> ![](media/image1.png){width="1.5840277777777778in"
> height="1.4465277777777779in"}
>
> **Tuberculosis Coalition for**
>
> **Technical Assistance**
>
> **Mid-Term Evaluation**
>
> **April 2004**
>
> **Evaluation Team**
>
> **Einar Heldal, M.D., Tuberculosis Specialist**
>
> **John Pielemeier, M.S., Team Leader**
>
> **Ronald Wilson, M.D., M.P.H., D.T.M.H., Public Health Specialist**

##  {#section .unnumbered}

# Contents

[Acknowledgments v](#acknowledgments)

[Acronyms and Abbreviations vii](#acronyms-and-abbreviations)

[Executive Summary ix](#executive-summary)

[I. Introduction 1](#__RefHeading___Toc70485865)

[I.A. Background 1](#i.a.-background)

[I.B. Objectives of the Evaluation
10](#i.b.-objectives-of-the-evaluation)

[I.C. Methodology 10](#i.c.-methodology)

[II. Program Goal and Progress to Date
13](#ii.-program-goal-and-progress-to-date)

[II.A. Program Goal, Objectives, and Indicators
13](#ii.a.-program-goal-objectives-and-indicators)

[II.B. Progress 15](#ii.b.-progress)

[II.C. Appropriateness of TBCTA Indicators
22](#ii.c.-appropriateness-of-tbcta-indicators)

[III. Programmatic Objectives: Progress and Issues
25](#iii.-programmatic-objectives-progress-and-issues)

[III.A. Capacity Building and Technical Objectives
25](#iii.a.-capacity-building-and-technical-objectives)

[III.B. Integration and Collaboration Objectives
39](#iii.b.-integration-and-collaboration-objectives)

[IV. Program Administration and Management
57](#iv.-program-administration-and-management)

[IV.A. TBCTA Management 57](#iv.a.-tbcta-management)

[IV.B. Financial Management 64](#iv.b.-financial-management)

[IV.C. Reporting 69](#iv.c.-reporting)

[IV.D. USAID Management 70](#iv.d.-usaid-management)

[IV.E. Conclusions 75](#iv.e.-conclusions)

[V. Recommendations 77](#v.-recommendations)

[V.A. Recommendations for the Remainder of the Grant Period
77](#v.a.-recommendations-for-the-remainder-of-the-grant-period)

[V.B. Key Recommendations Beyond the Grant Period
79](#v.b.-key-recommendations-beyond-the-grant-period)

Annexes

[Annex A: List of Contacts A-1](#annex-a-list-of-contacts)

[Annex B: Documents Reviewed B-1](#annex-b-documents-reviewed)

[Annex C: Financial Tables C-1](#annex-c-financial-tables)

[Annex D: Training Courses Implemented Wholly or Partially Funded by
TBCTA
D-1](#annex-d-training-courses-implemented-wholly-or-partially-funded-by-tbcta)

[Annex E: Scope of Work E-1](#annex-e-scope-of-work)

[Annex F: Questionnaire for USAID Missions
F-1](#annex-f-questionnaire-for-usaid-missions)

[Annex G: Questionnaire for National TB Program Managers
G-1](#annex-g-questionnaire-for-national-tb-program-managers)

## Acknowledgments

The evaluation team thanks the TBCTA partner organizations and USAID
officials for their frank and open dialogue in helping the team better
understand the difficulties, as well as the successes, of the TBCTA
program. We offer special thanks to TBCTA partners' (KNCV, the UNION,
and WHO) staff, and to the USAID Mission staff in Brazil, D.R. Congo,
and Indonesia, who hosted the evaluation team. They all provided special
courtesies and professional support, which made the team's work (and our
extensive travel schedule) easier and much more efficient.

In addition, the team thanks the national TB program managers and their
staffs, provincial and district health officials and clinical staff
members, and personnel of the collaborating NGOs, all of whom provided
the team with valuable advice and guidance on how the terrible disease
of tuberculosis can best be addressed in their respective countries.

Finally, the team thanks the staff of The Synergy Project, who also ably
supported our work over the past several months.

#  {#section-1 .unnumbered}

#  {#section-2 .unnumbered}

# Acronyms and Abbreviations

AIDS acquired immunodeficiency syndrome

ALA American Lung Association

ATS American Thoracic Society

BCC behavior change communication

CDC Centers for Disease Control and Prevention

CIDA Canadian International Development Agency

CTO cognizant technical officer

DOTS directly observed therapy--short course

GDF Global Drug Facility

GLC Green Light Committee

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria

GPSTB Global Plan to Stop TB

HIV human immunodeficiency virus

IEC information, education, communication

ISAC Intensified Support Action Countries

KNCV Royal Netherlands Tuberculosis Foundation

NGO nongovernmental organization

NTP national TB program

PAHO Pan American Health Organization

PMU Project Management Unit

RPM+ Rational Pharmaceutical Management Plus Project

SINAN Brazilian Notification System for Infectious Diseases

STAG Strategic and Technical Advisory Group

TASC Technical Assistance and Support Activity

TB tuberculosis

TBCTA Tuberculosis Coalition for Technical Assistance

TFT Task Force for Training

USAID United States Agency for International Development

WHO World Health Organization

# Executive Summary

## I. Overview

The Tuberculosis Coalition for Technical Assistance (TBCTA) is widely
recognized by major Stop TB Alliance partners as having provided unique,
high-quality technical assistance on tuberculosis (TB) with worldwide
scope. As such, it was an excellent choice to serve as an initial
collaborator for USAID's entry into the TB arena, linking USAID with
experienced and well-respected international expertise that is generally
not available in U.S. institutions. The new TBCTA for the first time
brought the key international TB organizations together into an
operational, program-focused structure. TBCTA is now recognized as an
innovative partnership that speaks with a single voice on major TB
issues in countries where USAID works. The coalition has successfully
collaborated to address international and national issues that have
limited the expansion of DOTS[^1] and has demonstrated that it is much
more than the sum of its individual partner institutions. USAID health
officers value this coordinated approach to TB, and it has been
suggested as a model for other health programs (e.g., HIV/AIDS,
malaria).

## II. Program Results: Accelerating DOTS

Despite only about two years of project implementation in most field
locations, the TBCTA is largely responsible for some significant
improvements in program indicators (such as treatment success rate, case
detection rate, and coverage), especially where substantial resources
are dedicated to target provinces and districts. Continued efforts are
likely to result in improvements in national TB program indicators in
several countries. In countries where TBCTA has moved into an
operational phase, program achievements are significant when measured
against intermediate indicators (e.g., presence of a strategic plan, a
drug-resistance survey, etc.). Program objectives can be fully met only
if the cooperative agreement is extended to allow a full five years of
activity.

TBCTA has generally done well in programming core funds to carry out
initial "advocacy" visits, to expand the quantity and quality of
international and regional training courses and training materials, and
to significantly increase participation by TB leaders from developing
countries in these courses. These courses are in high demand and will
continue to be the primary courses for training TB leaders in a growing
number of developing countries as global TB control efforts expand. Core
funds are being used to bring additional and innovative support to the
TB effort (e.g., a network of nurses and allied professionals, a new
course for TB managers, a new course on planning for human resources in
TB, and efforts to mobilize nongovernmental organizations (NGOs)). Core
funding at the present level of \$3 million per year is being well used.

The results of TBCTA support for in-country programs have been mixed
thus far. Initial advocacy visits to 15 countries were successful in
stimulating USAID Mission interest and knowledge about DOTS, and linking
Missions to national TB programs. However, USAID Mission requests for
the TBCTA support often have been significantly more complex than the
scope anticipated in the TBCTA's grant proposal (including commodity
procurement, local staff, and program operational costs, in addition to
the expected technical assistance, training, coordination, and
operational research). TBCTA has had considerable difficulty in
responding to broader Mission requests. Success stories include
Indonesia, the Dominican Republic, and the Democratic Republic of the
Congo (D.R. Congo), whereas TBCTA programs have been disappointing in
Brazil, Cambodia, and El Salvador. Program strengths include the
following: (1) there has been excellent support for strategic planning
and coordination; (2) the quality of technical assistance has been very
high; (3) training has been appropriate and effective; and (4)
institutional strengthening has been approached in a measured, step-wise
fashion.

Major weaknesses include the following: (1) insufficient in-country
management capacity, (2) delays in responding to some requests for
technical assistance, (3) slow procurement of commodities, and (4)
difficulties in moving funds to the field. In almost all countries,
USAID Missions report they are increasingly satisfied with TBCTA
performance and hope to continue working with TBCTA. Nevertheless, it is
not yet clear whether TBCTA will be able to accelerate its actions to
meet USAID Mission requests during the remainder of the grant period.

## III. Program Objectives: Capacity Building and Technical Objectives

### III.A. Meet global demands for technical assistance

The TBCTA partners have traditionally provided senior technical
assistance in the form of semiannual country program reviews. This
methodology remains valid, but it is insufficient. Additional short-term
and in-country long-term technical assistance, along with a more agile
approach, is needed to meet the increased demands associated with
accelerating DOTS, the presence of large grants from the Global Fund to
Fight AIDS, Tuberculosis and Malaria (the Global Fund), and links to the
President's Emergency Plan for AIDS Relief and the WHO 3×5 Initiative.
Newer models of providing technical assistance (traditional to USAID,
but new to most TBCTA partners) have gradually been established by
TBCTA, but often with significant delays.

### III.B. Expand technical assistance capacity

There are too few high-level international TB consultants available to
perform the work that needs to be done, although TBCTA has successfully
expanded its consultant base. TBCTA programs to train junior consultants
and domestic TB specialists for international responsibilities are just
gaining momentum and should be carefully evaluated prior to expansion.
An untapped pool of experienced personnel (such as ex-national TB
program managers) is increasingly available for TBCTA use.

### III.C. Develop institutional and technical capacity for TB control in target countries

*Trained TB program cadre.* More and better training for key TB staff
from target countries has been a major focus of TBCTA activities. TBCTA
funds for international and regional training courses have improved
course planning and greatly increased participation in existing courses
from countries where USAID TB support has been initiated. Gaps in
training have been identified, and new courses have been developed and
executed for TB human resource managers and for TB program managers. To
meet country-level training needs, a well-conceived approach has been
adopted that includes national or sub-national training plans, training
programs for master-trainers, development of course materials, and
follow-up supervision. This model, most fully applied in Indonesia and
South Africa, was evaluated in March 2004.

*Laboratory improvements.* Laboratory services are often a weak link in
TB control programs. TBCTA has done excellent work in providing
technical assistance, training, equipment, and supplies to strengthen
laboratory networks and the use of quality control measures for smear
microscopy. Further strengthening of microscopy networks is needed in
most countries. Technical assistance, training, and equipment provided
for reference laboratories will help ensure sufficient proficiency for
participation in national drug-resistance surveys in Brazil, D.R. Congo,
Indonesia, and a few other countries by 2004--2005. Further assistance
is needed in other countries.

*Supervision, monitoring, and information systems.* The quality of
supervision and the completeness and accuracy of TB data are weak in
many countries. In several countries, TBCTA has effectively supported
the provision of training, monitoring tools and methods, vehicles and
bicycles---and, in some cases, additional staff---so that supervisory
visits to regional, district, and other service facilities are regularly
conducted by trained supervisors.

*Program sustainability.* TBCTA's careful, step-wise approach is
appropriate and cost-effective to expand DOTS coverage while avoiding
multi-drug resistance associated with poorly administered treatment. The
major constraint to program sustainability is that host-country
financing is not adequate to continue donor field-supported programs at
their present levels (especially supervisory staff, supplies, per diem,
and operational costs). TBCTA has done little to develop advocacy tools
or to carry out training to encourage the greater level of funding
needed to sustain TB programs.

## IV. Program Objectives: Collaboration, Coordination, and Integration Objectives

*Promote collaboration and cooperation with international TB programs.*
The TBCTA has been effective in linking its actions in an almost ideal
fashion to the major international TB programs (the Stop TB Partnership
and its Global Plan to Stop TB \[GPSTB\], the Global Fund, the Global
Drug Facility \[GDF\], and the Green Light Committee \[GLC\]). TBCTA
semiannual visits and field activities provide valuable information to
key coalition partners who then use this information in the
decision-making processes of the Stop TB Coordinating Board, the Global
Fund, the GDF, and the GLC.

*Establish linkages between TB and HIV/AIDS programs.* This grant
agreement objective was vaguely defined and there has been no focus of
responsibility for it within the TBCTA structure. Some tension between
TB and HIV/AIDS programs exists at national and global levels because of
the greater size and influence of HIV/AIDS programs; most TB leaders
believe that efforts to develop such linkages must be initiated or
financed by HIV/AIDS programs. The team found little evidence of
significant coordination between TB and HIV/AIDS programs at the
service-delivery level; however, such initiatives are underway in Malawi
and are planned in Mozambique, Nigeria, Senegal, and South Africa. The
increased use of antiretroviral drugs makes coordination even more
urgent. Opportunities exist for a stronger TBCTA role, since WHO and the
Centers for Disease Control and Prevention (CDC) would now like to do
more to strengthen coordination between TB and HIV/AIDS programs, while
the International UNION Against Tuberculosis and Lung Disease (the
UNION) has a new USAID grant to carry out TB-HIV/AIDS clinical and
operations research. Most of these efforts would be supplements to
existing in-country TBCTA programs and would use existing WHO, CDC, and
UNION expertise.

*Strengthen linkages between TB control programs and multi-drug
resistant TB efforts.* TBCTA rightly decided to focus its efforts on the
prevention of multi-drug resistant TB by establishing effective DOTS
programs. As more countries have established DOTS programs, several have
been approved by the GLC for multi-drug resistant TB treatment or are in
the process of obtaining GLC approval, often funded by the Global Fund.
In many cases, TBCTA personnel have facilitated planning for multi-drug
resistant TB treatment activities to be integrated within national TB
programs. Brazil presents a special case that needs gentle TBCTA
advocacy to encourage fuller adherence to international standards.

*Integrate TB control efforts within primary health care services more
effectively.* TB diagnosis and treatment are generally located in
general health facilities and are therefore integrated into a
government's overall health system. In countries without a
well-developed primary health care network, nongovernmental
organizations and mission health services can play useful roles in
behavior change communication, and TB case detection at the community
and primary health care levels. Generally, TBCTA has worked with the
existing national structures and has not promoted structural changes.
Most of the recent country-level demand has been for guidance on how to
best use community health workers and volunteers in support of TB
control efforts; however, there is no current focus of responsibility
within the TBCTA structure for responding to these demands or for
promoting this broader objective.

*Engage private practitioners and hospitals in TB control programs.* In
countries with a strong private medical health care system, the
integration of private hospitals and medical practitioners into TB
control programs is crucially important. Many patients with TB are
diagnosed and treated in the private sector, but these cases are not
reported, and their treatments are not directly observed. A high
proportion of cases default and represent a significant risk for the
creation of multi-drug resistant TB. Advocacy to encourage adherence to
DOTS is urgently needed with local and national medical societies,
postgraduate medical schools, and senior health and other government
leaders. TBCTA has fostered a successful model with training courses for
private practitioners in private hospitals, outpatient clinics, private
practices, and universities. TBCTA could usefully utilize and expand on
guidelines established by the public-private mix subgroup of the DOTS
expansion working group and stimulate other approaches to increase
private-sector engagement.

*Promote collaboration and cooperation with other USAID-funded agencies
and stakeholders.* In most TBCTA countries, a high level of
collaboration and cooperation exists between TBCTA and other
USAID-funded cooperative agencies, stakeholders, and organizations
working in the field of TB. However, the team found two situations, both
in Brazil, where TBCTA collaboration and cooperation were not as
effective as they should be.

## V. Administration and Management

*TBCTA management.* The new TBCTA internal structure had major teething
problems, but has functioned surprisingly well for such an eclectic
coalition. Some problems (i.e., transferring funds through the WHO/Pan
American Health Organization structure) have taken time to resolve.

TBCTA is still learning USAID procedures and USAID expectations, and is
not as effective in communications and reporting as more experienced
USAID grantees. TBCTA management of core funds is reasonably good, but
efficient management of USAID Mission funds has been significantly below
Mission expectations. The Project Management Unit has not been
sufficiently rigorous in monitoring the responsibilities of the partners
and has done little to establish an effective monitoring and evaluation
system. The evaluation team identified several areas where steps to
improve TBCTA internal efficiency are quickly needed, and where program
and financial reporting need to be improved.

*USAID management.* Initially, USAID management of this grant was
inadequate (by the Global Health Bureau) to foresee and resolve serious
grant management issues, and inept (by the Office of Procurement). For
both offices, supervision was not sufficient or adequate to avoid or to
address these problems in a timely fashion. USAID's procurement office
has been slow to respond in resolving administrative problems, despite
an effective cognizant technical officer. On the other hand, USAID
technical management of the program has been consistently strong, and
USAID has suggested and supported positive and innovative initiatives.

## VI. Recommendations for the Remainder of the Grant Period

### VI.A. Primary programmatic recommendations

1\. After a thorough internal program review and pipeline analysis,
TBCTA should request a grant extension of at least one year to make up
for the first "lost" year of program operations and to allow more
complete achievement of program objectives. A USAID response needs to be
provided quickly, but no later than June 2004.

2\. TBCTA and USAID should determine what additional field support funds
can be reasonably accepted into the program, given the existing
pipelines and the present (or extended) grant period. USAID Missions
should be advised as soon as possible to facilitate final Fiscal Year
2004 decisions on the use of field support funds.

3\. TBCTA country work plans should not require annual USAID/Washington
approval if they are based on approved medium-term development plans and
if adequate funding is available. USAID Mission approval should be
sufficient under these circumstances.

4\. TBCTA should be proactive in identifying good models and locales for
TB and HIV cross-referral and coordinated treatment related to the
President's Emergency Plan for AIDS Relief and the WHO 3×5 Initiative.
The TBCTA Project Management Unit has an excellent opportunity to play a
more assertive leadership role by giving this objective a higher
priority and facilitating a process involving WHO, CDC, and the UNION
during the remainder of the grant period. The TBCTA should indicate a
focal point for TB-HIV activities.

5\. The Advocacy Task Force should quickly address identified needs
(Brazil for adherence to DOTS and multi-drug resistant TB; Indonesia for
private sector involvement and budget increases).

6\. TBCTA-funded technical support that might be provided in concert
with the recent Intensified Support and Action Countries Initiative
should be carefully designed to avoid undercutting low-paid national TB
program staff, and to ensure sustainable improvements.

7\. TBCTA and USAID should review the lengthy process and many steps
between work plan preparation and funding allocations to country
programs with the objective of reducing the lengthy time taken to date
(e.g., all key parties could meet to simultaneously discuss and approve
a new work plan, such as occurs in Brazil).

8\. Consultants' half-yearly reports could be more related to the
objectives of the national TB programs. The technical assistance could
also further stimulate routine reporting by the national programs to the
upper levels of the Ministry of Health, with copies made available to
donors, which would cover some parts of consultants' travel reports.

9\. Given the increasing concern of global multi-drug resistant TB,
TBCTA should raise the issue of direct supervision and seek
modifications to reduce the risk of producing multi-drug resistant TB.

10\. The program to train junior consultants should be carefully
evaluated before being expanded. The increasing number of experienced
personnel in national TB programs should be considered as candidates to
receive further training. They then could perform part-time
consultancies besides working at the central level in their own national
programs.

11\. Operational research should have as its main focus to build up
research capacity in the country, as much as possible within and
involving the national TB program.

### 

### VI.B. Implementation, monitoring, and reporting recommendations

12\. The Project Management Unit needs to play a more assertive role in
ensuring timely implementation by all partners. This should include
administrative monitoring visits where TBCTA programs include
significant provincial-and district-level activities.

13\. TBCTA program reports should focus on results rather than on
activities. More in-depth country annexes should be provided directly to
participating USAID Missions to meet their monitoring and reporting
needs. TBCTA should strengthen its practically nonexistent monitoring
and evaluation system, and should quickly finalize process indicators to
help measure project progress.

14\. Financial reports would be much more useful if they were more
timely and were expanded to include accrued expenditures and expected
expenditures for the next reporting period.

15\. The Project Management Unit should gather "lessons learned" and
models of program success, and disseminate them through various means
throughout its program network, to USAID, and to other key TB entities.

16\. To ensure effective coordination, USAID Missions should organize
periodic meetings of all its TB-funded implementing agencies; in some
cases, these meetings should include USAID's key HIV-funded implementing
agencies.

## VII. Key Recommendations Beyond the Grant Period

*USAID role.* USAID has now entered the TB arena and, with core and
field support funds, has begun to finance programs and activities that
are widely respected, as they fill important gaps, provide added value,
and add a major stimulus to the Stop TB initiative. USAID should
continue to be a major bilateral TB program donor, probably through the
Millennium Goal period (2015).

*Constraints to DOTS expansion---Core-funded activities.* There will
continue to be a strong demand for the primary core-funded activities
financed via TBCTA to provide essential, complementary support to
expanding field programs funded via the Global Fund, USAID, Canadian
International Development Agency, and TB-HIV initiatives. Significant
constraints to DOTS expansion are addressed through activities that
include program coordination, (especially linkages to the Global Fund,
GDF, and GLC) international and regional training programs to greatly
expand the TB capability in least-developed countries for program
leadership, planning, research and management, operational research,
preparation of advocacy tools, stimulation of private sector involvement
with and adherence to DOTS, and encouragement of appropriate social
mobilization models. Increased attention should be placed on developing
effective TB-HIV program coordination, multi-drug resistant TB, private
sector involvement, and social mobilization.

*Constraints to DOTS expansion---Mission-funded activities.* In
countries with at least moderately strong public health systems (i.e.,
those in South and Southeast Asia, Latin America, and the Caribbean),
the constraints to the expansion of DOTS can be addressed in five to
eight years with a national and provincial program that is similar to
the TBCTA program in Indonesia. This package of USAID-funded assistance
can be implemented at the national level and in a few provinces. The
"capital" that needs to be invested typically includes strategic
planning, improved data collection systems as key elements of a
monitoring and evaluation program, an upgraded laboratory network, a
well-organized and funded domestic in-service training program, and
finally, increased human resources, mobility, and funding for improved
supervision. Additional elements of the program should include working
with the private sector providers of TB services, coordination with HIV
programs, and advocacy to increase host country funding. The model, once
it is recognized as effective by the host country, can be used for
Global Fund and other donor-assisted provincial TB programs, as in
Indonesia.

In countries with weak public health systems (i.e., Haiti and most
African nations), the constraints to DOTS expansion are more
intractable, and will require a longer time frame (at least through
2015), greater numbers of consultants to provide long-term technical
assistance, and significant donor support for local cost financing. In
some countries, "capital" investment for DOTS will need to flow to
faith-based health service systems, other NGOs, and via broad,
donor-funded rural health initiatives (e.g., SANRU in D.R. Congo), as
well as through the public health system. Experience in several African
countries demonstrates that a strong TB program can be mounted and can
be effective despite the serious systemic constraints that these
countries face. In most of these countries, a stronger link to HIV
activities will be appropriate. A key issue is the gradual assumption of
local cost responsibility for TB programs by the host government, which
probably should be addressed as part of sector-wide health reform/health
financing improvement efforts by the donors.

*Country selection.* TBCTA presently works in eight of the 22
high-burden TB countries, in addition to six other countries. USAID TB
programs are present in some form in eight others. At present only three
high-burden countries with USAID Missions do not have some USAID-funded
TB activity. Although the TBCTA partners have limited capacity, they
already have worked in many of these non-TBCTA countries without USAID
funding, often performing semiannual planning or monitoring visits.
Unless TB earmarks are increased, USAID will probably need to select
only a few additional countries where it can provide a substantial level
of resource to have a significant impact, or where relatively modest
USAID funding can leverage and provide support to a major Global Fund
grant.

*TBCTA is a unique structure that is widely recognized as a positive
model for international collaboration.* Almost without argument, it
includes the most experienced and respected expertise in international
TB that is available to USAID or any other donor. It would be difficult
for USAID to find a major TB collaborating institution to carry out
core-funded activities, international coordination, and strategic
planning/monitoring for national TB programs at the present level of
success.

TBCTA has been stretched to provide the wide variety of country-level
program support that USAID Missions have requested. Managing major
provincial-level or state-level programs and large commodity
procurements has been particularly labor-intensive. These efforts, which
are not elements of TBCTA's comparative advantage, have required a great
deal of TBCTA management time. In the future, one of two models of
field-level support might be considered:

1.  Core plus limited field support: An agreement with a centrally
    funded entity with a statement of work that includes core-funded
    activities and allows buy-ins of field-level support to countries
    where the entity has been traditionally involved in program
    operations or where USAID plans to make major investments in TB. To
    increase on-the-ground program management capacity, the centrally
    funded entity might be encouraged to establish sub-grantee
    relationships with one to two experienced USAID grantees or
    contractors, or with strong, local non-TB NGOs, or both. These
    sub-grantees would establish national offices or use existing
    national offices, and would have primary management responsibility
    (but not technical) responsibility for field-level support where
    major provincial support is envisaged. Missions would use TASC II
    contractors or bilateral health program contractors or grantees for
    their other TB needs, especially those at the provincial and
    district levels.

2.  Core only: An agreement with a centrally funded entity with a
    statement of work that is similar to the original TBCTA proposal.
    This would include continuation of TBCTA core-funded activities and
    would include the following services for USAID Missions: "advocacy
    visits"; semiannual senior-consultant national TB program
    evaluations; training at international and regional courses for
    selected host country TB personnel; short-term technical assistance
    for program design, evaluation or redesign; and short-term technical
    assistance for problem resolution.

Under this model, the centrally funded entity would not provide the
following services to USAID Missions: commodity procurement, in-country
training, and in-country provision of local costs for provincial and
district supervision and operations. USAID Missions would be encouraged
to use TASC II contractors or bilateral health program contractors for
all of the services mentioned in the previous paragraph.

USAID management of a future program needs to recognize the
international nature of the DOTS expansion effort, as well as its
urgency. As has occurred in the case of HIV/AIDS programs, some
traditional USAID regulations should be relaxed or waived. In a few
transition countries, such as D.R. Congo, an exception to USAID's
prohibition of salary enhancements should be
considered.[]{#__RefHeading___Toc70485865 .anchor}

# I. Introduction

## I.A. Background

Globally, tuberculosis (TB) is a problem of enormous and growing
dimensions. In 2000, it was estimated that about eight million new cases
of TB occurred worldwide, resulting in two million deaths. TB kills more
people than any other single infectious agent except the human
immunodeficiency virus (HIV). Ninety-five percent of all TB cases and 98
percent of TB deaths occur in developing countries.

TB has a major impact on the economic development of countries with a
high incidence of the disease. In developing countries, three to four
months' of family income or up to 20 percent to 30 percent of annual
household income can be lost to TB. The potential cost to a nation in
lost productivity from TB is estimated to be between 4 percent and 7
percent of GDP. Not only does TB currently exact a heavy toll in human
suffering and economic losses, it is increasing every year. A major
contributing factor to the incidence of TB is infection with HIV. Today,
about 15 million people have dual infections with *Mycobacterium
tuberculosis* and HIV. In many African countries, where TB is often
perceived as being synonymous with the acquired immune deficiency
syndrome (AIDS), more than one-half of all patients with TB also have
HIV infection. In some countries, the HIV epidemic has led to a tripling
or even a quadrupling of the incidence of TB during the past ten years.
Many patients with AIDS die from TB.

### I.A.1. International strategy for tuberculosis control

Global TB control is possible through a well-established strategy known
as DOTS.[^2] Worldwide, 180 countries have now adapted the DOTS strategy
recommended by the World Health Organization (WHO) and the International
UNION Against Tuberculosis and Lung Disease.[^3] It is one of the most
cost-effective health interventions and is rigorously promoted around
the world.

Implementation of DOTS requires a strong primary health care system that
ensures sustained access for patients with TB to diagnosis, treatment,
and follow-up services. Important elements of such a system include a
network of capable laboratories, a recording and reporting system, and a
logistics system that ensures a secure supply of drugs. Political
commitment to fund and implement effective national TB control programs
is essential to promote global TB control and to avoid the consequences
of failure. In addition, implementation of DOTS requires improved access
to primary care services that are affordable, equitable, committed, and
well organized. Education and training are essential elements to ensure
the availability of human resources.

In the context of poorly-managed programs with inadequate screening and
diagnostic and treatment facilities, insufficiently trained and
overextended staff, significant rates of incomplete treatment, and
frequent shortages of drugs, there is considerable risk that poorly run
TB control programs can lead to the emergence of more widespread
multi-drug resistance. The cost of the drugs for a full program of
first-line TB treatment is approximately \$10--\$20. The cost of drugs
for second-line, multi-drug resistant TB treatment is approximately
\$4,000 through the Green Light Committee (GLC), but the cost is much
higher in the open market. Thus, TB programs must be carried out
carefully and with strong quality control. A poor TB program is worse
than no TB program.

The global targets[^4] are to reach 85 percent treatment success and 70
percent case detection of smear-positive TB cases by 2005, with special
focus on the 22 high-burden TB countries in order to reach the goal.

## 1.A.2. USAID's commitment to tuberculosis control

USAID's goal is to contribute to the global reduction of morbidity and
mortality associated with TB. In order to achieve this goal, USAID's
objective is to enhance the capacity of developing and transitional
countries to prevent and cure TB to achieve global targets of 70 percent
case detection and 85 percent treatment success rates for smear-positive
TB cases. Specifically, USAID provides financial and technical support
to:

-   Expand and strengthen DOTS programs

-   Increase and strengthen human resource capacity

-   Develop and disseminate new tools and approaches

-   Adapt DOTS to address special challenges

USAID is the largest bilateral donor, supporting global TB prevention
and control in 34 countries. Support for TB control and DOTS increased
from \$8 million in 1998 to \$75 million in 2003. USAID's TB effort is
concentrated in a limited number of countries (Table 1) in order to
focus financial resources, technical assistance from USAID/Washington
and its partners, and staffing. Priority countries (or sub-regions of
these countries) were selected on the basis of one or more of the
following criteria:

-   High incidence of TB (estimated incidence rates of greater than 100
    per 100,000 people), high number of total TB cases, or both

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-   HIV/AIDS burden

-   Risk of an escalating epidemic of multi-drug resistant TB

-   Government commitment and technical and managerial capacity

-   Capacity of USAID and other key TB partners

-   Foreign policy considerations

Table 1. Countries with Endemic Tuberculosis and USAID Assistance Levels

+-------+-----------------------------------------+--------+----------+
| **    | **Countries**[^5]                       | USAID  | USAID/W  |
| Categ |                                         | F      | TA       |
| ory** |                                         | unding | Priority |
+-------+-----------------------------------------+--------+----------+
| Tier  | Bangladesh, Brazil, Cambodia, D.R.      | Higher | Higher   |
| 1     | Congo, Dominican Republic, Ethiopia,    |        |          |
|       | Haiti, India, Indonesia, Kenya, Mexico, |        |          |
| \     | Nigeria, Pakistan, Philippines, Russia, |        |          |
| (17\) | South Africa, Uganda                    |        |          |
+-------+-----------------------------------------+--------+----------+
| Tier  | Armenia, Bolivia, El Salvador, Egypt,   | Lower  | Lower    |
| 2     | Georgia, Honduras, Kazakhstan,          |        |          |
|       | Kyrgyzstan, Malawi, Moldova, Nigeria,   |        |          |
| \     | Peru, Romania, Senegal, Tajikistan,     |        |          |
| (18\) | Turkmenistan, Ukraine, Uzbekistan, ANE  |        |          |
|       | Regional,[^6] E&E Regional[^7]          |        |          |
+-------+-----------------------------------------+--------+----------+

### I.A.3. USAID partners

USAID works with a wide array of partners, including health ministries,
national TB programs, local institutions at the national level,
multilateral and bilateral donors, international organizations such as
WHO, private corporations, foundations, faith-based groups, other
nongovernmental organizations (NGOs), and other U.S. Government
agencies, including the Centers for Disease Control and Prevention
(CDC), the National Institutes of Health, the Department of State, and
the Department of Health and Human Services. USAID also provides funding
to the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global
Fund).

**USAID and the Stop TB Partnership.** USAID is a financial supporter of
the Stop TB Partnership, is a member of the Stop TB Partnership
Coordinating Board, and is represented on all Stop TB Partnership
working groups (DOTS expansion, new TB drug development, DOTS-Plus for
multi-drug resistant TB, TB/HIV/AIDS, TB diagnostics, and TB vaccines).
USAID support was instrumental in the development of the Global Plan to
Stop TB (GPSTB), and to the establishment of national-level Stop TB
Partnerships and preparation of plans for DOTS expansion in all 22
high-burden countries.

**USAID and the Global TB Drug Facility.** An initiative of the Stop TB
Partnership, the Global TB Drug Facility (GDF), seeks to improve access
to high-quality anti-TB drugs and aims to provide free drugs for 10
million people by 2005. The GDF provides grants for drugs to countries
to support DOTS expansion, and offers a direct procurement mechanism for
countries and NGOs to purchase drugs with their own resources. Through
Fiscal Year 2003, USAID has provided \$6,250,000 to the GDF for the
purchase of TB drugs. USAID also provides technical assistance to the
GDF to ensure that adequate attention is paid to pharmaceutical
management issues in GDF grants. The GDF has contributed to the decline
of average international prices for a full course of TB treatment by 30
percent to about \$10, and has provided TB drugs for more than 1.6
million patients.

**The Tuberculosis Coalition for Technical Assistance.** The
Tuberculosis Coalition for Technical Assistance (TBCTA) is a
USAID-supported project executed through a unique partnership of six
organizations that are actively involved in global TB control. The six
partnership organizations came together to submit an unsolicited
proposal to USAID in 2000. The proposal was approved by USAID in
September 2000 after some modest revisions. The TBCTA then established
its formal and operational structures to manage this USAID-funded
program.

