Preparation of buffer solution, National Reference Laboratory, Tashkent, Uzbekistan
USAID ELIMINATING TUBERCULOSIS IN CENTRAL ASIA (USAID ETICA) PROJECT Year 1 Annual Report: October 2019 – September 2020
November 10, 2020
DISCLAIMER This report is made possible by the support of the American People through the United States Agency for International Development
(USAID). The authors’ views expressed in this publication do not necessarily reflect the views of USAID or the United States Government.
Submitted to: Arman Toktabayanov, COR, Regional TB Advisor, Health and Education Office, USAID/Central Asia, Almaty, Kazakhstan.
Lola Yuldasheva, Alternate COR, Project Management Specialist/Health, USAID/Tajikistan, Dushanbe
Abt Associates Inc. 1 6130 Executive Boulevard 1 Rockville, Maryland 20814 1 T. 301.347.5000 1 www.abtassociates.com
With:
PATH IML red RPX AFEW Kazakhstan Afif Tajikistan National Red Crescent Society of Tajikistan
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 1
USAID ELIMINATING TUBERCULOSIS IN CENTRAL ASIA (USAID ETICA) PROJECT Year 1 Annual Report: October 2019 – September 2020
Contract No.: 72011519C00002
DISCLAIMER: This report is made possible by the support of the American People through the United States Agency for International Development (USAID). The authors’ views expressed in this publication do not necessarily reflect the views of USAID or the United States Government.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 2
TABLE OF CONTENTS
LIST OF EXHIBITS ...... 5 LIST OF ANNEXES ...... 6 ACRONYMS AND ABBREVIATIONS...... 7 EXECUTIVE SUMMARY ...... 9 KEY ACHIEVEMENTS ...... 10 1. INTRODUCTION ...... 13 1.1 BACKGROUND ...... 13 1.2 ANNUAL REPORT STRUCTURE ...... 13 1.3 STATUS OF DELIVERABLES ...... 13 1.4 PERFORMANCE MONITORING ...... 14 1.5 IMPACT OF COVID-19 ON THE IMPLEMENTATION OF USAID ETICA ...... 15 2. TAJIKISTAN ...... 18 2.1 EXECUTIVE SUMMARY...... 18 2.2 SUMMARY OF STAFFING AND OPERATIONS ...... 21 2.3 COVID-19 RELATED ACTIVITIES ...... 21 2.4 OBJECTIVE 1: INCREASED DETECTION OF TB AND DR-TB ...... 22 2.5 OBJECTIVE 2: INCREASED TREATMENT SUCCESS FOR TB AND ALL TYPES OF DR-TB 32 2.6 OBJECTIVE 3: IMPROVED ENABLING ENVIRONMENT AND FINANCIAL SUSTAINABILITY OF TB AND DR-TB PROGRAMS ...... 36 2.7 PERFORMANCE MONITORING ...... 44 2.8 COORDINATION WITH PARTNERS ...... 49 2.9 OBSTACLES AND CHALLENGES ...... 50 2.10 WAY FORWARD ...... 50 3. UZBEKISTAN ...... 54 3.1 EXECUTIVE SUMMARY...... 54 3.2 SUMMARY OF STAFFING AND OPERATIONS ...... 55 3.3 COVID-19 ...... 56 3.4 OBJECTIVE 1: INCREASED DETECTION OF TB AND DR-TB ...... 56 3.5 OBJECTIVE 2: INCREASED TREATMENT SUCCESS FOR TB AND ALL TYPES OF DR-TB 63
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 3
3.6 OBJECTIVE 3: IMPROVED ENABLING ENVIRONMENT AND FINANCIAL SUSTAINABILITY OF TB AND DR-TB PROGRAMS ...... 66 3.7 COVID-19 RELATED RISKS AND CHALLENGES ...... 67 3.8 PERFORMANCE MONITORING ...... 67 3.9 COORDINATION WITH PARTNERS ...... 70 3.10 OBSTACLES AND CHALLENGES ...... 70 3.11 WAY FORWARD ...... 71 4. KAZAKHSTAN ...... 73 4.1 EXECUTIVE SUMMARY...... 73 4.2 SUMMARY OF STAFFING AND OPERATIONS ...... 76 4.3 OBJECTIVE 1: INCREASED DETECTION OF TB AND DR-TB ...... 77 4.4 OBJECTIVE 2: INCREASED TREATMENT SUCCESS FOR TB AND ALL TYPES OF DR-TB 83 4.5 OBECTIVE 3: IMPROVED ENABLING ENVIRONMENT AND FINANCIAL SUSTAINABILITY OF TB AND DR-TB PROGRAMS ...... 87 4.6 COVID-19 RELATED ACTIVITIES ...... 90 4.7 COVID-19 RELATED RISKS AND CHALLENGES ...... 90 4.8 PERFORMANCE MONITORING ...... 91 4.9 COORDINATION WITH PARTNERS ...... 93 4.10 OBSTACLES AND CHALLENGES ...... 93 4.11 WAY FORWARD ...... 94 5. GENDER ORIENTATION IN PROJECT ...... 97 5.1 PROJECT GENDER INTEGRATION STRATEGY ...... 98 5.2 PROJECT ACHIEVEMENTS ON GENDER INTEGRATION ...... 99 5.3 SUSTAINABILITY IN GENDER APPROACHES ...... 101 6. PERFORMANCE MONITORING ...... 102 BASELINE ASSESSMENT ...... 102 ASSESSMENT OF STIGMA, GENDER, AND OTHER SOCIAL BARRIERS TO TB DETECTION AND TREATMENT ...... 103 6.2 MONITORING, EVALUATION, AND LEARNING PLAN ...... 103 7. BUDGET EXPENDITURES ...... ERROR! BOOKMARK NOT DEFINED.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 4
LIST OF EXHIBITS
Exhibit 1. Trained personnel in Y1 ...... 21 Exhibit 2. Diagnostic Algorithm...... 27 Exhibit 3. Analysis of BDQ resistance research ...... 31 Exhibit 4. Digitalization of TB Continuum of care in Tajikistan ...... 39 Exhibit 5. Gender disaggregation in the indicators in pilot regions ...... 45 Exhibit 6. Achievement of targets, Tajikistan ...... 46 Exhibit 7. Online monitoring process ...... 47 Exhibit 8. Mapping of TB laboratories for developing sputum transportation routes ...... 59 Exhibit 9. Comparative analysis of Sputum smear microscopy conducted in Q1-2 of 2019 vs. Q1-2 of 2020 ...... 62 Exhibit 10. Comparative analysis of GeneXpert tests conducted in Q1-2 of 2019 vs. Q1-2 of 2020 .. 62 Exhibit 11. Achievement of targets, Uzbekistan ...... 69 Exhibit 12. Baseline Assessment of TB program performance ...... 75 Exhibit 13. Compliance of results of GeneXpert and Smear Microscopy tests ...... 79 Exhibit 14. Comparison of GeneXpert tests conducted in the first 6 months of 2019 and the first 6 months of 2020 ...... 80 Exhibit 15. Process of preparation for training for Doctors’ Consilia ...... 86 Exhibit 16. Results of media campaign against stigma and discrimination ...... 88 Exhibit 17. Achievement of targets, Kazakhstan ...... 92 Exhibit 18. USAID ETICA’s Gender Integration Strategy ...... 99 Exhibit 19. USAID ETICA Expenditures from project inception on September 8, 2019 through September 30, 2020 ...... Error! Bookmark not defined.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 5
LIST OF ANNEXES
Annex 1. Indicators of FY 2020 Annex 2. PITT and performance analysis for three countries Annex 3. Program status (by country) • Annex 3a. Progress Status Report_KZ • Annex 3b. Progress Status Report_UZ • Annex 3c. Progress Status Report_TJ Annex 4. List of public events for Y2Q1 Annex 5. Success stories Annex 6. Set of quality photographs for each country Annex 7. Clippings of press articles Annex 8. Public communications materials Annex 9. Summary of all completed publicity events and received media coverage Annex 10. Medium and Exposure stories describing the project achievements through photos Annex 11. List of commodities procured and revised inventory Annex 12. List of all reports, analyses, presentations, and other key documents produced during the year Annex 13. Personnel summary Annex 14. List of all subcontracts
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 6
ACRONYMS AND ABBREVIATIONS aDSM Active Drug Safety Monitoring and Management Afif Tajikistan Republican Public Organization "Afif" AFEW Public Fund “AFEW Kazakhstan” AMELP Activity Monitoring, Evaluation, and Learning Plan BBP Basic Benefit Package BDQ Bedaquiline BPaL Bedaquiline, Pretomanid, and Linezolid CAR Central Asia Region CBO Community based organization CIDLM Center of Innovative Distance Learning and Monitoring CLF Clofazimine COP Chief of Party COR Contracting Officer Representative CSO Civil Society Organization DHIS District Health Information Software DLM Delamanid DOT Directly observed treatment DR-TB Drug-Resistant Tuberculosis DS-TB Drug Sensitive Tuberculosis DST Drug Susceptibility Testing ECF Enhanced Case Finding ETICA Eliminating Tuberculosis in Central Asia Project FLD First line drugs GA Global Accelerator GDF Global Drug Facility GF The Global Fund HLC Healthy Lifestyle Center HR Human Resources IC Infection Control IT Information Technology KNCV Tuberculosis Foundation, Netherlands LHSS Local Health System Strengthening Project LIMS Laboratory Information Management System LTBI Latent tuberculosis infection LQMS Laboratory Quality Management System LZD Linezolid MDR-TB Multi-Drug Resistant Tuberculosis M&E Monitoring and Evaluation MOH Ministry of Healthcare (Kazakhstan), Ministry of Health (Uzbekistan), Ministry of Health and Social Protection (Tajikistan) MSF Médecins Sans Frontières mSTR Modified shorter treatment regimens MTB Mycobacterium Tuberculosis NLSP National Laboratory Strategic Plan NTBR National TB Register NTP National Tuberculosis Program NRCST National Red Crescent Society of Tajikistan NRL National Reference Laboratory
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 7
NSP National Strategic Plan (renamed National Program for the Protection of the Population from Tuberculosis) OR Operational research OpenMRS Open Medical Record System DST Drug Susceptibility Testing pDST Phenotypical Drug Susceptibility Testing PHC Primary Health Care PITT Performance Indicators Tracking Table PIU Project Implementation Unit PLHIV People Living with HIV PV Pharmacovigilance PWTB People with TB PPE Personal Protective Equipment PQM+ Promoting the Quality of Medicines Plus Q1-Q3 Quarter 1, 2 or 3 QMS Quality Management System RCHTPTS Republican Clinical Hospital of Tuberculosis, Pulmonology and Thoracic Surgery RPX Resource and Policy Exchange, Inc. SBC Social Behavior Change SES Epidemiological Surveillance Service SLD Second Line Drugs SLMTA Strengthening Laboratory Management toward Accreditation SOP Standard Operating Procedure SOW Scope of Work TA Technical assistance TB Tuberculosis TIFA Tuberculosis Implementation Framework Agreement TOT Training of Trainers TPMI Tajik Postgraduate Medical Institute TPT TB Preventive Treatment TSMU Tajik State Medical University TWG Thematic/Technical Working Group UN United Nations General Assembly high-level meeting on Ending TB US United States USAID United States Agency for International Development USAID ETICA USAID Eliminating Tuberculosis in Central Asia project VST Video Supported Treatment, which replaced Video Observed Treatment WB World Bank WGS Whole Genome Sequencing WHO World Health Organization XDR-TB Extensively Drug Resistant TB Y1 Year One Y2 Year Two
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 8
EXECUTIVE SUMMARY
The first year of implementation of the USAID Eliminating Tuberculosis in Central Asia project (ETICA) was comprised of a nearly simultaneous startup, collaborative workplanning with USAID and the National Tuberculosis Programs (NTP) / Ministries of Health (MOH), execution of planned activities, and responding to the COVID-19 pandemic. The startup consisted of an official project launch, staff recruiting, formal company registration, opening of bank accounts, identifying and renting office space, procuring equipment, and setting up operations in compliance with USAID rules. The USAID ETICA project team conducted extensive internal and external collaborative planning processes for year one (Y1) and year two (Y2) implementation in October 2019 and June- July 2020 respectively. This was informed by the lessons learned from activities and experience implementing the program under COVID-19. The project team submitted timely deliverables throughout the period of performance, and plans to submit a more detailed version of the baseline report, which required regional travel made impossible by the pandemic. The MOHs from all three focus countries approved the project’s Y1 workplans in the first half of 2020, which enabled the project to launch full-scale project implementation. The project leadership and USAID established a regular communication protocol with weekly update calls. The project also responded to a USAID request to prepare weekly implementation update reports to the client beginning in January 2020. The project has filled the majority of technical and administrative positions, reaching nearly a full staff level by the end of Quarter 3 (Q3) of Y1. The project identified office space in Uzbekistan and Kazakhstan and opened bank accounts in all three countries. In Tajikistan, the country and regional teams share the same office space. COVID-19 restrictions hampered project implementation in all three countries. The project managed to mitigate some of the negative impacts of the epidemic by preparing for and conducting meetings, workshops, and trainings online. Online activities, however, cannot substitute for all of the needed work in the field and visits to pilot sites. Activities requiring in-person participation at events and regional visits have been postponed until Y2. There were other obstacles to online implementation such as weak internet connectivity and the diversion of TB human and other resources to combat COVID-19. Despite these obstacles, the project made solid progress toward its Y1 goals.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 9
KEY ACHIEVEMENTS
Key achievements during the reporting period are summarized below by country. Tajikistan: Although the MOH approval of the Y1 workplan was delayed due to a Minister of Health change, the project began implementation while anticipating approval. USAID ETICA actively supported ongoing country efforts to fight COVID-19. The team revised the TB diagnostic algorithm to mitigate the impact of a delayed shipment of TB tests and involved project volunteers in disseminating information about the pandemic to more than 100,000 people. During Y1, USAID ETICA built good working relationships with in-country stakeholders including the MOH, NTP, and Civil Society Organizations (CSOs). This enabled a collaborative approach to carrying out TB-related activities and initiating full project implementation. USAID ETICA is aligned with the Global Accelerator to End TB key targets of “REACH, CURE, and PREVENT” TB. In line with the TB Global Accelerator’s area of “REACH”, the project developed a manual on TB case finding and guidelines for medical and social support for people with Drug Resistant (DR) TB for healthcare providers, volunteers, and outreach workers. Project volunteers screened 9,698 people for TB using the manual as a guide, which led to the detection of 89 TB positive cases. This can be considered as outstanding achievement, as 89 DR-TB patients make 6.4% of all tested people. Project volunteers provided social and treatment adherence support to 53 people with Multi-Drug Resistant (MDR) TB in pilot regions. The project team built the capacity of “REACH” through training project coordinators, volunteers, and outreach workers in active case finding, social support, and adherence to treatment. 100 volunteers visited 26,631 households (141,423 people), including 1,596 families (7,960 people) of people affected by TB, to raise awareness of TB and improve TB case detection. USAID ETICA started improving TB laboratory quality management systems (QMS) by developing checklists for assessments of TB tests, revising SOPs, conducting workshops for National Reference Lab (NRL) staff, and working on a redesign of laboratory information management. Accenting the TB Global Accelerator’s area of CURE, the project collaborated with other organizations in the investigation of causes of recent Bedaquiline (BDQ) and Delamanid (DLM) resistance among certain groups of TB infected individuals. The project revised the algorithm for outpatient care of people with DR-TB, prepared training materials for a workshop on new MDR-TB treatment regimens, and drafted an action plan for improved provision of quality, safe, and effective TB drugs in 2021-2023. In the TB Global Accelerator’s area of PREVENT the project supported NTP in developing a latent TB infection (LTBI) strategy for the detection of latent TB and TB preventive therapy (TPT) and produced a guide to TB control and prevention among target groups. USAID ETICA also started and made progress on the Global Accelerator’s area of SELF-RELIANCE by evaluating and exploring a variety of options to install or improve existing information system software and technologies; and by contributing to changing the financing mechanisms of the TB system in the country. Uzbekistan: Shortly after USAID approved the Y1 workplan, the project submitted it to the Uzbekistan MOH for review and approval. The MOH and the NTP provided comments, which USAID ETICA addressed in the resubmitted workplan. The MOH approved the plan on June 9, 2020. Despite the unexpected delay, USAID ETICA managed to make solid progress in many areas, one of
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 10
which was the development of the National TB Strategic Plan (NSP) for 2021-2025 and the National Laboratory Strategic Plan (NLSP). Under the TB Global Accelerator’s area of REACH, USAID ETICA evaluated national guidelines and policies on contact tracing and TPT against World Health Organization (WHO) standards, identified areas in need of improvement, and established a working group to devise solutions. The project team conducted regular comparative analysis of GeneXpert tests conducted in the country during the same period (2019). This analysis helped to understand the dynamics of TB testing during the COVID-19 pandemic. The project agreed with the NTP on preferred models to reach key population groups, including through multi-disciplinary teams (MDTs) in pilot sites, and prepared to conduct a study of gender, stigma, and other social barriers to accessing TB services. The project assessed various aspects of the existing TB laboratory network structure and operations to inform implementation plans. Our project experts conducted audits of NRL staff adherence to SOPs and amended TB diagnostic algorithms to mitigate the impact of COVID-19 on the supply of TB tests. In the area of CURE, the project assessed the outpatient treatment model against WHO TB care delivery standards and identified areas in the guidelines and policies in need of change. The project restarted the work of TB Consilia1 through online meetings and enabled online management discussions between the NTP and TB centers in pilot oblasts by capitalizing on the capacity for telemedicine at the Center of Innovative Distance Learning and Monitoring (CIDLM). The project provided expert support to the drafting of the section on pharmacovigilance (PV) in the NSP and conducted the first field visits to the project pilot districts in September 2020 when some COVID-19 related restrictions were lifted. In the domain of SELF-RELIANCE, USAID ETICA, as a member of technical working groups (TWGs) organized by the WHO office in Uzbekistan provided technical assistance on a) revising the draft version of the national guideline and supporting documents on LTBI management provided by the LTBI; and b) developing a protocol on Video Supported Treatment (VST). Kazakhstan: USAID ETICA in Kazakhstan also built healthy, collaborative relationships with the MOH, NTP, the Global Fund (GF) and CSOs to facilitate project implementation. During Y1, USAID ETICA supported TWGs and sub-groups developing NSP for 2021-2025 and revising other policy level documents. One of the important documents developed by the project team during the reporting period was an analytical report that elaborated on financial mechanisms of the TB system and recommendations for improvement. This report will inform the future decision of the state lawmakers. In the area of REACH, the project assessed CSOs’ capabilities to deliver TB services and started developing and delivering trainings to address skills and knowledge gaps. USAID ETICA prepared to conduct a study of gender, stigma, and other social barriers to accessing TB services, which will inform the design of future interventions. The project organized a contest of short video stories on the lives of people with TB. More than 500,000 people watched the videos, and USAID approved a project success story about the contest. Additionally, the project amended the TB diagnostic algorithm, developed technical specifications for the procurement of a whole genome-sequencing
1 Consilium is a consultative meeting of several doctors of one or several specialties, necessary to establish the patient's health status, diagnosis, determine the prognosis and approaches for medical examination and treatment and the expediency of referral to specialized medical facilities
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 11
(WGS) machine by the GF, and assessed various aspects of the existing TB laboratory network operations, information systems, and structure to inform implementation plans. Accenting the GA area of CURE, the project analyzed the TB PV system, identified problems, and proposed solutions. Additionally, the project drafted an active Drug Safety Monitoring (aDSM) roadmap, which will support capacity development plans, and proposed a system for standard classification and registration of adverse drug events. A concept note was also developed for supportive supervision in TB case management. In the area of PREVENT, the project assessed policies and regulations on LTBI and TPT and drafted a concept paper on TB preventive treatment in support of policymaking in this area. In the area of SELF-RELIANCE, a project review of health financing regulations revealed problems in need of solutions. The project became an active member of national and regional working groups on social contracting where it advocated for amendments in key regulations to attract CSO interest in TB funding mechanisms. From September 28, 2020 to October 2, 2020, USAID ETICA provided an opportunity for the project specialists and project partners, including NTP staff to participate in the international online training on "Programmatic and clinical management of drug-resistant tuberculosis to achieve the sustainable development goals," conducted by Latvian WHO Collaborating Center for Research and Training in Management of MDR-TB. Facilitators presented new recommendations for the use of rapid molecular testing for the diagnosis of DR-TB, new and MDR-TB treatment regimens, latent TB infection, infection control measures, DR-TB / HIV co-infection management, PV and aDSM where 33 participants (16 from Kazakhstan, 9 from Tajikistan, 3 from Uzbekistan and 5 from Kyrgyzstan) actively participated in the course.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 12
1. INTRODUCTION
1.1 BACKGROUND USAID launched the ETICA project with the intent to contribute towards the achievement of the agency’s regional TB goals and objectives of increased efficiency and sustainability of quality patient- centered services, and increased detection and improved treatment access, both of which contribute towards a reduced burden of TB and DR-TB in Central Asia. Countries in the region have made significant progress in strategic planning and aligning clinical practice guidelines with WHO recommendations. However, improving TB outcomes cannot be achieved at the service level alone. Historically, challenges in three domains have hampered progress: the rigid structure and financing of the health system; poor quality of clinical services; and lack of cooperation from the population. Within a constrained economic environment, both leadership capacity and systemic change are needed to shift from an ineffective and inefficient post-Soviet model of TB care towards the delivery of sustainable, high-quality, people-centered services. USAID ETICA is aligned with the Global Accelerator to End TB key targets of “REACH, CURE, and PREVENT” TB. Activities on screening, detection, and outreach of vulnerable and marginalized populations will contribute to reaching targets under “REACH.” Activities on laboratory performance strengthening will enhance diagnostic capabilities contributing to both “REACH” and “CURE”. Drug susceptibility test (DST) coverage will improve treatment outcomes under “CURE” even though all countries include DST in the algorithm of testing prior to initiation of the treatment. Community outreach and other community-based activities will contribute to stigma and discrimination reduction benefiting case detection and treatment success rate, thus contributing to “PREVENT”. Health systems strengthening activities will enhance system resilience and sustainability backing government commitment to the Journey for Self-Reliance.
1.2 ANNUAL REPORT STRUCTURE This report provides a snapshot of Y1 activities, status of deliverables, project performance monitoring mechanisms, activities related to the COVID-19 crisis in the three countries, descriptions of technical activities and results by country, and a presentation of project budget expenditures by country since USAID ETICA’s inception. The report includes a list of annexes including performance indicators, plan of events and other communication documents as stipulated in the contract. Annex 13 will be sent to USAID directly by Abt’s home office as it contains confidential information.
1.3 STATUS OF DELIVERABLES USAID ETICA submitted all deliverables on time to USAID and all deliverables have been approved. The work on the second “in-depth” baseline assessment was initiated, but was delayed due to difficulties with obtaining information from the MOH and NTP in Tajikistan and Uzbekistan. The second phase of the assessment is completed and the project is currently at the stage of report compilation. Hence, the Baseline Assessment Report will be submitted for approval in Y2. Table 1 provides a status update of deliverables as of the end of Y1.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 13
Table 1. Status of USAID ETICA Deliverables
Deliverable Submitted Feedback from Resubmitted Approved USAID
Y1 Workplan Yes Yes Yes Yes
Activity Monitoring Yes Yes Yes Yes Evaluation and Learning Plan
Environmental Mitigation Yes Yes Yes Yes and Monitoring Plan
Baseline Assessment Report Yes No*
Branding Implementation Yes Yes Yes Yes Plan
Marking Plan Yes Yes Yes Yes
Q1 Report Yes No No Yes
Q2 Report Yes Yes No Yes
Q3 Report Yes Yes Yes Yes
(Q3) 90% DR-TB cases Yes Yes Yes No diagnosed**
(Q3) 90% DR-TB cases Yes Yes Yes No enrolled**
Annual Performance Report Yes (inclusive of the Q4 Report)
(Q4) 90% DR-TB cases Yes diagnosed**
(Q4) 90% DR-TB cases Yes enrolled** * During one of the regular weekly calls, USAID informed the project that it anticipates to receive, review, and approve a detailed baseline assessment report (an “in-depth” second phase assessment) following the initial (first phase) baseline report which was duly submitted within 60 days of the project inception. The “in-depth” assessment was conducted and is at the stage of report preparation. ** The indicators were submitted with the Q3 report in the Performance Indicators Tracking Tables for each country. Both Q3 and Q4 indicators are attached to the annual report in Annex 1. Achievement of detection and treatment indicators in quarters 3 and 4.
1.4 PERFORMANCE MONITORING The project provided USAID with weekly update reports beginning in January 2020. The reports highlighted activities advancing Y1 workplan tasks in each country. Additionally, USAID ETICA senior management held regular weekly calls with the Contracting Officer Representative (COR), Alternate COR, and other USAID management staff in the three countries. The purpose of the calls was to discuss project implementation issues, answer questions, and exchange operational information as needed. The COVID-19 quarantine measures necessitated discussing COVID-19 related activities
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 14
and re-formatted activities, and performance targets with USAID. Continuous regular communications with the client were also maintained in each country through USAID ETICA Country Directors.
