NTP Presentation central meeting, sana'a, Yemen

NTP presentation for central meeting

1. Yemen NTP Report 2017 Ministry of Public Health and Population Services and Health Care Sector GD of disease control National tuberculosis control program Sana’a, Yemen Dr. Esam Mahyoub NTP Manager

2. Yemen MOPH&P structure Minister of PH&P Services and health care sector Planning Sector Pop. Sector GD of Diseases control & Surveillance GD of Family Health NTCP

3. Central level GD . OF Surveillance & Disease control NTP Manager Governorate level District (TBMU) level peripheral level Supervision HR Logistic PPM MDR Reference Lab. Training Surveillance Finance HE GTCs & GLS (22 Gove) TBMUs TBMUs TBMUs HUs H Us H Us H Us HUs HUs Organizational structure of NTP .

4. NTP Levels Central level National Tuberculosis Control Program Governorat level   22 governorates, including four main centers   (Sana'a, Aden, Taiz , Hodeidah ) District Level   333 centers and 270 TB laboratories Peripheral level   2,551 health units (primary health care units).

5. TASK AND RESPONSIBILIES

6. Central level Role of the NTP central unit : Planning and policy making Coordination of all tuberculosis control activities Training and human resources development Provide adequate supply of medicines and stock Coordination with the private sector Follow up the targeted population (Refugees, HIV, children and women) Supervision Prepare and update models for surveillance and data collection Consolidate and submit quarterly and annual reports Monitoring and evaluation Organizing meetings with program coordinators and supervisors in the governorates. Communicate and coordinate with donors and international organizations The national program include a reference laboratory that’s plays a role in planning, training, human resource development of the laboratory net work, and quality control.

7. Governorate level In each governorate there is a program coordinator and supervisor of the TB laboratory and follows the general administration of the health offices in the governorates. In each of these governorates, the TB coordinator and the laboratory supervisor are responsible for the following tasks: Participation in planning Participation in training Supervision to the Districts level Inter- sectoral coordination in the governorate. Monitoring and evaluation  Meetings with TB coordinators and laboratory technicians in the districts Distribution of medicines Compile quarterly reports from the districts and upload them to the central level. Conduct quality control for tuberculosis laboratories .

8. District level -Consisting of 333 tuberculosis units in all districts administered by the TB Coordinator of the district, which is responsible for tuberculosis control activities. -Each unit serves between 30,000 and 100,000 population     The tasks carried out at this level are: Diagnosis of tuberculosis cases and identification of suspected cases Recording cases of tuberculosis and reporting to the governorate level Health education for TB patients Communicate with interrupted TB patients Distribution of anti-tuberculosis drugs Referral of patients Supervision at the peripheral level There are 270 units with a tuberculosis testing laboratory, which serve as centers for diagnosing and recording cases, while the remaining 68 units rely on the diagnosis of other TB laboratories.

9. Peripheral level These units consist of a network of 2,551 health units (primary health care units) run by nurses, midwives or the Vaccine Officer. Their functions are: Identify suspected tuberculosis cases and refers them for diagnosis at tuberculosis centers in the Districts Health education for TB patients Communicate with interrupted TB patients Distribution of anti-tuberculosis drugs

10. TB Epidemiology in Yemen

11. Incidence rate: 48 case per 100,000 population Case detection: 77% Treatment success rate : 90% Mortality rate : 4.2 / 100,000 pop. Death rate = 2%. All forms of cases: 2017 Q1,Q2 & Q3 = 7288 cases all forms 2016 = 9498 cases all forms 2015 =7698 cases all forms. TB Incidence ,CD, Success Rate, Mortality and Death rate Notified TB cases 2015 to Q3-2017

12. Number of detected TB cases per governorate 2016 Governorates New + ve Retreatment Pul . - ve ETB Total % Abian 80 6 123 47 256   Aden 255 38 368 300 961 10% Albayda 73 56 56 185   AlDhala 41 2 35 53 131   Hodeidah 703 70 310 414 1497 15.8% Algawf 126 19 32 8 185   Almahrah 11 1 9 5 26   Al- Mahweet 25 1 34 28 88   Almukala & Soqatra 57 6 25 49 137   Amran 92 8 57 102 259   Dhamar 144 9 152 243 548   Hajjah 249 49 627 264 1189 12.5% Ibb 433 38 148 286 905 9.5% Lahjj 89 5 145 100 339   Marb 24 1 61 20 106   Saada 63 2 69 91 225   Sana'a Secretariat and NTI 365 22 198 824 1409 14.8% Sana'a 64 3 77 110 254   Sayon 13 3 20 18 54   Shabwa 21 1 42 22 86   Taiz 248 21 141 215 625 6.6% Rima 15 10 8 33   Total 3191 305 2739 3263 9498  

