Photo credit: Uasin Gishu County Referral Hospital,TB Clinic: Mr Hillary Ndiema the TB Clinician and TB Nurses.
EVALUATION OF KENYA USAID
TUBERCULOSIS SUPPORT PROGRAM
FINAL REPORT
November 30, 2022
Prepared by
Dr Mvondo Abeng Belinga Edwige, Lead consultant
Dr Amos Kutwa, National TB Expert
This publication was produced at the request of the United States Agency for International Development. It was prepared independently by
the Mission Support for the Journey to Self-Reliance Pivot activity, implemented by SoCha LLC. No part of this report may be circulated, 
quoted, or reproduced for distribution without prior written approval from USAID. 
1 
EXECUTIVE SUMMARY
In November 2022, the HPN TB team commissioned an evaluation of their TB programs.The evaluation
was carried out in five counties (Mombasa, Kilifi, Kisumu, Uasin Gishu and Nairobi) for three USAID
implementing partners a) TB ARCII (CHS ) with a five year budget of $34,933,017, b) HealthIT
(UNES) with a seven year budget of $23,758,506 and c) Komesha TB (KCCB) with a five year budget
of $3,500,000.The overall purpose of the evaluation was to evaluate the performance of USAID Support to
the Kenya NationalTB Program.
The evaluation used a mixed-methods design, involving secondary document and data reviews as well
as primary data collection through Key Informant Interviews (KIIs) and direct observations.The
evaluation team conducted 73 KIIs with various respondents1. The evaluation sought to answer 6 
evaluation questions.The major achievements, findings and recommendations per each evaluation
question are provided below:
Evaluation question 1:To what extent has the mix of TB ARC II – National TB Program partnership
in terms of technical assistance, service delivery, training, health care systems development and
strengthening, monitoring, evaluation and learning, etc. contributed to the overall strengthening of TB
prevention, care and treatment in the country?
Achievements:
● Provided Technical Assistance (TA) to the Division of National Tuberculosis and Leprosy
Program (DNLT-P) central unit for development of policies, guidelines and supported
supervision to the 47 counties.
● Supported the coordination of independent partners and stakeholders through quarterly
coordination forums and Technical Working Groups (TWG) which have aligned their
activities to the priorities of the National TB program (NTP).
● Introduced and supported co-creation of annual work plans and budgets for DNLT-P with all
partners.
● Supported theDNLT-P to pilot new technologies hence expanding diagnostic platforms for TB
by procuring and installing (iNTP) 8 digital x-rays+CAD, 38 TrueNat Machines, interferon
gamma release assay (IGRA) tests, sample referral systems, GeneXpert bundling, EQA for
laboratory services and provided capacity building.
● Partnered with the Union (IUATLD) and trained NTP program officers, County TB and
Leprosy Coordinators (CTLCs) and Sub county TB and Leprosy Coordinators (SCTLCs) on
analysis and utilisation of data for decision making.
1 Health care workers, CHVs,D NLT-P, Partners and USAID
2 
● Developed and installed Treatment Information for Basic Unit (TIBU) surveillance system,
provided registration tools, computers and tablets to county and sub county TB coordinators
and supported electronic capture of data.
● Supported Drug Resistant Tuberculosis (DRTB) patients with baseline and follow up tests.
● Conducted outreach campaigns in community hot spots and involvement of Private health
facilities to find missing TB patients , demand creation at facility and community levels
through ACCE.
Key findings
● Frequent shortage of GeneXpert cartridges affecting TB case finding.
● Lack of continuous maintenance and validation of laboratory equipment.
● Treatment Information for Basic Unit (TIBU) surveillance system aggregates patients’ data at
sub county and county levels and not at point of care.
● Lack of funding for research and documentations of best practices.
● Stock out of child friendly formulation in Uasin Gishu and Kilifi.
Recommendations: 1)There is a need for MoH and TB stakeholders to urgently address and solve
recurrent shortage of GeneXpert cartridges and the lack of continuous maintenance and validation of
laboratory equipment. 2) Fast track the implementation of TIBU lite at point of care.
Evaluation question 2:To what extent has the county-focus support to the 4 regions by TB ARC II
contributed to the extra strengthening of TB prevention, care and treatment in these counties?
Achievements:
● Deployed regional coordinators to the four regions to strengthen the capacity of counties in
TB prevention, care and treatment.
● Intensified supportive supervision and mentorship to the health facilities improving the quality
of care ofTB services being offered in the 11 counties.
● Enhanced coordination of USAID supported IPs in the counties.
Key findings
● All counties in TB ARC II regions, except Kilifi and Isiolo, show increasing trend in CNR post
COVID19 period. All counties except Nyamira, Kilifi, Migori and Kwale reported CNR above
national average (154 per 100,000 population) in 2021.
● The treatment outcome results have improved across the TB ARC II supported counties
except Nairobi, Mombasa,Kilifi and Kwale.
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Recommendations: Need to escalate lessons learnt from the four regions to the entire country by
deploying regional coordinators in the rest of high burden countries or the whole country availability
of funds allowing.
Evaluation Question 3:To what extent has the mix of TB ARC II – Komesha TB – HealthIT support
to the national and county programs contributed to the overall strengthening of TB prevention, care
and treatment in the country?
Achievements:
● TB ARC II:TB ARC II supported TB case finding activities through engagement of the
private-for-profit health facilities in 5 counties ( Meru, Kirinyaga, Mombasa, Kilifi and Nyeri).
146 health facilities (96 hospitals and clinics, 31 chemists/pharmacies, 11 standalone
laboratories and 8 corporate clinics) are engaged. In the period of evaluation,TB ARC II
trained a total of 410 health care workers from the private sector on TB control.
● HealthIT mechanism: Refurbished the TIBU M&E surveillance system and established a 
seamless interoperability with KHIS. Supported the development and is now piloting T-BU
lite app on an android system which captures patient data at point of care. Provided DNLT-P 
with computers and modems for GeneXperts to facilitate linkage and transmission of results.
Upgraded and supports the hosting of the DNLT-P website.
● Komesha TB project : Komesha TB focuses on Faith-Based and private health facilities in
nine counties in western Kenya.The PPM contribution to notified TB patients is increasing in
the KomeshaTB supported counties.
Key findings
● Lack of financial incentives for private-for-profit health facilities involved in TB care.
● High turnover of health personnel in faith-based and private health facilities.
● Disruption of Commodity supply – nutritional supplements, GeneXpert cartridges.
● Low priority for TB interventions in some private hospitals whose motive is profit.
Recommendations: 1)Kenya faith-based services consortium should be engaged during entry at
Faith-based organisations (FBO) health facilities to optimise coordination. Continuously collaborate
with MoH and IPs in the region for impact. 2)Training and capacity building be customised to
maximise attendance for staff at private facilities where time off equates to losses.
Evaluation Question 4: How has access to and utilisation of TB prevention, care and treatment
services changed over the period of implementation of TB ARC II, Komesha TB and HealthIT (TB
support)?
Achievements:
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● TB ARC 11
○ Developed and piloted five models of PPM including the institutional/ provider PPM
and corporate PPM models in 2019. It involved the Tunza Clinic network of 100
health facilities in Nairobi, Mombasa, Nakuru, Kiambu,Tharaka Nithi, Meru, Isiolo
and Embu counties.
○ Trained 88 health workers on the Integrated TB/leprosy and Lung diseases
guidelines.
○ Screened 36,068 persons of whom 2,500 were presumed to have TB; 2,024 were
sent for GeneXpert testing; one was diagnosed with TB by GeneXpert, 8 had X-rays
suggestive of TB. All 9 TB patients diagnosed were started on TB treatment.
● Komesha TB
○ Has engaged 140 health facilities, composed of 84 Faith Based health Facilities, 54
private health facilities and 2 public health facilities
○ Komesha TB has reported 6,889 TB patients since 2019 and treatment success rate
was 84% and death rate of 5%.
○ Mapped hot spots for TB in the community and conducted targeted outreaches to
find people withTB..
Evaluation Question 5: How has the mix of USAID support (to the national and county TB programs
via TB ARC II, HealthIT and Komesha TB) with Global Fund, GoK and other donors contributed to
the strengthening of TB prevention, care and treatment in Kenya? To what extent are the strategies
duplicative and to what extent are the strategies deficient considering UN HLM, NSP and USAID’s
GlobalTBAccelerator goals?
Achievements:
● All stakeholders support the implementation of the NSP which is aligned with the WHO
strategy to END TB by 2030. Involvement of all DNLT-P stakeholders in the planning process
limits duplication and ensures that all aspects of the strategy are considered during budgeting.
