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ANNUAL TBTEAM MEETING

2013

ANNUAL TBTEAM MEETING 2013

Geneva, Switzerland | 13-14 June 2013

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Background

TBTEAM looks at how countries can secure resources for effective TB control and

spend them effectively. Currently both Global Fund secretariat and TBTEAM staff are in

the midst of a learning process, related to the Transition and New Funding Model of the

Global Fund.

Through the TBTEAM mechanism, WHO and technical partners are engaged in this

process in order to help countries access these essential resources and utilize them.

properly.

The Annual TBTEAM Meeting took place on the 13-14 June 2013 in the Executive

Board Room of the World Health Organization in Geneva.

The meeting took place at a crucial time when the Global Fund is finalizing its

rethinking of all processes related to the management cycle of country grants and at

the same time working on the introduction of the new funding model (NFM).

The participation and active engagement of several Global Fund staff provided the

opportunity for up-to-date presentations on the vision and process underpinning the

new funding model and on the technical assistance required in order to improve the

implementation and performance of existing grants. The presence of several Fund

Portfolio Managers, of in-country WHO staff and technical partners, and of donor

agencies that provide financial support to technical assistance, made all ensuing

discussions adherent to the situation in recipient countries.

The second day of the meeting focused specifically on the initial aspects of technical

support, from the epidemiological impact assessment to the preparation and

conduction of National TB Programme reviews and, finally, the development or

updating of National Strategic Plans (NSPs). Beyond these initial and major

commitments, technical support needs to unfold as a continuum along the life-cycle of

Global Fund grants.

This report summarizes the issues discussed, the main conclusions and final

recommendations of the meeting.

This report summarizes the issues discussed, the main conclusions and final recommendations of the meeting.

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Introduction

The Annual TBTEAM Meeting was opened by the Assistant Director-General of WHO

Dr Hiroki Nakatani and by the Director of the Global TB Programme, Dr Mario Raviglione

Dr Nakatani welcomed all TB Technical partners who are working together as part of the

TB TEchnical Assistance Mechanism (TBTEAM) to provide coordinated technical support

at country level as well all WHO regional and country TB staff. He remarked that The

Global Fund continues to be one of the most important sources of external funding for

national TB control programs. The strategy of the Global Fund has undergone a transition

that encourages more coordinated engagement of the Global Fund with technical

partners in supporting the countries to implement the grants.

The TBTEAM has been at the forefront of building and strengthening connections

between countries and partners, and specifically with the Global Fund to assist in

providing the best technical assistance for Global Fund-related grants. In order to support

their TB programs to express their needs and funding gaps, countries need robust

strategic plans, based on country reviews. The TB Technical support unit in WHO

facilitates the coordination of these activities globally. Strategic plans and funding gaps

are central to making a good case to a funding agency such as the Global Fund. The

Annual TBTEAM meeting is an important opportunity to bring TBTEAM partners together

meeting under the WHO umbrella, to discuss challenges and opportunities in reaching

our common goal to Stop TB.

Dr Raviglione observed that the TBTEAM mechanism is a fundamental and joint effort of

all agencies and donors providing technical support and its importance cannot be

overemphasized. TBTEAM activities need to be strengthened and intensified not only to

support ongoing grants that need to be closely monitored, but also to prepare national TB

Programmes for the Global Fund New Funding Model. However, the level of work with

Global Fund is increasing and requires contact and interaction on a daily basis. The extent

of this commitment is perhaps not always fully understood by partners. This requires

better communication, especially at the political level. This work will become even more

intensive with new Global Fund demanding processes and other technical agencies and

WHO staff at all levels need to be actively involved. Intensifying TBTEAM activity also

means increasing fund-raising. In this effort TBTEAM can count on an ongoing effective

collaboration with Global Fund colleagues, which has been extremely good, particularly

over the last two years. This is now a priority for the whole Global TB Programme.

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Progress since June 2012 and 2013 priorities

The review of the last 12-month activities was introduced by a demonstration of how

the TBTEAM website works.

