y th
e ga
ps a
nd o
ppor
tuni
ties
of
the
curr
ent
TB t
rain
ing
curr
icul
um
Nat
iona
l tr
aini
ng
need
s as
sess
men
t (T
NA
) to
id
enti
fy
the
gaps
an
d op
port
unit
ies
of t
he c
urre
nt
curr
icul
um
1_
Stak
ehol
ders
mee
ting
s to
dis
sem
inat
e fi
ndin
gs o
f th
e TN
A a
nd s
hare
nee
d fo
r cu
rric
ulum
rev
iew
Stak
ehol
ders
m
eeti
ngs
to
diss
emin
ate
find
ings
of
the
TNA
an
d sh
are
need
fo
r cu
rric
ulum
rev
iew
1
Stak
ehol
der
mee
ting
s to
de
velo
p re
quir
ed
com
pete
ncie
s of
dif
fere
nt c
adre
s in
TB,
lep
rosy
&
lu
ng
dise
ase
serv
ice
deliv
ery
(bas
ed
on
TNA
fe
edba
ck a
nd s
take
hold
er i
nput
) an
d de
velo
pmen
t of
a c
urri
culu
m f
ram
ewor
k ba
sed
on t
he o
utpu
t of
th
e w
orks
hops
Tech
nica
l w
orki
ng
grou
p m
eeti
ngs
to
deve
lop
requ
ired
co
mpe
tenc
ies
of
diff
eren
t ca
dres
in
TB
, le
pros
y &
lu
ng
dise
ase
serv
ice
deliv
ery
(bas
ed
on
TNA
fe
edba
ck
and
stak
ehol
der
inpu
t)
and
deve
lopm
ent
of
a cu
rric
ulum
fr
amew
ork
base
d on
the
out
put
of t
he
wor
ksho
ps
An
inte
grat
ed T
B tr
aini
ng c
urri
cullu
mD
evel
op a
n in
tegr
ated
TB
trai
ning
cur
ricu
lum
n/a
Cond
uct
wri
ting
wor
ksho
ps
to c
onve
rt p
revi
ous
trai
ning
m
ater
ials
in
to
dist
ance
le
arni
ng
form
at
(incl
uded
tr
aini
ng
in
wri
ting
in
th
is
form
at)
n/a
Tech
nica
l re
view
w
orks
hops
by
ex
pert
s in
th
e di
ffer
ent
mod
ules
(an
d de
velo
pmen
t of
ad
junc
t m
ater
ial
– te
sts,
log
boo
ks
etc.
)
n/a
Wri
ting
w
orks
hops
to
co
nver
t pr
evio
us
trai
ning
m
ater
ials
in
to
dist
ance
le
arni
ng
form
at
(incl
uded
tr
aini
ng i
n w
riti
ng i
n th
is
form
at)
1
Educ
atio
nal
revi
ew o
f th
e m
odul
esn/
an/
a
Pilo
t of
the
cur
ricu
lum
at
sele
cted
sit
es c
ount
ry-w
ide
Eval
uati
on o
f th
e pi
lot
Post
-pilo
t re
view
w
orks
hops
fo
r fe
edba
ck
from
pilo
t sit
es a
nd re
visi
on
of c
urri
culu
m m
ater
ials
Educ
atio
nal
revi
ew
and
fina
l edi
ting
Roll
out
incl
udin
g m
onit
orin
g
A
TB
tech
nica
l as
sist
ance
m
anua
l de
velo
ped
Supp
ort
deve
lopm
ent
and
dis
sem
inat
ion
of a
TB
tech
nica
l ass
ista
nce
man
ual
Cond
uct
TWG
s m
eeti
ngs
on
de
velo
pmen
t of
TA
man
ual
n/a
Dis
sem
inat
ion
of T
A m
anua
ln/
a1
n/a
4.3.
2.1.
Cor
e D
OTS
Core
DO
TS O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Num
ber
of T
B co
ntac
t tr
acin
g to
ols
and
defa
ulte
r tr
acin
g to
ols
pri
nted
Dev
elop
too
ls f
or c
onta
ct t
raci
ng o
f TB
pat
ient
sRe
vise
/dev
elop
def
ault
er t
raci
ng
&
cont
act
trac
ing
tool
s to
inco
rpor
ate
cont
act
trac
ing
& T
B sc
reen
ing
in a
ll cl
inic
al s
etti
ngs
tool
s
15,0
0015
,000
15,0
0015
,000
Prin
t TB
con
tact
tra
cing
too
lsPr
int
5,00
0 co
ntac
t tr
acin
g bo
okle
ts,
5,00
0 co
ntac
t re
gist
ers,
5,
000
defa
ulte
r tr
acin
g bo
okle
ts
Prin
t 5,
000
cont
act
trac
ing
book
lets
, 5,
000
cont
act
regi
ster
s,
5,00
0 de
faul
ter
trac
ing
book
lets
Prin
t 5,
000
cont
act
trac
ing
book
lets
, 5,
000
cont
act
regi
ster
s,
5,00
0 de
faul
ter
trac
ing
book
lets
Prin
t 5,
000
cont
act
trac
ing
book
lets
, 5,
000
cont
act
regi
ster
s,
5,00
0 de
faul
ter
trac
ing
book
lets
Dis
sem
inat
ion
of c
onta
ct t
raci
ng t
ools
Cond
uct
a na
tion
al
diss
emin
atio
n w
orks
hop
and
deve
lop
and
rapi
d ad
vice
sen
t to
all
coun
ties
__
Num
ber
of T
B in
tens
ifie
d ca
se f
indi
ng
tool
s de
velo
ped
and
prin
ted
Supp
ort
prin
ting
of
algo
rith
ms,
SO
Ps &
pro
toco
ls
on T
B-D
M a
nd e
xten
ded
TB In
tens
ifie
d ca
se f
indi
ngSu
ppor
t pr
inti
ng
of
algo
rith
ms,
SO
Ps
&
prot
ocol
s on
TB
-DM
an
d ex
tend
ed
TB
Inte
nsif
ied
case
fin
ding
5000
Num
ber
of
coun
ty
diss
emin
atio
n w
orks
hops
for
TB-
DM
and
inte
nsif
ied
case
fin
ding
too
ls c
ondu
cted
Dis
sem
inat
ion
of T
B-D
M a
lgor
ithm
s to
all
coun
ties
n/a
n/a
Cond
uct
diss
emin
atio
n m
eeti
ngs
of
algo
rith
ms,
SO
PS a
nd p
roto
cols
on
TB -
D
M a
nd e
xten
ded
ICF
24Co
nduc
t di
ssem
inat
ion
mee
ting
s of
al
gori
thm
s,
SOPS
and
pro
toco
ls o
n TB
-
DM
and
ext
ende
d IC
F
23n/
an/
a
1.3
Coor
dina
tion
For
a
Num
ber
of n
atio
nal
TWG
mee
ting
s he
ldSu
ppor
t qu
arte
rly
nati
onal
TW
G
mee
ting
s (P
ed,
Lepr
osy,
TB
/HIV
an
d M
DR-
TB,C
omm
unit
y an
d G
ende
r, co
re D
OTS
)
TWG
mee
ting
s he
ld20
TWG
mee
ting
s he
ld20
TWG
mee
ting
s he
ld20
TWG
mee
ting
s he
ld20
Num
ber m
onth
ly N
TLD
Pro
gram
sta
ff
mee
ting
s he
ld
Hol
d m
onth
ly N
TLD
Pro
gram
sta
ff m
eeti
ngs
12
NTL
D
Prog
ram
st
aff
mee
ting
s he
ld12
12
NTL
D
Prog
ram
st
aff
mee
ting
s he
ld12
12
NTL
D
Prog
ram
st
aff
mee
ting
s he
ld12
12
NTL
D
Prog
ram
st
aff
mee
ting
s he
ld12
Num
ber
of q
uart
erly
TB
Inte
r A
genc
y Co
rdin
atin
g Co
mm
itte
(T
B IC
C)
mee
ting
s he
ld
Hol
d qu
arte
rly
TB IC
C IC
C m
eeti
ngs
TB I
CC
mee
ting
s he
ld4
TB I
CC
mee
ting
s he
ld4
TB I
CC
mee
ting
s he
ld4
TB I
CC
mee
ting
s he
ld4
Prop
orti
on
of
coun
ties
co
nduc
ting
bi
annu
al
co
unty
le
vel
TB
inte
r ag
ency
cor
dina
tion
mee
ting
s
Supp
ort
bian
nual
co
unty
-lev
el
TB
inte
rage
ncy
coor
dina
ting
for
a H
old
bi
annu
al
coun
ty-l
evel
TB
in
tera
genc
y co
ordi
nati
ng f
ora
100%
Hol
d
bian
nual
co
unty
-le
vel
TB
inte
rage
ncy
coor
dina
ting
for
a
100%
Hol
d
bian
nual
co
unty
-le
vel
TB
inte
rage
ncy
coor
dina
ting
for
a
100%
Hol
d
bian
nual
co
unty
-le
vel
TB
inte
rage
ncy
coor
dina
ting
for
a
100%
Num
ber
of
ST
OP
TB
part
ners
hip
busi
ness
con
fere
nces
hel
dCo
nduc
t ST
OP
TB
Part
ners
hip
and
reso
urce
m
obili
zati
on c
onfe
renc
esCo
nduc
t ST
OP
TB P
artn
ersh
ip a
nd
reso
urce
mob
iliza
tion
con
fere
nce
1Co
nduc
t ST
OP
TB
Part
ners
hip
and
reso
urce
m
obili
zati
on c
onfe
renc
e
1Co
nduc
t ST
OP
TB
Part
ners
hip
and
reso
urce
m
obili
zati
on c
onfe
renc
e
1Co
nduc
t ST
OP
TB
Part
ners
hip
and
reso
urce
m
obili
zati
on c
onfe
renc
e
1
Prop
otio
n of
sc
hedu
led
TB
pe
rfor
man
ce r
evie
w m
eeti
ngs
held
Cond
uct
bian
nual
na
tion
al
perf
orm
ance
re
view
m
eeti
ngs
Bian
nual
na
tion
al
perf
orm
ance
re
view
mee
ting
s10
0%
100%
Bian
nual
na
tion
al
perf
orm
ance
re
view
m
eeti
ngs
100%
Bian
nual
na
tion
al
perf
orm
ance
re
view
m
eeti
ngs
100%
Prop
orti
on
of
sub
coun
ties
pa
rtic
ipat
ing
in
quar
terl
y re
view
m
eeti
ngs
Cond
uct
coun
ty-b
ased
qu
arte
rly
perf
orm
ance
re
view
mee
ting
sCo
nduc
t
coun
ty-b
ased
qu
arte
ly
perf
orm
ance
rev
iew
mee
ting
s10
0%Co
nduc
t
coun
ty-b
ased
qu
arte
ly
perf
orm
ance
re
view
mee
ting
s
100%
Cond
uct
co
unty
-bas
ed
quar
tely
pe
rfor
man
ce
revi
ew m
eeti
ngs
100%
Cond
uct
co
unty
-bas
ed
quar
tely
pe
rfor
man
ce
revi
ew m
eeti
ngs
100%
Num
ber
of
na
tion
al
TB
part
ner
revi
ew m
eeti
ngs
held
H
old
quar
terl
y na
tion
al p
artn
ers'
rev
iew
mee
ting
s to
alig
n in
terv
enti
ons
and
acti
viti
esH
old
quar
terl
y pa
rtne
rs
revi
ew
mee
ting
s 4
Hol
d qu
arte
rly
part
ners
re
view
mee
ting
s 4
Hol
d qu
arte
rly
part
ners
re
view
mee
ting
s 4
Hol
d qu
arte
rly
part
ners
re
view
mee
ting
s 4
1.4
Supp
orti
ve S
uper
visi
on
Num
ber
of v
ehic
les
proc
ured
Proc
ure
vehi
cle
tran
spor
t fo
r th
e N
TLD
Pro
gram
to
fa
cilit
ate
regu
lar
tech
nica
l as
sist
ance
to
th
e co
unti
es
n/a
Proc
ure
vehi
cles
4Pr
ocur
e ve
hicl
es4
n/a
4.3.2.1. Core DO
TS
Core
DO
TS O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prop
orti
on
of
the
NTL
D
Prog
ram
ve
hicl
es
wit
h no
do
wnt
ime
of
mor
e th
an 2
wee
ks d
ue t
o la
ck o
f m
aint
enan
ce
Mai
ntan
ance
of
NTL
D P
rogr
am m
otor
veh
icle
s Co
nduc
t sc
hedu
led
mai
ntai
nanc
e of
N
TLD
Pro
gram
veh
icle
s10
0%Co
nduc
t sc
hedu
led
mai
ntai
nanc
e of
N
TLD
Pr
ogra
m v
ehic
les
100%
Cond
uct
sche
dule
d m
aint
aina
nce
of
NTL
D
Prog
ram
veh
icle
s
100%
Cond
uct
sche
dule
d m
aint
aina
nce
of
NTL
D
Prog
ram
veh
icle
s
100%
Prop
orti
on o
f N
TLD
Pro
gram
veh
icle
s fi
tted
wit
h ne
w s
et o
f ti
res
annu
ally
Proc
ure
tyre
s fo
r N
TLD
Pro
gram
mot
or v
ehic
les
Proc
ure
44
mot
or
tyre
s fo
r N
TLD
Pr
ogra
m v
ehic
les
100%
Proc
ure
60 m
otor
ty
res
for
NTL
D P
rogr
am v
ehic
les
100%
Proc
ure7
6 m
otor
tyr
es f
or
NTL
D P
rogr
am v
ehic
les
100%
Proc
ure
76 m
otor
tyr
es f
or
NTL
D P
rogr
am v
ehic
les
100%
Prop
orti
on o
f N
TLD
Pro
gram
veh
icle
s w
ith
no d
ownt
ime
of m
ore
than
1 d
ay
due
to la
ck o
f fu
el
Proc
ure
fuel
for
NTL
D P
rogr
am v
ehic
les
Proc
ure
fuel
for
11
vehi
cles
100%
Proc
ure
fuel
for
11
vehi
cles
100%
Proc
ure
fuel
for
11
vehi
cles
100%
Proc
ure
fuel
for
11 v
ehic
les
100%
Prop
orti
on o
f cou
nty
vehi
cles
wit
h no
do
wnt
ime
of m
ore
than
2 w
eeks
due
to
lack
of
mai
nten
ance
Mai
ntan
ance
of
coun
ty -
base
d m
otor
veh
icle
sCo
nduc
t sc
hedu
led
mai
ntai
nace
of
10 c
ount
y-ba
sed
vehi
cles
100%
Cond
uct
sche
dule
d m
aint
aina
ce o
f 10
co
unty
-ba
sed
vehi
cles
100%
Cond
uct
sche
dule
d m
aint
aina
ce o
f 10
co
unty
-ba
sed
vehi
cles
100%
Cond
uct
sche
dule
d m
aint
aina
ce o
f 10
cou
nty-
base
d ve
hicl
es
100%
Prop
orti
on o
f co
unty
veh
icle
s fi
tted
w
ith
new
set
of
tire
s an
nual
lyPr
ocur
e ty
res
for
coun
ty-b
ased
mot
or v
ehic
les
Proc
ure
tyre
s fo
r 10
cou
nty-
base
d m
otor
veh
icle
s 10
0%Pr
ocur
e ty
res
for
10 c
ount
y-ba
sed
mot
or v
ehic
les
100%
Proc
ure
tyre
s fo
r 10
co
unty
-bas
ed
mot
or
vehi
cles
100%
Proc
ure
tyre
s fo
r 10
co
unty
-bas
ed
mot
or
vehi
cles
100%
Prop
orti
on o
f cou
nty
vehi
cles
wit
h no
do
wnt
ime
of m
ore
than
1 d
ay d
ue t
o la
ck o
f fu
el
Proc
ure
fuel
for
cou
nty-
base
d ve
hicl
esPr
ocur
e fu
el
for
10
coun
ty-b
ased
ve
hicl
es10
0%Pr
ocur
e fu
el f
or 1
0 co
unty
-ba
sed
vehi
cles
100%
Proc
ure
fuel
for
10
coun
ty-
base
d ve
hicl
es10
0%Pr
ocur
e fu
el f
or 1
0 co
unty
-ba
sed
vehi
cles
100%
Prop
orti
on
of
coun
ty
mot
orcy
cles
w
ith
no d
ownt
ime
of m
ore
than
1
wee
k du
e to
lack
of
mai
nten
ance
Mai
ntan
ance
of
coun
ty-b
ased
mot
orcy
cles
Mai
ntan
ance
of
150
coun
ty-b
ased
m
otor
cycl
es10
0%M
aint
anan
ce
of
150
coun
ty-b
ased
mot
orcy
cles
100%
Mai
ntan
ance
of
15
0 co
unty
-bas
ed m
otor
cycl
es10
0%M
aint
anan
ce
of
150
coun
ty-b
ased
mot
orcy
cles
100%
Prop
orti
on
of
coun
ty
mot
orcy
cles
fi
tted
wit
h ne
w s
et o
f ti
res
annu
ally
Proc
ure
tyre
s fo
r co
unty
-bas
ed m
otor
cyc
les
Proc
ure
300
tyre
s fo
r co
unty
-bas
ed
mot
or c
ycle
s 10
0%Pr
ocur
e 30
0 ty
res
for
coun
ty-b
ased
mot
or c
ycle
s 10
0%Pr
ocur
e 30
0 ty
res
for
coun
ty-b
ased
mot
or c
ycle
s 10
0%Pr
ocur
e 30
0 ty
res
for
coun
ty-b
ased
mot
or c
ycle
s 10
0%
Prop
orti
on
of
coun
ty
mot
orcy
cles
w
ith
no d
ownt
ime
of m
ore
than
1 d
ay
due
to la
ck o
f fu
el
Proc
ure
fuel
for
mot
orcy
cles
for
the
sub
-cou
ntie
s to
fa
cilit
ate
regu
lar
supp
ort
supe
rvis
ion
to
the
faci
litie
s
Proc
ure
fuel
for
150
cou
nty-
base
d m
otor
cycl
es10
0%Pr
ocur
e fu
el fo
r 150
cou
nty-
base
d m
otor
cycl
es10
0%Pr
ocur
e fu
el
for
150
coun
ty-b
ased
mot
orcy
cles
100%
Proc
ure
fuel
fo
r 15
0 co
unty
-bas
ed m
otor
cycl
es10
0%
Prop
orti
on
of
Sub
Coun
ty
TB
&
Lepr
osy
cord
inat
ors(
SC
TLC
s)
wit
h no
m
otor
cycl
es
rece
ivin
g m
onth
ly
reim
burs
emen
t fo
r pu
blic
tra
nspo
rt
Supp
ort
publ
ic t
rans
port
for
the
sub
-cou
ntie
s TB
co
rdin
ator
s (w
itho
ut
mot
or-c
ycle
s)
to
faci
litat
e re
gula
r su
ppor
t su
perv
isio
n to
the
TB
faci
litie
s
Supp
ort
publ
ic
tran
spor
t fo
r 15
0 su
b-co
unti
es
TB
cord
inat
ors
(wit
hout
mot
or-c
ycle
s) t
o fa
cilit
ate
regu
lar
supp
ort
supe
rvis
ion
to t
he
faci
litie
s
100%
Supp
ort
publ
ic
tran
spor
t fo
r 15
0 su
b-co
unti
es
TB
cord
inat
ors
(wit
hout
m
otor
-cyc
les)
to
fa
cilit
ate
regu
lar
supp
ort
supe
rvis
ion
to t
he f
acili
ties
100%
Supp
ort
publ
ic
tran
spor
t fo
r 15
0 su
b-co
unti
es
TB
cord
inat
ors
(wit
hout
m
otor
-cyc
les)
to
faci
litat
e re
gula
r su
ppor
t su
perv
isio
n to
the
fac
iliti
es
100%
Supp
ort
publ
ic
tran
spor
t fo
r 15
0 su
b-co
unti
es
TB
cord
inat
ors
(wit
hout
m
otor
-cyc
les)
to
faci
litat
e re
gula
r su
ppor
t su
perv
isio
n to
the
fac
iliti
es
100%
Prop
orti
on
of
NTL
D
Prog
ram
st
aff
prov
ided
w
ith
mon
thly
ai
rtim
e (in
clud
ing
driv
ers)
Prov
ide
mon
thly
ce
ll ph
one
airt
ime
for
NTL
D
Prog
ram
sta
ffPr
ovid
e ce
ll ph
one
airt
ime
for
44
NTL
D P
rogr
am s
taff
100%
Prov
ide
cell
phon
e ai
rtim
e fo
r 44
NTL
D P
rogr
am s
taff
100%
Prov
ide
cell
phon
e ai
rtim
e fo
r 44
NTL
D P
rogr
am s
taff
100%
Prov
ide
cell
phon
e ai
rtim
e fo
r 44
NTL
D s
taff
100%
Prop
orti
on
of
coun
ty
TB
staf
f pr
ovid
ed
wit
h m
onth
ly
airt
ime
(incl
udin
g dr
iver
s)
Prov
ide
mon
thly
cel
l pho
ne a
irti
me
for
CTL
Cs
Prov
ide
cell
phon
e ai
rtim
e fo
r 50
Co
unty
TB
& l
epro
sy c
oord
inat
ors
and
10 d
rive
rs
100%
Prov
ide
cell
phon
e ai
rtim
e fo
r 50
Cou
nty
TB &
lep
rosy
co
ordi
nato
rs a
nd 1
0 dr
iver
s
100%
Prov
ide
cell
phon
e ai
rtim
e fo
r 50
Cou
nty
TB &
lep
rosy
co
ordi
nato
rs a
nd 1
0 dr
iver
s
100%
Prov
ide
cell
phon
e ai
rtim
e fo
r 50
Cou
nty
TB &
lepr
osy
coor
dina
tors
and
10
driv
ers
100%
Prop
orti
on o
f C
TLC
s pr
ovid
ed w
ith
mon
thly
off
ice
stat
ione
ry s
uppo
rtPr
ovid
e C
TLC
s w
ith
mon
thly
off
ice
stat
iona
ryPr
ovid
e 50
C
TLC
s w
ith
mon
thly
of
fice
sta
tion
ary
100%
Prov
ide
50
CTL
Cs
wit
h m
onth
ly o
ffic
e st
atio
nary
100%
Prov
ide
50
CTL
Cs
wit
h m
onth
ly o
ffic
e st
atio
nary
100%
Prov
ide
50
CTL
Cs
wit
h m
onth
ly o
ffic
e st
atio
nary
100%
Prop
orti
on o
f SC
TLC
s p
rovi
ded
wit
h m
onth
ly a
irti
me
Pr
ovid
e S
CTL
Cs
wit
h m
onth
ly c
ell p
hone
air
tim
ePr
ovid
e 2
86 S
CTL
Cs
wit
h m
onth
ly
cell
phon
e ai
rtim
e10
0%Pr
ovid
e 2
86 S
CTL
Cs
wit
h m
onth
ly c
ell p
hone
air
tim
e10
0%Pr
ovid
e 2
86 S
CTL
Cs
wit
h m
onth
ly c
ell p
hone
air
tim
e10
0%Pr
ovid
e 2
86 S
CTL
Cs
wit
h m
onth
ly c
ell p
hone
air
tim
e10
0%
Prop
orti
on o
f SC
TLC
s pr
ovid
ed w
ith
mon
thly
off
ice
stat
ione
ry s
uppo
rtPr
ovid
e SC
TLC
s w
ith
mon
thly
off
ice
stat
iona
ryPr
ovid
e 28
6 SC
TLC
s w
ith
mon
thly
of
fice
sta
tion
ary
100%
Prov
ide
286
SCTL
Cs
wit
h m
onth
ly o
ffic
e st
atio
nary
100%
Prov
ide
286
SCTL
Cs
wit
h m
onth
ly o
ffic
e st
atio
nary
100%
Prov
ide
286
SCTL
Cs
wit
h m
onth
ly o
ffic
e st
atio
nary
100%
4.3.
2.1.
Cor
e D
OTS
Core
DO
TS O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prop
orti
on
of
nece
ssar
y an
d su
ffic
ient
off
ice
equi
pmen
t, s
uppl
ies
and
infr
astr
uctu
re
in
plac
e an
d in
go
od w
orki
ng o
rder
Proc
ure
offi
ce e
quip
men
t, s
uppl
ies
and
supp
ort
IT
mai
ntai
nanc
en/
a10
0%Pr
ocur
e 3
prin
ters
10
0%n/
a10
0%Pr
ocur
e 3
prin
ters
100%
Proc
ure
asso
rted
off
ice
supp
lies
for
the
NTL
D P
rogr
amPr
ocur
e as
sort
ed
offi
ce
supp
lies
for
the
NTL
D
Prog
ram
Proc
ure
asso
rted
of
fice
su
pplie
s fo
r th
e N
TLD
Pr
ogra
m
Proc
ure
asso
rted
of
fice
su
pplie
s fo
r th
e N
TLD
Pr
ogra
m
Supp
ort
IT m
aint
anan
ceSu
ppor
t IT
mai
ntan
ance
Supp
ort
IT m
aint
anan
ceSu
ppor
t IT
mai
ntan
ance
Supp
ort
purc
hase
of
la
ptop
co
mpu
ters
for
Cou
nty
TB &
Lep
rosy
Co
ordi
nato
rs
n/a
0%Pu
rcha
se
50
lapt
ops
for
CTL
Cs
100%
n/a
Purc
hase
50
la
ptop
s fo
r C
TLC
s
Prop
orti
on o
f C
TLC
s pr
ovid
ed w
ith
com
pute
rsSu
ppor
t Pu
rcha
se
of
Lapt
ops
for
Coun
ty
TB
&
Lepr
osy
Coor
dina
tors
n/a
0%Pu
rcha
se
50
lapt
ops
for
CTL
Cs
100%
n/a
Purc
hase
50
la
ptop
s fo
r C
TLC
s10
0%
Stra
tegi
c A
ppro
ach
2: T
arge
t A
ctiv
itie
s to
Incr
ease
Cas
e N
otif
icat
ion
Pack
age
1 C
NR
< 1
75/1
0000
0 Co
unti
es -
Vih
iga,
Lai
kipi
a, K
isii,
Kak
ameg
a, N
arok
, Tra
ns N
zoia
, Sam
buru
, Tan
a Ri
ver,
Bung
oma,
Nya
mir
a, W
ajir,
Elg
eyo
Mar
akw
et, N
yand
arua
, Bar
ingo
, Nan
di, M
ande
ra
Prop
orti
on
of
heal
th
faci
litie
s sc
reen
ing
coug
hers
for
TB
Cap
acit
y bu
ild H
CW
s to
dia
gnos
e an
d m
anag
e TB
10 T
B/H
IV t
rain
ings
50%
20 T
BHIV
tra
inin
gs60
%20
TBH
IV t
rain
ings
75%
10 T
B/H
IV t
rain
ings
100
Cond
uct
univ
ersa
l sc
reen
ing
for
TB o
f al
l co
ughe
rs
at a
ll cl
inic
al c
are
poi
nts
Scre
en
all
coug
hers
fo
r TB
at
al
l ou
tpat
ient
poi
nts
Scre
en a
ll co
ughe
rs f
or T
B at
all
outp
atie
nt p
oint
sSc
reen
all
coug
hers
for
TB
at a
ll ou
tpat
ient
poi
nts
Scre
en a
ll co
ughe
rs f
or T
B at
all
outp
atie
nt p
oint
s
Prop
orti
on
of
smea
r po
siti
ve
TB
pati
ents
who
se h
ouse
hold
con
tact
s w
ere
trac
ed a
nd s
cree
ned
for
TB
Cond
uct
cont
act
trac
ing
of
all
noti
fied
sm
ear
posi
tive
TB
pati
ents
n/a
Car
ry o
ut c
onta
ct t
raci
ng o
f al
l TB
pati
ents
60%
Car
ry o
ut c
onta
ct t
raci
ng
of a
ll TB
pat
ient
s80
%C
arry
out
con
tact
tra
cing
of
all
TB p
atie
nts
>80
%
Pack
age
2 C
NR
175-
250/
100,
000
Cou
ntie
s -
Embu
, Mac
hako
s, N
akur
u, K
iam
bu, N
yeri
, Mar
sabi
t, K
eric
ho, K
itui
, Mer
u, K
ajia
do, K
ilifi
, Mur
ang’
a, T
urka
na, T
aita
Tav
eta,
Gar
issa
, Lam
u, U
asin
Gis
hu, B
omet
, Bus
ia, M
akue
ni, W
est
Poko
t, K
wal
e
Num
ber
of
heal
th
care
w
orke
rs
trai
ned
on
TB
diag
nosi
s an
d m
anag
emen
t di
sagg
rega
ted
by c
adre
, ty
pe o
f tr
aini
ng a
nd c
ount
y
Cap
acit
y bu
ild H
CW
s to
dia
gnos
e an
d m
anag
e TB
11 T
B/H
IV t
rain
ings
275
22 T
B/H
IV t
rain
ings
550
22 T
B/H
IV t
rain
ings
550
11 T
B/H
IV t
rain
ings
275
Prop
orti
on
of
hous
ehol
d co
ntac
ts
of
noti
fied
TB
pa
tien
ts
trac
ed
and
scre
ened
for
TB
Car
ry o
ut c
onta
ct t
raci
ng o
f al
l TB
pati
ents
Car
ry o
ut c
onta
ct t
raci
ng o
f al
l TB
pa
tien
ts40
%C
arry
out
con
tact
tra
cing
of
all T
B pa
tien
ts50
%C
arry
out
con
tact
tra
cing
of
all
TB p
atie
nts
75%
Car
ry o
ut c
onta
ct t
raci
ng
of a
ll TB
pat
ient
s>
80%
Pack
age
3 C
NR
> 2
50/1
00,0
00 C
ount
ies
- M
omba
sa, N
airo
bi, H
oma
Bay,
Kis
umu,
Isio
lo, M
igor
i, Si
aya,
Tha
raka
, Kir
inya
ga
4.3.2.1. Core DO
TS
Core
DO
TS O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prop
orti
on o
f TB
pat
ient
s in
tar
get
coun
ties
pr
ovid
ed
wit
h nu
trit
iona
l su
ppor
t
Stre
ngth
enin
g ac
cess
to
soci
al p
rote
ctio
n A
ctiv
itie
s co
vere
d un
der
soci
al
prot
ecti
onA
ctiv
itie
s co
vere
d un
der
soci
al p
rote
ctio
nA
ctiv
itie
s co
vere
d un
der
soci
al p
rote
ctio
nA
ctiv
itie
s co
vere
d un
der
soci
al p
rote
ctio
n
Perc
enta
ge o
f cou
ntie
s w
ith
effe
ctiv
e sp
utum
ref
erra
l net
wor
ksSt
reng
then
ing
sput
um s
ampl
e re
ferr
al n
etw
orks
Act
ivit
ies
cove
red
un
der
acce
lera
tion
of
appr
oria
te d
iagn
osis
Act
ivit
ies
cove
red
un
der
acce
lera
tion
of
ap
pror
iate
di
agno
sis
Act
ivit
ies
cove
red
un
der
acce
lera
tion
of
appr
oria
te
diag
nosi
s
Act
ivit
ies
cove
red
und
er
acce
lera
tion
of
appr
oria
te
diag
nosi
s
Stra
tegi
c A
ppro
ach
3: E
xpan
d sp
ecia
l ini
tiat
ives
to
reac
h m
ost
a ri
sk p
opul
atio
ns
Prop
orti
on o
f tr
aine
d he
alth
fac
iliti
es
scre
enin
g fo
r TB
in d
iabe
tic
clin
ics
Syst
emat
ic
scre
enin
g fo
r TB
in
pa
tien
ts
wit
h di
abet
es a
nd in
oth
er c
linic
al s
etti
ngs
0Se
nsit
ize
he
alth
care
w
orke
rs
from
2
faci
litie
s pe
r co
unty
in
16 c
ount
ies
to i
niti
ate
scre
enin
g fo
r TB
(D
M c
linic
s, M
CH
, in-
pati
ent
and
outp
atie
nt)
100%
Sens
itiz
e
heal
thca
re
wor
kers
fr
om
2 fa
cilit
ies
per
coun
ty i
n 16
cou
ntie
s to
in
itia
te
scre
enin
g fo
r TB
(D
M
clin
ics,
M
CH
, in
-pa
tien
t an
d ou
tpat
ient
)
100%
Sens
itiz
e
heal
thca
re
wor
kers
fr
om
2 fa
cilit
ies
per
coun
ty i
n 16
cou
ntie
s to
in
itia
te
scre
enin
g fo
r TB
(D
M
clin
ics,
M
CH
, in
-pa
tien
t an
d ou
tpat
ient
)
100%
Num
ber
of p
riso
n w
arde
ns t
rain
edPr
int
TB s
cree
ning
too
ls f
or p
riso
nsPr
int
boo
klet
s fo
r TB
scr
eeni
ng i
n pr
ison
s1,
500
Prin
t
book
lets
fo
r TB
sc
reen
ing
in p
riso
ns1,
500
00
Trai
n 48
0 pr
ison
w
arde
ns
on
a co
mpr
ehen
sive
se
rvic
e de
liver
y pa
ckag
e (T
B sc
reen
ing
upon
ent
ry
to p
riso
ns,p
rovi
ding
hea
lth
educ
atio
n an
d D
OT
to
inm
ates
)
Cond
uct
4 tr
aini
ng
for
pris
on
war
dens
120
Cond
uct
4 tr
aini
ng
for
pris
on w
arde
ns12
0Co
nduc
t 4
trai
ning
fo
r pr
ison
war
dens
120
Cond
uct
4 tr
aini
ng
for
pris
on w
arde
ns12
0
Num
ber
of p
riso
ns w
ith
TB IP
C p
lans
Enha
nce
TB i
nfec
tion
con
trol
pra
ctic
es in
pri
sons
0Co
nduc
t 15
TB
IPC
tra
inin
g ta
rget
ting
pri
son
staf
f15
015
Cond
uct
5 TB
IPC
tra
inin
g ta
rget
ting
pri
son
staf
f5
0Co
nduc
t TB
in
fect
ion
risk
as
sesm
ent
in 1
5 pr
ison
s0
Cond
uct
TB i
nfec
tion
ris
k as
sesm
ent
in 5
pri
sons
00
Dev
elop
TB
IPC
pla
ns fo
r 15
pr
ison
sD
evel
op T
B IP
C p
lans
for
5
pris
ons
Num
ber
of
pris
ons
prov
idin
g TB
m
anag
emen
t as
pe
r na
tion
al
guid
elin
es
Dev
elop
TB
heal
th e
duca
tion
too
ls f
or p
riso
ners
an
d pr
ison
sta
ff i
nclu
ding
su
ppor
ting
the
rev
iew
of
TB
cont
ent
in t
he r
ecru
it t
rain
ing
curr
icul
um a
t th
e K
PS T
rain
ing
Colle
ge a
nd r
evie
w a
nd u
pdat
e th
e PF
10.
0Co
nduc
t a
wor
ksho
p to
de
velo
p he
alth
ed
ucat
ion
tool
s fo
r pr
ison
ers
and
pris
on s
taff
15Co
nduc
t a
wor
ksho
p to
in
trod
uce
heal
th e
duca
tion
to
ols
for
pris
oner
s an
d pr
ison
sta
ff
15Co
nduc
t a
wor
ksho
p to
de
velo
p he
alth
ed
ucat
ion
tool
s fo
r pr
ison
ers
and
pris
on s
taff
20
1. N
umbe
r of
pri
sons
pro
vide
d w
ith
light
mic
rosc
opes
2.
Num
ber
of
pris
ons
wit
h X
pert
m
achi
nes
Proc
ure
and
inst
all
15 l
ight
mic
rosc
opes
and
3
Xpe
rt M
TB/R
IF f
or p
riso
n he
alth
ser
vice
sCo
vere
d un
der
acce
lera
ting
ap
pror
iate
dia
gnos
isPr
ocur
e an
d in
stal
l 15
ligh
t m
icro
scop
es
and
3 X
pert
M
TB/R
IF
for
pris
on
heal
th
serv
ices
1. 1
5
2
1. N
umbe
r of
hea
lth
care
wor
kers
in
pri
sons
tra
ined
on
use
of X
pert
m
achi
ne
2. N
umbe
r of
hea
lth
care
wor
kers
in
GoK
pri
sons
tra
ined
on
DO
Ts
Ensu
re
on-s
ite
diag
nost
ic
and
DO
T ca
paci
ty
in
pris
ons
Dev
elop
sc
reen
ing
algo
rith
m
for
pris
ons;
pro
vide
sen
siti
zati
onn/
aTr
aini
ng o
f H
CW
s in
pri
sons
on
DO
TS a
nd X
pert
9In
trod
uce
an
nual
TB
sc
reen
ing
as
part
of
ro
utin
e/pe
riod
ic
wel
lnes
s ex
amin
atio
n fo
r pr
ison
st
aff
40%
Intr
oduc
e
annu
al
TB
scre
enin
g as
pa
rt
of
rout
ine/
peri
odic
w
elln
ess
exam
inat
ion
for
pris
on
staf
f
50%
4.3.
2.1.
Cor
e D
OTS
Core
DO
TS O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Num
ber
of
cent
ers
of
exce
llenc
e es
tabl
ishe
d Es
tabl
ish
Cen
ters
of
Ex
celle
nce
(CoE
) fo
r m
anag
emen
t of
TB
,TB/
HIV
,MD
R-TB
an
d Lu
ng
Dis
ease
in N
airo
bi, M
omba
sa, K
isum
u, H
oma
Bay
&
Gar
issa
(ref
ugee
s/D
aada
b) c
ount
ies
Iden
tify
CoE
0Bu
ild c
apac
ity
staf
f at
the
si
te f
or C
oE f
unct
ion
3Bu
ild c
apac
ity
staf
f at
the
si
te f
or C
oE f
unct
ion
5Bu
ild c
apac
ity
staf
f at
the
si
te f
or C
oE f
unct
ion
5
Cap
acit
y bu
ildin
g of
HC
Ws
to d
iagn
ose
and
man
age
TB5
TB/H
IV t
rain
ings
9 TB
/HIV
tra
inin
gs9
TB/H
IV t
rain
ings
9 TB
/HIV
tra
inin
gs
Cap
acit
y bu
ildin
g of
lab
staf
f to
dia
gnos
e TB
Act
ivit
ies
cove
red
un
der
acce
lera
tion
of
appr
oria
te d
iagn
osis
Act
ivit
ies
cove
red
un
der
acce
lera
tion
of
ap
pror
iate
di
agno
sis
Act
ivit
ies
cove
red
un
der
acce
lera
tion
of
appr
oria
te
diag
nosi
s
Act
ivit
ies
cove
red
und
er
acce
lera
tion
of
appr
oria
te
diag
nosi
s
Prop
orti
on
of
hous
ehol
d co
ntac
ts
of
noti
fied
TB
pa
tien
ts
trac
ed
and
scre
ened
for
TB
Car
ry o
ut c
onta
ct t
raci
ng o
f al
l TB
pati
ents
C
arry
out
con
tact
tra
cing
of
all
TB
pati
ents
Car
ry o
ut c
onta
ct t
raci
ng o
f al
l TB
pati
ents
Car
ry o
ut c
onta
ct t
raci
ng
of a
ll TB
pat
ient
sC
arry
out
con
tact
tra
cing
of
all
TB p
atie
nts
Num
ber
of
dire
ctor
ies
of
info
rmal
he
alth
ca
re
prov
ider
s in
N
airo
bi,
Kis
umu
and
Mom
basa
ci
ties
de
velo
ped
Map
out
inf
orm
al h
ealt
h ca
re p
rovi
ders
, ch
emis
ts
and
pham
acis
ts in
urb
an s
lum
s in
Nai
robi
, Mom
basa
an
d K
isum
u ci
ties
Cond
uct
map
ping
of
urba
n sl
ums
in
Nai
robi
, K
isum
u (K
isum
u), M
omba
sa
Num
ber
of
CH
EWs
cove
ring
urb
an
slum
s tr
aine
d on
in
tens
ive
case
fi
ndin
g
Trai
n co
mm
unit
y he
alth
ex
tens
ion
wor
kers
co
veri
ng u
rban
slu
ms
on i
nten
sifi
ed c
ase
find
ing
tool
s
0Tr
ain
50
per
coun
ty
for
Nai
robi
, Kis
umu,
Mom
basa
150
Trai
n 50
pe
r co
unty
fo
r N
akur
u,
Uas
in
Gis
hu,
Kia
mbu
, Em
bu C
HEW
s
200
0
Perc
enta
ge
of
map
ped
in
form
al
heal
th
prov
ider
s co
nduc
ting
ac
tive
C
ase
find
ing
in u
rban
slu
ms
Inco
rpor
ate
the
info
rmal
he
alth
ca
re
prov
ider
s,
chem
ists
and
pha
rmac
ies
in a
ctiv
e TB
cas
e fi
ndin
g in
terv
enti
ons
in lo
w-i
ncom
e ur
ban
sett
lem
ents
0In
corp
orat
e ph
arm
acis
ts,
chem
ists
an
d in
form
al
heal
th c
are
prov
ider
s f
or
104
days
pe
r an
num
pe
r co
unty
by
50
C
HEW
s pe
r co
unty
20%
Inco
rpor
ate
phar
mac
ists
, ch
emis
ts
and
info
rmal
he
alth
car
e pr
ovid
ers
for
10
4 da
ys
per
annu
m
per
coun
ty b
y 50
CH
EWs
per
coun
ty
40%
Inco
rpor
ate
phar
mac
ists
, ch
emis
ts
and
info
rmal
he
alth
car
e pr
ovid
ers
for
10
4 da
ys
per
annu
m
per
coun
ty b
y 50
CH
EWs
per
coun
ty
>60
%
Prop
orti
on
of
trai
ned
CH
EWs
part
icip
atin
g in
qu
arte
rly
feed
back
m
eeti
ngs
Hol
d qu
arte
rly
feed
back
for
ums
for
the
CH
EWs
invo
lved
in T
B ca
se f
indi
ng in
urb
an s
lum
s0
Cond
uct
quar
terl
y fe
edba
ck
mee
ting
s fo
r C
HEW
S in
N
airo
bi, K
isum
u, M
omba
sa
100%
Cond
uct
quar
terl
y fe
edba
ck
mee
ting
s in
N
airo
bi, K
isum
u, M
omba
sa,
Kia
mbu
(T
hika
), N
akur
u,
Uas
in G
ishu
(Eld
oret
), Em
bu
100%
Cond
uct
quar
terl
y fe
edba
ck
mee
ting
s in
N
airo
bi, K
isum
u, M
omba
sa,
Kia
mbu
(T
hika
), N
akur
u,
Uas
in
Gis
hu
(Eld
oret
), Em
bu
100%
Pack
age
4 Tr
eatm
ent
Succ
ess
Rate
< 8
8% C
ount
ies
- N
airo
bi, H
oma
Bay,
Kis
umu,
Isio
lo, S
iaya
, Kir
inya
ga, M
acha
kos,
Nak
uru,
Kia
mbu
, Nye
ri, K
itui
, Mer
u, T
aita
Tav
eta,
Bus
ia, L
aiki
pia,
Kis
ii, S
ambu
ru, T
ana
Rive
r, Bu
ngom
a, E
lgey
o M
arak
wet
, Nya
ndar
ua, B
arin
go, N
andi
Prop
orti
on o
f de
faul
ters
tra
ced
and
retu
rned
to
care
Car
ry o
ut d
efau
lter
tra
cing
of
TB p
atie
nts
Car
ry o
ut d
efau
lter
tra
cing
of
5,00
0 TB
pat
ient
s60
%C
arry
out
def
ault
er t
raci
ng
of 5
,000
TB
pati
ents
>80
%C
arry
out
def
ault
er t
raci
ng
of 5
,000
TB
pati
ents
>80
%C
arry
out
def
ault
er t
raci
ng
of 5
,000
TB
pati
ents
>80
%
Stre
ngth
en a
cces
s to
cri
tica
l ena
bler
sW
eeky
SM
Ss t
o al
l pa
tien
ts
as
rem
inde
rs
of
clin
ic
appo
intm
ents
Wee
ky S
MSs
to
all p
atie
nts
as
rem
inde
rs
of
clin
ic
appo
intm
ents
Wee
ky S
MSs
to
all p
atie
nts
as
rem
inde
rs
of
clin
ic
appo
intm
ents
Impr
ove
heal
th e
duca
tion
Wee
ky
SMSs
to
pa
tien
ts
on e
xpec
ted
Aes
and
oth
er
heal
th e
duca
tion
mes
sage
s
Wee
ky
SMSs
to
pa
tien
ts
on e
xpec
ted
Aes
and
oth
er
heal
th e
duca
tion
mes
sage
s
Wee
ky
SMSs
to
pa
tien
ts
on e
xpec
ted
Aes
and
oth
er
heal
th e
duca
tion
mes
sage
s
Build
CH
EW c
apac
ity
to o
vers
ee f
amily
-bas
ed &
co
mm
unit
y su
ppor
ted
DO
TA
ctiv
itie
s co
vere
d un
der
com
mun
ity
enga
gem
ent
Act
ivit
ies
cove
red
unde
r co
mm
unit
y en
gage
men
t A
ctiv
itie
s co
vere
d un
der
com
mun
ity
enga
gem
ent
Pack
age
5 Po
vert
y Pr
eval
ence
> 4
5% C
ount
ies
- Bar
ingo
, Bom
et, B
ungo
ma,
Bus
ia, G
aris
sa, I
siol
o, K
akam
ega,
Elg
eyo
Mar
akw
et, K
ilifi
, Kis
ii, K
itui
, Kw
ale,
Lai
kipi
a, M
acha
kos,
Mak
ueni
, Man
dera
, Mar
sabi
t, N
andi
, Nya
ndar
ua, S
ambu
ru, T
aita
Tav
eta,
Tan
a Ri
ver,
Tran
s N
zoia
, Tur
kana
, Waj
ir, W
est
Poko
t
4.3.2.1. Core DO
TS
Core
DO
TS O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Num
ber
of p
riso
ns w
ith
docu
men
ted
refe
rral
fo
r pa
tien
ts
rele
ased
or
tr
ansf
erre
d
Dev
elop
ref
erra
l mec
hani
sms
for
pris
oner
s w
ho a
re
tran
sfer
red
or r
elea
sed
0H
old
two
day
cons
ulta
tive
m
eeti
ng t
o de
velo
p re
ferr
al
mec
hani
sms
for
pris
oner
s
15Se
nsit
ize
HC
Ws
in p
riso
ns
and
rece
ivin
g fa
cilit
ies
abou
t re
ferr
als
for
pris
oner
s
15Se
nsit
ize
HC
Ws
in p
riso
ns
and
rece
ivin
g fa
cilit
ies
abou
t re
ferr
als
for
pris
oner
s
15
Prop
orti
on
of
GoK
pr
ison
st
aff
scre
ened
for
TB
annu
ally
Intr
oduc
e a
nnua
l TB
scr
eeni
ng a
s pa
rt o
f ro
utin
e/pe
riod
ic w
elln
ess
exam
inat
ion
for
pris
on s
taff
Dev
elop
sc
reen
ing
algo
rith
m
for
pris
ons
and
cond
uct
sens
itiz
atio
nn/
aPe
rfor
m
an
nual
TB
sc
reen
ing
as
part
of
ro
utin
e/pe
riod
ic
wel
lnes
s ex
amin
atio
n fo
r pr
ison
sta
ff
25%
Perf
orm
annu
al
TB
scre
enin
g as
pa
rt
of
rout
ine/
peri
odic
w
elln
ess
exam
inat
ion
for
pris
on
staf
f
40%
Perf
orm
annu
al
TB
scre
enin
g as
pa
rt
of
rout
ine/
peri
odic
w
elln
ess
exam
inat
ion
for
pris
on
staf
f
50%
Num
ber
of
labo
rato
ry
tech
nolo
gist
s hi
red
and
retr
aine
d fo
r pr
ison
hea
lth
serv
ices
Recr
uit
15 l
abor
ator
y te
chno
logi
sts
for
pris
on h
ealt
h se
rvic
es0
n/a
Re
cr
ui
t an
d de
ploy
la
bo
rato
ry
tech
no
logi
sts
for
pris
on
he
al
th
serv
ices
15T
ra
in
lab
ora
to
ry
tech
no
log
ists
fo
r pr
ison
he
alth
ser
vice
s
15t
ra
in
lab
or
at
or
y te
chn
olo
gis
ts
for
pris
on
heal
th s
ervi
ces
Prop
orti
on
of
heal
th
faci
litie
s pr
ovid
ing
TB
man
agem
ent
serv
ices
w
ith
TB IP
C p
lans
Impl
emen
t TB
in
fect
ion
cont
rol
in
all
heal
th
faci
litie
sCo
vere
d un
der
TB/H
IV a
ctiv
itie
sn/
a0
n/a
0n/
a0
n/a
Perc
enta
ge
of
ti
ers
2,3
heal
th
faci
litie
s co
nduc
ting
annu
al
scre
enin
g of
HC
W f
or T
B
Dis
sem
inat
e re
vise
d TB
w
orkp
ace
polic
y th
at
reco
mm
ends
rou
tine
ann
ual s
cree
ning
of
HC
Ws
Cove
red
unde
r TB
/HIV
act
ivit
ies
Cove
red
unde
r TB
/HIV
ac
tivi
ties
25%
Cove
red
unde
r TB
/HIV
ac
tivi
ties
50%
Cove
red
unde
r TB
/HIV
ac
tivi
ties
>50
%
Cond
uct
annu
al T
B s
cree
ning
for
HC
Ws
as p
art
of a
re
vise
d w
orkp
lace
-bas
ed p
olic
y on
TB
cont
rol
n/a
Cond
uct
an
nual
TB
sc
reen
ing
for a
ll H
CW
s in
all
tier
5 a
nd 6
hea
lth
faci
litie
s
Cond
uct
annu
al
TB
scre
enin
g fo
r al
l H
CW
s in
ti
ers
4,5
and
6 he
alth
fa
cilit
ies
Cond
uct
annu
al
TB
scre
enin
g fo
r al
l H
CW
s in
ti
er
4,5
and
6 he
alth
fa
cilit
ies
Num
ber
of
heal
th
care
w
orke
rs
serv
ing
mob
ile
popu
lati
ons
trai
ned
on T
B/H
IV in
tegr
atio
n
Inte
grat
e TB
ser
vice
s in
the
alr
eady
exi
stin
g H
IV
serv
ices
for
mob
ile a
nd m
igra
nt p
opul
atio
nsn/
aTr
ain
he
alth
st
aff
from
H
IV c
linic
s se
rvin
g m
obile
po
pula
tion
s on
TB
,TB/
HIV
an
d in
tegr
atio
n of
ser
vice
s
150
Trai
n
heal
th
staf
f fr
om
HIV
clin
ics
serv
ing
mob
ile
popu
lati
ons
on
TB,T
B/H
IV
and
inte
grat
ion
of s
ervi
ces
150
n/a
0
Prop
orti
on o
f do
cum
ente
d co
ntac
ts
of i
ndex
TB
pati
ents
not
ifie
d am
ong
mob
ile p
opul
atio
ns w
ho a
re t
race
d by
pho
ne
Cond
uct c
ell-
phon
e tr
acin
g fo
r all
cont
acts
of i
ndex
TB
pat
ient
s no
tifi
ed a
mon
g m
obile
pop
ulat
ions
n/a
Cond
uct
cell-
phon
e t
raci
ng
for
all
cont
acts
of
inde
x TB
pa
tien
ts
noti
fied
am
ong
mob
ile p
opul
atio
ns
100%
Cond
uct
cell-
phon
e tr
acin
g fo
r al
l co
ntac
ts o
f in
dex
TB p
atie
nts
noti
fied
am
ong
mob
ile p
opul
atio
ns
100%
Cond
uct
cell-
phon
e tr
acin
g fo
r al
l co
ntac
ts o
f in
dex
TB p
atie
nts
noti
fied
am
ong
mob
ile p
opul
atio
ns
100%
Num
ber
of h
ealt
h ca
re w
orke
rs f
rom
un
ifor
med
ser
vice
s tr
aine
d on
TB/
HIV
in
tegr
atio
n
Supp
ort
inte
grat
ion
of
TB
serv
ices
in
al
read
y ex
isti
ng H
IV s
ervi
ces
to s
uppo
rt c
ase
find
ing
, cas
e ho
ldin
g an
d im
prov
e up
take
of
inte
rven
tion
s fo
r th
e co
-inf
ecte
d
Trai
n 12
0 he
alth
sta
ff o
n TB
,TB/
HIV
an
d in
tegr
atio
n of
ser
vice
s12
0Tr
ain
120
heal
th
staf
f on
TB
,TB/
HIV
an
d in
tegr
atio
n of
ser
vice
s
120
Trai
n 12
0 he
alth
sta
ff o
n TB
,TB/
HIV
and
int
egra
tion
of
ser
vice
s
120
Trai
n 12
0 he
alth
sta
ff o
n TB
,TB/
HIV
and
int
egra
tion
of
ser
vice
s
120
Prop
orti
on o
f do
cum
ente
d co
ntac
ts
of
inde
x TB
pa
tien
ts
noti
fied
by
un
ifor
m s
ervi
ce p
erso
nnel
who
are
tr
aced
and
scr
eene
d fo
r TB
Cond
uct
acti
ve t
raci
ng f
or a
ll co
ntac
ts o
f in
dex
TB
pati
ents
not
ifie
d by
uni
form
ed s
ervi
ce p
erso
nell
heal
th s
ervi
ces
n/a
Cond
uct
acti
ve
tr
acin
g fo
r al
l co
ntac
ts
of
inde
x TB
pa
tien
ts
noti
fied
by
un
ifor
med
ser
vice
per
sone
ll he
alth
ser
vice
s
50%
Cond
uct
acti
ve
tr
acin
g fo
r al
l co
ntac
ts
of
inde
x TB
pa
tien
ts
noti
fied
by
un
ifor
med
se
rvic
e pe
rson
ell h
ealt
h se
rvic
es
>80
%Co
nduc
t ac
tive
trac
ing
for
all
cont
acts
of
in
dex
TB
pati
ents
no
tifi
ed
by
unif
orm
ed
serv
ice
pers
onel
l hea
lth
serv
ices
>80
%
Prop
orti
on o
f G
oK u
nifo
rmed
ser
vice
pe
rson
nel s
cree
ned
for
TB a
nnua
llyIn
trod
uce
ann
ual
TB s
cree
ning
as
part
of
rout
ine/
peri
odic
w
elln
ess
exam
inat
ion
for
un
ifor
med
se
rvic
e pe
rson
ell
Perf
orm
an
nual
TB
sc
reen
ing
as
part
of
ro
utin
e/pe
riod
ic
wel
lnes
s ex
amin
atio
n fo
r un
ifor
med
se
rvic
e pe
rson
ell
50%
Intr
oduc
e
annu
al
TB
scre
enin
g as
pa
rt
of
rout
ine/
peri
odic
w
elln
ess
exam
inat
ion
for
unif
orm
ed
serv
ice
pers
onel
l
70%
Intr
oduc
e
annu
al
TB
scre
enin
g as
pa
rt
of
rout
ine/
peri
odic
w
elln
ess
exam
inat
ion
for
unif
orm
ed
serv
ice
pers
onel
l
70%
1. N
umbe
r of
hea
lth
care
wor
kers
at
refu
gee
cam
ps t
rain
ed o
n in
fect
ion
cont
rol
2. N
umbe
r of
ref
ugee
cam
ps w
ith
IPC
pl
ans
Enha
nce
infe
ctio
n co
ntro
l ca
paci
ty w
ithi
n re
fuge
e ca
mps
Cove
red
unde
r TB
HIV
an
d dr
ug
resi
stan
t TB
Cove
red
unde
r TB
HIV
an
d dr
ug r
esis
tant
TB
0Co
vere
d un
der
TB/H
IV a
nd
drug
res
ista
nt T
B0
n/a
4.3.
2.1.
Cor
e D
OTS
4.3.2.2. Programmatic Management of Drug Resistant TB1. Situational Analysis
Kenya notified 254 cases of MDR-TB in 2013, 28% of who were refugees from neighboring Somalia. The number of MDR-TB cases detected in Kenya has risen steadily since 2010, when only 112 cases were detected. World Health Organization estimates that there were 1,800 new MDR-TB cases in Kenya in 2012. A drug-resistance survey is underway to determine a more precise DR-TB estimate. With GeneXpert rollout, it is expected that the number of MDR-TB cases detected will increase dramatically.
In 2013, there were 226 MDR-TB treatment sites for the 254 newly registered MDR-TB patients across the country. The treatment success rate for the 135 MDR-TB cases notified in 2011 was 68%. The country revised the Programmatic Management of Drug Resistant TB (PMDT) guidelines in 2013. A national MDR-TB focal person provides technical assistance to the counties, and is supported by a national MDR-TB committee. At county level, county tuberculosis and leprosy coordinators are responsible for linkage of MDR-TB patients to care, treatment initiation and follow-up. The country largely uses ambulatory and community – based models of care. The country has 114 hospital-bed capacity to manage MDR−TB patients spread across the following four sites: Kenyatta National Hospital (15 beds), MTRH (8 beds), Homa Bay (11 beds) and Dadaab (80 beds). DOT is provided at selected health facilities networked to community health workers who treat patients in the community.
MDR-TB patients receive KSH 6000 (approx. US$ 75) per month for their transport costs to health care facilities and nutritional support if needed.
Figure 13: Number of Notified MDR-TB Cases by County, 2013
4.3.2.2. Programm
atic Managem
ent of Drug Resistant TB
Map 3: Number of Notified MDR-TB Cases and Overall Case Notification Rate by County, 2013
38
4.3.
2.2.
Pro
gram
mat
ic M
anag
emen
t of D
rug
Resi
stan
t TB
Case finding strategies are in accordance with WHO recommendations, including DR-TB surveillance among the populations most at risk, especially retreatment cases and refugees. The treatment regimens are also in line with WHO recommendations using WHO pre–qualified, quality assured second line drugs. The current treatment regimen is administered for a total of 20 months; Intensive phase of at least 8 months of Kanamycin, Levofloxacin, Cycloserine, prothionamide and pyrazinamide, and continuation phase of 12 months of Levofloxacin, Cycloserine, Prothionamide and Pyrazinamide.
Some of the drugs to manage side effects are also available free-of-charge at the treatment sites, while adverse drug events are reported using a pharmacovigilance platform provided by the Pharmacy and Poisons Board. DST for first-line drugs is done at NTRL, and second-line drugs (Kanamycin, Capreomycin and Ofloxacin) outside the country. There is an external quality assurance program for the NTRL provided by a supra-national laboratory.
2. Strategic Directions for 2015-2018
Priorities for the three-year period are geared towards increasing the case notification of DR-TB to at least 75% of estimated prevalence by 2017, and attaining a treatment success rate of at least 80% among all cases of DR TB by 2017. The NTLD Program is committed to ensuring that human rights principles are taken into account as the PMDT strategies are implemented.
These strategies include:
a) Strengthening systems that support PMDTb) Systematic surveillance of DR-TB, including childrenc) Reducing time to diagnosis of DR-TBd) Ensuring timely initiation of treatment (within 1-2 weeks of diagnosis)e) Improve monitoring and evaluation of presumptive and confirmed DR-TB casesf) Improve treatment outcomes for DR-TB patients, including children.
3. Proposed Approaches
Strengthening Systems that Support PMDT
The NTLD Program will continue offering oversight in the implementation of PMDT services in the country through the PMDT focal person, with the support of a national Technical Working Group meeting quarterly.
With extensive decentralization of PMDT services across the country, strengthening the quality of clinical care is imperative. As such, PMDT teams shall be established at each level of care to monitor patient management. The county PMDT committees will offer oversight and support for the sub-county teams. The sub-county TWGs will conduct mentorship and monthly patient reviews at a central site (sub-county or county hospital). The formation of sub-county TWGs will be targeted to sub counties with existing DR-TB patients.
Figure 14: DR-TB Case Notification Trends 2008-2013
39
Admission facilities shall be expanded across the country for DR-TB patients. The GLC review conducted during the MTR advised that each county have at least 4 beds for admission with appropriate infection control measures in place.
Development and dissemination of a tool for assessment of social security needs (i.e. nutrition & other social support) will be done as part of social protection for DR-TB patients. Promotion of availability of nutritional and other social support for eligible DR-TB patients on ambulatory and community-based models of care will also be done.
An interagency/inter-ministerial team to address the problem of cross border DR-TB will be set up and meetings will be held biannually.
The checklist for supervisory/support visits shall be updated to adequately cover DR-TB.
Strengthening Systematic Surveillance of DR-TB
To enhance surveillance of DR-TB, the country shall strive to improve the capacity of HCWs through sensitization, mentorship and training on DR-TB surveillance including the use of GeneXpert technology.
The NTLD Program shall disseminate and aggressively encourage the use of the updated GeneXpert diagnostic algorithm across all service delivery points. These guidelines shall be updated as often as possible to keep pace with the emerging evidence on Xpert use even in non-sputum specimens. In collaboration with the lab program, all the existing and new Xpert machines in the counties shall be networked while taking advantage of other existing and innovative strategies to improve sample referrals e.g. appending Xpert samples transport to the CD4 and viral load transport network in the HIV system and use of other locally available means of transport. These strategies shall go hand in hand with the plans to ensure there are 250 GeneXpert machines in the country by end of 2017. They shall be rationally distributed considering factors like TB burden, accessibility and existing machines.
New strategies to expand DR-TB surveillance in congregate settings (schools, prisons, HCWs, migrant populations, public transport - matatus through their associations) will be explored. In addition to ensuring that all TB retreatment cases access Xpert tests at start of TB therapy, special emphasis has been put on the use of Xpert as first line of testing among PLHIV and the pediatric age group.
Active contact tracing of all children exposed to DR-TB shall be logistically supported and quarterly screening of all DR-TB contacts done for up to a period of 2 years post culture conversion of the index DR-TB case. All symptomatic contacts of DR-TB (including children) will be prioritized to benefit from Xpert testing. More awareness in the community and congregate settings on DR-TB shall be carried out while at the same time strengthening systems to ensure early referrals among presumptive DR-TB cases.
The NTRL shall be encouraged to invest in second line DST for all MDR-TB patients systematically prior to treatment initiation to identify XDR-TB early enough to impact morbidity and mortality.
Reduction of time to diagnosis of DR-TB
GeneXpert test will be the first diagnostic tool for all presumptive DR-TB cases. Once the samples are networked to the GeneXpert laboratories, results shall be dispatched electronically as soon as they are run, and no later than 24-48 hours. Electronic real time result dispatch software shall be installed in all GeneXpert machines.
The system shall be used for automatic results transmissions to ordering clinicians, patients and the programs. How fast Xpert (and culture and DST) results are relayed back, received and acted on shall be actively monitored to improve the programs. Timely GeneXpert equipment servicing and secondary networking of new Xpert sites will also be done to reduce downtime of machines. For culture and DST results, a link will also be created between LIMS and TIBU to ensure timely dissemination of results.
Ensure timely initiation of treatment (within 1-2 weeks of diagnosis)
DR-TB patients will be registered immediately at diagnosis, baseline investigations (FBC, UECs, LFTs, TSH) done within 1-2 days of diagnosis and results dispatched electronically. The baseline investigations (including chest radiographs and audiometry) will be standardized and made free for the patients with the support of USAID and Global Fund.
The target is to ensure each county has a functional, portable and accessible audiometer machine for DR-TB patients by 2017. Structured clinical teams (DR-TB/HIV multidisciplinary teams) shall be set up and used to initiate and follow up treatment. The composition of such teams shall, at a minimum, have the sub-county TB and Lab coordinators, Pharmacist, DOT Nurse, PHO, Physician, Counselor, Nutritionist and Social Worker.
4.3.2.2. Programm
atic Managem
ent of Drug Resistant TB
40
4.3.
2.2.
Pro
gram
mat
ic M
anag
emen
t of D
rug
Resi
stan
t TB
To ensure no delays in treatment initiation, county pharmacists should have buffer stock to start patients on treatment while awaiting the ordered supply of second line medications. In collaboration with the counties, we shall work to establish a structured way for ordering and delivery of both DR-TB as well as other first line anti-TB medicines from the procuring and distributing agent/authority direct to the counties.
Improve treatment outcomes for DR-TB patients, including:
• Strengthening active pharmacovigilance (monitoring, recording and reporting of ADR through TIBU and PPB platforms) and their management, including the availability of auxiliary drugs e.g. Thyroxin, antipsychotics, hearing aids and implants
• Lobbying for, procuring, distribution and use of pediatric friendly DR-TB combinations• Revision of the DR-TB clinical tools used for the day-to-day management of patients• Introduction of case management of DR-TB in the TIBU system, which includes robust pharmacovigilance and
checks and reminders for lab and clinical monitoring. Linkages to NTRL’s LIMS shall also be explored• Planning for, procuring, distribution and use of capreomycin as first choice injectable for new MDR TB patients
(and existing patients intolerant to the current injectables)• Advocating for acceleration and uptake of new molecules, such as bedaquiline and delaminid once available
in the market• Establishing 7 regionally distributed Centers of Excellence (CoEs) in the country to offer mentorship and
technical assistance, support supervision, referrals, investigations, admissions, and ADR managements • Provision of financial support to DR-TB patients and DOTS nurses in community-based models• In consultation with the central government, ensure health insurance coverage for all DR-TB patients - both
in-patient and ambulatory. This can be done by enrolling DR-TB patients onto NHIF scheme using part of their social support funds
• Finalizing, printing and dissemination of DR-TB workplace policy documents• Developing, printing and distributing guidelines on community-based DR-TB care• Availing 12 portable digital X-rays for hard-to-reach areas and MDR-TB contacts• Conducting DR-TB sensitization and CME meetings in the private sector in a bid to standardize DR-TB
surveillance and treatment across the country.
Contribution to NSP Impacts Outcomes (MDR-TB)
Impact 1.1: Reduce the prevalence of MDR-TB among new patients by 15%, by 2018 compared to 2014
• Increase case notification of MDR-TB to at least 75% of estimated prevalence (baseline TBD following DR survey)
• Ensure treatment success of at least 80% among all cases of DR-TB, by 2018
• Reduce by 50% severe adverse events caused by second-line drugs
Impact 3: Reduce the proportion of affected families who face catastrophic costs due to TB, by 2018 (baseline TBD)
• Increase to 100% the proportion of MDR-TB patients who receive social protections, including food support and transportation subsidies
Table 6: Impact and Outcome Indicators for PMDT
41
PMD
T O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
1: S
tren
gthe
n sy
stem
s th
at s
uppo
rt P
MD
T
Num
ber
of
PMD
T fo
cal
pers
ons
at
NTL
D
Prog
ram
Rete
ntio
n of
PM
DT
foca
l pe
rson
at
N
TLD
Pr
ogra
mRe
tent
ion
of P
MD
T fo
cal
pers
on a
t N
TLD
Pro
gram
1Re
tent
ion
of
PMD
T fo
cal
pers
on a
t N
TLD
Pro
gram
1Re
tent
ion
of
PMD
T fo
cal
pers
on a
t N
TLD
Pro
gram
1
Rete
ntio
n of
PM
DT
foca
l per
son
at N
TLD
Pro
gram
1
Prop
orti
on o
f sc
hedu
led
quar
terl
y PM
DT
TWG
m
eeti
ngs
held
4 PM
DT
TWG
mee
ting
s he
ld y
earl
yH
old
quar
terl
y PM
DT
TWG
m
eeti
ngs
100%
Hol
d qu
arte
rly
PMD
T TW
G
mee
ting
s10
0%H
old
quar
terl
y PM
DT
TWG
m
eeti
ngs
100%
Hol
d qu
arte
rly
PMD
T TW
G
mee
ting
s10
0%
Prop
orti
on o
f co
unti
es w
ith
DR
pati
ents
wit
h fu
ncti
onal
PM
DT
team
s*F
unct
iona
l=do
cum
ente
d/m
inut
ed
mee
ting
s at
le
ast
once
qua
rter
ly
Esta
blis
h co
unty
-bas
ed
PMD
T te
ams*
to
ov
erse
e D
R-TB
pat
ient
man
agem
ent,
log
isti
cs
and
DR-
TB s
urve
illan
ce*C
ompo
sed
of
the
follo
win
g sp
ecia
litie
s at
a
min
imum
- T
B, H
IV,
Lab,
Pha
rmac
y, P
HO
, Ph
ysic
ian,
Cou
nsel
or, N
utri
tion
, soc
ial s
uppo
rt,
part
ners
and
cou
nty
adm
in/f
inan
ce/H
R
Esta
blis
h th
e co
mpo
siti
on,
crit
eria
an
d TO
R of
the
PMD
T co
unty
team
s10
%Th
e co
unty
PM
DT
team
s tr
ansa
ct
busi
ness
(a
t le
ast
quar
terl
y m
eeti
ngs)
. In
itia
l un
der
TA fr
om n
atio
nal o
ffic
e
60%
Qua
rter
ly r
evie
w m
eeti
ngs
100%
1. Q
uart
erly
rev
iew
mee
ting
s2.
