USAID ELIMINATING TUBERCULOSIS IN CENTRAL ASIA (USAID ...

USAID ELIMINATING TUBERCULOSIS IN

CENTRAL ASIA (USAID ETICA) PROJECT

Quarterly Report: October–December 2020

January 31, 2021

DISCLAIMER

This report is made possible by the support of the American People through the United States Agency for International Development

(USAID). The authors’ views expressed in this publication do not necessarily reflect the views of USAID or the United States Government.

Submitted to: Arman Toktabayanov, Contracting Officer Representative,

Regional TB Advisor, Health and Education Office, USAID/Central Asia,

Almaty, Kazakhstan

Lola Yuldasheva, Alternate Contracting Officer Representative,

Project Management Specialist/Health, USAID, Tajikistan, Dushanbe

Abt Associates Inc. 1 6130 Executive Boulevard 1 Rockville, Maryland USA 20814 1

T. 301.347.5000 1 www.abtassociates.com

With:

PATH

IML red

Resource and Policy Exchange, Inc.

AFEW Kazakhstan

Afif Tajikistan

National Red Crescent Society of Tajikistan

USAID ELIMINATING TUBERCULOSIS IN

CENTRAL ASIA (USAID ETICA) PROJECT

Quarterly Report: October–December 2020

Contract No.: 72011519C00002

DISCLAIMER: This report is made possible by the support of the American People through the United States

Agency for International Development (USAID). The authors’ views expressed in this publication do not

necessarily reflect the views of USAID or the United States Government.

USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | i

TABLE OF CONTENTS LIST OF EXHIBITS ....................................................................................................................II

ACRONYMS AND ABBREVIATIONS............................................................................... III

1. EXECUTIVE SUMMARY ..............................................................................................1

1.1 QUARTERLY REPORT STRUCTURE ............................................................................................ 2

2. TAJIKISTAN ....................................................................................................................3

2.1 OVERVIEW ............................................................................................................................................ 3

2.2 COVID-19 RELATED ACTIVITIES .................................................................................................. 5

2.3 OBJECTIVE 1: INCREASED DETECTION OF TB AND DR-TB ............................................ 5

2.4 OBJECTIVE 2: INCREASED TREATMENT SUCCESS FOR TB AND ALL TYPES OF DR-TB

9

2.5 OBJECTIVE 3: IMPROVED ENABLING ENVIRONMENT AND FINANCIAL

SUSTAINABILITY OF TB AND DR-TB PROGRAMS ........................................................................... 12

2.6 PERFORMANCE MONITORING .................................................................................................. 16

3. UZBEKISTAN .............................................................................................................. 21

3.1 OVERVIEW .......................................................................................................................................... 21

3.2 OBJECTIVE 1: INCREASED DETECTION OF TB AND DR-TB .......................................... 22


27



3.5 COVID-19 RELATED RISKS AND CHALLENGES ................................................................... 32


3.7 OBSTACLES AND CHALLENGES ................................................................................................ 33

4. KAZAKHSTAN ........................................................................................................... 36

4.1 OVERVIEW .......................................................................................................................................... 36

4.2 OBJECTIVE 1: INCREASED DETECTION OF TB AND DR-TB .......................................... 37


42




4.6 OBSTACLES AND CHALLENGES ................................................................................................ 49

5. BUDGET EXPENDITURES ........ ERROR! BOOKMARK NOT DEFINED.

USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | ii

LIST OF EXHIBITS Exhibit 1. Comparison of Y2Q1 and Y1Q1–4 indicators ........................................................................................ 4

Exhibit 2. Number of screened, tested, and diagnosed individuals through project-supported CSOs ........ 6

Exhibit 3. Treatment outcomes for 2018 cohort of patients with DS-TB ......................................................... 10

Exhibit 4. Treatment outcomes for 2017 cohort of patients with DR-TB ........................................................ 10

Exhibit 5. Summary of online monitoring .................................................................................................................. 18

Exhibit 6. Achievement of performance indicators, Y2Q1, Tajikistan ................................................................ 20

Exhibit 7. Progress of 2 main project indicators in pilot oblasts .......................................................................... 21

Exhibit 8. Notification of TB cases in 2019 and 2020 in the Jizzakh oblast ....................................................... 23

Exhibit 9. Notification of TB cases in 2019 and 2020 in the Syrdarya oblast.................................................... 23

Exhibit 10. Inventory of GeneXpert cartridges, as of September 2020 ............................................................. 27

Exhibit 11. Treatment success rate for DS-TB patients in first three quarters of 2020 (January–

September) in pilot oblasts ............................................................................................................................................ 29

Exhibit 12. Treatment success rate for DR-TB patients in first three quarters of 2020 (January–

September) in pilot oblasts ............................................................................................................................................ 29

Exhibit 13. Summary of monitoring visits to the Jizzakh and Syrdarya oblasts ................................................. 34

Exhibit 14. Achievement of targets of Y2Q1, Uzbekistan ..................................................................................... 35

Exhibit 15. Comparison of indicators of Y2Q1 and Y1Q1–Q4 ........................................................................... 37

Exhibit 16. Achievement of UNHLM commitments of TPT by Kazakhstan ...................................................... 39

Exhibit 17. Number of Xpert MTB/rifampin (RIF) tests by month in all GeneXpert laboratories (first 10

months of 2020) ............................................................................................................................................................... 40

Exhibit 18. Percent of MTB-positive among all conducted Xpert MTB/RIF tests by month in all

GeneXpert laboratories (first 10 months of 2020) ................................................................................................. 41

Exhibit 19. Percent of RIF-resistant among all conducted Xpert MTB/RIF tests by month in all

GeneXpert laboratories (first 10 months of 2020) ................................................................................................. 41

Exhibit 20. Tendency of GeneXpert testing conducted in the Aktobe region, first 10 months of 2020 ... 46

Exhibit 21. Number of positive results of GeneXpert tests in the Aktobe region ......................................... 47

Exhibit 22. Summary of monitoring findings in the Aktobe region, November 2020 ..................................... 48

Exhibit 23. Achievement of targets of Y2Q1, Kazakhstan ..................................................................................... 50

USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | iii

ACRONYMS AND ABBREVIATIONS

ACF Active case finding

aDSM Active drug-safety monitoring and management

AE Adverse event

AFEW Public Fund “AFEW Kazakhstan”

AIDS Acquired Immunodeficiency Syndrome

AMELP Activity Monitoring, Evaluation, and Learning Plan

BDQ Bedaquilin

BPaL Bedaquilin, pretomanid, and linezolid

CFZ Clofazimine

COVID-19 Coronavirus Disease of 2019

CSO Civil Society Organization

CT Complex tariff

DHIS2 District Health Information System 2

DLM Delamanid

DOT Directly observed treatment

DR Drug-resistant

DS Drug-sensitive

DST Drug susceptibility testing

ECF Enhanced case findings

ESCM Electronic Surveillance Case-Based Management System

GF Global Fund to Fight AIDS, Tuberculosis, and Malaria

GIS Geographic information system

GPS Global positioning system

HIV Human immunodeficiency virus

HLC Healthy Life-Style Center

ISO International Organization for Standardization

JTH Joint TB, HIV, and Viral Hepatitis

LIMS Laboratory Information Management System

LPA Line Probe Assay

LQMS Laboratory Quality Management System

LTBI Latent tuberculosis infection

LZD linezolid

MDR Multi-drug resistant

MDT Multidisciplinary team

M&E Monitoring and evaluation

MOF Ministry of Finance

MOH Ministry of Healthcare (Kazakhstan), Ministry of Health (Uzbekistan), Ministry of

Health and Social Protection (Tajikistan)

mSTR Modified short treatment regimen

MTB mycobacterium tuberculosis

N/A Not available

NRAM National Regulatory Authority for Medicines

NRL National Reference Laboratory

NSP National Strategic Plan (renamed the National Program for the Protection of the

Population from Tuberculosis)

NTP National Tuberculosis Program

OpenMRS Open Medical Record System

OR Operational research

USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | iv

PHC Primary Health Care

PITT Performance Indicators Tracking Table

PLHIV People Living with HIV

PWTB People with tuberculosis

Q1 Quarter 1

Q2 Quarter 2

Q3 Quarter 3

Q4 Quarter 4

QMS Quality Management System

RAC Republican AIDS Center

RECCFM Republican Educational and Clinical Center of Family Medicine

RIF Rifampin

RR Rifampicin-resistant

SHIF Social Health Insurance Fund

SLIPTA Stepwise Laboratory Quality Improvement Process towards Accreditation

SLMTA Strengthening Laboratory Management toward Accreditation

SOP Standard Operating Procedure

SoW Scope of Work

SSM Sputum Smear Microscopy

SSO State social order

SWOT Strengths, weaknesses, opportunities, and threats

TA Technical assistance

TB Tuberculosis

ToR Terms of Reference

TOT Training of Trainers

TPT Tuberculosis preventive treatment

TWG Thematic/Technical Working Group

UNHLM United Nations high-level meeting

USAID United States Agency for International Development

USAID ETICA USAID Eliminating Tuberculosis in Central Asia

VST Video-supported therapy

WGS Whole-genome sequencing

WHO World Health Organization

XDR Extensively drug-resistant

Y1 Year 1

Y2 Year 2

USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 1

1. EXECUTIVE SUMMARY

In Quarter 1 (Q1) of the second implementation year, the United States Agency for International

Development Eliminating Tuberculosis in Central Asia project (USAID ETICA) continued to adapt to the

realities and implications imposed by the Coronavirus Disease of 2019 (COVID-19) pandemic. Since

COVID-19 restrictions have been relaxed in the reporting quarter, the project conducted events using

online and mixed (online and in-person) methods. Monitoring visits were also conducted either in-

person or online, which provided wider opportunities to receive and verify the data and conduct on-

the-job coaching sessions. However, pandemic restrictions continued hampering the project’s

performance. The following narrative underscores achievements during the reporting period.

USAID ETICA is designed to help achieve the USAID Global Accelerator to End Tuberculosis (TB) key

targets of Reach, Cure, and Prevent.

Under Reach, building on Year I (Y1) efforts, USAID ETICA continued its notable progress toward

achieving project goals. To advance case detection, project volunteers and outreach workers continued

providing community-level support to the TB care system. During the reporting quarter, they visited

almost 7,000 families for screening and detected 11 TB positive cases, who were dropped out of eye-

sight of the TB care system. The project continued exploring opportunities to revive multidisciplinary

teams (MDTs) for improving active case findings (ACFs) and support the TB system in conducting the

screening, prevention, and treatment activities. Conducting the first Training of Trainers (TOT) among

Civil Society Organization (CSO) representatives on various TB-related topics expanded their capacity

to engage in community-level support.

In the laboratory sector, the project prepared local trainers to conduct drug susceptibility testing (DST)

for new drugs (i.e., clofazimine and linezolid), continued providing technical expertise on whole-genome

sequencing (WGS) operations, and continued analyzing the performance of the GeneXpert network. In

view of the upcoming expansion of the GeneXpert network in Uzbekistan, the project supported the

National Tuberculosis Program (NTP) to reorganize its laboratory network efficiently and to develop a

video tutorial on maintenance and utilization of the GeneXpert machines. Altogether, the project team

managed to update 404 out of 776 Standard Operating Procedures (SOPs) in all 3 countries as part of

the Quality Management System (QMS).

Under the domain of Cure, to improve treatment outcomes and to show decision-makers the progress

or deterioration of the treatment process, the project team continued analyzing treatment outcomes

among drug-sensitive (DS) and drug-resistant (DR) TB patients. In addition, the project assumed control

over three new districts (i.e., Rudaki, Vahdat, and Dushanbe in Tajikistan), where the team began

implementing not only regular prevention and treatment, and support; but also introduced a modified

short treatment regimen (mSTR) for extensively drug-resistant (XDR) TB patients through collaboration

with the World Health Organization (WHO) and the NTP. To enhance adherence support, teams of

volunteers and outreach workers distributed 357 food parcels to families of people affected by TB and

continued providing them information sessions. The project also continued supporting the Consilia of

doctors for timeliness and quality of service provision to people with TB (PWTB). As one important

element of patient-centered care, the project team continued working to establish better

pharmacovigilance with a functional, active drug-safety monitoring and management (aDSM) system.

Under the domain of Prevent, building on the gains of Y1, the team continued sensitizing NTP staff and

local partners on considering WHO recommendations and strengthening activities related to latent


tuberculosis infection (LTBI). Since LTBI remains a “grey” area for TB care, the project started training

and targeting other LTBI activities. USAID ETICA trained 54 NTP staff on LTBI based on the latest

WHO recommendations.

In the cross-cutting area of self-reliance, to enable a better environment in the TB program, USAID

ETICA signed contracts with local research agencies in each country to conduct a gender study. The

psychological counseling and support video, developed by the project and provided to the finance

Thematic/Technical Working Group (TWG), laid a good foundation to improve the environment for an

efficient TB care system. USAID ETICA continued working on reviving the GxAlert system, introducing

the Prevent TB Platform and continued supporting the Ministry of Health’s (MOH’s) initiative to connect

to MOH’s District Health Information System 2 (DHIS2) system and Uzbekistan TB Electronic

Surveillance Case-Based Management System (UZTB ESCM) used by NTP in Uzbekistan. Another

remarkable result of the reporting quarter was obtaining MOH approval on two important documents

on social contracting and TB financing reform in Tajikistan, which should presumably lay the basis for

improvements in TB care.

As part of regional efforts, USAID ETICA conducted laboratory activities aiming to support each

country’s National Reference Laboratory (NRL). Since the quality of patients’ lives and case management

depends on clinicians’ understanding of their laboratory test results, a project laboratory team

conducted a regional online webinar, "Interpretation of TB laboratory test results," with the

participation of 56 clinicians and laboratory specialists from 3 countries (Tajikistan, Uzbekistan, and

Kazakhstan). During the webinar, the project team paid special attention to specific issues such as

divergence of laboratory results and made recommendations to clinicians on the accurate interpretation

of test results to inform sound decision-making during their treatment of patients. The webinar received

much positive feedback from participants on their receipt of detailed explanations on various TB

diagnosis methods that are important for routine practical use. Webinar participants agreed to conduct

an international online Consilium with the participation of laboratory specialists and clinicians to discuss

difficult TB cases, joint interpretation of laboratory results, and monitoring the treatments that obtained

successful results.

To obtain QMS standards in laboratories, USAID ETICA developed training materials on Strengthening

Laboratory Management toward Accreditation (SLMTA) for laboratory specialists. The training was

conducted for the TB laboratory specialists in Kazakhstan, Tajikistan, and Uzbekistan; and the project’s

laboratory specialists in January 2021. The project used training materials for a series of regular, step-by-

step training sessions that were conducted to help the NRL achieve laboratory accreditation. Due to

COVID-19-related restrictions, the external auditors’ visit (IML red) to conduct the planned TB-SLMTA

assessment was postponed. In order to mitigate the risk of further delays, USAID ETICA strengthens

regional experts’ capacity and train the team of the regional TB laboratory auditors (from both the NRL

and the project) who would be capable of applying the Stepwise Laboratory Quality Improvement

Process towards Accreditation (SLIPTA) methodology.

1.1 QUARTERLY REPORT STRUCTURE

This report describes Year 2 (Y2) Q1 activities, the status of deliverables, project performance

monitoring mechanisms, activities related to the COVID-19 crisis in the three countries, results by

country, and a presentation of project budget expenditures by country since USAID ETICA’s inception.

The Plan of events for Y2 Quarter 2 (Q2) is attached to this report as Annex 6.


IMPLEMENTATION ACTIVITIES BY

COUNTRY

2. TAJIKISTAN1

2.1 OVERVIEW

In the first year of the project, substantial progress was made towards goals despite COVID-19. The

COVID-19 pandemic made the country's healthcare system more fragile and forced the MOH and the

government to redirect financial and other resources from TB to COVID-19 care. As a response to

limitations and challenges imposed by COVID-19, with the support of the partners, NTP started

adjusting the system to maintain existing gains of the continuum of care. This is automatically reflected in

the projects implemented in the country, which also tailored interventions to the COVID-19 restrictive

environment. Building on the achievements and results of Y1, USAID ETICA’s key achievement in Y2Q1

are summarized in the narrative below.

