Attachment_J.1_Statement_of_Objectives_(SOO).pdf

Attachment J.1

RFP 72011519R00004

USAID Eliminating Tuberculosis in Central Asia (ETICA)

PURPOSE

The purpose of the Eliminating Tuberculosis in Central Asia (henceforth called ETICA) is to reduce the burden of TB in Central Asia by building local and regional capacity for improving the detection and treatment of drug-resistant tuberculosis (DR-TB). USAID seeks to invest in services that will lead to measurable and sustainable improvements in the ability of the health systems in Central Asia to deliver quality DR-TB services by building the leadership, management, financing, and technical capacity of Central Asian institutions, communities, and civil society. The end result will be increased access to quality DR-TB diagnosis and appropriate treatment, improved TB and DR-TB treatment success, and an enhanced enabling environment promoting financially sustainable DR-TB services that meet international standards.

Interventions will target both facility- and community-level DR-TB services.

The Contractor must provide a set of solutions that achieves the outlined objectives and contributes to measurable improvements in key national TB indicators, which are collected and reported by National TB Programs (NTPs) in each country, and are also included in the annual Global TB Report published by the World Health Organization (WHO).

Changes in Central Asian Ministries of Health policies and programs, new diagnostic advances and anti-TB drugs, and fine-tuning of USAID development interests make it difficult to anticipate how USAID requirements will evolve over the life of the contract. As such, the contractor must be able to rapidly incorporate changes in United States Government and Central Asia DR-TB programming priorities and policies. In addition, state-of-the-art technical interventions and innovations, and international recommendations for quality DR-TB services will evolve during the life of contract performance. Therefore, the contractor must continuously seek ways to incorporate feasible, innovative, and evidence-based approaches in support of this program’s purpose and objectives.

SCOPE

ETICA will operate as one overarching regional activity with distinct interventions/activities taking place in each country (Tajikistan, Uzbekistan, Kazakhstan, Turkmenistan, and the Kyrgyz Republic) based on local context and needs. It is anticipated that a subset of program efforts will focus on cross-cutting regional DR-TB activities. Section 4 provides additional detail on anticipated Level of Effort across countries. While USAID/Central Asia has the overall responsibility for planning, programming, budgeting, monitoring and evaluating the program, the contractor will provide administrative, technical and program support to the Mission in the planning, management, implementation, and evaluation of the outcomes of the ETICA activity.

PLACE OF PERFORMANCE

DR-TB activities will be implemented in all five countries in Central Asia, including cross-cutting regional elements. The approximate breakdown of Level of Effort by country is as follows:

Country/Unit Approximate Level of Effort Tajikistan 48% Uzbekistan 26% Kazakhstan 16% Regional Activities 7% Turkmenistan 2%

Kyrgyz Republic* 1%

*While the Kyrgyz Republic bears the burden of having the highest rate of new MDR-TB cases globally, USAID/Kyrgyz Republic is already deeply engaged in addressing this burden through its own bilateral activities. It is, therefore, anticipated that ETICA will work with these bilateral activities only to assist in the coordination and convening of discussions relevant to regional TB control.

BACKGROUND

Problem Statement

TB drug resistance has grown steadily during the last decade, and Central Asia is a “hot spot” for MDR-TB. Globally, there were 600,000 estimated incident cases of multi-drug resistant TB (MDR-TB) in 2016. This is largely a result of increased transmission of drug-resistant forms of TB or clinical and programmatic mismanagement of drug susceptible TB, for example, where drugs are of low quality, providers do not prescribe the proper regimen, and/or patients do not receive support to ensure they take the full six months of treatment. MDR-TB is much more difficult to diagnose and treat, requiring specialized laboratory expertise and infrastructure and long duration regimens of rather expensive, toxic medications.

In Central Asia, all but Turkmenistan are ranked among the 30 highest-burden countries for MDR-TB globally. The estimated percentage of new TB cases with DR-TB among new TB cases in 2016 ranges from a high of 27% in the Kyrgyz Republic to a low of 14% in Turkmenistan, with the remaining countries at 26% (Kazakhstan), 24% (Uzbekistan), and 22% (Tajikistan). TB services are dominated by outdated—and financially unsustainable— approaches, practices and behaviors as a legacy from the former Soviet system, which focused primarily on long-term inpatient treatment of TB with financial allocations based on patients in beds. These approaches complicate attempts to transition toward internationally recommended and more efficient outpatient treatment models.