Rev
iew
of t
he p
erfo
rman
ce o
f th
e PM
DT
team
s
100%
Prop
orti
on
of
sub-
coun
ties
w
ith
func
tion
al
PMD
T te
ams
Esta
blis
h su
bcou
nty
team
s in
200
sub
coun
ties
Esta
blis
h su
bcou
nty
team
s in
20
su
bcou
ntie
s5%
Esta
blis
h su
bcou
nty
team
s in
80
sub
coun
ties
25%
Esta
blis
h su
bcou
nty
team
s in
80
subc
ount
ies
60%
Esta
blis
h su
bcou
nty
team
s in
20
subc
ount
ies
75%
Prop
orti
on o
f co
unti
es w
ith
at l
east
2 b
eds
for
adm
issi
on
of
DR-
TB
pati
ents
in
cr
itic
al
cond
itio
n
Expa
nd a
dmis
sion
s fa
cilit
ies
equi
tabl
y ac
ross
th
e co
untr
y fo
r D
R-TB
pat
ient
s (a
t le
ast
2 be
ds
per
coun
ty f
or D
R-TB
)
Enga
ge t
he c
ount
y te
ams
and
carr
y ou
t fa
cilit
y as
sess
men
t/ m
appi
ng10
0%Es
tabl
ish
adm
issi
on f
acili
ties
in
20
coun
ties
40
%Es
tabl
ish
adm
issi
on f
acili
ties
in
fur
ther
17
coun
ties
75
%Es
tabl
ish
adm
issi
on f
acili
ties
in
furt
her
10 c
ount
ies
100%
Prop
orti
on
of
mal
nour
ishe
d D
R-TB
pa
tien
ts
acce
ssin
g nu
trit
iona
l sup
port
Dev
elop
men
t an
d di
ssem
inat
ion
of a
too
l fo
r so
cial
se
curi
ty
need
s (i.
e.
nutr
itio
n &
ot
her
soci
al
supp
ort)
; Pr
omot
e th
e av
aila
bilit
y of
nu
trit
iona
l an
d ot
her
soci
al s
uppo
rt f
or D
RTB
pati
ents
(S
tren
gthe
n nu
trit
ion
asse
ssm
ent,
co
unse
lling
and
soc
ial s
uppo
rt (N
AC
S))
a)
Dev
elop
a
tool
fo
r as
sess
ing
soci
al s
ecur
ity
need
s an
d b)
Pilo
t te
st it
c) C
onti
nue
prov
idin
g RU
TF/F
BF
20%
a)
Prov
isio
n of
nu
trit
iona
l su
ppor
t to
des
ervi
ng D
R TB
pa
tien
tsb)
Pr
int
and
diss
emin
ate
the
tool
fo
r so
cial
ne
eds
asse
ssm
ent
50%
Prov
isio
n of
com
preh
ensi
ve
soci
al
supp
ort
(incl
udin
g nu
trit
ion)
to
de
serv
ing
DR
TB p
atie
nts
60%
Prov
isio
n of
co
mpr
ehen
sive
so
cial
su
ppor
t (in
clud
ing
nutr
itio
n)
to
dese
rvin
g D
R TB
pa
tien
ts
70%
Polic
y do
cum
ent
on c
ross
-bor
der
DRT
BSe
t up
an
in
tera
genc
y/in
ter-
min
iste
rial
te
am
and
othe
r re
leva
nt b
odie
s to
add
ress
the
cro
ss
bord
er D
R-TB
pro
blem
Esta
blis
h th
e
inte
rage
ncy/
inte
r-m
inis
teri
al
team
on
cr
oss-
bord
er
DR-
TB
Fina
lize
polic
y do
cum
ent;
Bi
annu
al m
etin
gs1
Bian
nual
met
ings
Bian
nual
met
ings
Num
ber
of C
MEs
on
PMD
T ta
rget
ing
the
priv
ate
sect
or h
eld
Con
duct
DR-
TB s
ensi
tiza
tion
/CM
E m
eeti
ngs
in
the
priv
ate
sect
orQ
uart
erly
se
nsit
izat
ion
of
the
priv
ate
prac
titi
oner
s in
CM
Es a
nd
othe
r pr
ofes
sion
al o
rgan
izat
ions
in
mai
n to
wns
25Bi
-ann
ual
sens
itiz
atio
n of
th
e pr
ivat
e pr
acti
tion
ers
in
CM
Es a
nd o
ther
pro
fess
iona
l or
gani
zati
ons
in m
ain
tow
ns
20Bi
-ann
ual
sens
itiz
atio
n of
th
e pr
ivat
e pr
acti
tion
ers
in
CM
Es a
nd o
ther
pro
fess
iona
l or
gani
zati
ons
in m
ain
tow
ns
40Bi
-ann
ual
sens
itiz
atio
n of
th
e pr
ivat
e pr
acti
tion
ers
in
CM
Es
and
othe
r pr
ofes
sion
al
orga
niza
tion
s in
mai
n to
wns
60
4.3.2.2. Programm
atic Managem
ent of Drug Resistant TB
4.3.
2.2.
Pro
gram
mat
ic M
anag
emen
t of D
rug
Resi
stan
t TB
PMD
T O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
2: S
tren
gthe
n sy
stem
atic
sur
veill
ance
of
DR
-TB
Prop
orti
on
of
elig
ible
pa
tien
ts
acco
rdin
g to
al
gori
thm
tes
ted
usin
g G
eneX
pert
6,00
0 H
CW
s se
nsit
ized
and
tra
ined
on
DR-
TB*
(sur
veill
ance
and
man
agem
ent)
*Sho
uld
pref
erab
ly b
e in
tegr
ated
into
the
com
preh
ensi
ve
TB/H
IV c
urri
culu
m
Dev
elop
H
CW
s se
nsit
izat
ion
curr
icul
lum
40%
Sens
itiz
e 2,
000
HC
Ws
60%
Sens
itiz
e 2,
000
mor
e H
CW
s80
%Se
nsit
ize
2,00
0 m
ore
HC
Ws
100%
Dis
sem
inat
ion
and
use
of u
pdat
ed G
eneX
pert
di
agno
stic
alg
orit
hm a
cros
s al
l ser
vice
del
iver
y po
ints
Sens
itiz
e C
TLC
s an
d su
b-co
unty
co
ordi
nato
rs o
n re
vise
d ge
ne X
pert
al
gori
thm
du
ring
qu
arte
rly
data
re
view
mee
ting
s
Sens
itiz
e H
CW
s at
the
gen
e ex
pert
sit
es (1
20 f
acili
ties
)Se
nsit
ize
HC
Ws
at
the
addi
tion
al g
ene
expe
rt s
ites
(8
0 fa
cilit
ies)
Sens
itiz
e H
CW
s at
th
e ad
diti
onal
gen
e ex
pert
sit
es (
50
faci
litie
s)
Expa
nd
DR-
TB
surv
eilla
nce
to
cong
rega
te
sett
ings
(s
choo
ls,
pris
ons,
H
CW
s,
mig
rant
s po
pula
tion
s,
publ
ic
tran
spor
t -
mat
atus
th
roug
h as
soci
atio
ns).
Uti
lize
othe
r ex
isti
ng
and
inno
vati
ve s
trat
egie
s to
im
prov
e sa
mpl
e re
ferr
al e
.g.
use
of l
ocal
mea
ns t
o tr
ansp
ort
sam
ples
Map
out
the
tar
get
grou
ps a
nd l
ay
a ba
sic
plan
wit
h as
sist
ance
of
the
coun
ties
on
how
to
carr
y ou
t th
is
acti
vity
Enga
ge
the
targ
et
grou
ps
thro
ugh
se
nsit
izat
ion.
En
gage
a f
ew m
atat
u sa
ccos
in
the
iden
tifi
ed h
ard
to re
ach
area
s an
d es
tabl
ish
a w
orki
ng
rela
tion
ship
on
sa
mpl
e re
ferr
al s
yste
m
Con
tinu
e w
ith
sens
itiz
atio
n of
mor
e of
the
tar
get
grou
ps
and
mat
atu
sacc
os
a) C
onti
nue
wit
h se
nsit
izat
ion
of m
ore
of t
he t
arge
t gr
oups
an
d m
atat
u sa
ccos
b) R
evie
w t
he p
erfo
rman
ce o
f th
ese
appr
oach
es w
ith
the
aim
of
lear
ning
bes
t ap
proa
ches
”
Prop
orti
on
of
TB
retr
eatm
ent
pati
ents
w
ho
acce
ss G
ene
Xpe
rt t
est
at t
reat
men
t in
itia
tion
Stre
ngth
en r
outi
ne D
R-TB
sur
veila
nce
amon
g al
l TB
ret
reat
men
t ca
ses
by u
se o
f G
eneX
pert
te
st
TB
retr
eatm
ent
pati
ents
te
sted
us
ing
Gen
e X
pert
ann
ually
75%
TB
retr
eatm
ent
pati
ents
te
sted
us
ing
Gen
e X
pert
an
nual
ly
85%
TB
retr
eatm
ent
pati
ents
te
sted
us
ing
Gen
e X
pert
an
nual
ly
95%
TB r
etre
atm
ent
pati
ents
tes
ted
usin
g G
ene
Xpe
rt a
nnua
lly10
0%
Prop
orti
on
of
sym
ptom
atic
ho
useh
old*
co
ntac
ts o
f D
R TB
acc
ess
Gen
e X
pert
tes
t
*hou
seho
ld
incl
udes
sh
arin
g th
e sa
me
acco
mod
atio
n fa
cilit
ies
in d
orm
itori
es, p
riso
ns e
tc
Stre
ngth
en r
outi
ne D
R TB
sur
veill
ance
am
ong
all
sym
ptom
atic
hou
seho
ld c
onta
cts
of D
R-TB
ca
ses
a) S
ensi
tize
the
cou
nty
team
s on
th
e us
e of
GX
pert
for
sym
ptom
atic
co
ntac
ts
of
DR-
TB
at
quar
terl
y re
view
mee
ting
sb)
All
sym
ptom
atic
con
tact
s of
new
D
R-TB
pat
ient
s un
derg
o G
xper
t te
st
100%
a) A
ll sy
mpt
omat
ic c
onta
cts
of
new
D
R-TB
pa
tien
ts
unde
rgo
Gxp
ert
test
b)
Qua
rter
ly
revi
ew
of
all
non-
sym
ptom
atic
con
tact
s of
D
R TB
pat
ient
s
100%
a) A
ll sy
mpt
omat
ic c
onta
cts
of
new
D
R-TB
pa
tien
ts
unde
rgo
Gxp
ert
test
b)
Qua
rter
ly
revi
ew
of
all
non-
sym
ptom
atic
co
ntac
ts
of D
R-TB
pat
ient
s
100%
a) A
ll sy
mpt
omat
ic c
onta
cts
of
curr
ent
DR-
TB p
atie
nts
unde
rgo
Gxp
ert
test
b) Q
uart
erly
rev
iew
of
all
non-
sym
ptom
atic
con
tact
s of
DR-
TB
pati
ents
100%
Stra
tegi
c A
ppro
ach
3: E
nsur
e ti
mel
y in
itia
tion
of
DR
-TB
trea
tmen
t (w
ithi
n 1-
2 w
eeks
of
diag
nosi
s)
Prop
orti
on o
f ne
w D
R-TB
pat
ient
s en
rolle
d in
to
care
wit
hin
1-2
wee
ks o
f di
agno
sis
Pati
ent r
egis
trat
ion
imm
edia
tely
aft
er d
iagn
osis
Esta
blis
h an
d di
ssem
inat
e po
licy
and
mec
hani
sm t
o en
sure
pat
ient
re
gist
rati
on
imm
edia
tely
af
ter
diag
nosi
s
Mon
itor
ing
to
ensu
re
impl
emen
tati
on o
f th
is p
olic
y75
%Re
view
of
polic
y to
ens
ure
adap
tati
on10
0%M
onit
orin
g to
en
sure
im
plem
enta
tion
of
the
revi
sed
polic
y
100%
Prop
orti
on
of
new
D
R-TB
pa
tien
ts
wit
h st
anda
rdiz
ed
base
line
inve
stig
atio
ns
done
w
ithi
n 48
hou
rs o
f di
agno
sis
Stan
dard
ized
la
bora
tory
in
vest
igat
ions
fo
r al
l ne
w D
R TB
pat
ient
s do
ne w
ithi
n 1-
2 da
ys
of d
iagn
osis
(rec
eipt
of
resu
lts
at c
ount
y) a
nd
resu
lts
elec
tron
ical
ly d
ispa
tche
d w
ithi
n 24
-48
hour
s
Esta
blis
h an
d di
ssem
inat
e po
licy
50%
a) P
olic
y im
plem
enta
tion
b) M
onit
orin
g of
pol
icy
75%
a) P
olic
y im
plem
enta
tion
b) R
evie
w o
f po
licy
100%
a)
Revi
sed
polic
y im
plem
enta
tion
b) M
onit
orin
g of
pol
icy
100%
Ava
ilabi
lity
of
stan
dard
ized
an
d fr
ee
base
linea
nd
follo
w
up
inve
stig
atio
ns
(FBC
, U
ECs,
LFT
s, T
SH)
incl
udin
g ch
est
radi
ogra
ph
and
audi
omet
ry in
all
the
coun
ties
Esta
blis
h m
echa
nism
s to
su
ppor
t fr
ee
inve
stig
atio
ns
incl
udin
g au
diom
etry
and
CX
R. S
uppo
rt 2
00
new
pat
ient
s fo
r ba
selin
es a
nd 6
00
for
follo
w u
p in
vest
igat
ions
Esta
blis
h m
echa
nism
s to
su
ppor
t fr
ee
inve
stig
atio
ns
incl
udin
g au
diom
etry
an
d C
XR.
Su
ppor
t 40
0 ne
w
pati
ents
fo
r ba
selin
es
and
600
for
follo
w
up
inve
stig
atio
ns
Esta
blis
h m
echa
nism
s to
su
ppor
t fr
ee
inve
stig
atio
ns
incl
udin
g au
diom
etry
an
d C
XR.
Su
ppor
t 40
0 ne
w
pati
ents
fo
r ba
selin
es
and
600
for
follo
w
up
inve
stig
atio
ns
Esta
blis
h m
echa
nism
s to
su
ppor
t fr
ee
inve
stig
atio
ns
incl
udin
g au
diom
etry
and
CX
R.
Supp
ort
400
new
pat
ient
s fo
r ba
selin
es a
nd 6
00 f
or f
ollo
w u
p in
vest
igat
ions
Prop
orti
on o
f co
unti
es r
epor
ting
no
stoc
k-ou
t of
DR-
TB d
rugs
Ava
ilabi
lity
of
2nd
line
TB
med
icat
ions
at
th
e co
unty
lev
el t
o al
low
fas
ter
init
iati
on o
f tr
eatm
ent
Esta
blis
h m
echa
nism
s to
ava
il 2nd
lin
e TB
med
s at
the
cou
nty
60%
a) P
olic
y im
plem
enta
tion
b) M
onit
orin
g of
pol
icy
60%
a) P
olic
y im
plem
enta
tion
b) R
evie
w o
f po
licy
80%
a)
Revi
sed
polic
y im
plem
enta
tion
b) M
onit
orin
g of
pol
icy
100%
Prop
orti
on
of
sub-
coun
ties
w
ith
func
tion
al
MD
T te
ams
for
DR-
TB/H
IVC
onst
itut
e st
ruct
ured
mul
ti-d
isci
plin
ary
(DR-
TB/
HIV
mul
tidi
scip
linar
y te
ams)
clin
ical
tea
ms
at
the
low
est l
evel
pos
sibl
e (s
ub c
ount
y) to
init
iate
tr
eatm
ent
and
follo
w u
p ca
re (
com
pose
d of
su
bcou
nty
TB
coor
dina
tor,
sCM
LT,
sCA
SCO
, La
b, P
harm
acis
t, D
OT
Nur
se,
PHO
, Ph
ysic
ian,
C
ouns
elor
s, n
utri
tion
ist)
Supp
ort
esta
blis
hmen
t of
mon
thly
D
R-TB
cl
inic
al
mee
ting
s in
ea
ch
coun
ty (
10 p
ax t
o di
scus
s D
R-TB
pa
tien
ts m
anag
emen
t)
30%
Supp
ort
esta
blis
hmen
t of
m
onth
ly
DR-
TB
clin
ical
m
eeti
ngs
in e
ach
coun
ty (
10
pax
to d
iscu
ss D
R-TB
pat
ient
s m
anag
emen
t)
60%
Supp
ort
esta
blis
hmen
t of
m
onth
ly
DR-
TB
clin
ical
m
eeti
ngs
in
each
co
unty
(1
0 pa
x to
di
scus
s D
R-TB
pa
tien
ts m
anag
emen
t)
80%
Supp
ort
esta
blis
hmen
t of
m
onth
ly
DR-
TB
clin
ical
m
eeti
ngs
in
each
co
unty
(1
0 pa
x to
dis
cuss
DR-
TB p
atie
nts
man
agem
ent)
100%
PMD
T O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
4: Im
prov
e M
&E
and
trea
tmen
t ou
tcom
es f
or D
R T
B pa
tien
ts, i
nclu
ding
chi
ldre
n
Prop
orti
on o
f D
R-TB
pat
ient
s fo
r w
hom
AD
R re
port
s ar
e re
cord
ed,
and
refl
ect
adeq
uate
m
anag
emen
t, in
TIB
U
Stre
ngth
en
acti
ve
phar
mac
ovig
ilanc
e (m
onit
orin
g,
reco
rdin
g &
re
port
ing
of
AD
R th
roug
h TI
BU
and
PPB
plat
form
s)
and
thei
r m
anag
emen
t in
clud
ing
the
avai
labi
lity
of
auxi
liary
dr
ugs
e.g.
th
yrox
in,
anti
psyc
hoti
cs,
hear
ing
aids
and
impl
ants
a) I
nteg
rati
on o
f PV
int
o th
e TI
BU
syst
emb)
Pla
nnin
g fo
r th
e au
xilia
ry d
rugs
an
d ai
ds
a) I
nteg
rati
on o
f PV
int
o th
e TI
BU s
yste
m a
nd s
ensi
tiza
tion
of
th
e (s
ub)
coun
ty
coor
dina
tors
in Q
RMs
b) P
rocu
rem
ent,
dis
trib
utio
n an
d us
e of
the
aux
iliar
y dr
ugs
and
aids
”
50%
a)
Mon
itor
ing
the
use
of
TIBU
PV
pl
atfo
rms
and
stre
ngth
en e
xist
ing
gaps
b) P
rocu
rem
ent,
dis
trib
utio
n an
d us
e of
th
e au
xilia
ry
drug
s an
d ai
ds
60%
a)
Revi
ew
of
the
TIBU
PV
pl
atfo
rms
in l
ine
wit
h pr
evio
us
year
’s fi
ndin
gsb)
Pr
ocur
emen
t,
dist
ribu
tion
an
d us
e of
the
aux
iliar
y dr
ugs
and
aids
”
75%
Num
ber
of A
udio
met
er m
achi
nes
avai
labl
e in
th
e co
unti
esPr
ocur
e 47
aud
iom
eter
mac
hine
s on
e fo
r ea
ch
coun
tyPr
ocur
e 10
aud
iom
eter
mac
hine
s fo
r th
e H
igh
bude
rn c
ount
ies
10Pr
ocur
e 20
au
diom
eter
m
achi
nes
30Pr
ocur
e 17
au
diom
eter
m
achi
nes
47n/
an/
a
Prop
orti
on
of
TB
coor
dina
tors
us
ing
the
upda
ted
supe
rvis
ory
chec
klis
t co
veri
ng D
R-TB
Upd
ate
chec
k lis
t fo
r su
perv
isor
y/su
ppor
t vi
sits
to
ade
quat
ely
cove
r D
R-TB
or
desi
gn a
spe
cifi
c D
R-TB
too
l
Revi
se/d
esig
n ch
eckl
ist
for
supe
rvis
ory/
supp
ort
visi
t to
cov
er
DR-
TB
n/a
Repr
int
and
dist
ribu
te
the
supe
rvis
ory
chec
klis
30%
Mon
itor
th
e us
e of
th
e ch
eckl
ist
100%
Revi
se t
he c
heck
list
100%
Prop
orti
on o
f ch
ildre
n w
ith
DR-
TB a
cces
sing
th
e pe
diat
ric
form
ulat
ions
Proc
ure,
dis
trib
ute
and
use
pedi
atri
c fr
iend
ly
DR-
TB c
ombi
nati
ons
Plan
for
pro
cure
men
t of
ped
iatr
ic
frie
ndly
DR-
TB f
orm
ulat
ions
n/a
Proc
ure,
di
stri
bute
an
d us
e pe
diat
ric
frie
ndly
D
R-TB
fo
rmul
atio
ns
30%
Proc
ure,
dis
trib
ute
and
use
pedi
atri
c fr
iend
ly
DR-
TB
form
ulat
ions
60%
Proc
ure,
di
stri
bute
an
d us
e pe
diat
ric
frie
ndly
D
R-TB
fo
rmul
atio
ns
100%
Prop
orti
on
of
faci
litie
s pr
ovid
ing
TB
care
se
rvic
es s
uppl
ied
wit
h re
vise
d D
R-TB
too
lsRe
vise
the
DR-
TB c
linic
al t
ools
* us
ed f
or t
he
day
to d
ay m
anag
emen
t of
pat
ient
s
*pat
ient
too
ls, r
egis
ters
, IEC
mat
eria
ls e
tc”
Revi
se t
he c
linic
al t
ools
, pl
an f
or
proc
urem
ent
n/a
Proc
urem
ent,
di
stri
buti
on
and
use
of t
he t
ools
100%
Mon
itor
the
use
of
the
tool
s10
0%Re
vise
the
too
ls,
Proc
ure
and
dist
ribu
te t
he u
pdat
ed t
ools
100%
Upd
ated
TIB
U s
yste
m w
hich
inc
orpo
rate
s D
R-TB
cas
e m
anag
emen
tIn
trod
uce
case
man
agem
ent
of D
R-TB
in
the
TIBU
sys
tem
whi
ch in
clud
es r
obus
t ph
arm
aco-
vigi
lanc
e an
d ch
ecks
and
rem
inde
rs f
or la
b an
d cl
inic
al m
onit
orin
g. E
xplo
re l
inka
ges
to N
TRL’
s LI
MS
Des
ign
and
intr
oduc
e a
robu
st D
R-TB
ca
se
man
agem
ent
into
TI
BU
syst
em
1Pi
lot
test
th
e ne
w
desi
gn,
mak
e re
visi
ons
and
cond
uct
trai
ning
s of
th
e TB
of
fice
rs
coun
tryw
ide
Mon
itor
use
Revi
se t
he D
R-TB
int
erfa
ce a
nd
cont
ents
in
TIBU
in
line
wit
h ne
w p
roto
cols
. U
pdat
e of
fice
rs
in Q
RM
Prop
orti
on
of
elig
ible
ne
w
DR-
TB
pati
ents
ac
cess
ing
capr
eom
ycin
as
fi
rst
inje
ctab
le
of
choi
ce
Plan
fo
r, pr
ocur
e,
dist
ribu
te
and
use
capr
eom
ycin
as
firs
t ch
oice
inje
ctab
le f
or n
ew
MD
R-TB
pat
ient
s (&
exi
stin
g pa
tien
ts in
tole
rant
to
the
cur
rent
inje
ctab
les)
Plan
fo
r th
e pr
ocur
emen
t of
ad
equa
te s
tock
s of
cap
reom
ycin
25%
Proc
ure,
di
stri
bute
an
d us
e th
e ca
preo
myc
in50
%Pr
ocur
e, d
istr
ibut
e an
d us
e th
e ca
preo
myc
in75
%Pr
ocur
e, d
istr
ibut
e an
d us
e th
e ca
preo
myc
in10
0%
Prop
orti
on o
f new
DR-
TB p
atie
nts
acce
ssin
g th
e ne
w m
olec
ules
Adv
ocat
e fo
r ac
cele
rati
on a
nd u
ptak
e of
new
m
olec
ules
suc
h as
bed
aqui
line
and
dela
min
id
once
ava
ilabi
lity
in t
he m
arke
t
Adv
ocat
e fo
r th
e av
aila
bilit
y of
the
ne
w m
olec
ules
in t
he c
ount
ryn/
aPl
an
for,
proc
ure
and
dist
ribu
te t
he n
ew m
olec
ules
fo
r us
e
n/a
Plan
fo
r, pr
ocur
e an
d di
stri
bute
th
e ne
w
mol
ecul
es f
or u
se
10%
Plan
for
, pr
ocur
e an
d di
stri
bute
th
e ne
w m
olec
ules
for
use
25%
Num
ber
of
wor
kpla
ce
DR-
TB
polic
ies
dist
ribu
ted
Fina
lize,
pri
nt a
nd d
isse
min
ate
18,0
00 D
R-TB
w
orkp
lace
pol
icy
docu
men
tsW
orkp
lace
po
licy
copi
es
prin
ted
and
dist
ribu
ted
6,00
0W
orkp
lace
po
licy
copi
es
prin
ted
and
dist
ribu
ted
4,00
0W
orkp
lace
po
licy
copi
es
prin
ted
and
dist
ribu
ted
4,00
0W
orkp
lace
pol
icy
copi
es p
rint
ed
and
dist
ribu
ted
4,00
0
Num
ber o
f N95
mas
ks p
rocu
red
and
dist
ribu
ted
Proc
ure
and
dist
ribu
te 6
0,00
0 N
95 m
asks
Proc
ure
and
dist
ribu
te N
95 m
asks
10,0
00Pr
ocur
e an
d di
stri
bute
N
95
mas
ks20
,000
Proc
ure
and
dist
ribu
te N
95
mas
ks20
,000
Proc
ure
and
dist
ribu
te
N95
m
asks
10,0
00
Num
ber
of D
R-TB
CoE
s es
tabl
ishe
dEs
tabl
ish
7 re
gion
ally
di
stri
bute
d C
entr
es
of
Exce
llenc
e (C
oEs)
in
th
e co
untr
y to
of
fer
men
tors
hip/
TA,
supp
ort
supe
rvis
ion,
re
ferr
als,
inv
esti
gati
ons,
adm
issi
ons,
and
AD
R m
anag
emen
ts(T
he p
ropo
sed
site
s ar
e K
enya
tta
Nat
iona
l H
ospi
tal,
Daa
dab,
Moi
Tea
chin
g an
d Re
ffer
al, J
aram
ogi O
ging
a O
ding
a te
achi
ng a
nd
reff
eral
hos
pita
l, H
omab
ay, P
ortR
eitz
and
…..)
Dev
elop
the
bas
ic r
equi
rem
ents
for
a
mod
el D
R-TB
CoE
,and
a p
ackg
ae
carr
y ou
t m
appi
ng
n/a
Esta
blis
h 3
sele
cted
m
odel
D
R-TB
CoE
3Es
tabl
ish
4 m
ore
DR-
TB C
oEs
4M
ento
rshi
p7
Prop
orti
on o
f el
igib
le D
R-TB
pat
ient
s re
ceiv
ing
soci
al s
uppo
rt
Prov
isio
n of
fina
ncia
l sup
port
to D
R-TB
pat
ient
s an
d D
OTS
nur
ses
in c
omm
unit
y ba
sed
mod
els
Prov
ide
supp
ort
to 6
00 p
atie
nts
at
KSH
S 6,
000
each
and
200
HC
Ws
60%
Prov
ide
supp
ort
to
600
pati
ents
at
KSH
S 6,
000
each
an
d 20
0 H
CW
s
80%
Prov
ide
supp
ort
to
600
pati
ents
at
KSH
S 6,
000
each
an
d 20
0 H
CW
s
80%
Prov
ide
supp
ort
to 6
00 p
atie
nts
at K
SHS
6,00
0 ea
ch a
nd 2
00
HC
Ws
80%
Prop
orti
on
of
TB
pati
ents
en
rolle
d on
N
HIF
sc
hem
eYe
arly
pay
men
t to
NH
IF u
ntil
afte
r co
mpl
etio
n of
tre
atm
ent
NH
IF y
earl
y su
bscr
ipti
on f
or 6
00
pati
ents
NH
IF y
earl
y su
bscr
ipti
on f
or
600
pati
ents
20%
NH
IF y
earl
y su
bscr
ipti
on f
or
600
pati
ents
30%
NH
IF
year
ly
subs
crip
tion
fo
r 60
0 pa
tien
ts50
%
Prop
orti
on o
f co
unti
es u
tilit
izin
g co
mm
unit
y-ba
sed
DR-
TB g
uide
lines
Dev
elop
and
pri
nt g
uide
lines
on
com
mun
ity
base
d D
R-TB
car
eD
evel
op t
he c
omm
unit
y ba
sed
DR-
TB c
are
guid
elin
esPr
int,
di
ssem
inat
e an
d di
stri
bute
6,0
00 c
omm
unit
y D
R-TB
car
e gu
idel
ines
20%
Sens
itiz
atio
n of
2,
000
com
mun
ity
mem
bers
on
C
omm
unit
y D
R-TB
car
e
40%
Sens
itiz
atio
n of
2,
000
com
mun
ity
mem
bers
on
co
mm
unit
y D
R-TB
car
e
50%
4.3.2.2. Programm
atic Managem
ent of Drug Resistant TB
4.3.
2.3.
Ped
iatr
ic T
B4.
3.2.
2. P
rogr
amm
atic
Man
agem
ent o
f Dru
g Re
sist
ant T
B
PMD
T O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Num
ber
of d
igit
al x
-ray
fac
iliti
es in
the
cou
ntry
12
Dig
ital
X-r
ays
for
hard
to
reac
h ar
eas
and
MD
R-TB
con
tact
sM
apin
g of
the
har
d to
rea
ch a
reas
an
d pl
an
for
acqu
isit
ion
of
the
mob
ile X
-ray
equ
ipm
ent
Inst
all
and
oper
atio
naliz
e 4
xray
mac
hine
s4
Inst
all
and
oper
atio
naliz
e 4
xray
mac
hine
s4
Inst
all a
nd o
pera
tion
aliz
e 4
xray
m
achi
nes
4
4.3.2.3. Pediatric TB
1. Situational Analysis
The infant mortality rate in Kenya dropped from 68 per 1,000 live births in 2000 to 43.6 per 1,000 in 2012, indicating an improvement in the Kenyan health system. In 2012, 10,634 TB cases were reported among children under the age of 15, comprising 10.7% of all TB cases.
Almost 28% of all child TB cases were in children under the age of one. Of the reported TB cases, 93% were tested for HIV and 30% were found to be HIV positive. Of those found positive, 90% were initiated on cART and 99% on cotrimoxazole. In 2012, 10 children were diagnosed with MDR-TB and treatment started. Among the pediatric MDR-TB cases, 20% were HIV positive. In Kenya, it is estimated that 20% of the children under the age of 5 years suffer from moderate malnutrition, while 6% suffer from severe malnutrition. The pediatric case notification chart below highlights the disparities among counties in the percentage of notified paediatric cases.
There are counties that notified a very high number of children with Turkana and Samburu having >12% of their total cases being children while some have child TB cases being less than 5% of the total TB cases notified. It is also important to note that counties where there is food insecurity due to climatic characteristics had more children diagnosed with TB. Map 5 indicates the ratio of children <5 years to those 5-15 years diagnosed with TB.
According to WHO, it is expected this ratio is 1:1.5-3.0. However, over 70% of the counties have a ratio of less than 1.5. This is indicative of under-diagnosis of children below the age of 5 years. There is therefore a need to evaluate the actual diagnostic practices among health care workers in
8.3.
2.3.
Ped
iatr
ic T
B
4.3.2.3. Pediatric TB
Map 5: Ratio of <5 to 5-15 Year Olds, 2013 TB
Notifications
Map 4: % of Pediatric TB Cases among All
Notifications
Figure 15: Notified Pediatric TB Cases by County, 2013
46
4.3.
2.3.
Ped
iatr
ic T
B
these very high and very low case notification areas to ensure that we are not over or under-diagnosing the children.
Several strides have been made to support childhood TB as well as the case notification of TB among children under the age of 15. A pediatric TB focal person is currently based in the central program, and is supported by a Pediatric TB technical working group with expert representation from the NTLD Program, KEMRI, NASCOP, University of Nairobi, Moi Teaching and Referral Hospital, CDC Kenya, CHS and ICAP. National guidelines for management of childhood TB, job aids; including diagnostic and preventive algorithms, treatment charts, training curricula and tools have been developed with the working group’s consensus.
The treatment guidelines are in-line with current WHO recommendations, while health care worker trainings are in progress, based on the revised pediatric TB treatment algorithms. The GeneXpert algorithm supports the diagnosis of children under the age of 15 years using Xpert. Pediatric anti-TB formulations (dispersible fixed dose combinations, Isoniazid 100mg and Ethambutol 100mg) are available in Kenya through KEMSA. In addition, there exists a case based electronic recording system for monitoring TB program activities allowing evaluation of child TB data. However, this system does not capture nutrition assessment data for children with TB. There is need to improve the facility TB register to ensure it captures the nutrition indicators for children and the same should be incorporated into TIBU.
Currently, there is limited screening for TB among child TB contacts and children living with HIV, with a small proportion of those eligible receiving Isoniazid prophylaxis. Diagnosis of TB in children has been a major challenge in the scale up of child TB services. There is a low index of suspicion by HCWs for TB among children and most are ill equipped to make an accurate diagnosis of TB in children. Diagnosis is limited to the chest clinic with missed opportunities in maternal and child health (MCH) clinics, pediatric clinics, emergency rooms and in-patient wards. There remain financial and geographical barriers to quality diagnostic services for children due to limited access to affordable, high quality x-rays for TB diagnosis. GeneXpert machines, though currently available, are not strategically placed and networked to ensure equitable access to all children. In addition, TST is not readily available in most health facilities.
Children exposed to DR-TB have a high risk of acquiring the infection. Once a case of DR-TB has been diagnosed, it is important to screen all household contacts including the children for any signs and symptoms of disease. This is not routinely done, hence, some of these cases may be missed. Follow up should be done for all contacts for at least two years because the signs and symptoms may develop after some time. Diagnosis of DR-TB in children is a challenge as the index of suspicion is low among health care workers. Diagnosis may be delayed as attempts to obtain specimens for bacteriological confirmation may be challenging without adequate capacity building. Once DR-TB has been diagnosed, few health care workers are trained to adequately manage children. Adult formulations are used to treat DR-TB in children with dose challenges, which result in a higher risk of toxicity from the drugs.
For all children with TB, malnutrition is often comorbidity. There is need to train health care workers to effectively conduct a nutritional assessment for all children with TB and once diagnosed with malnutrition, these children need nutritional support and supplementation. This is not consistently available.
Figure 16: Child Versus Adult TB Cases
47
2. Strategic Direction(s) for 2015-2018
The focus for the next three (3) years is to ensure that there is more emphasis on distinct pediatric TB control activities. These will include: a) active pediatric TB case finding; b) management, prevention, advocacy and integration of child TB services in other departments; c) scale up and sustain gains made in child TB surveillance; d) strengthen TB/HIV care for children; and e) continue with capacity building activities for HCWs.
The adoption and rollout of new diagnostic technologies with improved diagnosis of TB in children using GeneXpert, chest x-rays and TST will be fast-tracked to ensure equitable access. The capacity of HCWs will be developed to enable them conduct nutritional assessments and manage malnutrition in children with TB. Capacity will also be developed for HCWs on child TB case detection, diagnosis and treatment. All child contacts of patients with TB will be actively traced, screened and offered Isoniazid Preventive Therapy if eligible. Community engagement in TB control will be enhanced, allowing for contact and defaulter tracing of children and for care of OVCs. There will be institutional based TB screening for children in schools and children homes.
Increased awareness and advocacy is required on childhood TB. There will be systematic involvement of private providers, pediatric providers’ associations and all other stakeholders in child TB control.
There is need to focus on scale up activities for child asthma and management of chronic lung conditions in children as well as better case detection and rehabilitation for children with leprosy. Counties will be encouraged to engage pediatric experts in management of children with TB, leprosy and lung disease and equip county hospitals with all relevant tools to support this.
3. Proposed Approaches
Interventions towards pediatric TB management have significantly improved over the last year with introduction of revised treatment schedules, pediatric friendly TB medicines and a simplified approach to diagnosis and availability of GeneXpert.
Currently, there are disparities in the rate of child TB notification across the country. Though it would be more strategic to use these disparities as a basis for targeting the interventions in this strategic plan, this will not be done because there is need to first establish the origin of these disparities. Therefore, in the first year of implementation, a retrospective evaluation of the patients and their characteristics may shed light as to why these disparities exist. In the meantime, the proposed approaches will be rolled out countrywide.
In the final phase of the implementation of this strategic plan, an evaluation to establish the impact and effectiveness of these approaches will be conducted.
Lessons learnt from this evaluation will form the basis for targeted interventions in subsequent strategic plans.
4.3.2.3. Pediatric TB
Lessons Learned
TB-REACH: Eldoret, Kenya
A pilot project supported by TB-REACH has nurtured collaboration with communities to screen symptomatic individuals and transport sputum samples to smear microscopy centers, while making linkages to care. AMPATH has introduced a cough monitoring system to monitor case detection activity. A child tracking component registers children living in smear positive households to establish a way to locate children at high risk of TB. Children benefit from a screening package through TB REACH, including transportation costs, registration fees, chest radiograph and physical exam. If a child tests positive, he/she begins treatment immediately, and if negative, begins Isoniazid preventative therapy. GeneXpert laboratories at district and sub-levels are facilitating timely diagnosis.
Geographical Focus
Centre(s) of Excellence
As the implementation of pediatric TB services is rolled out countrywide, some sites will be identified and strengthened as centers of excellence. These will be centers that will be able to offer comprehensive child TB, MDR TB and Lung health services from diagnosis, treatment and prevention. They will be model sites for mentorship of other service provision sites.
Intensified Technical Support
Training and technical assistance will be offered to all sites to build capacity to implement the revised treatment guidelines for child TB.
Box 2
Box 3
48
8.3.
2.3.
Ped
iatr
ic T
B
Strengthen coordination of child TB services
Coordination of pediatric TB services will be done by a focal person at the program. The pediatric TB TWG will continue to provide policy direction and oversight for the implementation of child TB services.
Build capacity of health care workers for pediatric TB control
Continuous training for health care workers on child TB diagnosis, management and prevention as part of routine TB trainings will build their capacity to better manage children with TB. We will ensure printing and dissemination of up-to-date guidelines and job aids to facilitate the HCWs in service provision. There is need to support mentorship programs and on job training.
Child TB should be included in pre-service training for all HCWs to build their capacity on the current pediatric curriculum, including the nutritional aspects. Additionally, registering the NTLD Program as a CPD provider may encourage senior doctors to attend trainings and CMEs on TB.
Integrate child TB with other specialties
There is need to develop linkages between MCH clinics, PMTCT sites, pediatric outpatient clinics, casualty, pediatric inpatient wards and the TB clinic. This will strengthen TB systems in these different areas to close any present gaps in the screening, diagnosis, treatment and prevention of child TB. Additionally, this will help monitor and facilitate patient and information flow between departments, while surveillance data needs to be improved, in order to capture nutritional aspects of TB in children.
To minimize TB transmission to children within the health care settings, efforts will be made to improve IPC activities in health facilities through triaging all adults with cough and separating them from children.
Child TB drug procurement and ordering should be in line with program needs to avoid over and under-stocking. All children should be actively monitored for adverse drug reactions. To facilitate this, ADR monitoring questions are to be incorporated in the current patient monitoring tools.
Ensure affordable, high quality TB diagnostics
All children need to access quality TB diagnostics at no cost. This requires setting aside funds at national and county government levels towards basic child TB diagnostics. CXR facilities will need to be availed, either through mobile digital CXR services or installation of quality CXR services that are accessible to lower level health facilities with improved capacity for reliable interpretation by linking these facilities with adequately trained radiologists. This can be done through web linkage.
Current child TB diagnostic algorithms and tools will have to be made available at all facilities dealing with children at all key areas of child-care. Xpert testing should be the first diagnostic test for children with expectorated/induced sputum samples or gastric aspirate samples. There will be skills development for HCWs through mentorship to develop their capacity to obtain sputum samples from children. In addition, there is need to link all TB diagnostic facilities to available Xpert sites to ensure access to diagnosis.
49
Prevention of TB through community engagement and IPT provision
Communities should be actively engaged in the management of TB through contact tracing, supervision of DOTS for TB patients and tracing patients who default from treatment. Child TB contacts can be actively traced through engagement of community health workers to ensure the children are screened and either put on TB treatment or preventive therapy. The Orphans and Vulnerable children are more likely to fall off their TB treatment due to a lack of social support. Community based programs can be developed for them to ensure completion of treatment and other social support they may need.
Awareness and TB screening campaigns shall be conducted in schools, colleges and orphanages to increase awareness about TB and intensify detection of new cases. Through the engagement of community health workers, there shall be active tracing for child contacts among various TB patients, including smear positive and MDR-TB patients. Reverse contact tracing has also been done among children with TB.
IPT has been shown to have a protective benefit for children exposed to TB and those living with HIV.
Contact tracing and intensified case finding should be done at the facility level to exclude active TB. Success in this will depend on collaboration between facilities and communities. Children diagnosed with TB should be started on effective treatment regimen, while those without TB should be initiated on Isoniazid therapy for a period of six months with periodic review to identify suggestive symptoms or to be reviewed as soon as suggestive symptoms of TB arise.
Scale up nutrition interventions among children with TB
All health facilities need to be adequately equipped with anthropometric equipment to ensure that HCWs can assess the nutrition status of children with TB. Children found to have moderate and severe malnutrition will then be given nutrition supplementation. The surveillance system needs to be improved to adequately capture nutrition indicators for children.
Strengthen TB/HIV management in children
All children with TB must be tested for HIV. There is need to strengthen early infant diagnosis for all children under 18 months of age with PCR. All children found with HIV should be offered cART and CPT at the earliest opportunity. Children under five years exposed to smear positive TB and those above one year of age living with HIV should all be initiated on IPT once active TB disease has been ruled out.
DR-TB among children
All child DR-TB contacts should be traced and screened for TB. Those who screen positive should be initiated on the appropriate DR-TB regimen and followed up appropriately. These children should be reviewed by specialists to ensure appropriate management. Social support will be necessary to enable the caregivers of these children bring them for daily DOTS and to enable them to access follow up investigations. Those who screen negative during DR-TB screening should be followed up regularly for at least two years. There is need for continuous lobbying for pediatric friendly DR-TB drug formulations.
Senior clinicians managing children with MDR-TB should receive further specialized training to enable them effectively offer the service and to train other clinicians.
Establish and equip chronic care clinics for asthma and other chronic childhood lung conditions
Children with chronic respiratory conditions need special care. Medications and equipment for managing chronic lung conditions in children are neither readily available nor affordable. These commodities and equipment need to be procured and distributed to peripheral health facilities at no cost to these children. There is need to establish specialized lung health clinics for children in at least all county referral health facilities. Capacity building for HCWs in the identification, management and follow-up of asthma and chronic childhood lung conditions. All children with chronic lung conditions should be screened for risk factors. There is also need to establish a surveillance system to capture data on child chronic lung conditions.
Operational research
There is need to strengthen operational research on child TB and chronic lung health. This can be achieved through a mentorship program steered by the NTLD Program to enable the CTLCs and sub-county TB coordinators to plan and implement operational research projects. Operational research should be conducted on:
1. Evaluation of pediatric TB over and under diagnosis in Kenya2. Diagnostic effectiveness of the screening algorithm and treatment of TB in children3. Outcome of MDR-TB in children and child MDR-TB contacts 4. Evaluate adverse drug effects with the new pediatric regimen5. MDR-TB prophylaxis for young children.
4.3.2.3. Pediatric TB
50
8.3.
2.3.
Ped
iatr
ic T
B
Contribution to NSP Impacts Outcomes (Pediatric)
Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014
Increase the proportion of children among all notified cases (TBD: prevalence survey)
Impact 1.1: Reduce the prevalence of MDR-TB among new patients by 15% by 2018, compared to 2014
Increase case notifications of MDR-TB in children by 10-15%
Impact 1.2: Reduce the incidence of TB among PLHIV by 60% by 2018, compared to 2014
• Increase to 90% the proportion of children with TB and HIV who are initiated on cART within 2 months of TB treatment initiation
• Increase to 80% the proportion of child contacts, without TB, who receive IPT
Impact 2: Reduce mortality due to TB by 3% by 2018, compared to 2014
Ensure treatment success of at least 90% among all DS forms of TB
Impact 3: Reduce the proportion of affected families who face catastrophic costs due to TB, leprosy & other lung diseases, by 2018 (baseline TBD)
Increase to 95% the proportion of malnourished children with TB who access nutritional support
Impact 4: Reduce by 50% the proportion of cases with grade 2 morbidity due to leprosy by 2018
Increase by 10% the number of leprosy cases notified among children
Impact 5: Reduce morbidity due to chronic lung diseases (e.g. COPD, asthma)
Reduce the average number of acute episodes for children with asthma
Table 7: Impact and Outcome Indicators for Pediatric TB
51
Pedi
atri
c TB
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
1: S
tren
gthe
n co
ordi
nati
on o
f ch
ild T
B se
rvic
es
Num
ber
of p
edia
tric
ian
foca
l pe
rson
s at
NTL
D
Prog
ram
sup
port
edRe
tent
ion
of p
edia
tric
foc
al p
erso
n at
NTL
D P
rogr
amRe
tent
ion
of
pedi
atri
c fo
cal
pers
on a
t N
TLD
Pro
gram
1Re
tent
ion
of
pedi
atri
c fo
cal
pers
on
at
NTL
D
Prog
ram
1Re
tent
ion
of
pedi
atri
c fo
cal
pers
on a
t N
TLD
Pro
gram
1Re
tent
ion
of
pedi
atri
c fo
cal
pers
on a
t N
TLD
Pro
gram
1
Prop
orti
on o
f sc
hedu
led
quar
terl
y TW
G m
eeti
ngs
held
Hol
d qu
arte
rly
ped
TB
TWG
m
eeti
ngs
Hol
d qu
arte
rly
ped
TB
TWG
m
eeti
ngs
100%
Hol
d qu
arte
rly
paed
TB
TW
G m
eeti
ngs
100%
Hol
d qu
arte
rly
ped
TB
TWG
m
eeti
ngs
100%
Hol
d qu
arte
rly
ped
TB
TWG
m
eeti
ngs
100%
Stra
tegi
c A
ppro
ach
2: B
uild
cap
acit
y of
HC
Ws
for
pedi
atri
c TB
, lep
rosy
and
lung
hea
lth
Prop
orti
on o
f fa
cilit
ies
prov
ided
wit
h an
d us
ing
pedi
atri
c-re
late
d m
ater
ial b
y ty
pePr
inti
ng a
nd d
istr
ibut
ion
of 8
,000
co
pies
of
pe
diat
ric
TB
guid
elin
es
and
10,0
00
flip
char
ts
joba
ids,
m
anto
ux p
oste
rs 9
000,
dia
gnos
tic
algo
rith
m p
oste
rs 9
,000
Prin
ting
an
d di
stri
buti
on
of
4,00
0 co
pies
of
pedi
atri
c TB
gu
idel
ines
and
6,0
00 fl
ipch
arts
jo
baid
s,
man
toux
po
ster
s 6,
000,
di
agno
stic
al
gori
thm
po
ster
s 6,
000
50%
Prin
ting
an
d di
stri
buti
on
of
4,00
0 co
pies
of
pe
diat
ric
TB
guid
elin
es
and
4,00
0 fl
ipch
arts
jo
baid
s, m
anto
ux p
oste
rs
3,00
0,
diag
nost
ic
algo
rith
m p
oste
rs 3
,000
100%
n/a
100%
n/a
100%
Upd
ated
ped
iatr
ic T
B gu
idel
ines
Revi
ew o
f pe
diat
ric
TB g
uide
lines
Revi
ew
of
pedi
atri
c TB
gu
idel
ines
1Re
view
of
pe
diat
ric
TB
guid
elin
es1
Num
ber
of H
CW
tra
ined
on
pedi
atri
c TB
Trai
ning
of
8,
460
HC
Ws
on
pedi
atri
c TB
Trai
n 1,
410
HC
Ws(
1 t
rain
ing
per
coun
ty,
30pa
x ea
ch f
or 3
da
ys)
1,41
0Tr
ain
2,82
0 H
CW
s (2
tr
aini
ngs
per
coun
ty,
30pa
x ea
ch f
or 3
day
s)
2,82
0Tr
ain
2,82
0 H
CW
s (2
tra
inin
gs
per
coun
ty,
30pa
x ea
ch f
or 3
da
ys)
2,82
0Tr
ain
1,41
0 H
CW
s (1
tra
inin
g pe
r co
unty
, 30
pax
each
for
3
days
)
1,41
0
Num
ber
of H
CW
rea
ched
thr
ough
e-l
earn
ing
Dev
elop
e-
mod
ule
com
pone
nt
of
the
pedi
atri
c TB
gui
delin
ePe
d TB
tr
aini
ng
curr
icul
um
upda
ted
to in
clud
e e-
mod
ule
300
Trai
n 30
0 H
CW
s us
ing
the
E m
odul
e pe
diat
ric
TB t
rain
ing
Trai
n 30
0 H
CW
s us
ing
the
E m
odul
e pe
diat
ric
TB t
rain
ing
Num
ber
of
HC
Ws
and
pedi
atri
c pr
ofes
sion
als
reac
hed
thro
ugh
CM
Es a
nd a
ccre
dite
d75
2 Fa
cilit
y ba
sed
CM
Es c
ondu
cted
on
pe
diat
ric
TB(1
pe
r ye
ar
per
coun
ty)
Faci
lity
base
d C
MEs
con
duct
ed
on p
edia
tric
TB(
5 pe
r ye
ar p
er
coun
ty)
9023
5 Fa
cilit
y ba
sed
CM
Es
cond
ucte
d on
pe
diat
ric
TB (5
per
yea
r pe
r co
unty
)
241
235
Faci
lity
base
d C
MEs
co
nduc
ted
on p
eadi
atri
c TB
(5
per
year
per
cou
nty)
241
235
Faci
lity
base
d C
MEs
co
nduc
ted
on p
edia
tric
TB
(5
per
year
per
cou
nty)
180
278
pedi
atri
c TB
C
MEs
fo
r pr
ofes
sion
al
asso
ciat
ions
( 2
per
year
per
cou
nty)
45
pedi
atri
c TB
C
MEs
fo
r pr
ofes
sion
al
asso
ciat
ions
( 2
per
year
per
cou
nty)
4594
ped
iatr
ic T
B C
MEs
for
pr
ofes
sion
al
asso
ciat
ions
(2
per
yea
r pe
r co
unty
)
9494
pe
diat
ric
TB
CM
Es
for
prof
essi
onal
as
soci
atio
ns
(2
per
year
per
cou
nty)
9445
pe
diat
ric
TB
CM
Es
for
prof
essi
onal
ass
ocia
tion
s( 2
per
ye
ar p
er c
ount
y)
45
NTL
D P
rogr
am r
egis
tere
d as
a C
PD p
rovi
der
NTL
D P
rogr
am r
egis
tere
d as
a C
PD
prov
ider
Link
pe
d TB
tr
aini
ng
to
CPD
aw
ard
syst
ems
to
incr
ease
at
tend
ance
/dem
and
(Reg
istr
atio
n co
st
appr
ox
40,0
00)
1
Num
ber
of H
CW
s m
ento
red
on c
hild
hood
TB
and
HIV
Dev
elop
a m
ento
rshi
p ch
eckl
ist
for
pedi
atri
c TB
Dev
elop
a
men
tors
hip
chec
klis
t fo
r pe
diat
ric
TB20
in
10
co
unti
es20
in 1
0 co
unti
es20
in 1
4 co
unti
es20
in
13
co
unti
es
Prin
t an
d di
stri
bute
6,
000
men
tors
hip
chec
klis
ts
to
heal
th
faci
litie
s
Prin
t an
d di
stri
bute
3,0
00
men
tors
hip
chec
klis
ts t
o he
alth
fac
iliti
es (N
o. t
o be
de
term
ined
)
3,00
0Pr
int
and
dist
ribu
te
3,00
0 m
ento
rshi
p ch
eckl
ists
to
he
alth
fa
cilit
ies
(No.
to
be
de
term
ined
)
3,00
0Pr
int
and
dist
ribu
te
3,00
0 m
ento
rshi
p ch
eckl
ists
to
heal
th
faci
litie
s (N
o. t
o be
det
erm
ined
)
TA o
f H
CW
s on
chi
ld T
B an
d H
IV
serv
ices
TA o
f H
CW
s on
chi
ld T
B an
d H
IV s
ervi
ces
in a
reas
w
ith
low
tes
ting
upt
ake
TA o
f H
CW
s on
chi
ld T
B an
d H
IV s
ervi
ces
in a
reas
wit
h lo
w
test
ing
upta
ke
TA o
f H
CW
s on
chi
ld T
B an
d H
IV s
ervi
ces
in a
reas
wit
h lo
w
test
ing
upta
ke
Stra
tegi
c A
ppro
ach
3: In
tegr
ate
child
TB
wit
h ot
her
spec
ialt
ies
Num
ber
of o
ther
chi
ld h
ealt
h gu
idel
ines
wit
h ch
ild T
B sc
reen
ing
and
diag
nost
ic a
lgor
ithm
sIn
corp
orat
e pe
ads
scre
enin
g an
d di
agno
stic
al
gori
thm
in
to
IMC
I, IM
AM
an
d ot
her
child
he
alth
gu
idel
ines
Inco
rpor
ate
pead
s sc
reen
ing
and
diag
nost
ic a
lgor
ithm
in
to
IMC
I, IM
AM
an
d ot
her
child
he
alth
gui
delin
es
10
4.3.2.3. Pediatric TB
4.3.
2.3.
Ped
iatr
ic T
B
Pedi
atri
c TB
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prop
orti
on o
f ch
ildre
n se
en i
n he
alth
fac
iliti
es
scre
ened
for
TB
and
docu
men
ted
Doc
umen
t al
l pr
esum
ptiv
e ch
ild T
B ca
ses
scre
ened
for
TB
Doc
umen
t al
l pr
esum
ptiv
e ch
ild
TB
case
s sc
reen
ed f
or T
B
60%
Doc
umen
t al
l pr
esum
ptiv
e ch
ild T
B ca
ses
scre
ened
for
TB
80%
Doc
umen
t al
l pre
sum
ptiv
e ch
ild
TB c
ases
scr
eene
d fo
r TB
95%
Stra
tegi
c A
ppro
ach
4: E
nsur
e ac
cess
to
high
-qua
lity
TB d
iagn
osti
cs f
or a
ll ch
ildre
n at
no
cost
; im
prov
e ac
cess
to
x-ra
y se
rvic
es f
or c
hild
ren
Prop
orti
on o
f in
tend
ed x
-ray
mac
ines
pro
cure
d48
dig
ital
xra
y m
achi
nes
proc
ured
( at
leas
t 1
per
coun
ty,
38 f
ixed
and
10
por
tabl
e)
n/a
n/a
Proc
ure
16 d
igit
al x
rays
100%
Proc
ure
16 d
igit
al x
rays
100%
Proc
ure
16 d
igit
al x
rays
100%
Num
ber
of r
adio
grap
hers
/HC
Ws
trai
ned
on x
-ray
ta
king
and
inte
rpre
tati
onTr
aini
ng
of
200
HC
Ws
on
xray
in
terp
reta
tion
n/a
n/a
Trai
ning
of
HC
Ws
on X
ray
taki
ng a
nd in
terp
reta
tion
100
Trai
ning
of
H
CW
s on
X
ray
taki
ng a
nd in
terp
reta
tion
50Tr
aini
ng
of
HC
Ws
on
Xra
y ta
king
and
inte
rpre
tati
on50
Prop
orti
on
of
pres
umpt
ive
child
TB
ca
ses
rece
ivin
g di
agno
stic
se
rvic
es
for
acti
ve
TB
thro
ugh
Xpe
rt,
wit
h ga
stri
c as
pira
tion
an
d m
anto
ux
Scal
e up
uti
lizat
ion
of g
eneX
pert
ut
ilisa
tion
for
chi
ld T
B di
agno
sis
by
stre
ngth
enin
g re
ferr
al n
etw
orks
for
sp
utum
Scal
e up
ut
iliza
tion
of
ge
neX
pert
uti
lizat
ion
for
child
TB
dia
gnos
is b
y st
reng
then
ing
refe
rral
net
wor
ks f
or s
putu
m
n/a
Scal
e up
ut
iliza
tion
of
ge
neX
pert
ut
iliza
tion
fo
r ch
ild T
B di
agno
sis
by
stre
ngth
enin
g re
ferr
al
netw
orks
for
spu
tum
60%
Scal
e up
ut
iliza
tion
of
ge
neX
pert
uti
lizat
ion
for
child
TB
dia
gnos
is b
y st
reng
then
ing
refe
rral
net
wor
ks f
or s
putu
m
80%
Scal
e up
ut
iliza
tion
of
ge
neX
pert
uti
lizat
ion
for
child
TB
dia
gnos
is b
y st
reng
then
ing
refe
rral
net
wor
ks f
or s
putu
m
95%
Men
tors
hip
of
HC
WS
on
Xpe
rt
: ga
stri
c as
pira
tion
and
man
toux
in
all c
ount
ies
Men
tors
hip
of
HC
WS
on
Xpe
rt
:gas
tric
as
pira
tion
an
d m
anto
ux t
o 18
0 H
CW
s (T
OTs
)
n/a
2 m
ento
rshi
p se
ssio
ns/
coun
ty/y
ear
each
20
pa
x fo
r H
CW
s on
Xpe
rt,
gast
ric
aspi
rati
on
and
man
toux
2 m
ento
rshi
p se
ssio
ns/c
ount
y/ye
ar e
ach
20 p
ax f
or H
CW
s on
X
pert
, ga
stri
c as
pira
tion
an
d m
anto
ux
2 m
ento
rshi
p se
ssio
ns/c
ount
y/ye
ar e
ach
20 p
ax f
or H
CW
s on
X
pert
, ga
stri
c as
pira
tion
an
d m
anto
ux
Stra
tegi
c A
ppro
ach
5: P
reve
ntio
n of
TB
thro
ugh
com
mun
ity
enga
gem
ent
and
IPT
prov
isio
n
Prop
orti
on o
f th
e co
ntac
ts o
f sm
ear-
posi
tive
TB,
M
DR-
TB a
nd c
hild
TB
case
s th
at a
re t
race
d an
d sc
reen
ed
Scal
e up
ch
ild
cont
act
scre
enin
g an
d re
ferr
al:
Trai
n 1,
200
CH
Ws
on
cont
act
scre
enin
g(at
leas
t 1
trai
ning
pe
r co
unty
)
20%
Trai
n 40
0 C
HW
s on
co
ntac
t sc
reen
ing
40%
Trai
n 40
0 C
HW
s on
co
ntac
t sc
reen
ing
60%
Trai
n 40
0 C
HW
s on
co
ntac
t sc
reen
ing
80%
Faci
litat
e C
HW
s to
con
duct
act
ive
cont
act
trac
ing
and
defa
ulte
r tr
acin
g fo
r 15
0,00
0 TB
pat
ient
s
Faci
litat
e C
HW
s to
co
nduc
t ac
tive
co
ntac
t tr
acin
g an
d de
faul
ter
trac
ing
for
50,0
00
TB
pati
ents
Faci
litat
e C
HW
s to
co
nduc
t ac
tive
co
ntac
t tr
acin
g an
d de
faul
ter
trac
ing
for
50,0
00
TB p
atie
nts
Faci
litat
e C
HW
s to
co
nduc
t ac
tive
co
ntac
t tr
acin
g fo
r 50
,000
TB
pati
ents
Esta
blis
h lin
kage
s fo
r O
VC
s w
ith
TB
to c
omm
unit
y su
ppor
tEs
tabl
ish
linka
ges
for
OV
Cs
wit
h TB
to
com
mun
ity
supp
ort
Esta
blis
h lin
kage
s fo
r O
VC
s w
ith
TB
to
com
mun
ity
supp
ort
Esta
blis
h lin
kage
s fo
r O
VC
s w
ith
TB t
o co
mm
unit
y su
ppor
tEs
tabl
ish
linka
ges
for O
VC
s w
ith
TB t
o co
mm
unit
y su
ppor
t
Num
ber
of s
choo
ls/c
olle
ges/
orph
anag
es in
whi
ch
all c
hild
ren
have
bee
n sc
reen
ed f
or T
BC
ondu
ct
targ
eted
cont
act/
mas
s sc
reen
ing
cam
paig
ns
to
108
sch
oo
ls/c
oll
eg
es/
orp
ha
na
ge
s (4
sc
hool
s pe
r co
unty
pe
r ye
ar
in
Kir
inya
ga,
Nai
robi
, Em
bu,
Mom
basa
, K
isum
u,
Mig
ori,
Hom
a Ba
y, T
hara
ka a
nd Is
iolo
)
n/a
n/a
Con
duct
tar
gete
d sc
hool
-ba
sed
cont
act/
mas
s sc
reen
ing
cam
paig
ns
to
36
scho
ols/
colle
ges
(4
scho
ols
per
coun
ty
per
year
in K
irin
yaga
, Nai
robi
, Em
bu, M
omba
sa, K
isum
u,
Mig
ori,
Hom
a Ba
y,
Thar
aka
and
Isio
lo )
36C
ondu
ct
targ
eted
sc
hool
-ba
sed
cont
act/
mas
s sc
reen
ing
cam
paig
ns
to
36
scho
ols/
colle
ges
(4 s
choo
ls p
er c
ount
y pe
r ye
ar i
n K
irin
yaga
, N
airo
bi,
Embu
, M
omba
sa,
Kis
umu,
M
igor
i, H
oma
Bay,
Th
arak
a an
d Is
iolo
)
36C
ondu
ct
targ
eted
sc
hool
-ba
sed
cont
act/
mas
s sc
reen
ing
cam
paig
ns
to
36
scho
ols/
colle
ges
36
Num
ber
of
scho
ols/
colle
ges
in
whi
ch
TB
awar
enes
s ca
mpa
igns
wer
e co
nduc
ted
Con
duct
sc
hool
-bas
ed
awar
enes
s ca
mpa
igns
to
228
scho
ols/
colle
ges
(at
leas
t 4
scho
ols
per
coun
ty p
er
year
)
n/a
n/a
Con
duct
ta
rget
ed
scho
ol-b
ased
aw
aren
ess
cam
paig
ns t
o 76
sch
ools
/co
llege
s (4
sc
hool
s pe
r co
unty
pe
r ye
ar
in
Kia
mbu
, M
uran
g'a,
M
eru,
Ker
ich,
Lam
u, T
aita
Ta
veta
, N
akur
u,
Wes
t Po
kot,
Si
aya,
K
ajia
do
Kir
inya
ga,
Nai
robi
, Em
bu,
Mom
basa
, K
isum
u,
Mig
ori,
Hom
a Ba
y,
Thar
aka
and
Isio
lo )
76C
ondu
ct
targ
eted
sc
hool
-ba
sed
aw
aren
ess
cam
paig
ns
to
76
scho
ols/
colle
ges
(4
scho
ols
per
coun
ty p
er y
ear
in
Kia
mbu
, M
uran
g'a,
M
eru,
K
eric
h,
Lam
u,
Tait
a Ta
veta
, N
akur
u,
Wes
t Po
kot,
Si
aya,
K
ajia
do
K
irin
yaga
, N
airo
bi,
Embu
, M
omba
sa,
Kis
umu,
M
igor
i, H
oma
Bay,
Th
arak
a an
d Is
iolo
)
76C
ondu
ct t
arge
ted
scho
ol-b
ased
aw
aren
ess
cam
paig
ns
to
76
scho
ols/
colle
ges
(4 s
choo
ls p
er
coun
ty
per
year
in
K
iam
bu,
Mur
ang'
a, M
eru,
Ker
ich,
Lam
u,
Tait
a Ta
veta
, N
akur
u,
Wes
t Po
kot,
Sia
ya, K
ajia
do K
irin
yaga
, N
airo
bi,
Embu
, M
omba
sa,
Kis
umu,
M
igor
i, H
oma
Bay,
Th
arak
a an
d Is
iolo
)
76
Prop
orti
on o
f ch
ild c
onta
cts,
wit
hout
TB,
who
re
ceiv
e IP
T In
itia
te
IPT
for
all
elig
ible
ch
ild
cont
acts
Init
iate
IP
T fo
r el
igib
le
child
co
ntac
ts20
%In
itia
te
IPT
for
elig
ible
ch
ild c
onta
cts
40%
Init
iate
IP
T fo
r el
igib
le
child
co
ntac
ts60
%In
itia
te
IPT
for
elig
ible
ch
ild
cont
acts
80%
Pedi
atri
c TB
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prin
ted
IPT
algo
rith
m p
oste
rsN
umbe
r of
IPT
alg
orit
hm p
oste
rs
prin
ted
and
dist
ribu
ted
Prin
t an
d di
stri
bute
IP
T al
gori
thm
pos
ters
8,00
0Pr
int
and
dist
ribu
te
IPT
algo
rith
m p
oste
rs4,
000
Prin
t an
d di
stri
bute
IP
T al
gori
thm
pos
ters
4,
000
n/a
n/a
Prop
orti
on o
f pr
egna
nt w
omen
scr
eene
d fo
r TB
at
AN
C s
ites
Dis
sem
inat
e sc
reen
ing
algo
rith
m
and
card
s to
AN
C s
ites
Dis
sem
inat
e sc
reen
ing
algo
rith
m a
nd c
ards
to
AN
C
site
s
10%
Dis
sem
inat
e sc
reen
ing
algo
rith
m
and
card
s to
A
NC
sit
es
40%
Dis
sem
inat
e sc
reen
ing
algo
rith
m a
nd c
ards
to
AN
C
site
s
60%
Dis
sem
inat
e sc
reen
ing
algo
rith
m
and
card
s to
A
NC
si
tes
80%
Sens
itiz
e al
l H
CW
s in
AN
C o
n TB
sc
reen
ing
in p
regn
ancy
Sens
itiz
e al
l H
CW
s in
AN
C o
n TB
scr
eeni
ng in
pre
gnan
cySe
nsit
ize
all
HC
Ws
in
AN
C o
n TB
scr
eeni
ng i
n pr
egna
ncy
Sens
itiz
e al
l H
CW
s in
AN
C o
n TB
scr
eeni
ng in
pre
gnan
cySe
nsit
ize
all
HC
Ws
in A
NC
on
TB s
cree
ning
in p
regn
ancy
Scre
en a
ll pr
egna
nt w
omen
for
TB
in p
regn
ancy
Scre
en a
ll pr
egna
nt w
omen
for
TB in
pre
gnan
cySc
reen
al
l pr
egna
nt
wom
en
for
TB
in
preg
nanc
y
Scre
en a
ll pr
egna
nt w
omen
for
TB in
pre
gnan
cySc
reen
all
preg
nant
wom
en f
or
TB in
pre
gnan
cy
Off
er I
PT t
o al
l el
igib
le p
regn
ant
mot
hers
w
ith
HIV
fo
und
not
to
have
act
ive
TB
Off
er
IPT
to
all
elig
ible
pr
egna
nt
mot
hers
w
ith
HIV
fo
und
not
to h
ave
acti
ve T
B
Off
er
IPT
to
all
elig
ible
pr
egna
nt
mot
hers
w
ith
HIV
fo
und
not
to
have
ac
tive
TB
Off
er
IPT
to
all
elig
ible
pr
egna
nt
mot
hers
w
ith
HIV
fo
und
not
to h
ave
acti
ve T
B
Off
er IP
T to
all
elig
ible
pre
gnan
t m
othe
rs w
ith
HIV
fou
nd n
ot t
o ha
ve a
ctiv
e TB
Stra
tegi
c A
ppro
ach
6: S
cale
up
nutr
itio
n in
terv
enti
ons
amon
g ch
ildre
n w
ith
TB
Prop
orti
on
of
child
ren
wit
h TB
as
sess
ed
for
nutr
itio
nal s
tatu
sBa
selin
e as
sess
men
t of
nu
trit
ion
equi
pmen
t di
stri
buti
on a
nd s
tatu
sBa
selin
e as
sess
men
t of
nu
trit
ion
equi
pmen
t di
stri
buti
on a
nd s
tatu
s
n/a
100%
100%
100%
Proc
ure
and
dist
ribu
te 1
,500
adu
lt
wei
ghin
g sc
ales
wit
h st
adio
met
ers,
4,
000
pedi
atri
c be
am
bala
nce
scal
es
n/a
Proc
ure
500
adul
t w
eigh
ing
scal
es
wit
h st
adio
met
ers,
2,
000
pedi
atri
c be
am
bala
nce
scal
es
Proc
ure
500
adul
t w
eigh
ing
scal
es w
ith
stad
iom
eter
s,1,
000
pedi
atri
c be
am b
alan
ce s
cale
s
Proc
ure
500
adul
t w
eigh
ing
scal
es w
ith
stad
iom
eter
s, 1
,000
pe
diat
ric
beam
bal
ance
sca
les
Dis
trib
ute
500
adul
t w
eigh
ing
scal
es
wit
h st
adio
met
ers,
2,
000
pedi
atri
c be
am
bala
nce
scal
es
Dis
trib
ute
500
adul
t w
eigh
ing
scal
es
wit
h st
adio
met
ers,
1,
000
pedi
atri
c be
am b
alan
ce
scal
es
Dis
trib
ute
500
adul
t w
eigh
ing
scal
es w
ith
stad
iom
eter
s, 1
,000
pe
diat
ric
beam
bal
ance
sca
les
Serv
ice
cont
ract
s fo
r 1,
500
adul
t w
eigh
ing
scal
es w
ith
stad
iom
eter
s an
d 4,
000
pedi
atri
c be
am b
alan
ce
scal
es
n/a
Serv
ice
cont
ract
s fo
r 50
0 ad
ult
wei
ghin
g sc
ales
w
ith
stad
iom
eter
s an
d 2,
000
pedi
atri
c be
am
bala
nce
scal
es
Serv
ice
cont
ract
s fo
r 1,
000
adul
t w
eigh
ing
scal
es
wit
h st
adio
met
ers
and
3,00
0 pe
diat
ric
beam
bal
ance
sca
les
Serv
ice
cont
ract
s fo
r 1,
500
adul
t w
eigh
ing
scal
es
wit
h st
adio
met
ers
and
4,00
0 pe
diat
ric
beam
bal
ance
sca
les
Impr
ove
TB s
urve
illan
ce d
ata
tool
s to
capt
ure
child
TB
nu
trit
ion
asse
ssm
ent
data
Impr
ove
TB s
urve
illan
ce d
ata
tool
s to
capt
ure
child
TB
nu
trit
ion
asse
ssm
ent
data
n/a
n/a
n/a
Prop
orti
on
of
child
ren
wit
h m
oder
ate/
seve
re
mal
nutr
itio
n an
d TB
w
ho
rece
ive
nutr
itio
nal
supp
ort
Prov
ide
nutr
itio
n su
ppor
t to
80%
of
ch
ildre
n w
ith
mod
erat
e/se
vere
m
alnu
trit
ion
and
TB
Ass
ess
all
child
ren
wit
h TB
for
nu
trit
ion
stat
us40
%A
sses
s al
l ch
ildre
n w
ith
TB f
or n
utri
tion
sta
tus
60%
Ass
ess
all
child
ren
wit
h TB
for
nu
trit
ion
stat
us80
%A
sses
s al
l ch
ildre
n w
ith
TB f
or
nutr
itio
n st
atus
95%
40%
of
ch
ildre
n w
ith
mod
erat
e/se
vere
m
alnu
trit
ion
and
TB
rece
ive
nutr
itio
n su
ppor
t
60%
of
ch
ildre
n w
ith
mo
de
ra
te
/se
ve
re
mal
nutr
itio
n an
d TB
re
ceiv
e nu
trit
ion
supp
ort
80%
of
ch
ildre
n w
ith
mod
erat
e/se
vere
m
alnu
trit
ion
and
TB
rece
ive
nutr
itio
n su
ppor
t
95%
of
ch
ildre
n w
ith
mod
erat
e/se
vere
m
alnu
trit
ion
and
TB re
ceiv
e nu
trit
ion
supp
ort
Proc
ure
and
dist
ribu
te
nutr
itio
nal
supp
lem
enta
tion
(rea
dy
to
use
ther
apeu
tic
food
s RU
TF,
fort
ifie
d bl
ende
d fo
ods
FBFs
, M
ulti
ple
mic
ronu
trie
nts)
fo
r ch
ildre
n w
ith
mod
erat
e/
seve
re m
alnu
trit
ion
and
TB
Proc
ure
and
dist
ribu
te
nutr
itio
nal
sup
ple
men
tati
on
(rea
dy
to u
se t
hera
peut
ic f
oods
RU
TF,
fort
ifie
d bl
ende
d fo
ods
FBFs
, M
ulti
ple
mic
ronu
trie
nts)
fo
r ch
ildre
n w
ith
mod
erat
e /
seve
re
mal
nutr
itio
n an
d TB
Proc
ure
and
dist
ribu
te
nutr
itio
nal
supp
lem
enta
tion
(rea
dy
to
use
ther
apeu
tic
food
s RU
TF,
fort
ifie
d bl
ende
d fo
ods
FBFs
, M
ulti
ple
mic
ronu
trie
nts)
fo
r ch
ildre
n w
ith
mod
erat
e /
seve
re m
alnu
trit
ion
and
TB
Proc
ure
and
dist
ribu
te
nutr
itio
nal
supp
lem
enta
tion
(rea
dy
to
use
ther
apeu
tic
food
s RU
TF,
fort
ifie
d bl
ende
d fo
ods
FBFs
, M
ulti
ple
mic
ronu
trie
nts)
fo
r ch
ildre
n w
ith
mod
erat
e / s
ever
e m
alnu
trit
ion
and
TB
4.3.2.3. Pediatric TB
Pedi
atri
c TB
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
7: S
tren
gthe
n TB
/HIV
man
agem
ent
in c
hild
ren
Prop
orti
on o
f ch
ildre
n w
ith
TB w
ho a
re t
este
d fo
r H
IVTe
st 9
5% o
f ch
ildre
n w
ith
TB f
or
HIV
Test
chi
ldre
n w
ith
TB f
or H
IV93
%Te
st c
hild
ren
wit
h TB
for
H
IV94
%Te
st c
hild
ren
wit
h TB
for
HIV
95%
Test
chi
ldre
n w
ith
TB f
or H
IV95
%
Perc
enta
ge o
f H
IV e
xpos
ed c
hild
ren
< 1
8mon
ths
wit
h TB
wit
h co
nfir
mat
ory
HIV
PC
R te
stin
gTe
st
95%
H
IV
expo
sed
child
ren
<
18m
onth
s w
ith
TB
wit
h co
nfir
mat
ory
HIV
PC
R te
stin
g
Test
H
IV
expo
sed
child
ren
<
18m
onth
s w
ith
TB
wit
h co
nfir
mat
ory
HIV
PC
R te
stin
g
75%
Test
HIV
exp
osed
chi
ldre
n <
18m
onth
s w
ith
TB w
ith
conf
irm
ator
y H
IV
PCR
test
ing
80%
Test
H
IV
expo
sed
child
ren
<
18m
onth
s w
ith
TB
wit
h co
nfir
mat
ory
HIV
PC
R te
stin
g
90%
Test
H
IV
expo
sed
child
ren
<
18m
onth
s w
ith
TB
wit
h co
nfir
mat
ory
HIV
PC
R te
stin
g
95%
Perc
enta
ge o
f ch
ildre
n w
ith
TB a
nd H
IV in
itia
ted
on A
RT w
ithi
n 2
mon
ths
of T
B tr
eatm
ent i
niti
atio
nIn
itia
te 9
0% o
f ch
ildre
n w
ith
TB
and
HIV
on
ART
wit
hin
2 m
onth
s of
TB
tre
atm
ent
init
iati
on
Init
iate
chi
ldre
n w
ith
TB a
nd
HIV
on
ART
wit
hin
2 m
onth
s of
TB
tre
atm
ent
init
iati
on
84%
Init
iate
chi
ldre
n w
ith
TB
and
HIV
on
ART
wit
hin
2 m
onth
s of
TB
trea
tmen
t in
itia
tion
87%
Init
iate
chi
ldre
n w
ith
TB a
nd
HIV
on
ART
wit
hin
2 m
onth
s of
TB
tre
atm
ent
init
iati
on
90%
Init
iate
ch
ildre
n w
ith
TB
and
HIV
on
ART
wit
hin
2 m
onth
s of
TB
tre
atm
ent
init
iati
on
90%
Prop
orti
on o
f ch
ildre
n w
ith
TB a
nd H
IV w
ho a
re
init
iate
d on
CPT
Init
iate
100
% o
f ch
ildre
n w
ith
TB
and
HIV
on
CPT
Init
iate
chi
ldre
n w
ith
TB a
nd
HIV
on
CPT
99%
Init
iate
chi
ldre
n w
ith
TB
and
HIV
on
CPT
100%
Init
iate
chi
ldre
n w
ith
TB a
nd
HIV
on
CPT
100%
Init
iate
ch
ildre
n w
ith
TB
and
HIV
on
CPT
100%
Stra
tegi
c A
ppro
ach
8: S
tren
gthe
n PM
DT
and
cont
act
trac
ing
amon
g ch
ildre
n
Prop
orti
on o
f ch
ild c
onta
cts
acti
vely
tra
ced
and
scre
ened
C
ondu
ct
acti
ve
cont
act
trac
ing
and
scre
enin
g of
chi
ld c
onta
cts
for
100%
of
pati
ents
wit
h D
RTB-
Con
duct
act
ive
cont
act
trac
ing
and
scre
enin
g of
chi
ld c
onta
cts
for
pati
ents
wit
h D
R-TB
50%
Con
duct
ac
tive
co
ntac
t tr
acin
g an
d sc
reen
ing
of
child
con
tact
s fo
r pat
ient
s w
ith
DR-
TB
100%
Con
duct
act
ive
cont
act
trac
ing
and
scre
enin
g of
chi
ld c
onta
cts
for
pati
ents
wit
h D
R-TB
100%
Con
duct
act
ive
cont
act
trac
ing
and
scre
enin
g of
chi
ld c
onta
cts
for
pati
ents
wit
h D
R-TB
100%
Num
ber
of
seni
or
clin
icia
ns
trai
ned
on
man
agem
ent
of D
R-TB
Trai
n 6
seni
or
clin
icia
ns
on
man
agem
ent
of D
R-TB
(The
UN
ION
tr
aini
ng)
n/a
n/a
Trai
n se
nior
clin
icia
ns o
n m
anag
emen
t of
DR-
TB
(The
UN
ION
tra
inin
g)
2Tr
ain
seni
or
clin
icia
ns
on
man
agem
ent
of
DR-
TB (
The
UN
ION
tra
inin
g)
2Tr
ain
seni
or
clin
icia
ns
on
man
agem
ent
of
D
R-TB
(T
he
UN
ION
tra
inin
g)
2
Num
ber
of p
aed
DR-
TB f
orm
ulat
ions
ava
ilabl
e fo
r ch
ildre
nEn
sure
un
inte
rrup
ted
supp
ly
of
paed
fr
iend
ly
paed
D
R-TB
fo
rmul
atio
ns f
or 1
10 c
hild
ren-
Ensu
re
unin
terr
upte
d su
pply
of
pae
d fr
iend
ly p
aed
DR-
TB
form
ulat
ions
for
chi
ldre
n
20En
sure
un
inte
rrup
ted
supp
ly
of
paed
fr
iend
ly
paed
DR-
TB f
orm
ulat
ions
fo
r ch
ildre
n
25En
sure
un
inte
rrup
ted
supp
ly
of
paed
fr
iend
ly
paed
D
RTB
form
ulat
ions
for
chi
ldre
n
30En
sure
un
inte
rrup
ted
supp
ly
of
ped
frie
ndly
pe
d D
R-TB
fo
rmul
atio
ns f
or c
hild
ren
35
Num
ber
of
child
ren
wit
h D
R-TB
at
tend
ing
trea
tmen
t an
d D
OTS
Prov
ide
supp
ort
for
110
child
ren
wit
h D
R-TB
to
at
tend
tr
eatm
ent
and
DO
TS
Prov
ide
supp
ort
for
child
ren
wit
h D
R-TB
to
at
tend
tr
eatm
ent
and
DO
TS
20Pr
ovid
e su
ppor
t fo
r ch
ildre
n w
ith
DR-
TB
to
atte
nd
trea
tmen
t an
d D
OTS
25Pr
ovid
e su
ppor
t fo
r ch
ildre
n w
ith
DR-
TB
to
atte
nd
trea
tmen
t an
d D
OTS
30Pr
ovid
e su
ppor
t fo
r ch
ildre
n w
ith
DR-
TB t
o at
tend
tre
atm
ent
and
DO
TS
35
Num
ber
of
child
ren
wit
h D
R-TB
re
ceiv
ing
nutr
itio
nal s
uppo
rtPr
ovid
e nu
trit
ion
supp
ort
for
110
child
ren
wit
h D
R-TB
Prov
ide
nutr
itio
n su
ppor
t fo
r ch
ildre
n w
ith
DR-
TB20
Prov
ide
nutr
itio
n su
ppor
t fo
r ch
ildre
n w
ith
DR-
TB25
Prov
ide
nutr
itio
n su
ppor
t fo
r ch
ildre
n w
ith
DR-
TB30
Prov
ide
nutr
itio
n su
ppor
t fo
r ch
ildre
n w
ith
DR-
TB35
Num
ber
of f
ollo
w-u
p in
vest
igat
ions
con
duct
ed
for
child
ren
wit
h D
R-TB
Pr
ovid
e su
ppor
t fo
r fo
llow
-up
inve
stig
atio
ns f
or 1
10 c
hild
ren
wit
h D
R-TB
Prov
ide
supp
ort
for
follo
w-
up i
nves
tiga
tion
s fo
r ch
ildre
n w
ith
DR-
TB
20Pr
ovid
e su
ppor
t fo
r fo
llow
-up
inve
stig
atio
ns
for
child
ren
wit
h D
R-TB
25Pr
ovid
e su
ppor
t fo
r fo
llow
-up
inv
esti
gati
ons
for
child
ren
wit
h D
R-TB
30Pr
ovid
e su
ppor
t fo
r fo
llow
-up
inve
stig
atio
ns f
or c
hild
ren
wit
h D
R-TB
35
Prop
orti
on o
f D
R-TB
chi
ld c
onta
cts
follo
wed
up
for
at le
ast
2 ye
ars
Follo
w
up
90%
D
R-TB
ch
ild
cont
acts
for
at
leas
t 2
year
sFo
llow
up
DR-
TB c
hild
con
tact
s fo
r at
leas
t 2
year
s50
%Fo
llow
up
D
R-TB
ch
ild
cont
acts
fo
r at
le
ast
2 ye
ars
70%
Follo
w u
p D
R-TB
chi
ld c
onta
cts
for
at le
ast
2 ye
ars
80%
Follo
w u
p D
R-TB
chi
ld c
onta
cts
for
at le
ast
2 ye
ars
90%
Stra
tegi
c A
ppro
ach
8: C
omm
odit
y M
anag
emen
t an
d Ph
arm
acov
igila
nce
Num
ber
of
st
ock
outs
of
pa
edia
tric
TB
fo
rmul
atio
nsEn
sure
ste
ady
supp
ly o
f pa
ed T
B fo
rmul
atio
nsEn
sure
ste
ady
supp
ly o
f pa
ed
TB f
orm
ulat
ions
Ensu
re
stea
dy
supp
ly
of
paed
TB
form
ulat
ions
Ensu
re s
tead
y su
pply
of
paed
TB
for
mul
atio
nsEn
sure
ste
ady
supp
ly o
f pae
d TB
fo
rmul
atio
ns
Prop
orti
on o
f ch
ildre
n on
TB
trea
tmen
t re
view
ed
for
AD
RsRe
vise
th
e pa
tien
t re
cord
ca
rd
to
capt
ure
phar
mac
ovig
ilanc
e in
form
atio
n.