Kenya achieved and surpassed the Global 2020 targets as follows;
○ 32% reduction in TB incidence rate against a target of 20% and
○ 38% reduction in mortality rate against a target of 35%. However, the country still
faces a high burden ofTB, HIV and TB/HIV.
● Kenya has made progress towards achieving some of the UNHLM goal targets that include;
○ In 2021 Kenya drafted a multi-sectoral accountability framework.The program has
diagnosed and treated 330,792 people out of a target of 425,200 with TB which is a 
performance of 78%.
○ Expansion of culture labs from 2 to 5 and is in the process of availing more molecular
diagnostics through procurement of additional GeneXpert and Truenat machines.
Drug Sensitivity Testing (DST) coverage for all people with TB is now at 66% against
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Key findings
a target of 90%.
○ Development of latent TB infection (LTBI) guidelines.This guides the provision of TB
preventive therapy in targeted expanded at-risk populations which include ; PLHIVs,
TB contacts of all ages, HCWs, prisoners and selected clinical risk groups. Since
2018, over 180,000 people newly diagnosed with HIV were initiated on ART and over
32,000 contacts started on TPT.The roll out has been slowed by commodity
challenges especially lack of new molecules and testing kits.
● The main issue has been frequent stock out of commodities, especially GeneXpert
cartridges and new TPT regimens affecting the performance of the program.
● The COVID 19 pandemic affected the program negatively.
● The amount of funding available to DNLT-P has doubled since 2019 to 30,766,272.69 (USD)
in 2021.The funds are not in a common basket.The main challenge is poor absorption of
these funds because of low expenditure due to delays in procurement for NFM3 grants
including COVID-19 funding under the TB grant.TB ARC II absorbed 95% of the funds.
● Allowances paid to program officers by partners are not standard.
Recommendation:
● DNLT-P and GF partners to fast track implementation of NFM3 grants.
● Establish a common basket fund system that involves all partners.
● Harmonise per diem and fuel allowances across all partners and the state.
Evaluation Question 6: How can USAID best continue to support the national and county TB
programs in Kenya with regards to the most effective and efficient number of mechanisms,
geographical coverage (factoring devolution) and types and focus of support?
Key findings
● The majority of KII prefer multiple mechanisms to one single one.The two evaluators agree
that the USAID support to the TB program in Kenya should not be through one mechanism.
● One of the proposed mechanisms to provide national support to the Central Unit (CU) of
DNLT-P, maintaining the current technical assistance support and stewardship of the program,
develop competency and support rapid adoption of Global TB policies, dissemination of
policies and guidelines, and resource mobilisation.
● The mechanisms should also reach all the counties with TA and programmatic support.
● The mechanisms should support all thematic areas in TB care, prevention and treatment
according to information gathered from KIIs.
● Each of these mechanisms shall have regional coordinators and support supervision of health
facilities by paying allowances of CTLCs and SCTLCs through the TIBU Cash system.
SWOT Analysis: Relevance, Effectiveness and Efficiency of the three mechanisms.
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The SWOT analysis on the relevance, Effectiveness and Efficiency of the three mechanisms is annexe 
The evaluators found that: 1) The service package of the TB ARCII, HealthIT and KTB mechanisms 
meet the needs of the TB program. The relevance would be fairly well expressed when they are 
combined. 2) The effectiveness of all three mechanisms has been demonstrated, but the inability to 
work across the mechanisms limits performance. Sites with combined support have better 
performance. 3)for efficiency we cannot attribute an exclusive analysis to USAID support. The
co-creation and co-planning system in place makes all partners accountable for the performance 
produced 
Recommendation:
The overall recommendations to USAID across all the 6 evaluation questions are:
1. HealthIT to fast track implementation of TIBU lite.
2. Escalate lessons learnt from the four regions (TB ARC II) and Western Kenya (Komesha TB)
to the entire country by deploying Regional Coordinators in the rest of high burden counties
or the whole country if resources allow.
3. DNLT-P and Partners (USAID) to ensure program review meetings are held regularly at all
levels of TB care services by applying innovative technology.
4. DNLT-P and partners are requested to adopt and apply innovative strategies to find patients
suffering tuberculosis;ACF (e.g., Sema ATMs), community and or health facility initiatives
walk in sputum collection centers.
5. USAID to continue supporting programmatic areas (Reach, Cure, Prevent, Innovate and
Sustain) of the NSP to sustain the gains made in TB Care (County Supportive supervision)
6. It is recommended to use two mechanisms in the next support to DNLT-P. Both mechanisms
might have regional and county focus in all thematic areas (Reach, Cure, Prevent, Innovate
and Sustain) on TB care. One mechanism to have national focus for TA and coordination of
partners and stakeholders on all differentiated TB control approaches.
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TABLE OF CONTENTS
EXECUTIVE SUMMARY 1
ACRONYMS 7
ACKNOWLEDGMENTS 9
1.0 INTRODUCTION 10
1.1Background 10
1.2 Evaluation Objectives and questions 10
2.0 METHODOLOGY 11
2.1 Limitations 13
3. 0 FINDINGS 13
3.1 Responses to key evaluation questions 15
4.0 RECOMMENDATION 35
5.0 LIST OF ANNEXES 36
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ACRONYMS
ACCE
ACF
ADSM
ASAL 
CHMT
Advocacy, Communication and Community Engagement
Active Case Finding
Active Drug Safety Monitoring and Management
Arid and Semi-Arid Lands
County Health Management Team
CHS Centre for Health Solutions
CHV
CNR
Community Health Volunteer
Case notification rates
CTLCs County TB and Leprosy Coordinators
DNLT-P Division of National Tuberculosis, Leprosy and Lung Disease Program (NTLD-P)
DRTB
DST
Drug Resistant Tuberculosis
Drug Susceptibility Testing
DSTB Drug Sensitive Tuberculosis
IGRA
iNTP
IP
KCCB
KHIS
Interferon gamma release assay (IGRA) test
Introducing New Tools Project
Implementing Partner
Kenya Conference of Catholic Bishops
Kenya Health Information System
KNBS Kenya National Bureau of Statistics
KTB Komesha TB
KII 
LTBI
MDR TB
NHIF
Key Informant Interview
Latent Tuberculosis Infection
MultiDrug Resistant TB
National Health Insurance Fund
NTP National TB Program
NOFOS Notice of Funding Opportunity
NSP
PD 
PPM
QI
National Strategic Plan
Program Description
Public-Private Mix
Quality Initiatives
SCTLCs Sub-County TB and Leprosy coordinators
STAR
SOW
TA
Sustaining Technical and Analytic Resources
Scope ofWork
Technical Assistance
TB ARC II Tuberculosis Accelerated Response and Care II
TOR Terms of Reference
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TPT TB Preventive Treatment
UN HLM United Nations High Level Meeting
UNES University of Nairobi Enterprises Services
USAID United States Agency for International Development
WHO World Health Organization
XDR TB Extensively Drug Resistant TB
ACKNOWLEDGMENTS
The evaluation team thanks the USAID mission for the singular opportunity to conduct this End of
Term Evaluation of the Kenya USAID Support Program. Special thanks go to Dr Maurice Maina, Dr
Philip Owiti, Dr Immaculate Kathure, Evelyn Ng’ang’a and Judith Rono of USAID Kenya, and Dr Alex 
of USAID/Washington. Dr Stephen Kamau Macharia, USAID Technical Adviser to the DNLT-P for
sparing time out of his busy schedule of work to support the evaluation.Thanks to MSP for the
coordination and logistical support, particularly Rosemary Kagunda and James Kamau.
We thank the CEO of Centre for Health Solutions(CHS), Dr Paul Wekesa, the Chief of Parties of the
three mechanisms being evaluated; Dr Lorraine Mugambi of TB ARC II, Dr Milton Omondi and
Duncan Ochieng of Komesha TB Project and Hesbon Ooko of HealthIT for availing themselves and
their officers for the Key Informant Interviews.
Thanks to Dr Jackie Kisia, Head of DNLT-P and her entire team at Central Unit, DNLT-Program for
interviews granted. Finally and certainly not last, we thank all program coordinators we met and
interviewed at County, Sub County and Health facilities of Uasin Gishu, Mombasa, Kilifi, Kisumu and
Nairobi Counties.
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1.0 INTRODUCTION
The Kenya USAID Tuberculosis Support Program has three mechanisms, the largest being
Tuberculosis Accelerated Response and Care (TB ARC II) of Centre for Health Solutions (CHS)
currently in year five of implementation, Komesha TB of Kenya Conference of Catholic Bishops
(KCCB) in year four of implementation and HealthIT of University of Nairobi which is in year 7 of
implementation.This is an evaluation of the three mechanisms, documenting the successes, areas of
underperformance, lessons learnt and recommendations for the next project(s).
