4. Components Section Component 2: Support for the introduction of highly effective artemisinin-based combination therapy malaria treatment

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1 4. Components Section Component 2: Support for the introduction of highly effective artemisinin-based combination therapy malaria treatment 4.b Components Section Identify the component addressed in this section Contact persons for questions regarding this component National context for this Component Program Strategy Program and Financial Management Procurement and Supply Management b Component Budget Section Full and detailed Budget as an attachment to the Proposal Form Budget Summary Funds requested for functional areas Partner Allocations Key Budget Assumptions for Requests from the Global Fund

2 5. Components Section Component 2: Support for the introduction of highly effective artemisinin-based combination therapy malaria treatment [PLEASE NOTE THAT THIS SECTION AND THE NEXT SECTION NEED TO BE COMPLETED BY COMPONENT, so, for example, if the proposal s three components sections 4 and 5 must be completed three times. The system will automatically generate separate sections for each component.] 4.1 Identify the component addressed in this section HIV/AIDS Tuberculosis Malaria HIV/TB Integrated Indicate the estimated start time and duration of the component [Please take note of the timing of proposal approval by Board of the Global Fund (listed on the cover of the Proposal Form), as well as the fact that funds typically will not be released for a minimum of 2 months after Board approval] Table Proposal start time and duration From To Month and Year: January 2005 December Contact persons for questions regarding this component [Please provide full contact details for two persons this is necessary to ensure fast and responsive communication. These persons need to be readily accessible for technical or administrative clarification purposes.] Name Title Primary contact Dr.D.K.W.Lwamafa Commissioner Health Services National Disease Control Table 4.2 Component Contact Persons Secondary contact Dr.P.Langi Program Manager, Malaria Control Program Organization Ministry of Health, Uganda Ministry of Health, Uganda Mailing address P.O.Box 7272, Kampala Uganda P.O.Box 7272, Kampala Uganda Telephone Ext 256 Fax Mob: address 96

3 4.3 National context for this Component Disease burden [Please provide 1-2 paragraphs on each of the following]: Latest data on prevalence, incidence and other disease measurements, including data sources used Malaria transmission is high in 90% of Uganda, with 5% of the country, mainly in the highland areas, subject to low, unstable transmission and epidemic prone 1. It is estimated that 93% of the total population are at risk from malaria. Although all four species of the parasite exist in Uganda, plasmodium falciparum is responsible for over 95% of cases. This parasite has shown increasing resistance to both CQ and SP when used separately as monotherapy and more recently as a combination. Malaria contributes the major share of the disease burden with 39% of outpatient attendances and 35% of inpatient admissions being due to malaria 2. In recent years there has been an increasing trend in clinically diagnosed malaria cases reported in the HMIS (government and NGO health facilities) from 5 million cases in 1997 to 16.5 million cases in This translates into a 2003 incidence rate of 0.98 per person per year in children under 5 and 0.64 per person per year in older patients (based on HMIS data). The two major reasons for this increase are thought to be 1) the abolition of user fees in the public sector with increased utilization and 2) increasing treatment failures due to drug resistance. Since it is known from various surveys that approximately 60-80% of fever cases are treated in the informal and private sector, these figures translate into 65 million fever cases in 2003 treated as malaria. The estimated case fatality rate in 2001 was 4.05% of in-patient cases 3. Current estimated annual numbers of deaths from malaria are from 70,000 to 100,000. Prevalence rates for malaria parasitaemia (asymptomatic) range between 50% and 80% in young children, 20%-50% in older children and generally below 30% in adults Stage and type of epidemic, and most affected population groups As stated previously, malaria is endemic in 95% of the country with approximately 50% of the country experiencing very high transmission levels above 50 infective bites per person per year with maximum of 1,000 infective bites (holoendemic), 30% medium to high transmission level (10-50 bite per person), 15% low transmission (1-10 bites per person), and the remaining 5% has low or unstable transmission. This implies that in most of the country older children, adolescents and adults will have some degree of partial immunity and conversely, children under 5 and pregnant women (particularly first pregnancies) are the most affected population groups. Due to the increased levels of clinical malaria in AIDS patients and people living with HIV/AIDS, this group also has to be considered at increased risk Describe the political commitment in responding to the disease, including by reference to internationally agreed-to s (e.g., the commitment by African Heads of State to increase health sector spending to 15% of public expenditure) (1 2 paragraphs) The Government of Uganda has shown a growing commitment to health with an increased allocation of GoU resources to health over the years from 4.2% in 1997/8 to 10.2% in 2003/4. The health sector has received the largest proportionate rises in budget compared to other sectors in the last two GOU budgets. The overall resource envelop for health has been rising at 1 WHO, Malaria Consortium, UNICEF: Rolling Back Malaria in East Africa, 2003 Update 2 Ministry of Health, Quoted in: WHO, UNICEF, The Africa Malaria Report Malaria Control Programme, Ministry of Health, 2001: Baseline Survey for Monitoring and Evaluation of RBM Indicators in Uganda 97