AD
R m
onit
orin
g fo
r 10
0% c
hild
ren
on T
B tr
eatm
ent
Revi
se t
he p
atie
nt r
ecor
d ca
rd
to c
aptu
re p
harm
acov
igila
nce
info
rmat
ion.
A
DR
mon
itor
ing
for
100%
ch
ildre
n on
TB
tr
eatm
ent
100%
AD
R m
onit
orin
g fo
r 10
0%
child
ren
on
TB
trea
tmen
t
100%
AD
R m
onit
orin
g fo
r 10
0%
child
ren
on T
B tr
eatm
ent
100%
AD
R m
onit
orin
g fo
r 10
0%
child
ren
on T
B tr
eatm
ent
100%
4.3.
2.3.
Ped
iatr
ic T
B
4.3.2.4. Leprosy
1. Situational Analysis
Kenya is considered to be in the post-elimination phase of leprosy, having achieved the WHO elimination target of less than 1 case per 10,000 people in 1989. The number of new leprosy cases in the country has continued to steadily decline over the past three decades from more than 600 to 139 in 1986 and 2013 respectively. Despite the low number of reported cases, leprosy continues to cause high morbidity among those infected, with 48% of new cases notified in 2013 having advanced disease with disability grade 1 and 2.
Active transmission is ongoing in communities in both endemic and non-endemic areas. Childhood cases (the marker of active transmission) account for 1 in 5 (21%) of all new cases1. There are still pockets of leprosy in a number of counties. Kwale and Kilifi reported the most new cases in 2012, followed closely by Kisumu, as shown in Map 6.
Recent active leprosy case-finding exercises conducted in Kwale and Kisumu counties yielded remarkable numbers of new cases. Most cases were infectious Multi-Bacillary (MB) leprosy, including those affecting children. A large proportion of disability grade 2 among patients reported in 2013 implied late diagnosis of leprosy in Kenya.
The country continues to build the capacity of county and sub-county TB/Leprosy coordinators to diagnose and manage uncomplicated cases, and has recently developed a training curriculum for health care providers. Guidelines for leprosy management have been integrated within the National TB treatment guidelines, and are available country-wide. Similarly, recording and reporting structures have been integrated within the national web-based surveillance system (TIBU), making leprosy case-based data available at the national level.
Leprosy is a debilitating disease common among the poor. Thus, there is need for a multi-sectorial approach to ensure successful integration of those affected, into the community. Other than physical presence of disease, there are social, economic and legal issues that work against the patient. They must be addressed (Public Health Act, Cap 242). Deliberate efforts need to be made to ensure that leprosy patients with disabilities benefit from the disability management program as provided for in the constitution.
Despite the gains made in leprosy control, the recently concluded mid-term review highlighted a number of gaps and challenges that impact on leprosy control. They include:
• Low index of suspicion for leprosy among general health care workers in geographically endemic areas, suggesting that not all leprosy cases are being detected and late diagnosis remains a challenge as reflected by the high rates of disability
• Low level of awareness in the community/general population on leprosy, delaying health seeking behavior as underscored by high disability rates
• Inadequate attention paid to rehabilitative services, including those for special patient needs, such as prevention of disabilities, physical and social rehabilitation
• Lack of educational materials on leprosy in the entire country.
2. Strategic Direction(s) for 2015-2018
During the four-year period, a two-tiered strategy will differentially address: a) endemic areas; and b) non-endemic areas. Specifically, the strategy will aim to: a) appropriately increase the index of suspicion among health workers, especially in the 5 endemic counties; b) raise public awareness; and c) improve the quality of surveillance, clinical care and rehabilitation, and monitoring and evaluation.
_______________________________________________________________________________________________________________________________1 Endemic areas include: Kilifi, Kwale, Malindi, Kisumu, Siaya, Busia; and non-endemic areas include Mbeere, Nyatike, Isiolo, Igembe, Kisumu east, Kericho/Buret, Nakuru, Mumias, Nandi, Bugoma South, Busia, Kakamega Central, Bunyala, Butere, Teso, Dagoretti , Kirinyaga, Nyeri North, GanjoniMombasa), Taita , Taveta, Tharaka, Kitui , Kyuso, Mwingi, Kibwezi, Maara.
4.3.2.4. Leprosy
56
Map 6: Leprosy Case Notification
4.3.
2.4.
Lep
rosy
3. Proposed Approaches
Improving public awareness and political commitment
A communication strategy will be developed. It will consider the different needs for endemic and non-endemic areas, and will include activities such as the relevant use of IEC materials, circulated and displayed in appropriate public areas. The communication strategy will also include commemoration of World Leprosy Day. In endemic areas, there should be radio and television messages as well as public campaign activities to raise awareness about leprosy, encouraging early care seeking and discouraging stigma. School health talks on leprosy will be initiated in endemic areas.
Capacity building of general care providers
a) Human resource capacity building will be done by the county, with technical assistance from the NTLD Program, in both endemic and non-endemic areas through:
i. Inclusion of a leprosy training module in the ongoing TB/HIV, DR-TB and CTBC trainings.
ii. Training of general health care workers on the use of the revised recording and reporting tools. Training of new county and sub coordinators in leprosy clinical and programmatic management. Capacity building of leprosy managers on advanced leprosy control management will also be rolled out in the five endemic areas.
b) In endemic areas: i. Develop a robust plan for building and sustaining capacity for leprosy identification and management by all health care workers. Train and retrain general health care workers on diagnosis, management, and recording and reporting of leprosy cases at all levels. Develop on-the-job training tools and disseminate for use by general health care workers. These concern the use of the revised recording and reporting tools. Hold refresher courses for lab staff of AFB–leprosy (Microscopy) and histo-pathologists. Engage skin specialists in training of health care workers on leprosy. Intensify training of new county and sub-county coordinators in leprosy clinical and programmatic management.
ii. Continuously sensitize/orientate health care providers to improve the index of suspicion for early leprosy diagnosis and management.
Leprosy surveillance and active case finding
Several approaches will be used for surveillance and active case finding. In both endemic and non-endemic areas, the following strategies will be conducted:
Figure 17: Leprosy New Case and Cases on Register by end of Year, 1986-2012
57
a) Mapping of all leprosy cases diagnosed in the past two years to identify hot spots of transmission and to conduct contact tracing
b) Strengthening contact tracing in skin clinics by integrating leprosy screening activitiesc) Engaging and sensitizing CSOs implementing TB activities to integrate leprosy activities in their agenda.
In endemic areas: a) Tracing and screening of contacts of all children diagnosed with leprosy and adults in endemic areas b) Conducting dermatology polyclinics in endemic areasc) School contact tracing and educational campaigns to enhance detectiond) Integration of leprosy communication and active case finding material into the national community health service
kit.
Enhancing clinical care and rehabilitation
Enhancing clinical care and rehabilitation is core in leprosy elimination phase. Interventions will be implemented in both endemic and non-endemic areas. In both cases, there will be interventions aimed at:
a) Strengthening of linkages with local and international partners to ensure a continuous supply of MDTs and procurement and distribution of leprosy commodities, including MDT, auxiliary drugs for prevention and management of reactions
b) Mapping leprosy patient support groups and linking them to organizations that can help such groups to develop income generating activities
c) Engagement of skin experts in leprosy patient management and in mentoring health care workers on leprosy; e.g. Kenya Association of Dermatologist (KAD) and Kenya Association of Dermato-Venereology Officers (KDVO)
d) The national level will provide technical assistance to all counties.
In the five endemic areas, the strategic direction will focus on the following:
a) Training surgeons, medical and clinical officers and nurses on prevention of disabilities, rehabilitation and septic surgery
b) Training of physiotherapist, occupational therapist and social workers on leprosy rehabilitation c) Procurement of materials and equipment for patient’s rehabilitation, including crutches, other orthopedic
appliances and materials for their fabricationd) Reviving or integrating leprosy rehabilitative services in existing rehabilitative centers in the counties e) Training occupational therapists, physiotherapists, social workers and surgeons on rehabilitation of post-leprosy
disability management.
Strengthening monitoring and evaluation
In both endemic and non-endemic areas, recording and reporting will be strengthened through various approaches including:
a) Revision, printing and distribution of the existing data capture toolsb) Training of health care workers on the use of the recording and reporting tools and leprosy control indicatorsc) Revision of the leprosy module in TIBUd) Promotion of the inclusion of leprosy targets and M&E strategies within county health strategies and work plans e) Conducting a Leprosy KAP survey f) Undertaking operational research to assess the quality of care, including the patient perspective
In endemic areas:
a) Provide leprosy-specific mentorship, technical assistance and supportive supervision to the counties reporting leprosy casesb) The NTLD Program to dialogue with County Executives through various stakeholders’ forums to strategize on leprosy control at county levelsc) Engagement of clinicians belonging to the Kenya Association of Dermatologist (KAD) and Kenya Association of Dermato-Venereology Officers (KDVO) in mentoring health care workers on leprosy.
4.3.2.4. Leprosy
58
4.3.
2.4.
Lep
rosy
Contribution to NSP Impacts Outcomes (Leprosy)
Impact 3. Reduce the proportion of affected families who face catastrophic costs due to TB, leprosy and lung diseases by 2018 (baseline TBD)
• Increase to at least 60% the proportion of eligible leprosy patients who access nutritional support, transport or financial subsidies, especially to facilitate diagnosis and treatment
Impact 4. Reduce by 50% the proportion of cases with grade 2 morbidity due to leprosy by 2018
• Increase the proportion of leprosy patients receiving rehabilitative services by 25%
• Increase by 10% the number of leprosy cases notified among children
• Increase to 85% the proportion of leprosy patients notified prior to grade 2 disability
Table 8: Impact and Outcome Indicators for Leprosy
59
Lepr
osy
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
1: Im
prov
ing
Publ
ic A
war
enes
s an
d Po
litic
al C
omm
itm
ent
1. N
umbe
r of
cou
ntie
s w
ith
lepr
osy
guid
elin
es in
pla
ce
2.
Num
ber
of
sens
itiz
atio
n m
eeti
ngs
for
lepr
osy
amon
g po
licy
mak
ers
cond
ucte
d
1. D
evel
op a
inv
estm
ent
man
ual
on
post
elim
inat
ion
2. C
ondu
ctin
g se
nsit
izat
ion
mee
ting
s on
lep
rosy
fo
r po
licy
mak
ers
and
st
akeh
olde
rs
1.
Hol
d a
5 da
y w
orks
hop
for
15 p
ax
outs
ide
nair
obi
to d
evel
op a
lep
rosy
po
st e
limin
atio
n in
vest
men
t m
anua
l
2. P
rint
and
dis
trib
ute
500
copi
es o
f the
le
pros
y po
st e
limin
atio
n m
anua
l
3. H
old
a 2
days
sen
siti
zati
on s
emin
ars
at
nati
onal
le
vel
fo
r st
akeh
olde
rs
and
Hea
lth
po
licy
mak
ers
fo
r 25
Pax
in
Nai
robi
to
dia
logu
e on
the
ro
adm
ap t
o l
epro
sy p
ost
elim
inat
ion
stra
tegi
es d
isce
min
ate
the
lepr
osy
post
el
imin
atio
n m
anua
l, c
omm
unic
ate
the
posi
tion
in
chan
ge i
n th
e H
ealt
h bi
ll an
d Pu
bic
Hea
lth
Act
and
adv
ocat
e fo
r re
leva
nt c
hang
es
0 1
1.
Con
duct
,
1 da
y co
unty
le
vel
stak
ehol
der
sens
itiz
atio
n m
eeti
ngs
for
30
Pax
each
on
le
pros
y
to
diss
emin
ate
th
e le
pros
y m
anua
l an
d ad
voca
te f
or
reso
urce
allo
cati
on
20 2
1. C
ondu
ct,
1 da
y 3
0 pa
x co
unty
le
vel
sta
keho
lder
mee
ting
to
revi
ew
the
lepr
osy
cont
rol
and
reso
urce
al
loca
tion
sit
uati
on in
the
6 e
ndem
ic
coun
ties
30 2
1. C
ondu
ct,
1 da
y 3
0 pa
x co
unty
lev
el
stak
ehol
der
mee
ting
to
re
view
th
e le
pros
y co
ntro
l an
d re
sour
ce a
lloca
tion
si
tuat
ion
in t
he 6
end
emic
cou
ntie
s
47 2
Stra
tegi
c A
ppro
ach
2: C
apac
ity
build
ing
of g
ener
al c
are
prov
ider
s
Prop
orti
on
of
coun
ties
bo
th
ende
mic
an
d no
n en
dem
ic
repo
rtin
g ne
w
lepr
osy
case
s pr
esen
ting
wit
h di
sabi
lity
grad
e 2
1. C
ondu
ct
a na
tion
al T
OT
trai
ning
(t
o tr
ain
coun
ty
ToTs
on
le
pros
y)
2. C
ondu
ct t
rain
ings
for
hea
lth
care
w
orke
rs a
t th
e co
unty
leve
l
3. S
ensi
tiza
tion
mee
ting
s to
CH
WS
4.
Spon
sor
offi
cers
fo
r le
pros
y co
urse
s
5.
Ref
resh
er c
ours
es f
or L
ab s
taff
on
skin
slit
sm
ear
and
bact
erio
logi
cal
diag
nosi
s.
1.
Con
duct
tw
o ce
ntra
l tr
aini
ng
for
Cou
nty
and
nati
onal
TOT
Trai
ning
: 25
pax
each
fro
m e
ndem
ic a
reas
and
na
tion
al le
vel
2.Sp
onso
r 2
Surg
eons
fo
r Re
cons
truc
tive
cou
rse
3. T
o sp
onso
r tw
o le
pros
y of
fice
rs( O
ne
Nat
iona
l, on
e C
ount
y) t
o at
tend
the
le
pros
y ad
vanc
e co
urse
in A
LERT
4. T
rain
180
pax
of
HC
Ws
on l
epro
sy
diag
nosi
s an
d m
anag
emen
t in
6
ende
mic
are
as
5. H
old
CH
Ws
Sens
itiz
atio
n m
eeti
ng o
f 12
0 Pa
x pe
r C
ount
y in
end
emic
are
as
6.
Trai
n
50
CH
EWs
pe
r en
dem
ic
Cou
nty
on
lepr
osy
7. C
ondu
ct r
efre
sher
tra
inin
g to
30
lab.
st
aff i
n en
dem
ic a
reas
on
slit
ski
n sm
ear
and
bact
erio
logi
cal d
iagn
osis
30%
1.Tr
ain
100
pax
(HC
Ws)
on
lepr
osy
diag
nosi
s an
d m
anag
emen
t in
en
dem
ic
area
s an
d 15
0 i
n no
n- e
ndem
ic a
reas
fo
r 3
days
2.
Hol
d 2
CH
Ws
Sens
itiz
atio
n m
eeti
ng f
or 3
0 Pa
x in
end
emic
ar
ea
and
4 no
n-
ende
mic
re
port
ing
area
s
25%
1.Tr
ain
100
pax
(HC
Ws)
on
lep
rosy
di
agno
sis
and
man
agem
ent
in
ende
mic
ar
eas
and
150
in
no
n-
ende
mic
are
as f
or 3
day
s
2.
Hol
d 2
CH
Ws
Sens
itiz
atio
n m
eeti
ng f
or 3
0 Pa
x i
n en
dem
ic a
rea
and
4 no
n- e
ndem
ic r
epor
ting
are
as.
20%
1.Tr
ain
100
pax
(HC
Ws)
on
lepr
osy
diag
nosi
s an
d m
anag
emen
t in
end
emic
ar
eas
and
150
in
non-
end
emic
are
as
for
3 da
ys
2. H
old
2 C
HW
s Se
nsit
izat
ion
mee
ting
fo
r 30
Pax
in
ende
mic
are
a an
d 4
non-
en
dem
ic r
epor
ting
are
as.
15%
Stra
tegi
c A
ppro
ach
3: L
epro
sy s
urve
illan
ce a
nd a
ctiv
e ca
se f
indi
ng
A
func
tion
al
surv
eilla
nce
syst
em
repo
rtin
g on
all
lepr
osy
indi
cato
rs1.
Con
duct
con
sult
ativ
e w
orks
hop
to d
evel
op a
sur
veill
ance
sys
tem
on
lepr
osy
and
ref
er f
or d
iagn
osis
2. P
rocu
re l
ab c
onsu
mab
les
for
SSS
&H
isto
logi
es
3. C
ondu
ct O
pera
tion
al r
esea
rch
1.
Map
ping
ou
t of
al
l le
pros
y ca
ses
diag
nose
d in
the
pas
t 2
year
s (2
013/
14)
and
cond
ucti
ng c
onta
ct t
raci
ng
2.
To o
rgan
ize
and
cond
uct
a 5
day
cons
ulta
tive
for
um t
o re
view
map
ping
re
sult
s an
d de
velo
p a
surv
eilla
nce
syst
em
11.
C
ondu
ct
cont
act
trac
ing
of
all
inde
x ca
ses
in
all
coun
ties
re
port
ing
new
cas
es.
2. C
ondu
ct O
R on
qua
lity
of c
are
of
pati
ents
re
ceiv
ing
lepr
osy
serv
ices
3.
Mal
nutr
itio
n le
vels
am
ong
lepr
osy
pati
ents
det
erm
ined
1Re
view
w
orks
hop
to
eval
uate
pe
rfor
man
ce o
f th
e sy
stem
1
1. V
alid
atio
n of
lepr
osy
data
for
the
NSP
pe
riod
2.
Doc
umen
tati
on
lepr
osy
part
ners
for
th
e 4
year
per
iod
1
4.3.2.4. Leprosy
4.3.
2.4.
Lep
rosy
Lepr
osy
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prop
orti
on o
f le
pros
y re
ferr
ed f
or
scre
enin
g fr
om c
omm
unit
y
1.
Con
tact
tr
acin
g ac
tivi
ties
at
co
mm
unit
y le
vel
2.
Faci
litat
e ex
amin
atio
n of
sk
in
patc
hes
and
refe
rals
1.
Sens
itiz
e an
d su
ppor
t C
SOs
impl
emen
ting
EN
GA
GE
TB a
ctiv
itie
s t
o in
tegr
ate
lepr
osy
in t
heir
pro
gram
s
2.
Hol
d se
nsit
izat
ion
mee
ting
s fo
r C
HW
s to
inc
lude
scr
eeni
ng f
or l
epro
sy
duri
ng h
ouse
-to-
hous
e ca
mpa
igns
3.
To
cond
uct
hous
e-to
-hou
se
scre
enin
g fo
r s
kin
lesi
ons
4.
C
ondu
ct
rout
ine
‘SK
IN
Patc
h'
exam
inia
tion
on
all p
atie
nts
pres
enti
ng
wit
h hy
popi
gmen
ted
skin
pat
ches
5.
Con
duct
ing
Slit
ski
n sm
ears
tes
ts
in p
atie
nts
pres
enti
ng w
ith
susp
ecio
us
skin
le
ssio
ns
bu
t
wit
hout
le
pros
y ca
rdin
al s
igns
labo
rato
ries
6. T
rain
ing
of h
ealt
h ca
re w
orke
rs
at
coun
ty l
evel
to
incr
ease
the
ir l
evel
of
susp
ecio
n of
lepr
osy
7.
Refe
rral
of
pr
esum
ptiv
e le
pros
y ca
ses
for
scre
enin
g
70%
1.
CH
Ws
to
cond
uct
hous
e-to
-ho
use
scr
eeni
ng f
or s
kin
lesi
ons
2.
Con
duct
ro
utin
e ‘S
KIN
Pa
tch’
ex
amin
iati
on
on
all
pati
ents
pr
esen
ting
w
ith
atyp
ical
pr
esen
tati
ons(
ca
rdin
al
sign
s un
clea
r)
in
all
faci
litie
s w
ithi
n en
dem
ic
site
s
3.
C
ondu
ctin
g Sl
it
skin
sm
ears
te
sts
done
in C
ount
y la
bora
tori
es
4. T
rain
ing
of h
ealt
h ca
re w
orke
rs
at c
ount
y le
vel
to i
ncre
ase
thei
r le
vel o
f su
spic
ion
of le
pros
y
5. R
efer
ral o
f pr
esum
ptiv
e le
pros
y ca
ses
for
scre
enin
g
80%
1.
Con
duct
ho
use-
to-h
ouse
sc
reen
ing
for
ski
n le
sion
s
2.
Con
duct
ro
utin
e ‘S
KIN
Pa
tch’
ex
amin
iati
on
on
all
pati
ents
w
ith
atyp
ical
pr
esen
tati
ons
in
all
faci
litie
s w
ithi
n en
dem
ic
site
s
3.
Con
duct
ing
Slit
ski
n sm
ears
tes
ts
done
in C
ount
y la
bora
tori
es
4.
Tra
inin
g of
hea
lth
care
wor
kers
at
co
unty
leve
l to
incr
ease
the
ir le
vel o
f su
spic
ion
of le
pros
y
5.
Re
ferr
al
of
pres
umpt
ive
lepr
osy
case
s fo
r sc
reen
ing
90%
1. C
ondu
ct h
ouse
-to-
hous
e s
cree
ning
for
skin
lesi
ons
2.
C
ondu
ct
rout
ine
‘SK
IN
Patc
h'
exam
inia
tion
on
all
pati
ents
pre
sent
ing
wit
h at
ypic
al
pres
enta
tion
s(
card
inal
si
gns
uncl
ear)
in
al
l fa
cilit
ies
wit
hin
ende
mic
sit
es
3. C
ondu
ctin
g Sl
it s
kin
smea
rs t
ests
don
e in
Cou
nty
labo
rato
ries
4.
Trai
ning
of
he
alth
ca
re
wor
kers
at
co
unty
lev
el t
o in
crea
se t
heir
lev
el o
f su
spec
ion
of le
pros
y
5.
Ref
erra
l of
pre
sum
ptiv
e le
pros
y ca
ses
for
scre
enin
g
100%
Prop
orti
on o
f pl
anne
d sc
hool
he
alth
pro
gram
s co
nduc
ted
Scho
ol h
ealt
h pr
ogra
ms:
con
duct
he
alth
edu
cati
on in
sch
ools
in
ende
mic
are
as e
very
qua
rter
on
lepr
osy
Con
duct
hea
lth
educ
atio
n in
sc
hool
s in
end
emic
are
as e
very
qu
arte
r on
lepr
osy
100%
Con
duct
hea
lth
educ
atio
n in
sch
ools
in
end
emic
are
as e
very
qua
rter
on
lepr
osy
100%
Con
duct
hea
lth
educ
atio
n in
sch
ools
in
ende
mic
are
as e
very
qua
rter
on
lepr
osy
10
0%
Prop
otio
n of
sc
hool
s in
en
dem
ic
area
s in
w
hich
ch
ildre
n w
ere
scre
ened
for
lepr
osy
Con
duct
sch
ool h
ealt
h pr
ogra
m a
nd
scre
enin
g fo
r le
pros
yTr
aini
ng o
f sc
hool
goi
ng c
hild
ren
on
and
scre
enin
g
for
skin
pa
tche
s in
sc
hool
s n
eigh
bour
ing
a ho
mes
tead
of
a n
ew le
pros
y c
ase
1. S
ensi
tiza
tion
mee
ting
s (2
0 pa
x)
for
Com
mun
ity
heal
th c
omm
itee
in
all
6 en
dem
ic a
reas
2.
Con
duct
15
pu
blic
Ba
rasa
m
eeti
ngs
per
Cou
nty
in
each
en
dem
ic a
reas
per
yea
r
3.
Trai
ning
of
sc
hool
go
ing
child
ren
on a
nd s
cree
ning
for
ski
n pa
tche
s in
sch
ools
nei
ghbo
urin
g a
hom
este
ad o
f a
ne
w l
epro
sy
case
100%
1. C
ondu
ct 1
5 pu
blic
Bar
asa
mee
ting
s in
end
emic
are
as
2. C
ondu
ct s
choo
l he
alth
edu
cati
on
and
scre
enin
g in
20
scho
ols
in e
ach
ende
mic
are
a.
100%
1. C
ondu
ct 1
5 pu
blic
Bar
aza
mee
ting
s in
en
dem
ic a
reas
2.
Con
duct
sch
ool
heal
th e
duca
tion
and
sc
reen
ing
in 2
0 sc
hool
s in
eac
h en
dem
ic
area
.
100%
Stra
tegi
c A
ppro
ach
4: E
nhan
cing
clin
ical
car
e an
d re
habi
litat
ion
1. P
ropo
rtio
n of
pol
y sk
in c
linic
s co
nduc
ted
in t
he e
ndem
ic c
ount
ies
per
quar
ter
2. P
ropo
rtio
n of
lep
rosy
pat
ient
s w
ho a
re m
alno
uris
hed
who
rec
eive
th
erap
euti
c fo
od
1.
Dev
elop
men
t of
trea
tmen
t m
anua
l
2.
Reno
vati
on
and
equi
ping
of
re
gion
al
spec
ialis
ed
cent
re
to
impr
ove
clin
ical
car
e
3.
Prov
ide
ther
apeu
tic
feed
to
m
alno
uris
hed
pati
ents
1. T
o c
ondu
ct a
5
days
wor
ksho
p to
de
velo
p a
lepr
osy
post
el
imin
atio
n m
anua
l
2.
To
orie
ntat
e th
e ph
ysio
an
d oc
cupa
tion
al t
hera
pist
in
the
iden
tifi
ed
faci
litie
s on
m
anag
emen
t an
d re
habi
litat
ion
of le
pros
y pa
tien
ts
3.
Ass
essm
ent
and
iden
tifi
cati
on
of
appr
opri
ate
fa
cilit
ies
to
prov
ide
reha
bilit
ativ
e se
rvic
es
4.
Proc
urem
ent
of
mat
eria
ls
and
equi
pmen
ts
5.
Li
nk
mal
nour
ishe
d pa
tien
t w
ith
nutr
itio
n cl
inic
for
the
rape
utic
fee
ds
30%
N/A
1.
Con
duct
Po
ly
skin
cl
incs
in
en
dem
ic a
res
on q
uart
erly
bas
is
2.
Act
ive
cont
act
trac
ing
3.
Ass
essm
ent
and
iden
tifi
cati
on
of a
ppro
pria
te fa
cilit
ies
to p
rovi
de
reha
bilit
ativ
e se
rvic
es
4. P
rocu
rem
ent
of m
ater
ials
and
eq
uipm
ents
5. L
ink
mal
nour
ishe
d pa
tien
t w
ith
nutr
itio
n cl
inic
fo
r th
erap
euti
c fe
eds
60%
30%
1.
Con
duct
Po
ly
skin
cl
incs
in
en
dem
ic a
res
on q
uart
erly
bas
is
2. A
ctiv
e co
ntac
t tr
acin
g
3.
Ass
essm
ent
and
iden
tifi
cati
on
of a
ppro
pria
te
faci
litie
s to
pro
vide
re
habi
litat
ive
serv
ices
4.
Proc
urem
ent
of
mat
eria
ls
and
equi
pmen
ts
5.
Link
m
alno
uris
hed
pati
ent
wit
h nu
trit
ion
clin
ic f
or t
hera
peut
ic f
eeds
80%
60%
1. C
ondu
ct P
oly
skin
clin
cs i
n en
dem
ic
ares
on
quar
terl
y ba
sis
2. A
ctiv
e co
ntac
t tr
acin
g
3.
Ass
essm
ent
and
iden
tifi
cati
on
of
appr
opri
ate
fa
cilit
ies
to
prov
ide
reha
bilit
ativ
e se
rvic
es
4.
Proc
urem
ent
of
mat
eria
ls
and
equi
pmen
ts
5.
Link
m
alno
uris
hed
pati
ent
wit
h nu
trit
ion
clin
ic f
or t
hera
peut
ic f
eeds
100%
100%
Lepr
osy
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
5: S
tren
gthe
ning
mon
itor
ing
and
eval
uati
on
Prop
orti
on
of
coun
ties
bo
th
ende
mic
an
d no
n en
dem
ic
repo
rtin
g ti
mel
y an
d co
mpl
etel
y on
lepr
osy
1. U
pdat
ing
syst
em o
n le
pros
y
2. C
ondu
ct o
pera
tion
al r
esea
rch
1. U
pdat
ing
TIBU
sys
tem
to
accu
rate
ly
reco
rd d
isab
ility
gra
ding
80%
1.
Revi
sion
, pr
inti
ng
and
dist
ribu
tion
of
the
exis
ting
dat
a ca
ptur
e to
ols
2. T
rain
ing
of h
ealt
h ca
re w
orke
rs
on
the
use
of
the
reco
rdin
g an
d re
port
ing
tool
s an
d le
pros
y co
ntro
l ind
icat
ors
3. R
evis
ion
of t
he le
pros
y m
odul
e in
TIB
U
4.
Prom
otio
n of
th
e in
clus
ion
of
lepr
osy
targ
ets
and
M&
E st
rate
gies
w
ithi
n co
unty
he
alth
st
rate
gies
and
wor
k pl
ans
5. L
epro
sy K
AP
sur
vey
will
be
cond
ucte
d
6. O
R on
qua
lity
of c
are
(fro
m
the
eye
of
the
Pati
ent)
to
be
co
nduc
ted
85%
On
job
trai
ning
on
use
of d
ata
tool
s an
d on
pro
pmt
repo
rtin
g90
%1.
Pri
ntin
g an
d di
stri
buti
on o
f the
exi
stin
g da
ta c
aptu
re t
ools
2. O
n jo
b tr
aini
ng o
f ne
w h
ealt
h ca
re
wor
kers
on
the
use
of t
he r
ecor
ding
and
re
port
ing
3. O
R on
qua
lity
of c
are
(fro
m t
he e
ye o
f th
e Pa
tien
t) t
o be
con
duct
ed
4. K
AP
surv
ey o
n le
pros
y co
nduc
ted
>95
%
4.3.2.4. Leprosy
4.3.3. Engage All Care Providers - PPM1. Situational Analysis
Kenya has been a frontrunner in the implementation of the 4th component of the STOP TB strategy: Engaging All Care Providers. The non-state or private health care sector collectively provides almost 50% of all health care provided to Kenyans.
The range of providers in this sector is wide, extending from large health institutions that offer state of the art health care services to informal providers, some of whom are not approved by relevant regulatory bodies. The private sector in Kenya has both private not-for-profit and private self-financing sectors. The private not-for-profit includes faith-based (FBO) and non-governmental organizations (NGOs). They are the second largest providers of health services in Kenya after the public sector. The government supports most of the FBO/NGO-based health care facilities.
The FBO/NGO network of health care facilities has long been part of the network of TB service providers supported by the NTLD Program. Public-private mix (PPM) activities will target the inclusion of the private self-financing sector.
Kenya has been implementing a PPM initiative involving the private self-financing sector for over 15 years. The total number of cases notified from this sector rose from 7,160 in 2010 to 11,000 in 2012, representing 19% of total cases notified by the NTLD Program. The treatment success rate for new smear positive patients rose from 83% in 2010 to 88% in 2012. Though it is implemented in almost all counties in the country, the initiative is currently most vibrant in 15 urban centers in Kenya. About 255 private health facilities are included along with 185 private laboratories that are linked to the national public sector-led external quality assurance system for TB bacteriology. Currently, out of the 245 laboratories involved in PPM, only 75% are linked to the national EQA system. Therefore, the engagement of private health care providers and especially solo private providers remains a challenge.
In addition to the conventional private sector, other players, such as the corporate sector, traditional healers, herbalists and faith healers who interact with TB patients, need to be engaged. There is an opportunity to involve all these providers in TB control.
2. Strategic Direction(s) for 2015-2018
The priority is to scale-up the number and diversity of private sector actors engaged in quality TB case detection and management.
4.3.
3. E
ngag
e A
ll Ca
re P
rovi
ders
(PPM
)
63
Map 7: Distribution of Private Providers Notifying Cases by Population Density, 2013
Proposed Approaches
The approaches for engaging all health care providers include sustaining the capacity of those that are already engaged and extending the network of quality-assured actors to those that are not yet engaged in TB control activities.
Currently, PPM is being implemented in health facilities in urban areas of 14 counties. In these counties, the priority will be to ensure the continued quality of care through the private sector. PPM activities will be scaled up in the other 33 counties through a step-wise approach. Specific activities include:
a) Sustain the gain in areas where PPM is currently being implemented
i. Refresher training and on-the-job tools to support sustained capacity among health care workers engaged in PPM
a. undertake task-specific training, determined by cadre of health care provider, using the ISTC training materials and national TB/HIV training manual
b. Develop a web based training using the ISTC training materials and other TB/HIV training manuals c. Develop appropriate mechanisms to evaluate the training to different cadres of health care workers
ii. Support symposia, special sessions, workshops and other relevant forums at the annual scientific conferences of professional associations, including KMA, KPA, KAPT, KCOA, NNAK and PSK, and to reach individual members of these associations with TB task-specific messages
iii. Provide regular technical assistance by county TB and leprosy coordinators to link private providers to NTLD Program implementing facilities and ensure quality
iv. Identify and strengthen capacity for PMDT in at least one private health facility in each of the DR-TB high burden counties
v. Intensify the engagement of private-sector laboratories, including:a. Technical assistance on TB bacteriology to private laboratoriesb. Linkages between the public and private health facilitiesc. Networking of laboratories to the national EQA system d. Engaging a pool of TB laboratory experts to support establishment of new diagnostic sites through the PPL
taskforce
4.3.3. Engage All Care Providers (PPM
)
64
Figure 18: Private Sector Contribution to Indentification of TB Patients, 2013
e. Promoting referral of TB specimens between sectors
vi. Increase reporting by the private sector through dissemination of paper-based tools and capacity building for wider use of TIBU; incorporate private providers in NTLD Program data quality audits, capacity building for M&E, and use of data for decision-making.
b) Scale-up the number and diversity of private providers contributing to TB control activities, in all counties
i. Map all care providers in each county and prioritize new partners to engage, based on geographic coverage and potential to provide quality service
ii. Establish national guidance on the functions expected for various cadres of private providers
iii. Establish MOUs between the care providers and appropriate level of the NTLD Program (national, county or sub-county); provide technical assistance to facilities to organize the incorporation of quality TB, leprosy and lung health services
iv. Ensure availability of commodities and M&E tools for assessing progress around TB, leprosy and lung diseases
v. Revise, disseminate and distribute the PPM policy guidelines.
c) Strengthen coordination mechanisms for PPM at the national and county levels
i. Strengthen the national steering team /technical working group (TWG) on PPM and promote county-level TWGs
ii. Identify county level PPM focal person(s), and define functions to support PPM
iii. Hold an annual national PPM workshop to disseminate PPM
norms and standards, practices, reporting systems and review progress
iv. Hold annual regional PPM workshops to sensitize regional TB control teams on PPM norms and standards, practices, reporting systems and review progress
v. Establish a multi-sectoral collaboration forum with other ministries (e.g. Ministry of Environment, Water and Natural Resources; Ministry of Labor, Social Security and Services; Ministry of Education; Ministry of Land, Housing and Urban Development; and Ministry of Sports, Culture and the Arts), the health and non-health private sector players, health professional organizations, training institutions etc.
d) Ensure quality of PPM activities for TB, leprosy and lung disease
i. Identify centers of excellence in PPM from the 14 established counties to provide on-site mentorship, training and technical assistance to new sites. Establish a roster of experts/consultants at national and county level to provide mentorship in the private sector
ii. Empower regional TB, leprosy and lung disease coordinators to provide supervision and monitoring of services in the private sector
4.3.
3. E
ngag
e A
ll Ca
re P
rovi
ders
(PPM
)
Non-state providers to be targeted
• Private for-profit or self-financing hospitals: Health institutions that offer services similar to what is offered in national referral hospital or more
• Corporate Health Services: A number of corporate organizations provide health care services at the workplace or other site for their workers and their dependents. A range of other workplace TB care programs have been initiated and will be scaled up. These include training and support of peer educators, active screening of workers for TB, workplace treatment support for patients on TB medications and other activities
• Individual private for-profit health care providers (solo providers): This group comprises of medical doctors, clinical officers, nurses, medical laboratory technologists and others. A mapping exercise carried out in 20 urban areas in 2011 came up with a total of 1,745 providers, of which 45% were solo providers. Most of the solo private health providers of all cadres are concentrated in urban areas
• Retail pharmacies, chemists and drug shops: These are found in both urban and rural areas. These tend to be the first point of contact for patients, including TB patients, and can be networked for referral of presumptive TB cases
• Informal Care Providers: These include, but are not limited to, traditional healers and herbalists, faith healers, home-based care groups providing care to HIV positive patients and other health volunteers.
Box 4
65
iii. Ensure involvement of all private health providers in quality improvement activities, such as continuous quality improvements (CQIs) and data quality assessments (DQA), to improve the surveillance of TB, leprosy and lung diseases from the private sector
iv. Enforce mechanism for ensuring the government is notified of all TB patients
v. Assess the availability of anti-TB drugs in retail pharmacies and chemists; develop and enforce appropriate regulations to restrict and promote rational use of anti-TB drugs that become available through the retail pharmacies and chemists.
Contribution to NSP Impacts Outcomes (PPM)
Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014
• Increase case notification by the private and non-state sectors by 25% • Ensure treatment success of at least 90% of all DS TB patients managed by private providers
Impact 1.1: Reduce the prevalence of MDR-TB among new patients by 15%, by 2018
• Ensure treatment success of at least 80% of MDR-TB patients managed by private providers
Impact 2: Reduce mortality due to TB by 3% by 2018 • Ensure treatment success of at least 90% of all DS TB patients managed by private providers• Reduce deaths among HIV-infected TB patients man-aged by private providers to 5% or lower
Impact 3. Reduce the proportion of affected families who face catastrophic costs due to TB, leprosy and other lung diseases, by 2018
• Introduce reimbursements for TB-related expenses in all private and public health insurance schemes
Impact 4. Reduce by 50% the proportion of cases with grade 2 morbidity due to leprosy by 2018
• Increase to 90% the proportion of patients notified by the private sector prior to grade 2 morbidity
Table 9: Impact and Outcome Indicators for PPM
4.3.3. Engage All Care Providers (PPM
)
66
Enga
ging
All
Car
e Pr
ovid
ers
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
1; S
usta
in t
he g
ains
in a
reas
whe
re P
PM is
cur
rent
ly b
eing
impl
emen
ted
Num
ber
of
HC
Ws
trai
ned
on
TB/H
IV,
PMD
T,
Paed
iatr
ic T
B, P
AL
Trai
n H
CW
s o
n TB
usi
ng t
he n
atio
nal
TB/H
IV c
urri
cullu
m (1
5 co
unti
es)
n/a
5 tr
aini
ngs
150
5 tr
aini
ngs
150
5 tr
aini
ngs
150
Trai
n
HC
Ws
on
M
DR-
TB
us
ing
the
nati
onal
D
R-TB
cu
rric
ullu
m
(15
coun
ties
)
n/a
5 tr
aini
ngs
150
5 tr
aini
ngs
150
5 tr
aini
ngs
150
Trai
n H
CW
s o
n Pe
d TB
us
ing
the
nati
onal
cur
ricu
llum
( 5
coun
ties
)n/
a5
trai
ning
s 15
05
trai
ning
s 15
05
trai
ning
s 15
0
Trai
n H
CW
s o
n PA
L u
sing
the
nati
onal
cu
rric
ullu
m (1
5 co
unti
es)
n/a
5 tr
aini
ngs
150
5 tr
aini
ngs
150
5 tr
aini
ngs
150
Num
ber
of c
onfe
renc
es w
ith
TB s
ympo
sia
held
at
ann
ual
scie
ntif
ic c
onfe
renc
es o
f pr
ofes
sion
al
asso
ciat
ions
Supp
ort
sym
posi
a an
d sp
ecia
l ses
sion
s on
TB
at
the
annu
al
scie
ntif
ic
conf
eren
ces
of
prof
essi
onal
as
soci
atio
ns
incl
udin
g K
MA
, K
PA,
KA
PT,
KC
OA
, N
AK
, PS
K,
to
reac
h in
divi
dual
m
embe
rs
of
thes
e as
soci
atio
ns
wit
h TB
ta
sk
spec
ific
m
essa
ges
n/a
1/2
day
sym
posi
a in
six
con
fere
nces
61/
2 da
y sy
mpo
sia
in s
ix c
onfe
renc
es6
1/2
day
sym
posi
a in
si
x co
nfer
ence
s6
Num
ber
of f
acili
ty d
ialo
gue
mee
ting
s he
ld w
ith
priv
ate
heal
th f
acili
ty m
anag
ers
and
staf
fH
old
dial
ogue
m
eeti
ngs
wit
h 85
pr
ivat
e he
alth
fac
ility
man
ager
s an
d st
aff
to
desi
gn a
nd im
plem
ent
faci
lity
spec
ific
TB
and
TB/H
IV s
ervi
ce (
appr
ox
10 s
taff
per
fac
ility
)
10 d
ialo
gue
mee
ting
s he
ld a
t se
lect
ed f
acili
ties
10
25
dial
ogue
m
eeti
ngs
at
sele
cted
fa
cilit
ies
2525
di
alog
ue
mee
ting
s at
se
lect
ed
faci
litie
s25
25
dial
ogue
m
eeti
ngs
at
sele
cted
fac
iliti
es25
Num
ber
of s
uper
visi
on v
isit
s to
pri
vate
fac
ility
/cl
inic
ow
ners
Prov
ide
TA
(Sub
C
TLC
s,
PPM
C
oord
inat
ors)
to
priv
ate
faci
lity/
clin
ic
owne
rs
Hol
d qu
arte
rly
supp
orti
ve
supe
rvis
ion
in a
ll 25
51,
020
Hol
d qu
arte
rly
supp
orti
ve
supe
rvis
ion
in a
ll 25
51,
020
Hol
d qu
arte
rly
supp
orti
ve
supe
rvis
ion
in a
ll 25
51,
020
Hol
d qu
arte
rly
supp
orti
ve
supe
rvis
ion
in a
ll 25
51,
020
Num
ber o
f cou
ntie
s of
fere
d te
chni
cal a
ssis
tanc
e by
na
tion
al t
eam
Prov
ide
Tech
nica
l su
ppor
t/
supp
ort
supe
rvis
ion
by n
atio
nal l
evel
tea
mIn
tegr
ated
mis
sion
for
pri
vate
fa
cilit
y su
perv
isio
n ye
arly
in
15 c
ount
ies
15In
tegr
ated
mis
sion
for p
riva
te fa
cilit
y su
perv
isio
n ye
arly
in 1
5 co
unti
es15
Inte
grat
ed
mis
sion
fo
r pr
ivat
e fa
cilit
y su
perv
isio
n ye
arly
in
15
co
unti
es
15In
tegr
ated
mis
sion
for
pri
vate
fa
cilit
y su
perv
isio
n ye
arly
in
15 c
ount
ies
15
Num
ber
of p
riva
te H
CW
s se
nsit
ized
on
reco
rdin
g &
rep
orti
ngSu
ppor
t t
he n
atio
nal
TB s
urve
illan
ce
syst
em a
mon
g pr
ivat
e pr
ovid
ers
Con
duct
one
day
sen
siti
zati
on
mee
ting
s on
dat
a co
llect
ion
tool
s ta
rget
ting
30
he
alth
ca
re p
rovi
ders
fr
om p
riva
te
DO
T fa
cilit
ies
30C
ondu
ct
one
day
sens
itiz
atio
n m
eeti
ngs
on
data
co
llect
ion
tool
s ta
rget
ting
90
heal
th p
rovi
ders
fr
om
priv
ate
DO
T fa
cilit
ies
90C
ondu
ct
one
day
sens
itiz
atio
n m
eeti
ngs
on d
ata
colle
ctio
n to
ols
targ
etti
ng 9
0 he
alth
pro
vide
rs f
rom
pr
ivat
e D
OT
faci
litie
s
90C
ondu
ct o
ne d
ay s
ensi
tiza
tion
m
eeti
ngs
on d
ata
colle
ctio
n to
ols
targ
etti
ng
90
heal
th
prov
ider
s f
rom
pri
vate
DO
T fa
cilit
ies
90
Num
ber
of p
riva
te f
acili
ties
tra
ined
to
use
data
fr
om r
ecor
ding
& r
epor
ting
Supp
ort
2 da
y da
ta
feed
back
/CQ
I fo
rum
s (h
ealt
h ca
re
prov
ider
s an
d TB
co
ordi
nato
rs)
in 1
5 co
unti
es
bi a
nnua
lly.
(C
ount
y cl
uste
ring
3 c
ount
ies
per
mee
ting
, 5 m
eeti
ngs
wit
h 45
pax)
30Su
ppor
t 2
day
data
fe
edba
ck/C
QI
foru
ms
(hea
lth
care
pro
vide
rs a
nd
TB c
oord
inat
ors)
in
15 c
ount
ies
bi
annu
ally
.
(Cou
nty
clus
teri
ng
3 co
unti
es
per
mee
ting
, 5 m
eeti
ngs
wit
h 45
pax)
30Su
ppor
t 2
day
data
fe
edba
ck/C
QI
foru
ms
(hea
lth
care
pro
vide
rs a
nd
TB c
oord
inat
ors)
in
15 c
ount
ies
bi
annu
ally
.
(Cou
nty
clus
teri
ng 3
cou
ntie
s pe
r m
eeti
ng, 5
mee
ting
s w
ith
45pa
x)
30Su
ppor
t 2
day
data
fe
edba
ck/C
QI
foru
ms
(hea
lth
care
pr
ovid
ers
and
TB
coor
dina
tors
) in
15
coun
ties
bi
ann
ually
.
( Cou
nty
clus
teri
ng 3
cou
ntie
s pe
r m
eeti
ng, 5
mee
ting
s w
ith
45pa
x)
30
Stra
tegi
c A
ppro
ach
2: S
cale
-up
the
num
ber
and
dive
rsit
y of
pri
vate
pro
vide
rs c
ontr
ibut
ing
to N
TLD
Pro
gram
aim
s, in
all
coun
ties
Prop
orti
on o
f co
unti
es t
hat
have
map
ped
priv
ate
heal
th p
rovi
ders
Map
of
all
priv
ate
care
pro
vide
rs 3
2 ur
ban
cent
ers
in 3
2 co
unti
esC
ondu
ct
10
day
map
ping
ex
erci
se f
or p
riva
te p
rovi
ders
in
8
urba
n ce
ntre
s in
8
coun
ties
25%
Con
duct
10
day
map
ping
exe
rcis
e fo
r pr
ivat
e pr
ovid
ers
in
8 ur
ban
cent
res
in 8
cou
ntie
s
50%
Con
duct
10
day
map
ping
exe
rcis
e fo
r pr
ivat
e pr
ovid
ers
in
8 ur
ban
cent
res
in 8
cou
ntie
s
75%
Con
duct
10
da
y m
appi
ng
exer
cise
for
pri
vate
pro
vide
rs
in
8 ur
ban
cent
res
in
8 co
unti
es
100%
PPM
pol
icy
guid
elin
es u
pdat
edRe
vise
the
PPM
pol
icy
guid
elin
esn/
aC
ondu
ct
a 5
day
polic
y re
visi
on
wor
ksho
p fo
r PP
M p
olic
y gu
idel
ines
1n/
an/
a
Num
ber
of P
PM p
olic
y gu
idel
ines
pri
nted
Prin
t th
e PP
M p
olic
y gu
idel
ines
n/a
Prin
t 1,
000
copi
es o
f PP
M p
olic
y 1,
000
Prin
t 1,
000
copi
es o
f PP
M p
olic
y 10
00n/
a
4.3.
3. E
ngag
e A
ll Ca
re P
rovi
ders
(PPM
)
Enga
ging
All
Car
e Pr
ovid
ers
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prop
orti
on o
f co
unti
es w
ith
PPM
pol
icy
guid
elin
esD
istr
ibut
e th
e PP
M
polic
y to
al
l co
unti
esn/
aD
istr
ibut
e PP
M p
olic
y gu
idel
ines
to
47 c
ount
ies
100%
Dis
trib
ute
PPM
pol
icy
guid
elin
es t
o 47
cou
ntie
s10
0%n/
a
Prop
orti
on
of
coun
ties
w
ith
diss
emin
atio
n m
eeti
ngs
for
PPM
pol
icy
guid
elin
es h
eld
Hol
d di
ssem
inat
ion
mee
ting
s fo
r PP
M p
olic
y do
cum
ents
tar
gett
ting
32
urba
rn c
ente
rs in
32
coun
ties
n/a
Hol
d di
ssem
inat
ion
mee
ting
s fo
r PP
M
polic
y do
cum
ents
ta
rget
ttin
g 16
urb
arn
cent
ers
in 1
6 co
unti
es
50%
Hol
d di
ssem
inat
ion
mee
ting
s fo
r PP
M p
olic
y do
cum
ents
tar
gett
ting
16
urb
arn
cent
ers
in 1
6 co
unti
es
50%
n/a
Stra
tegi
c A
ppro
ach
3: S
tren
gthe
n co
ordi
nati
on m
echa
nism
s fo
r PP
M a
t th
e na
tion
al a
nd c
ount
y le
vels
Num
ber
of T
WG
mee
ting
s he
ldSu
ppor
ting
the
nat
iona
l PPM
TW
GH
old
quar
tely
PP
M
TWG
m
eeti
ngs
at n
atio
nal l
evel
4
Hol
d qu
arte
ly P
PM T
WG
mee
ting
s at
na
tion
al le
vel
4H
old
quar
tely
PPM
TW
G m
eeti
ngs
at
nati
onal
leve
l 4
Hol
d qu
arte
ly
PPM
TW
G
mee
ting
s at
nat
iona
l lev
el
4
Num
ber
of
annu
al
coun
ty
PPM
st
akeh
olde
r m
eeti
ngs
held
Supp
ort
annu
al
coun
ty
PPM
st
akeh
olde
rs m
eeti
ngs
n/a
Hol
d on
e da
y an
nual
PP
M
stak
ehol
ders
mee
ting
in e
ach
of t
he
47 c
ount
ies
47H
old
one
day
annu
al
PPM
st
akeh
olde
rs m
eeti
ng in
eac
h of
the
47
cou
ntie
s
47H
old
one
day
annu
al
PPM
st
akeh
olde
rs m
eeti
ng in
eac
h of
the
47
coun
ties
47
Num
ber
of p
laqu
es a
nd c
erti
fica
tes
prin
ted
and
awar
ded
Prin
t re
cogn
itio
n ce
rtif
icat
es
and
plaq
ues
n/a
47
plaq
ues
and
141
reco
gnit
ion
cert
ific
ates
for
bes
t pe
rfor
min
g si
tes
prin
ted
and
awar
ded
47 141
47
plaq
ues
and
141
reco
gnit
ion
cert
ific
ates
for
best
per
form
ing
site
s pr
inte
d an
d aw
arde
d
47 141
47
plaq
ues
and
141
reco
gnit
ion
cert
ific
ates
fo
r be
st p
erfo
rmin
g si
tes
prin
ted
and
awar
ded
47 141
Num
ber
of a
nnua
l PPM
mee
ting
s he
ldH
old
an
annu
al
nati
onal
PP
M
wor
ksho
p fo
r 15
0pax
to
diss
emin
ate
PPM
nor
ms
and
stan
dard
s, p
ract
ices
re
port
ing
syst
ems
and
revi
ew p
rogr
ess
n/a
Hol
d a
2 d
ay n
atio
nal P
PM m
eeti
ng1
Hol
d a
2 d
ay n
atio
nal P
PM m
eeti
ng1
Hol
d a
2 d
ay
nati
onal
PPM
m
eeti
ng1
Stra
tegi
c A
ppro
ach
4: E
nsur
e th
e qu
alit
y of
PPM
act
ivit
ies
for
TB, l
epro
sy a
nd lu
ng d
isea
ses
Num
ber
of c
ount
ies
wit
h pe
er t
o pe
er s
uppo
rtiv
e su
perv
isio
n he
ldD
evel
opm
ent
of t
he p
eer
revi
ew t
ools
Dev
elop
men
t of
th
e pe
er
revi
ew
tool
s15
n/a
15n/
a15
Supp
ort
a t
eam
of
cons
ulta
nts
in lu
ng
heal
th a
t na
tion
al a
nd C
ount
y le
vel
to p
rovi
de m
ento
rshi
p in
the
Pri
vate
se
ctor
n/a
Supp
ort
a te
am
of
cons
ulta
nt
to
cond
uct
peer
to
pe
er
supp
ort
supe
rvis
ion
in 1
5 co
unti
es
Supp
ort
a te
am
of
cons
ulta
nt
to
cond
uct
peer
to
pe
er
supp
ort
supe
rvis
ion
in 1
5 co
unti
es
Supp
ort
a te
am o
f co
nsul
tant
to
co
nduc
t pe
er
to
peer
su
ppor
t su
perv
isio
n in
15
co
unti
es
Supp
ort
data
qu
alit
y as
sess
men
ts
(DQ
A)/C
QIs
to
im
prov
e th
e su
rvei
llanc
e of
TB,
lep
rosy
and
lun
g di
seas
es f
rom
pri
vate
sec
tor
naC
ondu
ct
DQ
A
in
sele
cted
pr
ivat
e he
alth
fac
ililt
esC
ondu
ct
DQ
A
in
sele
cted
pr
ivat
e he
alth
fac
ililt
esC
ondu
ct
DQ
A
in
sele
cted
pr
ivat
e he
alth
fac
ililt
es
4.3.3. Engage All Care Providers (PPM
)
4.3.4. Promote and strengthen community engagement and build national commitment to TB, leprosy and lung disease
1. Situational Analysis
In 2013, the NTLD Program Annual Report indicated that 3,255 (4%, n=89,760) TB patients reached health facilities through referrals from community approaches, specifically CHWs, and 883 TB patients (1%, n=89,760) received treatment in the community, (map 8). Only 6 counties had more than 9% of cases referred by the community.
In the Kenya Health Policy Framework 2012-30, the community is recognized as a level of health service delivery (Tier 1). This policy boosts Kenya’s focus on the role of community participation in health and general socio-economic development actions. At community level, platforms exist which can be utilized for implementation of systematic contact investigation, referrals between health facilities and community members, as well as promotion of adherence to treatment.
In 1998, community-based TB care (CBTC) was launched nationally with the introduction of community health workers for case finding, case holding and health promotion activities in collaboration with the MOH. In 2006, the MOH developed a community health strategy to enable health service delivery at
4.3.
4. C
omm
unit
y En
gage
men
t
Map 8: % of Community-Referred Cases among All Case Notifications
Figure 19: Community Contribution to Identification of TB Patients, 2013
69
the household and community level through the introduction of 6,000 community units. The plan aimed to link each community program to a health facility under the management of a Community Health Extension Worker (CHEW), covering a population of 1,000 individuals and 25 community health workers (CHWs). In 2012, a national TB Civil Society Organzations (CSOs) coordination forum was established.
There are now 2,943 Community Health Units (CHUs) established across the country, although only 1,587 are fully functional. Figure 19 shows community-referred case notification, highlighting strong community contributions to case notification particularly in some urban areas, providing models of success upon which further expansion can be based.
The Ministry of Health, through the Community Health Services Program (CHS-Program) and the NTLD Program, together with development and implementing partners, have developed policies, guidelines and training manuals to harmonize the engagement and implementation of TB, leprosy and lung diseases activities at community level.
Two community-based care models were established in 1998 and 2010 respectively (see lessons learned).
Documentation of community TB interventions including presumptive TB screening and food security at community level are not yet incorporated into the systemic monitoring and evaluation of the NTLD Program. A mechanism for retrieval of treatment interrupters is in place but these efforts are not captured in the e-reporting (TIBU) system.
A national communication strategy exists and an advocacy strategy is still in its draft form. These two documents have not yet been fully disseminated and are underutilized at the community level.
