SUMMARY OF TERMINAL EVALUATION RESULTS
1. Outline of the ProjectCountry: Islamic Republic of Afghanistan

Project title: Tuberculosis Control Project Phase 2

Issue/Sector: Health

Cooperation scheme: Technical Cooperation

Division in charge: Health Division 4, HealthGroup 2, Human Development Department

Total cost: 532 million Japanese Yen at the time ofevaluation

Period of
Cooperation

Partner Country’s Implementing Organization:
Ministry of Public Health, National Tuberculosis Control
Program (NTP)

October 2009 - September
2014 (five years)
Record of Discussion:
August 23, 2009

Supporting Organization in Japan: None

Related Cooperation Project:-Grant Aid Project “The Project for Construction of Hospital for Communicable Diseases”,-Principle Recipient for the Global Fund to Fight AIDS, Tuberculosis and Malaria R10 “Reinforcing theRound 8 Program”
1-1. Background of the Project
The Tuberculosis Control Project (Phase 1) was implemented by Japan International Cooperation Agency(JICA) in collaboration with the National Tuberculosis Control Program (NTP) in the Ministry of Public Health(MoPH) and for five years (from September 2004 to August 2009) in the Islamic Republic of Afghanistan(hereinafter referred to as ‘Afghanistan’). Through implementing this project, NTP has developed its capacities
and achieved certain progress in Tuberculosis (TB) control.
Even after the collaboration effort of the project, needs of more improvement of the quality of TB control
services was observed. NTP was expected to continue efforts to establish quality DOTS, which was the basis
of TB, control, nation-wide. For ensuring and sustaining the quality DOTS, NTP was expected to develop its
capacities for program management. Moreover, in response to emerging needs such as multi-drug resistance
TB (MDR-TB), concurrent infection of TB/ Human Immunodeficiency Virus (HIV) and childhood TB etc.,
NTP needed to develop its capacities in these new areas. Thus the Government of Afghanistan requested for
Tuberculosis Control Project Phase 2 (hereinafter referred to as “the Project”) to provide quality TB services
by enhancing capacity of NTP and it was designed based on the achievements of the Phase 1.
The Project has been implemented with close collaboration with many donors, especially with the Global
Fund to Fight against AIDS, TB and Malaria (GFATM), which supports many activities of NTP and the
Project financially. The Project continuously offers technical support to NTP for capacity development tomanage the funds and program so as NTP to be able to handle the whole process of external fund management.
JICA Afghanistan Office, acting as Principle Recipient (PR) of GFATM Round10 program (GFATM R10)
from April 2012 to March 2014, has also supported the Project by smooth disbursement and procurement.
1-2. Project Overview<Overall Goal>
To reduce the burden of TB in Afghanistan in line with Millennium Development Goals (MDGs).
<Project Purpose>
TB control services through the Stop TB strategy are available and managed by NTP nation-wide inxiAfghanistan.
<Outputs>
Output 1: NTP’s organizational, institutional and functional capacities are strengthened to provide quality TB
control services through the Stop TB strategy.
Output 2: Bacteriological examination including direct sputum smear microscopy, culture and Drug
Susceptibility Test (DST) on TB control is performed within expected quality level throughout the country.
<Inputs>(at the point of the Terminal Evaluation)
Japan Side:
Long-term Experts:
3 persons (97.29M/M)
Short-term Experts:
1 person (30.06M/M)
Provision of Equipment:
Laboratory equipment such as centrifuge, autoclave Anti-TB Medicines etc.
Training in Japan:
18 persons
Local activity cost
243 million Yen
Training in third country(Egypt): 20
Exchange Visit(IRAN): 61
Afghanistan Side:Counterparts:
96 persons
Office spaces, buildings and facilities necessary for the implementation of the Project
Running expenses including staff salary; electricity, water and fuel fees; and consumables
2. Joint Terminal Evaluation Team
Members of the Joint Terminal Evaluation Team
LeaderCooperation Planning
Cooperation Planning

Mr. Tomoki KANENAWA
Mr. Nobuhiro KAWATANI
Ms. Aya KAGOTA

Evaluation Analysis

Mr. Shigeki TANIHO

Senior Representative, JICA Afghanistan office
Representative, JICA Afghanistan office
Staff, Health Division 4, Health Group 2, Human
Development Department, JICATA Networking Corporation