4 an average of 9% per annum. 4 These funds are particularly ed to funding the minimum health care package in which malaria control is a high priority. Uganda abolished taxes and tariffs on insecticides and materials for malaria control in 2000 which has brought down the price of Insecticide Treated Nets for malaria prevention. It also abolished user fees in 2001 which has lead to an increase in outpatient attendances and better access to anti malarial case management. Financial allocations to malaria control have been mainly through local government health services and an expanding network of primary health care facilities, thus ing the most vulnerable rural dwelling populations List the national disease control strategies consulted in the preparation of the proposal, and describe how lessons learned from the implementation of these strategies have been incorporated in this proposal (2 3 paragraphs) 1. This proposal is based on the Health Sector Strategic Plan 2000/1 to 2004/5 which prioritizes malaria in the provision of a minimum health care package. 2. The National Malaria Control Strategic Plan 2001/2-2004/5 (NMCSP) also is a key reference document in the preparation of this proposal. One of the four main malaria control strategies in the plan - case management, forms the basis of this proposal. The main aims of this strategy are to improve treatment seeking behaviour, improve access to effective diagnosis and treatment, and ensure an adequate supply of effective drugs and ancillary supplies. 5 The main set for case management in the plan is in accordance with that of Roll Back Malaria and the Abuja Declaration (i.e. to increase the proportion of the population at risk of malaria who receive appropriate treatment for malaria within 24 hours of onset of symptoms, to 60% by the end of 2005). Other supporting strategies listed in the NMCSP that are referred to are; advocacy, IEC and social mobilization, human resource development, systems strengthening and support supervision. 3. This global fund proposal also refers to the home based management of fever strategy and implementation guidelines and the current antimalarial drug policy which states choloroquine and sufadoxine-pyrimethamine in combination as its first line treatment. 4. The Integrated Management of Childhood Illness strategy is used for the management of all clinical cases of fever in children under five year of age. The Community IMCI approach will guide the introduction of ACTs at community level. Implementation of the NMCSP entailed a change in anti malarial drug policy in 2002/3 from a first line treatment using chloroquine to a combination of chloroquine and SP. The capacity built in management of this process at national, sub national and district levels, as well as the design of training and support materials, will be drawn upon heavily in the implementation of the next drug policy change List any broader development initiatives (e.g., Poverty Reduction Strategy Papers, Highly-Indebted Poor Countries initiative) ongoing in << Uganda >>, and describe the links between this proposal and these initiatives (2 3 paragraphs) The Poverty Eradication Action Plan (PEAP) is the name given to Uganda s PRSP. The PEAP emphasises the need to build up four main pillars to reduce poverty; 1. Fast and sustainable economic growth and structural transformation 2. Good governance and security 3. Increased ability of the poor to raise their incomes 4. Increased quality of the life of the poor. 4 Ministry of Health: Midtern Review Report, Health Sector Strategic Plan (2000/1-2004/5) 5 Malaria Control Programme, Ministry of Health: Malaria Control Strategic Plan 2001/2-2004/5 98

5 The provision of primary health care is seen as a key intervention in improving the quality of life of the poor (the fourth pillar of the PEAP). However, given the economic impact both direct and indirect of malaria on household livelihoods, the control of malaria contributes to the achievement of the first and third pillars as outlined above. Allocation of HIPC funds is based on the PEAP and most of the funds allocated to the health sector flow through a Poverty Action Fund (PAF). The PAF is mainly disbursed to the districts to support the processes of decentralisation of health services and the expansion of the primary health care network as well as the implementation of the minimum health care package, in which malaria is prioritised. At least fifty per cent of funds must be spent on purchase of drugs and antimalarials form a large bulk of these drugs. There is no specific HIPC funding ed towards the National Malaria Control Programme Describe how the proposal will contribute to broader efforts to reach the Millennium Development Goals (www.un.org/millenniumgoals) (1 2 paragraphs) Three of the MDG s goals and s for 2015 related to this proposal are: Goal No. 4: Reduce child mortality No. 5: Improve maternal health No. 6: Combat HIV/AIDS, malaria and other diseases Target No. 5: Reduce by two thirds the under five mortality No. 6: Reduce by three quarters the maternal mortality ratio No. 8: To have halted and begun to reverse the incidence of malaria and other major diseases Malaria contributes to: high morbidity and mortality, poverty (people who are sick do not work and the treatment costs money), poor performance at school (absenteeism of teachers and pupils due to ill health and partial residual brain damage leading to low mental capacity in patients who survive severe malaria) and poor pregnancy outcomes (severe anaemia, abortion, still birth, premature delivery and low birth weight babies). By providing effective malaria case management there would be a positive impact on under five and maternal mortality and the reversal of other major diseases Describe the links to international initiatives (e.g., the World Health Organization/UNAIDS 3-by-5 initiative to address the insufficient access to antiretroviral therapy, the Global Plan to Stop TB, and the Roll Back Malaria Partnership) (1 2 paragraphs) This proposal is in line with the National Malaria Control Strategic Plan which is fashioned on the RBM initiative and includes goals and s for all intervention strategies, including case management, based on those of the Abuja declaration. In a recent Roll Back Malaria country needs assessment (REAPING) by the global RBM partnership in conjunction with the country partnership, Uganda highlighted the drug policy change process among its essential interventions in need of support both financial and technical. Progress with interventions for malaria control is measured against baseline data for the RBM process. As a result of the RBM initiative, partnerships have been formed between various stakeholders at national level for improved malaria control. In addition, Uganda is a member of the East Africa Roll Back Malaria Network (EARN) which provides inter-country learning opportunities and an extensive technical support network. 99