1.1 Background
The implementation of the projects took into consideration Kenya’s devolved system of
administration consisting of forty-seven (47) independently run County Governments and one
National Government. USAID supports DNLT-P National Strategic Plan 2019-2023 through the
following five mechanisms; Centre for Health Solutions-TB ARC II; Kenya Conference of Catholic
Bishops-Komesha TB project, HealthIT of UNES, STAR and PEPFAR.This evaluation focused on the
Centre for Health Solutions-TB ARCII, Kenya Conference of Catholic Bishops-Komesha TB project
and HealthIT of University of Nairobi Enterprises and Services Limited (UNES).
1.2 Evaluation Objectives and Questions
The purpose of this exercise is to evaluate the performance of the USAID support to the TB
program in Kenya.The specific objectives of the evaluation are as follows;
● To conduct a final evaluation of the CHS – TB ARC II project, specifically an in-depth
assessment of the technical approaches, coordination and support to the national TB
program and specific focus counties in its in-depth regional support
● To conduct an evaluation of the support provided by the HealthIT and KCCB – Komesha TB
projects to the national and county TB programs in Kenya
● To conduct a program review of the projects’ achievements, based on the expected health
outcomes in TB and TB/HIV prevention, care and treatment activities, partnerships with
GoK, other donors (e.g., GF) and Implementing Partners (IPs)
● To draft possible new program description(s)/ scope of work (PD/SOW) to accompany the
NOFO(s) for the follow-on TB mechanism(s)
The evaluation questions for this exercise are as follows:
1. To what extent has the mix of TB ARC II – National TB Program partnership in terms of
technical assistance, service delivery, training, health care systems development and
strengthening, monitoring, evaluation and learning, etc. contributed to the overall
strengthening of TB prevention, care and treatment in the country?
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2. To what extent has the county-focus support to the 4 regions by TB ARC II contributed to
the extra strengthening of TB prevention, care and treatment in these counties?
3. To what extent has the mix of TB ARC II – Komesha TB – HealthIT support to the national
and county programs contributed to the overall strengthening of TB prevention, care and
treatment in the country?
4. How has access to and utilisation of TB prevention, care and treatment services changed
over the period of implementation of TB ARC II, Komesha TB and HealthIT (TB support)?
5. How has the mix of USAID support (to the national and county TB programs via TB ARC II,
HealthIT and Komesha TB) with Global Fund, GoK and other donors contributed to the
strengthening of TB prevention, care and treatment in Kenya? To what extent are the
strategies duplicative and to what extent are the strategies deficient considering UN HLM,
NSP and USAID’s GlobalTBAccelerator goals?
6. How can USAID best continue to support the national and county TB programs in Kenya
with regards to the most effective and efficient number of mechanisms, geographical coverage
(factoring devolution) and types and focus of support?
2.0 METHODOLOGY
Data collection and analysis was guided by a comprehensive data management strategy and work plan
that was designed to answer all the evaluation questions for the project as shown in figure 1.
Figure 1:The Evaluation Design
The evaluators employed both primary and secondary data for this exercise.As part of the
secondary data analysis, a preliminary review of the key program documents and data was done to
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gather understanding on the mechanisms. Primary data was collected mainly through Key Informant
Interviews (KII).The informants included the officers from USAID, Implementing Partners, national
and county program officers, health care workers, patients and community health workers.The
collected primary data was used to support the secondary data collected in order to achieve the
assessment objectives.
Two teams collected data; one covering the coastal region and the other Kisumu and Uasin Gishu
counties.The teams joined to cover the Nairobi region. Data was collected using prepared
questionnaires of each category of interviewee on purposefully sampled informants at national,
county, sub county and health facility levels conducted face-to-face during field visits.The teams also
collected data using direct observations of TB care services in the selected health facilities.An
observation checklist was used to collect observational data.The evaluators utilised reported data to
compare the situation before the support and currently using a checklist of indicators reported by
the counties through(TIBU) the M&E framework. Table 1 below shows the distribution of data
collection, sampling and analysis methods.
Table 1: Distribution of data collection, sampling and analysis methods.
Method Sampling Analysis
Desk review All projects’ documents; selected external
documents as agreed with USAID;TB data
review
Content analysis of documents;
consolidation and aggregation
of data,TIBU
Key Informant
Interviews (KII)
USAID, USAID implementing partners, DNLT-P 
staff at National, County, sub county, facility,
and community, and patients
Categorization to respond to 
the evaluation questions
Direct Observation Checklist was used at health facilities Content analysis responses on
the checklist
All three mechanisms of USAID TB support (TB ARC II, KomeshaTB, HeathIT) and DNLT-P were
purposely sampled. Five counties (Mombasa, Kisumu, Nairobi, Kilifi, Uasin Gishu) were sampled.
Mombasa, Nairobi and Kilifi from the eleven deep focus TB ARCII counties and Kisumu out of nine(9)
KCCB KOMESHA TB focus counties. Uasin Gishu county which receives basic support for
supervision from TB ARCII.The evaluation gathered data from 14 health facilities; 8 level four health
facilities and 6 level three health facilities.
The performance of the three mechanisms was reviewed using indicators from the NSP at baseline
and currently during implementation period. Evaluation included areas of focus of the NSP which at
least one of the three mechanisms addressed.The indicators used are:
● TB case finding strategies: including active case finding (ACF) and other strategic initiatives
● TB treatment and care for DSTB and DRTB
● Public-private mix
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● Program management, coordination and governance
● Health financing (Project allocation in relation to the action plan budget of the intervention
areas).
The Evaluation Evidence Matrix (EEM) tool was used to capture data collected during planning, field,
desktop review of documents,quality assurance information and findings.The following parameters;
relevance, coherence, effectiveness and efficiency were used to describe the findings.The relevance
discusses the adequacy of the support objectives towards the perceived needs of DNLT-P, coherence
establishes the link between the different components of the project, effectiveness is description of
the relationship between the objectives of the support and the DNLT-P performance achieved for the
components involved while efficiency stands for utilisation of allocated resources according to sites,
targets, and areas of intervention.
2.1 Limitations
This evaluation was conducted by interviewing officers in fourteen (14) health facilities in five
counties and ten sub counties.The findings may not apply to sites not visited.The other factor which
could have introduced bias is relying on the TB and leprosy coordinators (CTLC) and implementing
partners to choose level three health facilities to be visited.Time constraints was also a factor. Bias
might also arise from the fact that some officers in level three health facilities lacked information on
the USAID mechanisms. However, the secondary data from program documents has mitigated against
bias.
3. 0 FINDINGS
This section provides findings based on data collected.Table 2 shows summary profile of the
respondents and sites visited, table 3 provides the respondent gender and table 4 the years of
services for the respondents.
Table 2: Profile of respondents and sites included Analysis of interview
Number of counties Number of sub
counties
Level 4 Health
Facilities
Level 3 Health
Facilities
5 10 8 6
Table 3: Shows the Respondents' parameters
Gender/Years of service 0-1 2-3 3-4 4-5 6-10 11-20 20+
Grand
Total
F 1 1 5 2 15 7 3 34
M 3 6 8 3 5 7 3 35
(blank) 1 2 1 4
GrandTotal 4 8 13 5 22 15 6 73
Table 4: Respondent years of service
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Position/Year of service 0-1 2-3 3-4 4-5 6-10 11-20 20+
Grand
Total
CHVs 1 1 5 5 1 13
Coordinator-IP 1 1 2
Coordinator-IP-Others 1 1 2
COP 1 1 1 3
DCOP 1 1
HCW focal persons 2 2 2 1 7 2 1 17
Program officer 1 1 2
TB Coordinator 1 1
TB Lab Coordinator 2 1 2 3 1 9
Technical Advisor 1 1 2
County TB Leprosy
Coordinators 1 2 1 1 5
(blank) 1 1
Sub County TB Leprosy
coordinator 2 2 1 1 2 1 9
Section Heads, NTP 2 2 1 1 6
GrandTotal 4 8 13 5 22 15 6 73
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3.1 Responses to key evaluation questions
The relationship between the objectives of each mechanism and the needs and priorities identified in
the National Strategic Plans 2018-2023 is described below:
The National Strategic Plans (2018-2023) for TB control is a people centred framework developed
from data consolidated from; 1) People Not accessing the health system, 2) People with TB infection
at high risk of developing disease and 3) People notified but not treated successfully.The NSP
priorities are organised in such a way to address the above three scenarios.
