1. health and fitness

SUMMARY INFORMATION
Applicant Information
Country
Afghanistan
Component
Funding Request
Start Date
April 1, 2015
Funding Request
End Date
Principal Recipient(s)
Ministry of Public Health and
United Nations Development Programme, UNDP
TB
December 31,2017
STANDARD
CONCEPT NOTE
Funding Request Summary Table
A funding request summary table will be automatically generated in the online grant
management platform based on the information presented in the programmatic gap
table and modular templates.
Investing for impact against HIV, tuberculosis, or malaria
A concept note outlines the reasons for Global Fund investment. Each concept note should describe
a strategy, supported by technical data that shows why this approach will be effective. Guided by a
national health strategy and a national disease strategic plan, it prioritizes a country’s needs within a
broader context. Further, it describes how implementation of the resulting grants can maximize the
impact of the investment, by reaching the greatest number of people and by achieving the greatest
possible effect on their health.
A concept note is divided into the following sections:
Section 1:
A description of the country’s epidemiological situation, including health systems and
barriers to access, as well as the national response
Section 2:
Information on the national funding landscape and sustainability
Section 3:
A funding request to the Global Fund, including a programmatic gap analysis, rationale
and description, and modular template
Section 4:
Implementation arrangements and risk assessment
IMPORTANT NOTE: Applicants should refer to the Standard Concept Note Instructions to
complete this template.
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SECTION1: COUNTRY CONTEXT
This section requests information on the country context, including the disease
epidemiology, the health systems and community systems setting, and the human rights
situation. This description is critical for justifying the choice of appropriate interventions.
1.1 Country Disease, Health ,and Community Systems Context
With reference to the latest available epidemiological information, in addition to the portfolio
analysis provided by the Global Fund, highlight:
a. The current and evolving epidemiology of the disease(s)and any significant
geographic variations in disease risk or prevalence.
b. Key populations that may have disproportionately low access to prevention and
treatment services (and for HIV and tuberculosis [TB], the availability of care and
support services), and the contributing factors to this inequality.
c. Key human rights barriers and gender inequalities that may impede access to health
services.
d. The health systems and community systems context in the country, including any
constraints.
1. Current epidemiological features of tuberculosis
According to Global Tuberculosis Report 2013 (World Health Organization [WHO], 2013) Annex 1,
Afghanistan, with 27, 5 million inhabitants, ranked as one of 22 highly TB-burdened countries. The
estimated incidence of TB cases in all forms is 189 in 100,000 population per year, and prevalence
TB cases in all forms is 358 in 100,000 population per year. Put it simply, annually there will be
approximately 56,000 new TB cases occurring in the country, and existing (prevalence) number of
cases will be 110,000.
Afghanistan had a steep rise in TB case notification in 2003–4 owing to integration of TB services
into the general health system and rapid increase of access and implementation of the basic package
of health services (BPHS). That continued through 2007, followed by steady decline in 2008 and
2009. There are several reasons for this decline, including technical and financial reasons such as
interruption of Global Fund (GFATM) support after Round 4(R4) up to Round 8 (R8). However,
thereafter, from 2010 to present, the National Tuberculosis Program (NTP) Afghanistan, with strong
support by partners, sustained a steady increase in case notification. As a result, NTP Afghanistan
has progressed substantially beyond past decades, and the number of notified cases in 2013 (31,662
TB cases in all forms) increased three fold over 2001 (9,668).
There has been 6% increase in case notification yearly since 2011.In 2013, NTP notified 31,622
cases of all forms of TB (case notification rate of 115 in 100,000 population);among these, 30,507
(29,353 new and 1,154 relapse) were new TB cases. By using the number of total population by the
central statistical office (27.5 million), the case detection rate still remained low (54%) and it is
estimated that about 24,378 new TB cases remained undiagnosed.
This low case notification rate is the same for multi-drug resistance tuberculosis (MDR-TB).
According to WHO estimates, there are 1,150MDR-TB cases occurring in a year in Afghanistan that
is, 750 cases among instances of new and notified pulmonary TB cases, and 400 instances among
retreatment cases(Global Tuberculosis Report 2013).The 2010 sub national drug resistance survey,
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conducted in six provinces of Afghanistan, reports a higher incidence of MDR-TB in Afghanistan
than WHO estimates; the survey discovered the incidence of MDR-TB at 6.8% among combined
new and retreatment pulmonary sputum-smear positive cases (National TB Control Program,
“Results of Drug Resistance Survey in Six Provinces of Central Region in Afghanistan” [Ministry of
Public Health, 2010]) Annex 2 Although NTP has been maintaining good treatment success rate,
there might have been a huge number of cases that were not properly treated in private sectors,
resulting in the development of a certain number of MDR-TB cases. At this moment, NTP has
notified 140 MDR-TB cases since 2011, indicating a case notification rate of MDR-TB at only 5%.
For the geographic variations, the highest numbers of TB cases are accumulated in cities and
provinces with large populations (“Epidemiological Review of Tuberculosis in Afghanistan and NTP
Surveillance Data” ) Annex 3 .The number of TB cases from five major provinces with large
population (Kabul, Herat, Nangarhar, Balkh, and Kandahar) was 12,502 in 2013, which is almost
40% of all TB cases notified in the whole country. The mean case notification rate for these
provinces is 133 in 100,000 population. The mean rate for Kabul is 84; Nangarhar, 171; Balkh, 133;
Herat, 139; and Kandahar, 139 in 100,000 population.
Case notification rate for all forms of TB and treatment outcomesfor34 provinces in 2013 are listed
in table 1 and depicted in maps 1 and 2.
Table 1: Annual Case Notification and Treatment Success Rates
for All Forms of Tuberculosis, per 100,000 Population, 2013
No.
Province
Case Notification
Rate
Treatment Success
Rate
1
Kabul
87
74
2
Kapisa
63
95
3
Parwan
73
93
4
Panjsher
28
65
5
Wardak
39
88
6
Logar
90
93
7
Bamyan
101
93
8
Daikundi
107
95
9
Zabul
222
97
10
Ghazni
109
91
11
Paktia
144
95
12
Paktika
148
95
13
Khost
181
86
14
Nangarhar
205
89
15
Laghman
101
91
16
Kunar
175
91
17
Noristan
158
100
18
Urozgan
110
94
19
Badakhshan
113
93
20
Balkh
135
95
21
Jaozjan
168
96
22
Faryab
85
98
23
Samangan
90
95
24
Sar-E-Pul
71
95
25
Takhar
141
95
26
Baghlan
160
92
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27
Kunduz
130
95
28
Badghis
167
96
29
heart
142
90
30
Farah
95
96
31
Ghor
126
94
32
Nimroz
141
85
33
Helmand
102
90
34
Kandahar
141
84
Note: Fifteen provinces reached the TB case notification target (70% or more); the
remaining 19 provinces have not reached the target yet.
NTP Surveillance data 2013
There are regional variations in case notification rate: Six out of eight provinces in the central region
(nos. 1–8), three out of five in the north region (nos. 20–24), and Farah (no. 30) tended to show
lower notification than the national average. For Kabul, there has been significant progress in case
notification since the introduction of urban DOTS to incorporate non-NTP public health facilities and
private health facilities. NTP Afghanistan has made in-depth analysis in case notification and found
several possible reasons, including low suspect management, low capacity of sputum-smear
diagnosis, and low out-patient department (OPD) cases. Also, NTP points out that in some provinces
prevalence or incidence of TB might be significantly lower than that of national value (“TB Data
Annual Analysis” [2010]) Annex 4. Thus, the reason of low case notification in other provinces in
2013 might vary; further analysis is required.
There have been variations in TB case distribution by age and gender. For both genders, there exists
high incidence among people aged 15–44years old, with the highest incidence among the most
productive age group of 25–34 years old.
Contrary to the rest of the world, Afghanistan reported a higher proportion of TB cases among
women than men. For example, chronological data from NTP surveillance system (2007–13) shows
that around 60% of TB cases notified were among women, especially in reproductive ages. This
proportion is disseminated across the country and in all regions unanimously (Epidemiological
Assessment Report, pp. 22–23). However, there are some provinces, such as Kabul, Urzgan,
Kandahar, Nangarhar, and Panjshir, where the gender dissemination of TB cases was equally
distributed in 2013.
The gender distribution of notified MDR-TB cases is the same as that of all forms of TB, and female
cases represent 63%of total cases. However, the age distribution of MDR-TB cases is different from
that of all forms of TB, and cases among people less than 30 years old represent 58% of total cases.
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Map 1: Case Notification of New Episodes of Tuberculosis (New Cases and Relapse), by
Province, 2012 (Central Statistics Office Data)
Map 2: Population Distribution by Provinces, 2012 (Central Statistics Office Data)
The multiyear data analysis (2006–13) discovered that there is seasonal variation in TB case
notification in Afghanistan. Consistently, there has been a steep increase in TB case notification
during the second quarter and a sharp decline during the fourth quarter of each year. On average,30%
of all TB cases notified occur during the second quarter, and 20% during the fourth quarter of each
year (“Epidemiological Review of Tuberculosis in Afghanistan,” p. 21). The main barrier in the
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fourth quarter is the winter season, which limits access to health services in remote and hard-to-reach
areas owing to heavy snowfall, avalanches, and very cold temperatures. Thus, special intervention to
cope with this issue is necessary, and NTP has introduced the slide/sputum sending system (details of
which are described subsequently).
NTP Afghanistan has sustained higher rates of successful treatment outcome since 2006—largely
because, on average, more than 95% of notified cases have received treatment. For example, the
treatment success rate for sputum-smear positive TB patients has been maintained at levels of more
than 85% since 2006; it reached 90% in 2010 and has remained at this level since. The gender
distribution of treatment success rate was assessed in 2012, and it shows rates of 91% and 87% for
women and men, respectively (“Community Contribution in Tuberculosis Control in Afghanistan,”
International Journal of Tuberculosis and Lung Disease 16.12 [Dec. 2012]: S32) Annex 5. For all
forms of TB, the treatment success rate steadily improved from 82% in 2010 to 88% in 2012
(“Epidemiological Review of Tuberculosis in Afghanistan,” p. 37). The NTP surveillance data
analysis for 2013 shows that the mean treatment success rate for all 34 province is 92%(95%
CI=2.3%; standard deviation=6.7%), 27 provinces reached treatment success rates of more than 90%,
and five provinces reached 84–89% (table 1). There are two outliers, Kabul and Panjshir, which had
treatment success rates of 74% and 65%, respectively. Kabul is the capital of the country, and thus is
home for most TB cases since it is the final referral for all forms of health issues, including TB. It
has the highest transfer-out rate of 19%, which is five times higher than the national value of 4%.
Also, the defaulter rate in Kabul is 4%, compared to 2% at the national level. It is assumed that
residents of other provinces are diagnosed in Kabul and after a while travel back to their home cities
in other provinces, which leads to higher transfer-out and default rates. Furthermore, there is a
seasonal relocation of population from different provinces to Kabul—they travel to Kabul during
spring and summer to seek job opportunities, and leave it in winter. Therefore, TB cases notified
among this population resulted in higher transfer-out and default rates. To explain the lower
treatment success rate for Panjshir, further analysis is required. Thus, NTP need to strengthen the
referral system to reduce the transfer-out rate and to record treatment outcome of patients referred to
other provinces.
2. Under-covered key populations
The assessment of key affected populations supported by the Stop TB partnership (for details, see
“Engaging Key Affected Population” and “People Living with Diseases”[in the Concept Note
development) indicated the following groups of population as key affected populations: poor families
(labor workers in urban settings and farmers in rural areas);internally displaced persons
(IDPs);people living in distant areas, including nomads; females; children; and prisoners. As pointed
out by the assessment, those populations have certain hindering factors to receive TB control
services, such as no adequate knowledge of TB or a lack of transportation cost due to poverty; most
of these populations are considered, at the same time, as under-covered populations by TB control
services. The important issues regarding epidemiological figures are described here. For gender
issues, detailed descriptions are in the section 3.1.
Note: For the assessment, consultative workshops were held in Kabul, Herat, and Kandahar
provinces, inviting ex-TB patients, TB patients among prisoners, IDPs, etc.
People living in hard-to-reach areas:
Although the Ministry of Public Health (MoPH) has made significant progress to expand BPHS for
providing primary health care, still there are difficulties to access to health facilities especially in
rural areas. For example, the proportion of population who cannot access to health facility within two
hours by any means of transport varies from 17.3% in rural areas and 0.6% in urban areas (13.1% as
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the national average) (Central Statistics Organization, National Risk and Vulnerability
Assessment2011–12, Afghanistan Living Condition Survey [Kabul: CSO, 2014]) Annex 6 and it is
roughly estimated that about 36% people cannot access to health facility within one hour by any
means of transport.
IDPs, returnees, and prisoners:
There are around 700,000 conflict-induced IDPs and 70,000 natural-disaster induced IDPs in whole
country (United Nations High Commissioner for Refugees [UNCHR] Global Report 2012.
http://www.unhcr.org/gr12/index.xml) Annex 7 .There are also more than 3 million returnees and
deportees mainly from Pakistan and Iran (GulbadanHabibi and Pamela Hunte, Afghan Returnees
from NWFP, Pakistan, to Nangarhar Province [Afghanistan Research and Evaluation Unit,2006], p.
3). These groups of population are most vulnerable to TB, living in poor conditions, without a
nutritionally sufficient environment; indeed, they are at risk of developing infectious diseases in
general, including TB. The incidence of sputum-smear positive TB cases among this population is
three times that of general population (F. Delawer et al., “Identifying the Magnitude of Pulmonary
TB among Internally Displaced Populations in Afghanistan,” International Journal of Tuberculosis
and Lung Disease15.11 (Nov. 2011]: S255) Annex 8. However, these groups have not been
continuously covered by TB-control services, as outreach programs are necessary to cover them.
Only portions of these groups have been covered occasionally by support of the Rural Expansion of
Afghanistan’s Community-based Healthcare (REACH) program and the Japan International
Cooperation Agency (JICA).
Still there are 2 million refugees outside the country, mainly Pakistan and Iran, and annually there
are 20~30,000 returnees from Pakistan and 200,000 returnees and deportees from Iran. The previous
screening at the border revealed nearly two times higher incidence of TB compared to that of the
general population. Up to now, the screenings have been supported by JICA, but this intervention
covered only part of the total number of returnees.
There are about 30,000 prisoners in the country, and previous screenings revealed extremely high
incidence of TB (1%). Although there are medical clinics in prisons, this extremely high incidence of
TB requires special approaches, such as active screening; however, only small programs, supported
by REACH and JICA, were occasionally conducted.
Children:
According to the central statistics office, children aged five years and younger make up 20% (5.5
million) of the total population in Afghanistan. Considering the higher rate of infection, malnutrition,
and low coverage of immunization (39%) (Afghan Public Health Institute, MoPH, Afghanistan
Mortality Survey 2010[Kabul, 2011]) Annex 9 , this population group is considered to be vulnerable
to TB. During 2013, at least 1,283 cases of pulmonary TB among children aged five years and
younger (NTP, Surveillance Data 2013) were diagnosed, and there are 4,475 cases among children
aged 15 years and younger. These numbers dramatically increased after NTP started training on the
standard operating procedures for pediatric TB control and utilizing tuberculin skin testing as the
diagnostic tool. However, according to the health management information system (HMIS), annually
there are almost 40 million outpatient attendees to health facilities, and children comprise 25% of all
outpatient cases. The previous survey pointed out that a significant proportion of child TB suspects
were missed for diagnosis within health facilities (F.M. Delawer et al., “Management of Pediatric
Tuberculosis in Provincial and District Hospitals in Afghanistan,”Eastern Mediterranean Health
Journal 19 (2014): 698–703) Annex 10. Those cases could access to health facilities, but could not
access functionally to pediatric TB control. Thus, a proper screening system and appropriate
diagnostic facility could lead to increased case notification among children.
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3. Key human rights barriers
The concept of human rights is not pervasive in Afghanistan. This is not only in the field of TB
control, but also in the entire social sector. In the field of TB control, in addition to lacking a concept
of human rights, there remains a rampant stigma against TB that often hampers early consultation by
TB suspect in health facilities. Sometimes, health facility staff—including doctors and nurses—are
influenced by this stigma or lack a proper knowledge of the disease.
In a further barrier, females are generally not decision-makers in their families, especially in remote
and rural areas (although there are regional differences due to racial and cultural factors). Moreover,
most of rural people prefer female health facility staff to see their female family members, but there
are significant shortages of female doctors and nurses, especially in rural areas. These issues have
been pointed out in several surveys, and often hamper visits to health facilities for females, resulting
in failure to diagnose in the early stages of TB.
Moreover, according to various researches, health care staff has been identified as a group at higher
risk for contracting TB; NTP Afghanistan is working to ensure a safer working environment for
health care staff, clients, and community through the implementation of TB infection control
measures at various levels of the health care system.
4. Health system context
The Ministry of Public Health is one of the leading ministries in the government of the Islamic
Republic of Afghanistan. This ministry defined its health priorities in the national health strategic
plan for 2011–15: mother and child health and communicable disease. To address these challenges,
MoPH developed primary health care packages called the “basic package of health services” (BPHS)
and the “essential package of health services” (EPHS). The BPHS defines the level of service
delivery from community level to provincial level as follows:
Health post: This level of service delivery is located deep in the community: two volunteer
community health workers (CHWs), a male and a female, receive monthly kits of essential
medication and other supplies, and provide basic services such as education and information on
priority health problems, identifying and referring patients to health centers. As such, health posts
play a role of catalyst between communities and health centers. They also refer presumptive TB
cases for diagnosis to health facilities and provide DOT to TB patients in their villages. The CHWs
proved to be effective and efficient in TB case identification, early diagnosis, and treatment (BPHS
2010).The health post is located in an area of approximately two hours walking distance from the
upper level of health facilities and covers a population of 100–150 households, or 1,000–1,500
inhabitants. Health-post performance is monitored and supervised by community health supervision
(health care staff). Currently, there are14, 130 health posts (annual health information system [HIS]
publication 1392) Annex 11 and 23,000 CHWs working around the country.
Sub–health center (SHC): There are 526 SHCs in Afghanistan. Sub–health centers constitute the
second level of health service delivery located in the community. Sub–health centers are placed in
very hard to reach and remote areas, aiming at increasing access to primary health services; they each
cover a total population of 5,000–8,000. In each SHC, one nurse, one vaccinator, and one community
midwife are posted. Sub–health centers provide information, education, and communication;
vaccination services (fixed and outreach); outpatient attendees of primary health care; integrated
management of childhood illness; family planning; and reproductive health services. In 2013,
approximately 6 million clients and 44,000 presumptive TB cases attended to SHCs all over the
country.
Basic health center (BHC): There are823 BHCs active in Afghanistan. Basic health centers
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constitute the third level of contact between health services and patients. Each BHC covers a
population of 15,000–30,000 and is staffed with one nurse, two vaccinators, one community health
supervisor, and one midwife. Basic health centers do not provide laboratory services, and they act as
treatment and referral centers for TB. (Some BHC+ centers do provide TB laboratory and diagnostic
services.)
Comprehensive health center (CHC): There are 384 CHCs in Afghanistan. This fourth level
provides primary health care and also laboratory diagnostic services, including TB. Each CHC
covers a population of 30,000–60,000 and is staffed with two doctors, two nurses, two midwives,
two vaccinators, and two support staff.
District hospitals (DH): There are 732 DHs active in Afghanistan. At this level of basic health
service delivery, each DH covers a population of 60,000–100,000 and provides both primary health
care and laboratory diagnostic services, including TB. Each DH is also are equipped with X-ray
machines and has approximately 20 beds to accommodate patients.
Additionally, a total of 159 provincial hospitals, regional hospitals, and national and specialist
hospitals, along with some mobile clinics, are located at provincial and national centers. In addition,
a strong private sector exists at all 34 provinces of Afghanistan. They include general physicians,
private laboratories, drug stores, and private clinics and hospitals. Unfortunately, most of them are
outside of the public sector and, without a strong recording and reporting system, do not report to
national TB program.
See table 2 for the overall performance of all health facilities in attending presumptive TB cases in
2013. At all levels of health services, approximately, 47 million individuals and 408,000 presumptive
TB cases were attended. These data indicate the consultation per capita of 1.5, strengthening the case
that the health system assists NTP in notifying a large number of TB cases.
Table 2: Comparison of Clients and Presumptive TB Cases by Facility Type,2013
Health Facility Type
Number of Clients (2013)
Presumptive TB Cases Attended
Health Facilities (2013)
5,599,169
44,091
Basic health centers (BHC)
15,262,819
142,535
Comprehensive health centers (CHC)
14,660,845
122,368
District hospitals (DH)
5,900,167
48,404
Provincial hospital
3,219,214
34,325
Regional and specialist hospital
2,540,948
16,627
47,183,162
408,350
Sub-health centers (SHC)
Total
Source: Health Information System Unit ,MoPH 2013
5. Constraints related to the health system:
Current constraints related to the health system, except security problems, are summarized below;
most of those are common to all three programs.
1. Existence of a hard-to-reach geographical area for service delivery.
2. Lack of infrastructure and health equipment. (Back-up generators, X-ray machines, and
microscopes are often not properly equipped, used according to instructions, or properly
maintained.)
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3. Limitation in diagnostic services at health post, HSC, HMT, and BHC levels.
4. Lack of coordination between private and public sectors due to unregulated private sector
5. Limited mobility of women (due to the cultural issue of household decision-making and
insufficient female staff in primary healthcare facilities).
6. High turnover of staff in health facilities, including CHWs, especially in remote or insecure
areas.
7. Insufficient referral services and weak coordination among different levels and facilities of
the health system.
Among these constraints, for 5 it is difficult to cope with in this Concept Note, but for others
measures to mitigate these constrains are taken into this concept note (Detail are described in the
section 3.1)
6. Accuracy of data
NTP assessed the data accuracy and quality in Jan-Feb 2013 in 16 provinces and in 65 health
facilities. The team from central M&E unit of NTP developed the questionnaire to conduct interview
with health facility staff and collect data from TB registers and compared it with the reports that
already sent to NTP surveillance data. The findings revealed that the data accuracy for two key TB
indicators of cases notification for sputum smear positive and all forms of TB turned to be 97.7%
and 97.4% accurate. Furthermore, other data quality dimensions such as validity, integrity, timelines,
reliability and precisions were assessed. The findings demonstrate validity of 65%, reliability of
76%, system integrity of 89%, precision of 89% and timeliness of 78% (data accuracy assessment
report) Annex 12. The above-mentioned statement of the accuracy of data was acknowledged by the
epidemiological review of Tuberculosis in Afghanistan (page 16, epidemiological review of
Tuberculosis data).
1.2 National Disease Strategic Plans
With clear references to the current national disease strategic plan(s)and supporting
documentation (include the name of the document and specific page reference), briefly
summarize:
a. The key goals, objectives and priority program areas.
b. Implementation to date, including the main outcomes and impact achieved.
c. Limitations to implementation and any lessons learned that will inform future
implementation. In particular, highlight how the inequalities and key constraints
described in question1.1are being addressed.
d. The main areas of linkage to the national health strategy, including how
implementation of this strategy impacts relevant disease outcomes.
e. For standard HIV or TB funding requests1, describe existing TB/HIV collaborative
activities, including linkages between the respective national TB and HIV programs
in areas such as: diagnostics, service delivery, information systems and monitoring
and evaluation, capacity building, policy development and coordination processes.
f.
Country processes for reviewing and revising the national disease strategic plan(s)
and results of these assessments. Explain the process and timeline for the
development of a new plan(if current one is valid for 18 months or less from
funding request start date), including how key populations will be meaningfully
1
Countries with high co-infection rates of HIV and TB must submit a TB and HIV Concept Note. Countries with high burden of
TB/HIV are considered to have a high estimated TB/HIV incidence (in numbers) as well as high HIV positivity rate among
people infected with TB.
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engaged.
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1. Key goals, objectives, and priority program areas
The program goal, objectives, and key strategic areas of the national strategic plan for 2014–18,
according to NTP, are summarized below:
Goal: To reduce TB mortality by 50% at the end of 2018 compared to 2013
Objectives:
 To increase the case notification of all TB cases at least 6% by year and to at least maintain
treatment success rate 90% by 2018