1.5 IMPACT OF COVID-19 ON THE IMPLEMENTATION OF USAID ETICA The global pandemic of COVID-19 has struck the Central Asian Region (CAR) countries harshly. Due to their fragile economies and post-soviet model of health care, COVID-19 infection had a sizeable impact on all three USAID ETICA countries, particularly Tajikistan where quarantine was not imposed. Heads of national caucuses in Eastern Europe and Central Asia of the Global TB Caucus, met on-line on June 11, 2020, to discuss the current COVID-19 pandemic and its impact on other infectious diseases such as TB. Participants acknowledged the threat that the COVID-19 pandemic poses to global health and to the well-being of citizens, including the severe impact on societies and economies, and the sudden shift in priorities of other health services (Regional Eastern Europe and Central Asia resolution on COVID-19 and its impact on TB, June 2020). As implications and brunt of COVID-19 were significant, all three countries imposed serious restrictions on movement of people. Health authorities in the three countries were quickly overwhelmed with preparedness for response. Urgent issues related to tackling the challenge of the epidemic quickly replaced existing priorities. USAID and counterparts asked the project to join efforts to prepare the TB sub-systems in the three countries to respond to COVID-19. The project responded to the call readily and timely while continuing to pursue those tasks in the Y1 workplan. Despite the challenges with implementation of the workplan activities that required face-to-face meetings, group events, travel, or re-profiling of some TB facilities to the COVID-19 response, and engagement of MOH and NTP staff, USAID ETICA made all possible efforts to achieve project objectives using different modes of implementation. For example, the educational events and meetings were either held online or conducted in a mixed way, (i.e., some participants physically attended the events, while others joined the activities online to ensure social distancing). The project team organized both assessments and other types of research in the form of desk and literature reviews and online interviews and discussions. In Tajikistan, even monitoring of the project sites has been shifted online. Luckily, in the Q4, the quarantine measures were relaxed and the Uzbekistan team had a chance to visit the pilot sites. The team implemented the following COVID-19 related activities in Y1: • Participated in national task forces and committee meetings on COVID-19 management. • Supported USAID’s Local Health System Strengthening Project’s (LHSS) COVID-19 activities as needed. • At the request of NTP Tajikistan, provided Personal Protective Equipment (PPE) to help replenish depleted stocks of PPE for TB health workers: ➢ Respirators – 2000 pcs ➢ Surgical masks – 1000 pcs ➢ Protective suits – 1000 pcs • Initiated implementation of joint COVID-19 and TB activities at the community level in five districts of Sughd oblast of Tajikistan (Khujand, B. Ghafurov, J.Rasulov, Isfara, and Spitamen). One hundred (100) project volunteers visited 26,631 households (141,423 people), which includes
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 15
1,596 families of people affected by TB (7,960 people) to raise awareness on COVID-19 and TB and seek potential people for TB screening. • Supported TB centers and primary health care (PHC) facilities in the pilot districts to implement the MOH order on the distribution and delivery of anti-TB drugs to patients (i.e., a two month supply for DR-TB treatment and one month for TB treatment) to avow interruption of treatment due to COVID-19. Fifty-four (54) volunteers regularly delivered anti-TB drugs to 53 MDR-TB patients and worked with them and their family members on adherence to treatment. • Provided technical assistance to amend the temporary TB detection algorithm in Tajikistan and Uzbekistan. Such an immediate amendment was necessary as a response to a critical shortage situation with GeneXpert cartridges and supplies hampered by the crisis. • Reviewed the Y1 workplan to determine which activities will be impacted/delayed due to imposed restrictions, prepared a list, and sent it to USAID. • Proposed to USAID changes to targets on project indicators to account for the anticipated impact of the pandemic on national TB programs.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 16
IMPLEMENTATION ACTIVITIES BY COUNTRY
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 17
2. TAJIKISTAN
2.1 EXECUTIVE SUMMARY The USAID ETICA project launch in Tajikistan was held in Dushanbe on November 26, 2019 as part of the launch of the USAID TB Portfolio to improve prevention, detection, and treatment of DR-TB in Central Asia. The event was organized in collaboration with the MOH and featured nearly 130 attendees, including representatives from the USAID Central Asia Mission and MOH, the Parliament of Tajikistan, the National TB Program, WHO representatives in Tajikistan, regional representatives of health facilities, other donor-funded programs, stakeholders from the healthcare sector, and representatives from Tajik State Medical University (TSMU), Tajik Postgraduate Medical Institute (TPMI), and CSOs. Dilorom Sodiqova, Advisor to the Minister of Health of Tajikistan, chaired the event. Dr. Mirhamiddin Kamolzoda, Deputy Minister of Health, Mr. Christopher Edwards, USAID Central Asia Mission Director, and Dr. Galina Perfilieva, Head of WHO in Tajikistan, all delivered welcoming speeches. In his opening remarks, Mr. Christopher Edwards emphasized that: “The US Government is committed to supporting the governments of Central Asia countries to reach every person with TB information, cure those in need of treatment, and prevent the spread of the disease.” He also handed over a certificate for $250,000 to the Deputy Minister of Health Dr. Kamolzoda to be used toward the purchase of laboratory supplies, reagents, and consumables for rapid diagnostic of DR- TB. The event was covered by the US Embassy in Tajikistan, the MOH, USAID Central Asia social media, and a local blogger’s Facebook page.
Project launch in Tajikistan held in Dushanbe on November 26, 2019
Following the joint planning meeting (October 9-11, 2019) between USAID and USAID ETICA, the project focused most of its technical resources on drafting the Y1 workplan. USAID ETICA met with key partners to establish relationships and discuss their priorities, partners included the NTP, MOH, Finance Department, the Global Fund Project Implementation Unit (GF PIU), WHO, World Bank PIU, and Asian Development Bank PIU. USAID ETICA prepared and aligned the Y1 workplan taking into consideration the Government of Tajikistan’s plans and priorities and ongoing and planned donor activities.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 18
Following USAID approval of the Y1 project workplan, USAID ETICA applied for similar approval with the Tajikistan MOH. A change of the Minister of Health and the situation with COVID-19 delayed the approval. The MOH finally granted approval for project implementation on May 3, 2020. USAID ETICA organized a joint planning meeting with USAID from June 30 to July 2, 2020 to discuss the project implementation issues, needs for revision of the Y1 workplan and plan for the development of the Y2 workplan activities. The Y2 workplan was developed based on lessons from Y1 and inputs from USAID and Tajikistan government stakeholders. During the project’s first year, USAID ETICA made progress on the following tasks falling under the TB Global Accelerator’s area of REACH: A manual on TB case finding of people with DR-TB was prepared for volunteers and outreach workers. Project volunteers screened more than 9,698 people for TB, and detected 89 TB positive cases, including five DR-TB. Project volunteers provided social and treatment adherence support to 53 people with MDR-TB in pilot regions. The team strengthened the capacity for REACH through trainings for project coordinators, volunteers, and outreach workers in active case finding, social support and adherence to treatment. USAID ETICA continued to improve TB laboratory QMS by developing checklists for assessments of TB tests, revising SOPs, conducting trainings and workshops for NRL staff, developing the guideline for TB and primary health care (PHC) providers on laboratory diagnostics through an updated algorithm, and working on a redesign of laboratory information management. In the domain of CURE, the project continued to collaborate with other organizations in the investigation of causes of recent BDQ and DLM resistance among certain groups of TB infected individuals. The project provided support for the capacity building of DR-TB Consilia members by restarting the work of TB Consilia through online meetings. The project started to develop a guideline for outpatient care of people with DR-TB, prepared training materials for a workshop on new MDR-TB treatment regimens, and drafted an action plan for improved provision of quality, safe, and effective TB drugs in 2021-2023. The project was also prepared to implement the VST model in pilot districts. In the area of PREVENT the project team assessed existing policy documents on LTBI and TPT, supported the NTP to develop an LTBI strategy for LTBI detection and prevention and produced a guideline for CSOs on the provision of services in detection, treatment support and prevention of TB. The project also organized an information workshop for media and journalists from pilot regions on the justification and social significance of reducing stigma associated with TB. In the area of SELF-RELIANCE, the project initiated the establishment of a TWG on health financing and social contracting under the MOH, provided support to conduct TWG meetings, and became an active member of these groups to promote the implementation of new forms of financing for the TB service and social contracting for TB. USAID ETICA’s implementation partners in Tajikistan, Abt Associates (Abt), the National Red Crescent Society of Tajikistan (NRCST), and Afif Tajikistan, devised principles for dividing their efforts among specific population groups, pilot areas, and social support for TB patients to leverage each organization’s respective strengths, facilitate close collaboration, and avoid duplication of efforts. The partners discussed and agreed on techniques and approaches to identifying people with TB (PWTB) among high-risk groups, including people living with HIV (PLHIV), and follow-up during outpatient treatment. They also prepared for field activities by selecting outreach workers from among representatives of healthy lifestyle centers (HLC) (volunteers and mentors), nurses,
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 19
community leaders, deputy heads of mahallas2, representatives of Women Committees, active youth, teachers, representatives of religious leaders, and volunteers who previously worked with TB and MDR-TB patients as part of the activities of other CSOs and recruited all planned staff needed to fulfill their duties under the project. USAID ETICA received a Letter of Appreciation from the Director of NTP for the fruitful cooperation and technical assistance provided in the development of the National Program on Protecting Population from TB in the Republic of Tajikistan for the period of 2021-20253. Summary list of key activities and achievements in Y1: • Finalized the project baseline assessment. A report is being compiled after the completion Phase II data collection in 12 project districts. • Trained instructors, volunteers, and outreach workers to screen target groups, identify presumptive TB cases, refer them to TB testing, and provide psychosocial adherence support during the treatment as a part of the project’s Enhanced Case Finding (ECF) work. • Developed a guideline for CSOs on TB detection, treatment and prevention support. • Initiated establishment of a TWG to address the issues of strengthening outpatient TB case management in Tajikistan. • Audited existing SOPs and assessed the lab’s QMS; developed a guideline for TB and PHC providers on laboratory diagnostics including updated diagnostic algorithm and submitted to the NTP for approval (all in collaboration with the NRL project specialists). • Developed checklists to analyze turnaround time (TaT) and control the quality of tests conducted by TB laboratories. The Project trained NRL laboratory specialists on the introduction of advanced DST and quality control of DST for new TB drugs. • Supported the NTP to improve the forecasting and quality assurance system for TB drugs. The project also assessed the regulatory framework and aDSM system to facilitate better access to new and re-purposed TB drugs. • Initiated creation of TB Financing TWG under the MOH to promote new forms of financing for TB services. As a part of the TWG, project specialists conducted a literature review to support a shift in the health financing system for TB services. • Initiated establishment of a TWG to promote social contracting for TB. In agreement with the social department of MOH, the project drafted a SOW for the TWG, and as a member of TWG, the project provided technical assistance to develop the Action Plan for the TWG. • Conducted training sessions for health workers on reducing the level of stigma and discrimination against people affected by TB and key populations; and organized an awareness raising event (press café) for media / journalists from pilot regions on rationale and social importance of reducing stigma associated with TB.
2 Mahalla refers to a village 3 NSP Tajikistan in this document will further refer to the national program on protecting population from TB in the republic of Tajikistan for the period of 2021-2025
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 20
• Built local partner capacity by Exhibit 1. Trained personnel in Y1 training a total of 279 health and non-health workers on various TB related topics (see Exhibit 1). • Participated in the TWG tasked with developing the TB NSP and helped develop recommendations on: a) aligning TB indicators with NSP, b) implementation of TB finance reforms, and c) HR certification and health facility accreditation. • Provided rationales for amending important parts of current regulating documents on enhanced TB case finding and guidelines to align them with the new WHO recommendations. • Led the work of a TWG on development of the five-year NLSP for the period of 2020-2024 as part of NSP.
2.2 SUMMARY OF STAFFING AND OPERATIONS Staff recruiting activities were among some of the project’s top priorities during the startup period. All recruiting activities have been conducted in strict adherence with relevant Abt’s policies and all full-time positions were filled in according to the approved organogram. The positions of Oblast Coordinators are in the process of being filled. All project staff was oriented on USAID contract requirements and Abt policies. USAID ETICA rented office space and procured furniture, computers, and other equipment. During remote working conditions as per pandemic requirements, internet and communication support was provided to each staff member. The staff also considered both epidemiology and sanitation measures in the office and during transport situations as per pandemic requirements.
2.3 COVID-19 RELATED ACTIVITIES Since March 2020, COVID-19 has impacted the project staff and beneficiaries, as well as activity implementation in Tajikistan. In consultation with USAID, the project quickly applied proactive measures to ensure the health and safety of staff and beneficiaries, including enforcing social distancing, mask wearing, increased hand washing/ sanitizing and distribution of PPE. The project also took steps to spread information about prevention and symptoms of COVID-19 and implemented activities focused on COVID-19 and TB prevention. These activities included: • Procuring and distributing PPEs to contribute to the replenishment of depleted stocks of PPE for TB health workers (at the request of the NTP): ⮚ Respirators – 2000 pcs ⮚ Surgical masks – 1000 pcs ⮚ Protective suits – 1000 pcs
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 21
• Supporting the NTP to implement the Country Preparedness Plan on COVID-19 through the following activities: ⮚ Participating in the development of a temporary algorithm for TB diagnosis due to delays with delivery of GeneXpert MTB / Rif cartridges to the country. The delay in delivery was associated with COVID-19. ⮚ Involving project volunteers and outreach workers in the implementation of the preparedness plan for COVID-19. ⮚ 100 volunteers visited 26,631 households (141,423 people), including 1,596 families (7,960 people) of people affected by TB, to raise awareness of TB and improve TB case detection. This activity allowed for the timely identification and referral of patients with symptoms similar to COVID-19 and TB to health care facilities. ⮚ Supporting TB centers and PHC facilities in the project’s pilot regions to quickly implement the MOH order on advanced distribution of TB drugs to people with TB (two- month supply for DR-TB and one-month for DS-TB) to avoid risks of disrupted TB medicine administration due to COVID-19. ⮚ In a COVID-19 related media engagement, the project team conducted 28 events together with the state police in the pilot districts. USAID ETICA volunteers, together with the district traffic police made COVID-19 related announcements explaining preventive measures using car megaphones. The announcements reached an estimated 234,333 people. ⮚ Participated in an educational program aired on Sughd regional radio with estimated 145,000 listeners. The goal of the broadcast was to raise awareness and alert the population to COVID-19 preventive measures.
2.4 OBJECTIVE 1: INCREASED DETECTION OF TB AND DR-TB Community level support and cooperation are crucial for successful TB case finding. However, due to limitations imposed by COVID-19, such cooperation has become more complicated. Hence, USAID ETICA has adjusted its activities to online approaches wherever possible, and all in-person activities are carried out following social distancing and mask wearing guidelines. Throughout Y1, the project worked to quickly identify persons affected by TB, and since March has been adjusting activities to enable advancing TB case finding despite the COVID-19 restrictions. At the facility level, the timeliness and accuracy of the TB case detection fully rely on the effectiveness and quality of the TB laboratory network’s operations. To enhance the functionality and efficiency of the laboratories, the project continued providing technical assistance at the policy level, assessing the needs and quality of the work and conducting operational research.
2.4.1 ACTIVITY 1.1: PARTNER WITH CSOS TO IMPLEMENT ENHANCED CASE FINDING (ECF) AND WITH MOH TO STRENGTHEN SYSTEMS FOR CONTACT TRACING Community-level referrals and outreach work are an essential component of the project’s targeted and integrated interventions. USAID ETICA conducted a set of activities aimed at understanding the policies on and actual roles of CSOs in countering the spread of TB. The project conducted a desk review of existing policies on CSO roles in TB case detection to inform future project work. The desk review also helped the project team to understand whether or not screening methodologies and tools for referral of people with presumed TB for testing by CSOs
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 22
required a revision. The results of the review indicated that existing tools applied by CSOs in TB detection are adequate and do not require a revision. The project also assessed activities, tools, and models of CSO operations under previous donor- funded projects in TB, and developed a questionnaire as the assessment instrument. The assessment results revealed strengths and weakness in skillsets, tools, and approaches to CSOs’ work with communities. This informed the creation of the following documents which will be used for capacity building/improvement of CSOs in the area of TB: • “Guideline for CSOs on the provision of services in the field of detection, treatment support and prevention of tuberculosis”. This is a practical guide to planning and implementing effective methods for TB control in target groups intended to increase the accuracy of identifying TB cases. • Screening and case management instruments and reporting forms – part of a set of training materials for Training of Trainers (TOT) for volunteers and outreach workers at the community level. USAID ETICA collected and analyzed existing education and awareness raising materials on the issues of TB prevention and control developed by prior TB projects to inform whether or not the project needed to prepare similar materials. Since the materials were up-to-date and captured all the required information, the project printed them for distribution. Project volunteers will distribute these materials to the target audience. USAID ETICA conducted a series of capacity building activities to strengthen the capacity of CSOs and raise awareness of TB screening, detection by contact tracing, referral to specialists using a voucher system, adherence to treatment and effective approaches to increasing adherence among people with DR-TB. These activities included: • A two-day orientation workshop for 15 technical and administration staff from implementing partners NRCST and Afif Tajikistan. The purpose of the workshop was to strengthen their understanding of TB detection and outpatient treatment of TB and MDR-TB; existing diagnostic methods; issues surrounding the treatment adherence; and effective approaches to increase such adherence among people with TB. • NRCST and Afif Tajikistan engaged in activity planning and collecting information about vulnerable population groups including PLHIV, labor migrants, and TB patients and their close contacts in all districts of Khatlon and Sughd oblasts to build on the results of the orientation workshop. The project prepared to conduct outreach activities aimed at drawing the interest of and backing from local authorities and various community groups such as women’s committees, HLCs, medical workers etc. • USAID ETICA conducted a total of 12 round tables in Khatlon and Sughd regions. The goal of the round tables was to introduce project objectives and implementation plans targeting vulnerable groups and propose joint activities for bettering the lives of people with TB in the regions. • Conducted a ToT for 18 instructors from the pilot districts of Sughd and Khatlon oblasts. As a result, upon returning to their workplaces, the coordinators trained volunteers, emphasizing the importance of detecting and treating TB to ensure access to community-based services. They
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 23
also communicated that community members and individuals from vulnerable groups are more likely to be tested and complete TB treatment. • Carried out a two-day training for 27 coordinators from 12 target districts on the following topics: “Organizing community-based work to identify people with suspected TB among key populations and support controlled treatment of patients suffering from DR-TB” and "Early detection of TB and DR-TB cases and approaches to social support". Following this training, the coordinators conducted cascade sessions for more than 110 volunteers and outreach workers and distributed TB screening checklists, vouchers, and reporting forms.
Table 2. Number of individuals from vulnerable and high-risk populations, who received TB screening, tested for TB, and were detected through project-supported CSOs
Number of individuals from vulnerable and high-risk populations receiving TB Screened Tested Detected (DS / screening through project-supported CSOs DR)
PLHIV 47 17 2/1
Migrants 1,110 275 20/0
Contacts 8,541 1,103 67/4
Total 9,698 1,395 89/5
Trained field workers started to report active findings of TB cases in the pilot project areas. Home visits by volunteers resulted in identification of people with TB symptoms among family members of people affected by TB. In 12 pilot districts, USAID ETICA screened 9,698 people (as indicated in Table 2), out of whom, 1,395 people with TB-similar symptoms were referred and tested. Among those tested, 89 new TB positive patients were identified including 5 new patients with MDR-TB. All were enrolled in care and treatments prescribed.
USAID ETICA conducts training for volunteers and outreach workers and information sessions with population of pilot districts, Sughd oblast, Tajikistan
During the reporting year, 53 USAID ETICA volunteers and outreach workers monitored the treatment of 53 MDR-TB affected individuals through daily home visits and ensured adherence to prescribed drug regimens. To date, 2 out of 53 MDR-TB patients have successfully completed treatment.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 24
Infection Control (IC) consists of measures to reduce the risk of exposure to persons with infectious types of TB. Since IC is one of the important aspects of TB prevention, the project team conducted a desk review of the regulatory framework of TB IC in Tajikistan. Based on the review, the project will support the NTP to identify challenges and develop a joint workplan for the NTP and Sanitary and Epidemiological Surveillance Service (SES). Supporting cooperation between NTP and SES will ensure the sustainability of TB IC in the country. Scaling-up programmatic management of TPT is critical to ending the TB epidemic in the country. To support NTP to improve TPT, the project carried out the following activities: • Assessed the existing policy documents on TB contact tracing and LTBI, including their availability in the district TB centers and PHC facilities. • As a member of the TWG, USAID ETICA supported the NTP to develop an LTBI strategy based on WHO recommended approaches on TPT for detected LTBI cases. Médecins Sans Frontières (MSF) developed the first draft of the document, and USAID ETICA contributed to its finalization. The document is currently being translated and will be submitted to the MOH for approval. • Developed a package of training materials for online training on “Programmatic Management of TB TPT”. The project will conduct the training for the members of the TWG under NTP on LTBI as soon as the LTBI strategy is approved by the MOH.
2.4.2 ACTIVITY 1.2: IMPROVE TB DETECTION CAPACITY AND ACCESS AT ENTRY POINTS CLOSER TO PATIENTS To assess the baseline situation of TB laboratory diagnostic services, the project team developed the following checklists: • Laboratory network data checklist • Culture laboratory checklist • Xpert data collection tool • Xpert Ultra transitioning analysis checklist • Xpert MTB/Rif test TaT checklist With technical assistance from USAID ETICA, the NRL manager facilitated a workshop for the staff of the NRL and regional laboratory coordinators. During the workshop, the project team explained the purpose of the assessment and the use of checklists for data collection, disseminated the checklists, and demonstrated their use. The checklists are now in use for collection of laboratory data at NRL and oblast labs. They will open up opportunities to evaluate compliance with the diagnostic algorithms and coverage of patients by DST and to enhance quality control of laboratory diagnostics. The COVID-19 outbreak has negatively affected the total workload of the GeneXpert network. In comparison with the same time period in 2019 (January - June), the total number of Xpert MTB/RIF tests in 2020 fell from 36,060 to 18,815, which compares to only 52% of the previous year and the total number of MTB-positive tests dropped down from 2,018 to 1,356. Although the proportion of MTB-positive tests grew from 5.6% in the first half of 2019 to 7.2% for the same period of 2020, it
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 25
did not reach the standard 10% threshold, which can be the result of low quality of collected sputum and wrong or not targeted identification of TB presumptive individuals. The baseline assessment conducted by USAID ETICA contained a laboratory component. To discuss the results of the baseline assessment from pilot districts, the project team conducted a series of online meetings with NTP and international laboratory experts. Based on the results of the baseline assessment and use of NLSP, the team developed a detailed five- year project-plan for the USAID ETICA laboratory component to address the following priorities: • Laboratory strategic planning, including a plan for transitioning to GeneXpert Ultra. • Technical assistance with TB laboratory network optimization. • Capacity building with rapid molecular test and phenotypical Drug Susceptibility Testing (pDST) for new and repurposed drugs. • Implementation of pDST at regional TB laboratories. • Technical assistance with Quality Assurance of TB laboratory diagnostics and further implementation of Laboratory Quality Management System (LQMS). • Technical assistance with planning and further improvement of specimen referral networks. • Electronic laboratory data management.
2.4.3 ACTIVITY 1.3. STRENGTHENING THE QUALITY OF LAB SERVICES During Y1, there were noticeable developments in the area of laboratory improvement. USAID ETICA engaged the NTP in collaborative activities, such as development of the NLSP, capacity building of the laboratory staff, implementing QMS activities, and supporting the transition to the Xpert-MTB/RIF diagnosis system. As was mentioned earlier, to improve the effectiveness and quality of the TB laboratories’ performance, the laboratory TWG, jointly with USAID ETICA, has drafted a five-year NLSP, which was later incorporated into the NSP. The NSP is at the stage of NTP review and is currently pending approval from the MOH. The team also prepared a roadmap for the implementation of NLSP, which includes the definition of key indicators, a monitoring and evaluation system, budget and responsible persons. To improve planning for procurement purposes, USAID ETICA provided technical assistance in the development of a five-year laboratory budget reflecting anticipated funding needs for reagents, consumables, equipment procurement and maintenance, specimen transportation, and infrastructure upgrades of regional laboratories. The budget was submitted to NTP and used for the GF application. To support NTP on the way towards transitioning to a new generation of Xpert Ultra diagnostic tests, USAID ETICA drafted a new TB laboratory diagnostic algorithm and submitted it to NTP for further endorsement. Considering the fast-tracked transition to the Xpert-MTB/RIF diagnostics, which replaced the smear microscopy, a “TB laboratory diagnostics guide for clinicians” was developed and submitted to NTP for further endorsement. In addition to the updated algorithm, the guide also includes updated laboratory request forms for both diagnostics and follow-up. The main purpose of the guide is to help clinicians make informed decision based on laboratory results. It also
A TB lab specialist in Tajikistan USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020performs a Lowenstein - Jensen medium | 26 inoculation
describes common cases of test discrepancies and possible solutions. The updated algorithm is illustrated in Exhibit 2.
The project conducted a one-day workshop with NTP laboratory specialists and USAID StopTB Country TB-laboratory specialist on an analysis of the laboratory network. Workshop participants discussed a gradual and step-by-step transition to Xpert MTB/RIF Ultra cartridges and which laboratories should be given a priority for the transition. Strengths, weaknesses and possible risks
Exhibit 2. Diagnostic Algorithm
during the transition were also analyzed. It was agreed that the following steps are needed: a review of all SOPs related to Xpert MTB/RIF testing, including interpretation of results; and an update of the TB05d form to add the Xpert MTB/RIF Ultra to the form (form TB05d is used for reporting of test results). The QMS is a set of coordinated activities to direct and support an organization with regard to quality. QMS in a laboratory setting (LQMS) embraces all aspects of the laboratory operation including the organizational structure, processes and procedures, all of which need to be addressed to assure quality. To support NTP to strengthen QMS in the NRL, the team started collecting documents for a desk review and assessing the strengths and weaknesses of QMS. Since the QMS
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 27
assessment was partially completed, USAID ETICA met with NRL and presented the results of the “Management of Documentation” section as well as recommendations on how to improve the quality of SOPs in the laboratory. To assist NRL with further implementation of LQMS, USAID ETICA established a cloud-based platform enabling all laboratories and their staff online access to all current laboratory SOPs. This helps NRL to communicate timely, simultaneously and correctly all approved changes in SOPs and improves quality management of laboratory work. To date, about 120 QMS documents were revised and endorsed by NRL manager. USAID ETICA experts interviewed representatives from labs in pilot regions to understand the current functionality of the specimen referral system in terms of frequencies of specimen shipment from PHCs to labs, types of transportation means and providers used availability and use of proper containers for transportation, transportation patterns between regional and oblast labs. This will inform the design of an updated system. Additionally, the project has started outlining financing options for ensuring the re-designed system’s sustainability, which entails obtaining state funding to cover the maintenance expenditures. Currently, all costs related to transportation are covered by the GF grant and other projects. Starting from 2021, 30% of costs will have to be covered by the state with a gradual increase up to 70% by 2024. According to the new GF application for 2021-2023, the coverage of transportation costs will be reduced starting from 2021. The transition plan developed in 2016 with the financial support of the GF outlines a gradual transition of TB financing from the donors to state funding. If the plan is approved by the government, it would be a good mechanism of ensuring that additional TB financing is included in the state budget, including the cost of transportation from the state budget. Unfortunately, the plan was not approved; it is now, outdated and requires revision. NTP plans to revise the existing transition plan and when requested, USAID ETICA will provide technical assistance (including the design of Concept of sputum transportation). The project provided three-day skill-based training for 10 NRL laboratory specialists on the implementation of expanded DST, especially for new drugs such as BDQ, DLM, CLF, and LZD. Special attention was given to the handling (i.e., weighing, dissolving, storing) of new drugs including calculating their activity factors from the data provided in the product sheets. Also, the project provided 2-day practical training for 10 NRL laboratory specialists on the improved internal controls established for both drug solutions and test media for all four new drugs.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 28
Training on DST including new drugs, Dushanbe, Tajikistan
2.4.4 ACTIVITY 1.4. STRENGTHENING THE QUALITY OF MEDICAL SERVICES FOR IMPROVE CASE DETECTION In Y1, USAID ETICA provided urgent technical assistance in critical areas related to TB case detection and explored collaboration with other organizations involved in quality improvement of services. USAID ETICA initiated the establishment of a TWG to address strengthening out-patient TB case management in Tajikistan. The TWG will be a part of joint NTP / USAID ETICA efforts aimed at building an effective, efficient, and sustainable people-centered model of TB and DR-TB care. In agreement with NTP, USAID ETICA drafted a SOW for the TWG. To improve early detection and effective management and treatment of TB patients, a guideline and algorithm for the continuous care of DR-TB patients receiving new drugs and shorter treatment
DST Practical training, Dushanbe, Tajikistan
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 29
regimens (i.e., identification, registration and management of patients) at the outpatient stage are being developed. The project team presented and discussed a preliminary version of the document during the TWG meeting. The guideline builds upon the people-centered TB and DR-TB case management protocols, which were developed based on WHO recommendations. The guideline will support the outpatient approach to TB treatment and will strengthen linkages between the PHC and TB sub-systems. Strengthening local and regional capacities to better detect and treat DR-TB is essential to reduce the burden of TB. To enhance local and regional capacity, USAID ETICA developed a “Guide for public organizations on the provision of detection, support of treatment and TB prevention services”. The guide is a practical tool, which can be used by any organization to plan and implement realistic and effective methods for TB control in target groups. The project worked finalized the document’s design and will submit it to USAID for approval. The guide has been developed for CBOs, CSOs and other groups that would like to include a TB component in their programmatic work. It will be useful both for organizations taking the first steps in the fight against TB and for organizations that already have some experience in this area. USAID ETICA conducted a desk review of the documents on clinical auditing of DR-TB patients in the outpatient phase, existing monitoring, evaluation guideline, and monitoring checklists. The team will convey the findings resulting from the review to the health care staff of the pilot districts, who will be trained on how to improve the workflow and use of clinical audit tools. Clinical audit tools and checklists have been used during online monitoring and evaluation of PHC and TB centers together with representatives of the NTP in pilot areas. BDQ resistance research To support the NTP in making evidence-based decisions regarding the use of drugs for the treatment of DR-TB, the project collected data to study resistance to BDQ and DLM among MDR and XDR- TB patients who have been confirmed to be resistant to BDQ and DLM (the data source is the Open MRS and NRL database). Introducing new TB drugs into practice plays a significant role in increasing the effectiveness of chemotherapy in DR-TB treatment courses. Introduction of new MDR-TB treatment regimens using BDQ in Tajikistan started in 2017. In 2018, the NRL, with technical support from the SNRL (Gauting), introduced a phenotypic study of the pDST to BDQ. In 2019, monitoring of routine BDQ pDST tests revealed an unexpectedly high percentage of BDQ resistance. To prevent the further spread of DR-TB strains, the project initiated a study of patient resistance to BDQ and DLM. The project collected and analyzed patient data using Open MRS, NRL data sources, and MDR-TB patient treatment cards. As a result of the study, the project obtained the following information: • Total resistance to BDQ was identified in 89 people with TB. • In 47 cases (52.8%), resistance to BDQ was confirmed after re-checking. All people received treatment. Out of them, 26 patients had change of the regimen, and 21 continued the previous treatment regimen. Eight out of 26 with change of regimen, had BDQ in their new regimen. • NRL verification of pDST results was carried out using the implemented re-checking procedures for all identified resistant isolates. Exhibit 3 below, shows the outcomes for the 47 people with TB with confirmed BDQ resistance.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 30
Exhibit 3. Analysis of BDQ resistance research
The results of the study will enable the MOH and NTP to make informed and evidence-based decisions in preventing the spread of resistance to new TB drugs. Since NTP will be introducing a new mSTR which contains BDQ (BPaL), NTP will have to make timely, accurate and evidence-based decision on prescribing the treatment regimens. Procurement of drugs will be based on accurate prognosis of drugs, considering the rate of resistance and tendency of spread of resistant strains. USAID ETICA developed a draft textbook on Phthisiology that contains the latest information on TB and DR-TB recommended by the WHO. The textbook will align with the core curricula of pre- and post-graduate medical academia, including universities, colleges, and professional certificate programs. The draft of the textbook includes information on the history of the TB field, epidemiology and pathogenesis of the disease, methods of diagnosis, treatment, and classification of the disease and information on pulmonary and non-pulmonary TB and its differential diagnosis with other diseases. The internationally recognized high-level TB experts from Academy of science4 provided reference to the textbook. The project will hand over the ownership of the book to TSMU and TPMI during the World TB day.
