SOL-176-14-000006.pdf

Issue Date: January 15, 2014 Questions Due: January 22, 2014, 2:00 pm Almaty Time Closing Date: February 26, 2014, 2:00 pm Almaty Time

SUBJECT: Request for Proposals (RFP) RFP No.: SOL-176-14-000006 USAID TB Regional Program

To All Potential Offerors:

The United States Government, represented by the United States Agency for International Development Regional Mission to Central Asia (USAID/CAR), is seeking proposals from qualified organizations to implement a project entitled “USAID TB Regional Program” as detailed in Section C.

USAID anticipates awarding a cost reimbursement completion-type contract as a result of this solicitation, covering an estimated period of five (5) years, subject to availability of funds and satisfactory performance.

The estimated cost range for this procurement is of $23 million to $24.5million. Offerors must propose costs that they believe are realistic and reasonable for the work described herein.

This procurement will be conducted under full and open competition procedures, pursuant to Part 15 of the Federal Acquisition Regulation (FAR) (48 CFR Chapter 1). All types of organizations are eligible to compete.

If your organization decides to submit a proposal in response to this solicitation, it must be submitted in accordance with Section L of this RFP. Offerors must also carefully review Section M - Evaluation Factors for Award. Sections B through I of the solicitation will become a substantive part of the anticipated contract with blanks to be completed by the Contracting Officer upon award. Section K - Representations, Certifications and Acknowledgements must be filled out in full.

It is the responsibility of the recipient of this solicitation to ensure that the solicitation has been received from the FBO page in its entirety. USAID bears no responsibility for data errors resulting from download or conversion processes.

Offerors can register and use the Interested Vendor List (IVL) on the Federal Business Opportunities (FBO) website, so that firms can contact one another for consideration of teaming arrangements and/or small business subcontracting opportunities in response to this solicitation.

Questions and comments related to this RFP must be submitted electronically to Mr. R. Clark Pearson at rpearson@usaid.gov, with copies to the attention of Mr. Sam Kraegel at skraegel@usaid.gov and AlmatyAAsolicitations@usaid.gov no later than January 22, 2014 at 2:00 pm Almaty Time (UTC +6) using the following format for the email subject line: “SOL-176-14-000006, USAID TB Regional Procurement – [Name of Organization] Questions/Comments”.

Oral instructions or explanations given before the award of the contract resulting from this solicitation are not binding. USAID may consolidate and/or not respond to questions/comments and will publically post all responses as an amendment to this RFP. All amendments to this solicitation will be issued and posted on the FBO website. Offerors are encouraged to check this website (http://www.fbo.gov) periodically.

The Technical and Cost proposals must be separate and must be submitted according to Section L.7 of this RFP. Only electronic proposals will be accepted in response to this RFP. The subject line for Technical and Cost Proposal submissions must follow the following format: “SOL-176-14-000006, USAID TB Regional

RATING

AND AWARD

1. THIS CONTRACT IS A RATED ORDER

UNDER DPAS (15 CFR 700)

PAGE

OF PAGE(S)

SOLICITATION, OFFER

6. REQUISITION/PURCHASE NO.3. SOLICITATION NO. 5. DATE ISSUED4. TYPE OF SOLICITATION q SEALED BID (IFB)

NEGOTIATED (RFP)

2. CONTRACT NO.

01/15/2014SOL-176-14-000006

7. ISSUED BY

USAID/Central Asian Republi 41 Kazibek Bi St.

Almaty 050010, Kazakhstan

CODE

8. ADDRESS OFFER TO (If other than Ile. 7)

See Instructions at L.7cs

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder"

SOLICITATION

9.

Sealed offers in original and copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if handcarried, in the depository located in until -(hour) 1400 local time February 26, 2014. CAUTION LATE Submissions, Modifications, and Withdrawals: See

Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

10.

FOR INFORMATIJN

CALL:

A. NAME

Sam Kraegel

C. E-MAIL ADDRESS

skraegel @usaid.gov

B. TELEPHONE NO. (NO COLLECT CALLS)

lull CODE NUMBER EXT.

x

SEC DESCRIPTION

PART I - THE SCHEDULE

11. TABLE OF CONTENTS

PAGE(S)

(x)

SEC. DESCRIPTION

PART It - CONTRACT CLAUSES

PAGE(S)

X A SOLICITATION/CONTRACT FORM 3 X I CONTRACT CLAUSES 54-63

X B SUPPLIES OR SERVICES AND PRICE/COST 7-8 PART HI - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

X C DESCRIPTION/SPECS./WORK STATEMENT 9-26 X 1 LIST OF ATTACHMENTS 64

X D PACKAGING AND MARKING 27-28 PART IV - REPRESENTATIONS AND INSTRUCTIONS

X E INSPECTION AND ACCEPTANCE 29 x K REPRESENTATIONS, CERTIFICATIONS AND OTHER 65-78

X F DELIVERIES OR PERFORMANCE 30-37

STATEMENTS OF OFFERORS

X G CONTRACT ADMINISTRATION DATA 38-41

x

L INSTRS., CONDS., AND NOTICES TO OFFERORS 79-98

X H SPECIAL CONTRACT REQUIREMENTS 42-53 X M EVALUATION FACTORS FOR AWARD 99-103

OFFER (Must be fully completed by offeror)

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

12. In compliance with the above, the undersigned agrees, if this offer is accepted within 180 calendar days (60 calendar days unless a different period is inserted by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the designated point(s), within the time specified in the schedule.

13.

DISCOUNT FOR PROMPT PAYMENT 10 CALENDAR DAYS (%) 20 CALENDAR DAYS (%) 30 CALENDAR DAYS (%) CALENDAR DAYS (%) (See Section 1, Clause No. 52.232-8)

14.