To
detect and treat at least 50% of estimated MDR-TB cases by 2018
Key strategic areas and directions:
The following key areas were considered to develop the strategic directions:
1. Improving accessibility to TB care and control services
2. Enhancing contact management and suspect management
3. Enhancing screening for high-risk groups
4. Introducing concepts of human rights
5. Obtaining reliable data for the prevalence, incidence, and mortality of TB
(For details, see “General Situation Analysis of Tuberculosis Control Program, ”National Strategic
Plan, 2014–18, pp. 11)All strategic directions have been defined based on the general situation
analysis, including epidemiological analysis.
Strategic interventions and relevant activities were defined by detailed situation analysis on each
area of the TB-control program. (For details, see situation analysis under each strategic direction of
“NTP Vision, Goal, Objectives, Strategic Directions, Strategic Interventions and Activities,
“National Strategic Plan, 2014–18, pp. 14–28.)
NTP, National Strategic Plan 2014-2018 Annex 13
The national strategic plan for 2014–18 identifies nine strategic directions to respond the diseases in
country, which include:
Strategic direction1: Enhancing political commitment and DOTS expansion
1. Sustain political commitment for TB control at all levels.
2. Strengthen collaboration mechanisms with different departments of MoPH.
Strategic direction 2: Strengthen human resource development
1. Render NTP leaders more capable and enable them for day-to-day human resource
management and development to address all TB-related human resources needs for
implementation of the strategic plan at all levels in the health system.
2. Update curricula for all pre-service training in medical faculties and HSIs, according to
the revised NTP national guidelines, and train lecturers for implementation.
3. Provide needs-based quality in-service training and continuing education for all staff
(technical and nontechnical) involved in TB-control activities at all levels.
Strategic direction 3: Strengthening surveillance, monitoring, and evaluation
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1.Strengthen the surveillance system by introducing a new electronic surveillance system,
termed the TB information system (TBIS).
2.Ensure regular supervision and monitoring at all levels.
3.Enhance internal or self-evaluation mechanism through quarterly review meetings and
annual evaluation workshops.
Strategic direction 4: Drug supply and management system
Ensure effective, uninterrupted drug supply and management system at all levels.
Strategic direction 5: Strengthening laboratory network
1.Improve accessibility for TB diagnosis.
2.Maintain laboratory network and improve quality control for sputum-smear examinations.
3. Improve access to laboratory diagnosis by culture and drug susceptibility testing (DST) for
MDR-TB diagnosis and establish the capacity of rapid diagnosis for MDR-TB
management.
4. Introduce an innovative approach to enhance quality of TB diagnosis.
5.Ensure bio safety and TB infection control for TB diagnostic laboratory services.
Strategic direction 6: Address TB/HIV, MDR-TB, child TB, and the needs of poor and vulnerable
populations (IDPs, prisoners, refugees, etc.) and strengthening TB diagnosis and treatment among
the household contacts of patients with all forms of TB.
1. Strengthen collaboration mechanisms among NTP, the National AIDS Control Program
(NACP), and partners.
2. Scale up of HIV testing among TB patients.
3. Scale up TB screening and providing prophylaxis for people living with HIV.
4. Enhance pediatric TB-control program in all provinces.
5. Scale up case detection and access to effective treatment for MDR-TBat the national and
provincial levels.
6. Strengthen coordination and collaboration among the MDR-TB team, public hospital, and
the Ministry of Public Health.
7. Scale up TB-infection control in MDR-TB hospital wards and outpatient clinics.
8. Enhance TB detection in selected high-risk groups (nomads, IDPs/returnees, prisoners, and
refugees).
9. Develop cross-border mechanisms on TB control for returnees.
10.Strengthen TB diagnosis and treatment among household contacts for patients with all forms
of TB.
11.Increase early detection of female TB patients during pregnancy and postpartum.
12.Expand contact management of TB among women.
13.Increase community awareness and advocacy to reduce reproductive health factors as risks for
TB.
14.Provide preventative treatment for high-risk females regarding reproductive factors.
Strategic direction 7: Engage all care providers
1. Continue private public mix (PPM)-DOTS expansion to public and private healthcare
facilities nationwide.
2. Develop a monitoring and evaluation mechanism for PPM.
3. Involve private health care providers in raising TB awareness.
Strategic direction 8: Empower people with TB and communities through partnership
1. Expand partnership for advocacy communication and social monitoring.
2. Introduce the concept of the patient charter into healthcare services.
3. Pursue advocacy, communication, and social mobilization at all levels.
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4. Strengthen community participation in TB care, prevention, and health promotion.
Strategic direction 9: Enable and promote research
1. Strengthen the capacity of research teams to conduct operational research at national and
provincial levels.
2. Assess research needs and conduct operational research to enhance case finding and to
improve service delivery and health services.
The previous national strategic plan for TB control for the years 2009–13 was designed to guide the
national TB-control efforts at the country level; it was developed in line with components of Stop
TB strategy in order to achieve the United Nations’ Millennium Development Goals targets for TB.
The key strategies are summarized as follows:
Strategy 1:Pursue quality DOTS expansion and enhancement
Strategy 2:Adapt DOTS to respond to TB/HIV, MDR-TB, and other challenges
Strategy 3:Contribute to health-system strengthening
Strategy 4:Engage all health care providers
Strategy 5:Empower patients and communities
Strategy 6:Enable and promote operational research
2. Implementation to date, including the main outcomes and impact achieved
As a result of NTP strategies, at the end of 2013, there are 1,197 public and private DOTS centers
that can provide TB services and care according to international standards for TB care.The
estimated population that has access to DOTS facilities in Afghanistan has steadily increased to
96% by the end of 2013. However, this is a generous estimate of population coverage; it assumes
the whole population of a district is physically covered, even if only one health facility in a district
provides DOTS, regardless of the actual number of people that have access to that facility. As
described in the previous section, 13.1% of the population on average cannot access health facilities
within two hours by any means of transport.
The case notification rate has significantly increased during the period 1997–2013 from 7 to 115
per 100,000 population per year for all TB cases respectively. The treatment success rate is also
increased from 84% (2001) to 90% (2012) cohort. However, still around 50% of all TB cases and
an estimated 95% of MDR-TB cases remain undetected. TB service is not universally accessible,
particularly in remote, hard-to-reach areas and for vulnerable population such IDPs, nomads,
prisoners, etc.; the community is not fully involved in TB care; and the subcomponents of Stop TB
strategies have not been fully implemented.
These results of the national strategic plan implementation have been externally evaluated
periodically by the Eastern Mediterranean Regional Office of the WHO. The latest evaluation was
conducted in 2012, Annex A which confirmed most of the achievements described here.
3. Limitations to implementation and lessons learned
There have been a number of obstacles and limitations for the implementation of the strategic plan,
but the major technical weakness lies in focusing on passive case findings in the previous national
strategic plan. In the previous plan, expansion of high-quality DOTS was the main focus, and
passive case findings in health facilities were the main interventions of DOTS strategy. This
resulted in a significant proportion of under-covered population, as noted in section 1.1, due to
inaccessibility to TB-control services. NTP Afghanistan has realized the significance of this
weakness and the necessity to change strategies to cope with these under-covered populations.
Thus, NTP has started to evaluate effectiveness of active case findings in various settings through
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several small pilots, such as screening for IDPs and prisoners. With some favourable results of
these pilots, NTP has included various interventions for active case findings in the current strategic
plan, which covers 2014–18, mainly to cope with inequalities and geographical constraints found in
the epidemiological and general situation analysis, as described in the section 1.1.
The second issue was the weak capacity of NTP for program management. With weak capacity for
financial management, MoPH/NTP relies on donors for the operational budget to implement most
important interventions of the program; the GFATM is the main source of support. MoPH/NTP
asks other partners to work as principal recipients. To implement the strategic plan smoothly and
effectively in these difficult settings, NTP has needed a strong capacity for program management.
As a result, NTP has not been able to take initiatives in the implementation of the strategic plan due
to weak capacity for program management.
Weak financial management by the principal recipients also hampered smooth disbursement of the
budget to implement necessary interventions. In 2011, most of the activities supported by the
GFATM, including key activities for the program management, were canceled due to weak capacity
for financial management.
In addition to these obstacles and limitations in general areas to the implementation of the national
strategic plan, there are certain obstacles and limitations in each program areas such as high
turnover of staff in health facilities, weak quality-control mechanisms for several interventions, and
weak collaborating mechanisms with stakeholders at peripheral levels. These are addressed with
their effect on the implementation of the national strategic plan in the section for situation analysis
and interventions to cope with obstacles are developed in the current plan for 2014–18.(For details,
see situation analysis under each strategic direction of “NTP Vision, Goal, Objectives, Strategic
Directions,” pp. 14–28.)
In addition to the significance of active case findings, there are several other lessons learned from
the implementation of the previous strategy.
3.1 Enhancing collaboration with other departments of MoPH
Integrating TB services in the health system, as defined by both BPHS and EPHS, was a valuable
public health practices in Afghanistan.There has been progress in improving collaboration
mechanisms between departments within MoPH; during these process, NTP has learned the
importance of collaboration to change the approach from narrow-vertical to wide-multisectorial,
especially with departments such as Health Finance and Economy, HMIS, M&E, and Grant and
Contract Management—this is true not only for technical issues, but also for effective usage of the
limited budget. Thus, NTP will act to enhance these collaboration mechanisms in the current
national strategic plan.
3.2 Reducing stigma
The NTP has introduced the Afghan TB Patient Association, aiming at promoting TB-control
programs at community levels along with a pervading concept of human rights. As the results of
pilot activities, this intervention provided encouraging results in case notification and support to
ensure treatment (details are described in the section 3.2).One of the important factors of these
interventions is that they have helped to reduce rampant stigma in communities, which often
hampered interventions of the national strategic plan at community levels. Thus, NTP has come to
focus on reducing stigma and enhancing human rights to improve TB-control program, and several
interventions are included in the current plan for2014–2018.
4. Linkage to the national health strategy
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The MoPH strategic plan for2011–15 Annex F has been developed through a highly participatory
process . In addition to the active participation of a multi-stakeholder working group, a number of
consultations were carried out by the “new” planning team in the Strategic Planning Department.
Input was also invited and consensus built at a national workshop held in Kabul in December 2010,
from which the following ten strategic directions emerged:
These strategies of the TB-control program are linked to the national health strategy’s
strategic direction 3, strategic objective-3 (SO-3), and priority intervention 2.
Strategic directions:
1. Improve the nutritional status of the Afghan population
2. Strengthen human resource management and development
3. Increase equitable access to quality health services
4. Strengthen the stewardship role of MoPH and governance in the health sector
5. Improve health financing
6. Enhance evidence-based decision-making by establishing a culture that uses data for
improvement
7. Support regulation and standardization of the private sector to provide quality health
services
8. Support health promotion and community empowerment
9. Advocate for and promote healthy environments
10. Create an enabling environment for the production and availability of quality
pharmaceuticals.
Strategic objective-3 (SO-3): To increase the coverage of services to prevent and treat
communicable diseases and malnutrition
Priority interventions:
1. Expand and sustain the expanded program for immunization (EPI) coverage, with special
emphasis on hard-to-reach areas
2. Expand appropriate and effective interventions to combat TB, malaria, and HIV/AIDS
3. Support implementation of the Public Health Nutrition Strategy and Policy, 2009–13
4. Initiate and strengthen interventions for reducing demand-side barriers (e.g., health
education and community involvement)
5. Impact of health system strengthening (HSS) in the national health strategy on the TBcontrol program
The TB-control program is an important part of health-service delivery in Afghanistan, and it
integrated into the general health system, especially at the point-of-service delivery. The HSS in the
national health strategy has contributed substantially in various ways. As the TB-control program is
part of BPHS and EPHS, the HSS strategies to enhance the entire profile of BPHS and EPHS
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subsequently enhanced the TB-control program. These include developing health facilities in rural
areas and ensuring human resources such as community nurses, especially in distant areas. Also,
investment in laboratory infrastructure (expansion of laboratories in some BHCs, provision of
laboratory materials and equipment for regional reference labs) in the country level enhanced
diagnostic capacity of the TB-control program. Furthermore the HSS strategy has enhanced health
information system by increasing the routine use of health data, as well as integrating programs’
information systems (TB, malaria, and HIV) into the national HMIS.
6.TB/HIV collaborative mechanism
Although prevalence of HIV (0.01% in adult population, Afghanistan Health Fact Sheet 2014)
Annex 14 is low in Afghanistan, the HIV prevalence among TB patients is 0.2%; around 1,250
HIV-positive cases have been diagnosed in the country to date. NTP Afghanistan in collaboration
with NACP has started interventions to cope with TB/HIV co-infection. NTP and NACP developed
collaboration mechanisms by conducting working-group meetings. National policy, strategy, and
operational guidelines on TB/HIV have been developed. Also, the training curriculum was finalized
based on the guideline to train voluntary counseling and testing (VCT) staff and TB-center staff.
The referral system between TB and VCT centers was developed, and 10,033 TB cases in the highrisk groups were screened for HIV and 227 HIV cases were screened for TB, resulting in reporting
of 12 TB/HIV co-infected cases. However, still NTP and NACP need to enhance collaborative
mechanisms, especially for screening for both TB and HIV, including provision of IPT for those
cases.
7. Country process to review and revise the national strategic plan
For developing the current national strategic plan for 2014–18, NTP started to review the previous
strategic plan with all technical stakeholders in 2012. After careful review of the achievements and
constraints of the previous national strategic plan through SWOT analysis and the project-cycle
management method, NTP has determined a new national strategy for 2014–18. The technical
working group, including a member of the ex-patient association, mainly worked on drafting the
plan; after review by WHO or other technical partners, the national strategic plan was endorsed by
MoPH in early 2013. Thereafter, there were several opportunities, such as international workshops,
to review the plan and occasionally to make minor revisions. Also, the consultants from
international technical partners made extensive review; EPI assessment by country visits and
recommendations by them were incorporated in the final plan. The final version was endorsed in
January 2014 and has been approved by MoPH as the national strategic plan for2014–18.(Stop TB
partnership/community consultations.)
SECTION 2: FUNDING LANDSCAPE, ADDITIONALITY AND SUSTAINABILITY
To achieve lasting impact against the three diseases, financial commitments from
domestic sources must play a key role in a national strategy. Global Fund allocates
resources that are far from sufficient to address the full cost of a technically sound
program. It is therefore critical to assess how the funding requested fits within the overall
funding landscape and how the national government plans to commit increased resources
to the national disease program and health sector each year.
2.1 Overall Funding Landscape for Upcoming Implementation Period
In order to understand the overall funding landscape of the national program and how this
funding request fits within this, briefly describe:
a. The availability of funds for each program area and the source of such funding
(government and/or donor). Highlight any program areas that are adequately
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10 March 2014│ 17
resourced (and are therefore not included in the request to the Global Fund).
b. How the proposed Global Fund investment has leveraged other donor resources.
c. For program areas that have significant funding gaps, planned actions to address
these gaps.
a. During 2012 ~ 14, there have been a lot of sources for funding. For years 2012 and 2013, actual
expenditure of National TB Control Program (NTP) was reported US$ 14,432,719 (US$
1,325,752 by government, US$ 5,699,488 by external donors (WHO, JICA, TB CARE and TB
REACH) and US$ 7,407,479 by GF-R8 and R10) and the same years MOPH spent US$
88,825,100 as ordinary budget for its overall health expenditure. Allocated budget for year 2014
is US$ 7,139,864 to conduct National TB Control Program (NTP) activities (US$ 784,071 by
government, US$ 1,970,291 by external donors (WHO, JICA, TB CARE and TB REACH) and
US$ 4,385,502 by GFATM R8 and R10 funding, in 2012 the grant agreement of (grant #AFG012-G13-T) was signed and existed for 2 months in 2012. Despite this grant having such a short
lifespan, the amount of US$ 289,853 for AFG-012-G13-T was considered as past Global Fund
resources in this concept note, therefore the total past GFAMTM amount reached to US$
4,675,355and the same year MOPH allocated US $61,000,000 as ordinary budget for its overall
heath expenditure. The supported program areas by each funding source are summarized
below:
o
Government contribution: MoPH has mainly supported management cost (heating,
infrastructure, communication and transportation). Also, MOPH has supported
BPHS/EPHS, through donors’, support where TB control program has been included as the
component and certain amount of budget such as salaries of health facility staffs and
infrastructure of health facilities are supported by the cost for BPHS/EPHS. This budget for
BPHS/EPHS is not included into the expenditure here, as it is very difficult to estimate
proportion of allocated budget to TB control care services. (Roughly estimated, the
allocation is US$ 2.1 per a capita and yearly average of government resources towards
national strategic plan in current and previous years is US$ 703,274.