4 a) 1. Odinaev F.I. - Academician of the Russian Academy of Medical Sciences, Honored Worker of Science and Technology of the Republic of Tajikistan, Doctor of Medical Sciences, Professor b) Muradov A.M. - Academician of the Russian Academy of Medical and Technical Sciences, Laureate of the State Prize. I. Somoni, MD, DSc, Professor
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 31
2.5 OBJECTIVE 2: INCREASED TREATMENT SUCCESS FOR TB AND ALL TYPES OF DR- TB During Y1, USAID ETICA convened efforts to strengthen the capacity of health and non-health care providers, supported the NTP in revising existing documents to address gaps and identify areas for improvement, conducted operational research to identify the resistance to new drugs and started working hand in hand with the NTP to switch the focus of treatment to an outpatient modality. All efforts made by the Project focused on improving the outcomes and wellbeing of patients.
2.5.1 ACTIVITY 2.1: SUPPORT THE ADOPTION AND IMPLEMENTATION OF PATIENT-ORIENTED APPROACH IN TB CARE The patient-oriented approach in TB care relies on healthcare facilities working together with communities and families. Thus, one of the vital components of USAID ETICA is strengthening the capacity of outreach workers. During Y1, the project team developed educational materials for outreach workers on DOT to prepare them to work alongside health workers to improve patients’ adherence to TB and MDR-TB treatment. The role of CSOs in community-level work, including their work in case management and case findings, is significant. To respond to CSO needs in this area, the project developed a guideline for CSOs on TB detection, treatment and prevention. The project initiated establishment of a TWG on developing a guideline for integrated TB case management to be implemented in pilot regions. The guideline will support an outpatient approach to TB treatment. According to the guideline, since the PHC and TB facilities will have to provide coordinated and concerted TB services to patients, it will strengthen linkages between the PHC level and TB sub-system following a patient-centered TB and DR-TB case management approach, based on WHO recommendations. As this document stands as an important country policy document, the review and inputs from the clinical TB Adviser is necessary. The delay with onboarding of the adviser affected finalization of the guideline. To improve the patient-oriented approach in TB service, the project initiated a desk review of the existing outpatient model for TB and DR-TB care. The project also reviewed relevant guidelines and policies to evaluate this model against its compliance with standards for integration of TB services at the PHC level, including psychosocial support for TB/DR-TB patients. Based on the review, the project developed a package of training materials and trained the partner CSOs on providing outpatient services to patients. Project partners have applied recommendations resulting from the review in their daily work, and they have already observed some noticeable results. For example, recommendations on establishing close cooperation with the local migration services, AIDS centers, and religious leaders were already used by CSOs.
2.5.2 ACTIVITY 2.2: SUPPORT THE INTRODUCTION OF NEW PROCEDURES TO SUSTAIN PATIENT- CENTERED CARE USAID ETICA supported capacity building activities for sustaining patient-centered care by establishing a system for ongoing learning activities and participated in several Consilia meetings organized by the NTP.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 32
In Tajikistan, TB Consilia play the role of a final health destination for TB patients. Their job is to confirm the TB diagnosis and prescribe a proper regimen, rectify the previous regimen, and provide recommendations to doctors on follow-up steps related to patient management. NTP invited USAID ETICA specialists to participate in the Consilia meetings to discuss complicated DR-TB and TB cases, review cases with confirmed BDQ resistance, and analyze the increasing tendency of resistance to TB drugs. During the reporting year, 74 Consilia meetings were conducted, a total of 1,825 patient medical records were submitted to Central Consilium, out of which 345 (19%) had their diagnosis confirmed for the first time and treatment prescribed. Of the 1,825 submitted cases, 1,480 were patients whose cases were submitted and reported repeatedly, during the course of the treatment. Participation of USAID ETICA specialists enriched the Consilia meetings by providing up-to date information on treatment regiments, resistant strains, and most importantly development of the TB checklist for presenting the TB cases accurately and with all necessary information. Capacity building and continuous education of the DR-TB Consilium staff is a crucial element to ensure successful implementation of the TB program. USAID ETICA conducted an online training focusing on TB diagnosis, treatment of DR-TB, and clinical monitoring of people receiving DR-TB treatment for 15 members of Consilia through the National Training Center. The project strengthened the capacity of the Republican Clinical Hospital of Tuberculosis, Pulmonology and Thoracic Surgery (RCHTPTS) Consilium members and the Consilium of oblast level of Sughd region in the differential diagnosis of lung diseases and TB, as well as case management of COVID and TB, including monitoring of side effects. The practical section of this online training included the analysis of clinical cases presented at the Consilium of the Sughd region. The RCHTPTS is one of the main health facilities providing in-patient care for people affected by TB in Tajikistan. The training center has a well-established setting, which provides an excellent opportunity for medical specialists to improve their qualifications and skills on the job, without interrupting their functional duties. The project has studied the documents regulating the work of the National Training Center (prikaz, charter, training programs). The results of the review allowed the team to strategize the next steps of working with RCHTPTS and build future activities based on the strengths and capabilities of the Training center. The NTP and the RCHTPTS’s administration discussed using USAID ETICA support for online consultations and training sessions, including continued education of DR-TB Consilia using telemedicine. Within the framework of the project, a draft long-term multilateral agreement on cooperation was developed between the National Training Center represented by the RCHTPTS and state educational institutions such as the TSMU, National Center for Family Medicine, Medical College of Vahdat district, National University and the TPMI. The purpose of the agreement is to strengthen cooperation and capacity building of medical workers, students and postgraduates working in the field of TB and PHC. USAID ETICA specialists held discussions with the NTP and the responsible person for PV on the following topics: the opportunities and challenges of revising the legal framework, human capacity building, and coordinating and introducing active monitoring of TB drugs safety in all healthcare facilities involved in the provision of DR-TB services to patients. Based on these discussions, the project team updated the assessment tools on PV and the aDSM system and submitted extracted recommendations to the NTP to prepare an action plan on improving the current system. In addition, the project has proposed that legislative and regulatory norms of the PV system should be
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 33
updated as the new drugs are used "off label" and an increasing number of signals on misuse of drugs might be misinterpreted by the regulatory bodies. USAID ETICA has initiated a joint meeting with partners to develop an action plan for aDSM with clear objectives and timeframes over the next five years. The action plan will set a clear understanding of the segregation of tasks among NTP and other key players and reflect coordination of activities on aDSM. Accurate and proper data collection on aDSM requires additional financial and human resources in the current TB care settings, as the system does not have a specialist allocated for aDSM activities. The role of the aDSM responsible person would be to conduct active clinical monitoring at all levels of DOT of DR-TB patients. With technical advice from the NTP, USAID ETICA developed a SOW for an aDSM consultant to support the introduction of short BDQ-based treatment regimens for DR-TB and to provide technical support to NTP on implementation of aDSM activities.
2.5.3 ACTIVITY 2.3: BUILD CAPACITY FOR PHARMACEUTICAL MANAGEMENT (PM) USAID ETICA set the groundwork for the implementation of drug management activities. The project held meetings with NTP technical experts and donor-funded organizations, developed SOWs, and conducted regulatory reviews for management and registration of TB drugs. Project experts and the NTP’s National Drug Management Coordinator discussed the capacity building needs for managing pharmaceutical products and improving the forecasting of TB drug needs. The discussions helped to inform project workplans and development of SOWs for pharmaceutical experts. These experts would assist the NTP in introducing the internationally recognized quality standards for TB drugs and assist in the validation/implementation of their registration process. To enhance the system for TB drug forecasting based on the real number of patients with all forms of TB it is important to support the NTP to apply appropriate tools. Project staff participated in TWG meetings to discuss treatment regimens for DR-TB and to identify the country’s needs related to TB drugs using the QUAN TB tool. In addition, with the technical support of USAID ETICA, the TWG prepared a stock analysis of TB drugs and calculated the anticipated number of patients. Triangulation of all results enabled forecasting of the country’s coverage with the TB drugs under the current GF grant in 2020 and partially for 2021. USAID ETICA reviewed regulatory documents in registration and procurement of TB drugs in Tajikistan to provide technical assistance to NTP for second-line drug (SLD) registration. Project specialists participated in the discussions with the NTP and the Head of MOH’s Pharmacy Department on potential approaches to simplifying registration procedures or otherwise overcoming registration-related impediments to importing TB drugs needed for new treatment regimens. The project prepared a concept note describing the current situation and analysis of national regulatory documents for registration and procurement of TB drugs in the country. The document aimed to improve the system of continuous provision of quality, safe and effective medicines for 2021-2023 within the framework of TB and HIV services in the Republic of Tajikistan. Along with the concept note, USAID ETICA developed a SOW for a National Pharmaceutical Expert, whose role will be to assist in the implementation of the drug registration process. USAID ETICA participated in the discussions and the preparation of responses to the GF Technical Review Panel (TRP) comments related to strengthening procurement and supply chain management systems to ensure high -quality medicines and products for TB and HIV are delivered to Tajikistan. The response was developed in collaboration with the new Principal Recipient (UNDP). USAID ETICA specialists provided information on the current situation on drug procurement and
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 34
registration. The following are two main areas where legal changes are required to ensure the quality of imported drugs; these points were sent for inclusion to the GF proposal: • The existing Tajik procurement policy requires purchasing goods and pharmaceuticals at the lowest price, and does not stipulate any quality standard requirements. The current law also does not allow for the procurement of medicines via international procurement platforms. In 2019, the law was revised and submitted to the government for review and approval. The amended law allows for conducting procurement processes for socially important diseases such as TB without open tenders and through international platforms. • USAID ETICA highlighted the importance of applying the WHO approach on collaborative registration of drugs, which ensures accelerated registration of TB drugs in the country. The other recommendation was to recognize the registration of prequalified WHO drugs in the country (free of charge registration). Since this practice does not currently exist in the country, it was recommended to be included to the GF proposal.
2.5.4 ACTIVITY 2.4: STRENGTHEN COORDINATION MECHANISMS LINKING PWTB WITH OTHER HEALTH SERVICES AND SUPPORT The project had numerous meetings with the GF, NTP, WHO, MSF and other partners to improve accessibility and availability of services for PWTB. During these meetings, partners discussed coordination on technical assistance, ensuring the needs of PWTB are reflected in the GF application, making the HIV related services more accessible and non-stigmatized, building capacity of personnel on patient-oriented approaches, and providing psychosocial support for PWTB. Since Soviet times, Tajikistan’s TB and HIV programs have existed as two, standalone, parallel programs with very weak coordinating mechanisms. Such separate and poorly coordinated operations impose drawbacks in the timeliness of TB and HIV co-infection detection and management. To tackle the longstanding issue, the project team met with representatives of regional HIV and AIDS centers in pilot districts to discuss the timely referral of newly registered PLHIV for TB testing (taking into account the situation with COVID-19). This would allow for the timely detection and treatment of TB cases among HIV-positive people. The project met with the Coalition of Stop TB Partnership team, where needs and gaps of linking PWTB with other health services and support were discussed. Identified needs will be reflected in USAID ETICA’s TB case management model. In the reporting period, the project conducted a series of roundtable meetings in five target districts of the Sughd region with participation of all key partners and relevant stakeholders. The 60 participants in attendance included directors of districts’ TB centers, HIV/AIDS centers, HLCs, Deputy Heads of Hukumats, heads of districts’ education departments, heads of districts’ migration centers, heads of districts’ committees of youth, sports and tourism, representatives of business sector, project volunteers, MDR-TB patients. Project staff discussed the results and achievements of USAID ETICA’s first year and plans Y2. MDR-TB patients had the opportunity to talk about the assistance and support provided by USAID ETICA’s project volunteers in adherence to treatment necessary for a successful recovery. Participants also discussed the following topics: the need to attract new partners and expand opportunities to reduce the financial burden of people affected by TB, gender equity and social inclusion, and reducing stigma and discrimination toward people affected by TB.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 35
2.6 OBJECTIVE 3: IMPROVED ENABLING ENVIRONMENT AND FINANCIAL SUSTAINABILITY OF TB AND DR-TB PROGRAMS With assistance from USAID and other donors, Tajikistan has made significant strides towards a people-centered health system. The country increased community involvement in the detection and treatment of TB and enhanced capacity for delivery of quality care and innovation in diagnosis and treatment. An NSP 2021–2025 has been drafted and is undergoing a review at the MOH before approval. In addition, an application for a new grant from the GF has been prepared to secure much of the anticipated financial needs of the NTP. Reportedly, a recent increase in the compensation of TB specialists did not result in a measured improvement of detection rates, service delivery, or treatment outcomes. There is a disconnect between staff compensation and treatment outcomes, which must be addressed if the country is to meet its national and international commitments for TB control.
2.6.1 ACTIVITY 3.1: PROVIDING EFFECTIVE DETECTION TO WHERE PEOPLE FIRST SEEK CARE In Y1, USAID ETICA held meetings with donor-funded initiatives to collect information about past and present efforts to create point-of-services maps in the country as a basis for the mapping the Project will conduct in Y2. USAID ETICA collected the information to design a hotspot mapping, which will exhibit available TB services. The mapping will be used by health and non-care providers and by individuals with similar TB symptoms.
2.6.2 ACTIVITY 3.2: STRONG COMMUNITY SUPPORT INCREASE CIVIL SOCIETY AND COMMUNITY ENGAGEMENT IN DR-TB USAID ETICA conducts advocacy workshops in each pilot region to engage and gain the support of influential community leaders, local governments, CSOs, religious leaders, and healthcare providers regarding community needs and approaches to supporting people and families living with TB. In preparation for the workshop(s), the project collected field data and information for its baseline assessment, and used the results to develop materials for the advocacy workshop. During the workshop, participants expressed their willingness to work together to reduce the prevalence and incidence of TB at the district level. The project conducted two oblast-level working meetings of the network of TB service providing organizations in the cities of Bokhtar and Khujand in the Khatlon and Sughd regions respectively. Attendees of the working meetings included 68 representatives of departments of health and social protection of the population of Khatlon and Sughd regions, the national TB program, the republican center for AIDS prevention and control, departments on women and family affairs, departments of assistance and social protection, departments and agencies related to migration and population employment, reproductive health centers, and PHC system and public organizations of Khatlon and Sughd regions. During the working meetings, the participants discussed strengthening the coordination and cooperation between government agencies and public organizations on prevention and control of TB among labor migrants, PLHIV and other vulnerable population groups. Participants discussed possible ways to overcome barriers and reduce stigma and discrimination during TB treatment among key populations.
2.6.3 ACTIVITY 3.3. ENHANCE THE PROVISION OF TREATMENT ADHERENCE SUPPORT TO TB PATIENTS
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 36
During the reporting period, USAID ETICA examined the status of community-based treatment support in pilot oblasts as part of the project’s baseline assessment. Additionally, project experts participated in discussions with PIU GF and NTP on treatment regimens for DR-TB and preparation of the new GF grant application for 2021-2023. The adoption of new treatment regimens is essential to define the scope of adherence, which the project will support in its work with people with TB. The project volunteers have provided a total of 357 food packages to 53 financially vulnerable DR-TB affected individuals since the start of the program with funding from USAID and other donors (the list of TB affected was obtained from districts’ TB centers). In addition, USAID ETICA volunteers supported families and individuals affected by TB and MDR-TB by distributing TB drugs to minimize the risk of infection during the pandemic, ensure treatment adherence to TB regimens, and encourage those exhibiting symptoms of COVID 19 or TB to get tested.
2.6.4 ACTIVITY 3.4. EXPAND EFFORTS TO REDUCE STIGMA AND DISCRIMINATION During the reporting period, USAID ETICA supported the community of PWTB and their families to stand up against stigma and discrimination. The project has begun preparing for CSO trainings on TB, which will include the subject of stigma and discrimination among multiple other training topics. Additionally, in commemoration of World TB Day, the project prepared and executed activities aimed at highlighting the social consequences of stigma and discrimination toward PWTB. The Project organized a bicycle marathon on March 14, 2020. Forty members and volunteers of the NRCST took part in the event. They disseminated information materials on issues related to stigma and discrimination to the spectators of the marathon in the project pilot regions. With support from the leadership of the Children’s TB hospital in Dushanbe, the project engaged 54 children affected by TB and their parents in an event that educated and disseminated information on TB. The main message of the event was that “TB is curable and requires completing a full treatment course on time.” An animated entertainment show for children was organized to provide social support for children with TB. USAID ETICA, along with “Stop TB Partnership” in Tajikistan and NRCS participated in an international show of solidarity with TB affected individuals called “Light up for TB.” The initiative lights up in red many buildings or other landmarks on the same day and is held simultaneously in various capitals across the world. During home visits by project volunteers, the population in the pilot sites were informed about the advantages of timely access to medical institutions at the first onset of TB symptoms and on women's rights to receive medical services. These sessions also covered topics related to the prevention of stigma and discrimination against people affected by TB and their families. USAID ETICA project staff started studying the best practices and lessons learned from the previous USAID and other donor projects on stigma and discrimination to inform, develop, and conduct targeted information campaigns. Training sessions on "Reducing the level of stigma and discrimination against people affected by TB and key populations" was held in Norak, A. Jomi, Temurmalik and Danghara districts of Khatlon region. Eighty-two PHC workers attended the trainings and learned the concepts of “stigma” and “discrimination”. Participants also discussed how to create a sustainable system to counter the
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 37
manifestations of stigma in the health sector, in particular in relation to persons affected by TB, labor migrants and PLHIV. USAID ETICA organized an awareness- raising event for media representatives/reporters from national media and pilot oblasts to introduce the project goals and tasks, as well as to open discussion on the rationale and social importance of reducing stigma associated with TB. The press- café hosted 23 media representatives from Dushanbe and oblasts (5 people from Sughd and 2 from Khatlon were connected online). The reporters were presented with a project overview and basic information about the epidemiological situation of TB, and discussions focused on the standards of ethics and responsibility of the reporter while covering TB-related issues.
Press Café for Local Media to Reduce Stigma Associated with Tuberculosis, Dushanbe, Tajikistan
2.6.5 ACTIVITY 3.5. ROBUST DATA COLLECTION, ANALYSIS, AND FEEDBACK SYSTEMS On August 4, 2020, program specialists participated in a working meeting to discuss the results of NTP-led monitoring visits and the work of the electronic register of OpenMRS in the country’s TB centers. Meeting participants discussed the progress and challenges revealed during the visits and outlined an action plan to address the identified problems of the OpenMRS. These included: • Weak computer literacy of specialists • Poor quality internet connection in remote areas • Poor quality and untimely data entry • Inappropriate use of internet traffic • Staff turnover • The interest of specialists in working with the E-TB register • Frequent updating of reporting and accounting forms • Remote area technical support To have a clear strategy Working meeting to discuss the results of monitoring visits conducted by the NTP, for implementation of the Dushanbe, Tajikistan monitoring and evaluation
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 38
(M&E) activities in the TB system, the project team developed a Monitoring and Assessment Activity Plan for Y2 which is based on the project’s Activity Monitoring Evaluation, and Learning Plan (AMELP). One of the main components of USAID ETICA is the digitalization of the TB continuum of care (i.e., the development of information systems and e-platforms for TB service delivery). As illustrated in Exhibit 4, the project targets a) Prevent TB Platform and VST modules under the REACH component in the continuum of care; b) OpenMRS and LIMS in CURE; and c) seeking suitable approaches to link the TB systems with the government’s DHIS2 system.
Exhibit 4. Digitalization of TB Continuum of care in Tajikistan
I. E-detection tool “Prevent TB Platform” The project team will apply the e-Detection tool Prevent TB, recommended by WHO, to further enhance TB case finding by CSOs and community networks. Prevent TB facilitates the evaluation of contacts in their home and communities or a health facility. It allows monitoring throughout the cascade of preventive care, capturing data at the time of identification of the contact and registration, clinical assessment, screening for active TB, testing for infection and treatment. The project team started close cooperation with the developers of the Prevent TB Platform, Dure Technologies. The platform developers presented a demo version of the e-detection tool. The project reviewed, verified, and commented on the draft e-detection of the Prevent TB Platform against the requirements of the TB program. The USAID ETICA team sent the feedback and project requirements for adaptation of the system to developers for further discussion. II. Electronic TB register OpenMRS The OpenMRS is a web-based software with the use of a "concept dictionary" that describes all the data items that can be stored in the system such as clinical findings, laboratory test results, or socio- economic data. It is currently used by the NTP as the main TB register.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 39
USAID ETICA specialists started a functionality analysis of the OpenMRS TB and Laboratory modules. The analysis, when completed in Y2, will allow for the identification of areas for connection with existing and future information systems. Since USAID ETICA intends to improve the digital systems supporting TB services, the team requested the developer of OpenMRS to submit a tentative timeline and budget for upgrading the system as per user requirements. While OpenMRS is the database for registration and management of TB patients, treatment of TB patients is directly dependent on the results obtained from TB laboratories. The results of the laboratory tests should flow into OpenMRS from the LIMS database, which currently does not happen. A link between OpenMRS and LIMS is currently at the development stage and will be discussed after the selection of the LIMS software. One option is to use DHIS2, which is currently used by the MOH for the entire health care system. Since OpenMRS serves as a main register of the TB system and the paper data records of health care providers should carry/show the same data as in OpenMRS, all TB healthcare providers must be kept informed and updated on working with it. USAID ETICA conducted a training for 17 new employees of NTP on the usage of the electronic OpenMRS TB register. The main objective of the training was to build practical skills for accurate and timely data entry in the OpenMRS. Training materials developed by the previous USAID project were reviewed by USAID ETICA specialists to ensure that materials are up to date and can be applied during the training. The training materials included the following main topics: data entry for DS TB patients; data entry for DR-TB patients; and data entry to the Laboratory module.