ACKNOWLEDGMENT OF AMENDMENTS (The offeror AMENDMENT NO. DATE AMENDMENT NO. DATE acknowledges receipt of amendments to the SOLICITATION for offerors and related documents numbered and dated:

15A. NAME AND CODE FACILITY 16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER (Type or print)

ADDRESS

OF OFFEROR

15B. TELEPHONE NUMBER q 15C. CHECK IF REMITTANCE ADDRESS 17. SIGNATURE 18. OFFER DATE

AREA CODE NUMBER EXT. IS DIFFERENT FROM ABOVE - ENTER

SUCH ADDRESS IN SCHEDULE.

AWARD (To be completed by Government)

19. ACCEPTED AS TO ITEMS NUMBERED 20. AMOUNT 21. ACCOUNTING AND APPROPRIATION

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION

q 10 U.S.C. 2304(c) (

El 41 U.S.C. 253(c) (

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

(4 copies unless otherwise specified)

ITEM

24. ADMINISTERED BY (If other than Item 7 ) CODE 25. PAYMENT WILL BE MADE BY

CODE

26. NAME OF Contracting Officer (Type or print)

R. Clark Pearson

27. UNIT

ES

ME

,f

28. AWARD DATE

f piureofContracti ffieer) l

IMPORTANT: Award will be made on this Form, or on Standard Form 26, or by authorized official written notice.

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition not usable.

STANDARD FORM 33 (Rev. 9-97) Prescribed by GSA FAR (48 CFR) 51214(c)

33-I33

Table of Contents

PART I – THE SCHEDULE

SECTION B – SUPPLIES OR SERVICES AND PRICE/COSTS

B.1 PURPOSE

B.2 COST REIMBURSEMENT CONTRACT TYPE

B.3 TOTAL CONTRACT VALUE AND OBLIGATED AMOUNT

B.4 PRICE/COST SCHEDULE

B.5 FIXED FEE (CPFF)

B.6 INDIRECT COSTS (CPFF)

B.7 CEILING INDIRECT COST RATES (CPFF)

B.8 COST REIMBURSABLE (CPFF)

SECTION C – DESCRIPTION / SPECIFICATIONS/STATEMENT OF WORK

C.1 PURPOSE

C.2 PROGRAM OBJECTIVES

C.3 BACKGROUND

C.4 LINK TO THE U.S. STRATEGIC FRAMEWORK FOR FOREIGN ASSISTANCE

C.5 USAID AND OTHER DONOR RELATED ACTIVITIES

C.6 PROJECT DESCRIPTION COMPONENTS

SECTION D – PACKAGING AND MARKING

D.1 AIDAR 752.7009 MARKING (JAN 1993)

D.2 BRANDING AND MARKING POLICY

D.3 BRANDING STRATEGY

D.4 Approval of Branding Implementation Plan

SECTION E – INSPECTION AND ACCEPTANCE

E.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

E.2 INSPECTION AND ACCEPTANCE

SECTION F – DELIVERIES OF PERFORMANCE

F.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

F.2 PERIOD OF PERFORMANCE

F.3 PLACE OF PERFORMANCE

F.4 AUTHORIZED WORK DAY / WEEK

F.5 DELIVERABLES AND REQUIRED REPORTING

F.6 DELIVERABLES, DELIVERY SCHEDULE AND FIXED FEE PAYMENT SCHEDULE

F.7 KEY PERSONNEL

F.8 PERFORMANCE STANDARDS

F.9 752.7005 SUBMISSION REQUIREMENTS FOR DEVELOPMENT EXPERIENCE DOCUMENTS

(SEPTEMBER 2013)

F.10 752.242-70 PERIODIC PROGRESS REPORTS (OCTOBER 2007)

SECTION G – CONTRACT ADMINISTRATION DATA

G.1 CONTRACTING OFFICER'S AUTHORITY

G.2 ADMINISTRATIVE CONTRACTING OFFICE

G.3 CONTRACTING OFFICER’S REPRESENTATIVE (COR)

G.4 AIDAR 752.7003 DOCUMENTATION FOR PAYMENT (NOV 1998) (CPFF)

G.5 TECHNICAL DIRECTIONS/RELATIONSHIP WITH USAID

G.6 PAYING OFFICE

G.7 ACCOUNTING AND APPROPRIATION DATA

G.8 CONTRACTOR’S PRIMARY POINT OF CONTACT

SECTION H – SPECIAL CONTRACT REQUIREMENTS

H.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

H.2 AIDAR 752.7004 EMERGENCY LOCATOR INFORMATION (JUL 1997)

H.3 FOREIGN GOVERNMENT DELEGATIONS TO INTERNATIONAL CONFERENCES (JAN 2002) .. 42

H.4 INSURANCE AND SERVICES

H.5 AUTHORIZED GEOGRAPHIC CODE

H.6 NONEXPENDABLE PROPERTY PURCHASES AND INFORMATION TECHNOLOGY

RESOURCES

H.7 LOGISTIC SUPPORT

H.8 LANGUAGE REQUIREMENTS

H.9 SUBCONTRACTING CONSENT

H.10 EXECUTIVE ORDER ON TERRORISM FINANCING (FEB 2002)

H.11 REPORTING OF FOREIGN TAXES (JULY 2007)

H.12 USAID DISABILITY POLICY - ACQUISITION (DECEMBER 2004)

H.13 AIDAR 752.225-70 SOURCE AND NATIONALITY REQUIREMENTS (FEB 2012)

H.14 752.7007 PERSONNEL COMPENSATION (JULY 2007)

H.15 ORGANIZATIONAL CONFLICT OF INTEREST

H.16 INFORMATION TECHNOLOGY REQUIREMENT

H.17 MANAGEMENT OF INFORMATION TECHNOLOGY RESOURCES

H.18 PROHIBITION AGAINST DISCRIMINATION (OCT 2011)

H.19 GENDER CONSIDERATION

H.20 ENVIRONMENTAL COMPLIANCE

H.21 AIDAR 752.7032 INTERNATIONAL TRAVEL APPROVAL AND NOTIFICATION REQUIREMENTS

(JAN 1990)

H.22 APPROVAL OF INTERNATIONAL TRAVEL

H.23 NONDISCRIMINATION (JUNE 2012)

