Michelle Bromberg Abdulrazig Hummaida- AD GH 101 28 February 2011 Global Fund Proposal Tuberculosis in Nicaragua Political/Economic Situation Although

the political situation of Nicaragua has been wrought with instability and civil war, this country is now making efforts towards a path of democracy and neo-liberal economic policies. Nicaragua was devastated by structural adjustment plans and political turmoil during the 1980s. To assuage the gastronomical piles of accumulated debt, the International Monetary Fund required the cutting of social services, including funding to the health care sector. If the set backs caused by these policies were not enough, in 1998 Hurricane Mitch shredded the landscape, as well the economy. Since then, Nicaragua has worked with the IMF to develop a poverty reduction strategy. This has resulted in the cancellation of $200 million in debt by the IMF, and $1.5 billion by the World Bank. Nicaragua is also a participant of the Millennium Challenge Account, which was an initiative signed by President Bush in 2005 that provides increased assistance to countries that have a particularly low income and are interested in cultivating democracy, social development, and economic growth. Nicaragua does receive foreign support for political and economic development, but the country is still in need of assistance in terms of health care. Because of the policies of the IMF, health care spending was heavily reduced, leading to the dismissal of health care workers, inadequate funding for medication, sub par facilities, and many other issues. However, since the United States and other countries have deemed Nicaragua capable of managing private aid in an accountable manor, it seems reasonable to give this country the

health funding that it needs while it works on ameliorating its political, social, and economic matters. Health Care in Nicaragua The public health system suffers from a wide variety of issues, including inadequate supplies, insufficient human resources, unmotivated personnel, and poor infrastructure. The Ministry of Health provides free treatment for diseases that have been targeted by public health campaigns, including tuberculosis (TB). Unfortunately, this only occurs in theory, as the drugs are often unavailable. Most of the health services in Nicaragua are provided by the Ministry of Health. Social security programs cover approximately 5% of Nicaraguans, while 4% of the population is insured by the private sector. 1 Doctors are unmotivated due to low salaries The funding for health care comes from six major sources: grants to the government (30.1%), private companies (21.2%), taxes (16.1%), loans to the government (15.8%), outof-pocket payments by service users (11.9%), and NGOs (4.9%). 2 The MOH took over the administration of Nicaraguan social security (Instituto Nicaraguense de Seguridad Social [INSS]) and its health programs during the 1980s due to the IMFs policies regarding the consolidation of government. This INSS provides medical coverage for about 5% of the country. 3 There are 873 publicly owned primary health care units, 708 of which are health posts that are rarely used. These posts receive very few patients because they are understaffed and lack drug supply. Although underused, these facilities hold great potential for service
1 2

http://www.paho.org/english/HIA1998/Nicaragua.pdf http://www.paho.org/english/HIA1998/Nicaragua.pdf 3 http://www.paho.org/english/HIA1998/Nicaragua.pdf

provision. Only 10% of rural inhabitant must walk more than two hours to reach a health post. In regard to TB in particular, Pan American Health Organizations Strategic Plan claims an important challenge is the poor engagement of communities, affected persons and civil society organizations in TB control, as well as the weak participation of the private sector and some institutions of the public sector in not adhering to the International Standards for Tuberculosis Care (ISTC). 4 This proposal seeks to directly involve the community by training community health workers (CHW) and holding education programs about TB. Because the Global Fund is a private source, this grant would address the inadequate participation from the private sector, but also strengthen the public sector, as this proposal seeks to work closely with the MOH. The community health workers, as a part of the public sector, would be trained according to the ISTC, which would improve upon the non-adherence to these standards. Many of the targets of this proposal are similar to the targets of the program of the INSS through the MOH. The use of parallel targets is to acknowledge the competence of the governments program, which is a sound endeavor that lacks sufficient funding. Qualification for Global Fund Grant Nicaragua is a low-middle income country. In order to qualify for a Global Fund grant, the proposal must focus on poor or vulnerable populations and show regard for the cost sharing principles, which means that the support provided by the Global Fund must be less than 65% of the disease program budget. This proposal aims to treat and prevent TB throughout the country, but it still fulfills the requirements for funding in that it is the poor and marginalized population of Nicaragua
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http://www.paho.org/English/GOV/CE/ce142-div3-e.pdf 3

who are affected by TB. This proposal targets the populations that are the most vulnerable in Nicaragua, those being prisoners, impoverished and marginalized citizens, those living with HIV, migrant workers, and indigenous people. TB Statistics in Nicaragua According to the Global Fund, the current rate of incidence is 26 per 100,0000 people. The current number of all types of TB cases is 1,500. Eighty-six percent of TB cases are successfully treated.
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PAHO http://www.paho.org/English/GOV/CE/ce142-div3-e.pdf 4

Tuberculosis Cases per 100,000 People (2002)