6 4.3.7 Is there a sector-wide approach or other fund-pooling mechanism in place in the health sector? [If yes, briefly describe how it operates and if you anticipate using it to administer part/all of the Global Fund grant (1 2 paragraphs)] The sector-wide approach brings the MoH and a large number of its development partners together such that all are working towards a shared vision, plan and priorities as outlined in the National Health Policy 1999 and operationalised through a series of rolling five year Health Sector Strategic Plans (HSSP). The first of these strategic plans (2000/1-2004/5) is approaching its final year of implementation and preparations are already underway to prepare the HSSP 2. A number of the development partners are contributing to a common health sector basket of funding while others have committed themselves or started to commit themselves to general budget support through the Ministry of Finance and Economic Development. This common approach is governed through a number of structures, especially the Health Policy Advisory Committee. Progress is monitored and evaluated through Joint Review Missions and a Mid Term Review. The Global Fund grant will not be administered through this mechanism. [For HIV components only:] a. Is there a World Bank Multi-Country HIV/AIDS Program? Yes No Indicate names and types of key agencies providing technical assistance to the national response Table Technical Partners in National Response Name of Agency Type of Agency (academic/educational sector; government; nongovernmental Main technical focus (e.g., prevention, care and support, treatment, etc.) and community-based organizations; people living with HIV/AIDS, tuberculosis, and/or malaria; the private sector; religious/faith-based organizations; multi-/bilateral development partners) World Health Organisation Multilateral Prevention, treatment, IEC, health systems Malaria Consortium, East and Southern Africa International NGO Prevention, treatment, IEC, health systems USAID Bilateral Development Prevention, treatment, IEC African Medical Research and Education Foundation (AMREF) UNICEF Regional Centre for Quality Health Care UPHOLD (USAID/Malaria Consortium) Partner International NGO Multilateral Development Partner International NGO NGO Multi District Project Yes No Prevention, treatment, human resource development Prevention, treatment, IEC Human resource development and quality assurance Health systems 100

7 Earmarked financial contributions to the national response to this disease [List the financial contributions dedicated to the fight against this disease by all domestic and external sources.] Financial contributions to malaria control in Uganda comprise: Government budget national and local government Donor project funding NGO overseas donations Fee for service charged by private sector (NGOs, SCOs) Global Fund Malaria Project monies (2 nd Round application) The table below estimates resources spent on malaria control from 2001 to Given the proportionate burden of malaria, it is estimated that 30% of total health sector resources are being spent on malaria. Existing Global Funds monies secured for malaria control (2 nd Round application) for have been added to these annual estimates. Table Financial Contributions to National Response Estimated Financial contributions in USD (millions) Domestic External External (GF 2 nd Rd) Total resources available Total resource needs [Describe the total resources needed to combat this disease.] Table Total resource needs In USD (millions) Total resources available 73,000,000 73,000,000 73,000,000 62,000,000 69,000,000 Total need 73,000, ,803, ,240,637 94,173,544 99,104,194 Unmet need 0 31,803,244 35,240,637 32,173,544 30,104,194 [Describe the source of the resource needs (e.g., costed national strategies), or, if they were estimated for the proposal, how the estimates were developed (1 paragraph)} The total resource available are taken from The resources needed as outlined in table are estimates. While the round 2 proposal in conjunction with the resources available from Government are sufficient for the current year, the need for a change in drug policy to the more expensive ACTs is associated with unanticipated high costs. The unmet need reflects the monies requested in the current Global Fund proposal. The combined monies of both proposals along with government contributions will enable Uganda to implement its comprehensive multi-strategy five year plan and attain the Abuja s Describe plans to ensure that any Global Fund resources received would be additional to the existing and planned resources (2 3 paragraphs) There is already an existing arrangement with the principal recipient (Ministry of Finance, Planning and Economic Development) to the effect that GF funds will remain additional to existing funds committed to the Ministry of Health through its priority programmes. The same arrangement will be adhered to in the course of implementing this proposal. 101