Training on OpenMRS for 17 new NTP specialists, Dushanbe, Tajikistan
III. Development and implementation of LIMS Proper data recording, reporting and analysis provide a strong basis for evidence-based decision making, ultimately improving the wellbeing of the patients. Therefore, USAID ETICA specialists reviewed and analyzed the existing laboratory information systems, including the laboratory OpenMRS module and GxAlert system. The results of the analysis will be applied during the planning of implementation of LIMS and integration with the other existing systems. The LIMS is a holistic system connecting all other existing “pieces” or laboratory software and databases to form a full picture of the laboratory data management. During Y1, project specialists continued the assessment of the LIMS and held discussions on the integration of LIMS with other information systems of the TB service. To prepare a final version of LIMS specifications, a discussion was held with national laboratory specialists to determine the final priority areas for LIMS functionality. The required specifications for the development of an LIMS
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 40
encapsulating all existing laboratory information systems (GxAlert, lab module of OpenMRS) and the TB module of OpenMRS register have been developed and discussed with the NTP. Based on the discussed priority needs, the project team will prepare tender documentation for procuring LIMS. IV. GxAlert GxAlert is a web-based open-source data connectivity application, which includes a system for data management designed to work with any diagnostic device that can connect to the internet or a mobile network. Results from the GeneXpert machines are automatically sent to the GxAlert server, which provides robust and clear documentation to connect existing M&E systems and eliminates the need for manual reporting and recording of any transcriptions or submission of results. GxAlert was installed in all TB labs by the previous USAID project but is not functioning due to lack of financial support. USAID ETICA will restore the functionality of the GxAlert system. The project held a discussion with SystemOne, the developer of the GxAlert laboratory information system, regarding the renewal of a technical support subscription in Tajikistan. Following this discussion, USAID ETICA received a proposal from SystemOne for GxAlert re-engagement. USAID ETICA reviewed the proposal and engaged in a dialogue with SystemOne regarding budget details. The new proposal entails an updated GxAlert system enabling real-time connectivity between a future LIMS and the network of GeneXpert machines. V. Adaptation of VST tool Introducing VST is a crucial element for the successful treatment of patients with TB during quarantine measures, when health workers cannot directly observe the intake of medicines. The StopTB Partnership has introduced VST software, which allows the healthcare workers, including outreach workers and volunteers, to support patients on treatment through an online (mobile phone) application. Since the StopTB Partnership has been adjusting the software and VST to be used in their pilot districts, USAID ETICA is collaborating with them to bring the app to the project pilot sites. The StopTB Partnership cooperates with the Center for Policies and Studies, which implemented the VST module with good results in Moldova. The Partnership presented the VST module to USAID ETICA and suggested introducing a similar model in Tajikistan. USAID ETICA plans to implement VST as part of an operational study and has developed a concept for the implementation with the adaptation of the following materials as a part of the concept: ➢ Informed consent to VST ➢ Instructions for medical personnel ➢ Patient eligibility questionnaire for inclusion to VST ➢ Guidelines for selection of patients for enrollment to VST ➢ VST Organization Statement ➢ Practical guide for medical personnel ➢ Practical guide for the patient ➢ Agreement for the processing of personal data ➢ Tables generated from VST Tool
The project plans to introduce the VST in all project pilot areas, including three new districts under the OR. The criteria to joining the pilot are patients who: ➢ are newly diagnosed ➢ are enrolled to treatment ➢ have met the criteria for VST enrollment in pilot regions,
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 41
➢ and approximately 50% (which might be around 80 persons) of newly enrolled DR-TB patients
2.6.6 ACTIVITY 3.6: INCREASED LOCAL CAPACITY TO FINANCE AND IMPLEMENT TB SERVICES USAID ETICA specialists actively supported the development of the NSP for the period 2021-2025. Project experts drafted the NSP’s implementation plan, estimated the cost of laboratory interventions in it, supported the costing of the NSP’s drug management section, and prepared the overall NSP implementation budget. USAID ETICA shared the budget with GF consultants to help align its activity lines and costs in the country’s application for the GF funding. The current TB financing transition plan, developed with the GF assistance, covers 2018-2020 and needs to be revised and adjusted based on the new NSP’s implementation plan and budget. USAID ETICA calculated the costs for the implementation of a new TB program. The calculation showed the budget deficiency, which should be covered by the state budget. Improving the quality of TB services requires large financial investments, while the current allocation of state funds is insufficient. One of the options to tackle the issue is to re-program identified savings to the priority needs of TB care. Another option is to narrow the TB system financial deficit to support the health financing reforms being carried out under the leadership of the MOH. In Tajikistan, the health financing reforms are guided by the Strategic Plan for the Reform of Healthcare Financing in the Republic of Tajikistan for the period 2019-2021. The primary goal of the Strategic Plan is to achieve the following targets: • Improve the financing of PHC facilities augmenting per capita financing with results-based payment. • Introduce new hospital financing mechanisms and optimize the hospital networks through the introduction of the case-based payment, which relies on strong health information systems and infrastructure. Case-based payment enables the use of the Diagnostic Related Group as the core of hospital financing. • Prepare for the establishment of Mandatory Health Insurance (i.e., pooling of funds at the regional level and giving management autonomy to healthcare providers). • Strengthen the capacity of human resources in the health care system. Project specialists participated in the meeting of the inter-ministerial expert group on health financing under the auspices of the Ministry of Finance to discuss several issues and challenges related to health financing: • The importance of including diagnostic services for "TB contacts" (i.e., family members of people living with TB) in the guaranteed state package of free health services and prioritize the inclusion of free fluorography. • The necessity of developing a unified, standard budget format for TB facilities funded by the local administrations. To support the Ministry of Finance TWG with tangible input data, USAID ETICA collected additional data on health financing from the MOH and budget data from the pilot sites. Analysis of the collected data will allow for:
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 42
• Planning TB financing interventions in the area of PHC financing in collaboration with the World Bank on Result Based Financing. • Per capita formula elaboration. • Calculating hospital financing in collaboration with the Asian Development Bank on hospital e- based funding and Diagnostic Related Group. • Coordination with the Government to upgrade the content of the basic benefit package (BBP) related to TB detection. Following the TWG meeting, USAID ETICA specialists studied the regulatory framework and new forms related to financing in the healthcare sector. A desk review of the documentation showed the importance of establishing a finance TWG under the MOH to develop new methods of financing specifically for TB services. This TWG under the MOH will work on the development and implementation of new forms of financing for the TB service and will be supported by the USAID ETICA project whereas the expert group created under the MOF is supported by WHO and is engaged in analyzing the situation in the health sector as a whole. The Project team met with the head of the Economics and Budget Planning Department of MOH to discuss the implementation progress of the Strategic Plan for Health Financing Reform. It was agreed that USAID ETICA may participate in the revision of the BBP by piloting case-based funding in TB hospitals (Dehmoi and Machiton) after approval of a methodology, which will be developed by the Asian Development Bank and the introduction of result-based funding indicators on TB screening. MOH asked USAID ETICA to work closely with other development partners (Asian Development Bank, WB and WHO projects) to support health financing activities. Apart from the financing of the TB system and heightening the quality of TB service provision, the capacity of the local communities and CSOs should be enhanced. One of the important factors for an enabling environment to improve the CSO engagement in TB program is ensuring availability and accessibility of the state funding through a social order/ contracting mechanism. It will be critical to involve CSOs in the implementation of TB programs, which are currently fully dependent on the GF and other external donors. Although CSOs play a pivotal role in early detection and support for adherence of treatment, the government needs technical support to develop and introduce the mechanism to engage CSOs with TB programs using state funding. If the government is not supported promptly to do this, CSO participation in TB programs may deteriorate. USAID ETICA conducted a desk review of the legal and regulatory documents on social contracting and the experience of previous projects, and held meetings with the MOH to discuss the findings. The purpose of this legal and regulatory review was to elaborate on the rationale of including social contracting in the forthcoming NSP and outline future project activities toward identified gaps and weaknesses in social contracting. The team reviewed nine documents and proposed specific interventions to be integrated to the NSP. The majority of suggested interventions aimed at simplifying/streamlining the application process for CSOs which would be interested in bidding to obtain state financing on TB-related social services. To advance social contracting in TB services, the project initiated the establishment of a TWG to promote the issues of social contracting for TB. USAID ETICA drafted an SOW for the TWG. The order was signed by the MOH on September 4,
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 43
2020 No. 688 "On the establishment of a working group". The TWG includes experts from USAID ETICA, representatives from MOH, NTP, and CSOs. USAID ETICA organized and conducted a meeting of the MOH TWG on social contracting to discuss future steps for the introduction of social contracting in the area of TB. During the meeting, the Head of MOH's Social Department expressed readiness to include activities on social contracting in TB to MOH's 2021 working plan to start state financing of the TB program in 2022. Specific outcomes of the meeting include: • The MOH supported the idea of starting social contracting in TB care. • The MOH is ready to introduce social contracting through the action of establishing and supporting the work of the TWG. • The MOH understands the steps in introducing social contracting, and USAID ETICA will provide assistance to realize this initiative. • The MOH has accepted the TOR for the new TWG as developed by the project, but it should also be officially submitted to a relevant department of MOH in Tajik language along with meeting minutes. • Since partners working on HIV already have experience with social contracting, USAID ETICA should engage with those partners to understand their experience. • The MOH agreed with the project's vision/strategy on introducing social contracting and asked that a detailed action plan/roadmap be developed by the next meeting. • The MOH plans to include activities on TB social contracting in its working plan for 2021 (this is a general MOHSP plan which is supposed to be ready by end of Nov 2020). • The MOH suggests and supports the active involvement of TB NGOs in social contracting. • It was agreed that USAID ETICA will support the TWG in designing an action plan for TWG activities/performance and an overview of the legislation.
2.7 PERFORMANCE MONITORING As per the approved AMELP during this reporting period, Tajikistan reports on 12 indicators out of 14. Annex 2, attached to this report, illustrates a Performance Indicators Tracking Table for all three countries and provides analysis of performance against the targets for each indicator. Exhibit 5 below illustrates a summary of achieved annual results against set-up project indicators distributed by project objectives. The project was unable to report on two indicators as the situation with COVID -19 hampered implementation of relevant activities: • Indicator #8 “Percentage of participants reporting increased agreement with the concept that males and females should have equal access to social, economic, and political resources and opportunities”. Code: GNDR-4 – The gender assessment is shifted to Y2 and hence, the indicator cannot be reported in Y1. • Indicator #11 “Laboratories with QMS reaching 80% on TB-SLIPTA scale”. Conducting SLMTA assessment was postponed to Y2 due to travel restrictions. The reported indicators are collected at both the national and pilot levels. The data on national level indicators was obtained from the OpenMRS information system of the NTP. According to the NTP
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 44
reporting system, the data on the project indicators was generated from the reporting forms TB03, TB04, TB07, TB07U, TB08, and TB08U. The form TB07 and TB07U generate data on the detection and initiation of treatment. The form TB08 and TB08U report treatment outcomes. Information on the laboratory indicator (indicators 12.1 and 12.2) was obtained from the TB04 form. The registration journal TB03 was used for age and gender disaggregation. A short analysis of indicators with available gender-disaggregated data shows that women were screened and tested more than men in the pilot regions of the project (Exhibit 5). However, the percentage of diagnosed men is almost double that of diagnosed women were (61% vs. 39%). The tendency of the data corresponds to the national level data as the percentage of diagnosed men is also higher than among women (55% males to 45% females). Higher percentages of women screened and tested in the pilot regions are the result of the targeted work of project volunteers and outreach workers, who applied gender-sensitive approaches to eliminate gender- related barriers and improve detection and treatment among both genders. More in-depth analysis is expected from the gender research in Y2.
Exhibit 5. Gender disaggregation in the indicators in pilot regions
Indicators (services received)
51.4% Adherence support 64.8% 39.3% Diagnosed 60.7% 51.5% Testing 48.5% 64.8% Screening 35.2%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%
female male
Exhibit 6 illustrates the overall achievement of project targets in FY 2020.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 45
Exhibit 6. Achievement of targets, Tajikistan
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 46
As per the approved Y1 workplan, USAID ETICA planned to conduct joint monitoring visits with the NTP to district TB centers to verify data, check the effectiveness of laboratory performance, check the screening process at the PHC level, and drug provision at district levels. Unfortunately, due to the COVID-19 epidemic and various government restrictions on the movement and gatherings of people, this activity was not conducted. The USAID ETICA team has decided to conduct an online monitoring of the above-mentioned areas of the project. The team developed a specific mechanism for online monitoring. It includes four assessment areas / components as illustrated in Exhibit 7 below:
Exhibit 7. Online monitoring process
In September 2020, the project team conducted the online monitoring through the Viber and WhatsApp mobile applications in 12 pilot districts. The results of the online monitoring are presented in the Table 3.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 47
Table 3. Summary results and recommendations provided to TB and PHC services
Monitoring area Strengths Identified problems Comments
1.Late data entry into the Open MRS; 2.The data of the TB 03 form do not match with The data in OpenMRS was correct, based 1.Statistical data TB03U, TB 07 with TB07U; on verified statistical data on journals TB03/TB03U and reporting forms 3. The decrease in the detection rate of DR-TB TB07/07U. compared to the previous quarter.
The lab specialists were consulted on 1. Late submission of the request for the supply of 2.Laboratory Sufficient GeneXpert cartridges in all districts filling the lab module and data entry to the reagents; 2. Inaccurate filling of the Open MRS Lab information system services Module.
The National Drug Management 1. The regional warehouse has a sufficient supply Coordinator was notified about existing of TB drugs for 4-6 months, depending on the 1. Insufficient drug stock in the districts its available problems like drug shortages for side type of drugs. only for 2 months for some types of TB drugs; effects, as well as the absence of security system and an alarm system in drug 2. The pathogenetic drugs procured on the local 2. Lack of drugs for side effects; warehouses in the pilot districts. 3.Drug supply budget of the hospitals or district TB centers. 3.There is no alarm system in medical warehouses; Based on NTP information the country’s 3. The temperature regime in the drug stock of SLDs is enough until January warehouse corresponds to the established 4. In some districts, warehouses do not meet the 2021. However, NTP and GF informed norms and its data is entered to the registration standards of security. that a new batch of TB drugs for journal. Tajikistan will arrive at the end of September 2020.
Registration journals TB015 are filled up with delays Communication between TB service and PHC is not 1. Online recommendations were given to well established. 3. One of the tasks of the PHC and TB 1. Timely provision of chemo-prevention to family doctors on how to fill the service is the timely identification of persons with registration book TB015; contact persons with isoniazid. presumptive TB, diagnosis, adequate treatment and 2. PHC facilities had a sufficient amount of successful treatment outcome. Active contact 2. Online consultations were given to vouchers for persons with presumptive TB, identification is weak at the PHC level. Even after follow the diagnostic algorithm; 4. PHC services which is used as a referral coupon between positive laboratory tests (SM+), the patient is not always monitored on time. It leads to delayed initiation 3. All responsible people were informed PHC, TB facility and the laboratory. Absence of regarding the lost patient (from Mastchoh the voucher may hamper the registration of treatment, and the patient may be lost from the care. Family physicians and TB specialists do not provide district) and recommended to improve process and lead to losing the patient due to the monitoring and support to the DR-TB inability to trace. sufficient patient support for adherence to treatment, which affects the successful completion of treatment. In patients and thoroughly investigate the Mastchoh district one DR-TB patient was lost from case. follow-up.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 48
In addition to facility monitoring, video- based interviews were conducted with four patients through WhatsApp– Two patients were from B. Ghafurov district and two from Spitamen. These interviews were attended by managers of TB centers, directors of HLCs, representatives of the USAID ETICA project, and volunteers. Interviews with four patients were conducted using a checklist, comprising the following data requirements: patient data, treatment regimens, side effects, patient's knowledge of TB transmission routes, and patient support by Conduction of on-line monitoring. Interview with people affected by TB volunteers. Three patients conducted using the checklist, Dushanbe, Tajikistan demonstrated good adherence to treatment, despite the side effects, which were corrected by treating doctors after getting recommendations of the project specialists. The last patient, a 35 year- old man living in the Spitamen district demonstrated poor adherence to treatment. Since he had side effects, he missed taking drugs and refused the treatment. It was the third time he had received TB treatment. USAID ETICA specialists recorded the patient for active monitoring and monitoring of treatment to achieve a successful result of TB treatment.
2.8 COORDINATION WITH PARTNERS In Y1, USAID ETICA established a strong working relationship with the Government of the Republic of Tajikistan in the implementation of the National TB Program 2021-2025. The project coordinated work and activities with the MOH, WHO representatives in Tajikistan, GF PIU, WB PIU, Asian Development Bank PIU, regional representatives of health facilities, other donor-funded programs, stakeholders from the healthcare sector, and representatives from the TSMU, the TPMI, and CSOs. USAID ETICA also met with key partners to establish collaboration and discuss the implementation of the workplan priorities associated with the NSP. The MOH invited the project team to take part in the meeting of the TB Coordination Committee on July 2020, which resumed its work after a long break and following the appointment of the new Minister of Health. Doctor Aliev S.P. who was assigned to the position of Deputy Minister overseeing TB services, noted the need for regular coordination meetings of the Committee with partners implementing TB related programs in Tajikistan. The meeting participants included the heads of TB centers of Sughd and Khatlon oblasts and DRSs, as well as international partners and CSOs working in the area of TB. Partners discussed challenges in TB service provision, the impact of the COVID-19 epidemic on the implementation of TB program, and coordination of activities. During the reporting period, USAID ETICA held meetings with the Finance, Social Protection, Pharmaceutical Services, Health Reforms, PHC and International Relations, and SES Departments of MOH to understand their priorities and align them with the project’s ongoing and planned activities.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 49
The project participated in an online meeting with the TB Europe Coalition and Center for Health Policies and Studies and Stop TB Partnership Tajikistan within the TB-REP 2.0 project. The main goal of the online meeting was to discuss possible ways of cooperation in the framework of the TB-REP 2.0 project and organizing a National Dialogue to widely discuss TB program coordination with all in- country stakeholders. To improve the project outcomes and ensure a concerted approach of in-country partners striving towards improving TB service provision, USAID ETICA constantly collaborates and cooperates in joint activities with governmental, international, and non-governmental organizations. As such, the project actively collaborates with the Stop TB Partnership in Tajikistan on establishing VST with SystemOne on GxAlert; and with Dure Technologies on Prevent TB Platform and enhancing TB LIMS via Autoscribe Informatics Company (UK). The team also engaged with UN Women Tajikistan to brainstorm possible cooperation in providing women affected by TB with psychological support. For introducing modified short treatment regiments (mSTR) and BPaL in new pilot areas, the project specialists are in close contact with EURO-WHO, NTP, KNCV and USAID to ensure joint and more effective efforts in introducing the new initiatives. The operational research on mSTR and BPal are at the preparation stage, and partners met to discuss the potential roles of each agency under the coordinating role of the NTP.
2.9 OBSTACLES AND CHALLENGES A number of planned project activities had to be postponed due to the delay in the approval of the USAID ETICA Y1 workplan by the MOH. NTP staff were unable to participate in some USAID ETICA trainings (in- person and virtual) and other project activities due to two main factors: 1) their full-time, intensive involvement with measures to prepare the TB system to meet the challenges of COVID-19 and 2) absence of MOH approval for the USAID ETICA Y1 workplan needed to formally authorize NTP staff’s participation in planned USAID ETICA activities. Some workplan activities were cancelled due to international and regional travel restrictions. The following cancelled or delayed activities serve as an example: • External audit with SLMTA assessment of the NRL • Provision of technical assistance to conduct a clinical audit of DR-TB patients in outpatient phase (pilot sites) • Support NTP in enhancing proper monitoring and supportive supervision for the patient-centered approach implementation throughout the TB continuum of care (pilot sites)
2.10 WAY FORWARD Within the domain of “Communities”, USAID ETICA work will enable the provision of a continuum of TB care to vulnerable populations, including migrants and their families, PLHIV, and high- risk groups (households and close contacts of individuals with TB). In Y2, the project will build upon the gains of Y1 and support the second chain of the continuum of services. This will comprise of development and capacity building of workers on case management, which will include enrollment to treatment and adherence support. The project will introduce innovative platforms of Prevent TB and One Impact, which will directly support the community level workers on improving TB detection and case management, including VST.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 50
USAID ETICA will work to increase case findings and to introduce programmatic management of LTBI. This focus will be facilitated by the development and introduction of the Prevent TB platform. Increased community case findings and the scale-up of programmatic management of LTBI is critical to end the TB epidemic. Also, the project will implement a model of identification and preventive treatment of persons with LTBI in three new project pilot zones (i.e., Dushanbe, Rudaki and Vahdat) in collaboration with Euro-WHO and NTP. The model is described in the new National Guidelines on Treatment of Latent Tuberculosis Infection in Tajikistan: Clinical and Programmatic recommendations developed by TWG with technical support of USAID ETICA in Y1. At the first stage, medical workers will be targeted as a risk group of the activity with further expansion to the other vulnerable groups. Once detection and diagnosis of TB is improved and digitalized through the Prevent TB platform, the project will simultaneously introduce a new One Impact platform with cooperation of the new GF grant. The platform will take over the case management link of the TB continuum chain. This application will be useful both for health and non-health workers as well as people affected with TB as it will allow live monitoring of the patients’ data, timeliness and accuracy of prescriptions, time for check-ups and most importantly, the adherence to treatment. The project plans to enhance cooperation with in-country stakeholders, such as the NTP, Women’s and Youth’s Committees, CSOs, local government, and private sector representatives to discuss and promote the role of all community-level stakeholders in strengthening patient-centred services targeting vulnerable groups. USAID ETICA will give significant attention to building the TB capacity of PHC providers, establishing supportive supervision systems for quality treatment, and advocacy with regional health authorities to support a patient- centred model (with outpatient care approach) for MDR-TB. Additionally, USAID ETICA will build the skills of CSO representatives to provide psychological and adherence support and counselling to people with TB. In line with the reached agreements, USAID ETICA plans to provide technical assistance on conducting the operational research on a "Study of modified short-term treatment regimens for Rifampicin- Resistant (RR)-TB patients exclusively with all oral anti-TB drugs” in new project sites of Dushanbe, Vahdat and Rudaki. Project specialists started developing an implementation plan for the following research components: ➢ Baseline assessment ➢ Preparing a detailed action plan for PV and active aDSM ➢ Clinical audit ➢ Cohort analysis ➢ Control of data entry to the database ➢ Supervision ➢ Training ➢ Monitoring and evaluation of TB services and PHC ➢ Control over management as well as recording and reporting documentation in health facilities Under the framework of operational research, the USAID ETICA team discussed a draft checklist for assessing the process of diagnosis, treatment, and monitoring of drug safety to timely identify and remove barriers for optimal clinical monitoring of adverse events in the pilot district areas. This tool will simultaneously assess the availability of resources for clinical and laboratory monitoring for a baseline assessment in the pilot regions. The checklist will also allow for the collection of quality aDSM data,
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 51
because conducting regular aDSM and active clinical monitoring in all levels of DOT during the DR-TB treatment process is absolutely necessary. Within the framework of technical support on PV and aDSM, USAID ETICA started to discuss with NTP the agenda for the forthcoming training sessions on PV and aDSM in the new pilot regions where operational research will be conducted. USAID ETICA prepared presentations and training materials for conducting workshops for TB and PHC doctors on adverse drug reaction management and aDSM. Within the domain of “Services”, USAID ETICA has gained good momentum in identifying the areas for further improvement in the laboratory services. The project will continue supporting NRL earning QMS SLMTA scale and will enhance the LIMS and analytical skills of laboratory specialists through a variety of capacity- building activities and upgrading laboratory policies and documentation. Modernization and digitalization of the laboratory network through innovative e-platforms such as GxAlert, LIMS and connecting them with the other programmatic components will contribute to improving detection and timeliness of diagnosis. Introduction of GeneXpert Ultra cartridges in cooperation with the new GF grant and updating the new testing algorithm will improve the quality and timeliness of laboratory services and will contribute to easier access to services. The capacity of health and non-health workers will be improved through various workshops and engagements. USAID ETICA will continue providing technical support to TB centers and PHC facilities to reduce or eliminate roadblocks to receiving an adequate regimen of quality-assured medications. As per recent WHO Consolidated Guidelines on DR-TB (2020) and as a part of WHO/EURO initiative on the introduction of mSTR, the Project plans a noticeable transition to all oral mSTR under the Operational research in pilot sites. USAID ETICA, in collaboration with the NTP, will introduce the new regimens of mSTR and BPaL regimens (for RR/MDR-TB patients with additional resistance to fluoroquinolones) through the following activities: technical assistance, training and supervision for the NTP staff involved, provision of additional patient support through clinical monitoring, aDSM, and case management programs, including the introduction of the DR-TB Care Package in pilot areas. USAID ETICA will support NTP in the revision of existing and/or introducing national clinical guidelines for the management of individuals affected by DR-TB, and the national plan for PV and aDSM. The project team will incorporate these guidelines into the on-the-job supervision system. USAID ETICA will continue to provide training and follow-up mentorship to medical and non-medical staff in pilot sites to strengthen referral mechanisms and facilitate continuity of care between CSOs and government health partners, including at primary care facilities. USAID ETICA targeted activities will help TB-affected communities de-stigmatize the infection, increase the understanding and importance of finding and treating TB, improve access to people-oriented health services, making them more likely to get tested, start, and stay on TB treatment until they are cured. Within the domain of “System”, USAID ETICA will actively support the development of various strategic documents important for implementation and sustainability of the NTP. As such, the NLSP developed for the NRL, and the NTP will be used for the implementation of LTBI strategies through forecasting drugs for TPT. In line with the country reforms in the health sector, the project will engage in review and improvement of financing mechanisms of TB services, including per capita financing for inpatient care and basic benefits package (BBP) for TB case detection. As a result, TB health services will become more cost-effective and medical personal will be increasingly motivated to achieve set-up objectives through performance monitoring and financial incentives for TB treatment outcomes.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 52
The project plans to advance social contracting mechanisms to enable CSOs to participate in the delivery of critical TB services advancing patient-centred care. Social contracting exists in the country, but only in the disability sector; hence, more advocacy, channelling financing to TB service CSOs and making policy-level updates are planned in the upcoming project year. One of the TB system’s challenges is a weak transportation system for transporting sputum from districts to the oblast levels for diagnosis and confirmation tests. Various options of transitioning transportation costs to the government are being explored and will be included in the new concept of sputum transportation in Y2. USAID ETICA will continue building on the country’s experience in introducing BDQ and DLM and the shorter MDR-TB regimens. This will lead to developing a new TB and DR-TB package of regulatory documents based on WHO guidelines. The package will include an implementation protocol, the algorithm for molecular diagnostics using Line Probe Assay, an aDSM algorithm, a patient-centred care checklist and plan format, treatment materials, and training for health care providers. USAID ETICA will continue strengthening the pharmaceutical management components of the TB program, including forecasting and quantification, inventory management, distribution, rational use, and aDSM implementation. As individuals affected by TB are enrolled in outpatient care, USAID ETICA will expand Challenge TB’s aDSM system, prepare a roadmap for aDSM, convene an aDSM working group, and prepare training materials for training health personnel on all components of the aDSM program in TB service. In addition, USAID ETICA will support drug needs forecasting to build capacity for pharmaceuticals. In addition, USAID ETICA will supervise the use of the QuanTB tool, and support the Global Drug Fund (GDF) quantification method for the procurement of drugs and inventory management systems at the national and oblast levels. USAID ETICA will also develop and introduce an e-Detection tool. It will offer TB ECF, and will be used by CSOs and community networks in their TB detection work.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 53
3. UZBEKISTAN
3.1 EXECUTIVE SUMMARY The USAID ETICA project launch took place in Tashkent on March 11, 2020 in coordination with USAID, the MOH, WHO, and the Promoting the Quality of Medicines Plus (PQM+) project. There were on approximately 80 participants attending from the US Embassy, USAID Central Asia Mission, WHO Country Office in Uzbekistan, the Parliament of Uzbekistan, MOH, National TB Center, GF PIU, local CSOs, oblasts health departments and TB centers, State Center for Expertise and Standardization of Medicines, Medical Devices and Medical Equipment, TB survivors and other donor- funded programs and partners. The event received wide social media coverage through the US Embassy in Uzbekistan, the MOH, USAID Central Asia mission, and a local blogger’s Facebook pages. It was also widely covered by traditional and social media in Uzbekistan. The preparation of the USAID ETICA draft Y1 workplan for Uzbekistan was informed by the vision and expectations of USAID Uzbekistan, which shared its inputs during the project planning meeting in Dushanbe, Tajikistan, in the beginning of October Project launch in Uzbekistan held in Tashkent on March 11, 2020 2019. The project then engaged key staff from NTP in an extensive three-day collaborative planning in Tashkent in mid-December, where the revised draft workplan was presented. USAID ETICA and GF PIU, WHO, and other partners intensively discussed the workplan to explore synergies and avoid duplication. The project ensured workplan activities were aligned with the objectives of the “Complex Plan for Measures to Prevent the Spread of Tuberculosis and Non-specific Lung Diseases in 2019 – 2021.” The Uzbekistan MOH approved the project’s Y1 workplan at the end of April following consultations with the NTP and MOH. Before implementing the workplan, the project team modified it to fit the template/format required by the MOH for their required review and approval. The Project received feedback from NTP on the workplan with recommendations to combine descriptions of project activities to make the document shorter and to change the order of project activities (i.e., to start from the main technical areas). As requested, the project activities and areas were set up as 1) TB detection; 2) TB treatment; 3) Preventive treatment; and 4) Involvement of CSOs. The Y1 workplan was officially approved by the Uzbekistan MOH on June 09, 2020 with indicated date of approval April 30, 2020. The approval document was signed by Deputy Minister B.M. Nizomov. The project team organized an online meeting with the National TB Program team and USAID’s Sustaining Technical and Analytic Resources project TB advisor to discuss the implementation of Y1 workplan activities and activities to be included in the Y2 workplan.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 54
As elsewhere worldwide, Central Asian countries, including Uzbekistan have been heavily affected by the COVID-19 pandemic. According to WHO, as of October 19, 2020 the country has recorded 63,430 cases of COVID-19, including 529 deaths5 and treated 61068 cases6. Since March 16, 2020 the country introduced quarantine measures that affected a full-scale implementation of the USAID ETICA project. Despite that, the project team overcame implementation impediments and achieved project objectives to the maximum extent possible. The first project year consisted of start-up activities, project launch by the Uzbek Government and USAID, establishing partnerships with the MOH and other in-country partners and key stakeholders contributing to eliminating the TB burden in the country. Some key accomplishments of the project in Y1 include: • Y1 workplan was approved at the end of April 2020 following numerous consultations with the NTP and MOH. • Completion of a baseline assessment report based on information collected from NTP, WHO publications, and other local projects and partners. • Provided inputs to the NSP and GF proposal related to: finance of TB activities, TB diagnosis, treatment, TB drug management and activities related to key population, including migrants, PWID, PLHIV, TB contacts, patients with diabetes, etc. Since both documents are being developed in parallel, the data and information collected for the NSP are also used for the GF proposal. • Developed mechanisms to hold online Consilia for doctors based at TB facilities in Tashkent city and conducted several online meetings of the DR-TB Consilium for the health facilities in the city. Conducted eight online Consilia on treatment management and reviewed and provided recommendations on the cases of 17 people with DR-TB in Tashkent city. • Supported the review and update of the NLSP. The new draft was submitted for approval as an integral component of the TB NSP to the TWG on the development of the TB NSP. • Provided infrastructure support to the CIDLM to be prepared for online educational events, meetings, round tables and conducted training sessions. • USAID ETICA project specialists mapped national guidelines and policies on contact tracing and TB preventive therapy with the latest WHO recommendations and developed a manual for TB contact tracing based on the new WHO- recommended risk-stratified methodology. • USAID ETICA provided technical assistance in the revision of the national guideline and supporting documents on LTBI management and the development of a protocol on VST.