The geographical distribution of technical assistance shows that AFRO has requested

41% of all TA missions, which have increased from 200 to 300 per year. SEARO has

organized a lot of internal mission (e.g. in India) and these are not yet reflected on the

website.

The main reasons to request TA include in the following descending order: Laboratory

strengthening; MDR-TB/XDR; M&E/impact measurement; drug commodities

management; TB programming planning and review/regional meetings; Global Fund

processes (proposal development, grant negotiation) and others.

TBTEAM overview

The focus of TBTEAM work will be in 2013-14 on 42 priority countries.

Tracking grant performance requires regular engagement with Global Fund country

teams, linking them to technical partners whenever possible. This is achieved through

weekly meetings held at the Global Fund intended to identify under-performing grant

recipients as an early warning system and to put in place timely corrective actions.

These meetings also provide an opportunity to share TB technical knowledge with Fund

Portfolio Managers.

Other TB activities include preparation for the NFM through the training of consultants

(the first such training will take place in Geneva in July 2013), support to Phase

2/periodic reviews (including pre-CCM performance assessment, stakeholder

coordination and determining TA needs, CCM applications, pre-renewal preparations

and post-renewal follow up), ensuring that grants to do not get “stuck” during Phase 2

finalization. Other essential activities are the organization and facilitation of TBTEAM

regional trainings and workshops for country stakeholders and support provided for the

development of National Strategic Plans.

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The role of TB Focal Points within the Global Fund focuses on technical advice on

existing grants, and to NFM applicants, on the importance of strategic investment, on

grant renewals and reprogramming. TB focal points also support design and

development of strategic investment tools and processes; provide guidance on strategic

investment and prepare information notes; they are involved in the design of the

measurement framework (modular tool) and in the development of other tools. Their

other functions include: enhancing technical partner’s engagement and supporting key

Global Fund structure/committees; maintaining disease committees; representing

Global Fund at key meetings; engaging partners in Grants Approval Committee (GAC)

including pre-GAC meetings; coordinating technical support with TBTEAM; supporting

special initiatives of interest to Global Fund (e.g. TB in mining). Global Fund TB focal

points are also involved in joint or mid-term reviews in countries, including the

development of NSPs for NFM.

The view of TB Focal

This report summarizes the issues discussed, the main conclusions and final recommendations

of the meeting.

This report summarizes the issues discussed, the main conclusions and final recommendations

of the meeting.

The Global Fund TB Committee, composed of representatives of GTB, STP, The Union,

Global Fund, JICA, World Bank, UNITAID, UNDP and implementing countries has a

fundamental function to advise Global Fund on strategic investments and priorities.

Points at the Global Fund

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The first observations were on the need for a proper utilization of the TBTEAM website.

The number of reports uploaded has been increasing and mission reports are used to

follow up TA missions’ recommendations. Reports may sometimes not be uploaded if

they contain sensitive issues that require authorization by the country authorities.

Alternatively confidential information can be removed. Each report should build on

previous recommendations and ensure consistency in follow-up of recommendations. It

is important for TBTEAM to monitor and ensure quality of consultancies: an adequate

tool for ensuring this requires further discussion. The TBTEAM website continues to be

an opportunity to widen the circle of consultants of each technical agency. 80% of TA

missions are not done by TBTEAM registered consultants. Uploading the report allows

everyone to contact these consultants if need be and also find out if the TA mission was

of satisfactory quality.

Improving communication is important at the global level but also at the regional and

country levels. Collaboration and coordination among the partners are urgently

required.

One of the main areas of requested assistance are laboratory services; a roster of

laboratory consultants capable of providing technical assistance to countries is now

available.

It was reiterated that TBTEAM is not a funding mechanism for technical assistance:

financial resources are available at country level in Global Fund grant or through other

projects. It is important to coordinate with partners in order to find out who is already

providing assistance, or has funding for it.