8 [Global Fund financing should be additional to existing and planned resources in the fight against AIDS, tuberculosis and malaria, and so should not replace existing domestic or external resources] Analysis of gaps in coverage of key service delivery areas [Please list any key service delivery areas from Annex B that are included in national strategic plans but which are currently not available at all or not currently available at sufficiently wide scale] Prompt effective antimalarial treatment Home based management of fever Mass media Information, Education and Communication Insecticide Treated Nets Malaria in pregnancy Indoor Residual Spraying Health systems strengthening Procurement and supply management capacity building These key service delivery areas are to be addressed using the round 2 Global Fund grant Does this application focus primarily on scaling up existing interventions, introducing new interventions, or both? Scaling up New Both a. If scaling up or both, describe how the interventions addressed in the proposal build upon existing programs (2 3 paragraphs) b. If scaling up or both, describe how the interventions to be scaled up were identified from among other existing interventions (1 2 paragraphs) c. If scaling up or both, indicate the major barriers to scaling up the interventions that have been identified as proven and effective have not previously been scaled up [Check as many as apply, and then briefly (1 2 paragraphs) explain each barrier below.] Policies, standards and guidelines National capacity (health systems, human resources, etc.) Stigma, discrimination and human rights Gender-related issues Financing Other (please specify: ) a. If scaling up or both, describe any innovative aspects to scaling up these interventions (2 3 paragraphs) If new or both, describe how the new interventions addressed in the proposal complement and build upon existing programs (2 3 paragraphs) The change in antimalarial drug policy to ACT complements the existing National Malaria Control Programme objectives of reducing malaria related morbidity and mortality as well as preventing and minimizing the economic impact attributable to malaria as outlined in the NMCSP. This will be achieved through the key strategy of strengthening case management which aims to improve treatment seeking behavior at community level, improve access to effective diagnosis and treatment, and ensure an adequate supply of drugs and ancillary supplies. 102

9 This proposal will first focus on making effective malaria treatment available in all public and NGO health facilities and later at community level for home based management of fever as well as answering questions surrounding the operational use of Rapid Diagnostic Tests in case management to facilitate scaling up of this tool in a rational manner. The proposal will also address supply and drug management issues particular to ACTs which have a shorter shelf life than previous therapeutic options for malaria case management. A major element of the National Malaria Control Strategy as well as the previous Global Fund proposal is the Home Based Management of Fever Strategy (HBMF) which provides free, prepacked anti-malarials at community level for children less than 5 year of age. This programme component will continue to be an essential part of malaria control as it significantly improves access to adequate treatment outside the formal health facilities. In the first year of the proposal, ACTs will be introduced only at health facility level and in the second year the ACTs will be introduced at community level. As there is no previous experience with the use of ACT at community level through community health workers, a pilot study will be carried out in the first two years of this proposal in a limited number of districts. The findings of this pilot study will inform the scaling up of HBMF using ACT to the rest of the country during the remaining period of the proposal If new or both, describe how these interventions were identified (1 2 paragraphs) While not a new intervention, antimalarial drug policy change represents a significant change and adjustment of existing health systems in order to deliver this costly drug in an efficient manner that allows easy access to all groups, especially those most vulnerable. The need for this drug policy change was identified through an established network of sentinel sites throughout the country that monitor efficacy of current antimalarial drugs and give information on possible new efficacious antimalarials. Data indicate that parasite resistance (clinical and parasitological failure) to the current first line antimalarial combination chloroquine and sulfadoxine-pyramethamine- are at 16% on average, which exceeds the WHO threshold for change of drug policy (see section ) If new or both, describe why these interventions were not previously in widespread use (1 2 paragraphs) The intervention of case management has already been in use. ACTs have not been in use on a widespread basis due to their limited availability, high cost and the presence of cheaper, efficacious drugs up to this point. RDTs have not been in widespread use due to the highly endemic nature of malaria relative to the high cost of treatment kits. Given the high rates of asymptomatic parasitaemia (see section ), this made clinical diagnosis a more cost effective intervention. However, with the introduction of more expensive antimalarials and the reducing cost of RDTs, there is now a need to review this position and investigate the cost effectiveness of this tool in certain settings and groups where over-diagnosis may warrant more rational therapy (e.g Urban centres, adults, private sector) If new or both, describe any innovative aspects to these interventions (2 3 paragraphs) Not applicable 103

