Final Assessment and Evaluation Report
Tuberculosis Program
Implementation in the Central Asian Republics
Kazakhstan – Kyrgyzstan – Tajikistan – Turkmenistan - Uzbekistan
Submitted in fulfillment of Grant #176-A-00-04-00006-00
United States Agency for International Development
Grant Dates: April 1, 2004 - March 31, 2009
Project HOPE
The People-to-People Health Foundation, Inc.
Millwood, Virginia USA
This program has been made possible with the support of the American people through USAID. Project HOPE is responsible for
the content, which does not necessarily reflect the opinion of USAID or the United States Government.
Tuberculosis Program Final Assessment and Evaluation Report 2
Abbreviations
AIDS Acquired Immunodeficiency Syndrome
BCC Behavioral Change Communication
CAR Central Asian Republics
CDC U.S. Centers for Disease Control
DOT Directly Observed Treatment
DOTS The WHO-recommended strategy for effective TB control
DRS Drug Resistance Survey
DST Drug Susceptibility Testing
EQA External quality assurance (laboratory)
FDC Fixed dose combinations of anti-TB drugs
GDF Global Drug Facility
GFATM Global Fund to fight AIDS, Tuberculosis and Malaria
GLC Green Light Committee
HIV Human immunodeficiency virus
HLWG High level working group
HRD Human resource development
IEC Information, Education, Communication
ICRC International Committee of the Red Cross/Red Crescent
IDA Foundation International Dispensary Association
JHU/CCP Johns Hopkins University/Center for Communication Programs
JSI John Snow, Inc.
KfW German Development Bank
M&E Monitoring and evaluation
MDR TB Multi-drug resistant TB, resistance to at least isoniazid and rifampicin
MoH Ministry of Health
MSF Medecins Sans Frontieres
NCS National Communication Strategy
NJMS-GTBI New Jersey Medical School – Global Tuberculosis Institute
NTBC National Tuberculosis Center
NTP National Tuberculosis Program
OR Operational Research
PHC Primary Health Care
QA Quality assurance
TB Tuberculosis
TB/HIV Tuberculosis plus HIV infection
ToT Training of trainers
TWG Thematic working group, or Technical working group
USAID United States Agency for International Development
WFP World Food Program
WHO World Health Organization
Tuberculosis Program Final Assessment and Evaluation Report 3
Table of Contents
SUMMARY FINDINGS, CONCLUSIONS AND FUTURE PRIORITIES............................... 4
INTRODUCTION......................................................................................................................... 6
BACKGROUND........................................................................................................................... 7
FINDINGS OF PROJECT HOPE ACTIVITIES AND RESULTS, BY OBJECTIVE ............ 10
OBJECTIVE 1. BUILD POLITICAL SUPPORT..................................................................... 10
 Political commitment for TB in the CAR countries ....................................................... 11
OBJECTIVE 2. BUILD HUMAN AND SYSTEMS CAPACITY FOR TB CONTROL........ 13
 Integration of vertical control into general health care................................................... 13
 Strengthening the laboratory network............................................................................. 14
 Creating a rational drug management system................................................................. 16
 Human resource capacity building.................................................................................. 18
 Improve program management, reporting system and surveillance............................... 20
o Information system, monitoring and supervision
o Linked interventions and system strengthening
o Operational research
o Resource mobilization
OBJECTIVE 3: RAISE COMMUNITY AWARENESS.......................................................... 24
EPIDEMIOLOGICAL IMPACT OF THE TB CONTROL PROGRAMS ............................... 27
COUNTRY-SPECIFIC KEY FINDINGS.................................................................................. 30
CONCLUSION ........................................................................................................................... 43
ANNEXES
1. Evaluation team members
2. Regional and country maps and USAID/Project HOPE pilot sites
3. Final evaluation meetings: Countries visited and main persons interviewed
4. Activities by country
5. Examples of training activities, by country
6. Activities carried out in human resource development
7. Operational Research studies conducted by Project HOPE with national partners
8. Tuberculosis in the Central Asian Republics
9. GFATM TB grants status
10. Project HOPE matching funds
Tuberculosis Program Final Assessment and Evaluation Report 4
SUMMARY FINDINGS, CONCLUSIONS AND FUTURE PRIORITIES
USAID provided US$15 million in financial support to Project HOPE for a period of five years,
to assist the governments of the five Central Asian Republics (CAR) in strengthening political
commitment, upgrading clinical capacity, improving the quality and availability of services for
tuberculosis control and increasing public awareness. The cost sharing amount that the award
recipient (Project HOPE) agreed to expend of $2,721,929 at the time of the evaluation had
already been exceeded and was already more than $2,858,110.35 million USD (see Annex 10).
Project HOPE acted as lead agency for a Consortium that included John Snow, Inc. (JSI), John
Hopkins Bloomberg School of Public Health/Center for Communications Programs (JHU/CCP),
New Jersey Medical School Global Tuberculosis Institute (GTBI) and local NGOs, plus
CAMRIS International and Chemonics International for the initial part of the project. Project
implementation started on 1 April 2004 and was scheduled to end on 31 March 2009. A No Cost
Extension was received for all countries except Tajikistan. The final closing date of the project
will be October 14, 2009.
An evaluation team (see Annex 1) analyzed data and visited four of the countries on February 6-
21, 2009, and reached the following conclusions.
All the national partners and the staff of other organizations interviewed by the members of the
evaluation team stated great satisfaction with the support of Project HOPE, and noted that the
active cooperation and coordination provided were essential for the progress of the TB control
programs in the region.
The major achievements identified in the region during the project were:
 Increased political commitment and government funding for TB control;
 Improved coordination of partner support through the national High Level Working
Group (HLWG) (or equivalent organizations) and Thematic Working Groups (TWG);
 Development of National Tuberculosis Program (NTP) capacity and authority;
 Increased national capacity for human resource development and program management
and mobilization of financial resources for TB control;
 Project contributed to development of the capacity of the health system for disease
control and health management;
 Gradual acceptance of the DOTS Strategy;
 Expansion of case detection activities integrated into general health facilities, with
ownership and monitoring by the NTP;
 Gradual acceptance of technical and operational procedures towards current
international standards, with update of NTP manuals;
 Implementation of the TB laboratory network, including quality assurance and
development of national capacity for drug resistance surveys;
 Implementation of appropriate TB drug management, including a system of information
and logistics;
 Increased capacity for community mobilization activities;
 Reduction of stigma; and
 Reduction of the burden of TB disease and death.
Tuberculosis Program Final Assessment and Evaluation Report 5
The main regional priorities for future action are:
 To establish a rational balance between the investment in the effective DOTS strategy
intervention and the additional development of interventions such as for MDR TB.
 To promote international standards of TB care, such as diagnosis of laboratory-confirmed
cases by the family doctors (PHC) without reconfirmation by specialists; change from
systematic to selective hospitalization; and appropriate diagnosis and management of
TB/HIV and drug resistance.
 To promote elimination of ineffective practices, such as MMR and mass tuberculin
testing, and formalizing this through government prikazes.
 To support integration of TB control into the general health facilities.
 To monitor progress toward achievement of TB-related Millennium Development Goals.
 To intensify efforts for improved infection control.
 To increase knowledge about the magnitude of drug resistance, to develop an appropriate
strategy for case management of MDR TB, and to support rational implementation of
patient care for MDR TB in the health system.
 To improve coordination between TB control and HIV/AIDS control programs to
achieve joint management of care for TB/HIV patients.
 To improve the regional and national capacity for operational research, including:
o development and piloting of standard protocols for operational research on
essential program areas for TB (e.g., real prevalence of suspects among
outpatients) and training national staff to replicate and use the information for
action;
o identification of problem areas and development of appropriate studies (e.g.,
reasons for high failure in Kazakhstan, excessive radiological diagnosis in culture
negative retreatment patients in Kazakhstan);
o Interventions to reduce stigma, particularly gender-specific to protect women.
Tuberculosis Program Final Assessment and Evaluation Report 6
INTRODUCTION
Project HOPE supported implementation of the DOTS strategy for TB control from 1997-2001
in Kazakhstan and in the Central Asian Republics from April 2001 to March 2004, with funding
from USAID grants. An evaluation of the second project was carried out in March 2004 1
.
Implementation of the current project 2
started in April 2004, a mid-term evaluation was carried
out in January 20073
, and the final evaluation was conducted in February 2009. The final
evaluation was carried out by Shalva Gamtsemlidze, Kayt Erdahl, Fabio Luelmo (team leader)
and Stefan Talevski, from 6 to 21 February 2009. Two teams of two persons each visited
respectively Kazakhstan plus Kyrgyzstan and Tajikistan plus Uzbekistan. In each country the
teams interviewed national authorities and staff of Project HOPE and partner organizations, and
visited specialized and general health facilities. A list of the main persons interviewed and
institutions visited is attached as Annex 3. Discussion of the findings and recommendations and
debriefing took place in Project HOPE’s regional office from 16 to 21 February.
USAID provided US $15 million in financial support to the Project HOPE Consortium, for a
period of five years, to assist the governments of the five Central Asian Republics (CAR) in
strengthening political commitment, upgrading clinical capacity, improving the quality and
availability of services for tuberculosis control and increasing public awareness. Project HOPE
acted as lead agency for a Consortium that included John Snow, Inc. (JSI), John Hopkins
Bloomberg School of Public Health/Center for Communications Programs (JHU/CCP), New
Jersey Medical School Global Tuberculosis Institute (GTBI) and local NGOs, plus CAMRIS
International and Chemonics International for the initial part of the project. Project
implementation started on 1 April 2004; the final closing date will be October 14, 2009.
The project’s three general objectives were essential to increase the national capacity to
implement effective TB control programs and so reduce the burden of disease in the CAR
region. These objectives included the following strategies:
1. Build political commitment
 Establish high level working groups (HLWG)
 Establish thematic working groups (TWG)
 Support oblast roundtables
 Assess the TB program’s current burden of disease and policies
 Support the HLWG in deciding policy and program options in each country
1
Final Assessment and Evaluation Report, Project HOPE Tuberculosis Program. Implementation in the
Central Asian Republics. Grant #115-1-00-01-001-00, USAID.
2 USAID/Project HOPE Cooperative agreement 176-A-00-04-00006-00
3 Report of a mid-term evaluation, Project HOPE’s Central Asia TB Program. USAID Cooperative
Agreement 176-A-00-4-00006-00. Almaty, 3 February 2007.
Tuberculosis Program Final Assessment and Evaluation Report 7
 Promote sustainable financing of the NTPs
 Consolidate the findings and recommendations into National Plans
 Convene a regional meeting to discuss country assessments and policies
 Support meetings of national donor committees to improve coordination
2. Build human and systems capacity for TB control
 Recommend plans to integrate vertical TB control activities into the general health care
services
 Strengthen the TB laboratory network in each country
 Strengthen human resource capacity for TB control through training, ToT, developing of
training tools, continuous education and pre-service education
 Create rational TB drug management systems in each country
 Improve program management
3. Raise community awareness and encourage care seeking behavior
 Develop Behavioral Change Communication (BCC) strategies for TB and build capacity
among stakeholder agencies
 Raise awareness and conduct outreach to the general population and in clinical settings
 Support ACSM in targeted communities, with small grants when appropriate
 Advocate for a change of attitudes and priorities among policy makers
BACKGROUND
The WHO-estimated incidence of tuberculosis in the region in 2004, when the current project
started, was 74 000 new and relapse cases (129 per 100 000). In that year 61 000 TB cases were
reported by the five countries4
. However, only 17 000 new smear positive cases were reported of
the estimated 33 250, a rate of 30 per 100 000 and a smear positive case detection rate of 51%.
The reasons for this low case detection of sources of infection included very limited integration
of TB program activities in the general health care facilities; uncertain quality of microscopy;
and generalized use of radiology for diagnosis of pulmonary tuberculosis with negative or
unknown bacteriological results. The total TB cases reported included a high proportion of extra￾pulmonary forms (22–32 %), except in Kazakhstan, and of pulmonary cases with unknown
smear results. The proportion of smear positive among all diagnosed cases was under 30%.
In 2003, the baseline year for this evaluation, the new smear positive TB case detection rates
varied from 8% in Tajikistan to 81% in Turkmenistan. Reported treatment outcome was good in
most countries already in 2003, from 77% success in Turkmenistan to over 80% in Kazakhstan,
Kyrgyzstan and Uzbekistan (Tajikistan did not provide data to WHO for 2002). The TB control
strategy was in different stages of change; from the vertical specialized system of the old Soviet
Union to the DOTS strategy with services integrated in general health delivery. TB diagnosis
4 Global Tuberculosis Control. WHO Report 2006.
Tuberculosis Program Final Assessment and Evaluation Report 8
and indication of treatment is still performed by specialized professionals, with hospitalization of
the large majority of TB patients at least during the intensive phase of treatment. The first two
Project HOPE/USAID-supported projects in the region found major resistance to
implementation of the DOTS strategy in practice, even after formal adoption by the
governments. This resistance has diminished rapidly in Kyrgyzstan (helped by Health Sector
Reform), Tajikistan and Uzbekistan. Old practices such as mass screening have been abandoned
in those countries in favor of more effective interventions. In Kazakhstan and Turkmenistan old
practices are still maintained, but there is now a firm government commitment in Turkmenistan
to support expansion of the DOTS strategy which was done rapidly and completed in the whole
country in 2008.
In all countries, except Uzbekistan where the DOTS Centre is directly under the Ministry of
Health (MOH), the TB control program activities are under the umbrella of a National TB
Center or National TB Institute. Except in Uzbekistan, focal points for the key components of
the NTP work in different areas of the National Tuberculosis Centre (NTBC), usually do not
function as a team and have neither financial resources nor direct access to the officer
responsible for TB control in the MoH. In contrast, Project HOPE staff in each country
constitutes a well-defined team, and they collaborate with each of the focal points with variable
degrees of ownership of activities by the national counterparts.
Establishment of the NTP unit (i.e., a managerial team) responding directly to the head of TB
control in the Ministry of Health is the first basic operation for DOTS implementation in a
country5
. The absence of this unit weakens national ownership of TB control and the capacity to
plan, implement, monitor and supervise the program. As a result, Project HOPE continues
implementing some activities that should by now have been transferred and absorbed by the
NTP, although many activity areas have been transferred to national staff in the last two years. In
addition, except in Uzbekistan, NTP staff is part of the TB Center/Institute and not functionally
under the NTP. The TB Center/Institute is the highest specialized institution in TB but in
addition to tertiary level care it provides specialized care to TB patients that could be managed
by the general health facilities. The NTP as a public health program should have independence
to promote integration of TB activities in the general health system and rationalization of the use
of resources. In Uzbekistan the unit (DOTS Center) is based in the National TB Institute but
functionally responds directly to the responsible officer in the MoH: this seems an appropriate
model for the region. As in other countries of the former Soviet countries, the TB
Centers/Institutes are reluctant to depart from ineffective practices such as mass fluorography,
individualized treatment and long hospitalization, and NTP staff needs independence from the
formal structure and lines of authority of the Centers to promote change.
In all countries the basic TB-control documents such as TB or DOTS national strategies,
guidelines and manuals were either adopted by the governments or are currently being prepared.
Project HOPE played an important role in the development and dissemination of these
documents.
5 An expanded DOTS framework for effective tuberculosis control. WHO/CDS/TB/2002.297, page 9.
Tuberculosis Program Final Assessment and Evaluation Report 9
Donors play a very significant role in financing TB control in the region. In 2000-2003 the two
principal agencies financing TB in the region were USAID and KfW. The Global Fund for
AIDS, TB and Malaria (GFATM) is now very active in the region and plays a strong role in
further funding of activities for host governments who apply successfully for grants. The Global
TB Drug Facility (GDF) has become a critical player in ensuring that the poorer countries of the
region who meet strict program criteria are able to be supplied with sufficient quantities of
quality TB drugs. It is hoped that this will continue. The present donors and NGOs in the region
have their particular goals, objectives and specific activities. However all of them are aiming to
assist the institutional capacity of CAR NTPs to control the TB epidemic. Better coordination
and synchronization of these efforts will yield positive benefits for the future.
Implementation of the current project started in April 2004. The Project HOPE Consortium
included Project HOPE and five agencies supporting various aspects of project implementation.
A mid-term evaluation of strategies, achievements, and of the status and progress of the national
programs took place from 18 January to 3 February 2007. Key recommendations of the mid￾term evaluation were the following:
1. Strengthen national TB control program management in all countries by:
 Strongly advocating the consolidation of national TB management teams, with staff
based in the TB Center but responding functionally to the TB authority in the Ministry of
Health, to increase responsibility for managing the TB program.
 Advising on terms of reference for the NTP central unit staff to ensure clear lines of
authority, responsibility and supervision. Additional training and mentoring in their
managerial functions is urgently needed.
2. Give priority to strategic planning aimed to increase the national capacity to manage TB
control, by
 Gradually transferring routine managerial activities now carried out by Project HOPE
staff to trained, mentored and qualified national staff, particularly in areas of training,
supervision and quality assurance of microscopy. Project HOPE staff could complement
the national unit in the planning, implementation and monitoring of managerial activities
to provide on-the job training in appropriate methodologies.
