Disclaimer: The authors' views expressed in this publication do not necessarily reflect the views of the United 
States Agency for International Development or the United States Government.
ENDLINE EVALUATION OF 
CHALLENGE TB BURMA
Endline Evaluation Report
MORGANA WINGARD FOR USAID

ENDLINE EVALUATION OF 
CHALLENGE TB BURMA
Endline Evaluation Report
February 2020
Contract Number: AID-486-I-14-0001
Task Order: 72048219F0002
Social Impact, Inc.
Cover photo by USAID/Challenge TB
Authors/Evaluation Team
Dr. Beulah Jayakumar, Team Leader
Soe Myat Naing
Tushar Kanti Ray
iii
ABSTRACT
In 2014, the United States Agency for International Development (USAID) funded FHI 360 to implement 
the five-year Challenge TB (CTB) Myanmar to support Myanmar’s National Tuberculosis Program (NTP) 
in its efforts to actively find and effectively treat missing tuberculosis (TB) cases. USAID/Burma 
contracted Social Impact, Inc. to conduct an evaluation to examine activity effectiveness and intervention 
challenges and provide recommendations to guide decisions on future investments. The evaluation team 
used mixed methods including document review, key informant interviews, focus group discussions, 
observations and secondary data to identify findings that addressed USAID’s evaluation questions. The 
evaluation found that CTB Myanmar successfully contributed to case finding by addressing key issues and 
gaps in case finding and provided robust technical assistance (TA) for a range of TB thematic areas. At 
the same time, activity implementation was constrained by systemic issues like human resource 
deficiencies and poor buy-in from other relevant departments of the Ministry of Health and Sports 
(MOHS). Models designed by CTB Myanmar have been taken up by other grant projects to varying 
extents. Following the close-out of CTB Myanmar, weaknesses in current programming in the country 
include the scale back of active case finding (ACF), poor understanding of stigma, and lack of plans for 
provision of TA for NTP. Serious challenges in human resources and inter-departmental coordination 
limit the utilization of TA in implementation. Opportunities for investment include reaching migrants and 
ethnic organizations. The report makes nine recommendations directed to USAID/Burma on priorities 
for future design and implementation.
ACKNOWLEDGMENTS
The evaluation team express their sincere appreciation to various individuals who made significant 
contributions to the success of this end line evaluation. Special thanks go to Pyae Phyo Aung, Mission 
Monitoring and Evaluation Specialist of USAID/Burma and Dr. Htoo Aung Cho, Project Management 
Specialist (Health) of USAID/Burma, for their valuable assistance in facilitating field visits for the 
evaluation. 
The evaluation team is indebted to the valuable direction and assistance provided by Dr. Si Thu Aung,
Director Disease Control, Ministry of Health and Sports and Dr. Cho Cho San, Program Manager, 
National TB Program in executing evaluation activities. 
Special thanks go to the staff of FHI 360 and subgrantees for their unreserved support of this evaluation, 
without which this evaluation would not have been successful. They freely shared Activity 
documentation and databases, which were essential to the design and secondary analysis in this 
evaluation. 
Thanks are also due to Leah Ghoston/SI Program Director for her support in all stages of the 
evaluation; to Marissa Germain/SI Senior Program Associate, who served as the Project Manager; to 
Ibrahim Rashid/SI Program Assistant, for providing operational support; and to Brooke Hill/SI Program 
Manager who managed project finalization.
The evaluation team is thankful to staff of the national TB program, national agencies, partner 
organizations, government and subgrantee staff in the regions and states visited, staff of health facilities, 
volunteers, community members and patients who served as key informants and shared their 
perspectives. This evaluation would not have been successful without their participation. 
February 2020 The Evaluation Team
v
CONTENTS
ABSTRACT III
ACKNOWLEDGMENTS IV
CONTENTS V
LIST OF TABLES AND FIGURES VI
ACRONYMS VII
EXECUTIVE SUMMARY X
ACTIVITY BACKGROUND X
EVALUATION PURPOSE, DESIGN AND LIMITATIONS X
KEY FINDINGS AND CONCLUSIONS X
RECOMMENDATIONS XV
EVALUATION BACKGROUND 1
ACTIVITY BACKGROUND 1
EVALUATION PURPOSE 4
EVALUATION QUESTIONS 4
EVALUATION DESIGN, METHODS, AND LIMITATIONS 5
DOCUMENT REVIEW 5
PRIMARY DATA: KEY INFORMANT INTERVIEWS 6
PRIMARY DATA: FOCUS GROUP DISCUSSIONS 8
PRIMARY DATA: COMMUNITY INTERVIEWS 8
PRIMARY DATA: OBSERVATION 8
FINDINGS AND CONCLUSIONS 12
EVALUATION QUESTION 1 13
EVALUATION QUESTION 2 28
EVALUATION QUESTION 3 34
RECOMMENDATIONS 39
ANNEXES 41
ANNEX I: EVALUATION STATEMENT OF WORK 42
ANNEX II: DETAILED DESCRIPTION OF EVALUATION DESIGN AND METHODS 46
ANNEX III: EVALUATION DESIGN MATRIX 47
ANNEX IV: DATA COLLECTION TOOLS 51
ANNEX V: INFORMATION SOURCES 100
ANNEX VI: DISCLOSURES OF CONFLICT OF INTEREST 101
ANNEX VII: EVALUATION TEAM MEMBER PROFILES AND CVS 102
LIST OF TABLES AND FIGURES
Table 1: Categories of Key Informants interviewed 7
Table 2: Number and distribution of primary data collection activities 9
Table 3: Achievement by CTB Myanmar objective 13
Table 4: CTB Myanmar indicators: achievement against targets 13
Table 5: ACF intervention details 15
Table 6: Results from the DR TB activity in Yangon 20
Table 7: Progress in LQMS implementation 25
Table 8: Distribution of cases found by GPs in the study and its projection for Yangon 38
Table 9: Selection of sites and criteria used 46
Figure 1: Trends in TB incidence and TB mortality during CTB Myanmar 2
Figure 2: Geographic focus areas of subgrantees 3
Figure 3: Yield from ACF in hard-to-reach areas 16
Figure 4: Trend of case notifications before and during the ACF intervention 16
Figure 5: Yield from the drug seller engagement 22
vii
ACRONYMS
A2H Access to Health
ACF Active Case Finding
ACSM Advocacy Communication and Social Mobilization
aDSM Active Drug Safety Monitoring
ART Antiretroviral Therapy
BHS Basic Health Services
BSL Biosafety level
CBTBC Community-based Tuberculosis Care
CI Contact Investigation
CMBL Central Mandalay Branch Laboratory
CNR Case Notification Rate
CSO Civil Society Organization
CTB Challenge Tuberculosis
CXR Chest Xray
CYC Cover Your Cough (Campaign)
DOMS Department of Medical Services
DOPH Department of Public Health
DOT Directly Observed Treatment
DR Drug-resistant
DR-TB Drug-resistant Tuberculosis
DS Drug Sensitive
DSM Drug Supply and Management
DST Drug Sensitivity Testing
DS-TB Drug-sensitive Tuberculosis
ECG Electrocardiogram
EHO Ethnic Health Organization
EQ Evaluation Question
EQA External Quality Assurance
ET Evaluation Team
FAST Finding actively, separating safely and treating effectively
FDA Food and Drug Administration
FGD Focus Group Discussion
GF The Global Fund (to fight AIDS, TB and Malaria)
GLI Global Laboratory Initiative
GP General Practitioner
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HQ Headquarters
IEC Information, Education, and Communication
IRB Institutional Review Board
ISO International Standards Organization
JMM Joint Monitoring Mission
KII Key Informant Interview
KP Key Population
LPA Line Probe Assay
LQMS Laboratory Quality Management System
LTBI Latent Tuberculosis Infection
LTFU Lost to Follow-up
M&E Monitoring and Evaluation
MDR Multidrug-Resistant 
MHAA Myanmar Health Assistants Association
MMA Myanmar Medical Association
MOHS Ministry of Health and Sports 
MSF Médecins sans Frontières
MTB/RIF Mycobacterium Tuberculosis/Resistant to Rifampicin
NGO Non-governmental Organization
NNS Number Needed to Screen
NRL National Reference Laboratories
NSP National Strategic Plan
NTP National Tuberculosis Program
NTRL National TB Reference Laboratory
OPD Outpatient Department
OR Operations Research
ORW Outreach Workers
PCF Passive case finding
PGK Pyi Gyi Khin
PLHIV People Living with HIV
PMDT Programmatic Management of Drug-resistant Tuberculosis
PPM Public Private Mix
PSI Population Services International
RHC Rural Health Center
RR TB Rifampicin-resistant tuberculosis
SCC Sputum collection center
SI Social Impact, Inc.
SL Second Line
SL-LPA Second-line Line Probe Assay
SLIPTA Stepwise Lab Improvement Process towards Accreditation
SOP Standard Operating Procedures
SOW Scope of Work
ix
STR Shorter Term Regimen
STTA Short-term Technical Assistance
TA Technical Assistance
TB Tuberculosis
TBIC Tuberculosis Infection Control
TBTSG TB Technical Strategy Group
TPT TB Preventive Treatment
USAID United States Agency for International Development
WHO World Health Organization
WVM World Vision Myanmar
XDR-TB Extensively drug resistant Tuberculosis
EXECUTIVE SUMMARY
ACTIVITY BACKGROUND
Myanmar continues to be among the world’s 30 high-burden countries for tuberculosis (TB), TB HIV, 
and multidrug resistant (MDR) TB. With nearly 25 percent of TB cases being missed, the National 
Strategic Plan for 2016-’20 (NSP) calls for robust case-finding strategies and comprehensive patient￾centered TB care with the engagement of community health providers and the private sector.
Challenge TB (CTB) Myanmar aimed to support the national TB program (NTP) in its efforts to actively 
find and effectively treat missing TB cases by enrolling male and female patients into a comprehensive 
and inclusive TB prevention and care package. CTB Myanmar had four key objectives: 1) Reaching the 
hard-to-reach through public private mix (PPM) engagement and through ACF in remote and ethnic 
areas, 2) Strengthening access to high quality TB diagnostics, 3) Strengthening the national MDR-TB 
response in Yangon region and 4) Building the capacity of NTP through targeted technical assistance 
(TA) for policy/tool development around key technical priorities.
CTB Myanmar was implemented by FHI360, with support from KNCV Tuberculosis Foundation in The 
Hague, Netherlands. Subgrants were provided to six organizations for selected activities. 
Implementation concluded in June 2019, with full close-out in September 2019.
EVALUATION PURPOSE, DESIGN AND LIMITATIONS
The purpose of this evaluation was to assess and document the most significant achievements of CTB 
Myanmar and its contribution to the national response to TB, as well as challenges, lessons learned and 
promising practices. Findings from this evaluation are intended to inform future TB programming and 
highlight technical priorities and key issues for USAID’s TB investments in Myanmar.
The evaluation used a mixed-methods design, involving document review, primary data collection 
through key informant interviews (KIIs), focus group discussions (FGDs), observation, community 
interviews, and analysis of secondary program and project data. Multi-stage purposive sampling was used 
to determine sites for primary data collection. 
The evaluation team reviewed a range of documents on CTB Myanmar design, implementation, and 
evidence; NTP policy, strategy, guidelines and training material, and global resources. The evaluation 
team conducted 42 KIIs involving 66 individuals (41 men and 25 women) from USAID/Burma and 
partners, CTB, and government stakeholders at national, region/state, township and community levels, 
16 patient interviews, 2 FGDs with subgrantee staff and volunteers and 3 observations in labs. As the 
primary data was collected from a purposive sample, findings may not apply to sites not visited by the 
evaluation team. Limited availability of program data was mitigated by an extensive review of documents 
and literature related to TB control in Myanmar. 
KEY FINDINGS AND CONCLUSIONS
EVALUATION QUESTION 1: WHAT WERE CTB’S KEY CONTRIBUTIONS TO TB CONTROL IN MYANMAR 
AND TO WHAT EXTENT HAS CTB/BURMA ADDRESSED KEY TB ISSUES AND GAPS? 
xi
CTB Myanmar addressed issues and gaps in TB control through five key interventions implemented 
in specific geographies and technical areas: ACF in hard-to-reach areas, engaging drug sellers in Bago 
region, contact investigation (CI) for MDR-TB patients in Yangon, strengthening of the diagnostic 
network for MDR-TB and setting up the active drug safety monitoring (aDSM) mechanism.
Reaching hard-to-reach areas through ACF using the community-based TB care model was a 
principal strategy in CTB Myanmar’s approach to increasing case notification. CTB Myanmar
implemented ACF in 22 hard-to-reach townships across Sagaing region and Kayah and Chin states, 
through subgrants to four organizations, reaching a total population of just over 2.29 million. Key 
activities included conducting TB-related discussions in communities, accompanying symptomatic 
persons to the facility for testing and setting up sputum collection centers (SCC) through a cadre of 
community-level volunteers. Through CTB Myanmar’s ACF intervention, 46,091 presumptive persons 
were tested. A total of 2,678 cases, which constitute a third of all cases notified from the 22 townships 
between June 2017 and March 2019 were from this intervention. Many of the individuals notified would 
have faced formidable challenges in accessing care themselves. In particular, ACF volunteers helped 
symptomatic persons with the language barrier that existed between them and staff at the facilities. The
overall trend of case finding over the ACF implementation period was on the decline when the
intervention ended, but in some sites, the number of cases remained high until the last quarter of 
implementation. The ACF intervention faced significant challenges related to terrain, poor 
transportation and coordinating the collection and transportation of sputum samples. 
Case finding among close contacts of drug resistant (DR) TB patients was carried out in Yangon
through a revamped CI process and improved utilization of the Xpert™ Mycobacterium 
Tuberculosis/Resistance to Rifampicin assay. Key activities included training and deploying outreach 
workers and field staff to work with township-level TB officers and basic health service (BHS) staff to 
visit houses of DR TB patients soon after their diagnosis, to encourage household members to be 
tested. The intervention faced numerous limitations and challenges, chiefly a limited implementation 
period of nine months. It resulted in the screening of 3,811 household contacts of a total of 355 DR-TB 
patients and identified 445 presumptives to be tested. Of these, 53 had confirmed TB. However, only 7 
of these were DR TB patients and the remaining 46 had drug sensitive (DS) TB. CTB Myanmar
conducted a range of other activities for strengthening the MDR-TB response, including the hiring of an 
MDR-TB Advisor, who was instrumental in supporting key initiatives of CTB Myanmar in MDR-TB 
management. CTB Myanmar also trained and supported drug sellers in Bago region to improve 
case finding. This intervention resulted in the diagnosis of a total of 1,796 cases from March 2017 to 
February 2019 which contributed to 11 percent of all cases notified during its implementation period
from the 15 townships where it was implemented. 
CTB Myanmar successfully addressed several constraints in care seeking for TB in its target locations. 
Language and cost were the key barriers for both men and women patients that CTB Myanmar helped 
through its case finding interventions. Interviews done with volunteers and patients in the sites visited 
indicate higher awareness and willingness to seek care among women. Patients from prior to the 
implementation of CTB Myanmar’s interventions reported delays in diagnosis as a result of inappropriate 
care seeking. Delays due to diagnostic errors at facilities, related to chest X-ray (CXR) continued to 
take place during the intervention period. Misconceptions regarding the nature of TB and its spread 
were encountered in all the sites visited and included beliefs that TB ran in families (reinforced by high 
levels of transmission within families); that cough was a physiological process and is therefore “normal”;
and that weight gain during treatment was pathological. The most prevalent misconception was that 
having an “infectious” disease was cause for fear and shame. CTB Myanmar reports that it addressed 
these misconceptions for patients and their families through project activities, but the stigma resulting 
from them does not appear to have reduced. The evaluation team encountered several aspects of 
stigmatization of TB in communities: patients being shunned by neighbors or classmates, friends and 
family encouraging patients to stop treatment, and contacts hiding symptoms including hemoptysis. 
CTB Myanmar’s investments in the diagnostic network focused on improving services in the three labs 
providing culture and drug sensitivity testing (DST) and line probe assay (LPA) for first and second line 
(SL) anti-TB drugs. CTB Myanmar provided technical and financial assistance for critical improvements 
in the two national reference laboratories (NRLs), in coordination with other partners. The 
project was able to introduce the Lab Quality Management System (LQMS) and secure buy-in from NRL 
staff to pursue ISO 15189 accreditation for the two NRLs. CTB Myanmar provided follow up TA in 
collaboration with WHO and the Global Laboratory Initiative to ensure alignment with WHO updates 
related to the use of SL LPA, the expansion of Xpert sites, the sputum transportation system and the 
introduction of the shorter-term regimen (STR) for MDR-TB. As a result of the TA, NTP began to see 
CTB Myanmar as a credible technical partner. CTB Myanmar also conducted a range of lab-related 
procurements for the NRLs in coordination with other partners, in the area of biosafety. By the end of 
the project, the NRLs in Yangon and Mandalay had achieved 45 and 66 percent respectively of the 
LQMS standards required for ISO accreditation, falling short of the end-of-project targets of 55-64 and 
75-84 respectively for the two labs. Efforts to improve services in these labs were fraught with 
intractable challenges arising from multiple sources. The focus on accreditation may have diverted 
efforts from providing quality services. 
CTB Myanmar was instrumental in establishing the mechanism for aDSM, leading and engaging 
all TB technical partners in this effort. The mechanism has been functioning effectively and has been 
recognized internationally, but challenges in continued implementation of aDSM threaten its 
sustainability without continued partner support. CTB Myanmar also provided high-quality TA for 
improving the use of CXR for TB diagnosis in the context of possible overdiagnosis of TB among 
children, but it remains underutilized. Its intervention in the Xpert network and the sputum 
transportation system was minimal.
In conclusion, CTB Myanmar contributed to addressing key gaps and issues in TB control in the 
country. It successfully designed and implemented ACF, reaching nearly half of all people living across 
hard-to-reach areas and contributing to a third of cases notified during that period from these locations, 
who may not have sought care at appropriate facilities without facilitation from the intervention.
However, as the intervention stopped when the case finding trend was still high in some locations, pools 
of undiagnosed cases are likely persisting in those locations, leading to high transmission levels. The 
intervention among DR-TB patients did not contribute meaningfully to addressing the MDR-TB crisis in 
Yangon, due to severe time limitations as well as formidable challenges in implementation. The low yield 
of DR-TB cases from this intervention, along with a relatively high yield of DS-TB cases warrant support 
for further investigation. The intervention has helped draw national attention to the role of CI in 
addressing the MDR-TB situation. The drug seller intervention of CTB Myanmar contributed to 11 
percent of cases reported from intervention locations by engaging community-level resources. All of 
these interventions contributed to CTB Myanmar’s achievement of 4,520 additional cases, against its
goal of 5,300 additional cases, and also provided considerable learning for future use. 
xiii
CTB Myanmar helped overcome language and cost barriers for both men and women in hard-to-reach 
areas. Erroneous diagnosis contributed to delay in diagnosis during ACF implementation. Stigma and 
discrimination are widely prevalent, fueled by multiple misconceptions and these impact care seeking as 
well as treatment adherence among women, men and children. There were no gender-specific 
constraints for women in seeking care for TB. 
Investments in NRLs is among the largest from CTB Myanmar. The goal of obtaining accreditation for 
NRLs helped CTB Myanmar provide focused attention to improvements in NTRL, but the approach has 
not enabled the NTRL to focus additional resources on the more pressing goal of expanding PMDT 
services. aDSM is clearly one of CTB Myanmar’s success stories and testifies to the investment made in 
collaboration and coordination. CTB Myanmar’s technical and financial support has been critical to the 
improvements in the use of CXR as a diagnostic tool.
EVALUATION QUESTION 2: TO WHAT EXTENT HAS CTB’S TECHNICAL ASSISTANCE TO NTP AT 
DIFFERENT LEVELS ADVANCED TB PREVENTION AND CONTROL IN BURMA IN LINE WITH CTB 
GLOBAL-LEVEL OBJECTIVES AND CTB/BURMA’S PROJECT OBJECTIVES, AND PROMOTED 
SUSTAINABILITY?
CTB Myanmar provided effective and relevant TA and capacity building support to the NTP, in addition 
to that related to aDSM mentioned under EQ 1. It provided technical and financial support for the 
development of NSP 2016-‘20 and the Global Fund (GF) Concept Note, and TA for a range of TB￾related themes including the management of childhood TB, TB preventive treatment (TPT) for eligible 
children and interpretation of CXR. However, the use of these TA products by national stakeholders 
continues to be variable. CTB Myanmar also designed and conducted a comprehensive cost effectiveness 
evaluation of ACF activities. This evaluation has been effective in guiding investments in ACF beyond 
CTB Myanmar. 
Other TA provided by CTB Myanmar met with limited success due to their introduction late in the 
course of the project or due to challenges in securing buy-in from other departments of the Ministry of 
Health and Sports (MOHS). Key among these are the guidelines for mandatory notification of TB by 
private general practitioners (GPs), TB infection control (TBIC) and CI. Some TA and capacity building 
initiatives planned by CTB Myanmar could not be carried out due to delays in approval or shifting of 
NTP’s priorities. 
Models developed and/or implemented by CTB Myanmar to improve case finding continue under grants
from GF and Access to Health (A2H); CTB Myanmar’s ACF evaluation provided the evidence on cost 
effectiveness of these models. But the level of effort under GF/A2H grants is much lower than that 
under CTB Myanmar, such as in the number of volunteers, inclusion of hard-to-reach areas and training 
and supervisory support. The CI intervention for MDR-TB patients and the drug seller engagement also 
continue under new grants but with lower levels of effort. 
The models implemented by CTB Myanmar had several elements that were designed to sustain care 
seeking and foster regular coordination with township and BHS levels. They also had elements that were
heavily project-dependent, such as staff accompanying every symptomatic person to the facility for 
testing and conveying the results back to the patient/volunteer. These were possibly included due to 
CTB Myanmar’s emphasis on reaching case finding targets, to ensure the targets are met, but they have
not been included in the GF/A2H grants. Key informants from other partners engaged in TB care
emphasized that learning implementation models was a key strength of USAID grants, and hence, the 
overall emphasis of CTB Myanmar should have been on learning what works rather than on finding a 
certain number of cases. 
Health staff and community volunteers were highly appreciative of the contribution of CTB Myanmar’s 
models in case finding and expected the same level of support to continue in the new grants. Partners 
engaged in TB control also pointed out these initiatives, as with other donor-funded initiatives in TB and 
other programs in the country, are fully dependent on external funding, and that sustainability of 
initiatives in the country tends to be viewed in terms of continuing implementation with other donors.
In conclusion, CTB Myanmar’s support for NSP 2016-’20 and the GF Concept Note development 
ensured that TB prevention and control in Burma had a strategic reference point and guidance. CTB 
Myanmar provided high-quality TA for the development of guidelines, standard operational procedures 
(SOPs) and training manuals that are informed of the country’s context and reflect current international 
guidance. The ACF cost effectiveness evaluation provided the NTP and partners with the evidence base 
for continuing support for the intervention. These are in line with CTB’s Global objectives as well as 
with country level objectives of CTB Myanmar, which seek to meet the gaps outlined in the NSP. This 
task also demonstrated the agility of CTB Myanmar’s funding mechanism and of the team. These 
strategic investments have built NTP capacity and some of them continue to impact interventions 
beyond CTB Myanmar’s lifetime, being the foundation for ongoing support by other partners. However, 
the uptake of CTB Myanmar’s TA has been limited by systemic challenges, especially continued 
involvement of hospitals, which fall outside the purview of NTP, in the areas of childhood TB 
management, CI, TBIC and CXR interpretation. These challenges were outside the scope of CTB 
Myanmar to address.
Continued implementation of the case finding models are fully dependent on donor funding, to the 
extent that sustainability of interventions is viewed in their ability to be taken up by subsequent funding 
cycles. Certain elements in these models as implemented by CTB Myanmar make them inherently 
unsustainable, and this is likely due to the emphasis of CTB Myanmar on meeting case finding targets 
alongside the emphasis on learning what works. 
EVALUATION QUESTION 3: WHAT GAPS AND OPPORTUNITIES EXIST FOR FURTHER USAID 
INVESTMENT IN THE PRIVATE SECTOR AND COMMUNITY PROGRAMMING? 
Gaps in current programming identified during the evaluation following the close-out of 
CTB Myanmar include: a) scaling back of the level of effort for ACF in previously CTB-supported 
communities now continuing under GF and A2H grants, which runs the risk of losing the momentum 
built by CTB Myanmar as well as the opportunity to confirm a decline in the pool of undiagnosed cases; 
b) poor understanding and addressing of stigma, which continues to hamper care seeking and treatment 
adherence; c) the need for support in understanding the low yield of DR-TB cases among contacts of 
DR-TB patients and exploration of the effectiveness of implementation models; d) the need of NTP for 
robust TA, and USAID mechanisms being in the best position to provide it; and e) serious challenges in 
human resources and inter-departmental coordination that limit the utilization of TA in implementation, 
as up to half of the sanctioned posts in the labs and health offices visited were vacant at the time of the 
evaluation.
xv
Opportunities for future investment, in addition to addressing the gaps mentioned above,
include engagement of migrant populations working in mines in hard-to-reach townships, included in the 
new NSP; and NTP’s prioritization of mandatory notification by GPs.
Scaling ACF interventions back up to the level of effort supported by CTB Myanmar in the 22 townships 
where it was implemented would lead to the detection of an estimated 712 additional cases over one 
year and supporting notification by the GPs trained by CTB Myanmar would result in the detection of an 
estimated 1,923 cases over a year and an additional case notification rate (CNR) of 27.8 per 100,000 
population. 
In conclusion, the evaluation identified the scale back of ACF without follow-on programming by 
USAID or other partners at this juncture as a clear programmatic gap. The evaluation also identified a 
need for significant attention to understanding of stigma and its role in driving delays in care seeking and 
interruptions in treatment, which was not a major focus of the CTB Myanmar or other partner 
programming in the country at present. There is evidence that stigma continues to be a formidable 
barrier to care seeking for cough and adhering to treatment. There is a critical need to understand the 
epidemiology of MDR-TB in Yangon as well as other locations, including the size and nature of the 
problem, transmission mechanisms and assess the effectiveness of innovative models of care. 
The need for high-quality TA to NTP and the role of USAID in facilitating its provision is well recognized 
and documented, but systemic issues related to human resources in NTP and the wider health system 
constrain the utilization of TA in improving service delivery, and possibly contribute to missing a 
considerable number of cases in public hospitals. There is need to explore the extent of rollout of the 
SOPs and guidelines developed by CTB Myanmar, within these constraints, but also continue providing 
TA at the central level to enable the uptake of new guidance on the full range of thematic areas. 
Reaching migrant populations, as envisioned in the new NSP, presents an opportunity, as does 
facilitating the establishment of diagnostic and treatment facilities including training and supervision 
through coordination between ethnic health organizations (EHOs) and NTP to reach very hard-to-reach 
areas with possible high transmission. 
Preliminary estimations show that scaling ACF interventions back up to the level of effort supported by 
CTB Myanmar in the 22 townships were ACF was implemented would lead to the detection of an 
estimated 712 additional cases over one year. Although this number is low, the vulnerable nature of the 
population justifies this effort. Supporting notification by the GPs trained by CTB Myanmar would 
result in the detection of an estimated 1,923 cases over a year and an additional CNR of 27.8 per 
100,000 population. 