The World Health Organization(including Italian cooperation and the Canadian
International Cooperation Agency) has supported program-management cost (including
staff salaries); laboratory network; M&E; advocacy, communication and social
mobilization(ACSM); and research.

The Japan International Cooperation Agency has supported general capacity development
for program management, laboratory network (including culture and DST and molecular
diagnosis), MDR-TB, pediatric TB, PPM, ACSM, and research.

TB CARE has supported areas of M&E, operational research, ACSM, infection control,
community-based DOTS, and urban DOTS in Kabul.

TB REACH has supported contact management, active case findings for vulnerable
populations, including procurement of a digital X-ray machine.

The Stop TB Partnership–Global Drug Facility provided an emergency grant of about
USD$2 million for first-line drugs to cover those lost by the fire of the central warehouse.

The GFATM R8 and R10 programs have supported most of program areas, including
program management cost (including staff salary), all TB medicines, chemicals for sputumsmear examinations, external quality assurance (EQA), and training of health facility staff,
M&E, MDR-TB, pediatric TB, PPM, ACSM, and research.
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For the next three years (2015–17) a US$44,214,219 budget is proposed to cover the NTPplanned activities, based on the national strategic plan for 2014–18.

o
Government contribution to TB control program for the next three years (2015-2017)
covers US$ 2,908,693 (US$ 870,319 for 2015, US$ 966,054 for 2016 and US$
1,072,320 for 2017) to cover management cost in addition to the NSP proposed budget
and these annual amount corresponds to 18-27% of total funding request in this concept
note.
o
Government of Japan granted to pay US$ 12,000,000 to procure TB medicines (First
line drugs (FLDs) and Second line drugs (SLDs), lab-consumables (except sputum
caps, LED consumables and consumables for culture and DST), related capacity
building and supervisions, some small renovations/ rehabilitation of central and
provincial drug stocks and establishing drug information system (DMIS).For FLD,
about US$ 4.8 million shall be allocated and this will be enough to cover all cases
expected to be found with 25% buffer stocks. For SLD, US$ 2.7 million shall be
allocated and this will cover more than half of targets (Considering to avoid unspent
medicine, only limited amount of SLD, compared o the targets, were approved,). For
diagnostic kit (sputum smear examinations) and developing DMIS, 38,000 USD and
43,000 USD shall be allocated, respectively. Also, the budget for TA (one international
(60%) and one national expert) is included in this grant.
Other external funding partners have no commitment for years 2015–17 (to date).
Thus, about US$ 16,902,553 remains as the financial gap for implementing NTP-planned
activities; all program areas, except drug supply and drug management, remain unfunded.
In this Concept Note, US $12,402,973 (the full amount of indicative funding for years 2015–
2017) is requested to cover the most prioritized/vital activities among unfunded areas. This
amount covers the top priorities of TB-control activities.
Prioritization was done through following principals:

Interventions/activities that fill the programmatic gap, especially to increase case
notification(including MDR-TB), and have the potential of saving more lives

Interventions/activities that maintain the basic framework of the program, such as program
management, monitoring and evaluation, and human resource development.
Details for selected program areas and interventions are described in section 3.2.
b. Government has covered the cost of human resource development, infrastructure, maintenance
and operational costs; BPHS implementers have introduced-control activities in the field;
GFATM grants have covered the cost of the most crucial activities of TB-control program; and
NTP partners have covered the gaps of activities not covered by government. However, in the
coming three years, only the Japanese government has pledged to procure necessary TB drugs
and lab-consumables. Thus, although the government and BPHS implementers will cover the
above-mentioned areas, there exist significant funding gaps. As there is no pledge to cover these
gaps at this moment, NTP has to request the budget from the GFATM (the only funding source
at this moment) to cover basic interventions to maintain the framework of the program and
interventions with top priorities to achieve the targets in the national strategic plan’s
programmatic gaps analyzed by NTP and NTP partners. The table of this workshop is
summarized in Annex 15 XVII. The top and some of high prioritized activities that are not
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supported by government and other donors have been addressed to this Concept Note.
c.
For unfunded program areas and interventions (as described in section 3.2), MoPH will
continuously try to increase the budget allocation to the TB program. Possibly the US Agency
for International Development (USAID) and JICA will launch new technical cooperation
project in 2015, and MoPH/NTP will negotiate with those two donors to incorporate unfunded
interventions with high priority in the national strategic plan into the context of their projects.
2.2 Counterpart Financing Requirements
Complete the Financial Gap Analysis and Counterpart Financing Table (Table1).The
counterpart financing requirements are set forth in the Global Fund Eligibility and
Counterpart Financing Policy.
a. Indicate below whether the counterpart financing requirements have been met. If
not, provide a justification that includes actions planned during implementation to
reach compliance.
Counterpart Financing
Requirements
i. Availability of reliable
data to assess
compliance
ii. Minimum threshold
government contribution
to disease program (low
income-5%, lower lowermiddle income-20%,
upper lower-middle
income-40%, upper
middle income-60%)
Standard Concept Note Template
Compliant?
☐Yes
☐ Yes
☒ No
☒ No
If not, provide a brief
justification and planned
actions
There is no national disease
account in place ; a detailed
calculation per disease area
is not possible currently. The
programs and HSS with
close coordination of Health
Economics and Financing
Directorate (HEFD)/ MoPH
will work to provide reliable
data on the specific
contribution of the country
domestic resources for each
disease components and
HSS in long term programs
sustainability.
Afghanistan, health
expenditures may not be
categorized as domestic
funding, thus could not be
regarded as meeting the
counted as counterpart
financing requirement, as
they originate in large
extend from international
funding.
However, as most of the
funds originate from
international pooled funding,
the interpretation as
domestic funding is
inadequate.
10 March 2014│ 20
iii. Increasing government
contribution to disease
program
Though the amount seems
small, given the exceptional
economic and political crisis,
the weakened fiscal and
health budget outlook in
Afghanistan, and the fact
that major health funding
comes from international
donors, it is unlikely that
Afghanistan will meet the
WTP requirements in the
short/medium term.
☐ Yes
☒ No
However the application of
85% indicative budget rule
due to non-compliance to
WTP requirements may
affect the priorities that are
requested for funding under
the indicative funding, which
potentially affects the
achievement of major
program objectives as well
as impact.
b. Compared to previous years, what additional government investments are
committed to the national programs (TB and HIV) in the next implementation period
that counts towards accessing the willingness-to-pay allocation from the Global
Fund. Clearly specify the interventions or activities that are expected to be financed
by the additional government resources and indicate how realization of these
commitments will be tracked and reported.
c. Provide an assessment of the completeness and reliability of financial data
reported, including any assumptions and caveats associated with the figures.
b. Based on the plan of MoPH, total budget needed from ordinary budget for health sector for
the years of 2015 and 2016 are US$69,000,000 and US$78,000,000, respectively. Also, it is
expected that US$88,000,000 will be allocated in 2017. This indicates a 15% annual
increase as the average.
As discussed in the previous section, the government has plan to increase its expenditure to
the TB-control program by 11% annually, corresponding to the incremental increase of
overall expenditures .These amounts correspond to more than 18~27% of the requested
funding annually, and will continue to cover management cost (staff salaries, infrastructure,
communication, and transportation). They will also cover the management cost for
renovated hospitals for MDR-TB, which will be supported by this funding request.
c. A standard financial assessment tool was developed by the NTP central unit and was
circulated to all provincial TB coordinators to collect the government expenditure for the
TB-control program for the years 2012 – 2013 and the budget allocation for 2014. The data
was collected from below sources:
• Actual expenditure of the NTP central unit. All data were collected to fill the tool by NTP
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admin/finance section. The report is verified by the NTP manager, relevant MOPH
section, and the local funding agency.
• Actual expenditure of TB control at provincial levels. All necessary data were collected to
fill the tool, and thereafter the reports are verified by relevant department at provincial
level (finance unit) and approved by provincial health directorate (PHD).
• Overall government health expenditure for the years 2012–2013 allocated budget for 2014
and plan for 2015 –2017 reported by MoPH National Health Account. The reports were
verified by MOPH National Health Account and the local funding agency.
At the end, summary of information received from provinces including NTP central unit
were submitted to financial unit of MOPH for their approval.
Note: Government expenditures at the MoPH/NTP central unit and provincial levels
include followings; staff salaries, infrastructure (electricity or heating), communication,
transportation and stationary. For infrastructure at provincial levels, 10% of total
expenditure for related buildings was counted as expenditure to TB-control service.
• Other external health contribution (WHO, JICA, TB CARE1, and TB REACH) reported
by them. These were verified by their authorities accordingly.
• Expenditures by the GFATM R8 and R10 programs, reported by relevant principal
recipients (BRAC and JICA).These were verified by principal recipients and the local
funding agency as well.
SECTION 3: FUNDING REQUEST TO THE GLOBAL FUND
This section details the request for funding and how the investment is strategically
targeted to achieve greater impact on the disease and health systems .It requests an
analysis of the key programmatic gaps, which forms the basis upon which the request is
prioritized. The modular template (Table 3) organizes the request to clearly link the
selected modules of interventions to the goals and objectives of the program, and
associates these with indicators, targets, and costs.
3.1 Programmatic Gap Analysis
A programmatic gap analysis needs to be conducted for the three to six priority
modules within the applicant’s funding request.
Complete a programmatic gap table (Table2) detailing the quantifiable priority modules
within the applicant’s funding request. Ensure that the coverage levels for the priority
modules selected are consistent with the coverage targets in section D of the modular
template (Table3).
For any selected priority modules that are difficult to quantify (i.e. not service delivery
modules), explain the gaps, the types of activities in place, the populations or groups
involved, and the current funding sources and gaps.
1. Key modules
As described in section 1, NTP faces two major technical gaps: low TB case notification and
insufficient MDR-TB program management. Thus, by considering that these are prioritized areas
for funding, detailed programmatic gap analysis is done for the two modules (TB care and
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prevention—case detection and diagnosis and MDR-TB-case detection and diagnosis).
In both modules, for filling programmatic gaps by GFATM support (this means to achieve the
targets in the national strategic plan for 2014–18), to fill technical gaps including those based on
the epidemiological findings is crucial. Detailed explanations on technical gaps are described.
<MODULE: TB Care and prevention>
TB case detection and diagnosis
For low case detection, the epidemiological findings in section 1.1 indicate that the following
points be considered:
1. Generally, there low case detection all over the country with little geographical variations,
except in Kabul, the capital province, where the rate of case detection is even lower.
2. The highest numbers of TB cases are accumulated in cities and provinces with higher
populations.
3. There are seasonal variations in cases detection, with lower detection rates in winter due to
weather-impeded accessibility to health facilities.
4. There are key under-covered populations, especially:

People in hard-to-reach areas

IDPs, returnees, and prisoners

Children
In addition to these epidemiological findings, there are other important factors to be considered to
develop the programmatic interventions.
Suspect management in health facilities: Qualitative analysis of routine TB surveillance data and
findings from quarterly review workshops notify and generate hypotheses that approximately
higher number of undetected TB cases missed within the health system .For example, the
presumptive TB cases identification rate is only 2.4%, which should be up to 5% of outpatient
attendees. In 2013, in total 216,744 (2.4%) presumptive TB cases identified by health system out of
outpatient attendees and leaves a programmatic gap of unexamined presumptive TB cases of at
least 200,000.This is owing to a significant number of untrained health care workers, as only onethird of health care staff are trained on standard operating procedure for case detection and
treatment and there is a high turnover rate for front-line health care staff, especially in remote and
hard-to-reach areas. Addressing this challenge could lead to significant increases for TB-case
notification, especially pulmonary TB cases. Thus, the strategy to address this issue is providing
continuous opportunities for training on TB control, especially newly recruited staff in health
facilities.
Accessibility to diagnosis of TB: BHC, SHC, and health posts (at the community level) do not
have laboratory diagnostic facilities, which results in a large number of missed TB cases at these
levels. In total, there are 2,356 facilities of various types; of them, 1,100 (47%) are covered by
DOTS; thus, 1,256 facilities, mainly BHCs and SHCs, are still to be covered by DOTS. The
presumptive TB cases identified at BHC and SHC levels have to travel to the upper level of
comprehensive health centers or district hospitals for sputum-smear examinations or other types of
diagnosis, such as X-ray and TB/HIV screening. During this process, it is estimated that a
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significant number of presumptive TB cases, especially among people living in remote areas
(including nomads) become initial defaulters. Thus, strategies to address this challenge are
enhancement and improvement of the slide/sputum sending mechanism and engagement of
communities such as CHWs and patient association.
Insufficient contact management: Currently only passive management at health facilities is
conducted. In this intervention, index TB cases are asked to bring TB suspects among their family
members to health facilities.In 2013, 14,277 new infectious cases plus 2,269 previously treated
cases (16,546 sputum-smear positive) were notified; at least 99,276 individuals have contacted with
these infectious cases as the average number of household is 7. However, only 48,122 household
contacts (48.5%) were registered by this approach and 8,274 (80%) screened for tuberculosis.
Among screened people, 788 (9.5%) were diagnosed as active tuberculosis, and 390 (4.7%) were
diagnosed as pulmonary smear positive tuberculosis. The incidence for all types of TB among
contacts is 1.64%, and for smear-positive TB is 0.81%.During 2011, by the support of TB REACH
Wave 1, active household contact management was implemented in selected areas. In this
intervention, health facility staffs visited homes of index smear positive TB cases and directly
screened all family members. As a result, 16,145 household contacts were screened, and 822 TB
cases in all forms, including 606 sputum-smear positive cases, were found. This result indicates
that the incidence of all forms of TB among household contacts was about 5%.
Thus, it is strongly indicated that expanding active contact management through home visits could
increase case findings in early stages of the disease.
Missed cases in private sectors: According to research conducted in 2004, for 65% of patients the
first point of health-services contact is the private sector. Unfortunately, lack of recording and
reporting within private sectors resulted in not reporting TB cases to national program, and they
diagnosed and treated with non-recommended procedures. Thus, NTP has introduced PPM into 8
major provincial capitals that notified approximately 1,500 TB cases annually in 2013 and 2012.
The enhancement of this model will lead to increased TB-case notification and treatment
adherence.
For Kabul, the biggest city with dense population of more than 4million, in 2013, the total number
of TB cases notified was 3,548, which represents only 17% of all estimated cases. Urban DOTS
projects supported by TBCARE dramatically improved the situation, but still30% of facilities,
mainly private sectors, are not covered by DOTS in Kabul city. Thus, it is crucial to enhance urban
DOTS of which PPM is the main component.
Quality of laboratory network for sputum-smear examinations: Improving the quality of
established network for sputum-smear examinations is crucial. For this purpose, several efforts
should be made as there has been a high turnover rate for laboratory technicians, especially in
remote areas. Thus, in addition to conducting training on sputum-smear examinations for
laboratory technicians based on needs, enhancing quality-control mechanisms is crucial for better
diagnosis and subsequent increased case notification. For blind cross-checking for EQA, the
participation rate still remained around 70%. Percentages of poor laboratories declined to 15% in
2008, but thereafter increased up to around 20% in 2009–11. There still exists predominant high
false negative among major errors. Thus, it is crucial to improve performance of blind crosschecking. To scale up EQA, the NTP’s national reference laboratory has planned to conduct blind
cross-checking at the provincial level; this is currently conducted at the regional level. For this
purpose, the NTP’s national reference laboratory (NTP/NRL) conducted the operational research in
the central region and got favourable results in participant rate. Thereafter NTP/NRL has developed
a plan to introduce this new system to whole provinces. Based on this plan, NTP/NRL has started
training for assessors and cross-checkers in each province; by the end of 2014, NTP/NRL’s new
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system will be available in all provinces. Thus, it is crucial for NTP/NRL to maintain the newly
reformed EQA system.
Also, for sputum-smear examinations, WHO has strongly recommended replacing light
microscopes with LED microscopes; however, at this moment NTP/NRL distributed only ten LED
microscopes by support of TB CARE. Thus, it is also crucial to introduce more LED microscopes
into laboratories with high workloads.
Management of paediatric TB control: Children are defined as one of the under-covered
populations (see section 1). This is due largely to weak diagnostic capacity for pediatric TB,
because of at least two factors: (1) a shortage of skilled pediatricians or general practitioners in the
health facilities and (2) a lack or shortage of essential diagnostic tools, such X-rays and tuberculin
skin testing (TST). For proper diagnosis and management of TB among children, it is necessary to
provide essential diagnostic tools and train the existence health workers at the health-facility level.
For this purpose, to manage pediatric TB cases under integrated medical care, NTP developed a
standard operating procedure and diagnostic algorithm for pediatric TB. In this algorithm,
especially for children under five years old, both X-ray examinations and TST are mandated. Based
on this strategy, NTP conducted training on the management of pediatric TB for key health facility
staffs, including pediatric specialists in key hospitals in the country by support of the GFATM R10
program in 2012 and 2013. Simultaneously, NTP started to provide TST, also supported by
GFATM R10 program.
These measures have resulted in increased number of pediatric cases in 2013 (4,809 smear positive
cases and 3,181 other types of TB) compared to 2011 (4,206 and 1,989, respectively); however,
NTP still needs to enhance case notification of pediatric TB cases by introducing active case
findings in hospitals as a whole, since there are possibly TB suspects in departments other than
pediatric outpatient (such as nutrition). Also, NTP needs to provide adequate tools for diagnosis of
pediatric TB, which are not covered by BPHS/EPHS, such as TST. For X-ray examinations,
BPHS/EPHS have the responsibility to provide quality X-ray machines; but due to limited budgets,
most X-ray machines in public health facilities are old and cannot provide quality pictures. So,
NTP provided digital X-ray machines to three major provinces by support of the GFATM R10
program, JICA, and TBREACH; it would like to provide more. These may eventually result not
only in increased diagnostic capacity of TB, but also health system strengthening.
At the same time, NTP needs to strengthen the connections between the pediatric TB program and
other programs for the integrated management of childhood illness (IMCI) and reproductive,
maternal, newborn, and child health (RMNCH), as TB is often misclassified in children as
pneumonia, malnutrition, brucellosis, or some other infectious diseases.
For this purpose, the following interventions/activities are necessary

Coordination meeting with public nutrition, IMCI, and RMNCH programs

Updating current standard operating procedures for pediatric TB management based on the
latest WHO guidelines and integrated with public nutrition, IMCI, and RMNCH programs.

Conducting refresher training on revised standard operating procedures for pediatric TB
management
<MODULE:MDR-TB case notification and diagnosis>
As seen in the section 1, although NTP has successfully initiated the MDR-TB program, case
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notification of MDR-TB is far below the target. One of the main reasons for this gap is the limited
opportunity for MDR-TB diagnosis. To improve case notification, with support of the GFATM
R10 program, NTP has trained staff in health facilities on sample collection from MDR-TB
suspects—such as failure of category 1 and exposure to known MDR-TB cases, as defined in the
national guidelines (National Guidelines for the Management of Drug-Resistant Tuberculosis, p.
15) Annex 16 —and established sample transportation system from peripheral health facilities to
diagnostic centers for MDR-TB. However, at this moment, there are only three laboratories for
culture examination; another two laboratories are expected to start culture examinations. It is
expected that NRL can implement drug susceptibility testing as routine work soon, and yet
NTP/NRL still relies on the supranational reference laboratory, Agha Khan University. Thus, it is
crucial to improve and speed-up diagnostic procedures; a rapid molecular diagnostic system is
required in this regard with the maintenance of a nationwide sample collection/transportations
system. At the same time, NTP needs to enhance quality control on culture examinations with
support of the Agha Khan University.
For treatment of MDR-TB, up to now, NTP showed relatively good performance. (A total of 123
cases have been enrolled at the end of March 2014, and there are 27 cured cases and 39 cases in the
continuous phase with negative conversion. There are 13 death cases, 4 transfer-out cases, and 5
defaulters.) At this moment, NTP would focus on hospitalized care during the initial phase (at least
several months) to ensure treatment and better case management, while NTP plans to introduce
ambulatory care for the initial phase in the near future. For hospitalized treatment, there are only 56
beds in the newly constructed communicable disease hospital in Kabul, and NTP plans to provide
at least another 100 beds in five main provinces. This was planned previously, and the budget was
included in the GFATM R10 program; however, due to some administrative issues, the
construction and renovation of MDR-TB wards in five provinces were suspended.
For nearly two years, another crucial issue to providing adequate treatment has been the lack of
social welfare system. There is no social welfare system to support sick people, including MDRTB, in Afghanistan; as NTP has conducted ambulatory treatment in Kabul, patients shoulder a huge
cost for transportation that surpasses their monthly income. Thus, to launch the program
successfully and avoiding defaulters, JICA provided monetary patient support.
Thereafter, this support has been included in the GFATM R10 program (the extension period)
instead of support by JICA.
2. Other supporting modules
In addition to these two key modules, there are other important supporting modules. While
focusing on those two modules, simultaneously NTP needs to keep the basic framework of the
program and continue current important measures not only for case findings, but also for treatment
and prevention. These include areas of monitoring and evaluation and program management;
quantification of these modules is difficult, but as for the previous two modules, the programmatic
gaps in these areas are also nearly 100%. Explanations of these measures are addressed in two
supporting modules (HIS and M&E, program management) in this section.
<MODULE: HIS and M&E (routine reporting)>
Interventions in this supporting module regarding M&E that does not directly bring impacts on the
TB program, but are essential to concrete the framework of the program. NTP Afghanistan has
introduced an electronic information system (i.e., TBIS), but TBIS serves above the provincial
level, and the entire reporting system still relies on the older paper-based system. The electronic
reporting system (TBIS) was developed with assistance from USAID funded TB CAP and TB
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CARE I projects. Currently, this system is fully integrated into national HMIS and NTP with
assistance from TB CARE I and its follow on project (2015-2019) will continue its assistance with
NTP to maintain electronic reporting system. The coordination, training, supervisionand
monitoring of the system and periodic evaluation and data quality assessment will be assisted
through upcoming USAID TB project. HMIS unit of MOPH will ensure the sustainabilityof this
system along with national HMIS. For MDR TB patient NTP maintained an excell based nominal
recording that developed by NTP In these settings, quarterly review meetings at various levels play
key roles in adequate data collection, verifying quality and providing feedback to health facilities
(technical details to conduct those meetings are defined in the guideline [NTP, “Province Level of
Monitoring Event Guideline”]) Annex 17. These meetings have been implemented in all provinces
with support by the GFATM FundR8 program, resulting in significant reduction in missing data
and errors in reporting. Thus, it is crucial to continue these activities.
Supervisory visits to health facilities also play key roles not only in M&E, but also in improving
the quality of services of TB control; technical instructions for supervisory visits are defined in the
guideline as well[NTP, “Facility Level of Monitoring Event Guideline”] Annex 17.These
supervisory visits have also been supported largely by the GFATM R8 program.
To strengthen the surveillance system, research through several key surveys is necessary. As in the
national strategic plan, NTP would like to conduct a national prevalence survey; however, at this
moment and for the foreseeable future, this is not feasible due to the security situation. Thus, at
least, NTP needs to conduct alternatives such as capture-recapture study to obtain more accurate
incidence of TB cases. Also, an inventory survey is required to evaluate the current surveillance
system. The drug resistance survey was conducted in 2010, but in only limited regions, and a
nationwide survey is necessary to obtain full estimates of the MDR-TB burden. To improve the
quality of the program, several operational researches should also be done based on the needs
assessment.
<MODLE: Program management>
While the government of Afghanistan is increasing its expenditure for the health sector, NTP (like
other programs or departments) has little budget for providing basic management costs such as
consumables for office work or basic communications, resulting in hampering the performance of
NTP program management. Thus, in the GFAMT R10 program, the budget to support basic
management was incorporated. This includes the cost for providing IT equipment, Internet
maintenance and communication fee, etc. Also the government of Afghanistan is increasing its
staff salary scales by the support of the World Bank; still MOPH needs to budget for salary to
ensure its key staff with a decent livelihood. The GFATMR8 program has been supporting salaries
to NTP staffs at the central and provincial levels.
Although there is some progress in the government expenditure, there is no significant change in
the situation mentioned above; support for these areas shall be continued in the next funding
request by the GFATM.
3. Cross-cutting issues to fill programmatic gaps
In addition to those areas for programmatic gaps, there are important issues that also affect the
quality of the entire program. These concern gender issue and human rights, and are considered as
cross-cutting issues to define the strategic overview and select interventions.
Gender issue: As noted in section 1, there is a marked predominance of TB cases for females,
especially for women at reproductive ages. Therefore, NTP prioritized activities to reach women in
various ways as planned in the national strategic plan. The purpose of intervention for the gender
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issue is not to enhance case detection, but to decrease the burden of TB among females, although
efforts to increase case detection among females will be done in a comprehensive manner common
to those for males. Based on the results of the two surveys, and given the susceptibility of women
of childbearing ages, it is highly possible that reproductive factors such as early age marriage or
short birth interval might be important risk factors to developing TB among females. There are also
other risk factors, including nutrition and cultural issues such as limited morbidity and decisionmaking for females, but it is difficult to address these in the short term, and a multi-sectorial
approach is necessary. However, immediate actions should be taken to reduce the burden of TB
among females; NTP would start to conduct training on TB risks among pregnant female for
midwives and gynecological doctors for prevention and early diagnosis in collaboration with the
reproductive health department of MOPH. This content shall be included in routine training
curricula for pre-service and in-service training for midwives and gynecological doctors. For other
interventions, defined in the national strategic plan, contact management among females will be
done in the comprehensive manner of the contact management and activities to increase
community awareness regarding reproductive health factors as risk factors will be done in line with
comprehensive awareness activities.
For creating direct impact to female predominance, NTP has started to discuss the feasibility of
isoniazid preventive therapy (IPT) for females at high risk regarding reproductive health. As
described before, the recently conducted surveys indicated that reproductive factors such as early
age marriage, high fertility rate, or short-term birth intervals might be important risk factors for
females to develop TB, although malnutrition or other factors might also be responsible for this.
The surveys indicated that significant number of pregnant females develop TB within
6~12monthsafter delivery. This condition may provide the possibility of IPT for high-risk female
after delivery, although further discussion is required. Thus, with intensive discussion with
technical partners, NTP will develop plans of piloting of IPT in several provinces with extremely
high predominance of female cases.
Human rights: The concept of human rights is not pervasive in Afghanistan. This is not only in
the field of the TB-control program, but in the entire social sector. In the health sector, few health
facility staff can understand the concept of medical ethics, and the human rights of patients are not
respected. Also, there is very limited social support for patients with chronic illness or disabled
patients. Thus, necessary actions should be taken to enhance human rights through a multisectorial
approach, but possible measures in the field of TB-control program should also be initiated.
3.2 Applicant Funding Request
Provide a strategic overview of the applicant’s funding request to the Global Fund,
including both the proposed investment of the allocation amount and the request above
this amount. Describe how it addresses the gaps and constraints described in questions
1, 2 and 3.1. If the Global Fund is supporting existing programs, explain how they will be
adapted to maximize impact.
1. Strategy of funding request
To achieve the overall goal of the current national strategic plan for 2014–18, the main technical
gaps exist in insufficient case finding and weak management of MDR-TB program, as described in
sections 1 and 3.1.Thus, this Concept Note presents a funding request for interventions and
activities to address these gaps while maintaining the basic essential framework of the TB-control
program.
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Since there are huge financial gaps, as described in section 2, those interventions and activities that
have potential to bring maximum outcome were selected based on the previous achievement. At the
same time, measures to detect cases in the early stages have priority for reducing TB mortality,
which is the goal of the current plan. Also, concepts of gender and human rights were considered as
important factors.
Thus, among three core modules and four supportive modules, the requests are made for
intervention in two key modules (TB care and prevention, and MDR-TB) and two supporting
modules (M&E and program management).
Among the module for TB care and prevention, “treatment and prevention” is an important area,
but the programmatic gap of this area is very limited, as described below, and there is no standalone funding request in the intervention of “treatment.”
All first- and second-line medicines, including those for prophylactic use and laboratory kit for
sputum-smear examinations, shall be covered for three years (2015–17 Funding Proposal for Japan
Government) Annex 18 by the grant-aid assistance by the government of Japan. The planned
amount of procurement can cover estimated new cases as in the target of this Concept Note.
To ensure and maintain current treatment outcome, several measures should be taken. For
uninterrupted provision of medicine and reagents, capacity development of related staff on drug
management is crucial, and the plans to introduce an electronic drug management system and to
train related staff in drug management are included in the grant-aid support by the government of
Japan.
In addition to the uninterrupted supply of medicine, NTP Afghanistan ensures the strategies to
maintain and improve higher treatment success rate. These include implementation of communitybased DOTS, especially in rural areas, and strengthening TB patients association, in both urban and
rural areas (detailed description regarding these two interventions are described
subsequently).Also, other measures such as training of health staffs and supervisory visits to health
facilities are crucial to maintain current treatment outcome. The budget for all these interventions is
included in this funding request in the related areas in the other modules. The budget to maintain
health facilities that provide TB-control programs is covered by the government and donor support.
This is the same for “prevention,” and budget such as for ITP is included in the related areas.
Among three core modules, no funding request shall be made for TB/HIV. Although there exist
significant technical gaps, as indicated in the section 1.2, the total amount of the necessary budget
is little, and NTP can find other resources for funding, in collaboration with NACP.
<Coordination and integration among three programs and HSS for interventions at primary health
care facilities>
There is integration and coordination mechanisms among three programs at health facilities, and
these mechanisms work to reduce cost for program implementation for each other and subsequently
to reduce the funding request of this Concept Note.
According to the Afghan health system, all activities for three programs such as TB, HIV and
malaria are integrated into the general health system (i.e., BPHS) Annex 19. All these activities are
conducted under one roof at health facilities, especially in primary health care facilities, all over
Afghanistan. There is one microscope and a laboratory technician at each health facility supported
by BPHS to conduct test for malaria and TB. Thus, the collaborative activities could result in
reducing the cost of a laboratory system at the health-facility level. In addition, HIV testing is also
conducted at primary health care facilities. This could result in improved testing and screening of
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10 March 2014│ 29
TB patients for HIV (and vice versa) at the primary health care facility level.
Health system strengthening is a cross-cutting issue that benefits all three programs. For instance,
the reference laboratory system assists malaria and HIV programs with complicated testing, while
the TB program has reference laboratories in different settings due to infection control. Also, HSS
could integrate the case notification standard operation procedure for case detection of all three
programs into its curriculum to teach community midwifery and nursing education that will help all
three programs in case notification of tuberculosis, HIV, and malaria at the health-facility level.
<Strategic overview on TB case notification and diagnosis>
Based on the epidemiological findings and other important technical constraints in the section 3.1,
following strategic directions are taken in this Concept Note to define the interventions and
activities for funding request.
Enhancing case detection by:
1.
Strengthening PPM and urban DOTS in Kabul.
2.
Enhancing contact management.
3.
Enhancing suspect management in all clinics and hospitals.
4.
Improving accessibility in remote areas and in winter.
5.
Enhancing active case findings among key affected (under-covered) populations.
6.
Improving diagnosis and management of paediatric TB cases through integration of paediatric
TB control intoIMCI and RMNCH.
7.
Enhancing the quality of laboratory network, including introduction of LED microscopes.
8.
Decreasing stigma and introducing concepts of human rights.
Thus, the selected activities based on this strategic overview are classified into the six interventions
under the module of “TB care and prevention” as follows.
<MODULE: TB care and prevention>
1.1 Case detection and diagnosis

