Progress and Initiatives of National Tuberculosis Program in Nepal

The National Tuberculosis Program in Nepal has achieved significant milestones since its inception, including the adoption of strategic initiatives like the Stop TB Strategy and the implementation of DOTS. Various national and international commitments have been made towards ending TB, with a focus on developing innovative guidelines and expanding TB-free initiatives. The program faces funding gaps but receives support from organizations like the Global Fund, WHO, and NGOs to implement TB control activities effectively.

• Tuberculosis control
• National program
• Milestones
• TB-free initiatives
• Global commitment

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1. Overview of National Tuberculosis Program Overview of National Tuberculosis Program NATIONAL TUBERCULOSIS CONTROL CENTER

2. Evolution of TB Strategies

3. Milestones of National TB program Adoption of End TB strategy Stop TB Strategy adopted Use of fixed dose combimation(6 months regimen) DOTS All Over achieved NTP reviewed and recommended DOTS policy XDR TB management programme started Establishment of Tokha Sanatorium 1937 1989 1995 1996 2001 2005 2005 2008 2008 2009 2010 2014 2016 NTC and RTCestablished. DOTS implementation as pilot Adoption of PPM/ISTC Expansion of MDR TB management CB-DOTS initiated GLC recommended MDR TB management as a pilot

4. TB Free Initiatives NSP 2021- 26 Prevalence Survey 2018 NSP 2016-21

5. International and National Commitments to END TB 2014 - WHO End TB strategy established 2015 - UN SDGs adopted 2017 - WHO Global Ministerial Conference on Ending TB in the Sustainable Development Era Nov-2017 - The Moscow declaration to End TB Mar-2018 - The Delhi TB Summit Sep-2018 - UN High-Level meeting on TB Dec-2018 - Commitment from Nepal Parliamentarians

6. To achieve the End TB goals and targets NSP 2021-2026 developed and endorsed Various Guidelines such as ACF, CSS, PPM, Laboratory and TB free initiative guidelines developed for the successful implementation of NSP Rapidly expanded mWRD test- from 27 GX sites in 2016 to 125 by 2021 Reformed and initiated NRL for culture/DST services in NTCC Expansion of >1000 DOTS Center from 2016 to 2021 TB Free Initiatives rolled out to >125 Palikas Response to National TB Program All GeneXpert and DR Centers adopted NTPMIS and all DOTS Center DHIS2/HMIS Web and Case based reporting of DS TB has been rolled out up to HF levels Introduces Shorter regimen for the treatment of DR TB cases Global Fund and GoN are the prime source of Funding to NSP, however there is still around 40% funding gap to fully implement NSP Save the Children International supporting as a PR of Global Fund Grant to implement TB Program in Nepal. WHO is providing technical support actively to implement NSP GoN and Different NGOs are supporting to implement NTP activities in the country Damien Foundation, IOM and other organizations are also supporting to implement TB programs in the country.

7. Burden of TB in Nepal (Findings of National TB PS 2018/19) Mortality (HIV -ve & +ve) Year Incidence (all forms) Prevalence (all forms) 17,003 (9,000- 26,000) 2018 New estimates 69,000 (245 per 100k) 1,17,000 (416 per 100k) 2018 Prior estimates 42,000 (151 per 100k) 60,000 (215 per 100k) 5,500 (3,900 - 7,400) Revised burden, higher by: 1.6 1.8 3.1

8. Burden of TB in Nepal- 2021/22 Every Year (DSTB Estimated) 37,861 DSTB cases and 659 DRTB cases Notified Male: 67% TB is the major leading causes of death in Nepal 31000 TB cases Missed Female: 33% 69,000 New TB Cases 17,000 Death Every Year (DRTB Estimated) Almost half of Nepal's population are infected with TB (Latent Infection) Nepal is a High Burden Country 2800 New DRTB cases >2000 DRTB cases Missed

9. Vision TB Free Nepal Goals Decrease incidence rate from 238 in 2020/21 to 181 per 1000,000 population by 2025/26 Decrease mortality rate from 58 in 2020/21 to 23 per 100,000 population by 2020/21 Reduce the catastrophic cost of TB affected family to zero End TB epidemic by 2035 Eliminate TB by 2050 Objective To build and strengthen political commitment, sustainability and patient-friendly health system to end TB To ensure the identification, diagnosis, quality treatment and prevention of TB VISION, GOALS AND OBJECTIVE OF NSP 2021-26