RECOMMENDATIONS
The evaluation recommends the following priority investments for USAID and design and 
implementation considerations:
1) Explore ways to expand GF and A2H investments in ACF (preferably as part of the next GF 
grant writing cycle) to resume and maintain the pace of ACF developed under the CTB 
Myanmar model. Work with these two grants to understand the rationale behind the scaling 
back of effort and with TB teams at region/state and township levels to develop a nuanced 
approach that is able to identify pockets of high transmission and responds with a combination
of ACF, sputum transportation and mobile team activities, until well after a decline in case 
finding is documented from these areas. As CTB Myanmar reached about half of the estimated 
population living in all hard-to-reach areas of the country, consider expanding the ACF 
intervention to the remaining areas, especially those with ethnic minority groups and conflict￾affected areas. 
2) Consider support to the expansion of services to migrants working in mining areas, in line with 
what is envisioned in the new NSP. Develop interventions and broker relationships between 
mining companies and the local township health offices, to help operationalize strategies 
outlined in the new NSP.
3) Continue support for the rollout of mandatory notification of GPs, by supporting the 
establishment of a user-friendly reporting mechanism through robust TA and supporting training 
and supervision of GPs beginning with those that CTB Myanmar trained in Yangon. Simplified 
reporting mechanisms would be critical to secure and maintain the involvement of GPs.
4) Lead a joint effort to bring about greater collaboration with other departments under MOHS to 
help reach public and private hospitals with implementing the guidelines and SOPs developed 
with the support of CTB Myanmar, particularly in the areas of TBIC, CI, CXR use and 
interpretation and TPT for children.
5) Provide TA to further assess and characterize the MDR-TB problem in Yangon including its 
transmission pathways to inform current and future interventions. Examine reasons for the low 
yield in the CI intervention among DR-TB patients in Yangon under CTB Myanmar. 
• Consider including retrospective CI for all DR-TB patients in Yangon under the new
program cycle, especially for those contacts that did not receive Xpert testing during 
the early part of the CI intervention of CTB Myanmar.
6) Fund/build capacity for research that investigates stigma and discrimination related to TB, 
adapting existing tools for and social behavior change interventions for addressing this in a way 
that empowers local communities. One option is to support national NGOs to apply for (and 
subsequently implement) the Stop TB Partnership call for proposals for “Challenge Facility for 
Civil Society 2019” released in December 2019. This call includes activities for conducting 
stigma assessments.
7) Review/re-design the key messages of the Cover Your Cough (CYC) in the light of findings from 
the stigma assessment.
8) Collaborate with MOHS and partners to advocate with the central, region/state governments to 
mount a high-level, multisectoral response engaging education, labor, transport, women’s 
development and other departments to address misconceptions related to the disease and their 
sources, through high-profile counter-messaging.
9) Continue support to expanding aDSM and ensuring continued functioning of the core 
committee: ensure allocation of funds by the Food and Drugs Administration (FDA) for its 
xvii
membership at the WHO monitoring center, and for recruiting full time staff for aDSM, who 
will ensure the continued functioning of equipment and provision of supplies for clinical 
monitoring and management. 
10) Ensure that future program cycles focus on developing and testing models, documenting 
processes, and evaluating the effectiveness, rather than focusing on gap-filling.
• An important starting point would be to define objectives and performance metrics 
related to model development. 
• Include operations research, specifically to test the models that are developed and 
implemented. 
• Ensure that the models have inbuilt linkages to the existing primary healthcare system. 
• Learning from the CTB Myanmar experience, build in sufficient time for approvals at all 
stages in model development and implementation.

1
EVALUATION BACKGROUND
ACTIVITY BACKGROUND
CONTEXT
Challenge TB (CTB) served as the flagship global mechanism for implementing the strategy of the USAID 
to meet the global post-2015 goal of a world free of TB. The project supported the introduction, scale￾up, and sustainability of high impact TB interventions, primarily in 26 high-burden TB, MDR TB, and TB 
HIV countries, including Myanmar. 
According to the 2019 Global TB Report of the World Health Organization (WHO) approximately 10.0 
million people developed TB in 2018 and an estimated 1.2 million deaths among HIV-negative people 
and 251,000 deaths from TB among people living with HIV (PLHIV).
WHO lists Myanmar as one of the 30 high burden countries for TB, TB HIV, and MDR-TB. The TB 
prevalence in Myanmar has seen a dramatic decline in bacteriologically confirmed TB, but it is three 
times higher than the global average and is one of the highest in Asia. An estimated 181,000 people had 
TB in 2018 (incidence of 338 cases per 100,000 people), and approximately 21,000 died from the disease 
(not including HIV patients)1. MDR-TB patients constitute 4.9 percent among new cases and 20 percent 
among retreatment cases2. 
The NTP, with support from USAID and other partners, developed a NSP for 2016- ‘20. The Plan’s goal 
is to end the TB epidemic in Myanmar, indicated by fewer than 10 cases per 100,000/population, by 
2035. The NSP embraces four key principles: (1) government stewardship and accountability along with 
monitoring and evaluation; (2) strong coalition with civil society organizations and communities; (3) 
protection and promotion of human rights, ethics and equity; and (4) adaptation of the strategy and 
targets at decentralized levels, with NTP coordination. The NSP prioritizes ten groups for ACF as a 
strategy to find “missing” cases: health care workers, prisoners, migrants, miners, urban and rural poor, 
the elderly, people living with HIV or diabetes, and ethnic minorities. 
Under the broad framework of the NSP, and with support from local and international non￾governmental organizations (NGOs), including CTB Myanmar, PPM interventions helped identify 50 out 
of the 260 cases notified per 100,000 population in 20183. Programmatic management of drug-resistant 
TB (PMDT) was initiated in 2011. 
Over the past decade, the NTP has made major progress in the fight against TB countrywide. Prevalence 
surveys carried out in 2018 and 2009 showed major epidemiological impact. The prevalence of 
pulmonary culture positive tuberculosis by one morning sample declined from 520 (415-624) per 
100,000 in 2009 to 256 (173-339) per 100,000 in 2018, a decline of 51% over that period. According to 
WHO this indicates an estimated 4.9% annual decline in incidence over that time period. This puts 
1 WHO Global TB Report, 2019.
2
Ibid.
3
Final report of the 6th Joint Monitoring Mission, 2019.
Myanmar well on track to reach the target of an incidence reduction of 20% by 2020 as compared to 
2015. 
Since 2017, the MOHS has been procuring all of the first-line TB drugs used in the country and 40 
percent of its second-line TB drugs and instituted an effective procurement and distribution system for 
these drugs.
Figure 1: Trends in TB incidence and TB mortality during CTB Myanmar
Source: WHO Global TB reports
Despite epidemiological impact, Myanmar faces a persistent high TB burden countrywide. The situation 
is particularly of concern in Yangon, with a prevalence of 607 (468-747) per 100,000 adults and MDR-TB 
notification rate of more than 20/100,000 population, by far the highest and most complex in the 
country4. Additionally, as stated in the Prevalence Survey report, TB response remains largely limited to 
the health sector and it is severely constrained by the intractable human resource challenge faced by the 
health sector as a whole. Almost two-thirds of TB patients and their families face catastrophic costs for 
TB care5, while a quarter of TB patients go undetected or are unreported.
ACTIVITY OVERVIEW
CTB in Myanmar was implemented by FHI360, with support from KNCV in The Hague, Netherlands, 
with a primary emphasis on medium to long term technical assistance (TA) to NTP. Subgrants were 
provided to six organizations for selected activities. Implementation concluded in June 2019, with full 
close-out in September 2019.
The overarching focus of CTB Myanmar was to “support national efforts to actively find and effectively 
treat missing TB cases by enrolling male and female patients into a comprehensive and inclusive TB 
prevention and care package”. The overall objectives and sub-objectives directly aligned with the United 
States Government (USG) Global TB Strategy 2015-2019, and with the specific priorities outlined in the 
NSP: The Activity’s goal was to find and notify 5,300 more TB patients (all forms) in 2019 compared to 
4 MOHS, Govt of Myanmar and WHO. 4th National Tuberculosis Prevalence Survey, 2017-’18. Short report, 
version 1.3, August 2019.
5
Exceeding 20 percent of annual household income, as defined by WHO.
369 365 361 358 338
53 49 47 51 39
0
100
200
300
400
500
# per 100,000 population
2014 2015 2016 2017 2018
Incidence rate Mortality rate
3
2014 through project interventions6. By the end of Year 2, the intervention approach began to coalesce 
around four key objectives, with guidance from the Mission. 
Figure 2: Geographic focus areas of subgrantees
Key objective 1. Reaching the hard-to-reach 
through PPM engagement and through ACF in remote 
and ethnic areas.
CTB Myanmar supported the demonstration of 
community-level case-finding approaches to increase 
access to inclusive services in Kayah, Chin, and Sagaing 
to cover around 2.3 million people in 22 townships, 
implemented by four subgrantees: Pyi Gyi Khin (PGK), 
World Vision Myanmar (WVM), the Myanmar Health 
Assistants’ Association (MHAA), and the International 
Union Against Tuberculosis and Lung Diseases (The 
Union). Figure 2 gives the geographic focus areas of 
these subgrantees. CTB Myanmar also supported a 
fifth subgrantee, Population Services International (PSI) 
to accelerate TB case finding by engaging drug sellers 
in 15 townships in Bago Region.
Key objective 2. Strengthening access to high quality 
TB diagnostics 
CTB Myanmar provided capacity-building and technical 
assistance to the two NRL – the National TB 
Reference Laboratory (NTRL) at Yangon and the 
Central Mandalay Branch Laboratory (CMBL) to 
improve laboratory quality and work towards the 
International Standards Organization (ISO) 15189 
accreditation. CTB Myanmar also supported quality improvement in all three of the country’s biosafety 
level 3 (BSL 3) laboratories, the two NRLs and the laboratory in Taunggyi. 
Key objective 3. Strengthening the national MDR-TB response in Yangon region.
CTB Myanmar supported a sixth subgrantee, the Myanmar Medical Association (MMA), a local 
organization, to find DR-TB and DS-TB patients among contacts of index patients with Rifampicin 
resistance (RR) by implementing systematic CI and increased utilization of Xpert™ Mycobacterium 
Tuberculosis/Resistance to Rifampicin (MTB/RIF) assay7. CTB Myanmar also provided support for Xpert 
expansion across all 44 townships in Yangon and contributed to an increased number of TB diagnoses. 
6 The original goal was 10,000 cases; it was revised in Year 4 based on project approach and geographic focus.
7
From Cepheid, Sunnyvale CA., USA, an automated, cartridge-based nucleic acid amplification test that uses the 
multi-disease GeneXpert™ (Cepheid, Sunnyvale CA., USA) platform.
FIGURE SEQ FIGURE \* ARABIC2: GEOGRAPHIC 
INTERVENTION AREAS OF CTB MYANMAR
Key objective 4. Building the capacity of NTP through targeted TA for policy/tool development 
around key technical priorities.
CTB Myanmar provided NTP with technical support to strengthen its coordination and management 
system, including the roll out of nationally approved SOPs, guidelines and manuals on TB infection 
control (TBIC), childhood TB, CI, active drug safety monitoring and management (aDSM) and shorter 
treatment regimens for MDR-TB and advocacy, communication and social mobilization (ACSM) for TB. 
Furthermore, CTB Myanmar supported NTP to ensure approximately 1,000 registered GP in Yangon 
not registered with PPM schemes of NTP were trained in mandatory notification of TB. CTB Myanmar
also provided TA to pilot a CXR external quality assurance (EQA) system in seven sites in Mandalay and 
Yangon. And finally, the project supported the NTP to develop the NSP for 2016- ‘20.
The CTB Myanmar background document states that the de facto theory of change was that if TB case 
finding is increased, diagnostic capacity is improved, the NTP is strengthened and a National MDR-TB 
response is supported, then the TB burden in Myanmar will be decreased. The development hypothesis 
was that technical assistance, and subgrants for implementation can make a meaningful contribution to 
decreasing this burden by introducing new tools and approaches for TB control that can be continued 
and scaled by other partners, including the Government of Myanmar.
EVALUATION PURPOSE
The purpose of this evaluation was to assess and document the most significant achievements of CTB 
Myanmar and its contribution to the national response to TB, as well as challenges, lessons learned and 
promising practices. 
Findings from this evaluation are intended to inform future TB programming and highlight technical 
priorities and key issues for USAID’s TB investments in Myanmar. 
EVALUATION QUESTIONS
This evaluation addressed the following Evaluation Questions (EQ), drafted by USAID Burma/Office of 
Public Health in the initial Scope of Work (SOW) and finalized by the evaluation team (ET) in 
collaboration with them:
1. What were CTB Myanmar’s key contributions to TB control in Myanmar and to what extent 
has CTB Myanmar addressed key TB issues and gaps?
● To what extent did CTB Myanmar contribute to the overall national results in reducing 
the TB burden in Myanmar?
● What are the most important TB gaps and issues that CTB Myanmar focused on in its 
geographical areas, and how well did the selection of interventions and geographical 
areas align with need?
● What gender constraints/gaps were faced by women with TB and MDR-TB, especially in 
hard to reach remote areas and how were they addressed by CTB Myanmar?
● What were the key contributions of CTB Myanmar in the following technical areas?
o Increasing case notification and ACF
5
o Addressing the MDR-TB crisis in Yangon
o Strengthening TB and MDR-TB diagnostic network
o Assisting NTP in introducing aDSM for MDR-TB cases
o Engagement with private sector providers, drug sellers, and other non-public 
organizations in TB case finding
2. To what extent has CTB Myanmar’s technical assistance to the national TB program at different 
levels advanced TB prevention and control in Burma in line with CTB global-level objectives, and 
CTB Myanmar’s project objectives, and promoted sustainability?
● What technical assistance and capacity-building support provided by CTB Myanmar was 
most effective, and what activities were less effective? 
● To what extent were interventions (especially those related to hard to reach areas and 
the MDR-TB response in Yangon), models and tools introduced by CTB Myanmar
adopted and continued or scaled up with other resources (domestic or other donor)? 
What are examples of tools or approaches that were continued or scaled up?
● What efforts did CTB Myanmar undertake to ensure broader uptake of its approaches? 
What evidence exists of uptake?
3. What gaps and opportunities exist for further USAID investment in the private sector and 
community programming?
● Considering current programmatic coverage and findings from the TB Prevalence Survey 
of 2018-19, how might a scaled-up approach to engaging the private sector and 
community-based activities affect case finding efforts (namely in areas of high prevalence, 
high loss to follow up, or poor reporting)?
● What lessons and best practices from CTB Myanmar’s private sector interventions can 
be applied to future efforts to control TB and efforts to build country capacity?
EVALUATION DESIGN, METHODS, AND LIMITATIONS
The evaluation used a mixed-methods design that included document review; primary data collected 
through KIIs, observations, FGDs and interviews in communities with past and current TB patients; and 
analysis of secondary data. KIIs were used to collect in-depth information from those with the richest 
knowledge of the relevant topics. Observations provided evidence on service delivery, quality, and 
adherence to standards in laboratories. Community interviews provided evidence on issues related to 
access and patient perceptions. Secondary analysis investigated CTB Myanmar’s monitoring and 
performance data and TB program data and helped assess trends and progress toward key performance 
indicators and complemented the primary descriptive information. An evaluation design matrix linking 
each of these approaches with the EQs is included as Annex III. 
METHODS
DOCUMENT REVIEW
Several documents were reviewed to establish evidence on activity design, implementation, progress
toward goals, and lessons learned. Below is a list of categories of documents that were reviewed. A 
complete list of documents reviewed is provided in Annex II. 
Activity design: CTB Cooperative Agreement, technical proposal, monitoring, evaluation and 
reporting plan
Baseline/prior assessments: Reports of assessments, situational analyses and evaluations
Activity implementation: Annual work plans and reports; reports of short-term technical 
assistance, routine performance monitoring and visit reports, and manuals and SOPs developed with 
assistance from CTB Myanmar
National policy, strategies, and resources: NSP 2016 – ‘20, National guidelines for TB, MDR-TB 
and TB HIV, NTP annual reports of 2015 and 2016, published reports and studies regarding TB 
control in Myanmar, Reports of Joint Monitoring Missions (JMM), TB prevalence survey reports and 
reports of other partners
Global strategies and guidelines and literature: USAID Global TB strategy, WHO End TB 
strategy, WHO Global TB Reports and published studies 
PRIMARY DATA: KEY INFORMANT INTERVIEWS
KIIs gathered primary descriptive data related to the following topics:
• CTB Myanmar design considerations, rationale behind selection of issues and geographies to 
intervene, implementation approaches and the underlying assumptions; adaptations made to 
implementation
• Key achievements and challenges; contribution to overall national results
• Quality, relevance and adequacy of TA and its impact on NTP capacity to reach its 
objectives
• Coordination and collaboration with NTP and other stakeholders
• Stakeholder perceptions on achievements and challenges, sustainability and scale up
KII participants were selected based on their engagement and familiarity with CTB Myanmar and with 
TB control efforts in the country. They included selected individuals from CTB Myanmar staff, 
subgrantee staff and volunteers, NTP staff at all levels, USAID/Burma, partners engaged in TB care and 
control and community representatives.
Table 1 below lists the key informants who were interviewed. The KIIs are listed as individual activities 
rather than as composite ones for entire facilities, as each individual KII forms a separate unit. This 
method also enabled the evaluation team to keep track of and report on those that it completed. 
Informed consent was obtained from every participant and the interviews were conducted using KII 
guides developed for each participant category. The instruments were reviewed and approved by the 
Institutional Review Board (IRB) of Social Impact, Inc (SI).
7
The evaluation team conducted 42 KIIs involving 66 individuals – 41 men and 25 women, drawn from 
USAID and partners, CTB, and government stakeholders at national, region/state, township and 
community levels. 
Table 1: Categories of Key Informants interviewed
MOHS
• NTP manager, Director - Disease Control
• Deputy Director General - Disease Control
Partners at national level
• USAID/Burma, including the USAID-funded MDR-TB Advisor seconded to NTP (contracted under 
STAR)
• WHO Myanmar 
• Other stakeholders in TB control 
o PSM Project, Chemonics International
o JICA
o JATA
o GF Principal Recipients: UNOPS and Save the Children 
o FDA
CTB Myanmar Staff and its sub-partners
• Ex-Chief of Party and Ex-Dy Chief of Party
• Leads of subgrantees:
o PGK
o WV Myanmar
o MHAA
o The Union
o PSI
o MMA
Region and State TB Units: Yangon, Sagaing and Kayah
• Region/State TB Officer/ TB Team
• TB Team Leader
NRLs, Yangon and Mandalay
• Lab in charge/chief microbiologist
District TB Unit (in sampled townships), Sagaing and Kayah
• Unit in charge / TB clinic in charge 
Township TB/Health Unit (in sampled townships), Yangon, Sagaing and Kayah
• Unit in charge/team
District and Township hospitals, Sagaing and Kayah
• Head of the facility
• TB Lab technician
MMA Project site, Yangon 
• Outreach workers
TB HIV Hospital, Yangon 
• Head of facility
Rural Health Center
• Basic Health Service (BHS) staff
Community 
• Staff at Sputum Collection Centers (SCC)
• Drug sellers (Bago region)
PRIMARY DATA: FOCUS GROUP DISCUSSIONS
Two FGDs were conducted with subgrantee staff and volunteers totaling 17 participants (15 women and 
two men) to obtain in depth information on their perceptions and experiences working to promote 
awareness of TB in communities, as well as changes in perceptions regarding the disease in target 
communities over time. The following topics were covered:
• Community-level activities for ACF, awareness building, referral and follow up
• Changes in public perceptions related to TB, its diagnosis and treatment
• Enablers and barriers to timely and appropriate care seeking; specific challenges for women; 
specific challenges in hard-to-reach areas
• Contribution of CTB Myanmar in all these areas
Each FGD was a facilitated discussion on a range of pre-determined topics. Informed consent was 
obtained from participants and an FGD protocol, both approved by the IRB of Social Impact, Inc. was 
used to guide the discussion. 
PRIMARY DATA: COMMUNITY INTERVIEWS
Interviews were conducted in communities with current TB and MDR-TB patients as well as those who 
have completed treatment, who reside in hard to reach areas reached by CTB Myanmar. These 
interviews assessed their perceptions and experiences related to their care seeking practices, diagnosis, 
treatment initiation and follow up. They included questions that helped map the care seeking process for 
each patient, reflecting the patient’s pathway through the course of diagnosis and treatment. Interviews 
also assessed enablers, barriers and constraints in the patients’ families and communities for obtaining 
appropriate care, and the patients’ perspectives on further improving community perceptions and quality 
of service delivery. Specifically, the interviews focused on the similarities and differences in the 
experiences of men and women patients and between past and current patients. Patients were selected 
with assistance from subgrantee volunteers and BHS staff, based on criteria explained to them by the ET 
of having past and present TB patients, men and women and TB and MDR-TB patients, where feasible. 
The ET conducted individual interviews with 16 patients, 10 of whom were women, and 2 were 
children. 
Informed consent was obtained from all interviewees and FGD participants, and procedures for 
maintaining confidentiality and privacy were used. Detailed protocols used to guide the patient 
interviews were approved by the Social Impact IRB and field tested. The gender and age of patients were 
recorded, but other identifiers such as name, address and the name and location of the facility or 
community were not. 
PRIMARY DATA: OBSERVATION
The evaluation team observed laboratories supported by CTB Myanmar for: adherence to standards for 
TBIC, equipment functionality, handling, and maintenance; confirming expansion of new diagnostics; EQA 
and sample referral services and recording and reporting. The observations were carried out in the two 
NRLs and the two Xpert labs in the two districts that the ET visited. 
9
The ET used field-tested observation checklists and combined the observations with KIIs with the staff in 
the labs. The checklists combined quantitative and descriptive elements related to the themes noted 
above. No patient-related data was collected during the observations. 
Informed consent forms and data collection protocols for all the above methods are included in Annex 
IV.
SAMPLING FOR PRIMARY DATA COLLECTION
The evaluation team applied multistage purposive sampling to select regions/states, followed by 
townships within the selected regions/states and facilities within the selected townships. These served as 
sites for primary data collection in the form of KIIs, FGDs, community interviews and observations. 
The key criteria used for the selection of regions/states within CTB Myanmar’s geographic reach were 
a) the feasibility of conducting the site visit within the available time, b) the security situation and c) the 
presence of a special intervention. Kayah and Chin states have had comparable interventions for hard￾to-reach areas, and therefore one of them, Kayah was selected, based on accessibility. Criteria for the 
selection of townships reached by CTB Myanmar within selected regions/states was the performance of 
the region/state as indicated by the case notification rate (CNR) per 100,000 population in the NTP 
Annual Report of 2016. These parameters reflect a trade-off between what is feasible within the 
available time and ensuring that the entire range of CTB Myanmar’s interventions are included for 
primary data collection. While the parameters ensured that the task was feasible while also including 
areas with high and low performance, there is the risk that all possible perspectives are not obtained. 
This was mitigated by an exhaustive review of CTB Myanmar documents as well as those related to 
other efforts for TB control in the country. The details of criteria fulfilled in each selected site are 
provided in Annex II.
The total number of activities and their distribution across Regions/States and at the national level are 
outlined in Table 2 below. Sagaing Region and Kayah State were the only locations where the full 
complement of data collection activities was carried out. Data collection in Yangon focused on CTB
Myanmar’s support for MDR-TB related activities and for strengthening the NRL. In Mandalay, data 
collection was done only in the NRL and in Bago, it was limited to drug sellers.
Table 2: Number and distribution of primary data collection activities
Level KIIs KII 
Facility/L
ab
Observati
ons
Community 
Interviews
FGD
Region/State
Yangon
 Region/State TB Unit 1
 Thaketa Township 
 Outreach workers 2
 NTRL 1 1
 Mingalardon TB HIV hospital 1 1
Mandalay
 CMBL 1 1
Sagaing
 Regional TB Unit 1
 District TB Unit 1
 District hospital 1
 Mawlaik Township TB Unit
 Township Hospital 1
 RHC + SCC 1 4
 Community 4 1
Kayah
 Regional TB Unit 1 1
 District TB Unit
 District hospital
 Demosoe Township TB Unit 1
 Township Hospital
 RHC + SCC 1 4
 Community 4 1
Bago
Bago Regional TB Unit 1
 Drug sellers 4
Subtotals 13 7 3 16 2
National
NTP + Other departments 2
Other Partners 9
USAID/Burma 2
CTB Myanmar Staff 1
Subgrantee Staff 8
Subtotals 22 0 0 0 0
Totals 35 7 3 16 2
SECONDARY DATA ANALYSIS
The ET analyzed secondary quantitative data from CTB Myanmar’s performance monitoring database, 
annual work plans and reports and NTP annual reports of 2015 and 2016. The purpose of the secondary 
data analysis of service statistics was to establish the extent of service delivery and utilization and CTB 
Myanmar’s performance against targets and attribution of changes to case finding to CTB Myanmar
activities and assess gaps to be evaluated through in-depth inquiry into possible reasons. The analysis 
was exploratory and examined changes in the utilization of services supported under CTB Myanmar. 
The evaluation did not obtain patient-related data or utilization of services by individual patients. 
The ET triangulated data from all primary and secondary sources to assess CTB’s possible contribution 
to the observed changes and draw lessons for future use.
11
ETHICAL CONSIDERATIONS
The in-house IRB of SI reviewed data collection instruments for procedures to effectively safeguard 
participants, including confidentiality and data security, and whether the informed consent process was
appropriate, as the evaluation worked with vulnerable populations. All SI evaluation personnel—
including headquarters staff, field teams, and consultants— followed professional and ethical guidelines 
to ensure that the evaluation was carried out with honesty and integrity, respondents’ confidentiality 
and privacy are protected, and data security is ensured. This included ensuring the informed consent 
process, including informing respondents about the potential uses of the findings and any potential 
sharing or publication of their data. 
The location and timing of community interviews with patients ensured that the confidentiality related 
to the patients’ illness and reasonable privacy were maintained. ET members undertook personal 
protection measures such as the use of face masks and handwashing as provided for in national 
guidelines, while also ensuring that patient confidentiality was not compromised. 
DATA PREPARATION AND ANALYSIS
Data collection and handling: Data were collected over 3.5 weeks. During fieldwork, the ET 
prepared summary notes of the KIIs, observations, and community interviews each day to identify 
underlying themes emerging from the interviews and discussions. Secondary data and that from lab 
observations were added to other primary qualitative data for thematic analysis. After completion of 
fieldwork, the ET transcribed and organized notes captured during data collection. The evaluation 
questions and identified themes served as the organizing framework for the notes. 
Consent forms with the signatures of participants and consent forms with interviewer’s signatures for 
patient interviews and observations have been compiled and will be held until the final report is 
uploaded to the Development Experience Clearinghouse. Each KII (with respondent name), observation 
and community interview (both with no identifiers) was assigned an identification number and this list 
will stay with the ET until the end of report writing, along with data collection tools with raw data. Soft 
copies of lists of KII respondents are stored in password protected computers and accessible only to 
the ET. The coded analysis matrix references only the IDs and does not contain names of participants.
Coding: Transcripts from KIIs, observations, and exit interviews were analyzed manually based on the 
themes and subthemes contained in the data collection tools. Descriptive data was coded into a findings 
matrix template that includes pre-identified themes and subthemes from the evaluation design matrix 
and accommodate emerging subthemes. Emphasis was placed on comparing the responses across 
participant categories, geographies and facility type to identify similarities and differences in the data 
obtained. 