Originally, the project had a budget of almost \$29 million for the
five-year period September 2000--September 2005. Approximately half of
this funding was anticipated to be "core" funds provided by
USAID/Washington, and half were anticipated to be "field support" funds
provided by USAID Missions and USAID regional offices.[^8] Because of
the greater than anticipated demand for TB technical assistance by the
USAID Missions, at the end of Year 3, the ceiling was increased to
\$42.8 million. The following organizations form the partnership:

> 1\. The Royal Netherlands Tuberculosis Foundation (KNCV), based in The
> Hague, was established in 1903 as a unique public-private partnership.
> KNCV promotes effective and efficient TB control within a national and
> international context and acts as an implementing agency for projects
> financed by the Dutch government and other Dutch international
> foundations. Since the 1980s, KNCV has contributed to the development
> and implementation of effective TB control programs in low-income
> countries. Approximately two-thirds of its total 2003 expenditures
> were for international activities, whereas one-third was for domestic
> TB program support in the Netherlands. KNCV receives funding from a
> number of sources for its international program, including the Dutch
> government, Canadian International Development Agency (CIDA), the
> European Union, WHO, and the World Bank. It also hosts the
> International Tuberculosis Surveillance Centre and the Tuberculosis
> Surveillance Research Unit, contributes to international policy
> development, and collaborates with numerous international
> organizations. KNCV has a professional staff of 75 and uses a
> consulting network of approximately 25 primary consultants with a wide
> variety of experience and expertise. Many of the staff and consultants
> have many years of experience working and living in developing
> countries. It is the prime organization for this cooperative agreement
> (the "grantee"), and hosts the Project Management Unit (PMU), which is
> responsible for day-to-day administrative, financial, and grant
> management activities.
>
> 2\. The International UNION Against Tuberculosis and Lung Disease
> (i.e., the UNION), a nongovernmental organization headquartered in
> Paris, is comprised of constituent, organizational, and individual
> members. There are UNION regional organizations in North America,
> Latin America, Europe, Africa, Asia, and the Middle East. The UNION
> disseminates information on TB and lung disease, coordinates and
> assists the work of its members throughout the world, and maintains
> close links with WHO, other United Nations agencies, and governmental
> and nongovernmental organizations in the health and development
> sectors. The UNION's expertise and its activities are focused on
> technical assistance, education, and research. The headquarters office
> has a staff of approximately 20 professionals. Its annual budget is
> approximately \$17 million, and it manages donor funding from the
> governments of Canada, France, Norway, Switzerland, and the United
> States, as well as from the European Union, the Bill and Melinda Gates
> Foundation, the Norwegian Heart and Lung Association, and the Swiss
> Pulmonary League. In addition to the TBCTA, the UNION signed a
> cooperative agreement with USAID in September 2003 for a five-year
> program of clinical trials, regional TB-laboratory strengthening, and
> operational research for TB-HIV.
>
> 3\. The World Health Organization, headquartered in Geneva, has a
> presence in virtually all developing countries and has responsibility
> for defining the international health policy for TB control. It
> provides technical assistance and advice to countries on policy
> formulation, project planning and implementation, and monitoring and
> evaluation of TB control activities. The WHO maintains global
> surveillance and monitoring of TB drug-resistance incidence, and
> monitors the status of TB control programs. Three technical/medical
> officers work part-time to carry out, manage, and monitor
> TBCTA-related funds and program activities within the TB strategy and
> operations unit, a unit of the Stop TB Department.
>
> 4\. The American Lung Association (ALA), based in New York City, is
> the oldest voluntary health association in the United States and has
> 78 state and local organizations throughout the country. It is the
> constituent member in the United States to the UNION. Its mission is
> the prevention and control of lung diseases, and it performs its work
> primarily through public education, public policy, and advocacy
> activities. The ALA works internationally solely in the areas of
> advocacy and fostering the development of international protocols. The
> ALA is the "lead" organization for the TBCTA Advocacy Task Force.
>
> 5\. The American Thoracic Society (ATS), also based in New York City,
> was founded in 1905. It is an educational and scientific society with
> nearly 14,000 members, and is the major medical professional and
> scientific organization with an interest in TB. The ATS collaborates
> with CDC in developing guidelines for TB prevention and control used
> both in the United States and in other parts of the world. The ATS
> publishes a highly respected and widely read scientific journal. In
> addition, the ATS conducts an annual international conference that
> attracts 15,000--16,000 attendees, and is a major forum for the
> presentation of new information about TB and its control, and an arena
> for TB training and education. A broad range of specific technical
> expertise is represented in the organization. The ATS role in the
> TBCTA is focused primarily on international and national advocacy, and
> on broadening the base of international TB expertise.

6\. The CDC, based in Atlanta, Georgia, is a U.S. federal public health
agency. It promotes health and quality of life by preventing and
controlling disease, injury, and disability. Within the CDC, the
Division of Tuberculosis Elimination is responsible for domestic and
international TB prevention and control activities. Activities are
carried out in collaboration with state and local health departments,
academic/research institutions, and other partners such as ministries of
health in foreign countries, and domestic and international NGOs. CDC
provides technical assistance and consultation in a broad range of TB
control areas. Although it is not an official member of TBCTA, CDC
coordinates its annual work plan with TBCTA and participates in all
TBCTA board meetings. USAID funds provided to CDC via an interagency
agreement can be used to support TBCTA activities and objectives. In
addition, the CDC implements a major international HIV/AIDS program (the
Global AIDS Program), which is primarily funded by USAID, and which may
include HIV and TB activities.

The purpose of TBCTA assistance is twofold. First, it is meant to
improve and expand the capacity of USAID to respond to the global TB
epidemic by providing state-of-the-art, context-appropriate, technically
sound, and cost-effective consultation and technical assistance to
high-incidence countries and USAID Missions. In addition, it complements
and expands existing global TB control efforts, such as the Stop TB
Partnership, the programs of WHO, and the activities of individual TBCTA
partners. The ultimate goal of TBCTA is to work in collaboration with
other global TB partners to accelerate the pace of DOTS expansion in
order to meet the global targets mentioned above.

The TBCTA established two managerial levels to enable the partners to
operate efficiently and effectively:

-   A board of directors, which is responsible for overall policy,
    planning, quality assurance, and decision-making activities
    involving all partner organizations

-   A Program Management Unit, which is responsible for day-to-day
    project management, and which is based at the KNCV offices in The
    Hague.

The TBCTA programmatic objectives are as follows:

-   Accelerate implementation and expansion of the DOTS strategy with
    emphasis on the high-burden countries as well as other countries
    strategically important to USAID

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-   Develop institutional and technical capacity for TB control in
    target countries:

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-   Integrate TB control efforts within primary health care services
    more effectively

-   Develop or strengthen linkages between TB control programs and
    HIV/AIDS prevention and treatment programs, and multi-drug
    resistance efforts

-   Disseminate the objectives of the TBCTA to USAID Missions and the
    countries selected

-   Expand the capacity for providing high-quality technical assistance
    worldwide

TBCTA has received USAID funds from several USAID sources:

1.  "Core funds" (approximately \$3 million/year) provided by the
    USAID/Washington Bureau for Global Health. These funds are used
    for: (1) overall program management (TBCTA staff, the costs of
    program management \[quarterly board meetings and task force
    meetings\]) and reporting; (2) initial "advocacy visits" to
    countries where TBCTA assistance might be needed; (3) international
    and regional training courses and workshops, and some international
    meetings (these costs are normally shared with other donors);
    and (4) limited operational research.

2\. "Field support" funds provided by USAID Missions or USAID regional
offices to carry out specific scopes of work in each country or region.
At the time of the evaluation, TBCTA had received funding and was active
in 13 USAID countries (Brazil, Cambodia, D.R. Congo, the Dominican
Republic, El Salvador, Egypt, Haiti, Indonesia, Malawi, Mozambique,
Nigeria, Senegal, and South Africa). Ghana has since been added to the
TBCTA portfolio, but was not included in the evaluation. Each country
focuses on different gaps in the TB control program that need addressing
in order to reach the global targets. The financial transfers to date
have varied significantly. There are several large programs; these
countries have the largest "buy-ins":

> Indonesia, \$4.975 million; Brazil, \$1.852 million; D.R. Congo,
> \$1.554 million
>
> South Africa, \$1.45 million; Senegal, \$1.4 million

TBCTA has also been asked to manage quite small programs with the
smallest "buy-ins" from these countries:

> Mozambique, \$150,000; Cambodia, \$253,900; Dominican Republic,
> \$270,000

Mid-sized programs are located in these countries:

> Nigeria, \$1.076 million (one year of funding thus far); Haiti,
> \$800,000
>
> Malawi, \$500,000; El Salvador, \$499,000; Egypt, \$389,000 (beginning
> in 2003)

In addition, the four USAID regional bureaus---Asia and the Near East,
Latin America and the Caribbean, sub-Saharan Africa, and Europe and
Eurasia---as well as the East Africa Regional Office (REDSO), have
transferred funding to TBCTA, each with region-specific scopes of work.

Funding levels from these regional programs are as follows:

> Sub-Saharan Africa, \$700,000; Asia and the Near East, \$451,000
>
> Latin America and the Caribbean, \$444,500; REDSO, \$345,000
>
> Europe and Eurasia, \$235,000

Total field support funds transferred into the TBCTA grant (or
"obligated" into the grant) by USAID fiscal year have been as follows:

> FY 2001, \$1.0 million
>
> FY 2002, \$3.8 million
>
> FY 2003, \$8.4 million
>
> FY 2004, \$10.0 (estimated)

A summary of total funds obligated from each source appears in Annex C,
Financial Tables.

## I.B. Objectives of the Evaluation

The principal objective of this evaluation is to review the performance,
impact, and lessons learned from implementation of the TBCTA project on
a global level, as well as at the USAID Mission level. This report will
retrospectively examine the TBCTA cooperative agreement activities and
answer the principal question, "What is the evidence that TBCTA has made
or will make in accelerating the pace of DOTS expansion toward reaching
the global targets and building institutional and individual capacities
for TB control in targeted countries?"

Other key questions in the evaluation include:

-   Is the sum of the coalition greater than the individual parts? Has
    the coalition been advantageous for USAID, each of the partners
    individually, and the broader TB community?

-   Do the coalition partners meet the needs of USAID and the global
    demand for TB control? Is the coalition too broad or narrow in
    partners and focus?

-   Has USAID facilitated the work of the TBCTA?

-   How have the capacity of the partners been strengthened?

-   What are the overall lessons learned and best practices from the
    coalition effort?

The full set of evaluation questions, including technical,
collaboration/coordination, and management aspects, is found in the
evaluation scope of work, located in Annex E.

The results from this evaluation will be used to provide feedback to
TBCTA on project operations and management, and recommendations to TBCTA
and USAID on implementation progress and results. In addition, the
evaluation will inform USAID regarding the future design of a follow-on
activity.

## I.C. Methodology

The evaluation was carried out during the periods November 3--7, 2003,
and January 10--February 20, 2004, by a three-person team of independent
consultants (an evaluation specialist with significant USAID experience,
a TB specialist, and a public health specialist). The team gathered
information using a variety of sources:

-   On-site interviews with key USAID/Washington personnel and key TBCTA
    partner personnel at KNCV, the UNION, WHO, and ALA offices.

-   Telephone interviews with key TBCTA partner personnel at CDC and
    ATS, with some USAID/Washington personnel, with several USAID
    Mission health officers, and with several national TB program
    managers.

-   Field visits (5--7 days each) to project locations and sites in
    Brazil, D.R. Congo, and Indonesia. These visits included interviews
    with Ministry of Health personnel and local service providers and
    recipients, USAID Mission staff, and TBCTA program staff.

-   Written questionnaires that were sent to USAID Mission personnel and
    national TB program managers in TBCTA countries the team did not
    visit. Answers were provided by phone or in written format by all
    participating USAID Missions and by five national TB program
    managers in TBCTA countries.

-   Review of TBCTA program documents, including minutes and key
    documents discussed at all of the TBCTA board meetings and task
    force meetings, technical proposals, the cooperative agreement,
    yearly work plans, financial documents, progress reports, and other
    relevant materials.

-   USAID project documents and project correspondence.

-   USAID Mission documents and correspondence (in Brazil and
    Indonesia).

A list of persons with whom the evaluation team met appears in Annex A,
and a list of the documents the team reviewed appears in Annex B. The
evaluation scope of work is provided Annex E.

The criteria provided in the scope of work for selecting the countries
the evaluation team visited included the following: significant USAID
field support, implementation by each of the three main partners (KNCV,
WHO, and the UNION), and geographic diversity.

After consultations with USAID/Washington and USAID Missions, the team
elected to visit three countries in three regions where TBCTA has been
most active and where the TBCTA "lead" organizations differed (KNCV in
Indonesia, the UNION in D.R. Congo, and WHO in Brazil).

The evaluation team presented its draft conclusions and recommendations
to USAID/Washington staff on February 19, 2004, and to the TBCTA board
on February 24, 2004. In both cases, oral and written comments and
suggestions were solicited. The team received several useful comments
and clarifications. A draft report was prepared by March 15, 2004, and
was transmitted to USAID and TBCTA for review and comments. All comments
were received by April 5. The evaluation team then finalized the text of
the report by during the next week. The report underwent a final editing
and was prepared by The Synergy Project and was made available in
mid-April 2004.

# II. Program Goal and Progress to Date

## II.A. Program Goal, Objectives, and Indicators

The goal of TBCTA is: "With other partners, accelerate the pace of DOTS
expansion by reaching the global target of at least 85 percent cure and
70 percent detection of infectious cases in selected countries by 2005
rather than 2015."[^9]

The primary objective is to assist the Bureau of Global Health Office of
Population, Health, and Nutrition and USAID Missions and their local
public/private/NGO/donor partners in the furtherance of USAID's
infectious disease strategy as it relates to TB.[^10]

The Programmatic Objectives are these:

1.  Accelerate implementation and expansion of the DOTS strategy in
    developing countries. Initial emphasis was to focus on the 22
    countries that contribute to 80 percent of the estimated global TB
    burden and other countries to which USAID has given priority.

2.  Develop institutional and technical capacities for TB control in
    target countries.[^11]

3.  Integrate TB control efforts within primary health care services
    more effectively, thus enhancing overall health care delivery.

4.  Develop or strengthen linkages between TB control programs and
    HIV/AIDS prevention and treatment programs, and multi-drug
    resistance efforts.

5.  Disseminate the objectives of the TBCTA to USAID Missions and the
    selected countries by preparing and distributing information
    materials, and by conducting introductory visits to interested USAID
    Missions and countries.

6.  Expand the capacity for providing high-quality technical assistance
    worldwide by organizing training for and access to qualified
    consultants.[^12]

The Project Proposal mentions four intermediate results or areas of
concentration[^13]:

1\. Impact: accessibility to care (numbers of suspected cases examined),
affordability of treatment (percent of patients receiving free
treatment), and adherence to treatment (treatment success rate, default
rate, etc.)

2\. Outcome: reduction of TB mortality and prevalence (the target is a
50 percent reduction in 10 years)

3\. Output: cure rate (85 percent target), detection rate (70 percent
target), multi-drug resistance rate (continuous decrease)

4\. Process indicators: in order to accelerate the pace of DOTS
expansion, 14 process indicators ("sub-intermediate results") are
specified. These are:

-   The presence of a national development plan for TB control

-   Drug supply (target: drugs always available to all patients with TB)

-   Quality of drugs: a quality assurance system is in place (target:
    only drugs of known quality are to be distributed)

-   National and local funding for TB control (target: funding is
    increased to reach sustainability)

-   Staff availability (target: staff have sufficient time to ensure
    that the quality of TB control is sustained)

-   Staff capacity (target: staff knowledge at each level according to
    task description): (1) 125 staff trained at international training
    courses; (2) 1,550 national staff trained at the national level;
    and (3) 45 professionals trained as international consultants

-   A functional central TB unit

-   A national manual developed, disseminated, and utilized

-   A functional reporting and recording system

-   A function network of microscopy services

-   Laboratory supplies (target: supplies are available to all suspected
    cases and patients)

-   Treatment services are integrated at the local primary health care
    level

-   A functional supervision system exists at all levels

The TBCTA proposal appropriately uses the Stop TB Partnership
terminology and indicators for its objectives. The proposal identified
four output-level targets that would be the highest level of "management
interest" for the project. These are the main indicators agreed upon by
USAID and TBCTA to measure TBCTA success:

-   Number of selected countries that have developed a national plan for
    DOTS implementation countrywide (medium-term development plans for
    TB control)

-   Number of countries that have implemented drug resistance
    surveillance (defined as surveys or continuous surveillance per
    international guidelines using an internationally approved reference
    laboratory)

-   Proportion of population at risk for TB living in an area where a
    DOTS strategy is available

-   Number of countries that report cure rates of 85 percent or greater
    and case detection rates of 70 percent or more[^14]

This section of the report focuses on Programmatic Objective 1 (DOTS
expansion) and the main four indicators, which are fairly measurable and
presented in TBCTA documents.

Programmatic Objectives 2 (capacity building) and 6 (technical
assistance) are discussed in section III.A., and Programmatic Objectives
3 (primary health care) and 4 (HIV/AIDS and multi-drug resistant TB) are
discussed in section III.B.

## II.B. Progress

Preliminary results and projections, and plans for 2004--2005 by country
are presented in Table 2.[^15] Data in the table are largely taken from
annual WHO global TB reports.[^16]

### II.B.1. Selection of countries participating in TBCTA

TBCTA has not been able to choose the countries that use its services
from among the 22 high-burden countries. USAID Missions have made the
choice of providing Mission funds to TBCTA to carry out country
programs, normally after accepting initial "advocacy visits" that were
proposed by TBCTA. In addition, USAID does not have a Mission in several
of the high-burden countries.

TBCTA presently carries out national-level activities in 13 countries,
with Ghana being a very recent addition as a 14th country. Seven of the
countries are among the 22 high-burden countries on the priority list of
the Stop TB Partnership: Brazil, Cambodia, Indonesia, D.R. Congo,
Mozambique, Nigeria, and South Africa. USAID is providing country-level
support, outside the TBCTA mechanism, to another 9 of the 22 countries:
Afghanistan, Bangladesh, Ethiopia, India, Kenya, Pakistan, Philippines,
Russia, and Uganda. The six high-burden countries currently not
receiving USAID support for TB control are Burma, China, and Zimbabwe
(all due to political restrictions), and Tanzania, Thailand, and
Vietnam.

Criteria for including countries in TBCTA were as follows: high burden
of TB, interest from the USAID Mission, interest from the country
itself, and compatibility with USAID interests. Some countries were
ineligible for political reasons (Burma, China, and Zimbabwe). One
limitation to including more countries is lack of interest by USAID
Missions. (Following initial TBCTA advocacy visits, USAID/Uganda decided
not to use TBCTA and has instead used its already-existing technical and
financial resources for TB activities; in the Philippines, the USAID
Mission elected not to use TBCTA and has instead contracted with a U.S.
private consulting firm.)

TBCTA has had an impact beyond the 14 countries where it has received
Mission funding because national TB program personnel from many other
countries have attended the international and regional training courses
sponsored by TBCTA. Also, the individual TBCTA partners (e.g., KNCV,
WHO, and the UNION) are active in many non-USAID high-burden countries
using other donor funding. The coalition, fostered by USAID's funds, has
provided the environment for the interchange of experiences and "lessons
learned" from all of these countries.

All of the key TB experts interviewed by the evaluation team, including
the DOTS Expansion Working Group, indicated that the selection of TBCTA
countries was adequate.

**Table 2. Main Indicators in TBCTA Countries 2001--2003**

  ------------ ----------------- ------ ------ ------------------ ------ ------ --------------- -------------- ------ ------ ---------------- ----------- -------- --------- ---------------
               **Medium-Term**                 **Drug Resistance                                **Population                                  Case                           
                                               Surveys**                                        Coverage in                                   Detection                      
                                                                                                DOTS                                          Rate and                       
                                                                                                Areas**^c^                                    Treatment                      
                                                                                                                                              Success in                     
                                                                                                                                              DOTS                           
                                                                                                                                              Areas^d^                       

               **Development                   **Performed**^b^                 ***Planned***                                ***Expected***                                  *Expectation*
               Plans**^a^                                                                                                                                                    

  Country      2001              2002   2003   Previous           2001   2002   *2004--05*      2001           2002   2003   *2005*           2001        2002     2003      *2005*

  Brazil       \+                \+     \+     1996               --     --     *+*             7%             32%    25%                     8­-89        8--73    10--67    

  Dominican    --                --     \+     1995               --     --     *?*             7%             10%    40%    *100%*           6--81       10--79   43--85    *70--85*
  Republic                                                                                                                                                                   

  Egypt                                 \+                               \+                     NA             NA     100%   *100%*           NA          NA       53--82    *65/70--85*

  El Salvador  --                --     \+                        --     \+                     94%            100%   100%                    56--78      57--79   57--88    

  Haiti        \+                --     --                        --     --     *?*             68%            49%    45%                     49--70      48--73   55--75    

  Cambodia     \+                \+     \+                        \+     --                     99%            100%   100%   *100%*           56--93      52--91   60--92    *70--90*

  Indonesia    --                \+     \+                        --     --     *+*             98%            98%    98%    *100%*           19--50      20--87   27--86    *60/65--85*

  D.R. Congo   \+                \+     \+     1999               --     --     *+*             70%            70%    70%                     60--69      67--78   68--77    

  Malawi       --                --     \+                        --     --     *+*             100%           100%   100%   *100%*           42--71      41--73   36--70    *50--75/80*

  Mozambique                            \+     1999                             *+*             NA             NA     45%    *?*              NA          NA       58--77    *?*

  Nigeria                               \+                                      *?*             NA             NA     55%                     NA          NA       9--79     

  Senegal      --                \+     \+                        --     --     *+*             100%           100%   100%                    ?           59--52   54--53    

  South Africa --                \+     \+                        --     \+     * *             77%            77%    98%                     77--60      84--66   108--65   
  ------------ ----------------- ------ ------ ------------------ ------ ------ --------------- -------------- ------ ------ ---------------- ----------- -------- --------- ---------------

a (--) Indicates plan not in place or survey not performed; (+)
indicates plan in place or survey performed; (?) indicates unknown.
Source: Information from national TB programs, USAID country offices,
TBCTA partners, or the PMU.

b (--) Indicates plan not in place or survey not performed; (+)
indicates plan in place or survey performed; (?) indicates unknown.
Source: WHO Stop TB Department.

c Percent of population covered by DOTS as of December 31. Source: PMU.
Projections for 2005 made by KNCV.

d New smear-positive cases registered in 2000, 2001, and 2002 as percent
of estimated cases (case detection rate) and treatment success rate in
patients registered in 1999, 2000, and 2001. Source: PMU, based on WHO
data for the annual WHO Report of Global Tuberculosis Control.
Expectation for 2005 estimates by KNCV.

### II.B.2. National mid-term development plans

Mid-term development plans have been designed for nationwide DOTS
implementation in ten countries. These development plans were often the
first step in TBCTA involvement. In many cases plans were developed
through a process that promoted better coordination between the
partners, because plans needed to include all national treatment plan
activities being supported by different donors. Mid-term development
plans have also been useful because their development is a requirement
for support from the Global Fund to Fight AIDS, Tuberculosis and
Malaria. Egypt and Mozambique have recently developed multiyear
strategic plans that fulfill a similar role, though it in unclear
whether such plans exist in Haiti. Conclusion: The objective has been
achieved in 12 out of 13 countries.

### II.B.3. Drug resistance surveys

TBCTA is focusing on preventing multi-drug resistant TB through
effective DOTS programs. TBCTA therefore decided to support the
WHO/UNION Global Drug Resistance Survey Project, which receives funding
from a variety of sources. Thus far, four of the TBCTA countries
(Cambodia, Egypt, El Salvador, and South Africa) have carried out drug
resistance surveys since 2001, although the funding has not always been
from TBCTA. The main limiting factor to including more countries is a
lack of reference laboratories of acceptable proficiency. The WHO/UNION
Global Drug Resistance Survey Project staff expects to improve the
performance of national reference laboratories in 2004--2005 in five
additional TBCTA countries: Brazil, D.R. Congo, Indonesia, Malawi, and
Mozambique.[^17] Conclusion: There has been progress in implementing
drug-resistance surveys, but it has been slow.

### II.B.4. Population coverage of DOTS

DOTS coverage is defined as the proportion of the population living in
areas where DOTS is implemented. The amount or level of coverage has
evolved differently in TBCTA countries. There has been a rapid increase
in population coverage in some countries, such as the Dominican
Republic, where the USAID Mission reports a "substantial" TBCTA impact
on DOTS expansion. In others (Cambodia, El Salvador, Malawi, and
Senegal), population coverage was reported to be almost 100 percent from
the start of the project, and the impact has been on improved quality
(i.e., case detection and success rates). In Indonesia, DOTS was
proclaimed as having been officially implemented in all districts by the
late 1990s, but implementation was weak. Improvements are therefore not
measured in DOTS coverage, but in detection rate (see below).

The main limitation to increased DOTS coverage in many countries is
limited access to general health services, which is beyond the scope of
TBCTA to improve. The indicator is not defined the same way in all
countries, and is difficult to measure.[^18]

In conclusion, considerable progress has been made in most countries and
provinces that received TBCTA support that had not already reported 100
percent coverage at the start of the program.

### II.B.5. Countries reaching 70 percent case detection rate and 85 percent success rate

This indicator consists of two different components that will be
assessed separately.

**Seventy percent detection rate within a DOTS area.** Detection rate is
the percentage of estimated TB cases within the DOTS area covered by the
project, as estimated by WHO for each country, based on tuberculin
surveys and other data. There has been a considerable increase in some
countries, such as the Dominican Republic, Indonesia, and South Africa.
In Indonesia, the case detection rate in Central Java increased from 13
percent in 2001, to 27 percent in 2003, and in East Java, from 12
percent to 30 percent over that period.

In D.R. Congo, TBCTA is supporting the provinces of Kasai Occidental and
Kasai Oriental Sud, where the number of new smear-positive TB cases
increased by 71 percent and 49 percent, respectively, from 2001 to 2002.
This cannot be translated into a case detection rate, but it clearly
indicates considerable progress in case finding. In some countries, many
patients receive treatment, but they do so outside the national
tuberculosis program. In these countries, the case detection rate would
increase considerably if patients were referred to the national program
or other TB control activities that fulfill the DOTS criteria. In other
countries, such as Brazil, many TB cases are missed by the national
reporting system. Improvements to the reporting system would increase
the case detection rate and lead to rapid improvement in this
performance indicator.

In Brazil, DOTS coverage increased from 7 percent in 2000, to 32 percent
at the end of 2002, according to the national TB program.[^19] As
discussed elsewhere in this report, the definition of DOTS in Brazil may
be different from usual WHO definitions, especially regarding reporting,
DOTS, and treatment regimens.[^20]

High population coverage and a low detection rate indicate that public
health services are not sufficiently capturing patients with TB (this
occurs in Egypt and Indonesia). Mozambique has an 85 percent health
system coverage rate at the district level, but only 50 percent
population coverage by general health services, and the case detection
rate is estimated to be 58 percent. This indicator is also much debated
in the global TB community.[^21]

In conclusion, there has been a considerable increase in the case
detection rate in several countries (or provinces covered by the
project), but thus far, only South Africa has achieved the goal of 70
percent.

**Eighty-five percent treatment success within DOTS areas.** Treatment
success of 85 percent means that 85 percent of new smear-positive cases
were successfully treated.[^22] Three of the TBCTA countries improved
their success rate to reach the target by 2003 (Dominican Republic, El
Salvador, and Indonesia), whereas Cambodia had already reached that
target. TBCTA has contributed to better quality data.

Data quality is closely linked to the capacity of central and provincial
staff to make supervisory visits to provinces and districts, and to the
quality of these visits. The TBCTA has trained many staff members in
such skills (probably in all TBCTA-supported countries) and has
increased the capacity in several settings by adding staff,
transportation, and other elements. D.R. Congo and Indonesia offer good
examples of this. TBCTA support has included training for staff, regular
supervisory visits (transport means and per diem), chasing defaults, and
expansion of facilities so they are more accessible to patients. Success
rates have improved in some parts of D.R. Congo (from less than 40
percent in 2000, to near 78 percent in 2001, in Kasai Occidental; from
50 percent to 72 percent in Maniema; and from less than 40 percent to 75
percent in Kasai Oriental Sud). In Central Java, Indonesia, the high
success rate of 85 percent to 90 percent has been maintained despite a
rapid increase in the number of cases.

Low success rates are caused by high deaths rates, particularly due to
AIDS (20 percent in Malawi), delay in starting treatment, (or both), by
high rates of default (found in many programs), and by missing data (as
in Senegal). Death rates related to HIV/AIDS may be reduced to some
extent by increased use of antiretroviral drugs, but it may be hard to
reach the targets in countries with high HIV sero-prevalence rates.
Better access to and quality of health services that provide DOTS should
both reduce deaths caused by delay and reduce default rates. Because WHO
statistics include patients with missing results in the denominator, in
some countries, more complete reporting would quickly improve the
success rate.

In countries where little TB treatment takes place outside the national
treatment plan, the best balance has to be found between the speed of
DOTS expansion from a pilot stage to cover the entire region or country
and the success rate. If the speed of DOTS expansion occurs too quickly,
the success rate may be too low, and it could result in an increase in
the risk of development of drug-resistant strains of TB.

**Conclusion.** Four countries have reached the 85 percent target of
treatment success (Cambodia, Dominican Republic, El Salvador, and
Indonesia), whereas another four are near this target (i.e., they have
reached a treatment success rate of 75 percent or more). Only South
Africa has reached the 70 percent case detection target, but KNCV
projects that Cambodia, Dominican Republic, and perhaps Egypt as well,
will reach this target by 2005. Therefore, none of the countries has
reached the combined targets of 70 percent and 85 percent so far. In
countries with high HIV sero-prevalence rates (South Africa, Malawi, and
perhaps Mozambique), it may be unreasonable to expect that the treatment
success target will be met.

### II.B.6. Process indicators

Unfortunately, TBCTA has not yet begun to report country-level progress
using the 14 process indicators identified in the project proposal.[^23]
It is not clear whether TBCTA partners have baseline information to
measure progress against these indicators, nor how determined TBCTA
leadership is to use these indicators to measure project success. On the
basis of the evaluation team's visits and the questionnaire results, it
is the team's impression that good progress has been made in several
countries using the TBCTA model with the following indicators:

-   Laboratory quality (functional network of laboratory services, staff
    trained, microscopes distributed, availability of supplies, more
    patients diagnosed)

-   Effectiveness of national TB programs (trained staff, national
    manual in place, strong donor coordination, increased national
    funding for TB, improved communications and reporting capacity)

-   Improved monitoring and supervision (staff trained in supervision,
    increased availability of transportation and per diem, additional
    staff)

-   Improved and consistent drug supply and management, improved quality
    controls on drugs and drug use (GDF- and Global Fund--financed drugs
    available, trained managers, improved procurement and drug
    management system \[often with RPM+ assistance\])

-   Improved staff quality (via training for provincial and district
    staff in strategic planning, program management, logistics and drug
    management, supervision, DOTS diagnosis and treatment, etc.)

Unlike most USAID-funded projects of this magnitude, the Project
Management Unit does not have a monitoring and evaluation specialist
with the responsibility to establish and ensure the application of the
TBCTA monitoring and evaluation system.

## II.C. Appropriateness of TBCTA Indicators

TBCTA generally follows indicators that are well established in the TB
community and which are useful for assessing the impact of interventions
in national TB control. Indicators such as having in place a medium-term
development plan and a drug resistance survey are easy to measure. The
remaining indicators are all problematic, but this is a problem of
global TB control, and is not related to the TBCTA. Efforts are
currently under way with the involvement of most of the TBCTA partners
to refine the indicators used in TB control. In addition, the TBCTA
partners need to finalize and carefully measure the achievement of
process indicators.

In general, TB control has the objective of reducing incidence
(morbidity) and mortality of TB. These indicators are, however, not
expected to change in the few years of the project. In fact, the
notification rate would be expected to increase during the first years
because of better case finding and more complete reporting. Mortality
data are usually of low quality because they are based on vital
statistics, whereas fatality (i.e., the percentage of notified patient
cases who die before the end of the treatment) measured by cohort
analysis of treatment result should provide better-quality data.

The TBCTA indicators are logically constructed and do provide a good
framework for evaluating program success. Country-level improvements in
output-level indicators are possible, even in the short time frame of a
five-year project. For example, in Indonesia, significant improvements
in the large TBCTA target provinces of Central and East Java are
apparent from local data after two years of concerted activity.
According to Indonesia's national treatment plan director, significant
improvements in these two large provinces, which have a combined
population total of more than 60 million, may push Indonesia's national
indicators above WHO targets for treatment success by 2005. The more
sensitive indicator is the cure rate, whereas the detection rate might
not improve as the DOTS program expands.[^24] The "access" indicator
("availability of DOTS strategy," or, effectively, the availability of
DOTS services) requires careful definition. While access is normally
defined as the availability of a health service center within a
specified radius, a more precise definition would measure access to a
health service center *that has the resources to provide DOTS
treatment.*

**Attribution.** In Table 2, the column of indicators for case detection
rate and treatment success by country reflects activities that occurred
in the past. The 2003 column reflects the number of patients notified in
2002, and the result of treatment of patients who were notified during
2001. Because TBCTA implementation at the country level took place
primarily from 2003 onward, it would affect the case finding only from
2003 (measurable from 2004), and the treatment result of the same
patients who were notified in 2003, should be available in 2005.
Therefore, it is too early to clearly see the impact of TBCTA on these
indicators.

The level of support has varied greatly between countries, so that the
impact of TBCTA will be variable and difficult to assess. In some
countries, such as D.R. Congo and Indonesia, much of the TBCTA support
takes place only in specific provinces or districts. The evaluation
team's assessment therefore focuses on these areas. In some countries,
TBCTA supports only one or only a few components of the national
treatment plan, such as HIV and TB (in Malawi), monitoring and
evaluation (in South Africa), human resource development, and
operational research; therefore, the impact of TBCTA on overall
indicators is hard to measure.

A few questions of attribution arise when using the TBCTA output
indicators. In most cases, given the pervasiveness of TBCTA partner
international activities prior to the cooperative agreement, a strategic
plan or a drug resistance survey, if not carried out specifically by
TBCTA during the project period, probably exists at least in part based
on earlier work of a TBCTA partner. USAID Missions reported that TBCTA
was part of developing or revising a national TB strategy with only a
few exceptions.