Period of Evaluation: January 18- Feburary 5, 2014

Type of Evaluation: Terminal Evaluation

3. Summary Result of Review
3-1. Project Performance(1) Achievement of Outputs
1) Output 1
Output 1 is almost on track to be achieved, even though some activities were suspended or undone due todelay in disbursement of GFATM Round 8 program (GFATM R8) and the absence of Japanese Experts
resulting from security reason.
NTP has been facilitating wide range of activities such as DOTS expansion activities and the TB control
activities for the vulnerable groups. NTP had also put an effort and took actions for securing budget fromexternal funds since the internal budget for TB control was limited. However, it is necessary to accelerate thecapacity building including program and financial management to provide quality TB services in the wholecountry and to be a single PR of GFATM program. The Project has worked closely with NTP to strengthen
its capacity, but the effort was disturbed by the unexpected absence of Japanese experts because of security
situation and the late disbursement of the fund from GFATM R8.

xii2) Output 2
Output 2 is also on track. A nation-wide Sputum Smear (SS) slide sending/sample transfer system had alreadybeen implemented and also the enabling environment was prepared for the primary culture in regionalreference laboratories, though the speed of the progress defers in each laboratories.
The implementation of External Quality Assurance (EQA) had been suspended due to the financial hindrance
caused by the suspension of the disbursement of GFATM R8. Also, the nationwide introduction of the new
EQA system in which cross checking is done at provincial levels instead of regional levels in the current
system has not yet been initiated although pilot implementation in five provinces had been done successfully.
Moreover the Aga Khan University agreed to be the Supra-National Reference Laboratory which meant thatthe quality assessment system for NTP had already structured.
(2) Achievement of the Project Purpose
The Project Purpose has been on track to be achieved in many aspects of its initial intention. The institutional
capacity of NTP was strengthened as the result of the implementation of the nation-wide 6 months treatment
regime which was new to the nation and the activities focused on the social clusters which were vulnerable
to TB infection such as women, children, refugees and repatriated refugees while cultivating the ownershipof NTP. Also, as the rehabilitation of the regional reference laboratories progressed, the network between thelaboratories including culture examinations was developed, and the skills of laboratory technicians and thequality of TB tests were improved nation-wide. From the document review in the evaluation, it was found that
intense collaboration among the Project members made the achievement.
Although the Project has been achieving its purpose, challenges remain for NTP to take initiative for further
developing TB control across the nation. Specifically, quality development of TB control as well as the NTP’s
initiative in program and financial management is required.
(3) Implementation process
1) Project management
The Project has taken flexible approach as responding to the changes of external environment. For example,
some necessary reagents and medicines have been procured by the Project as an emergency measure for thepatients’ continuous treatment while the fund for procurement is stopped.
An effective communication among the Project, counterpart organization and other stakeholders has been
facilitated through holding Weekly Taskforce Meetings and Quarterly National Review Meetings. Also, theProject facilitated a close communication with the other major technical and financial partners including
WHO and TBCARE. Besides, it is notable that the Project has collaboration with NGOs for activities in thearea where Japanese experts are not allowed to visit due to security reasons.
The Project had mostly implemented planned activities on basis of the PDM. However, some activities arebehind the schedule or show no progress during the latter half of the Project result from delay of disbursement of
GFATM R8 and the absence of Japanese Experts. Moreover, two indicators which are to measure engagementof each public sector and community are not measurable since there are no reliable data while this fact was
found in the Mid-term Review of the Project. The Project was supposed to review its activities and indicatorsfor better management.
NTP took a leadership for implementing the program and the Project had been always cultivating the ownershipof NTP in all aspects while some other donors marginalize its ownerships in some settings. As the result of thecontinuous effort for the development of the ownership of NTP, NTP’s commitment to the Project had beenxiii