Goals The goals of this proposal cover a number of different facets of TB care, as well as health care in general. The main goal is to reduce the number of smear positive TB cases. This will be done in a number of ways. The funds of this grant will go to the INSS through the MOH. The specific programs outlined by this proposal compliment a preexisting program. A key component of this initiative, however, is greater emphasis on strengthening health care systems by training community health workers, who will fulfill multiple roles within their communities. The number of doctors in Nicaragua has risen since 1990, but the number of nurses and auxiliary workers has declined. 6 While doctors are important to health care systems, those who have had less training can oversee many of the cases that need medical attention. The training of CHW is important to help relieve the burden on the health system without creating a new financial burden. This proposal also aims to work within the framework of the StopTB campaign so that coordination between pre-existing TB programs in Nicaragua can be achieved. The
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http://www.paho.org/english/HIA1998/Nicaragua.pdf 6

goals of Stop TB are: 1) Achieving universal access to high-quality diagnosis and treatment tailored to patients. 2) Alleviate the suffering and socioeconomic burden associated with TB. 3) Protect the poor and vulnerable TB co-infection TB / HIV and MDR tuberculosis (MDR-TB). 4) Promote the development of new tools and enable their effective use as quickly.7 The goals of this proposal are as follows: 1) Detection and diagnosis: The first step to reducing TB prevalence is to detect all cases so that they can be treated and cured, which will eventually stop transmission. There are currently 2,336 smear positive TB cases that have been diagnosed in Nicaragua. Despite not knowing the quantity of undiagnosed cases, the target is to detect 93% of sputum smear-positive cases by 2014, which is the same goal as the INSS. The intention of this proposal is for trained community health workers to increase the number of diagnoses by asking member of the community about new/undiagnosed cases in the villages in which they work. An initial group of CHWs would be trained according to established ISTC and DOTS standards by DOTS workers that have already been trained by the existing Global Fund grant.8 These initial trainees would recruit more CHWs from all parts of the country, and training would be done in waves until sufficient numbers of CHWs are reached. An equal number of men and women will be hired, and they will receive the same salary. Another aspect of improved detection and diagnosis requires a technical aspect. A previous proposal made to the Global Fund in Round 10 requested more microscopes and trained lab technicians, but that request did not receive funding. This proposal delegates some funds to purchase these microscopes and train lab technicians. These technicians
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http://www.paho.org/French/AD/DPC/CD/stop-tb-strat.htm This agreement is assumed to have been discussed with the other parties involved prior to the creation of this proposal 7

would also be trained in the upkeep of the laboratory supplies so that the equipment does not become useless prematurely. They would be trained to perform monthly equipment checks. This equipment and the operators would be divided among four regional laboratories. This decentralization of equipment allows prevents inaccessibility to diagnostic services in rural areas. TB is detected through the analysis of sputum samples. The diagnosis process would be much more efficient due to the furnishing of preexisting health posts. When a new case of TB is suspected, a CHW would collect a sputum sample. Upon returning to the health post at the end of the workers shift, the sample would subsequently be sent to the closest regional lab for inspection. Upon detection of a TB case, the lab will notify the CHW, and prescription will be sent to the closest health post. 2) Treatment availability : Another goal is to increase the availability of treatment to those diagnosed with TB. This goal directly addresses the MOHs inability to consistently provide the drugs for TB treatment free of charge. The target of this goal is to provide 90% of those diagnosed with TB with a full course of treatment, which is the same target as the INSS. This will be done by purchasing drugs from domestic drug companies so as not to create dependence on foreign drug supplies. This proposal will also invest 3% of the grant into domestic pharmaceutical companies to ensure that enough medicine is available at appropriate prices for other diseases, as well. Community health workers will help in ensuring that those in the community who need treatment actually receive treatment by acting as a liaison between the stores of medicines in health posts and their patients. CHWs will distribute medication daily to those who have a prescription. 3) Treatment adherence: The final goal is to lower treatment abandonment to 4%, which mirrors the goals of the INSS. The current treatment success rate is 86%. 9 The
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http://portfolio.theglobalfund.org/Country/Index/NIC?lang=en 8

abandonment rate will be lowered by training CHWs to perform Directly Observed Treatment Short course (DOTS). Currently, DOTS coverage is at 90%.10 This proposal will train enough CHW so that everyone with TB will be seen daily. This may seem drastic, but it is important to ensure that the TB antibiotics are taken in order to prevent MDR-TB and MDRX-TB and eradicate TB. Since the Union and the INSS already have programs to fight TB set up in the area, the DOTS component of this proposal will function by using the pre-existing DOTS strategies that are used by this and other organizations. This will ensure consistency of treatment, prevent conflict between private funding sources, and ease the burden of coordination by the MOH. These DOTS strategies are: 1) Sustained government commitment to increase human and financial resources. 2) Case detection by sputum smear microscopy. 3) Standardized regimens treatment with proper case management and Directly Observed Treatment (DOT) when needed 4) Regular uninterrupted supplies of essential TB drugs. 5) Standardized recording and reporting. 11 4) Prevention: A smaller set of community health workers will be trained in teaching about TB and how it is spread, the number of which depends upon the following goal. These CHWs will be responsible for a region small enough that they can spend adequate time teaching about prevention to all villages in their assigned region in the span of a year. They will be connected to the same regional offices to which the DOTS CHWs report. After this initial teaching period of one year, the DOTS workers will ensure that good prevention practices are practiced in the villages. A few of the original trainers will be kept on board so that, if necessary, DOTS workers can call upon them to address prevention issues. These
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http://portfolio.theglobalfund.org/Grant/Index/NIC-202-G05-T-00?lang=en# http://www.theunion.org/tuberculosis/technical-assistance.html 9