Attribution questions are more likely to arise in countries where USAID
funds for TB are limited and where the TBCTA scope of work is focused at
central-level activities rather than at field-level activities. The very
systematic, stepwise assistance provided by TBCTA typically sets the
necessary framework (planning, trained human resources, and laboratory
capacity) to achieve success via programs funded by the Global Fund to
Fight AIDS, Tuberculosis and Malaria or by other donors.

#  {#section-4 .unnumbered}

# III. Programmatic Objectives: Progress and Issues

## III.A. Capacity Building and Technical Objectives

### III.A.1. Meeting demands for technical assistance

The primary objective of TBCTA is to assist USAID's Global Bureau Office
of Population, Health, and Nutrition and USAID Missions and their local
public, private, NGO, and donor partners in the furtherance of USAID's
infectious disease strategy as it relates to tuberculosis by providing
policy and programmatic guidance, as well as administrative, managerial,
and technical assistance.[^25]

From the start of the TBCTA, the partners first provided technical
assistance through advocacy visits to review national treatment plans,
to assess local needs, and to sensitize USAID Mission staff to use the
TBCTA to support national TB plans. In order to evaluate USAID
activities in TB control, USAID staff visited 15 countries during the
first two years,[^26] and in 2002, staff visited seven countries in
Eastern Europe.[^27] During Year 3, staff made additional visits to
Egypt (for advocacy work), Nigeria (for advocacy and review work),
India, Tanzania, and Uganda (to assess the regional center for quality
health care).

During the first two years, 11 USAID Missions pledged funds for TB
control through TBCTA,[^28] whereas two more Missions pledged funds at
the end of Year 3.[^29] TBCTA partners visited all these countries to
provide technical assistance in support of DOTS implementation and to
monitor activities that were described in country plans, usually
mid-term development plans.

The traditional UNION/KNCV/WHO approach to providing technical
assistance to national TB programs has been to visit countries on a
half-yearly basis; this approach was developed in the 1980s within the
Mutual Assistance Program of the UNION. Often, in the early years, an
expatriate physician worked on national TB programs at the central or
provincial levels. This approach was successful in a number of model
countries and was part of the development of the DOTS strategy.

The partners (the UNION, KNCV, and WHO) in the TBCTA project that
provided technical assistance to national TB programs in the past have
continued to do so, usually every six months. The quality of the
technical assistance was reported to be excellent.

The demand by USAID Missions for technical assistance has, however, been
greater than expected by the partners. Though some countries needed more
frequent visits, the capacity of the TBCTA partners to provide it has
been limited.

The global need for technical assistance has increased since the TBCTA
was started, partly because the Global Fund to Fight AIDS, Tuberculosis
and Malaria has offered funding for TB program implementation; often,
however, the Global Fund proposals or implementation plans have not
included funding for technical assistance. Most of the countries
receiving TBCTA support have received or have applied for support from
the Global Fund and the GDF. TBCTA partners have offered direct
technical assistance in the application process to some countries (e.g.,
Dominican Republic, El Salvador, Indonesia), which is often a demanding
process, whereas in other countries, TBCTA has created conditions that
have strengthened the application, such as mid-term development plans,
better information systems, supervision and monitoring, drug management,
and DOTS expansion.

Technical assistance has also been increasingly needed to address
specific topics such as program management, drug management, laboratory
network, training, and advocacy, and in these instances, additional
people who could provide this specialized assistance have been brought
in. This has happened more often, but with significant delays.

TBCTA technical assistance has included the strengthening of laboratory
services for drug-resistance testing by funding WHO to expand the
WHO/UNION Global Drug Resistance Survey Project. This has included
setting up a network of supranational and national laboratories that
perform drug-resistance testing with acceptable quality.[^30] Training
courses on standardization of drug resistance methods have been held for
francophone Africa and in countries of the former Soviet Union.

Drug management has been a weak point in many national TB programs.
TBCTA has promoted the strengthening of this component, usually through
Management Sciences for Health, which has offered advice on drug
management in several countries, often via USAID's RPM+ Project.

Because support in several countries has included direct involvement in
program implementation, such as procurement, the need for onsite
follow-up has become evident. At the same time, as part of a
decentralization process, several countries have been reducing their
central and provincial staffs and the responsibilities of their TB
programs so that their management capacity is now weak. In particular,
the provincial staffing levels have been dramatically reduced in Brazil
and Indonesia in recent years. In response, TBCTA partners have recently
contracted additional, full-time staff to offer on-site technical
assistance to some countries, in addition to the periodic follow-up
visits by the technical adviser.

TBCTA has successfully provided or financed this long-term, local
technical assistance in several countries as detailed below, but the
process has often been lengthy, especially in El Salvador and
Mozambique.

In Indonesia, after many requests from the USAID Mission, KNCV hired its
own office staff with a full-time resident director.[^31] To facilitate
collaboration, the KNCV office is located in the same corridor as the
national TB program office, where WHO also has some office space. KNCV
also hired medical and support staff for Central Java and East Java,
where TBCTA is providing support. These staff people are also co-located
with provincial TB program staff.

In Brazil, a technical specialist from CDC was contracted in June 2002
to coordinate Ministry of Health TB research activities[^32] and to
provide epidemiological support to the national TB program in Brasilia.
A WHO TB medical officer from the Pan American Health Organization was
contracted for 11 months, beginning in February 2004, to provide
technical assistance on tuberculosis and to assist Brazil with its TBCTA
contract.

Two years after the initial TBCTA assessment, El Salvador hired the
former manager of the national TB program in Venezuela to support its
national TB program.[^33] In Senegal, two physicians were hired as WHO
program officers in 2003 to strengthen the central unit of that
country's national TB program with the task of supervising some regions.

In Nigeria, WHO contracted one staff member at the central level and
will also contract three professional officers to work in three newly
established zonal offices. In Mozambique, the national TB program asked
TBCTA to include extra staff in its national TB program central unit as
part of the TBCTA HIV/TB project. A medical doctor has been identified
for the position, but there is still discussion about his terms of
reference.

A similar development is the Intensified Support Action Countries (ISAC)
plan,[^34] which was initiated in early 2004 by the DOTS Expansion
Working Group of the Stop TB Partnership. ISAC focuses on ensuring that
Global Fund grants are well used and encourages the hiring of
additional, long-term staff or consultants to provide technical
assistance (often under WHO auspices) at the national and provincial
levels in some key countries. ISAC is not part of TBCTA activities, but
it involves several TBCTA partners and is relevant for the discussion of
how to strengthen technical capacity at the country level. These
additional temporary staff may be important for speeding up DOTS
expansion; however, their "consultant" salaries will be considerably
higher than those of health ministry staff. The duration of ISAC is
unknown, and it is uncertain to what extent the ministries of health can
absorb these persons after so-called "emergency" donor funding is
terminated. Therefore, the TBCTA partners should assist in ensuring that
the initiative is well planned and that any TBCTA-supplied long-term
technical assistance avoids the roller-coaster results of other
short-term donor health programs, such as those that address child
survival issues.

The global demand for technical assistance in TB control is also
increasing now because of the HIV/AIDS-related 3×5 Initiative and the
U.S. President's Emergency Plan for AIDS Relief, for which patients with
TB are considered key for receiving antiretroviral treatment.

**Has the technical assistance provided by the TBCTA been sufficient?**
Where TBCTA has provided senior technical assistance in response to
requests by a national TB plan or a USAID Mission, the quality, without
exception, has reportedly been excellent. Examples of this have occurred
in the Dominican Republic, D.R. Congo, Haiti, Indonesia, Malawi,
Mozambique, Senegal, and South Africa. This is indeed a major
accomplishment.

Assistance to some other programs (particularly those in Cambodia and
Eastern Europe), however, has been delayed because senior TBCTA
consultants are unavailable to perform the work. One USAID Mission, for
example, wanted frequent visits by a high-level consultant, whereas the
national TB program manager wanted fewer but longer visits so that the
consultant could visit provinces. There is a limit to how intensive the
technical assistance should be in order to speed up DOTS expansion in
the long run. One main task of the TBCTA project is to assist a national
TB program to expand DOTS nationwide by first setting up the basic
conditions so that the national TB program can operate in the long run.
The more TBCTA becomes an implementing agency, the more difficult it may
be to ensure that national government programs can continue.

D.R. Congo has a well-functioning national TB program, even though
health services in the provinces are run by a variety of foreign NGOs.
TBCTA assistance, primarily through the UNION, has facilitated good
coordination between the actors, and GDF support has strengthened the
role of the national TB program by being responsible for drug
distribution. The NGOs are supporting the salaries of the TB program
staff at the provincial and district levels. Intense training and
supervisory visits have resulted in fairly complete data on case finding
and treatment outcome.

The half-yearly travel reports by TBCTA consultants are key instruments
for monitoring the progress of the national TB program in many countries
and are generally quite useful.

A major strength of global TB control efforts is the general consensus
regarding the DOTS strategy. The evaluation team was surprised that the
sites they visited in Brazil and Indonesia did not comply with WHO and
UNION recommendations (i.e., that treatment should be directly observed
by people other than family members). In Brazil, except in a few pilot
projects, patients receive weekly treatment without supervision between
visits. The concern is that Brazil's national TB program treatment
regimens (both for new cases and re-treatment) are inadequate, and its
information system is still incomplete.[^35] In Indonesia, a support
person, often a family member, was identified to help the patient adhere
to the drug regimen, but without observing the actual drug intake. This
system has been shown to be effective in the KNCV-supported program in
Sulawesi, but with rapid expansion to the rest of the country, it is not
certain that similar results will be achieved.

The WHO review of Indonesia's national TB program in early 2003
recommended that operational research be conducted to assess and
document the efficacy of treatment observation by family members. The
impression of the TBCTA evaluation team was, however, that the main
problem associated with TB control in Central and East Java was that
most patients were not receiving treatment as part of the national TB
program, and the challenge was how to attract these patients. It may not
be helpful to establish DOTS by non-family members as a policy if most
patients are not present. The most constructive approach could be the
introduction of DOTS by nonfamily members as an effort to improve
patient care (i.e., as one of the interventions to attract more
patients).

**Increasing capacity for technical assistance.** TBCTA was started
because there were too few high-level TB technical experts in the world
who could plan, implement, and evaluate national TB programs. For
decades there had been little focus on TB control, and only a few
organizations provided technical support to national TB programs,
namely, the UNION through its Mutual Assistance program, European NGOs
such as KNCV, two Norwegian NGOs, and the Swiss Lung Association. To
meet the expanded needs, TBCTA set an objective to "expand the capacity
for providing high quality technical assistance worldwide by organizing
training for and access to qualified consultants."[^36] Many of the
expatriate staff members who worked for European NGOs were successfully
recruited, but the demand for consultants is still greater than the
supply.

According to the project proposal, TBCTA should train 45 international
consultants.[^37] Only seven have begun formal training with KNCV, WHO,
and the UNION. A program by the North American chapter of the UNION and
ATS to encourage American TB specialists to enter the field presently
involves 25 medical personnel. Approximately 20 potential consultants
received training at consultant training courses in May and November
2003, in Sondalo, Italy.

TBCTA started training promising junior consultants to become general TB
consultants only in 2003. KNCV began training one person from a
low-prevalence country in June 2003, and another from a high-prevalence
country in October 2003. Both consultants have devised personal,
18-month development plans using a training tool developed by the Task
Force for Training (TFT).[^38] Their plans include regional TB training
courses, specialized courses in operations research, and participation
in missions to three different countries.

The UNION started training three junior consultants from high-prevalence
countries in early 2004, one each from francophone Africa, anglophone
Africa, and India. Each has been assigned to mentor one of the UNION's
senior consultants. Their training will last 18 months, is similar to
that of the KNCV model, and will include a special focus on TB and HIV.

In August 2003, WHO began an 11-month training program with a focus on
human resources development for one person from a low-prevalence
country. In addition, WHO has identified a person from Eastern Europe
who will be trained in its European office for 11 months, beginning in
March 2004.

The TFT guidelines for preparing a personal TB consultant training plan
explain that a competent consultant needs knowledge, skills, and
attitudes that cannot be acquired in one or more training courses, and
encourage field training with an experienced consultant.[^39] The level
of training may be different for full-time consultants who work for
KNCV, the UNION, or WHO, from that of individuals who perform
consultancies just once or twice a year. The guidelines suggest that a
consultant's experience must be diverse and should include general DOTS
expansion, human resource development, advocacy, and laboratory
practices.

It is too early to draw any conclusions about the training of junior
consultants. The training undoubtedly requires a wide range of
experiences; however, recruiting consultants should not be a difficult
task. Several national TB programs have many skilled people who could be
recruited and trained to perform the work part-time in other countries.

In more general terms, in order to meet the rapidly expanding program
needs in both TB and HIV/AIDS, in the evaluation team's view, for a
variety of reasons, the top priority should be the training of
consultants from developing countries. It is more cost-effective, more
such consultants are available, and their expertise is more acceptable
by staff in other developing countries. In developed countries, over the
long term, training for consultants should probably occur at health
training institutions because it is a means for strengthening preventive
medicine and public health in general, and because training in
epidemiology and related sciences in these disease-specific fields is
more readily available. In developing countries, the training should
also occur through field-oriented and field-based programs for greater
efficiency and cost-effectiveness.

### III.A.2. Develop institutional and technical capacity for TB control in target countries: Training/human resource development

The second programmatic objective of TBCTA is to develop institutional
and technical capacity for TB control in target countries. Activities
include: (1) staff training in general management, logistics management,
technical capacity, supervision, and operational research; (2) support
for administration, general management, logistics management,
supervision, and operational research; (3) development of standardized
monitoring (results) and quality control systems in national programs;
and (4) engagement of private practitioners and community organizations
in TB control. Activities consist of training courses, workshops,
intracountry and intercountry meetings, program review missions, and
consensus-building meetings.[^40] The project proposal describes
potential support in capacity building, and organizational and human
resource development,[^41] but there is a high degree of overlap in
activities.

The sub-intermediate results[^42] include quantitative targets for staff
capacity: (1) 125 staff in training at an international course; (2)
1,550 staff in training at the national level; and (3) 45 professionals
trained as international consultants.

It is difficult to define useful indicators for progress in capacity
building. The end result should probably be sufficient staff in place
with adequate training, supervision, and follow-up to carry out the
tasks of a national TB program at all levels. The result should be an
improvement in case detection and treatment success, the main TB program
indicators. TFT is currently defining indicators in the position
paper.[^43]

**Staff training.** TFT consists of training specialists from each TBCTA
partner. Its first meeting occurred in September 2001, and it has met
quarterly since then. The purpose of TFT is to support national TB
programs, as well as academic and medical institutions, to strengthen
their human resources to help reach global DOTS targets. Specific
purposes are: (1) to enhance the capacity of program managers at
central, intermediate, and district levels to adapt strategies for human
resource development to the needs and goals of national TB programs; (2)
to enhance the management capacity at central, intermediate, and
district levels; (3) to strengthen the capacity of peripheral health
workers in TB through field-oriented training; (4) to strengthen the
capacity of respiratory clinicians and university professors in the
public health aspects of TB control; and (5) train new consultants from
developing and developed countries for national and regional work.[^44]

In May 2003, the TBCTA board noted that the shortage of trained staff at
all levels is a major factor limiting DOTS expansion, that human
resources development and training were an extremely important TBCTA
activity, and that TFT would not be able to meet USAID's increasing
needs. The Board of Directors decided that a full-time person needed to
be appointed to support the efforts of the TFT and that TFT should be
represented in all board meetings. The board noted that more attention
should be given to national programs and that TFT's terms of reference
were not clear enough to give TFT adequate direction.

TFT, with the help of the PMU, developed a draft human resource
development position paper^44^ that includes indicators; this paper is
still under discussion.

TBCTA is debating whether TFT or the lead TBCTA partner in a particular
country is responsible for meeting the increasing demand for short-term
technical assistance. TFT staff explained that they do not have the
capacity to provide country-level technical assistance, however, the
full-time human resources development consultant in the PMU could do so
if the technical consultants and the countries requested it.

The PMU has contracted a human resource development consultant to
accelerate this work and to support the work of TFT. The consultant
works in collaboration with TFT, which underlines the need to have
consistent PMU follow-up between TFT meetings and to help carry out TFT
activities.

It is difficult to quantitatively assess the extent to which TFT has
reached its objectives, apart from the number of trained staff. A list
of international and regional courses supported by the TBCTA appears in
Annex D. In addition, TFT has implemented a lengthy list of valuable
activities such as the following:

-   *Review and development of training materials:* A general strategy
    for human resource development in national TB programs,[^45] a
    checklist for the human resource development component in national
    TB programs,[^46] the training coordinators handbook,[^47] training
    material for health center staff,[^48] participant manual for
    regional workshops for training focal points,[^49] and guidelines
    for preparing a personal training plan for future TB consultants for
    TBCTA.

-   *Workshops for TB human resource "focal points" (or sub-directors)
    from high-burden countries:* These new workshops are designed to
    encourage systematic human resource planning and training for TB
    personnel in high-burden countries. Workshops were held in The
    Hague, in November 2002, with 13 participants, mainly from Africa,
    and in Bangkok, in September 2003, with 20 participants from South
    and Southeast Asia. In both workshops participants designed a needs
    assessment for each country, and country-specific human resource
    work plans. USAID staff participated in both workshops. A follow-up
    workshop for the participants from Africa was held in November 2003,
    in Addis Ababa to evaluate the execution of the work plans that
    participants had developed during the first workshop. The national
    TB program manager and the human resource focal points were invited
    to the follow-up workshop.

-   A review of training and human resource development proposals
    submitted to TBCTA for funding, and regional training courses.

TBCTA partners are organizing regional training courses targeted to
managers of national, regional, and provincial programs. These courses
are held once or twice a year in Arusha, Tanzania (for English speakers
in Africa), in Cotonou, Benin (for French speakers in Africa), in
Managua, Nicaragua (for Spanish speakers in Latin America), in Hanoi/Ho
Chi Minh City (for English speakers in Asian countries) and in Warsaw,
Poland (for English and Russian speakers). These courses are normally
funded from a number of sources.

TBCTA funding is predictable and has led to a greater participation in
courses. TBCTA has also ensured better coordination of training
activities and has ensured that key national and provincial staff
receive priority enrollment and funding for the training courses they
need.

The training courses contribute to a common understanding of how DOTS
should be implemented, and to networking and exchanges. The outcome of
the courses has been assessed through post-training questionnaires. The
evaluation team discussed the need for a course in Brazil with a
curriculum similar to that of the course offered in Managua,
particularly for the 26 consultants who may be hired by Brazil's
Ministry of Health to support its state TB programs. In other large
countries where many provincial staff persons need training, national
courses could be adapted for use at the regional level.

WHO has developed material for national-level TB staff and has completed
the revision of the first part of its district-level manual. Training
manuals for health facility staff have been developed and distributed
(see previous page) and a CD-ROM is in preparation.

Through TBCTA, gaps in training have been identified, and new courses
have been developed and executed. The UNION took the lead to develop an
international training course that focuses mainly on management issues.
The first course, titled "International Financial, Logistics and
Procurement Management Course for NTP Managers," was held in Jaipur,
India, in February 2004.

TBCTA courses on laboratory skills and operational research are
described below.

**Support for national-level training.** Training is a key component in
most country plans. To meet national and sub-national training needs,
TBCTA has adopted a careful, stepwise approach (most fully in Indonesia
and South Africa) that includes national or sub-national training plans,
training for master-trainers, development of course materials, training
execution, and follow-up supervision. Local training facilities are used
when appropriate. This model, most fully applied in Indonesia, will be
evaluated there in March 2004, and the results are expected to be
valuable to other countries.

It is probably necessary for TFT to be involved at the national level in
some countries in order to obtain feedback on how training activities
are functioning in practice, perhaps by evaluating its training programs
(this is being planned in Indonesia). For example, in Indonesia,
training for health center staff was still a limitation to DOTS
expansion, and is caused by a lack of trainers. The training for this
group would therefore be speeded up.

**Operational research.** The program document includes operational
research as an activity under the programmatic objectives of developing
institutional and technical capacity for TB control in target countries,
by both staff training in operational research and support for
operational research.[^50] Under possible areas of support is "Capacity
building, both organizational and human resource development," for which
"operations research and quality assurance to improve program delivery,
to determine the prevalence of drug resistance and the quality of drugs,
to evaluate interventions addressed to special populations with less
access to care (e.g., women, scattered or hard to reach populations,
prisoners), and to measure program impact."[^51]

The routine information system in the DOTS strategy provides basic data
for operational research such as case finding and treatment results.
Routine analysis of national TB program data and operational research
overlap, whereas the routine information in a national TB program leads
to topics for operational research. It is useful to ensure that
operational research is closely linked to national TB programs so that
the right research questions are raised.

Most national TB programs have operational research in their work plans,
and some donors specify a certain budget percentage for that purpose.
Most national TB program staff are either too busy, or they have not
been trained to do research. Some institutes and universities are doing
research, but with limited links to national TB programs.

The UNION has offered training courses in applied epidemiology for
several years to participants from high-prevalence countries, using a
variety of funding sources. TBCTA has funded such courses in Paris in
2003, Addis Ababa in 2001, and in Latin America in 2002 and 2003.

TBCTA funds some operational research by KNCV in Indonesia and South
Africa. In South Africa, using a combination implementation and
evaluation study, Stellenbosch University has introduced sputum
registers to rural areas around Cape Town. In Johannesburg, one study
supports the development, implementation, and evaluation of a new TB
education and referral center at Baragwanath Hospital; and another
study, started in July 2003, examines TB practices in Baragwanath
Hospital and referrals to it from subdistrict clinics in Soweto.

The KNCV research unit visited Indonesia in February and March 2003, and
formulated plans for operational research activities.[^52] The result is
a national TB operational research working group with the objectives to:
(1) support operational research in the provinces, (2) build capacity
for TB research by actively supporting young researchers, and (3) assess
the relevance and quality of research proposals submitted to the
national TB program. In early 2004, six research teams were being formed
in East and Central Java, and in Yogyakarta, each consisting of four
persons, the program staff, and researchers.[^53] In May 2004, these
individuals will be trained in the basics of operational research, in
developing research proposals, implementing their research, and
analyzing the results under the guidance of the TB operational research
group and KNCV. The training course is titled "Designing and Conducting
Health System Research Projects," and was developed by the International
Development Research Center.

In Brazil, TBCTA is supporting surveys and surveillance of deaths from
TB, as well as the personnel costs of a full-time CDC research
specialist.

Several TBCTA-supported national TB programs have operational research
in their work plans, such as those in El Salvador (an annual risk of
infection), Malawi (HIV/TB), Senegal, Egypt, and D.R. Congo.

USAID supports operational research in many countries, often through the
CDC's Global AIDS Program, or through universities. In Brazil, for
example, USAID supports a DOTS expansion study in Rio de Janeiro and São
Paulo through Johns Hopkins University.

**Laboratory improvements.** Laboratory services are often a weak link
in TB control programs. TBCTA has supported creating better laboratory
networks and better use of quality control measures for smear
microscopy, which is the basis for TB diagnosis. A regional training
course in TB laboratory network management was held in Bangkok,
Thailand, in January 2003. TBCTA also supported a course in laboratory
management in Warsaw, Poland, in 2002 and in 2003. In Surabaya,
Indonesia, the reference laboratory is being upgraded and its staff
members are receiving training and workshops in quality control, and in
equipment use and maintenance.

TBCTA has been able to procure a large number of microscopes and
reagents as part of a broader program to strengthen laboratory quality:
ten light microscopes and one fluorescent microscope for Malawi; 35
microscopes for Haiti; 218 binocular Olympus (CH20) microscopes for
Surabaya, Indonesia; and ten binocular Olympus microscopes and one water
distiller for D.R. Congo.

In South Africa, the UNION has helped to define TB laboratory activities
and staff responsibilities in the newly created National Health
Laboratory Services. In D.R. Congo, WHO has aided the purchase of
equipment for seven regional laboratories, sponsored training for
technicians in the national reference laboratory, and supplied
transportation and per diem costs for TB laboratory supervision services
in seven provinces.

Planned activities include the following: in Senegal, funds to purchase
equipment for the national TB reference laboratory and to rehabilitate a
regional laboratory; in Egypt, overseas training courses for four
laboratory staff each year; in Nigeria, laboratory equipment; in the
Dominican Republic, laboratory training; in El Salvador, strengthening
the national laboratory network; and in Brazil, a drug resistance
survey. In general, most countries need stronger microscopy networks.

Technical assistance, training, and equipment have been made available
to reference laboratories to ensure sufficient proficiency for
participation in WHO/UNION drug-resistance surveys in Brazil, D.R.
Congo, Indonesia, and South Africa. Training courses on drug
susceptibility test standardization methods have been conducted in
countries of the former Soviet Union.

### III.A.3. Supervision, monitoring, and information systems

A key invention in the new DOTS strategy is the TB register. TB
registers are managed by district TB coordinators, and are updated from
treatment cards that health center staff members use to document and
facilitate patient follow-up. TB registers allow a quick analysis of
case detection and treatment results, which is a key component of visits
by provincial supervisors. TB registers also allow district-level staff
to themselves assess local situations. In theory, quarterly reports of
aggregated data on case finding and treatment outcome are compiled from
TB registers and are sent on to the provincial level, where data are
reviewed and forwarded to the national level.

The annual global TB reports published by WHO illustrate that many
countries have difficulty presenting data in sufficient quality and
states of completion, especially regarding treatment outcome. The
problem is often caused by a lack of adequate supervision from the
central to the provincial levels, and from the provincial to the
district levels, and, in countries with large districts, from district
centers to health units that treat TB patients. For example, East Java
Province, Indonesia, with 35 million inhabitants and 38 districts, had
only two provincial supervisors.

TBCTA has provided training for health care staff in monitoring tools
and methods (via supervisory checklists, monitoring meetings, etc.),
offered assistance with transportation and per diem, and, in some cases,
has supplied additional staff for extended supervisory visits. These
activities need to be maintained during and after DOTS expansion.

There is general agreement on the content of the information system used
in DOTS programs. But in many settings, the basic problem in TB control
has always been that TB registers are neither complete nor updated,
something that is not improved by the move from handwritten to
electronic registers. Some locations have introduced electronic TB
registers (Botswana; parts of South Africa; East Java, Indonesia).
Electronic registers can be quite useful in settings with good computer
facilities, especially if the caseload is large, but handwritten
registers should usually be maintained as well, unless frequent
printouts have proven sufficient. Where computer facilities are less
accessible, or where power outages are frequent, handwritten registers
should be maintained.

Registers do not always function well; in one lung clinic in Indonesia,
for example, not enough computer time is available for data entry; and
because the handwritten TB register had not been updated, no data were
available for review during supervisory visits. In Brazil, the nominal
notification system for infectious diseases (known as SINAN) is also
used as the main system for TB surveillance, but SINAN has a series of
weaknesses. TB registers were introduced many years ago, but they are
not in active use. It is hard to see how one can produce complete data
on treatment outcome without district TB registers along with stronger
supervision in provinces and districts. Ideally, the nominative system
and quarterly reports may strengthen each other, but priority should be
given to ensure good-quality TB registers.

**Innovation and creativity.** TBCTA has been a catalyst for new ideas,
including the following:

-   Regular workshops for a network of nurses and allied professionals,
    for which USAID funds are important

-   A management course in India that was organized when management
    problems at the national level became apparent

-   A new TB supervisor's manual, designed in Central Java

-   Innovative information booklets, designed in Indonesia

-   Health policy discussions with more focus

### III.A.4. Conclusions

**Meeting global demands for technical assistance.** The TBCTA partners
have traditionally provided technical assistance in the form of
scheduled semiannual country program reviews by an experienced TB
expert. This remains valid, but it is insufficient. In the presence of
large Global Fund grants and links to the WHO 3×5 Initiative, additional
short-term and long-term technical assistance, along with a more agile
approach, are needed to accelerate DOTS. Newer models of providing
technical assistance (including more topic-specific experts) have
gradually been established by TBCTA, but often with significant delays.

**Expanding technical assistance capacity.** The number of high-level
international TB consultants is quite limited, despite efforts by TBCTA
to expand the consultant base. TBCTA partnership programs to train
junior consultants and prepare domestic TB specialists for international
responsibilities are just gaining momentum and should be carefully
evaluated prior to expansion. An untapped pool of experienced personnel
from developing countries (i.e., ex-national TB program managers) is
increasingly available.

**Trained cadre of TB program specialists.** Increased training for key
TB staff from target countries has been a key element of TBCTA
activities. TBCTA funds for international and regional training courses
have improved course planning and greatly increased participation in
existing courses in strategic planning, laboratory skills, and
operational research. Gaps in training have been identified and new
courses have been developed and presented for TB human resource managers
and program managers. To meet national and sub-national training needs,
a well-conceived, stepwise approach has been adopted, most fully in
Indonesia and South Africa. The model has been most fully applied in
Indonesia, and will be evaluated in March 2004. The results are expected
to lead to replication in other countries.

**Laboratory improvements.** Laboratory services are often a weak link
in TB control programs. TBCTA has supported the strengthening of
laboratory networks and the use of quality control measures for smear
microscopy, which is the basis for TB diagnosis. Both technical
assistance and national laboratory training courses have been offered in
many countries. Microscopes and reagents have also been procured. Most
countries need further strengthening of microscopy networks. Technical
assistance, training, and equipment have been provided to reference
laboratories to ensure sufficient proficiency for participation in
WHO/Union drug-resistance surveys. Training courses on standardization
of drug susceptibility test methods have been conducted. While all
requisite conditions are still not in place in several countries, they
are expected to be in place in Brazil, D.R. Congo, Indonesia, and a few
other countries by 2004--2005.

**Supervision, monitoring, and information systems.** The quality of
supervision and the completeness and accuracy of TB data are weak in
many countries. TBCTA has supported training in monitoring tools and
methods, and supplied funds for transportation and per diem, and in some
cases, additional staff. These activities need to be maintained during
and after DOTS expansion.

**Program sustainability.** TBCTA support to national TB programs via
strategic planning, technical assistance, training, laboratory
improvements, and more supervision is likely to lead to sustained
improvement in TB program performance. The careful, stepwise approach to
expansion of DOTS coverage is appropriate and cost-effective for
avoiding multi-drug resistance associated with poorly administered
treatment. The major constraint to program sustainability is the low
level of host-country financing, which is inadequate to continue
donor-supported programs at their present levels. TBCTA has done little
to develop advocacy tools or to carry out training that could be used to
encourage the greater funding needed to sustain TB programs.

## III.B. Integration and Collaboration Objectives

### III.B.1. Collaboration and cooperation with international TB programs and initiatives

The coalition has been quite effective in linking its actions in an
almost ideal fashion to the major international TB programs and
initiatives, including the Stop TB Partnership and its Global Plan to
Stop TB, the Global TB Drug Facility, the Global Fund to Fight AIDS,
Tuberculosis and Malaria, and the Green Light Committee. TBCTA
semiannual visits and field activities provide valuable information to
key coalition partners (KNCV, the UNION, WHO, and CDC), and are used in
decision-making processes by the Stop TB Partnership Coordinating Board,
the Global Drug Facility, the Green Light Committee, and the Global
Fund.

KNCV provides assistance in 25 countries. Of those, 14 also receive
support through TBCTA, and KNCV is the lead TBCTA partner in eight
countries (Cambodia, Dominican Republic, Egypt, Ghana, Indonesia,
Malawi, Mozambique, and South Africa). The UNION is the lead TBCTA
partner in D.R. Congo and Senegal, and WHO is the lead TBCTA partner in
Brazil, El Salvador, Haiti, and Nigeria. Such country-level support
provides "real world" experience and perspectives that are crucially
important to the policy formulation, priority setting, and planning
activities of the major international TB programs and initiatives in
which TBCTA partners participate.

Clearly, the coalition partners have a long history of collaboration.
This collaboration continues to the present, and it has been enhanced by
the creation and functioning of the coalition. In interviews with
leaders and key staff of each of the TBCTA principals, the evaluation
team consistently heard that the coalition has led to stronger and
better collaboration among them, and, significantly, between them and
other international TB programs and initiatives, through which they now
speak with a more collective and influential voice.

**The Stop TB Partnership and the Global Plan to Stop TB.** KNCV, the
UNION, WHO, ATS, and ALA have all played pioneering roles in the
initiatives that led to the Amsterdam Declaration to Stop TB, the
creation of the Stop TB Partnership, and the founding of the GDF. The
UNION, and CDC are active members of the Stop TB Coordinating Board, for
which WHO serves as the host agency. Of the 27 members of the Stop TB
Coordinating Board, the Stop TB Partnership secretariat regards the
TBCTA members as the most important technical partners of its board.

The four key TBCTA partners (KNCV, the UNION, CDC, and WHO) also
participate in various Stop TB working groups that cover such important
areas as DOTS expansion, TB/HIV, DOTS-Plus, and multi-drug resistant TB,
and they contribute to the work of the WHO technical advisory group, the
GDF, and the GLC. These partners are all members of the Strategic and
Technical Advisory Group (STAG) of WHO. The director of KNCV serves as
chairman of STAG, represents the European region of WHO, and
participates as a member of the Stop TB coordinating board.

The Stop TB Partnership Coordinating Board secretariat also values the
contributions the coalition has made to national programs, such as
assisting in the development of proposals to the GDF and the Global
Fund, and for its influence with USAID Missions (e.g., in the Dominican
Republic) to bring greater support to TB programs. The secretariat would
be pleased if TBCTA continued to 2015 because of many contributions it
has made to high quality technical assistance, funding, and advocacy
efforts.

KNCV serves as the secretariat of the International Tuberculosis
Surveillance Center, which was established through the collaboration of
WHO, the UNION, and KNCV.

**The Global Fund to Fight AIDS, Tuberculosis and Malaria.** Established
in January 2002 at the urging of United Nations Secretary-General Kofi
Annan, the Global Fund is an independent agency that raises money from
governments, foundations, and individuals, and funnels those funds to
effective programs that bring greater fairness and efficiency to the
battle against the three diseases.

The first round of Global Fund grants for TB work was announced in April
2002 for proposals from China, Ethiopia, Ghana, India, Indonesia,
Mongolia, Panama, Thailand, Vietnam, and Zambia. The grants totaled
\$295 million; \$48 million in the first year alone. The first-round
grants also provided \$98.3 million for joint TB and HIV proposals,
including \$16.5 million in Year 1 for Moldova, Rwanda, and South
Africa. In Round Two, the Global Fund received proposals totaling
\$881.7 million, and awarded \$255 million over five years, including
\$67.7 million in Year 1 and \$122.5 million in Year 2 to 27 countries,
including the TBCTA countries of Cambodia, D.R. Congo, Egypt, El
Salvador, Mozambique, and Nigeria.