The project can report the attainment of two main project indicators:

1) “Percentage and number of DR-TB cases diagnosed” was reached by 100.7% (139 cases) of

the newly established target of 138 cases (Y2’s annual target is 550). The detailed performance

analysis of this indicator is provided in Annex 1 of this report. The new target was submitted to

the client in the recently revised Activity, Monitoring, Evaluation, and Learning Plan (AMELP)

based on last year’s achievements and considering the challenging environment. Last year’s

annual result for the same indicator was only 46.2% of the target. As indicated in Exhibit 1, last

year’s achievement of the target continually decreased, while in the reporting quarter the result

increased by 72% compared to the previous quarter.

2) “Percentage (and number) of DR-TB cases started on second-line drugs” was attained by 98.6%

(137 PWTB) of newly identified DR-TB cases (139 cases). This indicator is dependent on the

previous indicator of the number of DR-TB cases diagnosed. Two individuals not enrolled for

treatment in the reporting quarter started treatment in the second quarter. Thus, this indicator

1 Photos (from left to right: Information, Education and Communication materials distributed among target groups in the 12

pilot districts; Processing of the received biomaterial, NRL; Participants of the training on reducing stigma and discrimination

sharing their views and experience with their peers; Project volunteer conducts screening of contact in Isfara district


always reached the 100% level of the target (90%). As Exhibit I indicates, the percentage of DR-

TB cases detected and enrolled in treatment has increases comparing to the previous quarters

of Y1.

Exhibit 1. Comparison of Y2Q1 and Y1Q1–4 indicators

In the area of case detection, the team continued providing community-level support to conduct

ACFs of those presumptive TB persons unknown to the NTP. During the reporting quarter, nearly

7,000 families were visited for TB screening and 11 new TB positive cases were identified by project

volunteers and outreach workers. To expand ACF efforts, the project piloted the three new districts of

Dushanbe, Vahdat, and Rudaki for prevention, treatment, and care activities. Eleven coordinators in the

new districts were trained on the basics of implementing the project in these newly selected districts.

Capacity-building events and the availability of guidelines were triangulated with local governments’

support, which led to uninterrupted community-level support to people affected by TB.

As a continuation of the case management guideline developed in Y1, the project initiated the

establishment of a TWG to address the issues of strengthening outpatient TB case management in

Tajikistan.

As one of the emerging areas for TB programs worldwide, LTBI is becoming one of the central topics in

Tajikistan. USAID ETICA conducted a 5-day LTBI and tuberculosis preventive treatment (TPT) training

for 22 NTP and project specialists.

Building on the remarkable gains of the previous project year in the laboratory component, the project

managed to revise and update all 318 SOPs on the QMS.

To improve treatment process and outcomes, project outreach workers and volunteers continued

providing adherence support to patients to be engaged in ACFs. The project started the implementation

of the mSTR under the Operational Research (OR) mode in the new pilot districts.

To enable a better environment for TB program implementation, USAID ETICA coordinated and

encouraged the MOH for the functionality of TWGs for social contracting and financial reform in TB

care, which resulted in signing Action Plans for both TWGs by the Deputy Ministers of Health.

Based on last year’s achievements in digitalizing TB care, the project signed an agreement with

SystemOne Company to operationalize the GxAlert system; and also signed an agreement with Dure

Technologies Company to develop the prevent TB platform.

Year 2

Q1 Q2 Q3 Q4 Q1

Number of diagnosed 146 118 93 81 139

% of change compared to

previous quarter-19% -21% -13% 72%

Number of enrolled to treatment146 118 93 81 137



Year 1INDICATORS

Percentage and number of DR-TB cases diagnosed

Percentage (and number) of DR-TB cases started on second-line drugs


In advancing gender issues as a cross-cutting component, the project signed an agreement with Tahlil

and Mashvarat LLC, a local research company, to conduct a gender study; and conducted mini-

information sessions in the Sughd region that were devoted to the “16 days of activities against gender-

based violence" campaign.

In addition, USAID ETICA finalized the project baseline assessment as well as the report for Phase II

Data Collection in 12 projects.

2.2 COVID-19 RELATED ACTIVITIES

COVID-19 continued affecting project staff and beneficiaries, as well as activity implementation in

Tajikistan. Through providing support to the NTP, USAID ETICA:

➢ Involved project volunteers and outreach workers in the implementation of the country-level

preparedness plan for COVID-19 for the National Red Crescent Society of Tajikistan areas.

➢ Had 120 volunteers visit 5,552 households (27,978 individuals), including 1,594 families

(7,827 individuals) of people affected by TB, to raise awareness of TB and improve TB case

detection. This activity allowed for the timely identification and referral of patients with

symptoms similar to COVID-19 and TB to healthcare facilities.

➢ Supported TB centers and Primary Health Care (PHC) facilities in the project’s pilot regions

to quickly implement the MOH order on the advanced distribution of TB drugs to PWTB to

avoid risks of disrupted TB medicine administration due to the COVID-19 pandemic.

2.3 OBJECTIVE 1: INCREASED DETECTION OF TB AND DR-TB

Community-level support and cooperation are crucial for successful TB case finding. However, due to

limitations imposed by COVID-19, in-person activities have become risky and almost impossible. Hence,

USAID ETICA has adjusted its activities to online approaches wherever possible, and all in-person

activities are carried out following strict social distancing and mask-wearing guidelines. The project

continued applying the same pace of case finding, which were adjusted to have parallel activities on

COVID-19 and TB.

At the facility level, the timeliness and accuracy of TB case detection fully rely on the effectiveness and

quality of the TB laboratory network’s operations. USAID ETICA continued working on the Laboratory

Quality Management System (LQMS) and conducting online technical support to laboratory specialists

on various diagnostic methods.

2.3.1 ACTIVITY 1.1: PARTNER WITH CSOS TO IMPLEMENT ENHANCED CASE FINDING (ECF) AND

WITH MOH TO STRENGTHEN SYSTEMS FOR CONTACT TRACING

Community-level referrals and outreach work are essential components of the project’s targeted and

integrated interventions. USAID ETICA conducted a set of activities aimed at understanding the policies

on and actual roles of CSOs in countering the spread of TB.

To prepare the implementation of USAID ETICA partners working on the community level for ECF, the

team arranged various workshops and meetings linking outreach workers and volunteers with local

governments. Such linkages tie cooperation on achieving project goals and detecting TB cases at early

stages in new pilot regions (Dushanbe, Rudaki, and Vahdat). During the reporting quarter, the project

also finalized the “Guideline for CSOs on the provision of services in the field of detection, treatment

support and prevention of tuberculosis.” This practical guide to planning and implementing effective


methods for TB control in target groups is intended to improve TB case detection and treatment

outcomes. Capable and empowered CSOs can help significantly reduce TB morbidity and mortality, and

advance important national and United Nations high-level meeting (UNHLM) goals for eradicating TB.

Trained field workers continued to report active findings of TB cases in pilot project areas. Since April

2020, USAID ETICA initiated the implementation of joint COVID-19 and TB activities at the community

level. Home visits by volunteers resulted in the identification of PWTB symptoms among family

members of people affected by TB. In 12 pilot districts, USAID ETICA screened 9,705 people, out of

whom 370 PWTB similar symptoms were referred and tested. Among those tested, 11 new TB positive

patients were identified, including 2 new patients with multi-drug resistant (MDR) TB. All of these

individuals were enrolled in the care and treatments prescribed. The intensive work among target

population groups helps actively identify individuals with early-stage TB and connect them with effective

treatment.

Since USAID ETICA partners started the field stage of the detection activities only in mid-Y1, they could

access only a small number of migrants for screening and other prevention activities. This happened

because prior to accessing migrants, the project needed lists of migrants from local governmental

institutions, which took time. As displayed in Exhibit 2, in Y1 88.1% of all screened people were

contact persons of PWTB. During the reporting period, the proportion of persons in contact with

PWTB decreased up to 57% because the number of migrants screened increased in the total share of

screened people. Second, since the number of DR-TB patients is low in pilot districts, their contact

persons have been already covered by case detection activities in Y1, which leads to a decreased

number of vulnerable people eligible for screening. And third, the self-referral of people to healthcare

facilities increased due to COVID-19, shrinking the number of presumptive TB patients for USAID

ETICA.

Exhibit 2. Number of screened, tested, and diagnosed individuals through project-supported CSOs


The project continued distributing drugs to people with MDR-TB through the volunteer network in

pilot areas. During the reporting quarter, 127 USAID ETICA volunteers and outreach workers paid daily

treatment monitoring visits to 150 MDR-TB affected individuals. Volunteers also ensured that MDR-TB

affected individuals had a sufficient quantity of prescribed TB drugs and adhered to prescribed drug

regimens.

To address the social and economic determinants of the diseases, multi-sectoral collaboration and

actions are important. Since USAID ETICA expanded its coverage in Tajikistan, the project conducted

two induction roundtables in the new project districts of Vahdat and Rudaki to introduce participants

with project objectives and implementation plans. The deputy heads of executive authorities; the heads

of TB, human immunodeficiency virus (HIV), Healthy Lifestyle centers (HLC), PHC centers, and jamoats

(i.e., third-level administrative divisions); and committees for women and youth participated in the

roundtables. The project proposed working with vulnerable groups and recommended joint activities for

bettering the lives of PWTB in the regions. The parties agreed to provide social support based on the

needs of each patient and to develop a joint work plan.

USAID ETICA conducted training for 11 coordinators and volunteers of the Dushanbe, Vahdat, and

Rudaki new project districts on organizing community-based work for TB case detection and adherence

to treatment. Following this training, coordinators conducted cascade sessions and distributed TB

screening checklists, vouchers, and reporting forms to volunteers who will be working with the USAID

ETICA project in the three new districts.

The management of LTBI involves a comprehensive set of interventions: identifying and testing those

individuals who should be tested; delivering effective, safe treatment in such a way that the majority of

those starting a treatment regimen will complete it with no or minimal risk of adverse events (AEs); and

monitoring and evaluation (M&E) of the process. To ensure all WHO recommended interventions are

incorporated into the LTBI guideline, USAID ETICA actively participated in the respective TWG as a

member. The project supported the NTP in developing and finalizing an LTBI guideline, which strategizes

key new 2020 WHO recommendations, including the paradigm shift in ACF, which includes identifying,

diagnosing, and treating people with LTBI under all ACF strategies. The NTP submitted the final version

of the guideline to the MOH for approval.

In parallel, the project conducted online master training on the programmatic management of TPT and

LTBI for 22 NTP specialists and representatives of other partner organizations working with TB. This

training was aimed at improving the knowledge of trainees on standards of programmatic management

of TB preventive treatment following the new WHO guidelines. Participants learned the importance of a

programmatic approach to TPT, reviewed target groups and new schemes recommended by the WHO,

identified opportunities for TPT in Tajikistan, and shared best practices. It is expected that NTP

specialists will use the knowledge gained through the training in their daily work to enroll presumptive

cases in preventive TB treatment as early as possible to avoid the evolvement to active TB disease.

2.3.2 ACTIVITY 1.2: STRENGTHENING THE QUALITY OF LABORATORY SERVICES

During the reporting quarter, USAID ETICA continued advancing the laboratory component of the

project and build on previous attainments. Together with the NRL, project specialists worked on

capacity building of laboratory staff, implementing QMS activities, and supporting the transition to the

Xpert MTB/RIF diagnosis system.


Due to remarkable gains in Xpert Ultra-diagnostic tests, such as higher sensitivity and improved

performance, it was included as a first entry-point diagnostic test in the updated diagnostic algorithm.

USAID ETICA developed a guideline on laboratory diagnostics, which contains an updated algorithm and

modified TB 05 forms for both diagnostics and treatment monitoring. Changes in the TB 05 form

include updated reporting of Xpert MTB/RIF Ultra cartridges and Line Probe Assay (LPA) tests. The

main purpose of the guide is to help clinicians make informed decisions based on laboratory results. It

also describes common cases of test discrepancies and possible solutions.

Since both the newly updated testing algorithm and the guide describing the algorithm entail having the

GeneXpert technique as the only entry-point diagnostics test, USAID ETICA initiated analyzing the

locations and mapping of all existing GeneXpert laboratories and attached healthcare facilities through

the ArcGIS geographic information system (GIS). This exercise will apply intelligent algorithms to draw

the most optimal transportation routes for specimen transportation and will improve management and

logistics planning of the existing GeneXpert diagnostic network. The mapping analysis will also identify

the inventory of GeneXpert cartridges, as well as the number and capacity of GeneXpert machines.

The LQMS is a set of coordinated activities to direct and support a laboratory with regard to quality. To

support the NTP in strengthening the LQMS in the

NRL and other country laboratories, and align it

with the requirements of the International

Organization for Standardization (ISO) and WHO

QMS standards, USAID ETICA completed auditing

the laboratory system's SOPs jointly with the NRL

and, to date, has revised and updated all 318 SOPs.

2.3.3 ACTIVITY 1.4: STRENGTHENING THE

QUALITY OF MEDICAL SERVICES FOR IMPROVED CASE DETECTION

In the second year, as a member of the TWG on strengthening outpatient TB case management, USAID

ETICA continues working on improving early detection and effective management and treatment of TB

patients. For this purpose, a case management guideline for the continuous care of DR-TB patients

receiving new drugs and shorter treatment regimens (i.e., identification, registration, and management of

patients) at the outpatient stage has been developed. The draft version was discussed at the TWG and is

close to finalization.

To improve the capacity of healthcare providers and CSO staff, USAID ETICA initiated the development

of training materials on case management at the outpatient stage to conduct a series of training sessions

in the pilot districts. Increasing capacity in case management will make the provision of assistance to TB-

affected people correct and efficient. Upon approval by the donor, the training is planned for the next

quarter.

USAID ETICA supported the national working group to revise current national protocols on TB/DR-TB,

and to ensure incorporation of these guidelines into the supervision system. Guidelines for implementing

an integrated model of continuous care for TB were drafted, acknowledging the challenges currently

presented to TB systems by the COVID-19 pandemic.

In addition to the national protocol on TB/DR-TB, to improve early detection and effective management

and treatment of TB patients, the development of guidelines for implementing an integrated model of

USAID ETICA REVISED AND

UPDATED ALL 318 SOPS ON THE

QMS IN TAJIKISTAN


continuous care for TB at the outpatient stage was completed. The guidance will instruct TB care

providers and ultimately improve the TB case detection and tracking system in the country.


To improve treatment outcomes for all types of DR-TB, USAID ETICA continued convening its efforts

to improve integrated TB case management, and enhance the skills of TB specialists on

pharmacovigilance and aDSM. The project started analyzing the duration of sputum (i.e., mucus)

conversion from DS- and DR-TB cases, and cases lost due to lack of follow-up and failure of treatment.

2.4.1 ACTIVITY 2.1: SUPPORT THE ADOPTION AND IMPLEMENTATION OF THE PATIENT-ORIENTED

APPROACH IN TB CARE

Adherence support dictates the treatment outcome and prevents the evolution from simple TB to

either MDR or XDR, which will make the disease management more complex and expensive. However,

the worst cause of treatment interruption is the lack of drugs for the cure, depending on the individual

manifestation of the disease.

Community-level support reduces the risks of infection from both TB and COVID-19 among vulnerable

population groups, and helps ensure successful TB treatment through support for patients’ adherence to

prescribed drug regimens. During the reporting quarter, project volunteers continued providing

adherence support to DR-TB patients in the pilot regions of the country. They distributed TB drugs to

all patients and provided 357 food packages to 57 financially vulnerable DR-TB affected individuals, with

funding from USAID and other donors.