Furthermore, the diagnostic networks for TB are insufficient to rapidly detect all DR-TB cases, and availability of quality-assured drugs remains a challenge. In some countries, data reporting, analysis and use are weak and highly sensitive, facing various political, structural, and systemic barriers. The primary donor for TB services in the region is the Global Fund to Fight AIDS, TB and Malaria (Global Fund). However, Global Fund grants are increasingly phasing out in Central Asia, reducing the funds available to procure TB drugs and diagnostic tests and support other activities. Stigma and discrimination against people with TB remain a challenge, within communities and facilities alike.

Country Context and Lessons Learned

It is important to recognize the achievements TB programs have made to date. Central Asian countries have progressed in improving TB services, and expanded access to outpatient treatment. All countries in the region are working toward introducing or expanding access to new drugs for TB and putting active drug safety monitoring systems in place. Some countries have already introduced the new shortened treatment regimen for simple forms of multidrug resistant- TB, easing the treatment burden on eligible patients.

In addition, National TB Programs are increasingly addressing their health financing challenges.

The Kyrgyz Republic has changed its health financing system for TB - and across the board for health - under a new Mandatory Health Insurance Fund. Other countries are increasingly beginning to identify strategies to change how their financing is structured, which can significantly improve the cost-effectiveness of TB detection and treatment.

Such changes have led to decreased incidence of new cases of TB as well as mortality from TB.

However, the proportion of TB cases that are drug-resistant across the region is rising. By focusing on addressing this complex and growing DR-TB burden, this activity will contribute to countries reaching global goals toward ending all types of TB.

There are additional factors that contribute to the burden of DR-TB such as migration, limited economic growth, or external shocks. Factors that impact the individual country context and operating environment that are important to consider are enumerated by country, below.

Tajikistan

High rates of poverty, malnutrition, and migration are the dominant factors aggravating Tajikistan’s TB burden, especially drug-resistant forms. The 2017 Drug Resistance Survey (DRS) revealed very high levels of resistance and confirmed the WHO estimation of the prevalence of DR-TB in new and previously treated TB patients.

Tajikistan’s TB services are primarily financed by donors, including the majority of TB drugs and commodities, with the Global Fund and the US Government providing the most support.

Although the Tajik government demonstrates its commitment to combat TB by increasing year-to-year monetary contributions, the overall health financing system requires significant reform before Tajikistan can finance its own TB response. In addition, systemic issues such as sub-optimal laboratory sector operations, improper infection control, weak institutional capacity, and corruption impede access to and quality of TB services provided.

Tajikistan began introducing new drugs and shortened treatment regimens in 2015; the current Global Fund grant envisions scaling up these new approaches throughout the country. The NTP and Ministry of Health and Social Protection have approved a roll-out plan whereby USAID will introduce new regimens in 40 districts representing almost two-thirds of the country’s territory, while national partners cover the remaining districts.

Tajikistan is shifting TB services to reflect person-centered care. A February 2018 National workshop has mapped recommendations to address priority tasks to further implement and scale up person-centered TB care. Lastly, an e-TB register is being established to enter, process, and consolidate epidemiological information to inform policy and program decisions. This system requires support to be further operationalized and institutionalized.

Uzbekistan

Key elements of the National TB Program (NTP) in Uzbekistan moving forward include introducing improved treatment models in Tashkent city, Tashkent and Samarkand regions. The Government of Uzbekistan continues to introduce significant health sector reforms, including reforms of TB health services. TB reforms in the country are going in line with up-to-date WHO recommendations. There is a strong focus on optimizing hospital beds and expanding outpatient (ambulatory) care for TB and DR-TB patients.

Person-centered care is being addressed by establishing medical and labor rehabilitation centers for TB patients and centers of palliative care for DR-TB patients in lieu of sanatoria. Finally, the government of Uzbekistan is strengthening intersectoral coordination to fight TB.

USAID partners with NTP and other donors to support the adoption and implementation of WHO recommendations to improve guidelines and the performance of TB services.

TB drugs are largely financed by the Global Fund. Sixty-three percent of the new Global Fund TB grant is allocated for the procurement of first, second, and third-line TB drugs. Additionally, the grant assists the NTP to improve TB diagnosis through new diagnostic equipment and supplies and expanded TB diagnostic and treatment capacity. The USAID TB program leverages the Global Fund TB grant by supporting existing models for outpatient TB and MDR- TB treatment with the provision of comprehensive case management services to encourage patients to complete their treatment.