2. Strategic Direction(s) for 2015-2018
To optimize the use of community-level platforms for TB, leprosy and lung health, priority will be given to broadening and diversifying the array of partners at community level who incorporate TB, leprosy and lung health into their priorities, especially in areas with low levels of community-referred TB cases at present and in areas endemic to leprosy. Secondly, this plan aims to empower community-level partners and populations to develop and implement locally-relevant solutions to delayed case finding, morbidity and poor treatment outcomes.
3. Proposed Approaches
4.3.4. Comm
unity Engagement
Box 5
Lessons Learned
Improved treatment adherence utilizing community health workers1
A retrospective cohort study of patients registered for treatment between the periods 2005 to 2011 was conducted. 54% of the reviewed 2,778 TB patients utilized a Community Health Worker. Adherence was shown to be higher in patients who utilized CHW, especially in urban settings.
ENGAGE-TB
The Engage-TB Model brings on board health and non-health stakeholders that have not previously been involved in TB management. Its operational guidance and policies support NGOs/CSOs to integrate TB into their community-based work in sectors such as maternal, newborn and child health (MNCH), HIV care, primary health care (PHC), education, agriculture and livelihoods development programmes.
Other innovations in pilot phase
a) Livelihood and food security initiatives for eligible TB patients. MDR-TB patient support, including food support, in place through AMPATH
b) Use of mobiles technology platforms to send SMS reminders for TB clinic attendance (AMPATH)
c) Existence of psychosocial support groups for TB e.g. TB clubs, TB Ambassadors, TB Pamoja, Kinunga, Waso, Kibera Post Test
d) Health education forums - through barazas and radio programs, annual national events i.e. World TB Day
Build the foundation for systematic community and partner engagement
a) Identify opportunities for expansion of proven models: conduct mapping of community platforms and partners that may reach populations in need of TB, leprosy and lung health services. Examples include other health and development related programs such as nutrition and MNCH programs. Emphasis will be given to mapping areas with low community engagement.
b) Build a web of community organizations linked to the NTLD Program: Develop MoUs between NTLD Program or county health offices and CSOs, NGOs and community partners to define roles, responsibilities and resources. Use MoUs
_______________________________________________________________________________________________________________________________1 EOng’ang’o JR, Mwachari C, Kipruto H, Karanja S (2014) The Effects on Tuberculosis Treatment Adherence from Utilising Community Health Workers: A
Comparison of Selected Rural and Urban Settings in Kenya. PLoS ONE 9(2): e88937. doi:10.1371/journal.pone.0088937
70
to connect community-level actors to service delivery points for mentorship, monitoring and support.
c) Enhance capacity at community level: Develop a capacity building plan for CTBC, based on needs and capacities of newly identified community-level partners. Engage the implementers of successful models as Centers of Excellence, for on-site mentoring and training.
d) Engage communities and counties in planning: Include community stakeholders in coordination, annual planning, implementation, monitoring, and evaluation of activities at national and county level. Ensure NTLD Program participation in county health and NGO forums. Support county coordination committees to oversee implementation of community engagement and communication activities. Organize forums with governors to advocate for resource allocation for community based TB and Leprosy activities.
e) Create patient engagement guidelines and update other policy tools.
f) Actively participate in the harmonization of payment levels of CHWs across programs according to MoH guidelines.
Operationalize patient-centered care through community structures, scaling up proven community-based models
a) Train, mentor and support new community-level partners: Based on proven models of community-based engagement, provide targeted training, supportive supervision and mentorship in collaboration with county governments targeting CHWs and CHEWs. Disseminate updated CTBC policies, manuals and guidelines, including ENGAGE-TB guidelines.
b) Pilot new approaches to supporting patients through community structures, such as sustainable livelihood and nutritional support programs.
Improve monitoring and evaluation of community-based TB, leprosy and lung disease interventions to increase accountability to all stakeholders
a) Integrate community-based TB, leprosy and lung disease care indicators in the TIBU and DHIS systems to mirror the reporting of CSO involvement captured in the NTLD Program monitoring system; develop and disseminate related tools to ensure data capture and reporting by NGOs/CSOs and CHEWs.
b) Introduce a register for presumptive TB to allow capturing of screening and referral results, and to enable treatment follow-up.
c) Revise and update peripheral level health facility chalk boards to include comprehensive community TB indicators.d) Identify priority areas for OR jointly with key community stakeholders, including learning institutions. Fully evaluate
pilot projects.
STRATEGIC OBJECTIVES
4.3.
4. C
omm
unit
y En
gage
men
t
71
Contribution to NSP Impacts Outcomes (Community Engagement)
Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014
• Ensure treatment success of at least 90% among all DS forms of TB
• All newly diagnosed TB patients to be initiated on treatment within 2 days
Impact 1.1: Reduce the prevalence of MDR-TB among new patients by 15% by 2018, compared to 2014
• Increase case notification of MDR-TB to at least 75% of estimated prevalence (baseline TBD: DR survey)
• Ensure treatment success of at least 80% among all DR cases
Impact 2: Reduce mortality due to TB by 3% by 2018, compared to 2014
• Increase treatment success via CHWs to 90%
Impact 3: Reduce the proportion of affected families who face catastrophic costs due to TB, leprosy and other lung diseases, by 2018
• Increased proportion of TB patients accessing social and nutritional support
• Reduction in out-of-pocket expenditures attributed to TB care seeking
Table 10: Impact and Outcome Indicators for Community Engagement
4.3.4. Comm
unity Engagement
72
4.3.
4. C
omm
unit
y En
gage
men
t
Com
mun
ity
Enga
gem
ent
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
sY
ear
1 A
ctiv
itie
sY
r 1
Targ
etY
ear
2 A
ctiv
itie
sY
r 2
Targ
et
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
1: Id
enti
fy o
ppor
tuni
ties
for
exp
ansi
on o
f pr
oven
mod
els
Prop
orti
on o
f C
SOs
impl
emen
ting
EN
GA
GE
TB
acti
viti
es
1.
New
C
SOs
iden
tifi
ed
and
fund
ed
to
impl
emen
t EN
GA
GE
TB
2.
Sens
itiz
atio
n w
orks
hops
fo
r C
SOs
on
CBT
BC, L
epro
sy a
nd lu
ng d
isea
se a
ctiv
itie
s
1. M
appi
ng o
f C
SOs
by
Nat
iona
l go
vern
men
t in
col
labo
rati
on w
ith
Cou
nty
gove
rnm
ent
2. H
old
one
nati
onal
and
15
Cou
nty
mee
ting
s to
dis
sem
inat
e m
appi
ng
resu
lts
as
wel
l as
oper
atio
nal
guid
elin
es o
n EN
GA
GE
TB
3.
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
re
view
m
eeti
ngs
to
upda
te
and
herm
oniz
e ac
tivi
ties
im
plem
ente
d by
all
acto
rs
4.
Prov
ide
Fina
ncia
l su
ppor
t to
C
SOs
to
esta
blis
h co
mm
unit
y m
odel
s on
EN
GA
GE
TB
25%
1. P
rovi
de F
inan
cial
sup
port
to
CSO
s to
es
tabl
ish
com
mun
ity
Mod
els
on E
NG
AG
E TB
2.
Hol
d on
e na
tion
al
and
15
Cou
nty
mee
ting
s to
dis
sem
inat
e m
appi
ng
resu
lts
as
wel
l as
op
erat
iona
l gui
delin
es
50%
Prov
ide
fina
ncia
l su
ppor
t to
C
SOs
to
esta
blis
h co
mm
unit
y m
odel
s on
EN
GA
GE
TB
75%
Prov
ide
fina
ncia
l su
ppor
t to
C
SOs
to
esta
blis
h co
mm
unit
y m
odel
s on
EN
GA
GE
TB
100%
Prop
orti
on o
f lo
st t
o fo
llow
up
Ro
ll-ou
t us
e of
mob
ile t
echn
olog
ies,
incl
udin
g SM
S, f
or c
ase
dete
ctio
n an
d pa
tien
t fo
llow
-up
n/a
n/a
1.
Con
sult
ativ
e m
eeti
ngs
wit
h po
tent
ial s
ervi
ce p
rovi
ders
2. P
rocu
rem
ent
and
dist
ribu
tion
of
pho
nes
3. S
ensi
tiza
tion
mee
ting
s
1.
Con
sult
ativ
e m
eeti
ngs
wit
h po
tent
ial s
ervi
ce p
rovi
ders
2. P
rocu
rem
ent
and
dist
ribu
tion
of
pho
nes
3. S
ensi
tiza
tion
mee
ting
s
1.
Con
sult
ativ
e m
eeti
ngs
wit
h po
tent
ial s
ervi
ce p
rovi
ders
2. P
rocu
rem
ent
and
dist
ribu
tion
of
pho
nes
3. S
ensi
tiza
tion
mee
ting
s
Num
ber
of T
B pe
ers
enga
ged
for
coun
selin
gSc
ale-
up p
eer-
base
d m
odel
s fo
r cas
e de
tect
ion
and
trea
tmen
t su
ppor
t am
ong
vuln
erab
le a
nd
at-r
isk
popu
lati
ons
n/a
n/a
1. R
ecru
it T
B pe
ers
in 8
cou
ntie
s
2. T
rain
TB
peer
s in
8 c
ount
ies
3. H
old
outr
each
es in
8 c
ount
ies
601.
Rec
ruit
TB
peer
s in
8 c
ount
ies
2. T
rain
TB
peer
s in
8 c
ount
ies
3. H
old
outr
each
es in
8 c
ount
ies
120
1. R
ecru
it T
B pe
ers
in 8
cou
ntie
s
2. T
rain
TB
peer
s in
8 c
ount
ies
3. H
old
outr
each
es in
8 c
ount
ies
120
% i
ncre
ase
in t
he n
umbe
r of
pre
sum
ptiv
e TB
re
ferr
ed f
or s
cree
ning
fro
m t
he C
omm
unit
y "
1. C
SO L
inke
d to
Com
mun
ity
Uni
ts
2.
Dis
sem
inat
ion
mee
ting
s on
EN
GA
GE
TB
oper
atio
nal
guid
elin
es t
o bo
th n
atio
nal
and
coun
ty le
vels
3. H
arm
oniz
atio
n of
TB
Act
ors
wit
hin
Cou
nty
heal
th c
omm
itee
s an
d N
GO
s
Hol
d on
e na
tion
al
stak
ehol
ders
m
eeti
ng1.
H
old
one
nati
onal
an
d 15
C
ount
y m
eeti
ngs
to d
isse
min
ate
CSO
S m
appi
ng a
nd
oper
atio
nal
guid
elin
es o
n EN
GA
GE
TB
2.
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
rev
iew
mee
ting
s to
up
date
and
her
mon
ize
acti
viti
es
impl
emen
ted
by a
ll ac
tors
”
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
rev
iew
mee
ting
s to
up
date
and
her
mon
ize
acti
viti
es
impl
emen
ted
by a
ll ac
tors
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
re
view
m
eeti
ngs
to
upda
te
and
herm
oniz
e ac
tivi
ties
im
plem
ente
d by
al
l ac
tors
Stra
tegi
c A
ppro
ach
2: B
uild
a w
eb o
f co
mm
unit
y or
gani
zati
ons
linke
d to
the
NTL
D P
rogr
am
1. P
ropo
rtio
n of
CSO
s an
d pa
rtne
rs im
plem
enti
ng
com
mun
ity-
base
d TB
, le
pros
y an
d lu
ng h
ealt
h se
rvic
es
2.
Prop
orti
on
of
coun
ties
w
ith
form
al
inte
r-go
vern
men
tal a
gree
men
ts w
ith
NTL
D P
rogr
am
3.
Perc
enta
ge
of
coun
ties
ho
ldin
g qu
arte
rly
com
mun
ity
stak
ehol
ders
m
eeti
ngs
of
thos
e en
gage
d in
TB,
lepr
osy
and
lung
hea
lth
1.
Dis
sem
inat
ion
mee
ting
s on
EN
GA
GE
TB
oper
atio
nal
guid
elin
es t
o bo
th n
atio
nal
and
coun
ty le
vels
2. H
arm
oniz
atio
n of
TB
acto
rs w
ithi
n C
ount
y he
alth
com
mit
ees
and
NG
Os
3. F
orm
aliz
e in
ter-
gove
rnm
enta
l ag
reem
ents
be
twee
n th
e N
TLD
Pr
ogra
m
and
coun
ty
gove
rnm
ents
to
defi
ne r
oles
, re
spon
sibi
litie
s an
d re
sour
ces”
Hol
d qu
arte
rly
C
ount
y st
akeh
olde
rs
revi
ew
mee
ting
s to
up
date
an
d ha
rmon
ize
acti
viti
es
impl
emen
ted
by
all
acto
rs;
esta
blis
h in
ter-
gove
rnm
enta
l ag
reem
ents
20%
1.
Hol
d on
e na
tion
al
and
15
Cou
nty
mee
ting
s to
dis
sem
inat
e op
erat
iona
l gu
idel
ines
on
EN
GA
GE
TB;
esta
blis
h in
ter-
gove
rnm
enta
l agr
eem
ents
2.
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
rev
iew
mee
ting
s to
up
date
and
har
mon
ize
acti
viti
es
impl
emen
ted
by a
ll ac
tors
40%
1.
Hol
d on
e na
tion
al
and
15
Cou
nty
mee
ting
s to
dis
sem
inat
e op
erat
iona
l gu
idel
ines
on
EN
GA
GE
TB;
esta
blis
h in
ter-
gove
rnm
enta
l agr
eem
ents
2.
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
rev
iew
mee
ting
s to
up
date
and
har
mon
ize
acti
viti
es
impl
emen
ted
by a
ll ac
tors
60%
1.
Hol
d on
e na
tion
al
and
15
Cou
nty
mee
ting
s to
dis
sem
inat
e op
erat
iona
l gu
idel
ines
on
EN
GA
GE
TB;
esta
blis
h in
ter-
gove
rnm
enta
l agr
eem
ents
2.
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
re
view
m
eeti
ngs
to
upda
te
and
harm
oniz
e ac
tivi
ties
im
plem
ente
d by
al
l ac
tors
80%
Str
ateg
ic A
ppro
ach
3: E
nhan
ce c
apac
ity
at c
omm
unit
y le
vel
Prop
orti
on
of
TB
pati
ent
refe
rral
s fr
om
the
com
mun
ity
1.
Sens
itiz
atio
n of
co
mm
unit
y he
alth
co
mm
itee
s on
TB,
Lep
rosy
and
Lun
g D
isea
se
2.
Prov
ide
ince
ntiv
es
for
CH
Ws
base
d on
as
sign
ed
task
s (p
erfo
rman
ce
base
d)
inte
rven
tion
s
1.
Sens
itiz
atio
n m
eeti
ngs
for
stak
ehol
ders
incl
udin
g C
SOs
6%Se
nsit
izat
ion
mee
ting
s fo
r st
akeh
olde
rs in
clud
ing
CSO
s10
%Se
nsit
izat
ion
mee
ting
s fo
r st
akeh
olde
rs in
clud
ing
CSO
s.12
%Se
nsit
izat
ion
mee
ting
s fo
r st
akeh
olde
rs in
clud
ing
CSO
s.15
%
4.3.4. Comm
unity Engagement
Com
mun
ity
Enga
gem
ent
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
sY
ear
1 A
ctiv
itie
sY
r 1
Targ
etY
ear
2 A
ctiv
itie
sY
r 2
Targ
et
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
1: Id
enti
fy o
ppor
tuni
ties
for
exp
ansi
on o
f pr
oven
mod
els
Prop
orti
on o
f in
crea
se i
n th
e nu
mbe
r of
CSO
s im
plem
enti
ng E
NG
AG
E TB
act
ivit
ies
1.
N
ew
CSO
s id
enti
fied
an
d fu
nded
to
im
plem
ent
ENG
AG
E TB
2.
Sens
itiz
atio
n w
orks
hops
fo
r C
SOs
on
CBT
BC, L
epro
sy a
nd lu
ng d
isea
se a
ctiv
itie
s
1. M
appi
ng o
f C
SOs
by
Nat
iona
l go
vern
men
t in
col
labo
rati
on w
ith
Cou
nty
gove
rnm
ent
2. H
old
one
nati
onal
and
15
Cou
nty
mee
ting
s to
dis
sem
inat
e m
appi
ng
resu
lts
as
wel
l as
oper
atio
nal
guid
elin
es o
n EN
GA
GE
TB
3.
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
re
view
m
eeti
ngs
to
upda
te
and
herm
oniz
e ac
tivi
ties
im
plem
ente
d by
all
acto
rs
4.
Prov
ide
Fina
ncia
l su
ppor
t to
C
SOs
to
esta
blis
h co
mm
unit
y m
odel
s on
EN
GA
GE
TB
25%
1. P
rovi
de F
inan
cial
sup
port
to
CSO
s to
es
tabl
ish
com
mun
ity
Mod
els
on E
NG
AG
E TB
2.
Hol
d on
e na
tion
al
and
15
Cou
nty
mee
ting
s to
dis
sem
inat
e m
appi
ng
resu
lts
as
wel
l as
op
erat
iona
l gui
delin
es
50%
Prov
ide
fina
ncia
l su
ppor
t to
C
SOs
to
esta
blis
h co
mm
unit
y m
odel
s on
EN
GA
GE
TB
75%
Prov
ide
fina
ncia
l su
ppor
t to
C
SOs
to
esta
blis
h co
mm
unit
y m
odel
s on
EN
GA
GE
TB
100%
Prop
orti
on o
f re
duct
ion
in lo
st t
o fo
llow
up
Ro
ll-ou
t us
e of
mob
ile t
echn
olog
ies,
incl
udin
g SM
S, f
or c
ase
dete
ctio
n an
d pa
tien
t fo
llow
-up
n/a
n/a
1.
Con
sult
ativ
e m
eeti
ngs
wit
h po
tent
ial s
ervi
ce p
rovi
ders
2. P
rocu
rem
ent
and
dist
ribu
tion
of
pho
nes
3. S
ensi
tiza
tion
mee
ting
s
1.
Con
sult
ativ
e m
eeti
ngs
wit
h po
tent
ial s
ervi
ce p
rovi
ders
2. P
rocu
rem
ent
and
dist
ribu
tion
of
pho
nes
3. S
ensi
tiza
tion
mee
ting
s
1.
Con
sult
ativ
e m
eeti
ngs
wit
h po
tent
ial s
ervi
ce p
rovi
ders
2. P
rocu
rem
ent
and
dist
ribu
tion
of
pho
nes
3. S
ensi
tiza
tion
mee
ting
s
Num
ber
of T
B pe
ers
enga
ged
for
coun
selin
gSc
ale-
up p
eer-
base
d m
odel
s fo
r cas
e de
tect
ion
and
trea
tmen
t su
ppor
t am
ong
vuln
erab
le a
nd
at-r
isk
popu
lati
ons
n/a
n/a
1. R
ecru
it T
B pe
ers
in 8
cou
ntie
s
2. T
rain
TB
peer
s in
8 c
ount
ies
3. H
old
outr
each
es in
8 c
ount
ies
601.
Rec
ruit
TB
peer
s in
8 c
ount
ies
2. T
rain
TB
peer
s in
8 c
ount
ies
3. H
old
outr
each
es in
8 c
ount
ies
120
1. R
ecru
it T
B pe
ers
in 8
cou
ntie
s
2. T
rain
TB
peer
s in
8 c
ount
ies
3. H
old
outr
each
es in
8 c
ount
ies
120
% i
ncre
ase
in t
he n
umbe
r of
pre
sum
ptiv
e TB
re
ferr
ed f
or s
cree
ning
fro
m t
he C
omm
unit
y "
1. C
SO L
inke
d to
Com
mun
ity
Uni
ts
2.
Dis
sem
inat
ion
mee
ting
s on
EN
GA
GE
TB
oper
atio
nal
guid
elin
es t
o bo
th n
atio
nal
and
coun
ty le
vels
3. H
arm
oniz
atio
n of
TB
Act
ors
wit
hin
Cou
nty
heal
th c
omm
itee
s an
d N
GO
s
Hol
d on
e na
tion
al
stak
ehol
ders
m
eeti
ng1.
H
old
one
nati
onal
an
d 15
C
ount
y m
eeti
ngs
to d
isse
min
ate
CSO
S m
appi
ng a
nd
oper
atio
nal
guid
elin
es o
n EN
GA
GE
TB
2.
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
rev
iew
mee
ting
s to
up
date
and
her
mon
ize
acti
viti
es
impl
emen
ted
by a
ll ac
tors
”
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
rev
iew
mee
ting
s to
up
date
and
her
mon
ize
acti
viti
es
impl
emen
ted
by a
ll ac
tors
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
re
view
m
eeti
ngs
to
upda
te
and
herm
oniz
e ac
tivi
ties
im
plem
ente
d by
al
l ac
tors
Stra
tegi
c A
ppro
ach
2: B
uild
a w
eb o
f co
mm
unit
y or
gani
zati
ons
linke
d to
the
NTL
D P
rogr
am
1. P
ropo
rtio
n of
incr
ease
in t
he n
umbe
r of
CSO
s an
d pa
rtne
rs
impl
emen
ting
co
mm
unit
y-ba
sed
TB, l
epro
sy a
nd lu
ng h
ealt
h se
rvic
es
2.
Prop
orti
on
of
coun
ties
w
ith
form
al
inte
r-go
vern
men
tal a
gree
men
ts w
ith
NTL
D P
rogr
am
3.
Perc
enta
ge
of
coun
ties
ho
ldin
g qu
arte
rly
com
mun
ity
stak
ehol
ders
m
eeti
ngs
of
thos
e en
gage
d in
TB,
lepr
osy
and
lung
hea
lth
1.
Dis
sem
inat
ion
mee
ting
s on
EN
GA
GE
TB
oper
atio
nal
guid
elin
es t
o bo
th n
atio
nal
and
coun
ty le
vels
2. H
erm
oniz
atio
n of
TB
acto
rs w
ithi
n C
ount
y he
alth
com
mit
ees
and
NG
Os
3. F
orm
aliz
e in
ter-
gove
rnm
enta
l ag
reem
ents
be
twee
n th
e N
TLD
Pr
ogra
m
and
coun
ty
gove
rnm
ents
to
defi
ne r
oles
, re
spon
sibi
litie
s an
d re
sour
ces”
Hol
d qu
arte
rly
C
ount
y st
akeh
olde
rs
revi
ew
mee
ting
s to
up
date
an
d he
rmon
ize
acti
viti
es
impl
emen
ted
by
all
acto
rs;
esta
blis
h in
ter-
gove
rnm
enta
l ag
reem
ents
20%
1.
Hol
d on
e na
tion
al
and
15
Cou
nty
mee
ting
s to
dis
sem
inat
e op
erat
iona
l gu
idel
ines
on
EN
GA
GE
TB;
esta
blis
h in
ter-
gove
rnm
enta
l agr
eem
ents
2.
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
rev
iew
mee
ting
s to
up
date
and
her
mon
ize
acti
viti
es
impl
emen
ted
by a
ll ac
tors
40%
1.
Hol
d on
e na
tion
al
and
15
Cou
nty
mee
ting
s to
dis
sem
inat
e op
erat
iona
l gu
idel
ines
on
EN
GA
GE
TB;
esta
blis
h in
ter-
gove
rnm
enta
l agr
eem
ents
2.
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
rev
iew
mee
ting
s to
up
date
and
her
mon
ize
acti
viti
es
impl
emen
ted
by a
ll ac
tors
”
60%
1.
Hol
d on
e na
tion
al
and
15
Cou
nty
mee
ting
s to
dis
sem
inat
e op
erat
iona
l gu
idel
ines
on
EN
GA
GE
TB;
esta
blis
h in
ter-
gove
rnm
enta
l agr
eem
ents
2.
Hol
d qu
arte
rly
Cou
nty
stak
ehol
ders
re
view
m
eeti
ngs
to
upda
te
and
herm
oniz
e ac
tivi
ties
im
plem
ente
d by
al
l ac
tors
80%
Str
ateg
ic A
ppro
ach
3: E
nhan
ce c
apac
ity
at c
omm
unit
y le
vel
Prop
orti
on
of
TB
pati
ent
refe
rral
s fr
om
the
com
mun
ity
1.
Sens
itiz
atio
n of
co
mm
unit
y he
alth
co
mm
itee
s on
TB,
Lep
rosy
and
Lun
g D
isea
se
2.
Prov
ide
ince
ntiv
es
for
CH
Ws
base
d on
as
sign
ed
task
s (p
erfo
rman
ce
base
d)
inte
rven
tion
s
1.
Sens
itiz
atio
n m
eeti
ngs
stak
ehol
ders
incl
udin
g C
SOs.
6%Se
nsit
izat
ion
mee
ting
s st
akeh
olde
rs in
clud
ing
CSO
s.10
%Se
nsit
izat
ion
mee
ting
s st
akeh
olde
rs in
clud
ing
CSO
s.12
%Se
nsit
izat
ion
mee
ting
s st
akeh
olde
rs in
clud
ing
CSO
s.15
%
Com
mun
ity
Enga
gem
ent
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
sY
ear
1 A
ctiv
itie
sY
r 1
Targ
etY
ear
2 A
ctiv
itie
sY
r 2
Targ
et
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prop
orti
on
of
TB
pati
ent
refe
rral
s fr
om
the
com
mun
ity
1. S
uppo
rt C
HW
s w
ith
allo
wan
ces
whe
n un
dert
akin
g as
sign
ed t
asks
2. S
uppo
rt C
HEW
s w
ith
tran
spor
t al
low
ance
to
cond
uct
sup
ervi
sion
s on
TB
, Le
pros
y &
lu
ng
dise
as
acti
viti
es o
nce
a w
eek
per
CU
3. S
uppo
rt m
onth
ly d
ialo
gue
day
s in
all
func
tion
al C
Us
1.
Supp
ort
CH
Ws
wit
h al
low
ance
w
hen
unde
rtak
ing
assi
gned
tas
ks
2.
Su
ppor
t M
onth
ly
dial
ogue
da
ys in
all
Func
tion
al C
Us
1.
Supp
ort
C
HW
s w
ith
allo
wan
ce
whe
n un
dert
akin
g as
sign
ed t
asks
2.
Su
ppor
t M
onth
ly
dial
ogue
da
ys in
all
Func
tion
al C
Us
1.
Supp
ort
C
HW
s w
ith
allo
wan
ces
whe
n un
dert
akin
g as
sign
ed t
asks
2.
Supp
ort
Mon
thly
di
alog
ue
days
in a
ll Fu
ncti
onal
CU
s
Num
ber
of H
CW
s tr
aine
d 1.
Cap
acit
y bu
ildin
g fo
r co
mm
unit
y TB
act
ors
(CH
EWs,
CH
Ws,
CSO
s) o
n TB
, lep
rosy
and
lung
di
seas
es.
This
will
inv
olve
tra
inin
g in
clud
ing
on-j
ob-t
rain
ing
and
supp
ort
supe
rvis
ion
2.
Men
tors
hip
pr
ogra
m,
thro
ugh
wel
l pe
rfor
min
g ce
ntre
s of
ex
celle
nce
(oth
er
coun
ties
) on
com
mun
ity-
base
d TB
and
lep
osy
acti
viti
es
n/a
Trai
ning
of
H
CW
s fr
om
10
coun
ties
on
TB c
are
500
Trai
ning
of
H
CW
s fr
om
10
coun
ties
on
TB c
are
500
Trai
ning
of
H
CW
s fr
om
10
coun
ties
on
TB c
are
500
n/a
Trai
ning
of
C
HEW
s fr
om
10
coun
ties
on
TB c
are
500
Trai
ning
of
C
HEW
s fr
om
10
coun
ties
on
TB c
are
500
Trai
ning
of
C
HEW
s fr
om
10
coun
ties
on
TB c
are
500
n/a
Trai
ning
of
C
HW
s fr
om
10
coun
ties
on
TB c
are
1,
750
Trai
ning
of
C
HW
s fr
om
10
coun
ties
on
TB c
are
1,
750
Trai
ning
of
C
HW
s fr
om
10
coun
ties
on
TB c
are
1,
750
Num
ber
of p
eer
grou
ps t
rain
ed a
nd c
oord
inat
ed
by C
HEW
sM
ento
rshi
p by
C
HEW
S an
d C
HW
s to
pe
er
grou
ps o
n co
mm
unit
y TB
, Le
pros
y an
d Lu
ng
heal
th a
ctiv
itie
s
n/a
Men
tors
hip
by
CH
EWS
and
CH
Ws
to
peer
gr
oups
on
co
mm
unit
y TB
, Le
pros
y an
d Lu
ng h
ealt
h ac
tivi
ties
100
Men
tors
hip
by
CH
EWS
and
CH
Ws
to
peer
gr
oups
on
co
mm
unit
y TB
, Le
pros
y an
d Lu
ng h
ealt
h ac
tivi
ties
100
Men
tors
hip
by
CH
EWS
and
CH
Ws
to
peer
gr
oups
on
co
mm
unit
y TB
, Le
pros
y an
d Lu
ng h
ealt
h ac
tivi
ties
100
Prop
orti
on
of
faci
litie
s pa
rtic
ipat
ing
in
com
mun
ity
and
faci
lity
dial
ogue
for
ums
Supp
ort
Qua
rter
ly
Dia
logu
e fo
rum
s fo
r C
HEW
S an
d C
omm
unit
y ac
tors
on
Com
mun
ity
TB, L
epro
sy a
nd L
ung
Hea
lth
n/a
Supp
ort
Qua
rter
ly
Dia
logu
e fo
rum
s fo
r C
HEW
S an
d C
omm
unit
y ac
tors
on
C
omm
unit
y TB
, Le
pros
y an
d Lu
ng H
ealt
h
50%
Supp
ort
Qua
rter
ly
Dia
logu
e fo
rum
s fo
r C
HEW
S an
d C
omm
unit
y ac
tors
on
C
omm
unit
y TB
, Le
pros
y an
d Lu
ng H
ealt
h
75%
75%
Num
ber
of
com
mun
ity
unit
s pr
ovid
ing
TB,
lepr
osy
and
lung
dis
ease
ser
vice
sSt
reng
then
the
est
ablis
hed
but
non-
func
tion
al
com
mun
ity
unit
s to
impl
emen
t TB
. n/
aSt
reng
then
the
est
ablis
hed
but
non-
func
tion
al c
omm
unit
y un
its
to im
plem
ent
TB.
8St
reng
then
the
est
ablis
hed
but
non-
func
tion
al c
omm
unit
y un
its
to im
plem
ent
TB.
1524
Stra
tegi
c A
ppro
ach
4: E
ngag
e co
mm
unit
ies
and
coun
ties
in p
lann
ing
Num
ber
of c
omm
unit
y TB
pol
icie
s ,m
anua
ls a
nd
guid
elin
es d
istr
ibut
edD
istr
ibut
ion
of
stan
dard
ized
an
d up
date
d C
omm
unit
y TB
ca
re
docu
men
ts
such
as
po
licie
s,
man
uals
an
d gu
idel
ines
to
al
l im
plem
ente
rs,
acto
rs
and
stak
ehol
ders
on
co
mm
unit
y TB
inte
rven
tion
s an
d im
plem
enta
tion
to
faci
litat
e an
d ha
rmon
ize
appr
oach
es f
or r
each
ing
the
unr
each
ed
Dis
trib
ute
com
mun
ity
TB
docu
men
ts4,
500
Dis
trib
ute
com
mun
ity
TB
polic
ies,
man
uals
an
d gu
idel
ines
to
coun
ties
2,50
0D
istr
ibut
e co
mm
unit
y TB
po
licie
s,
m
anua
ls
and
guid
elin
es t
o co
unti
es
2,00
0
Num
ber
of s
take
hold
ers
sens
itiz
edSe
nsit
ize
stak
ehol
ders
on
ne
w
tool
s an
d po
licie
sn/
aSe
nsit
izat
ion
mee
ting
s fo
r ne
w
stak
ehol
ders
100
n/a
n/a
Num
ber
of
com
mun
icat
ion
and
awar
enes
s ra
isin
g ev
ents
tar
geti
ng t
he p
ublic
Prom
ote
awar
enes
s cr
eati
on t
hrou
gh p
ublic
fo
rum
s an
d ex
hibi
tion
s n/
aSe
nsit
ize
scho
ols
on T
B du
ring
an
nual
sch
ools
fes
tiva
ls
1Se
nsit
ize
scho
ols
on T
B du
ring
an
nual
sch
ools
fes
tiva
ls1
Sens
itiz
e sc
hool
s on
TB
duri
ng
annu
al s
choo
ls f
esti
vals
1
Recr
uit
cele
brit
ies
as T
B A
mba
ssad
ors
n/a
Recr
uit
cele
brit
ies
as
TB
Am
bass
ador
s 1
Recr
uit
cele
brit
ies
as
TB
Am
bass
ador
s 1
Recr
uit
cele
brit
ies
as
TB
Am
bass
ador
s 1
Sens
itiz
e th
e co
mm
unit
y on
TB
thro
ugh
med
ia a
nd in
pub
lic b
araz
as
Wor
k w
ith
loca
l med
ia o
rgan
i-za
tion
s to
dev
elop
and
air
a p
lay
on T
B
Sens
itiz
e th
e co
mm
unit
y on
TB
in p
ublic
bar
azas
Se
nsit
ize
the
com
mun
ity
on T
B in
pub
lic b
araz
as
Sens
itiz
e th
e co
mm
unit
y on
TB
in p
ublic
bar
azas
Inco
rpor
ate
TB s
tand
s in
to A
SK s
how
sPu
t up
a s
tand
in t
he A
SK s
how
s in
al
l cou
ntie
s 2
Put
up a
sta
nd in
the
ASK
sho
ws
in a
ll co
unti
es
10Pu
t up
a s
tand
in t
he A
SK s
how
s in
all
coun
ties
20
Put
up a
sta
nd in
the
ASK
sho
ws
in a
ll co
unti
es
30
4.3.
4. C
omm
unit
y En
gage
men
t
4.3.4. Comm
unity Engagement
Com
mun
ity
Enga
gem
ent
Ope
rati
onal
Pla
n
Out
put
Indi
cato
r(s)
Inte
rven
tion
sY
ear
1 A
ctiv
itie
sY
r 1
Targ
etY
ear
2 A
ctiv
itie
sY
r 2
Targ
et
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
5: C
reat
e pa
tien
t en
gage
men
t gu
idel
ines
and
upd
ate
othe
r po
licie
s an
d to
ols
Num
ber
of p
olic
ies,
man
uals
, gui
delin
e re
vise
d,
prin
ted
and
diss
emin
ated
1. D
evel
op p
atie
nt e
ngag
emen
t gu
idel
ines
for
C
HW
s an
d C
HEW
s
2. U
pdat
e ex
isti
ng p
olic
ies,
gui
delin
es a
nd
tool
s re
late
d to
com
mun
ity-
base
d ca
re
Dev
elop
pat
ient
eng
agem
ent
guid
elin
es1
Revi
se c
omm
unit
y TB
pol
icie
s,
m
anua
ls a
nd g
uide
lines
2
Stra
tegi
c A
ppro
ach
6: H
arm
oniz
e pa
ymen
t le
vels
for
CH
Ws
Har
mon
ized
pa
ymen
t le
vels
fo
r C
HW
s an
d C
HEW
s ac
ross
pro
gram
mes
, in
lin
e w
ith
MoH
st
rate
gy
Dev
elop
an
d di
ssem
inat
e a
com
mun
ity
deliv
ery
mod
el o
f ca
re f
or T
uber
culo
sis
Recr
uit
and
enga
ge a
con
sult
ant
to le
ad t
he t
eam
in d
evel
opin
g a
mod
el o
f ca
re
1
Hol
d co
unty
fo
rum
s to
di
ssem
inat
e th
e co
mm
unit
y de
liver
y m
odel
of
care
for
TB
1
Supp
ort
a on
e da
y tr
aini
ng a
t su
b co
unti
es
for
CH
Ws,
an
d ot
her
impl
emen
ters
on
the
new
C
omm
unit
y de
liver
y m
odel
of
ca
re f
or T
B
1,25
0Su
ppor
t a
one
day
trai
ning
at
sub
coun
ties
fo
r C
HW
s,
and
othe
r im
plem
ente
rs o
n th
e ne
w
Com
mun
ity
deliv
ery
mod
el
of
care
for
TB
1,25
0
Hol
d an
nual
ly
foru
ms
for
all
impe
lem
ente
rs
at
the
coun
ty
leve
ls t
o ev
alua
te, r
evie
w, s
hare
ex
peri
ence
s an
d do
cum
ent
prog
ress
of
impe
lem
enti
ng t
he
mod
el
188
Hol
d an
nual
ly
foru
ms
for
all
impe
lem
ente
rs
at
the
coun
ty
leve
ls t
o ev
alua
te, r
evie
w, s
hare
ex
peri
ence
s an
d do
cum
ent
prog
ress
of
impe
lem
enti
ng t
he
mod
el
188
Hol
d an
nual
ly
foru
ms
for
all
impe
lem
ente
rs
at
the
coun
ty
leve
ls t
o ev
alua
te, r
evie
w, s
hare
ex
peri
ence
s an
d do
cum
ent
prog
ress
of
impe
lem
enti
ng t
he
mod
el
188
Recr
uit
and
enga
ge a
con
sult
ant
to c
ondu
ct a
sur
vey
wit
h C
HEW
s es
tabl
ish
thei
r pr
effe
red
mod
e of
co
mpe
nsat
ion
and
deve
lop
ToRs
to
guid
e co
mpe
nsat
ion
1
Hol
d a
diss
emin
atio
n fo
rum
w
ith
stak
ehol
ders
4.3.5. Enhance multi-sectoral response to TB/HIV1. Situational Analysis
Kenya has a heavy dual burden of TB and HIV. HIV remains a key driver of the TB epidemic, with six in one hundred (5.6%) Kenyans aged 15-64 years being HIV infected. Some counties have reported up to four times the national HIV prevalence (See Map 9).
In 2013, over one-third (37%) of notified TB patients nationally were HIV infected, compared to 13% globally. Some regions reported up to 75% HIV infection among TB patients.
Despite the disease burden, Kenya has been recognized as a leader in implementing the recommended WHO TB/HIV collaborative activities. In 2013, 19 out of every 20 patients with TB disease (95%) had a documented HIV test result with 83% of those HIV-infected being put on cART and almost all on CPT. Intensified TB case finding has been strengthened. Data collected during the 2014 mid-term review revealed that 83% of PLHIV in care and treatment were screened for TB during their clinical visit. It was however noted that only 2% of those screening negative for TB were initiated on isoniazid preventive therapy (IPT). Guidelines for TB infection prevention and control (IPC) in health care and congregate settings were developed and disseminated in 2009. However, full operationalization at facility and community level is yet to be realized.
4.3.
5. M
ulti
-sec
tora
l Res
pons
e to
TB/
HIV
Map 9: Prevalence of HIV and Number of TB/HIV Cases Reported by County
Figure 20: TB/HIV and Overall Notification Rates by County, 2013
77
National TB surveillance data indicates that HIV-infected TB patients are three times more likely to die compared to those who are HIV negative. Similarly TB patients who decline an HIV test are two times more likely to die or get lost to follow-up compared to HIV negative TB patients. While there is near-universal HIV Testing and Counseling (HTC) coverage for TB patients, there is need to characterize populations not being tested for HIV to close the gaps in HTC. Sexual partner and family HIV testing needs to be enhanced by leveraging on the gains made by the HIV program.
This strategic plan focuses on closing gaps using innovative approaches in PITC, infection prevention and control, early initiation of cART, intensified TB case finding, as well as addressing TB/HIV program quality issues and institutionalizing TB/HIV collaborative activities.
2. Strategic Direction(s) for 2015-2018
Though gains have been made in Kenya in the implementation of TB/HIV collaborative activities, particularly of the 5Is, key elements to support sustainable TB/HIV practices are weak or lacking. The following TB/HIV strategic directions will be geared towards addressing these weaknesses to ensure sustainability in implementing all the TB/HIV collaborative activities, while drawing on innovations to scale up any successes achieved, such as those made during piloting of IPT in some regions. In addition, there will be need to leverage on devolution to support any gains made so far. Strategic interventions must include formation of TB/HIV coordinating bodies, scaling up IPT, and strengthening infection prevention and control at health care and congregate settings.
3. Proposed Approaches
a) Formation of TB/HIV coordinating bodies
TB/HIV coordinating bodies will support TB/HIV collaborative activities with clear terms of reference outlining the scope of work at each level of service provision, as developed by the national TB/HIV coordinating body. The coordinating body at national level will be charged with the revision and dissemination of the new TB/HIV guidelines using an integrated approach towards guideline development and dissemination. Guideline dissemination will involve the use of faster, low cost electronic/digital methods.
The national and county level coordinating bodies will seek sufficient human resources for health to support the expanded TB/HIV collaborative activities from national and county governments. This will include hiring or task shifting of health care workers, both at the national and county levels, to enable the planned scale up of TB/HIV collaborative activities. Increasing the capacity of existing health care workers to provide quality services is also a priority, and training will reflect the geographic focus (see box). Due to high staff turnover and the inherent need for refresher training, continuous capacity building is critical, and innovative sustainable approaches for conducting in-service staff training will include having structured and updated continuous medical education programs held at regular intervals (web-based learning modules, web-based CPD accredited self-taught modules). To capitalize on the successful models employed by some facilities, the evolution of these facilities as TB/HIV centres of excellence is envisioned to create hubs for more decentralized capacity building and mentorship.
The national coordinating body will also develop a TB/HIV Continuous Quality Improvement (CQI) framework as part of the larger TB CQI framework to give guidance on quality review of the TB/HIV program. The TB/HIV coordinating body at county level will be charged with coordinating TB/HIV CQI reviews at sub-county, facility and community levels. TB/HIV coordinating bodies and stakeholders at all levels will conduct regular TB/HIV performance reviews and agree on corrective
Figure 21: HIV Testing and Co-infection Rates among Notified TB Patients, 2008-2012
4.3.5. Multi-sectoral Response to TB/H
IV
78
Figure 22: ART and CPT Uptake
measure to address unmet targets.
b) TB/HIV monitoring and evaluation system
The establishment of monitoring and evaluation systems that comprehensively address all TB/HIV collaborative activities will be achieved through the development of a comprehensive TB/HIV M&E framework, integrated into the NTLD Program and NASCOP M&E framework.
This comprehensive TB/HIV M&E framework will guide the tracking of TB/HIV performance indicators by counties, uniformed forces, and key populations. Additionally, TB/HIV standardized program indicators will also be integrated into the national health management information system (HMIS).
Counties and sub-counties will have their capacities to analyze TB/HIV data enhanced. This will boost the utilization of data in decision making and for programme improvement.
c) IPT for all eligible PLHIV
IPT has been implemented successfully in a few select facilities in Kenya. The rapid scale-up of this strategic intervention to reduce development of TB disease among PLHIV will be pegged on collaborative efforts with NASCOP and NACC. In particular, strategies will be implemented to improve isoniazid commodity security, strengthen IPT M&E systems and scale up contact investigation.
d) Scale up of TB IPC in health care and congregate settings
The implementation of TB infection prevention and control measures within health facilities and congregate settings has been largely unsuccessful, despite the development of the national TB infection control guidelines in 2009. This strategic plan lays emphasis on preventing TB transmission within the health facilities and the community. It is a key component of the prevention strategy.
The scale up and institutionalization of TB IPC activities at facility and community levels will be achieved through revision and dissemination of new TB IPC guidelines to include development and implementation of TB and TB/HIV work place policies, continuous capacity building of TB managers, health facility managers, and HCWs using trained TB IC TOTs and mentors from an established web-based training database. In addition, resource mobilization for health facility infrastructural improvement at national and county levels will be required to ensure that infrastructural development is carried out in line with TB IC measures through leveraging on other ministries, such as the Ministry of Housing to change planning policies. Additionally, there is need to develop TB IPC CQI and M&E systems.
e) Integration of TB and HIV servicesDuring the 2014 mid-term review, 79% of the evaluated facilities reported integrated TB and HIV services, providing an
1 | P a g e
Sustain the gains, in the context of a newly devolved system
• Sustaining na;onwide coverage of HIV tes;ng among TB pa;ents and cART among TB/HIV co-‐infected
Intensify efforts to find “missing” cases
• Scale-‐up IPT, IPC and TB/HIV service delivery integra;on in coun;es with HIV prevalence of >5% in Year 1, and in coun;es with HIV prevalence of 2.5-‐5% in subsequent years
• Enhance M&E of TB/HIV collabora;ve ac;vi;es to beWer idenXy gaps in programme performance
Reduce transmission
• Intensify infec;on control in high HIV prevalence contexts
Prevent ac;ve disease and morbidity
• Scale up CPT and cARTfor all TB/HIV co-‐infected pa;ents
STRATEGIC OBJECTIVES
4.3.
5. M
ulti
-sec
tora
l Res
pons
e to
TB/
HIV
79
opportunity for Kenya to scale-up IPT, implement improved TB infection control practices, and refine other elements of the TB/HIV collaborative activities. There is need to leverage on the on-going scale up of eMTCT through option B plus (ART for all pregnant women living with HIV) to integrate TB services within all HIV providing facilities.
f) TB intensified case finding
Screening for TB among PLHIV is routinely offered to identify those with presumptive TB. Scaling up this strategic intervention to improve coverage of TB ICF will be done through leveraging on the national PITC strategy to conduct TB ICF in all HTC settings, addressing quality issues in screening and scaling up new diagnostic technologies, including making the Xpert MTB Rif test the first test for all PLHIV with presumptive TB.
Coverage of TB intensified case finding will be increased by leveraging on the PITC strategy to conduct TB ICF in all HTC settings, as well as the aforementioned eMTCT strategy to introduce TB ICF to key populations and in high risk settings. In addition, TB diagnostics will be supported by procuring more CXR machines, capacity building on X-ray interpretation and zero costing CXRs to improve access to quality radiography. In addition, there will be need to conduct remote (web-based) clinical and radiological consultations. CQI processes will be established to monitor the quality of TB ICF.
g) Immediate cART and CPT uptake
4.3.5. Multi-sectoral Response to TB/H
IV
Geographic Focus
Sustaining gains nationwide: The current efforts and gains already made in HIV testing and CPT uptake will be sustained in all the counties. Activities related to TB-HIV coordination, monitoring and evaluation for TB HIV activities, TB intensified case finding among PLHIV, immediate ART for TB HIV co-infected and IPT for children less than 5 years old exposed to smear positive index cases will be accelerated across all the 47 counties in Kenya.
Intensified action in most at-risk populations: focus on the scale-up of isoniazid prophylaxis, integration of TB/HIV service delivery and TB infection prevention and control in health facilities
>5% HIV prevalence: Year 1 focus in 21 counties with HIV prevalence in the general population above 5% (see chart)
2.5-5% HIV prevalence: Year 2-4 scale-up in 19 counties with HIV prevalence in the general population between 2.5-5%
<2.5% HIV prevalence: Sustained IPT, IPC and service delivery integration in 7 counties with HIV prevalence in the general population below 2.5%
Box 6Major achievements have been made in the provision of cART for TB/HIV co-infected patients. This strategic plan will address opportunities for further scale-up, ensuring that at least 95% of TB/HIV co-infected patients are initiated on ART and that the initiation of cART is done early in the course of TB treatment, i.e, within two months.
The scale-up of immediate cART and CPT will be achieved by ensuring the dissemination of revised national TB/HIV policies and clinical guidelines to all care providers, using innovative approaches to implement evidence based practices, integration of TB and HIV service delivery, leveraging on the decentralization of cART through the national eMTCT strategy, availing TB/HIV patient friendly treatment regimens, institutionalization of TB/HIV CQI activities, conducting routine monitoring, evaluation of early cART uptake and monitoring of TB/HIV treatment outcomes. It is necessary to use gains in HIV testing among TB patients to screen family members for TB/HIV, to reduce the burden of HIV.
h) Conduct operations research on 5I’s implementation
There is need to evaluate performance of the ICF/IPT screening tool to assess reasons why only 7% of all PLHIV screened positive. Measurement of the timing of cART initiation among co-infected TB patients will assess timeliness regarding the quality of care offered to co-infected TB patients. Additionally, there is need to evaluate implemented innovative approaches to improving access to TB diagnostics, such as the use of GeneXpert as an initial test for PLHIV, as well as incentives provided for diagnostic evaluation.
80
Contribution to NSP Impacts Outcomes (TB/HIV)
Impact 1.2: Reduce the incidence of TB among PLHIV by 60% by 2018, compared to 2014
• Increase to 100% the proportion of counties with functional TB/HIV coordinating bodies
• Increase to 95% the proportion of PLHIV in care screened for TB at their last clinical visit using the ICF screening tool in HIV clinics
• Sustain universal CPT coverage among HIV+ TB patients• Increase to 90% the proportion of HIV+ TB patients accessing
cART• Increase to 90%, the proportion of health facilities
implementing the minimum TB IPC package• Increase to 80% the proportion of eligible persons for IPT who
receive INH
Impact 2: Reduce mortality due to TB by 3% by 2018, compared to 2014.
• Increase to 75% the proportion of facilities implementing CQI in TB/HIV
Table 11: Impact and Outcome Indicators for Multi-sectoral Response to TB/HIV
4.3.
5. M
ulti
-sec
tora
l Res
pons
e to
TB/
HIV
81
TB/H
IV O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
1: F
orm
atio
n of
TB/
HIV
coo
rdin
atin
g bo
dies
Prop
orti
on o
f co
unti
es a
nd s
ub-c
ount
ies
wit
h ac
tive
TB/
HIV
coo
rdin
atin
g bo
dies
Hol
d na
tion
al,
coun
ty a
nd s
ubco
unty
TB/
HIV
coo
rdin
atin
g bo
dies
mee
ting
s4
mee
ting
s at
nat
iona
l,cou
nty
and
sub-
coun
ty25
4 m
eeti
ngs
at n
atio
nal,
coun
ty
and
sub-
coun
ty10
04
mee
ting
s at
nat
iona
l, co
unty
and
su
b-co
unty
100
4 m
eeti
ngs
at n
atio
nal,
coun
ty
and
sub-
coun
ty10
0
Con
duct
na
tion
al
TB/H
IV
stak
ehol
ders
' m
eeti
ng2
mee
ting
s2
mee
ting
s2
mee
ting
s1
mee
ting
Dev
elop
ToR
s ou
tlin
ing
the
scop
e of
wor
k of
nat
iona
l an
d co
unty
TB/
HIV
cor
dina
ting
bo
dies
1 m
eeti
ngn/
an/
an/
a
Hol
d co
unty
TB/
HIV
pla
nnin
g m
eeti
ngs
1 m
eeti
ng/c
ount
yn/
an/
an/
a
Hol
d qu
arte
ly
TB/H
IV
TWG
m
eeti
ngs
at
nati
onal
leve
l 4
mee
ting
s4
mee
ting
s4
mee
ting
s4
mee
ting
s
Num
ber
of
acti
ve
nati
onal
TB
/HIV
co
ordi
nati
ng b
odie
sH
old
bi
annu
al
nati
onal
le
vel
TB/
HIV
im
plem
enti
ng
part
ners
' m
eeti
ng
high
light
ing
prov
isio
nal s
uppo
rt b
y pa
rtne
rs
2 m
eeti
ngs
12
mee
ting
s1
2 m
eeti
ngs
12
mee
ting
s1
Stra
tegi
c A
ppro
ach
2: S
tren
gthe
n TB
/HIV
mon
itor
ing
and
eval
uati
on s
yste
m
Prop
orti
on o
f fa
cilit
ies
repo
rtin
g on
all
TB/H
IV
indi
cato
rs
mon
thly
th
roug
h th
e na
tion
al r
epor
ting
sys
tem
(DH
IS)
Nat
iona
l le
vel
wor
shop
to
deve
lop
TB/H
IV
prog
ram
in
dica
tors
fo
r in
tegr
atio
n in
to
nati
onal
HM
IS (I
PT ,
ICF,
con
tact
trac
ing,
IPC
) an
d TB
/HIV
CQ
Is f
ram
ewor
k.
1 w
orks
hop
800
>90
0>
900
>90
Cou
nty
sens
itiz
atio
ns
on
TB
H
IV
data
an
alys
is a
nd u
tiliz
atio
n of
dat
a fo
r de
cisi
on
mak
ing
incl
udin
g im
prov
ing
the
TB-H
IV
qual
ity
of c
are.
1 se
nsit
izat
ion/
coun
ty1
11
Sub-
Cou
nty
sens
itiz
atio
ns o
n T
B H
IV d
ata
anal
ysis
and
uti
lizat
ion
of d
ata
for
deci
sion
m
akin
g in
clud
ing
impr
ovin
g th
e TB
-HIV
qu
alit
y of
car
e.
47 s
ensi
tiza
tion
/cou
nty
00
0
Qua
rter
ly
coun
ty
TB/H
IV
perf
orm
ance
re
view
mee
ting
s4
coun
ty d
ata
revi
ew m
eeti
ngs
for
the
40 m
id a
nd h
igh
burd
en
HIV
pre
vale
nce
coun
ties
100
4 co
unty
dat
a re
view
mee
ting
s fo
r th
e 40
mid
and
hig
h bu
rden
H
IV p
reva
lenc
e co
unti
es
100
4 co
unty
dat
a re
view
mee
ting
s fo
r th
e 40
mid
and
hig
h bu
rden
HIV
pr
eval
ence
cou
ntie
s
100
4 co
unty
dat
a re
view
mee
ting
s fo
r th
e 40
mid
and
hig
h bu
rden
HIV
pr
eval
ence
cou
ntie
s
100
Prop
orti
on o
f pl
anne
d bi
ann
ual
supp
ort
supe
rvis
ion
of h
igh
burd
en c
ount
ries
don
e by
TB/
HIV
nat
iona
l coo
rdin
atin
g bo
dy
Con
duct
bi
annu
al n
atio
nal
leve
l te
chni
cal
assi
stan
ce o
f th
e 21
hi
gh b
urde
n co
unti
es
on im
plem
enta
tion
of
TB/H
IV a
ctiv
itie
s
21 c
ount
ies
(cou
ntie
s w
ith
HIV
pr
eval
ence
>5
%)
21 c
ount
ies
(cou
ntie
s w
ith
HIV
pr
eval
ence
>5
%)
21
coun
ties
(c
ount
ies
wit
h H
IV
prev
alen
ce >
5 %
)21
co
unti
es
(cou
ntie
s w
ith
HIV
pr
eval
ence
>5
%)
Stra
tegi
c A
ppro
ach
3: IP
T fo
r al
l elig
ible
PLH
IV a
nd c
hild
ren
unde
r 5
expo
sed
to T
B co
ntac
ts
Prop
orti
on
of
plan
ned
wor
ksho
ps
for
deve
lopm
ent o
f IPT
tool
s an
d se
nsit
izat
ion
pack
age
cond
ucte
d
Dev
elop
men
t of
co
mpr
ehen
sive
IP
T se
nsit
izat
ion
pack
age
at
TWG
leve
l1
mee
ting
2n/
a0
n/a
0n/
a0
Con
duct
a w
orks
hop
to d
evel
op a
n IP
T M
&E
fram
ewor
k in
clud
ing
IPT
data
re
port
ing
at c
ount
y an
d na
tion
al l
evel
s, a
s w
ell
as
stan
dard
izat
ion
of
all
ICF/
IPT
card
s,
IPT
regi
ster
, IPT
app
oint
men
t ca
rds
and
cont
act
trac
ing
regi
ster
s
1 m
eeti
ngn/
an/
an/
a
Prop
orti
on o
f el
igib
le P
LHIV
and
chi
ldre
n un
der
5 w
ho
are
cont
acts
of
sm
ear-
posi
tive
TB
pati
ents
put
on
IPT
Nat
iona
l ro
ll ou
t of
IPT
im
plem
enta
tion
to
incl
ude
impl
emen
ting
par
tner
s, M
oH (N
LTD
-Pr
ogra
m
&
NA
SCO
P),
as
wel
l as
co
unty
he
ads
1 m
eeti
ng25
%n/
a50
%n/
a80
%n/
a>
80% 4.3.5. M
ulti-sectoral Response to TB/HIV
TB/H
IV O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
1: F
orm
atio
n of
TB/
HIV
coo
rdin
atin
g bo
dies
Prop
orti
on o
f co
unti
es a
nd s
ub-c
ount
ies
wit
h ac
tive
TB/
HIV
coo
rdin
atin
g bo
dies
Hol
d na
tion
al,
coun
ty a
nd s
ubco
unty
TB/
HIV
coo
rdin
atin
g bo
dies
mee
ting
s4
mee
ting
s at
nat
iona
l,cou
nty
and
sub-
coun
ty25
4 m
eeti
ngs
at n
atio
nal,
coun
ty
and
sub-
coun
ty10
04
mee
ting
s at
nat
iona
l, co
unty
and
su
b-co
unty
100
4 m
eeti
ngs
at n
atio
nal,
coun
ty
and
sub-
coun
ty10
0
Con
duct
na
tion
al
TB/H
IV
stak
ehol
ders
' m
eeti
ng2
mee
ting
s2
mee
ting
s2
mee
ting
s1
mee
ting
Dev
elop
ToR
s ou
tlin
ing
the
scop
e of
wor
k of
nat
iona
l an
d co
unty
TB/
HIV
cor
dina
ting
bo
dies
1 m
eeti
ngn/
an/
an/
a
Hol
d co
unty
TB/
HIV
pla
nnin
g m
eeti
ngs
1 m
eeti
ng/c
ount
yn/
an/
an/
a
Hol
d qu
arte
ly
TB/H
IV
TWG
m
eeti
ngs
at
nati
onal
leve
l 4
mee
ting
s4
mee
ting
s4
mee
ting
s4
mee
ting
s
Num
ber
of
acti
ve
nati
onal
TB
/HIV
co
ordi
nati
ng b
odie
sH
old
bi
annu
al
nati
onal
le
vel
TB/
HIV
im
plem
enti
ng
part
ners
' m
eeti
ng
high
light
ing
prov
isio
nal s
uppo
rt b
y pa
rtne
rs
2 m
eeti
ngs
12
mee
ting
s1
2 m
eeti
ngs
12
mee
ting
s1
Stra
tegi
c A
ppro
ach
2: S
tren
gthe
n TB
/HIV
mon
itor
ing
and
eval
uati
on s
yste
m
Prop
orti
on o
f fa
cilit
ies
repo
rtin
g on
all
TB/H
IV
indi
cato
rs
mon
thly
th
roug
h th
e na
tion
al r
epor
ting
sys
tem
(DH
IS)
Nat
iona
l le
vel
wor
shop
to
deve
lop
TB/H
IV
prog
ram
in
dica
tors
fo
r in
tegr
atio
n in
to
nati
onal
HM
IS (I
PT ,
ICF,
con
tact
trac
ing,
IPC
) an
d TB
/HIV
CQ
Is f
ram
ewor
k.
1 w
orks
hop
800
>90
0>
900
>90
Cou
nty
sens
itiz
atio
ns
on
TB
H
IV
data
an
alys
is a
nd u
tiliz
atio
n of
dat
a fo
r de
cisi
on
mak
ing
incl
udin
g im
prov
ing
the
TB-H
IV
qual
ity
of c
are.
1 se
nsit
izat
ion/
coun
ty1
11
Sub-
Cou
nty
sens
itiz
atio
ns o
n T
B H
IV d
ata
anal
ysis
and
uti
lizat
ion
of d
ata
for
deci
sion
m
akin
g in
clud
ing
impr
ovin
g th
e TB
-HIV
qu
alit
y of
car
e.
47 s
ensi
tiza
tion
/cou
nty
00
0
Prop
orti
on o
f pl
anne
d bi
ann
ual
supp
ort
supe
rvis
ion
of h
igh
burd
en c
ount
ries
don
e by
TB/
HIV
nat
iona
l coo
rdin
atin
g bo
dy
Qua
rter
ly
coun
ty
TB/H
IV
perf
orm
ance
re
view
mee
ting
s4
coun
ty d
ata
revi
ew m
eeti
ngs
for
the
40 m
id a
nd h
igh
burd
en
HIV
pre
vale
nce
coun
ties
100
4 co
unty
dat
a re
view
mee
ting
s fo
r th
e 40
mid
and
hig
h bu
rden
H
IV p
reva
lenc
e co
unti
es
100
4 co
unty
dat
a re
view
mee
ting
s fo
r th
e 40
mid
and
hig
h bu
rden
HIV
pr
eval
ence
cou
ntie
s
100
4 co
unty
dat
a re
view
mee
ting
s fo
r th
e 40
mid
and
hig
h bu
rden
HIV
pr
eval
ence
cou
ntie
s
100
Con
duct
bi
annu
al n
atio
nal
leve
l te
chni
cal
assi
stan
ce o
f th
e 21
hi
gh b
urde
n co
unti
es
on im
plem
enta
tion
of
TB/H
IV a
ctiv
itie
s
21 c
ount
ies
(cou
ntie
s w
ith
HIV
pr
eval
ence
>5
%)
21 c
ount
ies
(cou
ntie
s w
ith
HIV
pr
eval
ence
>5
%)
21
coun
ties
(c
ount
ies
wit
h H
IV
prev
alen
ce >
5 %
)21
co
unti
es
(cou
ntie
s w
ith
HIV
pr
eval
ence
>5
%)
Stra
tegi
c A
ppro
ach
3: IP
T fo
r al
l elig
ible
PLH
IV a
nd c
hild
ren
unde
r 5
expo
sed
to T
B co
ntac
ts
Prop
orti
on
of
plan
ned
wor
ksho
ps
for
deve
lopm
ent o
f IPT
tool
s an
d se
nsit
izat
ion
pack
age
cond
ucte
d
Dev
elop
men
t of
co
mpr
ehen
sive
IP
T se
nsit
izat
ion
pack
age
at
TWG
leve
l1
mee
ting
2n/
a0
n/a
0n/
a0
Con
duct
a w
orks
hop
to d
evel
op a
n IP
T M
&E
fram
ewor
k in
clud
ing
IPT
data
re
port
ing
at c
ount
y an
d na
tion
al l
evel
s, a
s w
ell
as
stan
dard
izat
ion
of
all
ICF/
IPT
card
s,
IPT
regi
ster
, IPT
app
oint
men
t ca
rds
and
cont
act
trac
ing
regi
ster
s
1 m
eeti
ngn/
an/
an/
a
Prop
orti
on o
f el
igib
le P
LHIV
and
chi
ldre
n un
der
5 w
ho
are
cont
acts
of
sm
ear-
posi
tive
TB
pati
ents
put
on
IPT
Nat
iona
l ro
ll ou
t of
IPT
im
plem
enta
tion
to
incl
ude
impl
emen
ting
par
tner
s, M
oH (N
LTD
-Pr
ogra
m
&
NA
SCO
P),
as
wel
l as
co
unty
he
ads
1 m
eeti
ng25
%n/
a50
%n/
a80
%n/
a>
80%
4.3.
5. M
ulti
-sec
tora
l Res
pons
e to
TB/
HIV
4.3.5. Multi-sectoral Response to TB/H
IV
TB/H
IV O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Con
duct
co
unty
le
vel
IPT
sens
itiz
atio
ns
thro
ugh
impl
emen
ting
par
tner
s IP
T co
unty
lev
el s
ensi
tiza
tion
s fo
r 21
high
H
IV
bu
rden
co
unti
es
IPT
coun
ty
leve
l se
nsit
izat
ions
fo
r 19
cou
ntie
sn/
an/
a
Con
duct
fa
cilit
y le
vel
men
tors
hip
and
trai
ning
thr
ough
CH
MT
and
Impl
emen
ting
pa
rtne
rs
Faci
lity
leve
l tr
aini
ng
and
men
tors
hio
fo
r IP
T im
plem
enti
ng
site
s in
hi
gh
burd
ened
cou
ntie
s
Faci
lity
leve
l tr
aini
ng
and
men
tors
hio
for I
PT im
plem
enti
ng
site
s in
all
hig
h an
d m
ediu
m
burd
ened
cou
ntie
s
Faci
lity
leve
l tr
aini
ng
and
men
tors
hio
for
IPT
im
plem
enti
ng
site
s in
al
l
high
an
d m
ediu
m
burd
ened
cou
ntie
s
Faci
lity
leve
l tra
inin
g an
d m
ento
rshi
o fo
r IPT
impl
emen
ting
sit
es in
all
hig
h an
d m
ediu
m b
urde
ned
coun
ties
Prin
t co
ntac
t tr
acin
g re
gist
ers
06,
000
2,00
00
Prin
t IC
F/IP
T ca
rds
Prin
t 5
00,0
00 I
CF/
IPT
card
sPr
int
500
,000
IC
F/IP
T ca
rds
Prin
t 5
00,0
00 I
CF/
IPT
card
s0
IPT
pati
ent
appo
intm
ent
card
sPr
int
200,
000
IPT
appo
intm
ent
card
sPr
int
200,
000
IPT
appo
intm
ent
card
sPr
int
200,
000
IPT
appo
intm
ent
card
s0
IPT
regi
ster
Prin
t 20
00 IP
T r
egis
ters
0
Prin
t 2,
000
IPT
reg
iste
rs
0
Stra
tegi
c A
ppro
ach
4: S
cale
up
of T
B IP
C in
hea
lth
care
and
con
greg
ate
sett
ings
Num
ber
of
wor
ksho
ps
for
the
deve
lopm
ent
of T
B IP
C t
ools
and
pol
icy
guid
elin
es c
ondu
cted
Mul
ti-s
ecto
ral
stak
ehol
der'
s fo
rum
in
clud
ing
othe
r no
n-m
edic
al s
take
hold
ers
to
leve
rage
on
IP
C
supp
ort
by
othe
r m
inis
trie
s su
ch
as
Min
istr
y of
H
ousi
ng,
min
istr
y of
edu
cati
on.
1 w
orks
hop
4n/
an/
an/
an/
an/
an/
a
Dev
elop
TB/
HIV
wor
kpla
ce p
olic
y2
wor
ksho
psn/
an/
an/
a
Wor
k sh
op
to
revi
se
IPC
gu
idel
ines
, de
velo
pmen
t of
IPC
CQ
I and
IPC
indi
cato
rs
1 w
orks
hop
Num
ber
of
IPC
po
licy
docu
men
ts
and
tool
s pr
inte
dPr
int
TB/H
IV w
orkp
lace
doc
umen
ts6,
000
TB/
HIV
pol
icy
docu
men
ts
12,0
000
n/a
0n/
a0
n/a
Prin
t a
nd d
istr
ibut
e re
vise
d IP
C g
uide
lines
6,
000
IPC
gu
idel
ine
copi
es
prin
ted
00
0
Prop
orti
on
of
heal
th
faci
litie
s an
d co
ngre
gate
set
ting
s im
plem
enti
ng T
B IP
CD
isse
min
ate
IPC
gu
idel
ines
an
d TB
/HIV
w
orkp
lace
pol
icy
docu
men
t0
1 m
eeti
ng f
or c
oth
TB/H
IV p
olic
y an
d IP
C g
uide
line
diss
emin
atio
n25
%0
50%
050
%
Cou
nty
leve
l tr
aini
ngs
of
revi
sed
IPC
gu
idel
ines
01
trai
ning
/cou
nty
for
21
high
bu
rden
cou
ntie
s1
trai
ning
/cou
nty
for
19
mid
bu
rden
cou
ntie
s0
Con
duct
fac
ility
lev
el T
B in
fect
ion
trai
ning
an
d ri
sk a
sses
smen
ts0
Con
duct
TB
risk
ass
esm
ent
in 2
1 H
IV h
igh
prev
alnc
e co
unti
es (
7 he
alth
fac
iliti
es p
er c
ount
y)
00
Dev
elop
men
t of
faci
lity
leve
l IP
C
wor
k pl
ans
0D
evel
op h
ealt
h fa
cilit
y IP
C p
lans
in
21
HIV
hig
h pr
eval
ent c
ount
ies
(7 h
ealt
h fa
cilit
ies
per
coun
ty)
00
Stra
tegi
c A
ppro
ach
5: Im
med
iate
cA
RT
and
CPT
upt
ake
Prop
orti
on o
f H
IV p
osit
ive
TB p
atie
nts
put
on c
ART
Esta
blis
h eM
TCT
site
s as
cA
RT
prov
idin
g fa
cilit
ies
for
TB p
atie
nts
(NA
SCO
P)
80%
Esta
blis
h 65
0 eM
TCT
site
s as
cA
RT p
rovi
ding
sit
es85
%Es
tabl
ish
1,00
0 eM
TCT
site
s as
c
ART
pro
vidi
ng s
ites
90%
n/a
90%
Con
duct
3 n
atio
nal T
oT t
rain
ings
on
TB/H
IV
for
all c
ount
ies
TB/H
IV
ToT
trai
ning
s fo
r 10
0 To
Ts
(rep
rese
ntat
ives
fr
om
47co
unti
es)
n/a
n/a
n/a
Con
duct
cou
nty
leve
l HC
W t
rain
ings
on
TB/
HIV
0
21 c
ount
y TB
/HIV
tra
inin
gs f
or
35 p
arti
cpan
ts/c
ount
y 19
cou
nty
TB/H
IV t
rain
ings
for
35
part
icpa
nts/
coun
ty
n/a
Con
duct
fac
ility
lev
el m
ento
rshi
p of
car
e pr
ovid
ers
in T
B se
ttin
gs in
pro
visi
on o
f A
RT
0A
ll TB
cl
inic
s lo
cate
d in
si
tes
whe
re
ART
is
pr
ovid
ed
to
preg
nant
wom
en
All
TB
clin
ics
loca
ted
in
site
s w
here
ART
is p
rovi
ded
to p
regn
ant
wom
en
All
TB c
linic
s lo
cate
d in
sit
es w
here
A
RT is
pro
vide
d to
pre
gnan
t w
omen
Revi
sion
of
the
TB/H
IV g
uide
lines
, Ed
itin
g an
d fo
rmat
ting
of
revi
sed
TB/H
IV g
uide
lines
1 w
orks
hop,
co
ntra
ct
a co
nsul
tant
fo
r ed
itin
g an
d fo
rmat
ting
of
guid
elin
es
n/a
n/a
n/a
4.3.
