Contextual information: The Botswana National TB Program (BNTP) is funded with contributions from the Botswana Government (GOB), PEPFAR, the Global Fund Round 5 grant and the African Comprehensive HIV/AIDS Partnership (ACHAP).

Botswana, a middle-income country with a population of 1.86 million, is plagued by one of the most serious TB and HIV epidemics worldwide. It has one of the highest TB notification rates. In 2005 10,392 (all cases) have been notified which translates into a rate of 602 per 100,000 population. 93.4% were new, 6.6% re-treatment cases. But only 33.8% were sputum smear positive cases. In 44.7% of cases no smear was done. 12.1% are extra-pulmonary TB cases. The treatment success rates in new ss+ cases registered in 2004 were 71% with 11% death rate, 8% default rate, 9% transfer out rate and 1% treatment failure rate (overall 13% of patients were not evaluated). In 2006 only 8,519 (all cases) were notified (rate 453 per 100,000 population), 38% were new smear positive case. Treatment success in new ss+ patients registered in 2005 was equally low at 70% (37%), failure, default and transfer out rates similar to the year before. However, the death rate decreased from 11 to 7%. The decline in cases is rather related to the problems with data capturing at district level than caused by a real decline. There is a wide variation in performance between districts. There are more than 200 cases of MDR-TB have been detected in 2005. 4,583 TB cases or 53% of TB cases were tested for HIV of whom 71% tested positive (2006).

TB Infection Control (IC) is considered a serious problem by caretakers, and a national TB infection control manual was produced. Challenges remain at district and health care settings in terms of implementation. Scale-up of TB-IC - particularly in HIV/AIDS care settings - is not well established. New hospitals were constructed without any consideration to TB-IC. Admission/isolation facilities for X/MDR-TB patients are not present, not even in the main referral hospital, although a 17 bed ward was refurbished for this purpose in Gaborone. Turn-around time for sputum-smears in the hospital is around 3 days generally.

The scale-up of TB/HIV in Botswana appears to be rather successful in provision of provider initiated counseling and testing (PICT) to TB patients and ensuring care, with about 68% of TB patients having an HIV test result, Cotrimoxazole preventive treatment (CPT) being routinely offered, and about 30% of TB patients started on ART (ETR.Net reports, 2008).

Current situation and proposed activities: TB CAP was approached by the USAID country mission to support capacity building and accelerate scale-up of TB/HIV collaborative activities, MDR-TB management, and TB-IC through the recruitment and posting of three TB CAP technical staff in the Botswana Ministry of Health (MoH) and the National TB Reference Laboratory (NTRL). Assessment missions conducted by PMU TB CAP and KNCV consultants in November 2007 and March 2008 discussed with different stakeholders (MOH, CDC/BOTUSA, ACHAP, PENN, etc.) how the above mentioned areas could be strengthened. Job descriptions for 3 staff were discussed and agreed upon. Contracting modalities and financial management in Botswana were discussed. Since the formulation of a 5 year costed strategic plan is considered critically important by all stakeholders, TB CAP technical assistance to the development of this plan is a part of this proposal. In order to be able to manage the TB CAP project in an efficient manner, KNCV Tuberculosis Foundation was advised to register as an international NGO in Botswana and hire financial administrative services to manage any in-country expenditures.

Three technical staff were recruited:

1. TB Technical Advisor to the National Health Laboratory, based in the NTRL in Gaborone; working in close collaboration with BNTP and BOTUSA professional staff, focusing on capacity building and development of quality assured C/DST services, laboratory management system, data management, MDR-TB surveillance, new laboratory technology

2. Chief Medical Laboratory Technician, based in the NTRL in Gaborone; working closely with the Head of the NTRL and TB CAP NHL Technical Advisor, focusing on the development of External Quality Assurance (EQA) of the sputum smear microscopy network

3. TB/HIV Technical Advisor, seconded to the Central Unit of BNTP; assisting the Program Manager of the BNTP on collaborative TB/HIV activities and related components of the Stop-TB Strategy, functioning as the liaison between TB CAP, BNTP, the Department of HIV/AIDS Prevention and Control (DHAPC), and other important implementing partners in particular CDC/BOTUSA.