The first priority (1) addressing People who are seeking care anywhere in the health system focuses
on a) differentiating package of priority activity according to the local patients’ care seeking patterns
and infrastructure (county plans), b) Closing the diagnostic gap through conscious adoption of policy
on expanding diagnostic tests to molecular and Chest x-rays besides sputum smear microscopy, c)
Closing the private sector gap through optimising opportunities offered by the NHIF Universal Health
Coverage.
The second priority (2) for people at risk, screen for TB.Aim is to close the gap of pre-care seeking
behaviour hence identifying people with disease even before they seek care by scaling up contact
invitation,tracing, investigation, providing TB Preventive Therapy(TPT) to those at risk (new shorter
regimens) and foster close collaboration between primary health facilities and community( CHVs).
The third priority (3) is to take full advantage of opportunities therein Universal Health
Coverage(UHC). National Health Insurance Fund(NHIF) revised Essential Benefits Package (EBP)
includes infectious diseases (TB, Malaria and HIV/AIDS).This presents a sustainable opportunity to
finance health promotion, preventive and community health services in the country including finding
and successfully treating TB patients . NHIF shall also be used to buy services from the private
sector missing in the public health sector.
The three USAID mechanisms have adopted their objectives from the NSP as detailed below.
TB ARC II mechanism covers all priorities of the NSP through the following three sub purposes:
1) Increase timely use of quality TB,TB/HIV & DR-TB treatment which essentially involves finding,
diagnosing and successfully treating TB patients by strengthening capacity of care providers and the
performance of the health facility, 2) Participatory approaches to improve TB Service uptake by
creating awareness and demand of TB care services and PPM involvement and 3) Enhancing the
efficiency & sustainability of the DNLT-Program by strengthening policy framework and management
of resources.
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Health IT mechanism addresses the need for robust M&E by refurbishing and linking TIBU with
KHIS2. HealthIT's overall purpose is to strengthen National Policies, Strategies, Standards and the
related reporting to Kenya’s Health Information System (HIS) 2 hence support National and County
Level Health services by providing data for decision making.
Komesha TB mechanism focus is on finding missing TB patients and providing care through Faith
based and private for profit health facilities through three main goals:
● Goal 1: Improved access to high-quality, person-centred TB, DR-TB, and TB/HIV services
which include a) Improved screening rates for TB HIV co-infection to above 95% for all HIV
positive patients, b) Improved HIV testing for all patients diagnosed with TB to 100%, c)
Increased uptake of GeneXpert testing to 100% for all primary TB diagnosis, d) Increased
timely ART uptake to 100% in all TB/HIV co-infected patients, and e) Reduced gender
disparities in access to health care services, especially TB prevention and treatment
● Goal 2:TB service delivery platforms strengthened through a) Strengthened engagement of
non-state actors including faith affiliated institutions, private health clinics and community
based organisations, b) Development of TB Centres of Excellence, and c) Establishment of
integrated facility Multi-Disciplinary Team (MDT) meetings – TB included
● Goal 3:TB disease transmission and progression reduced through a) Improved screening
rates for TB infection to above 95% of clients in non-HIV settings, b) Reduced hospital
acquired TB in health service providers, and c) Improved public-private partnerships in TB
case finding
The section below provides the findings across the six evaluation questions:
Evaluation question 1:To what extent has the mix of TB ARC II – National TB Program partnership
in terms of technical assistance, service delivery, training, health care systems development and
strengthening, monitoring, evaluation and learning, etc. contributed to the overall strengthening of TB
prevention, care and treatment in the country?
USAID supports DNLT-P through TB ARC II project of Centre for Health Solutions (CHS) and is
premised on three sub purposes described above in detail.The following is the summary of support
to DNLT-P:
● Technical support for TB,TB/HIV care, prevention and laboratory services through program
officers based at national level who work closely with their counterparts at NTLP to develop
and disseminate policy and guidelines, SOPs, Job aids and training materials.This TA is
extended to the 47 counties through joint supportive supervision.
17
● Deployed four Regional Coordinators to provide TA to eleven (11) focus counties in four
regions; Upper Eastern (Meru,Tharaka Nithi and Isiolo), Nyanza (Siaya, Homa Bay, Migori,
Nyamira), Nairobi and Coast (Mombasa, Kwale and Kilifi).The coordinators work closely
with CTLCs by providing direct technical support to health facilities, coordinating co-creation
,development and subsequent implementation of quarterly County TB,TB HIV work plans
with all partners, and supporting and participating in quarterly data review meetings.
● Coordination of partners and leveraging on their expertise and funding for TB care in the
country and 11 counties through quarterly meetings, GeneXpert Meetings, Committees of
Experts (TWGs) and Performance Review Meetings for sharing of best practices.
● Piloted new interventions with DNLT-P, learning lessons before rolling the interventions to
the whole country with support from Global Fund. Examples are Active Case finding, PPM
models of care and currently iNTP (introducing New Technologies Program) to expand the
diagnostic algorithm in the country. USAID through the TBARCII project has procured and
installed 8 digital Chest X-rays+ CAD enabled and 38 TRUENAT machines.
● Developed TIBU, a surveillance tool for TB M&E which also supports timely reimbursement
of supervision allowances for fuel and lunch to all CTLCs and Sub County TB and Leprosy
coordinators (SCTLCs) throughTIBU Cash.
● Provides bundling of all molecular diagnostics, supports sample transfer for DR TB
surveillance and pays for baseline and follow-up tests for DR-TB patients.
● Partnered with the Union (IUATLD) to build capacity of the DNLT-P program staff, CTLCs
and SCTLCs to analyse and use data for decision making.
● Supportive supervision including building capacity of staff; continuous professional
development on integrated guidelines; provision of lab commodities and equipment (CO2
incubator for NTRL,Voltex mixer, surge protector for biosafety machines), microscopy and
GeneXpert bundling for online reporting; Lab support on EQA (+feedback) improved quality
and Sample referrals via riders to improve diagnosis.
● Advocacy Communication and Community Engagement by developing IEC materials,
supporting and participating in radio talks on TB disease, transmission and treatment and
visibility of care services in general, Infection prevention control activities at Health Facilities,
and implementingTB PreventiveTherapy to people at risk.
HealthIT mechanism has refurbished the TIBU surveillance system establishing seamless
interoperability with KHIS2, added more modules (training module on integrated TB guidelines),
developed and is piloting T-BU lite app for registering patients at point of care besides training
CTLCs and SCTLCs. HealthIT also provided DNLT-P with computers, and modems for GeneXperts
for on-line reporting to enhance linkage and transmission of results to officers who requested the
tests.
18
ACHIEVEMENTS (Q1)
● Provided TA to DNLT-P central unit for development of policies, guidelines and supported
supervision to all the 47 counties by paying supervision allowances to all CTLCs and SCTLCs
usingTIBU CASH
● Coordination of independent partners and stakeholders through quarterly forums and TWGs
which has aligned their activities to the priorities of NTP
● Annual work plan and budget co-planning for NTP with all partners
● Introduction of new technologies (iNTP) hence expanding diagnostic platforms for TB by
procuring and installing 8 digital x-rays with CAD4TB, 38 TrueNat Machines, and IGRA; and
DigitalAdherence technology (DAT).
● Supports sample referral systems, GeneXpert bundling and EQA for laboratory services.
● Capacity building at all levels: Partnered with the Union and trained NTP program officers,
CTLCs and SCTLCs on analysis and utilisation of data for decision making.
● Developed and installed TIBU surveillance system, provided registration tools, computers and
tablets to county and sub county coordinators and supported electronic capture of data.
● Supports DR TB patients with baseline and follow up tests.
● Conducted outreach campaigns in community hot spots and involvement of Private health
facilities to find missing TB patients , demand creation at facility and community levels
through ACCE
KEY FINDINGS
● Shortage of GeneXpert cartridges, lack of continuous maintenance and validation of
laboratory equipment.
● TIBU surveillance system aggregates patients’ data at sub county and county levels hence
delays notification of patients and occupies CTLCs and SCTLCs as data handlers instead of
focusing on supervision and mentorship.
● Lack of funding for research and documentations of best practices
● Stock out of child friendly treatment formulations in a few counties
Kenya still missing TB patients and lags behind the NSP target of successfully treating 90% of
diagnosed TB patients and the UN HLM commitment of putting 900,000 people on TPT.
RECOMMENDATIONS
● There is an urgent need to address and solve recurrent shortage of GeneXpert cartridges
and the lack of continuous maintenance and validation of laboratory equipment.