5. M
ulti
-sec
tora
l Res
pons
e to
TB/
HIV
TB/H
IV O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Con
duct
co
unty
le
vel
IPT
sens
itiz
atio
ns
thro
ugh
impl
emen
ting
par
tner
s IP
T co
unty
lev
el s
ensi
tiza
tion
s fo
r 21
high
H
IV
bu
rden
co
unti
es
IPT
coun
ty
leve
l se
nsit
izat
ions
fo
r 19
cou
ntie
sn/
an/
a
Con
duct
fa
cilit
y le
vel
men
tors
hip
and
trai
ning
thr
ough
CH
MT
and
Impl
emen
ting
pa
rtne
rs
Faci
lity
leve
l tr
aini
ng
and
men
tors
hio
fo
r IP
T im
plem
enti
ng
site
s in
hi
gh
burd
ened
cou
ntie
s
Faci
lity
leve
l tr
aini
ng
and
men
tors
hio
for I
PT im
plem
enti
ng
site
s in
all
hig
h an
d m
ediu
m
burd
ened
cou
ntie
s
Faci
lity
leve
l tr
aini
ng
and
men
tors
hio
for
IPT
im
plem
enti
ng
site
s in
al
l
high
an
d m
ediu
m
burd
ened
cou
ntie
s
Faci
lity
leve
l tra
inin
g an
d m
ento
rshi
o fo
r IPT
impl
emen
ting
sit
es in
all
hig
h an
d m
ediu
m b
urde
ned
coun
ties
Prin
t co
ntac
t tr
acin
g re
gist
ers
06,
000
2,00
00
Prin
t IC
F/IP
T ca
rds
Prin
t 5
00,0
00 I
CF/
IPT
card
sPr
int
500
,000
IC
F/IP
T ca
rds
Prin
t 5
00,0
00 I
CF/
IPT
card
s0
IPT
pati
ent
appo
intm
ent
card
sPr
int
200,
000
IPT
appo
intm
ent
card
sPr
int
200,
000
IPT
appo
intm
ent
card
sPr
int
200,
000
IPT
appo
intm
ent
card
s0
IPT
regi
ster
Prin
t 20
00 IP
T r
egis
ters
0
Prin
t 2,
000
IPT
reg
iste
rs
0
Stra
tegi
c A
ppro
ach
4: S
cale
up
of T
B IP
C in
hea
lthc
are
and
cong
rega
te s
etti
ngs
Num
ber
of
wor
ksho
ps
for
the
deve
lopm
ent
of T
B IP
C t
ools
and
pol
icy
guid
elin
es c
ondu
cted
Mul
ti-s
ecto
ral
stak
ehol
der'
s fo
rum
in
clud
ing
othe
r no
n-m
edic
al s
take
hold
ers
to
leve
rage
on
IP
C
supp
ort
by
othe
r m
inis
trie
s su
ch
as
Min
istr
y of
H
ousi
ng,
min
istr
y of
edu
cati
on.
1 w
orks
hop
4n/
an/
an/
an/
an/
an/
a
Dev
elop
TB/
HIV
wor
kpla
ce p
olic
y2
wor
ksho
psn/
an/
an/
a
Wor
k sh
op
to
revi
se
IPC
gu
idel
ines
, de
velo
pmen
t of
IPC
CQ
I and
IPC
indi
cato
rs
1 w
orks
hop
Num
ber
of
IPC
po
licy
docu
men
ts
and
tool
s pr
inte
dPr
int
TB/H
IV w
orkp
lace
doc
umen
ts6,
000
TB/
HIV
pol
icy
docu
men
ts
12,0
000
n/a
0n/
a0
n/a
Prin
t a
nd d
istr
ibut
e re
vise
d IP
C g
uide
lines
6,
000
IPC
gu
idel
ine
copi
es
prin
ted
00
0
Prop
orti
on
of
heal
th
faci
litie
s an
d co
ngre
gate
set
ting
s im
plem
enti
ng T
B IP
CD
isse
min
ate
IPC
gu
idel
ines
an
d TB
/HIV
w
orkp
lace
pol
icy
docu
men
t0
1 m
eeti
ng f
or c
oth
TB/H
IV p
olic
y an
d IP
C g
uide
line
diss
emin
atio
n25
%0
50%
050
%
Cou
nty
leve
l tr
aini
ngs
of
revi
sed
IPC
gu
idel
ines
01
trai
ning
/cou
nty
for
21
high
bu
rden
cou
ntie
s1
trai
ning
/cou
nty
for
19
mid
bu
rden
cou
ntie
s0
Con
duct
fac
ility
lev
el T
B in
fect
ion
trai
ning
an
d ri
sk a
sses
smen
ts0
Con
duct
TB
risk
ass
esm
ent
in 2
1 H
IV h
igh
prev
alnc
e co
unti
es (
7 he
alth
fac
iliti
es p
er c
ount
y)
00
Dev
elop
men
t of
faci
lity
leve
l IP
C
wor
k pl
ans
0D
evel
op h
ealt
h fa
cilit
y IP
C p
lans
in
21
HIV
hig
h pr
eval
ent c
ount
ies
(7 h
ealt
h fa
cilit
ies
per
coun
ty)
00
Stra
tegi
c A
ppro
ach
5: Im
med
iate
cA
RT
and
CPT
upt
ake
Prop
orti
on o
f H
IV p
osit
ive
TB p
atie
nts
put
on c
ART
Esta
blis
h eM
TCT
site
s as
cA
RT
prov
idin
g fa
cilit
ies
for
TB p
atie
nts
(NA
SCO
P)
80%
Esta
blis
h 65
0 eM
TCT
site
s as
cA
RT p
rovi
ding
sit
es85
%Es
tabl
ish
1,00
0 eM
TCT
site
s as
c
ART
pro
vidi
ng s
ites
90%
n/a
90%
Con
duct
3 n
atio
nal T
oT t
rain
ings
on
TB/H
IV
for
all c
ount
ies
TB/H
IV
ToT
trai
ning
s fo
r 10
0 To
Ts
(rep
rese
ntat
ives
fr
om
47co
unti
es)
n/a
n/a
n/a
Con
duct
cou
nty
leve
l HC
W t
rain
ings
on
TB/
HIV
0
21 c
ount
y TB
/HIV
tra
inin
gs f
or
35 p
arti
cpan
ts/c
ount
y 19
cou
nty
TB/H
IV t
rain
ings
for
35
part
icpa
nts/
coun
ty
n/a
Con
duct
fac
ility
lev
el m
ento
rshi
p of
car
e pr
ovid
ers
in T
B se
ttin
gs in
pro
visi
on o
f A
RT
0A
ll TB
cl
inic
s lo
cate
d in
si
tes
whe
re
ART
is
pr
ovid
ed
to
preg
nant
wom
en
All
TB
clin
ics
loca
ted
in
site
s w
here
ART
is p
rovi
ded
to p
regn
ant
wom
en
All
TB c
linic
s lo
cate
d in
sit
es w
here
A
RT is
pro
vide
d to
pre
gnan
t w
omen
Revi
sion
of
the
TB/H
IV g
uide
lines
, Ed
itin
g an
d fo
rmat
ting
of
revi
sed
TB/H
IV g
uide
lines
1 w
orks
hop,
co
ntra
ct
a co
nsul
tant
fo
r ed
itin
g an
d fo
rmat
ting
of
guid
elin
es
n/a
n/a
n/a
4.3.5. Multi-sectoral Response to TB/H
IV
TB/H
IV O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prop
orti
on o
f H
IV p
osit
ive
TB p
atie
nts
put
on c
ART
Prin
ting
of
TB/H
IV g
uide
lines
Prin
t 6,
000
copi
es o
f re
vise
d gu
idel
ines
n/a
n/a
n/a
Hol
d na
tion
al
TB/H
IV
guid
elin
e di
ssem
inat
ion
mee
ting
1 m
eeti
ngn/
an/
an/
a
Hol
d C
ount
y le
vel
TB/H
IV
guid
elin
e di
ssem
inat
ion
mee
ting
s47
cou
ntie
sn/
an/
an/
a
Hol
d su
bcou
nty
and
Cou
nty
leve
l TB
/HIV
gu
idel
ine
diss
emin
atio
n m
eeti
ngs
Faci
lity
leve
l tr
aini
ng
and
men
tors
hip
on n
ew g
uide
lines
us
ing
impl
emen
ting
par
tner
s
Faci
lity
leve
l tr
aini
ng
and
men
tors
hip
on
new
gu
idel
ines
us
ing
impl
emen
ting
par
tner
s
Faci
lity
leve
l tr
aini
ng
and
men
tors
hip
on
new
gu
idel
ines
us
ing
impl
emen
ting
par
tner
s
Faci
lity
leve
l tr
aini
ng
and
men
tors
hip
on n
ew g
uide
lines
usi
ng
impl
emen
ting
par
tner
s
Hol
d a
thre
e da
y w
orks
hop
to
deve
lop
cont
ent
for
the
elec
tron
ic T
B/H
IV t
reat
men
t gu
idel
ines
1 m
eeti
ng
for
cont
ent
deve
lopm
ent
Dev
elop
a T
B/H
IV g
uide
lines
mob
ile a
ppC
ontr
act
cons
ulta
nt
to
crea
te m
obile
app
for
TB/
HIV
gu
idel
ines
n/a
n/a
n/a
Pilo
t th
e TB
/HIV
gui
delin
es m
obile
app
Supp
ort
site
vis
its
to p
ilot
site
s in
2 s
elec
ted
cou
ntie
sn/
an/
an/
a
Laun
ch m
obile
TB/
HIV
gui
delin
esN
ews
pape
r ad
vert
SMS
to
clin
icia
ns
nurs
es
and
othe
r pa
ctit
ione
rsn/
an/
a
4.3.6. Accelerate appropriate diagnosis1. Situational Analysis
Laboratory services play a key role in TB diagnosis, prevention and control in Kenya. Smear microscopy (both light and fluorescence), molecular techniques (Line Probe Assay and Xpert MTB/RIF) and culture (solid and liquid media) are all available in the country for TB and MDR TB diagnosis. Both the NTLD Program and the National TB Reference Laboratory (NTRL) coordinate diagnostic services, while a laboratory technical working group guides in implementation of TB laboratory services. TB diagnosis is embedded in various national guidelines.
Sputum smear microscopy has been the mainstay of TB diagnosis in Kenya. Smear microscopy is provided through a network of 1,860 laboratories embedded within the general health services. Of these labs, 70% are public, 20% faith-based organizations and 10% private sector. In terms of coverage, most hospitals (91%) and health centers (78%) have TB diagnostic capacity. At lower levels, only 20% of dispensaries and 15% of clinics offer TB diagnostic services. The coverage of sputum microscopy currently stands at 1 light microscope for 25,000 persons, which is above the WHO recommendation of 1:50,000. A map of the geographic distribution of laboratories shows continued barriers to access in remote areas. Following WHO’s policy recommendation in 2010, Xpert MTB/RIF assay was introduced in 2011 and has been rolled out to 70 facilities nationwide.
The laboratory network is divided into three levels i.e. periphery, intermediate and central levels, with different technologies available at different levels, as indicated in Figure 23 below.
a) Peripheral/Level I: Laboratories at this level perform microscopy using ZN or FM, depending on the workload. They refer specimens for GeneXpert to the intermediate level laboratories. Upon clinicians’ request, some of these sites refer specimens to the central level laboratories for culture and DST.
b) Intermediate/Level II: The county and sub-county laboratories are involved in the diagnosis of new cases/treatment follow-up using either ZN or FM. Some of the facilities are equipped with a GeneXpert instrument. Specimens from
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Figure 23: Laboratory Network Levels
87
Map 10: Distribution of Smear Microscopy Sites by Population Density, 2013
all the retreatment cases are referred to the central level labs for further analysis.
c) Central/Level III: The NTRL performs solid culture (LJ), liquid culture (MGIT), drug susceptibility testing (DST) for 1st line drugs on liquid medium, microscopy (ZN & FM), LPA (R/H), GeneXpert and identification of M tuberculosis complex (MPT64). It is also involved in providing External Quality Assurance (EQA) for microscopy and technical assistance to county laboratories. Other facilities with culture and drug susceptibility testing (DST) capacity include KEMRI Kisian in Kisumu, IOM (Dadaab and Nairobi), Aga Khan and Nairobi hospitals, and KEMRI Nairobi. This translates to 0.75 per 5 million population.
A supranational reference laboratory, the Queensland Mycobacterial Reference Laboratory (QMRL) in Brisbane, Australia, provides technical assistance and training. It serves as the reference lab for proficiency testing (PT) for the NTRL.
2. Definition of opportunities for improvements, gaps/challenges that need to be addressed
a) Integrated Specimen referral: In 2010, a courier-based specimen referral system was initiated for routine surveillance of TB/MDR. In this system, specimens are delivered to the central level for culture and DST. This needs to be extended and decentralized to enable inter-county specimen referral.
b) Underutilization of Xpert: The Xpert MTB/RIF technology was recently adopted by the NTLD Program and the current utilization of the instruments stands at 20% of their capacity. Health care workers have not been adequately sensitized on the algorithm, availability of the services and the existing referral networks.
c) Delayed turnaround time (TAT): There is a delay in transmission of results from laboratories (mainly the NTRL) to clinicians. This is partly due to the delay in specimen transportation and the current system of result transmission through LIMS. Results are transmitted via email to the county and sub-county TB and Leprosy coordinators of the referring clinic, and do not reach the clinicians in good time.
d) Access to 2nd line DST: The NTRL is currently building capacity to test for 2nd line drug resistance.
e) EQA: About 88% of microscopy laboratories are covered under the national quality assurance scheme. The NTRL is enrolled in a proficiency testing program through the SRL in Brisbane, while the GeneXpert sites are enrolled in a CDC Atlanta-led PT scheme. This needs further expansion to ensure all sites are enrolled in an EQA program, and that feedback to participating laboratories is regular.
Figure 24: Laboratories Providing Sputum Smear Microscopy
4.3.6. Accelerate A
ppropriate Diagnosis
88
f) Integration of LIMS with TIBU: The NTRL has a robust laboratory information management system (LIMS) for data management, while the NTLD Program recently developed a patient management system called TIBU. There is an opportunity to further strengthen patient management by linking these systems.
g) Operational research: There is a need to strengthen the capacity of laboratory personnel for operational research.
h) Weak biosafety and infection prevention measures: Due to lack of equipment, appropriate personal preventive equipment (PPE) and inadequate laboratory infrastructure, biosafety in TB laboratories remains a challenge.
i) Limited geographical access to diagnosis in remote areas: As reflected in the map above, many populations must travel long distances to access diagnostic facilities, potentially delaying diagnosis.
3. Strategic Direction(s) for 2015-2018
Priorities for the next three years include: a) Adoption, roll-out and scale-up of GeneXpert technology countrywide as a diagnostic tool for all symptomatic HIV-infected individuals, presumptive pediatric and MDR-TB cases, health care workers and symptomatic refugees; b) Review and adopt policy to include self-referral to the diagnostic lab of presumptive TB cases; c) Enhance quality and strengthen the existing culture labs; d) Develop capacity for 2nd line DST at NTRL; e) Scale-up INH DST for all Xpert/MTB Rif MTB positive cases; f) Scale-up of fluorescence microscopy from the current 150 to 340 for all facilities performing an average of >2 smears per day; g) Enhance biosafety and infection prevention control measures in TB laboratories.
Particular emphasis will be given to reducing the distance to diagnostic services for rural populations, as well as the time to receipt of results.
4. Proposed Approaches
Accelerate time to diagnosis, especially among rural populations
Support county-level mapping of distances to diagnostic facilities, with the aim of prioritizing the addition of rural sputum collection points and transport networks to facilitate patient diagnosis.
Roll out and scale up Xpert MTB/RIF
GeneXpert will be the primary diagnostic test for all symptomatic HIV-infected individuals, presumptive pediatric cases, symptomatic health care workers, symptomatic refugees (WHO guidelines, MOH HIV rapid advice June 2014) and smear negative patients with suggestive radiological features. The algorithm in Figure 25 will be printed and distributed to all facilities. Sensitisation of health care workers will be done through Continuous Medical Education (CMEs) and integrated in various trainings for surveillance. All previously treated patients, DR-TB contacts, patients developing TB on IPT and smear positive patients at 2 months shall also be screened using Xpert MTB/RIF. With recommendation from NTRL, the NPHLS will appoint a dedicated national GeneXpert Coordinator to take the lead in the formation and coordination of a TWG.
Scale-up of GeneXpert machines in congregate settings, such as prisons and housing for uniformed services and students, will be prioritized.
GeneXpert sites will be expanded to cover all county hospitals and 60% of sub-county hospitals by 2018. The placement will be based on workload, accessibility as well as mobile communities and congregate settings to ensure equitable distribution.
The number of GeneXpert equipment to be placed in the country by the end of 2018 is projected at 250. Monitoring and evaluation – The GeneXpert online reporting system will be installed in all the GeneXpert equipment and used to monitor utilization, quality of testing and quantify the commodities and error rates. The TWG will provide oversight and continuous monitoring of implementation through site visits and periodic review meetings. Performance of GeneXpert sites will be evaluated using a set of indicators adopted from WHO for local use.
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Figure 25: GeneXpert Testing Algorithim
4.3.6. Accelerate A
ppropriate Diagnosis
_______________________________________________________________________________________________________________________________• WHO endorsed Xpert MTB/RIF in 2010 for rapid diagnosis of MTB and Rifampicin resistance as a proxy for MDR diagnosis (http://www.who.int/tb/features_archive/new_rapid_test/en/)
• A further policy update was published in 2013 to include extra pulmonary cases (http://www.who.int/tb/laboratory/policy_statements/en/)
• The national TB program has adopted Xpert MTB/RIF as initial test for HIV-infected individuals
• In Malaysia, case detection among prisoners was improved by use of Xpert. This supports scale-up of Xpert to congregate settings.
• The Diagnostic Performance of a Single GeneXpertMTB/RIF Assay in an Intensified Tuberculosis Case Finding Survey among HIV-Infected Prisoners in Malaysia: Haider Abdulrazzaq Abed Al-Darraji1et al
90
2. MDR TB surveillance
§ All previously treated patients: a. failures; b. relapses; c. treatment after loss to follow up • DR TB contacts • Healthcare workers with TB symptoms • Patients who develop TB on IPT • Refugees with symptoms of TB • Smear positive at 2 months • Prisoners with TB symptoms In areas where GeneXpert is available, this should be the first test. Patients diagnosed with GeneXpert should be followed up with microscopy
Indications for GeneXpert 1. TB Diagnosis
• HIV positive with TB symptoms • Children under 15 years with TB symptoms • All smear negative TB cases
Results of GeneXpert
TB positive and also Rifampicin resistance
TB positive but no resistance to Rifampicin
Patient has symptoms suggestive of TB but GeneXpert is negative for TB
Start on MDR TB treatment and ART if HIV positive
Send sample for culture & DST (First line and second line)
If any resistance for injectables and/or FQ –Discuss in MDR TB Clinical meeting for Individualized regimen. For PDR and mono-resistant TB, treat as per guidelines
If DST indicates resistance, treat as per PMDT guidelines
Do Sputum for Smear follow- up month 2/3 and 5
SS -ve SS +ve
Treatment success
X-ray, broad-spectrum antibiotics, clinical condition
Improvement; Continue and observe. If none consider other diagnosis and manage accordingly
Culture and DST and manage as per the MDR TB guidelines
For MDR TB surveillance group -Do culture & DST (Offer HIV testing) Treat with Cat I as per TB guidelines
For TB diagnosis (offer HIV testing) Treat with Cat I as per TB guidelines
If no resistance, continue treatment No
improvement and still TB suspect
Repeat GeneXpert for surveillance and also do culture and DST & manage as per the MDR TB guidelines
Networking of Xpert MTB/RIF machines
To ensure access for GeneXpert services, all counties should develop networking frameworks integrated with existing HIV CD4 networks and others. This is depicted in figure 26. GeneXpert sites should also develop secondary networks to ensure uninterrupted services in case of equipment breakdown.
TAT and results dissemination: The national TB program will optimize the use of electronic data tools, such as GXAlert on line reporting system and SMS printers to ensure quick TAT of GeneXpert results within 48 hours.
• Quality assurance: All Xpert testing sites shall be enrolled under a national quality assurance program coordinated by the NTRL.
• Logistics: Quantification, procurement and distribution of GeneXpert supplies will be centralized and coordinated by the national program. County governments will be engaged to provide equipment maintenance/service contracts and assured power supply for instruments at the county level.
• Public Private Partnerships: The NTLD Program will continue collaborating with private Xpert testing facilities to ensure all TB cases are reported to the national program and diagnostic algorithms are adhered to.
• Communication package: A standardized communication package for Xpert shall be developed to support the sensitization of HCWs on the use of Xpert. The package will also include information to be disseminated to presumptive TB patients.
There is need to pilot mobile GeneXpert services in learning institutions, marginalized, and migrant communities, with a vision for a wider roll-out and networking.
a) Enhancing quality and strengthening the existing culture capacity
Culture remains the gold standard for MTB diagnosis and drug susceptibility testing. The two existing public labs (NTRL and Kisumu Kisian) will be strengthened and their access and utilization optimized through enrolment in PT programs, better coordination and strengthened specimen referral networks.
Given the cost implications and complexity of establishing and maintaining culture labs and the thrust of Xpert MTB/RIF, which has increased access to accurate TB diagnosis and Rifampicin resistance testing, no scale-up toward more culture labs is planned within the strategic period. The NTRL will review standards for culture labs to guide facilities that are already offering culture services, in terms of research for future decentralization.
All patients with Rifampicin resistance results will be subjected to culture and DST, while patients on MDR-TB treatment will be subjected to culture for monitoring of treatment.
The sample referral mechanisms for culture samples via courier system will be continued to maintain quality.
Turnaround time of results will be monitored via MDR-TB suspect registers. At least 80% of the results feedback should be expected in one month. The LIMS should be linked to the TIBU system to ensure rapid result dissemination and improved patient management. Facilities with internet services will have their chest clinics and referral labs linked in order to have access to the results through LIMS. An evaluation of TAT will be conducted at NTRL and representative health facilities biannually, and the findings presented during the biannual county TB and Leprosy coordinators’ meetings.
To ensure quality of the existing culture labs, NTRL staff will receive capacity building and mentorship through regular training programs locally and regionally. The implementation of QMS towards accreditation (ISO 15189) and the strengthening of quality assurance measures will be enhanced at all levels, as well as regular participation in proficiency testing programs. A system to monitor NTRL essential equipment will be installed to alert the staff in case of breakdowns.
The national program shall support the maintenance and repair of NTRL’s infrastructure. County governments shall be
Figure 26: GeneXpert Networking
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Sample flow chart for Culture and DST
4.3.6. Accelerate A
ppropriate Diagnosis
Figure 27: Sample flow chart for Culture and DST
92
Specimen reception
Rejection/Acceptance criteria
Accepted Rejected
AFB smear
Notify sender within 24
hours Culture L-J Culture/Primary
MGIT
Growth
Positive Negative
Smear Negative
Smear Positive
Give preliminary feedback within 48
hours
Perform direct Hain
Give preliminary feedback within 48
hours
Give feedback within 48 hours
Perform rapid identif ication on Capil ia or
other kits
Give feedback within 48 hours Susceptible SIRE MGIT
DST Hain other species id
Resistant to R&I
Discordant results repeat MGIT DST MDR, 2nd Line DST
No MTB MTB
responsible for supporting infrastructural maintenance and repair for culture labs at the county level.
b) Scale up INH DST for all MTB positive retreatment cases
Within 2015-2017, the treatment regimen for retreatment cases will be guided by sensitivity of medications. Streptomycin will not be in the treatment option. Therefore, all MTB positive samples from retreatment patients will be subjected to culture and DST at the culture lab to rule out resistance to other drugs. In order to improve TAT, samples will be subjected to LPA to check INH sensitivity. Unpublished data from culture and DST showed INH mono-resistance of 5.5% (86 samples out of 1,545) via culture during the Jan-Dec 2013 period.
c) Developing capacity for 2nd line DST at NTRL
For all newly diagnosed MDR-TB patients, second line testing will be performed in order to identify early resistance. Currently, both the equipment and reagents for second line testing are available, but training is needed to enable staff to perform the tests routinely.
d) Scale up of LED microscopy
Smear microscopy remains the mainstay for TB diagnosis at the periphery level and for monitoring of treatment for drug-sensitive TB. In line with WHO recommendations, 150 LED microscopes were distributed between 2012 and 2013 to high volume laboratories. This will be expanded from current 150 sites to 340 by 2017. The LED microscopes will be placed in sites with an average of 2 smears per day and more.
All microscopy sites shall be enrolled into the national EQA program to ensure high quality services. The national program shall implement the existing capacity building plan for microscopy, including refresher and biosafety training. County governments will be engaged to build capacity for microscopy sites.
To improve access, all microscopy diagnostic sites will be networked to facilitate communication between health facilities and to enable referral of specimens from sites without microscopy equipment.
The county governments will be engaged to provide annual equipment maintenance for microscopes and conduct infrastructural upgrades on microscopy diagnostic sites to ensure adequate infection control and prevention measures. WHO-approved TB hoods shall be provided to high volume microscopy sites.
Logistics: Quantification, procurement and distribution of light and LED microscopy supplies will be centralized and coordinated by the NTLD Program.
Communication: The NTLD Program shall develop a communication and sensitization strategy for HCWs and for presumptive TB cases to create demand for smear microscopy.
Scale-up of light microscopes and the opening of new diagnostic facilities will be considered for hard to reach areas, guided by the GIS distribution of labs.
e) Enhancing biosafety and infection prevention in TB laboratories
Infection prevention control (IPC) for TB laboratory workers will be ensured through capacity building, provision of personal protective equipment (PPE), infrastructure upgrades, continuous screening of health care workers, proper waste management and proper documentation of those infected with TB.
The NTLD Program and NTRL shall develop an operational plan and accompanying policies to reinforce biosafety and infection control capacity and activities in health facilities and laboratories. The policies will ensure appropriate health facility and laboratory designs (adequate space, waiting areas and sputum collection booths) for each level, provision of TB hoods and biosafety cabinets, autoclaves and incinerators for waste management, and PPE (N95 masks). Additionally, the policies will outline a biosafety audit plan as well as an annual capacity building plan.
County Levela) Human resources: The NTLD Program and the NTRL shall lobby county governments to ensure adequate human
resources for all laboratories.
b) Capacity development: The NTLD Program and the NTRL will build capacity of the county TB laboratory coordinators on leadership and management, M&E, EQA, infection prevention and control and commodity management.
c) EQA: The NTLD Program and the NTRL shall lobby (and provide advice to) county governments to ensure adequate funds for sputum microscopy EQA activities.
4.3.
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93
Contribution to NSP Impacts Outcomes (Laboratory)
Impact 1. Reduce the incidence of TB by 5% by 2018, compared to 2014
80% of TB patients (all forms) diagnosed within 2 weeks of initial care seeking
Impact 1.1 Reduce the prevalence of MDR-TB among new patients by 15%, by 2018
At least 30% of estimated INH-resistant cases are identified
At least 80% of culture and DST sample results received within a turn-around time of 60 days
Table 12: Outcome and Impact Indicators for Appropriate Diagnosis
4.3.6. Accelerate A
ppropriate Diagnosis
d) Infection control: The NTRL and NTLD Program will provide advice and lobby county governments to strengthen the infection control measures through capacity building, provision of appropriate biosafety equipment and infrastructure development.
Operational Research a) Conduct research to evaluate the impact and cost effectiveness of Xpert and online reporting system.
b) Undertake longitudinal data analysis of smear microscopy EQA to determine quality improvement trends and recurrent gaps.
c) Peform longitudinal data analysis on culture and DST services to determine trends, efficacy and effectiveness.
94
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thro
ugh
LIM
S
100%
Net
wor
king
of
pu
blic
cu
ltur
e la
bs t
hrou
gh L
IMS
10
0%
Prop
orti
on
of
plan
ned
TWG
m
eeti
ngs
conv
ened
Form
TW
G
for
all
cult
ure
labs
(Pub
lic a
nd p
riva
te)
Form
TW
G f
or c
ultu
re
labs
C
ondu
ct
sem
i-an
nual
TW
G m
eeti
ngs
100%
Con
duct
se
mi-
annu
al
TWG
mee
ting
s10
0%C
ondu
ct
sem
i-an
nual
TW
G m
eeti
ngs
100%
4.3.
6. A
ccel
erat
e A
ppro
pria
te D
iagn
osis
Acc
eler
ate
App
ropr
iate
Dia
gnos
is O
pera
tion
al P
lan
Stra
tegi
c Pr
iori
ties
Stra
tegi
c A
ppro
ache
sO
utpu
t In
dica
tor(
s)A
ctiv
ity
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
2: S
tren
gthe
n ex
isti
ng q
ualit
y as
sura
nce
prog
ram
Stre
ngth
en
EQA
fo
r sp
utum
m
icro
scop
y fo
r bo
th l
ight
and
fl
uore
scen
ce m
etho
ds
Prop
orti
on
of
mic
rosc
opy
labo
rato
ries
wit
h at
lea
st 1
sta
ff
trai
ned
on E
QA
Trai
ning
of
mic
rosc
opy
labs
on
EQ
A
TOT
trai
ning
of
47
C
MLT
s on
EQ
An/
aBu
ild E
QA
cap
acit
y of
55
mic
rosc
opy
site
s25
Build
EQ
A
capa
city
of
55
mic
rosc
opy
site
s50
Build
EQ
A c
apac
ity
of 5
5 m
icro
scop
y si
tes
100
Prop
orti
on
of
mic
rosc
opy
labs
pa
rtic
ipat
ing
in q
uart
erly
EQ
ATO
T of
Cou
nty
med
ical
Lab
s on
EQ
A
Build
EQ
A c
apac
ity
of
55 m
icro
scop
y si
tes
90C
ondu
ct
refr
eshe
r tr
aini
ng f
or 1
25 M
LTs
>90
Con
duct
re
fres
her
trai
ning
for
125
MLT
s >
90C
ondu
ct r
efre
sher
tra
inin
g fo
r 12
5 M
LTs
>90
Con
duct
re
fres
her
trai
ning
on
EQ
A
Con
duct
re
fres
her
trai
ning
for
125
MLT
s C
ondu
ct
EQA
fo
r 10
0%
of
enro
lled
site
s
Con
duct
EQ
A f
or 1
00%
of
enr
olle
d si
tes
C
ondu
ct E
QA
for
100
% o
f en
rolle
d si
tes
Con
duct
mic
rosc
opy
EQA
Con
duct
EQ
A
for
100%
of
en
rolle
d si
tes
Proc
urem
ent
of 2
,500
slid
e bo
xes
Proc
urem
ent
of 2
,500
sl
ide
boxe
s
Pr
ocur
emen
t of
2,5
00
slid
e bo
xes
Proc
urem
ent
of
2,50
0 sl
ide
boxe
s
Proc
urem
ent
of
2,50
0 sl
ide
boxe
s
Impl
emen
tati
on
of
QM
S to
war
ds
accr
edit
atio
n an
d st
reng
then
ing
qual
ity
assu
ranc
e m
easu
res,
at
all l
evel
s.
NTR
L at
tain
s IS
O
1518
9 ac
cred
itat
ion
Trai
ning
of
N
TRL
staf
f on
Q
MS
Trai
ning
of
5
NTR
L st
aff
on Q
MS
n/
aTr
aini
ng
of
5 N
TRL
staf
f on
QM
S
n/a
Trai
ning
of
5 N
TRL
staf
f on
QM
S
n/a
Con
duct
m
anag
emen
t re
view
mee
ting
n/a
Con
duct
NTR
L au
dit
Revi
sion
of
N
TRL
docu
men
ts
Con
duct
man
agem
ent
revi
ew m
eeti
ngC
ondu
ct
man
agem
ent
revi
ew m
eeti
ng
Con
duct
m
anag
emen
t re
view
mee
ting
Con
duct
man
agem
ent
revi
ew m
eeti
ngC
ondu
ct a
udit
(K
ENA
S/SA
NA
S)
Con
duct
au
dit
(KEN
AS/
SAN
AS)
3: S
usta
in
com
mod
ity
man
agem
ent
Ensu
re
tim
ely
fore
cast
ing
and
quan
tifi
cati
on
of
all
com
mod
itie
s ar
e do
ne
Prop
orti
on
of
labs
re
port
ing
no
stoc
k ou
t fo
r co
mm
odit
ies
Con
duct
F&
Q m
eeti
ngC
ondu
ct F
&Q
mee
ting
100%
Con
duct
F&
Q m
eeti
ng10
0%C
ondu
ct F
&Q
mee
ting
100%
Con
duct
F&
Q m
eeti
ng10
0%
Proc
ure
AFB
, G
XPE
RT,
LPA
an
d cu
ltur
e Pr
ocur
e A
FB,
GX
PERT
, LP
A a
nd c
ultu
re
Proc
ure
AFB
, G
XPE
RT,
LPA
and
cul
ture
Pr
ocur
e A
FB,
GX
PERT
, LP
A a
nd c
ultu
re
Proc
ure
AFB
, G
XPE
RT,
LPA
an
d cu
ltur
e
Dis
trib
ute,
A
FB,
GX
pert
, LP
A,
cult
ure
and
DST
co
mm
odit
ies
Dis
trib
ute,
A
FB,
GX
pert
, LP
A,
cult
ure
and
DST
com
mod
itie
s
Dis
trib
ute,
A
FB,
GX
pert
, LP
A,
cult
ure
and
DST
com
mod
itie
s
Dis
trib
ute,
AFB
, G
Xpe
rt,
LPA
, cu
ltur
e an
d D
ST
com
mod
itie
s
Dis
trib
ute,
A
FB,
GX
pert
, LP
A,
cult
ure
and
DST
co
mm
odit
ies
De
ve
lo
p/
re
vi
ew
co
nsum
ptio
n da
ta t
ools
De
ve
lop
/re
vie
w
cons
umpt
ion
data
to
ols
4: S
cale
up
of
rapi
d m
olec
ular
TB
diag
nost
ics
Use
of
X
pert
as
fi
rst
line
diag
nosi
s fo
r H
IV-i
nfec
ted
pers
ons,
pre
sum
ptiv
e pa
edia
tric
ca
ses,
he
alth
ca
re
wor
kers
, sm
ear-
nega
tive
ra
diol
ogic
al
sugg
esti
ve
case
s an
d sy
mpt
omat
ic r
efug
ees
Prop
orti
on
of
targ
eted
ca
ses
rece
ivin
g X
pert
re
sult
s (d
isag
greg
ated
by
type
of
case
)
Mee
ting
to
Re
vise
of
di
agno
stic
alg
orit
hm
M
eeti
ng t
o Re
vise
of
diag
nost
ic a
lgor
ithm
Prin
ting
of
4,
000
diag
nost
ic a
lgor
ithm
s 50
% f
or e
ach
type
Trai
ning
of H
WC
s on
use
of
Xpe
rt75
%
for
each
typ
eTr
aini
ng o
f H
WC
s on
use
of
Xpe
rt>
85%
fo
r ea
ch t
ype
Prin
ting
of
di
agno
stic
al
gort
ithm
Prin
ting
of
2,
000
diag
nost
ic a
lgor
ithm
s D
istr
ibut
ion
of 4
,000
di
agno
stic
alg
orit
hms
Dis
trib
utio
n of
di
agno
stic
al
gori
thm
D
istr
ibut
ion
of 2
,000
di
agno
stic
alg
orit
hms
Tr
aini
ng o
f H
CW
s on
us
e of
Xpe
rt
4.3.6. Accelerate A
ppropriate Diagnosis
Acc
eler
ate
App
ropr
iate
Dia
gnos
is O
pera
tion
al P
lan
Stra
tegi
c Pr
iori
ties
Stra
tegi
c A
ppro
ache
sO
utpu
t In
dica
tor(
s)A
ctiv
ity
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Trai
ning
of
HC
Ws
on u
se o
f X
pert
Trai
ning
of
150
HC
Ws
on u
se o
f X
pert
Ensu
re s
yste
mat
ic r
ollo
ut a
nd
utili
zati
on o
f X
pert
MTB
/RIF
tes
t fo
llow
ing
nati
onal
pol
icie
s an
d gu
idel
ines
Incr
ease
d X
pert
sit
es f
rom
cur
rent
70
to
250
by 2
017
Map
ping
of
Xpe
rt s
ites
Map
ping
of X
pert
sit
es70
Map
ping
of X
pert
sit
es14
0M
appi
ng o
f X
pert
sit
esn/
aM
appi
ng o
f X
pert
sit
es25
0
Perc
enta
ge
incr
ease
in
th
e ut
iliza
tion
of
Xpe
rt
Pr
ocur
emen
t an
d in
stal
lati
on
of
Xpe
rt
inst
rum
ents
Proc
urem
ent
and
inst
alla
tion
of
50
GX
IV in
stru
men
ts
25%
Proc
urem
ent
and
inst
alla
tion
of
30
GX
IV in
stru
men
ts
50%
Proc
urem
ent
and
inst
alla
tion
of
50
GX
IV
inst
rum
ents
80%
Proc
urem
ent
and
inst
alla
tion
of
50
GX
IV
inst
rum
ents
>80
%
100%
of X
pert
faci
litie
s w
ith
acce
ss
to a
nd u
sing
onl
ine
repo
rtin
g
Proc
urem
ent
of m
odem
s fo
r X
pert
inst
rum
ents
Pr
ocur
emen
t of
50
m
odem
s fo
r X
pert
in
stru
men
ts
Proc
urem
ent
of
30
mod
ems
for
Xpe
rt
inst
rum
ents
Proc
urem
ent
of
50
mod
ems
for
Xpe
rt
inst
rum
ents
Proc
urem
ent
of
50
mod
ems
for
Xpe
rt
inst
rum
ents
100%
Trai
ning
of
HC
Ws
on u
se o
f on
line
repo
rtin
g to
ol
Trai
ning
of
240
MLT
s on
onl
ine
repo
rtin
g
Trai
ning
of
60 M
LTs
on
onlin
e re
port
ing
Tr
aini
ng o
f 10
0 M
LTs
on
onlin
e re
port
ing
Tr
aini
ng o
f 10
0 M
LTs
on
onlin
e re
port
ing
Ensu
re s
cale
up
of I
NH
DST
for
al
l Xpe
rt M
TB p
osit
ive
case
s Pr
opor
tion
of
Xpe
rt M
TB p
osit
ive
case
s w
ith
INH
DST
res
ults
Perf
orm
27,
000
test
sPe
rfor
m 6
,000
tes
ts25
Perf
orm
6,5
00 t
ests
50Pe
rfor
m 7
,000
tes
ts75
Perf
orm
7,5
00 t
ests
100
5: S
cale
up
of
mic
rosc
opy
serv
ice
Dec
entr
aliz
atio
n of
flu
ores
cent
m
icro
scop
y ce
ntre
s in
sit
es w
ith
>2
smea
rs p
er d
ay
Num
ber
of L
ED m
icro
scop
es in
use
Proc
urem
ent
of
190
LED
m
icro
scop
es
Proc
urem
ent
of
90
LED
mic
rosc
opes
14
0Pr
ocur
emen
t of
50
LE
D m
icro
scop
es
190
Proc
urem
ent
of 5
0 LE
D
mic
rosc
opes
24
024
0
Prop
orti
on o
f si
tes
wit
h >
2 sm
ears
pe
r da
y pe
rfor
min
g FM
Trai
ning
of
La
b pe
rson
nel
on F
M
Tr
aini
ng
of
50
Lab
pers
onne
l on
FM
Tr
aini
ng
of
50
Lab
pers
onne
l on
FM
25
%Tr
aini
ng
of
50
Lab
pers
onne
l on
FM
30
%50
%
Inst
alla
tion
of
ne
wly
pr
ocur
ed L
ED m
ocro
scop
esIn
stal
lati
on
of
90
proc
ured
LE
D
moc
rosc
opes
inst
alla
tion
of
50
pr
ocur
ed
LED
m
ocro
scop
es
inst
alla
tion
of
50
pr
ocur
ed
LED
m
ocro
scop
es
Dec
entr
aliz
atio
n of
lig
ht
mic
rosc
opy
serv
ices
in
hard
to
reac
h ar
eas
and
Cou
ntie
s w
ith
<1
mic
rosc
opy
site
per
50,
000
popu
lati
on
Prop
orti
on
of
coun
ties
w
ith
<1
mic
rosc
opy
site
pe
r 50
,000
po
pula
tion
Esta
blis
h at
lea
st 3
sm
ear
mic
rosc
opy
labs
in
12
pr
iori
ty
coun
ties
(T
urka
na,
Mar
sabi
t,
Gar
issa
, W
ajir,
Ba
ring
o,
Tana
Ri
ver,
Kit
ui,
Man
dera
, M
omba
sa,
Kw
ale,
K
ilifi
and
Lam
u)
Esta
blis
h at
le
ast
1 sm
ear
mic
rosc
opy
labs
in
12
pr
iori
ty
coun
ties
(T
urka
na,
Mar
sabi
t,
Gar
issa
, W
ajir,
Ba
ring
o,
Tana
Ri
ver,
Kit
ui,
Man
dera
, M
omba
sa,
Kw
ale,
K
ilifi
and
Lam
u)
Esta
blis
h at
le
ast
1 sm
ear
mic
rosc
opy
labs
in
12
pr
iori
ty
coun
ties
(T
urka
na,
Mar
sabi
t,
Gar
issa
, W
ajir,
Ba
ring
o,
Tana
Ri
ver,
Kit
ui,
Man
dera
, M
omba
sa,
Kw
ale,
K
ilifi
and
Lam
u)
25Es
tabl
ish
at
leas
t 1
smea
r m
icro
scop
y la
bs
in 1
2 pr
iori
ty c
ount
ies
(Tur
kana
, M
arsa
bit,
G
aris
sa,
Waj
ir, B
arin
go,
Tana
Ri
ver,
Kit
ui,
Man
dera
, M
omba
sa,
Kw
ale,
Kili
fi a
nd L
amu)
50Es
tabl
ish
at l
east
1 s
mea
r m
icro
scop
y la
bs
in
12
prio
rity
cou
ntie
s (T
urka
na,
Mar
sabi
t,
Gar
issa
, W
ajir,
Ba
ring
o, T
ana
Rive
r, K
itui
, M
ande
ra,
Mom
basa
, K
wal
e, K
ilifi
and
Lam
u)
100
Proc
ure
and
inst
all
light
m
icro
scop
es
Proc
ure
and
inst
all
48
light
mic
rosc
opes
Trai
n la
b pe
rson
nel o
n FM
Trai
n la
b pe
rson
nel
on F
M
4.3.
6. A
ccel
erat
e A
ppro
pria
te D
iagn
osis
Acc
eler
ate
App
ropr
iate
Dia
gnos
is O
pera
tion
al P
lan
Stra
tegi
c Pr
iori
ties
Stra
tegi
c A
ppro
ache
sO
utpu
t In
dica
tor(
s)A
ctiv
ity
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
6: Im
prov
ing
acce
ss
to q
ualit
y TB
di
agno
stic
s
Stre
ngth
en
spec
imen
re
ferr
al
netw
orks
Pr
opor
tion
of
pr
esum
ptiv
e M
DR-
TB p
atie
nts
wit
h cu
ltur
e an
d D
ST
resu
lts
docu
men
ted
Con
duct
sp
ecim
en
refe
rral
ne
twor
king
mee
ting
Con
duct
10
spec
imen
re
ferr
al
netw
orki
ng
mee
ting
100%
Con
duct
10
spec
imen
re
ferr
al
netw
orki
ng
mee
ting
100%
Con
duct
10
sp
ecim
en
refe
rral
ne
twor
king
m
eeti
ng
100%
Con
duct
10
sp
ecim
en
refe
rral
ne
twor
king
m
eeti
ng
100%
Proc
ure
stan
dard
spe
cim
en
colle
ctio
n,
pack
agin
g an
d tr
ansp
orta
tion
com
mod
itie
s
Proc
ure
20,0
00
zip
lock
bag
s an
d 4,
000
cool
box
es
Proc
ure
20,0
00
zip
lock
bag
s
Pr
ocur
e 20
,000
zip
lock
ba
gs
Pr
ocur
e 20
,000
zi
p lo
ck
bags
Con
duct
tr
aini
ng
of
HC
Ws
on
spec
imen
co
llect
ion,
pa
ckag
ing
and
tran
spor
tati
on
Con
duct
TO
T on
sp
ecim
en
tran
spor
tati
on f
or 9
4 H
CW
s
Con
duct
sp
ecim
ent
tran
spor
tati
on
Con
duct
TO
T on
sp
ecim
en
tran
spor
tati
on
for
94
HC
Ws
Con
duct
sp
ecim
ent
tran
spor
tati
on t
rain
ing
of
1500
HC
Ws
Con
duct
tra
inin
g of
cou
rier
pe
rson
nel
on
spec
imen
tr
ansp
orta
tion
Con
duct
sp
ecim
ent
tr
an
sp
or
ta
tio
n tr
aini
ng
of
1500
H
CW
s
Trai
ning
of
15
00
HC
Ws
Con
duct
sp
ecim
ent
tran
spor
tati
on
trai
ning
of
150
0 H
CW
s
Faci
litat
e tr
ansp
orta
tion
of
200
,000
spe
cim
ens
to
Xpe
rt s
ites
Faci
litat
e tr
ansp
orta
tion
of
spec
imen
s to
cu
ltur
e an
d G
eneX
pert
fac
iliti
es
Con
duct
55
TO
T fo
r co
urie
r pe
rson
nel
at
nati
onal
leve
l
Fa
ci
li
ta
te
tran
spor
tati
on
of
200,
000
spec
imen
s to
X
pert
sit
es
Con
duct
55
TO
T fo
r co
urie
r pe
rson
nel
at
nati
onal
leve
l
Faci
litat
e tr
ansp
orta
tion
of
10
,000
sp
ecim
ens
to
cult
ure
labs
Faci
litat
e tr
ansp
orta
tion
of
spec
imen
s to
cul
ture
labs
F
ac
il
it
at
e tr
ansp
orta
tion
of
20
0,00
0 sp
ecim
ens
to
Xpe
rt s
ites
Fa
ci
li
ta
te
tran
spor
tati
on
of
10,0
00 s
peci
men
s to
cu
ltur
e la
bs
Faci
litat
e tr
ansp
orta
tion
of
20
0,00
0 sp
ecim
ens
to X
pert
sit
es
Faci
litat
e tr
ansp
orta
tion
of
isol
ates
fro
m N
TRL
to S
RL
Fa
ci
li
ta
te
tran
spor
tati
on
of
10,0
00 s
peci
men
s to
cu
ltur
e la
bs
Faci
litat
e tr
ansp
orta
tion
of
10,
000
spec
imen
s to
cu
ltur
e la
bs
Cha
lleng
es
to
addr
ess:
Im
prov
e bi
osaf
ety
and
infe
ctio
n pr
even
tion
an
d co
ntro
l m
easu
res
in
TB
labo
rato
ries
Enha
nce
bios
afet
y an
d IP
C in
TB
labo
rato
ries
Pr
opor
tion
of
di
agno
stic
la
bs
mee
ting
min
imum
bio
safe
ty a
n IP
C
stan
dard
s
Revi
ew
stan
dard
s fo
r es
tabl
ishm
ent
of
TB
labo
rato
ries
Con
duct
1
mee
ting
to
re
view
st
anda
rds
for
esta
blis
hmen
t of
TB
labs
25C
ondu
ct
trai
ning
fo
r 1,
000
HC
Ws
on
bios
afet
y an
d IP
C
50C
ondu
ct
trai
ning
fo
r 1,
500
HC
Ws
on
bios
afet
y an
d IP
C
>75
Con
duct
trai
ning
for 1
,500
H
CW
s on
bi
osaf
ety
and
IPC
>80
Prop
orti
on
of
HC
Ws
wor
king
in
la
bs w
ho d
evel
op a
ctiv
e TB
Dev
elop
cu
rric
ulum
on
bi
osaf
ety
and
infe
ctio
n co
ntro
l in
TB la
bora
tori
es
Con
duct
1 m
eeti
ng t
o de
velo
p cu
rric
ulum
on
bio
safe
ty a
nd I
PC
in T
B la
bora
tori
es
<5
Proc
ure
50 B
SCs
and
50 a
utoc
lave
s
<5
Proc
ure
50 B
SCs
and
50
auto
clav
es
<5
Proc
ure
50 B
SCs
and
50
auto
clav
es
<5
Con
duct
TO
T fo
r C
ount
y la
b co
ordi
nato
rs
on
bios
afet
y an
d IP
C in
TB
labs
Con
duct
TO
T fo
r 60
C
ount
y TB
la
b co
ordi
nato
rs
Proc
ure
PPE
for
cult
ure
labs
Pr
ocur
e PP
E fo
r cu
ltur
e la
bs
Proc
ure
PPE
for
cult
ure
labs
Trai
n C
ount
y la
b pe
rson
nel
on b
iosa
fety
and
IPC
Pr
int
and
dist
ribu
te
60 b
iosa
fety
and
IP
C g
uide
lines
and
tr
aini
ng c
urri
cula
Con
duct
tr
aini
ng
for
1,00
0 H
CW
s on
bi
osaf
ety
and
IPC
Con
duct
tr
aini
ng
for
1,50
0 H
CW
s on
bi
osaf
ety
and
IPC
Con
duct
trai
ning
for 1
,500
H
CW
s on
bi
osaf
ety
and
IPC
Proc
ure
bios
afet
y eq
uipm
ent
for
TB la
bs
Proc
ure
serv
ice
cont
ract
s fo
r 50
BS
Cs
and
50 a
utoc
lave
s
Proc
ure
serv
ice
cont
ract
s fo
r 50
BS
Cs
and
50
auto
clav
es
Reno
vate
TB
la
bs
to
conf
orm
to
in
tern
atio
nal
stan
dard
s
4.3.6. Accelerate A
ppropriate Diagnosis
Acc
eler
ate
App
ropr
iate
Dia
gnos
is O
pera
tion
al P
lan
Stra
tegi
c Pr
iori
ties
Stra
tegi
c A
ppro
ache
sO
utpu
t In
dica
tor(
s)A
ctiv
ity
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
7:
Dev
elop
in
-co
untr
y ca
paci
ty f
or
2nd li
ne D
ST
Impl
emen
tati
on o
f 2nd
lin
e D
ST
at N
TRL
Prop
orti
on
of
MD
R-TB
pa
tien
ts
rece
ivin
g 2nd
lin
e D
ST
test
an
d re
sult
s do
cum
ente
d
Con
duct
tr
aini
ng
for
20
NTR
L pe
rson
nel
on 2
nd l
ine
DST
Con
duct
2nd
lin
e D
ST
trai
ning
fo
r 5
NTR
L st
aff
Con
duct
2nd
lin
e D
ST
trai
ning
fo
r 5
NTR
L st
aff
25%
Con
duct
2nd
lin
e D
ST
trai
ning
for
5 N
TRL
staf
f >
50%
Con
duct
2nd
lin
e D
ST
trai
ning
for
5 N
TRL
staf
f >
80%
Perf
orm
2nd
lin
e D
ST f
or a
ll M
DR-
TB c
ases
Perf
orm
2nd
lin
e D
ST
for 6
00 M
DR-
TB c
ases
Perf
orm
2nd
lin
e D
ST
for 2
50 M
DR-
TB c
ases
Perf
orm
2nd
line
DST
for
25
0 M
DR-
TB c
ases
Perf
orm
2nd
lin
e D
ST f
or
250
MD
R-TB
cas
es
8: N
ew In
itia
tive
s
Ensu
re
acce
ss
to
adva
nced
mol
ecul
ar
tech
nolo
gies
Dev
elop
in-c
ount
ry c
apac
ity
for
gene
tic
sequ
enci
ng
Num
ber
of g
ene
sequ
enci
ng s
tudi
es
done
Proc
urem
ent
of
gene
tic
sequ
enci
ng e
quip
men
t
Pr
ocur
emen
t of
gen
etic
se
quen
cing
equ
ipm
ent
1
Perf
orm
gen
etic
seq
uenc
-in
g on
50
MD
R-TB
cas
es
Con
duct
tra
inin
g on
gen
etic
se
quen
cing
C
ondu
ct g
enet
ic
sequ
enci
ng t
rain
ing
Perf
orm
gen
etic
se
quen
cing
on
50 M
DR-
TB c
ases
Ensu
re
acce
ss
to
prof
icie
ncy
test
ing
pane
ls
for
LED
m
icro
scop
y an
d X
pert
Dev
elop
in-c
ount
ry c
apac
ity
for
prof
icie
ncy
pane
l pro
duct
ion
Perc
enta
ge o
f X
pert
and
LED
lab
s en
rolle
d in
cou
ntry
PT
prog
ram
Con
duct
tr
aini
ng
for
20
NTR
L st
aff
on P
T pr
oduc
tion
C
ondu
ct
trai
ning
fo
r 20
NTR
L st
aff
on P
T pr
oduc
tion
Prod
uce
PT p
anel
s fo
r 24
0 LE
D s
ites
30
Prod
uce
PT
pane
ls
for
290
LED
sit
es
60Pr
oduc
e PT
pan
els
for
340
LED
sit
es
>80
Prod
ucti
on o
f PT
pan
els
Prod
uce
and
dist
ribu
te P
T pa
nels
to
25 p
ilot
LED
sit
es
Prod
uce
PT p
anel
s fo
r 12
0 X
pert
sit
esPr
oduc
e PT
pa
nels
fo
r 15
0 X
pert
sit
esPr
oduc
e PT
pan
els
for
250
Xpe
rt s
ites
Dis
trib
utio
n of
PT
pane
ls f
or
Xpe
rt a
nd L
ED m
icro
scop
y Pr
oduc
e an
d di
stri
bute
PT
pan
els
for
10 p
ilot
Xpe
rt s
ites
Ensu
re
acce
ss
to
rapi
d m
olec
ular
di
agno
sis
for
mob
ile
popu
lati
ons
Pilo
t m
obile
X
pert
un
its
for
mob
ile
com
mun
itie
s an
d le
arni
ng in
stit
utio
ns
Num
ber
of
mob
ile
Xpe
rt
unit
s op
erat
iona
lPr
ocur
emen
t of
2
mob
ile
Xpe
rt u
nits
Pr
ocur
emen
t of
2
mob
ile X
pert
uni
ts
1Tr
aini
ng a
nd u
tiliz
atio
n of
m
obile
Xpe
rt u
nits
2
Recr
uitm
ent
of p
erso
nnel
Recr
uitm
ent
of
pers
onne
l
Trai
ning
and
dis
patc
hing
of
uni
ts
Ensu
re
anal
ysis
an
d ut
iliza
tion
of
la
bora
tory
dat
a
Stre
ngth
en
capa
city
of
TB
la
bora
tory
pe
rson
nel
on
oper
atio
nal r
esea
rch
Num
ber
of l
ab p
erso
nnel
tra
ined
in
OR
Con
duct
tr
aini
ng
on
oper
atio
nal r
esea
rch
Con
duct
tr
aini
ng
on
oper
atio
nal r
esea
rch
Dev
elop
an
d su
bmit
m
anus
crip
ts
for
publ
icat
ion
Dev
elop
op
erat
iona
l re
sear
ch p
roto
cols
D
evel
op
oper
atio
nal
rese
arch
pro
toco
ls
Num
ber
of O
R pa
pers
acc
epte
d fo
r pu
blic
atio
nD
evel
op
oper
atio
nal
rese
arch
pro
toco
lsPr
esen
tati
on
of
publ
icat
ions
in
lo
cal
and
inte
rnat
iona
l co
nfer
ence
s
Dev
elop
an
d su
bmit
m
anus
crip
ts
for
publ
icat
ion
Dev
elop
an
d su
bmit
m
anus
crip
ts
for
publ
icat
ion
Dev
elop
an
d su
bmit
m
anus
crip
ts f
or p
ublic
atio
nPr
esen
tati
on
of
publ
icat
ions
in
lo
cal
and
inte
rnat
iona
l co
nfer
ence
s
Pres
enta
tion
of
pu
blic
atio
ns i
n lo
cal
and
inte
rnat
iona
l con
fere
nces
Pres
enta
tion
of
publ
icat
ions
in
lo
cal
and
inte
rnat
iona
l co
nfer
ence
s
4.3.
6. A
ccel
erat
e A
ppro
pria
te D
iagn
osis
4.3.7 Ensure a stable and quality supply of medicines, diagnostics and other commodities 1. Situational Analysis
Since 2008, the Government of Kenya has been allocating funds for the procurement of TB medicines and diagnostics, complemented by donor support. Prior to devolution, forecasting and quantification was done nationally by the NTLD Program in collaboration with technical partners. A procurement plan was developed and reviewed bi-annually. A centralized and competitive procurement mechanism was implemented through Kenya Medical Supplies Agency (KEMSA) for first-line drugs. Second-line drugs for PMDT were supplied through the Global Drug Facility (GDF), with direct procurement. The whole process from quantification, advertising for tender, submission of bids, evaluation, contract negotiation and signing to the time the TB medicines arrived in the country took about nine months.
KEMSA handled the clearing and warehousing of medicines and diagnostics in collaboration with NTLD Program. The medicines were distributed to 210 district stores countrywide on a quarterly basis. From the district stores, the commodities were supplied on a monthly basis to the treatment sites using a collection system, facilitated by the SCTLC. An electronic LMIS system was used to collect consumption data, which was then aggregated on a monthly basis at the national level for planning purposes. There was a quality assurance mechanism at each level of the supply chain, including pharmacovigilance for TB medicines at service delivery points. A post-market surveillance was last conducted in 2009 to check on the quality of medicines used by TB patients at the service delivery points.
To ensure that adequate quantities of TB medicines are maintained, the NTLD Program has set minimum- maximum stocks to be kept at each level. For instance, a sub-county level maximum stock level is six months and minimum stock level is three months. Meanwhile, health facilities are required to maintain a maximum of three months of stocks and a minimum of one month of stock. A 12-month buffer for all medicines and diagnostics is to be maintained at the national warehouse for both first- and second-line medicines.
There is a TB logistic management system (LMIS), which provides integrated commodity recording and reporting tools, including electronic and paper based monthly reporting forms for use at sub-county and health facility level respectively. There is also a facility dispensing register and stock cards. A functional TB commodity security sub-committee is in place at the national level. The committee provides an oversight role in the implementation of TB commodity management activities, including monthly stock status monitoring, forecasting, and procurement planning. A pharmacovigilance system hosted by the Pharmacy and Poisons Board of Kenya exists, and adverse events reporting tools are in place.
In 2013, as part of devolution, the national government funds for procurement of TB medicines and diagnostics were devolved to county governments. County governments now have a mandate to procure TB medicines and diagnostics. However, no counties procured TB medicines and diagnostics in the 2013/14 fiscal year. Procurement of second line TB medicines remains primarily donor-supported, and has not been affected by the devolution of funds. The counties are in the process of streamlining their systems. However, the NTLD Program will continue to ensure a steady supply by liasing with government and other partners.
Other challenges identified by the mid-term review included weaknesses in commodity management practices, delayed deliveries, no order requisitions made, lack of capacity to enable the pull system, and receipts of medicines by non-pharmaceutical personnel. The distribution challenges may be a direct result of the low LMIS reporting rates, inaccurate consumption reports from SDP points, and lack of pharmaceutical personnel involvement at peripheral levels. In addition, there is inadequate capacity of storage facilities at the sub-county level and poor inventory management practices. Weak pharmacovigilance systems means that adverse drug reactions (ADRs) are rarely reported.
2. Strategic Direction(s) for 2015-2018
The priority is to ensure that no drug shortages occur at any level of the health system during the period of the NSP. The strategic direction for this period will aim to ensure a stable and quality-assured supply of drugs and diagnostics nationwide. Specifically, the strategic directions are to:
a) Build political commitment at central and in all 47 counties for funding of TB medicines and diagnostics.b) Strengthen the capacity of counties to appropriately plan for, procure, store, distribute and manage inventories of
commodities.c) Improve the distribution system, including the integration of laboratory diagnostics.d) Strengthen and link the existing DHIS, TIBU and LMIS systems for better management of supplies.e) Ensure quality of TB medicines and diagnostics in the country and in each county. f) Establish commodity security committees at county level.
4.3.7. Medicines, D
iagnostics and Other Com
modities
100
3. Proposed Approaches The approaches highlighted below aim to ensure availability of the following: First and second-line drugs to treat TB; INH to support scale-up of IPT; anti-leprosy drugs; PAL-related commodities for lung health; and ancillary medication to manage TB treatment side effects. The approaches include:
Increase political commitment and government funding for TB, leprosy and lung health medicines and diagnostics, from both national and county budgets
The NSP calls for increasing national government allocation to procure TB medicines and diagnostics, including for DR-TB, from 2014/2015 onwards. The government will also allocate more funds for services related to procurement of TB medicines e.g. customs clearance, warehousing, distribution, quality assurance activities and drug management activities. The planning for complementary funding for procurement and supply management (PSM); i.e. to fill funding gaps using Global Fund and other donor resources is prioritized.
Pooled and centralized procurement of TB medicines and diagnostics, involving all counties, to assure quality and benefit from economies of scale
To ensure high-quality and the lowest costs, bulk procurement at central level is the most efficient modality for maintaining a consistent and high-quality national supply. A 12-month buffer stock at national level will be restored and sustained. The NSP recognizes that this transition to county-level PSM will require technical assistance and new tools to build capacity and ensure consistent procurement planning. In addition, technical assistance is required at the central level to improve distribution systems and efficiency with devolved quantification. Mechanisms for emergency procurement of TB and other medicines and diagnostics will be developed.
Increase county capacity to manage the supply chain for TB, leprosy and lung health medicines and diagnostics
Capacity building of county staff, especially pharmacists, will be carried out through training in TB commodity management and regular supervisory visits that deliberately focus on commodities. Pharmacists will take charge of TB, leprosy and lung health medicines and diagnostics management. New tools will be developed to support county-level quantification and management, based on past use. Inventory management tools will be provided in every store or facilities providing commodities.
Figure 28: Commodities Management Framework
4.3.
7. M
edic
ines
, Dia
gnos
tics
and
Oth
er C
omm
odit
ies
101
4.3.7. Medicines, D
iagnostics and Other Com
modities
Rationalize and increase the efficiency of distribution and storage
Activities covered by this approach aim to maintain a steady supply of pharmaceuticals and supplies to facilities where they are needed, while ensuring that resources are being used in the most cost-effective way. This includes designation of demand-driven distribution points for TB medicines and diagnostics in all the 256 sub-counties, with accurate inventory records at all levels of the supply chain. Capacity will be strengthened at county level for distribution to sub-counties. Monitoring and mitigation of medicine loss caused by storage and expiry will be regularized. Targeted and systemic changes, including audits, will be implemented to reduce theft, fraud and leakage in the distribution system. Efforts will be made to accelerate port clearing, receipt and inspection of goods.
Strengthen the existing logistics management and information system (LMIS)
The existing TB Logistics Management Information System (LMIS) will be strengthened to facilitate better information flow and allow data-driven decision-making. Periodic data quality audits of LMIS are planned, including investigation and response to factors causing under-reporting; integration of stock-related data validation into quarterly review meetings; building capacity of counties and promote stock related data aggregation, analysis and use at county level for timely decision making. As noted in the M&E section of the NSP, the integration of DHIS, TIBU and LMIS platforms will be prioritized to facilitate monitoring across the continuum of service delivery. Monthly electronic reporting from all sub-counties will be monitored, enabling a monthly analysis of stock status and reporting rates by counties and nationally. All service delivery points will have requisite inventory & reporting tools.
Implement a comprehensive quality assurance program
• Implement and ensure devolution of procedures to ensure that only medicine products that meet current standards for quality are bought (careful product and supplier selection, certificate of analysis).
• Update procedures to verify that shipped goods meet the specifications (pre and post shipment inspection, analytical pharmaceutical testing).
• Update proper storage and distribution procedures, and provide guidance to and training for counties on these policies.
• Introduce product defect and pharmacovigilance reporting programs at county level. • Active surveillance for selected TB medicines will be explored. Regular post market surveillance is planned. To
support this revitalized focus on PSM, there will be activities to strengthen collaboration with the Pharmacy and Poisons Board of Kenya (PPB) to improve the pharmacovigilance system for TB by encouraging ADR surveillance and reporting.
Contribution to NSP Impacts Outcomes (Commodities)
Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014
100% of patients newly diagnosed with TB start treatment within two days
Impact 1.1: Reduce the prevalence of MDR-TB among new patients by 15% by 2018, compared to 2014
At least 80% of TB patients with Rif resistance are on 2nd line treatment within two weeks of testing.
Impact 1.2: Reduce the incidence of TB among PLHIV by 60% by 2018, compared to 2014
• ]Increase to 90% the proportion of HIV+ TB patients accessing ART
• Increase to 90% the proportion of children with TB and HIV who are initiated on ART within two months of TB treatment initiation
• Increase to 80% the proportion of selected groups eligible for IPT to be enrolled on INH
Impact 2. Reduce mortality due to TB by 3% by 2018, compared to 2014
Ensure treatment success of at least 90% among all DS forms of TB
Impact 5. Reduce morbidity due to chronic lung diseases (e.g. COPD, asthma)
Increase to 80% the proportion of controlled asthma patients in areas with established PAL and asthma clinics
100% of commodities required to manage chronic lung diseases are available in each county
Enabling Environment: The NTLD Program and all counties have the required resources to implement the NSP
Nationally pooled and quality-assured drug supply is secured, with six-month buffer stock at central level for entire country
Table 13: Impact and Outcome Indicators for Medicines, Diagnostics and Other Commodities
102
4.3.
