Evaluation of the Tuberculosis Control Assistance Program (TB CAP)

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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)
Figure 2: Total US Dollar Value of PEPFAR Funding Through TB CAPRecommendationsPEPFAR contributions to TB CAP areincreasing each year (see Figure 2),however, they are mainly directed to HIVtesting of TB patients rather than TBdiagnosis and treatment in persons withHIV. The increased occurrence andconcern about multi-drug-resistant TB(MDR-TB) has resulted in some countriesplacing unbalanced emphasis on theseproblems at the expense of strengtheningcommunity and peripheral health servicebasedDOT. Without effective DOT atthese levels, drug resistance will beincreased.Joint planning with PEPFAR, CDC, and other TB partners needs to be better in a number ofcountries. Examples of how it is being effectively carried out should be shared.TB CAP should continue to offer NTPs a flexible means for financing emergency needs essential forthe functioning of the national program.Core and Regional ProjectsTB CAP core funding can be used to fund strategic core projects. All core projects are linked to an IR andits strategic approaches and should ideally benefit several countries. TB CAP core projects are seen bypartners and USAID as addressing priority areas in global TB control. The board has not continuouslyupdated the strategic plan or developed an agenda to prioritize core projects.Because the clientele is global, technical policies and guidelines are offered in a ―one size fits all‖ model.Countries and their priorities vary considerably and require TA to adapt these guidelines to their ownconditions while adhering to key principles. In some cases national guidelines did not reflect internationalrecommendations. Also, TB CAP tools may have been formally adopted but not incorporated intonational policy or plans. Many of the NTPs interviewed were not aware of the TB CAP product or tools.This varies by tool, with the ISTC being highly regarded in many countries.Partners see the planning and approval of core projects as time-consuming and inefficient. The one-yearplanning and approval process for products that require several years to develop, test, approve, andimplement causes problems for them. In some cases, it results in numerous small, fragmented projects,each requiring annual submission, review, and approval. In other cases, partners choose to compressmultiyear workplans into unrealistic, shorter workplans, with the expectation that uncompleted activitiescan be carried over into later years.RecommendationsThe board and working groups should maintain an up-to-date strategic program that prioritizes thedevelopment of core projects.Core projects requiring multiyear funding should be proposed and approved as a single project withannual adjustments.EVALUATION OF THE TUBERCULOSIS CONTROL ASSISTANCE PROGRAM (TB CAP) 19
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Page 4 and 5: This document (Report No. 08-001-19
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Page 8 and 9: PVOTATBTB CAPTBCTATB/HIVTREAT TBThe
Page 10 and 11: Impact on Patients and TB epidemiol
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Page 14 and 15: value this coordinated approach to
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Page 22 and 23: The TB CAP CTO seems to have provid
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Page 28 and 29: According to data from the PMU, the
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Page 36 and 37: to ensure a regular supply of drugs
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Page 40 and 41: ProportionFigure 4. TB patients Tes
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Page 44 and 45: TB CAP should intensify its efforts
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Page 56 and 57: How has TB CAP met the intermediate
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Page 70 and 71: March 19, SurabayaVisit to Puskesma
Page 72 and 73: April 1, Team 2Travel to Kachia LGA
Page 76 and 77: DateThursday, April 2, 2009Intervie
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TreatmentDrugsM&EMDRNumber of suspe
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Global Health Technical Assistance
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