● Building capacity of the remaining CTLCs and SCTLCs to analyse and use data for decision
making
● Fast track implementation of T-BU lite app at point of care
● Repeat prevalence survey to establish progress made since last one in 2016 in finding missing
TB patients and map the hotspots forTB
19
LESSONS LEARNED
● Division of National Tuberculosis, Leprosy and Lung Disease (DNLT-P) Program with TB ARC
II support from USAID generated evidence on interventions which are then scaled up
country wide e.g., ACF, iNTP, PPM models, and co-creation of work plan
● National mechanism coordination of independent partners and stakeholders leverages
resources for tuberculosis prevention, care and treatment.
Evaluation question 2:To what extent has the county-focus support to the 4 regions by TB ARC II
contributed to the extra strengthening of TB prevention, care and treatment in these counties?
ACHIEVEMENTS (Q2)
TB ARC II deployed Regional Coordinators to each of the four regions, whose main tasks are to:
● Support the CTLCs with coordination of partners implementing TB and TB HIV services in
the regions
● Support PPM implementation
● Support CTLCs and SCTLCs to intensify health facility (public and private) supervision which
has improved quality of care
● Support partner coordination in the counties to leverage on experience and resources for TB
andTB/HIV care
● Support optimisation of resources from partners, especially sample referral systems and
supervision of both public and private health facilities and implementation of TB/HIV
collaborative activities.
Other achievements include:
● Increased private sector contribution to case finding (purpose being to find missing TB
patients )
● Established coordination forums with County TB and Leprosy Coordinators (CTLC) through
❖ Quarterly County Work plan Development Meetings bringing together all partners
and CTLC, including Sub County TB Leprosy Coordinators to prepare a work plan
for joint implementation in the quarter.The strategic purpose of the meetings is to
leverage resources towards smooth implementation of TB control activities
❖ Quarterly County TB/HIV Stakeholder Fora; a collaborative approach in TB/HIV
management meetings bringing together all HIV independent partners in the county
and county teams from HIV and TB to leverage expertise and resources for TB HIV
care.The financial support to conduct the meeting is shared among the IPs on a 
rotational basis.
❖ Quarterly County GeneXpert TWG Meetings; for enhanced coordination of TB
diagnostics systems especially sample networking by rider system.
❖ Clinical Meetings: Monthly clinical and mortality audit review meetings bringing
together multi-disciplinary teams (MDT) managing drug resistant TB patients.These
20
meetings review progress made by patients, are forums for CMEs and make
appropriate plans for care of the patients
● Intensified supervision and mentorship to the health facilities improving the quality of care of
TB services being offered in the 11 deep focus counties.
● Providing logistical support to the county TB team through a fleet of three vehicles and
logistical officers to improve efficiency of the coordinators, ensure they supervise high
volume health facilities regularly and support dissemination of tools and redistribute TB
commodities within the county.
Every month a multidisciplinary clinical review meeting is held at the health facilities to evaluate care
provided to patients.This is followed by quarterly meetings of the regional Committee of Experts
(CoE) on Drug Resistant TB to review and advise on the management of DR-TB patients hence
improving quality of care.The extent of the contribution of county focus towards strengthening TB
management can be shown through results of case finding, case holding, PPM contribution,TB HIV
collaboration in the four regions.
Case finding: The case notification rates of the counties in the 4 regions supported by TB ARCII
decreased due to COVID-19 pandemic. All except Kilifi and Isiolo are showing an increasing CNR
trend post COVID period as shown in the table 5 below. Counties of Kilifi and Isiolo have not
recovered and continue on a downward trend CNR.Kilifi county changed the entire TB and Leprosy
control staff.
County/years 2015 2016 2017 2018 2019 2020 2021
Mombasa 360 295 313 302 285 262 277
Meru 236 217 279 308 274 228 235
Tharaka Nithi 239 238 290 335 265 240 227
Nairobi 311 305 272 274 242 208 226
Isiolo 315 295 345 398 334 209 198
Kenya 176 160 179 193 172 148 154
Nyamira 109 112 106 101 119 118 133
Kwale 151 136 106 127 104 90 96
Kilifi 144 125 131 157 126 96 89
Table 5:Trend of DSTB Case Notification Rates for TB ARC II Supported Counties
21
County
Homabay
Migori
2015
82.5
87.9
2016
82.2
86.5
2017
88.3
90.4
2018
88.8
89.7
2019
92.4
90.9
2020
93.4
92.3
Siaya and Homa Bay counties supported by both TB ARC II and Komesha TB mechanisms are above
national average and showing increasing trend in CNR. Migori is below national average but showing
increasing CNR as shown in table 6 below.
Table 6:Trend of DSTB Case Notification Rates for KomeshaTB and TB ARC II Supported Counties
County/
Year 2015 2016 2017 2018 2019 2020 2021
Siaya 205 175 189 209 203 212 276
Homabay 191 172 187 191 184 181 187
Kenya 176 160 179 193 172 148 154
Migori 177 147 139 168 149 126 131
Case holding: From table 7 below, the treatment outcome results have improved across the TB ARC
II supported counties except Nairobi, Mombasa, Kilifi and Kwale.Table 8 below shows that in Homa
Bay County, treatment success rate of DSTB has increased from 88.3% in 2017 to 93.4% in 2020,
with the death rate declining from a high of 9.6% to 5.5% in the same period. For DR TB, treatment
success rate of all DRTB patients improved from 44.4% in 2017 to 85.7% in 2019, with case fatality
rate improving from 22.2% to 7.1%.
Table 7: Trend DSTBTreatment Success Rate 2015 to 2022 :TB ARC 11 Supported Counties:
County 2015 2016 2017 2018 2019 2020
Nyamira 90.5 90 87.7 89.5 91.1 91.3
Tharaka Nithi 91.4 87.8 89.3 89.5 90.1 88.8
Isiolo 92.2 88.2 91.4 81.5 91.8 88.7
Meru 87.9 84.8 82.5 84.5 85.2 85.5
Kenya 87.2 82.3 83 84.5 85.8 84.3
Mombasa 88.3 84 87.2 83.1 85.9 83.8
Nairobi 85.4 74.3 73.7 85.7 84.6 82.5
Kilifi 84.8 80.1 80.2 79 81.7 79.8
Kwale 83 81.8 82.4 84.9 83.5 79.8
Table 8:Trend DSTBTreatment Success Rate 2015 to 2020 in Komesha TB and TB ARC II Supported Counties
22
Siaya 82.9 80 78.9 81.3 86.8 86.1
Kenya 87.2 82.3 83 84.5 85.8 84.3
Table 9:Trend of DRTBTreatment Success Rate 2015 to 2019 in KomeshaTB andTB ARC II Supported Counties
County/
Year
Treatment
Outcome 2015 2016 2017 2018 2019
Siaya TSR 67 64 33 86 67
Death Rate 22 21 50 11 22
Homa Bay TSR 67 91 44 82 86
Death Rate 33 9 22 18 7
Kenya TSR 72 67 59 75 77
Death Rate 15 19 14 11 13
Migori TSR 86 40 29 67 92
Death Rate 0 50 41 33 8
Private Public Mix (PPM): TB ARC II focus counties are finding TB patients through implementation
of PPM strategy. County Health Management Teams (CHMTs), CTLCs and the TB ARC II Regional
Coordinators jointly support and supervise private health facilities.Workshops are held to facilitate
cross learning and sharing of best practices among the private facilities.The private-for-profit health
facilities are linked to GeneXpert sites through sample networking and transfer by engaging and
sensitization of riders.The following counties achieved the national PPM targets of 20%: Nairobi
(33.2%), Homa Bay (24.7%), Migori(31.8%), Mombasa(31%). Six out of eleven counties are above
country average of 19.7% and target of 20% as seen in the figure 2 below:
Figure 2: Case Notification contributed by Private sector in in percentage in TB ARC II focus counties in 2021
23
KEY FINDINGS:
● All counties in TB ARC II regions except Kilifi and Isiolo show increasing trend in CNR post
COVID-19 period. All counties except Nyamira, Kilifi, Migori and Kwale reported CNR
above national average (154/100,000 populations).
● The treatment success rate improved across the TB ARC II supported counties except
Nairobi, Mombasa,Kilifi and Kwale.
● The case notification rates of the counties in the 4 regions supported by TB ARCII decreased
during the COVID-19 pandemic for all counties due to COVID pandemic.
● All counties in the four regions except Kilifi and Isiolo are showing increasing trend in CNR
post COVID-19 period as shown in the tables below. Counties of Kilifi and Isiolo have not
recovered and continue on a downward trend.
LESSONS LEARNT: The deployment of regional coordinators has improved the quality of care in the 
11 counties.This extra support to the CTLCs and SCTLCs ensures partners are coordinated with
increasing resources and logistical support besides intensified supervision, providing on-the-job
mentorship, clinical and mortality audit meetings of the health facilities.The team (SCTLCs, CTLCs
and Regional coordinators) identify and address unique problems at the health facilities.