7. M
edic
ines
, Dia
gnos
tics
and
Oth
er C
omm
odit
ies
Com
mod
itie
s O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
1: B
uild
pol
itic
al c
omm
itm
ent
at c
entr
al a
nd in
all
47 c
ount
ies
for
fund
ing
of T
B, le
pros
y an
d lu
ng h
ealt
h m
edic
ines
and
dia
gnos
tics
Num
ber
of
Mee
ting
s w
ith
Cou
nty
Exec
utiv
es,
Cou
nty
Phar
mac
ist
fo
r re
sour
ce m
obili
zati
on a
ctiv
itie
s
Polit
ical
eng
agem
ent
of
lead
ers/
ke
y in
flue
ncer
s to
allo
cate
fund
ing
for
TB c
omm
odit
ies
and
logi
stic
s in
Nat
iona
l/ C
ount
y bu
dget
s
Mee
ting
w
ith
Cou
nty
Exec
utiv
es, C
ount
y Ph
arm
acis
t fo
r re
sour
ce
mob
iliza
tion
ac
tivi
ties
1M
eeti
ng
wit
h C
ount
y Ex
ecut
ives
, Cou
nty
Phar
mac
ist
for
reso
urce
m
obili
zati
on
acti
viti
es
1M
eeti
ng
wit
h C
ount
y Ex
ecut
ives
, C
ount
y Ph
arm
acis
t
for
reso
urce
m
obili
zati
on a
ctiv
itie
s
1M
eeti
ng w
ith
Cou
nty
Exec
utiv
es,
Cou
nty
Phar
mac
ist
fo
r re
sour
ce
mob
iliza
tion
ac
tivi
ties
1
Hol
d co
nsul
tati
ve
mee
ting
s to
lo
bby
for
incr
ease
d fu
ndin
g fo
r TB
m
edic
ines
an
d di
agno
stic
s,
fund
ing
for
serv
ices
re
late
d to
PS
M, f
undi
ng f
or lo
gist
ics
Mee
ting
s w
ith
CTL
Cs
and
othe
r pl
anne
rs t
o bu
dget
and
re
solv
e an
y in
form
atio
n ga
ps
2M
eeti
ngs
wit
h C
TLC
s an
d ot
her
plan
ners
2M
eeti
ngs
wit
h C
TLC
s an
d ot
her
plan
ners
2M
eeti
ngs
wit
h C
TLC
s an
d ot
her
plan
ners
2
Perc
enta
ge
of
all
fina
ncin
g fo
r TB
co
mm
odit
ies
fund
ed
by
nati
onal
go
vern
men
t
Trac
k fu
ndin
g fo
r TB
com
mod
itie
s th
roug
h TB
NH
A
Trac
k fu
ndin
g fo
r TB
co
mm
odit
ies
thro
ugh
TB N
HA
40
Trac
k fu
ndin
g fo
r TB
co
mm
odit
ies
thro
ugh
TB N
HA
45
Trac
k fu
ndin
g fo
r TB
co
mm
odit
ies
thro
ugh
TB
NH
A
50Tr
ack
fund
ing
for
TB c
omm
odit
ies
thro
ugh
TB N
HA
60
Stra
tegi
c A
ppro
ach
2: S
tren
gthe
n th
e ca
paci
ty o
f co
unti
es t
o ap
prop
riat
e pl
an f
or, p
rocu
re, s
tore
, dis
trib
ute
and
man
age
inve
ntor
ies
of c
omm
odit
ies
thro
ugh
a na
tion
ally
poo
led
syst
em
Num
ber
of
coun
ties
re
ceiv
eing
bi
-an
nual
tec
hnic
al a
ssis
tanc
e re
late
d to
su
pply
cha
in m
anag
emen
t
Tech
nica
l as
sist
ance
fro
m K
EMSA
, N
TLD
Pr
ogra
m
and
part
ners
to
co
unti
es
Con
duct
bi
an
nual
na
tion
al
leve
l TA
fo
cusi
ng
on
the
supp
ly c
hain
sys
tem
47C
ondu
ct
bi
annu
al
nati
onal
le
vel T
A fo
cusi
ng o
n th
e su
pply
ch
ain
syst
em
47C
ondu
ct
bi
annu
al
nati
onal
le
vel
TA
focu
sing
on
th
e su
pply
cha
in s
yste
m
47C
ondu
ct
bi
annu
al
nati
onal
le
vel
TA
focu
sing
on
the
supp
ly c
hain
sys
tem
47
Num
ber
of
coun
ties
us
ing
an
inte
grat
ed s
uppl
y ch
ain
for T
B, H
IV a
nd
Mal
aria
at
all l
evel
s
Inte
rgra
ted
dist
ribu
tion
of
TB
m
edic
ines
an
d la
bora
tory
co
mm
odit
ies
n/a
Inte
rgra
ted
dist
ribu
tion
of
TB
m
edic
ines
an
d la
bora
tory
co
mm
odit
ies
to a
ll 47
cou
ntie
s
47In
terg
rate
d di
stri
buti
on
of
TB m
edic
ines
and
lab
orat
ory
com
mod
itie
s to
al
l 47
co
unti
es
47In
terg
rate
d di
stri
buti
on o
f TB
med
icin
es
and
labo
rato
ry
com
mod
itie
s to
al
l 47
co
unti
es
47
Num
ber
of
join
t Fo
reca
stin
g an
d qu
anti
fica
tion
mee
ting
s he
ld b
etw
een
Nat
iona
l and
cou
nty
gove
rnm
ents
Supp
ort
a Jo
int
Nat
iona
l TB
Pr
ogra
m &
Cou
nty
Gov
ernm
ents
Fo
reca
stin
g &
Q
uant
ific
atio
n M
eeti
ngs
for
TB
Med
icin
es,
Labo
rato
ry
Con
sum
mab
les
incl
udin
g G
X R
IF C
artr
idge
s
Revi
se o
pera
tion
al p
roce
dure
s w
ith
KEM
SA F
& Q
mee
ting
s2
F &
Q m
eeti
ngs
2 F
& Q
mee
ting
s2
Num
ber
of c
ount
ies
wit
h co
sted
TB
com
mod
ity
proc
urem
ent
plan
sTr
aini
ng
of
Cou
nty
phar
mac
ists
,Cou
nty
TB
cord
inat
ors
and
Cou
nty
labo
rato
ry
cord
inat
ors
on
TB
com
mod
ity
man
agem
ent
Con
duct
tra
inin
g fo
r C
TLC
s47
Con
duct
tra
inin
g fo
r C
TLC
s47
Refr
eshe
r tr
aini
ng;
on-t
he-
job
tool
s47
Refr
eshe
r tr
aini
ng; o
n-th
e-jo
b to
ols
47
Dev
elop
tem
plat
es f
or e
stim
atin
g bu
dget
s an
d pr
ovid
e TA
to
co
unti
es
Dev
elop
te
mpl
ates
fo
r es
tim
atin
g bu
dget
s;
nati
onal
F
and
Q m
eeti
ng t
o de
term
ine
com
mod
ity
need
s
1F
and
Q m
eeti
ngs
at c
ount
y le
vel
to
dete
rmin
e th
e co
untr
y’s
TB c
omm
odit
y ne
eds
47F
and
Q m
eeti
ngs
at c
ount
y le
vel
to
dete
rmin
e th
e co
untr
y’s
TB
com
mod
ity
need
s
47F
and
Q
mee
ting
s at
co
unty
le
vel
to
dete
rmin
e th
e co
untr
y’s
TB
com
mod
ity
need
s
47
Prin
ting
an
d di
stri
buti
on
of
inve
ntor
y m
anag
emen
t t
ools
Prin
t an
d di
stri
bute
boo
klet
s fo
r A
FB o
f 10
0 pa
ges
3,60
0Pr
int
and
dist
ribu
te
book
lets
fo
r A
FB o
f 10
0 pa
ges
3,60
0Pr
int
and
dist
ribu
te b
ookl
ets
for
AFB
of
100
page
s3,
600
Prin
t an
d di
stri
bute
boo
klet
s fo
r A
FB o
f 10
0 pa
ges
3600
Tech
nica
l as
sist
ance
to
co
unti
es
on in
vent
ory
man
agem
ent
Tech
nica
l as
sist
ance
pro
vide
d by
NTL
D P
rogr
am,
Cen
ters
of
Exce
llenc
e (o
ther
cou
ntie
s), o
r pa
rtne
rs
47Te
chni
cal
assi
stan
ce p
rovi
ded
by N
TLD
Pro
gram
, C
ente
rs o
f Ex
celle
nce
(oth
er c
ount
ies)
, or
pa
rtne
rs
47Te
chni
cal a
ssis
tanc
e pr
ovid
ed
by N
TLD
Pro
gram
, Cen
ters
of
Exce
llenc
e (o
ther
co
unti
es),
or p
artn
ers
30Te
chni
cal
assi
stan
ce
prov
ided
by
N
TLD
Pr
ogra
m,
Cen
ters
of
Ex
celle
nce
(oth
er
coun
ties
), or
par
tner
s
30
Num
ber
of
coun
ties
w
ith
acti
ve
com
mod
ity
secu
rity
com
mit
tees
Form
co
mm
odit
y se
curi
ty
com
mit
tees
at
coun
ty le
vel
Prov
ide
tech
nica
l as
sist
ance
an
d tr
aini
ng
on
com
mod
ity
secu
rity
25Pr
ovid
e te
chni
cal
assi
stan
ce
and
trai
ning
on
co
mm
odit
y se
curi
ty
22Su
ppor
t co
mm
odit
y se
curi
ty
com
mit
tees
47Su
ppor
t co
mm
odit
y se
curi
ty c
omm
itte
es47
Num
ber
of
requ
ired
co
mm
odit
ies
proc
ured
Proc
ure
firs
t lin
e TB
dru
gs, S
econ
d Li
ne a
nti
TB m
edic
atio
n fo
r M
DR
TB-P
atie
nts,
XD
R TB
m
edic
ines
, A
ncill
ary
drug
s fo
r 3
25 p
atie
nts
Proc
ure
pati
ent
kits
100,
000
Proc
ure
pati
ent
kits
100,
000
Proc
ure
pati
ent
kits
100,
000
Proc
ure
pati
ent
kits
100,
000
4.3.7. Medicines, D
iagnostics and Other Com
modities
Com
mod
itie
s O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Proc
ure
ison
iazi
d fo
r TB
pr
even
tive
the
rapy
INH
pr
ocur
ed
(all
form
ulat
ions
)20
0,00
0IN
H p
rocu
red
(all
form
ulat
ions
)20
0,00
0IN
H
proc
ured
(a
ll fo
rmul
atio
ns)
200,
000
INH
pro
cure
d (a
ll fo
rmul
atio
ns)
200,
000
Pr
ocur
emen
t an
d su
pply
of
Tu
berc
ulin
Tu
berc
ulin
Sk
in
Test
Sy
ring
es
(sin
gle-
dose
di
spos
able
tu
berc
ulin
syr
inge
tha
t ha
s a
one-
quar
ter t
o on
e-ha
lf in
ch, 2
7-ga
uge
need
le w
ith
a sh
ort
beve
l)
Pro
cure
men
t an
d su
pply
of
Tube
rcul
in
Tube
rcul
in
Skin
Te
st
Syri
nges
(s
ingl
e-do
se
disp
osab
le t
uber
culin
syr
inge
th
at h
as a
one
-qua
rter
to
one-
half
in
ch,
27-g
auge
ne
edle
w
ith
a sh
ort
beve
l)
2,00
0Pr
ocur
emen
t an
d su
pply
of
Tu
berc
ulin
Tu
berc
ulin
Sk
in
Test
Sy
ring
es
(sin
gle-
dose
di
spos
able
tu
berc
ulin
sy
ring
e th
at h
as a
one
-qua
rter
to
one-
half
in
ch,
27-g
auge
ne
edle
w
ith
a sh
ort
beve
l)
2,00
0 P
rocu
rem
ent
and
supp
ly o
f Tu
berc
ulin
Tu
berc
ulin
Sk
in
Test
Sy
ring
es
(sin
gle-
dose
di
spos
able
tub
ercu
lin s
yrin
ge
that
ha
s a
one-
quar
ter
to
one-
half
in
ch,
27-g
auge
ne
edle
wit
h a
shor
t be
vel)
2,00
0 P
rocu
rem
ent
and
supp
ly o
f T
uber
culin
Tu
berc
ulin
Ski
n Te
st S
yrin
ges
(sin
gle-
dose
di
spos
able
tub
ercu
lin s
yrin
ge t
hat
has
a on
e-qu
arte
r to
on
e-ha
lf
inch
, 27
-gau
ge
need
le w
ith
a sh
ort
beve
l)
2000
Proc
ure
and
supp
ly r
ifab
utin
for
TB
-HIV
co-
infe
cted
pat
ient
s on
2nd
lin
e A
RT
Proc
ure
and
supp
ly r
ifab
utin
fo
r TB
-HIV
co
-inf
ecte
d pa
tien
ts o
n 2nd
line
ART
600
pati
ents
Proc
ure
and
supp
ly
rifa
buti
n fo
r TB-
HIV
co-
infe
cted
pat
ient
s on
2nd
line
ART
600
pati
ents
Proc
ure
and
supp
ly r
ifab
utin
fo
r TB
-HIV
co
-inf
ecte
d pa
tien
ts o
n 2nd
line
ART
600
pati
ents
Proc
ure
and
supp
ly r
ifab
utin
for
TB-
HIV
co
-inf
ecte
d pa
tien
ts o
n 2nd
line
ART
600
pati
ents
Proc
ure
lepr
osy
med
icin
ePr
ocur
e le
pros
y m
edic
ine
250
pati
ents
Proc
ure
lepr
osy
med
icin
e25
0 pa
tien
tsPr
ocur
e le
pros
y m
edic
ine
250
pati
ents
Proc
ure
lepr
osy
med
icin
e25
0 pa
tien
ts
Proc
ure
Labo
rato
ry c
onsu
mab
les
susp
ects
fo
r A
AFB
m
icro
scop
y,
cons
umab
les
for
Gen
e X
pert
Proc
ure
Labo
rato
ry
cons
umab
les
susp
ects
fo
r A
AFB
m
icro
scop
y,
cons
umab
les
for
Gen
e X
pert
Proc
ure
Labo
rato
ry
cons
umab
les
susp
ects
fo
r A
AFB
m
icro
scop
y,
cons
umab
les
for
Gen
e X
pert
Proc
ure
Labo
rato
ry
cons
umab
les
susp
ects
fo
r A
AFB
m
icro
scop
y,
cons
umab
les
for
Gen
e X
pert
Proc
ure
Labo
rato
ry c
onsu
mab
les
susp
ects
fo
r A
AFB
m
icro
scop
y,
cons
umab
les
for
Gen
e X
pert
Prot
ecti
ve g
ear
(ass
orte
d)
Prot
ecti
ve g
ear
(ass
orte
d)
Prot
ecti
ve g
ear
(ass
orte
d)
Prot
ecti
ve g
ear
(ass
orte
d)
Prot
ecti
ve g
ear
(ass
orte
d)
Ann
ual C
alib
rati
on o
f G
eneX
pert
Ann
ual
Cal
ibra
tion
of
G
eneX
pert
Ann
ual
Cal
ibra
tion
of
G
eneX
pert
Ann
ual
Cal
ibra
tion
of
G
eneX
pert
Ann
ual C
alib
rati
on o
f G
eneX
pert
Proc
ure
LED
mic
rosc
ope
for
high
vo
lum
e ho
spit
als,
M
icro
scop
es
CX
31
Oly
mp,
G
ene
Xpe
rt
Equi
pmen
t
Proc
ure
LED
m
icro
scop
e fo
r hi
gh
volu
me
hosp
ital
s,
Mic
rosc
opes
C
X31
O
lym
p,
Gen
e X
pert
Equ
ipm
ent
125
Xpe
rtPr
ocur
e LE
D
mic
rosc
ope
for
high
vo
lum
e ho
spit
als,
M
icro
scop
es
CX
31
Oly
mp,
G
ene
Xpe
rt E
quip
men
t
340
LED
m
icro
scop
esPr
ocur
e LE
D
mic
rosc
ope
for
high
vo
lum
e ho
spit
als,
M
icro
scop
es
CX
31
Oly
mp,
G
ene
Xpe
rt E
quip
men
t
125
Xpe
rtPr
ocur
e LE
D m
icro
scop
e fo
r hi
gh v
olum
e ho
spit
als,
Mic
rosc
opes
CX
31 O
lym
p, G
ene
Xpe
rt E
quip
men
t
Cos
t fo
r fr
eigh
t an
d in
sura
nce
for
LED
and
ligh
t m
icro
scop
es
Cos
t fo
r fr
eigh
t an
d in
sura
nce
for
LED
and
ligh
t m
icro
scop
es
11%
of
p
rocu
rem
en
t co
sts
Cos
t fo
r fr
eigh
t an
d in
sura
nce
for
LED
and
ligh
t m
icro
scop
es
11%
of
p
roc
ure
me
nt
cost
s
Cos
t for
frei
ght a
nd in
sura
nce
for L
ED a
nd li
ght m
icro
scop
es
11%
of
p
roc
ure
me
nt
cost
s
Cos
t fo
r fr
eigh
t an
d in
sura
nce
for
LED
and
lig
ht m
icro
scop
es
11%
of
pr
ocur
emen
t co
sts
Aut
omat
ic w
ater
dis
tile
r, ca
paci
ty
4-12
lts
per
hr, d
isti
led
wat
er 3
µS
Aut
omat
ic
wat
er
dist
iler,
capa
city
4-1
2lts
per
hr,
dist
iled
wat
er 3
µS
Aut
omat
ic
wat
er
dist
iler,
capa
city
4-1
2lts
per
hr,
dist
iled
wat
er 3
µS
Aut
omat
ic
wat
er
dist
iler,
capa
city
4-
12lt
s pe
r hr
, di
stile
d w
ater
3 µ
S
Aut
omat
ic w
ater
dis
tile
r, ca
paci
ty 4
-12l
ts
per
hr, d
isti
led
wat
er 3
µS
PSM
fe
es
(pro
cure
men
t w
are
hous
ing,
insu
ranc
e, d
istr
ibut
ion)
PSM
fe
es
(pro
cure
men
t w
are
hous
ing,
in
sura
nce,
di
stri
buti
on a
t )
8%
of
pro
cure
me
nt
cost
PSM
fe
es
(pro
cure
men
t w
are
hous
ing,
in
sura
nce,
di
stri
buti
on a
t )
8%
of
pro
cu
rem
en
t co
st
PSM
fe
es
(pro
cure
men
t w
are
hous
ing,
in
sura
nce,
di
stri
buti
on a
t )
8%
of
pro
cu
rem
en
t co
st
PSM
fe
es
(pro
cure
men
t w
are
hous
ing,
in
sura
nce,
dis
trib
utio
n at
)8%
of
proc
urem
ent
cost
Stra
tegi
c A
ppro
ach
3: Im
prov
e th
e di
stri
buti
on s
yste
m, i
nclu
ding
the
inte
grat
ion
of la
bora
tory
dia
gnos
tics
Prop
orti
on o
f su
b co
unti
es r
epor
ting
co
mm
odit
y st
ock
outs
of
trac
er it
ems
Ensu
re a
cces
s to
TB,
Lep
rosy
and
Lu
ng h
ealt
h ph
arm
aceu
tica
ls a
nd
supp
lies
to s
ub c
ount
ies
50%
20%
5%5%
Map
dis
trib
utio
n po
ints
in a
ll su
b-co
unti
esM
appi
ng e
xerc
ise
1
Syst
emat
ic d
istr
ibut
ion
audi
tsSy
stem
atic
dis
trib
utio
n au
dits
1Sy
stem
atic
dis
trib
utio
n au
dits
1Sy
stem
atic
dis
trib
utio
n au
dits
1Sy
stem
atic
dis
trib
utio
n au
dits
1
Impr
ove
port
cle
arin
gIm
prov
e po
rt c
lear
ing
Impr
ove
port
cle
arin
gIm
prov
e po
rt c
lear
ing
Impr
ove
port
cle
arin
g
Rece
ipt
and
insp
ecti
on o
f go
ods
Rece
ipt
and
insp
ecti
on o
f go
ods
Rece
ipt
and
insp
ecti
on o
f go
ods
Rece
ipt
and
insp
ecti
on o
f go
ods
Rece
ipt
and
insp
ecti
on o
f go
ods
Dis
trib
utio
n to
sub
-cou
ntie
s ba
sed
on l
ocal
qua
ntif
icat
ion
usin
g pa
st
need
Dis
trib
utio
n to
su
b-co
unti
es
base
d on
loc
al q
uant
ific
atio
n us
ing
past
nee
d
50D
istr
ibut
ion
to
sub-
coun
ties
ba
sed
on l
ocal
qua
ntif
icat
ion
usin
g pa
st n
eed
80D
istr
ibut
ion
to s
ub-c
ount
ies
base
d on
loca
l qua
ntif
icat
ion
usin
g pa
st n
eed
95D
istr
ibut
ion
to
sub-
coun
ties
ba
sed
on
loca
l qua
ntif
icat
ion
usin
g pa
st n
eed
95
4.3.
7. M
edic
ines
, Dia
gnos
tics
and
Oth
er C
omm
odit
ies
Com
mod
itie
s O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
4: S
tren
gthe
n th
e ex
isti
ng lo
gist
ics
man
agem
ent
and
info
rmat
ion
syst
em (L
MIS
)
Stra
tegi
c A
ppro
ach
5: E
nsur
e qu
alit
y of
TB
med
icin
es a
nd d
iagn
osti
cs in
the
cou
ntry
and
cou
ntie
s
Prop
orti
on
of
drug
s co
nfor
min
g to
th
e m
inim
um s
tand
ards
in c
omm
odit
y m
anag
emen
t
90%
9597
97
Car
ry o
ut p
ost m
arke
t sur
veill
ance
Post
mar
ket
surv
eilla
nce
1Po
st m
arke
t su
rvei
llanc
e1
Post
mar
ket
surv
eilla
nce
1Po
st m
arke
t su
rvei
llanc
e1
Rand
om d
rug
qual
ity
test
ing
Rand
om d
rug
qual
ity
test
ing
Rand
om d
rug
qual
ity
test
ing
Rand
om d
rug
qual
ity
test
ing
Rand
om d
rug
qual
ity
test
ing
Prop
orti
on o
f hea
lth
faci
litie
s re
port
ing
on A
DRs
En
sure
AD
R re
port
ing,
wor
k w
ith
PPB
on e
-rep
orti
ng,
poor
qua
lity
med
icin
e re
port
ing,
PV
tra
inin
gs
Repo
rtin
g on
AD
Rs10
%Re
port
ing
on A
DRs
25%
Repo
rtin
g on
AD
Rs35
%Re
port
ing
on A
DRs
50%
Phar
mac
ovig
ilanc
e tr
aini
ng2
Phar
mac
ovig
ilanc
e tr
aini
ng2
Phar
mac
ovig
ilanc
e tr
aini
ng2
Phar
mac
ovig
ilanc
e tr
aini
ng2
4.3.8. Enhance evidence-based program monitoring and evaluation1. Situational Analysis
A robust and responsive surveillance, monitoring and evaluation (M&E) system is important for ensuring quality TB, leprosy and lung disease control. The NLTD-Program is implementing an electronic patient-based surveillance system it developed, called “TIBU”1. The first of its kind in Africa, “TIBU” is the Swahili word for “treat”, and is an acronym for Treatment Information from Basic Program. The aim of TIBU is to maintain electronic records of all patients, enabling real-time evaluation of programme performance at any level. TIBU is decentralized to the sub-county level, and data can be aggregated up to the national level. TIBU has yielded a robust database with comprehensive patient parameters. It has various functions for patient management and payment to patients and field officers.
The patient management system does the following:
1. Online data capture of patient-based information2. Data transfer in real time to central program3. Ability to generate real time reports at any level4. Identification of duplicate patient entries.
The payment module does the following:
1. Funds transfer to NTLD Program staff to reimburse them for supportive supervision and routine surveillance activities 2. Funds transfer to MDR-TB patients for financial support, using MPESA3. Improves governance and accountability through utilization of mobile money transfer.
Information generated from this system is further utilized for operational research at various levels of health care delivery. The NTLD Program has further made efforts to ensure that the quality of the data generated by this system is maintained through regular supportive supervision, data quality assessments (DQAs), data validation meetings and capacity building of health care workers. Primary data capture tools have been in use at the health facility level of care provision.
A national M&E plan was drafted in 2014, containing details for monitoring all core DOTS, TB/HIV and PMDT activities in the Kenyan context. The logical framework for the M&E system is shown below.
_______________________________________________________________________________________________________________________________1 TIBU was developed through a partnership with various organizations. Partners include the Government of Kenya, which provides policy guidance and is the main implementer of the system. Safaricom provides communication and data storage services with cloud hosting. The other two partners are TangazoLetu, which provides payment solutions for the system, and Iridium Interactive, which supports the patient management module. The USG through USAID provided funding for development and operationalization of the system.
Figure 29: M&E Logical Framework
4.3.8. Monitoring and Evaluation
106
4.3.
8. M
onit
orin
g an
d Ev
alua
tion
2. Strategic Direction(s) for 2015-2018
For the period of this NSP, the NTLD Program will focus on maintaining data quality and further decentralizing data management knowledge and skills to county and sub-county level health care workers to promote ownership and data use.
Based on successful early experience with the current surveillance system, the NLTD-Program can now refine the system to make it more integrated and to better serve all of the needs of the programme and other stakeholders. The platform can be extended to host data of other communicable diseases. Capacity building will be prioritized to enable the use of programmatic data and operational research for decision-making.
3. Proposed Approaches
Continuously improve monitoring and evaluation tools and capacities at all levels
1. Develop an M&E training curriculum that reflects the use of TIBU; operationalize a cascade of training on M&E, data management and data use for decision-making
2. Enhance supervision and on-the-job mentorship at county and facility levels to improve the quality of recording and reporting. Revise and promote the use of the supervision checklist to provide immediate feedback.
3. Ensure availability and usage of all standardized and up-to-date revised recording and reporting tools at all levels. 4. Revise M&E policies and components in the National Guidelines 5. Support the roll-out of ICD 10.
Strengthen TIBU and its integration with other surveillance platforms
1. Expand TIBU to:a. Link with the Laboratory Management Information System (LIMS), the Community-based Health Information System (CBHIS) through DHIS-2, and the overall Health Management Information System (HMIS).
b. Introduce new TIBU modules recommended by the mid-term review to support the capture of activities related to: PMDT, prevention and intensified case finding, collaborative TB/HIV, presumptive TB, contact tracing, community TB, supervision and others areas.
c. Create and implement a financial reporting tool within TIBU to monitor sub-sector (TB) finance expenditure.
d. Explore TIBU as an M&E platform for other communicable disease control programs.
2. Enhance the automated analytic functions of TIBU to aid in the utilization of the data. The NTLD Program plans to create a dashboard of key performance indicators at the various levels of TB control services (county, sub-county and service delivery points). The dashboard will also have warning signs when immediate action needs to be taken.
3. Improve the vital registration system to better capture TB deaths.
4. Support the mainstreaming of SHA-2011.
Improve TB financial reporting and quantification
Develop and pilot a financial reporting tool linked to the TB sub-sector health accounts monitoring.
Improve mortality statistics
Build capacity for ICD-10 classification and reporting.
Improve the quality and systematic use of strategic information
1. Conduct routine and systematic data quality assessments (DQAs) at county and national level to improve data completeness, consistency and accuracy
2. Conduct data validation meetings and monthly data review meetings at sub-county level3. Guide counties to develop their M&E plan as part of defining their health strategy, setting county specific targets
for TB, leprosy and lung health4. Maintain a functional M&E technical working group (TWG) at national level and support the formation of an M&E
TWG in each county. 5. Strengthen the infrastructure across the NTLD Program network for data use
107
4.3.8. Monitoring and Evaluation
6. Evaluate and communicate data use successes
Ensure availability of a supporting infrastructure
1. Establish a functional Data Management Program at central level to oversee all aspects of data management2. Provide tablets and computers, where needed, for data capture and management3. Improve the current email hosting to Google Cloud from group wise, to facilitate easy internet access and minimize
the occurrence of disconnections.
Promote impact assessment and prioritize research, including operational research, which will address programme challenges
To continue to build the evidence-base for TB, leprosy and lung disease control, capacity to conduct studies, including operational research (OR) will continue to be built among all TB stakeholders.
There will be a renewed focus on the application of evidence generated from studies to improve outcomes and show the impact of new approaches and ongoing activities. Staff will be encouraged to contribute to the regional and global evidence-base by presenting their findings at national and international conferences, and publish manuscripts in peer reviewed journals. To ensure research is focused and addresses the key challenges, a collaborative OR agenda will be developed with all key stakeholders. A preliminary list of operational research priorities is highlighted below (See Table 14).
Enhancing operational research will require the NTLD Program to:
1. Revamp the research task force at the national level and establish similar forums at county level. The research task force will be supported to mentor counties
2. Identify OR trainees who are well positioned to conduct and apply research; build for impact assessments and operational research; and enable them to serve as future trainers and mentors
3. Convene biannual forums to share research findings at the county level, including national lung health conference(s)4. Develop and implement a prioritized operational research agenda within the next three-year plan and continue
building operational research capacity (learning while doing/mentorship) throughout the health system.
108
4.3.
8. M
onit
orin
g an
d Ev
alua
tion
Operational Research Priorities
National, Ongoing
1. Prevalence Survey (2015-2016)2. DRS (2015)3. Mortality Study4. Pediatric TB HIV study5. Delay in diagnosis study (to be completed, ongoing)6. Inventory Studies
National
1. KAP (to be comprehensive – legislators, patients, HCWs, media, community)2. The impact of Xpert MTB on diagnosis of TB (as per the national protocol) 3. Outcomes of ICF and IPT implementation in routine clinical settings in Kenya4. Prevalence of pulmonary aspergilosis in PTB patients5. Burden of Lung Disease (BOLD) study nationally
Counties
1. In counties with treatment success <80%, assess factors2. Assess barriers to treatment adherence3. Assess models for improving case holding by community and family-based DOTS4. In counties where decline in case notification is >5%/year, assess if true decline and assess factors5. Routinely do exit interviews among the patients to capture information source of patient prior to
treatment as a quality of care assessment
Desktop Reviews
1. Ascertain the coverage of TB, Leprosy and LD in the mass media2. Longitudinal data analysis of smear microscopy EQA to determine quality improvement trends and
recurrent gaps3. Longitudinal data analysis on Culture and DST services to determine trends4. Outcome of MDR-TB in children and child MDR-TB contacts5. Documentation of best practices and timely application of best Social Protection Practices6. Impact of food support on TB treatment outcomes7. Determination of various factors associated with the different treatment outcomes8. Analysis of mortality statistics
Enhance research literacy among CHWs to enable them understand the results and the importance of research
Table 14: Operational Research Priorities
109
4.3.8. Monitoring and Evaluation
Mon
itor
ing
and
Eval
uati
on O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
1: C
onti
nuou
sly
impr
ove
surv
eilla
nce,
mon
itor
ing
and
eval
uati
on s
yste
ms,
too
ls a
nd c
apac
itie
s fo
r TB
, lep
rosy
and
lung
dis
ease
con
trol
Prop
orti
on
of
targ
eted
H
CW
tr
aine
dBu
ild
M&
E ca
paci
ty
of
both
na
tion
al,
coun
ty
and
sub
coun
ty T
B H
CW
Hol
d 2,
5 d
ay w
orks
hops
to
deve
lop
an
M&
E ca
paci
ty b
uild
ing
plan
for t
he N
TLD
Pr
ogra
m c
over
ing
both
the
Cou
nty
and
Nat
iona
l lev
els
of G
over
nmen
t
Con
duct
5 d
ay tr
aini
ng fo
r 100
nat
iona
l, co
unty
and
sub
coun
ty T
B H
CW
100%
Con
duct
5
day
trai
ning
fo
r 10
0 na
tion
al,
coun
ty a
nd s
ubco
unty
TB
HC
W
100%
Con
duct
5 d
ay tr
aini
ng fo
r 100
nat
iona
l, co
unty
and
sub
coun
ty T
B H
CW
100%
Num
ber
of
data
de
man
d an
d us
e gu
idel
ine
and
trai
ning
m
ater
ials
dev
elop
ed
Dev
elop
men
t of
dat
a de
man
d an
d us
er g
uide
line
and
trai
ning
m
ater
ials
n/a
Hol
d a
5 da
y w
orks
hop
to d
evel
op d
ata
dem
and
and
use
guid
elin
es a
nd tr
aini
ng
mat
eria
ls
2n/
aH
old
a 5
day
wor
ksho
p to
rev
iew
the
da
ta d
eman
d an
d us
e gu
idel
ines
and
tr
aini
ng m
ater
ials
2
Prop
orti
on
of
targ
eted
H
CW
tr
aine
d on
dat
a de
man
d an
d us
eTr
ain
2,40
0 H
CW
on
da
ta
dem
and
and
use
n/a
Trai
n 60
0 he
alth
ca
re
wor
kers
on
da
ta
dem
and
and
use.
(T
he
heal
th
care
wor
kers
are
dra
wn
from
CTL
C's
, SC
TLC
's,
hosp
ital
s, h
ealt
h ce
ntre
s an
d ho
spit
als)
100%
Trai
n 60
0 he
alth
car
e w
orke
rs o
n da
ta d
eman
d an
d us
e. (
The
heal
th
care
wor
kers
are
dra
wn
from
CTL
C's
, SC
TLC
s,
hosp
ital
s,
heal
th
cent
res
and
hosp
ital
s)
100%
Trai
n 60
0 he
alth
ca
re
wor
kers
on
da
ta
dem
and
and
use.
(T
he
heal
th
care
wor
kers
are
dra
wn
from
CTL
C's
, SC
TLC
's,
hosp
ital
s, h
ealt
h ce
ntre
s an
d ho
spit
als)
100%
Num
ber
of
guid
elin
es
and
polic
ies
deve
lope
d w
ith
M&
E co
mpo
nent
s in
corp
orat
ed
Revi
ew
M&
E co
mpo
nent
s in
po
licie
s an
d gu
idel
ines
Pa
rtic
ipat
e in
gu
idel
ines
re
view
m
eeti
ngs
and
ensu
re
that
th
e M
&E
com
pone
ts a
re in
corp
orat
ed
5Pa
rtic
ipat
e in
gu
idel
ines
re
view
m
eeti
ngs
and
ensu
re t
hat
the
M&
E co
mpo
nets
are
inco
rpor
ated
5Pa
rtic
ipat
e in
gu
idel
ines
re
view
m
eeti
ngs
and
ensu
re
that
th
e M
&E
com
pone
ts a
re in
corp
orat
ed
5
Prop
orti
on
of
sub-
coun
ties
re
port
ing
pres
umpt
ive
TB c
ases
Dev
elop
pr
esum
ptiv
e TB
re
gist
ers
Hol
d 1,
5 d
ay m
eeti
ng t
o de
velo
p th
e pr
esum
tive
TB
regi
ster
0n/
a25
%H
old
1, 5
day
mee
ting
to
revi
se t
he
pres
umpt
ive
TB r
egis
ter
50%
n/a
>85
%
Prin
t pr
esum
ptiv
e TB
reg
iste
rsn/
aPr
int
6,00
0 pr
esum
ptiv
e TB
Reg
iste
rs
Prin
t 6,
000
pres
umpt
ive
TB R
egis
ters
n/a
Dis
sem
inat
e p
resu
mpt
ive
TB
regi
ster
sn/
aH
old
a m
eeti
ng
to
diss
emin
ate
TB
pres
umpt
ive
regi
ster
to
47 c
ount
ies
n/a
Hol
d a
mee
ting
to
diss
emin
ate
revi
sed
TB p
resu
mpt
ive
regi
ster
to
47 c
ount
ies
Dis
trib
ute
pres
umpt
ive
TB
regi
ster
sn/
aU
se
cour
ier
serv
ices
to
di
stri
bute
6,
000
pres
umpt
ive
TB r
egis
ter
to a
ll 47
co
unti
es
n/a
Dis
trib
ute
6,00
0 pr
esum
ptiv
e TB
re
gist
ers
Prop
orti
on
of
sub-
coun
ties
re
port
ing
100%
of
th
eir
faci
litie
s us
ing
cont
act
regi
ster
s
Dev
elop
/ In
tegr
ate/
Revi
ew
cont
act
regi
ster
1. H
old
I m
eeti
ng t
o de
velo
p/ i
nteg
rate
th
e co
ntac
t re
gist
er0
n/a
25%
Hol
d 1
mee
ting
to
revi
ew c
onta
ct
regi
ster
50%
n/a
>85
%
Prin
t co
ntac
t re
gist
er
Prin
t 4,
000
copi
es o
f co
ntac
t re
gist
ern/
aPr
int
4000
cop
ies
of t
he c
onta
ct,
regi
ster
n/a
Dis
sem
inat
e co
ntac
t re
gist
ers
n/a
Hol
d a
mee
ting
to
diss
emin
ate
cont
act
regi
ster
s t
o 47
cou
ntie
sn/
aH
old
a m
eeti
ng t
o di
ssem
inat
e re
vise
d co
ntac
t re
gist
ers
to 4
7 co
unti
es
Dis
trib
ute
cont
act
reg
iste
rsn/
aD
istr
ibut
e 4,
000
copi
es
of
cont
act
regi
ster
s up
to t
o co
unty
leve
ln/
aD
istr
ibut
e 4,
000
copi
es
of
cont
act
regi
ster
s up
to t
o co
unty
leve
l
Prop
orti
on
of
faci
litie
s us
ing
the
inte
grat
ed
tool
to
re
port
th
roug
h D
HIS
Inte
rgra
te
case
find
ing
and
coho
rt
repo
rtin
g to
ol
into
M
OH
71
1 fa
cilit
y re
port
ing
tool
Hol
d a
2 da
y re
trea
t to
int
ergr
ate
the
tool
s0
n/a
2%H
old
a 2
day
mee
ting
to
revi
ew t
he
inte
grat
ed t
ool
80%
n/a
100%
Pret
esti
ng o
f th
e in
terg
rate
d to
ols
n/a
Pret
est
the
tool
in t
he 5
mod
el c
oun-
ties
tar
gett
ing
all t
he c
ount
y an
d su
b co
unty
hos
pita
ls
n/a
n/a
Prin
ting
of
the
tool
Prin
t 50
cop
ies
for
pret
est
Prin
t 4,
000
copi
es f
or d
isse
min
atio
nn/
aPr
int
4,00
0 co
pies
for
dis
sem
inat
ion
Dis
sem
inat
e in
terg
rate
d to
ols
n/a
n/a
Hol
d a
1 da
y m
eeti
ng t
o di
ssem
inat
e in
tegr
ated
too
l in
47 c
ount
ies
n/a
Dis
trib
ute
inte
rgra
ted
tool
sn/
an/
aU
se c
ouri
er t
o di
stri
bute
4,0
00
copi
es o
f in
tegr
ated
too
l up
to
coun
ty le
vel
n/a
4.3.
8. M
onit
orin
g an
d Ev
alua
tion
Mon
itor
ing
and
Eval
uati
on O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prop
orti
on o
f TB
dia
gnos
tic
labs
pr
ovid
ed w
ith
all
the
rele
vant
to
ols
Revi
se
labo
rato
ry
data
co
llect
ion
and
repo
rtin
g to
ols
Hol
d a
5 da
y m
eeti
ng t
o re
vise
eac
h of
the
12
type
s of
la
b re
cord
ing
and
repo
rtin
g to
ols
100%
n/a
100%
Revi
se, p
rint
and
dis
sem
inat
e ea
ch o
f th
e 12
typ
es o
f l
ab d
ata
colle
ctio
n to
ols
100%
n/a
100%
Prop
orti
on o
f TB
dia
gnos
tic
labs
pr
ovid
ed w
ith
all
the
rele
vant
to
ols
Prin
t A
FB m
icro
scop
y, X
pert
, cu
ltur
e/D
ST
requ
est
form
s .
Lab
regi
ster
s (A
FB,
Cul
ture
, X
pert
), EQ
A f
orm
s
3,60
0 bo
okle
ts f
or A
FB o
f 10
0 pa
ges,
4,00
0 bo
okle
ts o
f 50
dup
licat
e le
afs
for
cult
ure,
2,
500
AFB
reg
iste
rs,
200
Xpe
rt
regi
ster
s of
10
0 pa
ges,
20
,000
bo
okle
ts
of
GX
pert
re
ques
t fo
rms
of 5
0 pa
ges,
1,80
0 bo
okle
ts o
f EQ
A S
ampl
ing
form
s of
50
leaf
s,
1,80
0 bo
okle
ts o
f EQ
A a
naly
sis
form
s of
50
leaf
s,
500
book
lets
of E
QA
wor
kloa
d su
mm
ary
of 5
0 le
afs
in t
ripl
icat
e,
250
book
lets
of
EQA
dis
cord
ant
form
s of
50
leaf
s,1,
800
book
lets
of E
QA
che
cklis
t 50
leaf
s in
tri
plic
ate,
1,80
0 A
FB Jo
b ai
ds
3,60
0 bo
okle
ts f
or A
FB o
f 10
0 pa
ges,
4,00
0 bo
okle
ts o
f 50
dup
licat
e l
eafs
fo
r cu
ltur
e,
2,50
0 A
FB r
egis
ters
, 20
0 X
pert
re
gist
ers
of
100
page
s,
20,0
00
book
lets
of
G
Xpe
rt
requ
est
form
s of
50
page
s,1,
800
book
lets
of
EQA
Sam
plin
g fo
rms
of 5
0 le
afs,
1,
800
book
lets
of
EQA
ana
lysi
s fo
rms
of 5
0 le
afs,
50
0 bo
okle
ts
of
EQA
w
orkl
oad
sum
mar
y of
50
leaf
s in
tri
plic
ate,
25
0 bo
okle
ts o
f EQ
A d
isco
rdan
t fo
rms
of 5
0 le
afs,
1,80
0 bo
okle
tsof
EQ
A
chec
klis
t 50
le
afs
in t
ripl
icat
e,1,
800
AFB
Job
aids
3,60
0 bo
okle
ts fo
r AFB
of 1
00 p
ages
,4,
000
book
lets
of
50 d
uplic
ate
leaf
s fo
r cu
ltur
e,
2,50
0 A
FB r
egis
ters
, 20
0 X
pert
reg
iste
rs o
f 10
0 pa
ges,
20
,000
boo
klet
s of
GX
pert
req
uest
fo
rms
of 5
0 pa
ges,
1,80
0 bo
okle
ts
of
EQA
Sa
mpl
ing
form
s of
50
leaf
s,
1,80
0 bo
okle
ts
of
EQA
an
alys
is
form
s of
50
leaf
s,
500
book
lets
of
EQ
A
wor
kloa
d su
mm
ary
of 5
0 le
afs
in t
ripl
icat
e,
250
book
lets
of
EQ
A
disc
orda
nt
form
s of
50
leaf
s,1,
800
book
lets
of E
QA
che
cklis
t 50
le
afs
in t
ripl
icat
e,1,
800
AFB
Job
aids
3,60
0 bo
okle
ts f
or A
FB o
f 10
0 pa
ges,
4,00
0 bo
okle
ts o
f 50
dup
licat
e l
eafs
fo
r cu
ltur
e,
2,50
0 A
FB r
egis
ters
, 20
0 X
pert
re
gist
ers
of
100
page
s,
20,0
00
book
lets
of
G
Xpe
rt
requ
est
form
s of
50
page
s,1,
800
book
lets
of
EQA
Sam
plin
g fo
rms
of 5
0 le
afs,
1,
800
book
lets
of
EQA
ana
lysi
s fo
rms
of 5
0 le
afs,
50
0 bo
okle
ts
of
EQA
w
orkl
oad
sum
mar
y of
50
leaf
s in
tri
plic
ate,
25
0 bo
okle
ts o
f EQ
A d
isco
rdan
t fo
rms
of 5
0 le
afs,
1,80
0 bo
okle
tsof
EQ
A c
heck
list
50 le
afs
in t
ripl
icat
e,1,
800
AFB
Job
aids
Dis
sem
inat
e la
b re
cord
ing
and
repo
rtin
g to
oln/
aH
old
1 m
eeti
ng
to
diss
emin
ate
lab
reco
rdin
g an
d re
port
ing
tool
sn/
aH
old
1 m
eeti
ng
to
diss
emin
ate
lab
reco
rdin
g an
d re
port
ing
tool
s
Dis
trib
ute
lab
reco
rdin
g an
d re
port
ing
tool
sn/
aU
se c
ouri
er t
o di
stri
bute
var
ious
lab
re
cord
ing
and
repo
rtin
g to
ols
upto
co
unty
leve
l
n/a
Use
co
urie
r to
di
stri
bute
va
riou
s la
b re
cord
ing
and
repo
rtin
g to
ols
upto
co
unty
leve
l
Prop
orti
on
of
sub-
coun
ties
re
port
ing
100%
of
th
eir
faci
litie
s us
ing
pati
ent
card
s
Revi
se T
B pa
tien
t re
cord
car
dH
old
a TW
G to
revi
ew th
e pa
tien
t rec
ord
card
an
inco
pora
te n
ew d
efin
itio
ns10
0%n/
a10
0%n/
a10
0%n/
a10
0%
Prin
t pa
tien
t TB
rec
ord
card
Prin
t 10
0,00
0 pa
tien
t re
cord
car
ds-
Prin
t 10
0,00
0 pa
tien
t re
cord
car
dsn/
a
Dis
trib
ute
pati
ent
TB
reco
rd
card
n/a
Use
co
urie
r to
di
stri
bute
ca
rds
up
coun
ty le
vel
n/a
Use
co
urie
r to
di
stri
bute
ca
rds
up
coun
ty le
vel
Prop
orti
on
of
sub-
coun
ties
re
port
ing
100%
of
th
eir
faci
litie
s us
ing
lung
di
seas
es
reco
rdin
g to
ols
Revi
se l
ung
dise
ase
reco
rdin
g an
d re
port
ing
tool
sn/
a0%
Hol
d 5
day
mee
ting
to
re
vise
lu
ng
dise
ase
reco
drin
g an
d re
port
ing
tool
s50
%n/
a10
0%n/
a10
0%
Prin
t 4,
000
copi
es
of
lung
di
seas
e re
cord
ing
and
repo
rtin
g to
ols
n/a
Prin
t 4
,000
co
pies
of
lung
dis
ease
re
cord
ing
and
repo
rtin
g to
ols
n/a
n/a
Dis
sem
inat
e lu
ng
dise
ase
reco
rdin
g an
d re
port
ing
tool
sn/
aH
old
1 m
eeti
ng t
arge
ting
47
coun
ties
to
dis
sem
inat
e lu
ng d
isea
se r
ecor
ding
an
d re
port
ing
tool
s
n/a
n/a
Dis
trib
ute
lung
di
seas
e re
cord
ing
and
repo
rtin
g to
ols
n/a
Use
cou
rier
to
dist
ribu
te 4
,000
cop
ies
of lu
ng d
isea
se t
ools
upt
o co
unty
leve
l n/
an/
a
4.3.8. Monitoring and Evaluation
Mon
itor
ing
and
Eval
uati
on O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prop
orti
on o
f TB
dia
gnos
tic
labs
pr
ovid
ed w
ith
all
the
rele
vant
to
ols
Revi
se
labo
rato
ry
data
co
llect
ion
and
repo
rtin
g to
ols
Hol
d a
5 da
y m
eeti
ng t
o re
vise
eac
h of
the
12
type
s of
la
b re
cord
ing
and
repo
rtin
g to
ols
100%
n/a
100%
Revi
se, p
rint
and
dis
sem
inat
e ea
ch o
f th
e 12
typ
es o
f l
ab d
ata
colle
ctio
n to
ols
100%
n/a
100%
Prop
orti
on o
f TB
dia
gnos
tic
labs
pr
ovid
ed w
ith
all
the
rele
vant
to
ols
Prin
t A
FB m
icro
scop
y, X
pert
, cu
ltur
e/D
ST
requ
est
form
s .
Lab
regi
ster
s (A
FB,
Cul
ture
, X
pert
), EQ
A f
orm
s
3,60
0 bo
okle
ts f
or A
FB o
f 10
0 pa
ges,
4,00
0 bo
okle
ts o
f 50
dup
licat
e le
afs
for
cult
ure,
2,
500
AFB
reg
iste
rs,
200
Xpe
rt
regi
ster
s of
10
0 pa
ges,
20
,000
bo
okle
ts
of
GX
pert
re
ques
t fo
rms
of 5
0 pa
ges,
1,80
0 bo
okle
ts o
f EQ
A S
ampl
ing
form
s of
50
leaf
s,
1,80
0 bo
okle
ts o
f EQ
A a
naly
sis
form
s of
50
leaf
s,
500
book
lets
of E
QA
wor
kloa
d su
mm
ary
of 5
0 le
afs
in t
ripl
icat
e,
250
book
lets
of
EQA
dis
cord
ant
form
s of
50
leaf
s,1,
800
book
lets
of E
QA
che
cklis
t 50
leaf
s in
tri
plic
ate,
1,80
0 A
FB Jo
b ai
ds
3,60
0 bo
okle
ts f
or A
FB o
f 10
0 pa
ges,
4,00
0 bo
okle
ts o
f 50
dup
licat
e l
eafs
fo
r cu
ltur
e,
2,50
0 A
FB r
egis
ters
, 20
0 X
pert
re
gist
ers
of
100
page
s,
20,0
00
book
lets
of
G
Xpe
rt
requ
est
form
s of
50
page
s,1,
800
book
lets
of
EQA
Sam
plin
g fo
rms
of 5
0 le
afs,
1,
800
book
lets
of
EQA
ana
lysi
s fo
rms
of 5
0 le
afs,
50
0 bo
okle
ts
of
EQA
w
orkl
oad
sum
mar
y of
50
leaf
s in
tri
plic
ate,
25
0 bo
okle
ts o
f EQ
A d
isco
rdan
t fo
rms
of 5
0 le
afs,
1,80
0 bo
okle
tsof
EQ
A
chec
klis
t 50
le
afs
in t
ripl
icat
e,1,
800
AFB
Job
aids
3,60
0 bo
okle
ts fo
r AFB
of 1
00 p
ages
,4,
000
book
lets
of
50 d
uplic
ate
leaf
s fo
r cu
ltur
e,
2,50
0 A
FB r
egis
ters
, 20
0 X
pert
reg
iste
rs o
f 10
0 pa
ges,
20
,000
boo
klet
s of
GX
pert
req
uest
fo
rms
of 5
0 pa
ges,
1,80
0 bo
okle
ts
of
EQA
Sa
mpl
ing
form
s of
50
leaf
s,
1,80
0 bo
okle
ts
of
EQA
an
alys
is
form
s of
50
leaf
s,
500
book
lets
of
EQ
A
wor
kloa
d su
mm
ary
of 5
0 le
afs
in t
ripl
icat
e,
250
book
lets
of
EQ
A
disc
orda
nt
form
s of
50
leaf
s,1,
800
book
lets
of E
QA
che
cklis
t 50
le
afs
in t
ripl
icat
e,1,
800
AFB
Job
aids
3,60
0 bo
okle
ts f
or A
FB o
f 10
0 pa
ges,
4,00
0 bo
okle
ts o
f 50
dup
licat
e l
eafs
fo
r cu
ltur
e,
2,50
0 A
FB r
egis
ters
, 20
0 X
pert
re
gist
ers
of
100
page
s,
20,0
00
book
lets
of
G
Xpe
rt
requ
est
form
s of
50
page
s,1,
800
book
lets
of
EQA
Sam
plin
g fo
rms
of 5
0 le
afs,
1,
800
book
lets
of
EQA
ana
lysi
s fo
rms
of 5
0 le
afs,
50
0 bo
okle
ts
of
EQA
w
orkl
oad
sum
mar
y of
50
leaf
s in
tri
plic
ate,
25
0 bo
okle
ts o
f EQ
A d
isco
rdan
t fo
rms
of 5
0 le
afs,
1,80
0 bo
okle
tsof
EQ
A c
heck
list
50 le
afs
in t
ripl
icat
e,1,
800
AFB
Job
aids
Dis
sem
inat
e la
b re
cord
ing
and
repo
rtin
g to
oln/
aH
old
1 m
eeti
ng
to
diss
emin
ate
lab
reco
rdin
g an
d re
port
ing
tool
sn/
aH
old
1 m
eeti
ng
to
diss
emin
ate
lab
reco
rdin
g an
d re
port
ing
tool
s
Dis
trib
ute
lab
reco
rdin
g an
d re
port
ing
tool
sn/
aU
se c
ouri
er t
o di
stri
bute
var
ious
lab
re
cord
ing
and
repo
rtin
g to
ols
upto
co
unty
leve
l
n/a
Use
co
urie
r to
di
stri
bute
va
riou
s la
b re
cord
ing
and
repo
rtin
g to
ols
upto
co
unty
leve
l
Prop
orti
on
of
sub-
coun
ties
re
port
ing
100%
of
th
eir
faci
litie
s us
ing
pati
ent
card
s
Revi
se T
B pa
tien
t re
cord
car
dH
old
a TW
G to
revi
ew th
e pa
tien
t rec
ord
card
an
inco
pora
te n
ew d
efin
itio
ns10
0%n/
a10
0%n/
a10
0%n/
a10
0%
Prin
t pa
tien
t TB
rec
ord
card
Prin
t 10
0,00
0 pa
tien
t re
cord
car
ds-
Prin
t 10
0,00
0 pa
tien
t re
cord
car
dsn/
a
Dis
trib
ute
pati
ent
TB
reco
rd
card
n/a
Use
co
urie
r to
di
stri
bute
ca
rds
up
coun
ty le
vel
n/a
Use
co
urie
r to
di
stri
bute
ca
rds
up
coun
ty le
vel
Prop
orti
on
of
sub-
coun
ties
re
port
ing
100%
of
th
eir
faci
litie
s us
ing
lung
di
seas
es
reco
rdin
g to
ols
Revi
se l
ung
dise
ase
reco
rdin
g an
d re
port
ing
tool
sn/
a0%
Hol
d 5
day
mee
ting
to
re
vise
lu
ng
dise
ase
reco
drin
g an
d re
port
ing
tool
s50
%n/
a10
0%n/
a10
0%
Prin
t 4,
000
copi
es
of
lung
di
seas
e re
cord
ing
and
repo
rtin
g to
ols
n/a
Prin
t 4
,000
co
pies
of
lung
dis
ease
re
cord
ing
and
repo
rtin
g to
ols
n/a
n/a
Dis
sem
inat
e lu
ng
dise
ase
reco
rdin
g an
d re
port
ing
tool
sn/
aH
old
1 m
eeti
ng t
arge
ting
47
coun
ties
to
dis
sem
inat
e lu
ng d
isea
se r
ecor
ding
an
d re
port
ing
tool
s
n/a
n/a
Dis
trib
ute
lung
di
seas
e re
cord
ing
and
repo
rtin
g to
ols
n/a
Use
cou
rier
to
dist
ribu
te 4
,000
cop
ies
of lu
ng d
isea
se t
ools
upt
o co
unty
leve
l n/
an/
a
Mon
itor
ing
and
Eval
uati
on O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prop
orti
on
of
regi
ster
ed
CU
's
repo
rtin
g co
mm
unit
y TB
ac
tivi
ties
thr
ough
DH
IS/T
IBU
Dev
elop
/rev
ise
com
mun
ity
reco
rdin
g an
d re
port
ing
tool
sH
old
5 da
y m
etin
g to
re
vise
/dev
elop
co
mm
unit
y re
cord
ing
and
repo
rtin
g to
ols
0%n/
a50
%n/
a10
0%n/
a10
0%
Prin
t co
mm
unit
y re
cord
ing
and
repo
rtin
g to
ols
Prin
t 10
,000
cop
ies
of c
omm
unit
y to
ols
n/a
n/a
n/a
Dis
sem
inat
e co
mm
unit
y to
ols
Hol
d 1
day
diss
emin
atio
n m
eeti
ng
targ
etin
g C
TLC
and
com
mun
ity
prog
ram
co
ordi
nato
rs t
o di
ssem
inat
e co
mm
unit
y to
ols
n/a
n/a
n/a
Dis
trib
ute
com
mun
ity
tool
sn/
aU
se c
ouri
er t
o di
ssem
inat
e to
ols
upto
co
unty
leve
ln/
an/
a
Prop
orti
on o
f pr
inte
d to
ols
wit
h SO
Ps in
tegr
ated
Dev
elop
SO
Ps o
n us
e of
dat
a co
llect
ion
and
reco
rdin
g to
ols
deve
lope
d/re
vise
d
Dev
elop
SO
Ps o
n us
e of
dat
a co
llect
ion
and
reco
rdin
g to
ols
deve
lope
d/re
vise
d50
%Pr
int
and
diss
emin
ate
data
col
lect
ion
and
reco
rdin
g to
ols
wit
h SO
Ps
inco
rpor
ated
100%
Prin
t an
d di
ssem
inat
e da
ta c
olle
c -ti
on a
nd r
ecor
ding
too
ls w
ith
SOPs
in
corp
orat
ed
100%
Prin
t an
d di
ssem
inat
e da
ta c
olle
ctio
n an
d re
cord
ing
tool
s w
ith
SOPs
inco
r-po
rate
d
100%
Stra
tegi
c A
ppro
ach
2: S
tren
gthe
n TI
BU a
nd it
s in
tegr
atio
n w
ith
othe
r su
rvei
llanc
e pl
atfo
rms
TIBU
Ph
ase
III
com
plet
ed
and
sign
ed o
ffIm
prov
e TI
BU to
acc
omm
odat
e ne
w
func
tion
s an
d lin
kage
w
ith
othe
r sy
stem
s
Enga
ge
TIBU
Ph
ase
III
deve
lope
rs
to
resc
ope
and
star
t ex
pans
ion
of
the
syst
em t
o in
clud
e co
mm
unit
y, T
B/H
IV,
linka
ge
wit
h D
HIS
, G
eneX
pert
A
lert
sy
stem
and
LM
IS a
nd o
ther
fel
t ne
eds
n/a
1n/
an/
a
Hol
d 3
day
retr
eat
for
resc
opin
g TI
BU
Phas
e III
n/a
n/a
n/a
Build
con
sens
us o
n in
tegr
atio
n of
TIB
U w
ith
othe
r sy
stem
sC
ondu
ct 3
day
s st
akeh
olde
rs m
eeti
ng t
o bu
ild c
onse
nsus
on
inte
grat
ion
of T
IBU
w
ith
othe
r in
form
atio
n m
anag
emen
t sy
stem
s
n/a
n/a
n/a
Hol
d w
eekl
y op
erat
ions
TW
G
mee
ting
s (1
5 pa
x)Su
ppor
t op
erat
ions
TW
G t
o ho
ld w
eekl
y m
eeti
ngs
to
over
see
deve
lopm
ent
of
TIBU
Pha
se II
I
n/a
n/a
n/a
Hol
d m
onth
ly
polic
y TW
G
mee
ting
sSu
ppor
t po
licy
team
to
hold
mon
thly
m
eeti
ngs
to
give
di
rect
ion
on
TIBU
Ph
ase
III d
evel
opm
ent
n/a
n/a
n/a
Pilo
t TI
BU P
hase
III
Supp
ort 5
cou
ntie
s to
pilo
t TIB
U P
hase
III
and
give
fee
dbac
kn/
an/
an/
a
Roll
out
TIBU
Pha
se II
I Tr
ain
TIBU
end
use
rs f
or 3
day
s to
sta
rt
usin
g TI
BU P
hase
III
n/a
n/a
n/a
hold
a
2 da
y st
akeh
olde
rs
mee
ting
to
re
view
us
e an
d im
pact
of
TIBU
n/a
n/a
Supp
ort
a 3
day
stak
ehol
ders
m
eeti
ng to
dis
cuss
impa
ct o
f TIB
U to
in
clud
e M
OH
off
icia
ls,
NG
O,
dono
rs
and
deve
lope
rs
n/a
Con
duct
TI
BU
refr
eshe
r tr
aini
ng
n/a
n/a
Supp
ort a
2 d
ay re
fres
her t
rain
ing
for
TIBU
end
use
rs t
o ad
dres
s em
ergi
ng
issu
es
n/a
Prov
ide
cont
inuo
us
tech
nica
l su
ppor
t on
TIB
UD
evel
op t
ools
for
use
at
TIBU
hel
p de
sk
to
capt
ure
fiel
d is
sues
re
port
ed
and
resp
onse
pro
vide
d
Supp
ort
2 IT
sta
ff t
o m
an T
IBU
he
lp
desk
n/a
n/a
4.3.
8. M
onit
orin
g an
d Ev
alua
tion
Mon
itor
ing
and
Eval
uati
on O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
3: Im
prov
e TB
fin
anci
al r
epor
ting
and
qua
ntif
icat
ion
of n
eeds
Prop
orti
on o
f cou
ntie
s re
port
ing
TB f
inan
cial
dat
a an
nual
lyD
evel
op a
fin
anci
al r
epor
ting
to
olC
ondu
ct d
esk
revi
ew a
nd d
evel
opm
ent
of t
he N
TLD
Pro
gram
fin
anci
al r
epor
ting
to
ol
0%D
isse
min
ate
the
fina
ncia
l re
port
ing
tool
, inc
ludi
ng t
rain
ing
50%
Dis
sem
inat
e th
e fi
nanc
ial
repo
rtin
g to
ol, i
nclu
ding
tra
inin
g80
%D
isse
min
ate
the
fina
ncia
l re
port
ing
tool
, inc
ludi
ng t
rain
ing
100%
Mon
itor
ing
of s
ub-s
ecto
r (T
B)
fina
nce
expe
ndit
ure
Ana
lysi
s of
TB
su
b se
ctor
fi
nanc
ial
expe
ndit
ures
A
naly
sis
of
TB
sub
sect
or
fina
ncia
l ex
pend
itur
es
Ana
lysi
s of
TB
sub
sect
or f
inan
cial
ex
pend
itur
es
Ana
lysi
s of
TB
su
b se
ctor
fi
nanc
ial
expe
ndit
ures
Supp
ort
the
mai
nstr
eam
ing
of
SHA
-201
1 Su
ppor
t th
e pa
rtic
ipat
ion
of K
ey M
&E
staf
f in
the
pro
gram
to
part
icip
ate
in t
he
SHA
-pro
cess
for
Ken
ya
Supp
ort
the
part
icip
atio
n of
Key
M&
E st
aff
in t
he p
rogr
am t
o pa
rtic
ipat
e in
th
e SH
A-p
roce
ss f
or K
enya
Supp
ort t
he p
arti
cipa
tion
of K
ey M
&E
staf
f in
the
pro
gram
to
part
icip
ate
in
the
SHA
-pro
cess
for
Ken
ya
Supp
ort
the
part
icip
atio
n of
Key
M&
E st
aff
in t
he p
rogr
am t
o pa
rtic
ipat
e in
th
e SH
A-p
roce
ss f
or K
enya
Stra
tegi
c A
ppro
ach
4: Im
prov
e TB
, lep
rosy
and
lung
dis
ease
mor
talit
y st
atis
tics
Prop
orti
on o
f fa
cilit
ies
repo
rtin
g m
orta
lity
stat
isti
cs u
sing
ICD
-10
Trai
n 2,
400
HC
W
and
regi
stra
tion
age
nts
on t
he u
se
of v
erba
l aut
opsy
Con
duct
tr
aini
ng
600
Hea
lth
care
w
orke
rs
and
regi
stra
tion
ag
ents
on
V
erba
l aut
opsy
20%
Trai
ning
of 6
00 h
ealt
h ca
re w
orke
rs a
nd
regi
stra
tion
age
nts
on v
erba
l aut
opsy
50%
Trai
ning
of
600
Hea
lth
care
wor
kers
an
d re
gist
rati
on
agen
ts
on
Ver
bal
auto
psy
85%
Trai
ning
of 6
00 H
ealt
h ca
re w
orke
rs a
nd
regi
stra
tion
age
nts
on V
erba
l aut
opsy
>85
%
Trai
n 4,
800
heal
th
care
w
orke
rs
on
codi
ng/
cert
ific
atio
n
Trai
ning
of
1,20
0 H
ealt
h ca
re w
orke
rs
on IC
D-1
0 tr
aini
ngTr
aini
ng o
f 1,
200
heal
th c
are
wor
kers
on
ICD
-10
trai
ning
Trai
ning
of
1,
200
Hea
lth
care
w
orke
rs o
n IC
D-1
0 tr
aini
ngTr
aini
ng o
f 1,
200
Hea
lth
care
wor
kers
on
ICD
-10
trai
ning
Car
ry o
ut a
naly
sis
of m
orta
lity
stat
isti
cs
toge
ther
w
ith
CRD
an
d K
NBS
Hol
d 2
wor
ksho
ps t
o an
alyz
e m
orta
lity
stat
isti
cs a
nd p
rodu
ce a
rep
ort
Hol
d 2
wor
ksho
ps t
o an
alyz
e m
orta
lity
stat
isti
cs a
nd p
rodu
ce a
rep
ort
Hol
d 2
wor
ksho
ps
to
anal
yze
mor
talit
y st
atis
tics
an
d pr
oduc
e a
repo
rt
Hol
d 2
wor
ksho
ps t
o an
alyz
e m
orta
lity
stat
isti
cs a
nd p
rodu
ce a
rep
ort
Stra
tegi
c A
ppro
ach
5: Im
prov
e th
e qu
alit
y an
d sy
stem
atic
use
of
stra
tegi
c in
form
atio
n
Prop
orti
on o
f fac
iliti
es a
chie
ving
se
t da
ta q
ualit
y st
anda
rds
Con
duct
an
nual
ro
utin
e an
d sy
stem
atic
da
ta
qual
ity
asse
ssm
ents
(D
QA
s) a
t co
unty
le
vel
Con
duct
5
day
DQ
A
to
sub
coun
ties
by
cou
nty
team
s88
%C
ondu
ct 5
day
D
QA
to
su
b co
unti
es
by
coun
ty t
eam
s
>88
%C
ondu
ct
5 da
y D
QA
to
su
b co
unti
es
by
co
unty
te
ams
>90
%C
ondu
ct
5 da
y D
QA
to
su
b co
unti
es
by
co
unty
te
ams
>90
%
Prop
orti
on
of
plan
ned
annu
al
DQ
A a
ctiv
itie
s co
nduc
ted
at a
ll le
vels
Con
duct
an
nual
ro
utin
e an
d sy
stem
atic
da
ta
qual
ity
asse
ssm
ent
at
nati
onal
lev
el
to im
prov
e da
ta c
ompl
eten
ess,
co
nsis
tenc
y an
d ac
cura
cy
Con
duct
14
days
DQ
A to
cou
ntie
s by
the
nati
onal
tea
m90
%C
ondu
ct 1
4 da
ys D
QA
to
coun
ties
by
the
nati
onal
tea
m90
%C
ondu
ct 1
4 da
ys D
QA
to
coun
ties
by
the
nati
onal
tea
m90
%C
ondu
ct 1
4 da
ys D
QA
to
coun
ties
by
the
nati
onal
tea
m90
%
Prop
orti
on
of
sub-
coun
ties
co
nduc
ting
m
onth
ly
data
re
view
mee
ting
s
Car
ry o
ut m
onth
ly d
ata
revi
ew
mee
ting
s at
sub
cou
nty
leve
lSu
ppor
t su
bcou
ntie
s to
co
nduc
t m
onth
ly r
evie
w m
eeti
ngs
30%
Supp
ort
subc
ount
ies
to
cond
uct
mon
thly
rev
iew
mee
ting
s66
%Su
ppor
t su
bcou
ntie
s to
co
nduc
t m
onth
ly r
evie
w m
eeti
ngs
90
Dev
elop
/ Re
view
M/E
tra
inin
g cu
rric
ulum
n/a
Revi
ew
th
e M
/E
com
pone
nt
in
the
inte
rgra
ted
curr
icul
umn/
an/
a
Trai
n TO
TS
in
M/E
an
d da
ta
man
agem
ent
n/a
Con
duct
int
ergr
ated
TO
T tr
aini
ng f
or
coun
ty s
taff
n/a
n/a
Prop
orti
on
of
faci
litie
s w
ith
mon
thly
rep
orts
on
TB/M
DR-
TBC
ondu
ct
CM
Es
to
HC
Ws
on
data
man
agem
ent
n/a
Supp
ort
100
sess
ions
of
CM
Es i
n su
b co
unti
es25
%Su
ppor
t 10
0 C
ME
sess
ions
of
in s
ub
coun
ties
50%
Supp
ort
100
sess
ions
of
CM
Es i
n su
b co
unti
es>
80%
4.3.8. Monitoring and Evaluation
Mon
itor
ing
and
Eval
uati
on O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Prop
orti
on
of
coun
ties
w
ith
upda
ted
M&
E pl
ans
Gui
de
coun
ties
to
de
velo
p th
eir
M&
E pl
an
as
part
of
de
fini
ng t
heir
hea
lth
stra
tegy
n/a
n/a
Con
duct
TA
m
issi
ons
to
coun
ties
on
de
velo
pmen
t of
M/E
pla
ns25
%C
ondu
ct T
A m
issi
ons
to c
ount
ies
on
deve
lopm
ent
of M
/E p
lans
50%
Con
duct
TA
m
issi
ons
to
coun
ties
on
de
velo
pmen
t of
M/E
pla
ns10
0%
Supp
ort
use
of
real
ti
me
TIBU
da
ta
to
guid
e pr
ogra
m
acti
viti
es a
t al
l lev
els
Hol
d m
eeti
ng b
y th
e TW
G t
o de
velo
p a
tool
for
gui
ding
on
data
use
Con
duct
5 T
A m
issi
ons
to e
ach
of t
he
mod
el c
ount
ies
Con
duct
5 T
A m
issi
on t
o ea
ch o
f th
e m
odel
cou
ntie
s C
ondu
ct 5
TA
mis
sion
s to
eac
h of
the
m
odel
cou
ntie
s
Prop
orti
on
of
coun
ties
w
ith
func
tion
al T
WG
s on
M&
E an
d O
R
Mai
ntai
n a
func
tion
al
M&
E te
chni
cal
wor
king
gr
oup
(TW
G)
at N
atio
nal
leve
l an
d en
hanc
e th
e fo
rmat
ion
of M
&E
TWG
in e
ach
coun
ty.
n/a
Hol
d qu
arte
rly
TWG
mee
ting
s bo
th a
t co
unty
and
nat
iona
l lev
el10
0%H
old
quar
terl
y TW
G m
eeti
ngs
both
at
cou
nty
and
nati
onal
leve
l10
0%H
old
quar
terl
y TW
G m
eeti
ngs
both
at
coun
ty a
nd n
atio
nal l
evel
100%
Num
ber
and
type
of
da
ta
prod
ucts
pro
duce
d at
nat
iona
l le
vel a
nd d
isse
min
ated
Esta
blis
h an
d su
ppor
t da
ta
man
agem
ent
prog
ram
(D
MU
) at
the
nat
iona
l lev
el
Hol
d a
mee
ting
for
the
mem
bers
of
data
m
anag
emen
t pr
ogra
m t
o de
velo
p TO
RsH
old
a 2
day
retr
eat
to c
ompl
ete
the
data
man
agem
ent
man
ual a
nd S
OPs
5n/
a5
Hol
d a
2 da
y re
trea
t to
rev
iew
the
dat
a m
anag
emen
t m
anua
l and
SO
Ps5
n/a
Prin
t 3,
500
copi
es d
ata
man
agem
ent
man
ual a
nd S
OPs
n/a
Prin
t 3,
500
copi
es
of
revi
ewed
da
ta
man
agem
ent
man
ual a
nd S
OPs
n/a
Hol
d a
1 da
y m
eeti
ng t
o di
ssem
inat
e da
ta m
anag
emen
t m
anua
ls a
nd S
OPs
to
cou
ntie
s
n/a
Hol
d a
1 da
y m
eeti
ng t
o di
ssem
inat
e re
view
ed
data
m
anag
emen
t m
anua
ls
and
SOPs
to
coun
ties
n/a
Use
co
urie
r to
di
stri
bute
da
ta
man
agem
ent
man
ual a
nd S
OPs
n/a
Use
cou
rier
to
dist
ribu
te r
evie
wed
dat
a m
anag
emen
t m
anua
l and
SO
Ps
Prop
orti
on
of
coun
ties
de
velo
ping
an
d di
ssem
inat
ing
data
pr
oduc
ts
at
leas
t on
ce
ever
y 6
mon
ths
Proc
ure
data
ana
lysi
s so
ftw
are
Proc
ure
a da
ta a
naly
sis
and
map
ping
so
ftw
are
n/a
25%
50%
75%
Trai
n m
embe
rs
of
data
m
anag
emen
t pr
ogra
m o
n da
ta
anal
ysis
and
man
agem
ent
Hol
d a
5 da
y tr
aini
ng f
or m
embe
rs o
f da
ta
man
agem
ent
prog
ram
on
da
ta
anal
ysis
and
man
agem
ent
n/a
Hol
d a
refr
eshe
r co
urse
for
mem
bers
of
DM
Un/
a
Prop
orti
on o
f su
b-co
unti
es w
ith
tim
ely
repo
rts
and
mon
thly
re
turn
s
Prov
ide
tabl
ets
for
use
in t
he
surv
eilla
nce
syst
emPr
ocur
e
100
tabl
ets
fo
r ce
ntra
l pr
ogra
m s
taff
and
new
ly r
ecru
ited
fie
ld
TB m
anag
ers
100%
Proc
ure
100
tabl
ets
for
repl
acem
ent
of
old
stoc
k an
d ne
wly
rec
ruit
ed f
ield
TB
man
ager
s
100%
Proc
ure
100
tabl
ets
for
repl
acem
ent
of
old
stoc
k an
d ne
wly
re
crui
ted
fiel
d TB
man
ager
s
100%
Proc
ure
100
tabl
ets
for
repl
acem
ent
of
old
stoc
k an
d ne
wly
rec
ruit
ed f
ield
TB
man
ager
s
100%
Insu
re o
f ta
blet
sIn
sure
100
new
tab
lets
Insu
re 1
00 n
ew t
able
tsIn
sure
100
new
tab
lets
Insu
re 1
00 n
ew t
able
ts
Prov
ide
supp
ort f
or c
onti
nuou
s ru
nnin
g of
TIB
U s
yste
mPr
ovid
e m
onth
ly
inte
rnet
bu
ndle
s fo
r 40
0 ta
blet
s fo
r ru
nnin
g of
TIB
UPr
ovid
e m
onth
ly i
nter
net
bund
les
for
400
tabl
ets
for
runn
ing
of T
IBU
Prov
ide
mon
thly
inte
rnet
bun
dles
for
400
tabl
ets
for
runn
ing
of T
IBU
Prov
ide
mon
thly
int
erne
t bu
ndle
s fo
r 40
0 ta
blet
s fo
r ru
nnin
g of
TIB
U
Prov
ide
clou
d ho
stin
g of
TIB
U
data
Prov
ide
clou
d ho
stin
g fo
r co
ntin
uous
ho
stin
g of
TIB
U d
ata
Prov
ide
clou
d ho
stin
g fo
r co
ntin
uous
ho
stin
g of
TIB
U d
ata
Prov
ide
clou
d ho
stin
g fo
r con
tinu
ous
host
ing
of T
IBU
dat
aPr
ovid
e cl
oud
host
ing
for
cont
inuo
us
host
ing
of T
IBU
dat
a
Prov
ide
inte
rnet
co
nnec
tivi
ty
for
TIBU
dat
aPa
y m
onth
ly/a
nnua
l in
tern
et
fee
to
safa
rico
m f
or c
onne
ctiv
ity
to T
IBU
dat
a ho
sted
in t
he c
loud
Pay
mon
thly
/ann
ual
inte
rnet
fe
e to
sa
fari
com
for
con
nect
ivit
y to
TIB
U d
ata
host
ed in
the
clo
ud
Pay
mon
thly
/ann
ual
inte
rnet
fee
to
safa
rico
m f
or c
onne
ctiv
ity
to T
IBU
da
ta h
oste
d in
the
clo
ud
Pay
mon
thly
/ann
ual
inte
rnet
fe
e to
sa
fari
com
for
con
nect
ivit
y to
TIB
U d
ata
host
ed in
the
clo
ud
Ensu
re
inte
rnet
co
nnec
tivi
ty
for
NTL
D-
Prog
ram
Prov
ide
both
fix
ed a
nd w
irel
ess
inte
rnet
co
nnec
tivi
ty t
o N
TLD
Pro
gram
Prov
ide
both
fixe
d an
d w
irel
ess
inte
rnet
co
nnec
tivi
ty t
o th
e N
TLD
Pro
gram
Prov
ide
both
fi
xed
and
wir
eles
s in
tern
et
conn
ecti
vity
to
N
TLD
Pr
ogra
m
Prov
ide
both
fix
ed a
nd w
irel
ess
inte
rnet
co
nnec
tivi
ty t
o N
TLD
Pro
gram
Num
ber
of d
ownt
ime
epis
odes
pe
r m
onth
fo
r th
e N
TLD
Pr
ogra
m in
tern
et
Secu
re
TIBU
da
ta
by
havi
ng
back
up a
t N
TLD
Pro
gram
n/a
6Pr
ocur
e 2
serv
ers
wit
h re
leva
nt
soft
war
e fo
r da
ta b
acku
p an
d in
stal
l th
em a
t th
e N
TLD
Pro
gram
6C
onti
nuou
s up
date
of
back
dat
a in
th
e se
rver
5C
onti
nuou
s up
date
of
back
dat
a in
the
se
rver
4
4.3.