USAID supports NTP efforts to reduce the burden of TB and MDR-TB in Uzbekistan by assisting to increase more effective and accessible TB diagnosis and treatment. The Government of Uzbekistan has recently requested to expand USAID TB programs in three additional regions,--Andijan, Ferghana, and Jizzak. Thus, with additional regions, USAID TB programs currently cover two-thirds of the country’s population.

Kazakhstan

The Government of Kazakhstan demonstrates not only strong political commitment for their TB response, but also a continued largely self-financed national program. Kazakhstan funds the bulk of its TB services, TB drugs and commodities. There is a need to move beyond an extremely expensive inpatient treatment model toward more person-centered, cost-effective, and efficient outpatient care. The TB care delivery system is transitioning from a hospital- based treatment to outpatient care. While the number of TB hospital beds has been reduced, the MOH and NTP recognize this is insufficient and additional efforts are required. In addition to changes in how TB services are provided, Kazakhstan requires reforms of how TB services are purchased and paid for at all levels of the system. Since 2017, the MOH has introduced the health insurance system as a part of the health reform process. The TB program will be funded by the government through the program of the State Guaranteed Package of Free Health Services. Most of the state funds allocated for TB control are used to maintain TB service’s infrastructure, human resources, TB drugs and laboratory procurement. How these funds are allocated will need to change to respond to service provision and financing reforms, requiring significant technical assistance.

Despite increasingly producing its own TB drugs, some drugs being used in Kazakhstan are still imported. Although Kazakhstan has a well-established national regulatory authority for medicines, the quality of TB drugs remains a problem. The use of low-quality TB drugs creates further drug resistance, adding to the growing TB control crisis. Kazakhstan continues to implement and roll-out of modern diagnostic technologies, particularly GeneXpert rapid diagnostic test for MDR-TB across the country.

Kazakhstan is among ten priority countries under the USG’s National Action Plan to Combat MDR-TB. The Global Fund support is gradually phasing out, aiming the last TB grant application for the 2020-2022 timeframe.

Turkmenistan

The Turkmenistan economy is centrally managed and relies on hydrocarbons, particularly natural gas exports. The global fall in oil and gas prices has extensively negatively affected the country’s economy, most notably in relation to liquidity, macroeconomic stability, and interruptions in supply of staple and household goods. Such economic woes make Turkmenistan more susceptible to the interruption of an effective TB response.

Exacerbating this situation is the Global Fund’s plan to transition out of Turkmenistan, envisioning an end to its support in summer 2020. Turkmenistan has relied on Global Fund support for its National TB Program implementation since 2009. In light of the ongoing— and worsening—economic instability, corrupt customs procedures, poorly defined product standards, unevenly implemented laws and regulations, and untrained and poorly educated staff, the assumption that Turkmenistan will be able to self-finance and manage its National TB Program is questionable.

As the last of the Central Asian countries to implement DR-TB treatment, Turkmenistan requires significant technical assistance to introduce accurate diagnostics, new drugs, and shortened treatment regimens, and related processes. Complicating this, however, is the fact that the Ministry of Health remains suspicious of short treatment regimens and their positive treatment outcomes. While in 2017 new drugs were introduced and Bedaquiline was registered in Turkmenistan, there is a need to ensure proper use and rigorous monitoring of the use of these drugs.

Kyrgyz Republic

The Kyrgyz Republic suffers from the highest rate of new drug-resistant TB cases in the world:

Approximately 27% of new TB cases and 60% of relapse cases are DR TB. The treatment success rate for MDR TB was 56% and for XDR TB was 10% in 2016. Kyrgyzstan has procured first- and second-line TB drugs using GF funding since 2016.

In 2017, the Kyrgyz Government adopted a TB Optimization Roadmap, focusing on closing ineffective TB hospitals and shifting to outpatient (ambulatory) TB treatment. Outpatient treatment has been expanded to Bishkek, Chui oblast, and several rayons in Jalalabad oblast.

Cost savings from this outpatient shift will be reinvested to improve the quality of TB services and build the capacity of primary health care. Since Fall 2017, the Mandatory Health Insurance Fund has provided payment incentives to primary health care practitioners for successfully treated TB cases.