RECOMMENDATIONS: Escalate lessons learnt from the four regions to the entire country by deploying
regional coordinators in the rest of high burden countries or the whole country dependent on
available funds.
Evaluation Question 3:To what extent has the mix of TB ARC II – Komesha TB – HealthIT support
to the national and county programs contributed to the overall strengthening of TB prevention, care
and treatment in the country?
The design of all the three mechanisms took into consideration the contribution of private facilities
because of the fact that a significant 42% of patients with TB symptoms go to the private health
sector as the initial point of seeking care (Patient pathway analysis 2016).
TB ARC II: TB ARC II is supporting case finding activities in private for profit health facilities in 5 
counties; Meru, Kirinyaga, Mombasa, Kilifi and Nyeri since October 2020. PPM engaged private
providers in the five counties include 146 health facilities of which 96 are hospitals and clinics, 31
chemists/pharmacies, 11 standalone laboratories and 8 corporate clinics.TB ARC II has trained a 
total of 410 health care workers from the private sector on TB control.The 5 counties have been
supported to conduct joint support supervision with the County Health Management Teams
(CHMTs).This activity contributed significantly to strengthening partnership between the private
health providers and the county governments; it also provided a platform to lobby for additional
support for private health providers from the county governments who play a critical role in
24
providing overall leadership and oversight. Experience sharing workshops were also conducted and
these facilitated cross learning and sharing of best practices among the private health providers. In
order to strengthen access to more sensitive diagnostic tests (GeneXpert),TB ARC II supported
linkage of private-for-profit health facilities to GeneXpert sites.This was through engagement and
sensitization of riders who provided services at a cost sharing basis; therefore, both the facilities and
riders benefited from this activity thus enhancing sustainability.
Komesha TB project : Komesha TB employs four interventions as stated in the USAID Global TB
strategy 2023-2030: 1) Reach; Supports lead clinicians to take lead in finding TB patients in all
service delivery points in health facilities, Engages TB link assistants in areas the patient pathway
analysis revealed missed opportunities to identify TB patients, Collaborates with health management
teams to plan and implement TB services at the facility, Facilitates community health volunteers to
identify TB patients, referring and linking them to diagnostic and treatment centres. Komesha TB
facilitates TB sample riders to network samples to nearest GeneXpert sites (Spoke to hub system),
Pays for chest x-rays for needy children, and links TB patients to nutrition service centres. 2) Cure: 
This consists of establishing and supporting Multi-Disciplinary Teams (MDT) to manage TB patients,
including the management of the health facility. Provides support supervision to the lab, pharmacy,
and improving quality of care for TB services. Komesha TB supports joint county annual work plan co￾creation workshop, participates in TB planning meetings at county, sub county and facility level,
supports TB school health awareness programs by providing radio health talks, screening, treatment
of TB. Supports capacity building for providers in TB care through training, sensitization, mentorship,
On Job Training (OJT) and task shifting is applied to prevent breakdown in delivery of services and 
supports cross learning and benchmarking visits. 3) Prevent: This involves targeted screening for
active TB disease, contact invitation,tracing and investigation, mapping of TB hotspots in the
community and conducting mass screening. Further, Komesha TB implements TB infection control in
health facilities which consists of facility infection prevention control plans, provides personal
protective equipment for TB health care workers, and conducts surveillance of TB infection among
health care workers, introduction and implementation of management of latent TB infection for
people at risk at health facilities. For 4) Sustainability; Introduction and implementation of new
tools to prevent, detect and treat TB through piloting in collaboration with MoH for sustainability;TB
Quality Improvement, implementation research, abstracts success stories, innovations, and case
studies.
Table 10 below shows trends of the contribution of the private sector to notified TB patients in
selected counties supported by Komesha TB alone and Komesha TB & TB ARC II, starting from 2015
to 2021.
Table 10: Percent Contribution to Notified TB patients by Private Sector : Komesha TB supported Counties
2015 2016 2017 2018 2019 2020 2021
25
County 2015 2016 2017 2018 2019 2020 2021
Kisumu 30.1 29.5 34.9 31.5 31.2 39.1 31.5
Vihiga 19.3 17.4 22.7 12 14.1 20.2 27.1
Kakamega 12.2 16.1 19.7 14.9 17.4 20.2 21.6
Kenya 18.2 17.9 22.2 18 18.7 20.5 19.7
Busia 10.8 15 17 10.1 12.1 14 16
Kisii 11.3 9.9 17.2 14.5 15 16.8 15.4
Bungoma 3.9 2.9 21.5 15.2 13.7 11.4 12
The PPM contribution to notified TB patients is increasing in the Komesha TB supported counties. In
Kisumu,Kisii, Migori and Siaya, the trend declined in 2021.
Table 11: Percent Contribution to Notified TB patients by Private Sector :Komesha TB and TB ARC II Supported Counties
Migori
Homabay
Kenya
Siaya
13.4
21.1
18.2
14.5
12.8
19.4
17.9
15.3
24.9
20.7
22.2
15.4
22
15.8
18
12
29
18.9
18.7
13.6
33.6
22.6
20.5
15.4
31.8
24.7
19.7
13.5
26
The PPM contribution notified TB patients more in the counties that previously benefited from the
support of TB ARC II Tunza as Migori and Homabay.TB ARC II launched PPM in October 2020.The 
performance reported below in Figure 3 shows 81% screening, 63% testing and 100% TB treatment
uptake. The adjacent graph in figure 4 shows the increase in case notification over the quarters in
these private health facilities (TB ARC II report 2021).
Figure 3:Care cascade performance for the PPM CHS USAID project for the period (National Tuberculosis, Leprosy and Lung Disease
Program ANNUAL REPORT 2021) Jan - Dec 2021
Figure 4:TB patients identified through PPM pilot in 5 counties
ACHIEVEMENTS (Q3)
● Availability of PPM policy and action plans to guide PPM implementation
● Coordination of Public Private Mix (PPM) forum (CHMTs, CTLCs, SCTLs,TB ARC II regional coordinators)
27
● 15,574 TB patients (20% of all notified patients) who were from Public Private Mix (PPM) in
2021.This is a 2.3% increase from the previous year (national annual TB report 2021).
● The Komesha TB program supported counties reported 2,867 (of which 43% Female) TB
patients in 2021 from PPM including 227(6% Female) children. (Komesha TB presentation).
● Intensified health facility (public and private) supervision which has improved quality of care
● Partner coordination in the counties to leverage on experience and resources for TB/HIV
care.
● Optimisation of resources from partners, especially in sample transfer systems and
supervision of both public and private health facilities and implementation of TB/HIV
collaborative activities.
● Increased private sector contribution to case finding (missed patients )
KEY FINDINGS:
● Lack of financial incentives for private-for-profit health facilities involved in TB care.
● High turnover of health personnel in faith based and private health facilities.
● Commodity supply disruption – nutritional supplements, GeneXpert cartridges
● Incomplete referral from community to health facility
● Low priority for TB interventions in some private hospital whose motive is profit
RECOMMENDATIONS
● Frequent engagement of private health facilities to sustain TB control
● Drive implementation of community TB case finding through existing community health
strategy structures
● Frequent engagement of hospital administrators for ownership
● Champion a business model with private hospitals to strike a balance between TB control
and profit at the facility
● Advocacy at national TB level for availability of nutritional supplements and GeneXpert
cartridges
● Involvement of faith-based service consortium enhances coordination between the
interrelated FBO organisations
● Collaboration with host county department of health to align program interventions to
county priorities
● Frequent staff engagement to optimise quality of care and sustain intensified case finding
● Program Quality Improvement and Efficiency plays a key role in performance improvement
(PQE web siteTB program)
● Working closely with facility administration, enhances ownership and program performance
● Joint planning and implementation with IPs in the region of support to ensure coverage of 
scope of activities and efficient use of resource
28
County 2015 2016 2017 2018 2019 2020 2021
● Engage the faith-based services consortium during entry at FBO facilities to optimise
coordination
● Continuous collaboration with MoH and IPs in the regions for impact
● Training and capacity building be customised to maximise attendance for staff at private
facilities where time off equates to losses
Evaluation Question 4: How has access to and utilisation of TB prevention, care and treatment
services changed over the period of implementation of TB ARC II, Komesha TB and HealthIT (TB
support)?
The aspiration of the Division of National Tuberculosis and Leprosy program of the Ministry of
Health is that people with TB disease symptoms have access to diagnostic TB services, holistic quality 
care and TB prevention in the general population through support of GoK, GF and USAID (through
its three mechanisms).