3.2 SUMMARY OF STAFFING AND OPERATIONS During Year 1, Abt Associates registered in Uzbekistan, opened a bank account as the first steps in starting up the Project, and then, found an office location and hired project staff. The project office opened on July 01, 2020 and is mostly furnished, however, due to COVID-19 travel restrictions, there is still some procurement left to complete.
5 https://covid19.who.int/
6 https://kun.uz/
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 55
3.3 COVID-19 The fast spread of COVID-19 in the region led to quarantines across Uzbekistan and restricted local and international travel. This had a significant impact on planned and ongoing activities. The Project provided USAID with a list of Y1 activities, which will be delayed or canceled due to COVID-19. USAID ETICA participated in the weekly meetings of all implementing partners on COVID-19 response in Uzbekistan to discuss: key accomplishments over the previous week, challenges, and key activities/meetings planned for the upcoming period. USAID ETICA provided financial and administrative support for USAID’s Local Health System Strengthening Project’s start-up and execution of activities on preparedness and response to the COVID-19 pandemic.
3.4 OBJECTIVE 1: INCREASED DETECTION OF TB AND DR-TB
3.4.1 ACTIVITY 1.1: PARTNER WITH CSOS TO IMPLEMENT ECF AND WITH MOH TO STRENGTHEN SYSTEMS FOR CONTACT TRACING The role of CSOs is crucial for ECF and working at the community level to enhance TB case detection. Working with NTP and other health structures at the oblast and national level is also vital for tracing those lost to follow-up, improving policies regarding contact tracing, and improving the epidemiology of TB in the country. The MOH approved a government policy on CSO involvement 7 with TB Case Detection, but the policy has not yet been applied in practice. The project plans to work with the NTP to change this situation. Improving the policies and guidelines on ECF and contract tracing, including LTBI and TPT will be foundational to improving the epidemiology of the disease and ultimately, to saving the lives of patients. During the reporting period, the project assessed national guidelines and policies on contact tracing, TPT, LTBI, and identified areas for improvement based on WHO standards. The project will share a report on the main findings of this assessment with the TB-TWG. The report will identify the gaps in the national policies on contact tracing and highlight key recommendations based on the current 2020 WHO LTBI guidelines. Recommendations from the assessment include integrating TB service delivery into PHC and modifying terms and definitions in guidelines and policies. The main recommendations from the policy and guidelines’ review for the NTP are listed in Table 4 below. Table 4. Findings and recommendations on the assessment of existing policy documents on TB contact tracing Findings Recommendations Most policy documents (such as IC, M&E, TB contact tracing strategy needs to be developed pediatric TB, etc.) are outdated No Standard Operating Procedures (SOP) to Develop a SOP track contacts There are no clear definitions of TB contact Define and approve clear definitions on TB contact tracing tracing Guidelines for the management of people Approve guidelines and SOPs for the management of with LTBI are not approved. people with LTBI, develop an implementation plan Guidelines on Infection Control (IC) needs to Revise the guidelines on IC in the country be revised
7 Strategy on the engagement of Civil Society Organization to TB control approved by MOH in 2018
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 56
The manual on LTBI management revised by TWG has been submitted to MOH for final approval. Once the approval of MOH is granted, the USAID ETICA will continue working with the TWG, which was established for the development of the LTBI and TB contact tracing manual based on the new WHO- recommended risk-stratified methodology. MOH of Uzbekistan approved the establishment of the TWG and the list of experts to be included in this working group on August 17, 2020. Following the MOH approval, USAID ETICA plans to conduct a webinar on TPT with updates from the new 2020 WHO guidelines at the beginning of Y2. Apart from the policy level work, awareness- raising and capacity building of services providers working on the community level is crucial for reaching the key populations. USAID ETICA has adapted existing materials from USAID projects and partners (screening, referral to testing, patients’ adherence, and community-based support) for the upcoming trainings for volunteers, outreach, and health care workers in Uzbekistan oblasts. The Project added a module on psychosocial support for vulnerable populations to the training package. The training will take place once the government lifts COVID-19 quarantine. The team developed a draft information-education tool for outreach workers to raise awareness of TB among key populations. The tool is a package of fact-sheets comprising essential information on TB, such as TB symptoms, TB transmission, prevention, and treatment. This tool will help outreach workers provide information sessions systematically by using text and pictures, which makes the information easy to understand.
3.4.2 ACTIVITY 1.2: BUILD TB LABORATORY NETWORK CAPACITY FOR RAPID DIAGNOSIS AND NOTIFICATION During the reporting period, the USAID ETICA team made progress on many of the planned activities related to improving the work of the TB laboratory network. The Project conducted reviews and assessments of laboratory- related documents, assessed availability of tests throughout the country and their accessibility for patients and worked on TB laboratory network optimization. The results of this work are the basis for setting up further approaches for improving the TB laboratory network. The laboratory component of the baseline assessment was finalized. Information collected included the current TB laboratory network structure, availability of tests and equipment, TaT, times to report and accessibility of diagnostics for TB suspects and patients. A second assessment of the availability and accessibility of tests to patients was conducted in the entire country. To assess the needs of every particular region to reach optimal diagnostic coverage with Xpert MTB/Rif tests, the following variables were used: population, number of TB cases notified, number of cases of all forms of TB notified in 2019, expected number of presumptive TB and distance to the testing site. The number of additionally required GeneXpert instruments was calculated based on the needed estimated number of tests, the distances to the regional laboratories and potential alternative referral points. Based on the assessment, a roadmap for the GeneXpert network optimization was developed. The roadmap will be used for further TB lab network improvement and specimen logistics planning. Considering the progress and renewing WHO and international standards on TB laboratory operations, the demand for updating existing policy documents arises most of the time. The USAID ETICA team provided technical assistance to the revision and adaptation of the NLSP. The draft will be a component of the TB NSP to the TWG on the development of the TB NSP. Additionally, the Project worked with NTP to justify the proposed staffing plan for TB laboratories. The team prepared the staffing plan used the time-and-motion (T&M) tool for recording hands-on time for
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 57
all TB laboratory diagnostic assays to calculate laboratory staffing needs. The calculation confirmed that based on the existing annual diagnostic workload and additional regular laboratory management activities the NRL is understaffed (laboratory technicians and doctors) by more than 50%. The assessment results were submitted to the head of NRL to justify staffing needs and advocate to NTP management and MOH to add enough budget for additional laboratory staff. The project team conducted several online and offline meetings with NRL staff and clinicians to review and update the TB diagnostic algorithm to perform Xpert MTB/RIF, LPA, smear microscopy, culture and DST. The revision was initiated to address new recommendations of WHO on TB diagnostics.8 The algorithm was finalized and added to the NLSP as one of the key complementary elements.
Focus group on and open discussion of the diagnostic algorithm for tuberculosis at the laboratories with clinicians and laboratory staff, Tashkent, Uzbekistan
USAID ETICA provided technical assistance to NTP on TB laboratory network optimization and worked on mapping of TB laboratories and health facilities offering TB services in pilot oblasts to assess: • The current sputum transportation system: the Project determined (a) mapped sputum collection points and locations of TB labs with GeneXpert machines to calculate the distance between them, and (b) optimal routes of given locations of sputum pick up sites and GeneXpert laboratories. Maps of Ferghana and Syrdarya oblasts’ TB diagnostic coverage are inserted in Exhibit 8 below as examples. • The USAID ETICA developed a questionnaire to track the results of cultures for liquid media (MGIT), solid media (Lowenstein-Jensen), and DST for the1st and 2nd line drugs, as well as LPA Hain’s tests for the 1st and 2nd line drugs. Also, the Project collected 2019 data on the following quality indicators: 1) microscopy, according to Ziehl-Nielsen; 2) microscopy for fluorescence microscopy; and 3) molecular genetic method GeneXpert. The data is used to assess the effectiveness and quality of culture examination in TB diagnosis. The NRL also uses the above-
8 WHO operational handbook on tuberculosis Module 3: Diagnosis - Rapid diagnostics for tuberculosis detection, 2020, ISBN: 9789240007284
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 58
mentioned questionnaire to collect information from the oblast laboratories to assess the quality of certain specific culture examination tests.
Exhibit 8. Mapping of TB laboratories for developing sputum transportation routes
• The laboratories’ 2019 reports in USAID ETICA pilot oblasts were reviewed to analyze the utilization of GeneXpert machines versus other testing methods. Key findings are: ➢ The average positivity rate of the Xpert MTB/Rif test to detect MTB makes up 12% of all sputum samples countrywide. For pilot regions, it ranged from 6% in Syrdarya, 8% for Jizzakh and up to 11% in Ferghana regions. The positivity rate of sputum smear microscopy in pilot regions is 2% in Jizzakh, 4% in Syrdarya and 5% in Ferghana oblasts. Such low positivity rates of smear microscopy could be attributed to the low proficiency of laboratory staff involved in smear microscopy or a high proportion of persons with presumptive TB referred to diagnostics. This quality-related issue needs to be examined in depth during monitoring and laboratory visits to pilot sites to be conducted by USAID ETICA experts after the end of COVID-19 quarantine. ➢ The number of performed MGIT DST tests in Ferghana was low due to the insufficient capacity of the laboratory staff to operate the new BACTEC incubator installed last year. The laboratory, therefore, continues performing only culture examinations. The Project plans to train the laboratory staff to properly utilize MGIT DST technology. ➢ Lack of sufficient biosafety level: no functional ventilation system, BSCs are not calibrated. Based on USAID’s decision to procure 46 GeneXpert machines for laboratories in 13 country regions, USAID ETICA conducted an online rapid assessment on the readiness of TB laboratories to install and work with the 2-modular GeneXpert machines. Preliminary findings of the assessment show that although laboratories have different levels of readiness, 33 out of 36 (92%) have adequate conditions and capacity to prepare laboratories for installation of GeneXpert machines. Preparation of the laboratories might entail the procurement of air conditioners or small renovations. In the area of QMS support to laboratories, the project team collected documents needed to initiate a review of relevant information such as reporting forms, checklists, indicators, performance, and procurement requirements. The team evaluated all five laboratory M&E checklists: 1) Report on laboratory tests Microscopy, GeneXpert, LPA, Culture; 2) External Quality Assessment; 3) Quality control of microscopic testing; 4) Summary report of microscopic testing; 5) Assessment sheet for the laboratory (location, facilities, personnel, equipment, research methods. Analysis of the checklists will provide information on the strengths and weaknesses of TB laboratories’ QMS and will be used for improving the QMS.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 59
As a part of the QMS strengthening efforts, the NRL laboratory specialist with support of USAID ETICA, initiated a review and audit of all existing SOPs and forms for all laboratory diagnostic procedures and all SOPs guiding the operations of laboratory equipment. Current versions of SOPs are divided into three categories: 1) General; 2) Techniques 3) Equipment. Conclusions of the audit, comments, and recommended improvements were shared and discussed with the head of the NRL. Online training Identification of M. tuberculosis complex and Rifampicin resistance USAID ETICA provided technical by GeneXpert system, Tashkent, Uzbekistan assistance on the review and revision of the existing laboratory recording and reporting forms. The laboratory referral form was revised and updated in two languages: Uzbek and Russian. The updated referral form was shared with the head of NRL before presenting it to the NTP for final review and approval for subsequent widespread use in the country. As a part of capacity building activities for the laboratory staff, USAID ETICA developed training materials and conducted:
• Online training for oblast laboratory specialists on the Identification of Mycobacterium tuberculosis complex and Rifampicin resistance by the GeneXpert system. The training was held in August and was attended by 83 laboratory specialists from the entire country. Training participants provided highly positive feedback on the organization and the quality of the training. Information about the training was published on the website of the NTP. • The online training for five NRL laboratory specialists on the introduction of expanded DST, including new and repurposed TB drugs BDQ, DLM, CFL, and LZD was conducted in September. Training topics included: ➢ Introduction and importance of internal quality control for DST in liquid media ➢ Current WHO recommendations on Biological Safety in TB laboratories ➢ Safe operation with positive MGIT • Conducted a round table meeting on the interpretation of laboratory tests with the participation of the oblast clinicians and laboratory specialists in the Ferghana Oblast Center of Phthisiology and Pulmonology in September 2020. Twelve participants (5 laboratory technicians and 7 doctors) attended the meeting facilitated by the project staff. Meeting participants also discussed existing challenges to interaction and reciprocity among clinicians and laboratories, such as incorrect sputum collection, delayed receipt of test results by clinicians, lack of electronic communication for rapid test results, and the lack of a system for transporting samples.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 60
Based on approval of UZ MOH, USAID ETICA visited the project oblasts – Ferghana, Jizzakh and Syrdarya. During the visit, project laboratory specialists diagnosed and fixed defective microscope and GeneXpert machines. They also conducted a basic performance evaluation of the central oblast TB laboratories for cultural examination, as well as district laboratories with Xpert MTB/RIF Ultra diagnostics. The team also visited the cities and district laboratories for a basic evaluation of the rooms, where NTP plans to install additional GeneXpert machines.
On-the-job training on the use of GeneXpert Ultra The laboratory specialist of the project fixed the erroneous cartridges in the TB laboratory of Marghilon city module of GeneXpert machine in the laboratory of Boevut Ferghana oblast, Uzbekistan district of Syrdarya oblast Ferghana oblast, Uzbekistan
In addition to the planned Y1 activities, USAID ETICA provided the following technical assistance: • Assisted the GF PIU with estimating the budget for the procurement of the WGS platform for NRL. • The project team modified temporarily the existing TB diagnostic algorithm to minimize the anticipated impact of late delivery of GeneXpert cartridges due to COVID-19 quarantine. • Based on a request from the NRL, the project team developed a draft "Guide to TB bacteriological diagnosis for the staff of TB and PHC facilitates". The guide describes all steps of TB diagnosis from the moment of sample collection until the results are obtained. The guide embraces all detailed descriptions of laboratory diagnostic methods and tests while applying the algorithm of testing. The draft version is under final review with the NRL and NTP staff. • During the COVID19 restrictions, USAID ETICA, together with the head of NRL, conducted regular weekly online meetings to monitor the activities of all laboratories in the country, including regional cultural laboratories. The online meetings were arranged through CIDLM at the NRL and USAID ETICA laboratory specialist with the head of NRL facilities participated in the meetings. During the meetings, the project’s laboratory specialist conducted several online information sessions on accurate reporting, on the performance of GeneXpert machines, and on filling out reporting and recording forms. Other challenges such as mistakes in reporting forms and the high number of errors in the GeneXpert test results were discussed and recommendations provided. • Conducted a comparative performance analysis of smear microscopy tests between the first six months of 2019 and the first six months of 2020 to determine the impact of COVID-19 quarantine measures on TB testing and the performance of the laboratories. Project specialists conducted a preliminary analysis of available data, which shows an overall reduction of testing across the country
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 61
during the time of COVID-19 compared to prior periods. The decrease in TB case detection is anticipated to have a negative impact on TB control, TB drug procurement, storage of drugs, access to services etc. The reduction in smear microscopy and GeneXpert testing can be seen in Exhibits 9 and 10 below.
Exhibit 9. Comparative analysis of Sputum smear microscopy conducted in Q1-2 of 2019 vs. Q1-2 of 2020
14000 12000 10000 8000 6000 4000 2000 0
Q 1-2, 2019 Q 1-2, 2020
Exhibit 10. Comparative analysis of GeneXpert tests conducted in Q1-2 of 2019 vs. Q1-2 of 2020
10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0
Q 1-2, 2019 Q 1-2, 2020
According to NTP data, due to COVID-19 quarantine TB detection rate in the first half of 2020 decreased by 23-28% countrywide compared to the same period of 2019, and the DR-TB detection rate dropped by 39.0-54.0%. A similar picture can be observed in the pilot districts depicted in Table 5. The average reduction of TB detection among DS TB patients dropped by 28% on average in three project pilot oblasts, and 25% average reduction is among DR-TB patients. Table 5. Comparative review of the detection of TB cases in the project sites (Q1-2 of 2019 and Q1-2 of 2020)
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 62
Q1-2 of 2019 Q1-2 of 2020 Progress Pilot # of DS-TB # of DS-TB # of DS-TB # of RR+/MDR # of RR+/MDR # of RR+/MDR oblasts cases cases cases TB cases TB cases TB cases (new+relapse) (new+relapse) (new+relapse) Ferghana 726 125 607 108 -16% -14% Syrdarya 332 68 186 19 -44% -72% Jizzakh 406 29 309 32 -24% 10% Average in 3 oblasts -28% -25%
3.5 OBJECTIVE 2: INCREASED TREATMENT SUCCESS FOR TB AND ALL TYPES OF DR-TB
3.5.1 ACTIVITY 2.1: SUPPORT THE ADOPTION AND IMPLEMENTATION OF PATIENT-ORIENTED APPROACH IN TB CARE The project team supported the implementation of the patient-oriented approach in TB care through conducting an assessment, developing a VST protocol and tracing the clinical monitoring of TB patients conducted by clinicians. Prepared a draft assessment of the policy framework for the existing outpatient/PHC treatment model of TB and DR-TB care reflected in national treatment guidelines and policies. The model was assessed against WHO standards. The ultimate goal of the assessment is to propose an alignment of the current TB care model with the WHO standards; leading to closer TB service delivery integration with PHC through modified terms and definitions in the guidelines and policies. Once the quarantine is lifted for an extended period of time and the full-scale assessment is finalized, a workshop to discuss the assessment results with the heads of NTP and TB leading specialists will be arranged in Y2. USAID ETICA, as a member of the national TWG on development of VST, works with the WHO and counterparts to advance the VST protocol finalization and approval for implementation in the project pilot sites. The TWG members expect MOH approval of the VST protocol in October 2020. The project has started preparatory work to implement the VST in Ferghana oblast. This entails selection and agreement with the NTP and Head of Ferghana TB center the city/districts of the oblast to pilot VST, a search for an eligible service provider, and collecting information on the price of mobile devices and mobile internet services, and others.
3.5.2 ACTIVITY 2.2: SUPPORT THE INTRODUCTION OF NEW PROCEDURES TO SUSTAIN PATIENT- CENTERED CARE Patient-centered care can be defined as “providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions”.9 To ensure the introduction and systemic implementation of the patient-centered approach, the project drew its attention to capacity building activities for Consilia doctors, establishing a system for ongoing learning activities, and addressing the gaps in the PV of the TB care system. One of the reasons for weak PV activities in the TB programs of the post-Soviet countries is the different management of the institutions responsible for PV. The PV for the entire health sector is
9 https://apps.who.int/iris/bitstream/handle/10665/272467/who-cds-tb-2018.13-eng.pdf?ua=1
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 63
controlled by a separate department of MOH, which imposes a generalized approach of PV management without the required attention and approaches of PV in the TB system. USAID ETICA plans to conduct an assessment of the PV system and quality of current active safety monitoring to identify needs and gaps of the system. The preparatory work for conducting a PV assessment included a brief review of the human resources needed for the PV in the TB system. On the same note, data was collected for an analysis of the regulations on PV in TB system. Project staff was included in the TWG on development of the NSP 2021–2025 to provide technical support on drug management and PV. As a TWG member, the team collected regulatory and procedural documents on PV to be analyzed, and will present recommendations for improvements to the TWG. The project team supplemented the section with a description of the goals of PV, a brief description of the regulatory framework, legislative regulation of the PV system, and aDSM in the TB program. The project supported re-establishing the internet service at the CIDLM at the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology to conduct training and communication with oblasts and hold consultative meetings on treatment management of individuals with TB through the CIDLM. The project, jointly with NTP Management conducted online meetings with the TB centers of the project oblasts through the CIDLM. Conducting regular online meetings with oblast TB facilities allows NTP to keep the oblasts abreast of new requirements or procedures on patient-centered care or other TB program- related issues. As the role of Consilium of doctors is central in the continuum of care, it signifies their performance in the lives of patients. The work of DR-TB Consilia on TB treatment management was suspended due to the COVID-19 lockdown and quarantine measures in Uzbekistan starting at the end of March. To continue the treatment of people with TB, the Project supported organization of online consultations, which provided the Consilia doctors the opportunity to assign timely treatment to new patients, to correct the treatment prescription of people who are getting TB drugs and to ask critical questions on the real- time mode. The current mechanism of conducting DR-TB Consilium is burdensome for clinicians treating TB patients. The clinicians must personally be presented in the Consilium and report on the case. It requires paperwork and sometimes the use of personal financial means for transportation, etc. Moreover, doctors needing to find and use transportation to be present at the Consilia meetings was difficult during COVID-19 quarantine movement restrictions. Hence, USAID ETICA facilitated a number of online DR-TB Consilium meetings through the TB facilities in Tashkent. USAID ETICA developed a checklist that enables doctors to document a detailed history of each TB case, present it online to the DR-TB Consilium members, and receive recommendations on the treatment of people with DR-TB. From June-July 2020, the project supported eight online Consilia on treatment management and reviewed and provided recommendations on 17 cases with DR-TB. The Consilium of Tashkent city continues to provide timely consultations for the treatment of people with DR-TB, despite the COVID-19-related restrictions. Unfortunately, starting from August 2020, the online Consilia stopped as all TB dispensaries of Tashkent city were re-profiled to support COVID-19 patients. USAID ETICA supported the Tashkent Center of Phthisiology and Pulmonology to conduct a training needs assessment of specialists in Tashkent on presenting TB cases at the DR-TB Consilium. The needs assessment also identified the needs of specialists on modern principles of DR-TB case management and monitoring treatment according to the Clinical Treatment Protocol of Adults with TB in the Republic of
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 64
Uzbekistan approved in February 2020. The project plans to arrange the training sessions based on the results of the needs assessment, which will be conducted by the senior staff of the Tashkent Center of Phthisiology and Pulmonology. Capacity building and continuous education of the DR-TB Consilium staff is one of the crucial elements for the successful implementation of the TB program. To address the training needs of the Consilia doctors, the USAID ETICA team developed online training modules on TB diagnosis, treatment of DR- TB, and clinical monitoring of people receiving treatment of DR-TB. The online training sessions will be conducted through established, USAID-supported Centers of Innovative Distance Learning and Monitoring in Y2. After the training for Consilia doctors, the same training materials will be used for the training of other TB doctors. To enhance supportive supervision and the monitoring system of patient care, USAID ETICA has reviewed the existing guidelines on M&E of TB services as part of the baseline assessment. The recommendations on improving the system and making the M&E system user-friendly will be provided to the members of TWG for review. The establishment of the TWG to review existing country policy documents on M&E of the TB service was initiated by the project, and the MOH approved the establishment of TWG in September 2020.
3.5.3 ACTIVITY 2.3: BUILD CAPACITY FOR PHARMACEUTICAL MANAGEMENT (PM) In Y1, the project made advances in the area of capacity building for pharmaceutical management by conducting regulatory reviews, providing technical assistance to TWGs, and assessing the country’s need for TB drugs. The project team conducted a desk review of the national regulations for a baseline assessment of pharmaceutical management for new drugs for people with DR-TB. The study is a prerequisite for setting priorities in the implementation of activities related to drug management. As a part of this review, the project team analyzed regulations and policies on the registration and procurement of TB drugs in Uzbekistan. Project specialists prepared a summary of the analysis with descriptions of the current situation and analysis of national regulatory documents for registration and procurement of TB drugs in the country. Recommendations for improving the TB drugs procurement and supply chain system will be discussed with the NTP. Project activities to enhance the system for TB drug forecasting for all forms of TB (by using QuanTB program) and inventory management systems at the national and sub-national levels have not been fully implemented due to limited information on drug stocks and lack of opportunity to visit the storages of medicines. It was necessary to postpone these activities until Y2 due to COVID-19 restrictions. Activities will resume once quarantine measures are lifted. The project staff prepared a report reflecting the country’s need for TB drugs and the provision of non- injectable regimens for people with DR-TB for the GF application for 2021-2024. Technical assistance was provided in the preparation of a preliminary application for the purchase of SLDs needed for long and short treatment regimens under the GF UZ grant for 2021-2024. For the same application, the project experts participated in discussions on the clinical aspects to ensure patients are adequately monitored for the safety of new DR-TB regimens in line with the latest WHO guidelines. In addition, USAID ETICA has prepared a budget for an operational study for 600 patients who will be switched to the short modified regimens under a new GF grant in 2021-2024.
3.5.4 ACTIVITY 2.4. STRENGTHEN COORDINATION MECHANISMS LINKING PWTB WITH OTHER HEALTH SERVICES AND SUPPORT
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 65
USAID ETICA participated in several TB coordination meetings with partners and became a member of the national TWG developing the NSP for 2021-2025 and the country's application for the GF grant for 2021-2024. The project provided technical assistance for the development of certain sections of the NSP related to the following project objectives: TB diagnostics, strengthening of the laboratory service, TB treatment TB activities among key populations, migrants, drug management and calculation of drug purchases. In addition, the project supported the translation of draft NSP to English and Uzbek languages.