2.4.2 ACTIVITY 2.2: SUPPORT THE INTRODUCTION OF NEW PROCEDURES TO SUSTAIN PATIENT-

CENTERED CARE

In November 2020, the NTP began OR for the introduction of (1) bedaquiline, pretomanid, and linezolid

(BPaL) as a new treatment regimen for XDR-TB patients; and (2) mSTR as a short course of MDR-TB

treatment using exclusively oral TB drugs. Both of these OR launches were conducted under the

auspices of the WHO. However, the technical oversight of the OR on BPaL implementation was the

responsibility of the KNCV Tuberculosis Foundation (the Netherlands) and the KNCV Branch Office in

the Republic of Tajikistan in the framework of the TB REACH Wave 7 Project. This OR has already

commenced and currently has few patients on the BPaL regimen. The second OR on mSTR will be

implemented by the NTP, with technical support of USAID ETICA. The OR on mSTR will cover

150 MDR-TB patients at this stage. As a preparation for the OR on mSTR, the partners need to know

the initial or baseline situation in the pilot districts. To have a baseline situation analysis in the new

districts for the upcoming OR, the project team conducted a cohort analysis for DS- and DR-TB

patients. The results of this analysis are outlined in Exhibits 3 and 4.

Exhibit 3 indicates treatment outcomes of DS-TB patients enrolled in treatment in 2018 in three new

pilot districts and national-level data. The first two categories of “Cured” and “Treatment completed”

are considered positive treatment outcomes. The exhibit displays almost similar results for the new pilot

districts compared to national-level data. Since patients with failure of treatment and those are under

the category of lost -to-follow up have a higher risk of their condition evolving to DR-TB, the Rudaki

district (9.2% in total) is more in need of new OR compared to the other two districts: Dushanbe (4.8%)


and Vahdat (5.2%). The patients in these two categories (i.e., failure of treatment and lost-to-follow up)

will be analyzed individually, and were most probably enrolled in mSTR treatment.

Exhibit 3. Treatment outcomes for 2018 cohort of patients with DS-TB

A similar analysis was conducted for DR-TB patients who were enrolled in treatment in 2017. The later

cohorts cannot be analyzed as the treatment courses continue. Percentages of DR-TB patients with

results categorized as “failure” and “lost to follow-up” are much higher than among DS-TB patients.

Vahdat ranks highest, with 21.6% of PWTB in these two categories; while Rudaki ranks the lowest, but

the district still has a quite high (13%) range of people with the risk of evolving XDR forms of TB. These

patients will most probably be enrolled in the new BPaL regimen.

Exhibit 4. Treatment outcomes for 2017 cohort of patients with DR-TB

44.0%

47.9%

44.7%

46.1%

44.9%

39.0%

42.8%

41.7%

4.8%

8.3%

3.4%

7.0%

1.3%

1.0%

3.4%

0.9%

4.9%

3.8%

5.8%

4.3%

COUNTRYWIDE

DUSHANBE

RUDAKI

VAHDAT

Cured Treatment completed Died Failure Lost to follow up

46.1%

59.8%

52.2%

51.4%

19.3%

13.7%

24.6%

13.5%

15.2%

8.8%

10.1%

13.5%

6.3%

8.8%

5.8%

8.1%

11.0%

8.8%

7.2%

13.5%

2.1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Countrywide

Dushanbe

Rudaki

Vahdat

Cured Treatment completed

Died Failure

Lost to follow up Result not assessed / treatment continues


In Tajikistan, the role of the TB Consilia is to confirm the TB diagnosis and prescribe a proper regimen,

and provide recommendations to doctors on follow-up steps related to patient management. USAID

ETICA regularly participates in Consilia meetings to discuss resistant forms of TB. Consilia doctors

review more than 20 TB patient files with different types of resistance (per meeting), including patients

who enrolled or switched to new treatment regimens (i.e., BPaL and mSTR). To sustain previously

established online consultations and Consilia meetings through the national training and demonstration

center, the project proposed to sign and drafted a multilateral, long-term memorandum of cooperation

between the training center and educational institutions. The role of academia will be to support the

NTP in conducting educational activities.

2.4.3 ACTIVITY 2.3: BUILD CAPACITY FOR PHARMACEUTICAL MANAGEMENT

USAID ETICA has completed the recruitment process for NTP technical experts and revised previously

developed Scopes of Work (SOWs) to align with Y2 project work plan activities. Technical experts will

support the introduction of internationally recognized quality standards for TB drugs, assist in the

registration process implementation, and support the NTP in conducting the quality control of TB drugs

in a WHO-prequalified laboratory. The project team revised the SoWs for the TB Drug Registration

Expert and the National Pharmacovigilance Consultant, both of whom will work closely with USAID

ETICA technical staff to assist in the transition to new, non-injection DR-TB treatment regimens, with a

focus on aDSM. Implementation of aDSM (at the country level and in pilot regions) is a mandatory

program component to expand patient access to new, non-injection regimens; and requires additional

financial and human resources for the proper collection of data needed to monitor and determine the

safety of new regimens at all levels of direct treatment observation.

The project held several working meetings with the NTP, the MOH, and the National Regulatory

Authority for Medicines (NRAM) to discuss the drug registration process. According to the NTP,

NRAM urgently requested the NTP to begin registering TB drugs (around 20–25 drugs in total). Except

for a few drugs, all anti-TB drugs are imported and used in the country using a one-time import permit.

NRAM will start banning the use of TB drugs in the country if the NTP does not start registering these

drugs. Moreover, in September 2020, a new batch of drugs was received and NRAM required to submit

a dossier for the registration of drugs that arrived in the country.

That said, the MOH and the NRAM are ready to consider applying the WHO collaborative registration

strategy,2 which will shorten the registration time required for prequalified drugs but will not cancel

registration fees. Project specialists will continue to work with specialists from the NTP and the NRAM

to prepare for registration and cooperate in adapting the legal framework for registration. It should be

noted that Tajikistan is included in the Promoting Quality Medicine Plus Project, which is a new, five-

year project for joint implementation of the drug registration processes and procedures.

According to the situational analysis of 2020 conducted by USAID ETICA, the detection of TB cases in

Tajikistan decreased by more than 30%, and DR-TB by more than 50%. USAID ETICA started

preparations for the roundtable with the Country Coordination Mechanism, the MOH, the NTP, and

2 The collaborative registration procedure serves to facilitate and accelerate the national registration of

pharmaceutical products, which the WHO Prequalification of Medicines Team has already assessed and

prequalified.


partners to discuss the situation on the achievement of country indicators in connection with the

COVID-19 pandemic.

USAID ETICA initiated the establishment of a Pharmacovigilance Working Group to develop a national

aDSM plan for 2021–2025. This plan will outline stepwise interventions toward achieving the goal to

improve the current drug safety situation in the TB program. It will also embrace the mechanisms of

funds allocation and cooperation of all partners working in this area. This working group will also be

responsible for creating other important documents for aDSM improvement in the country, such as a

national guideline on pharmacovigilance, functional responsibilities of clinicians, and different aDSM

forms. Project specialists, together with the NTP, prepared a draft order for the establishment of the

Pharmacovigilance Working Group, including a list of its members. The order was signed by the director

of the NTP and the working group is formally launched. The group held its inaugural meeting to assist

the NTP in developing a national plan to improve pharmacovigilance and aDSM in TB programming in

January 2021.


SUSTAINABILITY OF TB AND DR-TB PROGRAMS

The success and sustainability of TB control interventions, similar to other public health priorities, will

depend on the capacity of the general health systems within which they are delivered. During the

reporting quarter, USAID ETICA directed their efforts to lay foundations in the financial reforms of TB

service and start-up activities of social contracting through fine-tuning the functionality of respective

TWGs. Quarterly activities also embraced various coordination-related meetings to think through

future self-reliance of the TB program by conducting information sessions against stigma and

discrimination, continuing digitalization of TB services, and advancing the gender study.

2.5.1 ACTIVITY 3.2: STRONG COMMUNITY SUPPORT TO INCREASE CIVIL SOCIETY AND COMMUNITY

ENGAGEMENT IN DR-TB

USAID ETICA held a series of meetings with representatives of the Republican Center for Promotion of

Healthy Lifestyle, the Republican AIDS Center (RAC), and the Republican Educational and Clinical

Center of Family Medicine (RECCFM) to discuss collaboration in the framework of the TB program. The

purpose of this meeting was for partners to discuss ways of involving representatives of these

organizations in pilot areas of USAID ETICA, and linking USAID ETICA project outreach workers and

volunteers with the Healthy Lifestyle Centers (HLCs), RAC, RECCFM, and Health Committees

(established and coordinated by HLCs) to improve TB active case finding and treatment adherence

support in pilot regions. Holding meetings is the first stage in developing common approaches in the

implementation of the anti-TB program and will improve the quality of care for people affected by TB.

To document and disseminate successful examples of TB, HIV, and viral hepatitis case detection and

management during the COVID-19 pandemic, the WHO Regional Office for Europe has issued a call to

member states, partners, and community organizations across the European region to submit their best

practices. To facilitate the process of submission and dissemination, the Joint TB, HIV, and Viral

Hepatitis (JTH) Programme at the WHO Regional Office for Europe has developed a Virtual Library. By

collecting best practices and using evidence, this initiative will amplify the collective effort for targeted

and tailored interventions, and build capacity in health systems to respond to these three deadly

epidemics. Project specialists prepared a draft article on Tajikistan’s best practices of case detection in

the COVID-19 pandemic environment. The article describes a project approach to improve TB case


detection, and integrate work on TB and COVID-19, with the close engagement of government agencies

and nongovernmental partners.

2.5.2 ACTIVITY 3.4: EXPAND EFFORTS TO REDUCE STIGMA AND DISCRIMINATION

USAID ETICA continued moving forward the assessment on gender barriers, stigma, and other social

barriers to detection, treatment, and prevention of TB in the country. The project signed an agreement

with the local research company Tahlil and Mashvarat LLC, which submitted the tools and methodology

for the upcoming study. The field stage of the research will begin once the Institutional Review Board

and USAID approvals are obtained for the research documents. The questionnaire was tested with

six patients and the list of respondents was finalized.

In November 2020, within the framework of the "16 days of

activities against gender-based violence" campaign, USAID

ETICA conducted mini-information sessions in the Sughd region

to reduce the level of violence, stigma, and discrimination among

populations toward persons affected by TB. Participants were

informed about types of violence and the existence of centers

where they can go for support in case of violence in the family

or society. This initiative provided an opportunity to reduce the

level of violence among the population and raise awareness of

their rights.

At the beginning of December 2020, an exhibition of young

artists living with HIV, dedicated to World Acquired

Immunodeficiency Syndrome (AIDS) Day, was arranged in

Dushanbe and Khujand. Since People Living with HIV (PLHIV)

are vulnerable to TB infection, attending HIV-related events is

important for collaboration and cooperation between two

parallel HIV and TB programs.

USAID ETICA conducted a TOT in pilot districts on reducing

stigma and discrimination toward people affected by TB. The project increased the knowledge and skills

of 15 instructors from the Khatlon and Sughd regions; and the districts of Rudaki, Vahdat, and Dushanbe

in the field of human rights, types of violence, and stigma. Trained trainers will conduct similar cascade

training sessions among volunteers and outreach workers in the field. In turn, these volunteers and

outreach workers will work with the population to reduce stigma and discrimination toward people

affected by TB, and contribute to better TB detection.

2.5.3 ACTIVITY 3.5: ROBUST DATA COLLECTION, ANALYSIS, AND FEEDBACK SYSTEMS

Supporting the NTP in the digitalization of the TB continuum of care (i.e., the development of

information systems and e-platforms for TB service delivery) correlates well with the government’s

electronic health strategies. During the reporting quarter, jointly with the NTP, the project continued

discussing and reviewing different software programs to establish robust and sound data collection and

reporting, and analyzing the TB system.

Electronic detection tool “Prevent TB Platform.” The Prevent TB Platform facilitates the evaluation of

contacts in their home and communities or a health facility. It allows monitoring throughout the cascade

USAID ETICA assumed

control over three new

districts, including Rudaki,

Vahdat, and Dushanbe in

Tajikistan, where the team

began implementing not

only regular prevention and

treatment, and enabling

environment support, but

also introduced a mSTR for

XDR TB patients through

collaboration with the

WHO and the NTP.


of preventive care, capturing data at the time of identification of the contact and registration, clinical

assessment, screening for active TB, and testing for infection and treatment. The project team began to

work in close cooperation with developers of the Prevent TB Platform, Dure Technologies. During the

reporting quarter, the project conducted technical discussions on the improvement of the mobile

application’s interface and dashboard. The mobile application embraces an electronic questionnaire for

presumptive TB people, and has a user-friendly data entry/collection for required information on contact

tracing. The questionnaire will be used through mobile devices, and the data entered through these

devices will be automatically accumulated in the server for further analysis. In addition to the

questionnaire, the project team created a file with data variables and system requirements for the

platform. The digital Prevent TB Platform will help TB service providers leverage active TB case finding

and preventive treatment activities to better manage these cases. USAID ETICA is currently in the first

planning stage of the Prevent TB Platform in Dushanbe, Vahdat, and Rudaki in the OR stage. The project

procures mobile devices and internet connections to equip outreach workers to be able to work with

the platform.

Video-supported therapy (VST) is a technological alternative to conventional directly observed treatment

(DOT). VST is a recorded or live-streamed remote interaction between the patient and care provider

via internet-enabled equipment, such as smartphones, tablets, or computers. USAID ETICA, in close

collaboration with the Stop TB Partnership Tajikistan, participated in the adaptation of documents

related to the VST system. USAID ETICA developed a step-by-step plan (i.e., methodology) and will

collaborate with the NTP on the implementation of the VST tool. The procurement process of

necessary mobile equipment and internet traffic has started.

Development and implementation of the Laboratory Information Management System (LIMS). LIMS is a holistic

system connecting all other existing “pieces” or laboratory software and databases to form a full picture

of laboratory data management.

Based on discussions with national

laboratory specialists and the database

specialist, and the expressed priority

needs of the NTP, the required

specifications for the development of an

LIMS encapsulating all existing laboratory

information systems [GxAlert,

Laboratory Module of the Open Medical

Record System (OpenMRS)], and the TB module of OpenMRS register have been developed. To

procure the services of a software/LIMS developing company, USAID ETICA conducted market research

and identified approximately 15 vendors having the capacity to deliver a LIMS that matches key

specifications, and can accommodate and potentially improve the workflow in TB diagnostic laboratories

in Tajikistan. The USAID ETICA team held meetings with shortlisted vendors and watched live

demonstrations of various platforms offered by each company to assess the practical implementation of

the platform, and evaluate subjective parameters such as ease of handling and user-friendliness level. The

USAID ETICA team is currently preparing required documents, including an evaluation strategy for

selecting LIMS vendors. Selected vendors will be contacted to submit a Request for Proposal, and

proposals will be evaluated according to the evaluation strategy.

GxAlert. GxAlert was installed in all TB laboratories by the previous USAID project but is not functioning

due to the lack of financial support. To restore the functionality of the GxAlert system. USAID ETICA

USAID ETICA conducted market research and identified

approximately 15 vendors having the capacity to deliver

a LIMS that matches key specifications, and can

accommodate and potentially improve the workflow in

TB diagnostic laboratories in Tajikistan


continued negotiations and preparations for contracting SystemOne, the developer of the GxAlert

laboratory information system, regarding the renewal of a technical support subscription in Tajikistan.

USAID ETICA signed the agreement with SystemOne to renew this subscription for technical support

for the GxAlert system software. This agreement will result in the resumption of the GxAlert system

and enable real-time connectivity between a future LIMS and the network of GeneXpert machines.

System users will be able to contact company representatives to obtain online support and update their

skills by going through online refresher training sessions, as well as obtaining support in case of technical

issues with the GxAlert software system.

The USAID ETICA team worked on drafting the data management strategy for the TB service,

considering the information systems as well as their future compatibility and integration to one another.

The draft will be discussed internally and presented to the NTP and partners for further review and

revision.

2.5.4 ACTIVITY 3.6: INCREASED LOCAL CAPACITY TO FINANCE AND IMPLEMENT TB SERVICES

Improving the quality of TB services requires large financial investments, while the current allocation of

state funds is insufficient. One of the options to narrow the TB system's financial deficit is to support the

health financing reforms being carried out under the leadership of the MOH.