Primary and secondary quantitative data were analyzed in spreadsheets for standard TB-related 
indicators appropriate for the data points, such as positivity rate, CNR and the number needed to 
screen (NNS)8. Although these data points are quantitative, they are not drawn from a representative 
sample, so the findings cannot be generalized. Throughout the analysis process, the ET looked for 
distinctive sub-themes and findings by geography and gender with descriptive and quantitative data. 
8 Defined as the number of contacts that needed to be screened for every confirmed case identified.
LIMITATIONS 
• This evaluation was not conducted in all locations where CTB Myanmar was implemented and 
did not engage all possible people involved with CTB Myanmar implementation, but a purposive 
sampling was used. While this was in line with the qualitative design of the evaluation and served 
the evaluation’s purposes, findings are not representative of CTB Myanmar’s overall 
performance. This limitation was mitigated by conducting a secondary analysis of CTB Myanmar
data and NTP data, as available.
• Observations of patient-provider interactions and interviews with facility staff could not be 
included in the evaluation design due to limited access to these sites. This was compensated for 
by careful review of all available reports containing such information, such as STTA and JMM 
reports.
• As CTB Myanmar had already fully closed out, several staff on the core team were not available 
for KII. 
• NTP data was available only up to 2015, and disaggregation was limited. 
• The ET consulted with USAID/Burma, CTB Myanmar and NTP to obtain insights for sampling. 
Although the team did not necessarily take instruction from these stakeholders on the actual 
sampling of sites, any biased selection of sites resulting from the information obtained from 
these stakeholders may have affected the accuracy of the findings. 
• Community-level interviews were conducted solely based on the selections made by subgrantee 
staff and volunteers, due to restrictions in accessing communities in some sites. 
• Participants provided information based on their informed consent; however, biases could have 
resulted from lack of information or poor understanding of the questions or from social 
desirability, especially from patient participants. The ET ensured adequate interviewing practices 
and correct phrasing and rephrasing of questions without changing the core meaning/subject of 
the questions.
FINDINGS AND CONCLUSIONS
This section describes findings from the evaluation and conclusions by EQ. It also includes an assessment 
of potential case finding strategies for the future. Preceding these detailed descriptions, Table 3 below 
gives a snapshot of overall achievements and key limitations by CTB Myanmar objective, and Table 4 
gives the achievement of the four key performance indicators of CTB Myanmar.
13
Table 3: Achievement by CTB Myanmar objective
Table 4: CTB Myanmar indicators: achievement against targets
Performance indicator Baseline Target Achievement
Notified cases DS TB all forms nationwide, number 138,352 154,643* 136,039
(87.9 percent of target)
CTB Myanmar activities will find 5,301 cases between 
2017 and ’19, number
- 5,301 4,520
(85.2 percent of target)
Source: CTB Final Report, 2019 (*Year 4 target is provided here as that is the most recent year for which the actuals are 
available)
EVALUATION QUESTION 1: WHAT WERE CTB’S KEY CONTRIBUTIONS TO TB CONTROL 
IN MYANMAR AND TO WHAT EXTENT HAS CTB/BURMA ADDRESSED KEY TB ISSUES AND 
GAPS?
FINDINGS
This section presents findings related to five key interventions implemented in specific geographies 
and technical areas: ACF in hard-to-reach areas, engaging drug sellers in Bago region and for MDR-TB 
Key Objective Key Accomplishments Limitations
• 1. Reach the hard-to￾reach through public 
private mix (PPM) 
engagement and through 
ACF in remote and ethnic 
areas
• Contribution to case finding 
through ACF and drug seller 
engagement
• Limited duration of 
implementation of all models
• Contribution to addressing MDR￾TB crisis in Yangon insufficient 
•
• 2. Strengthen access to 
high quality TB 
diagnostics
• Progress towards 
accreditation of NRLs
• TA for CXR interpretation
• Systemic issues impeded 
successful TA provision
• 3. Strengthen the 
national MDR-TB 
response in Yangon 
region
• Yield of DS-TB cases, through 
CI of DR-TB patients
• Contribution to developing 
the Yangon Regional Crisis 
Response Plan for MDR-TB
• Limited duration of 
implementation
• Causes for low yield not 
investigated
• 4. Build the capacity of 
NTP through targeted 
technical assistance (TA) 
for policy/tool 
development around key 
technical priorities
• NSP and GF Concept Note 
development
• Cost effectiveness of ACF 
interventions
• aDSM mechanism established 
and functioning
• Guidelines and SOPs for 
mandatory notification, 
childhood TB management, 
TBIC, MDR-TB management, 
utilized by NTP
• Limited coordination with health 
facilities constrained utilization of 
some TA products
patients in Yangon, strengthening of the diagnostic network for MDR-TB and setting up the aDSM 
mechanism. It also includes an assessment of their contribution to national results, and challenges to 
their implementation. Findings related to the choice of these interventions and their design are included 
across the entire section.
CONTRIBUTION TO INCREASING CASE NOTIFICATION THROUGH ACF
Reaching hard-to-reach areas was a principal strategy in CTB Myanmar’s approach to 
increasing case notification. CTB Myanmar’s reports and documents show that conducting ACF in 
hard-to-reach areas was a strategic priority of CTB Myanmar since its inception. This design choice for 
improving case notification is supported by the recently completed TB Prevalence Survey which found 
that “the farther we go from a diagnostic facility, the higher the prevalence9”. 
The General Administration Department of the Govt of Myanmar defines hard-to-reach areas based on 
road accessibility across seasons. These areas are further divided into moderate, hard and very hard-to￾reach. About 5.8 million people (12 percent of the country’s population) are estimated to live in such 
areas10. Almost all of these areas are populated by ethnic minority groups. 
CTB Myanmar trained staff of EHOs in Mon and Kayin states in Years 1 and 2. By the end of Year 2, 
CTB decided to add greater structure to this intervention through the subgranting mechanism, signifying 
a strategic shift in CTB Myanmar’s earlier emphasis on TA to the central level. As the subgranting 
process was done in consultation with the NTP, EHOs were not included, due to the low levels of 
openness in the government to formally contract with ethnic groups at the time. 
CTB Myanmar implemented ACF in 22 hard-to-reach townships across Sagaing region, 
Kayah and Chin states, through subgrants to four organizations, reaching a total 
population of just over 2.29 million. Six of these townships are in the hardest-to-reach category. 
Subgrantees deployed cadres of volunteers to conduct TB-related discussions in small and large groups; 
identify symptomatic persons and accompany them to the township facility for tests or collect and 
transport sputum specimen and mobilize communities ahead of visits from the mobile TB team. 
Subgrantees also set up 113 SCCs - in RHCs or in volunteers’ homes. Each subgrantee worked out an 
incentive package for volunteers, but in general, the package included an incentive for every education 
session, reimbursement of all transport costs, both for the patient and for the volunteer for transporting 
sputum, accompanying a patient to the facility and for participating in monthly meetings, and for directly 
observed treatment (DOT) support. As a norm, volunteers work for seven days every month. 
Subgrantees report that they selected volunteers using pre-determined criteria related to literacy, 
experience in community-based health work, and location, and the selections were done in close 
consultation with the township health office, the RHC team and community leaders.
9 MOHS, Govt of Myanmar and WHO. 4th National Tuberculosis Prevalence Survey, 2017-’18. Short report, 
version 1.3, August 2019.
10 Myanmar Information Management Unit, 2019. Map ID 1648 v01, Hard to Reach Areas, Myanmar. 
15
Table 5: ACF intervention details
Organization Region Townships Population Volunteers
MHAA Sagaing 8 948,648 399
The Union Sagaing 8 959,873 1,155
WVM Kayah 3 141,936 150
PGK Chin 3 147,524 151
Each subgrantee had its own adaptation of this overall intervention, such as variations in the ratio of 
villages to volunteers, and in the location of SCCs. These variations reflected the subgrantee’s 
understanding of the local context and their theory of how barriers to case finding would be overcome. 
In Kayah, for instance, the subgrantee, WVM worked with local ethnic organizations to identify 
symptomatic persons. A common feature across the sites was that project staff conveyed the results of 
sputum tests back to the RHC/SCC. Project staff also did joint supervision of volunteers work along 
with BHS staff stationed at RHCs, and report that this helped build the capacity of BHS staff, many of 
whom have been recently employed. It is notable that subgrantees were given targets for case finding, 
and these were not revised when one of the subgrantees had to withdraw from some locations owing 
to local-level conflict. 
Subgrantee teams and township level health staff reported effective coordination between them in all the 
project locations. This was most evident in the manner in which communities were mobilized ahead of 
mobile team visits. Mobile teams visited a township approximately once a year in Kayah and Chin and 
once in three to six months in Sagaing and covered certain locations within the township at every visit. 
Volunteers received information about the mobile team visit from the township TB clinic through 
project staff and mobilized the local population for accessing the services.
All subgrantee teams developed mechanisms for case-based data collection with the township TB focal/ 
TB team, using the unique code that is given for each patient at notification. This was carried out 
manually, but the small scale of this exercise ensured that errors were kept to a minimum while also 
helping disaggregate cases by the source of referral. Disaggregation by other variables such as age or sex 
was not included in this manual exercise. 
MHAA supports the salary of a TB lab technician in a regional hospital out of their organization’s funds, 
who was seconded by CTB as the current GF grant does not support that position.
A third of all cases notified from target locations during its implementation period were 
from ACF, many of whom would have faced formidable challenges in accessing care 
themselves. A total of 2,678 cases were notified from ACF locations, including 26 with MDR-TB, 
between June 2017 and March 2019, as summarized in Figure 3 below11. SCCs served 12,807 of these 
presumptive TB patients by transporting 25,614 samples for diagnosis (two samples per patient) and 
identifying 194 bacteriologically confirmed TB patients. This represents 27 percent of all notified 
bacteriologically confirmed patients from the 22 townships.
11 This data does not include those referred by volunteers to the mobile team in Sagaing and Chin.
In all sites visited, community members reported that they 
were unlikely to have sought care early, or not at all without 
the volunteer accompanying them to the facility, and in some 
cases, visiting their home repeatedly to encourage them to go 
to the facility for testing. Subgrantee staff and volunteers state 
that as language is a key barrier in ethnic minority communities 
where facility staff do not speak the local language, and the presence of volunteers with the 
symptomatics and patients helps them overcome this barrier. In one state, the regional TB officer 
reported that nearly half of the health staff are not local. In all locations, the long distances and the 
attendant transportation costs to the nearest township TB clinic for tests (and for some locations in 
Chin state, to the state capital) meant that symptomatic persons will not go until their illness became 
unbearable. Key informants at township and community levels also noted that subgrantee teams in 
ethnic minority areas have built a credible presence in hard-to-reach areas and have earned the trust of 
local communities and organizations of the minority groups. 
Figure 3: Yield from ACF in hard-to-reach areas
 
Data from ACF in hard-to-reach locations depicted in Figure 4 below provides a break-up of the cases 
notified by quarter to the NTP through passive case finding (PCF) prior to ACF implementation, and 
those that were notified to NTP through PCF and ACF during the time of implementation, starting from 
July – September 2017. There was an increase in the trend of cases notified through ACF activities for 
the first two-thirds of the implementation period, before declining over the last two quarters. The data 
provided in the graph shows that PCF also increased in a less pronounced manner during the same time 
period, which could be a result of the educational activities of ACF and an overall improvement in care 
seeking. It is also likely that, as pointed out in the JMM report of 201912, the increase in cases found 
through ACF reflects a reduction in the pool of undiagnosed cases in these communities.
Figure 4: Trend of case notifications before and during the ACF intervention
12 Final report of the 6th Joint Monitoring Mission, 2019.
Presumptives identified
Presumptives tested
Confirmed cases
46,661
46,091
2,678 (26 MDR TB)
“I don’t like TB, but I like working for TB. 
There are people with TB in our 
communities”
- ACF volunteer
17
 
There are site-specific variations in the trend, which has possible programmatic 
implications. The project-wide totals provided above hide important site-specific variations. In the 
sites that the ET visited, aggregate data displayed in township TB centers showed that, unlike the 
project-wide trend, the number of cases found through ACF was consistently high and was at its peak 
when the intervention ended in March 2019, followed by a drop to near-zero levels until July-Sep 2019. 
Therefore, while the overall results from the ACF work show a decline, either due to the winding down 
of activities with CTB Myanmar closing, or due to exhaustion of the pool of undiagnosed cases and 
disruption in transmission, in these sites, we do not know the size of the undiagnosed pool of prevalent 
cases and the level of transmission. We will not know this unless ACF activities continue uninterrupted 
until case finding rates decline. 
The ACF intervention faced significant challenges. The design and rollout of the intervention 
faced inordinate delays from its inception. Annual reports of CTB Myanmar reveal that conducting ACF 
in hard-to-reach areas was a priority from the start. CTB Myanmar proposed an initial ACF assessment, 
but could not carry it out due to delays in approval in Years 1 and 2. The delays occurred due to lack of 
clarity in CTB Myanmar about the process of obtaining approvals and the lack of staff stationed at Nay 
Pyi Taw to coordinate closely with MOHS. During these two years, CTB Myanmar trained staff of ethnic 
organizations as mentioned earlier, and the shift towards awarding subgrants took place in Year 3. This 
resulted in a relatively short implementation period of 1.5 years. There were also challenges in field 
implementation. Volunteers and staff report difficulty in coordinating the collection of samples from 
patients on a fixed day. Patients did not always bring the samples on the prescribed day, and this 
resulted in volunteers making more frequent trips to the facility than anticipated. While the project 
reimbursed the volunteers’ expenses for all the trips made, they ended up working longer than the 
seven days that they were paid for. Floods, hilly terrain and limited availability of ferries (to reach 
communities located across rivers) limited the mobility of volunteers. Generally, transportation to 
remote locations is improving and people are able to access facilities more easily than before, some 
challenges such as flooding and local-level conflict persist, which makes travel challenging. 
Volunteers and staff also report that incentives for participating in group education sessions led to 
community members in some locations demanding that they be paid for every interaction with the 
volunteer. Volunteers in both Kayah state and Sagaing region reported that persistent misconceptions 
1,061 1,021
774
894
1,010
767 742
868
780 719 650
849 884
738 743
111
344
437
514
600
427
245
0
200
400
600
800
1,000
1,200
Jul-Sep
Oct-Dec
Jan-Mar
Apr-Jun
Jul-Sep
Oct-Dec
Jan-Mar
Apr-Jun
Jul-Sep
Oct-Dec
Jan-Mar
Apr-Jun
Jul-Sep
Oct-Dec
Jan-Mar
2015 2016 2017 2018 2019
# cases notified
NTP - PCF ACF
regarding the nature of the disease, its spread and treatment necessitated repeated attempts by them to 
get symptomatic persons to go to the facility or to provide sputum samples. They also report that over 
time, they have built trust and credibility in their communities and seeing patients get cured with 
treatment has helped counter some of the misconceptions in some locations. 
Treatment for DS TB was not directly observed. The ET learned of patients with DS-TB 
receiving anti-TB medication every month from the facility but take the medicines themselves. ACF 
volunteers conduct follow up visits with patients on treatment and are often accompanied by BHS staff, 
but none provided feedback on DOT. Patients and volunteers report that patients with DS-TB receive 
medication every month themselves from the facility, often accompanied by volunteer (during CTB 
Myanmar implementation) and swallowed the medicines themselves, rather than be provided DOT.
Although this is an incidental finding – corroborated by the JMM 2019 report – and it was not an 
element of the ACF intervention of CTB Myanmar, it assumes significance in the light of reports of 
treatment interrupters among the workplace acquaintances of community members that the ET 
interacted with. It also points to the need for ensuring adherence to implementation standards. It is not 
the same in the case of DR-TB patients: the NSP notes that strict DOT should be implemented for 
MDR-TB patients, and the ET came across reports of DOT being provided for patients with MDR-TB.
CTB Myanmar designed and conducted a comprehensive cost effectiveness evaluation of ACF 
activities13, including ACF efforts by all partners from 2013- 2016. This is described in detail under EQ 2.
CONTRIBUTION TO ADDRESSING THE MDR-TB CRISIS IN YANGON
The intervention aimed to accelerate case finding among close contacts of DR TB patients, 
through a revamped CI process and improved Xpert utilization. The intervention had two 
distinct components: 1) encouraging screening of close contacts of notified RR patients (index cases) and 
ensuring TBIC through home visits and health education sessions in 13 out of 44 townships of Yangon 
that had higher notification rates for DR-TB14; 2) improving utilization of Xpert by setting up a sputum 
specimen transportation system from GP clinics in all 44 townships to the 11 Xpert testing sites in 
Yangon and providing tools and systems for better coordination.
The intervention trained and deployed 26 outreach workers (ORWs) and 13 field supervisors, all of 
whom were full-time staff, and such a heavy deployment was deemed necessary to reach the target for 
case finding. The intervention expedited the screening of contacts by short-circuiting the prescribed CI 
process whereby a project volunteer or BHS staff visited the home of the index case after DOT was 
initiated. The team worked out a system with the township TB center by which the project’s field 
coordinators obtained lists of notified RR patients from Xpert testing sites once a week and passed 
them on to the ORWs who mobilized patients and their close contacts to participate in counseling 
sessions carried out by BHS staff at the township health office. ORWs begin home visits soon after. This 
way, the intervention was able to initiate home visits earlier, in some cases even before DOT was 
initiated. ORWs also conducted home visits in the early mornings and late evenings when most family 
members were likely to be available in the home. Thus, they were able to meet with more close 
13 MOHS, USAID, Challenge TB. Active case finding in Myanmar: Program assessment and cost effectiveness 
analysis. A study report. July 2019.
14 Based on the 2016 annual TB report.
19
contacts than through the routine CI visits of BHS staff, which generally take place during the daytime. 
The project screened all staff twice during its implementation period for TB. 
The intervention also included the provision of equipment and supplies to GP clinics in all 44 townships 
of Yangon to collect and transport sputum specimen to the Xpert sites. The project developed an SCC 
register and distributed them to townships and GP clinics, as well as job aids for GPs on Xpert testing 
algorithm, adapted from national guidelines. The team worked with the Xpert sites and townships to 
identify and rectify errors in transferring notification data between the labs and treatment initiation sites 
at the township level, and conducted coordination meetings with the regional TB office and staff from all 
44 townships in Yangon, to improve Xpert utilization. However, the job aids were developed only after 
the team discovered that GPs and township TB officers alike were unclear about the use of Xpert in 
screening contacts of DR-TB patients. 
This intervention benefited from resources redirected from a patient-support component for MDR-TB 
patients intended for the hard-to-reach townships, which CTB Myanmar found was being supported 
under the GF and the 3MDG fund grants (the latter also supported by USAID).
The intervention faced numerous limitations and challenges. The intervention was 
implemented for nine months, due to delays related to approvals and due to changes in the subgrantee’s
organizational structure. This is a very short period of time for any intervention to mature and provide 
results and learning, although there was no timeframe set for it, as all the interventions of CTB Myanmar
evolved over time. Additionally, the proposed expediting of home visits could not take place in some 
townships where the TB officer mandated that the BHS staff accompany the ORW to patients’ homes, 
or that the ORW visit the home only after an initial visit by the BHS staff. 
The project team reports that many presumptives did not receive an Xpert test due to lack of clarity 
among providers in public facilities regarding NTP’s revised algorithm for screening contacts. This is 
similar to findings from a study done by CTB Myanmar in Bago region on patients enrolled between 
2016-’17, which found that 46 percent of MDR-TB presumptives, while eligible for Xpert testing, did not 
have one15. The study also found that providers were not aware of NTP’s updated Xpert eligibility 
criteria.
ORWs found that the patients and family members would not take time off from work to get tested and 
feared losing their jobs if found to have TB. These families were also overrun by several misconceptions 
about the nature and spread of the disease and did not want their neighbors to know of their diagnosis. 
ORWs discontinued the practice of wearing T-shirts with the project logo in order to protect patients’ 
anonymity, but patients’ families were also averse to the ORWs wearing masks or encouraging the 
families to use the same. Key informants from other partner organizations also noted the high levels of 
misconceptions related to TB among the urban poor in Yangon. ORWs report that several DR-TB 
patients are very poor and resort to taking high-interest loans to meet basic needs of their families when 
they are out of work during the initial phase of treatment. One ORW reported that she continues to 
support one such patient from her own finances. 
15Oo, T. et al. Magnitude and reasons for pre-diagnosis attrition among presumptive multi-drug resistant 
tuberculosis patients in Bago Region, Myanmar: A mixed methods study. Sci Rep 9, 7189 (2019) 
doi:10.1038/s41598-019-43562-3.
The low yield of DR-TB and high yield of DS-TB are both unusual and raise important 
questions. Project reports show that nearly 90 percent of all index cases had CI and an average of 5 
contacts were screened for every index case, as shown in Table 6 below, but the team reports that 
these constitute only about 60 percent of all close/household contacts of these patients. Thus, the 
coverage has been lower than anticipated, for an intervention of this intensity, using a parallel and stand￾alone structure. The intervention screened 3,811 household contacts of a total of 355 DR TB patients 
and identified 445 presumptives to be tested. Of these, 53 had confirmed TB. However, only 7 of these 
were DR-TB patients and the remaining 46 had DS-TB.
Table 6: Results from the DR TB activity in Yangon
Indicator
Activity
Home visits Counseling at township
# index cases registered 
during the intervention
650 -
# index cases who had CI 
(home visit/counseling)
582 -
# contacts screened 2,811 377
# presumptives identified 405 40
# presumptives investigated 331 24
# confirmed cases 48 5
 DS TB cases 41 5
 DR TB cases 7 0
Number needed to screen 58.6 75.4
Positivity rate 14.5 20.8
The yield of presumptives and cases have been higher than similar interventions employing similar 
metrics in Mandalay, Myanmar16 India17 and South Africa18. The NNS is also lower than global 
experience19. However, in this intervention by CTB Myanmar, the index cases were DR-TB patients, by 
design but the yield consists predominantly of DS-TB cases, and that of DR-TB cases has been low. This 
is not only unusual but also raises at least one significant question, about the source of MDR-TB cases in 
the country, which comprise 5 percent of all new TB cases in the country20. 
The interval between diagnosis and start of CI reduced from a median of 24 days at the start of the 
intervention to 10 by its end. At the township level, this interval reduced notably in some townships, 
16Htet KK et al. Improving detection of tuberculosis among household contacts of index tuberculosis patients by an 
integrated approach in Myanmar: A cross sectional study. BMC Infectious Diseases 2018. 
https://doi.org/10.1186/s12879-018-3586-7.
17Khaparde K, Jethani P, et al. Evaluation of TB case finding through systematic contact investigation, Chhattisgarh, 
India. Tuberculosis Research and Treatment. 2015; 2015:1–5.
18Thind D, et al. An evaluation of “Ribolola”: a household tuberculosis contact tracing program in north West 
Province, South Africa. Int J Tuberc Lung Dis. 2012;16(12):1643–8.
19Shapiro A et al. A systematic review of the number needed to screen to detect a case of active tuberculosis in 
different risk groups. 2013.
20WHO Global TB Report, 2019.
21
and increased marginally in others. However, it appears that this result can only be sustained with a level 
of effort as high as this intervention.
CTB Myanmar conducted a range of other activities for strengthening the MDR-TB 
response. CTB Myanmar trained 397 volunteers in community-based MDR-TB care through partners 
MMA, PGK and MHAA. It also trained BHS staff in MDR-TB counseling and management, and supported 
NTP, MMA and PGK for participating in an international conference on MDR-TB patient support. CTB 
Myanmar assisted the Yangon public health team to develop GIS maps for MDR-TB hot spots as support 
to the MDR-TB Crisis Plan for Yangon region. CTB Myanmar conducted an MDR-TB mass media 
campaign in Years 4 and 5, disseminating key messages through cable television, radio and 
communication material for facilities and reaching an estimated 18 million people. The campaign included 
three cured MDR-TB patients as advocates. According to the final project report of CTB Myanmar, a 
post-campaign evaluation found that 36 percent of evaluation respondents recalled the activity.
In Year 3, CTB hired an MDR-TB advisor for the Yangon region, and embedded him within the 
Yangon Regional TB Office. Key informants from NTP and CTB Myanmar report that the advisor 
provided technical expertise on a day-to-day basis (including training clinicians in WHO updated 
guidance on PMDT and providing case management support), and also helped CTB Myanmar receive 
updated program data from the regional TB office on the MDR-TB situation in Yangon. He also worked 
closely with the MDR-TB technical staff in the CTB Myanmar team in rolling out the aDSM system.
CONTRIBUTION TO ENGAGING PRIVATE SECTOR PROVIDERS, DRUG SELLERS AND 
OTHER NON-PUBLIC ORGANIZATIONS
CTB Myanmar reports reveal that NTP was more inclined towards supporting public-public mix rather 
than collaborating with private facilities. There were protracted discussions on facilitating coordination 
between NTP, which is under the Department of Public Health (DOPH) and hospitals which come 
under the Department of Medical Services (DOMS). This is part of a broader systemic issue and is 
further explored under EQ 3. When these discussions did not result in any progress, CTB Myanmar
decided to engage drug sellers, based on evidence on their role in care provision, and the impact of their 
engagement in case finding. 
CTB Myanmar trained and supported drug sellers to improve case finding. The intervention 
was based on the following findings: 26 percent of people with a chronic cough sought care at local 
pharmacies, as reported in the Prevalence Survey of 2009-2010, and a positivity of 24 percent among 
symptomatic persons referred by private providers described in the national situation analysis of public 
private engagement conducted by CTB Myanmar. It is important to note, however, that this engagement 
of drug sellers is not new. It was implemented through PSI since 2012, with an earlier USAID funding 
cycle, and through a GF grant since 2015 in 50 townships and through the present GF grant in 35 
townships. 
CTB Myanmar trained a total 515 drug sellers from across 15 townships in Bago region in identifying and 
referring TB symptomatic persons and also on the basics of TB. The drug sellers were trained to screen 
all who come to their pharmacy, with the aid of a pamphlet, and then inform field staff the details of 
symptomatic persons. Soon, clients of the drug sellers began to complain about the practice and hence it 
was discontinued and only those who presented with cough were encouraged to be tested. In that 
sense, this was not a screening intervention. Once the drug seller provided information regarding a
symptomatic, the project field staff took full responsibility to guide the patient from the drug store to 
the testing facility and further to the treatment. 
Programmatic challenges included push back from the township medical officers for engaging 
unregistered drug sellers who predominated rural areas where the subgrantee, PSI, had to expand to in 
order to meet the targets given. In those locations, the project referred symptomatic persons to the 
private clinics affiliated with PSI. Key informants reported that some drug sellers feared losing their 
clientele by pointing out possible TB disease. This is also noted in PSI’s report on factors influencing the 
performance of drug sellers in this intervention21. Two drug sellers the ET interviewed had developed 
helpful conversation starters that gently pointed coughers to the need for further investigation, without 
causing fear or offense. Subgrantee staff report that about 40 percent of drug sellers regularly referred 
symptomatic persons to the township facility for testing, and that there was no notable difference in the 
level of involvement among registered and unregistered drug sellers in referring symptomatic persons. 
The intervention resulted in anticipated outcomes in terms of contribution to case finding. 