3.6 OBJECTIVE 3: IMPROVED ENABLING ENVIRONMENT AND FINANCIAL SUSTAINABILITY OF TB AND DR-TB PROGRAMS
3.6.1 ACTIVITY 3.1: PROVIDING EFFECTIVE DETECTION TO WHERE PEOPLE FIRST SEEK CARE USAID ETICA developed the ToR to conduct a gender analysis to determine gender, stigma, and other social barriers to accessing TB services. The ToR was shared with NTP leaders, and the project selected a company to conduct the gender analysis in Y2.
3.6.2 ACTIVITY 3.2: STRONG COMMUNITY SUPPORT The central role of communities in the response to TB infection has long been recognized by policymakers and patients as an ethical and pragmatic imperative for successful programs. In Uzbekistan, like in many countries, especially where TB is considered more of a medical problem, government health-care providers have been outstripped of their ability to cope with the levels of service delivery needed to meet targets. Therefore, advance on the implementation of TB programs needs broader community engagement. During the reporting year, USAID ETICA not only assessed the possibilities of engaging CSO to counter the disease, but also explored the options of involving the people affected by TB in different decision- making processes. During the reporting year, the project conducted a baseline assessment on the status of community- based treatment supporters in pilot oblasts. USAID ETICA studied existing country documents, such as MOH orders and previous USAID project publications, as well as information obtained from communication with a CSO, working as a sub- recipient of the GF and TB-REP projects. The assessment revealed that there is no community-based treatment support in the project oblasts. Reportedly, only MDTs, which were established under the previous USAID TB Control project in Uzbekistan provided regular support at the community level. During the travel to the project sites in September, the project team found out that the previous USAID TB project conducted several trainings for nurses on psychosocial support of TB patients, organized “TB patients’ schools” in the TB hospitals of Ferghana and Jizzakh oblasts and established MDTs. However, all activities related to MDTs ended when the USAID project closed. The project provided technical assistance to support NTP efforts to establish a coalition of people affected by TB who were interested in becoming advocates to accelerate the TB response and reach all affected people with prevention and care. The NTP and the project agreed that USAID ETICA’s principal role would be to support the communication and public outreach needs of the coalition. NTP in turn, will lead and provide any type of political support to enable the official registration of the coalition. One of the outcomes of the joint effort was engaging them in the development of the NSP and the proposal for the GF grant by inviting them to the meetings of the TWG and enabling them to contribute to the development of the important country documents. Widespread lack of public
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 66
awareness of TB and its treatment is among the major causes of TB prevalence. When journalists learn how to accurately convey information on TB issues, they can play an important role in combatting the spread of the disease. Engaging the media and using social networks to promote best practices in TB prevention and care and communicating project achievements should contribute to overcoming TB stigma and discrimination. The project continued preparing training modules for journalists and scheduled the training for Y2. Public awareness events devoted to World TB day were cancelled due to COVID-19 quarantine measures.
3.6.3 ACTIVITY 3.3: ROBUST DATA COLLECTION, ANALYSIS, AND FEEDBACK SYSTEMS To ensure that health workers at all levels of the healthcare services are able to report accurate data, measure program performance, and use good quality data for decision making and planning, a robust TB register is required. Digitalization of the TB program in Uzbekistan requires an assessment to find the needs, gaps and alignment with the governmental digitalization strategy. USAID ETICA conducted a review of the existing National TB register (NTBR) as a part of the baseline assessment. The project collected a number of drafts and final documents providing a glimpse of national plans to develop a health management information system. The review of the collected documents will support the introduction of the new HMIS. Since the database does not respond to NTP requirements and needs, the project has not recommended its upgrading. On the other hand, in line with the government's request to establish an electronic health system, the WHO office has initiated a country- wide introduction of the DHIS2. Hence, instead of updating the existing TB system or developing a new one, USAID ETICA, jointly with NTP, decided to await further developments of the TB module DHIS2 and provide support depending on the needs of the NTP. The project actively participated in the discussion and testing of the draft TB module of DHIS2 developed by WHO and plans to support piloting the TB module in the project sites.
3.6.4 ACTIVITY 3.4: INCREASED LOCAL CAPACITY TO FINANCE AND IMPLEMENT TB SERVICES USAID ETICA produced a detailed SOW for an international consultant to conduct an assessment related to health finance with a focus on strategic purchasing and information systems. The consultant will review existing systemic impediments to health purchasing at each stage of the TB continuum of caretaking a very practical and concrete business management approach that helps ensure: 1) minimal barriers, fragmentation, or gaps in the TB continuum of care, and 2) value for money by investing in the most cost-efficient and effective services to reduce TB transmission, morbidity and mortality.
3.7 COVID-19 RELATED RISKS AND CHALLENGES Several project activities were postponed due to the ongoing COVID-19 quarantine and mandatory restrictions on movement and gatherings of people. The government introduced the COVID-19 quarantine measures in the middle of March 2020 and prolonged the quarantine several times. On August 15, 2020 the COVID-19 quarantine restrictions were relaxed, but not fully lifted. Transportation and market activities are expected to resume gradually. However, the restrictions related to gatherings of people for meetings and events remained in place until the end of Y1.
3.8 PERFORMANCE MONITORING
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 67
Obtaining data both at national and project pilot levels requires separate MOH permission. It has to be noted that some oblast TB centers such as Jizzakh, did not submit their quarterly reports to the NTP as they were re-profiled for working with COVID-19. Seven indicators out of 14 PITT indicators are reported with the annual report. The indicators are collected only for the first three quarters of the current fiscal year; information on the fourth quarter is not available for either the pilot or the national levels due to re-profiling of some TB centers to counter COVID-19. Reported data for indicators were generated from the NTP based on their reporting system. Data for indicators 12.1 and 12.2 was obtained from the laboratory register TB-04, register of TB patients TB-03. As shown in Exhibit 11 all performance targets were met except the one on training of health specialists which was impacted by COVID-19 restrictions on gatherings. The Annex 2 displays project performance against its targets and analysis of achievement of the indicators.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 68
Exhibit 11. Achievement of targets, Uzbekistan
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 69
3.9 COORDINATION WITH PARTNERS Coordination with partners and in-country stakeholders is one of the key elements in the successful implementation of both the national program and the project. It enables a concerted approach to reaching the goals and striving towards the well-being and health of the key populations and TB patients. In its first year, the project was successful in establishing good cooperation and relationships with the MOH and NTP. USAID ETICA continuously coordinates implementation of the project activities with the MOH and the NTP through regular activity planning, participation in different TWGs, including the development of TB NSP and the country proposal for the GF grant. The project has met and communicated with heads of oblasts’ TB hospitals in the project sites to present the goal and objectives of the project and shared the plan of activities in Y1. These coordinated efforts resulted in the approval of the project’s Y1 workplan, sharing data for project indicators, conducting online training sessions, and the start of the approval process of various project documents, such as SOP, SOW, etc. One of the examples of collaboration is a meeting with Dr. B.T. Odilova, the Director of the HLC and Increasing Physical Activity of the Population of UZ MOH. During the meeting, the team presented the goal and objectives of the USAID ETICA project and shared the plan of activities in Y1. The project team and Dr. Odilova agreed to coordinate and synergize activities related to raising the population’s awareness about TB, especially among vulnerable populations and high- risk groups and to develop a joint plan of activities in the project territories in line with the Y2 workplan. USAID ETICA cooperated and collaborated with national and international partners such as the WHO, the GF, and, the Tuberculosis Implementation Framework Agreement (TIFA) program to ensure coordinated, efficient, and timely support for the NTP. The project coordinates workplan activities with WHO’s TIFA project in Uzbekistan through regular discussion and meetings to avoid duplication and overlap of activities; and in opposite to find synergies in the activities. During the reporting year, the project planned to conduct joint World TB activities with the WHO country office. These activities were cancelled due to the COVID-19 quarantine. USAID ETICA also closely cooperates with the GF PIU, and provided technical assistance on the development of the GF proposal for 2021-2024.
3.10 OBSTACLES AND CHALLENGES During the reporting year, the following challenges hampered project efforts to reach the goals and objectives: • A number of planned project activities were impossible to implement or their implementation is severely impeded due to the COVID-19 quarantine which severely restricted the movement of individuals leading to the cancelation of planned events and meetings (e.g., canceled WG meeting on the development of TB NSP (March 18-19 2020) and the press conference devoted to the World TB Day (March 24, 2020). • The project had to receive formal approval of the Y1 workplan from the MOH before being allowed to engage public employees (MOH/NTP staff) in implementation. The approval process is bureaucratic and slow which led to a delay of planned activities – something that the project could neither foresee nor control. The project adheres to the same approval process for the Y2 workplan. • Engaging counterparts and participating in meetings remotely was impeded sometimes due to weakness in internet infrastructure and responsiveness of NTP staff.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 70
• NTP staff did not actively participate in all USAID ETICA planned activities due to the delay in workplan approval by the MOH and the health system’s focus on COVID-19 related measures. • There is a significant delay in the procurement of office IT and communications equipment as the vendors are out of stock of items with project specifications. There is no information on the timing of the next equipment shipments to the country.
3.11 WAY FORWARD USAID ETICA’s planned activity implementation will closely follow the intention, objectives, and scope of the USAID Journey to Self-Reliance and the Global Accelerator to End TB (GA). The project’s objective 1 (TB detection) corresponds to GA’s “reach” and objective 2 (TB treatment) relates to GA’s “cure.” Many of USAID ETICA’s technically enhanced activities will advance the GA objectives “prevent” and “reach” and “cure.” The project will work on the following three domains: communities, services, and systems. In the Community domain, the project will continue to hold regular coordination and collaboration meetings on ECF and other issues related to TB with prominent community members, community organizations, youth and women’s committees, local governments/mahalla, and religious authorities. The project will use the WHO-defined ECF approach, which uses interlinked components that include community engagement and social behavior change (SBC) communication, verbal screening of individuals in the key populations, and referral of persons with presumptive TB to testing facilities. USAID ETICA will focus on strengthening the capacity of existing and established MDTs to conduct ECF among high-risk populations, provide social and psychological support to PWTB, acquire and apply interpersonal communication skills, and manage TB drug-adverse effects. The project will prioritize the improvement of community-based referral mechanisms. A diagnostic referral system based on vouchers is expected to be introduced by the start of Y2. MDTs will use gender-differentiated approaches to improve detection rates among vulnerable and at-risk populations. In the next year, the project will give significant attention to building the TB detection, diagnosis, and treatment capacity of PHC providers and assist NTP efforts to establish a coalition of PWTB. This will include establishing supportive supervision systems not only for quality diagnostics and treatment, but also for advocacy with regional health authorities so PHC providers can voice their support for increased outpatient care approach for MDR-TB cases. The project will aim to build CSO capacity to participate in government social contracting mechanisms that are intended to allocate resources to organizations interested in and capable of delivering services on the TB continuum of care. In the Domain of Services, USAID ETICA will provide technical leadership in the development of instructions, job aids, and SOPs for TB contact tracing for the needs of specialty TB care providers, PHC facilities, and sanitation and epidemiology services. To enhance TB “prevent,” the project will develop and deliver trainings on LTBI for PHC and TB doctors in pilot oblasts. The training materials from that event will be used by the WHO to deliver LTBI trainings to TB and PHC practitioners in the rest of the country. USAID ETICA will improve laboratory and testing availability; ensure the quality of laboratory services using QMS; define the product profile of LIMS for the NRL; and promote effective, sensitive, and
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 71
patient-centered screening and diagnostic services for people with TB symptoms (or in contact with TB patients), particularly in pilot oblasts. The Project will strengthen linkages between providers to improve surveillance, contact tracing, and implementation of LTBI strategies. The project will prepare and conduct online trainings to enhance the capacity of PHC and TB specialists to interpret lab test results. USAID ETICA will assist the NTP with optimizing the smear microscopy laboratory network, which will be transformed into sputum collection centers. USAID ETICA will facilitate the policy dialogue needed for the optimization plans to undergo review and approval by the NTP and the MOH. The project will revise or develop national clinical guidelines for side effects and participate in national working groups tasked with developing a guide/manual on a patient-centered model of outpatient TB care. The project team will also support the development of the VST protocol and will organize a workshop with stakeholders to seek backing for the system-wide implementation of the model. USAID ETICA will lead to the development of a data management strategy for the TB laboratory networks. The strategy will envision the deployment of an LIMS and connectivity with the GeneXpert machine network through either C360 software (from Cepheid) or DataToCare connectivity solution (from Savics). In the Domain of Systems, USAID ETICA will provide input into the draft National TB Strategy for 2021– 2025. The project will prepare the NTP for the implementation of LTBI strategies through forecasting drug needs for TPT. To ensure quality drug procurement and use, USAID ETICA will focus on three main areas: 1) strengthening pharmaceutical management, especially drug supply at all system levels, to ensure consistent access to first- and second-line drugs of assured quality; 2) adopting the GDF drug quantification method for state budget procurement to ensure drug procurement and supply at all levels and avoid stock-outs; and 3) workshops for TB and PHC providers on management of adverse drug reactions. USAID ETICA will examine the readiness of health information systems and public financial management practices to support the introduction of strategic purchasing of TB services. The study will focus on existing systemic impediments to health purchasing at each stage of the TB continuum of care and potential solutions.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 72
4. KAZAKHSTAN
4.1 EXECUTIVE SUMMARY The official launch USAID ETICA project in Kazakhstan, “Launch of USAID TB Portfolio in Kazakhstan”, was held in Nur-Sultan on December 11, 2019. The event was attended by more than fifty representatives from the US Embassy, USAID Central Asia Mission, WHO Country Office in Kazakhstan, MOH, National TB and AIDS Centers, the GF PIU, CCM, Kazakh Medical University of Continuous Education, local CSOs, TB centers, and other donor- funded programs and partners. The Deputy Minister of Health, Mr. Kamalzhan Nadyrov, and the U.S. Ambassador to the Republic of Kazakhstan, William H. Moser, and the WHO Representative in Kazakhstan, Oleg Chestnov, all made opening remarks. During the event, US Ambassador stated: “We applaud the Government of Kazakhstan for their outstanding work to support tuberculosis prevention, diagnosis and care in the country. By working together, we can continue to make the changes that will save lives and keep families healthy in Kazakhstan across this region and around the world”. One of the highlights of the event was a ceremony for the Statement of Partnership between the MOH and USAID for the reduction of the TB burden in the country. The event had wide media coverage, including publications on Facebook, Instagram and USAID Central Asia social media.
Launch of USAID Eliminating TB in Central Asia Project on December 11, 2019, Nur-Sultan, Kazakhstan
Similar to other project countries, during Y1 Q1 USAID ETICA developed the Y1 workplan for Kazakhstan based on USAID input provided during the joint planning meeting in October 2019. The development of the first draft workplan was followed by planning and coordination meetings with NTP, the USAID TB advisor seconded to NTP, and the GF PIU manager in Kazakhstan. During a very USAID ETICA has aligned its workplan activities with the strategic objectives of the Complex TB Plan to fight
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 73
TB for 2021-2025 for Kazakhstan National Strategic Plan (NSP)10. The development of the workplan also entailed a careful review of the WHO and GF PIU implementation plans to avoid duplication and overlap. During the Year 2 planning events, USAID ETICA followed the same process of discussions and mutual agreements/alignments with partners and their key documents described above. Despite the COVID related restrictions and limitations in the country, the USAID ETICA project has made noticeable steps towards achieving project objectives and indicators in Kazakhstan. The project team focused more on start-up activities and setting up the project implementation environment in the first two quarters, and attained more tangible outcomes and results during the last two quarters. Activities implemented in Y1 laid an important foundation for the enhancement of numerous country documents, such as the NSP, the PV, and aDSM roadmaps, and the NLSP; engaging in distance learning and establishing an LIMS platform.
USAID Facebook page, Coverage of Project Launch, Nur-Sultan, Kazakhstan
Under the overarching umbrella of REACH of the Global TB Accelerator, the project assessed CSOs’ capabilities to deliver TB services and started developing trainings to address identified skills and knowledge gaps. USAID ETICA started preparatory work to conduct a study of gender, stigma, and other social barriers to accessing TB services, the results of which will inform the design of future gender- sensitive interventions. The project also organized a contest of short video stories on the lives of people with TB. The videos were viewed by more than half a million people, and USAID approved a project success story about the contest. In collaboration with the TWG on laboratory issues, USAID ETICA amended the TB diagnostic algorithm, developed technical specifications for the procurement of a WGS machine by the GF, and assessed various aspects of the existing TB laboratory network operations and information systems. In the area of CURE, the project analyzed the TB PV system, identified problems, and proposed solutions. We also developed a scope of work for TB specialists to work on aDSM at PHC facilities.
10 NSP refers to the complex plan to fight TB 2021-2025 for Kazakhstan, which is the full name of the document
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 74
Additionally, the project drafted an aDSM roadmap and proposed a system for standard classification and registration of adverse drug events. The project also developed a concept for supportive supervision in TB case management, which is one of the key elements of the TB monitoring system throughout the continuum of care. In the area of PREVENT, the project assessed policies and regulations on LTBI preventive therapy and drafted a concept paper on TPT to support policy-making. The document will form a basis for the development of an LTBI manual in Y2. The manual will be used to train TB service specialists and once endorsed by the MOH, it will also serve as a guide in the routine practice of medical doctors and nurses at PHC and TB facilities. In the area of SELF-RELIANCE, the project team reviewed health financing regulations, revealed challenges, and proposed certain recommendations to increase the efficiency and effectiveness of TB funding. Through active membership in national and regional TWGs on social contracting, the project experts advocated for amending key regulations, thus enabling improved CSO engagement in state social contracting. Due to the situation with COVID-19 and quarantine throughout the country, the project team could not conduct site visits, which would have enriched the assessment in various aspects. As part of the assessment, USAID ETICA supported the NTP to additionally review: a) existing outpatient (PHC) continuity of care model of TB and DR-TB; and b) existing M&E system of the NTP, policies, guidelines, protocols to identify needs for capacity building through mentoring. The results of the reviews were included in a combined assessment report that contains sections related to the assessment of the outpatient model and the M&E system. The results of the assessment will help NTP to make an informed decision on various aspects of the TB program. The timeframe of the assessment is provided in Exhibit 12 below.
Exhibit 12. Baseline Assessment of TB program performance
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 75
• The project managed to accomplish most of what it had initially planned, despite the impact of COVID-19. The following are highlights of the main accomplishments during Y1: • Updated the diagnostic algorithms for Xpert MTB/RIF, LPA, smear microscopy, culture and DST. The updated diagnostic algorithms have been submitted to the MOH for consideration and approval. • Developed an NSLP plan that includes the main directions for TB laboratory service development in the Republic of Kazakhstan for 2021-2025. This document is included in the NSP. • Provided technical support to NTP with the implementation of new laboratory technologies, specifically WGS. • Supported the development of a QMS in the NRL and created an electronic database of all QMS documents. • Strengthened the capacity of specialists through the development TB and DR-TB training courses for Doctors Consilia and presented those virtually due to COVID-19 restrictions. • Developed training materials (training module and presentations) on "Supportive supervision of TB and DR-TB case management” and trained medical specialists of TB dispensaries and NTP specialists with M&E responsibilities. • Through membership in TWGs, the project specialists provided technical assistance to develop NSP’s multiple components, such as PV, drug management, laboratory service, LTBI and chemoprophylaxis, training, and how to work with CSOs. • USAID ETICA became a member of the NTP’s PV TWG and participated in drafting the National Roadmap on the aDSM component of the NSP, which describes and includes guidance on active PV in Kazakhstan. • USAID ETICA was invited to become a member of a TWG on social contracting established by the Almaty city government. The project proposed a number of recommendations, which, if followed by the TWG, will lead to improved conditions for CSO’s participation in the state social procurement. These recommendations were considered in the drafting of a concept note on “Sustainable Development of Civil Society” by the TWG. • The project developed training materials for CSOs (e.g., module, agenda, presentations, list of participants). Based on developed and approved materials, the project, jointly with NTP and the GF, conducted online training for CSOs on TB case finding, infection control, stigma and discrimination, counselling skills, and other important topics. • In March 2020, USAID ETICA celebrated World TB Day with an initiative aimed at addressing TB stigma and discrimination in society. Six video stories of people affected by TB were shared with the public via Instagram and Facebook.
4.2 SUMMARY OF STAFFING AND OPERATIONS During the reporting period, USAID ETICA recruited and on-boarded staff in Kazakhstan per the approved organogram. The country team consists of: Country Director; Policy, Advocacy and Partnerships Specialist; Laboratory Advisor (Regional based in Almaty); SBC & Communications Specialist; M&E Specialist; Finance & Administration Manager; Office Assistant & Translator, and; Driver. Project implementing partner AFEW Kazakhstan also completed their recruitment process and started
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 76
activity implementation with a team comprising of Director, Finance Specialist, Project Manager, and Project Officer. Abt reactivated an old business registration in Kazakhstan and opened a bank account. Office premises were selected through a competitive process. Once COVID-19 restrictions are lifted, the project will sign an office lease. Office furniture has been ordered and laptops for staff are procured.
4.3 OBJECTIVE 1: INCREASED DETECTION OF TB AND DR-TB Enhancing TB detection relies both on the performance of TB laboratories and activities implemented at the community level to encourage testing. During the reporting year, despite COVID-19 related impediments, the project strived to strengthen the work of CSO and TB laboratories. USAID ETICA prepared and delivered a CSO training on TB, participated in the TWGs developing the CSO and laboratory sections of the NSP, provided technical assistance in the procurement of a WGS machine, and developed a package of training materials for the laboratory technicians on using WGS. Details of the project’s performance on Objective I are outlined below.
4.3.1 ACTIVITY 1.1: PARTNER WITH CSOs TO IMPLEMENT ECF AND WITH MOH TO STRENGTHEN SYSTEMS FOR CONTACT TRACING To build a sustainable capacity of CSOs in TB detection and care, CSOs must strengthen their understanding of the TB epidemiological situation, quality service provisions. The CSO staff also must better understand what is expected from them to serve key population groups and be aware of the gaps in the National TB program. USAID ETICA conducted a desk review to better understand the capacity and contribution of CSOs to identify the gaps in TB case detection, care and prevention. As a result of the desk review, the team produced a report mapping 14 CSOs’ delivery of TB prevention, care and support services to key populations and documenting the existing methodology and tools used by CSOs for TB screening, referral, testing and TB treatment adherence support. The findings and recommendations of the assessment served as a basis for planning project activities related to capacity building of CSOs and state social contracting for CSOs. In addition, USAID ETICA collected and reviewed available training materials and guidelines (such as the NTP’s guide on TOT methods) to assess the degree to which existing materials could be used for the capacity building needs of CSOs. USAID ETICA developed materials and presentations for a TOT on ECF and other critical topics for CSOs. The TOT included the following modules: TB epidemiological situation, TB and COVID-19, general information on TB, detection and diagnosis of TB, TB treatment, TB IC, counselling of people affected with TB, stigma and self-stigma reduction, protecting right of people affected with TB, TB advocacy, TB and gender, distance learning, interactive learning and VST. Due to COVID-19 restrictions, USAID ETICA was not able to conduct the TOT on the ECF and other critical topics for CSOs in-person and postponed the activity until Y2. Since the training requires the development of practical skills in conducting psychological counseling, enhancing the skills of a trainer, and leadership skills of participants using a face-to-face format, postponing the training until next year was considered more appropriate.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 77
USAID ETICA was included in the TWG under the NTP to develop the NSP. Jointly with the other members of the TWG, USAID ETICA developed a section on CSOs and advocacy, communication and social mobilization with activities, budget, assigning responsible persons, and continuous education of CSOs on TB related topics for improving access to state funding and gender- sensitive activities. Another critical area for ECF and improved detection is working with the healthcare providers on contact tracing and LTBI preventive therapy. USAID ETICA conducted a brief review of the existing policies and regulations, drafted a concept for TPT policy and defined key steps in LTBI prevention. The project team has also developed training materials that include LTBI and TPT topics. The project will determine the dates and list of participants for a forthcoming LTBI in October-November 2020.
4.3.2 ACTIVITY 1.2: IMPROVE TB DETECTION CAPACITY AND ACCESS AT ENTRY POINTS CLOSER TO PATIENTS To improve the detection of TB and access of patients to entry points on the continuum of care, laboratory services in the TB system should work smoothly and focus on patients’ needs. To advance the implementation of expanded DST, especially for new drugs such as BDQ, DLM, CFZ and LZD, USAID ETICA assisted the NRL to source DLM and BDQ pure substances. Additionally, the project provided technical assistance to the NTP to prepare technical specifications and requisitions for procurement of WGS equipment and reagents. The procurement of WGS and reagents is planned under the GF project. To support NRL and ensure noticeable contributions to enhancing the performance of TB laboratory networks, project specialists developed a detailed five-year plan for USAID ETICA’s laboratory-related activities in the country, which flows out of the project workplan. The country’s population has access to all testing methods in all regions of the country, including express GeneXpert testing. In the last few years (2019-2020), the country had actively expanded the access to GeneXpert at the district level with the support of a) USAID, which had introduced additional 50 GeneXpert platforms; and b) the GF, which procured additional 19 platforms amounting the total number of the machines to 128. Due to this expansion and increased access to testing, the country has updated the diagnostic algorithm to include the use of GeneXpert as an initial diagnostic test per the WHO recommendations. The NTP established a TWG to develop the diagnostic algorithm and the NLSP. As a member of the TWG, USAID ETICA, together with the NRL, revised all existing diagnostic algorithms at the PHC level and TB facilities (including monitoring of laboratory testing during treatment of DS TB and DR-TB). The updated diagnostic algorithms have been submitted to the MOH for review and approval, which is expected by the end of 2020. To prove the effectiveness of switching to GeneXpert testing as an initial test, project specialists collected information across the country to conduct a comparative analysis of smear microscopy and GeneXpert results to determine the diagnostic effectiveness of the latter test. The 2019 data was collected from the country’s regions and the results of GeneXpert and smear microscopy were matched on the same samples (i.e., if both tests produced similar or different results on the same samples). The results of the analysis are demonstrated in Exhibit 13 and illustrate the following: • A high rate of compliance between smear microscopy and GeneXpert tests. Both tests with positive results (6.2%) and with negative results (85.8%) make up the biggest proportion of the analysis. • The results of smear microscopy negative but Xpert MTB/Rif-positive specimens amount to 7.7%. This means that in 7.7% or 3669 samples the smear microscopy did not recognize the TB, while
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 78
GeneXpert has caught the disease in those samples. The added diagnostic value of the Xpert MTB/Rif test resulted in 3,669 additionally diagnosed TB cases. • At the same time, the proportion of smear microscopy positive but Xpert MTB/Rif-negative specimens was 0.3% (129 specimens in total). It is well known, that smear microscopy has lower specificity in comparison to Xpert MTB/Rif, since it cannot distinguish between TB mycobacteria (MTBC) and MTBC and non-TB mycobacteria (NTM).