Improving accessibility for TB diagnosis through conduction of slide/sputum sending
system

Strengthening EQA for enhancing quality of sputum-smear examinations

Procurement of LED microscopes

Conducting screening/triage for child TB suspects in hospitals

Procurement of TST
1.2 Key affected populations
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
Introducing active case finding among IDPs

Introducing active case finding among prisoners

Introducing active case finding among household contacts
1.3 Engaging all care providers
 Expanding PPM-DOTS into other big cities and enhancing existing PPM, including urban
DOTS in Kabul city
1.4 Community TB care and prevention
 Expansion of community DOTS supported by community health workers
 Expanding the TB Patient Association
 Introducing the concept of the patient charter
 Conducting awareness activities
1.5 Collaborative activities with other programs
 Improving coordination and collaboration with reproductive departments at the national
and provincial levels
 Introducing IPT to high-risk pregnant female
1.6 Others
 Training on health care providers
 Printing and distribution of the package of NTP documents (guidelines, standard operating
procedures, training materials, etc.)
<MODULE: Strategic overview on MDR-TB case notification and diagnosis>
At this moment, special epidemiological characteristics in low case detection are unclear, as the
MDR-TB control program has been just initiated. The following strategic directions, which are
generally to develop the system for diagnosis and treatment for MDR-TB, are taken in this Concept
Note to define the interventions based on the general situation analysis on the MDR-TB control
program. In this module, interventions regarding treatment are necessarily included, as the MDRTB control program still needs to develop an adequate treatment system. While NTP aims at
developing collaboration mechanisms with private sectors and civil service organization on MDRTB management, especially for case notification, during these three years, NTP focuses on
establishing good program management in public sectors. If possible, NTP shall involve private
sectors in Kabul city for case notification as a part of the urban DOTS project.
Enhancing case detection by:

Enhancing diagnostic network on MDR-TB including rapid diagnostic methods
Preparing adequate treatment system by:

Providing MDR-TB wards to for hospitalized treatment in the initial phase

Providing social welfare for MDR-TB patients
Thus, the selected activities based on this strategic overview are classified into the interventions
under this module as follows.
2.1 Case detection and diagnosis of MDR-TB
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
Establishing and maintaining sample transportation system for MDR-diagnosis

Procurement consumables for culture examinations and DST

Enhancing quality control of culture examinations and DST

Introducing GeneXpert with diagnostic kits
2.2 Treatment
 Renovation of TB wards for treatment of MDR-TB cases in five provinces

Providing living support for MDR-TB patients
<MODULE: Strategic Overview on HIS and M&E (routine reporting)>
As described in section 3.1, it is crucial to maintain the current HIS and M&E system; quarterly
review meetings at provincial and national levels and supervisory visits are key activities for this
purpose. Also, operational research to improve quality of the TB-control program is required, based
on the needs.
Ensuring the M&E mechanism, including routine reporting and surveillance by:

Sustaining the M&E system by conducting quarterly review meetings and supervisory
visits at various levels

Conducting necessary operational researches or surveys(inventory survey, DRS, female)
Thus, the selected activities based on this strategic overview are classified into the interventions
under this module as follows.
3. HIS & M&E
3.1 Routine reporting
 Revision of record and reporting forms

Conducting quarterly meetings

Conducting supervisory visits
3.2 Survey/operational research
 Conducting operational researches or surveys to strengthening surveillance system
<MODULE: Program management>
4. Program management
As in section 3.1, while the government of Afghanistan is increasing its expenditure for the health
sector (as for other programs or departments), there has been little improvement and support for
staff salary incentives and areas for good communications is still necessary for NTP as in the
previous funding programs by the GFATM as the cost for program management in addition to
routine grant management cost.
4.1 Policy, planning, coordination and management

Staff salaries at National and provincial level, the staffs salaries will be adjusted based on
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National Technical Assistance (NTA) Remuneration policy

Routine operational cost for NTP, including provision of IT equipment and other
communication materials
4.2 Grant management
 Principal recipient management cost

Mid-term review for the national strategic plan (30,000)
The following major interventions/activities are not included in this funding request due to
relatively low priorities:

Human resource development:
o
Introduction of TB program into pre-service education curriculum
o
Evaluation of training courses, including post-training monitoring
o
Introduction of competency assessment
o
Refresher training for several targets

M&E: Introduction of electronic system for supervisory checklists

Laboratory network: Introduction of liquid culture and DST by line-probe assay

Conducting the National Prevalence Survey
The following major interventions/activities are not included as supports by other donors are
expected:

Expansion of mechanisms for TB infection control

TB/HIV

Urban DOTS in Kabul and its extension
Also, there are several interventions/activities that are included with significant reduction of
quantity, such as ACSM activities.
3.3 Modular Template
Complete the modular template (Table3).To accompany the modular template, for both the
allocation amount and the request above this amount, briefly:
a. Explain the rationale for the selection and prioritization of modules and
interventions.
b. Describe the expected impact and outcomes, referring to evidence of effectiveness
of the interventions being proposed. Highlight the additional gains expected from
the funding requested above the allocation amount.
The rationale for the selection and prioritization of modules and interventions are described in
section 3.2. Following is a summary of the results:
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10 March 2014│ 33

Among three core modules and four supportive modules, no funding request shall be made in
TB/HIV.

No stand-alone requested budget for interventions for TB care and prevention: treatment and
prevention in the module of TB care and prevention.
The expected outcome of activities under the selected interventions and their rationale areas
follows, with brief explanation of budgeting.
1. TB care and prevention
1.1Case detection and diagnosis

Conducting slide/sputum sending systems
This intervention has been introduced by support of JICA and the GFATM R10 program to
improve accessibility to TB diagnosis for people living in hard-to-reach areas, including
nomads. NTP Afghanistan has gradually introduced this system in 23 provinces. For the other
11 provinces, NTP did not plan to introduce this system for several reasons, which include
geographical difficulties or few numbers of basic health facilities without laboratories. After the
introduction to 23 provinces, around 200 smear-positive TB cases per quarter were found.
Although counter-factual effect should be considered, this system could work to improve
suspect management in remote areas where a significant proportion of TB suspects defaulted
before receiving diagnostic examinations. Given that 30% of TB suspects are missing, 60 smear
positive TB cases per quarter (240 per year) are found by this intervention as the additional
gain. Also, this system could work to reduce the financial burden on poor people in remote
areas to access TB diagnosis. Thus, NTP plans to continue this system; but considering huge
cost to manage this system, NTP has revised the implementation strategy of and reduced the
number of health facilities for slide/sputum sending systems, which are more costly to manage.
Briefly, this system will be continued in 20 provinces excluding three provinces with low
performance, and the slide sending system will be continued in six provinces with significant
hard-to-reach areas and severe weather conditions in winter.
Thus, the budget request for this activity includes the operational cost of this system—mainly
the transportation cost for slide/sample sending and the management cost, including training in
case of staff turnover.

Strengthening EQA for enhancing quality of sputum-smear examinations
EQA has been implemented countrywide through blind cross-checking and subsequent
supervision and trainings based on the results of EQA. However, participants rate for blind
cross-checking still remain around 70%, and the percentage of poor laboratories also remains
around 20%. There still exists predominant high false negative among major errors. Thus, it is
crucial to improve performance of blind cross-checking to increase case notification, and
explained in section 3.1. For this purpose, based on the results of the operational research,
NTP/NRL has shifted blind cross-checking to provincial levels from regional levels in 2014.
Thus, the requested budget for EQA is to maintain this revised EQA system, including an
honorarium for cross-checkers and urgent supervision for EQA and microscopes for cross
checkers. Slide collection shall be done in the quarterly meetings.

Procurement of LED microscopes. NTP plans to introduce 50more LED microscopes to
laboratories with high workload, and the budget for procurement of microscopes with
reagent and training on staffs are requested. (Procurement of sputum cups is classified into
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this intervention based on the convenience of the budgeting.)

Conducting screening/triage for child TB suspects in hospitals

Procurement of TST

Procurement of digital X-ray machines
This activity aims to enhance the diagnostic capacity for pediatric TB cases. As explained in
section 3.1, there has been certain progress in pediatric TB management by the introduction of
standard operating procedure for training and utilization of TST, but NTP needs to introduce
more active measures to find child TB cases. For this purpose NTP will introduce screening in
hospitals as a new intervention. NTP Afghanistan will recruit one staff member in provincial
and district hospitals to screen and triage TB suspects not only in pediatric OPD, but also in all
related OPD, such as EPI and nutrition departments. This intervention has been initiated
recently in the children’s hospital in Kabul by support of TBREACH, and early results with the
combination of introducing digital X-ray machine were encouraging, though there has been no
official report yet.
Preliminary experiences of utilizing digital X-ray machines in Nangarhar and Kabul have
resulted in increased case notification, especially for pediatric cases (no official report is
available at this moment), indicating necessity of quality X-ray pictures. Thus, NTP plans to
provide two more digital X-ray machines to Maiwand hospital in Kabul, which has a large
pediatric OPD, and Herat regional hospital.
NTP Afghanistan will conduct the following interventions to integrate with IMCI and RMNCH
only through the support of other donors such as USAID and JICA, as these will work only
indirectly to increase case notification.

Coordination meetings with public nutrition, IMCI, and RMNCH programs; establishment
consultative committees in each hospital for diagnosis and management of pediatric TB
cases.

Updating current standard operating procedures for childhood TB management based on
the latest WHO guidelines and integrated with public nutrition, IMCI, and RMNCH.

Conducting refresher training on revised standard operating procedures of pediatric TB
management
Thus, the requested budget includes the cost for incentives to hospital staffs (one per hospital)
for screening/triage of childhood TB suspects and uninterrupted provision of TST and two
digital X-ray machines(with maintenance).
1.2 Key affected populations

Introducing active case findings among IDPs
Under TB REACH Wave 1 in 2011, NTP along with partners has initiated active TB case
finding among IDPs by designated mobile teams in eight provinces. In these activities, sputumsmear examinations after verbal interviews to identify TB suspects were the routine diagnostic
method. As the result, among about 220,000 IDPs, 5,139 suspects were found, and
subsequently 358 smear-positive TB cases were identified. This intervention identified twotimes higher amounts of TB cases among this group of population than the general population.
Also, by a similar concurrent intervention among 22,463 IDPs (utilizing a mobile digital X-ray
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unit in Nangarhar in 2012), 848 TB suspects were found, and subsequently 41 TB cases in all
forms were identified. These results also indicate considerably higher incidence of TB in all
forms among IDPs.
However, these interventions to utilize the mobile teams are not cost effective to screen the
general population, considering the number of TB cases detected. Thus, NTP will change the
methodology to screen IDPs through less costly means.
There are around 570,000 conflict-induced IDPs and 7,000 natural-disaster induced IDPs in
whole country (UNCHR Global Report 2012). According to UNHCR data, the majority of IDPs
accumulated in large camps in several provinces: Herat (106,000), Kandahar (46,000),
Nangarhar (70,000), Helmand (99,000), and Kabul (20,000). Thus, NTP will focus on these
five provinces.
In these five provinces, NTP will recruit one staff member in the provincial hospitals to manage
screening of IDPs. They will further recruit staffs inside the camps and train them to conduct
health education and to encourage TB suspects to visit health facilities as ordinary CHW in
rural areas. The number of staff in camps depends on the size of the camp, but as the average
one staffs per a 5,000 population will be recruited.
The expected numbers of TB cases detected by this intervention are listed in table 3.
Table 3. Expected Detection of TB Cases by Screening of Internally Displaced Persons in
Five Provincial Hospitals
Provinces
Total No.
of IDPs
Targets to Be
Covered in 2015
Targets to Be
Covered in 2016
Targets to Be
Covered in 2017
Kabul
20,000
18,000
18,000
18,000 (90%)
Nangarhar
70,000
63,000
63,000
63,000(90%)
106, 000
30,000
70,000
90,000(90%)
Kandahar##
46,000
0
10,000
20,000(44%)
Helmand##
99,000
0
20,000
40,000 (40%)
Total
341,000
111,000
18,1000
23,1000 (68%)
Heart
Expected TB cases
220
360
460
of all forms#
#The incidence is estimated as 0.2% as the minimum based on the previous experiences described above.
## Targets in Helmand and Kandahar are set at the low level due to security constraints.
The requested budget includes incentives to staff to manage the interventions, cost for initial
training for recruited CHW and incentives for CHWs.
There have been several large natural disasters in recent years; among them, severe flooding
often created huge numbers of IDPs, especially in spring and summer, resulting in an epidemic
of TB among IDPs. Thus, NTP will conduct urgent screening in this regard by utilizing existing
staff. Budget for these screenings is included.

Introducing active case findings among prisoners:
Through TB REACH Wave 1 in 2011, NTP along with the partner has initiated active TB case
finding among prisoners in eight provinces and among 3,000 prisoners,233 (8%) were
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identified as TB suspects and finally 5 (1%) were diagnosed as smear positive TB cases. Also,
current similar interventions in Nangarhar by utilizing a mobile digital X-ray unit, totally 18 all
form of TB cases, including extra-pulmonary TB and smear negative were found among 1,783
prisoners (1%). These findings clearly indicate the extremely high incidence of TB among
prisoners compared to general population and encourage to expand for further case notification.
There are around 30,000 prisoners in the entire country (Afghanistan 2013 Human Rights
Report) Annex 20.NTP Afghanistan will focus on the larger prisons, such as Kabul (8,000),
Nangarhar (1,500), Herat (3.500), Kandahar (3,500), Balkh (2,000), Kunduz (2,000), and Baghlan
(2,000). The total expected prisoners are 22,500.In other prisons, there are fewer prisoners, who are
incarcerated for shorter periods and are thereafter forwarded to other prisons or released.
In each prison, a team consisting at least two staff from provincial hospitals will visit three
times per a month, on average, and conduct screening for prisoners by collaboration with staff
in prison clinics. Sputum samples from TB suspects will be transported to provincial hospital
for examinations. In Kabul and Nangarhar prisons, mobile digital X-ray facilities will be
utilized for screening.
Throughout this intervention, NTP will train staff in prison clinics to develop a screening
system for incoming prisoners to enhance efficiency of screening.
Thus, it is expected that about 20,000 prisoners will be screened every year in the funding
period and that 200 TB cases will be found as additional cases.
The requested budget includes operational cost for this screening such as per-diem and
transportation cost for staff to visit prisons.
Note: For active case findings among returnees, the budget is not requested in this Concept
Note, considering the relatively small number of TB cases detected.

Introducing active case findings in household contacts
For contact management, as described in the section 3.1, currently only passive management at
health facilities is conducted, and introduction of active contact management by home visits
required for enhancing case findings in the early stages of disease. Thus, NTP will start home
visits for contact management, and it is expected that health facilities will make two visits per
month and as the average 144 contact, as the average, will be directly screened per a health
facility per a year with the assumption of average number of family members as 7.This
intervention will be applied to all 34 provinces, and it is planned to involve at least 400 TB
diagnostic centers in 2015, 600 in 2016, and 800 in 2017, including some TB treatment centers.
For the incidence of TB among household contacts, the results of passive contact management
in 2013 showed 1.6% for all forms of TB and 0.8% of smear-positive TB, while active contact
management in 2011 revealed 1.6% as the incidence for smear-positive TB cases (268 cases
among 16,645 contacts). Considering the feasibility, the estimation of additional TB cases, in
table 4, is presented using incidence of all forms of TB and smear-positive TB as 2% and 1%,
respectively.
Table 4. Additional TB Cases among Household Contacts
Criteria
2015
2016
2017
No. of health facilities (HFs) conduct contact management*
400
600
800
No. of contacts screened
57,600
86,400
115,200
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Incidence of all TB cases among contacts
2%
2%
2%
No. of all TB cases
1,152
1,720
2,304
Incidence of sputum smear positive TB cases
1%
1%
1%
No. of sputum smear positive TB cases
576
864
1,152
The requested budget includes per-diem and transportation cost for health facility staffs to visit
homes of index cases.
1.3 Engaging all care providers

Expanding PPM-DOTS into other big cities and enhancing existing PPM, including urban
DOTS in Kabul city
As in the national strategic plan and previous sections, NTP expanded PPM into capital cities in
eight provinces, resulting in finding about 3,500 TB cases yearly through referrals from private
practitioners. In addition to expansion of PPM in these eight provinces, urban DOTS in Kabul
have been implemented. This brought significant results in case finding (from 1,934 in 2009 to
3,555 in 2013). For other areas, it is difficult to estimate how many of these cases were
diagnosed as additional cases due to counterfactual effect, but early data suggest that introduced
PPM in Balkh resulted in 10% increase of total TB cases in the related area. Thus, it might be
estimated that among 3,500 notified cases through PPM about 350 cases are considered as
additional cases by this intervention.
Now, NTP plans to expand to another seven provinces (Kandahar, Takhar, Kunduz,
Badakhshan, Parwan, Baghlan, and Faryab). Considering several conditions, including
population of the capital city, more than 1,000,000 populations will be covered by PPM
expansion. Thus, a total of 5,808,000 population in these 16 provincial capitals will be covered
by PPM.(This number represents only people living within capital cities and more populations
will be covered in actuality.)It is expected that around 3,000 TB cases in all forms will be
notified through PPM in these 15 provincial capitals (although Kabul and about 300 cases
might be counted as additional cases to the current case notification through PPM). Also,
incremental increases of notified cases might be expected in Kabul by scaling up urban DOTS.
At the same time, it is essential to increase the participation rate in provinces where PPM has
been already introduced and to enhance M&E mechanism on the PPM program.
Thus, the requested budget includes cost for expansion in remaining provinces and scaling-up
in provinces where PPM is already in place, including urban DOTS in Kabul such as cost for
training for private practitioners, pharmacists and laboratory technicians for expansion to new
provinces and scaling-up in ongoing provinces including urban DOTS in Kabul and cost for
M&E to conduct regular workshops for M&E and recruit one focal point in a province to
manage and monitor activities by PPM.
1.4 Community TB care and prevention
As the assessment of key affected population indicated, generally, current ACSM activities utilizing
mass media are not effective, and high incidence of illiteracy among poor and rural populations
hinders acquiring adequate knowledge for TB. Thus, approaches to deliver messages and
knowledge directly to key affected populations are required. Thus, NTP will enhance community
approaches in these regards.
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
Expanding community DOTS supported by CHWs
Roles of CHWs are very important not only in case finding and treatment support, but also in
mitigating the barriers for females to access health service, especially in rural areas as described
in the section1. Thus, NTP has promoted community DOTS by support of the GFATM R8
program USAID funded TBCAP and and TBCARE I projects. The supported budget both from
GFATM and USAID has covered the cost for training of CHW and CHS and monetary
incentives on case findings and treatment support for CHW. According to data from six
selected provinces, Jowzjan, Herat, Bahghlan, Takhar, Badakhshan and Faryab, 1,482 and
1,089 cases were notified by CHW in 2012 and 2013, respectively. In 2013, nearly 7,000 CHW
received monetary incentives for case finding and treatment support in aforementioned six 4
provinces and rest of country through GF R 8 and USAID. As a result, for example, treatment
cure rate among those TB patients who received their DOT from CHWs (community DOTS)
were 96%, compared to 87% among those who received facility-based DOTS (“Identifying the
contribution of community health workers to the treatment outcome of Tuberculosis patients in
four provinces of Afghanistan, 2010, P.S88) Annex 21.
Based on these encouraging results, NTP and partners will expand this intervention to all
provinces in the same manner, and only the budget for incentives for CHWs is requested, given
that NTP and partners have finished training on CHW by GFATM R8 support.