 In collaboration with other partners (WHO, Gorgas, Caritas, CAPACITY, etc.),
concentrate on partner agreement on and promotion of appropriate national policies, joint
planning of support, compatible training and information materials and monitoring
indicators.
3. Advocate for a TB budget line in national health budgets, with at least minimum funding for
the managerial activities of the NTP (supervision, training, monitoring, drug distribution), to
be complemented by external support.
4. In Kazakhstan, promote a sustainable, good quality TB drug supply by advocating that the
national authorities maintain national funding and centralized procurement of TB drugs as
for other essential supplies for priority health programs, such as vaccines.
5. In Turkmenistan, use the opportunity of the current government commitment to expand
DOTS rapidly to guide and support a rational plan of expansion, in close collaboration with
WHO.
6. Develop a Project HOPE strategy and medium term plan to gradually prepare countries for
full NTP implementation and management of TB control; update Project HOPE staff on the
Tuberculosis Program Final Assessment and Evaluation Report 10
final structure desired (including health sector reforms such as changes in the funding and
use of TB hospitals and specialists); and strengthen their capacity to monitor progress.
Most of these recommendations were carried out in the past two years, with substantial increase
in national staff ownership of the TB control program and capacity to carry out and monitor
activities.
FINDINGS OF PROJECT HOPE ACTIVITIES AND RESULTS, BY OBJECTIVE
Project HOPE conducted many activities under the three program objectives. Key activities and
the contribution of Project HOPE to some of the changes in TB control in the region are
described in more detail by objective below. A summary table of activities conducted in each
country is listed in Annex 4.
Project HOPE conducted a number of activities that were not included or explicitly stated in the
original program plan, but were determined to be beneficial for improving TB control. These
include trainings requested by the NTPs, developed by Project HOPE, and conducted in several
different countries. They included training on epidemiology; on operational research to increase
the capacity of local counterparts to assess and interpret epidemiological data; on culture and
drug sensitivity testing (DST) for drug resistance; on infection control in response to increasing
MDR TB and TB/HIV cases identified. In Uzbekistan, training for supervision at rayon level
was developed so that the system of supervision from National to oblast and from oblast to rayon
would be more efficient - and rayons are now responsible for supervision and monitoring of
facilities in their areas. Drug management training for the rayon level was also developed and
conducted as a result of LMIS reviews and Project HOPE’s introduction of TB drug kit systems.
Also as a result of findings from an operational research study, training on patient counseling for
TB nurses was developed to reduce default rates. In Turkmenistan, additional funding was
provided by USAID to add activities to help the MOHMIT in achieving of 100% coverage of the
county by DOTS and a training centre was refurbished and equipped to increase the capacity of
the NTP in trainings.
Due to changes in the partnership structure during the second year of the project, activities
planned under Objective 1 were modified. Country policy assessments were conducted in 2
countries and determined to be unnecessary for the remaining countries given available
information. A migrant study was added to collect information on targeting this group, and a
financing study was added for Kyrgyzstan, which has just recently been completed. LMIS for
second line drugs and management training for MDR TB were also added.
Some activities originally planned under the cooperative agreement were not conducted. These
activities include development of a High Level Working Group in Tajikistan that was
unnecessary since a National Coordinating Committee to prevent and fight HIV/AIDS, TB and
Malaria chaired by the Deputy Premier Minister was already functioning in this role. A burden
of disease study was also planned but was already conducted by the World Bank in 2005, Small
Tuberculosis Program Final Assessment and Evaluation Report 11
Grants programs were not allowed under the laws of Uzbekistan and Turkmenistan; and several
activities planned for Turkmenistan were not approved by the MOH.
OBJECTIVE 1. BUILD POLITICAL SUPPORT
 Political commitment for TB in the CAR countries
All MOHs fully support the NTP implementation of the Stop TB partnership strategy and TB
control in all Central Asia countries, and have increased national funding for the TB program.
Tajikistan and Turkmenistan were the last countries where DOTS coverage reached 100%, in
2007. For Kazakhstan, the President of the Republic declared TB as a high priority in 2007.
The NTP teams are well staffed and are recognized, but frequent staff turnover is a problem in
Tajikistan and Uzbekistan. Although all elements of the TB strategy are in place, the quality of
DOTS services provided (work performed) is still not at a satisfactory level. All the countries
need further technical support. There are many challenges related to TB control that have been
recognized recently, such as TB in prisons, MDR/XDR TB, TB in Migrants, TB/HIV, and
Health System Reform. The MOHs show visible awareness of the need to solve these problems.
The initial phases of DOTS implementation have been done and policy makers should
concentrate their financial, human capacity to address new problems and strengthen the quality
of the current system.
The MOH awareness of DOTS strategy is visible everywhere, but real concerns still exist
regarding the persistence of old strategies for TB control (mass x-ray screening, tuberculin
diagnosis, long hospitalization, long term follow-up of the “chronics” category of patients) and
of legal instruments that help maintaining them. All positive results from the Project HOPE
pilot sites (see Annex 2) were accepted by the local NTP and approved by MOH for further
implementation countrywide.
Project HOPE provided all NTPs with sufficient support to build their organizational structure to
effectively address local needs, and to clearly define the responsibilities of different levels of
management. Kyrgyzstan has already begun integration of TB into the overall health system
through the Manas Taalimi health system reform project. Uzbekistan successfully started to shift
the main program activities and responsibilities from a vertical to horizontal system, presenting a
useful example for other countries. The supervision / monitoring structure and training are
shifting from the national to oblast level, and also from oblast to rayon and PHC. Many
activities could be done independently with less international assistance (for example
Uzbekistan) but the countries need additional technical support, especially Tajikistan and
Turkmenistan. There is a lot of work to be done and room for improvement.
There are differences in flexibility of the political will (more flexibility in Uzbekistan and
Kyrgyzstan, but less in other countries). However, the DOTS strategy was more easily accepted
in some cases at the periphery level than at the central level (for example in Tajikistan and
Uzbekistan). With Project HOPE support and assistance, and with good leadership of the TB
program, stakeholder collaboration and MOH support, effective implementation of TB control
Tuberculosis Program Final Assessment and Evaluation Report 12
happened in Uzbekistan. This could be an example of successful implementation and building
sustainability of TB programs for the future.
All countries have increasing funding for the NTP program. Because of different economic
situations, the financial input to the NTP varies between the countries. It is more evident in
Kazakhstan, Uzbekistan and Kyrgyzstan where governments invest more in the NTP, in
comparison with Tajikistan, where the program is mainly dependent on support from
international donors. For Kazakhstan and Uzbekistan a potential risk for the future of the TB
program is that large influx of external funds (mainly from GFATM grants, see Annex 9) might
divert efforts from the most effective interventions in primary health care to prevent TB
transmission. Also, some GFATM projects (both existing and pending approval) for Tajikistan
could reduce the focus on financial commitment from the government. Very useful collaboration
between Project HOPE, the MOH, the DOTS Centre and KfW in funding and activities has been
established in Uzbekistan.
Complete budget and expenditure data for the NTP program is not available. Specific
information about the cost effectiveness of the interventions is not available for all countries. A
costing study was conducted in Kyrgyzstan for some interventions.
Project HOPE has continued to play a leading role in advocating and assisting the NTP to
develop policy documents for Uzbekistan and Tajikistan, and in partner coordination.
Evidence of political commitment is seen in the strong cooperation between the MOH, NTP and
Project HOPE in all countries and in the active work of TWGs that were started by Project
HOPE and continue with strong input from other stakeholders in different thematic areas in all
countries. The number of the TWGs is different in each country, ranging from 2 in Turkmenistan
to 5 in Uzbekistan and 8 in Kyrgyzstan . The effective work of TWGs made possible to achieve
advanced results in many areas and the collaboration between national, local and international
groups has strengthened capacity for continuation of this work in the future. The topic areas of
the TWG are Laboratory, Training, Prisons, Drug management, Monitoring DOTS, IEC/BCC,
MDR TB and TB/HIV.
The importance of MoH political commitment is evident through the large number of prikazes
(executive orders) issued over the last several years, but the appropriate implementation and
follow-up for some of these prikazes is weak. The Project HOPE team has strongly supported
and assisted the NTP/MOH in preparation of many policy documents. New national policy
documents are ready (KAZ), already updated (Uzbekistan), or in process of development
(Tajikistan), all aiming to fully incorporate the Stop TB Strategy and Millennium Development
Goals for the period of 2010-2015.
With technical support from Project HOPE, TB technical manuals were developed in all
countries. However some of them should be updated according to international standards and
evidence-based medicine. Some of the new manuals, guidelines and protocols created during the
last two years are listed below:
 Monitoring/ Evaluation
 EQA for laboratory
Tuberculosis Program Final Assessment and Evaluation Report 13
 Treatment of MDR TB
 TB program manual
 Infection Control
 National Communication strategy (Oblast-level strategy in Kazakhstan pilot areas)
Integration of DOTS at the PHC level is still in process. However it has been started and
gradually improvement of implementation is visible. The area of health system strengthening for
diagnosis and treatment is not fully integrated in the PHC.
There is insufficient data showing the results of this integration. The leaders of the process of
integration are Kyrgyzstan and Uzbekistan. All policy document and projects (mainly
applications to GFATM) contain activities and a national strategic plan for implementation of
integration of the TB program to PHC. The process of integration of the TB program is fully
supported by Project HOPE and evidenced by training materials developed; multiple trainings
for General Practitioners, ToT and local trainers; supervision; transfer of knowledge to the
periphery levels; and ACSM activities for volunteers, Mahalla and other community leaders, and
women’ societies.
Project HOPE strengthened the mechanism of building links between NTPs, health care
providers and communities. However the community-based approach, public- private mix and
PAL strategies are still under consideration. Kyrgyzstan is the first country in the region piloting
PAL, to be followed by full implementation in the whole country. The first phase of Health
Sector Reform, which created Family Doctors in the general health facilities and the change in
funding of hospitals to a per patient basis and not by bed, is a positive factor to help incorporate
TB activities in the general health system. The Kyrgyzstan government received support from
Project HOPE, John Snow, Inc. and WHO to develop and test different methodologies for
integration.
OBJECTIVE 2. BUILD HUMAN AND SYSTEMS CAPACITY FOR TB CONTROL
 Integration of vertical control into general health care
Integration is taking place slowly as described above, and has lost momentum in most countries.
The main obstacle is that technical guidelines still reserve for TB specialists and TB hospitals
activities in patient care that can be done by general facilities more efficiently, with better
population access and with less interference with the life of the patient and the family. Some
examples are systematic hospitalization (no longer an international standard of care) and
reconfirmation of the microscopy diagnosis in smear positive patients found by the general
facilities. An opportunity to be used rapidly is the process of Health Sector Reform in
Kyrgyzstan; that could transfer many actions to the Family Doctor and insert the TB hospital as
a tertiary level of the general health system (possibly not only for TB but for lung or chest
diseases), to make best use of the available medical and nursing human resources.
Tuberculosis Program Final Assessment and Evaluation Report 14
 Strengthening the laboratory network
Project HOPE conducted baseline laboratory assessments, trained lab technicians and trainers on
both basic and advanced methods, conducted routine monitoring visits, created checklists,
developed guidelines and revised standards, and introduced an external quality assurance system
(EQA) for smear microscopy in the pilot sites. The EQA, based on double-blinded re-checking
of an annual sample of smears with statistical analysis seems to be working well and was
expanded country-wide by the national programs with support from Project HOPE and CDC. In
Kazakhstan, sample selection using the Lot Quality Assurance Sampling (LQAS) methodology
was used for slide sampling for blinded rechecking with good results, and a poster on this topic
was presented at the International Union Against Tuberculosis and Lung Disease (IUATLD)
World TB Conference in Paris in 2008. Support for the laboratory component included provision
of equipment, supplies and training in new methods and rational use of resources.
Since drug resistance was identified as a potentially significant program in the region, pilot drug
resistance surveys (DRS) were carried out to test and to train national staff in the methodology
of DRS. Training packages were prepared in local languages. Advanced training was provided in
all the CAR countries, including management of the laboratory network. A list of equipment and
supplies necessary for culture and DST examination was developed for Tajikistan and materials
procured for the DSRS with GFATM funding.
In Kazakhstan, Almaty oblast served as a model pilot and training area. Culture training was
introduced country-wide by Project HOPE as sub-recipient of GFATM Round 6 grant. In
Kyrgyzstan, with multiple donor partners, Project HOPE filled gaps, assisted in implementation
of training on microscopy, culture and DST and collaborated with the TB Centre in monitoring
and the production of national guidelines, policies, EQA and DRS. The main partners involved
were US/CDC, the National TB Institute, GFATM, and MSF and ICRC for the prisons. A
laboratory assessment in Kyrgyzstan in the initial years of the project showed poor results and
low workloads, and as a result the number of TB microscopy laboratories in that country was
reduced and smear positivity increased; a good example of rational planning. Field observation
in the central laboratory of Kyrgyzstan during this mission showed that the building facilities are
inadequate and that infection control measures seem insufficient for the higher risk procedures.
A new laboratory is planned, to be built with KfW funding, but the timing and plans are not yet
decided so improvement of infection control in the present laboratory is a priority.
In Tajikistan the laboratory network was supported since its establishment in 2002. Project
HOPE is the primary recipient of the GFATM Round 3 grant that started in 2004; this facilitated
the coordinated use of resources and technical assistance to the country. EQA is now established
country wide and the central lab was equipped and received continued training on management.
There are bridge funds from GFATM and a pending request for an extension; there are funds
from Round 6 through UNDP and an approved Round 8 GFATM proposal that is not yet signed
– all these inputs will require very careful planning and coordination to avoid duplication of
activities, inefficient use of resources and reduction of the financial commitment of the national
governments. In Turkmenistan, microscopy covers all oblasts and in one oblast, Balkan Velayat,
the central laboratory was specially supported with additional funding from USAID. The
national reference laboratory was equipped and staff trained, including on advanced technology.
Tuberculosis Program Final Assessment and Evaluation Report 15
A strategic plan was approved by the Ministry. In Uzbekistan training was provided at oblast and
local levels and a pilot area was developed in Samarkand; but an EQA CDC pilot project was
interrupted after one year highlighting the problem of sustainability.
Project HOPE also focused on capacity building of the National Reference Laboratories (NRL),
to increase skills, recognition of the NRL role in the laboratory network, and to assist the NRLs
with certification. Links and coordination with Supranational Reference Laboratories have been
developed in Kazakhstan, Kyrgyzstan and Uzbekistan, and are in process in Tajikistan.
Field visits to four countries showed that the microscopy network and EQA are well developed.
However there is a risk that most additional resources will go to new technologies not yet
appropriate for TB control and with little impact on transmission. Priority should be maintained
for microscopy in the integrated health facilities; and culture and DST implemented in selected
laboratories but ensuring that the results are well used by the program. Operational research by
the laboratory and the program should be used to find out if the number of suspects examined by
microscopy is sufficient to reduce the duration of transmission; to find out what is the
contribution of cultures to the diagnosis of pulmonary smear negative (KAZ) and extra￾pulmonary cases and to the confirmation of cure in patients that have completed treatment; and
to find out why sputum conversion is very slow in Kazakhstan.
Current Status of laboratory activities:
Component Kazakhstan Kyrgyzstan Tajikistan Turkmenistan Uzbekistan
Lab assessment completed completed completed completed completed
Rationalization completed completed In process In process In process
Training ongoing
(EQA)
ongoing: Basic
and Culture -
DST planned:
Advanced (Y4)
ongoing: Basic
and Culture –
DST planned:
Advanced Y4)
ongoing: Basic
planned:
Advanced (Y5)
To be
discussed
Monitoring
strategy
revision
revised In process In process In process revised
MDR TB
capacity
in place in place in process planned (Y5) Partially
achieved
NRL
certification
yes yes no no in process
Lab equipment GFATM GFATM;
KfW
GFATM￾Project
HOPE
Project
HOPE/USAID
KfW
Tuberculosis Program Final Assessment and Evaluation Report 16
 Creating a rational drug management system
An uninterrupted and efficient TB drug supply is a priority for all NTPs. At the beginning of the
current project, a variety of drug supply issues confronted each country and a lack of drug
management was present in varying degrees in all countries. Project HOPE and JSI experts
recognized problems related to rational drug use in drug management in the region and took a
lead role in assisting the NTPs to establish a rational system of drug management essential for
ensuring a stable drug management system required for TB control in the region.
In Tajikistan a situational analysis was done based on recently conducted monitoring visits in 52
(79%) districts by Project HOPE drug management specialists. There were a number of
challenges identified during the monitoring visits and recommendations were provided by
Project HOPE.
To strengthen drug management, Logistic Management Information Systems (LMIS) were
developed jointly with JSI, adapted to each country-specific situation, pilot tested and
implemented in all countries. Tools developed for use in the LMIS include TB drug recording
and reporting forms for all levels, and an LMIS manual. Trainings and workshops were
conducted for medical staff of different levels, and local training teams were prepared to support
nationwide roll-out of LMIS. Regular monitoring and evaluation has followed up all previous
activities, and as problems are identified, solutions are developed and implemented.