The three USAID mechanisms contributed to access and utilisation of TB prevention, care and
treatment services.TB ARC II main goal is to improve TB case finding through (1)Active Case finding
initiatives in all counties, promoting access to high quality patient-centred,TB, DR-TB and TB/HIV
services; (2)preventing TB transmission and disease progression, implementation of infection control
and TPT for all contact persons of a TB bacteriologically confirmed pulmonary case and PLHIV who
screen negative for TB, strengthening TB service delivery platforms & accelerating research and
innovation with the ultimate goal of decreasing incidence & TB related morbidity, and mortality in line
with the 90-95-0 targets to End the TB epidemic, (3) early treatment of diagnosed TB patients, and
(4) systematic screening and diagnosis of HIV among TB patients and subsequent initiation of life 
saving ARVs.
The interventions are coordinated through DNLT-P at national and county level.This ensures
harmonised policies and guidelines formulation, development of strategic framework and resource
mobilisation leading to rapid scale-up of strategic interventions, technical assistance and logistical
support towards sustainable TB control initiatives at National and Sub National levels.
Above collaborations and intervention’s purpose is to increase notified TB patients and reduce loss
of lives because of TB.
Case Notification Rate: Increasing trend of CNR among TB ARC II supported counties, in spite
of the setback of COVID 19 pandemic as shown in table 12 and 13 below:
Table 12:Trends of TB Case Notification Rate by county (TBARC II)
29
County
Siaya
Homabay
Kenya
Migori
2015
205
191
176
177
2016
175
172
160
147
2017
189
187
179
139
2018
209
191
193
168
2019
203
184
172
149
2020 2021
212 276
181 187
148 154
126 131
County
Mombasa
Meru
Tharaka
Nithi
Nairobi
2015
4
8
3
2016
5
21
4
2017
2
28
1
2018
7
45
7
2019
6
27
9
2020
15
73
12
2021
2
82
18
Isiolo
Nyamira
Kwale
Kilifi
Homa Bay
86
4
5
4
10
15
60
5
3
5
12
11
68
5
5
2
14
9
85
5
8
7
13
11
95
5
8
6
10
14
114
11
7
15
15
15
97
12
9
2
7
24
Mombasa 360 295 313 302 285 262 277
Meru 236 217 279 308 274 228 235
Tharaka Nithi 239 238 290 335 265 240 227
Nairobi 311 305 272 274 242 208 226
Isiolo 315 295 345 398 334 209 198
Kenya 176 160 179 193 172 148 154
Nyamira 109 112 106 101 119 118 133
Kwale 151 136 106 127 104 90 96
Kilifi 144 125 131 157 126 96 89
Table 13: KomeshaTB andTB ARC II Supported Counties
Table 14:Trends of DR TB Case finding by county 2015 – 2021:TB ARC II Supported Counties
30
Siaya 9 14 9 28 18 20 12
Migori 7 10 16 9 12 24 17
Kenya 450 441 516 681 687 959 804
Public Private Mix (PPM): In 2019, institution/provider PPM and corporate models were
supported through TB ARC II.This involved engaging Tunza clinics networks which include ‘small’
individual owned clinics. Some of these clinics are within nursing homes and medical centres that have
laboratories and admit patients.
A total of 100 health facilities were engaged in Nairobi, Mombasa, Nakuru, Kiambu,Tharaka Nithi,
Meru, Isiolo and Embu counties. Eighty-eight (88) health care workers were trained using the
integrated TB curriculum. By then, a total of 36,068 patients were screened in the Tunza facilities,
about 2,500 presumptive TB patients identified and 2,024 sent for diagnosis at various GeneXpert
sites. Out of the total presumptive patients tested, there were 61 patients diagnosed with TB.
TB ARC II also developed the corporate model of PPM to reach the males in the economically
productive age group. In 2019, health departments in priority industrial counties were engaged
including Kisumu, Nakuru, Nairobi, Mombasa, Kwale and Machakos counties. In 2019, a total of eight
(8) companies were reached and sensitised on TB. Screening for TB was done in three companies
with a total of 1147 workers screened, 107 Gene Xpert tests done, and of all tested one was Gene
Xpert positive and 8 had X-rays suggestive of TB.All the nine patients were initiated on treatment.
The 2021 DNLT-P Annual report reported that the PPM network through TB ARC II support had
146 health facilities; 96 hospitals and clinics, 31 chemists/pharmacies, 11 standalone laboratories and 8 
corporate clinics. In the same years,TB ARC II trained a total of 1,268 health care workers from the
private sector inTB control.
KOMESHA TB
Komesha TB project through KCCB started in October 2019 in nine counties in the western Kenya
region and focussed on Faith Based health facilities and private-for-profit health providers. In
summary, the focus of Komesha TB is to improve TB treatment outcomes, and identification of TB
patients through the 140 health facilities, composed of 84 Faith Based health Facilities, 54 private
health facilities and 2 public health facilities in Vihiga, Migori, Kisumu, Homa Bay, Nyamira, Kisii,
Kakamega, Busia and Bungoma counties. Komesha TB has reported 6,889 TB patients since 2019 and
treatment success rate was 84% and death rate of 5%.Tables 15-18 provide details of DS TB CNR
from the KomeshaTB supported counties and treatment outcomes.
31
County
Siaya
Homabay
Kenya
Migori
2015
205
191
176
177
2016
175
172
160
147
2017
189
187
179
139
2018
209
191
193
168
2019
203
184
172
149
2020
212
181
148
126
2021
276
187
154
131
Table 15: CNR for Komesha TB Supported Counties
County 2015 2016 2017 2018 2019 2020 2021
Kisumu 269 232 235 244 182 167 161
Kenya 176 160 179 193 172 148 154
Kisii 124 111 134 141 135 126 144
Vihiga 126 125 139 154 122 100 117
Busia 137 107 153 148 126 80 100
Kakamega 114 92 128 130 122 104 96
Bungoma 93 108 118 118 94 71 77
Table 16 CNR for KomeshaTB and TB ARC II Supported Countries
Table 17: DS-TBTreatment Success Rates (%) for KomeshaTB Supported Counties
2015 2016 2017 2018 2019 2020
Kisii 91.8 90.3 89.5 89.6 90.5 93.2
Kisumu 83.9 81.9 74.3 71.5 84.7 86.3
Kenya 87.2 82.3 83 84.5 85.8 84.3
Busia 85.4 83.8 83.3 83.7 83.3 84.1
Bungoma 87.5 85 85.5 85.2 83.6 80.9
Kakamega 85.9 86.2 86 85.2 85.3 80.1
Vihiga 87.3 82.5 81.6 85 81.3 75
32
Table 18: DS-TBTreatment Success Rates (%) for KomeshaTB andTB ARC II Supported Counties
2015 2016 2017 2018 2019 2020
Homabay 82.5 82.2 88.3 88.8 92.4 93.4
Migori 87.9 86.5 90.4 89.7 90.9 92.3
Siaya 82.9 80 78.9 81.3 86.8 86.1
Kenya 87.2 82.3 83 84.5 85.8 84.3
Evaluation Question 5: How has the mix of USAID support (to the national and county TB programs
via TB ARC II, HealthIT and Komesha TB) with Global Fund, GoK and other donors contributed to
the strengthening of TB prevention, care and treatment in Kenya? To what extent are the strategies
duplicative and to what extent are the strategies deficient considering UNHLM, NSP and USAID’s
GlobalTBAccelerator goals?
All stakeholders in the fight against TB aligned their strategies with the WHO strategy to END TB by
2030. Hence, the NSP for tuberculosis control in Kenya is a contextual replica of the WHO END TB
strategy.The NSP is also aligned with the new Global Fund funding model.The involvement of all
stakeholders in the design and planning process limits duplication and ensures that all aspects of the
strategy are considered.