13. Governorates New +ve Retreatment Pul. -ve EPT Total % Abian 52 1 89 31 173   Aden 183 25 314 219 741 10% Albayda 34 1 40 48 123   AlDhala 29 2 32 38 101   Hodeidah 549 32 224 341 1146 15.7% Algawf 66 16 12 7 101   Almahrah 15 4 2 5 26   Al- Mahweet 22 1 18 29 70   Almukala & Soqatra 61 8 23 29 121   Amran 67 2 56 85 210   Dhamar 94 6 113 172 385   Hajjah 200 32 350 160 742 10% Ibb 446 25 78 218 767 10.5% Lahjj 71 2 164 80 317   Marb 27 2 58 17 104   Saada 62 1 60 57 180   Sana'a Secretariat and NTI 259 25 186 747 1217 16.7% Sana'a 54 1 73 95 223   Sayon 13 1 18 23 55   Shabwa 13 3 31 21 68   Taiz 154 8 90 139 391 5% Rima 12 1 2 12 27   Total 2,483 199 2,033 2,573 7,288   Number of detected TB cases per governorate Q1,Q2 and Q3 - 2017

14. Number of detected TB cases per Northern governorate Q1,Q2 and Q3 - 2017 Governorates New +ve Retreatment Pul. -ve EPT Total % Albayda 34 1 40 48 123   Hodeidah 549 32 224 341 1146 15.7% Algawf 66 16 12 7 101   Al-Mahweet 22 1 18 29 70   Amran 67 2 56 85 210   Dhamar 94 6 113 172 385   Hajjah 200 32 350 160 742 10% Ibb 446 25 78 218 767 10.5% Marb 27 2 58 17 104   Saada 62 1 60 57 180   Sana'a Secretariat and NTI 259 25 186 747 1217 16.7% Sana'a 54 1 73 95 223   Taiz 154 8 90 139 391 5% Rima 12 1 2 12 27   Total 2,046 153 1,360 2,127 5,686  

15. Number of detected TB cases per Southern governorate Q1,Q2 and Q3 - 2017 Governorates New + ve Retreatment Pul . - ve EPT Total % Abian 52 1 89 31 173   Aden 183 25 314 219 741 10% AlDhala 29 2 32 38 101   Almahrah 15 4 2 5 26   Almukala & Soqatra 61 8 23 29 121   Lahjj 71 2 164 80 317   Sayon 13 1 18 23 55   Shabwa 13 3 31 21 68   Total 437 46 673 446 1,602  

16. Governorates 2013 2014 2015 2016 2017 (q1+q2+q3) total Sana’a 4 13 7 8 10 42 Taiz 1 10 1 1 2 15 Aden 4 17 9 16 14 60 Alhodiedah 10 6 8 8 32 Total 9 50 23 33 34 149 Case detection for MDR –TB patients per centre from 2013 to Q3 2017

17. Distribution of RR/MDR TB cases by governorates from 2013 to Q3 2017

18. TB patient type Center No. of cases started on second-line TB treatment treatment outcome Cured Treatment completed Treatment failed Died Lost to follow-up All confirmed RR-TB/MDR-TB cases Sana’a 4 3 1 Taiz 4 1 1 1 1 Aden 1 1 1 Alhodiedah Total 9 1 5 1 2 % 11% 56% 0% 11% 22% Treatment success rate 67% Annual treatment outcomes report for RR-TB/MDR-TB year 2013 in Yemen

19. TB patient type MDR TB centre No. of cases started on second-line TB treatment treatment outcome Cured Treatment completed Treatment failed Died Lost to follow-up Not evaluated All confirmed RR-TB/MDR-TB cases Sana’a 9 6 1 1 1 Taiz 17 5 6 1 3 1 1 Aden 5 1 2 2 Alhodiedah 10 9 1 Total 41 6 23 1 6 3 2 % 15% 56% 2% 15% 7% 5% Annual treatment outcomes report for RR-TB/MDR-TB year 2014 in Yemen Treatment success rate 71%

20. Progress update TB grants 1-July-31 Dec.2017

21. Gaps NTP started with IOM in 1 June 2017 by emergency plan for two years and the actual budget approved by GF in October 2017 and the implementation of activities started in November 2017 with many limitations Implementation of activities facing delay and difficulties due to Zero cash policy and absent of clear mechanisms for payments Multiple request for activities approval from GF for plan in general and separately per activity Ignoring the NTP strategic plan which include emergency plan

22. المعوقات التي واجهها البرنامج بدأ البرنامج مع المنظمة الدولیة للھجرة في 1 یونیو 2017 بخطة طوارئ لمدة عامان. وافق الصندوق العالمي على المیزانیه الفعلیه لخطة الطوارئ في أکتوبر 2017 . بدأ البرنامج بتنفيذ الأنشطة بشكل تدريجي في نوفمبر 2017. تجاهل الخطة الاستراتيجية لبرنامج السل ووضع خطة طوارئ بديله وحذف العديد من الأنشطه أو تقليصها بحجة الوضع الحالي في اليمن وبعض دول الشرق الأوسط.