According to the final report of CTB Myanmar, the intervention contributed to a total of 1,796 cases 
from March 2017 to February 2019 (487 in 2017, 1,109 in 2018 and 200 in the first quarter of 2019), 
which constitute 11 percent of all cases notified from the 15 townships during that period. Key 
informants report that about 20 to 30 percent of trained drug sellers were active during the 
intervention period. The target for symptomatic persons was not met but that for cases was, indicating 
that the positivity rate was underestimated. Key informants report that the intervention cost more than 
what NTP anticipated in terms of field staff positions, but that the subgrantee views these costs as 
essential for the success of the intervention. The ACF cost effectiveness study conducted by CTB 
Myanmar found that the incremental cost per case found through the drug seller intervention was US$ 
103 compared to that of ACF in hard-to-reach areas, at US$ 95. However, the ACF study period was 
prior to the drug seller intervention of CTB Myanmar. 
Figure 5: Yield from the drug seller engagement
KEY CONSTRAINTS IN CARE SEEKING AND TREATMENT ADHERENCE ADDRESSED BY 
CTB MYANMAR
Volunteers and subgrantee staff indicate higher awareness and willingness to seek care 
among women. Volunteers and subgrantee staff of ACF interventions report that the education 
21 USAID, Challenge TB, PSI. A report on factors influencing the performance of drug sellers in accelerated TB case 
finding in Bago Region, Myanmar: a quantitative and qualitative study, June 2019.
Presumptives identified: 8,054
Confirmed cases: 1,796
 Children: 26 %
 Bac positive: 38%
 Positivity: 22.3%
23
sessions that they conduct were mostly attended by women; men do not attend even if they are around. 
Some volunteers conducted their group sessions in the farms where men stay overnight during specific 
seasons, where they would be hard-pressed to not participate. They also report that women with 
symptoms approached them more readily than men did. 
Language and cost were the key barriers for both men and women that CTB Myanmar 
addressed in its target locations. Community members, both male and female as well as volunteers 
report that they find the transportation and CXR cost (when done in a private facility) prohibitive. 
Costs also include staying overnight at the township, as they live too far to return the following day. 
Patients, volunteers and health staff noted that ethnic minorities would not go to public facilities for fear 
of not being able to communicate in the national language. Patients from these areas stated that without 
the volunteer accompanying them, they would not have gone to the facility as early as they did, or not 
gone at all. 
Delays in diagnosis were the result of inappropriate care seeking prior to CTB Myanmar’s 
intervention period but those due to diagnostic errors at facilities reportedly persisted. Six 
of the 16 patients interviewed lived in locations that are two hours’ road travel or more from the 
nearest facility. Ten of the 16 patients had delays ranging from four months to two years. Of these, 
seven had visited several local shops and private hospitals before reaching a public facility where TB was 
diagnosed. The other three had delays in facilities: two were told at the township hospital that the CXR 
was normal, but as symptoms persisted for months, they went to the State/Regional hospital where the 
CXR was repeated and they were diagnosed with TB and transferred back to the township facility. The 
third patient had neck glands treated at the township hospital but when they did not heal for a year, she 
visited the State/Regional hospital and was diagnosed with TB. It must be noted that the sample of 
patients that the ET interacted with were all identified by ACF volunteers, but the ones with delayed 
care seeking were from prior to CTB Myanmar’s ACF intervention but the diagnostic delays were from
before and during the ACF intervention period. 
Misconceptions and the stigma and discrimination they fuel are widely prevalent. The ET 
came across a range of misconceptions regarding the nature of the disease, its spread and treatment: TB 
running in families (reinforced by high levels of transmission within families), cough being a physiological 
process, and weight gain during treatment being pathological. The most prevalent was that having an 
“infectious” disease was a cause for fear and shame. These 
were encountered in all sites visited - from semi-urban 
locations in Bago to rural locations in Sagaing. Those that 
reported that they delayed care-seeking stated that they 
thought the cough was “normal”. The ET encountered several 
aspects of stigmatization of TB in communities: patients being shunned by neighbors or classmates, 
friends and family encouraging patients to stop treatment, and contacts hiding symptoms including 
hemoptysis. In all locations where the interventions were implemented, volunteers and staff of the 
subgrantee teams of CTB Myanmar addressed the misconceptions for patients and their families through 
project activities, but the stigma resulting from them does not appear to have reduced. In light of these 
findings, it is interesting that two key informants at the national level did not perceive stigma to be very 
high for TB.
“One of our key tasks was to help 
people associate cough with TB”
- ACF field staff
The ET also came across reports of several treatment interrupters. Many patients and volunteers report 
that patients on TB treatment had become “weaker”. On further probing, it became clear that 
treatment adherence was poor in these patients. Deaths during treatment also reinforce the idea that 
TB treatment made patients weaker.
CONTRIBUTION TO STRENGTHENING THE TB AND MDR-TB DIAGNOSTIC NETWORK
CTB Myanmar’s investments in the diagnostic network focused on improving services in the three labs 
providing culture and DST and LPA for first and second line anti TB drugs, and on ensuring the quality of 
CXR interpretation, in the context of possible overdiagnosis of TB among children. Its intervention in 
the Xpert network and the sputum transportation system was minimal. 
CTB Myanmar provided technical and financial assistance for critical improvements in the 
two NRLs, in coordination with other partners. Key informant interviews with MOHS, partners 
and CTB Myanmar and a review of CTB Myanmar documents show evidence for the range of CTB 
Myanmar’s investments to obtain ISO 15189 accreditation for the two NRLs: NTRL in Yangon and the 
CMBL in Mandalay. CTB Myanmar facilitated the provision of short-term and ongoing TA and training 
from WHO, the CTB Global team and supra-national laboratories in India and Germany. Through these 
efforts, CTB Myanmar was able to introduce the Lab Quality Management System (LQMS) and secure
buy-in from NRL staff to pursue ISO accreditation. 
TA was also provided to the third biosafety level 3 lab in the country at Taunggyi. CTB Myanmar
facilitated training of staff from all three labs on a range of topics related to biosafety, conducting SL￾LPA, data visualization and overall lab management and advised other donors on technical aspects of the 
new NTRL structure in the same premises in Yangon. CTB Myanmar also reviewed existing SOPs for 
NRLs, revised and added new SOPs and manuals, including a site-specific biosafety manual for NTRL, as 
part of implementing LQMS and aiming for ISO accreditation. CTB Myanmar provided follow up TA in 
collaboration with WHO and the Global Laboratory Initiative to review progress in implementing 
improvements and developed action plans to ensure alignment with WHO updates related to the use of 
SL LPA, the expansion of Xpert sites; the sputum transportation system and the introduction of the 
shorter term regimen (STR) for MDR-TB. As a result of the TA provided for lab improvements, NTP 
began to see CTB Myanmar as a credible technical partner. 
In a strategic shift from providing only TA, beginning in Year 3, CTB Myanmar conducted a range of lab￾related procurements in coordination with other partners. This included biosafety improvements in the 
two NRLs, including environment-friendly incinerators, based on recommendations from TA experts 
and supplies and equipment needed to optimize workflow in the labs, in accordance with LQMS 
standards. CTB Myanmar also supported the calibration and certification of biosafety cabinets in all 
three BSL-3 labs in Year 4, from an international agency. 
CTB Myanmar’s effort to improve services in NRLs was fraught with multiple, intractable 
challenges arising from multiple sources. Key informants from the labs report that training events 
organized by CTB Myanmar were too short to be effective. The international lab advisor that CTB hired 
25
was not housed within NTRL but visited the facility once a week. Key informants from partners and the 
labs deemed this to be insufficient against a perceived need for day-to-day mentoring. Being external to 
the NTRL team, the advisor was not given access lab data, and this limited the support provided. More 
importantly, being part of the NTRL team was seen as necessary to build trust and a working 
relationship. Key informants also reported their perception of a lack of accountability and ownership of 
the LQMS and accreditation process by the NRL teams demonstrated by a commitment to tracking 
quality indicators, and scheduling and conducting routine safety checks. A TA report notes that NTRL 
fell short of providing strategic direction and oversight of the TB diagnostic network of the country but 
was limited to performing a service delivery role. 
Other challenges reported by key informants include mismatches in specifications of equipment 
purchased by CTB Myanmar with the need; SOPs being too complex and not addressing the resource￾constrained settings of the NRLs. In response, CTB Myanmar revised the SOPs and translated them 
from English to Burmese. The new NTRL building has not become fully functional owing to critical 
biosafety and other issues, which have been highlighted in CTB Myanmar’s TA reports and in the JMM 
2019 report. 
Both NRLs face considerable staffing constraints; just over half of all positions are filled and that, mostly 
by seconded staff. NTRL reports administratively to the national health laboratory and technically to the 
NTP and this contributes to the delays in addressing human resource challenges and also limit the voice 
of NTRL in staffing and funding decisions. The NRL teams have been facing an exponential increase in 
workload with the expansion of PMDT services as well as other tasks such as EQA for sputum smear 
microscopy for the entire network of microscopy centers in the country. High turnover of staff (as staff 
move to other labs or to the private sector) is also a significant constraint. CTB Myanmar’s efforts to 
build in-country capacity for calibrating biosafety cabinets is a case in point: it procured equipment 
needed for the calibration of biosafety cabinets and funded the training of biosafety engineers in 
conducting this annual exercise, but these staff moved out after being trained. 
By the end of Year 3, SL-LPA was being routinely conducted in the NRLs and patients were triaged to 
standardized STRs or individualized regimens, and NTRL has largely kept up with the pace of expansion 
of PMDT services. However, EQA for first- and second-line DST and LPA have not been done since 
2016; a partnership is being worked out with a supra-national lab in India for providing this support. 
Accreditation targets were not met; the focus on accreditation may have diverted efforts 
from providing quality services. Progress towards LQMS implementation improved over the years, 
with CMBL making greater progress than NTRL, but both have failed to reach end-of-project targets. In 
Year 5, CTB Myanmar moved from using the GLI-recommended process to the Stepwise Lab 
Improvement Process Towards Accreditation (SLIPTA), based on a TA recommendation. SLIPTA is 
expected to support closer monitoring of progress towards ISO accreditation. 
Table 7: Progress in LQMS implementation
NRL
Achievement, percent End-of-Project
Year 3 Year 4 Year 5 Target, percent
NTRL, Yangon 30 40 45 55-64
CMBL, Mandalay 30 40 66 75-84
Source: Annual Technical Performance Reports, CTB Myanmar
Key informants from partners engaged in supporting MDR-TB diagnosis were of the view that 
accreditation took attention away from delivering quality services and that ISO accreditation is more 
pertinent for commercial entities. They also do not see this pursuit as a judicious use of resources. They 
perceived the need of the hour for the NRLs to be the delivery of timely, quality-assured and traceable 
results across the country’s TB service network. Others stated that accreditation lends credibility and 
weight to lab results. The choice of indicators by CTB Myanmar to track the impact of its support to lab 
services appears to support the former view: these indicators focused on outputs related to 
accreditation (such as the number of SOPs developed and the number of GLI-approved standards met) 
rather than on outcomes related to quality, such as turn-around time. With input from the Mission, CTB 
began tracking the latter set of indicators in Years 4 and 5. Key informants also pointed out the need for 
maintaining the LQMS standards over time, which would require continued upkeep of processes related 
to these standards, and the related funding, which will continue to pose a challenge as NRLs are critically 
dependent on donor funding. Key informants report that the Pharmaceutical Chemistry Lab of FDA, the 
only lab in the country to have achieved and maintained ISO accreditation since 2016, is domestically 
funded and prioritizes on-the-job training of new staff, in order to counter the high turnover among 
staff.
CTB Myanmar provided central-level TA to the sputum transportation system and the 
Xpert network. CTB Myanmar successfully conducted an assessment of the sputum transportation 
system ahead of developing an SOP and disseminating it countrywide in Year 4. It also facilitated the 
procurement of products for transporting biological samples, to assist with a pilot on the use of 
Omnigene sputum transportation. CTB Myanmar worked with other partners to set up the GxAlert 
connectivity system for all Xpert sites, but its efforts to consolidate multiple diagnostic algorithms into 
one using Xpert were not successful until end of the project due to challenges in coordinating between 
NTP and the expert core committee that approves changes to algorithms. 
CTB Myanmar provided high-quality TA for improving the use of CXR for TB diagnosis, 
but it remains underutilized. CTB Myanmar facilitated the development of an SOP for EQA of 
interpretation of CXR findings in Year 3, and refined it further using results from a pilot carried out with 
other partners in Year 4. The pilot found high inter-rater variation and low specificity leading to under 
and over diagnosis, especially in hard-to-reach areas. CTB Myanmar and other partners shared these 
results widely and recommended the expansion of the EQA to 14 facilities by the end of 2019. CTB 
provided technical experts for a national level training on CXR interpretation, with GF funding. The 
presence of ACF work in Chin state provided an opportunity for CTB Myanmar to work with the 
regional TB office to assess the status of CXR use, particularly for diagnosing TB in children and to 
provide training. 
NTP staff at national and regional levels reported that the capacity for CXR interpretation did not go 
beyond the regional level. This was corroborated by statements from volunteers and community 
members about considerable delays in diagnosis due to incorrect interpretation of CXR findings at 
township hospitals, and additional costs incurred by the patients in accessing care at the regional/state 
level facilities. In other hard-to-reach areas the ET heard statements of clinicians being reluctant to use 
CXR, due to low confidence in their own capacity to interpret the findings. 
CONTRIBUTION TO SETTING UP OF ADSM FOR MDR-TB TREATMENT
27
CTB Myanmar was instrumental in establishing the aDSM mechanism. NTP introduced the 
new TB drugs bedaquiline and delamanid in March 2016 and STR in November 2017. A review of 
project documents and interviews with key informants show that CTB Myanmar coordinated and 
facilitated the establishment of aDSM, which is an essential in-country mechanism for quality recording, 
reporting and management of adverse effects of the new drugs and STRs. CTB Myanmar also 
coordinated and facilitated the setting up and regular meeting of a National Core Committee for aDSM 
(NCCA) with representatives from the NTP, FDA, clinical professors, medical superintendents from TB 
specialist hospitals, Médecins sans Frontières (MSF) Holland and WHO. CTB Myanmar also collaborated 
with WHO and MSF to assist the NTP to develop an aDSM manual and job aids in English and Myanmar 
languages, organized a national-level training on the subject, and provided technical and financial support 
for the clinical aspects of aDSM, in the form of equipment, SOPs and training for the use of 
electrocardiogram (ECG) and audiometry to monitor adverse effects of the drugs. 
Key informants from all stakeholders engaged in PMDT services report that as a result of these 
activities, NTP was able to start implementing the core aDSM package for patients on new and 
repurposed drugs, those on STRs and those being treated for extensively drug resistant (XDR) TB. 
NCCA meetings serve as the forum for causality assessment and case reviews. CTB Myanmar channeled 
NTP’s special interest in pharmacovigilance into establishing this system. 
The mechanism has been functioning effectively and has been recognized internationally. A 
review of reports related to the functioning of aDSM found that all the WHO-recommended steps of 
the system were functioning. CTB supported the participation of NTP, FDA and academicians in the 
Asia-Pacific Pharmacovigilance Workshop, where delegates from 10 countries were provided with an 
opportunity to develop and present country plans for aDSM implementation, including next steps and 
roles of each organization in the respective countries. FDA became an associate member of the WHO 
Programme for International Drug Monitoring at the Uppsala Monitoring Center, and NTP submits 
aDSM data to the global database through the NCCA. 
During the period of CTB Myanmar, 668 patients initiated on new drugs and regimens were covered 
under the aDSM system; 260 serious adverse events reported, and causality assessed. Eighteen percent 
of the events reviewed by NCCA were found to be causally related to anti TB drugs. More significantly, 
national policies on DR-TB management have been revised based on these reviews. 
Challenges in continued implementation of aDSM threaten its continued effectiveness. High 
turnover of staff trained in aDSM necessitates rapid upskilling of incoming staff, without which gaps in 
implementation will be inevitable; gaps in clinical oversight and stockout of supplies and maintenance of 
equipment related to monitoring side effects have been reported. The lack of a designated full-time staff 
member at FDA for aDSM also constrains routine monitoring of implementation. All activities related to 
aDSM are funded by donors, and tasks related to reporting are also carried out presently by staff of 
technical partners. 
CONCLUSIONS
 CTB Myanmar successfully designed and implemented ACF, reaching nearly half of all people living 
across hard-to-reach areas, but inordinate delays in getting it started resulted in a short implementation 
period. The ACF models implemented by the four subgrantees had important differences, but all of 
them include the essential elements for successful case finding. The ACF model successfully contributed 
to case finding, and these cases may not have sought care at appropriate facilities without facilitation 
from the intervention. However, as the trend of case finding was high in some locations when the 
intervention stopped, pools of undiagnosed cases are likely persisting in those locations, leading to high 
transmission levels. 
The intervention among DR-TB patients in Yangon contributed to an increased attention to the need 
for CI among MDR-TB patients. It did not however contribute meaningfully to addressing the MDR-TB 
crisis in Yangon, due to severe time limitations as well as formidable challenges in implementation. The 
low yield of DR-TB cases from this intervention, along with a relatively high yield of DS-TB cases 
warrant further investigation. The drug seller intervention of CTB Myanmar had a smaller reach than 
other similar interventions, and its contribution to case finding was along expected lines, based on global 
experience. All of these interventions contributed to CTB Myanmar’s goal of finding 5,300 additional 
cases, and also provided considerable learning for future use. 
CTB Myanmar helped overcome language and cost barriers for both men and women in hard-to-reach 
areas, which were key constraints to seeking care. Erroneous diagnosis contributed to delays in 
diagnosis among some patients, before and during ACF implementation. Stigma and discrimination are 
widely prevalent, fueled by multiple misconceptions and these impact care seeking as well as treatment 
adherence among women, men and children. There were no specific constraints for women in seeking 
care for TB. 
Investments in NRLs are among the largest from CTB Myanmar. The goal of obtaining accreditation 
helped CTB provide focused attention to improvements in NTRL, but the approach appears to have 
been a distraction from providing quality services in the face of expanding PMDT services. Systemic 
deficiencies slowed down progress along LQMS indicators. CTB Myanmar’s technical and financial 
support has been critical to the improvements in the use of CXR as a diagnostic tool. aDSM is a 
fundamental practice in MDR-TB patient management and indicates the ability of the system to detect 
and manage them. This has clearly been one of CTB Myanmar’s success stories and testifies to the 
investment made in collaboration and coordination to get this off the ground and ensure that it is 
sustained. The technical and advocacy skills of the MDR-TB Advisor contributed to the successful 
rollout of STRs and in setting up of aDSM.
EVALUATION QUESTION 2: TO WHAT EXTENT HAS CTB’S TECHNICAL ASSISTANCE TO 
NTP AT DIFFERENT LEVELS ADVANCED TB PREVENTION AND CONTROL IN BURMA IN 
LINE WITH CTB GLOBAL-LEVEL OBJECTIVES, AND CTB/BURMA’S PROJECT OBJECTIVES, 
AND PROMOTED SUSTAINABILITY?
FINDINGS
This section presents findings related to the national-level investments of CTB Myanmar in the form 
of TA and capacity building and their continuation beyond CTB Myanmar’s lifetime. Each the four 
objectives of CTB Myanmar listed earlier, and the activities related to them contributed to several of the 
global objectives and sub-objectives of CTB, listed below: 
Objective 1. Improved Access
Sub-objective 1. Enabling environment
29
Sub-objective 2. Comprehensive, high quality diagnostics
Sub-objective 3. Patient-centered care and treatment
Objective 2. Prevention
Sub-objective 4. Targeted screening for active TB
Sub-objective 5. Infection control
Objective 3. Strengthened TB Platforms
Sub-objective 7. Political commitment and leadership
Sub-objective 8. Comprehensive partnerships and informed community involvement
Sub-objective 9. Drug and commodity management systems
Sub-objective 10. Quality data, surveillance and M&E
Sub-objective 11. Human resource development
EFFECTIVENESS AND RELEVANCE OF TECHNICAL ASSISTANCE AND CAPACITY 
BUILDING SUPPORT
CTB Myanmar was successful in providing technical and financial support for the 
development of strategy documents and the Global Fund Concept Note. CTB Myanmar was a 
key contributor in the development, publication and dissemination of NSP (2016- ‘20) and its 
operational plan, the National Monitoring and Evaluation Plan for TB Control (2016- ‘20) and the 
National TB Spending Assessment (2011- ‘14). This was evidenced by findings from review of CTB 
Myanmar documents, the NSP document and perspectives of key informants. CTB Myanmar utilized the 
WHO planning and budgeting tool and the services of a health economist for the latter. These 
documents guided the country’s TB activities for the said period. CTB Myanmar used and had to 
reprioritize its activities to meet this requirement. CTB Myanmar conducted a financial gap analysis to 
determine available domestic and international funding for TB control and hired a consultant to write 
the GF Concept Note and address comments of the Technical Review Panel, in consultation with the TB 
Technical Strategy Group (TB-TSG). Key informants noted that the nature of the funding mechanism of 
CTB Myanmar provided the agility to move in rapidly and effectively fill this need, as well as the 
willingness and flexibility of the CTB Myanmar team to undertake major reprogramming.
CTB Myanmar provided successful TA for a range of TB-related themes but use of the TA 
products continues to be variable. In response to concerns of diagnostic challenges and possible 
overdiagnosis of primary TB in children (aged 0-14 years), CTB Myanmar provided TA to conduct an 
extensive assessment of the status of diagnosis of childhood TB and used its findings and 
recommendations to lead the development of a guideline, communication material and SOPs for the 
management of childhood TB. CTB Myanmar also worked alongside WHO to complement the GF
grant’s training activities. CTB Myanmar combined its TA for childhood TB with that for improving CXR 
interpretation during the assessment phase and in subsequent training events, in Chin state. The 
contribution of childhood TB to overall cases notified reduced from 25 percent in 2015 to 19 percent in 
201822, ostensibly the result of improved awareness and capacity among healthcare providers in 
22 CTB Myanmar Final Project Report, 2015-19.
interpreting CXR findings. However, as noted in the JMM 2019 report, and by key informants from the 
national program and partners, implementation of the guidelines is sub-optimal as it involves clinical 
providers who are outside the purview of NTP, particularly the use of sputum examination for older 
children and gastric aspirates for younger ones. This TA complemented the technical and financial 
support that CTB Myanmar provided for CXR interpretation, discussed under EQ 1.
The proportion of childhood cases in Chin state continues to be high (42 percent in 2018). CTB 
Myanmar subgrantee staff in the state report large-scale migration of adults outside the state, resulting in 
a skewed demographic that comprises mostly children and elderly people. This finding warrants rigorous 
assessment for the magnitude of the issue, as the high proportion of childhood TB cases in the state 
could very well be due to this distortion in the denominator that is not accounted for in the reporting of 
cases. 
TPT for eligible child contacts (under 5 years of age) of TB patients is an essential component in 
management of childhood TB, clearly articulated in the guidelines, but the JMM 2019 report notes that 
the implementation of this standard of care is nearly nonexistent, due to the difficulties in engaging 
clinicians who are outside the purview of NTP. There is no data on TPT coverage in the most recent 
annual report of NTP.
CTB Myanmar designed and conducted a comprehensive cost effectiveness evaluation of ACF activities
with TA from CTB Global and FHI 360 headquarters. The evaluation included ACF efforts by all 
partners from 2013 to 2016. As referred to earlier, the study assessed the incremental cost 
effectiveness of each ACF model, in the form of additional cost per case, and also identified 
programmatic opportunities to improve ACF efforts. The ET noted that the study assumed the drug 
seller intervention implemented by PSI in Bago region to be a screening one, while in reality there was 
no screening but only linking of symptomatic persons with project staff; hence the additional cost per 
case could have been overestimated for this intervention. Findings from the study showed all the models 
to be effective and cost effective, while the community-based ACF intervention (such as the one carried 
out in hard-to-reach areas by CTB Myanmar) have the lowest incremental cost per additional case 
found. The study recommended approaches be tailored to suit specific needs of the township. Findings 
from the study have been used in deliberations on ACF implementation models for the next cycle of 
interventions in the Global Fund and A2H grants. 
CTB Myanmar also supported the development of guidelines for MDR-TB treatment that key informants 
report is used effectively. TA provided by CTB Myanmar for aDSM for MDR-TB management was also 
highly successful in setting up the system and continues to be implemented after the end of the project, 
albeit in the same, limited scale. Key informants noted that these have been implemented well due to 
the robust technical support and strong working relationships of the MDR-TB Advisor seconded to 
Yangon region. Additionally, PMDT teams comprise mostly of seconded staff, and hence the technical 
capacity built in PMDT is not necessarily that of NTP’s.
Other TA provided by CTB Myanmar met with limited success. As a first for the country, CTB 
Myanmar worked with other partners to develop guidelines for mandatory notification of TB cases by 
private providers and trained over 1,000 private medical practitioners in Yangon, which is considered as 
the highest priority region for mandatory notification. CTB Myanmar reports and key informants noted 
that CTB Myanmar provided this TA due to the priority MOHS accorded to this area and had to 
31
discontinue the development of an electronic recording and reporting system for private providers to 
enable the notification process as NTP wanted to explore other options for reporting. 
CTB supported several TA missions on TBIC, revised and updated the TBIC guidelines, developed 
training material and conducted a national level training led by an international expert and advised GF 
and 3MDG grants on TBIC-related infrastructure in hospitals. CTB Myanmar also did a joint assessment 
of TBIC in facilities across six regions along with other partners, to advise on reprogramming GF funds 
towards TBIC activities in these facilities and to inform the country-specific FAST strategy, a focused 
approach to curtail the spread of TB in congregate settings. As part of rolling out FAST, CTB Myanmar
trained staff of four hospitals and provided TBIC related equipment to seven public hospitals. A key 
informant reported that compliance with TBIC guidelines in public hospitals was found to be poor 
during a GF grant audit done during Year 4 of CTB Myanmar. Project reports note that sustaining 
commitment and changes in hospital processes such as fast tracking the identification, separation and 
investigation of symptomatic persons in facilities is a challenge especially in high-volume hospitals 
without continual follow up and support. CTB Myanmar also provided technical and financial support for 
the development of an SOP for CI with clear linkages to TPT for child contacts, but its level of 
implementation is not known. This is again due to the need for engaging providers and departments 
other than NTP. 
Some TA and capacity building initiatives planned by CTB Myanmar could not be carried 
out as they did not receive NTP approval or were delayed to the extent that the project ran out of 
time or because they involved collaboration with other departments within MOHS. These include a 
situational analysis of CI, assessment of TB burden among healthcare workers, joint supervision visits 
and review of recording and reporting tools to assess TB HIV collaborative efforts. TA 
recommendations from CTB Myanmar on changes related to the present diagnostic algorithm have not 
been implemented due to challenges in coordinating the effort between the NTP and the national expert 
core committee that reviews and approves diagnostic and treatment protocol. 
ADOPTION, CONTINUATION OR SCALE UP OF MODELS AND TOOLS INTRODUCED BY 
CTB MYANMAR
The models developed and/or implemented by CTB Myanmar to improve case finding 
continue under other grants, through continued engagement of CTB Myanmar and 
USAID; CTB Myanmar’s ACF evaluation provided the needed evidence. GF and A2H grants 
have taken up ACF in all the 22 townships in hard-to-reach areas where CTB Myanmar implemented the 
intervention, and two of the four subgrantees of CTB Myanmar continue in the GF/A2H grants. CTB 
handed over details of activities, volunteers and SCCs to the local health system, from where they were 
taken up by implementers of the GF and A2H grants. Findings from the ACF evaluation were discussed 
extensively at TBTSG meetings. The group also facilitated discussions related to the taking over of the 
ACF interventions by the new grant programs – a discussion that was initiated by CTB Myanmar along 
with a proposed budget and activity plan.