H.24 ACCESS TO USAID FACILITIES AND USAID’s INFORMATION SYSTEMS (AUGUST 2013)

H.25 LIMITATION ON SUBCONTRACTING TO NON-LOCAL ENTITIES (MAY 2012)

H.26 USAID-FINANCED THIRD-PARTY WEB SITES (AUGUST 2013)

H.27 CONFERENCE PLANNING AND REQUIRED APPROVALS (AUGUST 2013)

H.28 AMMONIUM NITRATE AND CALCIUM AMMONIUM NITRATE RESTRICTION (SEPTEMBER

2011)

PART II – CONTRACT CLAUSES

SECTION I – CONTRACT CLAUSES

I.1 NOTICE LISTING CONTRACT CLAUSES INCORPORATED BY REFERENCE

I.2 52.204-1 APPROVAL OF CONTRACT (DEC 1989)

I.3 52.204-7 SYSTEM FOR AWARD MANAGEMENT (JUL 2013)

I.4 52.209-9 UPDATES OF PUBLICLY AVAILABLE INFORMATION REGARDING RESPONSIBILITY

MATTERS (JUL 2013)

I.5 52.215-19 NOTIFICATION OF OWNERSHIP CHANGES (OCT 1997)

I.6 52.216-24 LIMITATION OF GOVERNMENT LIABILITY (APR 1984)

I.7 52.216-25 CONTRACT DEFINITIZATION (OCT 2010)

I.8 52.222-50 COMBATING TRAFFICKING IN PERSONS (FEB 2009)

I.9 52.232-40 PROVIDING ACCELERATED PAYMENTS TO SMALL BUSINESS

SUBCONTRACTORS

I.10 752.227-14 RIGHTS IN DATA - GENERAL (OCT 2007)

PART III – LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACHEMENTS

SECTION J - LIST OF ATTACHMENTS

PART IV – REPRESENTATIONS AND INSTRUCTIONS

SECTION K – REPRESENTATIONS, CERTIFICATIONS, AND OTHER STATEMENTS

K.1 NOTICE LISTING SOLICITATION PROVISIONS INCORPORATED BY REFERENCE

K.2 52-204-3 TAXPAYER IDENTIFICATION (OCT 1998)

K.3 52.204-8 ANNUAL REPRESENTATIONS AND CERTIFICATIONS (JUL 2013)

K.4 52.209-5 CERTIFICATION REGARDING RESPONSIBILITY MATTERS (APR 2010)

K.5 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (JUL 2013)

K.6 52.215-6 PLACE OF PERFORMANCE (OCT 1997)

K.7 52.219-1 SMALL BUSINESS PROGRAM REPRESENTATIONS (APR 2012)

K.8 52.222-52 EXEMPTION FROM APPLICATION OF THE SERVICE CONTRACT ACT TO

CONTRACTS FOR CERTAIN SERVICES – CERTIFICATION (NOV 2007)

K.9 52.230-1 COST ACCOUNTING STANDARDS NOTICES AND CERTIFICATION (MAY 2012)

K.10 52.230-7 PROPOSAL DISCLOSURE—COST ACCOUNTING PRACTICE CHANGES (APR 2005)

K.11 INSURANCE - IMMUNITY FROM TORT LIABILITY

K.12 SIGNATURE

SECTION L - INSTRUCTIONS, CONDITIONS, AND NOTICES TO OFFERORS

L.1 52.252-1 SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB 1998)

L.2 NOTICE LISTING SOLICITATION PROVISIONS INCORPORATED BY REFERENCE

L.3 52.215-1 INSTRUCTIONS TO OFFERORS – COMPETITIVE ACQUISITION (JAN 2004)

L.4 52.216-1 TYPE OF CONTRACT (APR 1984)

L.5 52.233-2 SERVICE OF PROTEST (SEP 2006)

L.6 GENERAL INSTRUCTIONS TO OFFERORS

L.7 PROPOSAL SUBMISSION

L.8 INSTRUCTIONS FOR THE PREPARATION OF THE TECHNICAL PROPOSAL

L.9 INSTRUCTIONS FOR THE PREPARATION OF THE COST PROPOSAL

L.10 INSTRUCTIONS FOR THE PREPARATION OF BRANDING AND MARKING PLANS

SECTION M - EVALUATION FACTORS FOR AWARD

M.1 GENERAL INFORMATION

M.2 EVALUATION CRITERIA

M.3 COST PROPOSAL EVALUATION

M.4 DETERMINATION OF THE COMPETITIVE RANGE AND CONTRACT AWARD

M.5 SOURCE SELECTION

RFP No. SOL-176-14-000006

PART I – THE SCHEDULE

SECTION B – SUPPLIES OR SERVICES AND PRICE/COSTS

B.1 PURPOSE

The purpose of this contract is to obtain services as described in Section C. Statement of Work.

B.2 COST REIMBURSEMENT CONTRACT TYPE

This is a Cost-Plus-Fixed-Fee (CPFF) completion contract. For the consideration set forth below, the Contractor must provide the deliverables or outputs described in Sections C and F in accordance with the performance standards specified in Sections C and F.

B.3 TOTAL CONTRACT VALUE AND OBLIGATED AMOUNT

(a) The estimated cost for the performance of the work required hereunder, exclusive of fixed fee, if any, is TBD. The fixed fee, if any, is TBD. The estimated cost plus fixed fee, if any, is TBD.

(b) Within the estimated cost plus fixed fee (if any) specified in paragraph (a) above, the amount currently obligated and available for reimbursement of allowable costs incurred by the Contractor (and payment of fee, if any) for performance hereunder is TBD. The Contractor shall not exceed the aforesaid obligated amount.

(c) Funds obligated hereunder are anticipated to be sufficient through TBD.

B.4 PRICE/COST SCHEDULE

Amount

a. Direct Cost

b. Indirect Cost

c. Fixed Fee

d. Total Cost + Fixed Fee

B.5 FIXED FEE (CPFF)

Pursuant to FAR 16.306(d), the fixed fee payable under this contract will be tied to the Completion of the reports and deliverables specified in Section F.6 of this contract and in accordance with the final approved Fee Schedule.