The 2021 DNLT-P Annual report shows that Kenya achieved and surpassed the Global 2020 targets
as follows; 1)32% reduction in TB incidence rate against a target of 20% and 2) 38% reduction in
mortality rate against a target of 35%. However, the country still faces a high burden of TB, HIV and
TB/HIV.The performance from 2019 compared to 2021 in table 19 below gives an idea about the
overall fight againstTB in Kenya
Table 19: Performance against program targets: 2019 vs 2021
Indicator Target 2019 Target 2021 Results
2019
Results 2021
DSTB Case finding 147,000 101,366 86,504 77,834 (77%)
Paediatric patients notified 10% - 15% 10% - 15% 8393 (9.7%) 7.491 (9.6%)
Bacteriologically confirmed patients
notified
57%
Private sector Contribution (%) 25% 25% 15% 19.80%
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Proportion of males notified (%) 64% 66%
HIV testing (%) 100% 100% 98% 97%
Co-infection Rate (%) 26% 23%
ART Uptake (%) 100% 100% 96% 96%
DSTB Treatment Success Rate 90%(2018) 90%(2020) 84% 84%(2020)
Cure Rate 90%(2018) 90%(2020) 71% 71%(2020)
Death rate from <4% <4% 6.5% 6.2%(2020)
DST Coverage (New) 59% 61%
DST Coverage (Previously Treated) 100% 100% 81% 77%
DRTB Case finding 2,170 2,492 692 804
DRTB Treatment Success Rate 90%(2017) 90%(2019) 73% (2017) 77%
DRTB Cure Rate (2019) 90%(2017) 90%(2019) 59% 56%
Under 5 years on TPT 15866 7791 (49%) 6,191 (43.7%)
UNHLM Goal: The country is continuously tracking progress towards achievement of UN
High-Level Meeting (UNHLM) political commitments with targets aimed at ending Tuberculosis by
2035.The multi- sectoral approach is considered impactful in fighting the TB epidemic. So far, the
country has made progress towards achieving some of these targets that include;
● In 2021 Kenya, through the leadership of the Ministry of Health started the development of
the multi-sectoral accountability framework. A draft document is available.The final
document is planned for launching soon.
● The program had committed to diagnose and put on treatment 425,200 people with TB by
the end of 2021.The program managed to detect and treat 330,792 representing an
achievement performance of 78%.
● The country also committed to expand the diagnostic capacity to detect TB including
adoption of new technologies. It has so far expanded culture labs from 2 to 5 and is in the
process of availing more molecular diagnostics through procurement of GeneXpert and
Trunat machines. So far DST coverage for all people with TB is 66% against a target of 90%.
● The country developed LTBI guidelines to be used in TB preventive therapy and identified
populations to be reached that includes; PLHIVs,TB contacts, HCWs and prisoners. Since
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2018, over 180,000 people have newly been initiated on ART and over 32,000 contacts
started on TPT.The roll out has been slowed by lack of funds to train sub national levels as
well as commodity challenges especially lack of new molecules and testing kits
KEY FINDINGS:
The main issue has been the delayed procurement of commodities, especially GeneXpert cartridges
affecting the performance of the program.The programs have also been affected by the COVID-19
pandemic.The amount of funding doubled since 2019 to 30,766,272.69 (USD) in 2021 which are not
in a common basket, however there is a challenge in absorption especially the COVID-19 funds.The
low expenditure rates are attributed to ongoing procurement for Global Fund NFM3 grants.TB ARC
II absorption rate of funds was 95%.The evaluators recommend follow up of NSP funding supported
by co-creation and co-planning.Allowances paid to program officers by partners are not standard.
Recommendation:
● DNLT-P and GF partners to fast track implementation of NFM3 grants.
● Establish a common basket fund system that covers all partners.
● Harmonise per diem and fuel allowances across all partners and the state.
Evaluation Question 6: How can USAID best continue to support the national and county TB
programs in Kenya with regards to the most effective and efficient number of mechanisms, 
geographical coverage (factoring devolution) and types and focus of support?
KEY FINDINGS
The majority of KII prefer multiple mechanisms.The evaluation recommends that USAID support
DNLT-P to be channelled through two.
● Both mechanisms to have regional and county focus on all thematic TB care areas.
● One of the mechanisms to have national support to the Central Unit of DNLT-P, maintaining
the current technical assistance to ensure and maintain CU stewardship of the program and
competent policy promulgation, dissemination and resource mobilisation.
● The first mechanism (Eastern) will have national focus besides supporting twenty three(23)
counties in eastern, northern, central, coastal and Nairobi regions of Kenya.
● The second mechanism(Western) will cover the remaining twenty four(24) counties from
Rift valley,Western and Nyanza regions of Kenya.
● All mechanisms will support all thematic areas in TB care, prevention and treatment.These
mechanisms shall pay allowances of CTLCs and sub county coordinators through TIBU cash.
● Each of these mechanisms shall deploy Regional Coordinators to cover 2-3 counties and pay
allowances of CTLCs and sub county coordinators through TIBU cash.
SWOT Analysis: Relevance, Effectiveness and Efficiency of the three mechanisms.
The SWOT analysis on the relevance, Effectiveness and Efficiency of the three mechanisms is annexe 
7:.
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The evaluators found that: 1) The service package of the TB ARCII, HealthIT and KTB mechanisms
meet the needs of the TB program.The relevance would be fairly well expressed when they are
combined. 2) The effectiveness of all three mechanisms has been demonstrated, but the inability to
work across the mechanisms limits performance. Counties with combined support have better
performance. 3)for efficiency we cannot attribute an exclusive analysis to USAID support.The
co-creation and co-planning system in place makes all partners accountable for the performance
produced
4.0 OVERALL RECOMMENDATIONS
1. All DNLT-P stakeholders urgently address and solve recurrent shortage of
GeneXpert cartridges.
2. The stakeholders to ensure prompt and continuous maintenance and validation of
laboratory equipment
3. HealthIT is requested to fast track implementation of TIBU lite.
4. Escalate lessons learnt from the four regions (TB ARC II) and western Kenya
(Komesha TB) to the entire country by deploying regional coordinators in the rest of
high burden counties or the whole country if resources allow.
5. Faith-based services consortium is engaged during entry at FBO facilities to optimise
coordination.
6. Training and capacity building be customised to maximise attendance for staff at
private facilities where time off equates to losses.
7. The Division of National Tuberculosis Leprosy Program (DNLT-P) and Partners
(USAID) are requested to apply innovative technology and ensure program review
meetings are held regularly at all levels of TB care services.
8. The Division of National Tuberculosis Leprosy Program (DNLT-P) and partners are
requested to adopt and apply innovative strategies to find patients suffering
tuberculosis;
a. ACF in all health facilities, priority to high volume Health Facilities
b. ACF in the community initiatives walk in sputum collection centres.Adopt
the “Sema ATMs” next to HF stationed strategically to attract more
passersby.
c. Pilot community and HF sputum collection points for self referred clients to 
avoid long waiting times at HFs.
d. Conducting month-long nationwide campaigns, once or twice a year, aiming
for a heightened focus on finding presumptive TB in the community.
e. Conduct twice-yearly mass screening in mining areas, crowded urban
communes, refugee camps, prisons and other congregate settings.
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9. Engage existing community health strategy structures to drive and maximise on
contact invitations, tracing, investigations and community TB care in general.
10. USAID is requested to continue supporting programmatic areas (Reach, Cure,
Prevent, Innovate and Sustain) to sustain the gains made in TB Care in the country,
however, DNLT-P petition MoH to assume more responsibility funding TB care than
it is doing at the moment.
11. Routine program management: There is a need to expand and sustain
competencies in the program in order to avoid over relying on partners.TB program
partners, particularly USAID and WHO are requested to bring this to the attention
of MoH.There is an urgent need for MoH to consider deploying TB Regional
Coordinators(MPH) within the Regional Commissioners’ office to support the work
of CTLCs and SCTLCs and be groomed to take over the running of the program in
future.TB control skills, knowledge and practices are acquired through actual
implementation at county level hence the need to build a strong team of staff to
support the various thematic areas, with technical advice from the TWGs and TB
ICC
12. Continue financial support for Program review meetings are held at national, regional
and county levels, and fund supportive supervision, on the job trainings at sub
counties and health facilities
13. In the next Program description it is recommended to use two mechanisms to
DNLT-P. Both mechanisms have regional and county focus and all thematic areas
(Reach, Cure, Prevent, Innovate and Sustain) on TB care. One mechanism to have
national focus for sustaining TA to the Central Unit of TB program including
coordination of implementing partners and stakeholders.
14. National Tuberculosis Leprosy and Lung Disease Program (DNLT-P) and GF partners
to fast track implementation of NFM3 grants.
15. Establish a common basket fund system that involves all partners.
16. Harmonise per diem and fuel allowances across all partners and the state.
5.0 LIST OF ANNEXES
Annex 1:Activity Scope of
Work (SoW)
Scope ofWork
Annex 2:Analysis Matrix Analysis Matrix
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Annex 3: Data collection tools,
checklists and consent form
Tool 001: Patient Questionnaire
Tool 002: National and County Coordinators
Tool 003: Other Partners
Tool 004: TB focal points and beneficiaries
Tool 005:USAID Staff
Tool 006: NTP
Tool 007: Evaluation Checklist
Annex 4:Activity entry briefing
summary notes
Annex 5: List of indicators List of indicators
Annex 6:Weekly reports
Annex 7: SWOT analysis
Annex 8: Summary KII
Respondents
Annex 9: Checklist responses