Expanding TB Case Finding in the Face of COVID-19

In February 2020, as the spread of the COVID-19 accelerated across the globe, the Malawi National Tuberculosis and Leprosy Elimination Program (NTLEP) submitted a concept paper for a TB commitment grant (TCG). The concept focused on increasing facility-based case finding, an important intervention to find missing cases and increase TB case notification. Neither the NTLEP, TIFA, nor USAID recognized at the time that the pandemic would affect all of our lives for the foreseeable future. As understanding grew that grant development and TB services would need to adapt to a COVID-19 world, TIFA and the NTLEP found new ways to work together to implement interventions for Malawi’s TB-affected populations.

Adapting approaches to implement through COVID-19

JSI Research & Training Institute, Inc. which implements TIFA, adapted virtual grant co-design. To facilitate the process, TIFA provided airtime allowances to NTLEP staff so they could join the virtual co-design sessions from home. As NTLEP began developing its grant, staff took COVID-19 realities into consideration.

“We captured what we thought would be a challenge in the future and included the costs for multiple venues, multiple sessions, and airtime for staff involved in the implementation of the activities in our budget,” noted Birru Shigut, Senior Global Fund and TB Advisor, NTLEP Malawi. The result was an activity plan designed to succeed even in the face of COVID-19.

The NTLEP combined several strategies including smaller training sessions, virtual meetings, and, where feasible, hybrid meetings, with the implementation of the COVID-19 prevention measures such as wearing of masks, the use of hand sanitizer, and spacing to get the work done. In some cases, they found advantages they had not anticipated. “We had one activity where we reduced the number of participants, it was supposed to be one workshop, but we split it into three with fewer staff in the conference room. That helped us to facilitate the discussion, and it was a very interactive discussion because of the small groups,” described Shigut.

“In the beginning, we needed to get organized. This is a new approach, we had to face some challenges. Issues of getting accounts open took some time, coordinating different areas of the ministry. It took some time for activities to start flowing.”- Lameck Mlauzi, Officer, NTLEP

The NTLEP addressed new challenges to successfully get work done through virtual platforms. “For the activities planned at the national level, we planned for air time so that we could meet remotely. Because people are very busy, they are outside of the city on different assignments; we assigned a certain time—outside of working hours even—to have a discussion on the development of SOPs and training materials. Even though we could not meet physically, we allocated air time from the beginning to cover these challenges. Staff knew this would be provided, which made it easier to finalize things at the national level,” added Shigut.

NTLEP also budgeted for and provided personal protective equipment (PPE) for meetings, a necessary intervention that was welcomed by participants. Dr. Kuzani Mbendera, Care and Treatment Officer, NTLEP Malawi, explains, “The wearing of masks, the use of hand sanitizer, spacing—these are things that were always going to be well received by health workers. We had no issues with people understanding why we need these things and from what [we] see in the meetings, even for those that have to speak, they keep their masks on.” Providing PPE encouraged participation and facilitated implementation, in addition to protecting people and enabling safe, responsible activity implementation.

Working through challenges

With the successes also came challenges, the NTLEP also had to respond to COVID-19 service needs, and coordinate large programs funded by the Global Fund and the World Bank at the same time they were designing the TIFA grant.

“By the time we started developing the TCG, there were a lot of priorities for the NTLEP. There are several projects—World Bank, Global Fund….then the COVID-19 grant. The staff had a very tight schedule during that period, but we were able to manage and complete the first TCG development process,” notes Shigut.

Dr. Mbendera added that while the internet enables people to connect to calls and meetings from any location, all locations are not necessarily conducive to joining a virtual meeting. Staff sometimes struggled to join meetings while dealing with obligations at home or virtual meeting times conflicted with field visits or important in-person meetings at the Ministry of Health; yet expectations remained that, because the meeting was virtual, staff should always be available.

Outside of COVID-19, the Malawi NTLEP grappled with other challenges. The TCG was the first grant solely implemented by the NTLEP through the national health systems management structure. Previously the MOH put in place parallel project management teams with dedicated staff for Global Fund and World Bank supported activities. However, USAID and NTLEP opted to use the TCG to leverage the existing system with the aim of supporting a more sustainable management structure that could continue to function beyond the grant.

From the start, the NTLEP found itself scaling hurdles. The final grant agreement needed to be reviewed and approved by both the Ministry of Justice and the Ministry of Health, getting the grant through these agencies took longer than expected. In addition, the grant needed to be signed by the Permanent Secretary of the Ministry of Health. Once the grant was signed, the MOH finance and administration team ran into an unexpected challenge opening a bank account into which TIFA could deposit funds. It took NTLEP and the MOH finance and administration team five months to establish a functional operating account so that NTLEP could draw down TIFA funds.

Moving toward sustainable success

While slow and challenging, NTLEP showed remarkable resilience in the face of COVID-19 and other challenges faced, and the difficulties of using the government systems to manage its grant. The NTLEP attributes their success to their strong team. “Part of the success is because there is continuity, a mixture of expertise, it’s because we’ve been together for a long time. We are transferring lessons learned seamlessly as we move on to the next project, as we go between projects,” explains Dr. Mbendera.

The NTLEP’s second grant, focused on TB case finding in the private sector, took significantly less time—only a month—to work through the government system and be signed by the Principal Secretary. Once the MOH finance and administration team resolved the bank account issue, funds started flowing. Between May and October 2021, NTLEP achieved five milestones and TIFA has issued over $100,000 USD in payments for successful milestone completion. Perhaps most importantly, the NTLEP is expanding TB case finding while protecting staff and patients from COVID-19 through the safe strategies it built into its grant—ensuring social distancing, availability of personal protective equipment, and remote meetings.