In Uzbekistan, positive results were shown and the LMIS was scaled up by the DOTS Centre
throughout the country, with assistance and training provided by Project HOPE and JSI. The
MOH recognized that the LMIS model is useful not only for TB drugs management, but also for
management of other drugs. In addition Project HOPE facilitates drug registration and
certification of TB drugs in the country.
Specialists trained on drug management provide medical facilities with TB drugs regularly and
ensure that patients have a sufficient amount of drugs for the entire course of treatment. One
possible future approach would be closer collaboration with the MOH drug policy department to
incorporate all the developed and piloted forms in one Prikaz, with approved recording and
reporting forms. LMIS forms were introduced and distributed, but may not yet be properly used
countrywide in Tajikistan and Turkmenistan. Trained staff, with well-defined responsibilities,
and forms for drug recording and reporting are in place. However, the NTP team is not yet fully
prepared to lead drug management for the country.
Project HOPE facilitated drug registration, certification of TB drugs, and trained staff in
procedures to estimate drug needs. In Kyrgyzstan, Tajikistan and Uzbekistan, first line drugs are
currently purchased with GFATM funds from the GDF and second line drugs through IDA with
GLC involvement. The LMIS for second line drugs needs still major improvements. GDF has
provided a grant for Tajikistan. All GDF drugs are registered in the countries (except
Turkmenistan and Kazakhstan). Some problems have been identified in Kyrgyzstan related to
second-line drugs registration. The pediatric formulations are not registered in any country but
they are in use through permission of the MOH, and these are the only TB drugs received by
Tuberculosis Program Final Assessment and Evaluation Report 17
Kazakhstan from GDF. The expected date for registration of all GDF drugs (including pediatric
formulation) in Turkmenistan was mid-February 2009.
In Tajikistan, GDF has provided TB drugs since the first DOTS pilot opened. First line drugs
were procured under the GFATM R3 grant for the entire country by Project HOPE, and on￾going drug procurement will be covered under the GFATM R6 grant. TB drugs in Kazakhstan
are procured through use of national funds only, and Uzbekistan purchased first line TB drugs
through GFATM Round 4.
Specifically in Tajikistan, Project HOPE assisted with development of the drug management
system first developing Stop TB Kits and then ordering these kits from GDF to ensure access to
a full course of treatment for each patient. They also assisted in registration of GDF drug
formulations in Tajikistan. The Stop TB kits were introduced in the country in from the start of
this project in 2004, and rayon training on use of the kits for the full length of TB treatment was
developed. Currently the MOH has changed its strategy and advocates procurement of the
majority of TB drugs as separate drugs rather than in kits with fixed dose combinations; stating
that this is less expensive and will make it easier to adjust treatment when there are side effects.
This is not in accordance with Project HOPE or international recommendations and could create
problems with a move back toward individualized treatment and increased mono-therapy.
Although patient kits may not be the best alternative for the current system which hospitalizes
most patients, the presentation of drugs as FDC in blister packs is the most appropriate. A small
quantity of loose drugs should be sufficient for the occasional patients with drug toxicity that
need regimen adjustment.
An important issue on drug procurement in Kazakhstan was noted in the mid-term evaluation:
the country intended to decentralize TB drug procurement, with the risk of increased cost, lower
quality assurance and more difficult monitoring. The initiative was abandoned by the
government after information on potential impact was supplied. A current problem in
Kyrgyzstan is that some second line drugs are not yet registered but were used under special
dispensation; the central drug control agency has objected and supply to patients was in risk of
interruption. The problem is temporarily in abeyance, but opportune drug registration is a
priority.
GDF is present in all countries in the region. The funding situation with TB drugs presented a
problem a few years ago and continuous external assistance is still needed to ensure a consistent
drug supply. Kazakhstan provided all TB patients with drugs purchased through government
funding. Over the last three years, with the exception of Uzbekistan and Kazakhstan, counties
have utilized the GDF for provision of TB drugs. With close collaboration between local and
international partners, GDF has provided direct technical support to the countries, mainly in the
areas of monitoring and evaluation, assessment, training and problem solving. All 5 countries are
on the GDF eligibility country lists.
Green Light Committee (GLC): All countries in CAR are faced with MDR and XDR TB
challenges. Some DST surveillance (Kazakhstan, Uzbekistan, Kyrgyzstan) and a DST study
(Tajikistan) have been undertaken but there is not valid data available yet to show the true
magnitude of the problem of drug resistance. However, high rates of treatment failure and slow
Tuberculosis Program Final Assessment and Evaluation Report 18
smear conversion, mainly in Kazakhstan, may be due to MDR and misclassification of
previously treated patients for cohort analysis. Recognizing MDR as a problem for the future,
Project HOPE is assisting all NTPs (except Turkmenistan) in planning collection of information
on drug resistance. Kazakhstan, Uzbekistan and Kyrgyzstan have applied for GLC missions, and
pre-assessment missions were conducted last year. Tajikistan is planning to apply soon;
Turkmenistan is not yet at that stage.
Child formulations: GDF provided grants of TB drugs of confirmed quality to all CARs. It
included pediatric formulations in line with drug estimations done by NTPs supported by Project
HOPE specialists. The grant plan was for one year with intension of continuing to supply drugs
for the next two years. The drugs came by the middle or last quarter of 2008 and they are
gradually started to be used. There is no information or experience yet about their efficacy or
side effects.
Prikazes: The MOHs in CAR support the drug management systems that have been developed,
and political will for implementation of the system was visible through many prikazes related to
drug control issues. Some prikaz topics are listed below:
 Examination of drugs used by patients (Tajikistan, Kyrgyzstan)
 Use of TB drugs is forbidden in other health institutions, outside of TB services
(Tajikistan)
 Sale of TB drugs forbidden without prescription of TB specialists. (Tajikistan)
 Education of medical staff in TB for periphery for three months (only for these regions
without doctors) (Tajikistan)
 Development and introduction of LMIS forms (all countries)
 Law for drugs (Kyrgyzstan)
As can be noted, some of these resolutions may have a positive effect to reduce inadequate use
of TB drugs, but also the undesirable consequence of blocking integration of activities into
general health facilities (e.g., prescription restricted to specialists and to specialized institutions).
 Human resource capacity building
Project HOPE has taken the lead in drafting the national policy for TB control and in capacity
building of health providers. There is a very active role of the Project in the preparation of
training materials, training of trainers, direct training activities, as well as monitoring and
evaluation. Basic training was provided for TB specialists, PHC staff, nurses, laboratory
specialists, and training was also done on BCC and drug management. Training in cohort
analysis was provided to oblast managers and on DOTS for epidemiologists of SES. Various
training courses included: advanced DOTS training, peculiarities of the prison TB program,
M&E training, laboratory external quality assurance, IEC training, LMIS design workshop, drug
management training, workshop for journalists, drug susceptibility testing, Epi Info, MDR TB,
counseling skills, pharmaco-vigilance (monitoring for TB drug side-effects), TB Management
training for Heads of Oblast and Rayon Health departments (see Annex 5 for examples of people
trained). Ad-hoc materials were developed for special program challenges. Many of the training
materials are based on WHO modules. There is a need to strengthen national managerial
Tuberculosis Program Final Assessment and Evaluation Report 19
capacity for TB control to facilitate national ownership, implementation and sustainability of the
TB control program.
Project HOPE organized a ToT on clinical and case management for MDR TB that was
conducted in 2008 in Uzbekistan by a consultant from the Latvia Training Centre. Training
materials were adapted for Uzbekistan and the first training by Project HOPE and oblast-level
TB specialists was conducted in February 2009. Given the high estimates of MDR TB for
Tashkent and the national plans for expansion of MDR TB treatment in Uzbekistan, training is
needed; but the quality of the training and implementation of the activities should be monitored
to ensure a high level of quality in the early stages of the training.
In the Karaganda Oblast in Kazakhstan, Project HOPE has worked closely with the prison
system to improve TB control. Project HOPE established a training center at the Karaganda
prison, trained staff there, and that team has provided training to prison staff from other areas of
Kazakhstan, as well as to staff from all CAR countries that participated in trainings and study
visits to learn about methods to strengthen TB control in prisons for use throughout the region.
A conference on TB in prisons organized by WHO, KNCV and Project HOPE was conducted in
Astana, Kazakhstan in the first half of 2008., The lead facilitator and some presentations were
provided by Project HOPE, with participation of other national and international organizations,
and was enthusiastically received. A follow-up conference has already been requested by several
organizations and countries.
As in other former soviet countries, there is a recurrent complaint that the number of TB
specialists is insufficient and, because of their advanced average age, the problem will worsen.
This is true in some cases, but in general the specialists carry out many functions that could be
carried out by general physicians and also activities of low or no impact, such as post-treatment
controls and hospitalization of inactive TB cases. For instance, there is no reason to require a
specialist to diagnose or to initiate treatment with the national standard regimens for untreated,
uncomplicated pulmonary TB cases that were confirmed by the laboratory (two positive smears,
or positive culture); or to follow up cured patients without symptoms. International
recommendations and global general practice outside the former soviet countries reserve the
specialists (as for any disease) for difficult diagnosis (smear negative and extra-pulmonary TB),
and for follow up of patients with complications and associated diseases. The change of the TB
specialists’ role will take time, but it should be an area for advocacy and training activities of
future projects.
In general, although physicians in training receive teaching on TB, some of the curricula are not
in accordance with international standards and do not have a public health approach. Outdated
training materials (guidelines elaborated and published in 1960s) are still in use. Modern
materials need to be included in the curricula of advanced training institutes and replace the old
ones.
Currently a separate discipline of Phthisiology deals with TB – globally this specialty has been
incorporated into lung diseases. In Kazakhstan, the NTBC is not involved in development of
curricula, but rather provides training in practical skills. Its perspective is that education is the
responsibility of the Ministry of Education. Every five years, physicians must receive
Tuberculosis Program Final Assessment and Evaluation Report 20
continuing education certification. The Kyrgyz State Medical Institute for Continuing Education
has incorporated basic issues in the DOTS strategy in the training curricula approved by the
Ministry of Health. Project HOPE helped the Institute to revise the curricula and adapt
educational content to the needs of particular groups of trainees (TB specialists, PHC physicians
and nurses).
The main activities of Project HOPE at regional and country levels are included in Annex 4, and
additional detail on human resource development activities is provided in Annex 6.
The following HR development issues should be given priority in future USAID-supported
projects:
 Increase the national managerial capacity through on-the-job training (mentoring), especially
at the national level. Promote teamwork at the national and intermediate (oblast) levels to
plan, implement and monitor program activities.
 Delegate selected activities to national management staff and supervise and jointly monitor
the results (for instance organization and running of HLWG and TWG meetings, QA of
microscopy, training activities).
 Provide (in Russian and English) and discuss evidence-based sources to advocate for
changes in policy and practices.
 Translate training and IEC materials into the national languages and support dissemination.
 Provide forums for peer evaluation at the national level (for instance, for country staff to
present and discuss their activities and results) and for oblast level within countries.
 Continue support to medical and nursing teaching institutions to revise and update curricula
and to include DOTS as part of the educational program, following the example of
Kyrgyzstan.
 Improve program management, reporting system and surveillance
Information system, monitoring and supervision
The activities have been covered in previous sections of the report. The data available has
increased and improved in quality, particularly in the area of laboratory. DOTS coverage
expansion, use of standard protocols and forms, training of national managerial staff, and
coordination among the partner agencies have contributed to improve the information on the TB
control program and TB epidemiology. Project HOPE collaborated with the US/CDC in training
on the use of the reporting forms. WHO has systematically collected and analyzed the data
provided by the countries and published it in the Global TB Reports. Some of this information
was used by the evaluation team to draw conclusions; the most important indicators used are
included in Annex 8.
Currently the weakest point, and the priority for the future, is the capacity of national staff at all
levels to analyze the information and use it for operational and budgetary decisions.
Tuberculosis Program Final Assessment and Evaluation Report 21
Linked interventions and system strengthening
The lack of a comprehensive health sector strategy to better respond to the current challenges,
including TB, HIV/AIDS, and malaria was recognized throughout the region. Different MoH
identified development of a comprehensive health sector strategy as one of the top priorities.
All TB interventions conducted by Project HOPE during the project address not only
strengthening TB control, but also general health system strengthening. Effective contribution to
health system strengthening depends on developing a national strategy of joint activities and
responsibilities between different ministries and different health sectors (HIV, TB, lung diseases
etc.).
There are many constraints in all countries related to health strengthening. Some of these
challenges are listed below:
 Lack of integration between the TB program and PHC
 Lack of coordination between different ministries, oblast, district and regional health
managers and stakeholders
 Lack of funding for the health system in general; and in particular for primary health
care. Rational use of the funds is not coordinated by the national program.
 The registration system works but the data is not being used in MOH planning, no
analysis and forecasting system is established that could impact the MoH funding system
and quality of services.
 Poor quality of the health statistics and information exchange.
The interventions conducted by Project HOPE focus on supporting and assisting country TB
programs to ensure equal access to TB services for both men and women, and risk groups. These
interventions also aim to bring services close to the rural community, to contribute to faster
integration of TB into the PHC facilities, as well as promotion of community based DOTS.
A few fields of possible exploration for further improvement of the TB and health system in
general are creating well-functioning health information systems, strengthening health
management systems with involvement of all levels of health protection, and building of drug
management systems.
Lung Health: The Practical Approach to Lung health (PAL) strategy is not implemented in
Central Asian countries, except in Kyrgyzstan. Kyrgyzstan piloted PAL implementation during
the last few years and positive results achieved could serve as a model for other countries in the
region. Assuming that PAL could be an appropriate solution for further improvement in the
general health system and TB program as well, Uzbekistan and Tajikistan applications for
GFATM Round 8 contain activities related to PAL implementation. Exploring the possibility to
implement PAL in all CAR countries presents a real challenge for the health system in general in
the region. The following results would be expected:
• Contribution to improving TB case detection, and quality of TB diagnosis
• Maintaining the high profile of TB among respiratory conditions in daily practice
• Strengthening the integration of TB control into PHC services
• Improvement of the referral system for respiratory conditions and TB
Tuberculosis Program Final Assessment and Evaluation Report 22
• Strengthening PHC services (increasing PHC attendance for respiratory conditions)
• Reduction in unnecessary prescription of drugs, particularly antibiotics
External technical assistance will be required to develop the PAL strategy, conduct a needs
assessment, planning, piloting the plan, creation of a National Guideline on PAL, followed by
the gradual expansion of PAL country-wide. Looking for possibilities of PAL implementation in
the countries and strategy development with support of an international expert is strongly
suggested.
MDR TB: The NTPs are showing improvement in TB control program performance, with trends
showing either a decrease or stability in some key indicators. However there is increased
recognition of the problem of development of drug resistance and the impact on TB control.
According to a WHO report released in February 2008, drug resistance estimates are high in
Central Asia, and better information is needed on the real situation. In Tajikistan, with funding
from the GFATM, Project HOPE has assisted the NTP in training and conducting a small DST
study. Results show high levels of resistance. There are plans for DST studies in other countries
as well, primarily under GFATM funding. Uzbekistan currently has two DOTS+ programs being
implemented by MSF and the GFATM PIU in Karakalpakstan and Tashkent.
HIV: Reliable statistics on HIV are not available in any of the countries, but available data
shows that the region is one of the hot spots in the world where the HIV epidemic is still
growing. The countries have policies on TB/HIV that do not include clear guidance on
collaborative TB/HIV activities, or the methods and benefits of collaboration between the
programs. Organizational structures for joint work were set up; however the collaborative
activities are not yet functional in most places. Not all HIV-positive individuals are screened for
TB, which means no proper chemoprophylaxis or treatment for TB is being provided for those
not detected; and VCT for HIV is not offered for all TB patients nor is cotrimoxazol preventive
therapy (CPT) used routinely. VCT and TB screening exist in some countries at different stages
of implementation. For Tajikistan, VCT is starting to be implemented under the GFATM grant
Round 6. In Uzbekistan, HIV testing is provided on an opt-in basis, only with permission from
the TB patients.
Management capacity building: The current National TB Strategies may not be able to achieve
and sustain scaled up interventions to appropriately respond to TB threats. Human resources at
the top level in the National level have weaknesses in planning, program management, financial
management, monitoring of program implementation, prioritization of needs, and interventions.
There is also a problem in lack of qualified medical staff. Capacity building activities in the area
of management and leadership would help to better integrate the currently fragmented processes
of budget formulation, budget execution, and financial reporting.
Operational research
The information systems for tuberculosis control have progressed substantially, and now provide
ample data to monitor the program and its impact on the epidemic. However, the capacity of the
NTPs to interpret the data and in particular to use it for planning and corrective action is still
Tuberculosis Program Final Assessment and Evaluation Report 23
limited. An example is the limited use of microscopy and general outpatient data to monitor case
detection in all countries; the lack of clinical and operational analysis of the diagnostic criteria
for smear and culture negative re-treatments cases and the reasons for very high failure rates in
Kazakhstan; and of the results and cost-effectiveness of long term follow-up of cured TB
patients.