10 Does this application complement earlier grants from The Global Fund? Yes No If yes describe how this application complements earlier grants from the Global Fund (1-2 paragraphs) A first malaria proposal was approved in the second round of the Global Fund and a grant agreement signed in February 2004 (Grant Number UGD-202-G02-M-00). That proposal focuses on two main interventions, a national voucher scheme for the provision of subsidies to pregnant women and children under 5 for the purchase of ITNs and the expansion of community based distribution of a malaria combination therapy for the home based management of childhood fevers to national level (HBMF). In addition, the proposal covers training in malaria case management (uncomplicated and severe), including IMCI training, at various levels and strengthening of malaria microscopy as well as focused indoor residual spraying and social mobilization and advocacy for malaria control. The need for antimalarial drug policy change is clearly outlined in section The process of building consensus for a drug policy change is well under way. Although a definite decision has not been made, there is broad agreement among stakeholders that the new recommendation will consist of one of the currently available artemisinin-based combination therapies (ACT) as first line treatment in health facilities and later at community level. Since the current budgeting for malaria drugs within the Health Sector Strategic Plan (HSSP) is not able to accommodate neither the higher cost of the ACT nor the cost of its implementation, the new GF proposal is intended to close this gap. Scaling up of the HBMF strategy is supported by the second round Global Fund grant and this will be continued during this proposal using the a new and more effective first line malaria therapy. It is, therefore, directly complementing the previous proposal and will ensure that progress towards more effective treatment of malaria episodes is consolidated. 4.4 Program Strategy Goal, Objectives, Services to be delivered and Main Activities Table 4.4A: Goals and impact indicators Number Goal 1 Reduce malaria related morbidity and mortality Number Impact indicator Baseline 2-5 year 1 All cause mortality in children under 5 years 2 Number of hospital admissions in children under 5 due to malaria in public and NGO hospitals per 1000 population of under 5 ( to be determined in 5 sentinel hospitals) 3 Proportion of children age 6-23 months with severe anemia 4 Number of malaria cases treated within public and NGO health facilities 152/1000 (2000/01 UDHS) 74.5 (2003 HMIS) 15.4% (2000/01 UDHS) 16 million (HMIS) Year in which will be reached 95/ % million

11 Table 4.4B1: Objectives Goal Reduce malaria related morbidity and mortality Number Objective 1 To increase availability of highly effective artemisinin-based malaria treatment at health facility level. What percentage of the people reached by this objective will be 50% women? What percentage of the people reached by this objective will be 20% youth? What percentage of the people reached by this objective will be in: Rural areas 89% Urban areas 11% What percentage of the services in this objective will be delivered by: Government 75% Non-governmental partners 25% Private sector --- What percentage of people trained will be: Health personnel 100% Non-health personnel What percentage of people trained will be: Government 75% Non-governmental partners 25% Private sector ---- Describe, for each objective, which groups are important beneficiaries of this objective (check all that apply): Injecting drug users Men who have sex with men Mobile populations Orphans People living with HIV/AIDS Sex Workers Youth (in school) Youth (out of school) Other (please specify: general population) 105

12 Table 4.4C1: Services to be delivered Objective 1 To increase availability of highly effective artemisinin-based malaria treatment at health facility level. Number Services to be delivered 1 Category Prompt and effective antimalarial treatment Description Procurement and distribution of effective antimalarial treatment in a timely fashion to all government and NGO health facilities Coverage indicator Baseli ne Year 1 Year 2 Year 3 Year 4 Year 5 1 Proportion of 70%* 65% 80% 85% 85% 85% health facilities w/o stockout of antimalarial drugs (2002) Main activity Indicator Implementing partners 1 Procure antimalarial drugs through Project Management Unit One year supply of effective malaria drug combination delivered by end of each years 3 rd Project Management Unit 2 Distribute drugs to government health facilities through National Medical Stores 3 Distribute drugs to NGO health facilities and hospitals through Joint Medical Stores 4 Develop long-term finance strategy for ACT * current 1 st line drug combination of CQ/SP quarter Bimonthly drug distribution records Quarterly drug distribution records Strategic plan available National Medical stores Joint Medical Stores NMCP, Development partners, consultant 106

13 Objective 1 To increase availability of highly effective artemisinin-based malaria treatment at health facility level. Number Services to be delivered 2 Category Procurement and supply management capacity building Description Capacity building to ensure effective drug supply management at district, health sub-district and health facility level Coverage indicator Baseli ne Year 1 Year 2 Year 3 Year 4 Year 5 1 Number of health 0 5, workers trained 2 Number of 0 0 3,900 3,900 3,900 3,900 supervision visits Main activity Indicator Implementing partners 1 Develop guidelines and training Training materials available by end 2 nd NMCP, consultant, tech. partners, NDA manual for supply management quarter 2 Train staff from district, HSD level Number of staff trained NMCP, District health teams, NDA 3 Train health facility Number of staff trained DHT, NGO staff 4 Carry out regular supervision 5 Monitor drug supply flow Proportion of planned supervision visits carried out Annual reports on drug flow and leakage DHT, NGO DHT, NGO, NDA, academia Table 4.4C2: Services to be delivered Objective 1 To increase availability of highly effective artemisinin-based malaria treatment at health facility level. Number Services to be delivered 3 Category Monitoring, Evaluation and operations research Description Establishment and maintenance of a system of pharmacovigilance for new antimalaria treatment* Coverage indicator Baseli ne Year 1 Year 2 Year 3 Year 4 Year 5 1 Number of sentinel sites reporting on severe adverse events 2 Number of government and NGO hospitals reporting on severe adverse events Main activity Indicator Implementing partners 1 Establish reporting format and channels for severe adverse events System established by end of 2 nd quarter 1 st year National Malaria Program National Drug Authority, consultant 107