After establishing a finance TWG under the MOH to develop new methods of financing specifically for

TB services, USAID ETICA provided technical support on the development of a detailed Terms of

Reference (ToR) for the TWG. The project submitted the ToR to the MOH for review and approval,

and arranged a follow-up meeting with the head of the Economics and Budget Planning Department of

the MOH to discuss the implementation progress of the Strategic Plan for Health Financing Reform and

the details of the ToR. The action plan was subsequently approved by the MOH in January 2021.

Signing action plan for the TWG on TB financing for 2021

by 1st Deputy Minister, Mr. Muhsinzoda.

Signing action plan for the TWG on social contracting for

2021 by Deputy Minister, Mr. Shodikhon Jamshed.

A deep and timely engagement of communities and CSOs on combating TB infection elevates the quality

of TB service provision. To ensure the continuous support and involvement of CSOs in the TB program,

the availability and accessibility of state funding through a social order or contracting mechanism is

necessary. Currently, TB care benefits from CSO support originate from donor funding such as the

Global Fund to Fight AIDS, Tuberculosis, and Malaria (GF) and USAID, where CSO staff play a critical

role in early detection and support for the adherence of treatment.

To advance social contracting in TB services, during the last reporting period, the project initiated the

establishment of a TWG to promote the issues of social contracting for TB. USAID ETICA drafted a


SoW for the TWG and hosted its first meeting. Based on the last meeting outcomes of the TWG on

social contracting, USAID ETICA provided technical support on the development of an Action Plan and

ToR for the TWG on social contracting in TB care. Both documents were subsequently approved by

MOH.

In parallel, the TWG will start discussions and lobbying with relevant state agencies (e.g., social

protection agencies, the MOF) to consider funding social contracting for the 2022 state budget.

The previous GF project closed at the end of 2020. The next project started in January 2021 will no

longer support or finance internet connections of locations that have installed TB service databases and

the GeneXpert laboratory network. The project team participated in the previously mentioned online

finance TWG meeting, where TWG members discussed the options for sustainable internet

connectivity funding from the state budget. According to the NTP director, the annual cost of internet

connectivity in the TB system is 265,000 somoni. USAID ETICA will support the TWG to develop a

transition plan for financing internet connection from the state budget.

2.6 PERFORMANCE MONITORING

USAID ETICA initiated the development of an electronic database based on the requirements of the

Prevent TB Platform. This database is necessary for registering persons from key groups (e.g., migrants,

PLHIV, TB contacts), screened and tested presumptive TB patients, as well as those diagnosed as TB

positive in the project’s pilot regions. The electronic database will be the sole point of data entry for

USAID ETICA partners and project staff. Data will be entered from the pilot areas on activities related

to the first several stages of the TB continuum of care up until the testing stage. Once the database has

been successfully tested, it will be linked with the existing NTP software, such as OpenMRS, and will be

expanded to the national level.

As per the Y2 work plan, USAID ETICA had planned to conduct joint monitoring visits with the NTP to

district TB centers to verify data; and check the effectiveness of laboratory performance, the screening

process at the PHC level, and drug provision at district levels. Unfortunately, due to the COVID-19

pandemic and various government restrictions on the movement and gatherings of people, monitoring

was conducted only in the new pilot districts of Vahdat and Rudaki. The other 12 pilot districts were

monitored online as was done in Y1. Online monitoring included four assessment areas and

components: verification of statistical data, monitoring of PHC, and drug supply and laboratory services.

The findings are summarized in Exhibit 5.

As per recently revised and submitted AMELP, Tajikistan reports quarterly on 10 out of 14 indicators.

Annex 3, attached to this report, illustrates a Performance Indicators Tracking Table (PITT) and

provides an analysis of performance against the targets for each reported indicator. Exhibit 6 below

illustrates a summary of achieved quarterly results against set-up project indicators distributed by

project objectives. We report annually on the following 4 indicators:

➢ Indicator #8 “Percentage of participants reporting increased agreement with the concept that

males and females should have equal access to social, economic, and political resources and

opportunities”;

➢ Indicator #9 “Number of people reached by a USG funded intervention providing GBV services

(psychosocial counseling)”;

➢ Indicator #10 “Drug susceptibility test (DST) coverage for TB patients (%)”;

➢ Indicator #11 “Laboratories with QMS reaching 80% on TB-SLIPTA scale”.


The reported indicators are collected at both the national and pilot levels. The data on national level

indicators were obtained from the OpenMRS information system of the NTP. According to the NTP

reporting system, the data on the project indicators was generated from the recording and reporting

forms TB03, TB03U, TB04, TB07, TB07U, TB08, and TB08U. Forms TB07 and TB07U generate data on

the detection and treatment initiation, and forms TB08 and TB08U report on treatment outcomes.

Information on the laboratory indicator (indicators 12.1 and 12.2) was obtained from the TB04 form.

The registration journal TB03, TB03U was used for age and gender disaggregation.

The targets for testing indicator (#5) and diagnosis indicator (#6) in pilot districts were not reached,

making 19% (reached 3.8% against targeted 20%) and 60% (reached 3% out of targeted 5%) respectively.

Since the indicator of testing is calculated based on the number of screened persons (indicator #4),

USAID ETICA’s implementing partners tried to screen more people to improve the detection rate.

Since COVID-19 and TB have the similar manifestation of symptoms, a larger number of people become

eligible for TB screening. After screening, when presumptive TB individuals are referred to medical

facilities for testing, the healthcare providers select those who should go for testing, i.e. segregate and

send back those that do not exhibit relevant TB symptoms. This is one of the main reasons why the

testing indicator did not reach its target. This, in turn, affected the performance against the target for

the indicator of diagnosis (#6). A deeper analysis of performance against each indicator target is

provided in Annex 3.


Exhibit 5. Summary of online monitoring

Monitoring

area Positive results Identified problems Actions Recommendations

1. Statistical

data

* Each pilot area has a

responsible data-entry

specialist to work in

OpenMRS.

* The detection rate of DS-

and DR-TB increased

compared to the previous

quarter.

* Late data entry into OpenMRS;

* Data from the TB03 form do not

match the TB03R, TB07, with

TB07R forms in all 12 districts,

which is mainly due to the late entry

of the data in OpenMRS, leading to a

mismatch of the data.

* Not all patient pages in OpenMRS

contain information about adverse

effects and changes in treatment

regimens.

The data in OpenMRS were

corrected, based on verified and

checked statistical data in TB03

and TB03R journals; and

TB07/07R and TB08/08R

reporting forms.

* Since data entry is delayed systemically, it is

important to think of any mechanism or

algorithm of data entry to ensure timeliness and

accuracy of the data.

* Data-entry specialists must verify the entered

information against paper forms to ensure

matching of the data.

* Heads of epidemiological and statistical

departments of each district must cross-verify

the entered data.

2. Laboratory

services

Sufficient quantity of

GeneXpert cartridges in all

districts.

* Late submission of the request for

the supply of reagents in some

districts.

* Inaccurate completion of the

OpenMRS Laboratory Module in

some districts.

* One module of the GeneXpert

machine does not work in the Asht

district.

* Findings were shared with NTP

technical specialists, who were

requested to timely resolve

GeneXpert machine issues.

* Project specialists discussed

with the NTP the mechanisms of

timely submission and receipt of

laboratory goods.

* Laboratory specialists were consulted on the

timely submission of the Laboratory Module

and data entry to OpenMRS.

* Call an NTP laboratory technician to diagnose

and provide correct calibration of the Asht

GeneXpert machine.


Monitoring


3.Drug supply * The regional warehouse

has a sufficient supply of

some TB drugs for 4–6

months, depending on the

drug type.

* Some districts managed to

procure drugs for AEs from

local budgets of hospitals or

district TB centers.

* The temperature regime in

drug warehouses of all

districts was according to

established norms, and

entries were made in the

registration journal.

* Khujand procures some of

the AE drugs (partially).

* Insufficient stock of some drugs in

districts that are available only for

2 months.

* Lack of drugs for AEs in all

12 districts.

* No alarm system in medical

warehouses.

* In some districts, warehouses do

not meet security standards (i.e.,

Asht, J.Rasulov, Spitamen,

Temurmalik, and Jomi districts).

* As an example, J.Rasulov does not

have drugs for AEs so patients need

to purchase them with their own

personal funds.

* Not all drugs for AEs are available

in Khujand (e.g., absence of

pyridoxine, carsil).

* The National Coordinator for

Drug Management was notified of

existing problems such as the lack

of drugs for AEs, and the absence

of a security system and alarm

system in drug warehouses in

pilot districts.

* For the NTP to think of a mechanism or

algorithm for timely submission of requests for

anti-TB drugs to avoid out-of-stock drugs. The

availability of drugs on the regional level is not

sufficient. The buffer stock of all needed drugs

must be available at each health facility.

* Analyze the availability of AE drugs for each

country district based on the government’s

procurement.

* Advocate to increase/allocate budgets from

local governments for the procurement of AE

drugs.

* Advocate to increase/allocate budgets from

local governments to install a security system

for warehouses.

* Ensure that basic standards for warehouse

management are in place in each district.

4. PHC

services

* Preventive treatment

(i.e., isoniazid) is conducted

with all contact persons.

* PHC facilities use vouchers

for presumptive TB patients

referred for TB detection.

* Patients detected by

project partners receive full

social and healthcare

support.

* TB015 registration journals are

completed on a timely basis.

* Communication between TB

service providers and PHC centers

is not well established.

* ACFs are very weak at PHC

centers.

* Even after a positive Sputum

Smear Microscopy (SSM) result,

PHC providers do not trace and

follow up with a patient, which leads

to losing the patient or a delay in

treatment initiation.

* Lack of adherence to treatment

support from PHC family doctors

affect treatment outcomes.

* Online recommendations were

given to PHC providers (deputy

chief doctors and heads of

departments) on how to

complete the TB015 registration

book.

* Online consultations to follow

the diagnostic algorithm.

* All responsible people were

informed regarding lost patients

(from Mastchoh); it was

recommended to properly trace

DR-TB patients and thoroughly

investigate each case.

* Properly fill out TB015 registration journals.

* Improve ACFs and case tracing at the PHC

level.

* Conduct a thorough investigation of each lost

patient to locate and return them for

treatment.

* Conduct capacity building for family doctors

and nurses on ACFs and case management.


Exhibit 6. Achievement of performance indicators, Y2Q1, Tajikistan


3. UZBEKISTAN3

3.1 OVERVIEW

Like the rest of the world, Central Asian countries, including Uzbekistan, have been heavily affected by

the COVID-19 pandemic. Since March 2020, quarantine measures have been in effect, that has affected a

full-scale implementation of the USAID ETICA project. Despite that, the project team overcame

implementation impediments and achieved Y1 project targets to the maximum extent possible.

In the recently submitted AMELP, USAID ETICA indicated the challenges associated with data collection

and reporting in Uzbekistan. Such country-specific timelines make the project unable to report on

two main country-level indicators, which will be reported in the next quarterly report. However, the

project was able to obtain data for the pilot oblasts of Jizzakh, Syrdarya and Ferghana presented in

Exhibit 7 below. The number of diagnosed and enrolled to treatment DR-TB patients is low in the

reporting quarter compared to the same quarter of the Y1 due to COVID-19 related challenges.

Exhibit 7. Progress of 2 main project indicators in pilot oblasts

Indicators Y1Q1 Y1Q2 Y1Q3 Y1Q4 Y2Q1

Percentage and number of DR-TB

cases diagnosed 109 86 73 N/A 52

Percentage (and number) of DR-TB

cases started on second-line drugs 109 86 73 N/A 52

The project continued implementing Y1 delayed or postponed activities as well as activities approved in

the Y2Q1 work plan. Key project accomplishments for Y2Q1 can be summarized against project

components:

In the area of case detection, the project continued providing extensive support to the NTP and the

NRL. To improve collaboration and joint efforts of the laboratory and clinical departments of TB

dispensaries, the project team conducted roundtable meetings on "Interpretation of laboratory results"

for clinicians and laboratory specialists in the form of strengths, weaknesses, opportunities, and threats

(SWOT) analysis in the Jizzakh and Syrdarya oblasts. To further improve the understanding of the

clinicians, the team developed and upgraded laboratory forms and the "Guide to TB bacteriological

diagnosis for the staff of TB and PHC facilities.” To support LTBI and TPT efforts of the NTP, project

3 Photos (from left to right): Doctors and laboratory specialists are discussing interpretation of laboratory tests and SWOT

analysis, Syrdarya oblast; Participants in a webinar on programmatic management of preventive treatment of TB for NTP staff;

Process of regular annual calibration of GeneXpert analyzer modules, Jizzakh oblast.


experts contributed to the development of LTBI guidelines, which were subsequently submitted to the

MOH for approval. In addition, USAID ETICA organized the "Programmatic management of the TPT"

webinar for 25 NTP staff.

To continue strengthening the laboratory component, the team developed draft SOPs for collecting

biological material from suspected COVID-19 cases and using GeneXpert machines for diagnosing

COVID-19. Other key highlights related to the laboratory performance were:

➢ Developed video tutorials on the maintenance of GeneXpert machines;

➢ Provided technical support to regional and district laboratories on solving various problems with

the operation and maintenance of GeneXpert machines;

➢ Identified the potential shortage of GeneXpert cartridges and informed the NTP about possible

challenges;

➢ Reviewed and updated 25 SOPs and 79 short practical guidelines and formularies as a part of the

QMS system.

To enhance the treatment course for TB patients, the project supported the Gallaoral district of

Jizzakh oblast and the Yangier district of Syrdarya oblast laboratories to set up and calibrate the

biochemical analyzer. As was done in Y1, the team analyzed the treatment success rate of DS- and DR-

TB in pilot districts for the first nine months of 2020 to construct informed decisions by heads of

respective districts’ dispensaries. As an important cross-cutting element of the TB program, USAID

ETICA targeted improving the M&E system. In the reporting period, the team initiated the establishment

of a TWG for revising the M&E manual.

To enable the environment for better outcomes of the TB program, USAID ETICA started

developing a reorganization plan of the country’s microscopic laboratories for sputum collection and

transportation points. As a part of MOH’s digitalization plan, project experts supported the NTP in

adjusting the DHIS2 program to be in alignment with UZTB ESCM the TB care system. Since gender

should be studied as a social determinant of health, the project advanced conducting the gender study by

selecting a local research agency, Jjtimoiy Fikr, and contracted with them to conduct the study.


3.2.1 ACTIVITY 1.1: PARTNER WITH CSOS TO IMPLEMENT ECF AND WITH MOH TO STRENGTHEN

SYSTEMS FOR CONTACT TRACING

Detecting LTBI is important to prevent its evolvement to active TB. USAID ETICA’s goal for the

reporting period was to increase the detection of LTBI and enroll persons with LTBI into preventive

treatment, as per recommendations of the WHO. In Y1, the project participated in the TWG on

developing the LTBI manual based on the new, WHO-recommended risk-stratified methodology. As

members of the TWG, project experts participated in the development of the manual, which was

subsequently submitted to the MOH for approval.

Uzbekistan’s NTP, with support of the partners, makes a concerted effort in increasing the active

detection and prevention of TB and LTBI by aligning LTBI management with the latest WHO

recommendations. To support these efforts, USAID ETICA hosted the programmatic management of

the TPT webinar for 25 NTP staff to update them on the new, WHO LTBI recommendations and TPT

on November 27, 2020. The webinar provided participants with an overview of 2020 WHO

recommendations and programmatic aspects to scale up LTBI detection and TB preventive treatment at


the national level. The webinar supported NTP’s plans to adopt the best international LTBI management

practices to decrease TB morbidity and mortality in the country.

To enhance collaboration and cooperation with governments in pilot regions on the TB program,

USAID ETICA held a series of meetings with local partners in the Jizzakh and Syrdarya oblasts. During

those meetings, it was decided to jointly prepare and sign a joint USAID ETICA and local government’s

action plan; and organize joint public events dedicated to World Tuberculosis Day, competitions, and

meetings among the population to raise awareness about TB, with the aim to reduce stigma and

discrimination.

During joint onsite monitoring in the Jizzakh and Syrdarya oblasts with representatives of local

governments and TB doctors, USAID ETICA collected data and analyzed factors of decreasing TB

notification in each oblast. During the first nine months of 2020, the TB notification rate in the Jizzakh

oblast decreased by 50% in comparison with the same period in 2019 (Exhibit 8). As indicated in

Exhibit 9, the Syrdarya oblast displays similar results.