trainers will also be responsible for compiling and monitoring the data from their regions, which is intended to create a sense of ownership of their regions decrease in prevalence. 5) Coordination: This funding would compliment the strategies and programs that are already provided by many organizations that have come together to create the Stop TB strategy, which provides aid to Latin American countries to fight TB. Aside from the Nicaraguan MOHs own work, there are a number of organizations that collectively work against TB in Central America, but two of the main organizations involved in Nicaragua are the Union (formerly known as the International Union against Tuberculosis and Lung Disease) and the Global Fund (which is currently funding the INSS). Because there are other campaigns besides these two main private donors, the Union has raised concern about the observance of International Standards for Tuberculosis Care (ISTC). This proposal addresses these issues by training according to ISTC, establishing a committee consisting of representatives from these organizations that would coordinate efforts to fight TB. Another concern is the interference with domestic government programs. This proposal would give grant funding to the government to pay for the salaries of the CHWs. The most recent data from the Global Fund puts the national TB incidence at 26 per 100,000 people. This number is down from 50 per 100,000 that was seen in 2004. This decrease in incidence may be attributed to the Round 2 Global Fund grant that aided the INSS in funding detection and treatment programs in seven regions with highest TB incidences. With increased funding to this country, Nicaragua has the potential contain TB cases and prevent new ones from arising. This decrease would take place by targeting the most vulnerable populations of Nicaragua, those being prisoners, impoverished and marginalized citizens, those living with HIV, migrant workers, and indigenous people.
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PAHO, http://www.paho.org/English/GOV/CE/ce142-div3-e.pdf 10

This grant would pay to train community members to oversee DOTS in the villages in which they live. These community workers would go out to the houses of those infected with TB to watch them take their medications every day. These workers would also ensure that the TB patients have adequate supplies of medications and ask if any new cases had developed in the area, then report back to a central base for the region. This is an important component of TB treatment for the whole country. Those infected with TB and do not receive treatment run the risk of infecting others. Furthermore, those who do begin treatment but do not complete the full course of antibiotics can cultivate multi-drug resistant forms of TB, which is even more difficult to treat and could cause revival of TB in parts of the country where the disease is currently well contained. Another goal of this plan is to increase the rate of treatment adherence by 10% by 2015, which would bring the rate from 86% to nearly 95%. There would be enough trained DOTS community workers so that each TB patient would be visited every day. By the end of the first year of funding, at least half of all TB patients should have a trained, designated CHW to oversee their treatment. Priority will be given in areas where MDR-TB is at higher rates. This proposal covers not only covers the specific health issue of TB, but addresses gaps in the health care system, the economy, and the social structure of Nicaragua. Beneficiaries will receive continuous TB treatment and community support. The education and awareness programs of this proposal will involve all of the communities of the country. Those who oversee DOTS will be members of communities, and can act as a link between communities. To address issues of gender inequality, an equal number of male and female CHWs will be hired, and they will be paid the same salary. Also, the education of women

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alongside men about TB will prevent a gender gap in education about the disease. Social equality issues will be addressed by the fact that those with TB, who are often the most marginalized and impoverished members of the country, will receive free treatment. The use of local health posts allows for the inhabitants of the rural west coast (which are the poorest in the nation) have access to treatment. CHWs will visit all parts of the country, and the four diagnostic laboratories will be spaced equally within the four corners of the country. The creation of CHWs will address the MOHs lack of human resources. The creation of these jobs will also benefit the economy. Potential donor objection to this proposal could stem from Nicaraguas reputation for corruption. Nicaragua was ranked as one top ten Latin American countries where corruption is seen as rampant according to Transparency Internationals 2007 Corruption Perception Index.13 This is a valid concern, but efforts are being made to reduce this issue. The U.S. government has allocated USAID funds for the promotion of transparency of local governments and to increase the level of advocacy among citizens. Also, the Global Fund previously funded a program in Nicaragua did not raise any concerns around embezzlement. The goals of this proposal comprehensively address each contributing factor of TB control, including prevention, transmission, diagnosis, and treatment of TB for all infected with this disease. These goals not only address the health of TB patients, but also make strides toward involving the community through education and awareness, augmenting health care systems by bolstering the public sector, and improving the economy by creating jobs.

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Works cited Map generator: Globalis http://www.paho.org/English/GOV/CE/ce142-div3-e.pdf http://www.theunion.org/tuberculosis/technical-assistance.html http://portfolio.theglobalfund.org/Country/Index/NIC?lang=en http://www.paho.org/english/HIA1998/Nicaragua.pdf http://www.paho.org/French/AD/DPC/CD/stop-tb-strat.htm http://portfolio.theglobalfund.org/Grant/Index/NIC-202-G05-T-00?lang=en# http://www.theunion.org/tuberculosis/technical-assistance.html

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