Several operational research studies have been conducted in Central Asia as part of this project,
with a focus on formative research to design and target interventions appropriate for each
country or population, on programmatic research to determine what factors are influencing TB
control activities and to help develop appropriate interventions, and research to collect
epidemiological information to determine what the real situation is in the country (see Annex 7).
In most countries the first study was a KAP survey of health providers and TB patients (and of
the population in Tajikistan) which is described in more detail under Objective 3. The results
were used to help inform the design of National Communication Strategies and to target
activities to address gaps in knowledge, attitudes and practices. Follow-up KAP surveys are
being conducted in each country to check progress among groups surveyed.
Additional studies have been done, including reasons for TB patient default, rational drug use,
adverse reactions to first-line TB drugs, and TB among migrants. The results of these studies
have been shared with national and international organizations working in TB and the data is
used to adjust program activities to address the issues found in the studies to strengthen the TB
program.
All of the studies have been done in collaboration with the NTPs and TWGs. Training on how
to design, conduct and analyze operational research studies was developed by Project HOPE and
conducted with staff from the DOTS Centre in Uzbekistan, and then both groups worked
together on operational research in Uzbekistan. The training was expanded to all CAR
countries. Additional strengthening and support is still needed for national programs to
comfortably conduct operational research independently.
Priorities for future programs are:
 To develop the national capacity to use information for action, through joint preparation of
national and oblast plans and analysis of the results (workshops of the oblast managers are a
good method for peer education).
 To select key areas for operational studies directly aimed to improve detection and treatment
outcomes and population and patient access to TB care.
 To prepare standard regional protocols and support for the NTPs to adapt and implement
them in different geographical areas as necessary. This research would also complement
ACSM activities to change specialist criteria on the adequacy of prevalent old practices.
Major areas of interest have been mentioned above and include operational analysis of
interventions to reduce stigma, a particular problem for women.
Tuberculosis Program Final Assessment and Evaluation Report 24
Resource mobilization
Project HOPE has collaborated closely throughout the implementation of this project with both
national and international partners, focusing on development of national capacity to conduct TB
control programs. They have also provided support to NTPs in development of proposals for
external funding, such as GFATM and GDF grants. Project HOPE served as the Principal
Recipient for the Tajikistan Round 3 TB grant, and as a sub-recipient for other GFATM TB
grants in Tajikistan, Uzbekistan and Kazakhstan, scaling up activities to additional areas or
conducting activities complementary to this USAID-funded grant. Additional information on
GFATM grants in Central Asia is in Annex 9.
Project HOPE and the World Food Program (WFP) have been implementing an incentives and
enablers program for TB patients since 2002 as a complement to the USAID TB program. This
includes Institutional feeding for the inpatient phase of treatment and regular distribution of
take-home rations for TB patients and family members during the continuation phase. The focus
of the program is to improve treatment adherence and reduce default. Based on the results of the
program, the WFP have expanded this project to include other NGO’s and the National TB
Program.
Project HOPE has actively encouraged collaboration and communication with other international
organizations working in TB in the region, inviting them to collaborative meetings, to participate
in TWGs, conducting joint activities or trainings and providing technical input on TB issues as
needed. Other international and local NGOs provided very positive feedback about cooperation
with Project HOPE and also about this project’s impact on TB control and the NTPs.
OBJECTIVE 3: RAISE COMMUNITY AWARENESS
The Stop TB Strategy, introduced in 2006, recommends conducting activities to empower
communities and people with TB through advocacy, communication and social mobilization
activities and community participation in TB care. These activities were included in objective
three of this project, and several important contributions to improve TB control were made
through Project HOPE activities and cooperation with local, national and international partners.
These include collaborative development and implementation of National Communication
Strategies; Thematic Working Groups (TWG) for IEC/BCC; Knowledge, Attitudes and Practice
(KAP) surveys; IEC materials for TB; training for journalists; communication training for health
providers; a small grants program for local civil society groups; education and outreach for
community leaders; and an incentives program for TB patients.
As reported in the mid-term project evaluation, (National) Communication Strategies (NCS)
were developed in all countries and adopted at the national level in Kyrgyzstan, Tajikistan, and
Uzbekistan. The strategies were approved by the NTP/MOH or included in a TB prikaz for
approval in all countries, and have been used to guide and coordinate integrated, comprehensive
communication approaches to advocacy, communication and social mobilization (ASCM)
activities for key populations. These strategies were developed in collaboration with TWGs on
Tuberculosis Program Final Assessment and Evaluation Report 25
IEC/BCC, which are active in planning, review, development, coordination and monitoring
activities for increasing awareness of TB among health providers and the population and for
advocating for BCC activities.
As part of the development of NCS, KAP surveys were conducted in each country (except
Turkmenistan) among health providers and TB patients, and a larger study was conducted
including the general population in Tajikistan in 2005 and 2008. The IEC/BCC TWGs were
involved in analysis of the information collected with analysis of the TB situation in each
country. Follow-up surveys are being conducted in 2009 among the same groups, and data is
being analyzed. The largest KAP survey was conducted in Tajikistan with the follow-up survey
conducted jointly in December 2008 by Project HOPE and WHO. Initial results of this survey
were presented to the MOH in February, 2009 and the results were well received and plans are
being reviewed for adjustment in light of this information to address issues identified in the
survey.
To improve knowledge, behaviors and services for TB in each country, several strategies were
used, including training for health providers, TB patients and their families, journalists, Healthy
Lifestyle Centers, community groups and community leaders. Project HOPE first focused on
health providers, to improve TB services before conducting activities to bring more patients into
the system. Interpersonal Communication Skills (IPC) training was provided for health providers
to improve patient communication and reduce stigma, and additional communication training for
nurses was provided on patient counseling using a flip book developed by Project HOPE and the
TWG, to increase patient knowledge about TB and the importance of treatment adherence. This
last training was developed in response to an operational research study in Uzbekistan
examining reasons for TB patient treatment default, which determined that the main reason for
default was lack of knowledge about TB treatment.
In addition to training for health providers, training on how to report on TB was done for
journalists in all countries. This two-day training included journalists from print media, TV and
radio, and gave them an overview of the TB situation in each country, explained how to
correctly describe the situation and gave them an opportunity to speak with health providers and
patients. A wide range of stories came out in both national and regional media as a result of
these trainings, with concrete information on TB and the importance of community mobilization
for TB.
In Tajikistan, volunteers were trained for Treatment Support Groups (TSG). These groups are
led by a volunteer doctor, and work with TB patients in the community, visiting them in their
homes and providing DOT as needed, education on TB to patients and family members,
checking on patients with treatment interruption, and distributing IEC materials. These groups
are enthusiastic and active in their communities, and well-received by patients, increasing
openness in discussion about TB.
Another means of social mobilization and population education was through Healthy Lifestyle
Centers, and training for Community groups and leaders. The Healthy Lifestyle Centers already
operate throughout the former soviet countries, and provide education and outreach in health
facilities and during outreach sessions to patients and community members on important health
Tuberculosis Program Final Assessment and Evaluation Report 26
issues. Project HOPE provided training, support and IEC materials for them to include TB in
their education sessions, and they have reached a large number of people, and provided
responses to questions on TB, as well as referring people to available services. Training of
community groups, such as Mahallas in Uzbekistan, and community leaders (done through the
MOH Press Centre in Turkmenistan, and other groups in the other countries) has had a
significant impact on knowledge and behavior related to TB in communities. In Uzbekistan,
evidence of behavior change has been identified. Mahallas have small funds available for people
sick with TB or other diseases that can have an impact on their ability to work, and most people
were not accessing these funds through fear of informing other people in the community about
their TB disease status. Now people speak more openly about TB and are not afraid to disclose
that they have TB. Some areas of stigma remain, especially related to TB in young single women
who are afraid that if it is known they have TB they will not be considered for marriage.
Development and adaptation of IEC materials for health providers and the general population
was also a focus of this project, with regional training provided for local organizations and TWG
members on how to review, pre-test and develop effective IEC materials to target different
groups. Materials available prior to this project were developed independently by different
groups and not always tested for effectiveness or accuracy of messages. An important
consideration is that all TB materials are developed in collaboration with the IEC/BCC TWGs so
they obtain experience in determining what is appropriate for each country.
Public Service Announcements (PSA) were also developed in each country in collaboration with
the TWG, MOH and other local groups, and were widely distributed on local television stations
with hotline numbers for the local population. In Turkmenistan, collaboration has been
strengthened with the MOHMIT Press Centre, and they developed the PSA for Turkmenistan in
addition to jointly conducting trainings for mass media and community outreach with the general
population.
World TB Day is a focal point for providing information on TB to the general population. This
day has always been observed in Central Asia and Project HOPE was very active in
collaborating with national and local partners in conducting IEC/BCC activities in each country.
To increase involvement of local NGOs in TB community mobilization, small grants programs
were conducted by Project HOPE in 3 countries: Kazakhstan, Kyrgyzstan and Tajikistan. In
each country, NGO proposals on interventions to educate and promote behavior change in target
populations were solicited, and each country conducted 2-3 rounds of annual competitions. A
board involving local and international organizations reviewed and selected proposals for
implementation and Project HOPE provided training for the NGOs selected on TB and how to
monitor and evaluate small grant implementation and report on activities and outcomes. In
Tajikistan 10 grants were awarded and included theater performances, radio and television spot
development and distribution, and an intervention for railway workers to provide information
and education to labor migrants in-transit. Six grants were awarded in both Kazakhstan and
Kyrgyzstan. This program increased NGO awareness and activities in TB and the projects
reached additional groups in the population with information and advocacy.
Tuberculosis Program Final Assessment and Evaluation Report 27
Special populations that have been targeted by program activities are prisoners and migrants.
Project HOPE has conducted training and strengthening of TB services in prisons in Kazakhstan
and Kyrgyzstan, and developed IEC materials for prisoners. In 2008, Project HOPE conducted
an operational research study on migrants in Uzbekistan and Kazakhstan, conducting qualitative
focus group discussions to gather information and identify barriers for accessing TB services for
migrants. Lack of information and legal status were identified as key problems, and information
on TB services has been provided to these groups.
Since 2002, Project HOPE has been implementing a project for TB patients in Tajikistan in
collaboration with the World Food Programme that provides nutrition to inpatients and food
packages to outpatients. The objective was increasing patient compliance with TB treatment, and
food packages for outpatients are provided at key points in treatment when patients are being
given sputum tests and checked for treatment adherence. A comparison between patients with
and without food support in 2005 showed substantial differences in treatment outcomes
(improved success and reduced failure, default and death). An additional OR study is being
conducted in 2009 to determine impact of the program for treatment adherence. Results of the
study are not yet available.
EPIDEMIOLOGICAL IMPACT OF THE TB CONTROL PROGRAMS
The results of Project HOPE cooperation with the national governments can be measured by the
achievement of the planned activities; the changes in the national program policies and capacity
for TB control implementation; the improvement of TB control shown by operational indicators;
and the changes in epidemiological indicators. The first three have been described above, under
project activities. Except for the achievement of planned activities, it is not possible to assign
full responsibility for the outcomes exclusively to the national efforts or to any one of the
supporting partners. The achievements are the result of common work, with varied involvement
according to the intervention. Thus the epidemiological impact is the result of the NTP and MoH
actions, plus partner support, plus other development factors.
The main epidemiological indicators relate to TB transmission, measured through studies of
prevalence of infection in children; TB incidence, measured through case reporting; TB
prevalence, that requires costly population surveys and provides no data for program planning;
and TB mortality in the general population, measured through death certification provided by the
national statistics offices. Of these, TB case reporting and TB mortality data are usually
available during the implementation of projects. Mortality is a sensitive indicator, rapidly
influenced by control activities; however data is not always timely available. Cases reported and
the rate per 100 000 can be compared with estimates of total and smear positive TB incidence,
periodically updated by the WHO. The changes in reported incidence can be due to
improvement in case detection (increase), reduction of the TB prevalence in the community, or a
combination of both. An indicator of improvement in case detection of the main sources of
infection (pulmonary smear positive cases) is the number of persons examined by microscopy
for diagnosis. At a constant level, the trend of reported infectious cases corresponds to the trend
of TB disease. The total reported cases is influenced by the prevalence of TB, the access of the
Tuberculosis Program Final Assessment and Evaluation Report 28
population to health services and to TB diagnosis and also by the medical criteria and technical
resources to diagnose cases with negative bacteriology results. The expected result of
improvement in a TB control program is an initial increase of the number and rate of reported
smear positive cases (improve in case detection) and an increase in the proportion of cases
confirmed by smear or culture (due to improvement of diagnostic quality); followed by a
decrease of smear positive cases and total cases (decrease of TB prevalence in the community).
In addition, the epidemiological impact becomes evident quite late and after project completion,
because wide coverage of activities is only reached after mid-term of the project.
For 2003, before the start of the project, WHO estimated a total TB incidence of 127 per 100 000
(approximately 73000 new and relapse cases) and a pulmonary smear positive incidence of 57
per 100 000 (approximately 33000 cases) for the CAR. This year was used as baseline for this
report (Annex 8). The data on diagnosed cases for 2003 - 2006, and the outcomes for the cohort
of new smear positive cases were published in the WHO Reports on the TB epidemic of 2005 -
2008. Preliminary data for 2007 sent to WHO for publication in the 2009 Report was obtained
from the national programs. Mortality data to evaluate trends was available for some of the
countries.
By 2006 the CAR population was estimated at 59 million. The total number of cases reported
kept pace with the population increase, maintaining the reported incidence at 108 per 100 000.
The rate for smear positive went from 28 to 31 per 100 000, the case detection rate (CDR) from
50 to 54% and the proportion of smear positive cases from 26 to 29%. The global target for CDR
is 70% of the estimated new smear positive incidence and the expected proportion of total cases
confirmed by sputum microscopy is about 50%. Thus on the average there was a modest
increase in case detection and in confirmation of cases (suggesting changes in medical
diagnostic criteria and improvement in the laboratory capacity), but far below the global targets.
There were important differences by country. In Kazakhstan the rate of total cases has decreased
by 20% and the smear positive cases by 10% from 2003 to 2007 (four years), indicating a
reduction in TB. The reduction was less in cases confirmed by smear because more cases are
found by general health facilities and the specialist criteria for diagnosis is slowly improving. In
Kyrgyzstan the total case rate diminished from 138.2 to 107.7 from 2003 to 2008 (22% in 5
years) including prisons, and from 123.2 to 107.0 (13%) excluding prisons. The rates for smear
positive and case detection rate excluding prisons were relatively stable, and the proportion of
cases confirmed by microscopy increased. The TB mortality rate in general population
diminished by 31% in the same period, an average reduction of over 6% per year. In Uzbekistan
the estimates of incidence changed upwards; the program reported an expansion of the DOTS
strategy coverage from 56 to 100% of the population and a large increase in total and in smear
positive cases; the proportion of cases confirmed by smear increased from 23 to 30% but is still
low. The CDR increased to 49% but it is still quite far from the global target. All these factors
suggest that the program is still finding only a fraction of the infectious cases in the community
and that the reported incidence does not yet represent the TB epidemiology. However, the TB
mortality diminished from 11.5 in 2003 to 8.3 per 100 000 in 2007 (28% in 5 years), indicating
that TB treatment is making a significant impact. In summary, a reduction in TB seems evident
in these three countries.
Tuberculosis Program Final Assessment and Evaluation Report 29
The information provided by case reporting in Turkmenistan is less representative of the burden
of TB, as the DOTS coverage was still only 46% of the population in 2006 and although the
CDR is over 80% the denominator (estimate of real incidence) may not be accurate. The total
and smear positive cases reported have diminished from 2003 to 2006. In Tajikistan DOTS
coverage increased from 13 in 2003 to 79% in 2006; the incidence estimated by WHO increased
substantially from 168 to 204 and for smear positive from 76 to 92 per 100 000, suggesting that
not enough is known about the burden of TB; the notification rate increased from 4260 to 6672
total cases and from 342 to 2051 smear positive cases; the CDR grew from 8 to 31% in spite of
the change in denominator. All this impedes estimating the epidemiological impact of TB
activities at the present time.
Summary epidemiological charts:
TB Notification rate, new + relapse
0
20
40
60
80
100
120
140
160
180
200
2003 2004 2005 2006 2007
KAZ KRG TAJ TRK UZB
TB Notification rate, new SS+
0
10
20
30
40
50
60
70
2003 2004 2005 2006 2007
KAZ KRG TAJ TRK UZB
Tuberculosis Program Final Assessment and Evaluation Report 30
TB Mortality rates, preliminary data
0
5
10
15
20
25
2003 2004 2005 2006 2007
KAZ KRG TAJ TRK UZB
COUNTRY-SPECIFIC KEY FINDINGS
KAZAKHSTAN
All persons interviewed considered the support of Project HOPE very useful to guide and
implement national TB program activities. The collaboration of Project HOPE to develop
national capacity to implement the DOTS strategy covers the whole country, with emphasis on
laboratory, training, drug management and monitoring and evaluation. Implementation of
activities concentrated in the Almaty oblast and a prisons project in Karaganda; these became
models for the rest of the country and other countries in CAR. ACSM activities included
IEC/BCC, small grants to develop community involvement and support to local NGOs. While
development in the pilot oblasts is very good, there are areas of the country that are difficult to
access, and need further support.