accelerated.
2) Changes of the circumstances after the Project implementation started
Due to the security reason, the Japanese experts were not allowed to make a business trip to Jalalabad where
the important activities of the Project had been planned and also the nation-wide research on DST could not
be conducted. Also during the absence of the Japanese experts from the end of June to the end of September
in 2013, the Japanese experts still supported NTP technically from Japan using e-mail and Skype. However
the activities related to DST training were completely suspended.
3) Effective use of external funds
Since the budget of MoPH was limited so as the one of NTP, the Project had been conducting a technicalsupport on proposal making and NTP had successfully acquired the budget from the external funds as follows:● WHO/Stop TB Partnership Fund (TB REACH) in 2010 --- USD 630,000● WHO/Global drug facility in 2010 --- drug was delivered around JPY 5,000,000 worth● GFATM R10 in 2010 --- EUR 4,600,000● TB REACH WAVE3 in 2012 --- around USD 500,000 (partly accepted)4) Delay of the disbursement of GFATM R8
The transition from the first phase to the second of GFATM R8 was not conducted smoothly so that the
disbursement for the second phase of GFATM R8 was suspended for nine months from September 2011. The
suspension of the disbursement affected the progress of the Project as follows:●	The trainings planned by the Project had not been implemented excluding the trainings covered financiallyby the Project. The implementation of the trainings resumed in April 2013 when the disbursement of
GFATM R8 was approved and restarted.
●	Quarterly National Review Meetings were not held three successive times from the third quarter of theyear 2011.
●	EQA had been suspended since the third quarter of 2011 due to the suspension of SS slide sending. EQA
resumed in April 2012 when the budget from GFATM R8 became available.
●	Supervision for health facilities had been suspended since the third quarter of 2011. The implementationof the site visit and trainings for health facilities resumed in February 2012.
5) Collaboration with other projects
Since JICA Afghanistan Office became the PR of GFATM R10 in April 2012, the Project could offer technicalsupport efficiently, especially in NTP’s financial and program management capacity building through having
a practical training dealing with the actual external fund program.
Also, the newly constructed Communicable Disease Hospital, granted its construction and procurement ofequipment by the government of Japan, is expected to support the Project to ensure availability of TB care.
The hospital could also enable the Project to strengthen the capacity of the treatment of Multi-Drug Resistance
TB (MDR-TB), TB/HIV co-infection, and improve quality of the National Reference Laboratory (NRL).
3-2. Summary of Evaluation Results(1) Relevance: highConsidering the consistency with the needs of the Afghanistan and its political priorities; and the policies of
the Government of Japan, the relevance of the Project is considered as high.
The design of the Project was also evaluated as appropriate to carry on the outputs of the Phase1, and also
to further strengthen NTP’s capacity to address the issues related to EQA strengthening, MDR-TB control,
expansion of TB control services for the hard-to-reach population such as women, children and refugees.

xiv(2) Effectiveness: high
The Project was evaluated as effective. While there is a change of external conditions due to worsening
security situation in Afghanistan, most of the indicators are considered as achievable except for several
indicators which are obscure or hard to obtain during the Project period. The links between the two Outputs
and Project Purpose are logical so the achievement of the Outputs will lead to the possibility of the realizationof the Project Purpose.
The Project addresses most of the six components of the STOP TB Strategy especially, “pursue highquality DOTS expansion and enhancement”, “Address TB-HIV, MDR-TB, and the needs of poor andvulnerable populations”, “Engage all care providers”, and “Empower people with TB, and communities
through partnership” through the activities related to DOTS expansion and enhancement, Drug Resistance
Surveillance (DRS), GFATM grant guidance and tools, laboratories’ capacity building, MDR-TB, Gender and
TB, Public-Private Mix (PPM), and Community engagement in TB care. It is much apparent that Output 1“NTP’s organizational, institutional and functional capacities are strengthened to provide quality TB control
services through the Stop TB strategy” contains most of sub-components of the Stop TB Strategy, and Output
2 “Bacteriological examination including direct sputum smear microscopy, culture and DST on TB control”
promotes laboratory related issues. Both outputs contribute to the achievement of the Project Purpose.
On the other hand, when it comes to the issue of external conditions, some parts of the important assumptions
have not been met in the following three points. Firstly, some activities by R8 have been suspended because
the smooth transition from the first phase to the second of GFATM R8 was not seen and the disbursementof the fund was delayed accordingly. Secondly, rehabilitation and construction of the regional referencelaboratories underwent some defects in building and equipment (e.g. Herat Region Reference Laboratory),
and they put the implementation of the Project behind. Thirdly, although this is not set in the PDM as theimportant assumption, the Japanese experts had to temporarily leave from Afghanistan due to the deteriorationof the security situation.
(3) Efficiency: moderate
The efficiency of the Project was evaluated as moderate. The Project is designed well to enhance its efficiency,
while some of the activities’ implementation can be rated as inefficient.
Although there were frequent reassignment and changes of NTP officials, both quantity and quality of inputof human resources from the Afghanistan side was adequate. Provision of the Project office in Jalalabad was
conducted on proper timing. The allocation of the program activities budget sometimes caused difficulties inproject implementation due to delay or reduction of the budget originally from external resources.
Input from the Japanese side was moderate for its quantity and quality, and implemented mostly as planned.
Security situation sometimes disturbed the dispatch of the Japanese experts. The Project tries to avoid
stagnation by rescheduling implementation plan, giving guidance to Afghanistan side through the national
technical staff of the Japanese side, so that it did not result in serious problem for implementation of theactivities.
The Project occasionally faced the delayed budget for NTP and was obliged to respond to critical situation,
since program implementation of NTP relies on external resources. Because of the reduction of funding fromGFATM R8 (Phase 2), Ethambutol/Isoniazid, Streptomycin, were procured urgently as well as procurementof the drugs for MDR-TB which are indispensable items for TB control services. These actions can beconsidered as flexible measures and the Project may have enhanced management capacity of NTP by dealing
with irregular situations in coordination with the Japanese side and other partners. However, the total input