23. المعوقات التي واجهها البرنامج التأخير في تنفيذ الأنشطة والصعوبات التي تواجه البرنامج كانت بسبب: - فرض سياسة نقدية صفريه من قبل المانح وعدم وجود آليات واضحة أو بديله للصرف. الطلب المتكرر للحصول على الموافقة للأنشطة من الصندوق العالمي ( للخطة بشكل عام وبشكل منفصل لكل نشاط ) وكذالك موافقه مكتب المنظمه في عمان. فرض العديد من القیود وكثرة الطلبات والتفاصيل لكل نشاط والتي لم تكن موجوده في المنح السابقه . التعليمات والضوابط المتبعه من قبل المتلقي الرئيسي للمنحه كمنظمه دوليه.

24. ما تم إنجازه خلال 2017 تأمين امداد كاف بالأدوية وتوفير مخزون حتى منتصف العام 2018 وذلك بشراء ادوية الخط الاول والثاني وتوزيعها على وحدات مكافحة السل . الحفاظ على امداد كاف من المحاليل المخبرية والادوية للمرضى في مناطق الحرب رغم الصعوبات في توصيل الادوية. عمل الاستراتيجية الوطنية ل مكافحة السل في اليمن لمدة خمس سنوات 2017-2021 وبمساعدة فنية من خبراء منظمة الصحة العالمية. والتي تتكون من:

25. المتابعة المستمره لتنفيذ جميع الأنشطه في الخطه المعتمده للبرنامج مع المنظمة الدولیه للھجره وموافاتهم بجميع البيانات و الوثائق المطلوبه . التواصل مع المانح ومع منظمة الصحه العالميه لإيجاد الحلول المناسبه وتوفير مايلي : • إيجاد آلية مناسبة للدفع والمطالبه برفع السياسة النقدية الصفرية لتسهيل تنفيذ الأنشطة. • الموافقة على أنشطة التدريب المستبعده من الخطه نظرا لأهمية هذه الانشطة لتحسين أداء العاملين الصحيين والحفاظ على مستوى جودة خدمات السل المقدمه . • الموافقة على حوافز الموظفين في الوحدة المركزية وخاصة الذين يعملون في المختبر وإدخال البيانات، ورفع حوافز المنسقين والمشرفين في المحافظات. • تامين احتياج البرنامج من ادوية الخط الأول وادوية السل المقاوم والمحاليل المخبريه .

26. دعم تكاليف تشغيل مراكز السل في المحافظات لتغطية الاحتياجات اليومية لهذه المرافق مثل المنظفات، والتنظيف، والوقود، وإمدادات المياه . دعم تكلفة إرسال التقارير من المحافظة إلى مستوى المحافظة ومن المحافظة إلى المستوى المركزي. تحديث الدليل الوطني لبرنامج السل وفقا لمعايير منظمة الصحة العالمية تحديث دليل ال MDR وانشاء وحدة ال LPA . إدراج الأنشطه الھامه التي كانت ضمن الخطة الإستراتیجیه في خطة منظمة الھجرة لضمان المكافحة الفاعله للسل في الیمن . إعادة تأهيل مراكز السل المدمرة. التنسيق مع منظمة الصحة العالمية لبدء المسح الوطني للسل.

27. Challenges Find the proper mechanism for payment instead of the zero cash policy to facilitate the implementation of activities. Approve the training activities due to important of these activity to improve the health worker performance and to maintain acceptable quality level of delivered TB services . Approve the incentives of selected NTP central unit staff especially who are working in the culture laboratory , data entry, other staff in the important positions. Gene Xpert cartidages transportation ASAP or request urgent from the countries in the region FLD before April

28. Challenges Support running cost of TB centers in some governorates to cover the daily needs of these facilities such as: (detergent , cleaning, fuel, and water supply ). Support the cost of sending the reports from district to the governorate level and from governorate to the central level. Accelerate the releasing of activities funds to enable the programs to implement the activities on time.

29. Challenges Update the NTP guideline as per WHO standard Include the training of LPA and MDR new guideline in the coming year 2018. Include the strategic plan or the important activities from the plan in to the planned IOM activities to insure effective TB control in Yemen. Rehabilitation of damaged TB centers. Planning with WHO technical partners to start TB national survey.