Regional TB Strategies and Related Activities

Priority approaches for addressing TB and DR-TB globally are outlined in a number of core guiding documents, including the United States Government Global Tuberculosis Strategy, 2015-2019; the Presidential initiative National Action Plan for Combating Multidrug-resistant Tuberculosis released in December 2015; and global guidance and recommendations in the World Health Organization’s End TB Strategy and related documents.

National objectives to improve the health status of the populations in Central Asia are outlined in many national level and sector-specific strategies. This activity must take these strategies and priorities into consideration.

The overarching objective is to improve the detection and treatment of DR-TB to reduce the overall burden of TB in Central Asia. This includes a strong focus on:

● Improving access to and quality of DR-TB services;

● Strengthening leadership and governance of DR-TB services within the health system, including improved financing;

● Strengthening data collection systems and capacity to analyze these data for decision-making;

● Improving coordination of DR-TB services within the broader health sector; and

● Engaging civil society and subnational government to improve support for people with

DR-TB and to reduce stigma and discrimination.

While the focus of USAID/CA’s activities is on DR-TB, they also support the strengthening of the overall TB response, including the prevention, detection, and treatment of drug-sensitive TB as well. Building capacity to sustain interventions at national and subnational levels is crucial as Central Asian countries continue on the journey toward self-reliance.

USAID/Central Asia Mission Strategy

USAID’s goal in Central Asia, as outlined in its Regional Development Cooperation Strategy (RDCS) for 2015-2019, is enhanced regional cooperation and broad-based prosperity. ETICA supports this goal, and the activities support the RDCS Development Objective 3: More effective and inclusive governance institutions that serve the public good. USAID will support national and local government institutions of the region to be more responsive and accountable to citizens, and will support civil society to advocate for citizens’ needs, thus improving government’s ability to manage and maintain delivery of key public services in order to mitigate health threats and improve literacy. Activities will contribute to one Intermediate Result (IR) and three sub-IRs:

● IR 3.3: Increased use of health, education and other services by target population.

● Sub-IR 3.3.1: Increased access to services

● Sub-IR 3.3.2: Improved quality of services

● Sub-IR 3.3.3: Evidence-based laws, policies, and processes implemented

The RDCS emphasizes the importance of utilizing a regional approach that “allows us to work within a broader perspective, communicate across borders with counterparts on shared interests, and prioritize and implement regional and bilateral programs that can have a collective impact.”

Thus to achieve development synergies and maximize impact, USAID will utilize a regional platform for ETICA based on several additional key factors: 1) Avoiding duplication and build synergies across countries; 2) Seizing opportunities to build upon ongoing in-country programs;

and 3) Leveraging additional funding by coordinating with other donors.

USAID/Kyrgyz Republic Strategy

Despite having a Country Development Cooperation Strategy (CDCS) of its own for 2015- 2019, USAID/Kyrgyz Republic implements its CDCS in close coordination with USAID/CAR’s RDCS. Its goal is a democratic, well-governed, and prosperous Kyrgyz Republic. ETICA supports this goal, and the program activities support the Kyrgyz Republic’s CDCS Development Objective 2: Improved service delivery and policies for all citizens. Activities will contribute to one IR and one sub-IR:

● IR 2.2: Increased utilization of quality public services (health and education) by all citizens

● Sub-IR 2.2.2: Increased access to, and demand for, improved health services

Current USAID TB Interventions

The U.S. Government currently invests in activities to improve TB services in all five countries in Central Asia through seven programs. These activities provide essential support to improve TB service delivery and strengthen integration of TB services within the health systems, in line with national TB and health plans and priorities. They also work with civil society and community organizations and leaders to expand detection of TB and support for people during TB treatment.

1. USAID TB Control Program (Tajikistan, Uzbekistan, and Kyrgyz Republic). The

TB Control Program supports the following activities: 1) outreach to vulnerable populations including prisoners, migrants, women and people living with HIV to increase access to services; 2) strengthening laboratory services to improve TB/MDR-TB diagnosis; 3) supporting a patient- centered model of care; 4) updating national guidelines to meet international standards; 5) human resource development; 6) coordination between TB and other sectors and civil society organizations; and 7) improving electronic TB data management.

The USAID TB Control Program represents the primary source of technical assistance to the host-governments’ National TB Program and encompasses all aspects of TB control, including community-based case detection among vulnerable populations, enhancing laboratory capacity for diagnosis of TB and MDR-TB, electronic data management, human resource management, revision of national guidelines and transition towards outpatient care.