In Round 3, the Global Fund approved a proposal from Haiti. By the last
quarter of 2003, the Global Fund had awarded a total of more than \$2.1
billion in grants, including \$884 million in grants in January 2003,
but only \$623 million in grants in October 2003, for 71 disease
prevention and treatment programs in about 50 countries. The Global Fund
scheduled only one round of awards in 2004, acknowledging that the
demand for funding might outstrip its current resources. To date, about
60 percent of the funds have been awarded to HIV/AIDS programs, 23
percent to malaria programs, and only 17 percent to TB programs.[^54]

As the Global Fund has expanded its support for control activities,
TBCTA support for technical assistance has been particularly useful and
much appreciated in countries that receive TBCTA assistance and in those
also seeking monies from the Global Fund. Brazil is currently preparing
a proposal for Round 4. A TBCTA-assisted proposal for Senegal is under
consideration. The lack or insufficient level of TBCTA assistance in
Cambodia for these purposes was reported by interviewees, and the
evaluation team notes this with concern. For El Salvador, a medical
officer has been appointed as part of the TBCTA workplan. There are no
joint GFATM and TBCTA workplan, but both workplans have been developed
in coordination.

A representative from the UNION is on the technical review panel that
reviews proposals and formulates recommendations for action by the
Global Fund board.[^55]

The availability of Global Fund funds to support service activities (but
not for technical assistance) for the Millennium Development Goals, and
their implications for expanding DOTS, and for the new ISAC initiative
are expected to substantially increase the need and the demand for
technical assistance in the high burden countries, as well as change the
types of technical assistance and the ways that assistance is delivered.
Many TBCTA countries are already asking for more frequent technical
assistance visits of longer duration, or for full-time consultants, both
expatriate and local, as appropriate.

Global Fund focal points at WHO report that new models for technical
assistance are emerging in places such as Kenya and Uganda, where
consultant visits are now scheduled to occur every two months. As the
demand for TBCTA technical assistance increases in cooperation with the
Global Fund and other international TB programs and initiatives, TBCTA
will need to strengthen its capacity to respond, as well as the
flexibility of its response.

Two other international TB initiatives were organized to ensure the
supply of first-line TB drugs for DOTS expansion programs (the Global
Drug Facility) and the supply and rational use of second-line TB drugs
for DOTS-Plus programs (the Green Light Committee). The GDF secretariat
is under the Stop TB Partnership and is housed within WHO. The Green
Light Committee is also hosted by WHO, and, under the DOTS-Plus
multi-drug resistant TB working group, is one of the six working groups
of the Stop TB Partnership. The Global Drug Facility and the Green Light
Committee are discussed below.

**The Global Drug Facility.** The GDF was established in March 2001 to
expand access to high-quality, first-line TB drugs and to prevent
shortages of drugs that could threaten the implementation of DOTS
programs, especially in high-burden countries, and, thereby, to
indirectly facilitate DOTS expansion. GDF has four main activities:

-   Making grants of first-line TB drugs to countries that qualify for
    support

-   Processing applications by a technical review committee, followed by
    an ongoing monitoring and evaluation process to ensure the rational
    use of the drugs within the DOTS system

-   Procuring drugs through a contractual partner on a centralized-pool
    basis and shipping them to a country that then takes responsibility
    for drug management and delivery

-   Mobilizing Stop TB partners to provide technical assistance in areas
    such as preparing the application, setting up in-country drug
    management, and conducting monitoring and evaluation activities

The GDF is one of the most successful initiatives undertaken by the Stop
TB Partnership to date. The TBCTA relationship to the GDF, which is
informal but very effective, involves three principal mechanisms:

1.  Provision of country-level technical assistance to develop work
    plans and proposals, such as KNCV has done in the Dominican Republic
    and El Salvador with TBCTA funding, and in Kenya and Moldova with
    CIDA funding

2.  Provision of TBCTA funding to cover costs that cannot be covered by
    the GDF, such as the customs clearance costs of GDF-funded drugs,
    which KNCV provided with TBCTA funding in Indonesia

3.  Provision of additional technical assistance and support under the
    ISAC initiative, which aims to accelerate DOTS expansion by
    intensified efforts of the DOTS Expansion working group, the Global
    Fund, the GDF, and other partners. Of the 14 TBCTA countries,
    Indonesia has been selected as a Phase I ISAC country for
    intensified action.

The GDF now operates in 56 countries, including nearly all the TBCTA
countries. The PMU reports that, to date, no proposal to the GDF from a
TBCTA country has been rejected for lack of technical assistance
provided by TBCTA. In fact, technical assistance from coalition partners
enables countries to better leverage GDF support.

The Global Fund gave support for multi-drug resistant TB treatment in
some countries that did not receive approval by the GLC in the
beginning. This was unfortunate, but soon an agreement was made that
such drugs should be procured only for programs that had been approved
by the GLC, and this has been followed. For first-line drugs, there is
no mandatory link between the Global Fund and GDF. The concern is that
the Global Fund may fund drugs that governments will buy from suppliers
that do not fulfill international quality standards.

In summary, TBCTA works with the GDF to provide national-level technical
assistance for planning GDF proposals, to review proposals to the GDF,
or both, and informally reports on implementation of GDF-supported
activities in TBCTA countries. Management Sciences for Health generally
provides rational drug management technical assistance and training in
TBCTA and other countries, and WHO provides some support and formal
monitoring of implementation in most countries.

**The Green Light Committee.** The GLC evaluates DOTS-Plus proposals and
recommends qualifying projects for increased access to lower-cost,
high-quality, second-line anti-TB drugs needed for managing multi-drug
resistant TB. WHO and its partners have negotiated the prices, and
access is limited to programs approved by the GLC. Unlike GDF, the GLC
is not a supplier of drugs; rather, it is a technical committee. To
date, the GLC has approved DOTS-Plus proposals from only about 30
countries, in part because the prerequisites are stringent. WHO has only
about 10 consultants available to assist countries to submit their
proposals for DOTS-Plus programs.

TBCTA funds have also been used to fund the required drug-resistance
surveys and to upgrade laboratories. There is a potential role for TBCTA
to help build technical capacity within countries to manage DOTS-Plus
programs and to provide technical assistance for the training programs
needed to implement DOTS-Plus programs. TBCTA decided to support DOTS
and not DOTS-Plus programs, because a functioning DOTS program is a
prerequisite for an effective DOTS-Plus program. DOTS-Plus programs are
also increasingly seen as an integrated part of DOTS programs.
Management Sciences for Health provides technical assistance to many
countries in order to establish the drug management systems needed for
supporting DOTS-Plus programs.

As with the Global Fund, representatives from many of the TBCTA partners
are on the technical review panel that reviews proposals and formulates
recommendations for action by the GDF.

### III.B.2. Establishing linkages between TB and HIV/AIDS control programs

The grant agreement objective---*to develop or strengthen linkages
between TB control programs and HIV/AIDS prevention and treatment*
programs---was vaguely defined, and there has been no focus of
responsibility for this objective within the TBCTA structure.
Additionally, some tension between TB and HIV/AIDS programs exists at
national (and global) levels because of the greater size and influence
of HIV/AIDS programs. Most TB leaders believe that efforts to develop
such linkages must be initiated or financed by HIV/AIDS programs.
Consequently, the team found little evidence of significant coordination
between TB and HIV/AIDS programs at the service-delivery level in most
TBCTA countries. However, one of several initiatives underway in Malawi
with Médecins Sans Frontièrs offers possibly the best model for
delivering antiretrovirals, but it needs to address sustainability.
Other initiatives are being planned in Mozambique, Nigeria, Senegal,
(four pilot projects), and South Africa. In Indonesia, KNCV (via TBCTA),
Family Health International, the national TB program, and the HIV/AIDS
sub-directorate of the Ministry of Health are developing an initiative
to provide joint TB-HIV/AIDS services in ten prisons in Java.

While helpful guidelines for implementing collaborative, or at least
cooperative, TB and HIV program activities[^56] have been developed
recently by WHO's Department of HIV/AIDS and Stop TB Department within
the context of its strategic framework to decrease the burden of
TB-HIV,[^57] the general WHO experience to date appears to be that the
early attempts to implement collaborative TB-HIV programs, particularly
integrated TB-HIV programs, were difficult. WHO has piloted TB-HIV
models in several countries and is planning initiatives in D.R. Congo
and Haiti. However, the integration has not been attempted at any large
scale.

But the rationale for well-coordinated joint TB and HIV/AIDS programs is
compelling[^58] and the increasing use of antiretroviral drugs makes
coordination between TB and HIV/AIDS programs especially urgent.
Interventions to control TB in high HIV-prevalence countries involve
interventions directly against TB (prevention of new cases, and case
detection and treatment) and interventions against HIV, including the
prevention of HIV transmission and the provision of antiretroviral
treatment to increase and maintain immune function. The new strategy for
TB control in high HIV prevalence populations and the organization of
service delivery for joint TB-HIV/AIDS programs are summarized in the
previous two graphics.

Joint TB-HIV/AIDS programs are good for patients and good for health
systems because they can substantially improve both the efficiency and
the quality of service delivery. WHO, which assisted operations research
projects in Malawi, South Africa, Zambia, and Zimbabwe, concluded that
joint TB-HIV programs could increase efficiency by up to six times while
improving the quality, effectiveness, and affordability of clinical
care. While Malawi is seen to be the current "intellectual leader" in
this field, other good models are emerging in Kenya, Tanzania, and
Uganda.

Some TBCTA partners see the possibility that TBCTA could make
significant contributions in the important field of TB-HIV joint
programs through the following:

-   Continued participation in the Stop TB Partnership TB-HIV Working
    Group that meets annually

-   Participation in the Stop TB Partnership TB-HIV core group meetings
    that are held three to four times annually

-   Country-level technical assistance to plan and implement TB-HIV/AIDS
    projects, and operations research in this area

Two TBCTA partners, WHO and CDC, would like to do more to strengthen
coordination between TB and HIV/AIDS programs, while the UNION has a new
USAID grant to carry out TB-HIV/AIDS operations research. Therefore,
TBCTA has some excellent opportunities to make important contributions
to this field by:

-   The PMU's identifying a focal point of responsibility within the
    TBCTA structure, giving this objective a higher priority, and
    playing a more assertive leadership role during the remainder of the
    grant period

-   Facilitating a process involving KNCV, the UNION, CDC, and WHO that
    could help plan a few major national-level initiatives by the end of
    the current grant period for implementation in a possible extended
    grant period, or through a future TBCTA grant

### III.B.3. Strengthening linkages between TB control programs and multi-drug resistant TB efforts

TBCTA rightly decided to focus its efforts on the prevention of
multi-drug resistant TB by establishing effective DOTS programs. As more
countries have established DOTS programs, several have recently been
approved by the GLC for multi-drug resistant TB treatment or are in the
process of obtaining GLC approval, often with funding from the Global
Fund.

In Egypt, where more than 300 cases of multi-drug resistant TB have been
identified, pilot multi-drug resistant centers are being established,
and the first cohort of 70 patients with multi-drug resistant TB will
soon receive treatment with funding from the Global Fund.

In many cases, TBCTA personnel have assisted national teams in the
planning and preparation of Global Fund applications and, thereby,
facilitated planning for multi-drug resistant TB treatment activities to
be integrated within national TB programs.

Brazil, however, has taken a different approach. The multi-drug
resistant TB treatment program is operated as a separate program,
coordinated by the Helio Fraga Institute. Multi-drug resistant TB
treatment takes place at provincial hospitals and without consistent,
direct observation. The use of unusual treatment regimes for new cases
and re-treatment, the lack of direct observation, and incomplete
information about treatment results could unnecessarily substantially
increase the risk of developing an even more serious multi-drug
resistant TB public health problem in Brazil. A senior team from TBCTA
(representing WHO, the UNION, KNCV, and the Pan American Health
Organization) on a visit to Brazil's Ministry of Health and the Helio
Fraga Institute could play a useful role to help correct this
situation.[^59]

### III.B.4. Integrating TB control efforts within primary health care services more effectively

In most countries, TB is now diagnosed and treated in general health
facilities and is therefore integrated into the general health system. A
basic approach to the integration of selected TB control activities at
the primary health care level has been established in Indonesia where a
well-developed and staffed network of primary health care facilities
exists at the district and subdistrict levels of the government health
system. Each health worker at a primary health facility is assigned
responsibility for conducting information, education, and communication
(IEC) activities within a specified number of villages in order to
promote greater awareness about TB, to create greater demand for TB
services, to identify suspect cases, and to facilitate referral of
suspect cases to a "referral health center" that has a microscope. For
each referral health center there are three to five satellite health
centers without microscopes (smears are taken and sent to the referral
health center), where direct observation of treatment can occur after
the diagnosis is confirmed by the referral health center. Health center
staff perform village-level IEC, and coordinate suspect case detection
and referrals.

The Indonesia national TB program does not use the community-based
primary health clinic infrastructure that, in Central Java, for example,
includes more than 46,000 village health posts (*posyandu)*, 4,000
village family health care *polindas*, and 4,000 village midwives. The
Central Java government's priority is to create some 5,000 village-level
polyclinics, in part through community financing, which might eventually
be used for supporting a community-based DOTS program. Another
fundamental challenge for the national TB program in Central and East
Java is that most patients with TB choose not to go to the public health
centers; rather, they attend private clinics or public lung clinics.

In Brazil, several different models are being tested in different areas.
The Family Health Program, which operates in 92 municipalities, has
developed two DOTS models: one model is based at municipal health
centers and uses community health workers (called community health
"agents"), and another model that is also based at a municipal health
centers, but does not use community health agents. The roles of
community health agents are to raise awareness about TB, and to detect
and refer suspected TB cases mainly on the basis of respiratory
symptoms.

The Johns Hopkins University is conducting research in three areas of
Rio de Janeiro (AP10, AP5.1, and AP2.1) using different treatment
regimes, organizational approaches, and incentives to increase
compliance and reduce default rates, but the local Pan American Health
Organization TB advisor is skeptical because, in that person's opinion,
the approaches being tested would not be replicable and sustainable on a
national scale because of the high cost of financial incentives (food
vouchers, and bus tokens to cover transportation costs). One area,
AP2.1, is testing a decentralized DOTS approach that uses 40 community
health agents in a large slum with 9,000 residents, a church with two
nurses that serves as an "advanced health post," and three health
centers. The Johns Hopkins research hypothesis is that using community
health agents and incentives will improve cure rates more than routine
care will. The Johns Hopkins research projects deserve to be watched and
the results widely shared if cure rates are substantially improved, as
is expected; however, there appears to be a communication problem
between the Johns Hopkins research team and others working in the Brazil
TB community.

Another approach being used in Brazil is that of the largest NGOs,
BEMFAM. BEMFAM originally worked in reproductive health, family
planning, and maternal and child health, but has expanded its roles into
the fields of TB and HIV/AIDS. More than 1,000 municipalities in 16
states of northeastern, central, and southeastern Brazil have contracts
with BEMFAM. It has resident staff in nine of the 16 states in which it
works, and it operates 3 laboratories, one in Rio de Janeiro and two in
other states. BEMFAM aims to train community health agents in IEC, case
detection and referral, and treatment observation; to rapidly improve
DOTS coverage; to reduce default rates; and to improve treatment success
rates wherever it works. BEMFAM also seeks to integrate TB control and
primary health care services, and eventually to integrate TB and
HIV/AIDS services.

In countries without a well-developed health system or primary health
care network, such as in many African and Caribbean nations, NGOs and
faith-based mission health services can play useful roles in TB control
programs, at least by providing behavior change communication (BCC),
suspect case detection and referral services at the primary health care
and community levels, and by establishing community-based DOTS programs.
In D.R. Congo, for example, NGOs and faith-based mission health services
are prevalent throughout the country and provide the preponderance of
health care, given the weaknesses of the government health care system.
Of the 514 health zones in D.R. Congo, SANRU, the NGO umbrella
organization that is supported in part by Inter-Church Medical
Assistance (IMA, based in Maryland), has provided integrated primary
health care services and DOTS in 56 health zones since 2002. The
National League Against TB and Leprosy, another NGO in D.R. Congo,
provides social mobilization and integrated primary health care
services, including TB services, in 47 zones. The Damien Foundation,
which is supported by the American Leprosy Mission and similar
organizations in Germany (ALTI) and Belgium (LNAC), is a major NGO that
works in TB and leprosy control in D.R. Congo, and has been credited
with overcoming structural problems related to the weak government
health system. The Leprosy Mission International operates five leprosy
and TB projects that use health communicators for BCC work, but it might
stop its TB work as services from other organizations become available
in its areas.

It is interesting to note that the Country Coordinating Mechanism for
D.R. Congo includes four representatives from the Ministry of Health,
four from other government ministries (International Cooperation,
Planning, Finance, and the Stock Exchange Association), four United
Nations and European Union representatives, and ten representatives from
faith-based organizations and NGOs (including the Damien Foundation, the
Network of National Health NGOs, the NGO's AIDS Forum, National Anti-TB
League, Médecins Sans Frontières, and BASICS).

More guidance is needed on the nuts and bolts of how to promote,
establish, and sustain effective community involvement in support of TB
programs. In D.R. Congo, the Global Fund-funded TB program has a major
element focused on community involvement, but the national TB program
does not know quite how to proceed because the one-day-per-year "polio
eradication model" that had been so successful for polio is entirely
inappropriate for TB control programs. USAID in that country wanted to
promote community involvement too quickly, before the TB program
operations were sufficiently established and capable of meeting the
demand created by the heightened community awareness.

While some countries have made steady progress in using NGOs (e.g.,
Brazil, D.R. Congo, Indonesia), village organizations (e.g., Ghana),
community health workers (e.g., Brazil, D.R. Congo, Malawi), and in
integrating TB and primary health care services (e.g., D.R. Congo,
Malawi, Nigeria), several countries and USAID Missions have sought
guidance on how to best organize and use NGOs, community-based
organizations, community health workers, and volunteers to support TB
control efforts, and in methods to effectively integrate TB control
efforts within primary health care services. Unfortunately, there is
currently no focus of responsibility within the TBCTA structure for
capturing the valuable lessons that can be learned from field
initiatives that have begun or are planned, nor for promoting this
important objective.

A greater degree of TBCTA involvement in working with NGOs, faith-based
organizations, and other current and potential partners, and in
promoting more community-based activities, especially where joint
TB-HIV/AIDS programs are needed at the primary health care and community
levels, would be a "win-win" advance for the various national TB
programs and USAID Missions, as well as for TBCTA partners (particularly
KNCV) in order to develop greater capacities and provide more assertive
leadership for these crucial areas.

### III.B.5. Engaging private practitioners and hospitals in TB control programs

In countries with a strong private medical care system, the engagement
of private hospitals, clinics, and medical practitioners into the TB
control program is crucially important. In Indonesia, many patients with
TB are diagnosed and treated by the private sector, but these cases are
not reported, their treatments are not directly observed, and a high
proportion of these cases default. Therefore, these data do not enter
the TB control program database and they represent a significant risk
for the creation of multi-drug resistant TB. Advocacy with local and
national medical societies, postgraduate medical schools, and senior
health and other government leaders is urgently needed and will be
undertaken in provinces where the problem is recognized, such as Central
Java.[^60] This problem is not very well recognized in many countries.

In the Philippines, TBCTA helped design a private-sector-focused project
that was then "bid" by USAID/Philippines; although TBCTA could not place
a bid because it is not an American NGO, it would like to periodically
evaluate the program and seek important lessons that could be of value
in other TBCTA-assisted countries.

In many traditional societies, the traditional private practitioners
(traditional birth attendants, traditional healers, herbalists,
acupuncturists, spiritualists, etc.) can be engaged for providing
valuable BCC services to help raise awareness about TB, to detect
suspect cases based on symptoms, and to refer suspect cases to the
nearest DOTS centers for treatment.

TBCTA could play a useful role by establishing advocacy guidelines for
use in these situations, as well as for other situations described in
this report.

### III.B.6. Collaboration and cooperation with other USAID-funded agencies and stakeholders

A high level of collaboration and cooperation exists in most countries
between TBCTA and its principal client, the national TB program, and
other USAID-funded cooperative agencies, stakeholders, and groups
working in TB control. In Indonesia, for example, KNCV, the lead TBCTA
partner, regularly participates in the TB Partnership Forum, which
includes most NGOs and other donors, faith-based organizations, WHO, and
USAID implementing partners, such as Project Concern International and
others.[^61] KNCV and Indonesia's national TB program maintain close
working relations with the following organizations:

-   Koalisi untuk Indonesia Sehat (KuIS, the Coalition for Healthy
    Indonesia, an organization established through collaboration with
    The Johns Hopkins University Bloomberg School of Public Health
    Center for Communication Programs), which focuses on
    coalition-building and advocacy for demand creation, and which will
    be used at the district level to promote advocacy for health
    education and behavioral change with respect to DOTS

-   Aksi Top AIDS (ASA/STI/HIV/AIDS Prevention Support Project)
    implemented by Family Health International in collaboration with the
    Directorate General of Communicable Disease Control and
    Environmental Health of the Ministry of Health

-   Management and Leadership Program implemented by Management Sciences
    for Health, which provides assistance with drug management and
    logistics, and clearance and distribution of GDF drugs, and in
    preparing provinces and districts for distribution of GDF fixed-dose
    combinations through training and the upgrading of stores

In most countries, TBCTA has a positive cooperative and collaborative
relationship with Management Sciences for Health where it provides RPM+
training for DOTS and DOTS-Plus programs.

In Egypt, TBCTA collaborated effectively with the Naval Medical Research
Unit 3 (NAMRU-3), which provided assistance to strengthen the TB
laboratories used by the national TB program.

While TBCTA activities have been somewhat limited in Brazil, several
emerging programs deserve TBCTA attention, such as the USAID-funded
project PACS/FHP (the Community Health Agents and Family Health
Projects) and some NGOs, such as BEMFAM, to strengthen monitoring,
supervision, evaluation, and training in the priority municipalities
participating in the DOTS expansion program.

The team found only two projects in which cooperation could be improved:

1.  The Johns Hopkins University research projects in Rio de Janeiro
    (for which TBCTA should not be faulted, because the problem appears
    to be on the Johns Hopkins side), which could provide valuable
    lessons for the national TB program and TBCTA, and the problem might
    be resolved by the diplomatic intervention of USAID; and

2.  The Helio Fraga Institute in Brazil, which is in noncompliance with
    internationally accepted standards and procedures, and which poses a
    potential threat to a worsening of multi-drug resistant TB. The
    problem might be most effectively addressed by a senior team visit
    of TBCTA partners (WHO, Pan American Health Organization, the UNION,
    and KNCV) to the Ministry of Health and to the Helio Fraga
    Institute. The current RPM+ technical assistance activities with the
    Helio Fraga Institute, including decentralization of multi-drug
    resistant TB treatment, could also lead to modifications that would
    strengthen the project.

### III.B.7. Conclusions

**Collaboration and cooperation with international TB programs and
initiatives.** The coalition has been effective in linking its actions
in an almost ideal fashion to the major international TB programs and
initiatives. TBCTA semiannual visits and field activities provide
valuable information to key coalition partners that is then used in the
decision-making processes of the Stop TB Coordinating Board, the GDF,
the Global Fund, and the GLC.

**Establishing linkages between TB and HIV/AIDS programs.** This grant
agreement objective was vaguely defined, and there has been no focus of
responsibility for this objective within the TBCTA structure. Some
tension between TB and HIV/AIDS programs exists at national and global
levels because of the greater size and influence of HIV/AIDS programs;
most TB leaders believe that efforts to develop such linkages must be
initiated or financed by HIV/AIDS programs. The team found little
evidence of significant coordination between TB and HIV/AIDS programs at
the service-delivery level; however, such initiatives are taking place
in Malawi and are being planned in Mozambique, Nigeria, Senegal, and
South Africa. The increased use of antiretroviral drugs makes
coordination even more urgent. Two TBCTA partners, WHO and CDC, would
like to do more to strengthen coordination between TB and HIV/AIDS
programs, whereas the UNION has a new USAID grant to carry out
TB-HIV/AIDS operations research.

**Strengthening linkages between TB control programs and multi-drug
resistant TB efforts.** TBCTA rightly decided to focus its efforts on
the prevention of multi-drug resistant TB by establishing effective DOTS
programs. As more countries have established DOTS programs, several have
recently been approved by the GLC for multi-drug resistant TB treatment
or are in the process of obtaining GLC approval, often with Global Fund
funding. In many cases, TBCTA personnel have facilitated the integration
of multi-drug resistant TB treatment activities within national TB
programs. Brazil needs gentle TBCTA advocacy to encourage fuller
adherence to international standards.

**More effective integration of TB control efforts within primary health
care services.** TB diagnosis and treatment are typically provided in
general health facilities and are, therefore, integrated into the
general health system. A basic approach to the integration of selected
TB control activities at the service-delivery level has been established
in Indonesia where there is a well-developed and staffed primary health
care network. In countries without a well-developed network, NGOs and
mission health services can play useful roles in BCC, and TB
case-detection at the primary health care and community levels. Several
countries and USAID Missions have sought guidance on the best ways to
organize and use NGOs, community-based organizations, community health
workers, and volunteers to support TB control efforts, and on the best
ways to more effectively integrate TB control efforts with primary
health care services. Unfortunately, there is currently no focus of
responsibility within the TBCTA structure for capturing the valuable
lessons that can be learned from field initiatives that have begun or
are planned, nor for promoting this important objective.

**Engaging private practitioners and hospitals in TB control programs.**
In countries with a strong private medical health care system, the
integration of private hospitals and medical practitioners into the TB
control program is crucially important. In Indonesia, many patients with
TB are diagnosed and treated by private-sector practitioners, but these
cases are not reported, their treatments are not directly observed, and
a high proportion of these patients default on their treatment.
Therefore, these case data do not enter the TB control program database
and they represent a significant risk for creating multi-drug resistant
TB. Advocacy among local and national medical societies, postgraduate
medical schools, and senior health and other government leaders is
needed. TBCTA could play a useful role by establishing advocacy
guidelines for use in this situation, as well as for other situations
described in this report.

**Collaboration and cooperation with other USAID-funded agencies and
stakeholders.** In most TBCTA countries, collaboration and cooperation
exist between TBCTA and other USAID cooperative agencies, stakeholders,
and organizations. The TB Partnership Forum in Indonesia, for example,
brings together all NGOs working in TB control, the national TB program,
other donors, and faith-based organizations to improve coordination,
discuss common problems and seek solutions, share experiences, and
improve performance. Also, TBCTA has close relationships with:
Management Sciences for Health, which provides leadership and management
training; a Johns Hopkins University-assisted organization, the
Coalition for Healthy Indonesia (KuIS), which seeks to strengthen
advocacy for health education and behavior change with respect to DOTS;
and the Family Health International-led STI/HIV/IDS Prevention Support
Program in Indonesia. TBCTA practices similar levels of collaboration in
almost all countries.

# IV. Program Administration and Management

## IV.A. TBCTA Management

### IV.A.1. Management structure and efficiency

The TBCTA was established as an entity to manage and execute a USAID
cooperative agreement. Although TBCTA is open to receiving funds from
other donors, this has not yet occurred. The structure for program
management established by the six partners consisted of (1) a board of
directors that meets quarterly to make major decisions, and (2) a
program management unit, located at KNCV headquarters in The Hague, The
Netherlands, that manages the program on a day-to-day basis.[^62] KNCV
is the "grantee" organization that has operational subagreements with
each of its TBCTA partners.[^63]

A major delay was encountered in establishing the TBCTA operational
structure. The drafting of partner subagreements and operational
procedures involved several contentious issues (a common indirect cost
rate, WHO adherence to the same procedures as the NGO partners, audit
requirements) among the partners who had never formally worked together.
USAID review of draft subagreements and the eventual approval of these
common subagreements occurred only two years after the grant had been
signed. USAID and KNCV finally concurred in exempting WHO from the
common procedures of the other NGO partners.[^64] With few exceptions,
USAID funds did not flow from the PMU to the partners until the
subagreements had been signed, so program activities by the partners
were significantly delayed for 12--24 months, except when they advanced
their own funds for TBCTA activities.

Over time, in addition to the board of the directors and the PMU, two
additional mechanisms were established to facilitate program management
and coordination: (1) two task forces---training and advocacy---that
meet regularly with representatives from each partner and from USAID;
and (2) a more informal proposal review caucus, with representatives
from the key operational partners (KNCV, the UNION, and WHO). The
proposal review caucus meets annually to discuss and prioritize for the
board the partner's proposals to use core funding. Annual costs for the
PMU and program management, including the costs of quarterly board
meetings, total approximately \$1 million---about one-third of the "core
funds" provided by USAID/Washington. A portion of these costs relates to
the travel costs associated with board meetings.

The proposal significantly underestimated the person-power that would be
required to manage the USAID agreement, especially the time needed to
manage the magnitude of USAID Mission-funded activities that were not
anticipated by TBCTA. The PMU was initially to be led on a part-time
basis by a senior KNCV officer (50 percent and 75 percent over the first
two years) who would be supported by two newly hired, full-time PMU
staff members. A full-time director began work in September 2002. At
present, the PMU consists of a full-time project director, two program
staff, a financial administrator, an assistant financial administrator,
a human resources specialist, and a part-time coordinator for the Task
Force for Training. In addition, the director of KNCV allocates 10
percent of his time to the TBCTA, as does the KNCV director of finance
and organization, whereas the head of KNCV international programs
allocates 25 percent of his time to the TBCTA. All staff presently at
the PMU had little or no previous experience working with USAID. The
learning curve for understanding complex USAID regulations has been
steep. KNCV and UNION personnel have noted that USAID regulation
complexity is the most complex among their various donors, giving it a
rating of 5 on a 1--5 scale.

The TBCTA partners have been cautious or reluctant to immediately and
fully agree to several USAID regulations and procedures, especially
those that appear to conflict with European law (especially labor
laws[^65]), customary practice (travel procedures, timekeeping for
salaried employees), or those that would require a significant change in
a partner's operating procedures (organization-wide financial tracking
and reporting, standard \$500/day fee for consultants).[^66] The need to
resolve administrative matters dominated board meetings for the first 18
months of the grant. Over time, these issues have gradually been
resolved, usually by complying with standard USAID practice. However, in
some cases (travel procedures, salary ceilings) USAID initially required
TBCTA to follow contractor guidelines rather than USAID's more flexible
set of grantee guidelines. At this point, all partners appear to have in
place the appropriate written procedures required for USAID grantees
with one exception: basing a consultant's fee on his or her salary
history.

**Efficiency.** TBCTA decision-making normally occurs at quarterly
meetings---a process that is highly unusual for USAID-funded
organizations in which the prime grantee or contractor typically makes
decisions at its project headquarters, often without the need to consult
subcontractors or subgrantees. The somewhat less-immediate TBCTA
decision-making process reflects the collaborative needs of a true
partnership, which brings other significant advantages to this program
not typically found in prime-sub relationships. The advantages of
decision-making with all partners present include enhanced collaboration
and program knowledge that have often been translated into close
partner-to-partner cooperation to resolve country-specific problems, and
into greater institutional knowledge that often flows into deliberations
of the Stop TB Partnership, the Global Fund, the GDF and the GLC. The
PMU has, gradually, assumed some responsibility for making timely
decisions between board meetings, and it has used the Internet more
effectively to obtain partner agreement on urgent matters.

The TBCTA structure appears to function relatively efficiently for
decision-making and disbursement of monies from core funds. However,
USAID Missions have reported major delays in TBCTA decision-making and
in transferring funds for Mission-funded programs. In some cases, such
as vehicle and laboratory equipment procurement, the delays have been
partially due to time needed for USAID to process "source and origin"
procurement waivers, and, in some cases, to international shipping
restrictions during the second Gulf War. However, in other
circumstances, the PMU believes it has not had sufficient authority to
push a tardy partner or it has been overly collegial with the TBCTA
partners by not following up to ensure timely implementation of key
actions in a country work plan. Examples of this include the 18-month
delay in WHO follow-up for the Cambodia program,[^67] an 18-month delay
in moving from the assessment stage to the implementation stage in El
Salvador, and the delay in Brazil noted earlier in this report, which is
also partially due to actions taken and not taken by USAID/Brazil. In
addition, there was a half-year delay in initiating the Egypt program
due to the war in Iraq. Although the key consultant identified by the
TBCTA could not obtain a visa for more than a year, initial
responsibilities were covered by other TBCTA visits.

The PMU itself, although now strengthened with a well-qualified,
full-time project director, includes only one individual with
significant international experience and no one with significant
experience working with USAID procedures. Many functions typically
carried out by staff, such as preparing annual reports, making field
monitoring visits, and managing a monitoring and evaluation system, fall
primarily on the project director, who also continues to provide
technical leadership and support for certain program activities.

The task force mechanism was established first with the Task Force for
Training. The terms of reference for the TFT and its relationship to the
board were not clearly established until Year 3 of the program. The TFT
showed only modest results initially, especially at the country level,
largely because TFT members were each fully employed on other matters by
their institutions and could not spend much time on TFT matters between
meetings. This situation was improved in Year 3 with the hiring of extra
staff. A full-time PMU employee now supports the TFT on human resource
development issues at the country level, in addition to the part-time
PMU employee who has continued to coordinate the TFT. The Advocacy Task
Force, which was established only in Year 3, may need similar dedicated
personnel support to be effective.

The organization of responsibilities within the TBCTA is clearly
established for (1) the execution of each core-funded project, and (2)
the lead role of a particular partner for each Mission-funded program.
However, for some cross-cutting program objectives, such as TB-HIV
collaboration and TB--primary health care coordination, no individual or
organization within the TBCTA structure has been given primary
responsibility to achieve these objectives, so they have been given
little attention.