30. Status of NTP activities during IOM project (1/7-31/12/2017) Remarks Status type Activity NTP has sufficient stock till April 2018 only and we will face shortage of FLD after April 2018 Under process procurement Procurements( First line and second line drugs , lab supplies and reagents SLD, Ancillary drugs The four MDR centers facing severe shortage in Gene XPert cartridges Done procurement Procurement of Gene X-pert test cartridges NTP request GF to approve the Payment of salaries by USD as per other national staff working with IOM under GF grant ( Field coordinators, Mobile team and IOM National staff) Going well HR Monthly Operational cost and staff monthly salaries Unimplemented procurement Procurement of infection control equipment for 4 regional TB labs

31. Remarks Status Activity Due to the Zero cash policy there was delay in the payment of staff perdium and fuel cost which lead to delay in the exact time of implementation On going Half yearly supervisory visits from the central to the governorate - 23 governorates. Q3 disbursed and Q4 on going On going Performance based incentives to select staff in four MDR TB centres - for 4 centers Amount of 25000 should be transferred directly through IOM to GLC account Unkown Support to missions and international technical assistance of the Green Light Committee (GLC), (Y1 and Y2) Due to the Zero cash policy and the request of IOM to pay in advance and they will reimburse lead to improper and difficulty in implementation of this vital activity Implemented partially Transportation cost of the drugs and other materials from NTP ware house to the governorate and districts .- Progress update TB grants (1-July-31 Dec.2017)

32. Activities Status Remarks Maintenance of equipment already procured through GF investment Unimplemented   Support to the transportation of specimens on quarterly basis within the framework of EQA : blind rechecking (sending slides from TBMU to NRL) and proficiency testing/panel test (sending the slides from NRL to lab staff at governorate or district Under process Plan submitted to IOM Support for EQA (blind rechecking) for smear slides at NTI & Regional Reference Lab (Aden): (blind recheking of specimens conducted Under process Plan submitted to IOM Progress update TB grants (1-July-31 Dec.2017)

33. Progress update TB grants (1-July-31 Dec.2017) Activities status Remarks Support transportation cost for MDR specimens Pending This activity linked to availability of electricity , NTP recently installing the solar panel in the central unit and this activity will resume in March 2018 Support to the semi annual meetings of the GTCs &GLS at the central unit (3 days, 60pers)(Q1 and Q4, Y1 to Y2) Under process the plan submitted to IOM and the implementation will be in the second week of February Support to the Semi Annual meetings (had been modified to semi annual from Quarterly meetings) of the district TB coordinators (DTC) and surveillance officers (23 governorates X 4 annual meetings. Under process   The plan submitted to IOM and due to the Zero cash policy and absent the clear mechanism for payment this activity still under process

34. Activities status Remarks Support to the cost of communication of NTP central unit and within NTP network (internet, DSL, faxes, telephone, etc..) for 23 governorates   on process Plan submitted to IOM Printing of the new Recording and Reporting registers and forms under planning half yearly supervisory visits from the governorate to the district level (TBMUs), Q1 to Q4, Y1 and Y2. On process The plan submitted to IOM and due to the Zero cash policy and absent the clear mechanism for payment this activity still under process Support select office costs of NTP central unit and sub-national offices On process Due to the Zero cash policy and the request of IOM to pay in advance and they will reimburse lead to difficulty in implementation of this activity vehicle insurance On process Plan submitted to IOM Progress update TB grants (1-July-31 Dec.2017)

35. Progress update TB grants (1-July-31 Dec.2017) Activities status Remarks Update NTP program guidelines under planning Translate into Arabic, print, disseminate NTP guidelines under planning Maintenance of old and new motorcycles under planning Contact management program - visits to homes of pulmonary TB patients for screening / follow-up of contacts nit presenting to the health facility under planning Quarterly supervision of prison program under planning Refresher training to health workers in refugee camps / IDPs   under planning

36. Progress update TB grants (1-July-31 Dec.2017) Activities status Remarks Support monthly transportation cost for patient and TS to visit the referral treatment TB centre ( 12 visit per year .50U$*12*64 =38400 year1) = 9600 USD/quarter/patient On going Support to special investigations (audiometry, visual testing) for patients on treatment as needed   under planning Food Support for MDR Patients under planning support equipments for NTP warehouse at the central level   on process Support health Units workers semi-annual meeting at district level under planning Procurement and installation solar power system for TB units at governorate level as alternative of suspended public electricity due to the ongoing conflict in the country.   on going

37. Progress update TB grants (1-July-31 Dec.2017) Not approved activities Activities status Remarks Capacity building and training including the training of TB health workers and lab workers ( replacement and refreshing ) Not approved NTP request Performance –based incentives of selected NTP central unit staff (culture lab. technicians Data entry, accountant , others) Not approved Operational cost for 5 TB centers and 16 governorate level. Not approved

38. Thank you