In terms of financial sustainability, TBTEAM is currently funded by US government (from

its 5% contribution to the Global Fund). It is important to establish multiple donors for

the TBTEAM mechanism and avoid “double dipping” from the same donor (e.g. USG

providing funds to the Global Fund and for TA mechanisms and, again, Global Fund

supporting the same TA mechanisms).

The absence of important partners, like UNICEF, in the TBTEAM meeting was noted,

regarding the importance of the agency in improving access to TB services for children.

UNICEF has been collaborating with Childhood TB subgroup and childhood TB

community on Roadmap for Childhood TB; the final document will be launched with

UNICEF and other partners. Despite the opportunity to engage many partners this area

remains unfunded.

Synthesis of discussion

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Global Fund New Funding

Model Collaboration among partners

I. Description of NFM and experiences in 2013:

The NFM aims at greater alignment with country schedules, context and priorities

Focus is on countries with the highest disease burden and lowest ability to pay, while

keeping the portfolio global. Simplicity is important for both implementers and the Global

Fund.

The Global Fund is going to have a much greater involvement in country dialogue.

There is potential for technical TB support throughout the process and greater

engagement of partners at country level. The case of some early applicants and interim

countries selected for the transition period was presented.

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II. Preparing for full roll out:

The full roll-out of the Global Fund NFM will require a special effort in the following

areas:

Strengthening of NSPs: facilitate country reviews and work with partners to prioritize

countries for NSP support.

Improve data: review country diseases burden data used in allocation; work with

partners to strengthen epidemiological information, especially at regional level and

for Key Affected Populations (KAPs).

Ensure capacity for full roll-out: map and align technical support for early 2014

applicants; adapt Global Fund secretariat resourcing levels to handle the surge;

develop and roll-out training for country teams (CTs), partners and countries.

Involve key constituencies: target CCM funding to strengthen KAPs and civil society

engagement in CCMs (pilot in 2013); work with TA funders/providers to strengthen

KAP and civil society capacity.

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Early implementer, Full NFM - Myanmar

The presentation of the TB epidemiological situation was followed by some remarks on

the CCM structure. The CCM is chaired by MoH and it has been expanded to become an

health sector coordination mechanism for HIV/AIDS, TB, Malaria, MNCH and HSS.

Partners and donors have been increasingly involved into technical and financial

collaboration since 1994. The history of several Global Fund grants to Myanmar was

reviewed to highlight the opportunities now presented by the NFM.

The NFM will foster in-country partnerships between the TB, HIV and Malaria

communities (joint submission). There will also be greater engagement of the Global

Fund country team and greater predictability on the amount of resources and timeframe

for their utilization. This will be accompanied by intensified advocacy initiatives for

increased health funding by the Government.

Some emerging challenges were presented as well. The development of the Concept

Note seems to be as labor intensive as the preparation of previous proposals. The limited

timeframe makes it difficult to select new SRs. Also, two different budgets will have to be

prepared (indicative and incentive, with its inherent uncertainty) Finally, there will be no

other funding opportunity until 2017.

There is great interest by technical and financial partners to support health development

in Myanmar (as a result of the ongoing political changes). WHO therefore works closely

with the Ministry of Health to ensure that national strategic plans/priorities are followed.

The coordination is done by the CCM and the technical and strategic groups in different

health development areas.

Country experiences

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TB-Kazakhstan

Several partners are working and providing support in Kazakhstan, which is facing a crisis due to the high rates of MDR-TB (one third of all TB patients has MDR-TB). The preliminary stage for the NFM preparation started in March 2013, and the NSP has been prepared, including a plan of reform of the health services and for the country dialogue. This dialogue, and the preparation of an early Concept Note took from May to July 2013. The Concept Note with PRs selection is expected in October, while the grant making process with the final TRP and GAC review is expected by December 2013. Technical support was sought for NSP development and for an early concept note. The experience shows that the Global Fund can raise important issues about health services at an early stage of development of the Concept Note. Different countries need different timelines for this process and the Global Fund should have now the flexibility to accommodate this need.

