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Health Complex,
16-K, Gulberg III,
Lahore, Pakistan.

The Global Fund The Union (IUATLD) National TB Control Program (NTP) STOP TB Partnership

The Global Fund R-2 Project

The current national leadership of PATA reviewed and analyzed the strategy. After consensus among themselves they, by virtue of their new vision decided to plan for adaptation of WHO recommended DOTS strategy to fight tuberculosis, a major public health problem in Pakistan. PATA developed a project proposal and secured funding from The Global Fund (TGF) in GFATM R-2 initially for a period of two years.

The project was designed to:

“Provide TB DOTS coverage to additional 18 million population through Private-public partnership between PATA and NTP strengthening its country-wide selected 84 diagnostic centers”

The agreement was signed between PATA, the sub-recipient (SR) and Global Fund on 19th January 2003. Manager National AIDS Programme was designated as Principal Recipient (PR). Manager, National TB Control Programme (NTP) and Country Coordinating Mechanism (CCM) signed the project as technical supporter and country coordinator respectively. Funds were transferred to PATA on 20th February 2003. In due course of time, one Central office and four Provincial offices were established and the Steering Committee was formulated to coordinate the activities of project.

The process for adaptation of National guidelines started in last quarter of 2004 and first six days doctor training was conducted on 1st November 2004. The laboratory technicians were recruited and the process of training was replicated throughout the country for all the cadres with the generous support and facilitation of PR and NTP. By the end of Q-1 2005 the first phase of trainings was completed and 68 diagnostic centers were equipped with the trained manpower but the procurements were not available. It was anticipated that these procurements will cause undue delay in initiation of case detection and the laid down targets will not be achieved. A series of meetings were held with NTP and with their technical cooperation and provision of medicine the DOTS strategy was launched in these 68 centers. The DOTS strategy, thus launched was not uniform due to non functional laboratories. But this proved to be a mile stone in the development of Public Private Partnership in the country.

Managing No Cost Extension

During 2nd quarter 2005, PR pointed out the fact that the project was designed for just two years and the funding will cease on 31st December 2005. PATA has committed to sustain the interventions after this period. So there was no question of extension of the project. It was noted with great concern by all the three partners and they were unanimously of the opinion that withdrawal of funding and assistance at this point of time will ruin all the efforts made so far. The essence of Public-Private Partnership will be lost and PATA may move back to its conventional methods. After a series of consultative meetings among all the three partners, it was suggested that PATA.

should apply for one year no cost extension of the project and NTP and PR will facilitate PATA.

NTP offered assistance in monitoring & supervision through established network of its field force at National, provincial and district level. PATA after securing this support decided to surrender its four provincial health specialists, four provincial laboratory supervisors and three of its vehicles and assured voluntary services of its Medical Director (a retired Professor of King Edwards Medical College) for monitoring & supervision.

PR committed facilitation and assistance in securing one year no cost extension. This proved to be the corner stone in Public-Private Partnership between PATA and TB Control Program.

Implementation of Project Activities and Outputs

Most of the project activities and outputs were produced as planned.

PATA has 84 TB diagnostic centers/PMUs in all the four provinces of Pakistan:
Punjab          56
Sindh           14
NWFP          11
Balochistan   03

The cases registered at these diagnostic centers are provided treatment at more than two hundred treatment centers opened by PATA.

Information gathered through desk review can be presented as under:

Achievements of Project Outcomes

During 2007 PATA detected and registered 19438 cases of all type tuberculosis with break up of 12204 New Smear Positive, 5610 New Smear Negative, 1410 Extra Pulmonary TB cases, 147 Relapse, 8 Treatment after Failure and 59 Treatment after Default
Achieved The Global Fund target of 22000 NSS+ cases with 3731 as additional credit
Treatment Success Rate of patients, reported till December, 2007 is 94% against 85% WHO desired and The Global Fund target of number successfully treated patients was achieved up to 106%

Project Sustainability

The goal of the Global Fund project to support TB DOTS coverage by PATA is acknowledged as a long term ambition and undertaking. The project design and implementation strategy reflects this fact by focusing on building the capacities of the relevant institutions and putting in place systems and structures needed for effective management of TB care at PATA outlets. The PATA sustainability plan as designed and implemented, indicates that several building blocks have been put in place that will support sustainability of the project activities and impact.

Government support and ownership

The PATA GFATM Round 2 project has a strong ownership which emanates from the way it was designed and implemented. The project was initiated in strong partnership with Government. Therefore, from the start, it is seen as a joint venture between PATA and the Government sector through the commitments in the project agreement between the two institutions in terms of district level MOUs to ensure sustainability. This provides an enabling environment for its implementation and future support by the Government.

There is a direct linkage between the PATA project objectives and the National TB Policy objectives, especially the introduction of the public-private partnership in public service delivery.

Capacity building of and ownership by implementing local institutions

The institutional set up for project implementation through existing PATA local associations rather than creating new ones was aimed at building sustainability into the project interventions. The capacity building is targeting the associations that will be responsible for continuing with the project interventions beyond the project life as this is within their mandates. The implementing associations are appropriately aligned with project activities according to their mandate and normally assigned roles and areas of expertise. This approach has contributed to the integration of the TB DOTS activities into the operations of these associations and laid a good basis for project sustainability.

Strengthened capacities of staff of implementing associations through training in relevant skills provides a strong foundation for sustainability of the project interventions.

The project supported strategies, procedures; guidelines and education curriculum are all aimed at supporting long term work in TB DOTS. The sustainability of this project as a whole, therefore, will depend on the extent to which these instruments and tools will be internalized and utilized by the responsible local associations for the intended purpose as these activities are crucial in achieving the overall objective of sustainability.

Financial Report

Budget of PATA
Initially, the budget was for a period of two years; then the budget was broken downs to line items in the light of following six activities;
1. Establish the Central Unit for supervision.
2. Establishment of 4 Provincial Units for coordination for DOTS
3. Strengthening of diagnostic centers
4. Functioning & training of diagnostic & treatment centers
5. Adaptation of National Guidelines
6. Monitoring & Evaluation

Activity wise expenditure Report
The activity wise expenditure during the project life was as follows;
Figures in thousands ('000)

From the left graph it is clear that the major spending on activity 4 during each year except year 1. During year 1 the hiring process of lab technicians was completed almost at the end of the year and few trainings were done. But onward the major part of yearly expenditure belongs to that activity. In this activity the salaries of lab technicians and the training of doctors, technicians, paramedics and CHW were budgeted.
The second major spending is on activity 1 in which supervision cost is included. The supervision from head office to all its diagnostic centers was budgeted in this activity.

Click here to download complete Project End Evaluation report of GFATM R-2