Evaluation of the Tuberculosis Control Assistance Program (TB CAP)

two weeks). There is a solid consensus that the TB CAP approval process is not simple enough. It oftendelays the start of work beyond the start of the fiscal year.A significant problem is the many levels of approval involved, and the delays that can occur at each. Lackof a standardized system for recording milestones in workplan development and approval makes it hard toidentify where bottlenecks most often occur. However, it does appear from the sampling of workplansthat long delays often occur at the national level due to political or other complexities that cannot beprepared for, such as changes in the government, which in one country delayed NTP approval by threemonths. In other cases, getting the Memorandum of Understanding between TB CAP and the countrysigned was cited as causing delays (in one case, almost 6 months) in TB CAP start-up.Other long delays in workplan approval seem to be caused by a lack of involvement by key reviewers andapprovers in preparation of workplans. For example, in one country, after several weeks of preparationand agreement by the NTP and the TB CAP partner, the Mission, seeing the workplan for the first time,raised issues that required the NTP and partner to revisit it.Delays also result from a lack of information about planning and budgeting requirements, or lack of useof information available, within the Mission. In some cases, workplans approved by the Mission werechallenged by the CTO and thus needed to be clarified or adjusted by the TB CAP partner, delayingproject approval. Greater Mission understanding of what matters for CTO approval and areas wherejustification is required (for example, the number of backstopping days allowed or the reasons forchoosing an international rather than a national consultant) would decrease these types of problems. Ifpossible, the draft work plan should be seen concurrently by the Mission and the TB CAP CTO.RecommendationsThe process of planning projects should be standardized and performed consistently, and approval ofworkplans should be streamlined.The PMU should, wherever possible, use an existing USAID/country MOU when establishing its TBCAP project.If multiyear projects are introduced, TB CAP and USAID should consider how this can simplify theannual approval process.Implementing Country WorkplansIn some countries, TB CAP activities are out of phase with national priorities for TB control. In someinstances the activity or the geographic location requested is based on Mission priorities or input fromtechnical agencies, which may or may not match the needs of the national program.TB CAP has facilitated significant integration of TB into general health services, such as throughimprovements of diagnostic and drug management services that support other health needs and linkinghospitals with primary health facilities. However, the deterioration of primary care services and facilitiesin a number of countries in recent years makes it more difficult to provide quality diagnostic andtreatment services at the peripheral service level.There has been some progress in involving the private sector in TB control activities as a result of TBCAP interventions. The dissemination of the ISTC has played a major part in this success.The coordination of planning between TB CAP, PEPFAR, CDC, and other country partners is seen asimproving, but it varies greatly from country to country.18 EVALUATION OF THE TUBERCULOSIS CONTROL ASSISTANCE PROGRAM (TB CAP)