GF and A2H grants continue the ACF intervention with modifications that have important 
programmatic implications. CTB Myanmar supported the costs of transporting sputum deposited in 
the SCCs and also travel costs for volunteers for accompanying presumptive cases to the facility for
testing, based on fixed rates. This system of reimbursement, along with the challenges in coordinating 
the collection of the samples, led to most volunteers opting for accompanying patients for testing. GF 
and A2H grants have utilized this lesson in developing a common package of incentives. However, the 
level of effort under the GF/A2H grants appears to be much lower than that in CTB Myanmar, with only 
a third of volunteers re-deployed.
Volunteers in the areas where their numbers have been reduced reported that they are concerned and 
discouraged about covering the large area that they understand has now been allotted to them. They 
were of the view that they would be required to maintain the same level of effort in the expanded area. 
“We can’t spend all day in this work”, they said, indicating that they were not clear on what was 
expected of them in the GF/A2H grants. Subgrantee teams of CTB Myanmar that also implement the GF 
and A2H grants report that the frequency and intensity of training and on-site supervision are lower 
than that provided in CTB Myanmar. 
The MDR-TB and drug seller interventions also continue with modifications. The GF and 
A2H grants and the USAID Essential Health Services Project implemented by Jhpiego have taken over 
and expanded the drug seller intervention of CTB Myanmar in Bago as well as in Yangon and other sites. 
The latter two grants are of a short duration, and findings from the ACF cost effectiveness evaluation 
gave further impetus to continue the intervention under the GF grant. 
CI for index patients with DR-TB in Yangon region now continues with support from the GF grant at a 
larger geographic scale. However, the new program cycle has deployed a new set of field staff rather 
than utilizing the ones trained during CTB Myanmar’s intervention, ostensibly due to the long-time lapse 
between the two cycles. 
CTB Myanmar’s models for case finding have several elements that contribute to 
sustainability but dependence on donor funded activities persists. Several elements in the ACF 
intervention of CTB Myanmar were designed to sustain appropriate careseeking in communities through 
its activities to build awareness and address misconceptions through the network of volunteers. 
Volunteers who were engaged by CTB Myanmar in ACF but not included in the GF and A2H grants 
continue to encourage symptomatic persons to get tested and follow up with patients for their 
treatment adherence. One volunteer that the ET interacted with stated that she accompanies 
symptomatic persons to the facility, if someone bears the travel costs, and if she has the time. Thus, 
support for careseeking continues to be a need and the costs incurred in supporting careseeking are a 
critical element to sustain this process. CTB Myanmar documents report that drug sellers are motivated 
mainly by frequent visits from project staff; the incentive they get for referring symptomatic persons is 
“not much” but they are not likely to continue to do the work without it. The drug sellers that the ET 
interviewed stated that they are happy to refer symptomatic persons, but they are only used to linking 
the symptomatic person with project staff and they hadn’t yet met the project staff in the current GF 
and A2H grants. With a few exceptions, township and BHS staff that the ET interacted with appreciated 
the value added by CTB Myanmar interventions during their period of implementation and were keen 
that the same level of effort be restored through the current GF and A2H grants. 
The ACF strategy document of CTB Myanmar states the need for avoiding parallel structures, and this 
was the endeavor of the ACF intervention in hard-to-reach areas but not so in the CI intervention for 
DR-TB patients in Yangon. The ACF strategy also states that the model was designed to keep costs, 
especially patient-support costs to a level that can be taken on by other donors at the end of CTB. Key 
informants from a range of stakeholders noted that these initiatives, as with other donor-funded 
initiatives in TB and other programs in the country, are fully dependent on external funding, and that
33
sustainability of initiatives in the country tends to be viewed in terms of continuing implementation with 
other donors, and not being funded through domestic sources.
ACF models developed and/or implemented by CTB Myanmar have certain elements that 
are heavily project-dependent, likely due to its emphasis on reaching case finding targets.
Project staff in the ACF interventions conveyed results back to the patient/volunteer/SCC, and those in 
the drug seller intervention personally took over every symptomatic person from the point when they 
receive the information from the drug seller. The CI intervention for DR-TB patients in Yangon was 
structured in a manner that is completely parallel to the existing public health system (of township TB 
staff and BHS staff). Key informants from subgrantees noted that they were required to meet the targets 
of symptomatic persons and confirmed cases, even when the geographic scope of their intervention was 
reduced due to unforeseen reasons. Thus, the overall goal of CTB Myanmar (to find and notify 5,300 
more cases) seems to have driven the design and implementation of these models alongside the 
intention of learning and testing what works. Key informants from other partners engaged in TB care 
emphasized that learning implementation models was a key strength of USAID grants, and hence, the 
overall emphasis of CTB Myanmar should have been on learning rather than on finding a certain number 
of cases. It is not known if the new program cycle has included these elements (as they are still in the 
training and deployment phase). 
Tools and systems developed by CTB Myanmar continue to be used and expanded to 
varying extents. The aDSM system including the NCCA and SOPs for using ECG and audiometry 
continue to function with donor support, with no expansion beyond what was included in CTB 
Myanmar. GF grants continue to train health staff using guidelines for TBIC, CI and CXR interpretation, 
but the EQA for CXR, recommended by CTB Myanmar, has not been established yet. 
CONCLUSIONS
CTB Myanmar’s support for NSP 2016-’20 and the GF concept note development ensured that TB 
prevention and control in Burma had a strategic reference point, guidance and direction and that 
standards of care were aligned with international standards. These are in line with CTB Global 
objectives as well as with the country level objectives that seek to meet the gaps outlined in the NSP. 
This task also demonstrated the agility of the CTB Myanmar funding mechanism and of the team. 
CTB Myanmar provided high-quality TA for development of guidelines, SOPs operational plans and 
training manuals are informed of the country’s context and reflect current international guidance. These 
strategic investments have built NTP capacity and some of them continue to impact interventions 
beyond CTB Myanmar’s lifetime, being the foundation for ongoing support by other partners. However, 
guidelines and recommendations related to childhood TB management, CI, TBIC and CXR 
interpretation that require buy-in and ongoing coordination with actors outside NTP (such as clinicians 
in hospitals and the national expert core committee) have not been widely implemented. In other areas, 
such as mandatory notification by private providers, TA from CTB Myanmar could not be brought to its 
logical conclusion due to the lack of a clear strategic direction from NTP, and the limited time available 
to develop and implement the guideline. Thus, the impact of CTB Myanmar’s TA has been limited by 
systemic challenges. 
The ACF cost effectiveness evaluation conducted by CTB Myanmar, along with the coordinating 
function of TBTSG and the exit strategies of CTB Myanmar contributed to the continuation of all the 
case finding models developed and/or implemented by CTB Myanmar through new funding mechanisms: 
ACF in hard-to-reach areas, drug seller engagement and CI for DR-TB patients in Yangon. However, the 
reduction in geographic area and the intensity of effort in the GF and A2H grants (relative to that in 
CTB Myanmar) has not been managed well by the current grant projects as seen in the lack of 
understanding of ACF volunteers about the downscaling of their roles. It is also likely to slow the 
momentum that began during CTB Myanmar.
Continued implementation of ACF, CI and drug seller interventions is fully dependent on donor funding, 
to the extent that sustainability of interventions is viewed in their ability to be taken up by subsequent 
funding cycles. Certain elements in these models as implemented by CTB Myanmar make them 
inherently unsustainable, and this is likely due to the emphasis of CTB Myanmar on meeting case finding 
targets. 
EVALUATION QUESTION 3: WHAT GAPS AND OPPORTUNITIES EXIST FOR FURTHER 
USAID INVESTMENT IN THE PRIVATE SECTOR AND COMMUNITY PROGRAMMING? 
FINDINGS
This section presents gaps in current programming and opportunities that are aligned with 
USAID’s global vision for TB control. It also presents a preliminary assessment of the additional value 
that can be expected from two specific areas of investment.
GAPS IN CURRENT PROGRAMMING THAT CAN BENEFIT FROM USAID INVESTMENT
Scaling back of ACF under GF and A2H grants runs the risk of losing the momentum built 
by CTB Myanmar and the opportunity to confirm a decline in the pool of undiagnosed 
cases. With the exception of Chin state, other places have 
seen a reduction in the number of volunteers to a third of the 
size in CTB Myanmar. The catchment area of the re-deployed 
volunteers has also been increased to correspond to the 
reduction in the number of volunteers, but with no increase in 
the level of effort expected from volunteers. This implies a 
reduced overall effort in terms of fewer home visits and 
education sessions. As noted under Findings of EQ 1, the trend 
of case notification in some hard-to-reach locations was 
increasing when CTB Myanmar ended, and hence the size of 
the pool of undiagnosed cases (including new, incident cases) is not known. For this to be known, it will 
be important for ACF to continue it with the same intensity until the trends begins to decline. The 
Prevalence Survey (2017-’18) report also notes that lower yield of cases while case efforts are 
maintained/accelerated could point to cutting of transmission, but we won’t know if we reduced case 
detection efforts at this stage. Key informants from a range of partners expressed the need to continue 
the pace of case finding in these hard-to-reach townships.
The ET found a community in a hard-to-reach township close to a motorable road where several 
families living within a radius of a few hundred meters had patients currently on treatment or have 
“There are only 8 volunteers under the GF 
grant in the place of 27 under CTB. Each 
of them is expected to cover up to 18 
villages. The GF grant team should have 
done a situational analysis before deciding 
to scale down.”
-Head of facility in a hard-to-reach 
township
35
recently completed treatment. The ET also found two families where nearly all members had had TB 
over the past 5-7 years. 
Stigma continues to hamper care seeking and treatment adherence, and is poorly 
understood, along with mechanisms to address it. As noted under EQ 1, misconceptions 
regarding TB continue to fuel stigma in all locations that the ET visited – hard-to-reach areas as well as 
urban poor settlements in Bago and Yangon regions and there have been no efforts to gain in-depth 
understanding of the phenomenon. 
The ET found no evidence of any in-depth work undertaken to 
characterize stigma, particularly its impact on the various 
marginalized groups and potential mechanisms to address it. 
The ET also noted that the CYC campaign which was initiated 
during an earlier USAID program cycle and continued by CTB 
Myanmar, reached schools and congregant settings in Yangon 
in collaboration with departments of education and transport, and had cough etiquette as its key 
message. In the light of the specific misconceptions noted earlier, particularly the fear of having an 
“infectious” disease, this message is likely to reinforce the same fear which appears to be driving the 
stigma in the locations visited by the ET. While there is no evidence to link the two, the pervasiveness 
of the misconceptions that the ET encountered warrant the consideration of a possible link. While there 
is need to strengthen non-pharmaceutical interventions, to contain transmission, the strongest evidence 
for achieving that is from timely initiation of treatment.
Key informants of partner organizations and NTP noted the lack of attention to TB in the public 
discourse and in the media, and the related lack of awareness as one of the reasons for the unchecked 
spread of misconceptions. They also noted the lack of donor interest in the areas of improving 
awareness. The findings of in this evaluation also indicate the need for a coordinated multi-sectoral 
response to address it but this requires further exploring and validating through a better understanding 
of the nature and origins of the misconceptions that drive the stigma. 
There has been little characterization of the MDR-TB situation in Yangon and exploration 
of the effectiveness of implementation models. While the high burden of MDR-TB in Yangon has 
been recognized since 2013, and studies have shown potential sub-locations with higher risk for DR TB 
among previously treated patients23, there have been little further assessment of the contours of the 
situation in terms of patients’ demographics and social characteristics. There is also the need to assess 
current intervention models, including the CI among MDR-TB patients carried out by CTB Myanmar. 
NTP is in need of robust TA, and USAID mechanisms are best positioned to provide it. Key 
informants from all partner organizations working in TB noted the need for robust external TA to NTP 
in a range of areas, such as expanding quality assured diagnostic services along with sputum 
transportation and MDR-TB services in Yangon, especially in developing, testing and evaluating 
operational models and new approaches for expanding such services. Continued TA will also be 
required for the uptake of new guidance on TB care and control as they become available. In particular,
CTB Myanmar’s final report notes that while its TA was instrumental in supporting the initiation of STR 
23 Tun, Thanda & Nyunt, Wint et al (2016). Drug-resistant tuberculosis among previously treated patients in 
Yangon, Myanmar. International Journal of Mycobacteriology. 5. 10.1016/j.ijmyco.2016.06.004.
“We need to raise the profile of TB, not 
just on World TB Day, but all through the 
year”
- Senior NTP official
for MDR-TB patients, ongoing TA will be required as WHO guidelines shift to promote even better 
regimens in the near future.
Key informants also emphasized that TA is the strength and “specialty” of USAID, owing to the relative 
flexibility that USAID grants have in bringing in high-quality international TA as was done by CTB 
Myanmar and the USAID grants that preceded it. 
Serious challenges in human resources and inter-departmental coordination limit the 
utilization of TA in implementation. As noted under Findings related to EQ 2 above, reports of 
the prevailing serious deficiencies in staffing at all levels of NTP and the health system were widespread, 
along with significant challenges in coordination between NTP and other departments within MOHS, 
particularly DOMS and the national expert core committee. Most available staff are seconded staff under 
the GF grant, which plans to reduce these numbers from 2020. 
Guidelines and SOPs developed by CTB Myanmar incorporate 
current WHO guidance and reflect evidence-based practices 
from other contexts, but they are yet to be rolled out for want 
of such coordination between departments. A retrospective 
analysis of routine program data from 2007 to 2014 found poorer contribution of public hospitals to TB 
case finding and poorer treatment outcomes compared to private hospitals over the same period24. 
Despite these sobering findings related to TB diagnosis and treatment in public hospitals, there has been 
very little engagement of public hospitals in CTB Myanmar, both for FAST and for CI, ostensibly due to 
the challenges in dealing with services that are outside the purview of NTP. 
OPPORTUNITIES FOR FUTURE INVESTMENT
The new NSP includes engagement of migrant populations working in mines in hard-to￾reach townships. Key informant interviews and document reviews show that there has been no 
systematic effort in CTB Myanmar or other partners or NTP to reach these migrant populations. Key 
informants from regions and states transient populations and “simply disappear” when they receive a 
diagnosis of TB. These workers are not included in the official population of the townships but 
constitute a sizeable number. It is not clear to what extent they were represented in the recent 
prevalence survey. Patients interviewed by the ET who work in mines reported the presence of a range 
of misconceptions related to TB among their co-workers, owing to which they delay care seeking, and 
interrupt treatment. Partners also noted that the new NSP incorporates partnership with mining 
corporations in order to reach these vulnerable populations. 
MOHS is keen on pursuing mandatory notification and will require technical and financial 
support from partners. Key informants noted that the guidelines for this activity has been received 
well and that the plans to implement it will require a better understanding of ways to engage GPs, 
especially in the area of reporting, which requires further simplifying. CTB Myanmar intended to do the 
latter but did not complete it owing to time constraints. GPs will need to be continually engaged using 
models that have worked in similar contexts, and these need to be scale up beyond Yangon. 
24 Nwe et al. Engagement of public and private facilities in tuberculosis care in Myanmar: contributions and trends 
over an eight-year period. Infectious Diseases of Poverty (2017) 6:123 DOI 10.1186/s40249-017-0337-8.
“We cannot overburden health staff any 
further. One more brick on their shoulders, 
and their backs will break.”
- Head of a partner organization
37
MOHS is more open now than before to collaborate with EHOs. Case finding and case holding 
are challenges in ethnic minority areas. As noted under EQ 1, although the overall prevalence in the 
states has dropped, it is likely that these areas hold pockets of high transmission. Implementers of the 
GF grant have now begun discussions with NTP for setting up diagnostic facilities within areas that are 
served by EHOs. As the JMM 2019 report also notes, this is a more sustainable arrangement than ACF. 
However, key informants from partners noted the need for expanding this collaboration to include 
treatment facilities in these areas, with partner organizations and donor agencies facilitating training and 
supervision of EHO staff by NTP. 
ADDITIONAL CASE FINDING: A PRELIMINARY ASSESSMENT
Scaling ACF interventions back to the level of effort supported by CTB Myanmar will lead 
to the detection of an estimated 712 additional cases per year in the 22 townships. Assuming 
that high transmission persists in 11 out of the 22 townships that CTB Myanmar reached, which are 
categorized as hard and very hard-to-reach, and assuming that the median number of cases found 
through ACF and PCF during 2018 (the only full year of ACF implementation) continues, the number of 
cases that can be found through ACF and through the combined effort of ACF and PCF can be 
estimated as follows:
• Total population of the 11 townships: 792,335, or 36 percent of the total population of the 22 
townships
• Total number of cases notified during 2018 from 22 townships through ACF: 1,978
• Estimated median cases notified during 2018 from the 11 selected townships through ACF: 
1,978*36% = 712
• Total cases notified during 2018 from 22 townships, ACF and PCF combined: 5,099
• Estimated total cases notified during 2018 from the 11 selected townships through ACF and PCF 
combined: 5,099*36 percent = 1,835
Thus, restoring the level of effort to that found during CTB Myanmar in 11 of the 22 townships is 
expected to lead to the notification of an additional 712 cases through ACF alone, and a total of 1,835 
cases over one year. 
Supporting notification by the GPs trained by CTB Myanmar will result in the detection of 
an estimated 1,923 cases over a year. A study carried out in an urban location in India from 2015 
to 2017 to engage private GPs and specialists to identify and refer symptomatic persons for testing at 
public health facilities found about half of them to be actively referring symptomatic persons25. The study 
found a normal distribution of referrals by the physicians. About half of all the referrals were confirmed 
to have TB. 
25Ananthakrishnan R, Richardson MD, van den Hof S, et al. Successfully engaging private providers to improve 
diagnosis, notification, and treatment of TB and drug-resistant TB: the EQUIP public-private model in Chennai, 
India. Glob Health Sci Pract. 2019;7(1):41-53. https://doi.org/10.9745/GHSP-D-18-00318.
The median number of symptomatic persons they referred over a two-year period is given in Table 8 
below. Projecting these findings to Yangon, re-engaging the 1,043 GPs that CTB Myanmar trained in 
mandatory notification, training them further on reporting electronically and continued engagement will 
lead to an estimated 522 of them referring symptomatic persons at the same median rate as found in the 
study, as provided in Table 8. 
Table 8: Distribution of cases found by GPs in the study and its projection for Yangon
Study in urban site, India Projection for Yangon
# referrals 
(range)
# referrals 
(median) % GPs
# GPs trained by 
CTB Myanmar
that actively 
refer
# estimated 
referrals
1–5 3 62.6 326 978
6–10 8 14.5 76 608
11–30 20.5 13.7 71 1,456
31–50 40.5 6.2 32 1,296
51–70 60.5 0.9 5 303
71–100 85.5 0.9 5 428
100-120 100 1.3 7 700
Totals 100 522 5,768
Such an effort is expected to lead to the referring of an estimated 5,768 referrals, of which 2,883 are 
expected to be confirmed cases, over a 1.5-year period. The annualized number of confirmed cases 
would be 1,923. Given the total population of Yangon is 7 million, this will translate into an additional 
CNR of 27.8 per 100,000 population.
CONCLUSIONS
In the light of evidence suggestive of active transmission currently or at least until recently, in certain 
pockets of hard-to-reach townships, scaling back of ACF under GF and A2H grants runs the risk of 
losing the momentum built by CTB Myanmar and the opportunity to confirm a decline in the pool of 
undiagnosed cases. Thus, the scale back in ACF at this juncture is a clear programmatic gap. 
The biggest gap, arguably, is in the understanding of stigma and its role in driving delays in care seeking 
and interruptions in treatment. While stigma may not be as prevalent as for HIV, there is evidence that 
it continues to be a formidable barrier to care seeking for cough and adhering to treatment. What is 
more, the key message of CYC seems to run counter to the efforts at in the hard-to-reach areas and 
Yangon to address the fear of a contagious disease and seems to fuel the fear further. This warrants a 
re-examination of the rationale and impact of the campaign in the light of findings from assessments of 
stigma and discrimination. 
Another critical gap is in understanding the epidemiology of MDR-TB in Yangon as well as other 
locations, including the size and nature of the problem, transmission mechanisms and assess the 
effectiveness of innovative models of care. 
39
The need for high-quality TA to NTP and the role of USAID in facilitating the provision of is well 
recognized and documented but systemic issues related to human resources in NTP and the wider 
health system, and coordination between DOPH and DOMS, constrain the utilization of TA in 
improving service delivery, and possibly missing a considerable number of cases in these high-volume 
facilities. The JMM 2019 report notes an improvement in the extent of collaboration since March 2016, 
following restructuring of MOHS, but much remains to be done, especially at the central level where 
major activities involving policy making, planning, management and budgeting take place, the two 
departments have been kept distinct from each other. 
There is need to explore the extent of rollout of the SOPs and guidelines developed by CTB Myanmar, 
within these constraints, but also continue providing TA at the central level to enable the uptake of new 
guidance on the full range of thematic areas. 
There has been no effort in CTB projects or by partners or NTP to reach migrant populations, but this 
is envisioned in the new NSP, and therefore presents an opportunity for USAID to work with partners 
in developing viable models to intervene in this vulnerable population. Facilitating the establishment of 
diagnostic and treatment facilities including training and supervision through coordination between 
EHOs and NTP is another opportunity to reach very hard-to-reach areas with possible high 
transmission. 
Preliminary estimations show that scaling ACF interventions back to the level of effort supported by 
CTB Myanmar will lead to the detection of an estimated 712 additional cases. Although this number is 
low, the vulnerable nature of the population justifies this effort. Supporting notification by the GPs 
trained by CTB Myanmar will result in the detection of an estimated 1,923 cases over a year and an 
additional CNR of 27.8 per 100,000 population. 
RECOMMENDATIONS
CTB Myanmar has successfully established NTP capacity through high-quality TA and developed and 
evaluated models for improved case finding in strategic locations. The need to protect and further 
advance these gains from the past five years and the enduring issue of missed cases necessitate further 
support for TB care and control in the country. The following are priority investments for a future 
mechanism of USAID support to the NTP:
1. Explore ways to expand GF and A2H investments in ACF (preferably as part of the next GF 
grant writing cycle) to resume and maintain the pace of ACF that CTB Myanmar had built, 
building on the CTB model and approach. Work with these two grants and TB teams at 
region/state and township levels to develop a nuanced approach that is able to identify pockets 
of high transmission and responds with a combination of ACF, sputum transportation and 
mobile team activities, until well after a decline in case finding is documented from these areas. 
As CTB reached about half of the estimated population living in all hard-to-reach areas of the 
country, consider expanding the ACF intervention also to the remaining areas that were not 
included under CTB Myanmar, especially those with ethnic minority groups and conflict affected 
areas.
2. Consider support to the expansion of services to migrants working in mining areas, in line with 
what is envisioned in the new NSP. Develop interventions and broker relationships between 
mining companies and the local township health offices, to help operationalize strategies 
outlined in the new NSP.
3. Continue support for the rollout of mandatory notification of GPs, by supporting the 
establishment of a user-friendly reporting mechanism through robust TA and supporting training 
and supervision of GPs beginning in Yangon, and with those that CTB Myanmar trained. 
Simplified reporting mechanisms would be critical to secure and maintain the involvement of 
GPs
4. Lead a joint effort to bring about greater collaboration with DOMS to help reach public and 
private hospitals with implementing the guidelines and SOPs developed with the support of CTB 
Myanmar, particularly in the areas of TBIC, CI, CXR use and interpretation and TPT for children
5. Provide TA to further assess and characterize the MDR-TB problem in Yangon including its 
transmission pathways to inform current and future interventions. Examine reasons for the low 
yield in the CI intervention among DR TB patients in Yangon under CTB. 
• Consider including retrospective CI for all DR TB patients in Yangon under the new 
program cycle, especially for those contacts that did not receive Xpert testing during 
the early part of the CI intervention of CTB Myanmar.
6. Fund/build capacity for research that investigates stigma and discrimination related to TB, 
adapting existing tools for and social behavior change interventions for addressing this in a way 
that empowers local communities. One option is to re-program current USAID investments to 
include building the capacity of national NGOs to apply for (and subsequently implement) the 
Stop TB Partnership call for proposals for “Challenge Facility for Civil Society 2019” released in 
December 2019. This call includes activities for conducting stigma assessments.
7. Review/redesign key messages of the CYC campaign in the light of findings from stigma 
assessment. 
8. Collaborate with MOHS and partners to advocate with the central, region/state governments to 
mount a high-level, multisectoral response engaging education, labor, transport, women’s 
development and others to address misconceptions related to the disease and their sources, 
through high-profile counter-messaging.
9. Continue support to expanding aDSM and ensuring continued functioning of the NCCA: ensure 
allocation of funds by FDA for its membership at the WHO monitoring center, and for 
recruiting fulltime staff for ADSM, who will ensure the continued functioning of equipment and 
provision of supplies for clinical monitoring and management. 
10. Ensure that future program cycles focus on developing and testing models, documenting 
processes, and evaluating the effectiveness, rather than focusing on gap-filling. 
• An important starting point would be to develop objective statements and performance 
metrics related to model development 
41
• Include operations research, specifically to test the models to be developed and 
implemented
• Ensure that the models have inbuilt linkages to the existing primary healthcare system 
• Learning from the CTB Myanmar experience, build in sufficient time for approvals at all 
stages in model development and implementation.
ANNEXES
ANNEX I: EVALUATION STATEMENT OF WORK
SECTION C – STATEMENT OF WORK
C.1 BACKGROUND
Description of Activity to be evaluated:
Activity/Project Name Activity/Project Name Challenge TB-Burma
Implementer FHI360
Cooperative Agreement/Contract # AID-OAA-A-14-00029
Total Estimated Ceiling of the Evaluated 
Project/Activity (TEC)
$15,410,000
Life of Project/Activity 04/15/2015-9/30/2019
Active Geographic Regions National level, and Challenge TB Burma townships in Yangon, 
Mandalay, Sagaing, Kayah, Chin and Bago
Development Objective(s) (DOs) Mission DO: Health Status Improved
CTB project objectives
Objective 1. Increase TB Case Finding
Objective 2. Improve Diagnostic Capacity
Objective 3. Strengthened National TB Program
Objective 4: Support National MDR-TB Response
USAID Office USAID/Burma Office of Public Health
C.2.1 EVALUATION QUESTIONS
The illustrative evaluation questions below are closely linked to the CTB activity’s development 
hypothesis depicted in the Results Framework. The evaluation methodologies responding to the key 
questions below (as reflected in Section C.2.2) will be developed by the contractor in the evaluation 
design and work plan after execution of the contract.
1. What were CTB’s key contributions to TB control in Myanmar and to what extent has 
CTB/Burma addressed key TB issues and gaps?
● To what extent did CTB contribute to the overall national results in reducing the TB 
burden in Myanmar?
● What are the most important TB gaps and issues that CTB focused on in its 
geographical areas, and how well did the selection of interventions and geographical 
areas align with need?
● What gender constraints/gaps were faced by women with TB/MDR, especially in hard to 
reach remote area and how were they addressed by CTB?
● What were the key contributions of CTB in the following technical areas?