Expanding the Afghan TB Patient Association (introduction of the patient charter)
The Afghan TB Patient Association was established as a profiting organization that implements
activities previously supported by WHO/Canadian International Cooperation Agency in
December 2009 and gradually expanded into provinces (Kabul, Parwan, MaidanWardak,
Bamiyan, Ghor, Daikundi, Takhar, and Herat).This association has been working with a set of
following objectives.
o
Establishment of relation between patient and HF.
o
o
o
o
Strengthening of patient care according to international standards.
To promote patients’ rights.
Establishing strong coordination mechanism in community to fight against TB.
Ensure that every Afghan TB patient has access to effective diagnosis, treatment and
cure
To refer patient from community to health facilities.
o
By this association, up to now, a total of 5,122 TB suspect cases have been referred, 427
sputum-smear positive cases have been notified, and also 468 TB cases have been supported for
their DOT by members of the association. Although counterfactual effect should be considered
and actual additional case notification is not clear, it is judged that activities by this association
could make a significant impact on TB cases management at the community level. Also, this
association might work to reduce stigma at the community. Thus, NTP and partners plan to
expand this intervention to another four provinces with significantly bigger populations
(Nangarhar, Kandahar, Balkh, and Lagman), considering feasibility. In these 12 provinces, NTP
plans to recruit enough ex-patients to cover most districts. Also, NTP plans to introduce the
concept of the patient charter not only in these 12 provinces, but also in other 22 provinces
through training of health-facility staff.
The budget request for this intervention includes cost for training/workshops to establish the
association in other 26 provinces and the training of health-facility staff on the patient charter.
Also, to increase community awareness, including gender issues, the budget to develop
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materials used by CHW or ex-patients and the cost for some campaigns is included.

Conducting awareness activities
These activities are important to increase awareness for TB and reduce stigma among the
general population. However, effectiveness and impact by most approaches have not
thoroughly evaluated. Some of these activities have been conducted with the design to evaluate
effect by JICA, such as involvement of religious leaders, teachers, and community committee
leaders in Nangarhar and Panshijir provinces with significant effects on changing knowledge
and subsequent case notification (here is no published document on this). Thus, NTP plans
these kinds of activities, including concept of the patient charter in addition to awareness
activities on World TB day or some special campaign.
The requested budget includes cost for these activities and cost for developing materials for
these purposes.
1.5 Collaborative activities with other programs

Improving coordination and collaboration with reproductive departments at the national and
provincial levels

Introducing IPT to high-risk pregnant females
As described in the section 3.1, NTP would like to start immediate measures to reduce the
burden of TB among females. Among several activities, the requested budget in this
intervention includes the cost to improve coordination mechanisms with the reproductive
department at the national and provincial levels. For preventive therapy for females with high
risks regarding reproductive health, NTP will conduct pilots in several provinces to prove the
effectiveness of these interventions within these three years, and the budget for this is also
included in this Concept Note.
For other interventions, the budget is not included for following reasons: contact management
among females will be done in the comprehensive manner of the contact management; training
of midwives and gynecological doctors on reproductive risk factors for TB will be incorporated
into the current curricula in collaboration with reproductive health department and information;
education; and communication materials will be developed by the budget of conducting
community awareness.
1.6 Others

Training of health facility staffs
As mentioned in section 3.1, remediating suspect training of health facility staffs is crucial to
acquire proper knowledge on TB and standard operating procedures for case management.
Also, training of laboratory technicians is essential to maintain capacity of diagnosis by
sputum-smear examinations.
Thus, the requested budget includes cost for training doctors, nurses, and laboratory technicians
in health facilities. The requested budget will cover minimum numbers of training courses,
considering high turnover rate of staff. This budget can cover two trainings for eight regions in
the country per year (i.e., 16 trainings total) for each category. These batches will focus on the
newly recruited staff (due to staff turnover), and all new contents such as gender, pediatric TB,
and the patient charter will be included. It is assumed that 20 persons will participate per batch.
These may result in training ten staff members in each province every year for each category,
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which is enough to cover turnover of staff on average.

Printing and distribution of the guidelines, standard operating procedures, training
materials, etc.
NTP has provided all necessary documents such as the guidelines and standard operating
procedures to all health facilities as the DOTS packages so that all-important documents are
easily reviewed by all health care staff. NTP would like to continue the distribution of these
packages as some procedures or guidelines must be revised according to international
standards.
In summary, during year one, 2,500 additional cases will be found, compared to the baseline,
and 500 additional cases shall be expected in each year following. Finally during year 3, an
additional 3,500 TB cases are expected to be added to the baseline as the direct outcome of
slide/sputum sending, screening of child TB, contact management, screening of IDPs and
prisoners, and PPM. Other interventions such as EQA, LED microscopes, community
approaches, and routine training may bring certain additional gain, and it is expected that about
4,500 additional cases shall be found compared to the baseline and that 1,500 additional cases
shall be expected in each year. Finally during year 3, an additional 7,500 TB cases will be
added compared to the baseline as the minimum scenario by this funding program.
2. MDR-TB
2.1 Case detection and diagnosis of MDR-TB

Establishing and maintaining sample transportation system for MDR-diagnosis

Procurement consumables for culture and DST

Enhancing quality control for culture examinations and DST

Introducing GeneXpert (five units) with diagnostic kits
As already described, NTP has successfully launched the MDR-TB program, but still case
notification is far below the target. To increase case notification, enhancing current diagnostic
methods (culture and DST) is crucial, including sample collection system from targets at
peripheral health facilities to reference laboratories. (Targets for MDR-TB screening submit
sputum samples slides with reagents for GeneXpert and culture/DST while they receive routine
diagnostic procedures with sputum smear examinations.)NTP has already conducted training on
sample collection and transportation by support of GFATM R10 support, and key staffs at
peripheral health facilities have already received training. Given that is the fundamental of case
notification for MDR-TB to ensure access to diagnosis and driven that developing this system
brought increased case notification of MDR-TB, proper implementation to maintain this system
is crucial.
Also, introducing new innovative measures for rapid diagnosis are required to provide
treatment in early stages of the disease. In early 2014, NTP introduced GeneXpert for the
diagnosis of MDR-TB in NRL, resulting in increased case notification of MDR-TB. Now,NTP
plans to introduce GeneXpert into five provinces (Herat in west, Nangarhar in east, Kandahar in
south, Balkh in north, and Paktia in southeast). The first four provinces have or will have
regional reference laboratories that conduct culture examinations, and staff in those reference
laboratories have been or shall be well trained for culture examinations and utilization of
GeneXpert. Thus, by this introduction, most of these provinces will have access to
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examinations by GeneXpert.
Thus, the requested budget includes cost for sample collection and transportation, procuring
five GeneXpert and diagnostic kits, and cost for reagents for culture and DST. The system for
sample transportation was developed, and most of key staffs at peripheral health facilities have
already received training under the GFATM R10 program. Also, cost for quality control of
culture and DST by the NRL and SNRL is included.
2.2 Treatment

Renovation of TB wards for treatment of MDR-TB cases in five provinces

Providing living support for MDR-TB patients
For treatment of MDR-TB, as described in the section 3.1, NTP plans to provide 100 beds for
MDR-TB treatment in five provinces (Nangarhar, Herat, Balkh, Kunduz, and Kandahar). In
addition to the existing 56 beds in Kabul, NTP will be able to provide hospitalized treatment for
at least 300 MDR-TB cases per year.(This was already approved in GFATM R10, but due to
administrative constraints, the implementation was postponed.)
For patient support, NTP provides a fixed amount of support as living support for MDR-TB
patients in continuous phase. Patients do not need to spend money for transportation and daily
foods in the initial phase as hospitalized service is provided as free of charge. This support will
avoid defaulters and work as nutritional support and eventually bring favorable outcome for
patients.
Thus, the requested budget includes cost for these two activities; a small budget to develop
training material on MDR-TB and conducting training for doctors and operational cost mainly
for laboratories in MDR-TB hospitals and wards are also included
3. HIS & M&E
3.1 Routine reporting

Revision of record and reporting forms

Conducting quarterly meetings

Conducting supervisory visits

Conducting survey
This supporting module includes interventions regarding M&E. These interventions do not
directly bring impacts on the TB program, but are essential to support the framework of the
program. First, NTP must revise all recording and reporting formats, including the electronic
reporting system (TBIS). The entire reporting system still relies on the paper, though TBIS
serves as an electronic system above the provincial level. In these settings, quarterly review
meetings at various levels play key roles in adequate data collection with good quality and
providing feedback to health facilities; technical details to conduct those meetings are defined
in the guidelines. These meetings have been implemented in all provinces with support by the
GFATMR8 program, resulting in significant reduction in missing data and errors in reporting.
Thus, it is crucial to continue these activities. Supervisory visits to health facilities also play key
roles not only in M&E, but also in improving quality of services of TB control; technical
instructions for supervisory visits are defined in the guidelines as well.
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Thus, the requested budget in this module includes cost for conducting those interventions and
cost for supervisory visits, including visits for urgent supervision in the EQA and visits for
other purposes such as management of slide sputum/sending transportation system. Also, as in
the section 3.1, the budget to conduct surveys and operational researches is included.
4. Program management
4.1 Policy, planning, coordination, and management
As in the section 3.1, MOPH still needs support for basic operational cost of NTP and incentives to
NTP staff. Thus, the following budget is requested as the cost for program management.

Staff salaries: the staff’s salaries will be adjusted based on National Technical Assistance
(NTA) Remuneration policy and the same scales are used among all programs funded by
GFATM.

Routine operational cost for NTP: This include provision of IT equipment, Internet
maintenance cost for sustaining better communication among NTP staff, including
provincial levels. The amount is less than that currently supported by the GFATM R10
program.
4.2 Grant management
Principal-recipient management costs are requested as 10% of total requested budget; budget for the
external mid-term review of the national strategic plan is also included.
5. Measures to mitigate risks for effective program implementation
There are certain anticipated risks for effective program implementation. These are described as
follows, with measures to mitigate them. In general, as most of interventions and activities shall be
implemented at primary health care facilities NTP will strengthen the coordination mechanism
with NGOs that are implementers of BPHS.

Weak management capacity for implementation of interventions at field level
As there is limited number of staff in the NTP central unit and one PTC and one PLC at each
province, it is very difficult to manage and monitor all interventions at field level. To mitigate
stagnation of interventions and maintain quality, the request of funding includes recruiting focal
points to manage and monitor some important interventions, such as PPM, screening of IDPs,
and screening of pediatric TB in hospitals. Also, enough budgets are allocated for onsite
supervisions for certain activities.