Exhibit 8. Notification of TB cases in 2019 and 2020 in the Jizzakh oblast

Jizzakh oblast TB drug-sensitive cases

(new and relapses)

RR+/MDR TB cases

(new and relapses)

Total number of

notified cases

2019 (9 months) 758 90 848

2020 (9 months) 390 34 424

RR = Rifampicin-resistant.

Exhibit 9. Notification of TB cases in 2019 and 2020 in the Syrdarya oblast

Syrdarya Oblast TB drug-sensitive cases

(new and relapses)

RR+/MDR TB cases

(new and relapses)

Total number of

notified cases

2019 (9 months) 437 96 533

2020 (9 months) 242 26 268

The reasons for these decreases could be attributed to:

1) Reorganization of TB facilities to COVID-19 centers,

2) Impact of the COVID-19 quarantine on sputum transportation to laboratories, and

3) Self-isolation of citizens during the COVID-19 pandemic.

When the decline in the case findings was discussed with the management of both oblasts’ TB

dispensaries, they decided to prioritize areas and work, leading to the improved detection of TB, such as

increased TB screening among high-risk groups and children; and strengthening TB activities among

contacts and PLHIV. Improving the quality of sputum collection was also targeted by both oblasts as it

results in lowering errors or false testing results. Making a joint analysis of problems and challenges of

TB case identification was very helpful in showing decision-makers of each oblast what and how

problems and challenges should be addressed to alleviate the situation.

3.2.2 ACTIVITY 1.2: BUILD TB LABORATORY NETWORK CAPACITY FOR RAPID DIAGNOSIS AND

NOTIFICATION


During the reporting period, USAID ETICA continued providing multi-directional support to NTP

laboratories to improve the laboratory network’s performance. The team continued working on the

QMS, assisting the NRL with revisions, and developing and updating quality management documents. In

order to increase the use of rapid molecular tests in TB case findings, USAID ETICA initiated the

development of an optimization plan aimed at the reorganization of SSM laboratories so that sputum

collection, transportation, and laboratory data exchange points can serve as logistical hubs for the

GeneXpert laboratory network.

The project organized and facilitated an online discussion with the head of the NRL and heads of oblast

laboratories on various laboratory issues, and to agree on rules for the preparation and submission of

reports on performed tests (e.g., SSM, GeneXpert, LPA HAIN, cultures, DST) for the July–September

2020 period. The Jizzakh, Syrdarya, and Kashkadarya oblast laboratories were unable to submit regular

periodic reports on time due to the COVID-19 quarantine and difficulties in communication with district

laboratories. To avoid further delays or lack of reporting, it was agreed that all heads of oblast

laboratories would submit the reports on performed microscopy and culture tests weekly.

To improve laboratory performance and efficiency, the project finalized updating the following package

of documents:

• Laboratory referral forms,

• The laboratory test form with added information

on the interpretation of results, and

• The "Guide to TB bacteriological diagnosis for the

staff of TB and PHC facilities," describes all steps

of TB diagnosis from the moment of sample

collection until results are obtained.

The final versions of the above documents were

submitted to the donor for review and approval before sharing them with NTP and NRL management.

In addition to developed and updated reading materials, the capacity of specialists was enhanced through

open discussions at the meetings. In the Jizzakh and Syrdarya oblasts, USAID ETICA conducted

two roundtable meetings (one in each oblast) on the "Interpretation of laboratory results," with the

participation of 61 laboratory specialists and clinicians of the Jizzakh and Syrdarya oblasts in the oblasts’

Centers for Phthisiology and Pulmonology. Discussions were held in a friendly atmosphere, where

clinicians received much valuable information on the modern methodology of TB diagnosis. The project

team conducted a SWOT analysis, where laboratory technicians provided information on mistakes of

healthcare workers during sputum collection and in the referral forms for testing. Clinicians, in turn,

expressed their dissatisfaction with delayed results of TB tests. In conclusion, chief physicians of each TB

center (of both oblasts) pledged to take personal control of all recommendations relayed.

During the monitoring visits to pilot regions, the team held meetings with 22 staff of the Jizzakh and

Syrdarya oblasts and district laboratories to discuss performance, issues, and questions on microscopic

laboratories. Laboratory specialists expressed their interests in learning more, and acknowledged weak

skillset areas on (1) the proper collection and storage of sputum samples, and (2) GeneXpert testing for

TB diagnosis.

During the September monitoring visits of the USAID ETICA team to the project sites, the project

laboratory specialist revealed a lack of knowledge of laboratory staff on maintaining GeneXpert

machines. To address this issue and ensure the availability of continuous technical support to all

USAID ETICA developed the "Guide to

TB bacteriological diagnosis for the

staff of TB and PHC facilities," which

describes all steps of TB diagnosis

from the moment of sample collection

until results are obtained.


laboratory personnel, the project team initiated creating video tutorials on the maintenance of

GeneXpert machines, which were produced by Cepheid. Different materials and videos for GeneXpert

machine utilization and maintenance were collected. The project team submitted the video materials to

the NRL for comments and approval. Once approved, the materials will be translated to the Uzbek

language. The video will be uploaded to laboratory computers so it is available to laboratory specialists.

The effectiveness of the tutorial will be checked with the NRL based on laboratories’ requests for

external maintenance, and based on the GeneXpert testing error rate.

To reinforce the knowledge and skills of laboratory staff on the utilization and maintenance of

GeneXpert machines, USAID ETICA conducted training on maintenance and operation of these

machines based on materials from the manufacturer, Cepheid. Online training sessions were conducted

on December 22–23, 2020, with the participation of 16 laboratory specialists of district laboratories. In

response to the request of heads of the oblast laboratories, the training was conducted in Uzbek and

Russian languages.

In Y1, USAID ETICA assessed the percentage of staff engagement in the NRL, which showed the NRL

being understaffed by more than 50%. Since the NRL provides coordination and technical oversight for

all TB laboratories in the country, the understaffing makes the specialists overloaded. To alleviate the

workload, USAID ETICA has stepped in to support NRL’s support and supervision of the country TB

laboratory network including regional and district laboratories. To help them troubleshoot problems

with GeneXpert equipment impeding laboratory testing, the project laboratory specialist provided the

following online technical assistance to oblast and district laboratories through video calls:

➢ Conducted a video training to Boevut district laboratory and Syrdarya oblast staff on the

preparation of GeneXpert test reports and conversion of the GeneXpert report into a Microsoft

Excel file.

➢ Provided video technical assistance to the head of the Andijan oblast laboratory on the

interpretation of error codes on the GeneXpert machine and steps to be taken to eliminate these

errors.

➢ Provided technical assistance (TA) to Syrdarya oblast laboratory specialists on GeneXpert machine

errors. By the end of the working day, the laboratory assistant reported that their test results were

successful and without errors.

➢ Provided physical TA to the Jizzakh oblast laboratory that reported an issue with the second module

of their GeneXpert machine. The project recommended using the three remaining modules of the

machine, turning off the second module, and waiting for a visit from the NRL or the project

laboratory specialists. The module's door was broken and required repair by a trained specialist.

➢ Provided online technical assistance to the Bukhara oblast laboratory to resolve problems with the

second module of their GeneXpert machine. The Vabkent district laboratory machine had been

providing erroneous test results since October 2020. It was revealed that the laboratory does not

use an electricity voltage stabilizer, which is important for the proper functioning of the GeneXpert

machine and to ensure accurate test results. After the project recommendation to connect a voltage

regulator was followed, the GeneXpert machine started performing well and showing reliable

results.

Inadequate access to COVID-19 diagnostics testing, which is particularly pronounced in rural settings,

has been substantially impeding COVID-19 control efforts. In response to the COVID-19 pandemic, the

Food and Drug Administration authorized the emergency use of GeneXpert testing for COVID testing.

Therefore, the head of the NRL requested USAID ETICA to prepare an SOP for collecting biological

materials from presumptive COVID-19 cases, and using GeneXpert machines for diagnosing COVID-19.


The SOP was developed based on Global Laboratory Initiative materials and submitted to the NRL for

review. Using the existing country capacity to diagnose COVID-19 without harming TB diagnoses will be

advantageous in terms of effectiveness in use of the health infrastructure, equipment, the skillset of

laboratory technicians, as well as efficiency in the use of limited resources. Since COVID-19 and TB can

lead to a similar manifestation of symptoms, patients visiting health facilities with one of the diseases can

be screened for the other, which in turn will increase

TB case detection.

USAID ETICA discussed with NRL management a

gradual reorganization of the country’s microscopic

laboratories to sputum collection and transportation

points. Since the country endorsed the use of

GeneXpert testing as a sole entry-point diagnostic test

for TB detection, and given the anticipated

procurement of new GeneXpert machines, a

reorganization of the SM TB laboratories is of high

importance to maximize the use of these machines.

The increased number of sputum collection points will

expand access of the population to the TB service and

TB detection, in particular. The discussed

reorganization of microscopic laboratories in the form of a plan will be submitted to the NTP for

approval. The project started preparing a list of district laboratories in the pilot oblasts to be visited at

the end of 2020 to include them in the reorganization plan. Considering travel restrictions, the project

team could not travel to laboratories in pilot regions to collect global positioning system (GPS)

coordinates for preparing the plan. Thus, the project requested the heads of three oblast laboratories to

send the GPS coordinate of oblast and district microscopic laboratories. During the December

monitoring visits to the Jizzakh and Syrdarya oblasts, the USAID ETICA team visited remote areas of the

oblasts to pinpoint GPS coordinates of the laboratories for further development of the sputum sample

transportation map.

After reorganizing SSM laboratories to sputum collection points, the number of entry points for sputum

collection will increase across the country, expanding the access of patients to TB diagnostics. In turn, it

will increase the sputum collection and TB detection rates accordingly. Since personnel working in SSM

laboratories are skilled in sputum collection, the quality of sputum collected in the new collection points

should be of high quality, thus reducing the risk of erroneous results of GeneXpert testing.

USAID ETICA collected data on the number of performed GeneXpert tests and the stock of

GeneXpert Ultra cartridges at TB laboratories in the country to estimate potential shortages of these

cartridges in each region. The project will discuss the data and analysis with the NTP and provide this

information to USAID. An important outcome of this activity was the identification of a potential

shortage of cartridges (Exhibit 10). The USAID ETICA alerted the client and partners of the situation.

The NTP agreed with the GF Project Implementation Unit to organize the timely procurement of

GeneXpert cartridges for 2021.

By request from NRL USAID

ETICA prepared an SOP for

collecting biological materials

from presumptive COVID-19

cases, and using GeneXpert

machines for diagnosing

COVID-19.


Exhibit 10. Inventory of GeneXpert cartridges, as of September 2020

Regions

Inventory of

GeneXpert cartridges

(September 2020)

Monthly

needs

Anticipated time

until stock out

1 Tashkent 885 362 January 2021

2 Ferghana 871 340 January 2021

3 Namangan 864 354 January 2021

4 Andijan 2,778 281 August 2021

5 Surkhandarya 1,105 279 February 2021

6 Kashkadarya 670 237 January 2021

7 Syrdarya 1,098 262 March 2021

8 Jizzakh N/A N/A N/A

9 Samarkand 381 381 November 2020

10 Bukhara 771 592 December 2020

11 Navoi 1,211 198 May 2021

12 Khorezm 1,060 312 February 2021

13 Republic of Karakalpakstan 6,387 855 June 2021

14 Tashkent City 913 245 February 2021

15 NRL 2,700 41 September 2021

Total 21,694 4,739

N/A = not available.

Data recording and analysis in each step of the TB continuum of care are essential not only to track a

patient’s progress through the TB cascade of care but also to understand the performance of the TB

service in each stage of the continuum of care. Laboratory services also utilize both paper and electronic

data recording and analysis. To consolidate all paper and electronic databases and data forms, USAID

ETICA initiated developing the LIMS, which will permit having live data for required laboratory variables

for analysis and the ultimate decision-making process. LIMS will be interconnected with the existing TB

registry so that all laboratory test results are accessible to both clinicians and other TB care providers.

To prepare a final version of LIMS specifications, a discussion was held with national laboratory

specialists to determine the final priority areas for LIMS functionality. The project team had previously

announced a tender and shared the Request for Proposals, including the ToRs with all candidates. The

applied companies submitted a LIMS demonstration as part of their proposal. The project and NRLs will

discuss and choose a company. Based on their choice, the company could further develop and submit an

application for the selected LIMS platform considering adaptation to each country’s needs.

As a part of the QMS strengthening efforts, USAID ETICA initiated a review and audit of all existing

SOPs and forms for all laboratory diagnostic procedures, and all SOPs guiding laboratory equipment

operations. Up until the end of Y1Q2, the project completed the audit and upgrade of 61 existing SOPs

(out of 140). All documents were submitted to the head of the NRL and the QMS manager for review

and feedback.


Building on the start-up activities of Y1, USAID ETICA continued supporting the NTP to improve

treatment success through a VST initiative to provide psychological support for TB patients and capacity

building of Consilia doctors.


3.3.1 ACTIVITY 2.1: SUPPORT THE ADOPTION AND IMPLEMENTATION OF A PATIENT-ORIENTED

APPROACH IN TB CARE

During the reporting quarter, USAID ETICA, as a member of the national TWG on the development of

VST, collaborated with the WHO and counterparts to advance the VST protocol and getting their

approval for implementation in project pilot sites. The project team participated in the TWG meeting

held on October 5, 2020, on the development of the national protocol on Managing TB Treatment

under VST. TWG members discussed the guidelines’ content and agreed on a timeframe to finalize and

submit it for MOH approval. The team also tested demonstration versions of the mobile application for

VST provided by Moldova and Georgia developers to consider their possible adaption for use in

Uzbekistan.

To support implementing VST in pilot oblasts, USAID ETICA prepared to procure internet-enabled

smart mobile phones and tablets (three tablets for health staff who provide VST services and

90 smartphones for patients) that are in line with the USAID and Abt Associates procurement policy.

The VST application developer will be consulted to ensure phones with the correct specifications are

purchased.

To improve treatment success, psychological support should be conveyed to DR-TB patients in a

sustainable and uninterrupted manner. The project intends to adopt for Uzbekistan the video film on

psychological counseling that was developed in Kazakhstan. The script of the video film has been

translated into the Uzbek language and the draft version was shared with the NTP for their comments.

The video film will be used during the training of healthcare and outreach workers on TB patient

support during treatments, and distributed among relevant specialists in the country.

To improve the quality of TB services to ultimately lead to better outcomes of the TB program, project

specialists prepared a brief for healthcare workers on the mandatory and additional methods of TB

patients’ examinations and check-ups at outpatient and inpatient treatment levels. The information for

the brief was retrieved from the TB protocols approved by the MOH. The brief was developed to help

healthcare workers provide uniform and comprehensive TB medical check-ups to minimize missing

cases and ensure monitoring of TB treatment at all levels of care.

To support the NTP in making informed decisions and rectifying errors in treatment processes, USAID

ETICA continued analyzing the treatment success rate for both DS- and DR-TB patients in the pilot

oblasts. As Exhibit 11 shows, the trend of treatment success rate among DS-TB patients who

completed their treatment courses between QI and Quarter 3 (Q3) of 2020 in all three pilot oblasts

remained between 84.3% and 87.5%. This indicates that the efforts of the NTP are yielding good results.

The WHO recommends that a well-performing TB program should achieve at least a 90% treatment

success rate and an 85% cure rate.4 This indicates that the efforts of the NTP are promising.