10. Strategy 1-Increase TB notification / childhood TB cases Intensify active case finding of TB Meaningful involvement of private sector in TB program Community focused interventions Strengthen diagnostic centers DR TB management Capacity development of health workers and NTCC staff TB free initiatives Provide quality TB services through increased universal access to health care by further strengthening the health system of TB program Strengthen Community involvement and ownership in TB free Nepal Campaign Strengthen monitoring system of TB Program Ensured implementation of TB programs through integrated health system for its sustainability during natural disasters other emergencies Strategy and Key Priority Area Strategy 2- Strengthen laboratory services to further improve the management of TB diagnosis and treatment. Strengthen and Expansion of TB Laboratory Services Strategy 3- Quality Improvement of the services for TB prevention, notification and treatment Increase rate in notification of patients of DSTB and DR TB Increase TB treatment success Rate Expand TPT and coverage and strengthen infection control measures at all health facilities Implementation of multisectoral approach and addressing of high risks due to TB co- morbidities Ensure meaningful participation of private and non-governmental sector for effective management of TB services

11. Decrease TB Incidence rate from 238 of 2020/21 to 181/100,000 population by 2026 Decrease Morality rate of TB from 58 to 23/100,000 population by 2026 TB-affected families facing catastrophic costs due to TB (%) = 0% Increase domestic funding up to 70% by 2026 50% of TB cases managed and supported by community by 2026 100% health facilities using digitalized case-based surveillance system by 2026 100% Drug-susceptibility testing (DST) coverage for TB patients by 2026 90% coverage of Latent TB infection (LTBI) treatment coverage among eligible children < 5 yrs, among PLHIV and vulnerable groups by 2026 Decrease 85% and 90% case notification gap for DS TB and DR TB respectively by 2026. 30% TB notification contributed by private sectors by 2026. 100% Documentation of HIV status among TB patients by 2026 90% Treatment Success Rate for DS TB and throughout 2021-26 85% Treatment Success Rate for DR TB by 2026 TB in emergency / pandemic plan available and funded Expected Expected outcomes from outcomes from NSP 2021 NSP 2021- -2026 2026

12. NSP Budget and Gap Source Budget(USD)-In Million % 2021/22 2022/23 2023/24 2024/25 2025/26 Total Total costs for TB control 37.27 37.29 38.65 37.51 41.12 191.84 100% 36.9% GoN 8.23 10.05 17.00 17.05 18.46 70.78 20.1% Global Fund 10.50 6.00 3.99 9.04 9.04 38.56 0.1% WHO 0.10 0.04 0.03 - - 0.17 Estimated/Available 18.83 16.09 21.02 26.08 27.49 109.52 57.1% Funding GAP 18.44 21.20 17.62 11.43 13.63 82.32 42.9%

13. NSP Target and Achievement of TB Notification YEAR 2021/22 2022/23 2023/24 2024/25 2025/26 NSP Target 36800 41600 46400 51200 56000 Funded Target 34400 37800 41800 45200 48600 Achievement 37861

14. Diagnostic Services Province 1 Madhesh Province Bagmati Province Gandaki Province Lumbini Province Karnali Province Sudurpaschim Province GeneXpert site 16 20 21 8 23 7 10 105 Microscopy center 896 83 94 260 61 171 47 180 Culture/DST laboratory 2 1. National Tuberculosis Control Center 2. NATA/GENETUP 3 Culture Lab: Under Establishing (BPKIHS, Pokhara, Surkhet)

15. TB Treatment Services Province 1 Madhesh Province Bagmati Province Gandaki Province Lumbini Province Karnali Province Sudurpaschim Province DOTS center 980 1073 1187 792 841 458 640 5971 DR Center 22 4 3 2 3 3 2 5 DR Sub-center 81 12 18 24 10 13 2 2 DR Hostel 1 1 1 1 1 0 1 7

16. Procurement of Drugs and Lab Consumables TB free initiative activities External Quality Assurance of MC Biannual review of program Supervision and onsite coaching Capacity Building of Health worker- TB modular training, Lab modular training, eTB/DHIS2 training, Doctors training, DR TB Management training ACF in risk and high vulnerable populations Community mobilization in TB screening and referral of TB Contact tracing/TPT in non SR districts Red Book Activities