14 2 Train and supervise health workers from sentinel sites in reporting system 3 Train and supervise health workers from selected government and NGO hospitals in reporting system 4 Test antimalarial drugs for quality* At least 16 health workers from 4 sites trained by end year 1, additional 16 (4 sites) by end 2 nd quarter year 2 At least 40 health workers from 10 sites trained by end year 2, additional 40 (10 sites) by end year 3 Sentinel sites for drug sensitivity monitoring, District Health Teams, National Drug Authority District Health Teams, National Drug Authority NGO hospitals Annual reports on testing National Drug Authority available * monitoring of drug quality included in previous GFATM malaria grant for year 1 and 2 108

15 (continued) Goal Reduce malaria related morbidity and mortality Number Objective 2 To ensure demand for and correct and efficient use of highly effective artemisinin based malaria treatment. What percentage of the people reached by this objective will be 50% women? What percentage of the people reached by this objective will be 20% youth? What percentage of the people reached by this objective will be in: Rural areas 89% Urban areas 11% What percentage of the services in this objective will be delivered by: Government 65% Non-governmental partners 20% Private sector 15% What percentage of people trained will be: Health personnel 70% Non-health personnel 30% What percentage of people trained will be: Government 65% Non-governmental partners 20% Private sector 15% Describe, for each objective, which groups are important beneficiaries of this objective (check all that apply): Injecting drug users Men who have sex with men Mobile populations Orphans People living with HIV/AIDS Sex Workers Youth (in school) Youth (out of school) Other (please specify: general population) 109

16 Table 4.4C4: Services to be delivered Objective 2 To ensure demand for and correct and efficient use of highly effective artemisinin based malaria treatment. Number Services to be delivered 1 Category Health systems strengthening Description Training of health workers on new drug policy Coverage indicator Baseli ne Year 1 Year 2 Year 3 Year 4 Year 5 1 Number of health 0 17, workers trained Main activity Indicator Implementing partners 1 Develop training manual and materials on new drug policy Training materials available by end 2 nd quarter NMCP, IMCI, RH, consultant, tech. partners 2 Train central and district/zonal teams of trainers 3 Train health facility staff 4 Carry out regular support supervision Number of staff trained Number of staff trained Proportion of planned supervision visits carried out NMCP, District health teams DHT, NGO DHT, NGO, NMCP Table 4.4C5: Services to be delivered Objective 2 To ensure demand for and correct and efficient use of highly effective artemisinin based malaria treatment. Number Services to be delivered 2 Category Prompt and effective antimalarial treatment Description Implementation of communication campaign to promote new drug policy Coverage indicator Baseli ne Year 1 Year 2 Year 3 Year 4 Year 5 1 Number of districts covered by campaign Main activity Indicator Implementing partners 1 Design campaign and materials Concept available by 2 nd quarter year 1, materials tested and available end NMCP, HPE, NGOs, consultants 2 Carry out advocacy for new drug policy 3 Implement mass media and promotion campaign year 1 Number of political and opinion leader and health professionals reached Number of districts covered NMCP, HPE, NGOs NMCP, HPE, NGOs, 110

17 Table 4.4C6: Services to be delivered Objective 2 To ensure demand for and correct and efficient use of highly effective artemisinin based malaria treatment. Number Services to be delivered 3 Category Operations research / Health systems strengthening Description Develop a system to use Rapid Diagnostic Tests (RDT) to optimize effective use of antimalarial drugs, develop guidelines for application of RDT and implement these at national scale Coverage indicator Baseli ne Year 1 Year 2 Year 3 Year 4 Year 5 1 Number of districts involved in pilot 2 Number of districts applying RDT policy Main activity Indicator Implementing partners 1 Design RDT pilot project and implement in 3 districts Project proposal agreed upon by end 2 nd quarter, project implemented by end year 1 NMCP, consultants, tech. partners, academia (e.g. IPH) 2 Evaluate results of pilot and develop guidelines for rational RDT use 3 Procure RDT and distribute to gov and NGO HF, sell at subsidized price to private providers 4 Implement RDT policy Guidelines adopted by end 2 nd quarter year 2 RDTs available for distribution by end 2 nd quarter year 2 Number of districts applying RDT policy NMCP, consultants, tech. partners, academia (e.g. IPH) PMU, NMS, JMS DDHS, NGO, private health care providers 111

18 Table 4.4B2: Objectives Goal Reduce malaria related morbidity and mortality Number Objective 3 To implement ACTs at community level using the Home Based Management of Fever (HBMF) Strategy. What percentage of the people reached by this objective will be 0% women? What percentage of the people reached by this objective will be 100% children below five years of age? What percentage of the people reached by this objective will be 0% youth? What percentage of the people reached by this objective will be in: Rural areas 89% Urban areas 11% What percentage of the services in this objective will be delivered by: Government 80% Non-governmental partners 20% Private sector 0% What percentage of people trained will be: Health personnel 10% Non-health personnel 90% What percentage of people trained will be: Government 30% Non-governmental partners 70% Private sector 0% Describe, for each objective, which groups are important beneficiaries of this objective (check all that apply): Injecting drug users Men who have sex with men Mobile populations Orphans People living with HIV/AIDS Sex Workers Youth (in school) Youth (out of school) Other (please specify: children under five years) 112