[TBD UPON AWARD]

B.6 INDIRECT COSTS (CPFF)

Pending establishment of revised provisional or final indirect cost rates, allowable indirect costs will be reimbursed on the basis of the following negotiated provisional or predetermined rates and the appropriate bases:

Description Rate Base Type Period Indirect Cost X % 1/ 1/ 1/ Indirect Cost Y % 2/ 2/ 2/ Indirect Cost Z % 3/ 3/ 3/

1/Base of Application:

RFP No. SOL-176-14-000006

Type of Rate:

Period:

2/Base of Application:

Type of Rate:

Period:

3/Base of Application:

Type of Rate:

Period:

B.7 CEILING INDIRECT COST RATES (CPFF)

a) Reimbursement for indirect costs will be at the lower of the negotiated final (or predetermined) rates or the following ceiling rates:

Description Rate Base Type Period Indirect Cost X % 1/ 1/ 1/ Indirect Cost Y % 2/ 2/ 2/ Indirect Cost Z % 3/ 3/ 3/

1/Base of Application:

Period:

2/Base of Application:

Period:

3/Base of Application:

Period:

b) The Government will not be obligated to pay any additional amount should the final indirect cost rates exceed the negotiated ceiling rates. If the final indirect cost rates are less than the negotiated ceiling rates, the negotiated rates will be reduced to conform to the lower rates.

c) This understanding will not change any monetary ceiling, obligation, or specific cost allowance or disallowance. Any changes in classifying or allocating indirect costs require the prior written approval of the Contracting Officer.

B.8 COST REIMBURSABLE (CPFF)

Allowable costs will be limited to reasonable, allocable and necessary costs determined in accordance with FAR 52.216-7, Allowable Cost and Payment, FAR 52.216-8, Fixed Fee, if applicable, and AIDAR 752.7003, Documentation for Payment.

In addition, the requirement and conditions concerning estimated cost and funding apply as detailed in FAR 52.232-22, Limitation of Funds, incorporated by reference in Section I of this contract.

[END OF SECTION B]

RFP No.: SOL-176-14-000006

SECTION C – DESCRIPTION / SPECIFICATIONS/STATEMENT OF WORK

C.1 PURPOSE

The purpose of the award is to ensure more effective and more accessible TB diagnosis and treatment for all, including vulnerable populations, so as to reduce the burden of TB and the development of drug-resistant tuberculosis (TB) in Central Asia.

C.2 PROGRAM OBJECTIVES

1. More equitable access to comprehensive and appropriate TB diagnostic and treatment services for vulnerable populations;

2. Laboratory services provide more timely, quality TB and MDR-TB diagnosis;

3. Patient centered system for TB and MDR-TB implemented widely across the region;

4. Enhanced enabling environment promoting TB services that meet international standards;

5. Human and institutional capacity of health system to manage TB and MDR-TB services Strengthened;

6. Coordination and linkage of TB with other health sectors and CSOs improved;

7. TB service providers and managers using electronic TB MIS and using quality data for evidence-based decision making at all levels.

C.3 BACKGROUND

Over the past decade that USAID has supported Tuberculosis (TB) Control efforts in Central Asian Republics (CAR), TB morbidity and mortality indicators have significantly improved, with fewer TB cases and fewer deaths, compared to a decade ago. Yet TB still remains a high priority public health threat in all five CAR countries. The 2010 USAID Europe and Eurasia Health Vulnerability Analysis highlights CAR as the region with the highest overall estimated TB incidence rate of 147.6 per 100,000.

Tajikistan, in particular, has the highest TB incidence rate in the World Health Organization (WHO) European region at 193 cases/100,000 population; Kazakhstan is second at 137 cases. CAR’s TB case detection and treatment success rates continue to lag behind international targets. WHO data confirm an alarming increase over the past decade in rates of multi-drug resistance TB (MDR-TB) in CAR, which continues to present significant challenges for TB prevention and control and poses a threat to the economic development in the region. All five of CARs countries are included on the WHO list of 27 high MDR-TB burden countries in the world. High rates of migration, particularly from Tajikistan, Uzbekistan and Kyrgyz Republic have the potential to further increase the spread of TB, especially MDR-TB in the region. Across the region, Government commitment for TB prevention and control is strong as TB continues to be recognized as a public health priority. Policies and guidelines that support and promote international standards are at least partially in place or being developed. However, implementation of the WHO-recommended STOP TB Strategy is inconsistent across and within the five countries of the Region.

Overall, CAR countries still implement a hybrid approach to TB prevention and control with elements of internationally accepted standards of care and treatment that are intertwined or run in parallel with elements of the outdated Soviet-era model of TB control. This highly medicalized approach leads to a strong focus on clinical management of TB and MDR-TB, overuse of hospitalization during treatment, and an underdeveloped public health approach to TB and MDR-TB prevention and control. These factors have created incentives that reward case detection and hospitalization of patients in a highly vertical TB system. The lack of government and structural incentives to fully adopt and implement international standards of TB care and treatment have contributed to poor TB detection, care and (to an extent) treatment outcomes, widespread nosocomial transmission of active TB disease and increasing development and spread of X/MDR-TB.

TB Statistics CAR Region – 2012 data

Country Incidence (per 100,000)

Mortality (per 100,000)

MDR-TB as % of new TB cases

MDR-TB as % of retreatment cases

Kazakhstan 137 7.8 23 55

Kyrgyz Republic 141 9.5 23 68

Tajikistan 193** 19** 13** 54**

Turkmenistan 75 8.4 20* 34*

Uzbekistan 78 2.1 23 62

Data source: WHO Global TB Reports unless marked with * in which case source is The Global Fund and ** in which case source is taken from 2011 data

All five countries in CAR consider improved TB service delivery and reduced morbidity and mortality from TB as a top public health priority. In recent years, individual countries have increased resources for NTPs and have begun to develop national TB policies and strategies to move TB and MDR-TB care and treatment, in line with international standards, toward a more patient-centered, outpatient approach from a heavy reliance on more costly and less efficient inpatient treatment. There is increasing commitment toward prevention and education efforts to reduce the transmission of TB and MDR-TB. While National TB funding is increasing, it still covers only a fraction of all TB program costs in some CAR countries.