17. Districts Covered by SRs Districts Covered by SRs Bagmati Sewa Samaj (BSS) Japan-Nepal Health & Tuberculosis Research Association (JANTRA) Trisuli Plus Kapilvastu Integrated Development Services (KIDS 13 5 11 13 1. 2. 3. 4. 5. 6. 7. 8. 9. Kapilbastu Palpa Rupandehi Banke Bardiya Dang Pyuthan Rolpa Nawalparasi Wst. 1. 2. 3. 4. 5. 6. 7. Bhaktapur Chitwan Dhading Kathmandu Kavre Lalitpur Makwanpur 1. 2. 3. 4. 5. Illam Jhapa Morang Sunsari Udayapur 1. 2. 3. 4. 5. Achham Dadeldhura Doti Kailali Kanchanpur 1. 2. 3. 4. 5. 6. 7. 8. Saptari Siraha Bara Dhanusha Mahottari Parsa Rautahat Sarlahi 1. 2. 3. 4. Syangja Kaski Tanahun Nawalparasi Est. 1. 2. 3. 4. Surkhet Salyan Dailekh Kalikot M&E TB SR ORIENTATION NFM3

18. Major Intervention and District Coverage from SRs Screening of TB among Malnourished Children Sputum Courier 42 Contact Tracing 42 29 Screening of family members of Index DR TB cases Childhood TB screening in major hospitals Screening of DR Suspect 42 17 42 TB case finding from referral of Pharmacy Private Practitioners Engagement TPT for the Children 42 7 7 Screening & diagnosis of TB in major hospitals with FAST strategy ACF in Migrants (Cross borders) ACF in Migrants (Prison) 32/ 16 10 9

19. TB Yield in two years period of NFM3 from SRs TB Yield in two years period of NFM3 from SRs Change in Yield SR contribution in TB case Notification 10000 180% 40000 70% 162% 58% 9000 160% 35000 60% 8649 8000 140% 30000 50% 41% 7651 7000 38% 120% 7108 25000 6000 40% 100% 20000 5000 30% 71% 80% 15000 4000 20% 3979 60% 47% 10000 3000 2922 40% 10% 2700 5000 2000 22% 1002 20% 1000 0 0% 585 Jan20-Dec20 Jan21-Dec21 Jan22-Dec22 0 0% BWSN JANTRA KIDS Trisuli+ Total Cases Reported in HMIS Jan21-Dec21 Jan22-Dec22 Total Cases Notified Through SRs Increased By (%) SR Contribution % 19

20. Achievement against Target by SRs in 2021 and 2022 140% 124% 120% 112% 102% 98% 100% 93% 90% 76% 75% 80% 69% 66% 63% 59% 58% 56% 60% 51% 47% 46% 45% 35% 40% 27% 20% 0% Presumptive TB Diagnosis Presumptive TB Diagnosis Presumptive TB Diagnosis Presumptive TB Diagnosis Presumptive TB Diagnosis BWSN JANTRA KIDS Trisuli+ SRs_Total Jan21-Dec21 Jan22-Dec22 20 20XX PRESENTATION TITLE

21. Increment in TB Notification by Interventions Increment in TB Notification by Interventions Intervention Wise Yield 9000 200% 176% 169% 155% 8000 150% 7000 109% 101% 6000 97% 100% 5000 4000 33% 50% 3000 3% 2000 0% -19% 1000 0 -50% Sputum Contact Tracing: Childhood TB Management: DR TB P4P Pharmacy Referral FAST Strategy: ACF in Migrants (Cross borders) ACF in Prison Population Transporation at Hard to Reach Areas: Management : Jan21-Dec21 Jan22-Dec22 21

22. Intervention Intervention- -wise Contribution in TB Case Notification wise Contribution in TB Case Notification ACF in Migrants (Cross borders) 1% ACF in Migrants (Cross borders) 1% Jan21-Dec21 Jan22-Dec22 ACF in Prison Population 0% ACF in Prison Population 0% Sputum Sputum Transporation at Hard to Reach Areas: 37% Transporation at Hard to Reach Areas: 44% FAST Strategy: 25% FAST Strategy: 32% Pharmacy Referral 6% P4P 7% Contact Tracing: 4% DR TB Pharmacy Referral 11% Management : 2% Childhood TB Management: 7% DR TB Childhood TB Management: 9% Contact Tracing: 8% P4P 4% Management : 2% 22