### IV.A.2. Program and grant management

The TBCTA proposal described an anticipated set of program activities:
"the provision of technical consultation and assistance, building local
organizational and human resource capacity, and expanding the Stop TB
Initiative's network of organizations and institutions ...".[^68] In
addition, "as appropriate," the TBCTA planned to "establish a mechanism
for USAID field missions to easily access support or technical
assistance for TB control. The TBCTA, then in cooperation with national
authorities and other in-country partners, can 'contract' appropriately
qualified indigenous human resources or institutions to provide
technical assistance and monitoring, purchase supplies and equipment and
fund selected national program activities, and provide
supervision."[^69]

Twenty separate USAID organizational units (14 Missions and five
regional programs or offices, in additional to USAID/Washington core
funding) have decided to utilize the TBCTA program and have transferred
funds to the TBCTA (i.e., they have "bought into" the TBCTA concept).
The financial transfers to date have varied with the largest buy-in from
Indonesia (almost \$5 million), to the smallest buy-in of \$150,000 from
Mozambique.

Each of these 20 units has provided its own unique scope of work for
TBCTA to carry out. The scope of the activities that USAID Missions and
regional offices have requested has been much more diverse than
anticipated in the grant proposal. Missions have often anticipated that
TBCTA---the only centrally funded organization available to provide TB
support until 2003---would provide the same set of program-wide services
that traditional health grantees and contractors have provided, such as
family planning and child survival. This typically includes commodity
procurement, hiring local staff, providing some program operating costs,
running training programs, and working on a day-to-day basis with the
host government and other local partners. In many cases, the Missions
anticipated that TBCTA, like the traditional grantees/contractors, would
establish an in-country office to manage the Mission resources and
coordinate with the USAID Mission on a daily basis.

TBCTA's performance in managing USAID Mission funds has been mixed.
Success stories exist in Indonesia, D.R. Congo, and the Dominican
Republic; whereas performance execution in Brazil, Cambodia, and El
Salvador[^70] clearly has been disappointing.[^71] In most other
countries, performance has been acceptable and is getting better. On the
basis of the evaluation team's field visits, questionnaire responses
from other USAID Missions and national TB program coordinators, and
TBCTA self-assessments, the TBCTA program strengths generally include
the following: (1) it has offered excellent support for strategic
planning and coordination; (2) it provides very high quality technical
assistance; (3) its training is appropriate and effective; and (4) it
has taken a measured stepwise approach to institutional strengthening.
Its major weaknesses have been: (1) insufficient in-country management
capacity, (2) delays in responding to some technical assistance
requests, (3) slow procurement of commodities, and (4) difficulties in
transferring funds to the field.

Problems often have started with the planning process, although the
initial planning process started well. Despite the administrative
problems described above, initial advocacy visits to encourage USAID
Missions (and national TB program managers) to use TBCTA services were
carried out on a timely basis (in 2001 and early 2002) in 15 countries.
These visits often led directly to the development of TBCTA work plans,
ideally with the participation of TBCTA, the national TB program, and
the USAID Mission. A positive example is found in Indonesia, where a
five-year, \$8 million strategy was designed by the TBCTA, the national
TB program, and the USAID Mission. Annual work plans have been prepared
easily, reflecting the availability of USAID incremental funding and
implementation progress to date.

The work plan process, while important, often has been overly laborious
and time-consuming for at least two reasons. First, multiyear (or
life-of-project) strategies or work plans have rarely been prepared. The
USAID agreement with TBCTA specifically requires annual work plans be
approved by the cognizant technical officer (CTO). This has been
interpreted by operational personnel to mean that, even if a long-term
strategy has been approved, annual work plan approval by the CTO is
still necessary. Second, work plans have often been reviewed and
approved ad seriatim. The normal process has been that work plans are
prepared by the TBCTA with the national TB program and submitted to the
USAID Mission for approval; then, once approved, they are forwarded to
USAID/Washington for comments, changes, and eventual approval; then they
are sent with any changes to TBCTA for its final approval at the next
quarterly board meeting. This process could be significantly shorted to
only one or two days if, as recently occurred in Egypt and Nigeria, a
TBCTA representative, the national TB program, a USAID/Washington staff
person on temporary duty, and the USAID Mission would all meet to review
the work plan. If the USAID/Washington official could not travel to the
country in question, that person's inclusion in the deliberations via
speakerphone would normally also be feasible.

TBCTA expenditures may not begin simply because a work plan has been
approved. Once the board approves a work plan, the lead partner must
submit to the PMU a detailed request for funding. The PMU then requests
a funds transfer from USAID/Washington for the work plan, unless
sufficient pipeline funds are already available. Once USAID/Washington
provides an allotment of funds to the PMU, these funds are eventually
transferred to the lead partner's headquarters. The partner then may
spend the funds from the headquarters as appropriate, or it may transfer
the funds to a local partner (e.g., the KNCV office in Indonesia; the
Pan American Health Organization (PAHO) office in Brazil) or to an
executing partner (e.g., the Ligue Nationale Antituberculeuse et
Antilepreuse du Congo in D.R. Congo). This last step has proven
difficult for WHO and PAHO in both Brazil and Haiti, in part because WHO
funds must pass through PAHO/Washington before they are re-allocated to
a country PAHO office.[^72] Funds for all major international commodity
procurements are not transferred to the lead partner by the PMU, but are
transferred to a procurement subcontractor that is familiar with USAID
regulations. Delays can occur and often have occurred at any stage of
this lengthy chain of events. Half of participating USAID Missions
reported significant delays in TBCTA performance; however, almost all
participating Missions also indicated that TBCTA performance had
improved recently and said they hope to continue to use TBCTA services.

Program management is often identified by USAID Missions as being
related to a lack of TBCTA in-country presence. In most countries, TBCTA
partners do not have local offices (the exceptions are the traditional
WHO (and PAHO) offices in all of the TBCTA "lead" countries, and the new
KNCV office in Indonesia). For other countries, problem-solving or
trouble-shooting support must come from the partner's headquarters or
from the PMU, neither of which has excess personnel for short turnaround
visits. KNCV headquarters finally agreed to the need for a KNCV office
in Indonesia after a year of requests from USAID/Indonesia, which had
allocated the large sum of \$5 million to TBCTA. This model should be
closely evaluated by TBCTA to determine its effectiveness. In theory, it
should provide: (1) much closer monitoring of TBCTA/USAID funds,
especially those funds that flow down to provincial and district health
programs, (2) more timely problem identification and resolution, and (3)
more timely reporting and communication to USAID. The annual cost of
this office and its four staff is approximately \$82,000 excluding the
costs of the expatriate staff director.[^73] This cost is shared between
USAID, CIDA, and the Dutch Government---the three donors whose funds are
managed by the local KNCV office.

Another option for onsite management of TBCTA resources at the country
level has occurred in D.R. Congo, where funds are transferred to and
managed by a traditional KNCV partner (Ligue Nationale Antituberculeuse
et Entilepreuse du Congo), and yet another option is found by working
through WHO/PAHO offices in the Latin America and the Caribbean region.
For several countries (e.g., Brazil, D.R. Congo, Indonesia, and South
Africa) significant amounts of money are being expended to expand
provincial, district, state, or municipal DOTS programs. Monitoring the
decentralized use of these funds will require careful and periodic
oversight, which probably should include periodic trips by PMU personnel
to complement the technical visits of TBCTA technical experts.

The willingness and ability of WHO to implement TBCTA in-country
programs are still not certain. Although WHO/Geneva staff members are
dedicated to supporting TBCTA implementation, in Brazil, the WHO/PAHO
office director and staff have several times expressed reluctance to
take on additional project management responsibilities for the TBCTA
with the level of monitoring that is required.[^74] Although WHO is not
the lead agency in Indonesia, its leadership and staff have been
reluctant until recently to add wearing the hat of a cooperating TBCTA
partner to their traditional roles. WHO performance in Cambodia was
disappointing, with a major 18-month delay in the WHO regional
representative (based in Hanoi) following up to help execute a TBCTA
work plan. TBCTA leadership has subsequently been transferred to KNCV. A
similar 18-month delay occurred in finalizing a work plan in El
Salvador. WHO performance in Haiti, prior to the present turbulence, was
reported to be problematic by the USAID mission. However, in several
other TBCTA countries, WHO has proven to be a very valued TBCTA partner
as the most effective conduit for hiring additional national TB program
or provincial staff members, using TBCTA funds from other partners.

## IV.B. Financial Management

### IV.B.1. Systemic differences

Resolving the significant differences between the traditional financial
and administrative management procedures of the European TBCTA partners
(KNCV and the UNION) and USAID has been time-consuming and has only been
gradually and partially resolved.[^75] Some key examples of differences
between American and European systems include: (1) timekeeping---weekly
time sheets are not normally required in Europe; (2) consultant
fees---KNCV traditionally has paid its cadre of senior consultants a fee
based on each consultant's salary history; however, to simplify TBCTA
planning and budgeting, the TBCTA partners decided to use a standard
daily fee for TBCTA activities (equivalent to approximately \$500/day);
and (3) personnel policies---European NGO personnel policies are, in
fact, a collaborative bargaining agreement negotiated between the NGO
and its staff, within the context of standardized agreements between the
unions and the working sector.

Differences among the TBCTA partners have also caused the following
problems and delays: (1) attempts to agree on a common indirect cost
rate for the project failed---the KNCV charges 110 percent on labor
costs, while the UNION charges 22 percent on all project-related
costs[^76]; (2) attempts to agree on a common text for TBCTA partner
subagreements failed when it became apparent that WHO could not use NGO
guidelines but should, rather, use its internationally established
procedures[^77]; and (3) traditional travel regulations and per diem
rates differed among the partners.

USAID's inexplicable failure to conduct a pre-award survey of the TBCTA
partners is generally acknowledged to have been a major reason why the
partners only gradually became aware of their need to either change some
of their traditional practices to meet USAID requirements or to request
that USAID be flexible on some requirements. Problems were addressed
individually and only when they became apparent to the USAID CTO or to
the TBCTA.

### IV.B.2. Staffing and systems

The TBCTA realized the need for a full-time financial director for the
PMU, and this person (a seasoned specialist but with no USAID project
experience) began in September 2001.[^78] Presently, the PMU includes
this person and one assistant financial administrator. The UNION has
hired one full-time person to manage and monitor TBCTA funding and
expenditures, whereas a WHO staff member dedicates part of her time to
all TBCTA activities.[^79]

The financial tracking system at KNCV is considered old and has
difficulty segregating and reporting on the complexity of TBCTA funding
(i.e., 20 difference sources of USAID funds; transfer of funds to four
primary TBCTA partners and to subgrantees). The continuing difficulty
with this system is evident from the nature of the most recent PMU
financial reports, which appear in Annex C. The UNION, in contrast, has
just completed an upgrade to complete its financial management system
(at a cost of approximately \$50,000).[^80]

### IV.B.3. Financial reporting

Despite PMU efforts, some TBCTA partners have not provided complete
financial reports in a timely fashion, which complicates the ability of
the PMU to provide simple, straightforward reports to USAID. USAID
presently requires a quarterly expenditure report and six month
financial report. WHO, however, provides reports only on a six-month
basis, which complicates this process due to its status as an United
Nation agency. The financial reporting format and accompanying narrative
established by the PMU meet USAID's basic requirements, but leave the
USAID/Washington CTO and officers in the 19 other contributing USAID
Missions and offices with uncertainties and questions. Clear and
detailed semiannual financial reports are particularly important because
the TBCTA is not required to send any additional country-specific
financial reports directly to USAID Missions or regional offices. USAID
Missions and regional offices must rely on the financial data provided
in the semiannual reports. Some changes to be considered are these:

-   Not all funds included in the "transferred to partner" column have
    indeed been transferred to a partner. Funds for all international
    commodity procurement, except for the UNION, are transferred to the
    TBCTA procurement subcontractor. In recent reports, some funds that
    had been "transferred" to WHO had actually been transferred to the
    procurement subcontractor.

-   Accrued expenditures (in addition to actual expenditures) are not
    estimated.

-   Planned expenditures for the next reporting period are not
    indicated.

-   Until January 2004, there had been no discussion of the program
    pipeline or an estimate of the "burn rates" for USAID funding.

### IV.B.4. Cost sharing

Based on the TBCTA proposal, the cooperative agreement requires \$5
million in cost-sharing over the life of the program. TBCTA has not yet
reported any such cost-sharing, in part because of uncertainty on what
items would be accepted by USAID as cost-sharing and because it was
believed that the reporting need only be performed by the end of the
grant period. WHO has offered to provide the evidence of cost-sharing in
relation to its "lead" activities, many of which are funded by several
sources. A quick review indicates that there is no doubt that TBCTA will
meet (and can exceed) the \$5 million cost-sharing target. However, the
absence of periodic reporting on progress in meeting this goal
unnecessarily raises questions among USAID managers.

### IV.B.5. Transferring funds

The process for moving funds through the TBCTA system appears to be
unusually slow and cumbersome. The delays that accompany this process
account for some of the delay in carrying out country work plans. USAID
and TBCTA financial managers should review opportunities for simplifying
this process.

As noted above, WHO has had a particularly difficult time moving funds
expeditiously through its PAHO/Washington office to PAHO/Brazil,[^81]
and expending funds via PAHO/Haiti.

### IV.B.6. Financial monitoring

The most vulnerable elements of the TBCTA program and financial
management system are: (1) transferring funds to sub-grantees, such as
the "Ligue" in D.R. Congo, and (2) transferring funds to provincial or
district government bodies to pay for local cost activities (e.g.,
training courses, travel costs, supervision visits), as in Indonesia.
The KNCV office in Indonesia plans to monitor these expenditures
closely; and financial/administrative procedures have been formalized in
the form of a manual. District and provincial officials can receive
their monthly funding allotments only after receipt, review, and
acceptance of their accounting documents for the previous month.
However, in countries without a local TBCTA partner office, financial
monitoring will be less frequent and will require periodic monitoring
and inspection visits from the TBCTA partner's home office or from the
PMU.

### IV.B.7. Audit

The first (annual) audit of TBCTA is behind schedule and has not yet
been completed. The audit process for the TBCTA is complex, because both
ALA and ATS do not require an audit (because they expend less than
\$300,000/year), whereas WHO follows its standard practice as an
international organization of being audited once every two years.

KNCV did undergo an external audit from a USAID-certified European firm
in 2003; however, the UNION was not audited in the same period.[^82]
USAID took the unusual step of requesting a USAID audit of the TBCTA (by
the Defense Contract Audit Agency) in February 2003, and the draft audit
report was issued in September 2003. The audit remains incomplete due to
the absence of a subcontractor audit report from the UNION. The one
significant finding of the draft report is that TBCTA/KNCV consultant
fee charges totaling approximately \$1,200,000 are "unsupported due to a
lack of timekeeping system." KNCV and UNION have both now instituted new
timekeeping systems for TBCTA (KNCV from January 2003 and the UNION from
January 2004).

### IV.B.8. TBCTA cost recovery

**Exchange rate fluctuations.** The increasing weakness of the dollar in
relation to the euro over the past 18 months has clearly affected
TBCTA's ability to recover the costs of TBCTA program operations. The
TBCTA proposal budget assumed a 1:1 exchange rate between the dollar and
the euro; the rate when this report was written was 1:1.3, a 30 percent
decrease in the value of the dollar in relation to the euro. Therefore,
the PMU indicates that it presently bills consultant costs to USAID at
the rate of \$1,050 per day (including indirect costs); while their true
costs are approximately \$1,700/day.

**Charging indirect costs to Mission-funded programs.** TBCTA has shown
its inexperience with complex USAID programs, until recently, by
expending USAID Mission funds without charging those Missions an
indirect cost fee. More recent Year 4 Mission budgets now include an
indirect cost line item.

### IV.B.9. Pipeline

The TBCTA has been overwhelmed with the level of USAID Mission funding
already obligated into the cooperative agreement. The level of core
funding (approximately \$3 million/year) has been obligated at planned
levels, but the high level of USAID demand for TBCTA services has
required USAID/Washington to raise the program ceiling by almost 50
percent, from \$28.6 million to almost \$44 million. As noted above,
especially in the first year of the program, some USAID Missions quickly
obligated end-of-year TB-earmarked funds into the agreement without
having first performed a careful joint review with TBCTA of the
estimates of work plan costs.

While TBCTA expenditures rates are growing with TBCTA's experience, as
of February 18, 2004, the pipeline remains unusually high (see Annex C):
\$30.1 million has been obligated into the agreement (the most recent
obligation in September 2003). Core funding obligations have totaled
approximately \$12.7 million, whereas field Mission and regional office
buy-ins have contributed \$17.345 million, or about 58 percent.
Eighty-eight percent of the obligated funds are earmarked for approved
TBCTA work plans, whereas only 57 percent (\$17.3 million) has been
transferred to TBCTA partners. Total expenditures were only \$9.545
million, about 32 percent of the funds obligated. Therefore, the total
pipeline is approximately \$22 million, of which approximately 20
percent consists of core funds and 80 percent is Mission funds.

The burn rate for the past six months has increased to approximately \$1
million/month (a breakdown is not available in PMU reports to delineate
the burn rates of core and Mission funds). The highest ratios of
expenditures to obligations occur in Indonesia, Malawi, the Latin
America and the Caribbean Region, D.R. Congo, and Dominican Republic
(where at least 30 percent of obligations have been expended). TBCTA
estimates that program expenditures will increase significantly during
the remainder of original grant period (through September 2005).

Unfortunately, actual and estimated burn rates for each country and
regional office were not available until late January, 2004 when a
meeting in The Hague with PMU, KNCV, the UNION and WHO focused on the
pipeline issue and an estimate of the 'burn rates' for USAID funding.
Minutes of the meeting were then shared with the evaluation team and
distributed in the board meeting, February 2004.

## IV.C. Reporting

The TBCTA is new to the expectations of reporting to USAID, and several
improvements are desirable.

First, timing must be improved. TBCTA reports have been late, or worse,
nonexistent. No annual report for Year 1 of the project was submitted
because the USAID CTO accepted the quarterly reports as adequate
reporting. At the request of the second CTO and in accordance with the
cooperative agreement, a combined report for Years 1 and 2 was
eventually submitted in November 2003. The Year 3 annual report is still
in draft form four months after the end of the calendar year. Presently,
the CTO requires only that TBCTA submit annual reports. Quarterly
reports are no longer required.

Second, the content of performance reports does not meet USAID
expectations and does not show the work of the partnership in its best
possible light. Performance reports have largely listed a series of
activities such as consultancies and training courses carried out by the
TBCTA. USAID expects, however, that reporting be "results focused."
Project inputs can, of course, be delineated, but should be placed
within the context of outputs and the expected outcomes. Also, the TBCTA
reports have focused almost exclusively on the USAID-financed inputs and
have not explained how these inputs combine with other actions (by
Global Fund and GLC, and complementary activities by the host government
or other donors) to lead toward program objectives that are normally
shared by a national TB program and TBCTA.

Finally, the TBCTA reports have not met the needs of USAID Missions. The
grant agreement does not require separate TBCTA reports to each
participating USAID Mission. Most Missions complain that they see almost
no reporting on TBCTA activities in their country.[^83] Typically, a
one-page country summary is prepared as an annex to TBCTA reports. This
level of detail is far less than expected by Missions that may be
contributing \$1 million/year for TBCTA activities, and which must
report to USAID/Washington annually on the progress of their health
portfolios.

Reports within the TBCTA system, as much as possible, should be
coordinated with reporting within national TB programs. Ideally,
national programs would produce quarterly and annual progress reports to
their own Ministry of Health, which would also fulfill many of the needs
of the different donors and collaborators.

### IV.C.1. Information sharing

The TBCTA has done little to prepare documents that share the positive
(and negative) results of their work within the TBCTA system or with
other TB entities outside of TBCTA. For example, a very creative and
effective ten-page illustrated brochure designed by a TBCTA-funded
Indonesian staff member in Central Java has not yet been reprinted and
made available throughout Central Java or elsewhere in Indonesia.[^84]
Similarly, a well-conceived supervisory journal from Indonesia that
links traditional TB reporting with management decision-making could be
replicated for use elsewhere in Indonesia and perhaps adapted for
broader use in other countries. A first step in such information sharing
has been the introduction of a periodic TBCTA newsletter, but thus far
these newsletters have had a very limited purpose and limited
circulation.

## IV.D. USAID Management

### IV.D.1. Program design

USAID was not formally involved in the design of the TBCTA program, but
instead it responded to an unsolicited proposal prepared by the TBCTA.
Nevertheless, some farsighted USAID officers played several key roles
by:

-   anticipating the need for a TBCTA-type mechanism to provide
    high-level technical support to USAID/Washington and to USAID
    Missions when the U.S. Congress began to earmark health funds for
    tuberculosis in FY 1998

-   supporting the novel concept of a partnership modality to provide
    this assistance, where the best talent would be pooled rather than
    divided through a series of smaller grants to individual entities

-   supporting the unusual implementing mechanism (for USAID) of making
    a grant to a European NGO as the lead entity of the partnership

-   recommending a retired USAID health officer to assist the TBCTA in
    the design of their proposal

Once the initial TBCTA proposal was submitted to USAID in early 2000,
USAID responded quickly and positively with a few programmatic
suggestions, such as including a component for training additional TB
consultants, along with several questions regarding the proposed budget
and management structure. A revised proposal was submitted on June 23,
2000, and was rapidly approved. The USAID Office of Procurement was
asked to prepare and sign a collaborative agreement with the TBCTA prior
to the end of the fiscal year (September 30).

Unfortunately, at this stage of the "design" process, USAID officers
made a series of errors that had significant negative effects on program
performance. These mistakes and omissions would probably have been
recognized quickly by an organization with substantial experience
working with USAID. However, this new USAID recipient did not recognize
many of them, nor were the mistakes immediately recognized by the
program's USAID CTO, a recently hired TB specialist who was herself new
to USAID regulations and procedures.[^85] These mistakes and omissions,
finally, were also not identified by supervisors or clearance officers
in the Global Health Bureau or in the Office of Procurement. Mistakes
and omissions include the following:

1.  The procurement officer did not order a preaward survey of grantee
    administrative and financial procedures and capacity. This standard
    step for any new USAID grantee would probably have immediately
    identified (and suggested ways to resolve) many of the
    administrative and financial management differences between European
    and U.S. (e.g., USAID) systems that plagued the early years of the
    program.[^86]

2.  The procurement code for this grant to a European-led partnership
    was inexplicably "U.S. only" (Code 000), even though it explicitly
    anticipated subgrants to other European organizations (i.e., the
    UNION) and to an international organization (WHO). This was only
    corrected with modification #7 on July 15, 2002, when Code 935 was
    approved for procurement of technical services and for subagreements
    with non-U.S. recipients.[^87] However, Code 000 still remains in
    effect for procurement of commodities and equipment, which has led
    to a series of time-consuming waiver requests for laboratory
    equipment, microscopes, and vehicles.

3.  The indirect cost rate was mistyped or miscopied as 1.01 rather than
    the 1.10 clearly stated in the TBCTA proposal. Consequently, the
    total ceiling for the five-year grant was miscalculated in the
    original agreement. This was corrected in modification #2 on May 22,
    2001, and the total award level was increased from \$26,012,288 to
    \$28,161,573.

4.  Several important USAID standard provisions for a cooperative
    agreement were omitted from the award document. The TBCTA partners
    were not formally aware of many key USAID requirements.

5.  The cooperative agreement provided no guidance to the TBCTA on the
    programmatic and financial management of USAID Mission funds that
    were anticipated to make up more than 50 percent of the program
    ceiling. The grant language did not prepare the TBCTA for the wide
    range of Mission-requested assistance that would be requested---well
    beyond the scope of assistance anticipated by the TBCTA in its
    proposal.

6.  Finally, the CTO and her office in the Bureau of Global Health were
    unable to obtain a copy of the cooperative agreement from the Office
    of Procurement until nearly six months after the agreement had been
    signed.

### IV.D.2. Program execution---contract and financial management

USAID's performance in facilitating the work of the TBCTA was
technically strong (see below), but inadequate on administrative and
grant management issues. Problems were not foreseen and resolved early
in the grant period, but were addressed one-by-one as they surfaced.
Problem resolution was typically quite slow. TBCTA proposals and
requests seemed to receive little priority in USAID/Washington. The
first set of sub-agreements among the TBCTA partners was transmitted to
USAID in the spring of 2001 (about six months into program
implementation). Responding to USAID concerns and questions, they were
resent in October 2001 and January 2002, and were not approved by USAID
until July 2002.[^88]

Problems that were gradually identified and slowly resolved include: (1)
use of U.S. Government or United Nations per diem rates for travel (U.N.
rates were eventually approved); (2) use of U.S. Government or grantee
travel regulations (grantee travel regulations were accepted, with the
variation that U.S. carriers should be used, whenever possible); (3)
ceiling for consultant daily fees (USAID incorrectly advised TBCTA that
it must abide by the ceiling for USAID contractors---there is no such
ceiling for grantees if the fee can be justified[^89]); (4) timekeeping
procedures for employees (USAID has required that the partners adopt
weekly time sheets---a practice not typically used by European NGOs for
salaried employees---this practice was instituted in January 2004 by
KNCV and the UNION); (5) use of a standard daily fee of \$500 for
consultants (USAID has not accepted this standard practice by KNCV and
the UNION and is requiring a salary history and individual rate for each
consultant).

USAID resolution of many of these issues was slow, and sometimes (in
points 1--3 above) the verbal advice provided was initially incorrect.
Communication between the USAID CTO and the USAID/Washington
procurement, financial management, and legal offices appears to have
been very limited, especially in the first two years.[^90] The
procurement officer responsible for the grant changed repeatedly over
the first two years, making continuity difficult.

The grant has also been burdened by the delays inherent in preparing and
processing procurement waivers, especially for microscopes, laboratory
equipment, and vehicles. Unfortunately, procurement authorities would
not approve a blanket waiver for microscopes and laboratory equipment
that would have covered all anticipated needs through the life of the
grant, so individual waivers have been laboriously processed.[^91]

### IV.D.3. Coordination of field support funding

The TBCTA partners, as noted above, were initially surprised at the
broad scope of USAID Mission requests for TBCTA assistance (especially
commodity procurement, and local cost expenditures for salaries and
provincial/district activities). The CTO and other USAID/Washington
officers (e.g., health officers in regional bureaus) publicized the new
grant through e-mails, phone calls, and country visits as a ready
mechanism to help USAID Missions decide how to use their new TB funding.
Especially in the grant's first year, USAID Missions sometimes
transferred substantial funds into the TBCTA (e.g., Senegal) without
prior discussion with TBCTA on a budget. These Missions assumed (and
apparently were not disabused by USAID/Washington) that the TBCTA
agreement was structured like a traditional USAID/Washington "flagship"
grant (e.g., BASICS for child survival and Partners for Health Reform
*plus* for health reform). Despite these surprises, TBCTA never refused
to accept any proposed Mission funding, although in Senegal, it strongly
disagreed with a key component of the USAID proposed work plan and
eventually convinced the Mission to delay a community support component.

Communication between USAID/Washington and Missions regarding the new
TBCTA was reported to be good on technical matters, but very limited on
administrative matters. Most Missions report that communication from and
with USAID/Washington regarding TBCTA is adequate, although a few
describe USAID/Washington as proactive and helpful in resolving problems
(e.g., Haiti), whereas others report an absence of good communication
and delays in problem resolution (e.g., El Salvador).

Due probably to Mission staff turnover, several USAID Missions report
that they have limited information about the TBCTA program.
Unfortunately, two TBCTA requests to make explanatory presentations at
regional state-of-the-art meetings for health officers were not
approved.[^92]

CTO approval of annual work plans is one of the areas of "substantive
involvement" formally written into the cooperative agreement. This has
been interpreted to also include USAID/Washington review and approval of
annual work plans for each participating USAID Mission or regional
program. Thus, in the absence of multiyear strategies or work plans, up
to 18 work plans each year require USAID/Washington review and approval.
This review process has generally been handled efficiently, but there
have been major delays in work plan approvals for Brazil and D.R. Congo.
Work plan preparation and approval have best been accomplished when
representatives from TBCTA, USAID/Washington, the USAID Mission, and the
national TB program work together in the host country, as has occurred
in Egypt and Nigeria.

In 2003, a more experienced USAID officer with field experience was
appointed as CTO. Her previous experience and her interest in
problem-resolution for management and program issues are reported by
TBCTA to have made a major difference in just a short period of time.

### IV.D.4. Program execution---technical management

The quality of USAID technical management of the TBCTA collaborative
agreement has consistently been excellent, in contrast to the contract
and administrative management. From the initiation of the program, USAID
technical officers have participated in TBCTA country advocacy visits
and as contributing members of the TFT. TBCTA views USAID/Washington
comments on annual work plans as being very helpful. TBCTA is pleased
that USAID has not forced a particular technical philosophy upon the
TBCTA. USAID technical officers in Washington and in Missions have
accepted the TBCTA philosophy of subordinating a "USAID TB strategy"
within the international framework of the Stop TB Alliance and, in
individual countries, within the national framework of the national TB
program. The two USAID CTOs and other members of the USAID/Washington
technical team have, however, pushed the envelope by encouraging the
TBCTA to focus some attention on new topics and new program activities.
Examples include USAID's suggestion, in response to the first TBCTA
draft proposal, to include a project component to increase the number of
international consultants (the junior consultant program), a topic that
other donors had refused to fund in the past. USAID has supported the
establishment of a new management-training course for TB managers and
support networks for nurses working primarily in TB.

USAID/Washington managers have been strong advocates of the TBCTA
program with USAID Mission personnel. They have aggressively encouraged
TBCTA to make initial advocacy visits to a wide variety of countries,
including some countries where the USAID Mission subsequently decided
not to include the TBCTA in its country program (e.g., India,
Philippines and Uganda).

### IV.D.5. Collaboration with partners

The purpose statement in the TBCTA proposal included a goal "to
strengthen the Coalition of partners to more efficiently and
qualitatively work together in their collective efforts to reduce TB."
Aside from the "partners" included in the Stop TB Partnership and host
countries, these partners are the other entities that make up the
USAID-funded TB portfolio in Washington (RPM+, three TASC II TB
organizations), and the USAID-funded TB portfolio in each Mission where
TBCTA works.

USAID offices and Missions, as the funding entities, also have a
traditional role to play in facilitating collaboration among their
partners. Thus, USAID/Washington has encouraged and facilitated positive
interaction between TBCTA, the RPM+ Project, and the three TASC II
contractors. Little appears to have been done, however, to link TBCTA
more closely with USAID/Washington-funded HIV/AIDS program contractors
and grantees.

Although some USAID Missions use only TBCTA for all TB-funded
activities, most have funded a gradually broadening portfolio of at
least two to four organizations (often RPM+ for drug management and
local institutions for BCC or for community participation activities).
One standard operating practice for most Missions is to bring their
portfolio "partners" together at least once or twice a year under the
USAID aegis. These meetings would not replace or substitute for meetings
that a national TB program should normally organize each year with all
its partners, but would focus on ensuring that USAID partners were
complementing each other well within the context of USAID Mission health
sector objectives and had a common understanding in technical issues.
Although evidence is light, these USAID portfolio meetings do not seem
to be occurring as regularly as one might expect, and there is little
indication that USAID Missions have aggressively tried to link TBCTA to
USAID-funded HIV/AIDS implementing organizations.

## IV.E. Conclusions

### IV.E.1. TBCTA management

In the beginning of the TBCTA program, the TBCTA internal structure had
major adjustment problems, but it has functioned surprisingly well for
such an eclectic coalition of international and national organizations,
and European and U.S. NGOs. Some major problems (i.e., transferring
funds through the WHO/PAHO structure) remain unresolved. TBCTA personnel
are still learning USAID procedures and USAID expectations. The PMU has
not been sufficiently exigent in monitoring the responsibilities of the
partners. TBCTA management of core funds is reasonably good, but
efficient management of USAID Mission funds has been significantly below
Mission expectations. The evaluation team has prepared several
recommendations for which improvements in TBCTA internal efficiency are
quickly needed and for which program and financial reporting need to be
improved.

### IV.E.2. USAID management

Initially, USAID management of this grant was inadequate to foresee and
to resolve serious grant management issues (Global Health Bureau) and
inept regarding procurement matters (Office of Procurement). For both
offices, supervision was neither sufficient nor adequate to avoid or to
address these problems in a timely fashion. USAID's procurement office
has been slow to respond in resolving these problems, despite an
effective CTO. On the other hand, USAID technical management of the
program has been consistently strong. Technical management has suggested
and supported positive and innovative initiatives.

# V. Recommendations

## V.A. Recommendations for the Remainder of the Grant Period

### V.A.1. Programmatic recommendations

1\. After a thorough internal program review and pipeline analysis,
TBCTA should request a grant extension of at least one year to make up
for the first "lost" year of program operations and to allow more
complete achievement of program objectives. A USAID response needs to be
provided quickly, but no later than June 2004.

2\. TBCTA and USAID should determine what additional field support funds
can be reasonably accepted into the program, given the existing
pipelines and the present (or extended) grant period. USAID Missions
should be advised as soon as possible to facilitate final Fiscal Year
2004 decisions on the use of field support funds.

3\. TBCTA country work plans normally should not require annual
USAID/Washington approval if they are based on approved medium-term
development plans and if adequate funding is available. USAID Mission
approval should be sufficient. TBCTA should ensure that all its senior
consultants are fully informed of the menu of services and activities
that TBCTA can provide for use in country work plans.

4\. TBCTA should be proactive in identifying good models and locales for
TB and HIV cross-referral and coordinated treatment related to the
President's Emergency Plan for AIDS Relief and the WHO 3×5 Initiative.
The TBCTA has an excellent opportunity to play a more assertive
leadership role by giving this objective a higher priority and
facilitating a process involving WHO, CDC, and the UNION during the
remainder of the grant period. The TBCTA should indicate a focal point
for TB-HIV activities issues.

5\. The Advocacy Task Force should respond aggressively to address
identified needs (adherence to DOTS and multi-drug resistant TB in
Brazil, and private sector involvement and budget increases in
Indonesia).

6\. TBCTA-funded technical assistance that might be provided in concert
with the recent Intensified Support and Action Countries Initiative
should be carefully designed to avoid undercutting low-paid national TB
program staff, and to ensure sustainable improvements.

The evaluation team offers these additional recommendations:

7\. TBCTA and USAID should review the lengthy process and many steps
between work plan preparation and funding allocations to a country
program with the objective of reducing the lengthy time taken to date
(e.g., all key parties could meet simultaneously to discuss and approve
a new work plan, such as occurs in Brazil).