4 Source: World Health Organization. 2003. Treatment of tuberculosis: Guidelines for national programs.


Exhibit 11. Treatment success rate for DS-TB patients in first three quarters of 2020 (January–September) in

pilot oblasts

Exhibit 12 displays the results of the analysis conducted by the project team with regard to treatment

outcome rates among DR-TB patients of the pilot oblasts in the first three quarters of 2020. Compared

to the DS-TB patient data above, the results of treatment for DR-TB patients in Ferghana dropped

sharply from 75.4% in Q2 to 46.7% in Q3. This decrease is observed only in one pilot oblast. Both

Jizzakh and Syrdarya, on the contrary, show good progress. The analysis of other treatment outcomes of

the same cohort of patients in the Ferghana oblast showed that the proportion of death rate has

increased from 4.9% in Q2 to 18.3% in Q3; and the rate of treatment failure increased from 6.6% to

25.0%. Due to elevated negative outcomes of other treatment rates (death and failure), the rate of

successful treatment decreased. The project team plans to visit Ferghana oblast in Y2Q1 where a

deeper analysis of such poor outcomes will be conducted.

85.0

%

87.2

%

87.1

%

86.4

%

87.5

%

84.8

%

83.7

%

86.0

%

84.3

%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Jizzakh Syrdarya Ferghana

Q1 Q2 Q3

71.4%

71.4%

81.8%

41.7%

57.1%

66.7%

61.2%

75.4%

46.7%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Q1 Q2 Q3

Jizzakh Syrdarya Ferghana

Exhibit 12. Treatment success rate for DR-TB patients in first three quarters of 2020

(January–September) in pilot oblasts



CENTERED CARE

To ensure the introduction and systemic implementation of the patient-centered approach, the project

drew its attention to capacity-building activities for Consilia doctors, establishing a system for ongoing

learning activities, and addressing the gaps in the pharmacovigilance of the TB care system.

Capacity building and continuous education of DR-TB Consilium staff are two of the crucial elements for

the successful implementation of the TB program. To address the training needs of Consilia doctors, the

USAID ETICA team developed online training modules on TB diagnosis, treatment of DR-TB patients,

and clinical monitoring of people receiving treatment for DR-TB. The online training sessions will be

conducted through established, USAID-supported Centers of Innovative Distance Learning and

monitoring will be based on approval of the donor in Q2. After training Consilia doctors, the same

training materials will be used to train other TB doctors.

Another important element of the patient-centered approach is having infection control measures in all

health facilities. In line with the request of the NTP, USAID ETICA will provide technical support to

review and update the outdated National TB Infection Control Manual that was endorsed in 2013.

USAID ETICA has started analyzing policy documents related to TB infection control and will initiate the

establishment of the TWG to review and adapt the National TB Infection Control Manual. USAID

ETICA supported the TWG to revise current National Protocols on TB/DR-TB patients, and ensure

incorporation of these guidelines into the supervision system. Guidelines for implementing an integrated

model of continuous care for TB were drafted, acknowledging the challenges currently presented to the

TB system by the COVID-19 pandemic.

The WHO recommends the implementation of a comprehensive system of active monitoring and

control for the safety of anti-TB drugs (i.e., aDSM) as one of the important elements for improving the

effectiveness of treatment for patients with DR-TB and, in this regard, USAID ETICA aims to establish a

proper system for monitoring and control of aDSM in the TB system and the pilot zones in particular.

The project laboratory specialist conducted an introductory visit to the clinical laboratory of the

Gallaorol district medical unit in the Jizzakh oblast, which performs hematological and biochemical blood

tests. These tests are essential for ensuring regular access of patients to basic and ongoing clinical and

laboratory examinations to monitor adverse side effects during TB treatment. According to the head of

the laboratory, the biochemical analyzer produces elevated results of creatinine. The project laboratory

specialist provided technical assistance in setting up and calibrating the biochemical analyzer, and

provided recommendations to use standard reagents for internal quality control to the laboratory

specialist who works with the biochemical analyzer. The same technical assistance was provided to the

clinical laboratory of the Yangier district medical unit in the Syrdarya oblast.

USAID ETICA initiated the establishment of a national TWG to review existing policy and country

documents on the M&E system of the TB service. The MOH approved a list of experts to be included as

members of the working group and the establishment of the TWG. USAID ETICA hosted the TWG

meeting to review existing policy and country documents on the M&E system of the TB service on

December 28, 2020. The TWG will update the M&E guideline and checklists.



3.4.1 ACTIVITY 3.1: PROVIDING EFFECTIVE DETECTION TO WHERE PEOPLE FIRST SEEK CARE


USAID ETICA made advancements in conducting a gender analysis to determine gender, stigma, and

other social barriers to accessing TB services. The project team contracted with a firm to carry out the

assessment and organized an initial meeting with the firm to discuss preparations for the study. USAID

ETICA requested the agency to prepare and submit for review the tools and methodology on the

sampling, timeline, and data analysis framework. Additionally, the firm prepared documents to apply for

local ethics committee approval to conduct the study.

During the monitoring visit to the Jizzakh and Syrdarya oblasts in December, the project team met with

PWTB to create a map of entry points where people seek care. Identifying points of care will help in

designing a hotspot map, which will show available TB service provision sites. The map will be used by

health and non-healthcare providers, and by individuals with TB symptoms to spot locations where

services exist. During the monitoring visits, the team also checked the readiness of people affected by

TB to screen and seek care, as well as explored if and what types of gender and other barriers to access

may persist at the location.

3.4.2 ACTIVITY 3.2: STRONG COMMUNITY SUPPORT

The central role of communities in the response to TB infection has long been recognized by

policymakers and patients as an ethical and imperative engagement for successful programs. To improve

the engagement of communities and decision-makers, USAID ETICA continued preparing for a one-day

advocacy workshop on strengthening social support for people affected by DR-TB to attract influential

community leaders, local authorities, CSOs, religious leaders, facilities, members of the disability

commission, and service providers.

To further elevate community support for TB activities, USAID ETICA continued to engage mass media

and social network administrators to report on project achievements and promote best TB treatment

practices. The project contacted the network of journalists promoting health and TB issues for future

cooperation.


The WHO office has initiated a country-wide introduction of the DHIS2 system. USAID ETICA actively

participated in the TWG meetings and testing of the draft TB module of DHIS2 developed by the

WHO. Specifically, USAID ETICA supported the NTP to:

➢ Adapt all available data entry fields in the “TB module of DHIS2” to be in line with MOH

instructions; ➢ Review and adapt the output data from the “TB module of DHIS2,” taking into account the

approved recording and reporting TB forms in Uzbekistan; ➢ Unify the TB08/1 reporting form on treatment outcomes for DS and the TB08/2 reporting

form for DR TB cases; ➢ Make necessary changes to the “TB module of DHIS2” to be in line with the approved TB

diagnostic algorithm.

Linkages of the DHIS2 system with the TB registry will prevent the duplication of work for TB

specialists entering data into both systems, and will ensure outflowing relevant information to the MOH

at any time. The MOH will be able to generate outcome reports for the TB system and make timely and

informed decisions.


USAID ETICA provided technical assistance in updating the files of the e-register UZTB ESCM to ensure

the continuity of data collection, registration, and full functionality of the system in 2021. The NTP

distributed the updated 12 files of the e-register of UZTB ESCM to all 14 regions of the country for use.

Further, online technical assistance will be provided to reinstall the UZTB ESCM program.

The project team provided technical assistance to transfer paper-based reporting and recording forms

TB-07/1, TB07/2, TB-08/1, and TB08/2 to Microsoft Excel spreadsheets to automate statistical data

calculations using pre-set formulas in Excel, reduce the risk of inaccurate data analysis, and allow the TB

system’s statisticians to spend more time

on the analysis of the oblast

epidemiological situation. After completing

Q1 and Q2 reports, the specialist can

automatically prepare the semi-annual,

nine-month, and annual reports.

3.4.4 ACTIVITY 3.4: INCREASED LOCAL

CAPACITY TO FINANCE AND IMPLEMENT TB SERVICES

USAID ETICA improved the environment for TB activities by distributing small medical equipment to

district health facilities of the Syrdarya oblast, which were donated by the USAID ETICA partner

organization Resource and Policy Exchange, Inc. The small medical equipment will help district health

facilities diagnose PWTB and monitor the side effects of TB drugs during treatment. USAID ETICA

prepared a draft press release and the event is planned in Y2Q2.

The project participated in the TB coordination meeting organized by the NTP with the participation of

the GF and CSO “Intilish.” After reporting results of the year 2020’s nine-month work by each partner

organization, the NTP Director shared some of the meeting results with the President of Uzbekistan.

The meeting discussion elaborated on the ways to improve the primary healthcare system and promote

a healthy lifestyle among the population. The President noted that the Ferghana and Syrdarya oblasts

have the highest recorded cases of respiratory diseases. The Syrdarya oblast will be a pilot region to

implement mandatory health insurance. It should also benefit from improved and streamlined PHC-level

services through the introduction of the family medicine approach. The NTP Director requested to

speed up and strengthen technical assistance of the projects, especially to the Jizzakh and Syrdarya

oblasts.

The USAID ETICA team arranged a joint online meeting with WHO staff (regional office for Europe and

office in Uzbekistan) and USAID Uzbekistan country mission staff. The meeting aimed to discuss possible

collaboration in the implementation of the state health insurance model and TB in the Syrdarya oblast.

Participants agreed to share information and coordinate the implementation of the projects’ activities.

3.5 COVID-19 RELATED RISKS AND CHALLENGES

The project postponed several planned activities due to the ongoing COVID-19 quarantine and imposed

restrictions on movement and gatherings of people. On August 15, 2020, COVID-19 quarantine

restrictions were relaxed but not entirely lifted. Although transportation and general economic activities

will resume gradually, the limitation on gatherings of people for meetings and events is likely to remain

in place.

USAID ETICA provided NTP technical assistance in

updating the files of e-register UZTB ESCM to ensure the

continuity of data collection, registration, and full

functionality of the system in 2021



USAID ETICA conducted the second laboratory monitoring visit to the pilot regions of Jizzakh and

Syrdarya in December 2020. The visit was officially endorsed by the Uzbekistan MOH. The purpose of

the visit was to collect information on transportation routes, assess the performance of GeneXpert

machines in each oblast, provide technical assistance on the calibration of modules, and provide technical

assistance on the verification of TB reporting data on detection and treatment outcomes. The project

team also made plans to meet local authorities, partners, and CSO representatives to discuss joint

events; as well as to conduct roundtable meetings on the interpretation of laboratory results with the

participation of laboratory specialists and clinicians. The results of the monitoring visits are outlined in

Exhibit 13.

During the reporting period, USAID ETICA provided online technical assistance on data verification of

13 districts of the Jizzakh oblast for Q3. Together with the specialist from the Jizzakh regional TB

Center, the project specialist reviewed the TB07 reporting form on notification of patients and the

TB08 form for treatment outcomes for each district. All reporting forms had one or more errors, and

discrepancies were revealed between paper reports (TB07 and TB08) and the UZTB ESCM electronic

database. The team provided technical recommendations to the Jizzakh regional specialist on corrective

measures to be applied to avoid similar errors; and the errors were corrected.

In its revised AMELP USAID ETICA proposed to align reporting on performance indicators with the

NTP’s reporting timeframe. Hence, during this reporting period, the data on six out of 14 indicators

were collected and presented for three project’s pilot oblasts. It should be noted that these data are not

verified by the NTP. Fully verified national and pilot level data will be available at the end of February

and will be reported with the next Q2 quarterly report.

Annex 3 displays project performance against its targets and analysis of achievement for available pilot

level indicators. Exhibit 14 was derived from Annex 3 and displays a summary of achievements against

project indicators.

3.7 OBSTACLES AND CHALLENGES

During the reporting year, the following challenges hampered project efforts to reach goals and

objectives:

• Several project activities were postponed due to the ongoing COVID-19 quarantine, and

mandatory restrictions on movement and gatherings of people. The government introduced the

COVID-19 quarantine measures in mid-March 2020 and prolonged the quarantine several times.

• The project has adjusted implementation approaches to COVID-19 restrictions and conducted

some activities, such as training and meeting with local partners, remotely.

• Existing MOH approval procedural requirements impede project plans and the implementation

of activities, including (1) the project must submit an official letter to MOH’s Letters Office; and

(2) MOH’s processing time takes 20 business days, which is a long time lag.


Exhibit 13. Summary of monitoring visits to the Jizzakh and Syrdarya oblasts

Monitoring


1. Statistical

data

* Existing electronic TB

database – UZTB ESCM for

DS-TB cases

* Treatment success rate of

DS-TB cases has increased in

Q3 compared to the previous

quarter.

* Reporting forms TB07/1, TB07/2,

TB8/1, and TB08/2 were not fully

finalized at the oblast level due to the

late submission of paper-based

reports from districts.

* In some districts, recording forms

TB03/1, TB03/2, TB01/1, TB01/2, and

TB 089 had errors.

* Notification of TB cases decreased

by 50% for the Q1–Q3 2020 period

compared to the Q1–Q3 2019

period.

* Provided technical assistance to

finalize reporting form for Q3.

* Provided on-the-job training to

responsible specialists of TB

facilities on correcting mistakes

and completing the forms.

* Data-entry specialists must verify the

entered information against paper forms to

ensure matching of the data.

* Responsible specialists of each district

must cross-verify the entered data.

* Improve the detection of TB through

increased TB case findings among high-risk

groups and children, and strengthen TB

activities among contacts and PLHIV.

* Provide training to improve the quality of

sputum collection.

2. Laboratory

services

Sufficient quantity of

GeneXpert cartridges in all

monitored territories.

* Lack of knowledge of laboratory

staff on maintaining GeneXpert

machines.

* 10 modules of GeneXpert machines

have not passed calibration.

* Lack of transportation for collected

sputum to GeneXpert laboratories.

* Provided on-the-job training for

specialists of GeneXpert

laboratories.

* Findings were shared with NRL

technical specialists, who were

requested to resolve issues with

GeneXpert machines on time.

* Agreed with the chief doctor of

the district to prepare an order

for regular sputum transportation

from village health facilities to

GeneXpert laboratories.

* Organize online or offline training

sessions on the maintenance of GeneXpert

machines.

* Contact head of the NRL for arranging

timely calibration of GeneXpert machines.

* Establish a regular sputum transportation

mechanism from the district facilities to

GeneXpert laboratories.

3. PHC

services

* PHC facilities have DOT

cabinets.

* TB01 medical card

obtained for each TB patient

in the ambulatory treatment

phase.

* Lack of knowledge of PHC staff in

TB contact tracing.

* PHC does not fully follow the TB

diagnostic algorithm.

* Lack of support for treatment

adherence by PHC family doctors,

which affects treatment outcomes.

* Communication between TB service

and PHC facilities is not well-

established.

* Train PHC staff to be in line with MOH

order #383 related to TB contact tracing

activities.

* Conduct capacity building for family

doctors and nurses on the diagnostic

algorithm and case management.


Exhibit 14. Achievement of targets of Y2Q1, Uzbekistan


4. KAZAKHSTAN5

4.1 OVERVIEW

During Y2Q1, the project made progress with the previous year’s delayed and postponed activities, as

well as with performing Y2 work plan activities. The project team conducted online training sessions,

advanced preparations for the gender study, and continued work for the laboratory network’s

optimization. USAID ETICA continued tracking and analyzing the influence of COVID-19 on the

utilization of GeneXpert testing to see the pathway of case detection. The main activities and

achievements in Y2Q1 are summarized below.

USAID ETICA can confirm the attainment of two main indicators of the project:

(1) “Percentage and number of DR-TB cases diagnosed” was reached by 130% (1,256 cases) against an

established target of 968 cases (Y2’s annual target is 3,870). The detailed performance analysis of the

indicator is provided in Annex 1 of this report. Last year’s annual result for the same indicator was

117.6% of the target. Although the achievement of the target was always higher than 100%, it continued

to decrease throughout last year (Exhibit 15), while in the reporting quarter the result increased by

32% compared with the previous quarter.

(2) “Percentage (and number) of DR-TB cases started on second-line drugs” was attained by 100%

(1,256 PWTB) of newly identified DR-TB cases (1,256 cases). This indicator is dependent on the

previous indicator of the number of DR-TB cases diagnosed, and concurs with attainments each quarter

(Exhibit 15). This indicator has been always achieved at the 100% level.