23. Enrollment in TB Preventive Therapy (TPT) Enrollment in TB Preventive Therapy (TPT) (contacts of TB <5 (contacts of TB <5 yrs yrs) ) TPT Enrollment 4000 3372 3500 3000 2500 1992 2000 1654 1500 973 909 1000 634 545 500 289 185 175 0 BWSN JANTRA KIDS Trisuli+ Total Jan21-Dec21 Jan22-Dec22 23

24. Incidence Rate and TB Notification from 2000 to 2021 (WHO Estimation) 35000 140 TB Mortality Rate TB Notification and Incidence Rate 127 40000 450 30000 120 417 400 35000 25000 100 350 30000 300 260 20000 80 268 25000 250 65 229 20000 15000 60 200 58 15000 150 10000 40 10000 100 5000 20 5000 50 0 0 0 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Notificatio of TB (New and Relapse) Estimated Death Mortality Rate Estimated Incidence Rate( 100,000)

25. Distribution of TB by Age Group 30% 25% 20% 15% 10% 5% 0% 0-14 15-24 25-34 35-44 45-54 55-64 65+ 2055/56 2060/61 2062/63 2063/64 2065/66 2066/67 2067-68) 2068-69 2069-70 2070-71 2071/72 2072/73 2073/74 2074/75 2075/76 2076/77 2077/78 2078/79

26. Trend of testing presumptive TB and TB Notification Total Presumptive TB Test (Mc and GX) TB Detection- PBC Cases 450000 40000 400000 399263 35000 33755 350000 30000 300000 278713 25000 250000 250138 23546 236521 22155 21959 20000 200000 200289 193665 19122 18390 150000 15000 100000 10000 50000 5000 0 FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22 0 Total Test (Mc and GX) FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22

27. Trend of Notification vs Enrollment DS TB Diagnosis vs Enrollment DR TB Diagnosis vs Enrollment 40000 40 1000 40.00% 36 35000 35 900 35.31% 35.00% 34.48% 800 30000 30 30.04% 30.00% 27 700 25000 25 26.54% 25.00% 600 21 21 20000 20 500 20.00% 19.33% 16 15000 15 400 15.00% 10000 10 300 10.00% 6 5000 5 200 5.00% 0 0 100 FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22 0.67% 0 0.00% Total TB Cases Notified FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22 Total TB Cases Enrolled on Treatment RR Notified at GX Enrolled DR TB Cases Defulter % Defulter %

28. Trend of TB Notification at National and Province level TB case Notification_Province Wise Trends Trends of Case Notification 10000 140 40000 37861 15% 9000 8000 35000 10.5% 120 32474 13% 32043 31764 7000 6000 28677 30000 Numbers 27745 100 5000 4000 25000 3000 80 Numbers 2000 20000 1000 60 0 15000 7 1 Province 1 2 Madhesh Province 3 Bagmati Province 4 Gandaki Province 5 Lumbini Province 6 Karnali Province Sudurpashc him Province 40 10000 FY 2016/17 4014 6447 7763 2188 6605 1688 3059 20 FY 2017/18 4072 6585 7841 2181 7036 1631 3128 5000 FY 2018/19 4356 6844 7714 2260 6347 1374 3148 FY 2019/20 3828 5709 6586 1977 5665 1243 2737 0 0 FY 2020/21 3559 6641 6664 1876 5921 1191 2825 FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22 FY 2021/22 4433 8981 8832 2449 8090 1652 3424 FY

29. Trend of Distribution of TB by Types 25000 TB Notification in 2021/22 20000 28% 15000 57% 10000 5000 15% 0 PBC PCD EP FY 2016/17 FY 2017/18 FY 2018/19 PBC PCD EP FY 2019/20 FY 2020/21 FY 2021/22