8\. Consultants' half-yearly reports could be more related to the
objectives of the national TB programs. The technical assistance could
also stimulate further the routine reporting by a national TB program to
the upper levels of the Ministry of Health with copies to donors, which
would cover some parts of consultants' travel reports.

9\. Given the increasing concern of global multi-drug resistant TB,
TBCTA should raise the issue of direct supervision and seek
modifications to reduce the risk of producing multi-drug resistant TB.

10\. The program to train junior consultants should be carefully
evaluated before being expanded. Experienced personnel leaving national
TB programs should be considered as candidates to receive further
training as consultants who could also do the work as part-time
consultants besides working at central level in their own national TB
programs. Their curriculum should be adjusted to the current needs that
are more diverse than they were before.

11\. Operational research should have as its main focus to build up
research capacity in the country, as much as possible within and
involving a national TB program.

### V.A.2. Implementation, monitoring, and reporting recommendations

12\. The PMU needs to play a more assertive role in ensuring timely
implementation by all partners. This should include administrative
monitoring visits where TBCTA programs include significant provincial
and district activities.

13\. TBCTA program reports should focused on results rather than on
activities. More in-depth country annexes should be provided directly to
participating USAID Missions to meet their monitoring and reporting
needs. TBCTA should strengthen its practically nonexistent monitoring
and evaluation system and should quickly finalize process indicators to
help measure project progress.

14\. Financial reports provided to USAID/Washington (and to USAID
Missions) would be much more useful if they were more timely and were
expanded to include accrued expenditures and expected expenditures for
the next reporting period.

15\. The PMU should gather "lessons learned" and models of program
success, and disseminate them through various means throughout its
program network, to USAID, and to other key TB entities.

16\. To ensure effective coordination, USAID Missions should organize
periodic meetings of all its TB-funded implementing agencies. In some
cases, these meetings should include USAID's key HIV-funded implementing
agencies.

## V.B. Key Recommendations Beyond the Grant Period

**USAID role.** USAID has now entered the TB arena and, with core and
field support funds, has begun to finance programs and activities that
are widely respected because they fill important gaps, provide added
value, and add a major stimulus to the Stop TB initiative. USAID should
continue to be a major bilateral TB program donor, probably through the
Millennium Goal period (2015).

**Constraints to DOTS expansion---core-funded activities.** There will
continue to be a strong demand for the primary core-funded activities
financed via TBCTA to provide essential, complementary support to
expanding field programs funded via the Global Fund, USAID, CIDA, and
TB-HIV initiatives. Significant constraints to DOTS expansion are
addressed through these activities that include program coordination,
especially linkages to the Global Fund, GDF, and GLC; international and
regional training programs to greatly expand the TB capability in least
developed countries for program leadership, planning, research and
management, and operational research; establishing nursing and other
provider networks; preparing advocacy tools; stimulating private sector
involvement with and adherence to DOTS; and encouraging appropriate
social mobilization models. Increased attention should be placed on
developing effective TB-HIV program coordination, multi-drug resistant
TB, private sector involvement, and social mobilization.

**Constraints to DOTS expansion---Mission-funded activities.** In
countries with at least moderately strong public health systems (i.e.,
those in South and Southeast Asia, and in Latin America and the
Caribbean), the constraints to the expansion of DOTS can be addressed in
five to eight years with a national and provincial program that is
similar to the TBCTA program in Indonesia. This package of USAID-funded
assistance can be implemented at the national level and in a few
provinces. The "capital" that needs to be invested typically includes:
strategic planning; improved data collection systems as key elements of
a monitoring and evaluation program; an upgraded laboratory network; a
well-organized and well-funded domestic in-service training program; and
finally, increased human resources, mobility, and funding for improved
supervision. Additional elements of the program should include working
with the private sector providers of TB services, coordination with HIV
programs, and advocacy to increase host country funding. The model, once
recognized as effective by the host country, can be used for Global Fund
and other donor-assisted provincial TB programs---as it is in Indonesia.

In countries with weak public health systems (i.e., Haiti and most
African nations), the constraints to DOTS expansion are more
intractable, and will require a longer time frame (at least through
2015), greater numbers of consultants to provide long-term technical
assistance, and significant donor support for local cost financing. In
some countries, "capital" investment for DOTS will need to flow to
faith-based health service systems, other NGOs, and via broad
donor-funded rural health initiatives (e.g., SANRU in D.R. Congo), as
well as through the public health system. Experience in several African
countries demonstrates that a strong TB program can be mounted and can
be effective despite the serious systemic constraints that these
countries face. In most of these countries, a stronger link to HIV
activities will be appropriate. A key issue is the gradual assumption of
local cost responsibility for TB programs by the host government, which
probably should be addressed as part of sector-wide health reform/health
financing improvement efforts by the donors.

**Country selection.** TBCTA presently works in eight of the 22
high-burden TB countries, and in six other countries. USAID TB programs
are occurring in some form in eight other high-burden countries. At
present, only three high-burden countries with USAID Missions do not
have some USAID-funded TB activity. Although the TBCTA partners have
limited capacity, they already have worked in many of these non-TBCTA
countries without USAID funding, often performing semiannual planning or
monitoring visits. Unless TB earmarks are increased, USAID will probably
need to select only a few additional countries where it can provide a
substantial level of resources to have a significant impact, or where
relatively modest USAID funding can leverage and provide support to a
major Global Fund grant.

**TBCTA is a unique structure, widely recognized as a positive model for
international collaboration.** Almost without argument, TBCTA includes
the most experienced and respected experts in international TB available
to USAID or any other donor. It would be difficult for USAID to find
another major TB collaborating institution to carry out core-funded
activities, international coordination, and strategic planning and
monitoring for national TB programs at the present level of success.

TBCTA has been stretched to provide the wide variety of country-level
program support that USAID Missions have requested. Managing major
provincial-level or state-level programs and large commodity
procurements has been particularly management-intensive. These efforts,
not elements of TBCTA's comparative advantage, have required a great
deal of TBCTA management time. In the future, several models of
field-level support might be considered:

1.  Core plus limited field support: An agreement with a centrally
    funded entity with a statement of work that includes core-funded
    activities and allows buy-ins of field-level support to countries
    where the entity has been traditionally involved in program
    operations or where USAID plans to make major investments in TB. To
    increase on-the-ground program management capacity, the centrally
    funded entity might be encouraged to establish subgrantee
    relationships with one or two experienced USAID grantees or
    contractors, or with strong local non-TB NGOs, or both. These
    sub-grantees would establish national offices or use existing
    national offices, and would have primary management responsibility
    (but not technical) responsibility for field-level support where
    major provincial support is envisaged. Missions would use TASC II
    contractors or bilateral health program contractors or grantees for
    their other TB needs, especially those at the provincial and
    district levels.

2.  Core only: An agreement with a centrally funded entity with a
    statement of work that is similar to the original TBCTA proposal.
    This would include continuation of TBCTA core-funded activities and
    would include the following services for USAID Missions: "advocacy
    visits"; semiannual senior consultant national TB program
    evaluations; training at international and regional courses for
    selected host country TB personnel; short-term technical assistance
    for program design, evaluation, or redesign; and short-term
    technical assistance for problem resolution.

Under this model, the centrally funded entity would not provide the
following services to USAID Missions: commodity procurement, in-country
training, and in-country provision of local costs for provincial and
district supervision and operations. Instead, USAID Missions would be
encouraged to use TASC II contractors or bilateral health program
contractors for all of the services mentioned in the previous paragraph.

**USAID management of a future program needs to recognize the
international nature of the DOTS expansion effort, as well as its
urgency.** Similar to HIV/AIDS programs, some traditional USAID
regulations should be relaxed (e.g., they should use Code 935
procurement), or they should be waived. In a few transition countries,
such as D.R. Congo, an exception to USAID's prohibition of salary
enhancements should be considered.

# Annex A: List of Contacts

**USAID/Washington**

> Richard Greene, Director, Office of Health, Bureau for Global Health
> (by phone)
>
> Irene Koek, Team leader, Infectious Diseases, Office of Health
>
> Cheri Vincent, CTO, TBCTA, Office of Health
>
> Dr. Clydette Powell, former CTO, TBCTA, Office of Health
>
> Susan Bacheller, Infectious Diseases Team, Office of Health
>
> Dr. Amy Bloom, TB-HIV/AIDS Liaison, Office of HIV/AIDS
>
> Dr. Michael Zeilinger, Director, Infectious Diseases Division, Office
> of Health
>
> Tony Boni, CTO, RPM+ Project, Office of Health
>
> Paul Holmes, Health Officer, E&E Bureau
>
> Harry Pimpong, Office of Procurement
>
> Lisa Bilder, Agreement Officer, Office of Procurement
>
> Andrew Clements, Health Officer, ANE Bureau
>
> Connie Davis, Regional Health Officer, REDSO/E
>
> Peg Marshall, Health Officer, LAC Bureau
>
> Ahsan Malik, Office of Financial Management

**Management Sciences for Health**

> Thomas Moore, MSH, RPM+ Project

**KNCV**

> Dr. Jaap Broekmans, Executive Director
>
> Cees den Haan, Director of Finance and Administration
>
> Dr. Peter Gondrie, Director of International Programs
>
> Dr. Maarten van Cleeff, Director, PMU
>
> Mischa Heeger, Program Officer, PMU
>
> Elsbeth Gosens, Program Officer, PMU
>
> Susanne Verver, Research Officer
>
> Inge Pool, TFT Coordinator, PMU
>
> Max Peterken, Finance Director, PMU
>
> Netty Kamp, Junior Consultant

**International UNION Against Tuberculosis and Lung Disease**

> Dr. Nils Billo, Executive Director
>
> Dr. Paula Fujiwara, Deputy Executive Director
>
> Jose Luis Castro, Director of Finance and Development
>
> Dr. Nadia Ait-Khaled, Senior Consultant and Director of IUATLD Asthma
> Program
>
> Dr. Amaud Trebucq, Director of TB Division
>
> Dr. Hans Rieder,
>
> Francis Plumejeur, Finance Officer

**World Health Organization**

> Dr. Leopold Blanc, Coordinator, TB Strategy and Operations (TBS)
>
> Dr. Malgosia Grzemska, Medical Officer, TBS
>
> Lisa Veron, Technical Officer, TBS
>
> Dr. Mario Raviglione, Director, Stop TB Department
>
> Dr. Marcos Espinal, Executive Secretary, Stop TB Partnership (TBP)
>
> Dr. Paul Nunn, Coordinator, TB/HIV and Drug Resistance (THD)
>
> Dr. Chris Dye, Coordinator, TB Monitoring and Evaluation (TME)
>
> Karin Bergstrom, Scientist, TBS
>
> Dr. Giuliano Gargioni, Medical Officer, TBS

Andrea Godfrey, Technical Officer, TBS

> Yevgeny Goryakin, Technical Officer, GDF, TBP
>
> Dr. Kitty Lambregts, Medical Officer, THD
>
> Gini Arnold, Operations Manager, GDF, TBP

Johanna Shepherd, Technical Officer, TBS (and junior consultant on HRD)

**Centers for Disease Control and Prevention**

> Dr. Charles Wells, TBCTA Coordinator
>
> Wanda Walton, TFT member

**American Thoracic Society**

> Dr. Phillip Hopewell
>
> Dr. Jeffrey Blas, Professor, University of Wisconsin, TFT member

**American Lung Association**

> Francis de Melle, Executive Director

**The Netherlands**

> Harry van Shooten, International Development Corps, Foreign Ministry

**Brazil**

**USAID**

> Richard Goughnour, Director, USAID/Brazil
>
> Patricia Paine, TB Advisor, USAID
>
> Mike Berkley, Health Officer, USAID
>
> Jaime Rojas, HIV/AIDS Coordinator, USAID

**Pan American Health Organization**

> Jacobo Finkelman, Representative
>
> Luis Gerardo Castellanos, Coordinator of Disease Prevention and
> Control

**Centers for Disease Control and Prevention**

> William Brady, Chief of Party and Director of Global AIDS Program

**Ministry of Health**

> Joseney Santos, Manager, National Tuberculosis Program
>
> Marta Cruz, Technical Consultant for Tuberculosis
>
> Denise Garrett, Technical Consultant CDC/USAID/IUATLD
>
> Luiz Fernando Ramos, Technical Consultant for Tuberculosis
>
> Carmen Lucia Muricy

**State of Rio de Janeiro**

> Gilson Cantarino, State Health Secretary of Rio de Janeiro
>
> Lia Seling, ex Coordinator, State TB program
>
> Dr. Lisa Maria de Freitas, new Coordinator, State TB program

**Municipality of Rio de Janeiro**

> Dr. Solange Cavalcanti, Coordinator, TB program

**Helio Fraga Center**

> Dr. Miguel Hiijar, Director
>
> Maria Jose Procopio, Vice Director
>
> Maria das Graces Fermina, Research Dept.
>
> Maria Alice Sigaud, Training Dept.

**Bemfam**

> Dr. Marcio Thome, Coordinator, Dept of Statistics and Evaluation
>
> Dr. Claudia Presotto, Program Officer
>
> Karen ------, Planning Officer

**Management Sciences for Health**

> Karen Lassner, Director MSH/Brazil

**Johns Hopkins University**

> Dr. Bonnie King

Democratic Republic of the Congo

**National TB Program**

> Dr. Etienne Bahati, Director of the NTP
>
> Dr. André Ndongosieme, Deputy Director of the NTP
>
> Dr. Mbulula, Supervisor at the NTP
>
> Mr. Kabuya, Chief of the National Reference Laboratory
>
> Mr. Paulin Kisalambote, Administrator at the NTP
>
> Mr. Ghislain Magaya, Pharmacist at the NTP
>
> Dr. Valentin Bola, TB Coordinator for Kinshasa

**Damien Foundation**

> Dr. Pamphile Lubamba, Director and Country Representative
>
> Dr. Georges Bakaswa, Deputy Director

**Leprosy Mission International**

> Dr. Martin Ndombe, Director
>
> Mr. Alex Nowal, Administrator

**La Ligue National anti Tuberculeuse et anti-Lepreuse**

> Dr. Kaboto, Project Director

**Centre de Santé ELONGA**

> Dr. Nsanie, Physician at the Center
>
> Miss Manzambi, VCT focal point
>
> Mr. Lulendo, Laboratory focal point
>
> Mr. Mambueni, Responsible for the TB Unit

**USAID Mission**

> Mr. Anthony Gambino, Mission Director
>
> Mr. Reginald Hawkins, Health Team Leader
>
> Dr. Emile Bongo, Infectious Diseases Program Management Specialist

**World Health Organization**

> Dr. Leonard Tabsoba, Country Representative
>
> Dr. Henriette Wembanyama, NPO/DRC

**Ministry of Health**

> Mr. Aziz Kumbi, Vice Minister
>
> Dr. Mukengeshay, Director, Cabinet of the Ministry of Health

Indonesia

**USAID**

> Molly Gingerich, Director, HPN Office
>
> Ratna Kurniawati, Team Leader, HIV/AIDS and ID
>
> Jonathan Ross, Public Health Advisor

**KNCV**

> Dr. Benson Hausman, Country Representative, Indonesia
>
> Dr. Jan Voskens, KNCV Senior Consultant

**Centers for Disease Control and Prevention, Ministry of Health**

> Dr. Umar Fahmi Achmade, Director General of Communicable Disease
> Control and Environmental Health
>
> Dr. Rachmat Haikin, Director, Directly Transmitted Disease Control
>
> Dr. Rosmini Day, National TB Program Manager
>
> Dr. Asik Surya, Medical Staff
>
> Dr. Franky Loprang, National Professional Officer (WHO consultant)
>
> Dr. Sri Prinhatini Boestam, WHO consultant
>
> Dr. Triya Novita Dinihari, Medical Officer

**Other USAID partner organizations**

> Peggy Thorpe, First Secretary (Development), Canadian Embassy
>
> Dr. Firdosi Mehta, Medical Officer (TB), WHO/Indonesia
>
> Dr. Yos Eh, Management Sciences for Health
>
> Mark Lediard, Koalisi untuk Indonesia Sehat
>
> Dr. Stephen Wignal, Country Director, Family Health International

**TB Partnership Forum**

> Dr. Halim Danusantoso, PPTI
>
> Sister Margaretha, PERDHAKI
>
> Mary Lengkong, World Vision Indonesia
>
> Nenden, YPIS
>
> Dr. Atikah, Muhammadyah

**Central Java**

## Propinsi

> Dr. Budiharja, DTMH, MPH, Vise of Central Java Health Office
>
> Soenarko, SKM, MQIH, Head of Administration Division
>
> Dr. Kus Sularso, Head of Medical Service Control and Guidance Sector
>
> Dr. Lily Herawat, Mkes, Head of CDC Division
>
> Dr. Endang Agustinar, Mkes, Head of CDC Section
>
> Dr. Sutji Haryati, Staff of CDC Section
>
> Sri Retno Rinjaswati, Staff of CDC Section
>
> Eny Sihmawarni SKM, Staff of CDC Section
>
> Yekti Irmawanti SKM, Staff of CDC Section
>
> Dr. Nurhayanti Mkes, Head of Semarang Lung Clinic
>
> Trining SpM, Director of Wira Bhakti Tamtama, Semarang
>
> Dr. Inggrid Canesya, Head of Medical Service Tugurejo Hospital
>
> Elly Karlina, Staff of Provincial Laboratory
>
> Dr. Dwi Wastoro, SPAK, Child Division of DR Karyadi Section
>
> Dr. Yunita, Mkes, Head of Reference Section
>
> Drg Rosana Medalia, Staff of Health Promotion
>
> Drg Endang Nuraini, PPO TBCTA Central Java
>
> Endang Tri Wahyuningsih, ASO TBCTA Central Java

**Tegal District**

> Dr. Abdul Jalil, Mkes, Head of Tegal Health Office
>
> Riswatiningsih SKM, Head of CDC Section
>
> Ari Dwi Cahyani, SKM, Mkes, Head of CDC Section
>
> Susliastuti, Staff of CDC Section
>
> Djoko Kurnianto, SKM, Mkes, Head of Epidemiology Section
>
> Dr. Sumaryati Bimo, Head of Medical Service Control
>
> Dr. I Made Sutrisna, Head of Promotion
>
> BRA Hastuti, Head of Pharmacy
>
> Aries, Head of Pharmacy Section
>
> Dr. Isriati, Head of Kedung Banteng Health Center
>
> Kholil, Paramedic TB
>
> Darniti, Laboratory Technician TB Kedung Banteng Health Center

**Surakarta Municipality**

> Dr. Purnomo, Mkes, Head of Tegal Health Office
>
> Sri Kuswandari, Mkes, Head of CDC Section
>
> Djoko Hariadi, SKM, Head of CDC Section
>
> Hartati, Staff of CDC Section
>
> Sukito, Staff of CDC Section
>
> Dr. Sri Rahayu, Head of Medical Service Control
>
> Dr. Moelyono, Head of Promotion
>
> Dr. Yanti, Head of Administration Division
>
> Head of 15 health centers in Surakarta
>
> Daljono, Head of PPTI

**Surakarta Lung Clinic**

> Dr. Setiawan Usman, SpP, Head of Surakarta Lung Clinic
>
> Dr. Sri Wulandari, Staff of Surakarta Lung Clinic
>
> Dr. Aisyah, Staff of Surakarta Lung Clinic
>
> Dr. M. Syahril Mansyur, SpP, Pulmonologist of Surakarta Lung Clinic
>
> Dr. Hadi Subroto Wiryokusumo, SpP(K) MARS, Head of PDPI Indonesia
>
> Sri Surani, Administration of Surakarta Lung Clinic
>
> Sriyani, Administration of Surakarta Lung Clinic
>
> 3 laboratory technicians

**East Java**

> Dr. A. Ratgono, Head of CDC Division
>
> Dr. Achmad Djaelani, Section Head of CDC
>
> Dr. Djoko S. Rahardjo DTMH, PPO KNCV -- TBCTA SBY
>
> Sri Kushandojo, SKM, Wasor TB
>
> Muktiyo Suryadi, SKM, Wasor TB
>
> Sri Waras SKM, Mkes, Wasor TB
>
> Ariesita Surya Pratiwi Ssi Apt, ASO KNCV-TBCTA SBY

**Dinas Kesehatan Kabupaten Tuban**

> Dr. Tri Hadi Sanyoto MM, Head of District Health
>
> Dr. Saiful Hadi, Head of CDC Division
>
> Rolandra Dwi S, Section Head of CDC
>
> Agus Waskitho, Wasor TB
>
> Dr. Hj Nursant, Head of Health Center
>
> Teguh Subagio, TB Staff
>
> Insiyah, Laboratory Staff

**Dinas Kesehatan kab Mojokerto**

> Dr. Noer Windijantoro, Head of District Health
>
> H.M. Shaleh, Head of CDC Division
>
> Budi Djauhari, SKM, Section Head of CDC
>
> Wari Iin D SKM, Wasor TB
>
> Dr. Agus T., Head of Health Center
>
> H. Nyoman Dharma, TB Staff
>
> Anang K---, Laboratory staff

# Annex B: Documents Reviewed

**Contract Information**

> KNCV TBCTA Proposal, June 23, 2000
>
> USAID Award Letter, September 28, 2000
>
> Modifications to the Agreement (Nos. 1-10)

**Work Plan Approvals, Executive Summaries**

> Field Support Brazil, 2001-2005
>
> Field Support Cambodia, 2002-2005
>
> Field Support Dominican Republic, December 2001
>
> Field Support El Salvador, 2001-2005
>
> Field Support Haiti, 2001-2005
>
> Field Support Indonesia, 2002-2003
>
> Field Support Malawi, 2001-2005
>
> Field Support South Africa, 2002-2005
>
> Field Support Egypt, 2003-2005
>
> Expansion of NTP in Congo Year I, 2002-2003
>
> Expansion of NTP in Congo Year II, 2003-2004
>
> Plan for Expansion of DOTS in Senegal, 2002-2003
>
> Regional Support Asia and Near East, 2001-2004

**Annual Work Plans For Core Funding**

> Annual Plan of Activities Year 2
>
> Annual Progress Report Years 1 and 2
>
> Annual Plan of Activities Year 3
>
> Annual Plan of Activities Year 3, Approved Cost Savings Proposals
>
> Annual Plan of Activities Year 4
>
> Annual Plan of Activities Year 4, Attachment (Financial Information)
>
> Budget Core Funds FY 2004

**TBCTA Board of Directors Meeting, San Francisco, May 15--16, 2001**

> Minutes
>
> Agenda Proposal
>
> Agenda Explanation
>
> Annex 1: Action Points
>
> Annex 2: Draft Standard Subagreement Template
>
> Annex 3: Subagreement, WHO Template
>
> Annex 4: Comments to Standard Subagreement and Subagreement, WHO
> Templates
>
> Annex 5: Routing of TB Reports
>
> Annex 6: Federal Assistance Websites
>
> Annex 7: Short Progress Report, October 2000-March 2001

**TBCTA Board of Directors Meeting, The Hague, August 27--28, 2001**

> Agenda Proposal
>
> Agenda Explanation
>
> Annex 1: Action Points
>
> Annex 3: Relationship between USAID Country Mission-Partners-PMU:
> Email Communication between Paula Fujiwara, Peter Gondrie, and Nils
> Billo
>
> Annex 4: Costing Definitions, Office of Management and Budget Circular
> A-122
>
> Annex 5: Draft TBCTA Bulletin
>
> Annex 6: Content Page Documentation
>
> Annex 8: Short Progress Report, April 2001-August 2001
>
> Annex 9: Monitoring Projects Reports
>
> Annex 10: Annual Work Plan Year 2 (Draft), June 20, 2001

**TBCTA Board of Directors Meeting, Paris, October 30, 2001**

> Agenda Proposal
>
> Agenda Explanation
>
> Annex 1: Action Points
>
> Annex 2: Budget Allocations
>
> Second Draft Proposal of the PMU for the TBCTA Budget Year 2

**TBCTA Board of Directors Meeting, Vancouver, February 28, 2002**

> Minutes
>
> Agenda Proposal
>
> Explanation of Agenda
>
> Annex 1: Action Points
>
> Annex 2: Expense Report of TBCTA Partners Format
>
> Annex 3: Request for Advance/Reimbursement Form
>
> Annex 4: TBCTA Partner Financial Status Report Form
>
> Annex 5: Proposal Form TBCTA-PMU
>
> Annex 6: Schedule TBCTA Reports 2001-2002
>
> Annex 7: Short Progress Report, September 2001-December 2001
>
> Annex 8: Review of Country Activities, Debriefing Notes
>
> Annex 9: January 2002 TFT Meeting Minutes
>
> E-Mail from Claudette Powell to Peter Gondrie Regarding Allocable
> Costs (Vancouver 2002)

**TBCTA Board of Directors Meeting, Atlanta, May 16--17, 2002**

> Minutes
>
> Agenda Proposal
>
> Agenda Explanation
>
> Annex 1: Actions Points
>
> Annex 2: Explanation for TBCTA/PMU Partner Request for
> Advance/Reimbursement Form
>
> Annex 4: Short Progress Report, January 2002-April 2002
>
> Annex 5: TBCTA Partner Payments
>
> Annex 6: Questions of the TFT to the Board of Directors
>
> Annex 7: TB Indicators of TBCTA Supported High Burden Countries
>
> Annex 8: Schedule TBCTA Reports, 2001 and 2001
>
> Annex 9: 2002 Consultant Rates
>
> Annex 10: Budget Proposal Form

**TBCTA Board of Directors Meeting, The Hague, August 12--13, 2002**

> Minutes
>
> Agenda Proposal
>
> Agenda Explanation
>
> Annex 1: Action Points
>
> Annex 3: Accountant\'s Report
>
> Annex 5: Short Progress Report, May 2002-July 2002
>
> Annex 6: Proposal Annual Plan of Activities, Year III
>
> Annex 7: Monitoring and Evaluation
>
> Annex 8: Schedule TBCTA Reports, 2001-2002
>
> Annex 9: Minutes of the TFT Meeting, June 2002
>
> Annex 10: TFT Checklist for Assessment of Proposals for TB Training
> and Education TBCTA
>
> Inventory List of Equipment Form
>
> PMU Calendar for Coalition Partners

**TBCTA Board of Directors Meeting, Geneva, December 16-17, 2002**

> Minutes
>
> Agenda Proposal
>
> Agenda Explanation
>
> Annex 1: Action Points
>
> Annex 2: PMU Calendar for Coalition Partners
>
> Annex 3: TBCTA Website Proposal
>
> Annex 4: Short Progress Report, August 2002-November 2002
>
> Annex 5: Auditors Report TBCTA Year 1
>
> Annex 6: Monitoring and Evaluation: TB Indicators of TBCTA Supported
> High-Burden Countries
>
> Annex 7: Terms of Reference: Development of TBCTA Consultants Capacity
> (TFT)

**TBCTA Board of Directors Meeting, Seattle, May 14-13, 2003**

> Minutes
>
> Agenda Proposal
>
> Agenda Explanation
>
> Annex 1: Action Points
>
> Annex 2: Short Progress Report, February 2003-May 2003
>
> Annex 4: PMU Calendar for Coalition Partners
>
> Annex 5: Work Plan Approvals: Executive Summaries
>
> Annex 6: Format for Report Summary
>
> Annex 8: Financial Reports
>
> Annex 9: Second-Round Project Proposals
>
> GFATM Summary

**TBCTA Board of Directors Meeting, The Hague, August 11-12, 2003**

> Minutes
>
> Agenda Proposal
>
> Agenda Explanation
>
> Annex 1: Action Points
>
> Annex 2: PMU Calendar for Coalition Partners
>
> Annex 3: Work Plan Approvals: Executive Summaries
>
> Annex 4: APA4 Project Proposals Review Committee Report
>
> Annex 4.1: APA4 Project Proposals
>
> Annex 5: Short Progress Report, May 2003-August 2003
>
> Annex 6.1: Annual Progress Report APA1 and APA2
>
> Annex 7: Financial Reports as of August 4, 2003
>
> Annex 8.1: TFT Meeting Minutes: New York, July 1-2, 2003
>
> Annex 8.2: Letter from Jaap Broekmans (Chair TBCTA BOD) to Inge Pool
> Regarding Revision of TFT's Terms of Reference. June 24, 2003
>
> Annex 8.3: Letter from TFT to Jaap Broekmans (Chair TBCTA BOD); July
> 8, 2003
>
> Annex 9: External Evaluation of TBCTA: Scope of Work
>
> Discussion Paper: Collaboration with Private Voluntary Organizations.
> Phil Hopewell and Maarten Van Cleef; November 13, 2003

**TBCTA Board of Directors Meeting, Paris, October 27--28, 2003**

> Agenda Proposal
>
> Agenda Explanation
>
> Annex 1: Action Points
>
> Annex 2: Short Progress Report, August 2003-October 2003
>
> Annex 3: APA3 Monitoring Reports
>
> Annex 4: PMU Calendar for Coalition Partners
>
> Annex 5: Egypt and ANE Work Plan Approvals, Executive Summaries
>
> Annex 6: Monitoring and Evaluation, Country Reports
>
> Annex 7: Human Resource Development for TB Control, Position Paper
>
> Annex 8: TFT Advocacy Meeting Report, October 6, 2003
>
> Annex 9: External Evaluation of TBCT, Consultant\'s CV

**Task Force Training Meetings, The Hague, September 13--14, 2001**

> Minutes
>
> Attachment 1: Priority of Reviewed Project Proposals
>
> Attachment 2: New Training/Education Project or Product Proposal Form

## Royal Netherlands Tuberculosis Association (KNCV), The Hague, The Netherlands

> *Summary of Progress, TBCTA Indonesia, 2003.*
>
> *Purchasing Policy \[for\] Pharmaceuticals and Medical Supplies,
> International Projects,* December 1997.
>
> *USAID E&E Evaluation, Russia,* June 16--July 3, 2002

**Royal Netherlands Tuberculosis Association (KNCV)-TBCTA Provincial
Project Office East Java**

> *Annual Progress Report: KNCV-TBCTA Provincial Project Office, East
> Java, 2003.*

Kumpulan Quarterly Progress Report, KNCV-TBCTA Provincial Project
Office, East Java, Oktober \[sic\] 2002--December 2003. \[Four
documents: Budget Lines, Q1-2003, Q2-2003, Q3-2003, Q4-2003\].

*Rencana Kegiatan KNCV-TBCTA Provincial Project Office, East Java,
2004.*

######### Tuberculosis Coalition for Technical Assistance, The Hague, The Netherlands

> *TBCTA Newsletter No. 1,* 2003.
>
> *TBCTA Newsletter No. 2,* February 2004.
>
> *Inventory of Equipment,* October 29, 2003.
>
> Task Force for Training, *Checklist for the Review of the HRD
> Component of the National Plans to Control Tuberculosis.*
>
> Task Force for Training, *Training Coordinator\'s Handbook* (draft);
> November 2002.
>
> Task Force for Training, *Human Resource Development for TB Control.
> The role of TFT and Others within TBCTA. A Position Paper.* February
> 2004.
>
> *Report on the Meeting of the Second Ad Hoc Committee on the TB
> Epidemic,* September 18--19, 2003, Montreux, Switzerland.

######### United States Agency for International Development, Washington, DC

> *Infectious Diseases Results Framework SO5.*
>
> *Infectious Diseases Strategy.*
>
> *Expanded Response to Tuberculosis.* September 9, 2003.
>
> *Reducing the Threat of Infectious Diseases of Major Public Health
> Importance.* March 1998.
>
> *G/PHN SSO5 Performance Monitoring Plan.* August 1999.

######### World Health Organization, Geneva Switzerland

> *Global TB Annual Report, 2002.*
>
> *Global TB Annual Report, 2003.*
>
> *Global TB Annual Report* (draft, tables), 2004.
>
> *Treatment for Tuberculosis. Guidelines for National Programs.*
>
> *The Global Plan to Stop Tuberculosis, Stop TB Partnership,* 2002.
>
> *Guidelines for Implementing Collaborative TB and HIV Programme
> Activities,* 2003.
>
> *Strategic Framework to Decrease the Burden of TB/HIV,* 2003.
>
> *Intensified Support and Action Countries (ISAC),* January 2004.
>
> *Training for Health Facility Staff* (12 manuals), 2003.
>
> *Training for Better TB Control. Human Resources Development for TB
> Control. A Strategic Approach within Country Support,* 2002.
>
> *Review of Progress in Implementation of the National TB Control
> Programme--Indonesia: Report of the External TB Monitoring Mission,
> Indonesia, 27 January-7 February 2003.* \[WHO Regional Office for
> South-East Asia, New Delhi\], September 2003.
>
> *A Global Review of Primary Health Care: Emerging Messages. Global
> Report,* WHO/MNC/OSC/03.01.

**Miscellaneous Documents**

> Grant Application Forms (Forms 424 and 424A): Instructions for
> Completion and Sample
>
> Supplement Explanation to the SF 424A Form, Budget Summary
>
> USAID Certifications and Assurances and Other Statements of Recipient
>
> TBCTA Newsletter No. 1, 2003
>
> ID Results Framework SO5
>
> Infectious Diseases Strategy
>
> TB Expanded Response, September 9, 2003
>
> Human resource development for TB control. The roles of the TFT and
> other players within TBCTA. A position paper (draft). October 2003 and
> February 2004.

Ait-Khaled, Nadia, and Armand van Deun. n.d. Rapport d'evaluation du
programme No. 5, Rapport d'une visite effectuee du 21 Juin au 3 Juillet
2003. (Democratic Republic of Congo.) Paris: International UNION Against
Tuberculosis and Lung Disease.

Brazil's Family Planning Association (BENFAM). Projecto coalizao
anti-tuberculose. Plano de trabalho, January--December 2004. Recife:
BENFAM.

Borgdorff, Martien and Marieke van der Werf. 2003. *Report of a Mission
to Indonesia to Support Operational Research on Tuberculosis Control, in
Particular in Central and East Java.* February/March 2003. \[Additional
bibliographic information unavailable.\]

Democratic Republic of the Congo. n.d. *Proposal for Tuberculosis to the
Global Fund to Fight AIDS, Tuberculosis and Malaria.* Kinshasa:
Democratic Republic Congo.