There was evident improvement in political commitment to DOTS after the Mid-term Evaluation
mission. The President of the Republic identified TB as a high priority in 2007. Budgetary
resources for the program have increased. The NTP team is well staffed and has recognition.
New program and monitoring manuals are available. Drug procurement has been centralized as
recommended and drug management, based on the model of Almaty, was expanded by the NTP
to achieve national coverage. Coordination between the central and oblast levels of the program
has improved.
A potential risk for the future of the TB program is that the large influx of external funds (mainly
GFATM) and international emphasis on new laboratory technologies may divert efforts from the
essential elements of TB control: detecting and curing the sources of infection as rapidly as
Tuberculosis Program Final Assessment and Evaluation Report 31
possible, and integrating TB activities in the general health delivery system to improve patient
access to diagnosis and treatment.
Regarding diagnosis, cases found by the PHC facilities have increased but the proportion of
suspects detected and examined with microscopy is still low, and diagnosis of smear positive
patients requires reconfirmation by the specialists and repetition of the microscopy (plus culture)
in the specialized facilities.
The specialized facilities over-diagnose patients with abnormal pulmonary x-rays. In a series of
nearly 800 patients diagnosed, 60% were smear negative; of these only 21% (one in five) were
confirmed by culture. Nationally reported data show the same problem: in 2006 there were about
5000 retreatment cases classified according to WHO guidelines and 11 000 classified as “other
re-treatments” - probably without laboratory confirmation. As previously treated cases often
have radiological lesions for life and may have symptoms due to other infections, radiology is a
poor predictor of active TB and confirmation by culture should be the rule.
Use of MMR techniques has been reduced but has not yet disappeared, and the use of mobile
units is still common. Mass screening of children (most of them vaccinated once or twice with
BCG) with tuberculin testing may lead to excessive diagnosis of TB infection or disease.
Regarding treatment, the main (and very serious) problem is a very high and growing proportion
of treatment failures (16%), so far unexplained and not well studied. This coincides with very
slow conversion and low conversion rates in the cohort of new smear positive cases. Treatment
success has diminished from 81.6% the 2002 cohort to 72.1% in the 2005 cohort, due mainly to
increased failure rates, but also due to some changes that have improved reporting according to
international standards. Quality of DOT seems satisfactory; staff training and procedures in the
TB hospitals observed were good. All patients are hospitalized during the initial treatment phase
and until smear negative. The issue requires clinical, pathological and operational research. One
possibility is misclassification of patients with previous treatment (and therefore, with higher
chance of MDR) as new – repeated questioning of a sample of patients on treatment could give
some information on this factor.
The sites observed had sufficient first line drugs (mostly loose pills, some FDC2, FDC3 and
FDC4), and good drug management. Second line drugs are available in loose pills, in insufficient
quantities for the estimated load but enough for the current low coverage of detection of MDR
TB patients.
In the area of laboratory Project HOPE provided equipment and training, supported a model
quality assurance program to be expanded to the rest of the country and participated in a drug
resistance survey (DRS). The national central laboratory has qualified and trained staff and is
coordinated with a supranational laboratory for quality assurance.
Training centers were developed in Almaty and Karaganda, and has expanded to 9 locations
under full ownership of the NTP. Project HOPE supported training and ToT for the whole
country.
Tuberculosis Program Final Assessment and Evaluation Report 32
Infection control was seen as acceptable for normal patient care but insufficient for culture/DST
TB laboratories and management of MDR patients. The use of surgical masks by hospital and
laboratory staff is common, this seems an acceptable habit as long as the staff know that it does
not protect them from TB infection.
Project HOPE has collaborated with the CAPACITY project to implement pilot TB/HIV
interventions in Almaty, providing some IEC materials, review of materials developed and
monitoring support.
Project HOPE collaborated with KNCV in a program for TB control in prisons. Project HOPE
and ZdravPlus prepared protocols for follow up of patients after release, monitoring and cohort
analysis.
Community mobilization activities received high priority from Project HOPE. They included a
small grants program carried out in collaboration with other partners.
Epidemiological and operational data suggest a significant impact of the program. TB mortality
per 100 000 decreased from 22.4 in 2003 to 18.2 in 2007 (19% in four years). The total new case
notification rate diminished by 21% between 2003 and 2007, and notification of pulmonary
smear positive by 10%; the smaller decrease was probably due to better diagnosis and detection
of smear positive sources of infection by general health facilities. The proportion of new cases
confirmed by microscopy increased from 27.7% to 31.4%.
KYRGYZSTAN
The national authorities interviewed consider Project HOPE a key technical cooperation agency
and as a facilitator of linkages with other partners. Collaboration to support implementation of
the DOTS strategy covers the whole country, with emphasis on laboratory and training.
Improved political commitment is evidenced by active Thematic Working Groups (TWG) with
Project HOPE participation, improved acceptance of DOTS by the authorities and specialists,
and new TB manuals.
The first phase of Health Sector Reform which created Family Doctors in the general health
facilities and the funding of hospitals per patient and not by bed are positive factors to help
incorporate TB activities in the general health system. The government received support from
Project HOPE, John Snow, Inc. and WHO to develop and test the methodology. At present the
government is appraising the role and financial requirements of TB facilities with the intention
of integrate them in the system by 2011. USAID, Project HOPE, WHO, the London Imperial
College, ZdravPlus and CAPACITY collaborate in this activity which will also consider
HIV/AIDS.
Case detection is implemented in outpatients in general health facilities, identifying persons with
2 weeks or more of cough for microscopy examination of sputa (3 samples). However, diagnosis
still needs to be reconfirmed by the specialized facilities with repeated microscopy and diagnosis
Tuberculosis Program Final Assessment and Evaluation Report 33
by specialists. Culture (countrywide) and DST (in Bishkek) is also carried out in these facilities
for all smear-positive cases. Identification of suspects is done by the physician (in general
facilities the family doctor) with very low intensity. Observation during the visit showed slightly
more than 100 suspects examined in one year in a facility with over 100 000 adult outpatient
visits; as a result the positivity was high and the microscopy laboratory underutilized, with less
than 10 smears per week. A simple study of the real prevalence of cough over two weeks in a
sample of patients in these facilities would allow better evaluation of the effectiveness of
identification of suspects and help determine if corrective measures are required, such as
information to outpatients or systematic query regarding cough by the non-medical staff at
reception. National data confirms the observation: 13 654 persons were examined by the PHC
facilities in 2008 with 9.2% positivity; while 5898 were examined by the specialized facilities
with 27% positivity. This suggests that a large number of patients in the community arrive late at
the specialized facility; and probably visit general facilities several times for other reasons than
respiratory symptoms before being identified as suspects.
Case finding through mass radiology has been largely abandoned, but mass tuberculin testing in
children, once a year, continues; with an induration of 5 mm or more defined as positive
although most children are vaccinated with BCG in the first year of life. As a consequence it is
probable that many children are identified as TB infected and receive preventive or curative
treatment without need.
The laboratory network has received substantial support. Training and ToT was carried out at all
levels. A revised edition of the laboratory manual is in preparation; it will include rapid tests.
Quality assurance of microscopy was implemented in the whole network and is now the
responsibility of national staff, with Project HOPE providing monitoring and support when
required. A drug resistance survey was carried out in a small sample of patients in Bishkek with
Project HOPE and WHO assistance, to test and teach the methodology so the NTP can carry out
a national survey.
The national central laboratory has qualified and trained staff and is coordinated with a
supranational laboratory for quality assurance. It has modern equipment and is testing high level
technologies. However, the facilities are too small to separate the high risk areas, infection
control measures do not seem sufficient for culture and DST, and the routine workload of the
two microscopy readers is excessive. A new laboratory is planned for construction with KfW
financial support but the timing and building plans are not yet defined. Improvement of the
working conditions in the current lab seems urgent, in particular, for infection control measures.
Case management practices are changing very slowly. All cases are hospitalized in TB facilities
for the intensive phase of treatment, and longer in some cases with social problems. There are
plans to test ambulatory treatment from the start in smear negative and extra-pulmonary cases.
At the same time there are plans to build new sanatoria for MDR patients, which may not be a
cost-effective use of resources in view of the Health Sector Reform (current facilities could be
adapted if the hospitalization policy changes liberating TB beds and experienced staff).
Treatment success rate has increased from 82% (2003) to 85% (2006) and default rate was
maintained in the rage of 4-5%
Tuberculosis Program Final Assessment and Evaluation Report 34
Drug management was given high priority. A logistics management information system (LMIS)
was piloted, approved by the MoH in 2006 and implemented at the national level and in all
oblasts, including training and training of trainers to achieve national ownership. Project HOPE
facilitated registration and certification of TB drugs. Operational research on treatment practices
was carried out by the NTP, in collaboration with Project HOPE and IUATLD. Project HOPE
participated and trained staff in procedures to estimate drug needs. First line drugs are currently
purchased with GFATM funding from GDF and second line drugs through IDA Foundation
(IDA) with GLC involvement. The LMIS for second line drugs needs still major improvements.
MDR management was piloted in 2005 on 100 patients; then expanded to 530 including patients
from prisons. Project HOPE collaborated with other partners in organizational support and
training. Patients are hospitalized for up to 18 months in 3 sites (six month in each); the total
treatment duration is two years. Patients can be released for ambulatory treatment if culture
negative, but may remain until the end of treatment depending on living conditions. Success so
far has been around 62%.
TB/HIV is not yet a major problem in the country. Although 7% HIV infection was detected in
injecting drug users in prisons, systematic testing in TB patients has found prevalence under one
per thousand.
Community mobilization activities received high priority from Project HOPE. They included a
small grants program started after the midterm evaluation. Activities included: supporting local
NGOs to implement activities such as railway workers providing information for migrants, child
theater performances with audience of about 10 000, video spots for transmission by local
authority stations, mosque attendance and training in methodology to develop educational
materials. ACSM included workshops for community leaders.
Training and ToT on the DOTS strategy and all interventions (diagnosis, treatment,
management, drugs, laboratory, monitoring and evaluation) was supported at all levels. It
included training of nurses on methods to counsel patients. Participation in the TWG on TB
Education was important for activities in formal post-graduate education of specialists, family
physicians, nurses and laboratory staff, including certification to stimulate participation. There is
a high turnover of staff, in particular nurses, requiring a program of continuous training.
The main advances in monitoring were a change from the previous focus on punishment to on￾the-job training support, involving all stakeholders and improving the contact between the
central and oblast levels and development of checklists. A remaining problem is to achieve
similar results with DOTS-Plus, which is still complex and unclear.
TB in prisons (Ministry of Justice) activities were mainly in cooperation with partners: MSF and
ICRC, to provide technical guidance for policy. Incidence in prisons has decreased rapidly, in
part due to TB control interventions and in part because of a large reduction in the prison
population. An ongoing problem is high turnover of the prison staff.
The epidemiological and operational data suggest a significant impact of the program. TB
mortality rate for all TB cases per 100 000 population decreased from 16.3 in 2003 to 11.2 in
2007 (31% in 4 years). The total case notification rate diminished by 8% between 2003 and 2007
Tuberculosis Program Final Assessment and Evaluation Report 35
and notification of pulmonary smear positive by 2%; the smaller decrease was probably due to
better diagnosis and case detection by general health facilities. The proportion of new cases
confirmed by microscopy increased from 27% to 30.6%.
TAJIKISTAN
The national authorities interviewed consider Project HOPE a key technical cooperation agency
and a facilitator of linkages with other partners. Collaboration to support implementation of the
DOTS strategy now covers 13 rayons or cities in Tajikistan under the USAID grant, with
emphasis on training on all components of the DOTS strategy, monitoring and evaluation,
adapting and developing documents for support of DOTS implementation and strengthening of
the NTP.
Evidence of political commitment is seen in the strong cooperation between the MOH, NTP and
Project HOPE, and in the active work of TWGs that were started by Project HOPE and continue
with strong input from other stakeholders in the different thematic areas. Tajikistan and
Turkmenistan were the last countries in the region to have complete coverage of the population
by DOTS. Implementation of DOTS started in early 2002 and reached all regions of Tajikistan
by the end of 2007.
The TB program structure in Tajikistan is still vertical, so patients suspected of having TB are
sent to TB service locations to be diagnosed. There is no clear process for TB diagnosis or
treatment by PHC health providers at this time, though some TB specialists are based within the
PHC system.
Case detection is implemented in the general facilities, with the suspects identified by the doctor,
so probably restricted mostly to patients presenting with respiratory or chest symptoms. TB
suspects are referred to TB services for diagnosis, which is done through sputum, clinical
examination or x-ray examination. Emphasis on use of x-ray screening, the preferred method of
detection under the soviet system, is contributing to a low rate of confirmation of pulmonary TB
through smear microscopy, especially among new cases. The definition of “chronic” and “other”
TB cases is unclear, and there is no proper evidence of previous treatment for these cases. The
intensive phase of treatment is conducted as inpatient treatment for usually 2-3 months. Some
rayons are stronger in implementation of DOTS than others. The Deputy Minister of Health
suggested conducting additional activities in some weak areas to strengthen TB control. Testing
using culture and DST will only be performed in two locations, Dushanbe rayon and Macheton
Republican TB Hospital. A small DST study conducted by Project HOPE with Global Fund
support showed a very bad situation with MDR in some parts of the country, confirmed by the
Gauting Supra-national laboratory.
Case finding through mass radiology is still supported by the NTP on different levels and in the
prison system, though microscopy is also used. At the national level, they are interested in using
tuberculin, especially with children and contacts, but it is not clear who is providing tuberculin
or what the quality is. BCG vaccination is nationally recommended for use in all children in
Tuberculosis Program Final Assessment and Evaluation Report 36
Tajikistan, at birth especially, but sample testing of children showed a low level of coverage
indicating a potential problem with the vaccination program.
The total new case notification rate grew constantly, increasing by 43.7% between 2003 and
2007, in part due to expansion of coverage of activities and the DOTS strategy. Notification of
pulmonary smear positive cases is increasing. It was 51% in 2004 and 62% in 2006, a positive
change suggesting a progress in use of smear confirmation of TB cases for TB diagnostics.
The laboratory network has received substantial support during the current USAID grant, and
starting from the beginning of DOTS implementation in 2001. Training and ToT was carried out
at all levels. Quality control for smear microscopy has been done throughout Tajikistan, but
needs additional strengthening and support for improvement. The national staff is responsible for
the laboratory network, with Project HOPE providing technical assistance to the laboratory
through local laboratory staff and the regional laboratory specialist as needed. There is a
problem with retaining qualified laboratory staff in Tajikistan, due to low salaries and lack of
other professional opportunities for these staff members.
Culture examination is performed only by the National Reference Laboratory (NRL), based in
the NTP in Dushanbe, under supervision of the supranational laboratory from Germany. In the
Macheton Republican TB Hospital near Dushanbe, renovations are being done and this will be a
special center for treatment of MDR TB cases and also the NRL will be relocated there. KfW
will provide all equipment for this laboratory. Staff from the NRL is currently participating in a
study visit to the NRL in Uzbekistan to gain more experience in culture and DST testing.
There is no culture or DST currently conducted in the rest of the country. A DST study was
performed by Project HOPE under funding from the GFATM Round 6 grant for a small portion
of patients. Preliminary findings raise concern about potential high levels of drug resistance in
the country – even higher than previously estimated.
Infection control (IC) in all TB facilities is not being done appropriately in any of the three
areas: administrative, environmental and personal. There are no IC guidelines, no separation of
patients currently in Macheton, and no personal protection in active use in high risk TB settings.
Case management practices are changing very slowly. Most cases are hospitalized in TB
facilities for the intensive phase of treatment, for 2-3 months or in some cases for longer.
However, some cases are now treated on an outpatient basis with regular DOT at health facilities
near their homes. DOT may not be performed fully in accordance with international standards
during the continuation phase, because not all proper management processes are followed.
Over the period of the project, DOTS coverage increased from 13% in 2003 to 100% by the end
of 2007. Treatment success over the period was reported at between 84-86% from 2003-2005,
and for the first time in 2006 this was reported by the NTP to WHO as 84.4% (new smear
positive). It was noted that an incorrect definition is being used for differentiation between
treatment completed and cured. Usually, at the national and regional level, no patients were
classified in the treatment completed category – all were categorized as cured. Under closer
review, the final smear examination is not being conducted at the end of treatment, but the
patient is still categorized as cured.
Tuberculosis Program Final Assessment and Evaluation Report 37
Project HOPE has taken the lead in Tajikistan for drug management, developing policy,
standards, an LMIS system with JSI, training and follow-up. Specifically in Tajikistan, Project
HOPE assisted with development of the drug management system (no system existed before)
using Stop TB Kits provided by GDF. Project HOPE assisted in registration of GDF drug
formulations in Tajikistan. Funding from both USAID and GFATM has been used for
development of the drug management system, and first line drugs were procured under the
GFATM Round 3 grant for the entire country by Project HOPE.
