Impact update – UNDP’s work on Tuberculosis (TB) in Iran

29 Jul 2014

  

Iran has witnessed great progress in its fight against TB. In 1964, the TB notification rate was 143 per 100,000. In 2012, the latest year for which data is currently available, the figure stood at 14.4 per 100,000.

While the overall burden of TB is not extraordinarily high, still around 16,000 people develop TB and 2,200 die every year in Iran (WHO 2013).

Importantly, as observed in many countries with low to medium level of incidence, TB is increasingly concentrated in vulnerable populations mainly in the seven provinces (Hormuzgan, Sistan-Baluchistan, South Khorasan, Khorasan Razavi, North Khorasan, Golestan and Khouzestan). These provinces account for 50% of TB cases in Iran while inhabiting 23% of the total population.

Patients suffering from multi drug resistant TB (MDR-TB), prisoners and people living with HIV/AIDS are among the main vulnerable groups. TB incidence rate among prisoners is at least 50 times higher than the national average. HIV-TB co-infection is also an important problem, particularly among injecting drug users (IDUs). MDR-TB constitutes an emerging concern due to cross-border issues as some of the countries bordering Iran are suffering a high burden of TB/MDR-TB.

TB is among the leading causes of death from opportunistic infections among the people living with HIV/AIDS.


Directly Observed Treatment Short Courses (DOTS)- Visiting family members/close contacts with TB cases

ACHIEVEMENTS FOR TB

In line with the national plans and priorities, the Global Fund project on TB in Iran, for which UNDP Iran is Principal Recipient, has helped Iran to achieve the following:

  • Increased national attention and sensitization of decision-makers, personnel and health care workers towards TB control programme in prisons.
  • Improved TB programme technical standards by upgrading the labs, increase in number and performance of M&E personnel.
  • Establishing/upgrading 66 Direct Smear Microscopy (DSM) labs, 40 Culture Lab and 8 Drug Susceptibility Test labs.
  • Improvement in surveillance system (i.e., reporting, and recording system) in prisons.
  • Improvement in Directly Observed Treatment Short-Course (DOTS) coverage.
  • Contributing to a treatment success rate of 84.5% against the target of 84% per cent.
  • Procurement a consignment of 4 GeneXpert machines that will greatly help strengthen the capacities for detecting drug resistant TB cases Completion of isolation rooms and quarantine wards in all 65 large prisons and enhancement of quality of isolation rooms and quarantine wards.
  • Development, launch and implementation of Transition and Sustainability Plan of TB project to ensure that the investment and achievement of TB project is integrated into the national system and financial sustainability is guaranteed.

BACKGROUND

The Health System in Iran

The Constitution of the Islamic Republic of Iran stipulates that every Iranian has a right to enjoy the highest attainable level of health. The health system is overseen by the Ministry of Health, Treatment and Medical Education (MoH) that is responsible for designing and implementing the national health policy.

At subnational level, the health policy is implemented by medical universities in provinces. University chancellors are in charge of public health care facilities as well as medical education and report to the Minister.

Public health care and services are provided through a network that starts at primary care centres in villages and goes through secondary and tertiary level hospitals in larger cities. Such public services are provided either for free or at subsidized rates in public facilities. The structure of the public health sector.

The private sector is well developed, present in all parts of the country and playing a significant role in providing care and treatment.

The non-governmental organizations active in the area of health are focused in special fields like cancer, diabetes, thalassemia and the like.

Iran is currently restructuring its public healthcare system towards a new national health structure based on a ‘family physician’ system which will act as a guardian to ensure prevention and care for the public. It is hoped that this approach will also help alleviate the financial burden on citizens with regard to the high (60% on average) out-of-pocket costs for most Iranians.


Awareness raising on TB in high burden areas: distribution of TB pamphlets in schools

History to the Global Fund’s Work in Iran

The first Global Fund grant allocated to Iran took shape in 2005 in the area of HIV under the 2nd financing round of the Fund with a provision – as is the case in many countries – to apply the Global Fund Additional Safeguard Policy (ASP). As per the ASP, no national entity may be assigned the role of Principal Recipient (PR) of the Global Fund grants. UNDP has been given this mandate.

Country Coordinating Mechanism (CCM), a standing team of national stakeholders and international parties, oversees the partnership with GFATM.

The grants have grown over time to constitute a sizable portfolio of three projects.