5 Photos (from left to right): Assessment of the quality of GeneXpert diagnostics in the laboratory of the oblast TB

dispensary in Aktobe; USAID ETICA webinar on LTBI for NTP staff and members of the TWG on LTBI, Tamara Ivanenko,

trainer; Regional training on QMS in NRL; Meeting of Technical Working Group on the state social contracting


Exhibit 15. Comparison of indicators of Y2Q1 and Y1Q1–Q4

To improve case detection, the project team continued building on the gains of Y1 and built the

capacity of 19 CSOs to counter stigma and discrimination, deliver TB-related information to the

population, and provide motivational consultations. Since LTBI can evolve to active TB cases, it was

targeted by the project in the reporting quarter. The team hosted a webinar on LTBI for TWG

members to discuss the needs, plans, and further steps for the country to be able to adopt the new

WHO recommendations.

As a part of the laboratory network’s enhancement, project specialists analyzed the performance

effectiveness of GeneXpert laboratories and continued building the capacity of NRL specialists on using

WGS equipment installed in the NRL; and, to expand DST for new drugs, analyzed the quality of DST

for new drugs (i.e., clofazimine, linezolid). The country obtained MOH approval for the updated

diagnostic algorithm, which includes GeneXpert as an initial diagnostic test. The project managed to

revise and update all 318 SOPs and formulations in the framework of establishing the LQMS in TB

laboratories.

In the area of treatment, the project provided ongoing and sustained support to doctors of the central

Consilia and the M&E team through capacity-building training sessions. USAID ETICA continued building

a better pharmacovigilance system in the country, and drafted functional responsibilities of specialists

responsible for pharmacovigilance in the TB system and PHC facilities.

To enable the environment for a better-functioning TB system, USAID ETICA developed and posted

on social media a video on psychological counseling PWTB. As a member of the TWG on finance,

project experts, along with the NTP and TB finance advisor, analyzed the situation with TB financing and

took steps toward improving financing for TB care.


Enhancing TB detection relies both on the performance of TB laboratories and activities implemented at

the community level to encourage testing. Despite challenges associated with the new waves of

COVID-19, the project continued building on the achievements of Y1 to strengthen the work of CSOs

and TB laboratories. During the reporting period, USAID ETICA prepared and delivered a TOT for

CSO and NTP staff on ECF, conducted a monitoring visit to the Aktobe region jointly with the NTP,

and performed various activities toward laboratory network optimization.

Year 2

Q1 Q2 Q3 Q4 Q1

Number of diagnosed 1539 1477 1103 951 1256



Number of enrolled to treatment1539 1477 1103 951 1256



INDICATORSYear 1

Percentage and number of DR-TB cases diagnosed

Percentage (and number) of DR-TB cases started on second-line drugs


4.2.1 ACTIVITY 1.1: PARTNER WITH CSOS TO IMPLEMENT ECF AND WITH MOH TO STRENGTHEN

SYSTEMS FOR CONTACT TRACING

To prepare CSOs to provide TB-related services to the MOH/NTP and PWTB, the project assessed

their capacity to determine shortages and devised an approach to narrow the skills gap. The results

revealed shortages or absence of skills and knowledge in various areas such as ECF, TB treatment and

infection control, counseling of PWTB, stigma and self-stigma reduction, protecting the rights of people

affected with TB, TB advocacy, gender, and VST. To ensure the sustainability of efforts to narrow the

capacity gaps, the project decided to proceed with building not only technical skills and knowledge but

also capabilities to provide training on these topics within CSOs. USAID ETICA proceeded to prepare

training materials for a TOT in Y1 and selecting proper trainers and trainees. It was determined that the

training would be beneficial for capacity building within counterparts and partners, and the list of

potential participants was expanded.

In Q1 the team conducted an online TOT for 23

specialists from 10 CSOs, the NTP, the city’s polyclinic,

the HIV/AIDS Center, and the GF. The training consisted

of nine, two-hour online sessions focused on building

trainers’ skills in all the above-mentioned areas of skill

shortages, as well as interactive and distance learning

topics. This was the first training in Kazakhstan focused on

preparing trainers for the needs of future

institutional/organizational capacity building in respective

TB areas. All participants expressed their high level of

satisfaction with the training and improved knowledge on

learned topics. Nineteen out of the 23 specialists have

been actively participating and performing all assigned

home tasks, and received certificates of trainers. The

remaining four specialists received certificates of listeners.

Within the USAID ETICA work plan, 19 certified trainers

will conduct a series of cascade training sessions for other CSO, NTP, and PHC staff across the country.

Raising the level of knowledge among communities working with populations will contribute to the

timely diagnosis and treatment of TB among key groups of the population, increasing their adherence to

treatment, which will ultimately affect the reduction in the incidence of TB and the improvement of TB

treatment outcomes in the country. Apart from delivered knowledge, as an online support tool for

future trainers, USAID ETICA developed a video6 with a detailed step-by-step guide that included

interactive methods of conducting online webinars using the ZOOM platform. The video tool was

developed based on the requests from NTP and GF partners.

LTBI affects about one-third of the population worldwide. The NTP established a TWG to develop an

LTBI management guideline per the latest WHO recommendations. To support this process, USAID

ETICA hosted the first TWG webinar. The webinar provided 23 participants with an overview of new

key WHO 2020 recommendations, including the paradigm shift in ACFs, which includes identifying,

diagnosing, and treating people with LTBI under all ACF strategies. This webinar will serve as a basis for

further NTP TWG discussions aimed at developing the LTBI guideline. It is anticipated that, based on

6 https://youtu.be/pJyYmBql4vs.

USAID ETICA conducted an

online TOT for 23 specialists

from 10 CSOs, the NTP, the

city’s polyclinic, the

HIV/AIDS Center, and the

GF. Nineteen out of the 23

specialists have been actively

participating and performing

all assigned home tasks, and

received certificates of

trainers.

https://youtu.be/pJyYmBql4vs


the developed strategy, the country will test, treat, and manage LTBI to limit the progression of TB

infection to active disease, which will ultimately lead to decreased TB incidence in the future.

LTBI is one of the global targets endorsed by Heads of States in the Political Declaration on TB in the

UNHLM. The Stop TB Partnership has produced country breakdowns for these targets using the latest

WHO data on incidence estimates and country notifications to the WHO. Exhibit 16 indicates the

targets for Kazakhstan vs. achievements on LTBI.

Exhibit 16. Achievement of UNHLM commitments of TPT by Kazakhstan

According to Exhibit 16, Kazakhstan reported that the country mostly attained UNHLM targets for

PLHIV and children under 5 years of age, but the TPT among people above age 5 were not targeted by

the country and, respectively, these targets were not reached. This is one of the indications of the

country’s need to shift the paradigm toward LTBI and TPT among the population.

4.2.2 ACTIVITY 1.2: IMPROVE TB DETECTION CAPACITY AND ACCESS AT ENTRY POINTS CLOSER TO

PATIENTS

To improve TB detection and patients’ access to TB testing facilities, laboratory services in the TB

system should work smoothly and focus on patients’ needs. Following Y1 support on the sourcing of

delamanid (DLM) and bedaquiline (BDQ) pure substances, and introducing DST for clofazimine (CFZ)

and linezolid (LZD), USAID ETICA conducted an online meeting with the head of NRL and 27

laboratory specialists from 20 DST laboratories, including the penitentiary system, on the

implementation of BDQ DST. During the meeting, the SOP on BDQ DST was presented and discussed.

Expansion of DST to new drugs will help the NTP better manage the DR-TB treatment process, and

make timely and informed decisions on proper regimens.

WGS is a current alternative to the WHO-approved conventional and rapid molecular methods for TB

diagnosis and detection of drug resistance, genetic diversity, and transmission dynamics of the

mycobacterium tuberculosis (MTB) complex. During the reporting period, the GF TB project has

procured and delivered WGS equipment for the NRL. Building on last year’s support provided to the

NRL on WGS, USAID ETICA supervised the installation of WGS equipment to ensure that all required

steps of the process were in line with rules and instructions, and has been continuously providing online


consultations to the responsible NRL specialist. Project specialists attended a three-day training session

on the use of WGS equipment, which was conducted by engineers from the supplier company. Once

the COVID-19 prevention measures are relaxed, USAID ETICA will support training on WGS for

laboratory specialists from NRL Kazakhstan in Germany.

An updated diagnostic algorithm, in which the rapid molecular diagnostic methods assay (GeneXpert)

will be the initial diagnostic TB test, is being reviewed by the MOH. USAID ETICA analyzed the

GeneXpert network performance across the country for the first 10 months of 2020, with emphasis on

the COVID-19 impact on diagnostic coverage and to determine if the number of tests differed after the

introduction of the updated testing algorithm. The results of the analysis were presented and discussed

during an online workshop with heads of the NRL and all regional laboratories. During the workshop,

the participants revised the GeneXpert roadmap and provided recommendations on specimen

transportation and workload optimization.

As shown in Exhibit 17, the COVID-19 pandemic and related strict lockdown measures negatively

affected the total number of Xpert MTB/RIF tests. In comparison with January–February (the pre-

lockdown period), by September–October the total volume of testing dropped by 2–2.5 times. One can

associate this decrease with the deterioration of laboratory performance or the TB system in general

(e.g., fewer people referred for testing). However, this argument does not find proof while reviewing

Exhibits 18 and 19, which show the positivity rate (i.e., the number of MTB positive tests out of all

tests) and the percentage of RIF resistance among those who tested positive. As displayed in Exhibit 18,

the proportion of MTB-positive specimens averages 10% (ranging from 15.5% to 8.5%), which assumes a

good performance of laboratories. No significant drop in positivity rates could be observed: the

proportion of RIF-resistant specimens ranged from 29.2% to 36.2%, also without significant change of

the trend (Exhibit 19).

Thus, looking at these figures, the significant reduction of the number of GeneXpert testing does not

indicate a decrease in laboratory quality but rather shows the overall stress of the healthcare system:

clinicians are overwhelmed with COVID-19 diagnostics and treatment, so fewer specimens are being

sent to TB laboratories.

Exhibit 17. Number of Xpert MTB/rifampin (RIF) tests by month in all GeneXpert laboratories (first 10 months

of 2020)


Exhibit 18. Percent of MTB-positive among all conducted

Xpert MTB/RIF tests by month in all GeneXpert laboratories

(first 10 months of 2020)

Exhibit 19. Percent of RIF-resistant among all conducted

Xpert MTB/RIF tests by month in all GeneXpert laboratories

(first 10 months of 2020)

During the reporting quarter, USAID ETICA participated in a joint monitoring visit to Aktobe with the

NTP. During this visit, specialists assessed the effectiveness of GeneXpert diagnostics, the quality of drug

susceptibility tests for new drugs (i.e., clofazimine, linezolid), and the results of the previously distributed

electronic reporting forms. The outcomes of the visit will be used for further optimization of the

laboratory network, the introduction of Xpert MTB/RIF Ultra cartridges, improvement of DST, and the

potential revision of electronic reporting forms.

Laboratory quality assurance is impossible without the implementation of a comprehensive QMS, which

encompasses all aspects of laboratory operations. The ultimate goal of QMS implementation is to ensure

that the constant improvement process of laboratory quality is in place. In order to support NRL

management throughout this process, USAID ETICA continues to audit laboratory processes

concerning compliance with existing written SOPs and related forms. All SOPs with deviations from

ISO 15189 (international standard requirements for quality and competence in medical laboratories)

were revised, and new versions were officially endorsed by the head of the NRL. To support the

implementation process, the project’s laboratory specialist conducted on-the-job training sessions for

NRL staff. The project plans to place an electronic database of all QMS documents in a cost-free cloud

server for the possibility of expanding access to QMS documents to regional TB laboratories.

Better outcomes in the continuum of care are contingent on the collaborative concerted efforts of

clinicians and laboratory specialists. USAID ETICA initiated an online meeting on the interpretation of

laboratory test results for clinicians and laboratory specialists from Kazakhstan, Tajikistan, and

Uzbekistan. The meeting demonstrated the practical benefits of maintaining effective dialogue between

clinicians and laboratory specialists for ensuring the interpretation of laboratory test results is correct

and used to support informed decision-making of clinicians on the future treatment management of

patients. Also discussed were the reasons for discrepancies in the results of laboratory tests and

potential solutions.

14.1

11.212 11.7

15.5

10.2

8.5

12.912.2

10.8

0

2

4

6

8

10

12

14

16

18

29.5

36.233.7

31.829.2

35.5 35.433.2 33.8 34

0

5

10

15

20

25

30

35

40



Despite noticeable attainments in the treatment of both DS and DR-TB in the country, there are areas

for improving treatment success for all forms of TB. Although milder COVID-19 measures continued

hampering project activities, USAID ETICA still could not implement the project fully in offline mode

and focused on the capacity-building and monitoring components of the project. Jointly with national

counterparts, the project team was able to pay a first supervision visit and conduct several

pharmacovigilance training sessions.

4.3.1 ACTIVITY 2.1: SUPPORT THE ADOPTION AND IMPLEMENTATION OF A PATIENT-ORIENTED

APPROACH IN TB CARE

To achieve a patient-centered approach, which is key for successful TB treatment outcomes, the

capacity of healthcare providers, community stakeholders, and policymakers must be strengthened.

USAID ETICA built on the gains of Y1, such as technical support to develop various policy documents,

training materials for capacity building of relevant staff, etc.; and in the reporting quarter, the project

team continued strengthening the treatment component of the continuum of care by enhancing the

knowledge and skills of TB nurses’ MDTs and improving the distance-learning platform.

MDTs consist of TB/PHC nurses and PHC doctors working in TB and TB/HIV, whose role is to conduct

prevention activities, provide social support, as well as provide support for patient adherence to

treatment and the socialization of patients. USAID ETICA developed a package of materials for online

training of MDTs on a variety of topics that were selected through a survey of MDT specialists. These

topics included “Latent TB infection: From biology to global priorities,” “Programmatic aspects to scale

up TPT,” “Clinical aspects to scale up TPT,” “Analysis of treatment outcomes for DR-TB,” and “Cohort

and interim analysis of DR-TB treatment regimens.” The training is tentatively planned for Y2Q2.

Apart from enhancing MDTs in patient-oriented TB services, the team worked to establish a well-

functioning pharmacovigilance system. As a part of the capacity-building events on pharmacovigilance,

USAID ETICA participated in the development of training materials for a five-day TOT training, "Topical

issues of pharmacovigilance in the treatment of patients with DR-TB," for specialists responsible for

pharmacovigilance. Jointly with the NTP and the GF, USAID ETICA participated in two consecutive, five-

day training sessions conducted on October 5–9 and 12–16, 2019. Project specialists participated as

trainers and facilitators in separate sessions related to pharmacovigilance, and participated in joint

discussions on drafting functional responsibilities for specialists responsible for pharmacovigilance and

doctors from PHC facilities. The functional responsibilities will be included in the Guideline on

Pharmacovigilance, which will be developed by the NTP with GF assistance in 2021–2022.


CENTERED CARE

To ensure patient-centered care, drug safety, and prevent adverse drug effects, it is important to

conduct supportive supervision and enhance the capacity of TB care providers and members of the TB

Consilia.

Supportive supervision is the process of helping staff to continually improve their work performance. It

is carried out in a respectful and non-authoritarian manner, with a focus on using supervisory visits as an

opportunity to improve the knowledge and skills of health staff. USAID ETICA specialists participated in

the joint NTP field visits to support active drug safety monitoring activities in the framework of the TB


program. During this collaborative visit, local TB specialists were introduced to the elements of aDSM

supportive surveillance. Project specialists also distributed a previously (last year’s) developed checklist

on aDSM to clinicians to test it for further improvements. aDSM is included in the NTP

pharmacovigilance work plan and is necessary for the functionality of the active pharmacovigilance

system in the treatment of DR-TB patients. The aDSM functionality will focus on improving clinical

monitoring and increase the likelihood of detecting toxicity in new DR-TB treatment regimens when

AEs occur. AEs will be diagnosed at primary TB service levels and resolved with appropriate treatment.

Addressing AEs will ultimately increase the adherence of DR-TB patients to treatment and reduce the

negative consequences of adverse reactions to anti-TB drugs (e.g., drug resistance, treatment failure,

reduced quality of life, or even death).