In Tajikistan, the national budget covered only 14% of the TB control costs in 2010; although TGF estimates that Kazakhstan will cover almost 96% of TB control costs in 2013. In those countries where donors currently cover well over half of all TB control costs, this generally includes all or most first and second line TB drugs, and most costs related to diagnostics and laboratory support. As this award will focus specifically on activities in Tajikistan and Uzbekistan, these two countries are described in more depth, below:

Tajikistan

The Government of Tajikistan (GOTJ) has included TB as a development priority in the National Development Strategy, made annual increases of 30% to the NTP budget since 2006 and has banned the sales of first-line anti-TB drugs (FLDs) by private pharmacies. National Infection Control (IC) Guidelines, a National IC Plan and a MDR-TB management plan based on international standards have been developed with donor assistance and approved by the Government. Most basic functions of the TB program are carried out with donor funds, including procurement of FLDs, second-line anti-TB drugs (SLDs) and laboratory reagents, data management systems, specimen transportation, monitoring and supervision, and training. Although GOTJ policies still support hospitalization of TB and MDR-TB patients, a process of rationalization of TB beds is underway, as are efforts to integrate TB services into the PHC system. There is support for an out-patient based model for TB and MDR-TB care.

Considerable work remains to be done to fully implement quality TB care nationwide for all in accordance with international standards. Infection control is poor in most TB facilities and clinical TB skills are low overall, which becomes a barrier, especially when managing more complicated MDR-TB and HIV/TB.

Uzbekistan

The Government of Uzbekistan’s (GOU’s) commitment to TB control in Uzbekistan is reflected in planned annual increases of 20% in the government budget for TB from 2012-2014. The National TB Program (2011-2015) has a current funding level of approximately $100 million with the majority of the budget supporting construction, renovation and equipment purchases. There is a strong pool of qualified, trained and motivated health care staff, especially at the primary health care level, and the Institute of Health and Statistics is actively promoting TB education and prevention awareness among the population.

Despite the GOU’s commitment to TB control, the operational environment for donor organizations in Uzbekistan remains very challenging. Implementation is delayed by a lengthy approval process for work plans and project activities, difficulties obtaining permission to site visits, burdensome reporting requirements for implementing partners. Both FLDs and SLDs are provided through TGF and other donors, however, on two occasions the GOU purchased FLDs when shortages occurred. The GOU revised the national TB program to comply with international standards in 2011, and an optimization plan has already started to close facilities and reduce the number of hospital beds for TB. Currently, the government and partners are engaged in a planning process for unprecedented expansion of MDR-TB service coverage in the country. However, guidelines and regulations still need to be updated in line with international standards for treatment. The TB laboratory network does not meet the requirements for quality and rapid diagnosis of TB and MDR-TB. Critical systematic gaps and inadequate program management capacity hamper the implementation of successful TB and MDR-TB prevention, treatment and surveillance efforts.

The intensive phase of treatment is still being done on an inpatient basis in TB hospitals, including for the majority of patients who are sputum smear negative. Infection control in TB hospitals is weak, with multiple patients per ward for months, with unknown resistance status, which creates high risk for nosocomial transmission and further spread of drug-resistant TB strains in the community. There are outdated practices for treatment of TB in children, with some reports of hospitalization for nearly the full length of treatment. PHC providers currently participate in TB case management and TB case detection;

however there are fears and resistance to full outpatient treatment model, especially in regard to MDR-

TB.

C.4 LINK TO THE U.S. STRATEGIC FRAMEWORK FOR FOREIGN ASSISTANCE

This program falls under and supports Development Objective (DO) #3: “More accountable and inclusive governance institutions that serve the public need” and IR 3.3, “Improved utilization of key public and social services by target populations” of USAID/CAR’s draft Regional Development and Cooperation Strategy (RDCS). The procurement draws its technical guidance from USAID/CAR’s Regional Tuberculosis Strategic Plan, FY 2012-2015, the USG Global TB Strategy and WHO’s Stop TB Strategy.

Under the Foreign Assistance Framework, this procurement supports:

Program Objective: Investing in People Program Area: 3.1: Health Program Element: 3.1.2: Tuberculosis

Program Sub-elements: 3.1.2.1: Directly Observed Therapy, Short-Course (DOTS) Expansion and Enhancement; 3.1.2.4: Multi-Drug Resistant TB (MDR-TB); 3.1.2.5: Care and Support; 3.1.2.6:

Development of New Tools and Improved Approaches; 3.1.2.8: Host Country Strategic Information Capacity (TB)

C.5 USAID AND OTHER DONOR RELATED ACTIVITIES

USG programs are currently contributing to the achievement of the same goal and objectives, but will end in the near future. Selected promising interventions from the projects below will be continued or more widely implemented under the award:

● Dialogue on HIV and TB currently works in all five CAR countries to improve equitable access to HIV and TB services through outreach to most-at-risk populations, especially migrants, prisoners, people who inject drugs, people living with HIV/AIDS and at-risk youth through strengthened TB-HIV services, particularly in the prison sector. This project continues through September 2014.

● Quality Health Care Project supports activities in all five CAR countries to improve early access to quality TB diagnostic and treatment services through implementation of advocacy, communication and social mobilization (ACSM) support services, quality improvement of TB laboratory services and strengthened outpatient treatment models through the primary health care (PHC) system to decrease hospital transmission of TB. This project continues through September 2015.

● TB CARE I is currently working in Kazakhstan, Tajikistan, Uzbekistan and the Kyrgyz Republic to support introduction and scale up of GeneXpert for rapid diagnosis of MDR-TB; improve policies and implementation of Programmatic Management of Drug-Resistant TB (PMDT);

improve coordination between prison and civilian TB services to ensure continuation of TB treatment after prisoners are released; and pilot outpatient models to decrease hospital transmission of MDR-TB. This project continues through December 2014.