In its PR capacity, UNDP works with a number of national Sub-Recipients (SRs) and Sub-Sub-Recipents (SSRs) as listed in below table:

Disease Area

SRs

SSRs

HIV/AIDS

Centre for Disease Control (CDC-MoH)

Prisons Org.

Min. of Education

Medical universities

Welfare Org

Tuberculosis

CDC-MoH

Prisons Org.

WHO

Medical universities in 7 target provinces

Malaria

CDC-MoH

WHO

Medical universities in target provinces


Budget

Since the inception of Iran’s partnership with the Global Fund, approximately US$ 91 million has been allocated to Iran.

Currently, Iran has four ongoing projects – one project in each disease area plus a small grant to support the activities of the Country Coordinating Mechanism.

Challenges and Lesson

In the areas of TB and Malaria, Iran receives and responds to a significant level of disease burden from neighboring countries.

Given the current budgetary crisis and inflation, the primary healthcare funding issues are a challenge.

Extending the coverage of insurance system to all citizens and reducing out-of-pocket expenses are other urgent challenges. Government is aiming to reduce these from 60 to 30%.

The geopolitical situation has placed a significant burden on the country’s access to local markets of medicine and health supplies/equipment. UNDP and other UN agencies have tries to assist to some extent.

The ASP will require an international agency to serve as PR. The situation does not allow for the transfer of the role to national entities.

End-project transitioning and integration of the project achievements and services into national policies and implementation mechanisms is a challenge.

Future of the Projects

The Global Fund eligibility criteria focus on 2 indicators: national income (World Bank data) and burden of disease (WHO data).

Iran is an upper middle income country with low disease burden of TB and malaria. The country will not be eligible to receive funding in those two areas.

The TB project was concluded in March 2014. A Sustainability and Transition Plan has been developed under the TB project and officially endorsed by the Government.

The current malaria project will come to an end in 2016. A similar approach has been embedded into the malaria project plans. 

Under the HIV, where Iran is considered to suffer a medium level of disease burden, the country will be eligible to receive an additional level of funding for the period of 2015-2017. A proposal is being developed to be submitted to the Fund in August.

Post-project Prospects

Over the years and thanks to its engagement with the Global Fund projects, UNDP has developed a high level of partnership and trust with the public health authorities and stakeholders. This is something to build on given the direct link between health and development in the country. To that end, the CO has established its Health and Development Cluster and aims to continue the partnership with national counterparts through mobilizing resources from within the national public health sector and bilaterals. The latter remains to be influenced by the geopolitical aspects of the country’s engagement with the international community.

Public Health System Structure

22july2014malariastructure

Cumulative List of GFATM-funded Projects 

Grant

Grant amount (total signed)-USD

SRs

Start date

Program End date

Last Grant Rating

R2 - HIV Phase 1

5,698,000

Center for Disease Control; Prisons Org; Ministry of Education

1-May-05

30-Apr-07

A1

R2 - HIV Phase 2

10,224,855

1-Aug-07

30-Apr-10

Total

15,922,855


R8 - HIV Phase 1

9,295,097

Center for Disease Control; Prisons Org; Ministry of Education

1-Apr-10

30-Sep-12

A1

R8 - HIV Phase 2

19,599,212

1-Apr-12

31-Mar-15

Total

28,894,309





R7 - TB Phase 1

12,652,286

Center for Disease Control; Prisons Org; WHO

1-Oct-08

30-Sep-10

A1

R7 - TB Phase 2

6,305,126

1-Jan-11

31-Mar-14

Total

18,957,412


R7 - Malaria Phase 1

5,615,598

Center for Disease Control;   WHO

1-Oct-08

30-Sep-10

Consolidated with R10

R7 - Malaria Phase 2

1,281,814

1-Jan-11

30-Sep-11

Total

6,897,412


SSF (R10&7)- Consolidated - Malaria Phase 1

13,241,610

Center for Disease Control;   WHO

1-Oct-11

31-Mar-14

A2

R10- Consolidated - Malaria Phase 2 (incremental)

7,297,374

1-Apr-14

30-Sep-16

Total

20,538,984


CCM - Basic funding - 1

46,207

CCM

1-Aug-10

31-Jul-11


CCM - Basic funding - 2

33,846

CCM

1-Nov-11

31-Oct-12


CCM - Basic funding - 3

37,663

CCM

1-Nov-12

31-Oct-13


CCM - Funding - 4

134,973

CCM

1-Nov-13

31-Oct-15


Total

252,689



Total

91,463,661