19 Objective 3 To implement ACTs at community level using the Home Based Management of Fever (HBMF) Strategy Number Services to be delivered 1 Category Strengthening of the home based management of fever strategy Description Training of community drug distributors on new drug policy Coverage indicator Baseli ne Year 1 Year 2 Year 3 Year 4 Year 5 1 Number of , , CORPS trained Main activity Indicator Implementing partners 1 Prepare for implementation of ACTs at community level using the HBMF strategy Results of pilot study available for planning scale up of HBMF with ACTs NMCP, IMCI, consultant, tech. partners 2 Adapt the existing training manual and materials to include ACTs 3 Re-orient HBMF trainers and CORPs on the revised training materials 4 Carry out regular support supervision Revised manuals and materials available for training CORPS Number of CORPS trained Proportion of planned supervision visits carried out NMCP, IMCI, consultant, tech. partners NMCP, District health teams DHT, NGO, NMCP 113

20 Table 4.4C7: Services to be delivered Objective 3 To implement ACTs at community level using the Home Based Management of Fever (HBMF) Strategy. 2 Category Prompt and effective antimalarial treatment Description Procurement and distribution of effective antimalarial treatment in a timely fashion for use at community level (home based management of fever) Coverage indicator Baseli ne Year 1 Year 2 Year 3 Year 4 Year 5 1 Proportion of 70%* -- 50% 60% 70% 80% community drug distributors without stock-out of antimalarial drugs (2003) Main activity Indicator Implementing partners 1 Procure antimalarial drugs through Project Management Unit One year supply of effective malaria drug combination delivered by end of each years 3 rd quarter with effect from Project Management Unit 2 Distribute drugs to communities through National Medical Stores,, districts and health facilities the second year Bimonthly drug distribution records National Medical stores, Districts, health facilities Describe the quality and type of the training to be carried out (e.g., delivery of ART services according to national guidelines, or peer counseling in sexual and reproductive health, according to national youth mobilization guidelines). There are two major components of training: one for drug supply management and the other on the application of a new malaria drug policy. Both will follow a cascade training system using a central/zonal team as trainers of trainers, then training district and health sub-district staff which in turn will train health facility staff and CORPs. This system has been used in the past and there is good experience with it. As much as possible staff training at facility level will be on-site training during support supervision and both elements mentioned above will be combined wherever possible. At community level, the existing training guidelines will be adapted for orienting the existing CORPs in the use of ACTs in home management of fever. Training for the introduction of HBMF using ACT will be based upon the current National HBMF strategy and guidelines for implementation but with alterations made according to the findings from the pilot study. Much capacity has already been built among health workers in the operationalisation of this strategy Describe the broad approach for human resources development, including how adequate human resource capacity will be developed to support program scale up (2 3 paragraphs) Human resource development is not addressed in this proposal component. Rather it is catered for by the Health Sector Strategic Plan. 114

21 4.4.3 Describe the key risks and assumptions made in preparing this proposal (3 4 paragraphs) The costing of the estimated drug needs for ACTs is based on Coartem although a definite decision on the ACT to be used is still to be made. However, this assumption does not at all alter the rationale for the proposed programme nor will it influence any of the objectives or services suggested. It will only have implications for the actual cost and these potential changes are small since the price range of available WHO pre-qualified ACTs is quite narrow. A further assumption is that sufficient ACT drugs will be available on the world market in order to supply the calculated demand in the year This is a more critical assumption since the simultaneous change to ACTs in several African countries might put considerable stress on manufacturers and particularly growers of the Artemisia annua plant needed for production. It is also assumed that ACTs will remain efficacious for the period of this proposal and beyond. Finally, it is assumed that prices of commercially available ACTs will significantly decline over the time period giving increasing access to these drugs also in the private for profit sector. By extending training as well as availability of subsidized rapid diagnostic tests (RDT) to this important partner, this proposal will prepare the ground for effective use of the drugs Describe gender inequities regarding access to the services to be delivered (1 2 paragraphs) There is no indication that access to malaria treatment is in any way gender biased Describe how this proposal will contribute to minimizing these gender inequities (1 2 paragraphs) Not applicable Describe the populations that are particularly vulnerable to this disease (1 2 paragraphs) Populations vulnerable to clinical malaria episodes are children under 5 years of age, pregnant women and people living with HIV/AIDS (details see section ) Describe how these populations are involved in planning the program and how they will be involved in implementing and monitoring it (including, if appropriate, describe their role as service deliverers) (1 2 paragraphs) While the under fives are not involved in the planning and implementation, pregnant women and people living with HIV/AIDS are involved as part of the wider community. This involvement is described in Describe how principles of equity will be ensured in the selection of patients to access services, particularly if the proposal includes services that will only reach a proportion of the population in need (e.g., some antiretroviral therapy programs) (1 2 paragraphs) Not applicable Describe how this proposal will contribute to reducing stigma and discrimination against people living with HIV/AIDS, tuberculosis, and malaria, and other types of stigma and discrimination, including gender-based, that facilitate the spread of these diseases (1 2 paragraphs) Not applicable for malaria 115