xvfrom Japanese side accumulated higher than planned to achieve objectives because of unexpected inputs.
(4) Impact: not yet confirmed
Negative impacts have not been brought about by the Project, and there are some positive impacts as follows:●	Through the TB screening activities for repatriated refugees in Nangarhar and Herat province, thecollaboration with Pakistan and Iran, two neighboring countries sharing the border with the two provinces
respectively, had been developed.
●	Aga Khan University, located in Karachi, Pakistan, became the Supra-National Reference Laboratory andthe system for assessing the quality of NRL in Afghanistan was established.
●	For the collaboration with Iran, the trainings for Afghanistan officials on MDR-TB were conducted twice
in 2012, once in 2013 and one course of training on radiological diagnosis for chest diseases has been
already planned and will be conducted in 2014.
●	At the 41st Union World Conference on Lung Health, Afghanistan Partners Forum was held as assistancefor TB management in Afghanistan. After the discussion among NTP, international organizations anddonors “the Berlin Declaration to stop TB and improve women health in Afghanistan” was developed.
Considering the possibility of realization of Overall Goal, its indicator “Prevalence of TB will be reduced
from 231 (2008) to 167 per 100,000 by 2020” should be carefully followed up. The prevalence of TB in
2012 is 358 per 100,000 population (estimated interval 181 to 595). The figures of prevalence should be
carefully translated since there has not been nation-wide prevalence survey that leads accurate estimation,
proper case detection causes rise in TB numbers, and estimated prevalence has confident interval so that
simple comparison of figures may not be statistically correct.
(5) Sustainability
Since there are uncertain factors, the sustainability of the Project is considered moderate in terms of institutional,
financial and technical aspects. Since most of the budget comes from partners, NTP’s financial and program
management as the PR of GFATM R10 and subsequent new funding model of GFATM is important to mobilize
resources and manage its activities. Therefore, further development of NTP’s capacity is required.
1) Institutional Aspect
As the Country Coordination Mechanism (CCM) approved in October 2013, the PR during the extension periodof GFATM R10 would be transferred from JICA Afghanistan Office to NTP. This proves that institutional
capacity of NTP was enhanced to achieve minimum requirements to become PR through the project activities.
Although NTP has much experience by collaboration in the Project with current PR, JICA, and management
capacity has been enhanced, there is room for improvement especially in report writing, which is crucial whenacting as PR of GFATM program.
2) Financial Aspect
MoPH and NTP have limited amount of budget for TB control services that does not cover all the expenses.
Thus, they financially will continue to rely on external resources such as GFATM. However, TB control beinga prioritized issue globally, continuous financial support from partners can be expected if NTP has capacity tomobilize resources and manage its activities.
3) Technical Aspect
Technical aspect of NTP was developed through the Project activities such as expansion of quality DOTS.
This technical development will contribute to the continuous expansion of TB control services based on
the Stop TB strategy in Afghanistan. Furthermore, the Project assists the development of human resources

