Evaluation of the Tuberculosis Control Assistance Program (TB CAP)

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while providing for annual adjustments of activities and resourcing based on needs, progress, andfunds. Longer-term planning with the anticipation of funds would make country TB control measuresmore sound and help stimulate investment in the technical capacity needed to meet current andprojected country demand.B. STRATEGY AND GOVERNANCEThe TB CAP Board of Directors is responsible for developing policies, strategic planning, and budgeting.It also gives direction to program implementation and monitors its progress and quality. The boardresolves issues and determines ways to improve core, regional, and country-funded activities. 5 The PMUis responsible for overseeing day-to-day management of all projects. It must facilitate the drafting andapproval of plans for TB CAP work, transfer funds to reimburse partners for work performed, andmonitor and report on activities and cumulative impact. In practice, however, these roles are not strictly orconsistently applied. The work of the board puts too much emphasis on management and not enough timeand effort on medium- to long-term strategic planning.Members of the board are well qualified to make strategic program decisions, but are often asked to makeday-to-day program management decisions, which would be better left to the PMU. For a variety ofreasons (such as competing interests for the short time that board members have together, a lack ofprompting and preparation of strategic issues for discussion, or a failure to assert its role as a strategicallyfocused body), this strength is not being used optimally. For instance, the following issues would ideallybe addressed by the board:TB CAP support in countries would be more efficient and have more impact if it were better alignedwith the activities of the Global Fund to Fight AIDS, TB and Malaria (Global Fund) and withPEPFAR.The deterioration of primary health care services and facilities in a number of countries in recentyears makes it more difficult to provide quality TB diagnostic and treatment services at the peripheralservice level.Concerns about increased drug resistance and TB/HIV coinfection have led governments and theinternational community to give unbalanced emphasis to these problems at the expense ofstrengthening community and primary peripheral health service-based DOT.There are areas where TB CAP needs to increase its awareness and competence, especially advocacy,information management and dissemination, quality assurance, and the best indicators of TB control.Widespread dissemination and uptake of products and experience gained from TB CAP activitiesrequires an effective marketing strategy.Discussions with NTPs and partners and field observations identified a strongly felt need for TB CAPto support field operations research and use locally available data. The USAID TREAT TB projectoffers a significant mutual opportunity. However, it will be very important that the two projects,within their respective roles, are carefully coordinated to work synergistically.Although the board is responsible 6 for monitoring the progress of program implementation andquality, it has no clear mechanism for objectively evaluating and addressing underperformance.5 TB CAP Operational Manual, Version January 20096 ibid6 EVALUATION OF THE TUBERCULOSIS CONTROL ASSISTANCE PROGRAM (TB CAP)
The board should be responsible for approving all country and core workplans and budgets anddetermining the coordinating partner for each project, but the current approach allows for ambiguitybecause it does not always place responsibility for the decision squarely on the board.The indicators currently used in TB CAP are not always the most appropriate for evaluating theimpact on TB programs given the duration of project interventions.RecommendationsThe roles and responsibilities of the board, working groups, and the PMU should be clearlycommunicated, and the operational practices of each revisited to ensure they are acting on thesemandates.Working groups should institute regular meetings, electronically or telephonically when possible, sothat they can keep strategies for core and country projects up to date.TB CAP assistance in countries with weak peripheral DOT services should prioritize reinforcingDOT, consistent with the Stop TB Strategy, while also addressing, in a balanced way, the emergingproblems of drug resistance, infection control, and TB/HIV coinfection.Although there are many priority needs, TB CAP should focus on ensuring that the fundamentalbuilding blocks of an effective TB control program are in place, especially drug management systemsand the capacity and coordination of laboratory networks.TB CAP should shift focus from short-term, high-yield projects toward longer-term, country-wideprojects that scale up the experiences it has gained and convert them into national improvements andthus greater global impact.TB CAP should intensify its efforts to build the institutional and managerial capacity of nationalsystems of TB control. In its country workplans and strategies, TB CAP should give priority tosupporting the national strategy and guidelines of each country, consistent with the state ofdevelopment and TB control needs.DOTS health facility and community volunteer systems should be strengthened and integrated.More capability in advocacy, information management and dissemination, quality assurance, and bestindicators of TB control should be acquired by TB CAP, represented in governing bodies, and builtinto future program strategy.TB CAP should offer Missions TA to increase their understanding of strategic and programmaticissues in TB control and coordination of TB with other health activities, such as HIV and primaryhealth care.TB CAP should provide TA on operations research as needed to improve TB control at the servicedelivery level.Furthermore, USAID should ensure that coordination between TREAT TB and TB CAP, startingfrom Washington and cascading down into countries, is carefully managed and potential areas ofoverlap are identified in advance rather than addressed when issues arise.The PMU should recommend country as well as core projects for board decisions on coordinatingpartners. This will be especially important during any transitional period between TB CAP and afollow-on project. Partners being considered should recuse themselves from these board decisions.EVALUATION OF THE TUBERCULOSIS CONTROL ASSISTANCE PROGRAM (TB CAP) 7
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March 19, SurabayaVisit to Puskesma
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April 1, Team 2Travel to Kachia LGA
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DateThursday, April 2, 2009Intervie
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TreatmentDrugsM&EMDRNumber of suspe
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Global Health Technical Assistance
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Evaluation of the Tuberculosis Control Assistance Program (TB CAP)

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