TB component in HIV – Zimbabwe The Zimbabwe experience has been about establishing coordination between TB and HIV programmes in order to incorporate TB into the Global Fund HIV concept note. The epidemiology of TB and HIV in Zimbabwe requires establishing and strengthening mechanisms for delivering integrated TB and HIV services. At national level the HIV and TB programmes are housed under one directorate (the AIDS and TB programme), the National TB/HIV committee is operational and the National TB/HIV care and treatment partnership forum exists and is functional. The country has now a special focus on TB/HIV collaborative activities because in A previous Global Fund Round (R8) these activities were not developed enough. The selection of Zimbabwe as an early applicant gave the country an opportunity to seek more funding for TB/HIV. The challenge of an effective collaboration between the two programmes has emerged and has been addressed in the areas of harmonization of M&E tools, harmonization of procurement of commodities (e.g. Gene-Xpert machines and cartridges, additional INH), harmonization of capacity building – integrated training of health workers at health facility level and of strengthening of linkages/referral systems between TB and HIV services.

Early implementer

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Synthesis of the discussion

In the interest of country leadership, the development of the Concept Notes for the NFM

should focus on national processes, priorities and activities, all based on the country

dialogue and the gap analysis. Countries will lead the process, building on the findings of the

NTP review, updating the NSP accordingly and preparing a Concept Note based on its

strategic vision and on the gaps identified.

All partners in-country should be involved in the NSP development, so that it reflects as well

their commitment in their respective areas of operation, the contribution they can provide

to the plan and the support they may require; this is essential to prepare also their

engagement in the country dialogue and in grant implementation.

One critical element of the NFM is allocation of resources by disease bands; the CCM will be

responsible for the allocation of resources between the 3 diseases. It is essential that good

NSPs provide a strong rationale and justification to ensure adequate TB allocation. However

the criteria for the disease split of resources is still under discussion within the Global Fund.

It was clarified that country eligibility criteria will be discussed and revised during the Global

Fund Board meeting in the autumn. Countries can continue with existing PRs. The process of

selection of PRs happens before the concept note is submitted and the engagement of

partners is clearly essential at this stage.

The TRP considered all early applicants grant concept notes of very good quality and there

was a 100% success rate. Country leadership proved crucial but questions were raised on

what to do, as TBTEAM partners, if countries are not so successful. Some considerations

were devoted to the need for further development of existing human resources, as the

expectation of a grant is that people, including those without a specific TB related expertise,

will do more and better, at the central as well as at the peripheral level of the health system.

This means that training courses will be required but also that occasionally more people will

have to be recruited to strengthen the grant implementation.

Finally, some remarks focused on the situation of TB/HIV collaborative activities and on

complex emergencies, with reference to civil unrest affecting several countries particularly in

the Eastern Mediterranean Region. The Global Fund encourages countries to include TB in

HIV grant proposal and HIV in TB grant proposal. There is still funding of separate

programmes which assist on the ground people with a dual infection or disease. In some

countries people living with HIV have access to ARTs but not to TB care. If HIV related

activities are funded without proper support to TB control activities, PLHIV may die of TB.

on the New Funding Model

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In the context of complex emergency situations it was advised to consider integrating

plans and activities into the NSPs. Also, M&E indicators need to be adapted under these

circumstances. A question was raised on whether the Global Fund will be willing to

include these indicators in the Global Fund performance framework. The debate about

the role of Global Fund in fragile states or emergencies will be the object of discussion

during the senior management steering committee in the summer.