*Evaluation of the HDL Hospital DOTS Linkage Project in DI Yogyakarta,
Democratic Republic of Congo.* June 2003. \[Additional bibliographic
information unavailable.\]

Ministério de Saúde, Fundacion National de Saúde. Tuberculose. *Guia de
vigilancia Epidemiological.* October 2002.

Garrett, Denise. n.d. *Report of the Evaluation of SINAN-TB, the
National TB Surveillance System of Brazil.*

Garrett, Denise. n.d. *Epidemiologia do Tuberculosis no Brasil.*

\[Government of Brazil.\] *Proposal for RPM Plus Technical Assistance to
the Brazil National TB Reference Center.* June 2003.

\[Government of Democratic Republic of the Congo.\] Programme de Santé
Rurale (Soins de Santé Primaires en Milieu Rural, DR Congo). n.d. *Plan
d'action de lutte contre la tuberculose au cours de l'an III du project
SANRU III.*

\[Government of Indonesia.\] n.d*. Proposal to the Global Fund to Fight
AIDS, Tuberculosis and Malaria (TB component).*

Governor of the State of Rio de Janeiro. *Plano estrategico para o
contole da tuberculose no* estabdo do Rio de Janeiro, 2003 a 2005. Rio
de Janeiro: Governo do Estado Rio Janeiro.

\[Indonesia Ministry of Health.\] December 2001. *Proposal for USAID
Assistance to the National TB Program, Indonesia, through the TBCTA.*
\[Additional bibliographic information unavailable.\]

\[Indonesia Ministry of Health.\] *Country Profile.* November 2003.

\[Indonesia National TB Program.\] *Strategic Plan, Years 2002--2006.*

\[Indonesia National TB Program.\] *Booklet of NTP Statistics for East
Java, 2002 and 2003.* (In Indonesian.) January 2004.

\[Indonesia National TB Program.\] *Booklet of STP Statistics for the
District of Tuban, 2003.* (In Indonesian.) January 2004.

International UNION Against Tuberculosis and Lung Disease (IUATLD).
2000. *Management of Tuberculosis. A Guide for Low-Income Countries,*
5th ed. Paris: IUATLD.

Johns Hopkins University. *Expansao de DOTS com as equips de PACS e
PSF.* Rio de Janeiro.

Ministério de Saúde. *Manual tecnico para o controle da tuberculose.
Cadernos de atencao basica no. 6*. Brasilia: Ministério de Saúde.

Ministério de Saúde, Fundaçao Nacional de Saúde. Tuberculose. *Guia de
vigilancia Epidemiological.* October 2002.

Ministério de Saúde, Programa Nacional de Controle da Tuberculose.
November 19, 2003. *TB Program Evaluation, September 2003.* Brasilia:
Ministry of Health.

Ministério de Saúde, Fundaçao Nacional de Saúde. Centro de Referência
Prof. Hélio Fraga. Sociedade Brasileira de Pneumologia e Tisiologia.
2002. *Controle da tuberculose: uma proposta de integração
ensino-serviço.* 5th ed. Rio de Janeiro: FUNASA/CRPHF/SBPT.

Perkins, Mark D., and Paula I. Fujiwara. *Institutional Evaluation:
Reference Center H*é*lio Fraga.* November 8--12, 1999. \[Rio de Janeiro:
Centro de Referência Prof. Hélio Fraga.\]

United States Department of State. January 30, 2004. *President Bush\'s
Emergency Plan for AIDS Relief.* Washington: U.S. Department of State.

# Annex C: Financial Tables\*

Table C-1. Financial Summary Report, Core Funding APA3 (August 4, 2003)

  -------------- --------------- --------------- ------------- --------------- ---------------
  Coordinating   **Amount        Transferred to  Expensed by   Balance (Budget **Balance
  Partner        Allocated**     Partner         Partner       Transferred)    (Budget
                                                                               Expensed)**

  PMU (Salaries) 1,048,517       345,707         498,668       702,810         549,849

  PMU (Office    122,500         0               84,798        122,500         37,702
  Costs)                                                                       

  PMU Total      1,171,017       345,707         583,466       825,310         587,551

  IUATLD Total   1,679,746       920,337         102,664       759,409         1,577,082

  KNCV Total     628,465         130,070         997           498,395         627,468

  WHO Total      925,999         231,881         202,168       694,118         723,831

  ALA Total      100,480         0               0             100,480         100,480

  ATS Total      172,380         68,750          0             103,630         172,380

  **Grand        **4,678,087**   **1,696,745**   **889,294**   **2,981,342**   **3,788,793**
  Total**                                                                      
  -------------- --------------- --------------- ------------- --------------- ---------------

\*Source: TBCTA Board of Directors Meeting, August 11--12, 2003, The
Hague, The Netherlands. All figures in U.S. dollars.

WHO financial data in this table are as of February 2003.

> **Table C-2. Mission Cumulative Funding (August 4, 2003)**

  ---------------- ---------------- ---------------- -------------- ---------------- --------------- --------------- ------------------------ ---------------------
  **Modification   **Date of        **Coordinating   **Benefiting   **Amount         **Transferred   **Expensed by   **Balance                **Balance
  Number**         Modification**   Partner**        Area**         Pledged**        to Partner**    Partner**       (Budget-Transferred)**   (Budget-Expensed)**

  5                9/2001           WHO/PAHO         Brazil         890,000          121,198         111,141         768,802                  778,859

  9                9/2002                            Brazil         670,000          0               0               670,000                  670,000

                                                     **Subtotal**   **1,560,000**    **121,198**     **111,141**     **1,438,802**            **1,448,859**

  5, 8             9/01, 8/02       IUATLD           Cambodia       253,900          16,412          16,412          237,488                  237,488

                                                     **Subtotal**   **253,900**      **16,412**      **16,412**      **237,488**              **237,488**

  4                8/2001           WHO/PAHO         D.R. Congo     475,000          475,000         458,688         0                        16,312

  9                9/2002                            D.R. Congo     579,000          446,500         0               132,500                  579,000

  Expected                                           D.R. Congo     400,000          0               0               400,000                  400,000

                                                     **Subtotal**   **1,454,000**    **921,500**     **458,688**     **532,500**              **995,312**

  5                9/2001           WHO/PAHO         Dom. Rep.      270,000          70,848          43,734          199,152                  226,266

                                                     **Subtotal**   **270,000**      **70,848**      **43,734**      **199,152**              **226,266**

  Expected                                           Egypt          765,000          0               0               765,000                  765,000

                                                     **Subtotal**   **765,000**      **0**           **0**           **765,000**              **765,000**

  4                8/2001           WHO              El Salvador    499,000          426,494         48,388          72,506                   450,612

                                                     **Subtotal**   **499,000**      **426,494**     **48,388**      **72,506**               **450,612**

  4                8/2001           WHO              Haiti          400,000          288,848         113,848         111,152                  286,152

  9                9/2002                            Haiti          200,000          0               0               200,000                  200,000

  Expected                                           Haiti          200,000          0               0               200,000                  200,000

                                                     **Subtotal**   **800,000**      **288,848**     **113,848**     **511,152**              **686,152**

  1                6/2001           KNCV             Indonesia      500,000          500,000         295,378         0                        204,622

  4                8/2001                            Indonesia      500,000          500,000         0               0                        500,000

  8                8/2002                            Indonesia      2,000,000        435,000         0               1,565,000                2,000,000

  Expected                                           Indonesia      1,975,000        0               0               1,975,000                1,975,000

                                                     **Subtotal**   **4,975,000**    **1,435,000**   **295,378**     **3,540,000**            **4,679,622**

  **Modification   **Date of        **Coordinating   **Benefiting   **Amount         **Transferred   **Expensed by   **Balance                **Balance
  Number**         Modification**   Partner**        Area**         Pledged**        to Partner**    Partner**       (Budget-Transferred)**   (Budget-Expensed)**

  4                8/2001           KNCV             Malawi         500,000          493,100         0               6,900                    500,000

                                                     **Subtotal**   **500,000**      **493,100**     **0**           **6,900**                **500,000**

  8                8/2002                            Mozambique     150,000          0               0               150,000                  150,000

                                                     **Subtotal**   **150,000**      **0**           **0**           **150,000**              **150,000**

  Expected                          WHO              Nigeria        1,076,500        0               0               1,076,500                1,076,500

                                                     **Subtotal**   **1,076,500**    **0**           **0**           **1,076,500**            **1,076,500**

  4                8/2001           IUATLD           Senegal        800,000          550,000         0               250,000                  800,000

  9                9/2002                            Senegal        300,000          0               0               300,000                  300,000

  Expected                                           Senegal        300,000          0               0               300,000                  300,000

                                                     **Subtotal**   **1,400,000**    **550,000**     **0**           **850,000**              **1,400,000**

  7                7/2002           KNCV             South Africa   300,000          171,184         151,582         128,816                  148,418

  9                9/2002                            South Africa   500,000          0               0               500,000                  500,000

  Expected                                           South Africa   650,000          0               0               650,000                  650,000

                                                     **Subtotal**   **1,450,000**    **171,184**     **151,582**     **1,278,816**            **1,298,418**

                                                                                                                                              

                                                     **Total**      **15,153,400**   **4,494,585**   **1,239,172**   **10,658,815**           **13,914,228**
  ---------------- ---------------- ---------------- -------------- ---------------- --------------- --------------- ------------------------ ---------------------

**Table C-3. Regional Cumulative Funding (August 4, 2003)**

+-------+-------+-------+-----+-----+-------+-----+--------+-------+
| **Mo  | *     | **Co  | **A | **  | **T   | *   | **B    | **Ba  |
| dific | *Date | ordin | rea | Amo | ransf | *Ex | alance | lance |
| ation | of    | ating | Ben | unt | erred | pen | (      | (B    |
| Num   | Modi  | Part  | efi | Ple | to    | sed | Budget | udget |
| ber** | ficat | ner** | tin | dge | Part  | by  | Tr     | E     |
|       | ion** |       | g** | d** | ner** | Par | ansfer | xpens |
|       |       |       |     |     |       | tne | red)** | ed)** |
|       |       |       |     |     |       | r** |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
| 1     | 6     | I     | Afr | 1   | 7     | 71, | 78,072 | 7     |
|       | /2001 | UATLD | ica | 50, | 1,928 | 928 |        | 8,072 |
|       |       |       | re  | 000 |       |     |        |       |
|       |       |       | gio |     |       |     |        |       |
|       |       |       | nal |     |       |     |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
| 4     | 8     |       | Afr | 3   | 0     | 0   | 3      | 30    |
|       | /2001 |       | ica | 00, |       |     | 00,000 | 0,000 |
|       |       |       | re  | 000 |       |     |        |       |
|       |       |       | gio |     |       |     |        |       |
|       |       |       | nal |     |       |     |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
| Exp   |       |       | Afr | 2   | 0     | 0   | 2      | 25    |
| ected |       |       | ica | 50, |       |     | 50,000 | 0,000 |
|       |       |       | re  | 000 |       |     |        |       |
|       |       |       | gio |     |       |     |        |       |
|       |       |       | nal |     |       |     |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
|       |       |       | **S | **  | **71, | *   | **628  | *     |
|       |       |       | ubt | 700 | 928** | *71 | ,072** | *628, |
|       |       |       | ota | ,00 |       | ,92 |        | 072** |
|       |       |       | l** | 0** |       | 8** |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
| 5     | 9     | KNCV  | E&E | 2   | 23    | 2   | 0      | 0     |
|       | /2001 |       |     | 35, | 5,000 | 35, |        |       |
|       |       |       |     | 000 |       | 000 |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
|       |       |       | **S | **  | *     | **  | **0**  | **0** |
|       |       |       | ubt | 235 | *235, | 235 |        |       |
|       |       |       | ota | ,00 | 000** | ,00 |        |       |
|       |       |       | l** | 0** |       | 0** |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
| 5     | 9     |       | ANE | 2   | 0     | 0   | 2      | 27    |
|       | /2001 |       |     | 75, |       |     | 75,000 | 5,000 |
|       |       |       |     | 000 |       |     |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
|       |       |       | **S | **  | **0** | **  | **275  | *     |
|       |       |       | ubt | 275 |       | 0** | ,000** | *275, |
|       |       |       | ota | ,00 |       |     |        | 000** |
|       |       |       | l** | 0** |       |     |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
| 5     | 9     | I     | LAC | 2   | 24    | 1   | 0      | 7     |
|       | /2001 | UATLD |     | 44, | 4,500 | 74, |        | 0,218 |
|       |       |       |     | 500 |       | 282 |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
| Exp   |       |       | LAC |     |       |     |        |       |
| ected |       |       |     |     |       |     |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
|       |       |       | **S | **  | *     | **  | **200  | *     |
|       |       |       | ubt | 444 | *244, | 174 | ,000** | *270, |
|       |       |       | ota | ,50 | 500** | ,28 |        | 218** |
|       |       |       | l** | 0** |       | 2** |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
| 4     | 8     | KNCV  | RE  | 1   | 4,940 | 22, | 1      | 12    |
|       | /2001 |       | DSO | 50, |       | 250 | 45,060 | 7,750 |
|       |       |       |     | 000 |       |     |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
| Exp   |       |       | RE  | 1   | 0     | 0   | 1      | 19    |
| ected |       |       | DSO | 95, |       |     | 95,000 | 5,000 |
|       |       |       |     | 000 |       |     |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
|       |       |       | **S | **  | **4,  | *   | **340  | *     |
|       |       |       | ubt | 345 | 940** | *22 | ,060** | *322, |
|       |       |       | ota | ,00 |       | ,25 |        | 750** |
|       |       |       | l** | 0** |       | 0** |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
|       |       |       |     |     |       |     |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
|       |       |       | **T | *   | *     | **  | *      | **1   |
|       |       |       | ota | *1, | *556, | 503 | *1,443 | ,496, |
|       |       |       | l** | 999 | 368** | ,46 | ,132** | 040** |
|       |       |       |     | ,50 |       | 0** |        |       |
|       |       |       |     | 0** |       |     |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+
| ## R  |       |       |     | **  | **5   | *   | **     | **15  |
| egion |       |       |     | 17, | ,050, | *1, | 12,101 | ,410, |
|  + Co |       |       |     | 152 | 953** | 742 | ,947** | 268** |
| untry |       |       |     | ,90 |       | ,63 |        |       |
|  Gran |       |       |     | 0** |       | 2** |        |       |
| d Tot |       |       |     |     |       |     |        |       |
| al^†^ |       |       |     |     |       |     |        |       |
+-------+-------+-------+-----+-----+-------+-----+--------+-------+

**^†^** Totals for Tables 2 and 3 combined.

**Table C-4. Core Funding Financial Summary Report, Inception through
December 31, 2003**

  ---------------- ---------------- ------------- ------------- --------------- ---------------
  **Coordinating   **Budget**       Transferred   **Expensed by Balance (Budget Balance (Budget
  Partner**                         to Partner    Partner**     Transferred)    Expensed)

  PMU              **10,048,536**   513,407       324,593       **1,664,829**   **4,914,247**

  IUATLD                            2,194,233     1,019,653                     

  KNCV                              3,131,653     2,562,363                     

  WHO                               2,117,875     828,942                       

  ALA                               28,163        28,173                        

  ATS                               398,376       370,565                       

  **Totals**                        **8,383,707   **5,134,289                   
                                    (83%)^†^**    (61%)^‡^**                    
  ---------------- ---------------- ------------- ------------- --------------- ---------------

> †Percent of budget transferred.
>
> ‡Percent of budget declared transferred. WHO data do not include Year
> 3.

# Annex D: Training Courses Implemented Wholly or Partially Funded by TBCTA

-   International TB Course, Arusha, Tanzania, November 2003, 2002, and
    2001 (Africa Bureau)

-   International TB Course, Nicaragua, June 2003, 2002, and 2001

-   International TB Course, Hanoi, Vietnam, August 2003, 2002, and 2001

-   International TB Course, Ho Chi Minh City, Vietnam, March 2003
    (approx.) (Southeast Asia Training Course on TB control)

-   Advanced Course in Smear Microscopy, December 2003

-   Management of TB Laboratory Network Course (UNION), Bangkok,
    Thailand, March 2003

-   Applied Epidemiology for Operations Research, Paris, France, January
    2003

-   Applied Epidemiology for Operations Research in TB Control, Addis
    Ababa, Ethiopia, October 2001

-   Respiratory Epidemiological and Operations Research for Latin
    America, 2002

-   Training Methods for Epidemiological and Operational Research, Rio
    de Janeiro, Brazil, June 2003

-   TB Course for Doctors, Costa Rica, February 2002

-   International Course in MDRTB Management, Mexico, May 2002 (LAC
    funds) (also funds for follow-up visits to countries)

-   Regional Workshop on MDRTB in Bolivia, July 2002

-   International Financial, Logistics, and Procurement Management
    Course for NTP Managers, India, February 2004

-   TFT Follow-up Workshop, Addis Ababa, Ethiopia, November 2003

-   TFT Regional Workshop for TB Training Focal Points from African
    Countries, The Hague, November 2002

-   TFT Regional Workshop, Bangkok, Thailand, September 2003

-   WHO Training Course for TOT in Management at Health Center Level,
    Warsaw, Poland, October 2002

-   Training Course for TB Program Management, Warsaw, Poland, October
    2002 and 2003

-   Laboratory Management, Warsaw, Poland, 2002

-   TB Training Evaluation Course (UNION), Montreal, Quebec, Canada,
    November 2002

-   European TB Managers Workshop, Wolfheze, The Netherlands, June 2003

-   Nursing Workshop: Contribution to DOTS Strategy, Katmandu, Nepal,
    September 2003 (UNION, Eastern Regional conference)

-   Regional Workshop with Nurses and Allied Professionals about DOTS,
    Uruguay, December 2002

-   Drug Susceptibility Testing Training Course, with WHO CRS, Lyon,
    France, January 2003

-   Training Course on Standardization of DST Methods for Resistance
    Surveillance, for ex-Soviet countries (see Annual Report, APA3,
    p.13)

# Annex E: Scope of Work

**Scope of Work**

**Evaluation of the Tuberculosis Coalition for Technical Assistance
(TBCTA)**

**November 1, 2003 through April 15, 2004**

## I. IDENTIFICATION OF THE TECHNICAL ASSISTANCE

General Description: The U.S. Agency for International Development,
Bureau of Global Health, Office of Health, Infectious Diseases and
Nutrition (USAID/BGH/HIDN) seeks the services of The Synergy Project to
review the performance, impact, and lessons learned of the Tuberculosis
Coalition for Technical Assistance (TBCTA) project, a USAID-sponsored
partnership formed in the October 1, 2000 to control TB globally.

**II. BACKGROUND**

Globally, TB is a problem of enormous dimensions. In 2000, it was
estimated that there were about eight million new cases of TB worldwide
with two million deaths. TB kills more people than any other single
infectious agent except the human immunodeficiency virus (HIV).
Ninety-five percent of all TB cases and 98 percent of TB deaths occur in
developing countries. However, TB also has an impact on industrialized
countries with certain groups, especially those persons born in high TB
incidence countries.

TB has a major impact on economic development both in countries with a
high incidence of the disease as well as globally. In developing
countries, 3-4 months of family income or up to 20-30 percent of annual
household income can be lost due to TB. The potential cost to a nation
due to lost productivity from TB is estimated between 4-7 percent of
GDP. Not only does TB exact a heavy toll in human suffering and economic
losses currently, it is increasing every year. A major contributing
factor to the incidence of TB is infection with HIV. Today about 15
million people have dual infections with Mycobacterium tuberculosis and
HIV. In many African countries, where TB is often perceived as being
synonymous with AIDS, more than one half of TB patients are
HIV-positive. In some countries, the HIV epidemic has led to a tripling
or even quadrupling in the incidence of TB during the past ten years.

[Strategy for Tuberculosis Control]{.underline}:

Global TB control is possible through a well-established strategy known
as DOTS (\[Directly Observed Treatment Short Course). The DOTS strategy
recommended by the World Health Organization (WHO) and the International
UNION Against Tuberculosis and Lung Disease (IUATLD) has now been
adopted by 119 countries worldwide. It is one of the most cost-effective
health interventions and is rigorously promoted around the world.

Implementation of DOTS requires both a strong primary health care system
that ensures sustained access for TB patients to diagnosis, treatment
and follow-up services. Important elements of such a system include a
network of capable laboratories, a recording and reporting system, and a
robust logistics system that ensures a secure supply of drugs. Political
commitment to fund and implement effective national tuberculosis control
programs is essential to promote global TB control and avoid the
consequences of failure. In addition implementation of DOTS, requires
improved access to primary care services that are affordable, equitable,
committed and well organized. Education and training are essential
elements to ensure the availability of human resources.

The global targets for the twenty-two high burden TB countries is to
reach 85 percent treatment success and 70 percent case detection by
2005.

[The Tuberculosis Coalition for Technical Assistance]{.underline}:

The Tuberculosis Coalition for Technical Assistance (TBCTA) is a
USAID-supported project, executed through a unique partnership of six
organizations [^93] actively involved in global TB control. Originally,
the project had a budget of almost \$29 million for the 5-year period
September 2000 - September 2005. Due to the great demand for TB
technical assistance by the Missions, at the end of year 3 the ceiling
was increased to almost \$44 million. The organizations that form the
partnership are as follows:

> 1\. The Royal Netherlands Tuberculosis Foundation (KNCV), based in The
> Hague, was established in 1903 as a unique public-private partnership.
> KNCV promotes effective and efficient tuberculosis control within a
> national and international context and acts as an implementing agency
> for projects financed by the Dutch Government and other Dutch
> international foundations. Since the 1980s, KNCV has contributed to
> the development and implementation of effective TB control programs in
> low-income countries. It also hosts the International Tuberculosis
> Surveillance Centre (ITSC) and the Tuberculosis Surveillance Research
> Unit (TSRU); contributes to international policy development
> especially within its collaboration with WHO and the IUATLD; and
> collaborates with numerous international organizations. KNCV has a
> highly qualified staff in a wide variety of fields of experience and
> expertise, many of which have long working/living experience in
> developing countries. It is the prime organization for this
> cooperative agreement and responsible for administrative management.
>
> 2\. The International UNION Against Tuberculosis and Lung Disease
> (IUATLD), an NGO headquartered in Paris, is comprised of constituent,
> organizational, and individual members. There are IUATLD regional
> organizations in North America, Latin America, Europe, Africa, Asia,
> and the Middle East. The IUATLD disseminates information on TB and
> lung disease, coordinates and assists the work of its members
> throughout the world, and maintains close links with WHO, other UN
> agencies, and government and non-government organizations in the
> health and development sector. The IUATLD's expertise and its
> activities are focused on the areas of technical assistance, education
> and research.
>
> 3\. The World Health Organization (WHO), headquartered in Geneva, has
> a presence in virtually all developing countries as well as having
> responsibility for defining the international health policy for TB
> control. It provides technical assistance and advice to countries on
> policy formulation, project planning and implementation, and
> monitoring and evaluation of TB control activities. WHO maintains
> global surveillance and monitoring of TB incidence drug resistance,
> and the status of control programs.
>
> 4\. The American Lung Association (ALA), based in New York City, is
> the oldest voluntary health association in the United States and has
> 78 state and local organizations throughout the country. It is the
> constituent member in the United States to the IUATLD. Its mission is
> the prevention and control of lung disease and its work is done
> primarily through public education, public policy and advocacy
> activities. The ALA works internationally solely in the areas of
> advocacy and in fostering the development of international protocols.

5\. The American Thoracic Society (ATS), also based in New York City,
was founded in 1905. It is a 14,000-member educational and scientific
society and is the major medical professional and scientific
organization with an interest in tuberculosis. The ATS has considerable
experience in collaborating with the Centers for Disease Control and
Prevention \[CDC\] in developing guidelines for TB prevention and
control used both in the United States and in other parts of the world.
The ATS publishes a highly respected and widely read scientific journal.
In addition, the Society conducts an annual international conference
that attracts 15,000-16,000 attendees and is a major forum for the
presentation of new information about TB and its control as well as
providing an arena for tuberculosis training and education. A broad
range of specific technical expertise is represented in the
organization.

> 6\. The Centers for Disease Control and Prevention (CDC), based in
> Atlanta, is the U.S. Federal public health agency. It promotes health
> and quality of life by preventing and controlling disease, injury, and
> disability. Within CDC, the Division of Tuberculosis Elimination
> (DTBE) is responsible for domestic and international tuberculosis
> prevention and control activities. Activities are carried out in
> collaboration with state and local health departments,
> academic/research institutions, and other partners such as ministries
> of health in foreign-countries, and domestic and international
> non-governmental organizations. CDC provides technical assistance and
> consultation in a broad range of TB control areas. Although it is not
> a legal member of TBCTA, CDC coordinates on their annual work plan and
> participates in all the TBCTA Board meetings.

The purpose of TBCTA assistance is two-fold. First, it improves and
expands the capacity of USAID to respond to the Global TB epidemic by
providing state-of-the-art, context appropriate, technically sound and
cost-effective consultation and technical assistance to high-incidence
countries and USAID missions. In addition, it complements and expands
existing global TB control efforts, such as the Stop TB Initiative, the
programs of the WHO and the activities of the individual TBCTA partners.
The ultimate goal is to work in collaboration with other global TB
partners to accelerate the pace of DOTS expansion in order to meet the
global targets mentioned above.

The TBCTA has two managerial levels that enable the partners to operate
efficiently and effectively. The levels include the following:

-   A Board of Directors that is responsible for overall policy,
    planning, quality assurance, and decision-making level involving all
    partner organizations

-   A Program Management Unit (PMU) that is responsible for day-to-day
    project management, and which is based at the Royal Netherlands
    Tuberculosis Association (KNCV) in the Hague

TBCTA programmatic objectives:

-   Accelerate implementation and expansion of the DOTS strategy with
    emphasis on the high burden countries as well as other countries
    strategically important to USAID.

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-   Develop institutional and technical capacity for TB control in
    target countries.

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-   Integrate TB control efforts within primary health care services
    more effectively

-   Develop or strengthen linkages between TB control programs and
    HIV/AIDS prevention and treatment programs, and multi-drug
    resistance (MDR) efforts.

-   Disseminate the objectives of the TBCTA to USAID missions and the
    countries selected

-   Expand the capacity for providing high quality technical assistance
    worldwide

Within TBCTA a special group*,* the Task Force Training (TFT)*,* has
been established to address the human resource development issues. The
TFT develops guidelines and universal materials that can be adapted and
included in international courses or trainings as well as provides
technical assistance with the human resource development needs at the
country level. The TFT works with NTPs, academic and medical
institutions by strengthening their human resource capacity in TB
control in order to reach and maintain the overall program targets or
case detection and treatment.

Currently, TBCTA has received field support from thirteen USAID
countries including Brazil, Cambodia, DR Congo, Dominican Republic, El
Salvador, Egypt, Haiti, Indonesia, Malawi, Mozambique, Nigeria, Senegal,
and South Africa. Each country focuses on different gaps in the TB
control program that need strengthening in order to reach the global
targets. In addition, the four USAID regional bureaus and REDSO provide
field support to TBCTA.

**III. PURPOSE**

The purpose of the evaluation is to review the performance, impact and
lessons learned of the TBCTA project on a global level as well as at the
USAID Mission country level. The team will look retrospectively at the
TBCTA cooperative agreement activities and answer the principal
question: What is the evidence that TBCTA have made or will have made
accelerations on the pace of DOTS expansion towards reaching the global
targets and building institutional and individual capacity for TB
control in targeted countries?

The results will be used to provide feedback to TBCTA on project
operations and management, and provide recommendations to TBCTA and
USAID on implementation progress and results. In addition, the
evaluation will inform USAID in the future design of a follow-on
activity.

**IV. SPECIFIC OBJECTIVES**

[Overarching Issues]{.underline}

-   What are the overall lessons learned and best practices from the
    Coalition?

-   Is the sum of the Coalition greater than the individual parts? Has
    the Coalition been advantageous to USAID, each of the partners
    individually and the broader TB community?

-   Do the Coalition partners meet the needs of USAID and the global
    demand for TB control? Is the Coalition too broad or narrow in
    partners and focus?

-   Has USAID facilitated the work of TBCTA?

-   How have partner's capacity been strengthened?

####### Administrative/Management

-   Evaluate to what extent TBCTA has met the management functions
    outlined in the cooperative agreement including planning, allocation
    of funds and coordination of sub-agreements.

-   Evaluate the efficiency and effectiveness of the administrative
    structure and management of TBCTA including the PMU and individual
    TBCTA partners.

-   Evaluate to what extent TBCTA has supported the administrative
    components of the country work plans.

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-   How has TBCTA's monitoring and evaluation plan effectively captured
    and informed program results?

-   What are some of the strengths and weaknesses of the four high-level
    indicators for the project? Are there other indicators that would
    reflect the TBCTA efforts?

-   How has USAID's oversight and management aided or hindered TBCTA
    accomplishing results?

-   Identify the key strengths and weaknesses that influence the
    management (operation) of TBCTA.

-   Evaluate to what extent in-country TBCTA presences made a difference
    in project progress?

####### Technical

-   Evaluate to what extent TBCTA has met the technical and programmatic
    objectives described in the technical documents and cooperative
    agreement.

-   How has TBCTA met the intermediate results described in the
    technical documents and cooperative agreement?

-   How has TBCTA met the TB technical needs of USAID Global and
    Missions?

-   Evaluate to what extent TBCTA has been innovative and creative in
    their approach to controlling TB.

-   How did TBTCA improve and expand USAID and partner's capacity to
    respond to the TB epidemic?

-   Evaluate the product/outputs of the TBTCA combined efforts to
    control TB worldwide.

-   What is the perceived impact (value added) TBCTA has on stakeholders
    working in TB control?

-   Evaluate to what extent TBCTA has built institutional or individual
    capacity regional or at the country level.

-   How has TBCTA contributed to the integration of TB control within
    primary health care services?

-   Evaluate to what extent TBCTA has contributed to the availability of
    high quality technical assistance worldwide.

######## Coordination and Collaboration

-   How has TBCTA collaborated with other USAID-funded cooperating
    agencies, stakeholders and other organizations and groups working in
    the field of TB control?

-   Evaluate to what extent TBCTA has played a role in the global
    response to TB control.

-   What has TBCTA contributed to the global TB policies and strategy
    planning?

-   How does TBTCA relate to and work with Stop TB?

-   What role has TBCTA played in assisting countries with GFATM
    proposals, program development and implementation?

# V. METHODOLOGY

The evaluation will gather information through TBCTA staff and local
partner interviews, reports and data review, focus group discussions and
interviews with MOH personnel and local service providers and
recipients, as well as interviews and field visits with USAID Mission
and Washington staff. Issues related to project management,
implementation, and attainment of results will be addressed. It would be
useful if the team would develop an evaluation tool for ensuring
consistency of information at every site. In addition, the team should
develop a standardized questionnaire for interviewing all the USAID
Regional and Country Mission providing field support to TBCTA. Sources
of information and methods used should be described in the final report.

[Document Review]{.underline}

-   USAID/Washington will provide the team with historical program
    documents before the team planning meeting. These documents will
    include the technical proposal, cooperative agreement, yearly work
    plans, financial documents, progress reports and any other relevant
    materials. Also, pertinent documents on the countries chosen for the
    site visits will be provided.

-   The TBCTA partners will be a good source of information for
    additional documents on their project activities. These documents
    will be made available upon request.

-   Upon request, information on other USAID/Missions working with TBCTA
    will be provided.

-   The evaluation team will be responsible for collecting and reviewing
    any other relevant documents throughout the evaluation.

[Briefing Sessions]{.underline}

-   A team planning meeting will be held in Washington before the
    evaluation begins. The meeting is essential for the following
    reasons:

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-   Enabling USAID personnel, such as the CTO, TB Team, and others to
    present the team with the purpose and agenda of the assignment;

-   Agreeing upon approach for working with the USAID;

-   Developing a common understanding for the individual team members'
    responsibilities and roles;

-   Establishing a team atmosphere for working together;

-   Reviewing and clarifying logistical and administrative procedures
    for the assignment;

-   Developing a common understanding of the assignment's objectives and
    outcomes;

-   Developing a preliminary draft outline of the team's report; and

-   Sharing information on individual working styles and agreeing on a
    procedure for resolving difference of opinion both within the team
    and with the client.

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-   Brief Country Missions on arrival and departure.

-   Ongoing discussions with USAID on the changes, adaptations and
    developments of the evaluation.

-   Once the report is in the final draft format, the team will provide
    a debriefing in which the findings will be presented to USAID/W and
    TBCTA for comments.

[Interviews and Site Visits]{.underline}

-   USAID/W (CTO, former CTO, TB team leader, Division Chief, AO)

-   USAID Regional Bureaus

-   USAID Missions providing field support

-   PMU

-   Each Partner Headquarters Office

-   Observe one Board meeting

-   TFT Members

-   Observe one TFT meeting or activity (if feasible)

-   Stop TB Partnership Members

-   Country-level\*

    -   USAID Missions

    -   Senior Governmental Health Officials

    -   National Tuberculosis Program Manager and Staff

    -   Other local Tuberculosis institutions partnering with TBCTA

    -   TBCTA employees in the field

    -   International Organizations implementing TB activities

    -   Health Care Workers and Managers at Project Field Sites

    -   Clients

\*The criteria for choosing the countries to visit are the following:

-   Significant USAID field support

-   Implementation by each of the three main partners (KNCV, WHO,
    IUATLD)

-   Geographic diversity

**PERIOD OF PERFORMANCE**

The assignment will be conducted from October 1, 2003 through April 15,
2004. The following table is the projected schedule for implementing the
methodology. It may be refined as a result of the team-planning meeting
that will take place at the beginning of this assignment.

