Global Fund Grant TLS-T-MOH Narrative Proposal
Hamutuk Nasaun Saudável

May 2023

A. Background and Rationale for the Proposal

In Timor-Leste, rates of both tuberculosis (TB) and malnutrition are high. The TB incidence rate in Timor-Leste is the second highest in Southeast Asia. Among mothers, ~ 37% of pregnant women are anaemic (DHS, 2016); ~ 25% of non-pregnant women are thin; and ~ 38% of children 0-59 months are underweight, with ~13% between 6-11 months with acute malnutrition (wasting) (UNICEF Nutrition Survey, 2013). The two are linked: malnutrition increases the relative risk for active TB disease by three times, therefore the benefit of diagnosing and treating both diseases is twofold.

However, the burden of TB among malnourished mothers and their children in Timor-Leste is unknown. Operationally, diagnosis of TB among children under five years and, especially, under two years, is a global challenge. More evidence is required in this area, as well as innovative solutions. Solutions could be in the form of integrated malnutrition and TB screening activities, technology innovation, empowerment of mothers for initiating and continuing breastfeeding, prompt linkages with TB treatment and malnutrition correction, and better integration between nutrition and Maternal and Child Health (MCH) departments. Such solutions could help to both improve MCH outcomes and accelerate progress towards ending TB in Timor-Leste.

Beyond diagnosis, it is important that people diagnosed with TB start treatment as soon as possible. As TB illness is extremely infectious, spreading easily in situations where there is long, frequent, and close exposure over time, such as in family settings, a contact tracing regime to screen and test household members is important. Further, beyond starting treatment, it can be difficult to maintain patient compliance to TB medication. A large proportion of the Timor-Leste population live remotely and access to health care can be difficult, meaning that often people do not start treatment as advised, or do not return to clinics for follow-up care.

All Community Health Centres (CHCs) in Timor-Leste have both ANC and nutrition clinics, providing opportunity for integrated TB screening among malnourished mothers and children. This can be done by 1) Fast-tracking of TB diagnosis by assessing for acute malnutrition in mothers and
children when they visit ANC and/or nutrition clinics at CHCs, artificial intelligence in reading X-rays, and rapid diagnosis by molecular diagnostic test; and 2) Empowering pregnant and lactating
women to improve nutrition for themselves and their children by accessing nutrition counselling and
participation in nutrition-focused mother support groups at the CHC.

B. Program Description

The ”One Stop” Mobile Diagnostic Van has a digital X-ray machine, artificial intelligence to read the X-rays, and a molecular diagnostic tool and since October 2022 has been conducting Intensified Case Finding (ICF) activities in four CHCs and related health posts of Dili Municipality. The focus of the mobile diagnostic van is to screen for TB among malnourished mothers (Both ANC and PNC
mothers), children, and general adult presumptive TB at four CHCs in Dili. HAMNASA (Hamutuk Nasaun Saudável) is the Sub-Recipient that has been implementing the project. HAMNASA proposes a continuation of the project beyond the pilot, from 1 January 2024 to 31 December 2026. HAMNASA proposes:

1) Continuation of the current intensified case finding model, with diagnostic screening of patients referred to the van at CHCs. In coordination with health staff at each CHC, health providers screen patients for TB and malnutrition and refer presumptive or vulnerable cases to the mobile van for X- ray, and sputum test if required. HAMNASA health staff refer positive cases back to the health providers for treatment. HAMNASA also liaises with health providers at health posts to have sputum transported to Dili for testing.

2) Continuation of the nutrition focused mother support groups monthly at each CHC and counselling of pregnant women and mothers with young children regarding nutrition and TB status. Improving nutrition status is integral to preventing TB infection; HAMNASA refers people for TB and nutrition counselling and liaises with the health providers at the CHCs to provide monthly nutrition support groups for mothers. The groups discuss nutritious foods and healthy ways to prepare food. Between December 2022 and March 2023, HAMNASA organised eight nutrition support groups at four CHCs.

3) Continuation of the “camps” or community engagement activities at selected sites around Dili, in coordination with local authorities. HAMNASA identifies sites in communities around Dili to locate the mobile van for a day and liaises with relevant local authorities to mobilise the community to access the van for screening and testing on that day. Between October 2022 and March 2023, HAMNASA organised camps in which communities screened and tested 4,079 people through this activity.