Turnover of staff in health facilities
To cope with turnover of staff in health facilities, in addition to ordinary training for health
facility staff, additional training courses shall be provided as key interventions for which
ordinary training course is difficult to cover, such as slide/sputum sending and PPM.
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3.4 Focus on Key Populations and/or Highest-impact Interventions
This question is not applicable for low-income countries.
Describe whether the focus of the funding request meets the Global Fund’s Eligibility and
Counterpart Financing Policy requirements as listed below:
a. If the applicant is a lower-middle-income country, describe how the funding request
focuses at least 50 percent of the budget on underserved and key populations
and/or highest-impact interventions.
b. If the applicant is an upper-middle-income country, describe how the funding
request focuses 100 percent of the budget on underserved and key populations
and/or highest-impact interventions.
½ PAGE SUGGESTED
SECTION 4: IMPLEMENTATION ARRANGEMENTS AND RISK ASSESSMENT
4.1 Overview of Implementation Arrangements
Provide an overview of the proposed implementation arrangements for the funding
request. In the response, describe:
a. If applicable, the reason why the proposed implementation arrangement does not
reflect a dual-track financing arrangement (i.e. both government and nongovernment sector Principal Recipient(s).
b. If more than one Principal Recipient is nominated, how coordination will occur
between Principal Recipients.
c. The type of sub-recipient management arrangements likely to be put into place
and whether sub-recipients have been identified.
d. How coordination will occur between each nominated Principal Recipient and its
respective sub-recipients.
e. How representatives of women’s organizations, people living with the three
diseases, and other key populations will actively participate in the implementation
of this funding request.
a. Civil society organizations submitted an Expression of Interest, however following an
assessment by the CCM PR Selection Committee against agreed criteria the CCM nominated the
MoPH and UNDP as Co-Principal Recipient (PR) (the Co-PRs) of this grant. The minutes of the
CCM meeting of 14 July 2014 nominating the Co’PRs was shared with GFATM through CCM
secretariat. The Grant Agreement will commence on 1 April 2015 and will be consolidated with the
HSS grant under the NFM.
b. UNDP and the MoPH will nominate a focal point responsible for coordination. Monthly
coordination meetings will be held with UNDP, NTP/HSS/MoPH, SRs and technical partners. A
quarterly meeting will be dedicated to reviewing and providing feedback on Progress Updates
(PUs), and six monthly meetings will be designated to review management letters from GFATM
and examine and refine implementation arrangements. Annual review meetings will be held after
receipt of Sub-Recipient (SR) audit reports to prepare and submit Annual Commitment
Disbursements Decision request to the GFATM and review implementation arrangements. The
Co’PRs will coordinate preparation of joint reports to the GFATM as per the requirements of the
grant agreement and the CCM. In addition, the Co’PRs will prepare a joint M&E Plan, and
Training and Technical Assistance Plans to ensure synergies and avoid duplication. Joint
monitoring missions will be held with the NTP/MoPH, UNDP and the CCM. It will be critical for
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the NTP/MoPH and UNDP to engage with the writing teams of the CN for Malaria and HIV to
ensure synergies, efficiencies and avoid duplication of activities, as they have already done for the
HSS CN. UNDP will coordinate with the MoPH on leveraging additional domestic and
international resources for the TB and HSS programme and shall focus on capacity development
activities for the transition of the PR’ship to MoPH.
c. UNDP has completed a preliminary mapping of the current SRs and PRs under TB grants funded
by the GFATM with prospective SRs identified. As far as possible, there will be no change in SRs
from the current GFATM grants with the exception of the addition of the current PRs (AFG-809G07-T; AFG-011-G12-T) subject to satisfactory capacity assessments, approved programme
activities, value for money and willingness of SRs to continue in their designated function. UNDP,
NTP/MoPH and the current PRs, will work together to ensure a smooth transition to the new
implementation arrangements. The SRs identified will be those under the BPHS, including MOVE
Welfare Organization, Agency for Assistance and Development of Afghanistan, Aga Khan
Foundation, Afghan Health and Development Services, Bakhtar Development Network,
Afghanistan Center for Training and Development, Humanitarian Assistance and Development
Association for Afghanistan (HADAAF), International Medical Corps UK, and Solidarity for
Afghan Families. In addition, BRAC and Health NETPro. To ensure a smooth transition to the new
implementation arrangements the CO’PRs will request the CCM to appointing a PR transition
committee.
SR management arrangements - MoPH
The proposed implementation arrangements for this grant are based on the standard procedures
established by the GoIRA and the MoPH as well as the past recommendations of the GFATM. The
SRs involved in the health sector include national and international NGOs with proven experience
and capacity having demonstrated expertise under the BPHS. The SRs have been selected through
approved transparent procedures established by the MoPH.
SR management arrangements - UNDP
UNDP has strong systems which ensure requisite resources are available for identifying and
assessing SRs and for overseeing the SRs once engaged. Additionally, UNDP carefully addresses
and manages potential risks involved in working with SRs, while supporting SRs in implementing
effective and sustainable programmes, based on an understanding of their needs and challenges.
UNDP will work to build the skills, knowledge and experience of its SRs so that they can
successfully implement GFATM programme activities. The capacity building work will focus on
the priorities, policies and desired results that have been mutually identified with the
NTP/HSS/MoPH and the SR(s) and are in step with other donor funded programmes (e.g., BPHS,
SEHAT). A SR Operating Manual will be developed in consultation with national stakeholders
drawing on lessons learnt from prior rounds.
UNDP Afghanistan will conduct capacity assessments of proposed SRs prior to signing of SR
Grant Agreements and transfer of funds. The assessments of SRs capacity and discussions with the
SRs will feed into Capacity Development Plans (CDP), to be annexed to the SR Agreements, or
included in the SR Annual Work Plans. The CDPs will define a clear and practical plan, schedule,
and budget to build capacity in the identified areas of weakness, while maintaining and
strengthening capacity in other areas. For more information on UNDP Capacity Development
Initiatives please refer to the CD Toolkit.
UNDP’s SR agreements will be consistent with the terms and conditions of UNDP's Grant
Agreement with the Global Fund. Routine monitoring and evaluation of SR activities will provide
UNDP with a strong evidence-baseto inform decision making and propose changes to
programming as well as appraise SR funding requests. These reports will be shared during the
quarterly meetings with the NTP/MoPH.
d. UNDP will nominate a focal point within the Programme Management Unit (PMU) for SR
coordination (programme and operations) and will develop the SR Operating Manual in addition to
holding regular SR trainings, based on feedback from SRs and performance reviews by UNDP. In
addition, as outlined in the previous section UNDP will hold monthly coordinating meetings with
the NTP/HSS/MoPH, SRs, and technical partners, to review PUs and implementation
arrangements, six monthly performance review and annual review meetings following receipt of
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SR audit reports.
Coordination of SRs - MoPH
Considerable experience with previous GFATM grants ensures close coordination among these
relevant units of the MoPH leading to frequent technical and administrative support to monitor
project performance in accordance with GFATM grant procedures and the MoPH Terms of
Reference. Constant efforts are made to ensure responsible implementation and performance in
accordance with GFATM protocols and consistent with MoPH policies, strategies, rules and
regulations and in conformance with contractual obligations to achieve planned progress toward
stated targets.
e. The Co’PRs will strongly encourage the direct involvement of representatives of women’s
organizations, people living with the disease and other Key Affected Populations in the design and
implementation of programmes. NTP/HSS/MoPH and other national programmes receiving
GFATM funding under the NFM (malaria and HIV) and UNDP and partners will request the CCM
to convene a sub-committee of representatives of women's organizations, KAPs and people living
with the three diseases to be engaged in the review of programme implementation. In the past, a
wide range of BPHS implementing NGOs, Provincial Councils, local communities, grass-roots
women’s organizations, religious leaders and community leaders have been actively involved in the
planning and implementation of GFATM-supported activities and policy discussions. Efforts will
be made to ensure similar active participation in future GFATM grant activities.
4.2 Ensuring Implementation Efficiencies
Complete this question only if the Country Coordinating Mechanism (CCM) is overseeing
other Global Fund grants.
Describe how the funding requested links to existing Global Fund grants or other funding
requests being submitted by the CCM.
In particular, from a program management perspective, explain how this request
complements (and does not duplicate) any human resources, training, monitoring and
evaluation, and supervision activities.
This grant will be a continuation of Rd 8 and 10 GFATM TB grants (AFG-809-G07-T, AFG-011G12-T). The grant will be implemented by MoPH and UNDP in a Co-PR’ship role, which will
facilitate coordination with national programmes and key stakeholders (e.g., technical partners, bilaterals). CN development has been coordinated with the strong engagement of all national
programmes to ensure synergies and avoid duplication.
Compo
nent
Round
HIV
Rd 7, TFM (AFG-708G04-H; AFG-708G05-H)
TB
Rd 8 AFG-809-G07-T
Rd 10 AFG-011-G12T
BRAC
JICA
Malari
a
AFG-809-G09-M
AFG-809-G10-M
AFG-812-G14-M
BRAC,
HealthNetPro,
Mop
Standard Concept Note Template
Current PRs
MoPH, GIZ
CCM
Nomination
Grant End
Dates and
Start Dates
CN
Submission
Date
UNDP/MoPH
30 Sept 2015
Start Date 1
October 2015
April 2015
31 March
2015, 30 Sept
August 2014
2014
UNDP/MoPH
Start Date 1
April 2015
30 June 2015 October 2014
TBC
UNDP/MoPH
31 January
1 February
2015
2012
10 March 2014│ 46
HSS
AFG-S-Mop
Mop
MoPH, UNDP
31 March
2014
Start Date 1
April 2015
August 2014
The TB and HSS activities of the NFM will be consolidated under one grant agreement, thereby
reducing the administrative burden on the PRs, GFATM and LFA (e.g., reporting etc), which will
decrease the number of staff required. The CCM and the Co’PRs will discuss with the GFATM
Secretariat opportunities for further simplification of grant implementation arrangements in line
with GFATM policies (e.g., number of grant agreements, reporting etc) during the preparation of
the CNs for malaria and HIV and the grant making process.
To avoid duplication of activities and ensure synergies for the three disease components and HSS
grants UNDP will work to ensure there is a:
1. Consolidated M&E plan
2. Consolidated PSM plan
3. Consolidated training plan
4. Consolidated technical assistance plan
5. Consolidated capacity development plan
6. Consolidated human resource compensation plan (e.g., incentives, top-ups, salaries)
7. Focal point appointed from each of the national disease programmes (TB, malaria, HIV) and
Health Services Strengthening Coordination Unit (MoPH)
8. Joint SR Operating Manual
As detailed in Section 4. ‘Implementation Arrangements’ UNDP and the MoPH and partners have
acknowledged the need to enhance the coordination between SRs, national disease programmes and
other funded programmes, which will be facilitated through the following mechanisms: 1. Monthly
coordinating meetings will be held with UNDP and NTP/MoPH, SRs and technical partners; 2.
Quarterly meeting will be dedicated to reviewing and providing feedback on PUs; 3. Six monthly
meetings will be designated to review management letters from GFATM and examine and refine
implementation arrangements; 4. Annual review meetings will be held after receipt of SR audit
reports to prepare and submit Annual Commitment Disbursements Decision request to the GFATM;
5. NTP/MoPH and UNDP will coordinate preparation of joint reports to the GFATM as per the
requirements of the grant agreement and the CCM; and 6. Standard Operating Procedure (SPO), to
ensure maximum impact and engagement of national programmes on HSS, malaria and HIV.
To enhance the transparency of GFATM funded activities, the Co-PRs will use a web-based KM
platform (Share point) to share key documents with CCM and national partners, donors etc, and to
produce a quarterly newsletter.
4.3 Minimum Standards for Principal Recipients and Program Delivery
Complete this table for each nominated Principal Recipient. For more information on
minimum standards, please refer to the concept note instructions.
Principal Recipient 1
Name
Ministry
of Public
Health
Gov’t
Sector
Does this Principal Recipient
currently manage a Global Fund
grant(s)
for
this
disease
component or a cross-cutting HSS
grant(s)?
X Yes ☐No
AFG-S-MOPH grant (EUR 15.8 million)
AFG-708-G04-H grant (USD 2.4 million)
AFG-809-G09-M grant (USD 1.7 million)
Minimum Standards
CCM assessment
Standard Concept Note Template
10 March 2014│ 47
1. The
Principal
Recipient
demonstrates
effective
management structures and
planning
MOPH is responsible for coordinating and managing
all financial issues of the Global Fund Grants to
Ministry of Public Health, overall including
management of grant activities and agreements;
disbursement of funds; consolidation of information
available on grants and to coordinate all efforts through
other relevant departments of MoPH, and to report on
consolidated expenditures from the funds provided by
the donor. Through this approach, the following results
can be expected:
1. Having a well-professional and capable staff
inside the MOPH to smoothly implement the
grants.
2. Strengthened capacity of the National Programs
to effectively and efficiently manage the GF
grants.
3. Strengthened health system including TB,
HIV/AIDs and Malaria
In order to have proper mechanism for grant
management, on behalf of MOPH, HSS Coordination
Program will be responsible for the entire GF grants in
MOPH; therefore Technical and financial staff who are
currently involved in grant implementation in MOPH
will be part of this team as per the scope and load of
work; meanwhile, this team shall be having close
coordination and communication with national
programs and relevant departments.
The team who are currently managing almost USD 20
million of GF HSS grant will be responsible for NFM
grant as well and this team is composed of; Senior
Technical Consultant with more than 8 years
experiences in the Global Fund grant, Technical
Officers, finance team (having Master degrees in
finance), procurement staff, M&E Experts and Grant
Consultants. To effectively implement the Global Fund
grants in MOPH, a team of few members will be
working as Co-PR for all Global Fund grants under the
Health System Strengthening Coordination Program.
This team will be led by a team leader and the team
leader will be reported to the head of HSS Coordination
Program
2. The Principal Recipient has the
capacity and systems for
effective management and
oversight of sub-recipients (and
relevant sub-sub-recipients)
Standard Concept Note Template
MOPH has rich technical experience and developed an
extensive network of sub-recipients (NGOs) for
training of community health nurses, provision of
Laboratory services and bringing improvement in
national HMIS through GFR support, which is clear
from the number of projects implemented and managed
by HSS Department of MOPH. MOPH has extensive
knowledge about the requirements set by the Global
Fund and on the roles assigned to the PR. MoPH M&E
staff are well trained and experienced in monitoring
and evaluating HSS component in the country. The
teams – including finance, logistic and program staff –
have attended a number of GF related meetings in the
10 March 2014│ 48
region. MoPH is aware of the reporting requirements
and formats, the role of LFA and how to communicate
with them. MoPH is familiar and has direct experience
with the mechanisms for monitoring sub-recipients.
MoPH understands that the selected PR will be legally
responsible
for
program
results,
financially
accountable, manage a number of sub-recipients,
receive periodic disbursements of funds directly from
the GF Trustee accounts and these funds towards the
implementation of the proposed activities. MoPH also
understands that the PR should provide periodical
reports to LFA and monitor the performance of SR(s).
MoPH proposes to use the existing resources within
ministry while adding to its strength to fulfill its role as
PR.
a. Sound financial management is critical to project
implementation and hence the achievement of the
desired development objectives. Relevant, reliable
and timely financial information provides a basis
for better decision-making, improved management
of physical and financial resources, and efficient
implementation of project activities. An effective
financial management system is vital for
development projects because of the need to
deliver services to target groups/people quickly
over a large geographic area. Following are some
points, which a smooth Financial Management
System provides:
b. Essential information to those who manage,
implement and supervise projects; Comfort to
stakeholders (SRs and SSRs) and the donor
community that funds have been used efficiently
and for the purpose intended; and a deterrent
(discourage) to fraud and corruption, because the
incorporate strong internal control and transparent
financial reporting systems which identify unusual
occurrences and deviations.
c. Financial management, procurement and audit
functions for the government Development
Projects (discretionary) will be undertaken
through the agents contracted under the Public
Administration Capacity Building project and
non-discretionary project will be undertaken
through the donor agent (LFA) respectively. This
is the primary instrument for continuing to
strengthen the fiduciary (involving trust) measures
put in place for ensuring transparency and
accountability of funds provided by donor (Global
Fund).
d. MOPH technical staff is responsible for planning,
coordination of stakeholders (amongst the MOPH
departments, SRs LFA and donor), HR related
issue, decision making related to GF and SRs
technical areas and the finance team of HSS grant
funded by the Global Fund is responsible for
Standard Concept Note Template
10 March 2014│ 49
e.
f.
g.
h.
maintaining all financial records of the project
based on all contracts signed by both parties of
contract. Any financial record/transaction is
processing under the government of Afghanistan
laws and regulations.
HSS finance team of DBD has managed USD 34
million of GAVI project for 5 years and currently
managing USD 20 million from the ongoing
Global Fund HSS grant (single stream funding).
Each grant was audited at the end of each year and
the reports of audit have been shared with the
GAVI, Global Fund and LFA.
To build or strengthen financial management and
other fiduciary capacity has been prepared, the
Project will make sufficient resources available in
Special Account to successfully implement the
action plan within the agreed timetable and before
project implementation begins. HSS Project will
normally use a Special Bank A/C in central bank
of Afghanistan for the smoothly running of
Project transactions.
DBD section of HSS project (funded by the
Global Fund) are visiting from SRs offices in
capital to verify the expenses reports of any SRs
(vouchers checking), while SRs are reporting to
PR.
MoPH
development
projects,
Financial
Managements Unit are gathering under the deputy
minister of Finance and admin meetings each
month. It discusses the problems and obstacles in
financial documentation and record as well as
finds the solutions for its problems.
The Budget Department of the Ministry of Finance has
the responsibility to work with the Line Ministries to
develop and formulate the annual budget for
Afghanistan. They manage the budget process by
providing guidance to Line Ministries through Budget
Circulars and other instructions. The Accounting
Information System (or Treasury) is not used in the
budget formulation process other than to provide
historical expenditure data and other financial reports.
However, the Accounting Information System is
essential to budget execution after the annual budget
has been approved by Parliament and the Budget
department of MoF.
3. The internal control system of
the Principal Recipient is
effective to prevent and detect
misuse or fraud
Standard Concept Note Template
A key internal control process under the cash basis of
accounting is the reconciliation of bank Statements
with accounting records. Internal control procedures of
all MoF and other policies are keys to eliminate waste,
abuse and fraud in the GoIRA. A key tool in the budget
execution process is AFMIS as it is used to record
budget
transactions
including
appropriations,
allotments and sub-allotments. Commitment is
10 March 2014│ 50
recorded for projects in the development budget.
In addition, AFMIS has several internal controls built
into its design and use. Specifically, each level of
budget
execution
(appropriation,
allotment,
expenditure, etc.) cannot be processed unless the
previous level has been completed and recorded in
AFMIS. For example, no allotments can be made
unless an appropriation has been approved and
recorded in AFMIS or no expenditure can be made
without an allotment.
In addition, total transactions of one budget execution
level cannot exceed the recorded amount of the
previous level, e.g. sub-allotments cannot exceed
allotments. Each step of budget execution is processed
using a budget form. They are as follows:
 B‐3 –Approved Budget (Appropriations)
 B‐20 – Sub-allotments
 B‐23 – Request for Budget Transfer
 B‐27 ‐ Allotments
And other forms such as PCS (project coding sheet),
B2 (Commitment)
Since AFMIS has enabled the Ministry of Finance to
centralize budget execution process as per the
requirements of the PEFML (Public Finance and
Expenditure Management Law), much of budget
execution is the responsibility of the Treasury,
specifically the Allotments and Commitments Unit.
Primary and secondary budget units also play an
important role in budget execution. Non‐salary
expenditures in the Ordinary Budget are the most
common and typical type of transactions and all other
transaction types are a variation of the processes
detailed in this Section. Specifically, the roles and
responsibilities identified in each step of the scenarios
and the different internal controls will be the same or
similar for other procedures with modifications. In
addition, internal controls and procedure steps will vary
between transactions completed at the Treasury and
those completed at the Mustofiats (Provincial Finance
office). Therefore, additional steps and internal control
requirements for Mustofiats are highlighted.
Disbursements of expenditure can either be made using
direct deposits from Treasury bank accounts or the
issue of checks directly to bonded trustees. However,
the accounting procedure will be same in either case
until the disbursement step. Therefore each scenario is
applicable to both types of payments (i.e. checks or
direct deposit). The most vital toolkit of control system
reconciliation is performing in various conditions. Each
financial institution is reconciling monthly, quarterly,
semi-annual and annually reports of Ministry of
Finance along with Bank Statements and line ministries
expenditure reports.
Standard Concept Note Template
10 March 2014│ 51
4. The financial management
system
of
the
Principal
Recipient is effective and
accurate
5. Central
warehousing
and
regional
warehouse
have
capacity, and are aligned with
good storage practices to
ensure adequate condition,
integrity and security of health
products
Standard Concept Note Template
Financial management under the scope of MOPH
through the Global Fund NFM grants would be the
responsibility of the assigned finance team who are
working under the Global Fund HSS current grants. In
order to further ensure transparency and accountability,
the head of relevant program/department will sign the
relevant documents prior to processing by finance
team. All financial procedures should be complied with
