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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
3.3 OBJECTIVE 2: INCREASED TREATMENT SUCCESS FOR TB AND ALL TYPES OF DR-TB
27
3.4 OBJECTIVE 3: IMPROVED ENABLING ENVIRONMENT AND FINANCIAL
SUSTAINABILITY OF TB AND DR-TB PROGRAMS ........................................................................... 30
3.5 COVID-19 RELATED RISKS AND CHALLENGES ................................................................... 32
3.6 PERFORMANCE MONITORING .................................................................................................. 33
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
4.3 OBJECTIVE 2: INCREASED TREATMENT SUCCESS FOR TB AND ALL TYPES OF DR-TB
42
4.4 OBJECTIVE 3: IMPROVED ENABLING ENVIRONMENT AND FINANCIAL
SUSTAINABILITY OF TB AND DR-TB PROGRAMS ........................................................................... 43
4.5 PERFORMANCE MONITORING .................................................................................................. 46
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 2
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 3
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 4
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
% of change compared to
previous quarter-19% -21% -13% 69%
Year 1INDICATORS
Percentage and number of DR-TB cases diagnosed
Percentage (and number) of DR-TB cases started on second-line drugs
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 5
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 6
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 7
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 8
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 9
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.
2.4 OBJECTIVE 2: INCREASED TREATMENT SUCCESS FOR TB AND ALL TYPES OF DR-TB
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%)
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 10
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 11
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 12
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.
2.5 OBJECTIVE 3: IMPROVED ENABLING ENVIRONMENT AND FINANCIAL
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 13
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 14
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 15
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 16
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”.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 17
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 18
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 19
Monitoring
area Positive results Identified problems Actions Recommendations
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 20
Exhibit 6. Achievement of performance indicators, Y2Q1, Tajikistan
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 21
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 22
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 OBJECTIVE 1: INCREASED DETECTION OF TB AND DR-TB
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 23
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 24
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 25
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 26
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 27
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.
3.3 OBJECTIVE 2: INCREASED TREATMENT SUCCESS FOR TB AND ALL TYPES OF DR-TB
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 28
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 29
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 30
3.3.2 ACTIVITY 2.2: SUPPORT THE INTRODUCTION OF NEW PROCEDURES TO SUSTAIN PATIENT-
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 OBJECTIVE 3: IMPROVED ENABLING ENVIRONMENT AND FINANCIAL
SUSTAINABILITY OF TB AND DR-TB PROGRAMS
3.4.1 ACTIVITY 3.1: PROVIDING EFFECTIVE DETECTION TO WHERE PEOPLE FIRST SEEK CARE
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 31
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.
3.4.3 ACTIVITY 3.3: ROBUST DATA COLLECTION, ANALYSIS, AND FEEDBACK SYSTEMS
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: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 32
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: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 33
3.6 PERFORMANCE MONITORING
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 34
Exhibit 13. Summary of monitoring visits to the Jizzakh and Syrdarya oblasts
Monitoring
area Positive results Identified problems Actions Recommendations
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 35
Exhibit 14. Achievement of targets of Y2Q1, Uzbekistan
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 36
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 37
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.
4.2 OBJECTIVE 1: INCREASED DETECTION OF TB AND DR-TB
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
% of change compared to
previous quarter-4% -25% -14% 32%
Number of enrolled to treatment1539 1477 1103 951 1256
% of change compared to
previous quarter-4% -25% -14% 32%
INDICATORSYear 1
Percentage and number of DR-TB cases diagnosed
Percentage (and number) of DR-TB cases started on second-line drugs
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 38
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 39
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 40
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)
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 41
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 42
4.3 OBJECTIVE 2: INCREASED TREATMENT SUCCESS FOR TB AND ALL TYPES OF DR-TB
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.
4.3.2 ACTIVITY 2.2: SUPPORT THE INTRODUCTION OF NEW PROCEDURES TO SUSTAIN PATIENT-
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 43
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.
4.4 OBJECTIVE 3: IMPROVED ENABLING ENVIRONMENT AND FINANCIAL
SUSTAINABILITY OF TB AND DR-TB PROGRAMS
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 44
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.
4.4.2 ACTIVITY 3.2: ROBUST DATA COLLECTION, ANALYSIS, AND FEEDBACK SYSTEMS
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 45
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 46
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.
4.5 PERFORMANCE MONITORING
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
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 47
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%
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 48
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.
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 49
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).
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 50
Exhibit 23. Achievement of targets of Y2Q1, Kazakhstan
USAID ETICA: QUARTERLY REPORT: OCTOBER–DECEMBER 2020 | 51