4) Expansion of the current model to Metinaro CHC. To date the intervention has been focused on the four city CHCs in Dili Municipality; it is possible for the van to travel to Metinaro, located just outside of Dili city, hence the new intervention proposes to also include Metinaro CHC, meaning that all Dili CHCs will be included.

5) Expansion of the current model to include contact tracing of TB positive patients to their household members and referral of presumptive or at-risk cases to health facilities for appropriate treatment. This activity would operate in all CHCs in Dili, including Metinaro. HAMNASA’s CHC Focal Points would expand the scope of their work to include contact tracing and referral back to health facilities. Health providers can prescribe treatment of positive TB cases if necessary, or Tuberculosis Preventive Treatment (TPT) for others.

6) Change in the current model of paying health providers for sputum, to transporting TB presumptive patients from the health post to the van at the closest CHC. This new approach will be in line with the Standard Operating Procedures (SoPs) of the diagnostic van that requires X-ray screening before sputum testing. Transported patients will be able to be tested directly. A local transport mechanism will be used for this.

HAMNASA has been implementing the mobile diagnostic van project since October 2022 and has shown strong results thus far. Between October 2022 and March 2023, HAMNASA has been able to meet and exceed targets in six instances, for the following indicators: ICF: Presumptive TB examined >5% of OPD there was 30% achievement, 100% of mothers sensitized on TB and counselled at the health facilities, 100% of TB presumptive patients identified by the counsellors and referred to the diagnostic facility, a total of 4,079 X-rays conducted between October 2022 to March 2023, and 66% of malnourished children (<5 years) screened for TB. After six months of implementation, TB focal points have screened 1,260 pregnant women.

Program goals and objectives remain the same as the current HAMNASA-run project.
C. Program Goals

1. To reduce the incidence of TB infection among the general adult population

2. To reduce the incidence of TB infection among pregnant women, mothers, and children

3. To reduce the incidence of TB infection among pregnant women mothers and children diagnosed with malnutrition

4. To integrate TB screening, diagnosis and treatment into routine antenatal, postnatal and nutrition services for pregnant women, mothers and children in order to reduce risk and improve health outcomes

D. Program Objectives

1. Increase in TB screening, detection and treatment among the general adult population

2. Increase in TB screening among pregnant women, mothers and children under five, including those who are malnourished

3. Increase in TB case detection particularly among pregnant women, mothers and children under five and those who are malnourished

4. Increase in number of people, particularly pregnant women, mothers, and children under five and those who are malnourished, who successfully complete TB treatment

E. Program Activities

1. Intensified Case Finding (ICF) in all CHCs in Dili including Metinaro CHC:
1.1. At high patient load health facilities

− Fast-tracking TB diagnosis and treatment initiation among all OPD patients in five
CHCs in Dili

− Integrated TB screening among malnourished mothers and children and patients with diabetes

− Testing in the ‘One Stop Mobile Diagnostic Van’ that has digital X-ray machine, artificial intelligence to read the X-rays, and molecular diagnostic tool (Truenat)

− Contact tracing among household members of confirmed TB positive patients, including referral to health facilities for Tuberculosis Preventive Treatment (TPT)

1.2. Vulnerability mapping and screening of vulnerable populations to include malnourished mothers, children, and pregnant women, including those accessing PNC services and people with diabetes

2. Screening for malnutrition among mothers and children, followed by screening of TB among them and adults.

2.1. Apply MUAC in assessing for acute malnutrition, in both pregnant and non-pregnant mothers, and their children. MUAC will be done by health staff at the health facilities in accordance with MoH guidance: <23 cm for any form of malnutrition and <19 cm for severe malnutrition.

2.2. Through the screening for malnutrition (MUAC) mechanism the project will screen a child if the child has: 1) persistent cough or (unspecified) fever for more than 14 days; or
2) history of unexplained weight loss (i.e. loss of more than 5% body weight as compared to highest weight recorded in last 3 months) or no weight gain in past 3 months; or 3) history of exposure to a sputum-smear microscopy positive TB case,
followed by either a positive sputum-smear microscopy result or a combination of Mantoux tuberculin skin test (TST) of ≥10 mm and chest radiograph suggestive of TB. Mothers and children diagnosed with TB will be referred to the health facility to initiate treatment.