● WHO Public International Organizations (PIO) Grant supports the introduction and scale up of GeneXpert for rapid diagnosis of MDR TB, strengthening national capacity on PMDT, infection control (IC) in TB facilities, and TB control in children; improving national monitoring and evaluation (M&E) at all levels including implementation of eTB Manager, and pilots outpatient treatment models to decrease hospital transmission of MDR-TB in Turkmenistan and Uzbekistan through 2015. A WHO PIO grant beginning September 2013 will support the strengthening of TB/HIV coordination and TB surveillance through embedded staff in the Ministry of Health (MOH) and the National TB Program (NTP) in Kyrgyz Republic.

● Centers for Disease Control (CDC) Field Epidemiology Training Program (FETP) provides assistance in Turkmenistan, Uzbekistan and Kyrgyz Republic to improve the MOH’s capacity to track, monitor and respond to the TB epidemic, through 2015.

● Research Study on TB in Migrant Populations will estimate the prevalence rate of TB, levels of knowledge about TB, access to TB services, and identify multi-level risk factors associated with TB among migrant workers from Kyrgyz Republic, Tajikistan and Uzbekistan. Findings from this study should be available in 2015 and will assist the award in identifying more effective interventions for improving access to TB and MDR-TB services and care in the vulnerable migrant population.

Other donors and partners are supporting TB control efforts in the CAR region, most significantly, the Global Fund to Fight AIDS, TB and Malaria (TGH), Medecins San Frontieres (MSF), German KfW Entwicklungsbank (KfW), International Committee of the Red Cross (ICRC) UNITAID and Caritas Luxemburg.

TGF is currently providing active TB grants for all five CAR countries totaling $ 238 million.

● Tajikistan – Funding from a Round 3 extension and Rounds 6 and 8 consolidated grants through 2015 totals $65.7 million. Principal recipients are Project Hope and the UNDP. Funding supports FLDs, SLDs, laboratory reagents, training, support to TB and MDR-TB patients to facilitate Directly Observed Treatment Short Course (DOTS), specimen transportation, diagnostics for prisoners and migrants, support supervision visits and development of an electronic database. Sub-recipients of funding are WHO, the International Organization on Migration (IOM), and the World Food Program.

The Transitional Funding Mechanism (TFM), totaling $17.1 million starts January 2014 and continues through 2015.

● Uzbekistan – Funding from the second phase of Round 8 TB grant, totaled US$31 million,ended on November 30, 2013. The Round 8 TB grant priorities were to increase access to second-line treatment and to address challenges in programmatic management of TB. Activities to strengthening the NTP included staff training, improving M&E, use of electronic surveillance, reporting and targeting activities for high risk groups for TB, laboratory network strengthening, and piloting outpatient treatment models. TGF’s Transitional Funding Mechanism (TFM), totaling $28,991,068, has started on December 1, 2013 and will continue through November 30, 2015. TFM breakdown is:

77% will be spent on FLDs and SLDs, while 10% on health products, including laboratory equipment and supplies.

Medecins San Frontieres is implementing program in three CAR countries:

● Tajikistan -- MSF provides treatment for children with MDR-TB. This had previously been a deficient area due to lack of expertise, pediatric drug formulations and national staff skepticism precluding the possibility of the occurrence of MDR-TB among children. MSF works in existing facilities, including the pediatric TB hospital in Dushanbe, the MDR-TB ward of Machiton hospital and the TB dispensary in Kulyab.

● Uzbekistan -- MSF supports comprehensive diagnostic and treatment support for both TB and MDR- TB treatment throughout Karakalpakstan Republic, facility renovation, centralized lab services and implementation of an outpatient treatment model for both TB and MDR-TB cases.

KfW collaborates with national and international partners on diagnosing contagious TB patients and administering standardized out-patient treatment as well as installation of laboratory equipment, provision of TB drugs and training for health professionals. KfW is supporting lab strengthening in the Kyrgyz Republic through the construction of a national reference laboratory (NRL) at the National TB Center. In Uzbekistan, KfW supports the national TB program to implement the DOTS strategy. In Tajikistan, KfW recently completed the construction of a National Reference Laboratory in the Machiton Republican TB Hospital and plans to provide limited support and training for laboratory staff and engineers for an additional three years. KfW also supports a reconstruction project for the Digmai Regional TB Hospital in Soghd oblast, which includes MDR-TB beds.

UNITAID, through the Expand TB program is focused on expanding and accelerating access to new and rapid diagnostic technologies, especially for MDR-TB, including procurement of laboratory equipment and training for lab strengthening. UNITAID assistance is channeled through the Foundation for Innovative New Diagnostics (FIND) in all CAR countries except Turkmenistan.

Caritas Luxemburg has worked in Tajikistan in support of TB control activities in prisons since 2005 with funding planned through 2014.

C.6 PROJECT DESCRIPTION COMPONENTS

USAID has provided essential technical assistance support for TB prevention and control in the region for over a decade, and this support has been important in demonstrating proof that the DOTS strategy, an out-patient approach to treating TB, can work in the region. In collaboration with partners and stakeholders, USAID has been instrumental in encouraging Governments to adopt international standards for TB control, incorporate them into their policies and strategic plans and strengthen linkages between specialized TB and PHC sectors in the detection, treatment and care of individuals with TB.

In accordance with WHO’s Stop TB Strategy and the USG Global TB strategy, the USAID/CAR TB team developed a 2012 – 2015 USAID/CAR TB strategic plan that focuses on high impact interventions to control TB and slow the development of MDR-TB and XDR-TB. This activity will support and build upon the progress made under this strategic plan.