2. Challenge TB (all five countries). Challenge TB (CTB) serves as one of USAID’s main country-level TB implementation mechanisms across all countries in Central Asia.

Aligned with the WHO Global End TB Strategy and the new USG TB Strategy to enhance focus on improving patient-centered quality TB services, CTB works to build local capacity and improve use of innovations and new technologies to advance the global fight against TB. CTB is implemented by lead partner KNCV Tuberculosis Foundation.

WHO is a particularly important sub-partner in this activity, especially in countries where some implementing partners have not been able to work, like Turkmenistan and Uzbekistan. The project provides an array of services to reach, cure and prevent TB under three overarching objectives: (1) expand access to TB prevention, including strengthening infection control in public and private sector facilities, active case finding, and promotion of latent TB infection treatment in targeted populations and communities;

(2) improve patient-centered quality care systems for TB, DR-TB and TB/HIV, including universal access to appropriate treatment, strengthening laboratory networks, improving comprehensive care services, and engaging all care providers; and (3) strengthen the health system as it relates to TB, particularly for improving political commitment and leadership for TB, developing and strengthening TB partnerships, increasing demand for quality services, improving drug policies and management, strengthening monitoring and evaluation systems, and building human resources capacity.

3. Defeat TB (Kyrgyz Republic). Defeat TB reduces the Kyrgyz Republic’s burden of tuberculosis (TB) and supports universal and equitable access to quality TB services through a strengthened health system. The program has three objectives: 1) improving access to TB services for those at highest risk; 2) strengthening the national human and institutional capacity to provide quality anti-TB services; and 3) improving national TB data quality and use. The project’s activities work to: a) improve equitable access to comprehensive TB diagnostic and treatment services; b) develop a patient-centered system for treating TB and multi-drug-resistant TB (MDR-TB); c) strengthen human and institutional capacity of the Kyrgyz health system to manage TB and MDR-TB services;

d) support laboratories to improve timeliness and quality of TB and MDR-TB diagnosis;

and e) train TB service providers and managers to use an electronic TB management information system for evidence-based decision making.

4. Promoting Quality of Medicines (Kazakhstan and Uzbekistan). The Promoting the

Quality of Medicines (PQM) project supports the following activities: 1) assisting local TB drug manufacturers by providing a Good Manufacturing Practices (GMP) assessment and developing comprehensive audit reports and corrective action plans, as well as providing on site and remote technical assistance to address shortcomings; 2) GMP training for their staff; 3) training for quality control laboratory staff on Good Laboratory Practices; 4) assisting in the establishment of a medicine quality control laboratory; 5) procuring equipment for select laboratories to improve the quality of anti-TB medicines.

5. TB CARE II (Kazakhstan). TB CARE II works to: 1) improve the quality of, and access to, tuberculosis (TB) and MDR-TB prevention, diagnosis and treatment; 2) improve the coordination between TB/HIV collaborative activities; and 3) strengthen TB systems. In Kazakhstan, TB CARE II’s primary focus is to assist the National TB Program to scale-up the implementation of new TB drugs and shorter MDR-TB treatment regimens in collaboration with the Global Fund and close coordination with Challenge TB. This will help the National TB Program achieve full country coverage with new TB drugs and shorter treatment regimens.

6. The Stop TB Partnership (Kazakhstan, Tajikistan, Kyrgyz Republic). The global purpose of the Stop TB Partnership is to realize the goal of elimination of TB as a public health problem, and ultimately to obtain a world free of TB. Its mission is to: 1) ensure that every TB patient has access to effective diagnosis, treatment, and cure; 2) stop transmission of TB; 3) reduce the inequitable social and economic toll of TB; and, 4) develop and implement new preventive, diagnostic, and therapeutic tools and strategies to stop TB. An important partner in USAID’s TB program, this grant focuses on two main areas: 1) support for the Global TB Drug Facility (GDF) and; 2) support for key activities of the Stop TB Partnership Secretariat related to priority areas of USAID’s strategy. The GDF expands access to and availability of high-quality TB drugs through bulk procurement and technical assistance (TA) to National TB Programs (NTPs) around the world.

USAID/Central Asia currently has two centrally-funded TB Advisers that support the NTPs in both Kazakhstan and Tajikistan. The governments have praised the work of these advisers and have requested additional assistance.