Table 1: Tentative Implementation Schedule

  ------------------------------- -------------- -------- ------------ ---------- --------
  **Task**                        **Duration**   **Core   **Team       **Senior   **TB
                                                 Team Due Leader**     Public     Spec**
                                                 Date**                Health     
                                                                       Spec**     

  **1. Assignment Start-Up**                                                      

  **1.1 Review of Documents**     Ongoing                 2.00         2.00       2.00

  **1.2 Team Planning Meeting                                                     
  (TPM)**                                                                         

  1.2.1 Conduct TPM (USAID/W)     Nov 3--7       07 Nov   2.00         2.00       2.00
                                                 03                               

  1.2.1 Adjust Scope of Work      Nov 3--7       07 Nov   0.50         0.50       0.50
                                                 03                               

  1.2.3 Obtain CTO approval of                   07 Nov                           
  work plan                                      03                               

  **1.3 Develop evaluation tools                                                  
  and guidelines**                                                                

  1.3.1 Develop interview         Nov 3--7       07 Nov   1.00         1.00       1.00
  questions and analysis                         03                               
  guidelines                                                                      

  1.3.2 Conduct USAID/W and other Nov 3--7       07 Nov   1.50         1.50       1.50
  local interviews                               03                               

  **1.4 Logistical preparations**                                                 

  1.4.1 Coordination with         Nov 17--Dec 31 31 Dec   USAID/W                 
  USAID/W, Missions, Bureaus, and                03                               
  TBCTA members                                                                   

  1.4.2 Preparation of flight                    31 Dec   Synergy                 
  itineraries, visas, hotel                      03                               
  accommodations, etc.                                                            

  **2. Interviews and Site                                                        
  Visits**                                                                        

  2.1 Conduct telephone           Nov 17--Dec 31 31 Dec   5.00         5.00       5.00
  interviews                                     03                               

  2.2 Europe-based site visits:   Jan 7--16      16 Jan   9.00         9.00       9.00
  Hague, Paris, Geneva                           03                               

  *2.2.1 TBCTA Board Meeting will Feb 23         Feb 23   1.00         0.00       0.00
  be held in Washington, DC                                                       
  2/23-24/03; team leader will                                                    
  observe.*                                                                       

  2.3 Africa Region/Country level Jan 17--24     24 Jan   8.00         8.00       8.00
  site visits (1 country)                        04                               

  2.5 ANE Region/Country level    Jan 25--Feb 1  01 Feb   8.00         8.00       8.00
  site visits (1 country)                        04                               

  2.6 E&E Region/Country level                            0.00         0.00       0.00
  site visits (included in                                                        
  telephone interviews)                                                           

  2.7 LAC Region/Country level    Feb 2--9       09 Feb   8.00         8.00       8.00
  site visits (1 country)                        04                               

  **3. Report Preparation and                                                     
  USAID/W Debriefing**                                                            

                                                                                  

  **Task**                        **Duration**   **Core   **Team       **Senior   **TB
                                                 Team Due Leader**     Public     Spec**
                                                 Date**                Health     
                                                                       Spec**     

  3.1 Prepare and submit Draft #1 Feb 10--27     27 Feb   10.00        7.00       7.00
  Executive Summary & Full Report                04                               
  to USAID/W and TBCTA                                                            

  3.1.1 Review of Draft #1 by     Mar 1--5       05 Mar   0.00         0.00       0.00
  USAID/W and TBCTA                              04                               

  3.2 Debrief USAID/W and TBCTA   Mar 8--12      12 Mar   1.00         1.00       1.00
  Members, separately                            04                               

  3.3 Receive comments from       Mar 15--19     19 Mar   0.00         0.00       0.00
  USAID/W and TBCTA Members                      04                               

  3.4 Revise Draft #1 (becomes    Mar 22--26     26 Mar   5.00         3.00       3.00
  final version)                                 04                               

  3.5 Feedback to final           Mar 29--31     31 Mar   0.00         0.00       0.00
  version/approval by USAID                      04                               

  3.5 Synergy edits final version April 1--7     07 Apr                           
  of the Executive Summary and                   04                               
  Full Report                                                                     

  3.6 Submit Executive Summary                   09 Apr   0.00         0.00       0.00
  and Full Report to USAID/W (one                04                               
  hard copy; diskette in Word and                                                 
  .pdf files, the latter for                                                      
  website use if chosen by                                                        
  USAID/W                                                                         

  **4. Assignment Close-Out**                                                     

  4.1 USAID approval of                          15 Apr   0.00         0.00       0.00
  deliverables and completion of                 04                               
  Synergy evaluation form                                                         

  **Total Consultant Days**                               62.00        56.00      56.00

  **Total Consultant Days (All)**                         **174.00**              
  ------------------------------- -------------- -------- ------------ ---------- --------

\[N.B. VI. and VII. heads are missing from format. Editor.\]

**DELIVERABLES AND CLOSE OUT**

#### Assignment Deliverables

**1. Team Planning Meeting:** All team members shall participate in a
Team Planning Meeting at USAID/Washington and at The Synergy Project in
Washington, D.C. at the beginning of the project. The purpose will be
to:

> \(a\) Review the goals and objectives of the assignment
>
> \(b\) Develop a work plan, which will include, as needed, revision of
> the implementation schedule and initial development of the interview
> guides
>
> \(c\) Begin in-person interviews with key USAID/Washington staff, if
> time permits. **Interviews and Site Visits:** Team members will
> conduct interviews and site visits in accordance with the schedule
> developed during the TPM.

3\. Draft Executive Summary and Full Report and Briefing with USAID/W
and the TBCTA Members: **A detailed evaluation report with a summary of
findings, including results and indicators for the project, feedback on
performance and implementation, and recommendations for improved
implementation and results. The evaluation team is required to provide
the following report and briefing deliverables:**

> 3.1 A draft report will be provided to USAID/W and TBCTA no later than
> March 15, 2004. The report should not exceed 50 pages with an
> executive summary of no more than 5 pages.
>
> 3.2 Shortly after submitting the report, a meeting should be held with
> USAID and TBCTA in order to present the findings and receive comments.

**4. [Final Executive Summary and Full Report]{.underline}:** After
comments have been received from USAID and TBCTA on the first draft, the
final Executive Summary and Full Report entitled, "Evaluation Report of
the Tuberculosis Coalition for Technical Assistance (TBCTA)-Executive
Summary (April 2004)" and "Evaluation Report of the Tuberculosis
Coalition for Technical Assistance (TBCTA)-Full Report (April 2004)"
will be prepared incorporating the comments received from the review of
the drafts. This step entails a final review by the technical backstop
officer and editing by The Synergy Project. The final versions shall be
submitted to USAID/W on diskette in Word format and .pdf format for
posting to the USAID website should USAID/BGH/HIDN decide to post the
document. One hard copy will be provided. USAID/BGH/HIDN will be
responsible for distributing copies to TBCTA.

> **B. Assignment Closeout**
>
> **[Acceptance of the final products and completion of the Synergy
> evaluation form]{.underline}:** USAID/Washington will give to The
> Synergy Project written acceptance of the final version of the
> Executive Summary and the Full Report, and it will complete the
> Synergy evaluation form, which will be provided to USAID/Washington by
> The Synergy Project.
>
> **VIII. TEAM COMPOSITION, QUALIFICATIONS, AND LEVEL OF EFFORT**

-   [Team Leader]{.underline}: A public health expert in USAID program
    design, implementation, and evaluation. The person should have an
    excellent understanding of USAID operational, management and
    technical approaches. In addition, S/he should have strong
    leadership skills.

-   [Senior Public Health Specialist]{.underline}: An expert in
    international public health with a good understanding of
    Tuberculosis and the current global strategy to combat it. S/he
    should have experience with USAID operational, management and
    technical approaches. A good understanding of human resource
    development is desired.

-   [Senior TB Specialist]{.underline}: Expert in the field of
    international tuberculosis control with excellent understanding of
    the global strategy and its implementation. S/he should have many
    years of experience monitoring and evaluating various DOTS programs
    throughout the world. An understanding of USAID is desired.

> The level of effort for each consultant is estimated and outlined in
> Section VI, Table 1, Tentative Implementation Schedule.

## IX. RELATIONSHIPS AND RESPONSIBILITIES

**[Team Leader]{.underline}:** The Team Leader will be responsible for
the overall organization of the work; conducting U.S. and in-country
briefings; and facilitating productive working relationships among the
team members. The Team Leader will consult with the client,
USAID/BGH/HIDN, throughout the assignment to ensure progress is sound
and the key scope of work issues are being addressed. The Team Leader
will facilitate the preparation of the Executive Summary and the Full
Report among all the team members; assure that the draft and final
products are prepared in accordance with the Scope of Work; and that the
required revisions for the final report are incorporated. Should changes
to the Scope of Work be necessary, the Team Leader has authority to
negotiate such changes with USAID/BGH/HIDN and shall officially inform
The Synergy Project, in writing, of said changes. The Team Leader will
manage local expenditures.

**[Team Members]{.underline}:** The Senior Public Health Specialist and
the TB Specialist will work under the direction of the Team Leader. All
team members will:

a.  Participate in the team planning meeting

b.  Participate in any briefings as requested by the Team Leader

c.  Foster productive team working relationships

d.  Facilitate the preparation of all deliverables

e.  Maintain records and notes of all interviews and meetings

f.  Submit to The Synergy Project consultant trip reports

**[Client]{.underline}:** Technical direction from USAID/BGH/HIDN will
be as follows:

Ms. Cheri Vincent, MSPH, Public Health Advisor and Cognizant Technical
Officer USAID/BGH/HIDN/ID

1300 Pennsylvania Ave., N.W.

Washington, DC 20523-3700

Telephone 202-712-1279; Fax 202-216-3702

Email: cvincent@usaid.gov..

**[The Synergy Project]{.underline}:** Synergy will provide a senior
technical specialist who will provide technical oversight as needed;
give insights to the draft executive summary and full report, and review
the final version prior submission. Editing services will be provided
for the final version of the Executive Summary and full report, as well
as a diskette with the documents in Word format and .pdf format (for
posting to the USAID website, if chosen by USAID/BGH/HIDN). A program
manager will identify and recruit team members and will mange and
support the team during the assignment period. Logistical support will
be provided as described in Section X.) The Synergy Project points of
contact are:

The Synergy Project

TvT Global Health and Development Strategies

a Division of Social & Scientific Systems, Inc.

1101 Vermont Ave., N.W., Suite 900

Washington, D.C. 2005

Telephone: 202-842-2939/Fax: 202-842-7650

Gary Merritt, PhD, Technical Backstop

Extension 129/Email: gmerritt@s-3.com

Deanna Crouse, MHS, Program Manager

Extension 124/Email: dcrouse@s-3.com

A contact list for all team members will be provided to the client and
all team members at project start-up.

**X. LOGISTICS**

The Synergy Project will provide the following technical and logistical
support:

> Identify and recruit team members, and manage and support the team
> while on assignment

Administrative support for arranging all consultant travel, visas, DBA,
Medex, and related preparations for consultant departure

> Provide an advance to the team leader prior to departure to manage the
> local expenses
>
> Provide support and editing services for the preparation of the final
> versions of the deliverables

USAID and TBCTA will provide the following logistical support:

> USAID/BGH/HIDN to arrange the schedule of interviews with TBCTA
> members and USAID regional and country missions
>
> TBCTA to coordinate travel schedules and interviews with its
> implementing partners for the regional site visits
>
> USAID country missions for administrative support for coordinating the
> mission interview schedules, making hotel reservations, and providing
> workspace and a computer station for team members. If needed, the
> country missions will facilitate cash checking privileges for the team
> members

**XI. REFERENCE MATERIALS**

See "Document Review" in Section V. Methodology. The Synergy Project
will provide consultants with as many documents electronically as it can
that it receives from USAID/BGH/HIDN. Any additional documents that are
collected by the team members during the assignment period shall be
tracked and recorded by the consultants for inclusion into the full
report.

**XII. FUNDING**

This assignment will be funded by Global Funds earmarked for
tuberculosis.

# Annex F: Questionnaire for USAID Missions

Background: The Bureau for Global Health has asked Synergy to carry out
an independent mid-project evaluation of the TBCTA (TB Coalition for
Technical Assistance) project. TBCTA provides technical assistance,
training and other selected support in thirteen countries, including
yours.

The independent evaluation team, hired by Synergy, plans to ask the
following questions of USAID missions in each of the countries where
TBCTA has been working. You have been identified as the Mission backstop
for TBCTA. An evaluation team member will soon contact you by email to
set up a time for a telephone interview when he will request your views
on these questions. The sources of information gathered as part of this
evaluation will remain confidential.

1\. GENERAL

-   What are the major gaps (constraints) in increasing DOTS coverage in
    your country?

-   Summarize the Mission's TB strategy and TBCTA's role in that
    strategy.

-   How close is the Mission's working relationship with the national TB
    program? Through a country coordinating mechanism? How close is
    TBCTA's working relationship with the national TB program?

2\. PROJECT RESULTS

-   Has the TBCTA played a role in developing a national multi-year work
    plan (a.k.a. a mid-term development plan) for DOTS implementation
    and in assessing the national TB program?

-   Has the project played a role in planning and assessing the national
    TB program

-   Do you have an adequate TBCTA work plan and is it on schedule (if
    not, why not).

-   To what extent has TBCTA contributed significantly to DOTS expansion
    (and is likely to contribute during the final 2 years of the
    project).

3\. CAPACITY BUILDING AND TECHNICAL

-   Describe the Project's activities in increasing national HR capacity
    (to date and in the future)

-   How effective has project training and TA been (selection of
    courses, participants, follow-up, sustainability);

-   How effective has the TBCTA been in supporting USAID technical needs
    in TB (planning, STTA)

4\. INTEGRATION AND COLLABORATION

-   What role has the project played in encouraging HIV-TB
    collaboration?

-   What role has the project played in integrating TB with the
    country's PHC system?

-   What role has the project played in collaboration with TB partners
    (e.g., the STOP TB initiative, the GFATM, the Global Drug Fund)?

5\. MANAGEMENT (USAID AND TBCTA)

-   Has TBCTA management been responsive to mission and country
    requests?

-   Have communications with the Washington CTO regarding the project
    been clear and effective.

-   Does the project have a significant pipeline of mission funds? If
    so, what have been the key factors that have built up the pipeline?

-   What management weaknesses need to be addressed?

6\. FUTURE

-   What role does the mission see for TBCTA in the future (the
    remaining two years of the project)?

-   What role might TBCTA play over a longer period?

# Annex G: Questionnaire for National TB Program Managers

QUESTIONS FOR NTP MANAGERS

Background: USAID is carrying out a routine mid-project evaluation of
the TBCTA (TB Coalition for Technical Assistance) project. TBCTA
provides technical assistance, training and other selected support in
several countries, including your country.

The independent evaluation team plans to ask the following questions of
NTP managers in each of the countries where TBCTA has been working. An
evaluation team member will soon contact you by email to set up a time
for a telephone interview when he will request you to answer these
questions. The sources of information gathered as part of this
evaluation will remain confidential.

1\. GENERAL

-   Is there a national plan for DOTS implementation?

-   Is there a functioning country coordinating mechanism for DOTS
    implementation including the NTP and donors?

-   What is the current DOTS coverage in the country and how is DOTS
    expansion defined in your statistics.

-   What are the major gaps (constraints) in increasing DOTS coverage

2\. PROJECT RESULTS

-   Has the TBCTA played a role in developing a national plan for DOTS
    implementation and in assessing the national TB program

-   To what extent has TBCTA contributed significantly to DOTS expansion
    in your country (and is likely to contribute during the final 2
    years of the project).

3\. CAPACITY BUILDING AND TECHNICAL

-   What activities has TBCTA performed to increase national Human
    Resource capacity (to date and future)

-   How effective has TBCTA training and Technical Assistance been
    (selection of courses, participants, follow-up, sustainability);

4\. INTEGRATION AND COLLABORATION

-   Has TBCTA played a role in encouraging HIV-TB collaboration?

-   Has TBCTA played a role in integrating TB with your country's PHC
    system?

-   Has TBCTA collaborated and coordinated with other major TB
    organizations (local and international) working in your country
    (e.g., the STOP TB initiative, the GFATM, the Global Drug Fund)?

5\. MANAGEMENT (USAID AND TBCTA)

-   Has USAID been responsive to country requests for assistance from
    TBCTA?

-   Has TBCTA management responded to country requests for assistance in
    a timely manner and with high quality support?

-   Do you feel you have a satisfactory working relationship with both
    USAID and TBCTA? If not, how could it be improved?

6\. FUTURE

-   What role do you see for TBCTA assistance in the future (remaining 2
    years of the project)?

-   What role might TBCTA play in your country over a longer period?

[^1]: ^\*^ The World Health Organization (WHO) indicates that it no
    longer uses DOTS as an acronym. Previously, WHO used DOTS as an
    acronym for "directly observed treatment--short course."

[^2]: WHO indicates that it no longer uses DOTS as an acronym.
    Previously, WHO often used DOTS as an acronym for "directly observed
    treatment--short course."

[^3]: The International UNION Against Tuberculosis and Lung Disease
    operates in English, French, and Spanish, with a different name and
    acronym for each language (IUATLD in English, UICTMR in French, and
    UICTER in Spanish). Because none of these acronyms are easy to
    pronounce, most people refer to the organization as "The UNION." In
    this report, we refer to the IUATLD as "the UNION."

[^4]: According to the 2002 WHO Global TB Control report, 22 countries
    account for about 80 percent of the global TB burden. In order of TB
    burden they are: India, China, Indonesia, Nigeria, Bangladesh,
    Ethiopia, Philippines, Pakistan, South Africa, Russia, Democratic
    Republic of the Congo, Kenya, Vietnam, Tanzania, Brazil, Thailand,
    Uganda, Burma, Mozambique, Cambodia, Zimbabwe, and Afghanistan.

[^5]: Burma, China, Mozambique, Tanzania, Thailand, and Zimbabwe are
    among the 22 top high-burden countries but do not appear in the
    table. Despite substantial TB burdens (and in many cases, multi-drug
    resistant TB and HIV/AIDS), significant legal and/or operational
    obstacles exist to USAID support for TB control. If country
    circumstances should change so that these obstacles are no longer
    present, USAID will consider adding that country to the priority
    list provided adequate funds are available.

[^6]: Some support is provided to Lao People's Democratic Republic and
    Vietnam.

[^7]: Some support is provided to Estonia, Kosovo, Latvia, Lithuania,
    and Romania.

[^8]: Core fund obligations were estimated to be approximately \$3
    million/year, or a total of \$15 million over five years.

[^9]: Project Proposal, p.12. \[TBCTA submitted a project proposal to
    USAID, which was accepted. We refer to this proposal throughout this
    evaluation\].

[^10]: This will be accomplished by providing policy and programmatic
    guidance, as well as administrative, managerial, and technical
    assistance. This collaboration will be evidenced by the elimination
    of duplicative activities, consolidation of separate efforts to
    achieve a common objective, and by joint programming and pooling of
    resources both in the field and at headquarters. Project proposal,
    p. 12.

[^11]: Activities include: (1) staff training in a variety of related
    fields (general management, logistics management, technical
    capacity, supervision, operational research); (2) support for
    administration, general management, logistics management,
    supervision, and operational research; (3) development of
    standardized monitoring \[results\] and quality control systems in
    national programs; and (4) thorough engagement of private
    practitioners and community organizations in TB control. Activities
    consist of training courses, workshops, intracountry and
    intercountry meetings, program review missions, and
    consensus-building.

[^12]: Activities include organizing formal trainings and on-the-spot
    trainings by "trainee" participation in TBCTA consultation,
    evaluation, and monitoring missions. Project proposal, pp.12--13.

[^13]: Project proposal, pp. 19--20.

[^14]: Project Proposal, pp. 21--24.

[^15]: Updated from the draft annual report October 2002--September
    2003, pp.18--19. Note that the last year in the table, 2003, shows
    cases notified during 2002 and result of treatment of cases notified
    during 2001.

[^16]: WHO Global TB Report 2004 (draft tables only).

[^17]: The third report of the WHO/UNION Drug Resistance Survey Project
    was to have been published in March 2004, and will provide
    additional detailed information on this issue.

[^18]: The definition of DOTS population coverage is problematic. A WHO
    working group is currently revising

    the definitions by focusing on population. Another indicator that
    may better express achievements in TBCTA would be health facility
    coverage (the proportion of facilities with the minimum resources
    and equipment within national TB program plans to provide DOTS that
    actually provide this service). It would be reasonable to expect 100
    percent health facility coverage within a few years, and then the
    real population access to DOTS would depend on health system
    coverage. The WHO global report survey inquires how many health
    facilities/administrative units (districts) there are and how many
    of these are implementing DOTS, but it does not calculate the
    percentage. This indicator requires further fine-tuning of the role
    of outreach services, NGOs, and the private sector in a national TB
    plan.

[^19]: Garrett, Denise. *Epidemiologia do tuberculosis no Brasil.*

[^20]: A recent SINAN \[in Brazil, diseases of mandatory notification\]
    report showed 30% of cases not reported.

[^21]: It is difficult to estimate what constitutes 100% of cases. The
    rate appears to be far too low in Malawi, which for many years has
    had significant health system coverage and a good national TB plan.
    A case detection rate of only 50% in Egypt is also surprising. The
    indicator could be used to assess trends over time, but in
    Indonesia, the incidence corresponding to 100% has been changed each
    year. This indicator should not be used at regional/provincial
    levels.

[^22]: WHO/UNION defines treatment success as the sum of: completed
    treatment with negative sputum smear microscopy at the end (usually
    called "cured"), and completed treatment without the last smear
    control at the end (usually called "completed"). WHO usually sets
    the goal at an 85% success rate, but the evaluation team noticed
    that in some TBCTA documents and national programs the 85% cure rate
    was used.

[^23]: Project proposal, page 20.

[^24]: Case detection is based on a global estimate of 135 cases per
    100,000 people. The WHO accepts that the number of actual cases may
    be significantly higher or lower in any location.

[^25]: Project Proposal, p. 12.

[^26]: Brazil, Cambodia, D.R. Congo, Dominican Republic, Egypt, El
    Salvador, Ethiopia, Haiti, Indonesia, Kenya, Malawi, Philippines,
    Senegal, Uganda, and South Africa.

[^27]: Estonia, Kazakhstan, Kosovo, Latvia, Russia, Ukraine, and
    Uzbekistan. This evaluation was not considered a success. The
    reports from these Eastern European visits have been much delayed,
    partly because KNCV consultants were not available on a timely
    basis, because the focus was not clear enough (USAID expected not
    only technical issues but also advocacy to be addressed), and
    because of problems associated with the writing and editing
    processes.

[^28]: Brazil, Cambodia, D.R. Congo, Dominican Republic, El Salvador,
    Haiti, Indonesia, Malawi, Mozambique, Senegal, and South Africa.

[^29]: Egypt and Nigeria.

[^30]: Draft third report, planned for publication in April 2004.

[^31]: The staff consists of a medical officer as project manager, a
    program coordinator, an accountant, an office manager, an office
    assistant, and a driver.

[^32]: This person was initially contracted by KNCV for a six-month
    period. Her contract was subsequently continued by the UNION.

[^33]: WHO points out that recruitment took only four months after the
    subagreement was signed for the TBCTA program in El Salvador.

[^34]: ISAC note, January 2004.

[^35]: Suggestions for strengthening Brazil's national TB program were
    raised in the mid-2003 review by Rodolfo Rodriguez et al., and in
    1999, Mark Perkins and Paula Fujiwara performed an institutional
    evaluation of the national reference laboratory.

[^36]: Project Proposal, pp. 12--13.

[^37]: Project Proposal, p.20.

[^38]: Guidelines on how to prepare a personal training plan for future
    TB consultants for TBCTA, 77 pp. Includes an inventory of relevant
    courses and materials.

[^39]: Guidelines on how to prepare a personal training plan for future
    TB consultants for TBCTA, p.7.

[^40]: Project Proposal, pp. 12--13.

[^41]: Project Proposal, p. 16.

[^42]: Project Proposal, p. 20.

[^43]: *Human resource development for TB control. The roles of the TFT
    and other players within TBCTA. A position paper (draft).* October
    2003 and February 2004. 11 pp.

[^44]: TFT Terms of Reference, December 5, 2001.

[^45]: *Training for better TB control. Human resource development for
    TB control. A strategic approach within country support.*
    WHO/CDS/TB/2002.301 13 pp.

[^46]: *Checklist for the review of the HRD component of national plans
    to control tuberculosis.* Draft.

[^47]: *The training coordinator's handbook.* Chapters 1--6, November
    2002.

[^48]: *WHO training modules for health center staff.*
    WHO/CDS/TB2003.314.

[^49]: *Participant manual for regional workshops for TB training focal
    points from high-burden countries.* Bangkok, September 2003.

[^50]: Project Proposal, p. 13.

[^51]: Project Proposal, p. 16.

[^52]: Borgdorff, Martien, and Marieke van der Werf. *Report of a
    mission to Indonesia to support operational research on tuberculosis
    control, in particular in Central and East Java.* February/March
    2003. 31 pp.

[^53]: Voskens, Jan. *Summary of progress TBCTA Indonesia 2003.* Draft.

[^54]: David Brown "Global funds cuts grants for fighting three
    diseases," *The Guardian Weekly,* October 2--29, 2003, p. 34,
    columns 1--5; and David Brown, "Global Fund Slows Aid Going to Fight
    3 Diseases," *The Washington Post,* October 17, 2003, p. A.2.

[^55]: Although she serves on the panel in her personal, rather than her
    institutional, capacity, she inevitably brings with her in-depth
    country knowledge provided via the TBCTA program activities.

[^56]: *Guidelines for Implementing Collaborative TB and HIV Programme
    Activities,* World Health Organization, 2003.

[^57]: *Strategic Framework to Decrease the Burden of TB/HIV,* World
    Health Organization, 2003.

[^58]: The increasing number of TB infectious cases in people living
    with AIDS poses an increased risk for TB transmission to the general
    community. HIV has also been shown to increase the risk for
    recurrent TB. Therefore, in addition to there being a number of
    points at which specific anti-TB interventions can be made (BCG
    vaccination, preventive treatment for TB, and treatment of active TB
    cases), there are also several points at which anti-HIV
    interventions can be made that will reduce the chance for active TB
    developing (e.g., condom promotion, treatment of sexually
    transmitted infections, safe injecting drug use, and highly active
    antiretroviral therapy). The most powerful intervention against TB
    beyond case finding and treatment is to prevent new HIV infections
    from occurring in the first place in people already infected with
    TB, as this will greatly reduce the likelihood that latent TB
    infection will progress to active TB disease. \[From *Guidelines for
    Implementing Collaborative TB and HIV Programme Activities,* WHO,
    2003. See rationale for additional interventions beyond TB case
    finding and treatment to control TB in high HIV prevalent
    populations, page 16.\]

[^59]: A survey in 1995--1996 published in the first WHO/UNION drug
    resistance report showed a low level of multi-drug resistant TB
    cases but did not include hospitals. A considerable number of
    multi-drug resistant TB cases are being treated, but without better
    routine data in the national TB program, it is difficult to assess
    what proportion this represents. Until the next survey occurs, we
    will not know the size of the multi-drug resistant TB problem, but
    several conditions are present that in other settings have been
    shown to increase the risk of multi-drug resistant TB: no directly
    observed treatment by health staff, only three drugs in the first
    treatment, and a very risky re-treatment regimen. In addition, the
    lack of information is a concern, because a potential problem is not
    being detected.

[^60]: Evaluation of the HDL Hospital DOTS linkage project in DI
    Yogyakarta, in collaboration with PERSI, the Ministry of Health,
    KNCV, UAB Gorgas, and the WHO, June 2003.

[^61]: The TB Partnership Forum also includes, among others, World
    Vision, Indonesia, Yayasan Pembangunan Indonesia Sehat (YPIS),
    Persatuan Dharma Karya Indonesia (PEFDHAKI), Perkujpulan
    Pemberantasan Penyakit Tuberkulosis Indonesia (PPTI) and Netherlands
    Leprosy Relief (NLR).

[^62]: KNCV was chosen as the home for the PMU and as the grantee
    because it was registered as an NGO with USAID and therefore could
    receive USAID funds. The UNION, which some viewed as the more
    logical home for the grant, had let its USAID registration lapse and
    could not be an eligible recipient until it had re-registered.

[^63]: An exception is CDC.

[^64]: CDC did not have to establish standard TBCTA procedures because
    no TBCTA funding flows through CDC. CDC activities are funded via a
    separate USAID participating agency service agreement.

[^65]: For example, "Since 1 January 2002, all companies/organizations
    operating in France are subject to a 35-hour statutory working week.
    The 'statutory working week' refers to the number of hours which may
    be worked before overtime rates must be paid, and overtime hours
    counted towards annual overtime quotas. The 35-hour week is *not*
    the maximum working week. As a consequence, the 'penalties' for
    non-compliance are an obligation to pay overtime rates,
    non-entitlement to state subsidies, and using up employees'
    permitted annual overtime quotas."

[^66]: KNCV continues to use financial management software that is
    limited in its ability to provide the detailed reporting that would
    be most beneficial for the TBCTA and for USAID. The UNION, however,
    has just complete upgrading its financial management software at a
    cost of \$50,000.

[^67]: TBCTA leadership was eventually transferred to KNCV.

[^68]: Project Proposal, p 10.

[^69]: Ibid.

[^70]: WHO reports that since the recruitment of an international
    consultant in El Salvador, activities have been implemented in a
    timely fashion.

[^71]: Also, a major study of TB in Eastern Europe, requested by the E&E
    Regional Bureau in November, 2001 has never been satisfactorily
    completed. The request was made to KNCV, not to the TBCTA.
    Therefore, according to KNCV, the participation of WHO and CDC in
    the study was not permitted.

[^72]: WHO indicates that the problem in Brazil was the eventual
    transfer of funds to the Municipality of Rio de Janeiro.

[^73]: These costs, approximately \$250,000 per year, are consistent
    with USAID estimates for placing contract long-term technical staff
    members in overseas posts.

[^74]: WHO indicates that, depending on the work load in its country
    offices, its country office staff cannot guarantee close monitoring
    of additional projects, such as TBCTA. This is why WHO often
    recruits national TB program officers (e.g., in Nigeria) or
    international TB medical officers (e.g., in El Salvador and Brazil)
    to help monitor these projects.

[^75]: Efforts to resolve these issues have already proven beneficial in
    easing the startup of a new USAID grant to the UNION, and should
    prove useful for future USAID grants to European organizations
    (e.g., in Iraq and Afghanistan).

[^76]: USAID regulations allow for indirect costs to be calculated in
    four ways, including the two chosen by TBCTA partners.

[^77]: This was also agreed to by USAID, although only after a lengthy
    delay in transferring TBCTA funds to WHO.

[^78]: The PMU financial staff at one point wrote to USAID to ask for
    "the USAID definition" of core costs and attributable costs.

[^79]: ALA and ATS involvement is too small (approximately \$150,000 and
    \$100,000, respectively) to require additional financial management
    staff. CDC does not receive funds via the TBCTA.

[^80]: KNCV's decision not to upgrade appears to reflect a general
    unwillingness to make organization-wide changes because of the
    singular exigencies of a single new donor (USAID) whose duration as
    a donor was (and is) uncertain.

[^81]: A final version of the work plan was approved more than two years
    after the State of Rio de Janeiro submitted an initial work plan to
    USAID/Brazil. WHO transferred an initial \$50,000 to PAHO/Washington
    in August 2003, which eventually transferred these funds to
    PAHO/Brazil. Despite pleas from Rio TB officials, PAHO/Brazil
    decided it needed to close its financial ledgers before the holiday
    season. As of February 2004, the funds had not been retransmitted to
    PAHO/Brazil or to the Rio program. Meanwhile, the Rio TB program
    director resigned in frustration (per a team interview). When the
    evaluation team was in Brazil in January 2004, the whereabouts of
    the funds for Rio were a mystery. PAHO/Brazil, incorrectly,
    indicated to the team that all funds had been returned either to
    PAHO/Washington or to WHO headquarters. WHO comments on the draft
    version of this report state that the WHO funds never left Brazil.

[^82]: The UNION states that when it approached the only USAID-approved
    audit firm in France, they were first told that no personnel were
    immediately available, and subsequently were quoted a very high
    price. No funds had been budgeted for the audit.

[^83]: Lengthy TBCTA reports do not typically include a discussion of
    TBCTA-specific program progress or TBCTA-specific financial
    reporting, nor do they include semiannual national TB program
    assessments.

[^84]: The TBCTA staff says that funds are not available to reprint the
    brochure.

[^85]: Although the Congress had begun earmarking funds for TB in FY
    1998, USAID hiring restrictions made it impossible to hire a TB
    specialist until two years later, when a new hire came on board.

[^86]: USAID has apparently learned this lesson. A new health grant to
    the UNION in September 2003 was preceded by a preaward visit by a
    USAID officer that "was exceedingly valuable" in identifying and
    resolving administrative and financial issues, according to the
    UNION.

[^87]: The change in the procurement code from 000 to 935 (Free World)
    was written in a way that its effect was retroactive to the
    effective date of the cooperative agreement (e.g., any Code 935
    procurement from the beginning of the agreement period was
    acceptable).

[^88]: USAID had some legitimate issues concerning the subagreements
    (e.g., eventually WHO was not required to follow the same procedures
    as other TBCTA partners, and its subagreement reflects its status as
    an international organization and the use of procedures of public
    international organizations). The issue is slow responsiveness by
    USAID/Washington and the absence of clear communication with TBCTA.

[^89]: The basic differences between USAID contract and grant
    regulations also elude other U.S. Government entities. The Defense
    Contract Audit Agency's draft audit of KNCV, dated September 15,
    2003, consistently refers to the USAID grant to TBCTA as a contract.
    Happily, however, the Audit Agency indicates its audit review
    applied the standards from Office of Management and Budget
    regulations for nonprofit organizations.

[^90]: A KNCV letter dated October 31, 2002, justifying the actual KNCV
    indirect cost rate for Year 2000 was never acknowledged as received,
    nor was it formally accepted or rejected. The USAID response, to
    KNCV's surprise, was to initiate a long-overdue preaward audit in
    January 2003.

[^91]: An exception was a \$64,000 waiver that included the microscopes
    and laboratory equipment needed for five TBCTA countries (D.R Congo,
    Haiti, Malawi, Nigeria, and Senegal).

[^92]: USAID reports that these requests were not approved due to
    overall limitations on the time devoted to TB at the
    state-of-the-art meetings and USAID's general reticence to have
    implementing partners present their programs at such meetings.

[^93]: Current TBCTA partners: American Lung Association (ALA); American
    Thoracic Society (ATS); Centers for Disease Control and Prevention
    (CDC); International UNION Against Tuberculosis and Lung Disease
    (IUATLD); Royal Netherlands Tuberculosis Association (KNCV); and the
    World Health Organization (WHO).