43
i. Increasing case notification and active case finding
ii. Addressing the MDR-TB crisis in Yangon
iii. Strengthening TB and MDR-TB diagnostic network
iv. Assisting NTP in introducing active drug safety monitoring and management 
(aDSM) for MDR-TB cases
v. Engagement with private sector providers, drug sellers, and other non-public 
organizations in TB case finding.
2. To what extent has CTB’s technical assistance to the national TB program at different levels 
advanced TB prevention and control in Burma in line with CTB Global-level objectives, and 
CTB/Burma’s project objectives, and promoted sustainability?
● What technical assistance and capacity-building support provided by CTB was most 
effective, and what activities were less effective?
● To what extent were interventions, models and tools introduced by CTB adopted and 
scaled up with other resources (domestic or other donor)? What are examples of tools 
or approaches that were continued or scaled up?
● What efforts did CTB undertake to ensure broader uptake of its approaches? What 
evidence exists of uptake?
3. What gaps and opportunities exist for further USAID investment in the private sector and 
community programming?
● How many missing TB cases could be identified through further scale-up of private 
sector engagement (including, but not limited to, mandatory reporting, diagnostics, and 
drug seller networks) and community-based efforts, considering current programmatic 
coverage and the 2018-19 TB Prevalence Survey findings?
● What lessons and best practices from CTB private sector interventions can be applied 
to future efforts to control TB and efforts to build country capacity?
C.2.2 EVALUATION DESIGN AND METHODOLOGY
The evaluation team is expected to assess the progress made in achieving CTB-Burma’s intermediate 
objectives Objective 1: Increase TB Case Finding; Objective 2: Improve Diagnostic Capacity; Objective 3: 
Strengthened National TB Program; and Objective 4: Support National MDR-TB Response.
This evaluation anticipates using a mixed methodology with data sources, including but not limited to 
CTB Myanmar work plans, trip reports, deliverables, research surveys, studies, evaluation reports, and 
similar project-related documents; project M&E; evaluation reports and project progress reports; data 
on coverage of CTB project activities; data from field observation, key informant interviews; national 
statistics on TB indicators as well as information from 2018 national TB prevalence survey report, which 
is expected to be released in June 2019 and will be made available to the evaluation team.
Questions Suggested Data 
Sources
Suggested Data 
Collection Methods
Suggested Data 
Analysis Methods
1. What were CTB’s 
key contributions to 
TB control in 
Myanmar and to what 
extent has CTB/Burma 
addressed key TB 
issues and gaps?
NTP NSP (2016-2021), 
CTB work plans and 
reports, other reports 
of related TB activities 
such as Active Case 
Finding (ACF) Review, 
CTB Hard to reach 
activities evaluation, 
Operational Research 
of PSI pharmacy 
channel review, 2018 
TB Prevalence survey 
preliminary results and 
available data from 
Prevalence survey.
-- Qualitative (key 
informant interview 
and/or focus group 
discussions etc. as 
relevant), 
-- Desk review, 
secondary analysis as 
necessary.
-- Phone interviews 
with health providers 
located outside of 
Yangon.
Interview with 
subrecipients of 
FHI360; WHO 
country office, PRs of 
the Global Fund Grant, 
Assess to Health Fund.
Interview with NTP 
and NTRL staff in the 
country.
To be proposed by the 
contractor
2. To what extent has 
CTB’s technical 
assistance to the 
national TB program at 
different levels 
advanced TB 
prevention and control 
in Burma in line with 
Global CTB and 
CTB/Burma project 
objectives, and 
promoted 
sustainability?
NTP NSP (2016-2021), 
CTB work plans and 
reports, other reports 
of related TB activities 
such as ACF Review, 
CTB Hard to reach 
activities evaluation, 
Operational Research 
of PSI pharmacy 
channel review, 2018 
TB Prevalence survey 
preliminary result and 
available data from 
Prevalence survey, 
Gender Analysis 
reports from CTB and 
other sources (donors, 
CSOs, DHS)
-- Qualitative (key 
informant interview 
and/or focus group 
discussions etc. as 
relevant),
-- Desk review, 
secondary analysis as 
necessary. 
-- Phone interviews 
with health providers 
located outside of 
Yangon.
Interview with 
subrecipients of 
FHI360; WHO 
country office, PRs of 
the Global Fund Grant, 
Assess to Health Fund.
--Interview with NTP
and NTRL staff in the
country.
-- Case study of a
sample of women with 
TB/MDR-TB.
To be proposed by
the contractor
45
3. What gaps and 
opportunities exist for 
further USAID 
investment in the 
private sector and 
community 
programming?
NTP NSP (2016-2021), 
CTB work plans and 
reports, other reports 
of related TB activities 
such as ACF Review, 
CTB Hard to reach 
activities evaluation, 
Operational Research 
of PSI pharmacy 
channel review, 2018 
TB Prevalence survey 
preliminary result and 
available data from 
Prevalence survey; 
program coverage data 
from Global Fund and 
Access to Health Fund 
(UNOPS); literature 
on private health 
sector in Myanmar; 
national community 
health policy.
-- Qualitative (key 
informant interview 
and/or focus group 
discussions etc. as 
relevant),
--Desk review, 
secondary analysis as 
necessary.
--Phone interviews 
with private sector 
stakeholders, donors 
and partners involved 
with private sector and 
community efforts; 
WHO country office, 
PRs of the Global Fund 
Grant, Assess to 
Health Fund. 
--Interview with NTP 
staff
To be proposed by the 
contractor
C.3 EVALUATION TEAM COMPOSITION AND QUALIFICATIONS
USAID does not have any specific qualifications for the evaluation team, but the contractor shall provide 
a team that has any necessary qualifications to successfully achieve the objectives of this task order.
ANNEX II: DETAILED DESCRIPTION OF EVALUATION DESIGN 
AND METHODS
DOCUMENTS REVIEWED
SAMPLING PROCEDURE FOR PRIMARY DATA COLLECTION
The evaluation team applied multistage purposive sampling to select regions/states, followed by 
townships within the selected regions/states and facilities within the selected townships. These served as 
sites for primary data collection in the form of KIIs, FGDs, patient interviews and observations. 
The key criteria used for the selection of regions/states within CTB Myanmar’s geographic reach were 
a) the feasibility of conducting the site visit within the available time, b) the security situation and c) the 
presence of a special intervention. Kayah and Chin have had comparable interventions for hard to reach 
areas, and therefore one of them was selected, based on accessibility. Criteria for the selection of 
townships reached by CTB Myanmar within selected regions/states was the performance of the 
region/state as indicated by the case notification rate (CNR) per 100,000 population in the NTP Annual 
Report of 2016. The proposed townships are those with both high and low CNR. Selection of large 
facilities was based on specific interventions carried out in these facilities. These parameters are a trade￾off between what is feasible within the available time and ensuring that the entire range of CTB 
Myanmar’s interventions are included for primary data collection. Table 9 below lists the proposed sites 
and the criteria used for their selection.
Table 9: Selection of sites and criteria used
Re Region/State District/Town
ship
Criteria for selection of 
Region/Township Facility
Additional 
criteria for 
selection of 
Facility
Yangon Thaketa 
Township
Strengthening DR TB 
contact investigation
NRL strengthening
Outreach workers
Mingalardon TB HIV 
hospital
NRL
ACF implemented
Mandalay NRL strengthening NRL
Sagaing Mawlaik 
Township
CNR <= 148*
Hard-to-reach area 
strategy implemented
Kalay General Hospital ACF implemented
Kayah Demosoe 
Township
CNR <=148
Hard-to-reach area 
strategy implemented
Loikaw General Hospital ACF implemented
Bago Waw Township CNR <= 220 
Intervention with drug 
sellers implemented
Drug sellers
*From NTP Annual Report, 201
47
ANNEX III: EVALUATION DESIGN MATRIX
Evaluation 
question Main themes/sub questions (provided by USAID)
Potential 
questions/in
quiry
Data collection 
method(s)
Data source/type of 
respondent
Data analysis 
method
EQ 1: What 
were CTB’s 
key 
contribution
s to TB 
control in 
Myanmar 
and to what 
extent has 
CTB/Burma 
addressed 
key TB 
issues and 
gaps?
1.a. To what extent 
did CTB contribute 
to the overall 
national results in 
reducing the TB 
burden in Myanmar?
What do NTP and CTB 
documentation/data tell regarding 
CTB’s contribution to changes in 
national TB burden? What 
assumptions underpin this 
estimation and how 
reasonable/valid is each? 
Document review, secondary data 
analysis; KII
CTB design documents and 
APA reports; CTB/NTP, NTP 
quarterly and annual data;
CTB core team, 
USAID/Burma, NTP team, 
GF/WHO/JICA
Thematic analysis of 
qualitative data using 
pre-determined and 
emerging subthemes; 
triangulate from 
multiple sources; 
analysis of secondary 
quantitative data
1.b. What are the 
most important TB 
gaps and issues that 
CTB focused on in 
its geographic areas, 
and how well did the 
selection of 
interventions and 
geographic areas 
align with need?
(What was the rationale behind the 
selection of project geographies)
What methods did CTB use to 
identify the key gaps and issues by 
selected geographic area, and how 
adequate and relevant were they? 
What were the issues and gaps 
identified?
What considerations went into 
CTB’s prioritization of identified 
issues?
To what extent did CTB follow 
through with maintaining these 
priorities, through its period of 
implementation? Where it did not, 
what were the reasons?
In hindsight, how effective was 
prioritizing these needs and gaps 
(over others) in reducing the TB 
burden? How effective was the 
level of effort (LOE) given to 
addressing each gap/issue?
What else could have been done?
Document review; secondary data 
analysis; KII 
CTB design documents and 
APA reports; CTB/NTP 
quarterly and annual data;
CTB core team, 
USAID/Burma, NTP 
team, GF/WHO/JICA
Thematic analysis of 
qualitative data using 
pre-determined and 
emerging subthemes; 
triangulate from 
multiple sources; 
analysis of secondary 
quantitative data
1.c. What gender 
constraints and gaps 
were faced by 
women with 
TB/MDR-TB, 
especially in hard to 
Delays in diagnosis: duration, 
reasons, treatment shopping, 
provider attitudes, specific 
constraints faced in family, 
community and health facilities.
Document review; KII; interviews 
with men and women with TB and 
MDR-TB 
CTB design documents and 
APA reports; CTB/NTP 
quarterly and annual data;
CTB-MMA staff; MDR-TB staff 
at facilities;
Thematic analysis of 
qualitative data using 
pre-determined and 
emerging subthemes; 
triangulate from 
multiple sources; 
reach remote area 
and how were they 
addressed by CTB?
Delays in obtaining results, and in 
initiating treatment; specific 
constraints faced in family, 
community and health facilities
Challenges with continuing with 
treatment, follow-up visits –
family, financial, community and 
other
How are all of the above similar 
and dissimilar between men and 
women?
What interventions within CTB 
design and implementation 
address each of the above issues, 
and to what extent did they 
alleviate the issue?
KII with TB and MDR-TB 
patients (men and women) 
analysis of secondary 
quantitative data. 
Mapping of the care 
seeking process for 
each patient, 
reflecting the patient 
pathway, including 
timelines and easily 
recognizable 
notations for key 
events.
1.d. What were the 
key contributions of 
CTB in the following 
technical areas?
i. Increasing case 
notification and 
active case finding 
(overlap with v)
ii. Addressing the 
MDR-TB crisis in 
Yangon
iii. Strengthening TB 
and MDR-TB 
diagnostic network
iv. Assisting NTP in 
introducing active 
drug safety 
monitoring and 
management (aDSM) 
for MDR-TB cases 
(overlap with EQ 2)
v. Engagement with 
private sector 
providers, drug 
sellers, and other 
non-public 
organizations in TB 
case finding
For all technical areas:
What specific gaps in [technical 
area] existed at the start of CTB, 
and how did CTB prioritize the 
ones to address?
To what extent were CTB 
activities responsive to these gaps 
and how well were they 
implemented – success, 
challenges, lessons?
What contributions [to technical 
area] can be considered key, and 
why? 
For ACF:
What was CTB’s contribution to 
the design of NTP’s ACF 
strategies?
What ACF strategies did CTB 
directly support and how 
successful were they? What 
challenges were faced and 
addressed and what lessons were 
learned?
Document review; analysis of 
secondary data; KII; direct 
observations in in labs, FGDs
CTB design document and 
APA reports; CTB/NTP, NTP 
quarterly and annual data;
NTP staff, USAID/Burma staff, 
CTB core team, PGK, WVM, 
MMAA, Union, PSI, MHA staff, 
Region/state, district and 
township TB and lab staff, 
public facility TB staff, private 
clinics, drug sellers, volunteers 
of partner organizations; 
observations in labs; aDSM 
related aggregate data
Thematic analysis, 
using pre-determined 
and emerging 
subthemes; triangulate 
data from multiple 
sources; anecdotal 
evidence, where 
available
49
EQ2: To 
what extent 
has CTB’s 
technical 
assistance to 
the national 
TB program 
at different 
levels 
advanced TB 
prevention 
and control 
in Burma in 
line with 
CTB Global￾level 
objectives, 
and 
CTB/Burma’
s project 
objectives, 
and 
promoted 
sustainability
?
2.a. What technical 
assistance (TA) and 
capacity-building 
(CB) support 
provided by CTB 
was most effective, 
and what activities 
were less effective? 
How were TA needs assessed and 
TA sourced?
What criteria should be used for 
assessing the effectiveness of TA 
and CB?
What TA and CB were most 
effective and why?
Which TA and CB were not as 
effective and why?
Document review; analysis of 
secondary data KII
CTB Myanmar design 
document and APA reports; 
NTP reports; CTB/NTP, NTP 
quarterly and annual data;
NTP staff, USAID/Burma staff, 
CTB core team, 
GF/WHO/JICA staff
Develop criteria for 
assessing effectiveness 
of TA; Thematic 
analysis, including pre￾determined and 
emerging subthemes; 
triangulate data from 
multiple sources; 
anecdotal evidence, 
where available; 
analysis by CTB 
objective
2.b. To what extent 
were interventions 
(especially those 
related to hard to 
reach areas and the 
MDR-TB response in 
Yangon), models and 
tools introduced by 
CTB adopted, 
continued and scaled 
up with other 
resources (domestic 
or another donor)? 
What are examples 
of tools or 
approaches that 
were continued or 
scaled up?
What are the tools, models and 
interventions introduced by CTB?
What parameters should be used 
to assess the extent of their scale 
up?
Based on these parameters, what 
is the extent of scale up of each?
What factors enabled or hindered 
the successful scale up (or lack 
thereof) of each?
Which of the interventions of 
CTB for hard to reach areas have 
been taken up by NTP/partners? 
To what extent?
Which aspects of the MDR-TB 
response in Yangon have been 
taken up by NTP/Partners? To 
what extent?
Document review; KII CTB APA narrative and 
special reports including OR 
publications; NTP reports, 
guidance documents and 
SOPs; NTP staff, 
USAID/Burma staff, CTB core 
team, GF/WHO/JICA staff
An inventory of tools, 
models and 
interventions; 
Thematic analysis, 
including pre￾determined and 
emerging subthemes; 
triangulate data from 
multiple sources; 
anecdotal evidence, 
where available; 
analysis by CTB 
objective
2.c. What efforts did 
CTB undertake to 
ensure broader 
uptake of its 
approaches? What 
evidence exists of 
uptake?
To what extent were the above 
successes and scale up due to the 
efforts of CTB?
Thematic analysis, 
including pre￾determined and 
emerging subthemes; 
triangulate data from 
multiple sources; 
anecdotal evidence, 
where available; 
analysis by CTB 
objective
EQ3. What 
gaps and 
opportunitie
3.a Considering 
current 
programmatic 
How many estimated cases are 
being missed (by type of TB) and 
Document and literature review; 
KII; brainstorming
Literature including but not 
limited to the Finding Missed 
Cases guide from KNCV, in 
Developing/document
ing assumptions and 
estimating potential 
s exist for 
further 
USAID 
investment 
in the 
private 
sector and 
community 
programmin
g?
coverage and the 
findings of the TB 
Prevalence Survey of 
2018-19, how might 
a scaled-up approach 
to engaging the 
private sector and 
community-based 
efforts affect case 
finding efforts, 
(namely in areas of 
high prevalence, high 
loss to follow up or 
poor reporting)?
how many can be found through 
the various interventions
country documents and earlier 
estimations; evidence from 
published and grey literature; 
CTB/NTP/DHIS2 data
cases found; 
triangulate data from 
multiple sources
3.b. What lessons 
and best practices 
from CTB private 
sector interventions 
can be applied to 
future efforts to 
control TB and 
efforts to build 
country capacity?
What are the lessons and best 
practices in these areas, what 
qualifies them as such, what scale 
are they currently at, and what 
future scale up is feasible
Document review, secondary data 
analysis, KII
CTB APA narratives and 
special reports, 
CTB staff and partners, WHO, 
NTP, USAID
Triangulate data from 
multiple sources; 
develop a matrix of 
lessons and best 
practices
51
ANNEX IV: DATA COLLECTION TOOLS
INFORMED CONSENT FORMS
Key informant interview consent form – individual KIIs (Total 55, except heads of facilities)
Title: Challenge TB Burma Review
Review team: Beulah Jayakumar, Soe Myat Naing 
Sponsor: USAID/Burma
Introduction
Hello, my name is----------. I am part of a team from Social Impact (SI) currently conducting an independent 
review of Challenge TB (CTB). CTB is a USAID-funded activity which supports the National TB Program 
of the Ministry of Health and Sports, Govt of Myanmar, to improve the quality of and access to TB services 
and is implemented by FHI 360 and its partners. This review is intended to identify lessons and to obtain 
opinions about how new activities can better support the NTP in the future. 
I would like to request you to read (or have read to you) this Consent Form. I want to be sure that you 
understand the purpose of this review and your responsibilities before you decide if you want to be in it 
or not. Please ask me to explain any words or information that you may not understand.
Information about the interview
If you agree to this interview, we are going to ask you and other key informants about the interventions 
of CTB that you may know of, and your perceptions of their results. We will also ask you about the 
successes and challenges CTB encountered and how future activities could be improved to achieve more 
significant results. We plan to conduct interviews like this with about 60 respondents across the locations 
where CTB works. The information you share will be kept confidential and will not be disclosed to anyone 
in a way that can be linked to you. Although we will share the opinions you give us in a report to other 
entities outside of the review team, all your answers will be treated with confidentiality and will be 
anonymized in the report. This interview will take about 1 to 2 hours. I will not write down your name 
on this form and your name will not appear when we analyze the data or in the report, so that the answers 
you give cannot be linked to you. You have the right to tell whomever you choose about this interview.
If you decide not to participate
You are free to decide if you want to participate in this interview or not. You have the right to refuse to 
answer any questions, stop the interview or leave at any time. Your relationship with CTB or other 
organizations that provide similar services or will use the review results will not be affected at all. 
Possible risks
We do not anticipate any significant risks to you or your organization/facility because of your participation 
in this interview. However, this interview will result in time away from your regular activities. 
Possible benefits
The results of this review are expected to inform USAID’s planning and decision-making, assess the results 
of CTB and improve strategies for more significant public health impact in the future. By participating in 
this interview, you will, however, get no immediate and direct personal benefit.
Confidentiality
We will protect information about you and your involvement in this review to the best of our ability. Only this team 
will have access to your name and the name of your facility. We will not record your name in our data collection 
tools or notes, but only in this consent form, which we will keep separately from the notes and transcripts of this 
interview. We will also not indicate your name in the any of the reports we prepare, but only your official 
designation and place of work in an annex to the report. We will not tell your peers, supervisors, or friends about 
your participation or about the information you give. After we remove your personal information, the data we 
collect may be combined with other study participants’ data and findings included in the report. 
If you have a question about the review
If you have any questions about this review, you may contact Marissa Germain via email address 
mgermain@socialimpact.com. You can also contact the Social Impact Internal Review Board. The 
contact person is Leslie Greene Hodel; phone number +1-703-465-1884; email address: 
irb@socialimpact.com.
VOLUNTARY AGREEMENT
I certify that the nature and purpose, the potential benefits, and the possible risks associated with 
participating in this interview have been explained to me.
__________________________________________________ ____________________
 Signature of participant Date
53
KEY INFORMANT INTERVIEW CONSENT FORM – HEADS OF FACILITIES (Total 6)
Title: Challenge TB Burma Review
Review team: Beulah Jayakumar, Soe Myat Naing 
Sponsor: USAID/Burma
Introduction
Hello, my name is----------. I am part of a team from Social Impact (SI) currently conducting an independent 
review of Challenge TB (CTB). CTB is a USAID-funded activity which supports the National TB Program 
of the Ministry of Health and Sports, Govt of Myanmar, to improve the quality of and access to TB services 
and is implemented by FHI 360 and its partners. This review is intended to identify lessons and to obtain 
opinions about how new activities can better support the NTP in the future. 
I would like to request you to read (or have read to you) this Consent Form. I want to be sure that you 
understand the purpose of this review and your responsibilities before you decide if you want to be in it 
or not. Please ask me to explain any words or information that you may not understand.
Information about the interview
If you agree to this interview, we are going to ask you and other key informants about the interventions 
of CTB that you may know of, and your perceptions of their results. We will also ask you about the 
successes and challenges CTB encountered and how future activities could be improved to achieve more 
significant results. We plan to conduct interviews like this with about 6 respondents across the locations 
where CTB works. We also seek your consent to interview staff at the TB clinic and the lab in this facility 
and observe the functioning of the lab, in terms of adherence to standards of infection control, functioning 
of equipment and expansion of new diagnostics. The information you share will be kept confidential and 
will not be disclosed to anyone in a way that can be linked to you. Although we will share the opinions 
you give us in a report to other entities outside of the review team, all your answers will be treated with 
confidentiality and will be anonymized in the report. This interview will take about half an hour. I will not 
write down your name on this form and your name will not appear when we analyze the data or in the 
report, so that the answers you give cannot be linked to you. You have the right to tell whomever you 
choose about this interview.
If you decide not to participate
You are free to decide if you and your facility want to participate in this interview or not. You have the 
right to refuse to answer any questions, stop the interview or leave at any time. Your relationship with 
CTB or other organizations that provide similar services or will use the review results will not be affected 
at all. 
Possible risks
We do not anticipate any significant risks to you or your facility because of your participation in this 
interview. However, this interview will result in time away from your regular activities. 
Possible benefits
The results of this review are expected to inform USAID’s planning and decision-making, assess the results 
of CTB and improve strategies for more significant public health impact in the future. By participating in 
this interview, you will, however, get no immediate and direct personal benefit.
Confidentiality
We will protect information about you and your involvement in this review to the best of our ability. Only 
this team will have access to your name and the name of your facility. We will not record your name in 
our data collection tools or notes, but only in this consent form, which we will keep separately from the 
notes and transcripts of this interview. We will also not indicate your name in the any of the reports we 
prepare, but only your official designation and place of work in an annex to the report. We will not tell 
your peers, supervisors, or friends about your participation or about the information you give. After we 
remove your personal information, the data we collect may be combined with other study participants’ 
data and findings included in the report. 
If you have a question about the review
If you have any questions about this review, you may contact Marissa Germain via email address 
mgermain@socialimpact.com. You can also contact the Social Impact Internal Review Board. The 
contact person is Leslie Greene Hodel; phone number +1-703-465-1884; email address: 
irb@socialimpact.com.
VOLUNTARY AGREEMENT
I certify that the nature and purpose, the potential benefits, and the possible risks associated with 
participating in this interview have been explained to me.
__________________________________________________ ____________________
 Signature of participant Date
55
PATIENT INTERVIEW CONSENT FORM (Total 16 patients)
Title: Challenge TB Burma Review
Review team: Beulah Jayakumar, Soe Myat Naing 
Sponsor: USAID/Burma
Hello, my name is----------. I am part of a team from Social Impact (SI) currently conducting an independent 
review of Challenge TB (CTB). CTB is a USAID-funded activity which supports the National TB Program 
of the Ministry of Health and Sports, Govt of Myanmar, to improve the quality of and access to TB services 
and is implemented by FHI 360 and its partners. This review is intended to identify lessons and to obtain 
opinions about how new activities can better support the NTP in the future. 
I would like to read to you this Consent Form. The volunteer (name) informed us that s/he 
supports/supported you in your treatment and hence your opinions regarding the services you obtained 
is important to us. I want to be sure that you understand the purpose of this review and your 
responsibilities before you decide if you want to be in it or not. Please ask me to explain any words or 
information that you may not understand.
Information about the interview
If you agree to be part of this interview, we are going to ask you and other patients about your perceptions 
and experiences related to your TB care, things that help or hamper your ability to get care, and your 
ideas about how your care could be improved We plan to conduct interviews like this with about 16 
respondents across the locations where CTB works. The information you share will be kept confidential 
and will not be disclosed to anyone in a way that can be linked to you. Although we will share the opinions 
you give us in a report to other entities outside of the review team, all your answers will be treated with 
confidentiality and will be anonymized in the report. I will not write down your name on this form and 
your name will not appear in when we analyze the data or in the report, we write so that the answers 
you give cannot be linked to you. You have the right to tell whomever you choose about this review. This 
interview will take about 1 hour.
If you decide not to participate 
You are free to decide if you want to participate in this interview or not. Your relationship with CTB or 
other organizations that provide similar services or will use the review results will not be affected at all. 
Your decision to participate or not to participate in this interview will in no way affect the services you 
currently receive or the support you receive from CTB. You have the right to refuse to answer any 
questions, stop the interview or leave at any time. 
Possible risks
We do not anticipate any significant risks to you because of your participation in this interview. However, 
this interview will result in time away from your regular activities. 
Possible benefits
The results of this review are expected to help in the planning and provision of better services for those 
with TB and for the community. By participating in this interview, you will, however, get no immediate 
and direct personal benefit.
Confidentiality
We will protect information about you and your involvement in this review to the best of our ability. We 
will not record your name in our data collection tools or notes or in this consent form, or in the reports 
we prepare, but only your age and gender will be noted for the report. We will not tell your peers,
community members or friends about your participation or about the information you give. After we 
remove your personal information, the data we collect may be combined with other study participants’ 
data and findings included in the report.
If you have a question about the interview
If you have any questions about this review, you may contact Marissa Germain via email address 
mgermain@socialimpact.com. You can also contact the Social Impact Internal Review Board. The 
contact person is Leslie Greene Hodel; phone number +1-703-465-1884; email address: 
irb@socialimpact.com.
VOLUNTARY AGREEMENT
The participant read the consent form (or the form was read to him/her) and gave consent to be 
interviewed. 
__________________________________________________ ____________________
Signature of Interviewer Date
57
INTERVIEW CONSENT FORM FOR GUARDIANS OF MINOR PATIENTS (Total 16 patients –
INCLUDING NONMINORS)
Title: Challenge TB Burma Review
Review team: Beulah Jayakumar, Soe Myat Naing 
Sponsor: USAID/Burma
Hello, my name is----------. I am part of a team from Social Impact (SI) currently conducting an independent 
review of Challenge TB (CTB). CTB is a USAID-funded activity which supports the National TB Program 
of the Ministry of Health and Sports, Govt of Myanmar, to improve the quality of and access to TB services 
and is implemented by FHI 360 and its partners. This review is intended to identify lessons and to obtain 
opinions about how new activities can better support the NTP in the future. 
I would like to read to you this Consent Form. The volunteer (name) informed us that s/he 
supports/supported you in your treatment and hence your opinions regarding the services you obtained 
is important to us. I want to be sure that you understand the purpose of this review and your 
responsibilities before you decide if you want to be in it or not. Please ask me to explain any words or 
information that you may not understand.