7. The HIV Flagship (Kazakhstan, Kyrgyz Republic and Tajikistan). By introducing innovative peer-driven approaches and rapid oral saliva testing to detect new cases of HIV and PWID/PLHIV and their partners and link them to care, the HIV Flagship provides newly identified PLHIV intensive support for the first six months of treatment, including active linkage to Methadone Assisted Therapy (MAT) and TB services when applicable, and case management in communities to ensure treatment adherence and viral suppression. Case management includes escorting to facilities for routine appointments and tests, treatment education, community support groups, TB screening and referral, psychosocial support and other services. Peer navigators in the community work closely with ICAP patronage nurses and HIV treatment clinics to find PLHIV who are lost to follow up and bring them back to treatment. These activities fill important gaps that are not currently sufficiently addressed by government strategies and will demonstrate the feasibility of these approaches for national scale up.

PERFORMANCE OBJECTIVES

The Contractor is required to prepare a Performance Work Statement (PWS) to address the USG’s performance objectives with cost- effective and innovative solutions. The PWS will be broken down by regional and country- specific approaches since each country has a specific development context that necessitates specialized approaches or areas of greater focus.

Objective 1: Increased detection of TB and DR-TB

Since TB is an airborne infectious disease, to reduce DR-TB transmission it is essential to identify people with active DR-TB early and start them on appropriate treatment as soon as possible. A number of factors contribute to detection delays among people with DR-TB in Central Asia: inadequate information about TB symptoms and services; limited access to appropriate diagnostic tests; delays in conducting and transmitting results of diagnostic tests;

delays in TB contact tracing; and stigma and discrimination. Limited integration of TB services within primary health care services is a significant factor in delaying identification of TB symptoms and connecting symptomatic people with appropriate diagnostic testing.

Illustrative Indicators

● TB and DR-TB mortality and incidence rates.

● Number and percentage of Primary Health Care (PHC) facilities providing timely access to TB and DR-TB diagnosis.

● Number and percentage of TB facilities providing timely access to TB and DR-TB diagnosis.

● Number and percentage of TB facilities using rapid molecular diagnosis of TB and DR-

TB.

● Number and percentage of PHC facilities using rapid molecular diagnosis of TB and DR-

TB.

● Number of DR-TB cases (all forms: rifampicin resistant, multidrug resistant, pre-extensively drug resistant, extensively drug resistant) detected and notified.

Expected Results*

• Improve the access to TB and DR-TB rapid diagnostic services by 10% or more each year in comparison to the baseline starting from Year 1.

• Increase the percentage of detected DR-TB cases (all forms) by 10% or more each year in comparison to the baseline starting from Year 1.

*Note that the diagnosis and treatment targets listed in above will be evaluated based on progress towards country level targets, not aggregated for the Central Asia region.

Objective 2: Increased treatment success for TB and all types of DR-TB

To reduce disease transmission, people with DR-TB must be started on appropriate treatment as soon as possible. Non-adherence to treatment can lead to even greater drug resistance, failure of treatment, and continued transmission of TB. Access to TB services can be limited, in particular, due to geography. Additional challenges include limited availability of drugs to treat various forms of DR-TB (including limited access to and barriers to use of new TB drugs), limited capacity to treat DR-TB, policies/guidelines not updated in line with current DR-TB treatment recommendations, and the like. Taking into account the recent updates to WHO treatment guidelines on DR-TB there is a need to provide technical assistance to Central Asian countries to ensure they are able to implement the newest WHO recommendations for DR-TB detection and treatment, infection control, and latent TB infection where appropriate.

Digital technology is revolutionizing prevention, treatment, and care of infectious disease globally. Keeping this in mind, it is important to explore opportunities in Science, Technology, Innovations and Partnership to promote, pilot, endorse and scale-up new strategies and technologies to achieve greater results where appropriate.

● Percentage of bacteriologically confirmed TB cases successfully treated (cured plus treatment completed) among the bacteriologically confirmed TB cases registered for treatment during a specified period.

● Number and percentage of DR-TB cases on appropriate treatment.

● Number of days (time) spent to initiate appropriate DR-TB treatment.

● Number and percentage of DR-TB cases on individual (new) treatment regimens.

● Number and percentage of DR-TB cases on shorter treatment regimens.

● Number of DR-TB patients on outpatient care and management in line with WHO standards.

• Increase the percentage of detected DR-TB cases (all forms) initiated on appropriate treatment by 90% or more each year in comparison with the baseline starting from Year 1.

• Improve treatment outcomes for DR-TB by 2% or more each year in comparison with the baseline starting from Year 1.