The geographical focus of the project is primarily Tajikistan and Uzbekistan as defined via the objectives below. Specific project sites will be selected in conjunction with government counterparts and USAID, once the award has been made. The project may also include specific activities geared toward supporting a broader regional response for improved TB-related outcomes in the region. Should USAID/CAR receive future funding for TB control activities in Turkmenistan and/or Kazakhstan, this award may be modified at a later date to also operate in these two additional countries. Strategic priorities for Turkmenistan and Kazakhstan under this award’s objectives would be identified at a later date, in close coordination with Government counterparts and depending on funding levels. These activities should also coordinate closely with TB control activities managed by USAID/Kyrgyz Republic. Illustrative regional activities might include:

● Regional workshops or observation tours to highlight successful models or activities within the CA region that focus on outpatient models; scaling up PMDT in prisons; successful referral systems that better link TB and PHC, HIV and or CSOs for improved patient care and support; TB bed optimization schemes that have resulted in budget savings that were used for increased outpatient treatment and support; involvement of CSOs for improved outreach to vulnerable populations and community linkages; long distance e-leaning for more sustainable in-service training; and use of electronic TB MIS;

● Regional activities for migrants, that could be informed through the findings from the Research Study on TB Risk Factors in Central Asian Migrants that is funded through USAID/CAR (preliminary study findings are expected in early 2015) and other sources;

● Advocacy and promotion with partners and TGF for CAR country procurement of TB drugs manufactured in Kazakhstan that meet international standards and guidelines, for increased commercial integration within the region.

The seven focal objectives related to work in Tajikistan and Uzbekistan, including the following:

Objective 1: More equitable access to comprehensive and appropriate TB diagnostic and treatment services for vulnerable populations

Vulnerable and high risk groups such as prisoners, migrants and socially disadvantaged persons continue to be underserved and are more vulnerable to TB and MDR-TB. Reducing barriers to access for these vulnerable groups is key to improving equitable access and reducing the burden of TB and MDR-TB as well as slowing the further development of drug resistant TB in the region.

Limited access to TB diagnosis and care, insufficient infection control measures, poor nutrition and high-density living conditions put prisoners at higher risk of TB infection. TB patients who are released from the penitentiary system are often not linked with health services in the civilian sector, leading to reduced adherence or cessation of TB treatment which contributes to the development of MDR-TB. The International Organization for Migration estimates that 5 million Central Asians migrate each year for employment opportunities in other countries. Many of these migrants are undocumented and therefore less likely to seek TB diagnosis and treatment due to the fear of deportation from the countries in which they work. Internal migrants that move within a country may find it difficult to receive the necessary consistent treatment and support they require due to their constantly shifting from one health service catchment area to another within country.

Vulnerable populations, including those co-infected with HIV and TB, often face stigma and discrimination at access points, further discouraging their chances of receiving timely diagnosis, treatment and support. Although statistics show that men are disproportionally affected by TB, women are less likely to seek early TB diagnosis due to stigma and cultural restrictions on women. Vulnerable and socially disadvantaged groups require special outreach efforts to support and link them with established TB diagnosis and treatment services within the health system as well as to provide an additional range of psychological and social support including counseling, nutrition supplements, etc. In the case of women, improved access to TB services might better be facilitated through linkages between TB and maternal and child health (MCH) and other female-focused efforts at the community level. Community groups and CSOs are often already working with vulnerable and high-risk groups and represent an opportunity for supporting and facilitating their improved access to TB and MDR-TB diagnosis and treatment. Those CSOs working with younger, more mobile TB clients may consider piloting the use of electronic/social media for increased TB outreach and sustained support. The Project will work closely with USAID/CAR’s Democracy and Governance Office as CSOs are increasingly involved in outreach, advocacy and issues around stigma and discrimination for TB patients from vulnerable populations.

Uzbekistan

USAID is currently supporting strengthened collaboration between penitentiary and civilian care services for prisoners through the TB CARE I project. These efforts will continue under the award. Few CSOs operate in Uzbekistan due to numerous entry barriers and heavy regulation of registered CSOs. There are on the other hand, numerous parastatal organizations working with youth, women, neighborhood communities that can be approached to expand their activities into TB outreach and support for vulnerable populations. Uzbekistan illustrative input activities that support objective 1:

● Establish/continue dialogue with penitentiary system to support implementation of PMDT with particular focus on prisons;

● Develop and operationalize strategies for improved continuum of treatment and care of prisoners as they transfer within the prison sector and between prison and civilian sectors, which includes provision of psycho-social-economic (PSE) support;

● Develop materials and methods for educating prisoners, their families and prison staff on TB and

HIV;

● Strengthen community knowledge and awareness of TB through CSOs and parastatals in order to increase TB and MDR-TB case detection rates and reduce stigma and discrimination against TB patients, especially from vulnerable populations;

● Develop appropriate activities to reduce access barriers, including linkages with PHC/MCH services and community based referral systems to TB diagnosis for female TB suspects;

● Support outreach, referral and follow-up of those on TB and MDR-TB treatment through local CSOs and parastatals to address the special PSE support needs of populations vulnerable to TB and MDR-TB, including prisoners, internal and external migrants, and other socially disadvantaged groups;

● In collaboration with partners, support policy dialogue and sharing of experiences on a regional level.

Tajikistan

PMDT in prisons was introduced in Tajikistan in 2009; however, due to lack of resources and limited access to the penitentiary settings, the quality of TB diagnostics and DOT remains insufficient. The roll-out of PMDT in prisons is an urgent issue as well as establishment of stronger linkages between prison and civilian sectors to insure continuum of care after prisoners are released. Although the GOTJ does not have clear mechanisms to work with CSOs, many CSOs are currently working with donor supported programs. In its National ACSM strategy, the MOH does recognize the critical and unique role CSOs can play in TB behavior change communication and social mobilization activities. Tajikistan illustrative input activities that support objective 1:

● Implementation/roll out of PMDT with particular focus on prisons;

● Develop and operationalize strategies for improved continuum of treatment and care of prisoners as they transfer within the prison sector and between prison and civilian sectors, which includes provision PSE support;

● Develop materials and methods for educating prisoners, their families and prison staff on TB and

HIV;

● Strengthen knowledge and awareness of TB in order to increase TB and MDR-TB case detection rates and reduce stigma and discrimination against vulnerable and high-risk populations;

● Develop appropriate activities to reduce access barriers, including linkages with PHC/MCH services and community based referral systems to TB diagnosis for female TB suspects;

● Continued support for policy dialogue between the MOH and CSOs to maximize their role and efforts for ACSM;

● Support outreach and follow-up of those on TB and MDR-TB treatment through local CSOs to address the special PSE support needs of populations vulnerable to TB and MDR-TB, including prisoners, internal and external migrants, and other socially disadvantaged groups;

● In collaboration with partners, support policy dialogue and sharing of experiences on a regional level.