3. Specimen collection and transportation from all the health facilities’ three CHCs to the mobile van as per its weekly rotation:

3.1. Establish specimen collection and transportation (SC&T) of the presumptive TB patients from the health facilities to the ‘One-Stop TB Diagnostic Van’ by the existing NTP staff.

The model will change from the current model of SC&T that has not proved to be useful to the mobile diagnostic van due to the van’s SoPs that require that the X-ray needs to first take place in the van with presumptive diagnosis for the sputum to be collected. Sputum cannot be tested in the van without the patient first receiving a presumptive diagnosis from
an X-ray taken in the van. Transferring sputum only is not useful. The model will be changed so that presumptive TB patients are instead referred to the van for both X-ray and sputum collection. This will be coordinated by health providers at health posts, who will bring
together a group of presumptive TB patients who will be transported by a vehicle organised by HAMNASA.

4. Mothers assessed as at risk of or currently suffering malnutrition will be referred to mother support groups held monthly at the CHCs for nutrition discussion.

5. Counselling for mothers with TB on treatment adherence by health providers at the health facilities and on nutrition.

6. Camps/community engagement and screening – a set number of camps per month in communities, coordinated with local authorities. The diagnostic van travels to communities where people are tested.

7. Contact tracing of household members of positive TB patients, with referral either to mobile van or health facility for testing and to a health facility for prescribing of TPT if eligible. HAMNASA will follow existing systems and workflows for contact tracing for screening of household members. HAMNASA will employ existing strong relationships with health providers at CHCs to refer presumptive and positive cases. Through the contact tracing mechanism, HAMNASA will identify mothers including pregnant mothers who can be referred to the CHC for nutrition testing and counselling.

Workflow
The implementation of the program activities requires a close working relationship between HAMNASA staff and health providers at the CHCs as well as the relevant TB officials at the municipality health service and on the National Tuberculosis Program (NTP). HAMNASA staff will be primarily responsible for the operation of the equipment in the mobile diagnostic van and referring patients to the van for testing, and back to the CHC for treatment, follow-up, and
counselling. CHC health providers will also refer screened patients for testing to the van, specifically the general population, mothers and children diagnosed with malnutrition and diabetes patients. HAMNASA will conduct contact tracing of household members and refer presumptive and eligible preventive cases to health facilities for treatment. HAMNASA will organise quarterly meetings with TB health teams including municipal TB officer, NTP and health facility staff.

F. Proposed institutional framework and ability to work with others in ensuring grant performance and sustain intended impact of the Global Fund grant.
The overall coordination of PR and SRs is managed through regular coordination committee meetings. Performance review meetings are held on a quarterly basis with all SRs at the central level. The meetings discuss the strengths and weaknesses of implementation, and feedback is also provided to respective SRs on achievement of their program targets.

Institutional and Technical Implementation:
HAMNASA is a national legal and registered NGO in Timor-Leste with a very good reputation with the Timor-Leste Ministry of Health, as well as with local communities, municipal health authorities and international donors. HAMNASA has recently transitioned from international NGO status as Health Alliance International (HAI). HAMNASA has all the essential resources to implement this project.

HAMNASA has a technically strong team of senior managers, program managers, health promotion and clinical staff, who all have skill and experience implementing health programs in Timor-Leste, particularly focused on health promotion, community engagement, and clinical training and follow- up in maternal and child health. HAMNASA has worked closely with the Timor-Leste Ministry of Health as HAI for over 17 years.

HAMNASA has organisational systems in place to support effective program and fiscal management including a senior leadership team, skilled and experienced finance and administration team and monitoring and evaluation staff. HAMNASA has all required policies in place, a high-quality procurement system and is experienced at donor reporting, including Global Fund reporting. HAMNASA’s Board of Directors meets every two months to discuss key issues relevant to the organisation.

HAMNASA has established, strong relationships with the MoH, MCH Department and Dili Municipality Health Service. HAMNASA’s long history of providing support to the MoH in Timor- Leste has facilitated the creation of a close partnership model. This partnership approach has been evident so far during the implementation of the mobile diagnostic van program since mid-2022, through the strong working relationships that HAMNASA staff have created with the health providers and officials at CHCs in Dili. An extension and expansion of the mobile diagnostic van program will see a continued strong partnership approach led by HAMNASA.