• Scale up the outpatient care and management of DR-TB by 10% or more each year in comparison with the baseline starting from Year 1.

*Note that the diagnosis and treatment targets listed above will be evaluated based on

Objective 3: Improved enabling environment and financial sustainability of TB and DR-TB programs

To move toward ending TB, it is necessary to work within the health system, but beyond it as well. This objective includes areas that cut across both DR-TB detection and treatment, addressing critical factors that hamper National TB Programs from reaching their goals.

Improving the underlying enabling environment would serve as a critical part in achieving the anticipated results.

Providing Effective Detection to Where People First Seek Care

Finding DR-TB is not limited to TB services – it is crucial to engage the primary health care (PHC) system as well. Efforts have been ongoing to expand health worker and institutional capacity to address DR-TB at lower levels of the health system where specialized care is limited.

There is a need to increase the level of skill, confidence, and comfort in identifying, referring, and managing treatment of these more complex cases at all levels of the health system. It is important to explore how to effectively integrate TB services into the PHC system, specifically focusing on capacity building and human resource development related to TB/DR-TB detection and referral to improve treatment outcomes. Furthermore, the stigma and discrimination health workers feel toward those with TB must also be addressed.

Strong Community Support

With long and sometimes arduous treatment regimens, treatment adherence can be a challenge, particularly for the poor and vulnerable. A strong community component that complements the medically-focused interventions in Objectives 1 and 2 can mitigate this issue. Community support includes civil society engagement to provide holistic support for people with DR-TB, advocate for—and hold local facilities accountable for—state-of-the-art quality of care, including psychosocial and nutritional support. NGOs can also help address youth, gender, migration status, and other factors that impede access to care.

As with HIV in some Central Asian countries, NGOs can become strong allies in reaching the unreached, improving diagnosis and treatment adherence, providing psychosocial support, and combating stigma. NGOs may also be able to shape the extremely nascent notion of Corporate Social Responsibility in Kazakhstan and the Kyrgyz Republic to focus on addressing TB, whether through resource mobilization for community-based, holistic TB support programs or corporate in-kind support of such programs.

Robust Data Collection, Analysis, and Feedback Systems

To truly understand how and where to focus country efforts, it is fundamental to have access to and use quality data to improve decision making. Thus a concerted effort must take place to address the various deficiencies in the quality of data, systems that house the data, and how the data are routinely analyzed and used to make geographic, human resources for health, procurement, ensuring a reliable DR-TB supply chain, service delivery, and related decisions to ensure the DR-TB response is optimized.

Increased Local Capacity to Finance and Implement TB services

As a country increases its commitment and capacity to manage its own development, its level of self-reliance increases. This means that USAID’s partnership with countries must evolve in parallel. USAID needs to understand where a country’s strengths and weaknesses are and then reorient its partnerships accordingly to ensure that its programs support each country’s evolving journey toward self-reliance. Self-reliance cannot be achieved without strong national capacities to carry out the TB response in the region.

With the Global Fund transitioning away from support in Central Asia, focusing on DR-TB financing becomes an issue of critical importance. Thus the development of a Transition Plan in collaboration with Government/MOH and other donors becomes an integral part towards self-reliance and sustainability. Some countries in the region are modifying outdated models of funding inputs (e.g., driven primarily by line item allocations such as per bed), moving towards outcomes-based payments. Others are undertaking costing exercises to understand how TB services, including DR-TB, should be included in various health insurance schemes, and identify the optimal payment structures. There is a need to provide concerted support for addressing countries’ cost structures and financing needs, positioning them for self-reliance. This includes improving National TB Program efficiency, and mobilizing domestic resources for the DR-TB response.

● Proportion of Ministry of Health and National budget dedicated to TB.

● Number and percentage of labs providing regular sustainable maintenance to the equipment.

● Domestic funds provided to address national DR-TB response for the reporting period.

● Number and percentage of facilities using active TB drug-safety monitoring and management systems.

● Number and percentage of civil society and communities engaged in DR-TB case management.

● Number and percentage of facilities with high quality of DR-TB data collection, analyzing and reporting (electronic) systems.

● TB treatment included in national health insurance schemes.

● Number of national procurements conducted to purchase the WHO prequalified first and second line drugs.

• Improve the integration of TB and primary health care services by 10% or more each year in comparison with the baseline starting from Year 1.

• Expand the use of outpatient treatment for DR-TB by 10% or more each year in comparison with the baseline starting from Year 1.