Information about the interview
If you agree to be part of this interview, we are going to ask you and other patients about your perceptions 
and experiences related to the TB care your ward received, things that help or hampered your ability to 
get care for your ward and your ideas about how your care could be improved We plan to conduct 
interviews like this with about 16 respondents across the locations where CTB works. The information 
you share will be kept confidential and will not be disclosed to anyone in a way that can be linked to you. 
Although we will share the opinions you give us in a report to other entities outside of the review team, 
all your answers will be treated with confidentiality and will be anonymized in the report. I will not write 
down your name or the name of your ward on this form and your name or that of your ward will not 
appear in when we analyze the data or in the report, we write so that the answers you give cannot be 
linked to you. You have the right to tell whomever you choose about this review. This interview will take 
about 1 hour.
If you decide not to participate 
You are free to decide if you and your ward want to participate in this interview or not. Your relationship 
with CTB or other organizations that provide similar services or will use the review results will not be 
affected at all. Your decision to participate or not to participate in this interview will in no way affect the 
services your ward currently receives or the support you receive from CTB. You have the right to refuse 
to answer any questions, stop the interview or leave at any time. 
Possible risks
We do not anticipate any significant risks to you or your ward because of your participation in this 
interview. However, this interview will result in time away from your regular activities. 
Possible benefits
The results of this review are expected to help in the planning and provision of better services for those 
with TB and for the community. By participating in this interview, you will, however, get no immediate 
and direct personal benefit.
Confidentiality
We will protect information about you and your ward and your involvement in this review to the best of 
our ability. We will not record your name or that of your ward in our data collection tools or notes or 
in this consent form, or in the reports we prepare, but only your ward’s age, gender and official designation 
and place of work in an annex to the report. We will not tell your peers, community members or friends 
about your participation or about the information you give. After we remove your personal information, 
the data we collect may be combined with other study participants’ data and findings included in the 
report.
If you have a question about the interview
If you have any questions about this review, you may contact Marissa Germain via email address 
mgermain@socialimpact.com. You can also contact the Social Impact Internal Review Board. The 
contact person is Leslie Greene Hodel; phone number +1-703-465-1884; email address: 
irb@socialimpact.com.
VOLUNTARY AGREEMENT
The participant read the consent form (or the form was read to him/her) and gave consent to be 
interviewed. 
__________________________________________________ ____________________
Signature of Interviewer Date
59
FOCUS GROUP DISCUSSION - CONSENT FORM (Total 2 FGDs)
Title: Challenge TB Burma Review
Review Team: Beulah Jayakumar, Soe Myat Naing 
Sponsor: USAID/Burma
Hello, my name is----------. I am part of a team from Social Impact (SI) currently conducting an independent 
review of Challenge TB (CTB). CTB is a USAID-funded activity which supports the National TB Program 
of the Ministry of Health and Sports, Govt of Myanmar, to improve the quality of and access to TB services 
and is implemented by FHI 360 and its partners. This review is intended to identify lessons and to obtain 
opinions about how new activities can better support the NTP in the future. 
I would like to request you to read (or have read to you) this Consent Form. I want to be sure that you 
understand the purpose of this review and your responsibilities before you decide if you want to be in it 
or not. Please ask me to explain any words or information that you may not understand.
Information about the discussion
If you agree to be part of this discussion, we are going to ask you and other key informants about the 
interventions of CTB that you may know of, and your perceptions of their results. We will also ask you 
about the successes and challenges CTB encountered and how future activities could be improved to 
achieve more significant results. We plan to conduct discussions like this with about one other group in a 
location where CTB works. The information you share will be kept confidential and will not be disclosed 
to anyone in a way that can be linked to you. Although we will share the opinions you give us in a report 
to other entities outside of the review team, all your answers will be treated with confidentiality and will 
be anonymized in the report. I will not write down your name on this form and your name will not appear 
in when we analyze the data or in the report, we write so that the answers you give cannot be linked to 
you. You have the right to tell whomever you choose about this review. This discussion will take about 1 
to 2 hours. 
If you decide not to participate 
You are free to decide if you want to participate in this discussion or not. You have the right to refuse to 
answer any questions, stop the discussion, or leave at any time. Your relationship with CTB or other 
organizations that provide similar services or will use the review results will not be affected at all. Your 
decision to participate or not to participate in this discussion will in no way affect the services you 
currently receive or provide or the support you receive from CTB. 
Possible risks
We do not anticipate any significant risks to you or your organization/facility because of your participation 
in this discussion. However, this discussion will result in time away from your regular activities. 
Possible benefits
The results of this review are expected to inform USAID’s planning and decision-making, assess the results 
of CTB and improve strategies for more significant public health impact in the future. By participating in 
this discussion, you will, however, get no immediate and direct personal benefit.
Confidentiality
We will protect information about you and your involvement in this review to the best of our ability. We 
will not record your names in our data collection tools or notes, or in this consent form. 
If you have a question about the discussion
If you have any questions about this review, you may contact Marissa Germain via email address 
mgermain@socialimpact.com. You can also contact the Social Impact Internal Review Board. The 
contact person is Leslie Greene Hodel; phone number +1-703-465-1884; email address: 
irb@socialimpact.com.
VOLUNTARY AGREEMENT
The participants read the consent form (or the form was read to them) and gave consent to be part of 
the discussion. 
__________________________________________________ ____________________
Signature of Interviewer Date
61
KEY INFORMANT INTERVIEW – IMPLEMENTING PARTNER, FHI360
Interviewees: Country Director, Technical Director, Regional Directors, M&E Director
Interviewer: ____________________ Designation: _________________________________
Interview date: ________________ Time: __________
Note: Any of the questions below that are addressed by the IP’s initial presentation to the 
evaluation team, will not be repeated in the KII
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1a. To what extent did CTB contribute to the overall national results in reducing the 
TB burden in Myanmar?
1. What do NTP and CTB documentation/data tell regarding CTB’s contribution to changes in 
national TB burden? 
a. What assumptions underpin this estimation and how reasonable/valid is each?
b. Please describe the process by which TB program data (esp. regarding case notification) 
is disaggregated by public/nonpublic. What steps have been taken to assure quality in 
this process?
c. In what ways did CTB contribute to improved data quality – at what levels?
EQ 1b. What are the most important TB gaps and issues that CTB focused on in its 
geographical areas, and how well did the selection of interventions and geographical areas 
align with need?
2. What was the rationale behind the selection of project geographies?
3. What methods did CTB use to identify the key gaps and issues by selected geographic area, and 
how adequate and relevant were they? 
4. What were the issues and gaps identified? What considerations went into CTB’s prioritization of 
identified issues?
5. To what extent did CTB follow through with maintaining these priorities, through its period of 
implementation? 
a. Where it did not, what were the reasons?
6. In hindsight, how effective was prioritizing these needs and gaps (over others) in reducing the 
TB burden? 
a. How effective was the LOE given to addressing each gap/issue? 
b. What else could have been done?
EQ 1d. What were the key contributions of CTB in the following technical areas?
EQ 1di. Improving case notification
7. What specific gaps in existed at the start of CTB in case notification in your area, and how did 
CTB prioritize the gaps it addressed?
8. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
9. What contributions to increasing case finding can be considered key, and why? 
10. What was CTB’s contribution to the design of NTP’s ACF strategies?
11. What ACF strategies did CTB directly support and how successful were they? 
a. What challenges were faced and addressed and what lessons were learned?
EQ 1dii. Addressing the MDR-TB crisis in Yangon
12. What specific gaps in existed at the start of CTB in addressing the MDR-TB crisis in Yangon, and 
how did CTB prioritize the gaps it addressed?
13. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
14. What contributions to addressing this crisis can be considered key, and why? 
EQ 1diii. Strengthening TB and MDR-TB diagnostic network
15. What specific gaps in existed at the start of CTB in the diagnostic network, and how did CTB 
prioritize the gaps it addressed?
16. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
17. What contributions to strengthening the diagnostic network can be considered key, and why? 
EQ 1div. Assisting NTP in introducing active drug safety monitoring and management 
(aDSM) for MDR-TB cases
18. What specific gaps in existed at the start of CTB in aDSM and how did CTB prioritize the gaps 
it addressed?
19. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
20. What contributions to strengthening aDSM can be considered key, and why? 
EQ 1dv. Engagement with private sector providers, drug sellers, and other non-public 
organizations in TB case finding
63
21. What specific gaps in existed at the start of CTB in engaging the private sector, and how did 
CTB prioritize the gaps it addressed?
22. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
23. What contributions to strengthening the private sector engagement can be considered key, and 
why? 
EQ 2. To what extent has CTB’s technical assistance to the national TB program at 
different levels advanced TB prevention and control in Burma in line with CTB Global-level 
objectives, and CTB/Burma’s project objectives, and promoted sustainability?
24. What was the reasoning behind re-organizing CTB Myanmar’s hierarchy of objectives differently 
than CTB Global objectives? What were the benefits and challenges that came from this change?
EQ 2a. What technical assistance and capacity-building support provided by CTB was most 
effective, and what activities were less effective? 
25. How were TA needs assessed and TA sourced?
26. What criteria should be used for assessing the effectiveness of TA and CB?
27. What TA and CB were most effective and why?
28. Which TA and CB were not as effective and why?
EQ 2b. To what extent were interventions, models and tools introduced by CTB adopted 
and scaled up with other resources (domestic or other donor)? What are examples of tools 
or approaches that were continued or scaled up?
29. What are the tools, models and interventions introduced by CTB?
30. What parameters do you use, to assess the extent of their scale up? Based on these parameters, 
what is the extent of scale up of each?
31. What factors enabled or hindered the successful scale up (or lack thereof) of each?
32. In your perception, in what ways did CTB approaches ensure sustainability of the gains made?
33. Which of the interventions of CTB for hard to reach areas have been taken up by 
NTP/partners? To what extent?
34. Which aspects of the MDR-TB response in Yangon have been taken up by NTP/Partners? To 
what extent?
EQ 2c. What efforts did CTB undertake to ensure broader uptake of its approaches? What 
evidence exists of uptake?
1. To what extent were the above successes and scale up due to the efforts of CTB?
EQ 3. What gaps and opportunities exist for further USAID investment in the private 
sector and community programming?
EQ 3b. What lessons and best practices from CTB private sector interventions can be 
applied to future efforts to control TB and efforts to build country capacity?
2. What are the lessons and best practices in these areas, what qualifies them as such, what scale 
are they currently at, and what future scale up is feasible?
3. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
65
KEY INFORMANT INTERVIEW – SUBGRANTEE national/region/state levels
Interviewees: CTB focal persons in each subgrantee: PGK, MHAA, WVM, the Union, PSI
Interviewer: _______________________Designation: ____________________________
Interview date: ________________ Time: __________
Note: Any of the questions below that are addressed by the IP’s initial presentation to the 
evaluation team, will be deleted from this tool
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1b. What are the most important TB gaps and issues that CTB focused on in its 
geographical areas, and how well did the selection of interventions and geographical areas 
align with need?
1. What was the rationale behind the selection of project geographies?
2. What methods did CTB use to identify the key gaps and issues by selected geographic area, and 
how adequate and relevant were they? 
3. What were the issues and gaps identified? What considerations went into CTB’s prioritization of 
identified issues?
4. To what extent did CTB follow through with maintaining these priorities, through its period of 
implementation? 
a. Where it did not, what were the reasons?
5. In hindsight, how effective was prioritizing these needs and gaps (over others) in reducing the 
TB burden? 
a. How effective was the LOE given to addressing each gap/issue? 
b. What else could have been done?
EQ 1d. What were the key contributions of CTB in the following technical areas?
EQ 1di. Increasing case notification and active case finding
6. What specific gaps in existed at the start of CTB in case notification in your area, and how did 
CTB prioritize the gaps it addressed?
7. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
8. What contributions to increasing case finding can be considered key, and why? 
9. What was CTB’s contribution to the design of NTP’s ACF strategies?
10. What ACF strategies did CTB directly support and how successful were they? 
a. What challenges were faced and addressed and what lessons were learned?
EQ 3. What gaps and opportunities exist for further USAID investment in the private 
sector and community programming?
EQ 3b. What lessons and best practices from CTB private sector interventions can be 
applied to future efforts to control TB and efforts to build country capacity?
11. What are the lessons and best practices in these areas, what qualifies them as such, what scale 
are they currently at, and what future scale up is feasible?
12. To what extent were hard to reach area strategies and/or MDR-TB response (in Yangon) taken 
up by NTP/Partners? What is the evidence of that uptake?
13. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
67
KEY INFORMANT INTERVIEW – SUBGRANTEE – MMA (national or region/state levels)
Interviewees: MMA CTB focal person
Interviewer: ________________________ Designation: ____________________________
Interview date: ________________ Time: __________
Note: Any of the questions below that are addressed by the IP’s initial presentation to the 
evaluation team, will be deleted from this tool
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1d. What were the key contributions of CTB in the following technical areas?
EQ 1dii. Addressing the MDR-TB crisis in Yangon
1. What specific gaps in existed at the start of CTB in addressing the MDR-TB crisis in Yangon, and 
how did CTB prioritize the gaps it addressed?
2. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
3. What contributions to addressing this crisis can be considered key, and why? 
EQ 1div. Assisting NTP in introducing active drug safety monitoring and management 
(aDSM) for MDR-TB cases
4. What specific gaps in existed at the start of CTB in aDSM and how did CTB prioritize the gaps 
it addressed?
5. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
6. What contributions to strengthening aDSM can be considered key, and why? 
EQ 3. What gaps and opportunities exist for further USAID investment in the private 
sector and community programming?
EQ 3b. What lessons and best practices from CTB private sector interventions can be 
applied to future efforts to control TB and efforts to build country capacity?
7. What are the lessons and best practices in these areas, what qualifies them as such, what scale 
are they currently at, and what future scale up is feasible?
8. To what extent were hard to reach area strategies and/or MDR-TB response (in Yangon) taken 
up by NTP/Partners? What is the evidence of that uptake?
9. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
KEY INFORMANT INTERVIEW – NTP
Interviewees: NTP Manager
Interviewer: _______________________Designation: ________________________
Interview date: ________________ Time: __________
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1b. What are the most important TB gaps and issues that CTB focused on in its 
geographical areas, and how well did the selection of interventions and geographical areas 
align with need?
1. What was the rationale behind the selection of project geographies?
2. To what extent did CTB follow through with maintaining focus on key issues and gaps, through 
its period of implementation? 
a. Where it did not, what were the reasons?
3. In hindsight, how effective was prioritizing these needs and gaps (over others) in reducing the 
TB burden? 
a. What else could have been done?
EQ 1d. What were the key contributions of CTB in the following technical areas?
EQ 1di. Increasing case notification and active case finding
4. What specific gaps in existed at the start of CTB in case notification, and how did CTB prioritize 
the gaps it addressed?
5. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
6. What contributions to increasing case finding can be considered key, and why? 
7. What was CTB’s contribution to the design of NTP’s ACF strategies?
8. What ACF strategies did CTB directly support and how successful were they? 
a. What challenges were faced and addressed and what lessons were learned?
EQ 1dii. Addressing the MDR-TB crisis in Yangon
9. What specific gaps in existed at the start of CTB in addressing the MDR-TB crisis in Yangon, and 
how did CTB prioritize the gaps to address?
10. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
69
11. What contributions to addressing this crisis can be considered key, and why? 
EQ 1diii. Strengthening TB and MDR-TB diagnostic network
12. What specific gaps in existed at the start of CTB in the diagnostic network, and how did CTB 
prioritize the gaps it addressed?
13. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
14. What contributions to strengthening the diagnostic network can be considered key, and why? 
EQ 1div. Assisting NTP in introducing active drug safety monitoring and management 
(aDSM) for MDR-TB cases
15. What specific gaps in existed at the start of CTB in aDSM and how did CTB prioritize the gaps 
it addressed?
16. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
17. What contributions to strengthening aDSM can be considered key, and why? 
EQ 1dv. Engagement with private sector providers, drug sellers, and other non-public 
organizations in TB case finding
18. What specific gaps in existed at the start of CTB in engaging the private sector, and how did 
CTB prioritize the gaps it addressed?
19. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
20. What contributions to strengthening the private sector engagement can be considered key, and 
why? 
EQ 2. To what extent has CTB’s technical assistance to the national TB program at 
different levels advanced TB prevention and control in Burma in line with CTB Global-level 
objectives, and CTB/Burma’s project objectives, and promoted sustainability?
EQ 2a. What technical assistance and capacity-building support provided by CTB was most 
effective, and what activities were less effective? 
21. How were TA needs assessed and TA sourced?
22. What TA and CB were most effective and why?
23. Which TA and CB were not as effective and why?
EQ 2b. To what extent were interventions, models and tools introduced by CTB adopted 
and scaled up with other resources (domestic or other donor)? What are examples of tools 
or approaches that were continued or scaled up?
24. What factors enabled or hindered the successful scale up (or lack thereof) of each?
a. Discuss this for each model/ tool that has been described and documented by CTB
25. What factors enabled or hindered the successful scale up (or lack thereof) of each?
26. In your perception, in what ways did CTB approaches ensure sustainability of the gains made?
27. Which of the interventions of CTB for hard to reach areas have been taken up by 
NTP/partners? To what extent?
28. Which aspects of the MDR-TB response in Yangon have been taken up by NTP/Partners? To 
what extent?
EQ 2c. What efforts did CTB undertake to ensure broader uptake of its approaches? What 
evidence exists of uptake?
29. To what extent were the above successes and scale up due to the efforts of CTB?
EQ 3. What gaps and opportunities exist for further USAID investment in the private 
sector and community programming?
EQ 3b. What lessons and best practices from CTB private sector interventions can be 
applied to future efforts to control TB and efforts to build country capacity?
30. What are the lessons and best practices in these areas, what qualifies them as such, what scale 
are they currently at, and what future scale up is feasible?
31. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
71
KEY INFORMANT INTERVIEW – Region/State/District/Township TB Unit
Interviewees: TB Unit in charge
Interviewer: ______________________ Designation: __________________________
Interview date: ________________ Time: __________
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1d. What were the key contributions of CTB in the following technical areas?
(Use only those that are applicable to the geographic area)
EQ 1di. Increasing case notification and active case finding
1. What specific gaps in existed at the start of CTB in case notification, and how did CTB prioritize 
the gaps it addressed?
2. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
3. What contributions to increasing case finding can be considered key, and why? 
4. What ACF strategies did CTB directly support and how successful were they? 
a. What challenges were faced and addressed and what lessons were learned?
EQ 1dii. Addressing the MDR-TB crisis in Yangon
5. What specific gaps in existed at the start of CTB in addressing the MDR-TB crisis in Yangon, and 
how did CTB prioritize the gaps to address?
6. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
7. What contributions to addressing this crisis can be considered key, and why? 
EQ 1diii. Strengthening TB and MDR-TB diagnostic network
8. What specific gaps in existed at the start of CTB in the diagnostic network, and how did CTB 
prioritize the gaps it addressed?
9. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
10. What contributions to strengthening the diagnostic network can be considered key, and why? 
EQ 1div. Assisting NTP in introducing active drug safety monitoring and management 
(aDSM) for MDR-TB cases
11. What specific gaps in existed at the start of CTB in aDSM and how did CTB prioritize the gaps 
it addressed?
12. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
13. What contributions to strengthening aDSM can be considered key, and why? 
EQ 1dv. Engagement with private sector providers, drug sellers, and other non-public 
organizations in TB case finding
14. What specific gaps in existed at the start of CTB in engaging the private sector, and how did 
CTB prioritize the gaps it addressed?
15. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
16. What contributions to strengthening the private sector engagement can be considered key, and 
why? 
EQ 3. What gaps and opportunities exist for further USAID investment in the private 
sector and community programming?
EQ 3b. What lessons and best practices from CTB private sector interventions can be 
applied to future efforts to control TB and efforts to build country capacity?
17. What are the lessons and best practices in these areas, what qualifies them as such, what scale 
are they currently at, and what future scale up is feasible?
18. To what extent were hard to reach area strategies and/or MDR-TB response (in Yangon) taken 
up by NTP/Partners? What is the evidence of that uptake?
19. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
73
KEY INFORMANT INTERVIEW – Senior TB Laboratory Supervisor
Interviewees: STLS
Interviewer: __________________________Designation: __________________________
Interview date: ________________ Time: __________
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1d. What were the key contributions of CTB in the following technical areas?
(Use only those that are applicable to the geographic area)
EQ 1di. Increasing case notification and active case finding
1. What specific gaps in existed at the start of CTB in case notification, and how did CTB prioritize 
the gaps it addressed?
2. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
3. What contributions to increasing case finding can be considered key, and why? 
4. What ACF strategies did CTB directly support and how successful were they? 
a. What challenges were faced and addressed and what lessons were learned? 
b. What more can be done for active case finding in your area?
EQ 1dv. Engagement with private sector providers, drug sellers, and other non-public 
organizations in TB case finding
5. What specific gaps in existed at the start of CTB in engaging the private sector, and how did 
CTB prioritize the gaps it addressed?
6. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
7. What contributions to strengthening the private sector engagement can be considered key, and 
why? 
8. What more can be done in your area to involve private providers better?
9. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
KEY INFORMANT INTERVIEW – SCC
Interviewees: SCC staff
Interviewer: __________________________ Designation: __________________________
Interview date: ________________ Time: __________
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1d. What were the key contributions of CTB in the following technical areas?
(Use only those that are applicable to this area)
EQ 1di. Increasing case notification and active case finding
1. What specific gaps in existed at the start of CTB in identifying presumptive and collecting 
samples, and how did CTB prioritize the gaps it addressed?
2. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
3. What contributions to increasing case finding can be considered key, and why? 
4. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
75
KEY INFORMANT INTERVIEW – WHO
Interviewees: TB officer, WHO
Interviewer: ________________________ Designation: ____________________________
Interview date: ________________ Time: __________
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1a. To what extent did CTB contribute to the overall national results in reducing the 
TB burden in Myanmar?
1. What do NTP and CTB documentation/data tell regarding CTB’s contribution to changes in 
national TB burden? 
a. What assumptions underpin this estimation and how reasonable/valid is each?
EQ 1b. What are the most important TB gaps and issues that CTB focused on in its 
geographical areas, and how well did the selection of interventions and geographical areas 
align with need?
2. What was the rationale behind the selection of project geographies?
3. To what extent did CTB follow through with maintaining focus on issues and gaps, through its 
period of implementation? 
a. Where it did not, what were the reasons?
4. In hindsight, how effective was prioritizing these needs and gaps (over others) in reducing the 
TB burden? 
a. What else could have been done?
EQ 1d. What were the key contributions of CTB in the following technical areas?
EQ 1di. Increasing case notification and active case finding
5. What specific gaps in existed at the start of CTB in case notification, and how did CTB prioritize 
the gaps to address?
6. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
7. What contributions to increasing case finding can be considered key, and why? 
8. What was CTB’s contribution to the design of NTP’s ACF strategies?
EQ 1dii. Addressing the MDR-TB crisis in Yangon
9. What specific gaps in existed at the start of CTB in addressing the MDR-TB crisis in Yangon, and 
how did CTB prioritize the gaps to address?
10. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
11. What contributions to addressing this crisis can be considered key, and why? 
EQ 1diii. Strengthening TB and MDR-TB diagnostic network
12. What specific gaps in existed at the start of CTB in the diagnostic network, and how did CTB 
prioritize the gaps to address?
13. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
14. What contributions to strengthening the diagnostic network can be considered key, and why? 
EQ 1div. Assisting NTP in introducing active drug safety monitoring and management 
(aDSM) for MDR-TB cases
15. What specific gaps in existed at the start of CTB in aDSM and how did CTB prioritize the gaps 
to address?
16. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
17. What contributions to strengthening aDSM can be considered key, and why? 
EQ 1dv. Engagement with private sector providers, drug sellers, and other non-public 
organizations in TB case finding
18. What specific gaps in existed at the start of CTB in engaging the private sector, and how did 
CTB prioritize the gaps to address?
19. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
20. What contributions to strengthening the private sector engagement can be considered key, and 
why? 
EQ 2. To what extent has CTB’s technical assistance to the national TB program at 
different levels advanced TB prevention and control in Burma in line with CTB Global-level 
objectives, and CTB/Burma’s project objectives, and promoted sustainability?
77
EQ 2b. To what extent were interventions, models and tools introduced by CTB adopted 
and scaled up with other resources (domestic or other donor)? What are examples of tools 
or approaches that were continued or scaled up?
21. What factors enabled or hindered the successful scale up (or lack thereof) of each?
a. Discuss this for each model/ tool that has been described and documented by CTB
22. To what extent were hard to reach area strategies and/or MDR-TB response (in Yangon) taken 
up by NTP/Partners? What is the evidence of that uptake?
EQ 2c. What efforts did CTB undertake to ensure broader uptake of its approaches? What 
evidence exists of uptake?
23. To what extent were the above successes and scale up due to the efforts of CTB?
EQ 3. What gaps and opportunities exist for further USAID investment in the private 
sector and community programming?
EQ 3a. Considering current programmatic coverage and findings from the TB Prevalence 
Survey of 2018-‘19, how might a scaled-up approach to engaging the private sector and 
community-based activities affect case finding efforts (namely in areas of high prevalence, 
high loss to follow up, or poor reporting)?
24. How many missed cases can be potentially found through scaled up efforts? What does available 
evidence and WHO experience in other contexts tell us?
EQ 3b. What lessons and best practices from CTB private sector interventions can be 
applied to future efforts to control TB and efforts to build country capacity?
25. What are the lessons and best practices in these areas, what qualifies them as such, what scale 
are they currently at, and what future scale up is feasible?
26. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
KEY INFORMANT INTERVIEW – JICA/JATA/UNOPS/Save the Children/Chemonics
Interviewees: TB focal persons at JICA, IOM, MSF, etc.
Interviewer: __________________________ Designation: ___________________________
Interview date: ________________ Time: __________
EQ 1a. To what extent did CTB contribute to the overall national results in reducing the 
TB burden in Myanmar?
1. What do NTP and CTB documentation/data tell regarding CTB’s contribution to changes in 
national TB burden? 
a. What assumptions underpin this estimation and how reasonable/valid is each?
EQ 1b. What are the most important TB gaps and issues that CTB focused on in its 
geographical areas, and how well did the selection of interventions and geographical areas 
align with need?
2. What was the rationale behind the selection of project geographies?
3. To what extent did CTB follow through with maintaining focus on issues and gaps, through its 
period of implementation? 
a. Where it did not, what were the reasons?
4. In hindsight, how effective was prioritizing these needs and gaps (over others) in reducing the 
TB burden? 
a. What else could have been done?
EQ 2. To what extent has CTB’s technical assistance to the national TB program at 
different levels advanced TB prevention and control in Burma in line with CTB Global-level 
objectives, and CTB/Burma’s project objectives, and promoted sustainability?
EQ 2b. To what extent were interventions, models and tools introduced by CTB adopted 
and scaled up with other resources (domestic or other donor)? What are examples of tools 
or approaches that were continued or scaled up?
5. What factors enabled or hindered the successful scale up (or lack thereof) of each?
a. Discuss this for each model/ tool that has been described and documented by CTB
EQ 2c. What efforts did CTB undertake to ensure broader uptake of its approaches? What 
evidence exists of uptake?
6. To what extent were the above successes and scale up due to the efforts of CTB?
EQ 3. What gaps and opportunities exist for further USAID investment in the private 
sector and community programming?