Project experts adjusted a checklist/tool developed by a previous USAID project (Challenge TB in

Ukraine) and used it to collect data on aDSM at various levels (e.g., regional hospital departments, city

polyclinics, district polyclinics) for enhancement of supportive supervision in the introduction of aDSM.

The checklist efficacy will be tested in practice and revised if needed before implementation. The project

team is exploring potential methods for automating the data sorting and analysis to help health

authorities streamline their decision-making using the data analysis results. The analyzed results will

improve the planning of resources for clinical and laboratory monitoring of DR-TB patients, and

strengthen the readiness of the pharmacovigilance

system for implementation of aDSM.

To further improve the pharmacovigilance system in

the TB program, the project team took part in

pharmacovigilance TWG discussions with the NTP.

Participants discussed the final version of the

pharmacovigilance budget to be included in the

National Strategic Plan (NSP) and the development of

the aDSM roadmap budget for the next three years.

As a part of the aDSM support, the project team

revised the SoW for the TB Drug Registration Expert and the National Pharmacovigilance Consultant.

Both will work closely with USAID ETICA technical staff to assist the NTP with the transition to new,

non-injection DR-TB treatment regimens, with a focus on aDSM. As aDSM requires additional financial

and human resources for the proper data collection on the safety of new regimens at all levels of DOT,

the recruitment of these two experts is expected to facilitate the process.



To ensure stewardship of the NTP to keep TB elimination high on the country’s strategic priority list

through political commitment, investments, and oversight, while making rapid progress toward building a

resilient environment and social protection, USAID ETICA continued providing multi-directional

technical support to the NTP. During the reporting quarter, gender analysis was advanced up to the

data collection stage. The team also continued to actively advocate for elevating the social contracting

and financial reforms related to TB.

4.4.1 ACTIVITY 3.1: STRONG COMMUNITY SUPPORT

USAID ETICA revised all SOPs with

deviations from ISO 15189

(international standard requirements

for quality and competence in

medical laboratories) and new

versions were officially endorsed by

the head of the NRL.


Strong community support for TB detection and treatment is one of the key success factors in the fight

against TB. Promoting gender equity, improving communication and social engagement of stakeholders,

and fighting against stigma and discrimination are some of the key factors in combating TB in any

country. These areas were central in the reporting quarter for the team to concentrate on.

During the reporting period, USAID ETICA developed a video on psychological counseling of PWTB.

The purpose of this video is to inform health workers and specialists from CSOs about the need for

psychological counseling and motivate them to obtain counseling skills. This video was developed for

healthcare workers and specialists of CSOs working in the field of TB prevention and treatment. It will

serve as a methodological guide and complement the training materials for trainers who participated in

the recently conducted TOT described above.

Kazakhstan, like any other high TB burden country, has an urgent need to understand how the risks and

effects of TB are determined by sex and gender roles. USAID ETICA continued preparations for the

study on gender, stigma, and other social barriers to accessing TB services; and made progress both on

the logistical and programmatic parts of the research.

On the programmatic side of the gender study, the research agency developed an inception report

containing tools and methodology, sampling, a timeline, and a data analysis framework. The agency also

prepared questionnaires for healthcare service providers, family members of PWTB, PLHIV, and

migrants. The materials were reviewed and accepted by the project.

The research agency obtained the approval of the study from the Ethics Committee before proceeding

to the field stage. The subcontractor used the approved methodology, sampled sizes of beneficiaries, and

used questionnaires to conduct In-depth interviews with PWTB, migrants, PLHIV, service providers, and

key experts in TB. The subcontractor also conducted focus group discussions with key experts working

in the healthcare sector. These findings will be used to directly inform activities and ensure interventions

are gender-sensitive. It will also determine the availability of health and social services to target groups

and measure the stigma associated with TB.

The WHO sent a request to all country partners calling for examples of best practices to combat TB,

HIV, and viral hepatitis during the COVID-19 pandemic. Selected best practices will be published in the

WHO journal. USAID ETICA and NTP specialists co-authored an article on a successful media campaign

against the stigma associated with TB that was conducted in recognition of World TB Day. The article

was submitted jointly with the NTP on behalf of the Kazakhstan TB program to the WHO.

To better promote the use of social media and elevate the engagement of stakeholders in the TB

program, USAID ETICA used the existing Public Fund “AFEW Kazakhstan” (AFEW) website to promote

project activities. This website had been developed by AFEW within the framework of the previous

project, "Improving TB/HIV prevention and treatment – creating models for the future," which was

implemented jointly with the Nederland’s Tuberculosis Foundation KNCV in 2015–2019. USAID

approved the USAID ETICA proposal to use the existing “hivtb-almaty.kz” website. USAID

recommended a separate USAID ETICA tab to be added to the website. During the reporting quarter,

technical specifications for the updated site were finalized, and a designated USAID ETICA project tab

will be added to the website.


During the reporting period, the project team participated in an online meeting organized by Kazakhstan

associations and Unions of People living with HIV, which was attended by CSOs and donor-funded


organizations, to present and discuss plans for the introduction of One Impact software in the country.

One Impact is a digital health solution platform for community-based TB responses to enhance people-

centered approaches to TB. USAID ETICA and other attendees were invited to review the online

demonstration version of the application and to provide feedback on the software for a subsequent

meeting where the features of the final platform would be discussed and finalized. USAID ETICA

provided recommendations on improving the application to make it useful and easy-to-understand for

the population.

4.4.3 ACTIVITY 3.3: INCREASED LOCAL CAPACITY TO FINANCE AND IMPLEMENT TB SERVICES

Based on NTP’s request, USAID ETICA has been supporting the development of the finance section in

the NSP since Y1. USAID ETICA proposed the purchase of TB health services within the Guaranteed

Volume of Free Medical Care Package for 2021, with an inflation adjuster. This will help the TWG better

formulate the NSP finance section by understanding the

importance of connecting planned and actual budgets with

prices of inputs (i.e., goods and services) to determine the

actual cost of TB care.

USAID ETICA supported the USAID TB Financing Advisor’s

efforts to propose changes to the PHC per capita rate

formulation methodology. The newly proposed method would

increase the financing of PHC facilities, and ultimately

encourage the wider spread and adoption of outpatient TB

treatment practices. USAID ETICA obtained and shared with the advisor data and information from the

Social Health Insurance Fund (SHIF), which is important for financial reforms. The project also

developed a list of suggestions for SHIF aimed at improving tariffs for calculating financing of the TB

sector with the SHIF’s Tariff Formation Department.

On December 2, 2020, USAID ETICA, along with the NTP director, USAID TB advisors, and heads of

TB Centers, participated in an online meeting defining the next steps in strengthening TB financing.

During the meeting, project specialists presented recommendations on improving TB financing by

modifying the complex tariff (CT). The project suggested applying correction factors for the

computation of CT to identify the amount for TB case reimbursement. The project also recommended

budget modeling of anti-TB services at the PHC and TB care levels, which will improve calculating

(1) the comprehensive per capita standard rate for PHC, and (2) the CT for one TB patient.

In countries such as Kazakhstan that are transitioning from foreign aid to domestic financing, the

sustainability of the TB response requires more than just a sufficient TB budget allocation. A legal

framework, effective mechanisms, and transparent procedures that allow governments to contract

CSOs for the provision of TB-related services to everyone who needs them are key.

On August 27, 2020, by Edict #390 of the President of the Republic of Kazakhstan, the country adopted

the Concept for the Sustainable Development of Civil Society until 2025. USAID ETICA, as a member of

TWG under the akimat of the City of Almaty, took part in the development of the concept

implementation plan, which included a section on improving state funding with a grants mechanism for

CSOs.

USAID ETICA continued advocating for the inclusion of TB in state social contracting.

USAID ETICA developed

and disseminated in social

media a video on

psychological counseling

of PWTB.


On November 24, 2020, within the framework of the TWG on social contracting, USAID ETICA

participated in a meeting organized by the Kazakhstan Union of People Living with HIV to develop a

consolidated position of partners on the inclusion of TB projects in the state social order (SSO)

allocated to CSOs by local governments. It was agreed that CSOs will calculate the basic costs of TB

services provided by their outreach workers. Such costing will inform CSOs’ proposal budget

development when bidding for state funding.

Simultaneously, the project team began collecting feedback through emails from 19 CSOs working under

the GF TB grant on the challenges they see in the SSO. Some of the expressed challenges that prevent

CSOs from applying for and/or receiving SSOs on the local level are the lack of interest of decision-

makers in funding CSOs. The healthcare departments report to akimats on improving the TB

epidemiological situation, which indicates no reasons for budgeting and releasing SSO funding for TB

activities. Small budgets allocated from SSOs and the short duration for project implementation (from

three to six months per year) also demotivate CSOs to apply for SSO funding. Collected CSO feedback

will be documented by USAID ETICA and presented at the TWG meetings for addressing their

comments, while developing a Concept of SSO for implementation.


During the reporting period, the government has relaxed COVID-19 related restrictions and project

team members were able to join the NTP monitoring visit to the Aktobe region. USAID ETICA

conducted joint monitoring at the laboratory. During the visit, project specialists assessed the

effectiveness of GeneXpert diagnostics, the quality of DST for new drugs (i.e., CFZ, LZD), and the

results of previously distributed electronic reporting forms. The outcomes of the visit will be used for

further optimization of the laboratory network, the introduction of Xpert MTB/RIF Ultra cartridges,

DST improvement, and the potential revision of electronic reporting forms.

As displayed in Exhibit 20, GeneXpert testing fluctuated during the first 10 months of 2020, with an

overall reduction of testing due to COVID-19 prevention measures. If testing in Aktobe is compared

with countrywide testing, it shows the same tendency of fluctuation: a slight increase of testing in June

when quarantine measures were relaxed, and a wave of decreases afterward.

Exhibit 20. Tendency of GeneXpert testing conducted in the Aktobe region, first 10 months of 2020

Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20

Coverage by GeneXpert testing, 2020

GX coverage, abs Kazakhstan GX coverage, abs Aktobe region


To verify the quality of case finding by laboratories, the number of positive TB results was collected for

the first nine months of 2020. The benchmark for previous years in Kazakhstan for MTB out of all

GeneXpert tests was 10%. Looking at 2020 data for the whole country results in an average 11.2%

positivity rate, and 8.9% for the Aktobe region, as illustrated in Exhibit 21. These results conclude that

case finding and the quality of laboratory performance remain at the same level, but insignificantly

decreases in the Aktobe region.

Exhibit 21. Number of positive results of GeneXpert tests in the Aktobe region

The project started the validation of DST for new drugs (i.e., CFZ, LZD) in all 20 TB laboratories and

updated SOP and DST forms in Y1. In July 2020, the project initiated an online meeting to discuss the

results of DST quality control. Checking the results and accuracy of DST implementation in the Aktobe

region was also targeted by the project. Based on findings, recommendations were provided. During the

monitoring visit to the Aktobe region, inconsistencies were identified (see Exhibit 22).

Average for KZ

11.2%

Average for

Aktobe 8.9%


Exhibit 22. Summary of monitoring findings in the Aktobe region, November 2020

Area of

monitoring Findings Actions taken Further recommendations

GeneXpert

testing

* GeneXpert coverage is 97.2%, which is a good indication of performance

(with the benchmark of 95%). Coverage with GeneXpert had the same trend

that was seen in the entire country. A total of eight GeneXpert machines

serve the region’s population.

* The GeneXpert positivity rate was slightly lower than the country-level

data.

* The error rate for GeneXpert testing averages 2.11% in the region, which is

below 3% and indicates good performance of GeneXpert laboratories.

Met with the head of the regional

bacteriological laboratory to discuss all findings

and provide recommendations.

Analyze the increased rate of

errors in three laboratories:

Aktobe oblast TB dispensary, and

the Aiteke bi and Khromtau

districts.

DST * Use of the old SOP format and form.

* Incomplete adherence to the DST procedure.

* The LZD working solution passed quality control, but CFZ failed.

Quality control of DST for CFZ and LZD was

reassessed after the updated SOP and related

forms (i.e., job aids and recording forms) were

implemented. Both drugs have successfully

passed quality control.

The quality control of DST on

CFZ and LZD should be further

monitored on a monthly basis.

GeneXpert

machines’

calibration

In line with planned annual maintenance, calibration of the GeneXpert

machine was conducted.

Successfully calibrated the GeneXpert machine

in the Aktobe oblast TB dispensary.

Other * Paper-based reporting forms are used.

* The region is fully equipped for the accelerated diagnosis of TB, including

drug-resistant forms: BACTEC, LPA HAIN; two GeneXpert devices are

based in the bacterial laboratory of the oblast TB dispensary.

* Service maintenance of expensive equipment (BACTEC, LPA HAIN, and

GeneXpert) for accelerated TB diagnosis can be performed by in-country

experts representing certain companies.

* The testing algorithm is followed: all presumptive patients undergo both

microscopy and GeneXpert testing at the initial stage of diagnosis.

* With the introduction of the new Turnaround Time (TAT) form (developed

and introduced by USAID ETICA), analyzing the performance of the TB

logistic system became possible. The analysis of 2020 data showed that the

network of organizations (TB and PHC facilities) providing TB services has a

well-organized logistic system. The time from sample collection up to the

time of receipt of the result by a clinician met the requirement of the NSP of

up to three days, except for one case where the TAT was four days.

Presented an electronic reporting form for the

collection of all laboratory TB data.

Collect and analyze data on

laboratory testing based on

electronic reporting forms.

Conduct regular monitoring of

TAT in laboratories by using a

provided checklist.


As per recently revised and submitted AMELP during this reporting period, Kazakhstan reported on 10

out of 14 indicators. The reported indicators are collected at the national level and display the

achievement of performance indicators of USAID ETICA in Kazakhstan in Q1 of Y2. The following

remaining four indicators are not reported as they have an annual pattern of reporting:

➢ Indicator # 8 “Percentage of participants reporting increased agreement with the concept that males

and females should have equal access to social, economic, and political resources and opportunities

Code: GNDR-4”;

➢ Indicator #9 “Number of people reached by a USG funded intervention providing GBV services

(psychosocial counseling) Code: GNDR-6”; ➢ Indicator #10 “Drug susceptibility test coverage”;

➢ Indicator # 11 “Laboratories with QMS reaching 80% on TB-SLIPTA scale”.

Data for the four indicators related to the work of CSOs was provided by the GF project of Kazakhstan.

The GF does not have a common database where the data on vulnerable groups, gender and age could be

obtained and analyzed. For this reporting period, information was provided only for the total number of

screened, tested, and confirmed cases through the CSOs activities.

Data on the other six indicators were obtained from the NTP. According to the NTP reporting system,

the data on the project indicators was generated from the reporting forms TB07, TB08, and TB01 used

for the gender and age disaggregation. Form TB07 shows data on the detection and initiation of treatment,

while form TB08 reports on treatment outcomes. Information on the laboratory indicator was obtained

from the National TB Register, namely, from the reporting form "Laboratory-based summary analysis of

TB cases, including GeneXpert".

Annex 3 displays project performance against its targets and the analysis of the achievement of the

indicators. Exhibit 23 was derived from Annex 3 and displays a summary of achievements against project

indicators. All targets were met or exceeded, except the target of two indicators: a) #7 on testing of

vulnerable groups, and b) enrollment of DS-TB patients to outpatient care. The target was achieved by

33.3% (7% of screened people were tested against 21% targeted) and 82% (37% of outpatient treatment

among DS-TB patients versus 45% of the target) respectively. Analysis for underachievement is provided

in Annex 3.

4.6 OBSTACLES AND CHALLENGES

Due to COVID-19 related restrictions, the five-day onsite DST training for new drugs (TOT) for

15 laboratory specialists of the NRL will be moved to the next period. The training will be aimed at

preparing a national team of trainers in DST for new drugs.

Besides, per the GF request, the following two events were also shifted to the second quarter:

➢ Online seminars for TB and PHC providers on AE/Adverse drug reaction management and

monitoring;

➢ Online webinars to reach CSO and PHC audiences on the topics of stigma reduction, the rights of

PWTB, gender specifics, and advocacy skills needed for work with decision-makers).


Exhibit 23. Achievement of targets of Y2Q1, Kazakhstan


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