Exhibit 13. Compliance of results of GeneXpert and Smear Microscopy tests
Compliance of results of GX and SM 100.0% 90.0% 85.8% (40751) 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 7.7% (3669) 10.0% 6.2% (2962) 0.3% (129) 0.0% GX+ & SM+ GX+ & SM- GX- & SM+ GX- & SM-
USAID ETICA conducted a baseline assessment of TB laboratory services at the national level, including data collection and an assessment of the country's existing TB laboratory network. As part of the assessment, project specialists developed data collection tools (checklists) to evaluate the following: 1. Structure of the existing TB laboratory network 2. Availability of laboratory TB diagnostic methods, including express methods. This tool will also check existing transportation modes of pathological samples, workload, test turnover time, laboratory equipment, and external quality assurance (EQA) 3. QMS 4. Electronic database 5. Training needs of laboratory personnel Following the development of the checklists, USAID ETICA conducted a meeting with NRL staff and representatives of regional laboratories to discuss and clarify the purpose of the assessment and the use of the checklists for data collection. NRL approved the checklists, not only for the baseline assessment, but also for regular collection of laboratory data at the NRL and regional laboratories. This will enable access to comprehensive information on the performance of country laboratories and allow NRL and regional TB labs to make timely and adequate decisions based on the conducted data analysis. The project team held a series of online meetings with the NRL to discuss the results of the baseline assessment, effective use of GeneXpert machines at the district level, and reporting forms on laboratory testing. It was noted that some of the reporting forms were outdated, in most cases the paper format was used instead of electronic data entry. To advance the work of laboratories and ease the reporting processes, USAID ETICA plans to convert the reporting forms to electronic format, which will also
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 79
allow easy data entry and monitoring of the data. The results of the assessment will be used for further improvement of the TB laboratory network. Since the introduction of GeneXpert technology, the confidence and trust of healthcare workers have significantly increased as they prefer the use of GeneXpert testing versus “old-fashioned” microscopy. The number of GeneXpert MDR-TB/Rif tests increased by 4.6 times between 2013 and 2019 from 14,500 to 66,836 tests respectively. As demonstrated in Exhibit 14, the NTP reports that despite COVID-19, the number of GeneXpert MDR-TB/Rif tests performed in PHC facilities over the first six months of 2020 increased when compared to the same period in 2019, 26,311 tests compared to 24,530.
Exhibit 14. Comparison of GeneXpert tests conducted in the first 6 months of 2019 and the first 6 months of 2020
The analysis conducted by USAID ETICA demonstrated improved effectiveness and reliability of the GeneXpert testing over smear microscopy and serves as evidence for a recent change of the testing algorithm. With the support from USAID ETICA, the NRL had recently revised the algorithm for early detection of TB. Following a recent update in the TB diagnostic algorithm, the GeneXpert MTB/Rif has been assigned as a primary TB test. Applying the GeneXpert MTB/Rif test as the first and main diagnostic method of TB testing across the country, will be the basis of the TB laboratory network optimization. WGS is a current alternative to the WHO-approved probe-based methods for TB diagnosis and detection of drug resistance, genetic diversity and transmission dynamics of MTB complex. WGS has proved to provide a rapid and comprehensive view of the MTB genotype, with the potential to reliably predict drug susceptibility within a clinically allowable timeframe. USAID ETICA provided technical assistance to the NTP and the GF in preparation for the procurement of equipment and reagents for WGS by the GF. The project developed the technical specifications of the equipment, reagents and consumables; supported choosing the location for the machine, and developed SOPs for WGS operations.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 80
The project team developed training materials and conducted a first introductory online training on WGS for NRL specialists. Trainings on sequencing will become regular in the future to enhance the capacity of the NRL specialists on working with the new technology.
GeneXpert machines at NRL, Almaty, Kazakhstan
Due to quarantine restrictions, WGS equipment delivery was delayed and is expected in October 2020. USAID ETICA plans to assist NRL in the installation of equipment, validation of this new technology, and determining to what stage of the existing diagnostic algorithm the sequencing should be added. In June, USAID ETICA started to work on the implementation of a QMS in NRL. QMS in the laboratory encompasses all aspects of the laboratory operation, including the organizational structure, processes and procedures, which need to be addressed to assure quality. A QMS assessment conducted in the TB laboratories by SRL (Gauting) prior to the initiation of the project, and the project’s laboratory baseline assessment showed which of the laboratory SOPs required an update. USAID ETICA, in collaboration with the NRL Manager, initiated an audit of all the SOPs and in Y1, 131 out of 318 SOPs were updated in accordance with the latest WHO recommendations. The project plans to place an electronic database of all QMS documents in a free cloud server for the possibility of expanding access to QMS documents to regional TB laboratories. Due to the COVID-19 quarantine measures, the project postponed a QMS audit by international experts and the QMS training until Y2. USAID ETICA assisted with the implementation of expanded DST, especially for new drugs such as BDQ, DLM, CLF, and LZD, and supported the procurement of pure substances for DST. The pure substances for BDQ and DLM had not been available in the country, and thus, NRL had started DST for CLF and LZD since the beginning of 2020. To enhance the performance of the laboratories and bring them closer to QMS standards, the project provided technical assistance to NRL comprising of 23 updated SOP forms, conducting several online meetings with all laboratories in the country including those in the penitentiary system, and carried out analyses to assess the quality of DST for new drugs (CLF and LZD) in each TB laboratory. The project will continue enhancing DST over the life of the project. The project team identified a variety of challenges in the operations of the DST laboratories. The following are a few examples: • Pure substances for BDQ and DLM for the needs of DST are hard to obtain as they are not commercially available. This creates a challenge for DST laboratories, which need pure substances to
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 81
conduct DST. Thus, USAID ETICA provided assistance in obtaining pure BDQ and DLM substances (registration on the supplier's website for a free drug receipt). • DST laboratories lack SOPs for DST of new anti-TB drugs. USAID ETICA developed a SOP on DST for new drugs and conducted two meetings to present the SOP. • There are shortages of staff trained to conduct DST and perform quality control of DST for new anti-TB drugs. The project conducted online meetings with 20 laboratories to introduce the newly developed SOP, familiarize laboratory personnel with the process of DST for CLF and LZD, and started validating DST for CLF and LZD in 20 laboratories across the country.
QMS audit in NRL, Almaty, Kazakhstan
USAID ETICA conducted a regional laboratory assessment focusing on sample transportation and logistics, turnaround timing, and time to report to find potential areas for improvement of logistics. The assessment showed that there is a well-established sample transportation system, which enables the collection of samples from microscopy laboratories and delivery of samples to the dedicated GeneXpert laboratory for further analysis taking a maximum of two days in 92.0% of surveyed cases (81 out of 88 sites); and up to three days in 8% of cases (7 of 88 sites). Furthermore, the project will help optimize the network of GeneXpert laboratories by developing a transition plan to the use of Xpert MTB / RIF Ultra Cartridges and conducting training for staff to facilitate the transition. A new generation of GeneXpert Ultra MDR-TB / Rif tests, which are faster and more sensitive than GeneXpert MDR-TB / Rif, will be introduced under the new NSP period. Quality data management is an essential element of a functioning TB program. There are two electronic TB databases in the country: National Register of TB patients and Complex Medical Information System, both of which include laboratory components. USAID ETICA specialists analyzed the existing laboratory information systems and are working on the report. The results of the analysis will be used to plan improvements to the existing LIMS.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 82
To enhance the capacity of the TB laboratory specialists, USAID ETICA started developing virtual training modules on the following topics: 1) QMS in TB laboratories; 2) quality control of TB laboratory tests; 3) interpretation of TB lab results; 4) DST for TB drugs; 5) molecular genetic diagnosis of TB and MDR-TB using Xpert MTB/Rif, Xpert MTB/Rif Ultra; and 6) laboratory diagnosis of TB using luminescent microscopy. Trainings are planned for Y2. Jointly with the TWG, USAID ETICA developed the NLSP, as a complementary part of NSP. It describes the main objectives and activities for strengthening TB laboratory services in Kazakhstan for 2021-2025. The project team also developed a document on "Improving the availability of modern effective technologies for the diagnosis and treatment of TB and M/XDR", which was also included in the NSP as its integral part. The document clearly outlines definitions, responsible persons, and the budget for three years, and timelines for implementation.
4.4 OBJECTIVE 2: INCREASED TREATMENT SUCCESS FOR TB AND ALL TYPES OF DR-TB
4.4.1 ACTIVITY 2.1: SUPPORT THE ADOPTION AND IMPLEMENTATION OF PATIENT-ORIENTED APPROACH IN TB CARE To achieve a patient-centered approach, which is key for successful TB treatment outcomes, the capacity of healthcare providers, community stakeholders, and policymakers must be strengthened. During Y1, USAID ETICA worked jointly with the NTP to perform much- needed capacity building of Consilia doctors, healthcare providers working within TB centers, and staff working in PHC facilities to develop the NSP sections on drug management and aDSM. The project also aimed at building the capacity of NTP staff, and laid out a plan for ensuring regular and accurate recording and reporting of adverse events of all TB drugs. Training materials on PV and aDSM were also prepared for doctors working within the TB system and PHC. USAID ETICA tackled a variety of PV aspects contributing to improved patient treatment. One of them was upgrading and enhancing PV data collection and reporting. The project specialists participated in drafting technical specifications for creating an additional module for PV in the electronic NTBR. Digitalizing of data entry, data collection, and reporting on PV through a new module in NTBR will enable TB care workers to conduct data analysis, ensure timely alerts, and obtain data across the country on serious adverse events among TB patients in a timely, effective, and accurate manner. Along with changes in the NTBR, USAID ETICA discussed with NTP the potential expansion of registration of adverse events in the NTBR. The project proposed a method based on international standards for sorting/classifying all potential adverse events from each drug based on the treatment regimens used (i.e., either the first or second- line TB drugs). The project recommends that the NTP embed the classifier to the national TB register, and respectively, enable proper recording and data analysis, which will upgrade the information systems on PV. One of the major gaps revealed during the baseline assessment was the lack of capacity and skills of healthcare providers on PV and aDSM. USAID ETICA discussed and agreed with the NTP on 12 topics to be included in a PV training, which will be given via distance learning in Y2. Training sessions and modules target doctors and responsible personnel from PHC facilities. The topics include management of adverse events in the treatment of TB, and basic information on monitoring of aDSM. The project plans to provide an intensive training program for specialists within the framework of post-graduate training programs. Materials will be available through online courses of NTP, which will substitute for the in-person, more expensive mode of training even in the absence of donor assistance. Improved
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 83
access to information and training courses will keep healthcare workers abreast of updated information on aDSM and PV. On the policy level, as a part of the TWG sub-group on PV and aDSM, the project provided technical support to define key objectives and priority activities in the roadmap, which will complement the forthcoming NSP. The roadmap will also serve as NTP’s guiding document for the planning of important PV activities for the next five years and will be used for the capacity building of healthcare providers on PV and aDSM. USAID ETICA was involved in the implementation of joint activities on PV and helped to develop the TWG work plan for 2020–2021. The project also convinced NTP to amend the M&E performance indicators for aDSM of patients with DR-TB and include the indicators in the National M&E Guide. Capacity building of healthcare professionals and keeping them abreast of the latest developments on TB treatment is vital for the successful implementation of the national program. USAID ETICA developed a training module and presentations on "Supportive supervision of TB and DR-TB case management”. On September 29-30, USAID ETICA conducted a two-day online training for 20 medical specialists responsible for M&E from TB dispensaries from all regions of Kazakhstan. The training focused on the importance of conducting supportive supervision in daily M&E work, the use of checklists during supportive supervision to enhance effectiveness, and how to ensure the quality of the M&E performance, among other topics. As a part of the patient-centered approach in outpatient TB treatment, the project supported the NTP to identify gaps and challenges for switching to VST. For this purpose, a preliminary assessment was undertaken on the condition, and availability of IT equipment for VST, such as laptops, tablets, smartphones, etc.). During the reporting period, the project started working on the VST concept, the draft Doctors from Kostanai region participate in the analyses of which already includes the preliminary description, a of clinical of the DR-TB patient on individual treatment budget and timeframes. The project will continue regimen, Kazakhstan assessing the need in VST recommended by WHO and will finalize the concept upon all clarifications. It is expected that the activities described in the concept paper will allow for the improvement of the treatment adherence rate among patients with TB.
4.4.2 ACTIVITY 2.2: SUPPORT THE INTRODUCTION OF NEW PROCEDURES TO SUSTAIN PATIENT- CENTERED CARE To ensure patient-centered care, drug safety, and adverse drug effects, conducting supportive supervision and enhancing capacity of TB care providers, including the members of TB Consilia are important to monitor. The project team’s analysis of the PV system consisted of a TB drug safety quality assessment and an assessment of the performance of the regulatory body. The assessment resulted in a proposed set of recommendations that included the revision of the existing regulations to ensure the reporting of adverse events. An analysis of the legal framework for PV also outlined some areas for improvement. In
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 84
line with the WHO requirements, some of the recommended measures were prioritized to enhance the effective management of the PV system in the country. For example, most drugs used to treat DR-TB in Kazakhstan are used “off label”. As a part of the approved National Treatment Protocols and WHO recommendations, a review of the reporting requirements should be conducted to ensure that adverse effects are being appropriately recorded when these drugs are used. In addition, the responsibilities of medical specialists for managing adverse reactions are not clear in their job descriptions and should be included. The mentioned priorities were taken into account while preparing the National Roadmap for aDSM, which will be a part of the NSP. Through active participation in the development of NSP, USAID ETICA made major contributions to the drug management and PV sections. Specifically, a final list of activities and deadlines for implementation of the drug management section has been detailed with input from the TWG members. Active monitoring of drug safety is one of the missing points in the functional responsibilities of the personnel in PHC facilities. As a member of the TWG, alongside NTP and the GF, USAID ETICA was tasked to prepare a SOW for TB specialists on conducting active monitoring of drug safety in PHC facilities. The draft SOW for TB specialists has been finalized who will take over the responsibilities related to PV in the healthcare system. Additionally, USAID ETICA developed SoWs for national aDSM and drug management consultants to provide technical expertise in support of anticipated implementation activities. Supportive supervision is a process of helping staff to improve their own work performance continuously. It is carried out in a respectful and non-authoritarian manner with a focus on using supervisory visits as an opportunity to improve the knowledge and skills of health staff. The project has also begun to work on the development of a supportive supervision concept to strengthen PV for the diagnosis and treatment of adverse events in the TB program. It includes an evaluation tool for diagnosis and aDSM to identify and remove barriers for the optimal clinical management of DR-TB patients. To identify training needs and knowledge gaps, USAID ETICA conducted a survey among regional specialists of Doctors Consilia, which helped identify training topics. During working meetings with representatives of NTP and GF, the project team discussed and agreed on joint training plans. USAID ETICA developed an online training module. It includes a concept, presentations, and training program for specialists from Doctors Consilia. USAID ETICA, jointly with the NTP and the GF, conducted online training for specialists from Doctors Consilia from NTP and regions on September 23-25. Training sessions included topics on treatment management of sensitive and DR-TB cases, clinical issues, PV, and aDSM. Enhancing the skills of doctors in the Consilium will lead to the provision of improved support for TB diagnosis and treatment. The process of training preparation is outlined in Exhibit 15.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 85
Exhibit 15. Process of preparation for training for Doctors’ Consilia
4.4.3 ACTIVITY 2.3: BUILD CAPACITY FOR PHARMACEUTICAL MANAGEMENT (PM) Pharmaceutical management is one of the essential components of the “CURE” stage in the continuum of care. Availability, safety, timelines of intake and other aspects of drug management is coordinated by NTP with close support from USAID ETICA, the GF, and other partners. During the reporting year, the role of USAID ETICA was crucial in terms of the provision of technical assistance to ensure the transition to more efficient and non-injectable regimens, drug selection in line with the latest WHO updates, and ensuring patients are continuously treated with quality medicines. One of the areas of project contribution is improving the management of pharmaceutical products and ensuring a smooth transition of the procurement of the entire volume of TB drugs from international donors to the procurement under the guaranteed Volume of Free Medical Care (Governmental procurement mechanism). USAID ETICA participated in two planning events for the provision of TB drugs in the context of the transition to non- injectable and individual treatment regimens for DR-TB patients. The project used the events as an opportunity to coordinate planned activities with the GF and other international donors and implementers. USAID ETICA representatives took part in training, organized by NTP on the introduction of a quantification method for drug procurement in the TB program. The training was conducted for the country's local TB coordinators. During the training, the project specialists assisted with the calculations of the procurement needs of TB drugs for 2021. Under the same objective, the project specialists also provided a set of recommendations on estimating the type and quantities of TB drugs for procurement in 2020-2022. Practical recommendations were elaborated on a methodology of calculating anti-TB drugs with considerations of the country’s transition to non-injectable regimens for the treatment of DR-TB and the introduction of new regimens and new TB drugs in the penitentiary system. The recommendations are a mix of national criteria with WHO guidelines for the treatment of patients with DR-TB in the penitentiary system. In consultations with partners and in-country stakeholders, USAID
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 86
ETICA estimated the type and quantity of TB drugs to be procured by the GF for the treatment of 75 XDR-TB patients in the penitentiary system. The USAID ETICA team reviewed current NTP policies and national reports and provided feedback based on the new 2020 WHO LTBI guidelines. A draft of the TPT webinar with updates from the new 2020 WHO LTBI guidelines has been developed.
4.5 OBECTIVE 3: IMPROVED ENABLING ENVIRONMENT AND FINANCIAL SUSTAINABILITY OF TB AND DR-TB PROGRAMS
4.5.1 ACTIVITY 3.1: STRONG COMMUNITY SUPPORT Strong community support for TB detection and treatment is one of the key success factors in the fight against TB. USAID ETICA implementation efforts this year featured a short video contest dedicated to World TB day, participation in a seminar aimed at reducing stigma and discrimination; and strengthening the capacity of CSOs to take part in state-sponsored TB case finding and provide treatment adherence support to the TB affected. To ensure the safety of trainees during COVID-19, USAID ETICA conducted online seminars for CSOs. The project identified and selected for the occasion a distance learning platform called Moodle which will be used by NTP and the GF to deliver online content/training in the future. The project recorded the training presentations to enable sustainability and replicability of trainings in an environment of resource constraints. USAID ETICA prepared the content for and selected most participants for the future online training on advocacy for enhanced social support to DR-TB patients. A major objective of this effort is to train trainers from CSOs who would then train their colleagues and active community leaders on countering stigma and discrimination, engaging effectively in advocacy, and addressing gender- specific issues. Envisioned as a live event to enable the building of proper skills, the TOT had to be postponed until Y2 with the hope of lifted COVID restrictions. The project specialists developed 15 modules for the training. In addition to the presentations, USAID ETICA developed a video on psychological counseling for people with TB that will be demonstrated during trainings and webinars as an interactive instrument, which will help CSOs to understand the information in a more effective way.
On-line Training on Counselling of People with TB, Kazakhstan
In September, USAID ETICA, jointly with NTP and the GF conducted online training for coordinators and social workers from 19 CSOs from all regions of Kazakhstan. USAID ETICA’s trainers used one of the modules developed for the ToT, covering the topics of psychological counseling of patients with TB, stigma reduction, advocacy and patient rights, while NTP and GF trainers covered the topics of the
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 87
epidemiological situation of TB, general information on TB, detection and treatment of TB, TB and COVID-19, IC were covered by the NTP and the GF. The project continued preparing to assess social barriers that affect access to TB services, including gender, stigma and discrimination. A research organization was selected and contracted and a study questionnaire was drafted. In February 2020, USAID ETICA participated in a seminar organized by the CSO Kazakh Network of PLHIV on the results of the TB-REP 2.0 project’s (funded by the GF) assessment of stigma, rights, and gender barriers to accessing TB diagnosis and treatment services among key populations. On behalf of one of the working subgroups of the seminar, the project specialists delivered a presentation on key barriers to timely TB diagnosis, and took part in the development of recommendations for an action plan to remove identified social barriers. Exhibit 16. Results of media campaign against stigma and In recognition of World TB Day, USAID discrimination ETICA organized a national video contest Social media campaign among people affected by TB. The contest was announced through social media. The project team shortlisted six videos in which participants told their stories of living with TB and touched on issues of stigma and Reposts 81 discrimination. The videos had a wide Comments 127 public resonance, generating 526,660 views from individual viewers and 2,200 “likes” Video views 308231 followed by positive comments/feedback Coverages 526660 and re-posts (Exhibit 16). At the same time, not a single dislike, negative comment, spam, or complaint were received. The videos have informed communities about TB, and have also likely contributed to decreasing stigma against people living with TB. The six finalists in the contest received awards.11 USAID ETICA developed a success story on the video competition, which was exhibited on USAID’s website in English and Russian.12
4.5.2 ACTIVITY 3.2: ROBUST DATA COLLECTION, ANALYSIS, AND FEEDBACK SYSTEMS During the reporting year, USAID ETICA focused on the review of existing health information systems, data analysis to develop a database for CSOs and assessment of VST. To support the National TB Program to better coordinate implementation of the NSP and keep track of CSO activities in the TB system, an agreement was reached with NTP and the GF on developing a database on CSOs providing TB services. The project also conducted a preliminary rapid analysis of existing services provided by CSOs. Some of the findings include the following:
11 https://www.facebook.com/afewkazakhstan/posts/3574457009237024?__tn__=k-r) 12 https://www.usaid.gov/kazakhstan/program-updates/may-2020-its-time-to-talk-about-tuberculosis
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 88
• There is an absence of unified reporting forms and modalities. As a result, the data collected by CSOs cannot be compared or combined to complete a larger picture of the key populations affected by TB. • The data that is supposed to be collected is often incomplete or not actually collected.
4.5.3 ACTIVITY 3.3: INCREASED LOCAL CAPACITY TO FINANCE AND IMPLEMENT TB SERVICES The NTP has requested that USAID ETICA provide technical support to the subgroup on finance, which is working under the TWG developing the NSP. Specifically, NTP asked the project to develop a document for the group discussions and outlining key financing issues stemming from the prior NSP that need to be addressed in the forthcoming NSP. To support the development of the NSP, USAID ETICA developed an analytical paper evaluating the current system of TB financing with considerations of regulatory norms, health codes, and the different health financing mechanisms in Kazakhstan. The document contains certain recommendations aiming to enhance the efficiency and effectiveness of TB services financing; upgrade the complex tariff for TB patients; improve the collaboration between TB services and PHC services and other rehabilitation services; and capacity building of key TB specialists. Capacity-building activities include, but are not limited to, the development of a training module on TB finance management based on the new TB financing principles. The USAID Advisor on TB Financing in Kazakhstan has reviewed a draft of the document and provided comments. The recommendations were used in the development of the NSP in the TB financing section. Within the framework of NSP working group on TB finance, USAID ETICA developed a vision of a budget designing approach for NSP and a brief report comparing portions of the state budget of the TB care/service for the first half of 2020. The report also contained a list of recommendations for the NTP on adjusting the budget and taking up preventive measures for the absorption of the "under-utilized" funds from the current year. Recommendations were as follows: • Regular monitoring of the progress of budget utilization by TB organizations. In case of confirmed saving, inform MOH by submitting proposals on redistribution of financial resources for other priority needs. • One of the possible areas for re-allocation of savings is to equalize the Complex Tariff for TB patients in the 4th quarter of 2020. Equalizing the Complex Tariff entails bringing the health spending per person of low income generating country regions to par with that of median income regions. This will increase the allocation of funds per TB patient in such low-income regions. • Another potential area for re-programming of funds is the creation of a back-up stock through the procurement of effective TB drugs with a good shelf life to ensure the continuity of treatment for TB patients, considering restrictions associated with coronavirus. In countries like Kazakhstan that are transitioning from foreign aid to domestic financing, the sustainability of the TB response requires more than just a sufficient TB budget allocation. A legal framework, effective mechanisms, and transparent procedures that allow governments to contract CSOs for the provision of TB- related services to everyone who needs them are key. To advocate for inclusion of TB in state social contracting and upgrading further changes in state social contracting at the national level, USAID ETICA became a member of the TWG under the Public Counsel of Almaty city. Active participation of CSOs in TWGs on social contracting is also crucial to provide the perspective of the organizations which will eventually help put in practice declared, but unfulfilled state social roles and responsibilities. Hence, USAID ETICA, with the help of GF sent letters to Public Councils under akimats
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 89
of all regions of Kazakhstan to include CSOs working in the area of TB in the TWG to promote improvements in the social contracting legislation. Each akimat in every region has a Public Council with an active TWG with the involvement of CSOs. The TWGs work and promote various initiatives based on regional priorities, including improvement of the legislation on social contracting. USAID ETICA also analyzed the legal and policy environment for social contracting for CSOs and produced a set of recommendations on improving the access of CSOs to state funding. Specifically, recommendations embraced issues such as what is the best, most effective way to distribute state funds according to the needs of the regions, how to ensure participation of CSOs in each stage of state social order, simplification of the reporting forms, etc. USAID ETICA began compiling an overview of postgraduate education to arrange data storage of a high- quality training and educational materials, ensure the sustainability of project capacity building activities, and have medical training sessions accredited by the government. Based on the findings and obtained materials, the project explored how project materials can be incorporated into the curricula of postgraduate education and the ways of assigning credit hours for training sessions conducted by the project. The report is drafted and will be finalized in Y2.
4.6 COVID-19 RELATED ACTIVITIES On June 25, USAID ETICA participated in the coordination meetings of partners involved in the implementation of activities to control TB in Kazakhstan. The purpose of the meeting was to discuss the impact of COVID-19 infection on the implementation of projects during the first half of 2020, including its challenges and solutions. USAID ETICA presented the idea of cooperation within the distance learning platform, specifically the establishment of a center for distance learning at NTP, based on which other partners and USAID ETICA could conduct online training and webinars for medical personnel on PV, laboratory, clinical issues), and on psychosocial support, stigma and discrimination, counselling for CSOs (see photos from partners meeting below).
4.7 COVID-19 RELATED RISKS AND CHALLENGES COVID-19 pandemic had a sizeable impact on USAID ETICA in Kazakhstan. Cases were detected and serious restrictions on the movement of people were imposed. Implications for USAID ETICA’s project reflected the cancellation and /or postponing of some activities. Due to the limitations of COVID-19 quarantine, implementation of the following activities was re- formatted, delayed or put on hold: • Participation in assessments of outpatient continuity of care model of TB and DR-TB, existing TB Information Systems, and learning TB service financing systems at different levels of the health system. • Training of laboratory specialists at the NRL in Borstel (on WGS technologies) and events that depend on the purchase of WGS equipment in the country was postponed to Y2 due to travel restrictions. This included updating the diagnostic algorithm; technical support for NTP with the integration of WGS into the existing diagnostic system; TOT with the participation of SRL Gauting. • TOT for CSOs on ECF and other critical topics for CSOs postponed for Y2. • Online training on advocacy for enhanced social support to DR-TB patients under ETICA project postponed to Y2.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 90
• Office lease and furniture purchases were delayed. • Regional mentorship and support visits and participation in the regional events were postponed until Y2.
4.8 PERFORMANCE MONITORING As per the approved AMELP during this reporting period, Kazakhstan reported on 11 out of 14 indicators. The reported indicators are collected at the national level and display the achievement of performance indicators of USAID ETICA in Kazakhstan in Y1. The following remaining three indicators have been shifted to Y2 due to postponed relevant activities: • Indicator # 8 “Percentage of participants reporting increased agreement with the concept that males and females should have equal access to social, economic, and political resources and opportunities Code: GNDR-4” – the gender assessment will be conducted during the second year of project implementation. • Indicator #9 “Number of people reached by a USG funded intervention providing GBV services (psychosocial counseling) Code: GNDR-6”. USAID ETICA has not been able to work with CSOs providing GBV services during Y1 due to COVID-19 restrictions. • Indicator # 11 “Laboratories with QMS reaching 80% on TB-SLIPTA scale” – due to announced COVID-19 quarantine and strict restriction on movements, the activities related to this indicator were not possible to implement and were shifted to the second year.