30. Trend of Male Female and Child TB Ratio Trends of Child TB notification (%) Male- Female Ratio (%) 10 70% 64% 64% 64% 63% 8.8 62% 62% 9 60% 8 50% 6.6 7 6.0 5.6 38% 38% 6 5.5 5.5 37% 40% 36% 36% 36% 5 30% 4 20% 3 2 10% 1 0% FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22 0 FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22 Female Male

31. Trend of Private Sector and Community Contribution % of Community Contribution in TB Case Notification % of Private Sector Contribution 22 35 21 33.16 20.63 31.81 20 20 30 19 18.68 25 18 18 23 22 20 19 16 18 15 14 10 12 5 10 0 FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22 FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22

32. Contribution of Private and Community Sector in TB Notification of FY 2021/22 Private Sector Contact Investigation Type of TB Community Pulmonary (BC) Pulmonary (CD) Extra Pulmonary (EP) 4528 4900 1597 2273 1015 263 5243 1157 110 11954 (32.32%) 7072 (18.98%) 1970 (5.29%) Total

33. Impact of C19 in the TB Notification Impact of Covid19 on TB case notification - Trimester Wise Trends 16000 14573 14000 12373 49.44% 11828 11460 12000 10198 9916 9710 9552 9472 9468 9381 10000 8277 8000 6000 4000 2000 0 1st Trimester 2nd Trimester 3rd Trimester FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22

34. TB HIV Collaborative Activities Trend of HIV Test among TB Patients ART Enrollment of TB/HIV Coinfected Patients 40000 37861 35000 221 32474 217 32043 31764 211 206 89% 196 28677 30000 185 27745 162 159 74% 155 25000 144 123 113 69% 20000 67% 72% 54% 15000 51% 10000 5000 FY FY FY FY FY FY 0 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 FY FY Total TB cases FY FY FY FY No of HIV Positive TB Cases No of HIV Positive on ART 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22

35. Treatment Success Rate Trend of DS TB Treatment Success Rate Trend of DR TB Treatment Success Rate 76 96 75 94 74 74 92.4 91.5 91.4 73 92 90.6 90.6 90.5 90.3 90.1 72 90 70 70 70 88 86 68 67 84 66 82 64 80 1 Province 1 3 Bagmati Province 5 Lumbini Province 7 Sudurpashchim Province 62 FY 2016/17 FY 2019/20 FY 2017/18 FY 2020/21 FY 2018/19 FY 2021/22 FY FY FY FY FY FY 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22

36. Death Rate 20% 18% 18% 17% 16% 15% 14% 14% 13% 12% 10% 10% 8% 6% 4% 4% 3% 3% 3% 3% 3% 2% 0% FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22 Death Rate (DS TB) Death Rate (DR TB)

37. Sputum Examination of Presumptive TB 160000 40.00% TB Diagnosed from Sputum Microscopy 151865 300000 26.91% 140000 35.00% 26.24% 247398 250000 120000 30.00% 207964 21.41% 196362 100000 25.00% 200000 182830 19.05% 18.60% 172588 155740 80000 20.00% 69386 150000 13.92% 60000 15.00% 100000 8.64% 40000 10.00% 6.48% 5.25% 50000 4.71% 4.67% 4.61% 20000 5.00% 13563 13170 12062 10672 10110 10062 12336 20192 0 0 0.00% FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22 FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22 Total test Positive Total Test Total TB Diagnosed Prevalence of RR TB Positivity Rate

38. GeneXpert Utilization GeneXpert Utilization - 2021/22 GeneXpert Machine Vs Utilization Rate 30 100 28 93 90 84 25 80 22 72 70 20 60 56 15 55 15 50 45 40 37 9 9 10 30 7 27 25 23 21 20 19 5 3 10 0 0 FY 2016/17 FY 2017/18 FY 2018/19 FY 2019/20 FY 2020/21 FY 2021/22 <1% 1-10% Utilization 11-20% Utilization 21-50% Utilazation 51-75% Utilization 76-100% Utilization >100% Utilization Utilization GX Utilization Rate No to Total GX Machine