Epidemiological impact assessments linked to Programme Reviews and update on prevalence survey implementation and outcomes, as well as impacts indicators A large number of country prevalence surveys has been funded by the Global Fund grants and TA facilitated by TBTEAM. Synthesis of results and lessons learned and also a data repository and book are in development, informed by the surveys conducted. A 6- country analysis workshop is planned for November 2013 in Geneva (Gambia, Pakistan, Rwanda, Nigeria, Tanzania and Thailand). Epidemiological and TB surveillance assessments can be linked to TB programme reviews and evidence on impact on TB disease burden needs to be further strengthened. Systematic assessments of TB surveillance are conducted during or shortly in advance of programme reviews, using WHO TB surveillance checklist, and developing also a related M&E investment plan. Further investments are needed in many settings, to improve the existing (routine TB) surveillance system (i.e. vital registry). Results and recommendations can feed into programme strategy and Global Fund (and other) investments. This is particularly important as surveillance systems become an ever important component for requests for funding to Global Fund. A TB surveillance checklist and related user guide have been developed to facilitate and simplify data collection, analysis and interpretation. Synthesis of discussion: It was agreed that linkages of epi-pre-review mission assessment

and overall strengthening of surveillance systems will help produce more sound data,

which can thus better serve public health TB control interventions and serve more clearly

and robustly future concept note development processes for Global Fund TB applications.

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National Strategic Plans (NSPs) for TB control represent key instruments for NTP

management and should be based on clear situation analysis of the TB epidemic and of the

TB control programme, stating clear goal(s) and targets and identifying the interventions to

achieve them. They should be used to mobilize resources to implement these interventions.

Several objectives of TB county reviews were presented, and the fact that reviews can well

inform development or updating of existing NSPs.

Essential plan components are:

1) Narrative description of the core plan. 2) Budget plan. 3) Monitoring and evaluation plan. 4) Operational plan. 5) Technical assistance plan. Several key principles should guide the NSP development/update, such as the NSP should be in line with the National Health Plan, all 5 components highlighted should be included and gaps analysis, objectives, interventions and related budgets should all be consistent with each other. Systematic review planning constitutes a prerequisite for successful review missions. These

consist mainly (but not exhaustively) of:

1) Appointing a review coordinator. 2) Establishment of a review task force. 3) Definition of the objectives. 4) Setting the dates. 5) Selection of review members and definition of roles and responsibilities. 6) Selection of sites for the field visits. 7) Planning of logistics. 8) Preparation of a budget and identify/secure funding. 9) Preparation of data collection tools and background documents and identification of a lead report writer (working with the international review coordinator).

TB Programme Reviews and National TB Strategic

Planning linked to Global Fund processes

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NSPs can guide the mapping of available partners and resources and help identify gaps and priorities as well as represent a basis for identification and inclusion of new partners in both advocacy and implementation activities. NSP should be used to mobilize resources at national and international levels, through bilateral and multilateral mechanisms (e.g. Global Fund). In conclusion, a well-designed programme review will inform the development or updating of a NSP, and the latter constitutes the basis of a concept note to the Global Fund. Synthesis of discussion: All stakeholders agreed on and reiterated the importance of good linkage of reviews, NSPs and further concept note development.

Global Fund involvement and support to Program

The presentation highlighted the flexibility of the new concept note-based funding model, while underlining the importance of sound NSPs. These are helpful in many respects, such as helping to rate the impact and indirectly helping the grant management (i.e. With regards to future reprogramming). Good data in the plans is key to inform impact measurement. Funding allocation was outlined with regards to programmatic results towards targets (indicator rating), progress towards results and country absorptive capacity. The way forward foresees that program funding requests from countries be based on the National TB Strategic Plans, and be informed by: • Assessment of data quality and surveillance systems, that identifies gaps and investing opportunities to strengthen major components of the national health information systems; • Epi analysis conducted preferably, as part of program review, or as part of Country Dialogue, prior to the development of a Concept Note; • Actionable recommendations stemming from Program Reviews. The Global Fund will continue to work closely with countries, WHO and other technical and funding agencies, to ensure that programmatic and funding decisions are fully informed by data and guided by evidence. Synthesis of discussion: All agreed and welcomed the how Global Fund underscores the importance of sound NSPs and data being the groundwork of those plans, further informing sound concept notes.

