Uganda

Uganda is one of the 22 high-burden TB countries and also one of the sub-Saharan African countries which is enduring the impact of the dual TB/HIV epidemic. Uganda achieved 100% DOTS coverage in the late 1990s and adopted CB-TB care as a national strategy in 2002. This national TB control policy includes community sensitization and mobilization, as well as offering every TB patient DOT by a community volunteer.

The country has increased the number of diagnostic centers for sputum-smear microscopy and treatment centers for TB. Despite these efforts, the NTLP has been unable to ensure that all the components of the DOTS strategy and CB-DOTS are operating at optimum throughout the country due to lack of financial support and dedicated and competent personnel. There has also been a lack of funding to support national supervision, communications to improve community awareness and political and financial commitment from the district health management committees. The challenges faced by the NTLP have resulted in case detection rates below the internationally recognized 70% target. Similarly, Uganda has only achieved a 68% treatment success, again below the target of 85% driven down by a high default rate of 16%. The TB/HIV dual epidemic has seriously affected Uganda, and is the main explanation for the doubling of case-notifications between 1991 and 2004.

The goal of TB CAP, which started in 2007, is to decrease the burden of TB among PLWA and the burden of HIV among notified TB patients by: strengthening TB control activities, providing diagnostic HIV counselling and testing to TB patients and increasing active TB case finding at HIV service points. This project draws on the expertise and strong country knowledge of The Union which has been selected as the implementing partner and other TB CAP partners, such as WHO and CDC.

TB CAP Highlights Uganda

Rapid improvement in performance through improved coordination and planning for TB/HIV at district level

TB CAP is a three year program that is supporting Ministry of Health and districts in Uganda to deliver integrated services for TB and HIV. The goal of the program is to decrease the burden of TB among people living with HIV/AIDS (PLWHAs) and the burden of HIV among notified TB patients. Prior to TB CAP, coordination of TB/HIV services at district level was very limited. A situation analysis done in 26 districts at the start of the program showed that district coordination mechanisms and planning for TB/HIV were weak or non existent. Some of the reasons for this were inadequate understanding of the National TB/HIV policy guidelines among district and health sub district health team; limited funding for health activities and lack of guidance on how to plan for TB/HIV activities and establish district coordination mechanisms. Partners implementing TB and HIV activities at the district level were not regularly involved in planning, coordination and monitoring of health activities including TB and HIV services at District and Health Sub-district level.

With TB CAP support, joint planning workshops between the TB and HIV programs were conducted in each of the 12 districts selected in year one of the program. Participants included political leaders, administrative heads, district health teams and health sub-district teams. Performance regarding the implementation of TB/HIV collaborative activities and the DOTS strategy was reviewed, key gaps and challenges to implementation identified and solutions to these gaps proposed. The key output from the workshop in each district was a costed district work plan which was based on guidelines from TB CAP. As a result, districts gained skills and knowledge to develop district specific TB/HIV work plans and cost them. The district TB/HIV work plans are now a strong advocacy tool for resource mobilization given the inadequate funding for health activities from the public sector. All DHT members now have more ownership and responsibility towards implementing TB and HIV programs, a responsibility that was previously left to the TB or HIV district focal persons. This has contributed to smooth implementation of activities and rapid improvement in core indicators in the 12 districts.

The figures indicate that the proportion of TB patients tested for HIV rose from 20.3% at baseline (Sept 2007) to 73% by the third quarter of the first year of implementation (July – September 2008). The proportion of TB/HIV co infected patients started on Cotrimoxazole rose from 42% to 90% and the treatment success rate for new smear positive TB patients improved from 42% to 52% (for 11 districts) over the same period.

The major challenge faced by TB CAP is to ensure effective TB–IC in the different settings of the health care facilities. In 8 out of the 12 districts were TB CAP activities are implemented, we trained health care workers, conducted TB-IC assessments of the outpatient departments, inpatient wards, and laboratories of the health facilities.

In majority of the health facilities assessed, there was inadequate ventilation attributed to a number of factors including; poor structural design of health facilities and the increased number of patients attending health facilities to seek HIV care services that led to partitioning of existing rooms to create space to provide HIV counseling, anti-retroviral service, prevention of mother to child transmission, etc. Although capacity to address this challenge has been built through training in TB-IC, including training of an engineer of the infrastructure division of the Ministry of health, resources required to implement structural adjustments to provide adequate ventilation in the health facilities are not locally available. For the moment, TB CAP is addressing the challenge by increasing awareness and advocating for TB–IC among decision makers and stakeholders in the health care delivery in Uganda.

TB CAP Project Period (2005-2010)

Expected output(s)

1. Increased capacity at the national and district level to support TB/HIV coordination and supervision.
2. Increased access of HIV-positive TB patients to HIV services and PLWHA to TB services through improved implementation of integrated TB/HIV and community based TB care (CBDOTS).
3. Increased ability of the MOH to provide guidance and support to health facilities on TB and TB/HIV infection control (TB-IC).