Illustrative indicators for both countries include:

● Number of prisoners where PMDT is being implemented;

● Number of CSOs providing outreach support for TB to vulnerable populations;

● Number of vulnerable populations contacted;

● Number of released prisoners continuing treatment in civil sector;

● Number and percentage of women and men with cavity lesions on diagnostic CXR;

● Number and percentage of women and men with bacteriological confirmation of TB.

Objective 2 – Laboratory services provide more timely, quality TB and MDR-TB diagnosis

Under the award, the expanded implementation of GeneXpert for the diagnosis of drug-resistant TB will be undertaken within the larger context of TB laboratory strengthening activities that will assist governments in planning, deploying and managing laboratory diagnostic resources effectively and efficiently. Proper integration of GeneXpert into overall systems for PMDT will ensure that patients receive adequate treatment after diagnosis. At the national and oblast level, the award support to the development of fully functional TB laboratory systems will prioritize laboratory strategic planning and systems strengthening to enhance internal and external quality assurance. Improved quality of sputum samples and the transportation systems that deliver these samples to the laboratories are also needed in order to promote quality assured smear microscopy, culture and drug susceptibility testing (DST) services. Agreements with private companies that make regularly scheduled deliveries to remote areas is one approach that may be pursued in developing transportation systems for sputum samples.

In Uzbekistan, the Quality Management System (QMS) for laboratories is currently being developed under the Quality for Health Project that ends in 2015. Guidelines for QMS are currently being developed and once approved, QMS will be rolled-out in laboratories. Implementation support will ensure continued roll-out and functioning of the QMS. Uzbekistan illustrative input activities that support objective 2:

● Continued support to roll-out of laboratory QMS to promote quality-assured bacteriology, including smear microscopy, culture and DST;

● Support the MOH to promote rational use and maintenance of GeneXpert technology for improved MDR-TB outcomes;

● Support development and/or strengthening and dissemination of national guidelines, clinical and treatment algorithms for scaled up rollout of diagnostic technologies such as light-emitting diode (LED) fluorescence microscopy, GeneXpert, line probe assays (LPA) and automated mycobacteria growth indicator tube (MGIT);

● Provide training in logistics management, forecasting of laboratory supplies and expendables including disposable cartridge needs and planning for routine equipment servicing needs;

● Promote program for training and certification of national laboratory engineers for repair and timely calibration of lab equipment

● Promote designation of national lab experts to be trained to mentor new and rotating lab staff in use of rapid diagnostic and other lab equipment;

● Assist in development of sustainable sputum transport systems to ensure faster, more reliable sputum transportation to laboratories;

● Update all standard operating procedures (SOPs) and protocols for laboratories at all levels of the laboratory system against international standards;

● Advocate for increased number of national lab maintenance staff to be hired and trained.

Tajikistan

The QMS for microscopy laboratories was introduced and roll-out nationwide was begun under USAID’s Quality Project in 2012. A National GeneXpert Strategy has been approved and is being implemented.

This project will continue assistance to the implementation of both activities. Tajikistan illustrative input activities that support objective 2:

● Continued support to roll-out of laboratory QMS to promote quality-assured bacteriology, including smear microscopy, culture and drug susceptibility testing (DST);

● Support the MOH to promote rational use and maintenance of GeneXpert technology for improved MDR-TB outcomes;

● Support development and/or strengthening and dissemination of national guidelines, clinical and treatment algorithms for scaled up rollout of diagnostic technologies such as light-emitting diode (LED) fluorescence microscopy, GeneXpert, line probe assays (LPA) and automated mycobacteria growth indicator tube (MGIT);

● Provide training in logistics management, forecasting of laboratory supplies and expendables including disposable cartridge needs and planning for routine equipment servicing needs;

● Promote program for training and certification of national laboratory engineers for repair and timely calibration of lab equipment;

● Promote designation of national lab experts to be trained to mentor new and rotating lab staff in use of rapid diagnostic and other lab equipment;

● Assist in development of sustainable sputum transport systems to ensure faster, more reliable sputum transportation to laboratories;

● Develop SOPs for improving the quality of sputum samples collected and smear microscopy;

● Develop or update all SOPs and protocols for laboratories at all levels of the laboratory system against international standards;

● Advocate for increased number of national lab maintenance staff to be hired and trained.

● Number of labs implementing quality management systems;

● Percentage of lab staff performing their job responsibilities as required by standard operating procedures for GeneXpert and other rapid diagnostic equipment;

● Number of lab staff trained to utilize/operate rapid diagnostic technology;

● Number of national lab trained maintenance staff employed;

● Percentage of TB smear samples delivered to diagnostics lab deemed “quality samples” sufficient for analysis;

● Number of new smear positive TB cases identified;

● Number of MDR-TB cases identified.

Objective 3: – Patient centered system for TB and MDR-TB implemented widely across the region

CAR countries still maintain an outdated model of care with long term in-patient hospital admission of TB and MDR-TB patients, largely due to the high levels of drug resistance and the difficulty in differentiating between drug susceptible TB (which reacts well to first line treatment) and MDR-TB (which requires second line treatment). By keeping patients in hospital settings, direct transmission can be contained, assuming effective IC measures are properly administered; however, hospitalization increases opportunities for transmission of MDR-TB, especially of undiagnosed MDR-TB, to other patients in TB wards. Long term admission to hospitals also has important negative social, psychological and emotional effects, not only on patients but their families as well.