Reviews and National TB Strategic Plans

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Country experience – Papua New Guinea and Cambodia Discussion on linking programme reviews, National TB strategic plan and Global Fund grants The presentation gave the country example of Papua New Guinea (how reviews inform NSP development and then the Global Fund grant/concept note development). What helped a lot to reach a high level of in-country partner inclusiveness and ownership were several well-tailored and planned internal and external reviews, each in tandem covering important aspects of data collection. The NSP from 2006 to 2010 was developed during a participatory in-country platform based in country dialogue, and included the 5 essential NSP components mentioned before.

Key for success had been the wide and inclusive consultation (country dialogue) and country ownership throughout the entire development process. In Cambodia the same process was undertaken, and in addition to the above example of Papua New Guinea further helped to consolidate existing Global Fund grants and further simplify the in-country situation. TBTEAM helped identify external consultants and some additional funding needed for the NSPs update. As a conclusion, the described process can also help to simplify the country support situation by mapping and streamlining the funding and support input to the national TB control interventions and efforts. Synthesis of discussion: Colleagues widely acknowledged and supported the usefulness of TBTEAM at country level in addressing bottlenecks and challenges related to the process of review and TA planning and organization and the resulting NSP development or refinement. .

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Brief presentation of the European Respiratory Society (ERS)

In view of the prevailing challenge of M/XDR-TB in the WHO European Region, it was considered worthwhile to develop an easy-access tool for clinicians to discuss “difficult to-treat” M/XDR-TB cases. The designed tool is managed by ERS, in collaboration with WHO Europe (based on a formal agreement) and the European Centre for Disease Prevention and Control (ECDC). Its objectives are to allow a European clinician, free cost, to load patient’s data and receive in 1 working day suggestions by 2 experts on how to manage a difficult-to treat TB case(s) and to support follow-up of TB patients travelling within Europe. The developed tool is a www-based regional platform uniting a specialized team able to cover several perspectives of M/XDR-TB (i.e. clinical for both adults and children, surgical, radiological, public health, psychological, nursing, etc.). www.tbconsilium.org. Cases are presented (uploaded by the requesting physician, confidentiality ensured), and replies received within 2 working days. The tool is available in English and Russian at present. The principle is to keep it “light” and very pragmatic (outcome-oriented), and in the future the inclusion of a drug-o-gram (to allow specified information relating to drug use) and further translations into other languages are foreseen. The consilium so far has been successfully applied many times and the number of experts giving expert advice has been steadily increasing. Synthesis of discussion: All participants recognized the added benefit of the e-consilium for the management and treatment of some M/XDR-TB cases and that this mechanism nicely complements - from a clinical perspective - the more programmatic and public health population focus of the Green Light Committee.

WHO EURO e-consilium

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Monitoring Global Fund performance and getting ready for 2014 new funding model

Different sources of information (such as the principal recipient, the Global Fund country team, respective data, management letters, grant performance reports, monthly data from Global Fund information hub) are available and give indications about the grant performance. WHO and other stakeholders can receive and analyse the data at different levels (i.e. global, regional and country) in order to proactively address any challenges and bottlenecks in grant implantation. NSPs need to be of good quality and costed in order to serve the purpose of concept note development. TBTEAM has been engaged in organizing regional workshops with the purpose of strengthening national capacity for NSP development, is currently organizing a global workshop for preparing all involved for the new concept note development process, is supporting partner mapping for synergetic resource use and providing technical assistance to countries in need for development of updating of national strategic plans. The new concept note model will require good deal of concerted planning ahead, as many countries will be soon eligible to apply, and a big first wave of demand is thus expected (i.e. for country support/technical assistance). Synthesis of discussion: Proactive information gathering, sharing and “corrective” action is useful in ensuring good grant performance, as bottlenecks can be avoided or tackled quickly before causing unnecessary deleterious impact. All partners should have the philosophy of sharing information with others, so that concerted action can be taken rapidly and efficiently.

The overall meeting was concluded and partners agreed to continue their excellent collaboration.