xvi

for laboratories such as cultivation test. However, the implementation of nation-wide EQA, ability of X-ray
diagnosis, proper introduction of new diagnosis, and establishment of effective mass screening at the prisonsand refugee camps has been put in behind at the time when the Terminal Evaluation Study was conducted.
Those technical points are essential for the development of quality TB control services and expected to bestrengthened.
3-3. Factors Promoting Sustainability and Imapact(1) Factors Concerning Planning- The Project has proper design to achieve its purpose.
(2) Factors Concerning the Implementation Process-	The Project has been well managed based on the PDM. Activities under the Project were planned andimplemented based on the disucussion with counterparts.
-	The Project activities are monitored efficiently and effectively by weekly task force meeting which NTP
and other donors attend.
-	Although there are some challenges during the Project Period, such as delay of disbursement and reductionof GFATM R8 and restriction of travel to Afghanistan for Japanese experts, the Project responds in flexible
manner with close communication among JICA HQ, Afghanistan office and other donors.
3-4. Factors Inhibiting Sustainability and Impact(1) Factors Concerning Planning: None
(2) Factors Concerning the Implementation Process- Delay of disbursement and reduction of GFATM R8 has heavily influenced project activities.
-	Staff of NTP were changed frequently which affected smooth decision making and implementation of the
Project.
4. Conclusion
The Project has mostly completed the planned activities. While facing the suspension of GFATM’s budget
and deterioration of the security situation in Afghanistan, the Project’s inputs and its effective approach has
resulted in achieving expected outputs.
Following milestones of the Project, especially, are confirmed to have contributed to advancement of TB
control services through the Stop TB strategy in Afghanistan; the Project introduced the 6 months treatment
throughout the nation and built a network among NRL and reference laboratories.
Although the Project has been achieving its purpose, challenges remain for NTP to further strengthen capacityof financial and program management and to take initiative for further developing TB control across thenation.
5. Recommendation
5-1. Recommendation for NTP/the Project(1) Transferring of PR role from JICA to NTP●	Since NTP will be the PR of the extension period of GFATM R10, NTP is required to conduct a proper
financial and program management in a self-reliant manner. For this to realize, the planning andxvii

implementation of the activities with less support of the Project is required.
●	NTP/MoPH should ensure a stable institutional setup including human resources allocation for proper
financial and program management as the PR during the extension period of GFATM R10.
(2) Activities related to TB control services●	In order to ensure quality TB control services including SS, the Project needs to implement nation-wide
EQA by its completion.
●	It is recommended to enhance quality control of culture examination and DST.
●	The Project is urged to establish NRL in the newly established Communicable Disease Hospital as well as
to improve quality of slide sending system for direct smear examination.
●	The activities related to DST which had been suspended due to the absence of the Japanese experts,
need to be resumed. It requires discussions among the persons and organizations concerned to determine
how to deal with the issue. Dispatch of experts from third country and to conduct training in Agha Khan
University in Pakistan can be considered as options.
●	Enhancement of PPM activities needs to be included in the proposal for the GFATM’s new funding model.
The plan may have monitoring budget for PPM such as regular meeting and for allocation of focal points
in cities where NTP and the Project have implemented the PPM activities. The prioritized sites would bedetermined after having further discussions among concerned parties.
●	Management of community DOTS also needs be discussed at the time of planning for the New Funding
Model of GFATM. For a better management, the practical situation of the communities, careful analysisof giving incentives, and enrollment of Community Health Workers (CHWs) by closer collaboration with
Community Based Health Department of MoPH, which supervises CHWs and their activities, should beconsidered.
(3) Others●	NTP and MoPH have just started to increase the budget for TB program. This effort needs to be stimulated
for financial sustainability of the program.
5-2. Recommendation for NTP/JICA●	The project period should be extended 6 months, until March 2015, to further enhance the program
management capacity of NTP. This will allow NTP to manage the extension period of GFATM R10 andthe expected following phase which are indispensable for the TB control program in Afghanistan.
●	In January 2015, GFATM’s new funding model will be implemented and it has larger scale than GFATM
R10. For smooth transition into the new funding model, three-month support will be reasonably needed
after the transition.
●	Also, for the above proposed extension period of the Project, following activities are also recommended to
be enhanced to achieve the Project’s purpose:- Enhancement of skills for digital X-rays and establishment of TB screening system- Strengthening of the system for identifying MDR-TB positives- Propose adequate intervention to address TB control for women●	In January 2014, the Communicable Disease Hospital built by Japanese Grant Aid started operation. NTP/JICA should involve the hospital for the Project’s activities including TB control and MDR-TB treatment.

xviii