22 Describe how the beneficiaries of this proposal (e.g., people living with HIV/AIDS, tuberculosis, and/or malaria) and/or affected communities are involved in planning the program and how they will be involved in implementing it (including, if appropriate, describe their role as service deliverers) (1 2 paragraphs) Not applicable Describe how the communities involved in this proposal are involved in planning the program, and how they will be involved in implementing it (including, if appropriate, describe their role as service deliverers) (1 2 paragraphs) There is increasing evidence that communities and their leaders give malaria issues and treatment in particular high priority., Communities are participating in decision making on issues affecting health service delivery at health facility and community level as members of Health Unit management Commitees (HUMCs), Parish Development Committees and Village Health Teams (VHTs). In those districts currently implementing HBMF, communities are playing a direct role in service delivery through improving availability, access, and correct use of the current first line anti malarials. They also actively participate in choosing their community drug distributors to provide this service. This involvement will be scaled up during the implementation of the round 2 proposal and complemented through the introduction of a highly effective malaria treatment during this current proposal For malaria components only: If the proposal contains anti-malarial drugs or insecticides, include data on drug resistance and/or resistance of vectors in the country or in the population/area (1 2 paragraphs) Uganda has established a sentinel surveillance system for anti-malarial drug sensitivity testing in 1998 in the context of the East Africa Network for Monitoring Antimalarial Treatment (EANMAT) using a standard protocol according to WHO guidelines. This system is further supported since 2002 by the Uganda Malaria Surveillance Project (UMSP), a collaboration between MoH, Makerere University and University of California, funded by CDC. Data on resistance is complemented by studies carried out by MoH before 1998 as well as studies by other partners such as Epicentre, Medical Research Council (MRC) or German Technical Corporation between 1995 and Before the year 2000 resistance testing was limited to chloroquine (CQ) and sulphadoxine-pyrimethamine (SP) but with the change of drug policy to a CQ/SP combination therapy (implemented in 2002) testing of single drugs was abandoned. To date results are available for the following combinations: CQ/SP, Amodiaquine (AQ)/SP and Artesunate (AS)/SP. One study on COARTEM is ongoing, another in preparation and AS/AQ is currently tested at 3 sites. All data presented in the following paragraph refer to clinical failure rates within 14 days of follow-up in children below the age of 5 years. Failure rates to CQ averaged (median) 28.5% (10 sites, range 9-81%) between 1995 and 1998 and 33% (11 sites, range %) between 1999 and Respective values for SP were 5.5% (8 sites, range 3-25%) and 12% (15 sites, range 0-18%) and increased further in to 16% (2 sites, 9-26%). The combination CQ/SP was tested at 3 sites and 7 sites in The median failure rates were 7% (0-12%) and 11.7% (5.5-45%) respectively. The AQ/SP combination was tested in 3 sites and 4 sites and failure rates were 1% (0-3%) and 7% (0-16%). AS/SP was only tested in 2 sites between 2001 and 2002 with rates of 1% and 2.8%. In view of these data and the current availability of options it is evident that the current 1 st line anti-malaria treatment with CQ/SP is soon reaching the end of its useful life and the only option currently is to move to an artemisinin-based combination therapy. 116

23 4.5 Program and Financial Management [In this section, CCMs should describe their proposed implementation arrangements, including nominating Principal Recipient(s). See the Guidelines for Proposals, Section V.B.3 for more information.] Will implementation be managed through a single Principal Recipient or multiple PRs? Single Multiple [Every component of your proposal can have one or several Principal Recipients. In table below, you must nominate the Principal Recipient(s).] Responsibility for Implementation Table Implementation Responsibility Nominated Principal Recipient(s) Ministry of Finance, Planning and Economic Development (MOFPED) Area of Responsibility Health Contact Person Permanent Secretary, Secretary to the Treasury MOFPED Address, Telephone & Fax, address P.O. Box 8147 Kampala, Uganda Fax: Describe the process by which the CCM nominated the Principal Recipient(s). [Minutes of the CCM meeting at which the Principal Recipient(s) was nominated should be included as an Annex to the proposal] The MOFPED is the only organization mandated by law to receive any money on behalf of a government agency or from a foreign entity such as the Global Fund. [If there are multiple PRs, questions should be repeated for each one.] Describe the relevant technical, managerial, and financial capabilities for each nominated Principal Recipient. THE MOFPED has extensive experience in donor funded projects and bilateral funding mechanisms, operating at national and district levels, and involving public and private sectors and civil society organizations. The Ministry of Health currently has several project implementation units and project desk officers with the capacity to disburse, track and compile accounts for funds intended for potential recipients. The PMU managing the GFATM programs needs to be expanded. We have recommended that the following staff be added: one fulltime coordinator, monitoring and evaluation expert, and administrative assistant Has the nominated PR(s) previously administered a Global Fund grant? Yes No 117

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