8. M
onit
orin
g an
d Ev
alua
tion
Mon
itor
ing
and
Eval
uati
on O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Impr
ove
the
curr
ent
emai
l ho
stin
g to
Goo
gle
Clo
ud f
rom
gr
oup
wis
e
Mov
e cu
rren
t em
ail
host
ing
to G
oogl
e C
loud
fro
m g
roup
wis
e an
d op
en e
mai
l ac
coun
ts f
or a
ll N
TLD
Pro
gram
sta
ff
Prov
ide
cont
inuo
us
mai
ntan
ance
of
em
ail
acco
unts
for
all
NTL
D P
rogr
am
staf
f
Prov
ide
cont
inuo
us m
aint
anan
ce o
f em
ail a
ccou
nts
for
all N
TLD
Pro
gram
st
aff
Prov
ide
cont
inuo
us
mai
ntan
ance
of
em
ail
acco
unts
for
all
NTL
D P
rogr
am
staf
f
Proc
ure
com
pute
rs fo
r 5 m
odel
co
unti
es
for
impl
emen
tati
on
of
TIBU
at
co
unty
an
d su
b co
unty
fac
iliti
es
n/a
n/a
Proc
ure
and
prov
ide
com
pute
rs t
o th
e co
unty
and
sub
-cou
nty
faci
litie
s in
5 m
odel
cou
ntie
s
n/a
Num
ber
of
cum
ulat
ive
ORs
co
nduc
ted
and
docu
men
ted
Reva
mp
the
rese
arch
ta
sk
forc
e at
the
nat
iona
l lev
el a
nd
advo
cate
for
sim
ilar
foru
ms
at
coun
ty l
evel
; pr
omot
e im
pact
as
sess
men
t an
d pr
iori
tize
re
sear
ch,
incl
udin
g O
R th
at
will
ad
dres
s pr
ogra
mm
e ch
alle
nges
Hol
d on
e m
eeti
ng to
dra
w T
ORs
fo
r the
ta
skfo
rce
and
nom
inat
e th
e m
embe
rs5
Hol
d qu
arte
rly
rese
arch
ta
skfo
rce
mee
ting
s5
Hol
d qu
arte
rly
rese
arch
ta
skfo
rce
mee
ting
s5
Hol
d qu
arte
rly
rese
arch
ta
skfo
rce
mee
ting
s5
Build
the
capa
city
of
mem
bers
of
the
res
earc
h ta
skfo
rce
Con
duct
a
3 da
y tr
aini
ng
for
the
task
forc
en/
aC
ondu
ct a
3 d
ay
refr
eshe
r tr
aini
ng
for
the
task
forc
en/
a
Dev
elop
a
trac
king
sy
stem
fo
r nu
mbe
r o
f pe
ople
tra
ined
on
OR
and
num
ber
of s
tudi
es
cond
ucte
d
Enga
ge d
atab
ase
deve
lope
rC
onti
nous
use
of
the
syst
emC
onti
nous
use
of
the
syst
emC
onti
nous
use
of
the
syst
em
Dev
elop
a
crit
eria
fo
r id
enti
fica
tion
of
OR
trai
nees
hold
1
day
ta
skfo
rce
mee
ting
to
deve
lop
the
crit
eria
for
OR
trai
nees
n/a
Hol
d 1
day
task
forc
e m
eeti
ng
to
deve
lop
the
crit
eria
for
OR
trai
nees
n/a
Supp
ort
the
rese
arch
tas
kfor
ce
in
unde
rtak
ing
coun
ty
leve
l m
ento
rshi
p se
ssio
ns
n/a
Hol
d,1,
3 d
ay
join
t ta
skfo
rce,
men
tor/
men
tee
men
tors
hip
wor
ksho
pH
old
1,
3 da
y
join
t ta
skfo
rce
, m
ento
r/m
ente
e m
ento
rshi
p w
orks
hop
Hol
d 1
,3 d
ay
join
t ta
skfo
rce,
men
tor/
men
tee
men
tors
hip
wor
ksho
p
Prop
orti
on
of
trai
ned
men
tees
w
ith
com
plet
ed
and
docu
men
ted
OR
Build
ca
paci
ty
of
fiel
d TB
m
anag
ers
on
impa
ct
asse
ssm
ent
and
OR
hold
a 5
day
tra
inin
g fo
r 25
fie
ld T
B m
anag
ers
on O
R30
%H
old
a 5
day
trai
ning
for
100
fie
ld T
B m
anag
ers
on O
R80
%H
old
a 5
day
trai
ning
for
100
fiel
d TB
m
anag
ers
on O
R>
80%
Hol
d a
5 da
y tr
aini
ng f
or 5
0 fi
eld
TB
man
ager
s on
OR
>80
%
Prop
orti
on o
f tr
aine
d m
ente
es
atte
ndin
g an
d pr
esen
ting
in
di
ssem
inat
ion
mee
ting
s
Con
duct
bi
annu
al
foru
ms
to
shar
e re
sear
ch f
indi
ngs
at t
he
coun
ty le
vel
n/a
Hol
d 2
mee
ting
s fo
r ta
rget
ing
OR
men
tee
and
men
tors
to
shar
e pr
ogre
ss,
good
pra
ctic
es a
nd c
halle
nges
.
>90
%H
old
2 m
eeti
ngs
for
targ
etin
g O
R m
ente
e
and
men
tors
to
sh
are
prog
ress
, go
od
prac
tice
s an
d ch
alle
nges
>90
%H
old
2,
2 da
ys m
eeti
ngs
for
targ
etin
g O
R m
ente
e
and
men
tors
to
sh
are
prog
ress
,goo
d pr
acti
ces
and
chal
leng
es.
>90
%
Num
ber
of
conf
eren
ces
held
an
d do
cum
ente
dC
ondu
ct b
ienn
ial
lung
hea
lth
conf
eren
ces
n/a
Hol
d m
onth
ly
secr
etar
iat
mee
ting
s in
pr
epar
atio
n fo
r th
e bi
enni
al
lung
co
nfer
ence
1n/
aH
old
mon
thly
se
cret
aria
t
m
eeti
ngs
in
prep
arat
ion
for
the
bien
nial
lu
ng
conf
eren
ce
1
Hol
d sc
ient
ific
re
view
co
mm
itte
e m
onth
ly m
eeti
ngs
for
3 si
x m
onth
sH
old
scie
ntif
ic
revi
ew
com
mit
tee
mon
thly
mee
ting
s fo
r 3
six
mon
ths
Hol
d 3
days
bi
enni
al
lung
he
alth
co
nfer
ence
for
800
pax
Hol
d 3
days
bi
enni
al
lung
he
alth
co
nfer
ence
for
800
pax
Fina
l dr
ug
resi
stan
ce
suve
y re
port
s de
velo
ped
and
shar
ed
thro
ugh
web
site
Con
duct
Dru
g Re
sist
ant
Surv
ey
Dat
a co
llect
ion,
an
alys
is
and
repo
rt
wri
ttin
gH
old
a on
e da
y m
eeti
ng t
o di
ssem
inat
e fi
ndin
gs o
f dr
ug r
esis
tanc
e su
rvey
to
stak
ehol
ders
1n/
an/
a
Fina
l pr
eval
ence
suv
ey r
epor
ts
deve
lope
d an
d sh
ared
thr
ough
w
ebsi
te
Con
duct
Pre
vale
nce
surv
ey
Com
plet
e de
velo
pmen
t of
sur
vey
SOP
Con
duct
a 3
day
trai
ning
of t
he re
sear
ch
pers
onne
lH
old
a on
e da
y m
eeti
ng
to
diss
emin
ate
find
ings
of
prev
alen
ce
surv
ey t
o st
akeh
olde
rs
1n/
a
Map
ping
of
all t
he e
ligib
le p
arti
cipa
nts
Con
duct
dat
a da
ta c
olle
ctio
n, a
naly
sis
and
repo
rt w
ritt
ing
n/a
n/a
4.3.8. Monitoring and Evaluation
Mon
itor
ing
and
Eval
uati
on O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
itiv
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Proc
urin
g of
sur
vey
equi
pmen
tH
old
a on
e da
y m
eeti
ng t
o di
ssem
inat
e fi
ndin
gs
of p
reva
lenc
e su
rvey
to
100
stak
ehol
ders
Recr
uitm
ent
of r
esea
rch
per
sonn
eln/
a
Fina
l su
rvey
on
de
lay
in
diag
nosi
s de
velo
ped
and
shar
ed
thro
ugh
web
site
Con
duct
a s
urve
y on
Del
ay i
n D
iagn
osis
C
ompl
ete
fiel
d da
ta c
olle
ctio
nH
old
a on
e da
y m
eeti
ng t
o di
ssem
inat
e fi
ndin
gs
of d
elay
dia
gnos
is
surv
ey t
o 10
0 st
akeh
olde
rs
1n/
an/
a
Con
duct
da
ta
an
alys
is
and
repo
rt
wri
ting
n/a
Fina
l m
orta
lity
surv
ey
repo
rts
deve
lope
d an
d sh
ared
thr
ough
w
ebsi
te
Con
duct
a M
orta
lity
Surv
ey
n/a
Dev
elop
su
rvey
pr
otoc
ol
and
data
co
llect
ion
tool
sC
ondu
ct
data
an
alys
is
for
the
mor
talit
y su
rvey
and
rep
ort
wri
ting
1n/
a
Pres
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4.3.9. Enabling environment
4.3.9.1. Policy1. Situational Analysis
The rapidly evolving health system, including devolution and a move toward universal health coverage, will require adaptations in how the NTLD Program operates. Tuberculosis, leprosy and lung health will need to become part of essential health package that is formed on the basis of emerging/expanding demand-side, performance-based and social support financing schemes. For example, the direct facility cash transfer program called the Health Sector Services Fund (HSSF) or the health insurance for poor families called the Health Insurance Subsidy Programme (HISP), does not currently include TB prevention and control services.
Over the next three (3) years, it is estimated that the NTLD Program will face a financing gap totaling 50% of its required funding. Data from the National Health Accounts (NHA) suggested that while TB accounts for over 6% of deaths and nearly 5% of DALYs in the country, it receives only 1% of total health expenditures for priority areas. This is in contrast to malaria’s contribution to nearly 6% of deaths and 7% of DALYs, but in receipt of 25% of total health expenditures for priority areas.
TB particularly harms the poor in Kenya. Over half of patients are malnourished, to some degree, at the onset of treatment, with 17% being severely malnourished and a further 22% being moderately malnourished. Poor nutritional status is known to negatively impact treatment adherence and outcomes1. A review of case notifications by county poverty rate demonstrated that case finding is lagging in the poorest counties. It is not known if this is a reflection of the actual epidemiology or barriers to care, but it is cause for concern and should be further investigated. The majority of nutrition support programs that can benefit TB patients target women and children, leaving male TB patients without equitable access.
2. Strategic Direction(s) for 2015-2017
The priority is to position the activities of the NTLD Program within the priorities of the health sector, social protection agenda, and other relevant sectors. Ensuring the full integration of TB within county priorities and national financing of universal health care is similarly important.
3. Proposed Approaches
Actively participate in national policy and planning process in the move towards universal health coverage, ensuring that TB and leprosy control are appropriately positioned.
i. Articulate the investment case for TB control in Kenya, with targeted policy briefers to inform county and national level policy-development. It may be necessary to change perceptions that TB and leprosy are sufficiently funded or can operate sustainably on supply-side financing.
ii. Define the reimbursement package that would be required to fully reimburse service delivery providers for the care of a TB or MDR-TB case. Ensure that these are made available to the NHIF, for the purposes of consideration under the HISP and other future insurance schemes.
iii. Ensure the inclusion of TB and leprosy where appropriate, in broad sector strategies and initiatives. Actively collaborate across the MoH, including with NHA, NACC, NASCOP, and Policy and Planning; with other sectors such as labor, education, and social protection; and with external partners working on devolution, such as the World Bank.
Some of the immediate needs include:
_______________________________________________________________________________________________________________________________1 http://digitalcommons.calpoly.edu/cgi/viewcontent.cgi?article=1009&context=fsn_fac
4.3.
9.1
Enab
ling
Envi
ronm
ent:
Pol
icy
117
4.3.9.1 Enabling Environment: Policy
1. Social protection: Develop a strategy to enhance linkages to social protection schemes by TB patients: e.g. nutritional, transportation and cash support.
2. Monitor the impact (positive and negative) of devolution and emerging financing modalities on TB case notifications and treatment outcomes, with a view to learning lessons for scale-up of what works.
NTLD Program to actively seek to expand its partner base; to facilitate the mainstreaming of programme priorities into the devolution and Universal Health Care (UHC) processes.
i. Systematic collaboration with other government actors should include National Health Accounts (NHA), Treasury, MoH Policy and Planning division, Social Protection, Ministry of Labor (workplace-based DOTS and labor policy to protect TB and leprosy patients), Ministry of Education (potential information raising and TB screening in schools) and NACC (TB/HIV).
ii. Engaging non-governmental partners and donors who are key partners in the health sector such as the World Bank and DANIDA, to ensure that TB and leprosy are well integrated in emerging pro-poor, insurance and social protection strategies.
iii. Seek to harmonize efforts with other disease programs within the communicable diseases division, e.g.1. Integrate other communicable diseases within TIBU, or a TIBU-like system 2. Single planning/financing tool (e.g. WHO TB financing tool, simplified)3. Shared capacity building activities4. Shared advocacy to counties for appropriate priority-setting and planning for communicable diseases5. Hire an economist and statistician at division level to support analytical work required to monitor impacts of
new technical approaches and devolved implementation.
Address the social determinants of TB through policy change and social protection schemes
i. Evaluate the financial barriers for TB patients as part of the prevalence survey, or conduct participatory poverty assessments (PPAs) to prioritize social health protection measures that would best support TB patients.
ii. Identify and explicitly remove the financial barriers contributing to diagnostic delay and at the point of care; e.g. promote free diagnostic services for children
iii. Evaluate the impact of current nutritional support programs on TB case finding and treatment outcomes. Explore the expansion of programs to include male TB patients
iv. Pilot test the inclusion of TB in a demand-side financing model as part of the roll-out of HISP, which includes a transport subsidy.
Update national policies
i. Make x-rays and Xpert testing free for children. The financial barriers to diagnosis may delay notification of childhood TB cases. Consideration should be given to removing the financial cost of diagnostic tests to all presumptive TB patients, particularly for the poor and among those living with HIV.
ii. Establish enforcement modalities for mandatory notification of TB, leprosy and lung diseases by private providers
iii. Establish legal framework to protect TB and leprosy patients from workplace-based discrimination
iv. Make mandatory the inclusion of TB and leprosy benefits within insurance packages (public and private)
v. Establish TB and leprosy as qualifying events for access to social protection benefits
vi. Introduce Xpert as the 1st diagnostic tool for PLHIV, children, retreatment cases, refugees and health care workers
vii. Add PAL medications; e.g. inhalers, to the essential drugs list.
118
4.3.9.2. Advocacy and communications
1. Situational Analysis
Given current resource availability, the NTLD Program estimates that there will be a budget shortfall of more than 50% of the total required to fully implement this NSP.
Increasing government investments in TB, leprosy and lung health will require political commitment and resource prioritization by not only the central government but also by the county governments. It will require that the programme realize efficiency gains through the integration of TB and leprosy control activities into other service delivery platforms (e.g. MCH), financing modalities (e.g. insurance schemes), and policies (e.g. workplace). Complementary and increased funding from donors and partners will be needed to sustain core activities and enable the roll-out of new innovations. In all cases, targeted communication and advocacy to the respective constituencies will need to be developed and delivered.
According to Kenya Demographic and Health Survey (KDHS, 2009), 98% of men and women in Kenya have heard about TB, with 89% of women and 92% of men recognizing that it can be cured. The KDHS suggested that stigma persists, with 25% of women and 10% of men noting that if a family member had TB, they would want to keep it a secret. In rural areas, knowledge about TB is significantly less common and stigma is higher than in urban settings1. The only TB-specific Knowledge, Attitudes and Practice (KAP) surveys done recently were among school children, and do not adequately guide planning.
Despite widespread general knowledge, care seeking is commonly delayed. Studies from various regions within Kenya have shown care seeking and diagnostic delays ranging from weeks to months. Furthermore, almost 5% of patients default from treatment.
There is anecdotal evidence suggesting that provider perceptions about the effectiveness and impact of some interventions, such as the provision of IPT, limit their willingness to deliver these services. Among health care workers who develop TB, treatment success rate is lower (75%) than in the general population (>85%), suggesting stigma or other constraints to treatment adherence.
A communication and advocacy strategy was developed by the NTLD Program in 2012, but has not been implemented.
2. Strategic Direction(s)
Communications and advocacy efforts will contribute to the acceleration of case detection and increase of treatment success rate by ensuring that relevant information and targeted messages reach those who can influence individual, community, provider, government or donor behavior. Mobilization of political will and resources, financial and human, is a priority for advocacy-related activities.
3. Proposed Approaches
The proposed approaches outlined below respond to the recognition that different programmatic needs are best addressed by advocacy and communication activities that target different audiences. (See Figure 31)
A foundational economic and social investment case for TB, leprosy and lung health will be developed, from which messaging for many of the constituencies highlighted below can be derived; i.e. framing the case for “why invest in TB, leprosy and lung health” at all levels of the government, and among partners, communities and households.
_______________________________________________________________________________________________________________________________1 Demographic and Health Survey, Kenya; 2008-9
4.3.
9.2
Adv
ocac
y an
d Co
mm
unic
atio
ns
119
Figure 30: Weekly Use of Information Sources
4.3.9.2: Advocacy and Com
munications
Package 1: Build political will and mobilize resources at county government level
Building political will and mobilizing resources for TB, TB/HIV, leprosy and lung health at the county level will require that the burden of these diseases in each county be contextualized. Situational analyses that build on this NSP are planned for each county that should yield baseline information and propose county-specific targets to be monitored, including programme performance, financial commitments and disbursement, and funding gaps per county. These county-specific advocacy and communications plans will take into account the local challenges and opportunities described in the section on Core DOTS. Opportunities for resource mobilization in support of counties with limited local resources will be prioritized.
Issues related to the control of TB, leprosy and lung health can be incorporated into county health fora. The NSP supports the establishment of a STOP TB Partnership office to coordinate communication and advocacy efforts in every county with CNR >175/100,000 as these are areas with multiple partners and high needs. Furthermore, medical parliamentarians (i.e. members of parliament on the health committee) will be engaged to promote local political will in their home areas.
Some illustrative activities under this package include: a) hosting a breakfast meeting during the Governors’ council just before the annual work planning process; b) convening of county stakeholder meetings to review health budgets against yardsticks for funding allocations; c) identify TB champions for each county; d) develop TB portals within each county’s website.
Package 2: Build political will and mobilize resources at national government level
The existing communications and advocacy plan does not sufficiently respond to the redefinition of central level roles and responsibilities. The NTLD Program must enhance communications and advocacy across the central government, broadening ownership of the programme and integrating TB, leprosy and lung health issues into social protection schemes and other health and non-health sector development plans.
The engagement of the Parliamentary Health Committee and the Senate will be sought, with regular briefs provided by the NTLD Program. The NTLD Program must concurrently facilitate access to information about the diseases and its programs among the citizenry and stakeholders. Finally, the central NTLD Program must operationalize its increased communication and advocacy role vis-à-vis the counties. The national communications and advocacy strategy will therefore be updated. KAP evidence will emerge as part of the national prevalence survey and can enhance the update.
Package 3: Build political will and mobilize resources at donor level
The NSP has dual objectives of sustaining close collaboration with existing donors and nurturing new donor partnerships. National and county-level Stop TB Partnerships will be supported to engage new donors from the private and other non-state sectors, including businesses. The NTLD Program and its partners will proactively and creatively mobilize new funds through events, such as races, rhino charge; and innovative financing, e.g. tax breaks, charity pledges. A database of existing and potential donors will be established to better target resource mobilization where large gaps remain.
Figure 31: Communications and Advocacy Framework
120
Package 4: Accelerate case detection and increase treatment success through health providers
To ensure health providers have all the relevant technical information as well as the motivation to provide quality services, activities are planned to: a) disseminate existing tools; b) develop new communication and advocacy materials targeting the specific needs of HCWs, such as tools for adherence counseling and health education, fact sheets on IPT and contact tracing. Motivating HCWs through professional development opportunities and performance-based recognition will form part of the advocacy strategy.
The NTLD Program will update pre-service and in-service medical training for all cadres of personnel to ensure that training is consistent with the norms and policies of the NTLD Program. Key faculty will be engaged to design and deliver potentially online, short courses or modules that communicate the components of NTLD Program guidelines. These modules and courses will be promoted as integral components of pre-service training.
Package 5: Reduce stigma, accelerate care seeking, and enhance case holding through communities
New communication materials and messages, including print, radio and mobile-phone based (depending on the local context), will be developed and translated for use at community level. Tools will be developed and activities supported to empower CHEWs, CSOs, religious leaders and other community leaders to inform, educate and support their patients, patient families and communities. TB, leprosy and lung health activities will be integrated into the training curriculum and terms of reference for CHEWs.
Similarly, tools to facilitate the referral of presumptive and confirmed patients between health facilities and the community will be developed. Tools to engage informal providers such as drug sellers, and to engage workplaces in the referral of presumptive cases, will also be developed. The NTLD Program will incorporate TB, leprosy and lung health messages into community health days and other health-related platforms at community level.
A specific focus on gender-based differences in knowledge, care seeking and treatment adherence will render gender-specific activities. For example, male-specific clubs led by male, former TB patients/champions will focus on overcoming the higher rate of default among men.
Package 6: Increase awareness of symptoms among patients and their expectations during treatment
Communication efforts targeting patients aim to provide information and resources to successfully complete treatment. Former and current TB patients, especially amonth the youth, will be engaged in crafting the messages and determining the best delivery platforms, e.g. web-based, social media, SMS, health workers.
The NTLD Program will consider how to best deliver information, based on known access to different forms of communication (See Figure 32). Existing tools, such as the patient charter (International Standards of Tuberculosis Care 2014), will be updated and made available to all DOT supporters. An interactive website and TB hotline will be hosted to facilitate confidential communication channels for patients.
Patient-centered communication will be developed in collaboration with the relevant partners, to refer TB, leprosy and lung health patients to social protection schemes, social support systems, and income generation activities. This messaging will evolve as the NTLD Program mobilizes support for the inclusion of TB and leprosy patients in social protection. Advocacy to partners to establish incentives for patients to complete treatment; e.g. Bata Shoe Co. voucher, will be pilot tested in selected areas with low treatment success.
Figure 32: Access to Information and Communication Technologies
4.3.
9.2
Adv
ocac
y an
d Co
mm
unic
atio
ns
121
4.3.9.2 Advocacy and Com
munications
Adv
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Adv
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lan
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tegi
c A
ppro
ach
2: B
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pol
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al w
ill a
nd m
obili
ze r
esou
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at
nati
onal
gov
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leve
l
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mee
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ld w
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a
4.3.
9.2:
Adv
ocac
y an
d Co
mm
unic
atio
ns
4.3.9.3 Gender and H
uman Rights
4.3.9.3. Human rights and gender1. Introduction
Human rights are universal legal guarantees protecting individuals and groups against actions that interfere with fundamental freedoms and human dignity. Gender refers to the social attributes and opportunities associated with being male or female and the relationships between women and men and girls and boys, as well as the relations between women and those among men. Gender determines what is expected, allowed and valued in a woman or a man in a given context. Gender equity is the absence of discrimination on the basis of a person’s sex, especially in connection with opportunities, allocation of resources or benefits and access to services. Gender equality entails the provision of fairness and justice in the creation of opportunities, distribution of benefits and responsibilities between women and men/girls and boys1. Gender mainstreaming is the strategy used to achieve equality in both women and men. For the case of TB, leprosy and lung diseases, this would mean integrating gender concerns into all laws, policies, regulations and programs concerning TB, leprosy and lung diseases care prevention and management.
The human rights based approach to programming is a process that infuses key human rights principles into programming with a view to ensuring that programs effectively address what they set out to, and produce an outcome that is desirable, sustainable, entrenched, and fully owned by the community. The human rights based approach aims at achieving a desirable outcome by focusing on the rights of the people the program intends to benefit. The key human rights principles that form part of the rights based approach are equality and non-discrimination, participation, accountability and people centered approaches. Human rights based approach in the case of TB, leprosy and lung diseases would involve integrating human rights principles in the design, implementation, monitoring and evaluation of TB, leprosy and lung diseases programs.
2. How human rights and gender impact on TB, leprosy and lung diseases
When human rights principles are not respected, and when gender inequalities are not taken into account, people are likely to be more vulnerable to TB, leprosy and lung disease infections. This is because they are less likely to access available services due to the barriers created by failing to address the human rights and gender barriers2. Key vulnerable groups in the context of TB, leprosy and lung diseases are more likely to be exposed to conditions that are conducive to TB, leprosy and lung diseases development, and less likely to have the information, power and resources necessary to ensure their access to health services. The stigma and discrimination associated with TB, leprosy and lung diseases, the and overlapping discrimination based on gender, poverty, or HIV status, can affect people’s employment, housing and access to social services3. Gender inequalities can impact health risks, health seeking behavior and responses from health systems, leading to poorer outcomes for everyone. It is thus important to address the different needs of women and men, girls and boys taking into account their diversity. This may involve undertaking gender responsive programming where one takes into account the prevailing gender norms or undertaking gender transformative programming, where one seeks to change harmful gender norms that act as a barrier to accessing health services4.
3. Country context on human rights and gender
The Constitution of Kenya 2010 provides the main legal framework to ensure a comprehensive rights-based to health services delivery. All laws and policies must be in line with the provisions of the Constitution of Kenya 2010. The Constitution makes provision for the right to the highest attainable standard of health, which includes reproductive health rights. It makes provision for people not to be denied emergency medical treatment, and obligates the State to provide appropriate social security to persons who are unable to support themselves and their dependents5.
The Constitution obligates the State and every state organ to observe, respect, protect, promote and fulfill the rights in the constitution and to take “legislative, policy and other measures, including setting of standards, to achieve the progressive realization of the rights guaranteed in Article 43.” State organs and public officers have a constitutional obligation to address the needs of the vulnerable groups6 in society and to domesticate the provisions of any relevant international treaty that Kenya has ratified7.
Article 46 of the Constitution makes provision for the protection of consumer rights, including the protection of health safety and economic interests. Article 27 of the Constitution outlaws discrimination on the basis of one’s health status. It provides for equality between men and women, and takes into account the use of affirmative action programs and policies to redress any disadvantage suffered by people because of past discrimination. The Constitution has provided
_______________________________________________________________________________________________________________________________1 Available at http://www.un.org/womenwatch/osagi/conceptsandefinitions.htm accessed on 1st August 2014. 2 UNDP (2013). Discussion Paper: The Role of Human Rights in Responses to HIV, Tuberculosis and Malaria. http://www.undp.org/content/dam/undp/library/hivaids/English/TheRoleofHRinResponsestoHIVTB, leprosy and lung diseases Malaria-UNDP-DP-web.pdf 3 Global Fund Information Note: Human Rights for HIV, TB, leprosy and lung diseases, Malaria and HSS Grants (February 2014) Available at http://www.the-globalfund.org/en/fundingmodel/support/infonotes/4 Global Fund (April 2014) Information Note Addressing Gender Inequalities and Strengthening Responses for Women and Girls Available at http://www.the-globalfund.org/en/fundingmodel/support/infonotes/5 Article 43 of the Constitution of Kenya 2010 Available at http://kenyalaw.org/kl/index.php?id=398 6 These include women, older members of society, persons with disabilities, children, and youth, members of minority or marginalized communities and mem-bers of particular ethnic and religious or cultural communities.7 Article 2(6) of the Constitution recognizes ratified international treaties as part of the laws of Kenya.
124
values and principles, which all state organs and officers are expected to employ in the delivery of services. The principles are captured in Articles 10 and 232, Chapter 6 and 12 of the Constitution. The relevant articles of the Constitution that touch on the right to health are Articles 2, 10, 20, 26, 27, 43, 53-57 and 174.
The Public Health Act Chapter 242 of the Law of Kenya8 has provisions under Section 27 which allows for the isolation of persons who have been exposed to infection9. Section 28 of the Act makes it an offence to willfully expose others to an infectious disease. These sections of the law, in the case of TB, leprosy and lung diseases management, have been the subject of a number of court decisions that have challenged the manner in which the Sections have been enforced10. The courts have also sought clarification on the contemplated place of isolation11. The country is in the process of developing a health law and policy that are equally likely to impact TB, leprosy and lung diseases management.
Gender factors influence epidemiological differences in exposure, risk of infection and progression from infection to disease. In Kenya, men between 24-40 years have higher TB, leprosy or lung disease burden and are more likely to default from treatment. In 2013, among smear positive pulmonary TB, leprosy and lung diseases patients, aged 15-54 years, men were twice as affected by TB, leprosy and lung diseases than females. Male gender norms in many contexts mean that men have delayed health-seeking behavior. Women are more susceptible to HIV12 and HIV is a risk factor for TB, leprosy and lung diseases. The lower numbers could be caused by structural barriers, limited access to resources, information and time. This raises the question about the possibility that women are not coming out for treatment, for example13. Focused efforts are needed to diagnose, treat and prevent TB, leprosy and lung diseases among women. Societal structures see a majority of women not enjoying the same rights, opportunities and access to health services as men, placing them at greater risk and at a disadvantage with respect to treatment and care. Their access to information and finances, in many contexts, is determined or controlled by men as heads of households, who often have greater economic power14. These differences should be taken into account when developing strategies for interventions in the tuberculosis, lung diseases and leprosy programs.
4. Gaps and challenges on human rights and gender in the context of TB, leprosy and lung diseases
Some of the identified gaps and challenges on issues relating to gender and human rights in the context of TB, leprosy and lung diseases include:
• Inaccessibility to quality health care e.g. barriers of gender, age, type of disease, social setting, geographical barriers, distances and inability to pay.
• Prevalent and increasing levels of poverty amongst the vulnerable groups.• Legal and policy barriers that hinder optimal provision of services to the key and vulnerable populations. • Inadequate interventions to address management and infection control for TB, leprosy and lung diseases cases and
mainstream gender and human rights needs and concerns.• Inadequate knowledge on gender and human rights among the general public and key stakeholders.• Inadequate national baseline data revealing the relationship of gender and human rights, including social, cultural
and economic factors in interventions for TB, leprosy and lung diseases.• Reluctance to embrace rights based approach to programming and service delivery for TB, leprosy and lung diseases
care, which takes into account gender concerns.
5. Strategic Priorities for 2015-2018
Monitoring and reforming laws, regulations and policies relating to TB, leprosy lung diseases
This can be achieved by the successful implementation of programs that address:
• Review of laws, policies and law enforcement practices to see whether they impact the response to TB, leprosy and lung diseases positively or negatively, taking into account the human rights and gender gaps.
• Assessment of access to justice for people infected with TB, leprosy and lung diseases or vulnerable to TB, leprosy and lung diseases infection.
• Advocacy and lobbying for law and policy reform with the relevant stakeholders on matters relating to TB, leprosy and lung diseases.
• Promotion of the enactment and implementation of laws, regulations and policies that prohibit discrimination and support access to TB, leprosy and lung diseases prevention, treatment, care and support.
• Develop tools to monitor incidents of rights violations, including discrimination, gender based violence and denial of health care services for TB, leprosy and lung diseases patients.
• Training community groups on how to use the tools and report incidents of human rights and gender based violations.
4.3.
9.3
Gen
der a
nd H
uman
Rig
hts
_______________________________________________________________________________________________________________________________8 Chapter 242 of the Laws of Kenya available at http://www.kenyalaw.org:8181/exist/kenyalex/actview.xql?actid=CAP.%20242 9 Available at kelinkenya.org/wp-content/uploads/2010/10/Advisory-Note-on-Arrest-of-TB, leprosy and lung diseases -Patients-in-Kapsabet.pdf 10 Available at kelinkenya.org/wp-content/uploads/2010/10/Misc-Criminal-App-No.-24-of-20111.pdf 11 Available at kelinkenya.org/wp-content/uploads/2010/10/Ruling-on-Petition-No.-3-of-2010.pdf 12 Kenya AIDS Indicator Survey 2012 Available at http://www.google.co.ke/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0C-CcQFjAA&url=http%3A%2F%2Fnascop.or.ke%2Flibrary%2F3d%2FPreliminary%2520Report%2520for%2520Kenya%2520AIDS%2520indicator%-2520survey%25202012.pdf&ei=K1nbU4-hF4bD7Aa774DwCQ&usg=AFQjCNEVSaGbVsyBVlgroBAlEUWSTlV2ZA&bvm=bv.72197243,d.ZGU 13 National Tuberculosis, Leprosy and Lung Disease Program 2014 Annual report http://www.nltp.co.ke/index.php?option=com_content&view=section&lay-out=blog&id=5&Itemid=38 14 Sexual Inequality in Tuberculosis; Oliver Neyrolles & Luis Quintana Available at http://www.oalib.com/paper/85316#.U9tiIGOcxco
125
4.3.9.3 Gender and H
uman Rights
Removal of the legal, human rights and gender barriers to access to TB, leprosy and lung diseases services
This can be achieved by the successful implementation of programs that address:• Stigma and discrimination reduction programs that include community-based interventions (including media) that
provides accurate information about TB, leprosy and lung diseases transmission.• Conducting legal literacy (know your rights) campaigns to improve legal and human rights literacy of people infected
and affected by TB, leprosy and lung diseases in relation to the identified human rights and gender gaps based on the legal assessment.
• Provision of TB, leprosy and lung diseases-related legal services to those who face human right violations.• Active case finding in communities affected by TB, reaching out to women and other economically disadvantaged
who do not have means to access services without paying for transportation. Integrate TB services into Reproductive Maternal and Child Health (RMNCH)-related health services to facilitate access by women and girls.
Training of lawmakers, law enforcement agents and health care workers
This can be achieved by the successful implementation of programs that pursue the following:
• Sensitization of law makers, law enforcement agents regarding TB, leprosy and lung diseases, modes of transmission and the negative consequences of illegal police activity on justice and on the TB, leprosy and lung diseases response.
• Facilitated discussions and negotiations among TB, leprosy and lung diseases service providers, those who access services, and the police, to address law enforcement practices that impede prevention of TB, leprosy and lung diseases, treatment, care and support efforts.
• Information and sensitization sessions for parliamentarians, member of county assemblies, governors, judicial officers, prosecutors, lawyers, staff members of human rights and gender commissions, on the legal, health and human rights aspects of TB, leprosy and lung diseases and on relevant national laws and the implications for enforcement, investigations and court proceedings.
• Training for prison personnel regarding the prevention, health care needs and human rights of detainees infected with or at risk of TB, leprosy and lung diseases.
• Training to ensure that health care providers know about their rights to health (TB, leprosy and lung diseases prevention and treatment, universal precautions, compensation for work-related infection) and to non-discrimination in the context of TB, leprosy and lung diseases.
• Training to reduce stigmatizing attitudes in health care settings and to provide health care providers with the skills and tools necessary to ensure patients’ rights to informed consent, confidentiality, treatment and non-discrimination.
Formation of inter-sectoral partnerships between the Ministry of Health (NTLD Program) and other parts of government to embed TB, leprosy and lung diseases concerns
This can be achieved by the successful implementation of programs that:
• Sensitize relevant government staff to ensure equal access for TB, leprosy and lung diseases patients to agricultural subsidies, housing allocation and other social benefits.
• Sensitize government actors to mainstream, TB, leprosy and lung diseases considerations in national policies and programs relating to labor, nutrition/food security, housing/urban planning, corrections, social protection and other development initiatives.
• Sensitize National Human Rights Institutions, Gender Commission and Office of the Ombudsman, on human rights dimensions of TB, leprosy and lung diseases.
Research, knowledge management and M & E
This can be achieved by the successful implementation of programs that:
• Conduct a baseline survey to document the magnitude and nature of human rights violations and gender disparities in TB, leprosy and lung diseases, Leprosy and lung diseases.
• Conduct a baseline survey on social and economic impact of TB, leprosy and lung diseases.• Develop a TB, leprosy and lung diseases stigma index to measure TB, leprosy and lung diseases-related stigma in
communities and health care settings.
126
4.3.
9.3
Gen
der a
nd H
uman
Rig
hts
Gen
der
and
Hum
an R
ight
s O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
1: M
onit
orin
g an
d re
form
law
s, r
egul
atio
ns a
nd p
olic
ies
rela
ting
to
TB
Ass
essm
ent
repo
rt o
f la
ws,
pol
icie
s an
d la
w e
nfor
cem
ent
prac
tice
s th
at
impa
ct p
osit
ivel
y or
neg
ativ
ely
on T
B
Aud
it o
f la
ws,
pol
icie
s an
d la
w
enfo
rcem
ent
prac
tice
s A
udit
th
e la
ws
and
polic
ies
and
deve
lop
a re
port
on
the
prac
tice
s an
d la
ws
on T
B H
R an
d ge
nder
1Im
plem
enta
tion
of
the
find
ings
of
the
audi
t an
d di
ssem
inat
ion
of t
he r
epor
tn/
aIm
plem
enta
tion
of
the
find
ings
of
the
audi
t an
d di
ssem
inat
ion
of t
he r
epor
tn/
a
Dra
ft
TB,
lepr
osy
and
lung
he
alth
di
seas
es b
illD
evel
op a
dra
ft T
B, l
epro
sy a
nd
lung
bi
ll1.
Hol
d co
nsul
tati
ve f
orum
s w
ith
key
stak
ehol
ders
an
d m
embe
rs
of
the
publ
ic a
t bo
th n
atio
nal
and
coun
ty
leve
ls
2.
Dra
ft T
B Le
pros
y an
d Lu
ng B
ill
1Pr
esen
t the
bill
to p
arlia
men
t thr
ough
th
e re
leva
nt c
omm
itte
e fo
r de
bate
n/
aA
dvoc
acy
and
lobb
y m
eeti
ngs
for
la
w
and
polic
y re
form
w
ith
the
rele
vant
st
akeh
olde
rs
on
mat
ters
re
lati
ng t
o TB
n/a
Prom
otio
n of
th
e en
actm
ent
and
impl
emen
tati
on
of
law
s,
regu
lati
ons
and
polic
ies
that
pro
hibi
t di
scri
min
atio
n an
d su
ppor
t ac
cess
to
TB
pr
even
tion
, tr
eatm
ent,
ca
re
and
supp
ort
thro
ugh
vari
ous
mee
ting
s an
d co
nsul
tati
ons
n/a
Num
ber
of
mon
itor
ing
tool
s di
ssem
inat
edD
evel
op
tool
to
m
onit
or
inci
denc
es
of
righ
ts
viol
atio
ns
incl
udin
g di
scri
min
atio
n, g
ende
r ba
sed
viol
ence
an
d de
nial
of
he
alth
ca
re
serv
ices
fo
r TB
pa
tien
ts
1. D
evel
op a
mon
itor
ing
tool
2.
Tes
t th
e to
ol in
one
cou
nty.
3. W
orks
hop
to i
ncor
pora
te c
hang
es
on t
ool b
ased
on
test
.
4.
Fin
alis
e to
ol a
nd r
oll o
ut t
ool
0D
isse
min
ate
the
tool
for
use
1,00
0A
naly
sis
of
data
co
llect
ed
and
utili
sati
on o
f th
e fi
ndin
gs t
o in
form
pr
ogra
mm
ing
1,00
0A
naly
sis
of d
ata
colle
cted
and
uti
lisat
ion
of t
he f
indi
ngs
to in
form
pro
gram
min
g1,
000
Num
ber
of T
OTs
tra
ined
on
hum
an
righ
ts is
sues
and
the
use
of
the
righ
ts
viol
atio
ns' m
onit
orin
g to
ol
Trai
ning
com
mun
ity
grou
ps o
n ho
w t
o us
e th
e to
ols
and
repo
rt
inci
denc
es o
f hu
man
rig
hts
and
gend
er b
ased
vio
lati
ons
Trai
n 30
tra
iner
s of
tra
iner
s (T
OT)
per
co
unty
in 1
0 pi
lot
coun
ties
300
Impl
emen
t us
e of
the
too
l, co
llect
ion
of i
nfor
mat
ion
and
anal
yses
of
data
co
llect
ed
and
utili
sati
on
of
the
find
ings
to
info
rm p
rogr
amm
ing
Impl
emen
t us
e of
the
too
l, co
llect
ion
of i
nfor
mat
ion
and
anal
yses
of
data
co
llect
ed
and
utili
sati
on
of
the
find
ings
to
info
rm p
rogr
amm
ing
Impl
emen
t us
e of
th
e to
ol,
colle
ctio
n of
in
form
atio
n an
d an
alys
es
of
data
co
llect
ed a
nd u
tilis
atio
n of
the
fin
ding
s to
info
rm p
rogr
amm
ing
Stra
tegi
c A
ppro
ach
2: R
emov
al o
f th
e le
gal,
hum
an r
ight
s an
d ge
nder
bar
rier
s
Val
ue o
f th
e st
igm
a in
dex
in h
ealt
h ca
re s
etti
ngs
and
com
mun
itie
sSt
igm
a an
d di
scri
min
atio
n re
duct
ion
prog
ram
mes
incl
udin
g ra
dio/
TB
and
prin
t ad
vert
s,
stig
ma
redu
ctio
n IE
C
Dev
elop
IE
C
mat
eria
ls
wit
h no
n-st
igm
atis
ing
mes
sage
s.75
%C
omm
unit
y in
tera
ctio
ns
and
disc
ussi
ons
tar
geti
ng
wom
en,
men
, yo
uth,
pe
rson
s w
ith
disa
bilit
ies,
el
derl
y, r
elig
ious
lea
ders
, hea
lth
care
pr
ovid
ers,
le
arni
ng
inst
itut
ions
an
d in
volv
ing
TB p
atie
nts
in 1
0 co
unti
es.
50%
Use
m
edia
in
clud
ing
skit
s,
play
s,
adve
rtis
emen
ts d
esig
ned
to e
duca
te
as w
ell
as t
o am
use
and
inte
grat
ion
of n
on-s
tigm
atis
ing
mes
sage
s on
TB
and
beha
viou
r ch
ange
int
o TV
and
Ra
dio
show
s
25%
1. C
omm
unit
y fo
rum
s an
d us
e of
the
m
edia
sh
ows
invo
lvin
g co
mm
unit
y re
cogn
ized
le
ader
s,
to
pass
no
n st
igm
atiz
ing
mes
sage
s.
2 En
gage
men
t w
ith
relig
ious
an
d co
mm
unit
y le
ader
s an
d ce
lebr
itie
s to
pr
omot
e no
n-st
igm
atis
ing
mes
sage
s on
TB
, Le
pros
y an
d be
havi
our
chan
ge in
10
coun
ties
15%
Num
ber
of p
eopl
e tr
aine
d, u
sing
new
hu
man
ri
ghts
an
d ge
nder
tr
aini
ng
mod
ule
Con
duct
ing
lega
l lit
erac
y (k
now
yo
ur
righ
ts)
cam
paig
ns
to
impr
ove
lega
l an
d hu
man
rig
hts
liter
acy
of p
eopl
e in
fect
ed a
nd
affe
cted
by
TB
in
re
lati
on
to
the
iden
tify
hu
man
ri
ghts
an
d ge
nder
gap
s ba
sed
on t
he l
egal
as
sess
men
t
Dev
elop
hum
an r
ight
s a
nd g
ende
r tr
aini
ng
mod
ules
an
d in
terg
rate
in
to T
uber
culo
sis,
Lep
rosy
an
d Lu
ng
Dis
ease
s tr
aini
ng p
rogr
am
Con
duct
the
tra
inin
gs o
f ta
rget
ttin
g 10
0 pe
ople
fro
m 5
cou
ntie
s10
0C
ondu
ct t
he t
rain
ings
of
targ
ettt
ing
200
peop
le f
rom
10
coun
ties
200
Con
duct
the
tra
inin
gs o
f ta
rget
ttin
g 1
00
peop
le f
rom
5 c
ount
ies
100
Perc
enta
ge
of
TB-r
elat
ed
hum
an
righ
ts
viol
atio
ns
for
whi
ch
lega
l se
rvic
es a
re p
rovi
ded
Prov
isio
n of
TB
re
late
d le
gal
serv
ices
to
th
ose
who
fa
ce
hum
an r
ight
vio
lati
ons
Trai
ning
law
yers
, re
pres
enta
tive
s of
hu
man
rig
hts
com
mis
sion
s o
n TB
and
hu
man
rig
hts
in t
he 1
0 co
unti
es
1. C
ondu
ct o
ne le
gal a
id c
linic
in e
ach
of t
he 1
0 co
unti
es e
very
yea
r.
2. Id
enti
fy h
uman
righ
ts o
rgan
isat
ions
an
d in
stit
utio
ns
that
ca
n pr
ovid
e le
gal
serv
ices
and
adv
ice
on a
dai
ly
basi
s fo
r w
alk
in c
lient
s
40%
1. C
ondu
ct o
ne le
gal a
id c
linic
in e
ach
of t
he 1
0 co
unti
es e
very
yea
r.
2. Id
enti
fy h
uman
righ
ts o
rgan
isat
ions
an
d in
stit
utio
ns th
at c
an p
rovi
de le
gal
serv
ices
and
adv
ice
on a
dai
ly b
asis
fo
r w
alk
in c
lient
s
60%
1.
Con
duct
on
e le
gal
aid
clin
ic
in
each
of
the
10 c
ount
ies
ever
y ye
ar.
2.
Iden
tify
hu
man
ri
ghts
or
gani
sati
ons
and
inst
itut
ions
tha
t ca
n pr
ovid
e le
gal
serv
ices
and
adv
ice
on a
dai
ly b
asis
for
w
alk
in c
lient
s
100%
4.3.9.3 Gender and H
uman Rights
Gen
der
and
Hum
an R
ight
s O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
(s)
Yea
r 1
Act
ivit
ies
Yr
1 Ta
rget
Yea
r 2
Act
ivit
ies
Yr
2 Ta
rget
Yea
r 3
Act
ivit
ies
Yr
3 Ta
rget
Yea
r 4
Act
ivit
ies
Yr
4 Ta
rget
Stra
tegi
c A
ppro
ach
3: T
rain
ing
of la
w m
aker
s, la
w e
nfor
cem
ent
agen
ts a
nd h
ealt
h ca
re w
orke
rs
Num
ber
of p
erso
nnel
tra
ined
Sens
itiz
atio
n of
he
alth
ca
re
wor
kers
, la
w
mak
ers,
la
w
enfo
rcem
ent
agen
ts
incl
udin
g po
lice
offi
cers
, an
d pr
ison
s of
fici
als,
ju
dici
al
offi
cers
, la
wye
rs,
pros
ecut
ion
offi
cers
, on
gen
der
and
hum
an r
ight
s in
Tu
berc
ulos
is,
Lepr
osy
and
lung
di
seas
es
Four
day
wor
ksho
ps
trai
ning
s o
n ge
nder
an
d hu
man
ri
ghts
is
sues
re
late
d to
TB
, le
pros
y an
d lu
ng
dise
ases
on
e in
ea
ch
of
the
47
coun
ties
, 30
part
icip
ants
per
cou
nty
1,41
0Fo
ur d
ay w
orks
hops
tr
aini
ngs
on
gend
er
and
hum
an
righ
ts
issu
es
rela
ted
to
TB,
lepr
osy
and
lung
di
seas
es
one
in
each
of
th
e 47
co
unti
es, 3
0 pa
rtic
ipan
ts p
er c
ount
y
1,41
0M
eeti
ngs
to
co
llect
fe
ed
back
fr
om
the
trai
ned
pers
onel
l a
nd e
valu
ate
the
impa
ct o
f th
e tr
aini
ng
Num
ber
of d
ialo
gue
fora
hel
d w
ith
stak
ehol
ders
Faci
litat
e di
alog
ues
disc
ussi
ons
and
nego
tiat
ions
am
ong
TB
serv
ice
prov
ider
s,
thos
e w
ho
acce
ss
serv
ices
an
d po
lice
to
addr
ess
law
en
forc
emen
t pr
acti
ces
that
im
pede
TB
pr
even
tion
, tr
eatm
ent,
car
e an
d su
ppor
t ef
fort
s
Con
duct
one
cou
nty
dial
ogue
for
um
in e
ach
of t
he 4
7 co
unty
wit
h th
e di
ffer
ent
stak
ehol
der
repr
esen
tati
ve
of t
hose
who
wer
e tr
aine
d
47C
ondu
ct o
ne c
ount
y di
alog
ue f
orum
in
eac
h of
the
10
coun
ty w
ith
the
diff
eren
t st
akeh
olde
r re
pres
enta
tive
of
tho
se w
ho w
ere
trai
ned
47C
ondu
ct o
ne c
ount
y di
alog
ue f
orum
in
each
of
the
10 c
ount
y w
ith
the
diff
eren
t st
akeh
olde
r re
pres
enta
tive
of
thos
e w
ho
wer
e tr
aine
d
47
Stra
tegi
c A
ppro
ach
4: F
orm
atio
n of
Inte
rsec
tora
l par
tner
ship
s be
twee
n th
e M
inis
try
of H
ealt
h an
d ot
her
part
s of
gov
ernm
ent
to e
mbe
d TB
con
cern
s
Num
ber
of s
take
hold
ers
and
part
ners
tr
aine
d to
add
ress
the
dis
pari
ties
in
gend
er a
nd h
uman
rig
hts
Sens
itiz
e re
leva
nt
gove
rnm
ent
inst
itut
ions
on
pa
rtne
rshi
ps
wit
h N
TLD
Pr
ogra
m
to
real
ize
hum
an r
ight
s an
d br
idge
gen
der
disp
arit
y in
TB
, Le
pros
y an
d lu
ng
dise
ases
an
d m
ains
trea
m
TB
polic
ies
in
nati
onal
co
nsid
erat
ions
Iden
tify
all
part
ners
and
sta
keho
lder
s bo
th
gove
rnm
ent
and
CSO
's
and
crea
te a
dat
a ba
se i
ndic
atin
g th
eir
resp
onsi
bilit
ies
in
mai
nstr
eam
ing
gend
er a
nd h
uman
rig
hts
in T
B le
p an
d lu
ng d
isea
se.
Thre
e da
y tr
aini
ng o
n TB
, Lep
and
LD
, ge
nder
an
d hu
man
rig
hts
citi
ng t
he
gend
er a
nd h
uman
rig
hts
issu
es o
f co
ncer
n an
d th
e po
ssib
le a
reas
of
inte
grat
ion
30Th
ree
day
foru
m
to
addr
ess
the
disp
arit
ies
in
gend
er
and
hum
an
righ
ts a
nd h
ow b
est
to m
ains
trea
m
both
into
the
ava
ilabl
e pr
ogra
ms
30Tw
o da
y se
nsit
izat
ion
foru
m t
o es
tabl
ish
wha
t pa
rtne
rs a
re d
oing
in
an e
ffor
t to
m
ains
trea
m
gend
er
and
hum
an
righ
ts
into
the
ir p
rogr
amm
es
4.3.9.4 Social protection
1. Situational Analysis
In 2011, Kenya published a National Social Protection Policy to build on the government’s commitment to poverty reduction as articulated in Vision 2030.
The National Social Protection Policy acknowledges that 46.7% of Kenyans (16.3 million people) live in poverty, unable to meet the cost of basic food. It also recognizes that “health risks that require a household to pay for medical treatment are of special concern to poor households.”
The National Social Protection Policy includes the following objectives1:
1. Protect individuals and households from the impact of adverse shocks to their consumption that is capable of pushing them into poverty or into deeper poverty
2. Support individuals and households to manage these shocks in ways that do not trap them in poverty by reducing their exclusion and strengthening their ability to graduate from social assistance and to become financially self-sufficient
3. Cushion workers and their dependents from the consequences of income-threatening risks, such as sickness, poor health, and injuries at work, as well as from the threat of poverty in their post-employment life
4. Promote key investments in human capital and physical assets by poor and non-poor households and individuals that will ensure their resilience in the medium-term, and that will break the intergenerational cycle of poverty. Promoting synergies and integration among social protection providers as well as positive interactions among stakeholders.
TB is more widespread among low income groups. The 2008/2009 Kenyan Demographic and Health Survey indicated that financial barriers to care were a primary cause of delayed care seeking. In particular, costs related to transportation and fee-based diagnostic tests, as well as lack of nutritional and financial support during the intensive phase of treatment was highlighted2. A study was undertaken in 2008 to estimate TB patients’ costs among 208 Nomadic Populations in Kitui North and Mutomo districts. It suggested that TB patients had a substantial burden of
_______________________________________________________________________________________________________________________________1 ibid, KNSPP2 Kenya NTLD Program Midterm Report 2014
Map 11: % of TB patients with BMI<18 among all notified cases
Map 12: % of malnourished (BMI<18) TB patients who receive caloric food
support
4.3.
9.4
Soci
al P
rote
ctio
n
129
direct (out of pocket: USD 55.8) and indirect (opportunity: USD 294.2) costs due to TB. It also showed that inability to work was a major cause of increased poverty, confirming an existence of a ‘medical poverty trap’ in the two districts. Other costing studies have shown similar barriers to care seeking and treatment compliance.
The NTLD Program estimates that over half of TB patients are malnourished at the onset of treatment, with 17% of those with TB being severely malnourished and a further 21% being moderately malnourished3. As illustrated in the maps, more than 50% of TB patients in some districts have BMI<18. Poor nutritional status is known to negatively impact treatment adherence and outcomes. Malnutrition weakens the immune system, and this increases the likelihood of latent TB turning into active TB. However, the majority of nutritional support programs active in Kenya do not prioritize food for TB patients. Furthermore, the majority of nutrition support programs target women and children, leaving out the male TB patients.
2. Strategic Directions
In May 2014, the World Health Assembly endorsed targets for TB control post-2015. This NSP will be one of the first to adopt the new global target of “no affected families facing catastrophic costs due to TB.”
To achieve this, a multi-pronged approach to extend social protections for TB patients will be sought. They will aim to reduce the direct and indirect costs of care seeking and treatment, while also addressing geographic, sociocultural and gender-related barriers to care.
3. Proposed Approaches
1. Promote policies and plans to ensure the inclusion of TB, leprosy and lung health patients in the current and emerging social protection schemes: Social protection schemes that address the indirect costs of illness and enable care seeking will be targeted for expansion to include TB and leprosy as qualifiers for benefits, such as: a) conditional cash transfers for care seeking, especially for women and children; b) transport voucher programs; and c) income generating activities.
a) Generate new, policy-relevant knowledge about the impact of social protection interventions on TB and leprosy control in settings characterized by different resources and epidemiological profiles; generate evidence for scale up in County Strategic Plans and other stakeholder plans
b) Develop a sub-plan and NTLD Program policy related to social protection, in collaboration with relevant stakeholders
c) Establish collaborative partnerships among those advancing the social protection agenda nationally and at county level; establish a mechanism (e.g. technical working group) for collaboration among social protection stakeholders
d) Advocate for County Governments to set aside resources for Social Protection for TB and leprosy patients.
2. Roll out nutritional support for TB and leprosy patients through existing platforms for food supporta) Targeted therapeutic feeding for all severely malnourished adults and children; both in and outpatients, as per WHO IMAM recommendations
b) Targeted supplementary feeding for all moderately malnourished adults and children meeting the criteria of BMI less than 18.5, as outpatients
c) Alternative feeding options to infants born of MDR-TB/PLHIV if and when mothers are unable to breastfeed exclusively on demand for the first six months
d) Multiple Micronutrient supplementation for all TB and leprosy cases during the intensive phase of treatment. It is important to note that the micro-nutrient survey conducted in 2003 showed that 76% of the Kenyan population were Vitamin A deficient. In arid areas, micro-nutrient supplementation is highly recommend as part of the nutrition policy
e) Promote TB and leprosy as automatic eligibility criteria for inclusion in food safety nets
f) Scale-up the use of nutrition education and screening as an integral component of community-based care and household visits
_______________________________________________________________________________________________________________________________
3 ibid, Midterm Report
4.3.9.4 Social Protection
130
_______________________________________________________________________________________________________________________________5 National Strategic Plan for Tuberculosis, Leprosy and Lung Health 2015-2018
g) Build capacity of health workers to improve on quality of nutrition assessment, counseling, care and support of all patients
h) Increase availability and access to nutrition assessment, counseling, and support (NACS) at community and facility levels.
3. Promote policies to reduce the direct costs of TB diagnosis and treatment.
a) Ensure the mandatory inclusion of TB benefits within health insurance packages, both public and private, to help mitigate the direct expenses associated with TB diagnosis and care5
b) Eliminate diagnostic fees for children
4. Promote a legal framework to protect TB patients in the workplace from discrimination and the fear/reality of lost income.
4.3.
9.4
Soci
al P
rote
ctio
n
131
4.3.9.4 Social Protection
Soci
al P
rote
ctio
n O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
sY
ear
1 A
ctiv
itie
sY
r 1
Targ
etY
ear
2 A
ctiv
itie
sY
r 2
Targ
etY
ear
3 A
ctiv
itie
sY
r 3
Targ
etY
ear
4 A
ctiv
itie
sY
r 4
Targ
et
Stra
tegi
c A
ppro
ach
1: P
olic
y de
velo
pmen
t fo
r so
cial
pro
tect
ion:
ens
urin
g th
e in
clus
ion
of T
B an
d le
pros
y pa
tien
ts a
mon
g th
e be
nefi
ciar
ies
of s
ocia
l pro
tect
ion
sche
mes
Num
ber
of n
atio
nal
polic
y do
cum
ents
and
an
nual
pl
ans
(n
atio
nal)
deve
lope
d an
d di
ssem
inat
ed o
n so
cial
pro
tect
ion
of T
B pa
tien
ts
Inte
grat
e an
d co
ordi
nate
so
cial
pr
otec
tion
pr
ogra
mm
es
and
prog
ram
min
g fo
r TB
& l
epro
sy i
n th
e co
untr
y
Hol
d st
eeri
ng c
omm
itte
e an
d TW
G m
eeti
ngs
1H
old
quat
erly
TW
G m
eeti
ngs
Con
duct
2 s
take
hold
ers/
dia
logu
e/se
nsit
izat
ion
mee
ting
s, T
A
2H
old
quat
erly
TW
G m
eeti
ngs
Con
duct
2 s
take
hold
ers/
dia
logu
e/se
nsit
izat
ion
mee
ting
s
2H
old
quat
erly
TW
G m
eeti
ngs.
Con
duct
2
stak
ehol
ders
/dia
logu
e/se
nsit
izat
ion
mee
ting
s
n/a
Prop
orti
on o
f ta
rget
ed s
take
hold
ers
that
ha
ve b
een
brie
fed
on n
eed
to i
nclu
de T
B in
soc
ial
prot
ecti
on p
latf
orm
s; a
nd p
lans
dr
afte
d
Hol
d
nati
onal
TB
so
cial
pr
otec
tion
st
akeh
olde
r m
eeti
ngs
25H
old
bian
nual
so
cial
pr
otec
tion
st
akeh
olde
r m
eeti
ngs
50H
old
bian
nual
so
cial
pr
otec
tion
st
akeh
olde
r m
eeti
ngs
75H
old
bian
nual
so
cial
pr
otec
tion
st
akeh
olde
r m
eeti
ngs
100
Prop
orti
on o
f co
unti
es b
rief
ed o
n ne
ed t
o in
clud
e TB
in s
ocia
l pro
tect
ion
plat
form
s5
Hol
d bi
annu
al
TB
soci
al
prot
ecti
on s
take
hold
er m
eeti
ng in
15
cou
ntie
s
33H
old
bian
nual
TB
soci
al p
rote
ctio
n st
akeh
olde
r m
eeti
ng in
15
coun
ties
66H
old
bian
nual
TB
soci
al p
rote
ctio
n st
akeh
olde
r m
eeti
ng in
15
coun
ties
100
Prop
orti
on o
f co
unti
es h
avin
g in
vent
orie
s of
soc
ial
prot
ecti
on r
esou
rces
, an
d co
unty
pl
ans
deve
lope
d fo
r su
ppor
t to
TB
pati
ents
Prin
t TB
3,
600
soci
al
prot
ecti
on p
olic
y do
cum
ents
Hol
d 4
TB
soci
al p
rote
ctio
n po
licy
deve
lopm
ent
wor
ksho
ps.
10D
istr
ibut
e TB
soci
al
prot
ecti
on
polic
y do
cum
ents
to
47 c
ount
ies
25H
old
47
Cou
nty
di
ssem
inat
ion
mee
etin
gs
for
the
TB
so
cial
pr
rote
ctio
n po
licy
docu
men
t
25
Num
ber
of
coun
ties
w
ith
TB
soci
al
prot
ecti
on p
olic
y do
cum
ents
ava
ilabl
eTe
chni
cal
assi
stan
ce
to
15
coun
ties
for
soc
ial
prot
ecti
on
plan
ning
15Te
chni
cal
assi
stan
ce
to
15
coun
ties
fo
r so
cial
pr
otec
tion
pl
anni
ng
30H
old
a na
tion
al
diss
emin
atio
n m
eeti
ng f
or t
he T
B so
cial
pro
tect
ion
polic
y do
cum
ent,
less
ons
lear
ned
47Te
chni
cal
assi
stan
ce t
o 15
cou
ntie
s fo
r so
cial
pro
tect
ion
plan
ning
47
Reim
burs
emen
t le
vels
for
TB
diag
nosi
s an
d ca
re in
hea
lth
insu
ranc
e qu
anti
fied
Dev
elop
co
st
reim
burs
emen
t sc
hedu
le f
or T
B di
agno
sis
and
care
wit
hin
heal
th i
nsur
ance
sc
hem
es (t
echn
ical
ass
ista
nce)
1
Prop
orti
on
of
heal
th
insu
ranc
e po
licie
s (p
ublic
and
pri
vate
) th
at h
ave
man
dato
ry
cove
rage
of
TB p
atie
nts
Hol
d ad
voca
cy m
eeti
ngs
for
TB
soci
al p
rote
ctio
n w
ith
rele
veva
nt
agen
cies
e.
g N
atio
nal
Hos
pita
l In
sura
nce
Fund
5H
old
10 a
dvoc
acy
mee
ting
s fo
r TB
so
cial
pr
otec
tion
w
ith
rele
veva
nt
agen
cies
e.
g N
atio
nal
Hos
pita
l In
sura
nce
Fund
20H
old
10 a
dvoc
acy
mee
ting
s fo
r TB
so
cial
pr
otec
tion
w
ith
rele
veva
nt
agen
cies
e.
g N
atio
nal
Hos
pita
l In
sura
nce
Fund
50
Prop
orti
on o
f TB
pati
ents
cov
ered
by
heal
th
insu
ranc
e5
2050
Stra
tegi
c A
ppro
ach
2: R
oll o
ut n
utri
tion
al s
uppo
rt f
or T
B an
d le
pros
y pa
tien
ts t
hrou
gh e
xist
ing
plat
form
s fo
r fo
od s
uppo
rt
Prop
orti
on o
f el
igib
le T
B pa
tien
ts r
ecei
ving
nu
trit
ion
supp
ort
Cap
acit
y bu
ildin
g am
ong
heal
th
care
wor
kers
for
nut
riti
on n
eeds
am
ong
TB p
atie
nts
Trai
n 18
0 he
alth
ca
re
wor
kers
on
TB n
utri
tion
fro
m
coun
ties
w
ith
high
est
rate
s of
m
alnu
trit
ion
amon
g TB
pa
tien
ts
30Tr
ain
180
heal
th c
are
wor
kers
on
TB n
utri
tion
fro
m c
ount
ies
wit
h hi
ghes
t ra
tes
of
mal
nutr
itio
n am
ong
TB p
atie
nts
50Tr
ain
180
heal
th c
are
wor
kers
on
TB
nutr
itio
n fr
om c
ount
ies
wit
h hi
ghes
t ra
tes
of
mal
nutr
itio
n am
ong
TB
pati
ents
80Tr
ain
180
heal
th c
are
wor
kers
on
TB
nutr
itio
n fr
om c
ount
ies
wit
h hi
ghes
t ra
tes
of
mal
nutr
itio
n am
ong
TB
pati
ents
80
Tool
s de
velo
pmen
t fo
r he
alth
w
orke
rs a
nd C
HEW
s on
nut
riti
onal
as
sess
men
t an
d nu
trit
iona
l sup
port
Dev
elop
on-
the-
job
tool
s fo
r he
alth
fac
iliti
es a
nd C
HEW
s D
isse
min
atio
n to
all
coun
ties
Dis
sem
inat
ion
to a
ll co
unti
es
Con
duct
nati
onal
te
chni
cal
assi
stan
ce
(TA
)
on
TB
nutr
itio
n,
targ
etin
g co
unti
es
wit
h w
orst
m
alnu
trit
ion
amon
g TB
pat
ient
s on
tr
eatm
ent.
Con
duct
na
tion
al
te
chni
cal
assi
stan
ce (T
A)
on T
B nu
trit
ion
tart
egtt
ing
coun
ties
w
ith
wor
st m
alnu
trit
ion
amon
g TB
pa
tien
ts o
n tr
eatm
ent.
Con
duct
tech
nica
l as
sist
ance
(T
A)
on
TB n
utri
tion
tar
tegt
ting
co
unti
es w
ith
wor
st m
alnu
trit
ion
amon
g TB
pat
ient
s on
tre
atm
ent.