Stop TB Kits, containing FDC anti TB drugs, were introduced in the country in 2005, and rayon
training was developed and done throughout the country. This system has worked well for
maintaining access to quality drugs for the full length of treatment for each patient. However,
now the MOH is advocating a change to a majority of drugs being procured as loose drugs rather
than kits (Fixed dose combination drugs), saying that this will make it easier to adjust treatment
when there are side effects, though no study on side effects has been done. This is not in
accordance with Project HOPE recommendations and could create problems with a move back
toward individualized treatment.
Trained staff is in place with clear responsibilities, and forms for drug recording and reporting
are in place. However, the National TB team is not yet fully prepared to lead drug management
for the country.
Project HOPE assisted the NTP for TB drug needs calculation for child formulas for a GDF
application.
An operational research study was conducted in Tajikistan and Uzbekistan on Rational Drug Use
(RDU), which was the first study of its kind in the region. The results identified that even with
free treatment for TB, prescription of additional drugs for TB patients creates a financial barrier
for patients access to treatment. There are also non-GDF TB drugs in the country from other
former Soviet countries used for treatment of TB provided through the pharmacies and can be
purchased, potentially without prescription. However a new prikaz just introduced restricts sale
of TB drugs to those with prescriptions.
NTP staff participated in training in the Latvia WHO training center for MDR TB case
management in October 2008. DST is available only for a limited number of patients. They are
not currently implementing a DOTS+ program, though preparation is underway for this at
Macheton. The preliminary results of the small DST study found MDR TB in about 15% of new
TB patients and in more than 50% of retreatment cases. The criteria of patients included in the
study may not have been properly followed.
Second line TB drugs will be provided by GFATM Round 6 and 8 grants (if Round 8 final
negotiations are approved). At the beginning, drugs will be provided only for 50 patients, and
then will expand to provide treatment for up to 200 additional patients.
TB/HIV has not been identified as a major problem in the country. There is not appropriate data
about HIV prevalence among TB patients, or vice versa, and no systematic testing is being
Tuberculosis Program Final Assessment and Evaluation Report 38
conducted. Under the HIV GFATM grant, VCT is starting to be implemented. There is not yet a
link between these two vertical programs, especially in recording and reporting of patients.
ACSM activities have played a very important role in the Project HOPE program in Tajikistan.
Initial activities focused primarily on health care providers and patients in both TB services and
PHC, and then on the general population, including training, development of a TWG and
National Communication Strategy, KAP surveys, health education and a small grants program.
The TWG on IEC/BCC has been very active in Tajikistan, from development of the National
Communication strategy through development and implementation of education and BCC
activities. All materials, trainings and plans are discussed with this group.
In Tajikistan, a larger baseline and final KAP survey was conducted than in the other countries.
This included both TB patients and health providers in both TB services and PHC, and members
of the general population. The first survey was conducted by Project HOPE in early 2006 and
the final survey was conducted jointly with WHO at the end of 2008. Preliminary findings have
been analyzed and were presented in early February 2009 to the MOH. The information from
this study is very useful for the MOH and NTP to plan activities for the future, and already
discussions are taking place to make changes to address findings.
Interpersonal communication skills training to improve patient communication and reduce
stigma was conducted with health providers. Patronage nurses were also trained to work with
patients. Later in the program, flipcharts were developed regionally and adapted for use in all
countries, and patient consultation training for nurses including use of the flipcharts was
conducted.
A Small Grants program was conducted for 3 years working with 10 local NGOs in pilot
regions, and Project HOPE provided technical assistance and IEC materials. Some of the
activities have included community initiatives, mass media outreach through public service
announcements and radio broadcasts, theater performances on TB, and railway outreach with
migrant workers.
Treatment Support Groups (TSG) have been organized and trained to conduct patient outreach
and DOT in pilot regions to support health care workers and patients with good success and
much enthusiasm from participants. Journalists have been trained on how to report on TB issues
in the mass media. Healthy Lifestyle Center staff were trained through cascade trainings on TB
education and provided with IEC materials, and include this in their health outreach and
education sessions. Community leaders were also trained on TB.
Public and private collaboration is not a focus of the program, due to the nature of the vertical
TB system in Tajikistan. The policy is that TB can only be treated in the public health sector.
One of the main activities of the project in Tajikistan was TOT and training on all areas of the
DOTS Strategy (diagnosis, treatment, management, drugs, laboratory, supervision, monitoring
and evaluation) to build capacity of the NTP and health providers at all levels of the TB
program. Funding for trainings came from both the USAID and the GFATM Round 3 grants. As
a result of these trainings and TOT, the country has a cadre of trainers and qualified staff to
Tuberculosis Program Final Assessment and Evaluation Report 39
conduct activities nationally. The teams of trainers have been participating regularly in seminars
to provide updated information and refresher trainings. The NTP and TB staff have requested
additional trainings for more staff to build more capacity. In spite of training focused on
international standards, some remnants of the previous system still exist, such as interest in
tuberculin testing and extra-pulmonary TB clinical interventions.
The main advances in monitoring were a change from the previous focus on punishment to on￾the-job training support activity; involving all stakeholders and improving the contact between
the central and oblast levels; and development of checklists. TB staff are very open to
monitoring visits and see them as an opportunity to get questions answered. The NTP has gained
much experience in monitoring and stated that they are ready to conduct monitoring
independently and have been doing so for the last year.
TB in prisons is not addressed under this grant in Tajikistan.
RDU and DST operational research studies have been conducted in Tajikistan as mentioned
above.
Project HOPE has been implementing an incentives and enablers program for TB patients since
2002 as a complement to the USAID TB program. The program started in 2 regions and
expanded to 7 under Project HOPE, and also other regions under the support of additional
program implementers. This includes Institutional feeding for the inpatient phase of treatment
and regular distribution of take-home rations for TB patients and family members during the
continuation phase. The focus of the program is to improve treatment adherence and reduce
default. A case study was published and several presentations have been given on this project at
international conferences. At this time a study on the impact of this project is being conducted.
Project HOPE has been implementing Global Fund program activities in Tajikistan, as the
Principal Recipient of Round 3 from 2004-2008, and also as a sub-recipient for Round 6 in
training, monitoring and conducting the DST survey. The advantage of implementing both
USAID and GFATM grants is the chance to increase the scope and scale through leverage of
both programs and to work both in pilot areas as well as nationally. Project HOPE is continuing
Round 3 activities under bridge funding from GFATM pending the results of the Rolling
Continuation Channel GFATM proposal submission.
When asked about the continuation of the TB control program after this project is completed, the
deputy Minister of Health stated that there will be a vacuum, especially in the areas of
laboratory, management and drug management and asked that this project continue.
TURKMENISTAN
The Republic of Turkmenistan was not visited during the final evaluation mission. The
information on the country TB program and results, and on Project HOPE activities was
collected during the visit for the Medium Term Evaluation in January 2007 and updated with
national reported data and information provided by the Project HOPE Regional staff.
Tuberculosis Program Final Assessment and Evaluation Report 40
UZBEKISTAN
The national authorities interviewed consider Project HOPE a key technical cooperation agency
and a facilitator of linkages with other partners. Collaboration to support implementation of the
DOTS strategy covers the whole country, with emphasis on laboratory and training.
Improved political commitment is evidenced by active Thematic Working Groups (TWG) with
Project HOPE participation, improved acceptance of DOTS by the authorities and specialists,
active collaboration between Project HOPE and the DOTS Center/MOH/Republican TB Institute
and new TB manuals. A new policy document, an update from the previous National Program
for 2002-2008 that Project HOPE assisted with, has been prepared in Uzbekistan with
participation of the DOTS Centre and is pending MOH approval. It defines the NTP strategy for
2010-2015, and incorporates the Stop TB Strategy and Millennium Development Goals.
Integration of the TB program in PHC is still in early stages in Uzbekistan, but there is an
understanding among the national teams that it will be needed to improve access to TB services
in the future. TB centers are located in general policlinics in every district where TB patients are
treated under DOT during the continuation phase of treatment. At the village level there are PHC
facilities with TB ambulatory treatment provided.
For case detection, patients identified as TB suspects are sent to TB services from PHC for
diagnosis using smear microscopy. Culture and DST testing are done only in the NRL (and
culture also done in Nukus related to MSF MDR project), which is certified by the Supranational
laboratory in Borstel, Germany. There is a plan to build 5 additional culture testing laboratories
at the oblast level, however the positive culture results will be sent for DST in the NRL only.
Labs will be built by the MOH, equipped by KfW, and the staff will be trained first by Project
HOPE until the end of the project, and then by national trainers.
Project HOPE has worked with laboratories at the oblast and rayon level since 2001 and
continued to strengthen them under the current grant. Monitoring and on-the-job training is
conducted jointly with NRL staff and has resulted in increased quality. There are more than 300
laboratories for smear microscopy in the country. Staff turnover is still a challenge. Plans for the
future are linked with GF, KfW and local funds. Plans for laboratory training and monitoring
were developed together with the DOTS Center. Training for EQA was done by Project HOPE
for the NRL and oblast level labs in 2006-2007, and the oblast labs monitor rayon-level
laboratories, while they are monitored by the NRL.
MDR - The NRL will perform DST for first and second line TB drugs. This means that MDR
TB treatment will be individualized.
Infection Control training was developed and provided by Project HOPE for TB staff in pilot
regions and under GFATM for the rest of the country. Topics included administrative,
environmental and personal protection. Plans for infection control have been developed,
especially in relation to MDR TB treatment. Project HOPE has provided input in this area since
the prior grant, including provision of masks.
Tuberculosis Program Final Assessment and Evaluation Report 41
Case finding through mass radiology has decreased, but is still in use. BCG vaccination and
revaccination is done in children.
The total new case notification rate increased from 77 in 2003 to 84.5 in 2007, and notification
of pulmonary smear positive increased from 21 in 2003 to 26 in 2006, suggesting better
diagnosis and case detection.
Case management practices have improved significantly due to training provided by Project
HOPE, which gave a good base for TB control improvement. Only some cases are hospitalized
in TB facilities for the intensive phase of treatment. In Tashkent city patients can go to the
nearest PHC facility to their home for DOT during treatment.
Treatment success has been maintained at around 80-81% from 2003 to 2006 and national
default rate has stayed between 7 and 9%. Deaths during treatment have remained stable at 5-6%
and the failure rate also has stayed at 6%.
Drug management was given high priority. A logistics implementation system (LMIS) was
developed with JSI and piloted in 3 rayons. Positive results were shown and the LMIS was
scaled up by the DOTS Center throughout the country, with assistance in training from Project
HOPE. Importantly, the MOH recognized that the LMIS model is useful not only for TB drug
management, but also for management of any drugs. Project HOPE facilitated registration and
certification of TB drugs in the country. TB drugs are available in all TB facilities free of charge,
and are also distributed to PHC for DOT throughout Uzbekistan.
The DOTS Center is reviewing programs for drug management of second line drugs with
assistance from JSI and Project HOPE. Second line drugs will be procured under the new Round
8 GFATM grant. Small amounts of second line drugs were procured under the previous GFATM
grant for a limited number of patients in Tashkent pilot.
Addressing MDR TB is a high priority for Uzbekistan. In the global Drug Resistance report
released by WHO in February 2008, Tashkent city had some of the highest rates of drug any
resistance among both new and retreatment cases in the world. Two DOTS+ pilots are being
conducted in Karakalpakstan by MSF and in Tashkent city by the DOTS Center PIU Round 5
GFATM grant. Through support of Project HOPE, a 2-week TOT training was conducted in
Uzbekistan for oblast Chief TB managers and their deputies on clinical and case management of
MDR cases by trainers from Latvia. A team of trainers led by Project HOPE and oblast trainers
conducted the first training by local trainers in mid-February 2009, and trainings will cover staff
working in both civilian and prison sector. A guideline for treatment of MDR TB was developed
in May 2008. An Interagency group is being restarted on the initiative of the DOTS Centre and
the first meeting topic is MDR TB.
For TB/HIV, there is no systematic process for registration or testing of suspected TB/HIV
patients, though a program is reportedly in development in Tashkent city. No additional data was
available for this site or the country. VCT is provided for patients only with their permission.
Community mobilization activities have played an extremely important role for TB knowledge
and behavior change in Uzbekistan. Activities focused on health providers included IPC training
Tuberculosis Program Final Assessment and Evaluation Report 42
for health providers and communication training for nurses, with the use of a flip book
developed for the project. An OR study on defaulters in Tashkent identified a lack of patient
education as one key reason for default, so a training was developed to address that issue and
reduce default rates. Monitoring and supportive supervision activities have also contributed to
behavior change among health providers. Through supervision training and by observation of
Project HOPE staff using on-the-job training and explanations of problems found, rather than
focusing on punishment as under the prior system, supervisors have realized the effectiveness of
this approach and changed their style of monitoring.
Many IEC materials were developed in Uzbekistan, in collaboration with the NTP and TWG on
IEC/BCC, including the flipbook mentioned above, information for patients, information for
migrants, and a Public Service Announcement in both Uzbek and Russian which was broadcast
throughout the country with referral of questions to a hotline in the DOTS Centre. World TB
Day activities were conducted jointly with the NTP and other partners. No small grants program
was conducted in Uzbekistan due to restrictions under local laws. Previously, reporting on TB
was considered taboo, but training of journalists in collaboration with the Centre for Preparation
of Journalists, raised interest and understanding and several stories about TB have come out in
the local and national news, with the journalists receiving many questions in response to these
articles.
Additional community mobilization activities included conducting a talk show with well-known
singers and students to talk about TB and encourage people to discuss it openly, which was well￾received. Training for Mahallas, community leaders and women’s groups is increasing openness
and awareness of TB issues and services, and reducing stigma among the population. Even
customs officials at the border crossing openly asked questions about TB and the link with HIV.
More work in this area is still needed in Uzbekistan, since there is still a stigma attached to
young women, and concern about acceptability for marriage remains a barrier to seeking
treatment.
Training and ToT on the DOTS strategy and all interventions (diagnosis, treatment,
management, drugs, laboratory, monitoring and evaluation) was done at all levels by Project
HOPE. It included training of nurses on methods to counsel patients. There is turnover of staff,
in particular laboratory staff, requiring a program of continuous training.
Training is also transferring responsibilities from Project HOPE to the national team and
trainers, trainers from one oblast going to other oblasts to provide training and support. There
were many training seminars, with great input received. Teams of trainers were developed in
pilots and used in other parts of country, and supportive supervision for oblast and rayon level
using a cascade methodology was prepared by Project HOPE and strongly accepted by the NTP.
The main advances in monitoring were a change from the previous focus on punishment to on￾the-job training support activity. Supportive supervision and monitoring done by Project HOPE
helped change behaviors among TB specialists doing monitoring as well as among the
physicians being monitored. These physicians know they will not be punished for mistakes as in
the past, but will get support and training to improve their knowledge and skills. Also Project
HOPE at the beginning of the project, found that checklists used for monitoring were not
Tuberculosis Program Final Assessment and Evaluation Report 43
standardized and took the initiative to work with the TWG to develop a single checklist for each
area that is now used by all organizations for TB control.
TB in prisons – no work has been done in this area except inclusion of prison health staff in
some training, due to lack of access to the prison system.
Project HOPE conducted additional training and monitoring activities as a sub-recipient under
the current GFATM grant in Uzbekistan, which has contributed to scale-up of activities to
additional parts of the country and the ability to train a larger number of health providers.
CONCLUSION
In summary, the evaluation team concluded that the project was successful in implementing the
planned activities, executed additional work as required and achieved most of the objectives.
The support of USAID through Project HOPE was considered essential for the national and
regional programs and for coordination among the partners and with the national institutions at
all levels. The joint efforts have achieved substantial improvement in the quality and coverage of
the national programs and there is evidence of epidemiological impact on the burden of TB.
The countries still require additional input to adopt the international standards for TB control, in
particular integration of TB care into the general health facilities and more rational use of TB
specialists and TB beds; to abandon obsolete and ineffective practices; and to develop their
capacity to manage the programs and use the information for action. Major challenges for the
future are increased use of general health facilities to diagnose and treat cases; efficient
prevention and management of MDR TB and TB/HIV; and rational use of the external financial
resources to avoid inappropriate use of funds and technologies and the diversion of the NTP staff
time from the key interventions of the DOTS strategy.
Tuberculosis Program Final Assessment and Evaluation Report Annex 1
Final Evaluation team members
Fabio Luelmo, Consultant, TB Control Programs (team leader)
Stefan Talevski, National TB Program Manager, Macedonia
Shalva Gamtsemlidze, Regional Technical Director, Project HOPE
Kayt Erdahl, Program Specialist, Infectious Diseases, Project HOPE
Tuberculosis Program Final Assessment and Evaluation Report Annex 2
Regional and country maps and USAID/Project HOPE pilot sites
Central Asia
Kazakhstan
Project HOPE pilot sites: Almaty Oblast, Prison System in Karaganda Oblast.