EQ 3a. Considering current programmatic coverage and findings from the TB Prevalence 
Survey of 2018-‘19, how might a scaled-up approach to engaging the private sector and 
79
community-based activities affect case finding efforts (namely in areas of high prevalence, 
high loss to follow up, or poor reporting)?
7. How many missed cases can be potentially found through scaled up efforts? What does available 
evidence and WHO experience in other contexts tell us?
EQ 3b. What lessons and best practices from CTB private sector interventions can be 
applied to future efforts to control TB and efforts to build country capacity?
8. What are the lessons and best practices in these areas, what qualifies them as such, what scale 
are they currently at, and what future scale up is feasible?
9. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
KEY INFORMANT INTERVIEW – USAID/Burma
Interviewees: TB officer/AOR
Interviewer: ________________________ Designation: ____________________________
Interview date: ________________ Time: __________
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1a. To what extent did CTB contribute to the overall national results in reducing the 
TB burden in Myanmar?
1. What do NTP and CTB documentation/data tell regarding CTB’s contribution to changes in 
national TB burden? 
a. What assumptions underpin this estimation and how reasonable/valid is each?
EQ 1b. What are the most important TB gaps and issues that CTB focused on in its 
geographical areas, and how well did the selection of interventions and geographical areas 
align with need?
2. What was the rationale behind the selection of project geographies?
3. What methods did CTB use to identify the key gaps and issues by selected geographic area, and 
how adequate and relevant were they? 
4. What were the issues and gaps identified? What considerations went into CTB’s prioritization of 
identified issues?
5. To what extent did CTB follow through with maintaining these priorities, through its period of 
implementation? 
a. Where it did not, what were the reasons?
6. In hindsight, how effective was prioritizing these needs and gaps (over others) in reducing the 
TB burden? 
a. How effective was the LOE given to addressing each gap/issue? 
b. What else could have been done?
EQ 1d. What were the key contributions of CTB in the following technical areas?
EQ 1di. Increasing case notification and active case finding
7. What specific gaps in existed at the start of CTB in case notification, and how did CTB prioritize 
the gaps it addressed?
8. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
9. What contributions to increasing case finding can be considered key, and why? 
10. What was CTB’s contribution to the design of NTP’s ACF strategies?
81
11. What ACF strategies did CTB directly support and how successful were they? 
a. What challenges were faced and addressed and what lessons were learned?
EQ 1dii. Addressing the MDR-TB crisis in Yangon
12. What specific gaps in existed at the start of CTB in addressing the MDR-TB crisis in Yangon, and 
how did CTB prioritize the gaps it addressed?
13. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
14. What contributions to addressing this crisis can be considered key, and why? 
EQ 1diii. Strengthening TB and MDR-TB diagnostic network
15. What specific gaps in existed at the start of CTB in the diagnostic network, and how did CTB 
prioritize the gaps it addressed?
16. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
17. What contributions to strengthening the diagnostic network can be considered key, and why? 
EQ 1div. Assisting NTP in introducing active drug safety monitoring and management 
(aDSM) for MDR-TB cases
18. What specific gaps in existed at the start of CTB in aDSM and how did CTB prioritize the gaps 
it addressed?
19. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
20. What contributions to strengthening aDSM can be considered key, and why? 
EQ 1dv. Engagement with private sector providers, drug sellers, and other non-public 
organizations in TB case finding
21. What specific gaps in existed at the start of CTB in engaging the private sector, and how did 
CTB prioritize the gaps it addressed?
22. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
23. What contributions to strengthening the private sector engagement can be considered key, and 
why? 
EQ 2. To what extent has CTB’s technical assistance to the national TB program at 
different levels advanced TB prevention and control in Burma in line with CTB Global-level 
objectives, and CTB/Burma’s project objectives, and promoted sustainability?
EQ 2a. What technical assistance and capacity-building support provided by CTB was most 
effective, and what activities were less effective? 
24. How were TA needs assessed and TA sourced?
25. What criteria should be used for assessing the effectiveness of TA and CB?
26. What TA and CB were most effective and why?
27. Which TA and CB were not as effective and why?
EQ 2b. To what extent were interventions, models and tools introduced by CTB adopted 
and scaled up with other resources (domestic or other donor)? What are examples of tools 
or approaches that were continued or scaled up?
28. What are the tools, models and interventions introduced by CTB?
29. What parameters do you use, to assess the extent of their scale up? Based on these parameters, 
what is the extent of scale up of each?
30. What factors enabled or hindered the successful scale up (or lack thereof) of each?
31. In your estimation, in what ways did CTB approaches ensure sustainability of the gains made?
32. Which of the interventions of CTB for hard to reach areas have been taken up by 
NTP/partners? To what extent?
33. Which aspects of the MDR-TB response in Yangon have been taken up by NTP/Partners? To 
what extent?
EQ 2c. What efforts did CTB undertake to ensure broader uptake of its approaches? What 
evidence exists of uptake?
34. To what extent were the above successes and scale up due to the efforts of CTB?
EQ 3. What gaps and opportunities exist for further USAID investment in the private 
sector and community programming?
EQ 3b. What lessons and best practices from CTB private sector interventions can be 
applied to future efforts to control TB and efforts to build country capacity?
35. What are the lessons and best practices in these areas, what qualifies them as such, what scale 
are they currently at, and what future scale up is feasible?
36. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
83
KEY INFORMANT INTERVIEW – Head of facility (District and township hospitals, MMA PPM and TB 
HIV hospitals, RHC)
Interviewee: Head of facility
Interviewer: _____________________________ Designation: _____________________
Interview date: ________________ Time: __________
Person interviewed______________________ Position_________________________
Length of service in this position________ years
Introductory questions
1. What kinds of TB services are provided in your facility? 
a. Diagnosis: Smear microscopy (Light/LED), Xpert, CXR, FNA, biopsy, cytology, Culture & DST
b. DOTS (DS and DR TB), inpatient services
(Use only relevant sections below)
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1b. What are the most important TB gaps and issues that CTB focused on in its 
geographical areas, and how well did the selection of interventions and geographical areas 
align with need?
1. What methods did CTB use to identify the key gaps and issues in your facility, and how 
adequate and relevant were they? 
2. What were the issues and gaps identified? What considerations went into CTB’s prioritization of 
identified issues?
3. To what extent did CTB follow through with maintaining these priorities, through its period of 
implementation? 
a. Where it did not, what were the reasons?
4. In hindsight, how effective was prioritizing these needs and gaps (over others) in reducing the 
TB burden?
5. What more can be done, in your facility, to address TB related gaps?
EQ 1d. What were the key contributions of CTB in the following technical areas?
EQ 1di. Increasing case notification and active case finding
6. What specific gaps in existed at the start of CTB in case notification, and how did CTB prioritize 
the gaps it addressed?
7. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
8. What contributions to increasing case finding can be considered key, and why? 
9. What ACF strategies did CTB directly support and how successful were they? 
a. What challenges were faced and addressed and what lessons were learned? 
b. What more can be done for active case finding in your facility?
EQ 1dii. Addressing the MDR-TB crisis in Yangon
1. What specific gaps in existed at the start of CTB in addressing the MDR-TB crisis in Yangon, and 
how did CTB prioritize the gaps it addressed?
2. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
3. What contributions to addressing this crisis can be considered key, and why? 
EQ 1diii. Strengthening TB and MDR-TB diagnostic network
4. What specific gaps in existed at the start of CTB in the diagnostic network, and how did CTB 
prioritize the gaps it addressed?
5. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
6. What contributions to strengthening the diagnostic network can be considered key, and why? 
EQ 1div. Assisting NTP in introducing active drug safety monitoring and management 
(aDSM) for MDR-TB cases
7. What specific gaps in existed at the start of CTB in aDSM and how did CTB prioritize the gaps 
it addressed?
8. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
9. What contributions to strengthening aDSM can be considered key, and why? 
EQ 1dv. Engagement with private sector providers, drug sellers, and other non-public 
organizations in TB case finding
10. What specific gaps in existed at the start of CTB in engaging the private sector, and how did 
CTB prioritize the gaps it addressed?
11. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
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12. What contributions to strengthening the private sector engagement can be considered key, and 
why? 
13. We have come to the end of this interview. Is there anything else you would like to tell us at this 
time?
Thank the participant(s) for his/her/their time
KEY INFORMANT INTERVIEW & OBSERVATION – NRL
Interviewees: Director/In charge
Interviewer: ___________________________Designation: __________________________
Interview date: ________________ Time: __________
Position of person interviewed_____________ 
Length of service in this position ------- years
EQ 1d. What were the key contributions of CTB in the following technical areas?
EQ 1diii. Strengthening TB and MDR-TB diagnostic network
1. What specific gaps in existed at the start of CTB in your laboratory, and how did CTB prioritize 
which gaps to address?
2. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
3. What contributions to strengthening the diagnostic network can be considered key, and why? 
4. What more needs to be done to improve the capabilities of your facility?
# Data Points
Responses
Yes/No Other Reasons, 
perceptions, 
opinions
National Laboratory
1 Is the number of staff appear adequate as per national guidelines?
2. Is laboratory facility equipped with the following functional items 
today? 
● Light microscope
● LED microscope
● Xpert 
● Supplies for Xpert
● Liquid Culture & DST
● Solid Culture & DST
● Supplies for culture &DST
● Other supplies (Reagents, Sputum cups…)
3 Observe the process of sputum sample handling:
● Proper sputum sample reception/collection
● Labeling of the sample container
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● Proper processing of samples (Smear preparation, 
staining, fixing & reading)
● Recording of result
• Disposal of remaining sputum sample
4 Liquid culture
● Turnaround time acceptable Trend:
● Contamination rate acceptable? Trend:
● Negative pressure maintained at present?
5 Solid culture
● Turnaround time acceptable
● Contamination rate acceptable?
● Negative pressure maintained at present?
6 LPA
● Is the turn round time acceptable
● Contamination rate acceptable?
● Negative pressure maintained at present?
● For SLDs – routinely performed?
7 Is there TB Lab register?
Does it have complete information?
8 Is the most recent Lab report available? (Quarterly, annual...)
9 Is your lab receiving fixed slides for AFB microscopy? If yes, 
● Is the turnaround time acceptable?
● What is the positivity rate
● What is the wastage rate/ proportion of unreadable slides?
10 Is Xpert used in your facility for TB diagnosis? What is the yield, 
what is the turnaround time?
● Is the turnaround time acceptable?
● What is the positivity rate
● What is the utilization rate
11 Is there tissue crusher available for tissue sample preparation for 
Xpert? 
12 Availability and utilization of Personal protection equipment 
(N95) 
13 Samples sent to IRL for QC?
14 Are you receiving sputum sample collected at other facility?
If yes, how is the sample transported
Is the turnaround time acceptable Trend:
15 Are technical guidelines, SOPs, manuals available? 
16 Are you using national algorithm for TB diagnosis?
17 Is performance data displayed on wall by graphs or tables?
18 Is the result communicated to clinicians timely? Indicate How? 
See report
19 Is there EQA in place? How often you do EQA?
20 Is the most recent EQA report available? See the report? Check 
if regularly done?
21 Is this laboratory accredited internationally?
22 Are you conducting supportive supervision to facilities? How is 
the frequency & your feedback mechanism, see report
5. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
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KEY INFORMANT INTERVIEW & OBSERVATION – Xpert lab
Interviewees: Director/In charge
Interviewer: _________________________Designation: __________________________
Interview date: ________________ Time: __________
Position of person interviewed___________________________ 
Length of service in this position ________years
EQ 1d. What were the key contributions of CTB in the following technical areas?
EQ 1diii. Strengthening TB and MDR-TB diagnostic network
1. What specific gaps in existed at the start of CTB in your laboratory, and how did CTB prioritize 
the gaps to address?
2. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
3. What contributions to strengthening the diagnostic network can be considered key, and why? 
4. What more needs to be done to improve the capabilities of your facility?
# Data Points
Responses
Yes/No Other Reasons, 
perceptions, 
opinions
Xpert lab
1 Is the number of staff appear adequate as per national 
guidelines?
Number trained in Xpert tests adequate?
Number trained in Xpert maintenance adequate?
2. Is laboratory facility equipped with the following functional 
items today? 
● Light microscope
● LED microscope
● Xpert 
● Cartridges for Xpert
● Other supplies (Reagents, Sputum cups…)
● Power supply maintenance
3 Is there a designated sputum collection area
4 Is the area well ventilated
5 Observe the process of sputum sample handling:
● Proper sputum sample reception/collection
● Labeling of the sample container
● Proper processing of samples (Smear preparation, 
staining, fixing & reading)
● Recording of result
● Disposal of remaining sputum sample
6 Is there TB Lab register?
Does it have complete information?
Is there a column for referring entity?
7 Is the most recent Lab report available? (Quarterly, 
annual...)
8 Is your lab receiving fixed slides for AFB microscopy? If 
yes, 
● Is the turnaround time acceptable?
● What is the positivity rate
● What is the wastage rate/ proportion of unreadable 
slides?
9 Is Xpert used in your facility for TB diagnosis?
● Is the turnaround time acceptable?
● What is the positivity rate
● What is the utilization rate
10 Is there tissue crusher available for tissue sample 
preparation for Xpert? 
11 Availability and utilization of Personal protection 
equipment (N95) 
12 Samples sent for QC?
13 Are you receiving sputum sample collected at other 
facility?
If yes, how is the sample transported
Is the turnaround time acceptable Trend:
14 Are there technical guidelines, SOPs, manuals available? 
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15 Are you using national algorithm for TB diagnosis?
16 Is performance data displayed on wall by graphs or tables?
17 Is the result communicated to clinicians timely? Indicate 
How? See report
18 Is there EQA in place? How often you do EQA?
19 Is the most recent EQA report available? See the report? 
Check if regularly done?
20 Are you conducting supportive supervision to facilities? 
How is the frequency & your feedback mechanism, see 
report
5. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
KEY INFORMANT INTERVIEW – TB clinic
Interviewees: In charge
Interviewer: ___________________________ Designation: __________________________
Interview date: ________________ Time: __________
Position of Person interviewed___________________ Length of service in this position_____ years
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1b. What are the most important TB gaps and issues that CTB focused on in its 
geographical areas, and how well did the selection of interventions and geographical areas 
align with need?
1. What methods did CTB use to identify the key gaps and issues in your facility, and how 
adequate and relevant were they?
2. What were the issues and gaps identified? What considerations went into CTB’s prioritization of 
identified issues?
3. To what extent did CTB follow through with maintaining these priorities, through its period of 
implementation? 
a. Where it did not, what were the reasons?
4. In hindsight, how effective was prioritizing these needs and gaps (over others) in reducing the 
TB burden?
5. What more can be done, in your facility, to address TB related gaps?
EQ 1d. What were the key contributions of CTB in the following technical areas?
EQ 1di. Increasing case notification and active case finding
1. What specific gaps in existed at the start of CTB in case notification in the facility, and how did 
CTB prioritize the gaps it addressed?
2. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
3. What contributions to increasing case finding can be considered key, and why? 
4. What more can be done to improve case finding in this facility?
5. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time.
KEY INFORMANT INTERVIEW – MMA PPM Clinic and PPM General Practitioners
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Interviewees: Director/In charge
Interviewer: _____________________________ Designation: ________________________
Interview date: ________________ Time: __________
Position of Person interviewed__________________________
Length of service in this position______ years
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1d. What were the key contributions of CTB in the following technical areas?
EQ 1dii. Addressing the MDR-TB crisis in Yangon
1. What specific gaps in existed at the start of CTB in addressing the MDR-TB crisis in Yangon, 
and how did CTB prioritize the gaps it addressed?
2. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
3. What contributions to addressing this crisis can be considered key, and why? 
EQ 1diii. Strengthening TB and MDR-TB diagnostic network
4. What specific gaps in existed at the start of CTB in the diagnostic network, and how did 
CTB prioritize the gaps it addressed?
5. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
6. What contributions to strengthening the diagnostic network can be considered key, and 
why? 
EQ 1div. Assisting NTP in introducing active drug safety monitoring and management 
(aDSM) for MDR-TB cases
7. What specific gaps in existed at the start of CTB in aDSM and how did CTB prioritize the 
gaps it addressed?
8. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
9. What contributions to strengthening aDSM can be considered key, and why? 
EQ 1dv. Engagement with private sector providers, drug sellers, and other non-public 
organizations in TB case finding
10. What specific gaps in existed at the start of CTB in engaging the private sector, and how did 
CTB prioritize the gaps it addressed?
11. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
-What contributions to strengthening the private sector engagement can be considered key, 
and why? 
12. Which aspects of the MDR-TB response in Yangon have been taken up by NTP/Partners? 
To what extent?
13. We have come to the end of this interview. Is there anything else you would like to tell us 
at this time?
Thank the participant(s) for his/her/their time
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KEY INFORMANT INTERVIEW – Drug sellers
Interviewees: Drug seller
Interviewer: _________________________ Designation: _________________________
Interview date: ________________ Time: __________
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1d. What were the key contributions of CTB in the following technical areas?
EQ 1dv. Engagement with private sector providers, drug sellers, and other non-public 
organizations in TB case finding
1. How long have you been in this profession? 
2. What kinds of health-related advice or treatment do people generally seek from you? How do 
you respond to such requests?
3. In what specific ways did CTB engage drug sellers in TB diagnosis and treatment?
4. What are the challenges you face in carrying out these tasks? How have you overcome them? 
To what extent did CTB help you in overcoming them?
5. In what ways has your involvement in TB diagnosis and treatment helped improve access to TB 
diagnosis and care in your community?
EQ 3. What gaps and opportunities exist for further USAID investment in the private 
sector and community programming?
6. What more can be done to improve the finding of cases from your community?
7. How better can drug sellers be engaged?
8. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for his/her/their time
INTERVIEW – PATIENTS/GUARDIAN OR PARENT
Facility/Community: _______________________Facility level: _________________________
Patients Age: __________
Sex: Male _________Female__________
Interviewer: _____________________________ Designation: ________________________
Interview date: ________________ Time: __________
1. How far from here is the facility where you receive(d) treatment?
€ More than 10 km
€ 5 to 10 km 
€ Less than 5 km 
2. How long did/does it take for you to get there?
€ More than 2 hours
€ 1 to 2 hours
€ Less than an hour
3. What was the major complaint/symptom you (or in your ward) went to the hospital for?
€ Cough 
€ I was told I have TB / Referred by another facility or HEW
€ Other symptoms
4. How long did you (or your ward) have the symptoms before you (or your ward) began treatment?
5. Where did you first seek treatment or care (for yourself or for your ward)?
6. What happened at that place? What treatment did you (or your ward) receive, and how did you (or 
your ward) feel after that? 
7. Where did you (or you and your ward) go next? How long after the previous place did you (or you 
and your ward) go to this place?
8. What happened at that place? What treatment did you (or your ward) receive, and how did you (or 
your ward) feel after that? 
9. How many other places did you (and your ward) go? Please describe
10. Who first suspected/considered that you (or you ward) might have TB?
€ In this facility (OPD/Triage/other)
€ Came here with referral from volunteer/other facility
€ Other…………………………….
11. How long did it take, after your (or your ward’s) symptoms began, for you (or your ward) to be 
diagnosed with TB?
€ Less than a month
€ 1-2 months
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€ More than 2 months
12. Could you tell us about the experience you (or you and your ward) went through, from the time 
your (or your ward’s) symptoms began, until you (or your ward) were diagnosed with TB? Probe 
for:
Number of places visited: 
Type of places of visited:
Cost incurred:
13. How many days after you (or your ward) got the diagnosis, did you (or your ward) start the 
treatment? If delayed, ask for reasons for delay
Patient Satisfaction/Quality of Care for TB
14. What is your perception of services in the facility where you (or your ward) were treated? 
Probe for:
Opening hours of facility
Waiting time
Staff attitudes
Privacy and comfort
Allowing you to ask questions/concerns
Addressing concerns
Providing all relevant information about your (or your ward’s) illness
Cleanliness of premises
15. Could you describe for us the advice you (or you and your ward) received regarding your (or your 
ward’s) illness? Probe for: Advise on importance of continuing TB treatment/ Advise on cough 
hygiene/ Advise on bringing family members for screening
16. Please tell us about your experience in receiving TB treatment for yourself (or for your ward). 
Probe for: 
For current patients: Which month of treatment are you (or your ward) in? 
How is/was the drug administered to you (or your ward) in the first two months of treatment –
Swallow medicine every day at health facility (DOT), took medicines with the help of treatment 
supporter, collect drug daily and swallow it yourself (or give your ward) at home, collect drug 
for a few days or weeks and return for refill.
17. When and where did you first learn about TB? Probe for: work of volunteer in his/her community
Perspectives on improving access
18. To what extent do you think people in your community know about TB and how and where to 
get tested and treated for it? 
12.1. What can be done to further improve the awareness of people 
19. What do you think can be done to improve the awareness of people on TB in your community?
20. What can you recommend on how to get people with symptoms of TB get tested early enough? 
Probe for – awareness, mobilization, location of facilities/distance, package of services offered, 
lab services, staffing, DOT and treatment support
21. What do you think you can do for others with TB, to get proper care early enough? 
Thank the patient/guardian or parent for his/her time.
FOCUS GROUP DISCUSSION: Staff and Volunteers 
Region/state: ____________________Township: ___________________
Total number of participants_______Male: ______ Female: __________
Interviewer: _____________________________ Designation: _______ __________________
Interview date: ________________ Time: __________
EQ1: What were CTB’s key contributions to TB control in Myanmar and to what extent 
has CTB/Burma addressed key TB issues and gaps?
EQ 1b. What are the most important TB gaps and issues that CTB focused on in its 
geographical areas, and how well did the selection of interventions and geographical areas 
align with need?
1. What methods did CTB use to identify the key gaps and issues in your area, and how adequate 
and relevant were they? 
2. What were the issues and gaps identified? What considerations went into CTB’s prioritization of 
identified issues?
3. To what extent did CTB follow through with maintaining these priorities, through its period of 
implementation? 
a. Where it did not, what were the reasons?
4. In hindsight, how effective was prioritizing these needs and gaps (over others) in reducing the 
TB burden? 
a. How effective was the LOE given to addressing each gap/issue? 
b. What else could have been done?
EQ 1d. What were the key contributions of CTB in the following technical areas:
EQ 1di. Improving case notification
5. What specific gaps in existed at the start of CTB in case notification in your area, and how did 
CTB prioritize the gaps it addressed?
6. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
7. What contributions to increasing case finding can be considered key, and why? 
8. What was CTB’s contribution to the design of NTP’s ACF strategies?
9. What ACF strategies did CTB directly support and how successful were they? 
99
a. What challenges were faced and addressed and what lessons were learned?
EQ 1dv. Engagement with private sector providers, drug sellers, and other non-public 
organizations in TB case finding
10. What specific gaps in existed at the start of CTB in engaging the private sector, and how did 
CTB prioritize the gaps it addressed?
11. To what extent were CTB activities responsive to these gaps and how well were they 
implemented – success, challenges, lessons?
12. What contributions to strengthening the private sector engagement can be considered key, and 
why? 
EQ 3. What gaps and opportunities exist for further USAID investment in the private 
sector and community programming?
EQ 3b. What lessons and best practices from CTB private sector interventions can be 
applied to future efforts to control TB and efforts to build country capacity?
13. What are the lessons and best practices in these areas, what qualifies them as such, what scale 
are they currently at, and what future scale up is feasible?
14. We have come to the end of this interview. Is there anything else you would like to tell us at 
this time?
Thank the participant(s) for their time
ANNEX V: INFORMATION SOURCES
RESPONDENTS FOR KEY INFORMANT INTERVIEWS
1. NTP Officials – 2
2. USAID Burma – 2
3. MDR-TB Advisor, seconded to NTP – 1
4. CTB Myanmar staff – 2
5. Subgrantee national staff – all six subgrantees
6. Other partners in TB control: JICA, JATA, FDA, GF Principal Recipients, Chemonics Int’l
7. WHO TB officer
8. Regional TB officers – Sagaing, Yangon, Bago, Kayah
9. TB team leaders, region/state
10. District hospital – heads of facility
11. Township TB officers/ TB clinic incharge
12. Lab incharge – two NRLs, Xpert labs in districts
13. Subgrantee staff in the field
14. Outreach workers in Yangon -2
15. Drug sellers in Bago – 4
16. BHS staff in rural health centers
PARTICIPANTS FOR FOCUS GROUP DISCUSSIONS
1. FGD in Mawlaik – 2 men, 7 women
2. FGD in Demosoe – 8 women
LIST OF TB PATIENTS INTERVIEWED
# Age (in years) Sex Location
1 68 M
2 20 F
3 43 F
4 43 F
5 37 F
6 37 F
7 60 F
8 59 F
9 25 M
10 45 F
11 40 M
12 14 M
13 7 M
14 62 F
15 34 F
16 39 F
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ANNEX VI: DISCLOSURES OF CONFLICT OF INTEREST

103
ANNEX VII: EVALUATION TEAM MEMBER PROFILES AND CVS
Dr. Beulah Jayakumar, Team Leader. Dr. Jayakumar is a medical doctor and evaluation specialist 
with over 19 years of experience monitoring and evaluation of public health programs in Ethiopia, 
Afghanistan, South Sudan, and Bangladesh. A highly experienced Team Leader, she has led evaluations of 
USAID-funded TB and health-related programming and provided technical expertise to evaluations, 
surveys, and assessments since 2009 as an independent consultant. Recently, Dr. Jayakumar served as 
Team Leader for the final performance evaluation of the USAID/Ethiopia Challenge TB program, where 
she led the evaluation design, oversaw fieldwork and data collection efforts, and authored the final report. 
Earlier in her career, Dr. Jayakumar designed multiple USAID-funded Reproductive and Child Health and
TB projects in India as World Vision India’s Public Health Coordinator and implemented three such 
programs during several years as a program manager. Dr. Jayakumar holds a Diplomate of National Board 
in Family Medicine from the National Board of Examinations. She is fluent in English and Hindi. 
Mr. Tushar Kanti Ray, Senior Tuberculosis Specialist. Mr. Ray is a Public Health and Social 
Development expert with over 30 years of experience in the field and more than 17 years of experience 
in TB project planning and management. He has worked as the USAID Country Director for TBCARE 
and has worked as the Country Technical advisor to STOPTB Partnership through UNOPS. As the Senior 
TB Specialist, he will provide remote expertise to inform and ensure TB-specific accuracy and specificity 
throughout the evaluation design. He has an M.A. in Sociology and a post graduate diploma in Rural 
Development. 
Mr. Soe Myat Naing, Mid-level Evaluation Specialist. Mr. Soe brings ten years of experience in 
international development conducting and supporting evaluations and assessments in Burma. An 
experienced evaluator, Mr. Naing has expertise in semi-structured evaluation methods, qualitative data 
collection through FGDs and KIIs, and data analysis with SPSS software. He spent six years in Burma 
supporting TB and health-related programming, as an M&E Assistant for the IOM’s TB Reach Project and 
as a M&E Officer with Medical Emergency Relief International (Merlin), where he supported the design 
and review of projects, designed questionnaires and data collection tools, verified data quality, and 
conducted other M&E support activities. Most recently, Mr. Naing was a Program Manager at Oxfam 
Burma, where he worked to embed gender analysis and learning in program activities. He holds a B.A. in 
Philosophy from the University of Pathein and speaks fluent Burmese and advanced English.
U.S. Agency for International Development
Ronald Reagan Building
Washington, DC 20052