Con
duct
te
chni
cal
assi
stan
ce (
TA)
on T
B nu
trit
ion
tart
egtt
ing
coun
ties
w
ith
wor
st m
alnu
trit
ion
amon
g TB
pa
tien
ts o
n tr
eatm
ent.
Con
duct
te
chni
cal
assi
stan
ce (
TA)
on T
B nu
trit
ion
tart
egtt
ing
coun
ties
w
ith
wor
st m
alnu
trit
ion
amon
g TB
pa
tien
ts o
n tr
eatm
ent.
Dev
elop
po
siti
on
pape
r an
d co
nduc
t ad
voca
cy f
or i
nclu
sion
of
TB p
atie
nts
by o
ther
foo
d su
ppor
t pr
ovid
ers
Dev
elop
po
siti
on
pape
r on
re
leva
nce
of
food
su
ppor
t fo
r el
igib
le
TB p
atie
nts
(and
fa
mili
es)
Targ
eted
adv
ocac
y fo
r inc
lusi
on o
f TB
pat
ient
s in
foo
d pr
ogra
mm
esN
atio
nal p
olic
y dr
afti
ng: T
B pa
tien
ts
auto
mat
ical
ly e
ligib
le f
or f
ood
Targ
eted
adv
ocac
y fo
r in
clus
ion
of
TB p
atie
nts
in f
ood
prog
ram
mes
Soci
al P
rote
ctio
n O
pera
tion
al P
lan
Out
put
Indi
cato
r(s)
Inte
rven
tion
sY
ear
1 A
ctiv
itie
sY
r 1
Targ
etY
ear
2 A
ctiv
itie
sY
r 2
Targ
etY
ear
3 A
ctiv
itie
sY
r 3
Targ
etY
ear
4 A
ctiv
itie
sY
r 4
Targ
et
Proc
ure
ther
apeu
tic
and
supp
lem
enta
ry f
eeds
for
elig
ible
TB
pati
ents
not
cov
ered
by
othe
r fo
od
supp
ort
prog
ram
s
Proc
ure
ther
apeu
tic
and
supp
lem
enta
ry
feed
s fo
r 50
,000
TB
apti
ents
Proc
ure
ther
apeu
tic
and
supp
lem
enta
ry f
eeds
for
50,
000
TB a
ptie
nts
Proc
ure
Nut
riti
onal
sup
plem
ents
for
30
,000
M
oder
atet
ly
Mal
nour
ishe
d TB
Pat
ient
s
Proc
ure
Nut
riti
onal
sup
plem
ents
for
30
,000
M
oder
atet
ly
Mal
nour
ishe
d TB
Pat
ient
s
Proc
ure
ther
apeu
tic
feed
s fo
r 20
,000
Se
vere
ly
Mal
nour
ishe
d TB
Pa
tien
ts
Proc
ure
ther
apeu
tic
feed
s fo
r 20
,000
Se
vere
ly M
alno
uris
hed
TB P
atie
nts
Prop
orti
on
of
elig
ible
br
east
feed
ing
mot
hers
wit
h M
DR-
TB g
iven
the
opt
ion
of
alte
rnat
ive
feed
ing
for
infa
nts
Prov
ide
alte
rnat
ive
feed
ing
opti
ons
to i
nfan
ts b
orn
of M
DR-
TB i
f an
d w
hen
mot
hers
ar
e un
able
to
br
east
feed
exc
lusi
vely
on
dem
and
for
the
firs
t si
x m
onth
s
Prov
ide
alte
rnat
ive
feed
ing
7 M
DR-
TB
brea
stfe
edin
g m
othe
rs
20Pr
ovid
e al
tern
ativ
e fe
edin
g 7
MD
R-TB
bre
astf
eedi
ng m
othe
rs50
Prov
ide
alte
rnat
ive
feed
ing
7 M
DR-
TB b
reas
tfee
ding
mot
hers
75Pr
ovid
e al
tern
ativ
e fe
edin
g 7
MD
R-TB
bre
astf
eedi
ng m
othe
rs10
0
Stra
tegi
c A
ppro
ach
3: E
stab
lish
colla
bora
tive
par
tner
ship
s am
ong
thos
e ad
vanc
ing
the
soci
al p
rote
ctio
n ag
enda
at
nati
onal
and
cou
nty
leve
ls
Prop
orti
on
of
elig
ible
TB
pa
tien
ts
part
icip
atin
g in
IGA
sSu
ppor
t th
e in
corp
orat
ion
of
TB
pati
ents
in
to
exis
ting
/em
ergi
ng
inco
me
gene
rati
ng a
ctiv
itie
s (IG
As)
Inve
ntor
y IG
As
in
coun
try
and
docu
men
t ac
cess
by
TB
pati
ents
Incl
ude
TB p
atie
nts
in I
GA
s i
n 15
co
unti
es
mos
t af
fect
ed
by
mal
nutr
itio
n am
ong
TB p
atie
nts
15In
clud
e TB
pa
tien
ts
in
IGA
s
in
15
coun
ties
m
ost
affe
cted
by
m
alnu
trit
ion
amon
g TB
pat
ient
s
25In
clud
e TB
pa
tien
ts
in
IGA
s
in
17
coun
ties
m
ost
affe
cted
by
m
alnu
trit
ion
amon
g TB
pat
ient
s
30
Prop
orti
on o
f el
igib
le T
B pa
tien
ts r
ecei
ving
su
ppor
t th
roug
h m
onth
ly c
ash
tran
sfer
Supp
ort t
he in
clus
ion
of T
B pa
tien
ts
in
cond
itio
nal
cash
tr
ansf
er
sche
mes
Inve
ntor
y co
ndit
iona
l ca
sh
tran
sfer
pro
gram
s an
d ac
cess
by
TB
pati
ents
Prom
ote
incl
usio
n of
TB
pati
ents
in
co
ndit
iona
l ca
sh
tran
sfer
pr
ogra
ms
(sta
keho
lder
m
eeti
ngs
and
targ
eted
ad
voca
cy
in
10
coun
ties
)
10Pr
omot
e in
clus
ion
of T
B pa
tien
ts i
n co
ndit
iona
l ca
sh t
rans
fer
prog
ram
s (s
take
hold
er m
eeti
ngs
and
targ
eted
ad
voca
cy in
15
coun
ties
)
25Pr
omot
e in
clus
ion
of T
B pa
tien
ts i
n co
ndit
iona
l ca
sh t
rans
fer
prog
ram
s (s
take
hold
er m
eeti
ngs
and
targ
eted
ad
voca
cy in
20
coun
ties
)
50
Prop
orti
on o
f el
igib
le T
B an
d pr
esum
ptiv
e TB
cas
es r
ecei
ving
tra
nspo
rt v
ouch
ers
for
diag
nost
ic a
nd c
are
serv
ices
Supp
ort t
he in
clus
ion
of T
B pa
tien
ts
in t
rans
port
sch
emes
Inve
ntor
y tr
ansp
ort
reim
bu
rse
me
nt/
vo
uc
he
r pr
ogra
ms
and
acce
ss
by
TB
pati
ents
Prom
ote
incl
usio
n of
TB
pati
ents
in
tr
ansp
ort
vouc
her
prog
ram
s (s
take
hold
er
mee
ting
s an
d ta
rget
ed a
dvoc
acy
in 1
0 co
unti
es)
10Pr
omot
e in
clus
ion
of
TB
pati
ents
in
tr
ansp
ort
vouc
her
prog
ram
s (s
take
hold
er m
eeti
ngs
and
targ
eted
ad
voca
cy in
10
coun
ties
)
25Pr
omot
e in
clus
ion
of
TB
pati
ents
in
tr
ansp
ort
vouc
her
prog
ram
s (s
take
hold
er m
eeti
ngs
and
targ
eted
ad
voca
cy in
10
coun
ties
)
50
Esta
blis
h co
sts
incu
rred
by
pa
tien
ts
in
acce
ssin
g TB
dia
gnos
is a
nd t
reat
men
tRe
sarc
h on
co
sts
incu
rred
in
ac
cess
ing
Tb m
anag
emen
tRe
sear
ch
on
cost
s in
curr
ed
in
acce
ssin
g TB
man
agem
ent
Resa
rch
on
cost
s in
curr
ed
in
acce
ssin
g Tb
man
agem
ent
4.3.
9.4
Soci
al P
rote
ctio
n
4.4.1 Practical Approach to Lung H
ealth
4.4. Halt/Reverse Non–Communicable Diseases
4.4.1. Expand utilization of practical approach to lung health
1. Situational Analysis
In Kenya, respiratory disease conditions form 25% of outpatient morbidity1. Pneumonia accounts for 9% of hospital admissions, while tuberculosis contributes 2%. Summary data from public health facilities categorize respiratory tract conditions into pneumonia and tuberculosis, and ‘others.’ Among the causes of mortality in the Kenya population, pneumonia contributes 12% and tuberculosis 5.5%.
There are no population-based studies in Kenya that have examined the prevalence of asthma among all age groups or chronic obstructive pulmonary disease (COPD). These would be important to provide a baseline to measure the effects of implementing the Practical Approach to Lung Health (PAL) strategy. Kenya has participated in the International Studies of Asthma and Allergic Disease in Childhood (ISAAC) Phase 1 and 3 at two sites: Nairobi and Eldoret. The prevalence of wheeze in the past 12 months among 13-14 year old children in the ISAAC Phase 1 study carried out in 1995 was 17.1% and 10.4 % in Nairobi and Eldoret respectively2. In the ISAAC Phase 3 study of 2000, this prevalence had increased to 18% and 13.8 % in Nairobi and Eldoret respectively3. Based on the results of the ISAAC studies, it is estimated that about 10% of the Kenyan population, or nearly 4 million people, have asthma.
PAL aims at improving the quality of care for patients with respiratory conditions. The focus is patients treated in primary health settings with cough and are not diagnosed with tuberculosis.
The NTLD Program and partners have adopted the PAL strategy to address lung health issues comprehensively and to improve the case management of TB, especially at the primary health care level. The PAL strategy is also expected to contribute to health system strengthening for TB and lung health. The Kenyan PAL strategy focuses on the following diseases: TB, asthma, COPD, acute respiratory illness, and TB/HIV.
PAL was initiated in 2011 with the formation of a national task force comprising of members from the TB program, KAPTLD, KEMRI, WHO and community representatives. A step-wise approach to PAL implementation was adopted as outlined below:
a) Obtaining political commitment
b) Preliminary assessment aimed at determiningi. Potential challenges for PAL implementation in Kenyaii. Opportunities for PAL implementationiii. The country’s capacity to implement PAL.
c) Development and adoption of guidelines and M&E tools
d) Adoption/review of existing training material and development of a core group of trainers and researchers at the national and county level
e) Piloting PAL implementation in one county
f) Evaluation of the pilot at 6 months, followed by phased scale-up to other counties.
Several challenges hindered this process and much of what was planned was not done. The main challenge was limited funds. To date, the following has been achieved:
134
a) A national focal person for PAL implementation was identified and two trainers were trained by the South African PALSA program, the pioneer in Africa on PAL implementation
b) PAL guidelines, training materials and educational materials were adapted from the PALSA program
c) Asthma registers and patient management cards were developed and printed
The following gaps currently exist in PAL implementation:
a) An evaluation of the first phase of PAL implementation has not been conducted and it is difficult to tell if the trained TB distrct managers cascaded the training to primary health care workers
b) The national team has not been sufficiently trained on PAL to support the roll-out of the strategy
c) The PAL TWG has not been consistent in convening to provide strategic direction to implementers
d) There is an inadequate supply of essential equipment and commodities to support diagnosis and treatment at the health facilities
e) There is no defined M&E plan for the PAL strategy.
Most of the existing processes need to be sustained and improved to enhance detection and efficient management of the chronic lung illnesses in all health facilities. In addition, there are opportunities for improvement and scale-up of the PAL strategy. They include:
a) Ensuring political commitment among the county governments and stakeholders
b) Advocating for resource allocation for implementation of PAL from the county and national governments, private sector and the donor community
c) Mapping of partnerships and resources from organisations and institutions with common interests for leveraging
d) Dissemination of PAL policy documents and guidelines
e) Establishing coordination mechanisms for PAL implementation at the county level, while strengthening the exisiting structures at national level
2. Strategic Directions 2015-2018
For PAL implementation to be effective in Kenya, three main areas need to be prioritized, namely,
a) Strengthen coordination mechanisms at the national level and establish coordination structures at the county levels b) Establish the burden of respiratory diseases in Kenya and develop a robust respiratory disease surveillance systemc) Assess the impact of the first phase of PALd) Scale-up PAL implementation, including procurement of necessary equipment and medicines, capacity building of
health care workers and strengthening referral systems for lung health.
3. Proposed Approaches
Strengthen coordination mechanisms at the national level and establish coordination structures at the County levels for the implementation of PAL. The following is proposed:a) Revamp the national PAL technical working group (TWG) and ensure regular quarterly meetingsb) Promote county forums with county management teams and stakeholders to establish political commitment for the
management of respiratory conditions through the PAL strategy in the countiesc) Advocate for the formation of county TWGs on PALd) Mapping of partnerships and resources from organisations and institutions with common interests for leveraginge) Provide technical assistance through identified Centers of Excellence - either public or private.
Establish the burden of respiratory diseases in Kenya and develop a robust respiratory disease surveillance systema) Conduct baseline population based survey on the burden of lung diseases defined in the Kenya PAL strategyb) Complete assessment of the impact of the first phase of PAL implementation
_______________________________________________________________________________________________________________________________1 Ministry of Health report, 2009, Kenya2 The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variations in the prevalence of asthma symptoms: the International Study of Asthma and Allergies in Childhood (ISAAC). Eur Respir J 1998; 12: 315 – 335. 3 Ait-Khaled N, Odhiambo J, Pearce N, Prevalence of symptoms of asthma, rhinitis and eczema in 13- to 14-year-old children in Africa: the International Study of Asthma and Allergies in Childhood Phase III. Allergy. 2007 Mar; 62(3): 247-58.
4.4.
1 Pr
acti
cal A
ppro
ach
to L
ung
Hea
lth
135
4.4.1 Practical Approach to Lung H
ealth
c) Introduce cough registers at the out-patient departments (OPDs) to enable tracking of all patients/clients with respiratory illnesses
d) Establish a surveillance system on PAL i. Develop an M&E plan for PALii. Disseminate recording and reporting tools iii. Include PAL indicators in the TIBU system and streamline the reporting system with the other disease areas.
Scale-up PAL implementation, including ensuring availability of necessary equipment and medicines, capacity building of health care workers and strengthening referral systems for lung health.
a) Capacity building of health care workers through:i. Training TOTs at the National and county levelii. Facilitating the TOTs to conduct regular health facility based on-the-job training iii. Recruiting a team of respiratory resource persons to conduct ongoing mentorship to the trained health care providersiv. Evaluation, retaining, mentoring and offering continuous technical assistance and CMEs in already established model
unitsv. Developing, printing and disseminating job aids, diagnostic algorithms and IEC materials for targeting community,
workplaces, health care providers informing them of triggers including biomass fuels and tobacco smokingvi. Developing an e-learning package for respiratory diseases with certification of health care providersvii. Sensitize county pharmacists on PAL commodities
b) Ensure availability of commodities required for PAL implementation in all the Counties by advocating for the inclusion of the following medicines in the essential drug package of all PHC facilities: antibiotics for community acquired pneumonia (CAP) and acute respiratory infections (ARIs), inhaled corticosteroids, inhaled bronchodilators, analgesics, antitussives and anticholinergics.
c) Ensure availability (or access) to diagnostic facilities and essential equipment for management of common lung conditions. These include:i. Radiological services: X-Ray equipment and training in radiology techniques, interpretation, quality control of chest
radiographs, radiation protection etc.ii. Essential medical equipment: Oxygen sources, pulse oximeters, nebulizers, peak flow meters with disposable mouth
pieces, spirometers and spacers
d) Develop model lung health units in the 47 counties to be used for mentorship and engage previoulsy trained TOTs. The health units will have a minimum package as outlined below:
• Trained personnel on PAL diseases• Equipment e.g. at least a peak flow meters with or without a spirometer, nebulizers, mouth pieces, spacers• Commodities: PAL drugs (Relievers and controllers)• M&E tools - Registers, Patient management cards, Appointment cards, Supervision tools, IEC materials
The following counties will be targeted for establishing these lung units in Year 1: Nairobi (Mbagathi and Mama Lucy Kibaki hospitals), Machakos county hospital, Nyeri county hospital, Kericho County Hospital, Coast County Referral Hospital, Kakamega County Hospital, Kisumu County Hospital, Kisii County Hospital, Garissa County Hospital, Isiolo County Hospital and Kitale County Hospital. These are former provincial and level 5 hospitals that have medical outpatient clinics (MOPC) running.
The lung health clinics will be integrated within the MOPCs on selected specific days. Lessons learnt from the established model clinics of year 1, will support the creation of other model lung health units in other counties on phased out implementation manner to cover all counties. We anticipate that on a yearly basis, additional 12 lung units will be established to increase county coverage.
e) Communication and advocacy strategy for PALi. Develop a communication strategy for lung health targeting the community, the patients and the health care workersii. Develop educational messages for respiratory patients and their familiesiii. Advocate for resource allocation for implementation of PAL from the government, private sector and the donor
communityiv. Advocate for multisectoral involvement in lung health in Kenya.
Ministry of Education1. Include PAL guideline in the training curricula for medical schools, public health schools 2. Introduction of PAL messages in primary and secondary schools
136
Ministries of Labor and Industry
1. Regulations for prevention of occupational related lung diseases e.g. cement factories, mining etc.2. Care of respiratory (communicable diseases) in congregate settings e.g. orphanages, prisons, street families
etc.
Disaster Preparedness and Management Units
1. Anticipation and planning for respiratory disease outbreaks in camps following disasters or population displacements
2. Planning for management of those with chronic illnesses in camps of displaced people.
Research Institutions
Non-Communicable Disease Department
Contribution to NSP Impacts Outcomes
Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014
• Increase case notification of new TB cases to 85% of estimated prevalence
Impact 5: Reduce morbidity due to chronic lung diseases • Reduce the average number of annual acute episodes for children with asthma by 15% in areas with established asthma clinics
• Increase to 80% the proportion of controlled asthma patients
Table 15: Impact and Outcome Indicators for PAL
4.4.
1 Pr
acti
cal A
ppro
ach
to L
ung
Hea
lth
137
4.4.1 Practical Approach to Lung H
ealth
Lung
Hea
lth
Ope
rati
onal
Pla
nO
utpu
t In
dica
tor(
s)In
terv
enti
on(s
)Y
ear
1 A
ctiv
itie
sY
r 1
Targ
etY
ear
2 A
ctiv
itie
sY
r 2
Targ
etY
ear
3 A
ctiv
itie
sY
r 3
Targ
etY
ear
4 A
ctiv
itie
sY
r 4
Targ
et
Stra
tegi
c A
ppro
ach
1: S
tren
gthe
n co
ordi
nati
on m
echa
nism
s at
the
nat
iona
l lev
el a
nd e
stab
lish
coor
dina
tion
str
uctu
res
at t
he C
ount
y le
vels
for
impl
emen
tati
on o
f PA
L
Num
ber
of P
AL
TWG
mee
ting
s he
ldRe
vam
p th
e N
atio
nal
PAL
tech
nica
l w
orki
ng g
roup
(TW
G)
Hol
d qu
arte
rly
TWG
m
eeti
ngs
2H
old
quar
terl
y TW
G m
eeti
ngs
4H
old
quar
terl
y TW
G m
eeti
ngs
4H
old
quar
terl
y TW
G m
eeti
ngs
4
Num
ber
of
mul
tise
ctor
al
cons
ulta
tive
br
eakf
ast
mee
ting
s he
ld A
dvoc
ate
for m
ulti
sect
oral
invo
lvem
ent
in lu
ng h
ealt
h in
Ken
yaH
old
mul
tise
ctor
al
cons
ulta
tive
br
eakf
ast
mee
ting
s
2H
old
mul
tise
ctor
al c
onsu
ltat
ive
brea
kfas
t m
eeti
ng1
Hol
d m
ulti
sect
oral
co
nsul
tati
ve
brea
kfas
t m
eeti
ng
1H
old
mul
tise
ctor
al
cons
ulta
tive
br
eakf
ast
mee
ting
1
Prop
orti
on o
f C
ount
ies
allo
cati
ng f
unds
for
PA
L im
plem
enta
tion
.C
ount
y fo
rum
s to
m
obili
ze
polit
ical
co
mm
itm
ent
and
reso
urce
mob
ilisa
tion
Hol
d m
eeti
ng w
ith
coun
ty
heal
th
man
agem
ent
team
s (1
2)
25%
Hol
d m
eeti
ng
wit
h co
unty
he
alth
man
agem
ent
team
s (4
7)50
%H
old
mee
ting
w
ith
coun
ty
heal
th
man
agem
ent
team
s (4
7)60
%H
old
mee
ting
w
ith
coun
ty
heal
th
man
agem
ent
team
s (4
7)75
%
Con
sult
ativ
e fo
rum
s w
ith
coun
ty s
take
hold
ers
1C
onsu
ltat
ive
foru
ms
wit
h co
unty
sta
keho
lder
s1
Con
sult
ativ
e fo
rum
s w
ith
coun
ty
stak
ehol
ders
1C
onsu
ltat
ive
foru
ms
wit
h co
unty
st
akeh
olde
rs1
Prop
orti
on o
f C
ount
ies
wit
h fu
ncti
onal
TW
Gs
Prov
ide
tech
nica
l as
sist
ance
to
coun
ty
TWG
s.Pr
ovid
e te
chni
cal
assi
stan
ce
to
coun
ty
TWG
s (1
2)
25%
Prov
ide
tech
nica
l as
sist
ance
to
coun
ty T
WG
s (4
7)50
%Pr
ovid
e te
chni
cal
assi
stan
ce
to
coun
ty T
WG
s (4
7)
75%
Prov
ide
tech
nica
l as
sist
ance
to
co
unty
TW
Gs
(47)
75%
prop
orti
on
of p
artn
ers
map
ped
part
icip
atin
g in
lung
hea
lth
Map
ping
of
part
ners
hips
for
PA
LH
old
a se
nsit
isat
ion
mee
ting
(n
atio
nal
brea
kfas
t m
eeti
ng)
for
map
ping
par
tner
s
20%
Hol
d a
sens
itis
atio
n m
eeti
ng
(nat
iona
l bre
akfa
st m
eeti
ng) f
or
map
ping
par
tner
s
40%
Hol
d a
sens
itis
atio
n m
eeti
ng
(nat
iona
l br
eakf
ast
mee
ting
) fo
r m
appi
ng p
artn
ers
60%
Hol
d a
sens
itis
atio
n m
eeti
ng (n
atio
nal
brea
kfas
t m
eeti
ng)
for
map
ping
pa
rtne
rs
75%
Stra
tegi
c A
ppro
ach
2: E
stab
lish
the
burd
en o
f re
spir
ator
y di
seas
es in
Ken
ya a
nd d
evel
op a
rob
ust
resp
irat
ory
dise
ase
surv
eilla
nce
syst
em
Nat
iona
l ba
selin
e da
ta
of b
urde
n of
lun
g di
seas
es a
vaila
ble
Con
duct
ba
selin
e po
pula
tion
ba
sed
surv
ey o
n th
e bu
rden
of
lung
dis
ease
sC
ondu
ct b
asel
ine
stud
yC
ondu
ct B
asel
ine
stud
y1
Nat
iona
l pla
n de
velo
ped
to a
ddre
ss b
urde
n of
lu
ng d
isea
ses
Base
d on
re
sult
s of
ba
selin
e su
rvey
, co
nven
e TW
G
and
deve
lop
mul
ti-
sect
oral
pla
n
Stak
ehol
der
mee
ting
s to
dis
sem
inat
e re
sult
s of
ba
selin
e su
rvey
; dr
aft
nati
onal
pl
an
wit
h C
ount
y in
volv
emen
t
2N
atio
nal
plan
fo
r ad
dres
sing
lu
ng
dise
ases
in
corp
orat
ed
into
C
ount
y he
alth
pla
ns
1
Nat
iona
l M
&E
plan
s an
d to
ols
for
PAL
surv
eilla
nce
avai
labl
eD
evel
op a
n M
&E
plan
and
too
ls f
or P
AL
Fina
lize
deve
lopm
ent
of
the
PAL
M&
E t
ools
and
pl
an
1
Num
ber
of o
f M
& E
too
ls a
nd p
lans
for
PA
L pr
inte
dPr
int
PAL
M&
E t
ools
Prin
t M
&E
tool
s (f
acili
ty
regi
ster
s,
man
agem
ent
card
s an
d ap
poin
tmen
t ca
rds
)
3,00
020
,000
20,0
00
Prin
t M
&E
tool
s (f
acili
ty
regi
ster
s,
man
agem
ent
card
s an
d ap
poin
tmen
t ca
rds
)
3,00
020
,000
20,0
00
Prin
t M
&E
tool
s (f
acili
ty
regi
ster
s,
man
agem
ent
card
s an
d ap
poin
tmen
t ca
rds
)
3,00
020
,000
20,0
00
Prop
orti
on o
f C
ount
ies
wit
h M
&E
wor
kpla
ns
and
tool
s D
istr
ibut
e PA
L re
cord
ing
and
repo
rtin
g to
ols
25%
Dis
trib
ute
PAL
reco
rdin
g an
d re
port
ing
tool
s 50
%
Dis
trib
ute
PAL
reco
rdin
g an
d re
port
ing
tool
s 75
%
Dis
trib
ute
PAL
reco
rdin
g an
d re
port
ing
tool
s 75
%
Prop
orti
on
of
Cou
ntie
s re
port
ing
on
PAL
thro
ugh
TIBU
Incl
ude
PAL
indi
cato
rs
in
the
TIBU
sy
stem
and
str
eam
lin
e th
e re
port
ing
syst
em
PAL
repo
rtin
g th
roug
h TI
BU s
yste
m25
%PA
L re
port
ing
thro
ugh
TIBU
sy
stem
50%
PAL
repo
rtin
g th
roug
h TI
BU s
yste
m75
%PA
L re
port
ing
thro
ugh
TIBU
sys
tem
75%
Stra
tegi
c A
ppro
ach
3: S
cale
-up
PAL
impl
emen
tati
on, i
nclu
ding
ens
urin
g av
aila
bilit
y of
nec
essa
ry e
quip
men
t an
d m
edic
ines
, cap
acit
y bu
ildin
g of
HC
Ws
and
stre
ngth
enin
g re
ferr
al s
yste
ms
for
lung
hea
lth
Num
ber
of N
atio
nal T
OTs
tra
ined
Trai
n 25
TO
Ts o
n PA
L at
the
Nat
iona
l le
vel
Trai
n na
tion
al T
oTs
on P
AL
25
Num
ber
of c
ount
y TO
Ts t
rain
ed o
n PA
LTr
ain
150
TOTs
at
coun
ty l
evel
(3
per
coun
ty) o
n PA
LTr
ain
Cou
nty
ToTs
on
PAL
150
00
0
Num
ber
of C
ount
y H
CW
s tr
aine
d on
PA
LC
ondu
ct P
AL
trai
ning
s in
the
cou
ntie
s 25
HC
Ws/
coun
ty t
rain
ed
in 1
2 co
unti
es30
025
HC
Ws/
cou
nty
trai
ned
in 3
7 co
unti
es87
525
H
CW
s/co
unty
tr
aine
d in
47
co
unti
es1,
175
25
HC
Ws/
coun
ty
trai
ned
in
47
coun
ties
1175
100
% o
f co
unti
es w
ith
IEC
mat
eria
lsD
evel
op jo
b ai
ds ,
diag
nost
ic a
lgor
ithm
s an
d IE
C m
ater
ials
for
PA
LD
evel
op
po
ster
s,
flye
rs
and
diag
nost
ics
algo
rith
ms
for
PAL.
Prin
t PA
L jo
b ai
ds ,
diag
nost
ic a
lgor
ithm
s an
d IE
C m
ater
ials
Prin
t 5,
000
post
ers,
50
,000
fl
yers
, 50
0 di
agno
stic
s al
gori
thm
s.
Prin
t 10
,000
pos
ters
, 10
0,00
0 fl
yers
, 1,
000
diag
nost
ics
algo
rith
ms.
Prin
t 10
,000
pos
ters
, 100
,000
fly
ers,
1,
000
Dia
gnos
tics
alg
orit
hms.
Pr
int
10,0
00 p
oste
rs,
100,
000
flye
rs,
1,00
0 D
iagn
osti
cs a
lgor
ithm
s.
Lung
Hea
lth
Ope
rati
onal
Pla
nO
utpu
t In
dica
tor(
s)In
terv
enti
on(s
)Y
ear
1 A
ctiv
itie
sY
r 1
Targ
etY
ear
2 A
ctiv
itie
sY
r 2
Targ
etY
ear
3 A
ctiv
itie
sY
r 3
Targ
etY
ear
4 A
ctiv
itie
sY
r 4
Targ
et
Dis
trib
ute
PAL
job
aids
, di
agno
stic
al
gori
thm
s an
d IE
C m
ater
ials
Dis
trib
ute
5,00
0 po
ster
s,
50,0
00
flye
rs,
500
diag
nost
ics
algo
rith
ms.
Dis
trib
ute
10,0
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4.4.
1 Pr
acti
cal A
ppro
ach
to L
ung
Hea
lth
4.5.1 IPC, Contact Tracing and IPT
4.5. Minimize Risk Factor Exposure
4.5.1. Prevent transmission and disease: infection prevention and control, contact tracing and Isoniazid preventive therapy
1. Situational Analysis
a) Infection Prevention and Control
Transmission of TB in congregate and health care settings remains a major problem in Kenya. Most of the health facilities in the country were designed to serve smaller populations than they currently handle, and without much attention to TB prevention. It is estimated that one untreated infectious TB patient will infect 10 people each year. Thus, the high volume of infectious TB patients visiting the facilities makes them a fertile transmission setting.
Kenya developed TB infection prevention and control guidelines in 2009, followed by sensitization and training of high volume facilities. However, the country still lacks data on the extent of spread of TB in health care and other congregate settings. Moreover, TB surveillance is not specifically done for these settings, save for prisons. Health care workers suffer more than three times the national TB burden. Studies conducted in Eastern and Nairobi regions in 2012 and 2013 revealed a TB case notification rate of greater than 800/100,000 population1.There is thus an urgent need to redefine and address national IPC priorities.
Structured TB Infection prevention and control (IPC) implementation commenced in 2009 with the establishment of national coordination at NTLD Program and identification of a focal person. The national TB infection control policy materials and a training curriculum including a health facility TB infection control assessment tool were developed. Training on TB infection control of selected members of hospital staff from 254 health facilities drawn from across the county was done with national leadership, followed by development of IPC plans. The extent and result of the implementation of these plans are however unknown. Additionally, implementing partners have trained staff and supported some sporadic implementation of IPC activities, though MOH ownership has generally been lacking. IPC practices in the country have generally been disjointed, inconsistent, and poorly implemented or non-existent in most health facilities.
Majority of the health facilities in Kenya have not sustained the implementation of TB IPC activities. This sub-optimal IPC implementation has allowed nosocomial transmission of TB to continue. Owing to the nature of most health facilities, significant amount of resources are needed for infrastructural modification to attain the required standards. There is therefore need to engage partners in TB control to ensure that prevention of TB transmission in health facilities is made a priority and adequate resources are allocated. Further opportunities lie in integrating the TB IPC activities into existing general infection control practices to leverage on available resources as well as engagement of county governments and other stakeholders in development of a standard for construction of TB IPC compliant facilities.
Opportunities to leverage on in expanding contact investigation and management include availability of WHO guidelines that can be adapted locally, and availability of successful pilots locally that can inform expansion plans. These pilots have tools and registers that can also be adapted nationally. Gaps include lack of policy, guidelines and tools for contact investigation and management, as well as limited financial resources for scale-up. These gaps need to be addressed.
b) Contact Tracing
Active TB case finding among contact TB patients has been demonstrated to yield a high number of active and Latent TB cases. In 2013, Kenya notified a large number of infectious TB cases, including 34,643 smear positive PTB and 285 MDR-TB. Some 7,403 childhood TB cases were also notified. National guidelines recommend investigation and management of household contacts of all smear positive PTB and DR TB cases. While the guidelines are silent on screening household contacts of children index TB cases, new evidence recommends this. There is no national data on contact tracing, including the number of eligible contacts for screening, as well as number or proportions screened and their outcomes. Kenyan studies suggest that each adult TB index patient has 0.41 household contacts aged less than 5 years, in addition to older children and adults who would benefit from screening.
Implementation of TB contact tracing in Kenya is largely unstructured and lacks official tools and registers. The services are
_______________________________________________________________________________________________________________________________
1 D. Guwatudde, M. N., E. C. Jones-Lopez, A. Maganda, A. Chiunda, R. D. and J. J. E. Mugerwa, G. Bukenya, and C. C. Whalen (2003). “Tuberculosis in Household Contacts of
Infectious Cases in Kampala, Uganda.” American Journal of Epidemiology 158(9).
140
While WHO has issued guidance on contact investigation, national guidelines recommend screening of contacts of infectious TB, including MDR-TB, but do not describe how this should be done. Also, tools to support this, including registers, are not available. Kenya pediatric TB guidelines, while describing what should be done for children less than five years old (IPT for those without TB), do not describe what method of screening should be carried out, and are silent on recommendations for older children. This lack of clear guidance has resulted in very little contact investigation as established during the MTR. It was not routinely carried out at most health facilities. This therefore constrains efforts to identify new TB cases early and to issue Isoniazid Preventive Therapy (IPT) to minimize TB incidence among asymptomatic contacts.
Opportunities to leverage on in expanding contact investigation and management include availability of WHO guidelines that can be adapted locally and availability of successful pilots locally that can inform expansion plans. These pilots have tools and registers that can also be adapted or adopted nationally. Gaps include lack of policy, guidelines and tools for contact investigation and management, as well as limited financial resources for scale-up. These gaps need to be addressed.
c) Isoniazid Preventive Therapy (IPT)
By end of April 2014, 615,621 PLHIV and 61,588 CLHIV were on ART in Kenya. Guidelines recommend routine screening for TB among PLHIV and placement on IPT for those who are asymptomatic. Of PLHIV screened for TB, 80% will screen negative, hence are eligible for IPT. Among children less than five years who are household contacts of patients with smear positive PTB, 10% are likely to have secondary TB, hence 90% will be eligible for IPT. Despite these figures of persons eligible for IPT, only 600 children aged less than five years exposed to smear positive PTB and approximately 5,600 PLHIV, including CLHIV were initiated on IPT in 2013, according to the TB health information system TIBU.
While the current policy provide for IPT for children less than 5 years exposed to PTB+ and PLHIV, the uptake is low. Implementation is scanty, particularly for PLHIV. It varies greatly, depending on implementing partners’ support. The MTR found the uptake of IPT to be very low everywhere, with almost universal unavailability of IPT registers and tools. A skills gap was identified among HCWs in use of IPT, and many still had misconceptions that IPT would result in development of DR TB strains. Guidelines on IPT use, while existent, were not available at facilities, and job aids were missing. The MTR further found that while ICF for PLHIV uptake was good (82% of PLHIV screened), uptake of IPT was quite low with only 2% of those eligible on it.
Opportunities to support IPT use include the current TB and HIV policies and guidelines that provide for IPT, creating an enabling policy environment for implementation and scale-up. Further, there have been successful pilots of IPT implementation, from which best practices and lessons can be shared and which can host exchange programs. Many of these pilots have also embedded continuous quality improvement plans in their implementation, which can be adapted during scale-up. The recent increase in interest and willingness to support IPT from development and implementing partners also serves as an opportunity to scale-up. Gaps include less than optimal TB/HIV coordination at national and county levels; inconsistent IPT commodity availability; and knowledge, skill and attitude gaps, both among service providers and managers.
4.5.
1 IP
C, C
onta
ct T
raci
ng a
nd IP
T
carried out in an ad hoc manner, with great variation across the country. While guidelines provide for contact tracing for children under 5 years of age exposed to smear positive TB, this is poorly done in some cases, with only 1% being screened. National guidelines are silent on tracing of contacts of index pediatric TB cases. The midterm review found that contact investigation and management is not routinely practiced at most health facilities, with most staff not convinced of the benefits of contact management. There was particular concern that IPT might result in development of resistant strains of TB.
141
4.5.1 IPC, Contact Tracing and IPT
Strategic Direction(s) for 2015-2018
a) Intensifying early case finding through structured contact tracing. b) Scale-up of IPT with a focus to reach all eligible PLHIV and children exposed to PTB+.c) Accelerate the operationalization of infection control plans, starting in high-volume facilities
3. Proposed Approaches
a) Mainstream IPT, IPC and CT into the core functions, guidelines and tools of the NTLD Programi. Revise and disseminate guidelines on CT, IPT and IPC ii. Incorporate aspects of IPC, CT and IPT into all other capacity building and supportive supervision activities of the
NTLD Program. Update TIBU to capture activities related to CT, IPT and IPC.
b) Scale up successful models of IPT for PLHIV and for children in contact with active TB casesi. Ensure INH commodity security, including pediatric formulationsii. Assess provider beliefs and willingness to provide IPT; revise communications and training materials to directly
address misconceptionsiii. Identify and engage centers of excellence for IPT to conduct on-site mentorship and training for new sites. Prioritize
IPT delivery among high-risk populations, such as counties with >5% HIV prevalence in the general population and low ART coverage.
c) Scale-up successful models of contact investigation and management.
i. Sustain ICF and CT efforts in HIV care and treatment settings; and pilot the extension to ICF and CT activities to schools and congregate settings
ii. Expand and intensify contact tracing to cover all household and other close contacts of patients with PTB+, DR TB, pediatric TB (index patients), and leprosy
iii. Establish and roll-out structure contact tracing including guidelines detailing which index cases require contact tracing, steps for conducting contact tracing, dissemination of tools.
d) Operationalize the Infection Prevention and Control plans existing and national and sub-national levels, and expand to other settings:i. Integrate TB IPC in general IPC committees at facilitiesii. Develop and implement TB and TB/HIV work place policies to promote infection control iii. Leveraging on other ministries e.g. housing, to embed IPC in planning policiesiv. Allocate resources for health facility infrastructural improvement especially at county level (starting with high
volume facilities).
142
Contribution to NSP Impacts Outcomes (IPT, IPC and CT)
Impact 1: Reduce the incidence of TB by 5% by 2018, compared to 2014
• 75% of all health facilities providing TB services are implementing an infection control strategy
• Increase to 80% the proportion of eligible child contacts who receive IPT
• Increase to 80% the proportion of eligible persons who receive INH
Impact 1.1: Reduce the prevalence of MDR-TB among new patients by 15% by 2018
Increase to 100% the child and other close contacts of DR TB patients who are screened for TB
Impact 1.2: Reduce the incidence of TB among PLHIV by 60% by 2018, compared to 2014
Increase to 80% the proportion of eligible PLHIV who receive IPT
Table 16: Impact and Outcome Indicators for IPT, IPC and CT
4.5.
1 IP
C, C
onta
ct T
raci
ng a
nd IP
T
_______________________________________________________________________________________________________________________________
2 D. Szkwarko, F. O., P. Owiti, E. J. Carter (2013). “Implementing a tuberculosis child contact register to quantify children at risk for tuberculosis and HIV in Eldoret, Kenya.” Public Health
Action 3(3).
3 WHO (2007 ). Tuberculosis: fact sheet no. 104. accessed at: http://www.who.int/mediacentre/factsheets/fs104/en/index.html
4 E. Masini and J.Kangwele(2012).Tuberculosis among public health facility satff in Eastern Province,Kenya.Poster presentation at the World Lung Health Conference in Kuala Lumpur
Malaysia.PC 275-16 pg 235.
5 E. Wahome,1 L. Makori,1 M. Gikera,1 J. Wafula,1 J. Chakaya,2 M. E. Edginton,3 A. M. V. Kumar(2013). Tuberculosis treatment outcomes among hospital workers at a public teaching
and national referral hospital in Kenya. Public Health Journal. Vol 3 no 24 pg 323-327.
143
4.5.1 IPC, Contact Tracing and IPT
CHAPTER 5
RESOURCE IMPLICATIONS FOR THE NTLD PROGRAM STRATEGIC PLAN 2015 – 2018Introduction
Health financing provides resources and economic incentives for the operation of health systems. It is a key determinant of health system performance in terms of equity, efficiency, and health outcomes. Health financing also involves providing individuals with a basic package of benefits that is designed to improve health outcomes and ensure financial protection. Health system sustainability has been defined as the “capacity of the health system to replace withdrawn donor funds with funds from other, usually domestic, sources”. Additionally, sustainability of an individual program is defined as the “capacity of the grantee to mobilize the resources to fund the recurrent costs of a project once it is terminated1”.
Evidence shows that higher levels of out of-pocket financing in the health system are correlated with greater incidence of catastrophic payments2. Kenya has over 45% of its population living below the poverty line, with a large share treating financing health care as out-of-pocket expenditure3. Countries with high levels of out-of-pocket spending have limited opportunities for risk pooling, which hinders allocative efficiency and financial protection efforts. Moreover, low overall spending levels result in limited access to essential services and limited financial protection, particularly for the poor. This has resulted in huge inequities in access to health care. Therefore, a reform of the existing health care system by restructuring it to create universal access to health care service is needed.
Preventing individuals from falling into poverty because of catastrophic medical expenses and protecting and improving the health status of individuals and populations by ensuring financial access to essential public and personal health services, provides strong basis for public intervention in financing health systems. Ensuring financial protection means that no household spends so much on health that it falls into and cannot overcome poverty. Achieving adequate levels of financial protection requires maximizing prepayment for insurable health risks; achieving the largest possible pooling of health risks within a population, thereby facilitating redistribution among high and low-risk individuals; ensuring equity through prepayment mechanisms that redistribute costs from low to high-income individuals; and developing purchasing arrangements that promote efficient delivery of good quality services.
This chapter assesses the health financing policy in the fight against Leprosy, Tuberculosis and Lung diseases in Kenya. It analyzes the basic financing challenges facing the NTLD Program as a result of revenue mobilization constraints. The chapter describes in detail, the level of resource requirements for the period of the strategic plan, the available resources and the funding gap. It further sets out likely future costs for some of the key strategies being considered as part of the NSP 2015 to 2018.
Resource Requirements
The Strategic Plan was costed using the Input-Based Costing (IBC) approach. The IBC uses a bottom-up input-based approach, indicating the cost of all inputs required to achieve NSP targets for the financial years of 2014/15 – 2017/18. Over time the rest for all the thematic areas provides important details that will initiate debate and allow the NTLD Program management and development partners to discuss priorities and decide on effective resource allocation. The aim of the costing review is to provide a broad framework on resource requirements as a means of informing donor and government allocations in support of its implementation.
_______________________________________________________________________________________________________________________________ 1 Knowles, Leighton, and Stinson (1997, 39)
2 Xu et al. 2003; van Doorslaer et al. 2005
3 Republic of Kenya, Ministry of Health, National Health Accounts (NHA), 2009/10 indicated that households financed 26 percent of the Total Health Expenditure (THE) for Tuberculosis and Lung diseases.
144
Available Resources (FY 2014/15 – 2017/18)
In the 2001 Abuja Declaration on HIV/AIDS, TB, and other related infectious diseases, African leaders pledged to increase health spending to 15 per cent of their government’s budgets.
The national government’s total budget and the amount allocated to health is usually public information and can be used to evaluate the government’s commitment to health. Information on government health expenditure channeled through the Ministry of Health is usually available through the National Treasury. The global funds have also added a new dynamic to global health policy and a new level of influence over developing countries.
The starting point for estimating available resources is based on budgets and budget projections. These reflect the total amount of available resources. The analysis was done for a four-year period, starting from 2014/15 to 2017/18. Both the Government as well as development partners have planned to commit a total of KES 6.3 Billion to support the NTLD Program for the period of the NSP as shown in the table below.
FY 2014/2015 FY 2015/2016 FY 2016/2017 FY 2017/2018 TOTAL
Source(s) Available Available Available Available Available
Government 1,146,960,426 1,146,960,426 1,146,960,426 1,146,960,426 4,587,841,704
Loans - - - -
Global Fund 736,143,801 680,408,295 - - 1,416,552,096
Other Grants 150,576,816 150,576,816 - - 301,153,632
TOTAL (KES) 2,033,681,043 1,977,945,537 1,146,960,426 1,146,960,426 6,305,547,432
Table 18: Available Resources by Source(s)
According to the Input-Based Costing, the NTLD Program requires KES 26.9 billion for the plan period in order to achieve its targets. This has further been disaggregated by thematic areas as shown in the table below.
Thematic Area (s) FY 2014/2015 FY 2015/2016 FY 2016/2017 FY 2017/2018 TOTAL
Requirement Requirement Requirement Requirement Requirement
TB HIV 475,551,250 501,374,000 476,950,000 275,470,000 1,729,345,250
Childhood TB 163,852,875 722,582,900 690,015,375 631,675,800 2,208,126,950
Lab 414,898,720 365,053,700 369,283,700 359,451,920 1,508,688,040
Leprosy 74,085,200 111,664,000 96,974,000 96,974,000 379,697,200
M & E 325,625,800 712,809,501 314,879,200 336,293,375 1,689,607,876
PAL 107,760,500 266,689,750 257,750,750 197,750,750 829,951,750
Social Protection 658,795,000 656,823,000 652,940,000 662,326,000 2,630,884,000
Commodity 2,018,546,661 1,543,463,842 2,273,678,230 1,775,131,636 7,610,820,369
PPM 51,630,000 113,369,100 115,630,100 115,630,100 396,259,300
Gender 155,759,250 168,397,000 157,580,000 116,227,000 597,963,250
Community Engagement 764,415,000 904,406,250 821,777,250 772,037,250 3,262,635,750
CORE TB 720,881,462 884,040,152 887,167,462 738,620,652 3,230,709,728
Policy and Planning 41,431,200 46,368,200 46,368,200 81,368,200 215,535,800
Communication and Advocacy 222,239,500 140,406,250 157,419,750 143,836,750 663,902,250
PMDR TB 83,637,500 267,485,500 249,373,250 256,231,000 856,727,250
TOTAL (KES) 6,275,476,518 7,401,299,745 7,564,153,867 6,555,391,033 27,796,321,163
Table 17: Resource Requirements by Thematic Area(s)
145
Funding Gap (FY 2014/15 – 2017/18)
This section analyzes financial requirements to achieve the targets outlined in this strategic plan and the available resources. It presents the funding shortfall for the NTLD Program over the NSP period. This involves two steps. First, the use of costing estimates to compute the resource requirements, and secondly, consolidating the available resources and thereafter computing the funding gap for the NTLD Program.
The identification of the funding gap provides an opportunity for potential stakeholders to see when additional resources will be most useful. Overall, the NTLD Program has a funding gap of KES 20.6 Billion over the NSP period of FY 2014/15 to 2017/18 as shown in the table below. The funding gap presents the financing that other stakeholders in the health sector need to come on board and fill.
FY 2014/2015 FY 2015/2016 FY 2016/2017 FY 2017/2018 TOTAL
4,241,795,475 5,423,354,208 6,417,193,441 5,408,430,607 21,490,773,731
Table 19: Funding Gap
Recommendations
A good financing system raises adequate funds for health in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for these services. It provides incentives for providers and users to be efficient4.
The above findings show that funds are likely to be insufficient, thus, there will be need to mobilize more funds from both internal and external sources in order to bridge the funding gap. Actions that need to be taken to mobilize resources include, but are not limited to the following:
• Engage and strengthen the private sector through the Public-Private Partnership (PPP)• The existing PPP model for creation of health post will be strengthened and other areas of the health sector where PPP
can be applied will be explored• Improve financial management• Increase capacity of community health workers’ cooperatives in financial management and mobilize them to investment
in health• Explore all opportunities for grants• Build the capacity in proposal writing and grant application• Sustain and improve performance in grant management• The need to select priorities for funding such as sustaining the high-impact interventions.
Recommendations from the Mid-Term Review
The policy recommendations emanating from the MTR were broadly classified into five (5) thematic areas:
1. Inadequate fiscal space to finance health2. Improving efficiency of sector outlays3. Re-prioritizing spending (within the existing budget)4. Increasing public investments in health5. Improving access to health services.
From the review, the following recommendations have been proposed for the NTLD Program in order to mitigate the financing challenges:
i. The Constitution of Kenya 2010 hints on avenues of financing:a. Apart from direct budgetary allocations at both national and county levels, additional resources can be secured
from the national government’s share of revenue
b. There is need to develop a national and county specific financing strategy to take full advantage of the new public financing opportunities
ii. Intensify advocacy for increased and dedicated national and county level budget allocations
_______________________________________________________________________________________________________________________________4 World Health Organization, 2007: Everybody’s business: Strengthening health systems to improve health outcomes –WHO’s Framework for Action
146
iii. Continue country dialogue on planning and udget process and bring more players on board (where applicable)
iv. Fill the financing gap through supply and demand-side financing
a. Increase availability of services by scaling up health financing innovationsb. Reduced HH out-of-pocket expenditures by expanding the SHI to include more basic and essential services
v. Donor harmonization or alignment among donors in order to reduce fragmentation in financing and service provision (e.g. gains by HS integration, donor pooling)
vi. Work with MOH and Treasury to develop a framework for disbursing conditional grants
vii. Rationalize expected impact outcomes and intervention objectives to match budgets
viii. Annual budget review of NSP to address emerging issues and allow flexibility within budgets for re-allocation
ix. Enhance absorptive capacity through building capacity in the areas of financial management, supply chain management and simplification of the reporting system
x. Promote and monitor programs within county health plans
xi. Leprosy and Lung Disease finance profiling
xii. Establishing linkages between the current social protection strategy and the NTLD Program
xiii. Enhance partnering with the private health sector.
147
ANNEXES
148
ANNEX 1: NSP Writing Team
NAME ORGANIZATION NAME ORGANIZATION
JOY MUTHONI ALP HILLARY CHEBON MOH - HQ (CHSU)
ULO BENSON AMREF HEALTH AFRICA JOYCE MUTHUURI MOH - HQ (GENDER MAINSTREAMING)
MAGDALENE MANG’UT AMREF HEALTH AFRICA KIOGORA GATIMBU MOH - ISIOLO
MARGRET MBURU CDC THOMAS OGARO MOH - NAIROBI
HERMAN WEYENGA CDC WARIARA MUGO MSF
ALICE WAIRIA TB ARC, CHS BEATRICE KIRUBI MSF
JOHN NJENGA TB ARC, CHS CHARLES NJUGUNA MSH
BRENDA MUNGAI TB ARC, CHS PHILIP OWITI MTRH - AMPATH
LORRAINE MUGAMBI – NYABOGA CHS BERNARD MWAURA NACC
KADONDI KASERA CHS SUSAN GACHERI NTLD – PROGRAM
CHRISTY HANSON CHS ANNE KATHURE NTLD – PROGRAM
JANICE NJOROGE CHS RICHARD MUTHOKA NTLD – PROGRAM
RUTH WANJALA TB ARC, CHS MASINI ENOS NTLD – PROGRAM
SHEILLA CHEBORE TB ARC, CHS WESLEY TOMNO NTLD – PROGRAM
ROSE WANDIA TB ARC, CHS NEWTON ANG’WA NTLD – PROGRAM
KINYANJUI SAMUEL TB ARC, CHS JACKSON KIOKO NTLD – PROGRAM
DAVID NJUGUNA CHS ROSE WAMBU NTLD – PROGRAM
FRIDA NJOGU - NDONGWE CHS SAMUEL MISOI NTLD – PROGRAM
CECILIA MWANGI TB ARC, CHS FAITH NGARI NTLD – PROGRAM
HELLEN KALILI CHS CHRISTINE WAMBUGU NTLD – PROGRAM
JOSEPH SITIENEI DCDPC SYLVIA KOECH NTLD – PROGRAM
JESSE WAMBUGU FIND LANGAT BERNARD NTLD – PROGRAM
MAUREEN SYOWAI ICAP KENYA PAMELA JUMA NTRL
GRACE GITONGA KAPTLD RONALD NG’IELA TB ARC, PATH
SAMMY ARITHI KAPTLD OBY OBYERODHYAMBO TB ARC, PATH
ALLAN MALECHE KELIN SUSAN KWAMBOKA TAC
JANE ONG’ANG’O KEMRI LUCY CHESIRE TAC
HEATHER NJUGUNA KEMSA MAURICE MAINA USAID
JOHN MUCHIRI MOH JOEL KANGANGI WHO
PAUL LODI MOH – BUNGOMA HILLARY KIPRUTO WHO
149
ANNEX 2: Stakeholder Meeting Participants
NAME SEX DESIGNATION COUNTY ORGANIZATION
1 A. GIRO TUTU M CTLC ISIOLO MOH - ISIOLO
2 ABDILLE NUR FARAH M CTLC GARISSA MOH - GARISSA
3 ABDULKARIM ZUBERI M CTLC LAMU MOH - LAMU
4 ABRAHAM KIMUTAI M CTLC BARINGO MOH - BARINGO
5 AGATHA MANDU F TB TECHNICAL ADVISOR KISUMU APHIA PLUS NYANZA WESTERN
6 AGERE EGO M CTLC NAKURU MOH - NAKURU
7 AIBAN RONO M M&E OFFICER NAIROBI NTLD - Program
8 ALFRED CHENGWI M CMLC BUNGOMA MOH - BUNGOMA
9 ALFRED KIVISHA M CTLC TRANS NZOIA MOH - TRANS NZOIA
10 ALICE TEBES F CTLC NAKURU MOH - NAKURU
11 ALICE WAIRIA F M & E OFFICER NAIROBI TB ARC, CHS
12 ALWYN KIMALEL M ADMINISTRATION NAIROBI NTLD - Program
13 ANASTASIA MAKENGE F SCMO NAIROBI MOH - NAIROBI
14 ANDOLE MWALE M CTLC KAKAMEGA MOH - KAKAMEGA
15 APOLLO ODONGO M CTLC HOMA BAY MOH - HOMA BAY
16 BEATRICE KARIUKI F CMLC NAKURU MOH - NAKURU
17 BEATRICE KIRUBI F MEDICAL COORDINATOR NAIROBI MSF FRANCE
18 BEATRICE MUIA F CHIEF PHARMACIST KITUI MOH - KITUI
19 BEN KITOLE M SMLT KILIFI MOH - KILIFI
20 BENJAMIN ONYANGO M REGIONAL OFFICER NYANZA/WESTERN TB ARC, CHS
21 BENSON KITOLE M CMLC KILIFI MOH - KILIFI
22 BERNARD BOSIRE M CTLC BUSIA MOH - BUSIA
23 BERNARD LANGAT M PROGRAM OFFICER NAIROBI NTLD - Program
24 BERNARD MACKENZIE M CDH KWALE MOH - KWALE
25 BERNARD SAWE M CTLC ELGEYO MARAKWET MOH - ELGEYO MARAKWET
26 BERTINA MORAA F INTERN NAIROBI NTLD - Program
27 BRENDA BARASA MAKHOHA F CDH KAKAMEGA MOH - KAKAMEGA
28 BRENDA MUNGAI F DEPUTY CHIEF OF PARTY NAIROBI TB ARC, CHS
29 CHAKAYA MUHWA M PHYSICIAN NAIROBI KAPTLD
30 CHARLES BEGI M US NAIROBI DPSM
31 CHARLES ODUOR M DM NAIROBI MOH - NAIROBI
32 CHRISTINE WAMBUGU F PROGRAM OFFICER NAIROBI NTLD Program
33 CHRISTY HANSON F CONSULTANT NAIROBI CHS - KENYA
34 CLAVER KIMATHI M CHIEF PHARMACIST ISIOLO MOH - ISIOLO
35 CONSOLATA WANGECHI F ADMINISTRATION NAIROBI CHS
36 DAVID MUGAMBI M SCMO NAIROBI NTLD - Program
37 DAVID MULEWA M CDH LAMU MOH - LAMU
38 DAVID MUREITHI M CTLC LAIKIPIA MOH - LAIKIPIA
39 DAVID MUSYA M CTLC TAITA TAVETA MOH - TAITA TAVETA
40 DAVID NYAMUHANGA M CTLC MIGORI MOH - MIGORI
41 DECHE SANGA M CTLC KILIFI MOH - KILIFI
42 DINAH ATIENO F CHIEF PHARMACIST BUNGOMA MOH - BUNGOMA
43 DOROTHY MIBEI F EPIDEMIOLOGIST NAIROBI NTLD - Program
44 DRUSILLA NYABOKE F EPIDEMEOLOGIST OFFICER NAIROBI NTLD - Program
45 DUNCAN BARKEBO M REGIONAL OFFICER ISIOLO TB ARC, CHS
46 ELIZABETH CHIRCHIR F CTLC KERICHO MOH - KERICHO
150
NAME SEX DESIGNATION COUNTY ORGANIZATION
47 EMILY KIBUCHI F PROGRAM MANAGER NAIROBI KANCO
48 EMILY NYAGAKI F A. MANAGER NAIROBI WOOF
49 ESTHER ONYANGO F CTLC KISUMU MOH - KISUMU
50 EUNICE KANANA F CTLC MERU MOH - MERU
51 EUNICE MAILU F M & E OFFICER NAIROBI NTLD - Program
52 EUNICE N. KIILU F SCTLC MACHAKOS MOH - MACHAKOS
53 EUNICE OMANYA M HIV/TB MANAGER NAIROBI APHIA PLUS
54 EZEKIEL KAPKURUI M CDH KAJIADO MOH - KAJIADO
55 EZRA KIPROTICH M TECHNICAL ADVISOR NAIROBI CDC
56 FAITH NGARI F PROGRAM OFFICER NAIROBI NTLD - Program
57 FELISTERS MUMA F CTLC NYAMIRA MOH - NYAMIRA
58 FRANCIS K. KIIO M CDH NAROK MOH - NAROK
59 FRANKLIN MWENDA M CTLC KIRINYAGA MOH - KIRINYAGA
60 GIBSON NYAMONGE M BD NAIROBI BD
61 GLORIA KAARI F ADMINISTRATION NAIROBI NTLD - Program
62 GODANA MAMO M REGIONAL OFFICER COAST TB ARC, CHS
63 GRACE GITONGA F NAIROBI KAPTLD
64 HASSAN HUSSEIN M CMLC GARISSA MOH - GARISSA
65 HASSAN IBRAHIM M REGIONAL MANAGER NAIROBI LANCET KENYA
66 HELLEN KALILI F PHARMACIST NAIROBI CHS
67 HENRY KANDIE M ACCOUNTANT NAIROBI NTLD - Program
68 HILLARY KIPRUTO M MEA NAIROBI WHO
69 HILLARY NDIEMA M CTLC UASIN GISHU MOH - UASIN GISHU
70 HIRAM MATHENGE M CTLC NYERI MOH - NYERI
71 HUSSEIN MOHAMMED M CTLC WAJIR MOH - WAJIR
72 J. K. THIONGO M CDH THARAKA NITHI MOH - THARAKA NITHI
73 JACK KIOKO M Program HEAD NAIROBI NTLD - Program
74 JACK MAGARA M CDH NYAMIRA MOH - NYAMIRA
75 JACOB NAKULEU M CTLC TURKANA MOH - TURKANA
76 JAMES GITONGA M CHIEF OFFICER MERU MERU
77 JAMES SEKENTO M PROGRAM OFFICER NAIROBI NTLD - Program
78 JANE ONG'ANG'O F CONSULTANT NAIROBI KEMRI
79 JESSE WAMBUGU M PROGRAM MANAGER NAIROBI FIND
80 JOEL GONDI M CDH MIGORI MOH - MIGORI
81 JOEL KANGANGI M WHO NAIROBI WHO
82 JOHN KANGWELE M SCTLC MAKUENI MOH - MAKUENI
83 JOHN KEMBE M SENIOR PROGRAM OFFICER NAIROBI MOF
84 JOHN NJENGA M M & E SPECIALIST NAIROBI TB ARC, CHS
85 JORAM SUNGUTI M SDA NAIROBI APHIAPLUS KAMILI
86 JOSEPH BETT M HIV/TB MANAGER KERICHO WRP
87 JOSEPH MUKOMA M CTLC MACHAKOS MOH - MACHAKOS
88 JOSEPH NJINJU M CTLC EMBU MOH - EMBU
89 JOSEPH SITIENEI M DIVISION HEAD NAIROBI DIVISION OF COMMUNICABLE DIS-EASE PREVENTION & CONTROL
90 JOSEPHINE MBURU F Program HEAD NAIROBI NTRL
91 JOSPHAT BETT M TBHIV COORDINATOR KERICHO WRP - KERICHO
92 JOY MUTHONI F PROGRAM OFFICER NAIROBI AIDS LAW PROJECT
93 JOYCE KIARIE F PROGRAM OFFICER NAIROBI NTLD - Program
94 JOYCE MUTHUURI F GENDER OFFICER NAIROBI MOH HEADQUARTERS
95 JUDITH OBOBE F M & E OFFICER NAIROBI NTLD - Program
151
NAME SEX DESIGNATION COUNTY ORGANIZATION
96 KADONDI KASERA M ASSISTANT CONSULTANT NAIROBI CHS
97 KANYI W. W. F CDH MURANG'A MOH - MURANG'A
98 KATHURE ANN F PROGRAM OFFICER NAIROBI NTLD - Program
99 KIMANI EVELYNE F CTLC KIAMBU MOH - KIAMBU
100 KIOGORA GATIMBU M PHARMACIST ISIOLO MOH - ISIOLO
101 KIPLAGAT KIPRUTO M CDH KERICHO MOH - KERICHO
102 KIRATHE DICKSON M IT NAIROBI NTLD - Program
103 KOMBO MOHAMMED M CEC HEALTH LAMU LAMU
104 LAMECK DIERO M AMPATH UASIN GISHU AMPATH
105 LILIAN KARIMI F CMLC MERU MOH - MERU
106 LINOY OKOTH M HIV/TB MANAGER NAIROBI APHIAPLUS
107 LUCY IRUNGU F CTLC MURANG'A MOH - MURANG'A
108 LUTOMIA MELSA F CDH BUSIA MOH - BUSIA
109 M. WANYEE F DIRECTOR KIAMBU MOH - KIAMBU
110 MAGDALENE MANGUT F PROGRAM OFFICER NAIROBI AMREF
111 MARGARET NYAMU F CH NAIROBI CHS
112 MARGRET MBURU F CDC NAIROBI CDC
113 MARK MAKOMERE M PHARMACIST NAIROBI ICAP
114 MARTHA MUTHONI F ADMS NAIROBI MOH HEADQUARTERS (HIS)
115 MARY J. WAMBURA F CTLC SIAYA MOH - SIAYA
116 MARY KARIUKI F SENIOR TECHNICAL ADVISOR NAIROBI PATHFINDER INTERNATIONAL
117 MARY OSANO F HAO NAIROBI MOH - NAIROBI
118 MARY SOME F CONSULTANT NAIROBI CHS
119 MASINI ENOS M PROGRAM OFFICER NAIROBI NTLD - Program
120 MATTHEW KYALO M CMLC KITUI MOH - KITUI
121 MAUREEN SYOWAI F HIV C&T ADVISOR NAIROBI ICAP
122 MAURICE MAINA M USAID NAIROBI USAID
123 MELBA KATINDI F PROGRAM OFFICER NAIROBI KELIN
124 MICAH CHEBURET M CTLC NAROK MOH - NANDI
125 MICHAEL NYACHAE M PHARMACIST MIGORI MOH - MIGORI
126 MICHAEL OWIGI M PSK NAIROBI PSK
127 MIURA TAKASH M LAB TECHNICAL ADVISOR NAIROBI JICA
128 MOLU HUKA M CDH ISIOLO MOH - ISIOLO
129 MUIA BEATRICE F CHIEF PHARMACIST KITUI MOH - KITUI
130 NDUTA WAWERU F PROGRAM OFFICER NAIROBI NTLD - Program
131 NEWTON ANGWA OMALE M PHARMACIST NAIROBI NTLD - Program
132 NG'IELA RONALD M TECHNICAL ADVISOR NAIROBI TBARC, PATH
133 NICHOLAS NJERU M CTLC THARAKA NITHI MOH - THARAKA NITHI
134 NOUH D. ABDILLAHI M CTLC MANDERA MOH - MANDERA
135 NYACHAE MICHAEL M CHIEF PHARMACIST MIGORI MOH - MIGORI
136 OBADIAH NJUGUNA M PROGRAM OFFICER NAIROBI NTLD - Program
137 OBY OBYERODHYAMBO M STRATEGIC COMMUNICATIONS NAIROBI PATH
138 OKOTU BORU M CTLC MARSABIT MOH - MARSABIT
139 OLGA MASHEDI F RESEARCH OFFICER NAIROBI KEMRI
140 OMONDI JOHN M CTLC KISII MOH - KISII
141 OWATTO H. OBBO M ACHP NAIROBI HPU
142 PAMELA JUMA F PROGRAM OFFICER NAIROBI NTRL
143 PAUL KIAGE M M&E OFFICER NAIROBI COMMUNICATIONS AUTHORITY OF KENYA
152
NAME SEX DESIGNATION COUNTY ORGANIZATION
144 PAUL LODI M CTLC BUNGOMA MOH - BUNGOMA
145 PAUL WEKESA M CEO NAIROBI CHS
146 PETER MULWA M SENIOR ECONOMIST NAIROBI MINISTRY OF LABOUR AND SOCIAL SERVICES
147 PHILIP MBITHI M CDH TRANSNZOIA MOH - TRANSNZOIA
148 PHILOMENA ATSIANYA F CTLC NYANDARUA MOH - NYANDARUA
149 PIUS KIOKO M CTLC KITUI MOH - KITUI
150 RACHEL MALOWA F PROGRAM OFFICER NAIROBI TAC
151 RAPHAEL GIKERA M PO NAIROBI AKMLSO
152 RICHARD KIPLIMO M M&E OFFICER NAIROBI NTLD - Program
153 RICHARD MUTHOKA M PROGRAM OFFICER NAIROBI NTLD - Program
154 ROSE BARAZA F SCTLC VIHIGA MOH - VIHIGA
155 ROSE MUTHEE F S.O. NAIROBI NTLD - Program
156 ROSE WAMBU F PROGRAM OFFICER NAIROBI NTLD - Program
157 ROSE WANDIA F ADVOCACY OFFICER NAIROBI TB ARC, CHS
158 RUTH WANJALA F COMMUNICATION OFFICER NAIROBI CHS
159 SALIM GARISE M CTLC TANA RIVER MOH - TANA RIVER
160 SALOME WANJOHI F HCM NAIROBI AAR
161 SAMMY ARITHI M PROGRAM OFFICER NAIROBI KAPTLD
162 SAMMY OSORE M CDH ELGEYO MARAKWET MOH - ELGEYO MARAKWET
163 SAMMY ROP M CTLC NANDI MOH - NANDI
164 SAMSON KIOKO M CTLC MOMBASA MOH - MOMBASA
165 SAMUEL BARGOTIO M CTLC WEST POKOT MOH - WEST POKOT
166 SAMUEL KINYANJUI M CHIEF OF PARTY NAIROBI TB ARC, CHS
167 SAMUEL MISOI M PROGRAM OFFICER NAIROBI NTLD - Program
168 SHEILLA CHEBORE F LAB TECHNICAL OFFICER NAIROBI TB ARC, CHS
169 SHOBHA N. VAKIL F TECHNICAL ADVISOR NAIROBI NASCOP - Program
170 SOLONKA PILIPILI M CTLC KAJIADO MOH - KAJIADO
171 SOME ELIAD M CONSULTANT NAIROBI CHS
172 STEPHEN MURAGE M CTLC SAMBURU MOH - SAMBURU
173 SULEIMAN MWATENGA M CMLC TAITA TAVETA MOH - TAITA TAVETA
174 SUSAN GACHERI F PO NAIROBI MOH- NAIROBI
175 SYLVIA KOECH F INTERN NAIROBI NTLD - Program
176 THOMAS OGARO M CTLC NAIROBI MOH - NAIROBI
177 TIMOTHY KANDIE M ICT OFFICER NAIROBI TB ARC, CHS
178 VALENTINE NGELESO F CHIEF PHARMACIST LAIKIPIA MOH - LAIKIPIA
179 VICTORIA NGENO F SCTLC BOMET MOH - BOMET
180 WALTER MUKHWANA M LFA NAIROBI PWC
181 WESLEY TOMNO M PO NAIROBI NTLD - Program
182 WILLIAM MURAAH M CEC HEALTH MERU MERU
183 WINNIE MIGWI F SMLT NAKURU MOH - NAKURU
184 Z. KARIUKI GICHUKI M CEC HEALTH NYANDARUA NYANDARUA
185 MAUREEN KAMENE F PROGRAM OFFICER NAIROBI NTLD - Program
186 KEVIN CAIN M KISUMU CDC
187 KHAIRUNISA SULEIMAN F PUBLIC HEALTH CONSULTANT
188 SIBUSISO HJATJWAKO M AERAS
189 EVANS AMUKOYE M DIRECTOR - CRDR NAIROBI KEMRI
190 ELIZABETH OBIMBO F PEDIATRIC PULMONOLOGIST NAIROBI UNIVERSITY OF NAIROBI
191 IRENE MUKUI F PROGRAM MANAGER NAIROBI NASCOP - Program
153
Printed with support from USAID through Tuberculosis Accelerated Response and Care (TB ARC)
For more informantion contact:
National Tuberculosis, Leprosy and Lung Disease Program P.O. Box 20781 - 00202, Nairobi
Email: [email protected]: www.nltp.co.ke