Tuberculosis Program Final Assessment and Evaluation Report Annex 2
Kyrgyzstan
Project HOPE supports the whole country.
Tajikistan
Project HOPE pilot sites: Dushanbe City, Rudaki rayon, Vosse rayon, Kulyab City, Kulyab rayon,
Farhor rayon, Hamadoni rayon, Mominobad rayon, Taimur Malik rayon, Shourobad rayon,
Nurek rayon, Khowaling rayon, Baljuwan rayon.
Tuberculosis Program Final Assessment and Evaluation Report Annex 2
Turkmenistan
Project HOPE pilot sites: Ashgabat city, Mary city, Balkan velayat (oblast).
Uzbekistan
Project HOPE pilot sites: Chilanzar rayon of Tashkent city, Shayhontohur (Akmal-Ikramov) rayon
of Tashkent city, Samarkand city, Urgut rayon of Samarkand Oblast, Yangier city in Syrdarya
Oblast, Syrdarya rayon of Syrdarya Oblast, Fergana city, Fergana rayon of Fergana Oblast,
Andijan city, Namangan city.
Tuberculosis Program Final Assessment and Evaluation Report Annex 3
Final Evaluation meetings: Countries visited and main persons interviewed
February 9-13, 2009
Kazakhstan
Name Position Affiliation
Almaty oblast
Maralbek Meirbekov Head Health department of Akimat of
Almaty oblast
Maira Egemberdiyeva Deputy of Head Health department
Salavat Sarsembayev Head doctor Oblast TB dispensary
Kenzhe Bektursynova Deputy head doctor Oblast TB dispensary
Smailova Aigul Deputy head doctor Oblast TB dispensary
Maya Kusemisova Head of microbiology laboratories Oblast TB dispensary
Inna Khvan Head of TB pulmonary department Oblast TB dispensary
Manat Suleimenova Head of drugstore Oblast TB dispensary
Tleuberdi Zhansengirov Head doctor of PHC (policlinic #1) Taldykorgan city
Bakhyt Zhapparkhanova Deputy of Head doctor
of PHC (policlinic #1)
Taldykorgan city
Gani Agibayev Head doctor, Koksu rayon, Almaty oblast Balpyk Bi village
Bibigul Zheldikova TB specialist Balpyk Bi village
Almaty City
Shakhmurat Ismailov Director of National TB Center National TB Center
Klara Baymukhanova Head of department National TB Center
Venera Bismilda Head of National Reference Laboratory National TB Center
Arman Toktabayanov Manager of PIU GFATM (TB component) National TB Center
Bakhtiyar Babamuradov Manager Project HOPE Kazakhstan
Daribek Assemgaliyev TB/Drug management specialist Project HOPE Kazakhstan
Bekzat Toksanbayeva Lab specialist Project HOPE Kazakhstan
Madina Aitukenova IEC/BCC Coordinator Project HOPE Kazakhstan
Kyrgyzstan
Name Position Affiliation
Avtandil Alisherov Director National Center of Phthisiology
Altyn Asanbekova Director Family Medical Center №9
Valentina Sorokina Curator Bishkek TB center
Mairapat Moydunova Director Bishkek TB center
Irina Gubankova Chief of monitoring department Bishkek TB center
Elmira Abdrahmanova Senior Scientific Specialist National Center of Phthisiology
Ainura Esenalieva Chief of Reference Lab National Center of Phthisiology
Atyrkul Toktogonova Chief of MDR Department National Center of Phthisiology
Kybanych Mamatov Manager Global Fund TB Component
Baktygul Akkazieva Health Reform Department MoH
Timur Aptekar TB Program Manager Project HOPE
Anvar Beisembaev TB Specialist Project HOPE
Tuberculosis Program Final Assessment and Evaluation Report Annex 3
Jibek Cholokova IEC/BCC Specialist Project HOPE
Tatiana Bobkova Lab Specialist Project HOPE
Totugul Murzabekova Monitoring Specialist Project HOPE
Jyldyz Ysykeeva TB Drug Specialist Project HOPE
James Bates Consultant JSI
Trisha Long Consultant JSI
Tajikistan
Name Position Affiliation
Sohibnazar Rahmonov Deputy Minister of Health Ministry of Health Tajikistan
Oktam Bobokhodjaev Director of Medical Services Department Ministry of Health
Sadullo Saidaliev Director National TB Program Republican TB Center
Umrinisso Sirojiddinova Chief of TB department, National
coordinator for training component
Tajik State Medical University
Asliddin Rajabov National coordinator for drug
management
Republican TB Center
Zebo Boronova Medical nurse Family Health Centre # 7, Dushanbe
Tanzilija Abdurahimova Nurse Family Health Centre # 7, Dushanbe
Aziz Mirzoev TB Coordinator DOTS Centre, Family Health Centre #
1, Dushanbe
Turakhon Nabiev Chief Healthy Life Style Centre, Dushanbe
Davron Pirov Deputy Head Republican Healthy Life Style Centre
Begidjon Saidrahmonov Head of rayon TB centre Rudaki Rayon TB centre
Zebo Burieva TB Coordinator Rudaki Rayon DOTS # 3
Muzafar Akhmedov Treatment Support Group Coordinator Rudaki rayon
Alexei Korobitsyn TB Program Manager Project HOPE
Mavlyuda Makhmudova Regional Drug Specialist Project HOPE
Jurahon Rajabov Drug Management Officer Project HOPE
Mavjigul Azizulloeva Deputy Program Manager Project HOPE
Jamilya Ismoilova Regional Social Mobilization/ small grants
Specialist
Project HOPE
Malika Omonova Chief Laboratory Specialist Project HOPE
Saodat Kasimova Social Mobilization/small grants
coordinator
Project HOPE
Jemma Yusupjanova Educator Project HOPE
Obidjon Norov TB Specialist, Monitoring and evaluation
coordinator
Project HOPE
Fozil Mamadjanov Training coordinator Project HOPE
Parviz Tabarov Incentives/ Enablers program coordinator Project HOPE
Zumrad Maksumova TB grant manager GFATM Program Implementation
Unit/ UNDP
Sayohat Hasamova Country Program Coordinator for STIs/
HIV/ AIDS
Tajikistan WHO country office
Mavjuda Kasymova Head of NGO “Nabzi Solim”, healthy generation
(TJK NGO)
Numon Abdulhamedov Head of public organization “ SVAST” (TJK Public organization)
Bahrinisso Isaeva Deputy Health Program Manager Mercy Corps
Tuberculosis Program Final Assessment and Evaluation Report Annex 3
Firuza Saidova National Coordinator for IEC/BCC, head of
local NGO ‘Nekroi’
Republican TB Centre
Jahongir Dehkonov Deputy Program Manager, community
health program
Japan Fund for Poverty Reduction
Carolyn (Teddy) Bryan Tajikistan Country Director USAID
Kevin Dean Tajikistan Deputy Country Director USAID
Malika Makhkambaeva Project Management Specialist/Health
and Education
USAID
Uzbekistan
Name Position Affiliation
Prof. Abdulla Ubaydaliev Director Republican Institute for TB Research
Dr. Marat Khodjibekov Deputy Minister Ministry of Health
Gulnoza Uzakova Director PIU GFATM
Gulnoza Murmusaeva Head National Reference Laboratory
Lazis Tiraev Lab. Specialist National Reference Laboratory
Hursand Ismatrulaeva Head City TB Dispensary. Tashkent
Artur Niyazov Program Manager/ Deputy Country
Representative
Project HOPE
Shakhnoza Usarova TB Specialist Project HOPE
Umida Yuldashova Drug Management Specialist Project HOPE
Umid Asamidinov Clinical Monitoring Specialist Project HOPE
Gulandom Elmuradova Laboratory Specialist Project HOPE
Rano Kurbanova DOTS Trainer Project HOPE
Marhabo Rakhimova Social Mobilization Assistant Project HOPE
Andreas Brunder Head of the Mission Medecins Sans Frontiers (MSF)
Nana Zarkua Medical Coordinator MSF
Fozil Khasanov Medical Officer MSF
G.Tsogt Regional TB Specialist WHO
Mishel Tailhades Head WHO Uzbekistan
Jamshid Gadoev National Professional Officer, TB Control WHO Uzbekistan
Benjamin Mills Health Adviser USAID
Gulnara Babajanova Director Centre of Journalist Education
Feruza Mamanazarova Health Promotion Manager ZdravPlus
Elena Tsoy Medical Education Program Specialist ZdravPlus
Tuberculosis Program Final Assessment and Evaluation Report Annex 4
Activities by Country
OBJECTIVE ACTIVITY KRG KAZ TKM UZB TAJ
Building political Support and participate in HLWG X X X
support Support interagency meetings X
Support laboratory TWG1 meetings X X X X
Support training TWG2 meetings X X
Support prison TWG3 meetings X X X
Approved policy/prikaz prisons X
Support drug management TWG3 X X X X X
Support monitoring DOTS TWG5 X X X X
Approved policy/prikaz X X X
Support IEC/BCC TWG6 meetings X X X X X
Approved policy/prikaz X X
Support MDR TB TWG7 meetings X X X
Draft TOR TB/HIV TWG8 X X
Support TB/HIV TWG8 meetings X X
Support round tables in 2 oblasts X X X X X
Initial policy assessments X X
Sustainable financing-analyze resource
generation
X
Assist in GFATM applications X X X X
Assist establishing donor committees
Conduct policy/operational research X X X
Integration of Develop strategy, revise roles X X
TB control into Monitor integration X X
health system Report results X X X
Provide training in pilot sites X X
Update DOTS materials X X X
Strengthening laboratory – assess inventory X X
Strengthening labs – rationalization X
Laboratory – situation analysis X X
Laboratory – EQA for microscopy X X X X
Laboratory – EQA responsibility shifted to
oblast staff
X X X X
Laboratory – develop training plan X X X
Laboratory – training X X X X
Laboratory – advanced training X X X X
Laboratory – cadre of trainers X X
Laboratory – training in culture/DST X X
Tuberculosis Program Final Assessment and Evaluation Report Annex 4
OBJECTIVE ACTIVITY KRG KAZ TKM UZB TAJ
Laboratory – monitoring and supervision X X X X
Lab monitoring /supervision shifted to NTP X X X X X
DST survey protocol X
Monitor DST implementation X X
National reference lab (NRL) certification X
Procurement of equipment X X
Strengthen Needs assessment and training plans X X
human resource Training of trainers (TOT) X X X X
capacity Basic DOTS training for PHC X X X X
Advanced DOTS training X X
Training of nurses X X X X
Follow up of released prisoners X
On the job training X X X
NTP Management training X X
Pre service education curricula X
Training in operational and epidemiological
research
X X X
Participation of national staff in international
meetings
X X X
Training in infection control for TB specialists X
Creating rational LMIS training X X X X X
drug Develop indicators for logistics X X
management Collect and analyze information X X X X X
systems Pharmacological surveillance for TB drugs X
Operational research on side effects X
Operational research on RUD X
TB drug formulary X X
TB drug pipeline manual, training and
monitoring
X
LMIS for second line drugs X
Improve Training in cohort analysis X X
program Evaluate data, analyze performance X X
management Quarterly report review w/ NTP staff X X X
and treatment Supervisory skills training X X X
outcomes Improving surveillance – assist in DST surveys X X
Support monitoring and supervision visits X X X X X
Training in cohort analysis for oblast level X
Management training for oblast level X
Tuberculosis Program Final Assessment and Evaluation Report Annex 4
OBJECTIVE ACTIVITY KRG KAZ TKM UZB TAJ
TB program manual X X X X
MDR TB Support drafting of manual and monitoring X
Training in Tashkent X
TB/HIV Monitoring indicators development and
training
X X
Development of management protocol X
Assess training (with CAPACITY) X X
Study tour to Karaganda X X
TB in prisons Participate in TWG, develop work plan X X X
Training and protocols X X
Operational research X
Participation in program “before release” X
Communication National strategies: develop IEC/BCC
materials
X X X X
Regional workshop and training of journalists X X X X X
Develop Library for IEC/BCC X
Support mass media & World TB Day X X X X X
Support KAP survey X X X X
Develop video spots X X X X
Arrange broadcasting X X X X X
Non medical staff: education materials,
training for community leaders,
monitoring/evaluation
X X X
Tool kit for providers X X X X
Training providers in IPC X X X
Monitoring use of tool kit X X X X
Refresher training for social workers and
nurses
X X
Train in health education-tool kit for nurses X X X
Training of trainers in counseling X X X X
Train providers, monitoring and assessment X X X X X
Advocacy for policymakers X
Develop small grants program X X X
Enablers/ incentives implementation and
operational research
X
Administrative Quarterly reports, success stories, closing X X X X X
Tuberculosis Program Final Assessment and Evaluation Report Annex 5
Examples of training activities, by country
KAZAKHSTAN
# Component name Date City Participants
(Male/Female)
1 Advanced DOTS training 27-29 Oct 2004 Karaganda 22 (3/19)
2 Refresh DOTS training 15-17 Mar 2005 Taldykorgan 22 (3/19)
3 TOT training 11-15 Apr 2005 Karaganda 17 (4/13)
4 Peculiarities of the Prison
Program
18-20 Apr 2005 Karaganda 11 (2/9)
5 TOT training 3-7 May 2005 Taldykorgan 8 (0/8)
6 DOTS strategy training (audit) 1-3 June 2005 Taldykorgan 11 (2/9)
7 DOTS strategy training (audit) 22-24 June 2005 Taldykorgan 11 (1/10)
8 Peculiarities of the Prison
Program Realization
20-24 June 2005 Karaganda
support AED for
participants
15 (7/8)
9 Peculiarities of the Prison
Program (audit)
8-11 Aug 2005 Karaganda 11 (9/2)
10 DOTS strategy training (audit) 24-26 Aug 2005 Taldykorgan 15 (14/1)
11 Peculiarities of the Prison
Program Realization (audit)
26-29 Sep 2005 Karaganda 11(9/2)
12 DOTS strategy training (audit) 23-25 Nov 2005 Taldykorgan 12 (2/10)
13 DOTS strategy training (audit) 13-15 Dec 2005 Taldykorgan 14 (4/10)
14 DOTS strategy training (audit) 25-27 Jan2006 Taldykorgan 15 (3/12)
15 Advanced DOTS training 06-09 Feb 2006 Taldykorgan 16 (2/14)
16 DOTS training
(Local TB Team)
06-11 Feb 2006 Karaganda 12(8/4)
17 DOTS strategy training (audit) 01-03 Mar 2006 Taldykorgan 15 (1/14)
18 DOTS training
(Local TB Team)
10-13 Apr 2006 Karaganda 13(5/8)
19 DOTS training
(Local TB Team)
12-14 April 2006 Taldykorgan 15 (2/13)
20 TOT training 24-28 Apr 2006 Almaty 19 (3/16)
21 DOTS training for PHC 02-04 May 2006 Almaty 21 (3/18)
22 DOTS training
(Local TB Team)
17-19 May 2006 Taldykorgan 13(5/8)
23 Advanced DOTS strategy training 23-26 May 2006 Almaty 15(1/14)
24 DOTS training
(Local TB Team)
29 May-01
June,2006
Karaganda 13 (7/6)
25 M & E training 05-09 June 2006 Taldykorgan 18(1/17)
26 DOTS training
(Local TB team)
19-21 June 2006 Taldykorgan 15 (7/8)
27 Laboratory
(External Quality Assurance)
20-22 June 2006 Taldykorgan 10 (0/10)
28 IEC training 21-23 June 2006 Almaty 18 (3/15)
Tuberculosis Program Final Assessment and Evaluation Report Annex 5
29 Advanced DOTS strategy training 18-20 July 2006 Almaty 15(6/9)
30 LMIS design workshop 18-20 July 2006 Taldykorgan 15 (0/15)
31 DOTS strategy training 16-18 Aug 2006 Talgar 15 (6/9)
32 M&E training 21-25 Aug 2006 Karaganda 15 (6/9)
33 DOTS training
(Local TB Team)
12-14 Sep 2006 Taldykorgan 16 (6/10)
34 Monitoring & Evaluation training 25-29 Sep 2006 Almaty 14 (5/9)
35 M&E of BCC Activities workshop 03-04 Oct 2006 Almaty 15 (4/11)
36 Workshop for journalists 05-06 Oct 2006 Taldykorgan 11 (2/9)
37 LMIS workshop 23-24 Oct 2006 Taldykorgan 30 (0/30)
38 DOTS training (audit) 01-03 Nov 2006 Issyk 13 (3/10)
39 DOTS training
(Local TB Team)
06-09 Nov 2006 Karaganda 13 (8/5)
40 Monitoring training 13-17 Nov 2006 Karaganda 8 (1/7)
41 DOTS training 15-17 Nov 2006 Taldykorgan 13 (2/11)
42 Monitoring training 04-08 Dec 2006 Taldykorgan 7 (0/ 7)
43 DOTS training (audit) 06-08 Dec 2006 Almaty 10 (3/7)
44 DOTS training (audit) 07-09 Feb 2007 Almaty oblast 15 (1/14)
45 Drug management workshop 19-20 Feb 2007 Almaty 36 (6/26)
46 DOTS training
(Local TB Team)
26 February-01
March
Karaganda 10 (3/7)
47 DOTS training (audit) 27 February-02
March 2007
Almaty oblast 13 (5/8)
48 DOTS training 09-11 Apr 2007 Karaganda 4(2/2)
49 Drug management workshop 19-20 Apr 2007 Almaty 36 (10/26)
50 Advanced DOTS training 25-27 Apr 2007 Almaty oblast 14 (1/13)
51 Monitoring workshop 02-04 May 2007 Almaty 19 (6/13)
52 DOTS training 14-17 May 2007 Karaganda 10(5/5)
53 EQA training 04-08 Jun 2007 Taldykorgan 9(0/9)
54 Advanced DOTS training 06-08 Jun 2007 Almaty oblast 14 (2/12)
55 EQA training 18-22 Jun 2007 Taldykorgan 9(0/9)
56 Advanced DOTS training 27-29 Jun 2007 Almaty oblast 12 (1/11)
57 DOTS training 12-14 Sep 2007 Almaty oblast 14(1/13)
58 Monitoring & Evaluation training 24-28 Sep 2007 Almaty 15 (5/10)
59 EQA training 19-23 Nov 2007 Taldykorgan 14(0/14)
60 EQA implementation 13 Dec 2007 Taldykorgan 13(3/10)
61 Drug resistance test (introduction
on operational research)
14 Dec 2007 Taldykorgan 14(0/14)
62 DOTS training 13-15 Feb 2007 Almaty oblast 15(1/14)
63 DOTS training 12-14 Mar 2007 Almaty oblast 15(3/12)
64 Epi Info training 14– 17 Apr 2007 Almaty 11 (4/7)
65 Monitoring & Supervision 21 – 25 Apr 2007 Almaty oblast
(Sought region)
16 (4/12)
66 Monitoring & Supervision 05– 09 May 2007 Almaty oblast
(North region)
15 (5/10)
Tuberculosis Program Final Assessment and Evaluation Report Annex 5
67 DOTS training 12.05 – 14.05 Almaty oblast, Issyk 13 (2/11)
68 LMIS training observation 26.05 – 30.05 Almaty oblast 216 (2/214)
68 EQA introductory training 19 – 20 Jun 2007 Almaty oblast 25 (0/25)
69 DOTS training 16 – 18 Jul 2007 Almaty oblast,
Kapshagai
14 (0/14)
70 Laboratory advanced training 28 Jul-1 Aug 2008 Almaty oblast,
Taldykorgan
8 (1/7)
71 Monitoring & Supervision 06 – 10 Oct 2008 Karaganda 15 (2/13)
72 DOTS training 22 – 24 Dec 2008 Almaty oblast,
Kaskelen
13 (0/13)
KYRGYZSTAN
Number of specialists trained by Project HOPE 2004 - 2008
Period Total No of
participants
TB
physicians
Primary care
physicians
Lab.