39. Progress against Performance Framework (PF) target of NFM 3 160% 140% 120% 100% 80% 60% 40% 20% 0% TCP-5.1 <5 children in contact with TB patients who began preventi 95% 122% 96% TCP-7a Number of notified TB cases (all forms) contribute d by private sector 120% 142% 111% MDR TB- 3 RR-TB and/or MDR-TB that began second- line treatment 103% 114% 80% TB/HIV- 6 HIV positive TB patients on ART during TB treatment TB/HIV-5 TB patients with document ed HIV status TCP-1 Number of notified cases of all forms of TB MDR TB- 2 RR-TB and/or MDR-TB notified M&E-2a Complete ness of facility reporting TCP-2 Treatment success rate Total 16 March to 31 December 2021 1st Jan to 31 June 2022 1st July to 31 December 2022 92% 108% 93% 97% 98% 95% 120% 119% 102% 96% 86% 88% 94% 89% 74% 109% 104% 95% 103% 111% 93%

40. National National Tuberculosis Tuberculosis Program Program Management Management Information Systems Information Systems (NTPMIS) (NTPMIS)- - Nepal Nepal https://ntpmis.gov.np/ 40

41. Reporting Mechanism Reporting Mechanism- -NTP NTP

42. Program and Data Quality Assurance Approaches Frequency Mechanism (Process) Program review workshop on program, logistics, laboratory services and data quality conducted in all Palikas, districts, province and national level subsequently Biannual program review at all level Biannual SDPs is/are determined based on the information received from different MIS. Usually sites are selected on the discrepancies (under/over or no reporting). 1) Supportive Supervision 2) Onsite coaching Monthly Usually done against the commodities, reported vs recorded, reported vs estimation. 1) Data Triangulation 2) Data Verification Quarterly SDPs is/are determined based on the sampling methodology as mentioned by the RDQA SOP. Routine Data Quality Assessment (RDQA) Annual

43. WHO Key technical partner Partner s engaged with National TB Program The Global Fund (GF) with Save the Children (SCI) Key financial partner including technical support NATA, BNMT, JATA, BWSN, JANTRA, KIDS, Trisuli Plus. Key national partner to increase TB case notification Damien Foundation, NATA/Genetup, TB Nepal Key partners for diagnosis and management of DR TB

44. Issues/Challenges Way forward Establish and mobilize End TB Committee at national, provincial and local level for sufficient resources both HR and budget Implementation of Micro Planning Increase resource from GoN and Donors BIG Funding Gap in NSP Capacity building of Province/District and Palikas in TB Program Management Expansion of TB Free initiatives 100% notification of TB from private sector engaged in PPM intervention. Expansion of PPM in other big Municipalities Capacity building of community in TB diagnosis and Management, Expansion of community and family-based DOTS Procurement of sufficient supply and timely distribution, mapping and relocation of GX, develop referral linkage between GX sites and periphery health facilities. Effective mechanism for timely collection and exchange of broken modules. Training and internet facility to all HFs in collaboration with HMIS and Full coverage of eTB Register. Interoperability between HMIS and NTPMIS (eTB, DR TB, GX) Quality Implementation of the program NTP Challenges and Way forward Meaningful engagement of private sectors and community in TB diagnosis and management Expansion, maintenance, and utilization of rapid molecular diagnostic test- GeneXpert Nationwide scale-up of digitized case base surveillance and full integration with HMIS Mobilization of GX centers, ORWs for tracing initial defaulter cases, develop biomatrices in GX services to avoid duplicate tests High number of Initial Defaulters

45. Issues/Challenges Way forward Mapping of highly affected communities and locations and develop catchup plan for TB diagnosis Find appropriate measures to motivate HWs, community people and mobilize for TB cases finding. Big gap in treatment coverage (TB case notification agist estimated incident TB cases) Find different programmatic topics involving NTP stakeholders and conduct ORs and develop mitigatation plan Operational research to identify and address programmatic gap NTP Challenges and Way forwards Capacitate PPHL to lead the QC activities- trainings, equipment, refurbishments and establish a mechanism for slide/sample collections to QC centers Restoration of QC system for sputum microscopy and mWRD (GX test) Capacity building of HWs in reporting of NTP services from DHIS2, upgrade DHIS2 with more validation rules. Supply computers/internets to HFs Quality reporting of NTP services from HMIS- timely, complete and accurate Sufficient drug and Cartridges Capacity building of provincial and district stores for proper management of logistics (use of ELMIS system) Logistic and Management

46. TB is a Global Issue with Global impact and only by working together we can eliminate it.