• Improve the use of quality electronic TB and DR-TB databases by 10% or more each year in comparison with baseline starting from Year 1.

*Note that the diagnosis and treatment targets listed above will be evaluated based on

PROGRAMMATIC FACTORS

Political and donor context

Economic diversity, a wide range in health system structures and quality, and other health challenges present significant differences in the countries that are relevant to planning approaches. Political will and other factors can also have a significant effect on introduction and implementation of activities in each country, and must be incorporated into the planning process.

There is a limited donor landscape, with few private sector partners involved in health in the region. Global Fund grants that have been providing the largest portion of external donor funding for TB and HIV are dwindling, and moving into a transition phase in several countries. This coordination with other donors and implementers in this context is very important to ensure complementarities and synergies in programmatic approaches and prevent duplication of efforts.

The Contractor will coordinate closely with the Global Fund grants and other key in-country actors such as the U.S. Centers for Disease Control, Unitaid, and other bilateral and multilateral donors to share programmatic approaches, data, and collaborate where possible.

OPERATING PARAMETERS

A. Self-Reliance and Sustainability

USAID’s ultimate objective is to help its partner countries achieve self-reliance, which is a country’s ability to plan, finance, and implement solutions that will effectively address and ultimately solve its development challenges. To accelerate action, USAID has announced a new innovative model, “The Global Accelerator to End Tuberculosis” that will leverage additional resources from countries, private sector partners, and other local organizations in order to meet the UN target of treating 40 million people by 2022. It will focus on the countries with high burdens of TB in which USAID already has existing partnerships, and where the Agency could reprogram funds to better align with local communities and partners to deliver performance-based results towards the global target. This is a change in approach to ensure USAID is fighting to end TB effectively and efficiently.

Accordingly, a sustainability plan must be prepared by the Contractor at the beginning of implementation to adequately plan for capacity building of local governments and strengthen the commitment (political and financial) of national level policy leaders to address TB. The Contractor must undertake an institutional approach to activities that partner with sustainable government, non-government, and/or private sector training venues and systems. This approach must help the partners to increase the scope, breadth, and quality of services. The Contractor must also collaborate with partners to identify with other, sustainable revenue streams to support ongoing training.

B. Collaboration and Coordination

Stakeholders and counterparts include government entities, private sector organizations, non-governmental organizations, professional associations, and other development partners (donors).

The Contractor must leverage other donors and other USAID implementing partners working in relevant areas to identify means of coordination and collaboration to achieve sustainable results and leverage resources.

C. Gender Considerations

Gender integration is a mandatory requirement in all USAID funded projects and activities as per ADS 205 In order to reduce gender gaps, USAID/CA programs are aligned and integrated with USAID’s Gender Equality and Female Empowerment (GEFE) Policy (March 2012). The Policy aims for three clear outcomes:

1. Reduce gender disparities in access to and control over economic, social, political, and cultural opportunities, services, and resources;

2. Reduce gender based violence (GBV) and mitigate its harmful effects on individuals and communities; and

3. Increase capability of women and girls to realize their rights, determine their life outcomes, and influence decision making in households, communities, and societies.

One of the desired outcomes of USAID’s GEFE policy is to reduce gender disparities in access to and control over economic, social, political, and cultural opportunities, services, and resources. Gender related power imbalance and societal norms plays a crucial role in both women and men accessing information regarding TB prevention, diagnosis and treatment. TB rates in Central Asia are generally higher in men than women and the activity must therefore determine differential gender-based behaviors and practices (such as smoking), health seeking and treatment conduct, access to services, and risk for developing TB infection and disease.

Understanding the variety and details of these barriers is critical for planning and implementation of TB control activities. The contractor must demonstrate how they will identify gender–related barriers and address them in all stages of implementation.

Involving adolescent boys, youth and men is critical to increase TB control effectiveness.

Considering that men are more likely than women to develop tuberculosis in Central Asia, males must be a specific target of community outreach activities in the high–transmission TB areas and in formal and informal employment settings. In addition, men are far more likely to smoke than women and smoking is an important risk factor for tuberculosis.

The Contractor must utilize USAID’s gender policy and demonstrate a sophisticated understanding of TB specific gender issues and the ways to address them. The Contractor must also demonstrate how the activity will ensure equitable access to TB prevention, detection, diagnosis, and treatment and fully engage men and women in their family, social, and economic roles.

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