Specialists
Nurses Others
Total 2987 479 1996 30 347 135
TAJIKISTAN
Number of specialists trained by Project HOPE (USAID+GFATM) in 2004-2008
Total
participants
TB
physicians
Primary care
physicians
Lab. Spec. Nurses TSG IPC/C
Nurses and
HLSC workers
BCC TWG
members
Monitoring
Specialist
Others
3501 415 723 110 709 252 33 32 350
TURKMENISTAN
Number of specialists trained by Project HOPE in April 2004 – December 2008
Total participants TB physicians Primary care
physicians
Lab. Specialists Nurses Others
1468 275 345 44 580 224
Tuberculosis Program Final Assessment and Evaluation Report Annex 5
UZBEKISTAN
Number of specialists trained by Project HOPE in 2004–2008
Period Total
participants
TB
physicians
Primary Care
physicians
Lab.
Specialists Nurses Others
April 2004 – March 2006 546 88 147 10 294 7
March 2006 funded by
PIU/GFATM 28 14 0 1 13 0
April - June 2006 162 0 89 0 73 0
April - June 2006 funded
by PIU/GFATM 53 53 0 0 0 0
July - September 2006 271 0 33 0 238 0
October – Dec. 2006 117 0 0 0 117 0
January - March, 2007
funded by PIU/GFATM 63 63 0 0 0 0
January - March, 2007 17 11 0 1 5 0
April - June, 2007 146 130 0 0 14 2
July - September, 2007
funded by PIU/GFATM 88 88 0 0 0 0
July - September, 2007 9 0 0 9 0 0
October- Dec. 2007 49 19 0 0 26 4
January - March, 2008 197 130 0 0 30 37
January - March, 2008
funded by PIU/GFATM 1054 186 0 0 868 0
April- June, 2008 28 0 0 0 28 0
April - June, 2008
funded by PIU/GFATM 426 20 0 0 405 1
July - September, 2008 178 90 53 0 32 3
July - September, 2008
funded by PIU/GFATM 64 33 31 0 0 0
October - December, 2008 176 82 17 2 37 38
October – Dec. 2008
funded by PIU/GFATM 30 15 15 0 0 0
Total: 3702 1022 385 23 2180 92
Tuberculosis Program Final Assessment and Evaluation Report Annex 6
Activities carried out in human resource development
Regional:
 Development of Training of Trainers (TOT) program utilizing adult learning
methodologies was implemented in all 5 countries.
 Training curricula and materials were developed for training in DOTS for Primary Health
Care, TB Specialists, Nurses, and Laboratory Specialists in all 5 countries.
 Overall, a considerable knowledge and human resource base has now been created in
the region through the many persons trained.. The wealth of training materials and
trained trainers now available in the region will permit faster progress.
 Two Program Managers Workshops were held in conjunction with WHO, IUATLD, CDC
and other partners. These two week training sessions were held in the style of the WHO
Warsaw program managers’ workshop held every year.
 Assistance to local universities for training of medical students in the DOTS strategy and
modern TB control was provided in all of the countries.
 An International Conference was held in Bishkek for all CAR and other countries in the
Euro region for dissemination of the USAID evaluation of funded TB programs in the
region.
 KAP studies were conducted in two of the countries, utilizing results to improve
education and motivation of the general population on TB.
 Assistance to governments in all countries for review of TB guidelines, laws and orders
for TB control.
 Collaboration with CDC on laboratory training activities in all countries.
 Establishment of Internet libraries in all five countries. The project provided the
computer equipment necessary using funds donated by the US National Library of
Medicine. The Internet Libraries provide access to the internet, Medline, and links to
Tuberculosis information around the world.
 Poster presentations and lecture sessions on results of the project. These presentations
have been provided by HOPE teams and counterparts from all five countries at regional
and international conferences such as IUATLD and other international and regional
meetings, also the WHO Collaborative on Training and others.
Tuberculosis Program Final Assessment and Evaluation Report Annex 6
Kazakhstan:
 7 Training Centers were developed for 7 oblasts, this included the TOT for trainers in the
oblasts, funding for 10 additional monitored trainings by Project HOPE mentors and the
equipping of a training center. This activity provides sustainability for continuous
education for each of the oblasts.
 Drug Management principles was taught at the regional level. Because Kazakhstan buys
all its anti-TB drugs the local staff was taught how to calculate buffer stock and in￾service training provided at the time of monitoring visits.
Kyrgyzstan:
 Training of PHC specialists was integrated with programs of the Kyrgyzstan post￾graduate institute branches located in the regions. Faculty of the oblast branches were
trained in DOTS strategy and the training was integrated into the curriculum to build
ongoing training capability in the country for the TB program.
Tajikistan:
 Developed a cohort analysis training program to utilize with pilot and national
managers.
Turkmenistan:
 Fellowship to the New Jersey Medical School National TB Center was provided for MOH
counterparts and HOPE Staff. The team was introduced to US TB control procedures.
Uzbekistan:
 Training Center for TB control was opened at the Republican Research Institute for TB,
established by CDC and Project HOPE, to provide good educational conditions for
training in all aspects of the DOTS strategy.
 Developed and implemented management program for directors and managers of TB
facilities and hospitals and clinics. The program provided six 5-day trainings (split 3 days
and then 2 days two to three months later), each for 20 people, to introduce them to
organizational design, strategic planning, budgeting, human resources etc. with focus on
improvement of effectiveness and efficiency of the TB system. Each institution’s team
developed as part of the course a plan for solving a management problem at their
institution. The program culminated in a national conference in December 2003, where
selected plans and solutions were shared with all teams.
Tuberculosis Program Final Assessment and Evaluation Report Annex 7
Operational Research studies conducted by Project HOPE with national partners
Kazakhstan
1. Drug Resistance survey, 2007- ongoing.
2. Initial Knowledge, Attitude and Practice survey, 2005.
3. Knowledge, Attitude and Practice survey, 2008.
4. Low conversion rate among new SS+ TB cases – ongoing.
Kyrgyzstan
1. Impact of socio-demographic factors on treatment compliance among TB patients in
Bishkek, 2004.
2. Knowledge, attitude, and practices survey regarding tuberculosis, health professionals and
TB patients in Kyrgyzstan, 2006.
3. Adverse reactions to the first-line anti-tuberculosis drugs under DOTS-based program, 2007.
4. Drug Resistance Survey in Kyrgyzstan, 2008.
5. Operational research on reasons for high failure and defaulter rates in new TB smear+ cases
in Bishkek, 2008.
6. Knowledge, Attitude and Practice survey, 2008.
Tajikistan
1. Knowledge, Attitude and Practice survey, 2005.
2. Rational Use of TB drugs in Tajikistan, 2007.
3. Drug Resistance survey, 2008- ongoing.
4. Knowledge, Attitude and Practice survey, 2008.
5. Food Impact on treatment outcomes of TB patients in Tajikistan, 2008- ongoing.
Turkmenistan
No operational research studies were conducted in Turkmenistan.
Uzbekistan
1. Knowledge, Attitude and Practice survey, 2005.
2. Case finding, 2006.
3. “Defaulters” quantitative study, 2006.
4. “Defaulters” qualitative operational research. 2007.
5. Rational Use of TB drugs in Uzbekistan, 2007.
6. Study on TB among Migrants from Uzbekistan, 2008.
7. Knowledge, Attitude and Practice survey, 2009.
Tuberculosis Program Final Assessment and Evaluation Report Annex 8
Tuberculosis in the Central Asian Republics
TOTAL CAR
Year 2003 2006
Population in millions 57.1 59
Estimated TB incidence per 100 000 127 128
Estimated incidence of smear + TB per 100 000 57 58
New TB cases reported 61839 63696
TB notification rate 108 108
New sputum smear positive 16195 18455
New sputum smear positive rate per 100 000 28 31
Case detection rate (CDR) for smear + (%) 50 54
% of smear positive among new TB cases 26 29
Persons living with HIV (UNAIDS estimate for 2007) 42700
NOTES: Reported data for 2003 and 2006 was extracted from WHO TB Global Report 2005 and 2008.
The treatment outcomes correspond to patients reported in the previous year. Preliminary data for
2007 was provided by the NTPs to WHO, to be published in the WHO TB Report 2009.
TUBERCULOSIS IN KAZAKHSTAN
Year 2003 2006 2007
Population in millions 14.9 15.3 15.4
Population covered by DOTS (%) 100 100 100
Estimated TB incidence per 100 000 145 130 130 1
Estimated incidence of smear + TB per 100 000 65 59 59 1
New TB cases reported 23 943 23728 19584
TB notification rate 160.4 155.0 127.2
New sputum smear positive 6 627 6205 6140
New sputum smear positive rate per 100 000 44.5 41.0 39.9
Case detection rate (CDR) for new smear + (%) 68.5 69.5 67.6
% of smear positive among new TB cases 27.7 26.2 31.4
TB mortality rate per 100 000 22.4 20.3 18.2
Treatment success rate (%) 81.6 71.0 72.1
Died during treatment (%) 4.8 5.0 4.4
Failure rate (%) 11.2 12 16.0
Persons living with HIV (UNAIDS estimate 2007) -- -- 12000
1 WHO estimates for 2006
Tuberculosis Program Final Assessment and Evaluation Report Annex 8
TUBERCULOSIS IN KYRGYZSTAN
Year 2003 2006 2007
Population in millions 5.0 5.2 5.3
Population covered by DOTS (%) 100 100 100
Estimated TB incidence per 100 000 124 123 123
Estimated incidence of smear + TB per 100 000 56 55 55
New TB cases reported 6172 6174 5623
TB notification rate 123.2 117 107.0
New sputum smear positive 1671 1833 1720
New sputum smear positive rate per 100 000 33.4 35 32.7
Case detection rate (CDR) for new smear + (%) 57 63 59
% of smear positive among new PTB cases 27 30 30.6
TB mortality rate per 100 000 16.3 12.8 11.2
Treatment success rate (%) 81.9 85 82.2
Died during treatment (%) 4.4 3 4.5
Failure rate (%) 7.1 5 5.4
Persons living with HIV (UNAIDS estimate 2007) -- -- 4200
TUBERCULOSIS IN TAJIKISTAN
Year 2003 2006 2007
Population in millions 6.2 6.6 NA
Population covered by DOTS (%) 13 79 100
Estimated TB incidence per 100 000 168 204 NA
Estimated incidence of smear + TB per 100 000 76 92 NA
New TB cases reported 4260 6671 NA
TB notification rate 68 81 NA
New sputum smear positive 342 2051 NA
New sputum smear positive rate per 100 000 6 31 NA
Case detection rate (CDR) for new smear + (%) 8 34 NA
% of smear positive among new TB cases 8 38 NA
TB mortality rate per 100 000 6.1 7.1 6.4
Treatment success rate (%) NA 86 NA
Died during treatment (%) NA 4 NA
Failure rate (%) NA 6 NA
Persons living with HIV (UNAIDS estimate 2007) - - 10000
1 Data for 2005
Tuberculosis Program Final Assessment and Evaluation Report Annex 8
TUBERCULOSIS IN TURKMENISTAN
Year 2003 2006 20071
Population in millions 4.9 4.9 5.1
Population covered by DOTS (%) 36 46 NA
Estimated TB incidence per 100 000 67 65 NA
Estimated incidence of smear + TB per 100 000 30 29 29
New TB cases reported 3771 3223 NA
TB notification rate 77 66 NA
New sputum smear positive 1197 1155 1288
New sputum smear positive rate per 100 000 25 24 25
Case detection rate (CDR) for smear + (%) 81 81 86
% of smear positive among new TB cases 31.7 35.8 NA
TB mortality rate per 100 000 8.4 9.0 8.1
Treatment success rate (%) 77 81 NA
Died during treatment (%) 5 7 NA
Failure rate (%) 13 5 NA
Persons living with HIV (UNAIDS estimate 2007) <500
1 Preliminary data
TUBERCULOSIS IN UZBEKISTAN
Year 2003 2006 2007
Population in millions 25.3a 27.0 27.0
Population covered by DOTS (%) 52 100 100
Estimated TB incidence per 100 000 115 121 121
Estimated incidence of smear + TB per 100 000 52 55 55
New TB cases reported 20700 23900 17042
TB notification rate 79 89 63
New sputum smear positive 4690 7211 5333
New sputum smear positive rate per 100 000 18 27 20
Case detection rate (CDR) for new smear + (%) 35 49 36
% of smear positive among new TB cases 23 30 31
TB mortality rate per 100 000 11.5 7.7 7.6
Treatment success rate (%) 80 81 NA
Died during treatment (%) 5 6 NA
Failure rate (%) 8 6 NA
Persons living with HIV (UNAIDS estimate 2007) -- -- 16000
Tuberculosis Program Final Assessment and Evaluation Report Annex 9
GFATM TB grants status
COUNTRY ROUND # AMOUNT
(US$ million)
RECIPIENT STATUS
KAZAKHSTAN 6 9.8 Nat. TB Center
(P. HOPE sub-recipient)
Start Sep 2007. Phase 1 disbursed
8 69.9* Nat. TB Center
(proposed)
Approved, not yet signed. Phase I approved $37.6m
KYRGYZSTAN 2 2.7 Nat. TB Center Start Mar 2004. Total disbursed.
6 10 Nat. TB Center Start July 2007. First phase till June 2009, 3.2m disbursed
TAJIKISTAN 3 2.76 Project HOPE Start Sep 2004. Disbursed $2.27m. Bridge funds received.
Continuation requested to GFATM RCC
6 14.6 UNDP
(P. HOPE sub-recipient)
Start Aug 2007. Disbursed $6.5m, phase I
8 22.3 Pending Not yet signed
UZBEKISTAN 4 13.27 DOTS TB Center
(P. HOPE sub-recipient)
Start Feb 2005. Disbursed 9.57m, phase II
8 56.1* Pending Not yet signed
Source: www.theglobalfund.org
(*) Indicates that the total approved may be reduced, depending of GFATM available funds.
Tuberculosis Program Final Assessment and Evaluation Report Annex 10
Matching program funding provided by Project HOPE
Non-federal funding promised in original program budget: $2,721,929
Gift In Kind provided by Project HOPE, through April 2009: $2,858,110.35