KNCV will provide technical support through backstopping, country visits and facilitating of training for the recruited staff where appropriate, in order to ensure high quality technical assistance, appropriate for the needs of the Botswana BNTP.

Rationale: Given the operational challenges faced by the BNTP, TB CAP support is considered strategically important to provide support to the strengthening of the laboratory services for TB control, as well as the program management of patients dually infected with TB/HIV, with or without drug resistant tuberculosis. TB CAP wishes to support, in good partnership with MOH, the development of the NTRL/CRL into a well-functioning laboratory, fully equipped and capable of performing the roles and responsibilities needed for supporting excellent clinical management of drug susceptible and X/MDR-TB, routine drug resistance surveillance, and quality assurance of the sputum-smear microscopy network. TB CAP will support coordination between the many different partners now supporting TB, TB/HIV and TB-IC activities, in particular: MOH, CDC/BOTUSA, ACHAP, PENN, I-TECH and URC.

Comparative advantage: TB CAP conducted a TB-IC training followed by a TB-IC country strategic workshop in Botswana in February and May 2008 in Gaborone. KNCV has participated in the World Bank (WB) mission in 2007 for the upcoming HIV/TB WB loan to the Botswana Government and participated in the IPT program joint review in May 2008. The composition of partners in TB CAP, and their track record in building strong TB programs, is considered an important comparative advantage.

Attribution: TB CAP will operate in Botswana in partnership to BOTUSA/CDC, PEPFAR, GAP, UPenn, ACHAP and URC, which all support TB and TB/HIV work. The impact of TB CAP support can so far only be measured by the successful performance of the three staff it will recruit. This technical assistance can be strategically very important for capacity building, and improved management of the laboratory and the BNTP. It is however obvious that much of the capital inputs for improving program operations will come from GOB and other donors.

Project technical approach:

1. Registration as international NGO

KNCV registered as an international not-for-profit NGO in Botswana, and as a USAID technical partner in TB, thus benefiting from the USAID/GOB bilateral agreement. A local organization familiar with the USAID/GOB bilateral agreement and procedures for registering as a foreign organization was contracted to assist with recruitment of staff, with opening of a bank account in Botswana, and with other support in managing payments of the salaries of the three TB CAP staff that will be hired, and with facilitating country visits of KNCV consultants.

2. Recruitment of three professionals

All three staff were in place by October 2009.

3. Memorandum of Understanding BMOH/KNCV

KNCV signed a Memorandum of Understanding with the Botswana MOH. This MOU describes how KNCV and BMOH will administratively cooperate under the existing USAID-MOH bilateral agreement, in order to achieve transparency and accountability of KNCV's operations with the MOH and vice versa.

4. Professional development TB CAP/KNCV staff

Capacity building of and knowledge transfer to the Botswana colleagues is considered critically important and core to this projectKNCV values that the KNCV contracted staff remains up-to-date with latest policies and technical standards and therefore provides support for professional development where this is considered relevant for contract staff. Funding will be set aside for in-service training of recruited KNCV staff as considered appropriate.

5. External technical assistance

It is important that the KNCV staff is also properly supported, advised and supervised. KNCV will therefore provide external technical assistance to the three staff both during country visits as well as from a distance. This support will also be available to supporting the Central Unit BNTP in whatever issue that needs technical support and needs the assistance from the external KNCV advisor.

Next steps and relation with other interventions and IRs:

One of the three staff was appointed as Coordinator of the TB CAP Project (COP) in Botswana. Personal annual workplans will be developed and in-service training will be conducted as required. KNCV will guarantee regular distant support by e-mail and telephone. Three country field visits are budgeted during the project period in support of staff and general technical support according to pre-agreed TORs with BMOH and USAID. Reporting on progress and activities will be quarterly. Annual performance evaluation with employees and beneficiaries will be conducted