Information for the four indicators related to the work of CSOs was provided by the GF project of Kazakhstan. The GF does not have a common database where information on vulnerable groups, gender and age could be obtained and analyzed. For this reporting period, information was provided only for the total number of screened, tested, and identified through the CSOs activities. Information on the other indicators was obtained from the NTP. According to the NTP reporting system, the data on the project indicators was generated from the reporting forms TB07, TB08, and TB01 used for the gender and age disaggregation. The form TB07 generates data on the detection and initiation of treatment, while the form TB08 reports on treatment outcomes. Information on the laboratory indicator was obtained from the National TB Register, namely, from the reporting form "Laboratory-based summary analysis of TB cases, including GeneXpert". Gender disaggregation is available only for the first two indicators on detection and treatment. According to NTP, of all people diagnosed with TB and put on treatment in Y1 66% are men and 34% are women. Such difference suggests that there are gender related barriers to receiving TB services which disproportionately affect women. A comprehensive analysis of the actual barriers, their causes and potential solutions is needed. A gender research will be conducted for that purpose in Y2. The Annex 2 displays project performance against its targets and the analysis of the achievement of the indicators. Exhibit 17 was derived from the Annex 2 and displays summary of achievements against project indicators. All targets were met or exceeded, except the target of the indicator #14 on education sessions for service providers which was not met due to the COVID-19 quarantine. The target was achieved by 78% (156 people trained against set up target of 200 people).
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 91
Exhibit 17. Achievement of targets, Kazakhstan
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 92
4.9 COORDINATION WITH PARTNERS Successful implementation of the NSP’s goals and objectives and reaching the ultimate goals of the TB program greatly depends on the coordinated and concerted efforts of all in-country partners and stakeholders. Coordination activities are chaired by the NTP, and USAID ETICA is one of the key players among contributors to noticeable TB program achievements. Coordination and collaboration among state institutions, international and national partners, including CSOs are reflected in the form of meetings, round tables devoted to discussing various urgent and planning activities. Joint activities such as training, seminars, developing certain policy levels or technical documents through establishing TWGs boil down budgetary gaps in TB system and lead to better outcomes. In Y1, USAID ETICA actively participated in the following coordination events: • The annual coordination meeting was held on February 13-14. The project delivered a presentation on its planned activities and took part in the proceedings of the working groups on Finance, CSOs, and Clinical & Laboratory. • Coordination meeting of partners to discuss the impact of COVID19 infection on the implementation of projects during the first half of 2020 held on June 25 to discuss challenges and solutions. USAID ETICA presented the idea of cooperation within the distance learning platform. The project discussed the establishment of a center for distance learning at NTP, based on which other partners and USAID ETICA could conduct online training and webinars for medical personnel on PV, laboratory, clinical issues), and on psychosocial support, stigma and discrimination, counselling for CSOs. • The project actively collaborates with local partners, such as the Kazakh Network of PLHIV and participates in a number of key meetings with participation of CSOs to discuss gender assessment issues, stigma, rights, and gender barriers to accessing TB diagnosis and treatment services among key populations. The meetings usually involve elaboration on the future steps in collaboration with national and international partners, a key factor in coordination. • As a member of various TWGs, USAID ETICA worked together with NTP and other partners on the NSP development. NTP formally established the working subgroup and included project experts as its members. • USAID ETICA meets regularly with the NTP, GF PIU, AFEW, IMLred, and PATH to effectively coordinate the implementation of the working plan and obtain necessary agreement on the scope of work.
4.10 OBSTACLES AND CHALLENGES During Y1, several planned project activities were impacted due to the COVID-19 quarantine. NTP staff have been unable to participate, even remotely, in USAID ETICA planned activities due to the health system-wide focus on COVID-19 related measures. Some training sessions have been reformatted to be presented virtually. However, the implementation of some activities requires the physical presence of participants/facilitators such as conducting trainings at the workplace and conducting activities with the participation of international experts. These too have been hampered due to restrictions of COVID- 19. Conducting TOTs on ECF and other critical topics for CSOs were postponed to Y2, as an online
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 93
format would not guarantee the minimum quality of the knowledge and skills sharing compared to the classic version of educational sessions. COVID-19 related restrictions on the movement of people and travel bans deterred numerous activities of the Lab component, which were postponed until Y2: • Development of an updated diagnostic algorithm on WGS. As the equipment and technique are new for the country, after its application in practice, the MOH and NTP will decide on the use of WGS and nesting the WGS testing to the diagnostic algorithm. • Technical assistance to NTP for the integration of the WGS technique into the current diagnostic system. • Implementation of expanded DST, especially for new drugs such as BDQ, DLM, CLF and LZD. A 3- day ТОТ with participation of SRL Gauting was postponed since the practical part of the training requires in- person participation and skills development. • Two-day ТОТ with the participation of SRL Gauting on implementation of internal quality controls of new drugs. • Provision of a common advanced QMS training with regional laboratories on quality management with the participation of SRL Gauting. • External audit with SLMTA assessment of the NRL with the participation of experts from SRL Gauting. • Further development of the QMS of the NRL. Completion of the project’s gender assessment may also be deterred due to travel restrictions. The selection process of an organization for conducting a gender assessment has been finalized, and the company will be able to start the assessment activities as a desk review; the fieldwork will be postponed until the COVID-19 limitations are lifted.
4.11 WAY FORWARD Anticipated economic hardship due to COVID-19 could constrain health budgets. COVID-19 has been drastically changing health funding priorities and has diverted resources from TB to pandemic-related needs. This has created a high degree of uncertainty about upholding government commitments and buy-ins as well as about the sustainability of future project interventions. USAID ETICA will continue to use evidence-based approaches to generate common understanding, build political will, and ensure cross-stakeholder collaboration. For example, in each country, USAID ETICA will fully engage the USAID Mission, the NTP, and other government entities in evidence- generation and dissemination, open discussions, and advocacy to ensure that all stakeholders are informed about and have input into these processes. As a standard methodology and to the degree possible given constraints due to COVID-19, USAID ETICA will encourage and support national or local government/self-government staff to lead and facilitate initiatives where appropriate to bolster ownership and leadership. During Y1 implementation, USAID ETICA demonstrated its strong intent to learn from and build on the successes of prior donor projects in TB. The project will continue on that path in Y2, supported by the experience gained and lessons learned in Y1. The project will continue to strengthen the capacity of communities and CSOs, health care providers, government staff, and other
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 94
partners to plan agendas, collect and analyze data, draft policies, and facilitate advocacy and training. All of these steps empower stakeholders and build momentum for support. In the domain of communities USAID ETICA will continue to deliver training for CSOs in collaboration with the GF and the NTP. Distance learning provides an opportunity to strengthen ties and exchange experiences among CSOs that are scattered geographically throughout the country. It also provides an opportunity for the development of networks of peers or communities. The implementation of distance learning on TB will advance the education of local professionals on best practices, initiate projects to improve the quality of services, reduce the costs of travel to attend training, and reduce the time that specialists are away from the workplace due to training. USAID ETICA will support the active involvement of CSOs in addressing the challenges of access to quality TB diagnostics and treatment services by improving their advocacy skills. Leaders from CSOs and TB-affected communities will be trained on leadership skills, including advocacy activity skills. To do this, the project will develop training materials (modules and presentations on the topics of leadership, communication, rights of people affected by TB, advocacy, working with decision-makers). In the domain of services USAID ETICA will build on the success of previous USAID projects to reinforce the role of CSOs, community players, and providers in TB detection and service delivery. The project will identify gender and other barriers to accessing TB service. At the treatment level, USAID ETICA will coordinate with the government and facilities to ensure that PWTB receives an adequate regimen of quality-assured medications. In addition, USAID ETICA will revise or develop national clinical guidelines for DR-TB treatment and side effects management of individuals affected by TB, and will incorporate these guidelines into the project’s on-the-job supervision system USAID ETICA will focus on building the capacity of personnel; providing technical assistance to strengthen infrastructure and procurement mechanisms; and carrying out activities to improve the regulatory mechanism, such as updating/developing policy documents. Specifically, the project plans to improve laboratory and testing availability; ensure the quality of laboratory services using QMS; explore improvements to the LIMS; and ensure effective, sensitive, and people-centered screening and diagnostic services for people with TB symptoms and the contact persons of PWTB. USAID ETICA will support the update of diagnostic algorithms for different types of presumptive TB and monitor their implementation. The project will also build the capacity of laboratory specialists on WGS technologies. USAID ETICA will assist with the implementation of expanded DST, especially for new drugs such as BDQ, DLM, CLF and LZD and will support the procurement of pure substances for DST. Additionally, USAID ETICA will conduct a peripheral laboratory assessment focusing on sample transportation and logistics, TaT, and TTR to find solutions for the potential improvement of logistics. Furthermore, USAID ETICA will develop a plan for the distribution of GeneXpert machines in the country and provide technical assistance to implement the GeneXpert lab network optimization plan. Laboratory training for NTP experts on genome sequencing at reference laboratories in Germany will motivate and enable staff to operate genome sequencing machines and will elevate TB lab practices to the most advanced international levels. This will support better system performance for speed and quality outputs, resulting in enhanced bacteriological diagnostic and treatment coverage and increased
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 95
success rates for TB and MDR-TB. Trainings, information campaigns, and community advocacy are expected to benefit TB prevention by raising awareness about risk factors and lowering stigma to encourage voluntary diagnosis. In the domain of systems USAID ETICA will review and update the NLSP for the NRL and prepare the NTP for drafting and operationalizing plans for tackling LTBI issues. USAID ETICA will build on the country’s experience introducing BDQ and DLM and the shorter MDR-TB regimens to develop a new TB and DR-TB package of documents based on WHO guidelines (stipulated in NTP plans and needs). The package will include an implementation protocol, the algorithm for molecular diagnostics using LPA, and aDSM algorithm, a people-centered care checklist and a format for a people-centered care plan, treatment materials, and training for health care providers. In Y2, USAID ETICA plans to be part of the working group on the revision of treatment protocol for DR-TB forms following the latest WHO recommendations. The project will also build the capacity of TB system specialists by conducting training on the latest WHO recommendations related to DR-TB treatment and will support the implementation of a VST system in two selected sites. USAID ETICA will provide technical assistance for the development of LTBI guidelines under the latest WHO recommendations. USAID ETICA plans to support the NTP in the implementation of an operational study and implementation of the mSTR in two selected sites (with the provision of support for local specialists and support for VST). To ensure procurement and use of quality drugs, USAID ETICA will focus on three main areas: • Strengthening pharmaceutical management, especially the drug supply at all system levels, to ensure consistent access to the first- and second-line drugs of assured quality. • Adopting the GDF’s drug quantification method for state budget procurement to ensure drug procurement and supply at all levels and to avoid stock-outs (through participation in national TWG discussions and joint work based on needs). • Implementing an aDSM strategy at all levels for new drugs and regimen implementation. USAID ETICA participates in the preparation of the chapter on TB finance in the NSP and will support the implementation of selected tasks under that chapter to examine preparedness. USAID ETICA will also help the NTP review IT systems used in labs and hospitals for clinical data management; this will serve as a groundwork for a data management strategy to be subsequently developed together with counterparts. USAID ETICA has assessed existing health information systems to determine the appropriate system for integrating the information on TB services provided by CSOs. During Y2, the project will continue to address the NTP’s request to develop a tool/database for collecting information from CSOs about the services provided on TB referral, detection, and TB treatment support.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 96
5. GENDER ORIENTATION IN PROJECT
Gender analysis and gender-responsive programming are comparatively new to the field of TB. Yet, with TB among the leading causes of death globally, there is an increasingly urgent need to direct efforts and resources to understand how the risks and effects of TB are determined by sex and gender roles. Gender is a factor that drives people’s ability to access services and their care preferences, and has a profound impact on the risk of TB exposure, transmission, access to and delivery of TB services. From a gender perspective, both women and men in all of the CAR countries benefited from the Soviet Union’s focus on gender equality in education, health care, and employment. After independence, women and men have faced different pressures with the economic collapse and restructuring of the economic, political, and social sectors. Initial research throughout the whole former Soviet Union indicated that women suffered additional challenges as the social safety net was rapidly crumbling or being actively dismantled in many countries. Moreover, there are competing socio-political models of “womanhood” – the Soviet past, the new influence of Islam, the redefining of a historically-based national identity – all of which contain patriarchal elements. Thus, it also influenced the return and strengthening of national traditions and cultures that limit the role of women in society. The loss of status caused by unemployment and sinking earning potential drove some men into depression and unhealthy lifestyle activities, such as drinking, drug use, and risky and violent behavior. Many men across the region have sought employment outside their home countries. Women still carried the majority of the burden for household work, including responsibility for housework, children, and the needs of the elderly – resulting in the double burden.13 In communities and at the household level, social norms and patriarchal traditions may inhibit women’s decision-making power that may cause barriers to access health services. Within households, male heads of households, often make decisions about the allocation of resources, based on their priorities. Although access to healthcare is guaranteed equally for men and women by the constitution in all CAR countries, the influence of social determinants of health (limited access of women to various types of resources, decision-making processes, violence against women, etc.) is poorly taken into account in existing TB policies. Many of the official strategies and guidelines on TB are uninformed by any gender analysis, despite existing evidence of the impact of gender norms, roles and relations on health, and TB specifically. Gender-informed approaches in TB related communications are also largely missing. The results of the desk review of TB related policies in Tajikistan and Kazakhstan conducted in 2019 by GF TB REP grant, revealed that the existing TB policies do not consider the influence of social determinants of health, structural causes of inequality between women and men (limited access of women to various types of resources, decision-making processes, violence against women, etc.). This is largely due to either gaps in or lack of gender-sensitive statistics on a range of TB issues. One of the gender biases in the context of TB in Kazakhstan is the termination of pregnancy. Termination of pregnancy of women with pulmonary TB is regulated by the Order of the Minister of Health of the Republic of Kazakhstan dated October 30, 2009 No. 626 "On approval of the Rules for the artificial termination of pregnancy." According to this document, all active forms of TB are a medical indication for artificial termination of pregnancy.
13 USAID/CAR gender assessment, 2010
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 97
Women from key populations are most exposed to violence, including domestic violence. There are 28 crisis centers for victims of domestic violence in Kazakhstan. According to the study conducted by GF TB REP grant, if a woman with TB comes to the crisis center, she will not be accepted due to how the crisis centers interpret the Kazakhstan MOH order No. 107927 "On approval of the standard for the provision of special social services to victims of domestic violence" from October 2016. The list of indications for refusal of services in the order indicates TB in the active stage of the process14. This can be misinterpreted by people and cause refusal of services to a certain group of people. An analysis of scientific publications on TB problems in the region reveals weak gender mainstreaming in research, studies of various aspects of gender differences and characteristics that affect the risk of getting TB, the processes of identifying and treating TB cases in men and women, and access to TB services. As a result, general conclusions are drawn without taking into account gender differences. When developing interventions on TB issues, a gender-neutral approach is used, or they are guided by the fact that the majority of TB patients are men. The implications of the approaches with gender neutrality lead to gender equality and not equity in TB services. Ultimately, women’s needs and specific life situations are not considered to result in poorer outcomes compared to men. Designing such TB approaches and interventions work against solutions to the problems, which should be changed and conveyed to decision- makers. To address the gender-specific dimensions of TB, it is necessary to drive resources towards interventions. Future research and programming must address existing gaps and should specifically identify interventions that respond to the gender-specific needs and vulnerabilities of people affected by or at risk of TB.
5.1 PROJECT GENDER INTEGRATION STRATEGY USAID ETICA’s strategy is to support NTPs to implement a gender-responsive TB program that acknowledges different norms and roles for women and men; considers gender-specific needs; addresses the causes of gender-based health inequity; identifies ways to transform harmful gender norms, roles and relations that influence access to TB services; promotes gender equality; and includes strategies to foster equal access to TB services for women, men. The gender-sensitive approaches are nested in all project objectives, which will boost project deliverables (Exhibit 18).
14 “Assessment of legal environment, gender, stigma and human rights barriers for key populations in the TB response in Almaty city and Almaty region”, TB-REP 2.0 funded by the Global Fund to fight AIDS, Tuberculosis and Malaria, 2019.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 98
Exhibit 18. USAID ETICA’s Gender Integration Strategy
To address the gender-specific dimensions of TB, the USAID ETICA project focuses on three approaches: • Gender mainstreaming in TB policies • Promote a Gender-sensitive approach in TB programs • Strengthen gender-sensitive monitoring and evaluation (Table 6) Table 6. Gender Integration Strategy approaches Gender Revision of country-level TB guidelines, treatment protocols and national TB mainstreaming in TB strategies to integrate gender-sensitive approaches, address the needs and policies vulnerabilities of both men and women, girls and boys. Promote the gender- Development and implementation of interventions to promote gender equity sensitivity of TB in attendance and adherence, with gender-specific targets. To maximize the programs entry points to TB care for women at all levels, strategic partnerships and synergies would be fostered among TB, HIV, maternal and child health programs, and primary care services. The project will build the gender capacity of healthcare providers, and community health workers through occupational training materials. Strengthen gender- The project will support the collection of data that is disaggregated by sex sensitive monitoring and age for TB, including for TB case detection, treatment initiation, and evaluation adherence, and outcomes.
5.2 PROJECT ACHIEVEMENTS ON GENDER INTEGRATION Gender mainstreaming in TB policies
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 99
To promote gender mainstreaming in TB programs in CAR, the project contributed to the development of the NSPs for 2021 -2025 in Tajikistan, Kazakhstan and Uzbekistan and the development of the new GF grant proposals, where gender-sensitive and human rights-based approaches were integrated. Introducing special programs for young girls, including gender issues to the CSO training, conducting gender assessments are some examples of including gender sensitivity into the main country documents. To integrate gender and ensure understanding of the gendered issues, stigma and other social barriers that affect demand for, access to, and quality of TB care, the USAID ETICA project has finalized preparations for analyzing a) gender-related barriers to accessing and using TB information and services, and b) gender-related behavior increasing the risk of TB infection. The findings will be used to revise country-level TB guidelines, manuals, and other policy- level documents to enable equal access to services and information in all layers of the TB system. The results of the analysis will also directly inform gender- sensitive activities and ensure that interventions are gender-responsive with recognition of gender differences in barriers and opportunities. More importantly, the recommendations and opportunities revealed by the gender analysis will be conveyed to MOH and NTP to ensure the inclusion of gender- sensitive approaches in various documents of the TB system. During the reporting period, USAID ETICA developed a SOW to assess gender barriers, stigma, and other social barriers to detection, treatment, and prevention of TB in Kazakhstan, Tajikistan, and Uzbekistan. The assessment will be conducted in selected geographic areas of the countries by subcontracted research companies. The assessment methodology framework, data collection tools, and study protocols were developed by the research companies and will be submitted for Ethics Committee approval in all countries and to Abt’s IRB for approval. The completion of the gender assessment is delayed due to COVID-19 related travel restrictions. Therefore, the companies received tasks to conduct the desk review stage, while the field-level assessment was postponed until travel restrictions are lifted. Promote the gender-sensitivity of TB programs USAID ETICA developed a guideline for CSO engagement in TB case detection, care, and prevention using gender-differentiated approaches to improve detection rates and treatment outcomes among project key populations. The real stories and situations reported by the project partners served as a basis to elaborate on activities with consideration of gender equity, peculiarities and traditions of the countries related to a different attitude towards men and women. The guideline includes information on the risks of TB exposure among men and women, possible gender- associated barriers affecting access to TB services and examples of interventions on removing gender- associated barriers. The gender-differentiated approach is also integrated into the CSO model of TB case detection, care and prevention activities implemented by the USAID ETICA project. To strengthen the gender capacity of TB service providers, the project has developed a package of training materials for CSOs and health providers that includes information on the need for a gender- sensitive approach to TB prevention, diagnostic and treatment, and examples of gender- specific interventions and indicators. The materials have been approved by USAID. Training sessions were conducted for partner CSO organizations in Tajikistan and CSOs in Kazakhstan. Strengthen gender-sensitive monitoring and evaluation
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 100
Not all TB related data in CAR are disaggregated by gender and age. There is no access to gender- disaggregated statistical data on TB treatment outcomes and TB mortality. None of the USAID ETICA countries have a full range of available gender- disaggregated system of data collection and analysis. Since the Soviet era, the TB systems have had a gender- neutral focus in their strategies and operations and the registration, analysis and reporting of data cannot be otherwise organized. The project raised these issues with NTPs and provides support for the revision of existing M&E tools to promote better monitoring and evaluation of TB programs, ensuring that gender-related barriers are identified and addressed, that sex- and age disaggregated data on TB are collected and fully utilized to improve prevention and care, and that indicators are harmonized.
5.3 SUSTAINABILITY IN GENDER APPROACHES The USAID ETICA project uses a cross-cutting gender integration approach focusing on four main areas: support development/revision of existing legislative and strategic documents on TB with the inclusion of gender-sensitive and human rights approach; improve the gender sensitivity of TB programs; build human capacity on this issue; and strengthen gender-sensitive monitoring and evaluation. All of these areas have been elaborated and are implemented to ensure sustainability. To ensure a strategic approach and sustainability of gender integration in TB programs, the USAID ETICA project in Y2 plans to support NTPs to develop and implement the Gender Framework to guide a gender-responsive approach in TB care. The Gender Framework will stem from the results of the gender assessment.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 101
6. PERFORMANCE MONITORING
During this reporting period, USAID ETICA made preparations for three assessments that were planned and partially conducted - in Kazakhstan, Tajikistan, and Uzbekistan: 1. A baseline assessment 2. An assessment of stigma, gender and other social barriers to TB care 3. A capacity assessment of national counterparts The progress on each assessment is specified below.
BASELINE ASSESSMENT USAID ETICA’s baseline assessment consisted of several assessments combining baseline data and analysis of the status of TB detection and treatment and the enabling environment for TB care in the three countries. The USAID ETICA project studied various aspects of the TB program during the baseline assessment, such as policies and governance, the role of PHC facilities in diagnosis and care; sputum transportation system; social support for PWTB; TB screening system; infection control in hospitals and communities, and others. The findings from each above- listed sections provided a comprehensive picture for better planning of project activities and will be used to address sensitive issues related to TB treatment and prevention. The results of the assessments from all three countries will be combined and presented in the USAID ETICA baseline assessment report. The project collected much of the data and information needed for the assessments in the first and second quarters of 2020. In Kazakhstan and Uzbekistan, COVID-19 travel restrictions limited the project’s ability to collect the remainder of the data. USAID ETICA had to change its approach, limiting it to mostly desktop research and collection of anecdotal evidence through formal and informal phone or online interviews in Kazakhstan and Uzbekistan, while field visits were possible in Tajikistan to collect on-the-site data in addition to the desk research. USAID ETICA conducted a review of regulatory frameworks and other project activity reports including KNCV, HOPE, WHO and GF in all three countries. Additionally, the clinical guidelines and protocols in TB care as well as types of TB laboratory services offered to the population were collected for review and planning purposes. As a part of the baseline assessment, USAID ETICA staff reviewed the a) Uzbekistan Complex Plan for Measures to Prevent the Spread of Tuberculosis and Non-specific Lung Diseases in 2019 – 2021, and c) Tajikistan National Program on Protecting Population from TB for the period of 2021-2025. USAID ETICA conducted a baseline assessment in two stages. During the first stage, the project team conducted a desk review of the strategic and previous USAID projects’ documents (USAID TB CARE I and USAID Challenge TB projects’ reports; NSPs (TB, WHO Joint Annual Review); NTP data; WHO NTP reviews) and held discussions with key stakeholders. A report with the results of the assessment was prepared and submitted to USAID. During the second stage, the project conducted a "deep dive" assessment of barriers, challenges, and opportunities to inform evidence-based long-term implementation activities. Assessment activities included reviews of protocols, guidelines, policies; laboratory and health facility assessments; health information system reviews; SBC assessment of common misconceptions and sources of misinformation.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 102
It also entailed a field- level data collection in Tajikistan. USAID ETICA presented the results in a descriptive part of the report that included six types of assessment tools on TB financing, laboratory, TB diagnosis and treatment, TB-IC and CSOs.
ASSESSMENT OF STIGMA, GENDER, AND OTHER SOCIAL BARRIERS TO TB DETECTION AND TREATMENT During the reporting period, USAID ETICA developed a SOW for an assessment of gender barriers, stigma, and other social barriers to detection, treatment, and prevention of TB in the three countries. The assessment will be conducted in selected geographic areas by a research organization, which USAID ETICA will select through a competitive process. The specific objectives of the assessment are: • To provide benchmark information on the USAID gender strategic indicator for future comparison. • To assess how gender affects vulnerability to TB infection and impacts access to TB services, including early detection, timely treatment initiation, adherence to treatment and treatment outcomes. • To assess how gender and other social determinants affect the TB epidemic. • To assess in which settings and stages of care TB stigma are being experienced by TB patients and their families (or TB affected populations) and its manifestations. • To assess the catastrophic costs related to TB treatment. • To develop recommendations for project staff on gender-oriented, communication, and behavior change activities.
6.2 MONITORING, EVALUATION, AND LEARNING PLAN USAID ETICA developed the AMELP and submitted it for approval to USAID in the first quarter. It is a living document, which USAID ETICA will review annually and propose changes to USAID when necessary. The AMELP is a guide and essential management tool for implementing the USAID ETICA project. Its purpose is to: 1) provide a framework to measure impact; 2) provide data for continual improvement of activity effectiveness; 3) facilitate adaptive learning; and 4) support USAID internal reporting needs. The AMELP includes a description of the project’s approach to collecting, analyzing, reporting, and using data, as well as a list of performance indicators that the USAID ETICA team will track to measure progress against activity objectives. The USAID ETICA project technical team has identified specific indicators that reflect the project’s priority strategic objectives; we will use these indicators to measure both the ongoing and ultimate results of project activities. The AMELP also reflects appropriate US Government standard indicators. The AMELP also includes Performance Indicator Reference Sheets (PIRS) for each indicator and the PITT. The PIRS includes the indicator definitions, information on disaggregation, data sources, responsible entities for data collection, data collection methods, units of measurement, data collection frequency, when baseline information will be collected, and annual targets. The PITT provides information about baseline data, annual targets, and actual achievements. These are the basis for documenting progress during implementation and will be used to record progress against each indicator at the end of each quarter and year. Due to COVID-19 quarantine measures in project countries, many
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 103
of the planned activities were shifted to the second year, which affected the performance of some indicators in the countries. Thus, during the planning process for the second year, the targets for some indicators for the following years were revised. The changes will be documented in the adjusted AMELP and each change in indicators will be justified and indicated in PITT. All USAID ETICA implementing partners: ILMred, PATH, AFEW Kazakhstan, AFIF Tajikistan and NRCST contributed to the development of the AMELP and provided all requested information.
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 104
USAID ETICA: YEAR 1 ANNUAL REPORT: OCTOBER 2019 – SEPTEMBER 2020 | 105