rules, regulations and agreed working procedures of the
Government of Afghanistan, Global Fund requirements
and approved budget/work plan.
Project financial management is a process which brings
together planning, budgeting, accounting, financial
reporting, internal control, auditing, procurement,
disbursement, and the physical performance of the
project’s activities with the aim of managing resources
to achieve the planned/targeted objectives.
Development Budget Department (DBD) of The Global
Fund which is headed by the Finance Manager that will
provide all the support and guidance for establishing a
proper financial management and accounting system
within the frame work of Government of Islamic
Republic of Afghanistan and with The Global Fund
rule and regulation. MoF has introduced a financial
database (Budget & Expenditure Tracking database)
especially designed for the financial management of the
entire development project within all ministries of
Afghanistan. The financial database is a kind of
software that can produce basic books of cash book,
ledgers, different allotment, expenditure disbursement
forms (M16, B27 etc.) and different kinds of financial
reports to MoF and donors (rarely, because every donor
required different form of report).
MoPH has developed ample in-house capacity and has
put standard procedures into practice for procurement.
Besides, MoPH is well aware of and knowledgeable
about the content of the policy documents of the
GFATM including Procurement and Supply
Management, Performance Based Funding, and
Fiduciary Arrangements for Grant Recipients. These
policy documents will be the guides for playing the role
of PR for the GF NFM grants.
Upon renovating the regional labs, warehouse was
considered not only to have enough space, but also to
be equipped with refrigerators and freezers to keep all
health products in good conditions until used. The
Central Lab, although it has reliable facility, but it will
need to expand to accommodate the newly established
network demands’ i.e. more health products will be
ordered for the regional and provincial labs. These
products may need more space than the available.
Currently, it can absorb the needs. Future use will need
some rehabilitation and space expansion.
10 March 2014│ 52
6. The distribution systems and
transportation
arrangements
are
efficient
to
ensure
continued and secured supply
of health products to end users
to avoid treatment/program
disruptions
7. Data-collection capacity and
tools are in place to monitor
program performance
8. A functional routine reporting
system
with
reasonable
coverage is in place to report
program performance timely
and accurately
MoPH has developed ample in-house capacity and has
put standard procedures into practice for procurement.
Besides, MoPH is well aware of and knowledgeable
about the content of the policy documents of the
GFATM including Procurement and Supply
Management, Performance Based Funding, and
Fiduciary Arrangements for Grant Recipients. These
policy documents will be the guides for playing the role
of PR for the GF NFM grants.
Upon renovating the regional labs, warehouse was
considered not only to have enough space, but also to
be equipped with refrigerators and freezers to keep all
health products in good conditions until used. The
Central Lab, although it has reliable facility, but it will
need to expand to accommodate the newly established
network demands’ i.e. more health products will be
ordered for the regional and provincial labs. These
products may need more space than the available.
Currently, it can absorb the needs. Future use will need
some rehabilitation and space expansion.
Health products will be flowing swiftly from the central
level to the regional level which in turn will take the
responsibility to distribute the products to the
provincial and district lab levels. Transportation is
available either by road or by flights, namely UN
domestic flight through WHO pouch. Cold chain of
Polio Eradication Program is now everywhere in
Afghanistan and if need be, this polio eradication
network will be used to cover remote areas as
necessary.
Data Collection Capacity and Tools:
Two main capacities are exist:
 At central level the M&E focal points collecting,
analyzing, interpreting and using the data, and
preparing report on the base of analysis. Data
entry is also one of the tasks.
 At provincial level the PPHOs, are doing the same
activities.
The M&E Directorate developed several checklists for
monitoring of Health facilities, like:
 NMC (National Monitoring Checklist), HNCM
(Hospital National Monitoring Checklist), Lab
Checklist, CHNE Checklist (Community Health
Nursing Education Checklist)
 HMIS tools (several monthly reports like; MIAR,
HMIAR, MAAR, MAR…
 HFA tools for Balance score card
A functional routine reporting system with reasonable
coverage is in place to report program performance
timely and accurately. HMIS is covering 93 % of
Public Health Facilities which 97 % of which
provide timely reporting, the quality of HMIS for
Standard Concept Note Template
10 March 2014│ 53
specific indicators, assessed by third party is more than
90%, but for complete system the quality of data need
to be improved. The utilization also there are some
good evidence that could show us how well HMIS
data utilized but at programs level there are huge gap
and need some efforts and investment to strengthen
data use.
9. Implementers have capacity to
comply
with
quality
requirements and to monitor
product quality throughout the
in-country supply chain
The whole process of supply chain will be carried out
by MoPH Lab Staff with minor support from WHO as
necessary. Lab staffs are well trained in sample
collection and transportation which will reflect
positively on the distribution of goods and kits. In case
of shipping bulky items or pouch is sent by air, lab
technicians will prepare the shipment and also lab staff
at the other end will be responsible of collecting the
goods to keep it at the optimum conditions.
The key aim of this approach is to provide joint efforts
and venture to the National Control Programs including
TB, HIV/AIDs, Malaria and HSS and further
opportunity to build their capacity in technical
management of the grants, including financial
management, M&E, PSM and. In order to realize a full
integration of the GF grants in health system, it was
envisaged that eventually programmatic and financial
aspects would be brought down at the level of the
individual programs.
The available human resources who are funded by the
Global Fund and GAVI grants will be used for the
better implementation of the NFM grants and they will
be fully involved with national programs/departments
in grant implementation. As HSS will be responsible
for the entire NFM grants of MOPH; therefore
technical, financial and procurement staff who are
currently involved in grant implementation will be part
of this team; meanwhile, this team shall be having close
coordination and communication with national
programs and relevant departments. Ultimately this
approach will assist the national programs and HSS to
have better understanding with other PR in order to
effectively manage the M&E, PSM and financial
activities of the grant.
10.
4.3 Minimum Standards for Principal Recipient (PR) and Program Delivery
Complete this table for each nominated PR. For more information on Minimum
Standards refer to the Concept Note Instructions.
PR 2 Name
UNDP
Standard Concept Note Template
Sector
Multilateral
10 March 2014│ 54
Organization
Does this principal recipient currently
manage a Global Fund stand-alone crosscutting HSS or a disease component
grant(s)?
X Yes ☐No
UNDP is PR in 25 countries and a regional
programme (South Asia, 7 countries), managing
53 grants
Minimum Standards
CCM assessment
1. The principal recipient demonstrates
effective management structures and
planning
2. The principal recipient has the capacity
and systems for effective management
and oversight of Sub-Recipients (and
relevant Sub-Sub-Recipients)
3. The internal controlsystem of the
principal recipient is effective to
prevent and detect misuse or fraud
4. The financial management system of
the principal recipient is effective and
accurate
5. Central warehousing and regional
warehouse have capacity, and are
aligned with good storage practices to
ensure adequate condition, integrity
Standard Concept Note Template
UNDP will implement programmes in
accordance with its rules and procedures
(Article 2 Standard Terms and Conditions of the
Grant Agreement). The Programme and
Operations Policies and Procedures (POPP) are
the basis for all aspects of UNDP operations.
UNDP' systems are designed to ensure
transparency, accountability, cost effectiveness
and
value-for-money.
A
Programme
Management Unit (PMU) will be established
under supervision of UNDP senior management,
with support from UNDP's Global Fund
Partnership Team and other UNDP Country
Offices bringing in global experience to the PR
role.
UNDP has strong systems which ensure
resources are available to identify and assess
SRs and to oversee the SRs once engaged.
Additionally, UNDP carefully addresses and
manages potential risks associated with working
with SRs, while supporting SRs in
implementing
effective
and
sustainable
programmes, based on an understanding of their
needs and challenges.
UNDP's internal control system (ICS) is
effective in preventing and detecting misuse or
fraud. The ICS ensures consistent adherence to
policies and procedures and compliance with its
grant agreement with the Fund. UNDP's risk
management tools and processes have been
integrated into one comprehensive system,
enabling the organization to identify, prioritize
and manage risks from all sources, to inform
decision making related to programme
management, serve partners and achieve
development results. UNDP has a special audit
regime for GFATM funded grants, which has
been agreed to with the GFATM. All audit
reports are available on UNDP's public website.
As
detailed
above,
UNDP
financial
managements systems for the implementation of
GFATM funded programmes are been approved
by GFATM and no additional capacity
assessment is required.
As detailed above, UNDP procurement systems
for the implementation of GFATM funded
programmes have been approved by GFATM
and no additional capacity assessment is
required. Under this programme, UNDP has a
10 March 2014│ 55
and security of health products
6. The
distribution
systems
and
transportation
arrangements
are
efficient to ensure continued and
secured supply of health products to
end users to avoid treatment / program
disruptions
7. Data-collection capacity and tools are
in
place
to
monitor
program
performance
8. A functional routine reporting system
with reasonable coverage is in place to
report program performance timely and
accurately
9. Implementers have capacity to comply
with quality requirements and to
monitor product quality throughout the
Standard Concept Note Template
limited volume of procurement of health
commodities. Although UNDP currently does
not have warehousing services dedicated to
pharmaceutical and health commodities, UNDP
will sub-contract such facilities and ensure they
adhere to UNDP standards, which are in line
with the WHO.
See Section 5
UNDP has extensive experience in obtaining
reliable data for monitoring programme
performance, which is part of routine processes
in its programming practice as well as in the
technical and capacity development support
UNDP provides to government and CSO
partners. Ideally, monitoring data originates or is
collected from national sources dependent on
data availability and quality. In an increasing
number of countries, analytical data comes from
national development information systems.
Specific attention is given to establishing
baselines, identifying trends and data gaps, and
highlighting constraints in country statistical and
monitoring systems. In Afghanistan, UNDP
assists regularly in Household Income and
Expenditure surveys analysis in partnership with
stakeholders.
All monitoring efforts in UNDP address the
following at a minimum:
- Progress towards outcomes;
- Factors contributing to impeding achievement
of the outcomes (this necessitates monitoring the
country context and closely link to risk
management); and
- Individual partner contribution to the outcome
through outputs.
UNDP has an extensive monitoring and
evaluation capacity and works towards a robust
monitoring system through effective policies,
tools, processes and systems so that it can meet
the multiple monitoring challenges it faces.
While the prime objective of monitoring in
UNDP is achievement of results, it is also
necessary to monitor the appropriate use of
resources at all levels. UNDP does this through
monitoring at three levels: outputs and projects,
outcomes and programme alignment with the
key reference for monitoring which is the M&E
framework associated with the grant documents.
UNDP has extensive knowledge of the GFATM
Quality Assurance policy and has systems in
place to comply with it, including procurement
10 March 2014│ 56
in-country supply chain
10.
Capacity building of programme
staff and SRs
systems that ensure supply of quality-assured
products. A quality assurance plan will be
developed to ensure that all aspects of quality
assurance will be monitored, it will cover the
following areas: product selection, international
transport, transit, reception, quality control,
central storage, peripheral storage, distribution,
waste management, pharmacovigilance, rational
use and development of capacities. Quality
control will be performed at reception of the
medicines in country and along the supply
chain. The national medicines regulatory
authority will be the key national partner in this
area.
UNDP’s role as Principal Recipient is an interim
arrangement that lasts until one or several
national entities (i.e.: government entities and/or
CSOs) are ready and able to take over grant
implementation. While supporting countries in
implementing grants and ensuring timely
delivery of services, UNDP also helps develop
the capacity of national entities to take over this
PR role. UNDP has robust systems and
processes for CD work in the context of
GFATM programmes. For more information on
UNDP Capacity Development Initiatives please
refer to the CD Toolkit.
4.4 Current or Anticipated Risks to Program Delivery and Principal Recipient(s)
Performance
a. With reference to the portfolio analysis, describe any major risks in the country and
implementation environment that might negatively affect the performance of the
proposed interventions including external risks, Principal Recipient and key
implementers’ capacity, and past and current performance issues.
measures
(including
technical
Type
Risk
Mitigation
Strategic
b. Describe
the
proposed
risk-mitigation
assistance)included in the funding request.
Dependency
on
donor
funding:
despite
strong
commitment
of
the
Government and MoPH, the
total government expenditures
on the national TB control
program (NTP) were less than
9% of total amount of the
necessary budget as reported
in the TB Global Report
(2014). The TB control budget
heavily relies on partners such
as GFATM, USAID, JICA,
WHO, CIDA and Italian
cooperation. Such dependency
poses risks associated with
sustainability of funding and
So far, significant external funding has been secured
for NTP in Afghanistan. Advocacy efforts will
continue to ensure donors’ pledges and timely
disbursements of funds. International support is
being withdrawn slowly to allow gradual increase of
domestic funds.
NTP is a priority for the Government. In line with
the NSP Strategic Direction 1 (Enhancing Political
Commitment and DOTS expansion), NTP along with
stakeholders continues advocating for an increase of
the domestic funding for TB care.
The MoPH in consultation with the stakeholders will
prepare accurate budget plans with allocations for
prioritized
interventions/projects.
NTP
will
implement the initiatives with proven costefficiency.
Standard Concept Note Template
10 March 2014│ 57
Programmatic
timely availability of funds in
the country.
Insufficient
budget
allocation for NTP. The
funding gap (45% NSP 20152017)
adversely
impacts
implementation
of
the
National Strategic Plan for
2014-2018, especially with
regard to costly MDR-TB
interventions.
Insufficient
funding poses a risk for
sustainability
and
consolidation of the recent
gains of the Afghan NTP.
Weak coordination between
stakeholders involved in TB
control activities including the
NTP central and provincial
teams. Weak coordination
poses the risk of duplication
of activities and ineffective
use of resources.
Low
implementation
capacity of health facility
staff.
The low implementation
capacity is due to different
factors including: lack of
qualified staff; high turnover
of health workers; and lack of
mechanisms
to
ensure
adherence to the SOPs and
guidelines. The risk correlates
with remoteness of the service
delivery point.
Standard Concept Note Template
It has been acknowledged that efficient coordination
and information mechanisms exist in MoPH
Afghanistan, which help with avoiding duplication
of efforts and resources by various partners.
The TB-TEAM is working in the country, and some
members of the CCM are also on the team. In
addition, the NTP is conducting national and
provincial meetings at the end of each quarter and
there is also the monthly Provincial Health
Coordination meeting. The TB Task Force meets
regularly at the NTP; the meetings are attended by
relevant NTP managers and stakeholders.
On the community level the TB Patients Association
helps with coordination of community-based
activities and partnership building.
With regard to the GFATM grant, coordination
mechanism between UNDP, MoPH, SRs, donors and
other stakeholders (women’s groups and KAPs) will
be established by:
 Clearly defining the roles and responsibilities of
all parties (refer Section 4.1. and 4.2 above)
With regard to strengthening the coordination
between NTP central and provincial levels, the
current CN includes funding for NTP operational
costs, including internet communication, and for
systematic monitoring visits and follow-up meetings.
In line with the NSP Strategic Direction 2
(Strengthen the Human Resource Development), the
current CN includes a series of capacity development
activities:
 Initial and Refresher DOTs trainings (medical
doctors and nurses)
 Trainings for diagnostic facilities staff (LED-FM,
DST, etc.)
 Drug management trainings
 Community-based DOTs trainings for community
health workers
 MDR-TB case management
NTP recently developed a decentralized training
system and updated training curricula based on a
needs assessment. Quality of trainings will be
improved through the use of standard (e.g. WHO)
10 March 2014│ 58
Potential for high staff
turnover within the MoPH
due
to
the
ministry’s
compliance with GFATM
conditions
regarding
implementation of national
salary
scales
for
all
programmes. This risk could
extend to have an impact on
the
achievement
of
programme targets.
Lack of involvement from
the private sector, due to
factors such as reluctance, and
no mechanisms for monitoring
private sector activities and
performance.
NTP’s capacity to provide
adequate
coverage
of
supervision visits (due to
remote areas, logistics, and
safety) so as to ensure quality
of TB services in all service
delivery points.
The quality of MDR-TB case
management
might
be
affected due to insufficient
capacity of the TB doctors,
and inadequate laboratory
support
for
treatment
monitoring
and
timely
detection of side effects,
especially during out-patient
treatment.
High default rates among
MDR-TB cases over 2 year
period of treatment. As
experience
from
other
countries has shown, it is
extremely challenging to keep
MDR-TB patients in treatment
over the 2 year period
necessary
for
successful
completion of treatment,
especially when providing
out-patient care. The reasons
are various, and include: cost
of transportation to health
Standard Concept Note Template
modules, engagement of master-trainers, and M&E.
Funding is requested for salary top-ups as means of
retaining health workers.
Also funding is requested for M&E of the
programme, which will contribute to ensuring
adequate implementation.
Monitoring implications of compliance with
GFATM conditions and developing mitigation plan
in consultation with NTP/MoPH, GFATM and other
donors.
Required staff for health facilities will be recruited
from the local community.
Involvement of the private sector will be executed in
line with the NSP Strategic Direction 7: Engage all
care providers, with strong support from the MoPH.
Funding is requested to hire M&E personnel in each
province. Regular M&E workshops will be
conducted to identify issues in a timely manner
Policy engagement between MoPH (Private Health
Directorate), Afghan Private Health Association and
other relevant ministries.
Funding is requested to cover the cost of an adequate
number of supervision visits, and programme
activities will take place in relatively easy to access
areas to ensure adequate monitoring of grant
implementation.
Funding is requested for trainings of health workers
on MDR-TB case management as well as trainings
for diagnostic facilities staff, refurbishing of
laboratories and new diagnostic equipment.
5 wards will be renovated in five main provinces by
this grant.
Funding is requested for patient living support.
Strengthening the reference system.
Considering high defaulter rate in NTP quarterly
review meetings.
10 March 2014│ 59
PSM
facility,
psychological
considerations, development
of side effects, need to work,
family support etc.
Timely
and
consistent
availability
of
health
products
and
pharmaceuticals. Relevant
factors
for
consideration
include:
 Complicated preexisting
financial and procurement
systems in the MoPH. All
1st and 2nd line TB drugs
as well as laboratory kits
for sputum microscopy
will be procured by the
NTP
through
the
Government of Japan
funding.
An
intricate
financial and procurement
process may delay the
arrival of the health
products
on
which
GFATM grant activities
depend.
 Capacity to accurately
calculate needs
 Lack of experience in
ordering luminescent kits
and Xpert cartridges with
short shelf life (estimated
need is2 orders per year)
taking into account buffer
stocks and expiry dates
 Capacity for development
of specifications, e.g. for
new lab equipment may be
lengthy
 Capacity to monitor stocks
and
provide
early
notification of potential
shortage and expiration, as
well as notification of
excess stocks
Shortage of quality assured
2nd line TB drugs on the
global market due to high
demand. This may lead to
delays or interruption in
supply flow, or availability of
drugs with a short shelf life,
which might not be utilized
before expiry date
Storage
conditions
for
reagents and TST, especially
in remote facilities
Standard Concept Note Template
This will be mitigated through:
 Coordination and information sharing
between GFATM grant and other
programmes
 Early initiation of the procurement cases
 Ensuring buffer stocks are in place
 Enhancing capacity of NTP for demand
forecasting
 Monitoring stocks of TB drugs and lab
reagents on a quarterly basis
 Training on drug management for all
provinces (Gov’t of Japan).
 Establishment of the DMIS (Gov’t of Japan).
 Regular in field visits (Gov’t of Japan).
 Drug inventory in health facilities will be
reviewed in ¼ ‘ly NTP meeting.
Based on lessons learned in other countries,
procurement of 2nd line TB drugs should be initiated
approximately 1.5 years in advance of the required
delivery to NTP.
Special attention will be given to shelf life of the 2nd
line drugs. Terms shall be agreed with the
procurement agent.
See above item for other mitigation measures.
Allocation of proper storage facilities for anti TB
drugs will be reviewed and reflected in the PSM Plan
in accordance with international standards.
10 March 2014│ 60
Country context
TSD reagents will be stored at DHC and upper level
facilities where refrigeration is available.
This risk will be mitigated through:
 Careful development of specifications for
procurement
of
appropriate
medical
equipment
 Capacity building on use of the procured
equipment, e.g. LED microscopy trainings
 The equipment purchased through the
GFATM grant will be procured by the PR
through its procurement agent, and the
contracts will include the cost of calibration
and maintenance
 The fund requested for maintenance of LED
and GeneExpert.
Challenges associated with
maintenance and repair of
procured
medical
equipment. This might be due
to:
 Lack of capacity to
develop specifications
which may result in
procurement
of
inappropriate
equipment that is
either
too
sophisticated
or
unsuitable for the
room size or national
electricity parameters.
 Lack of capacity to
use equipment, e.g.
annual calibration of
Xpert machines
 Insufficient
local
market
for
maintenance
and
repair of medical
equipment
Renovation work, which is The following factors are considered for risk
scheduled to take place in 5 mitigation:
provinces. Associated risks
 Careful estimates of the budget for
include
poor
building
renovation
conditions, logistical delays,
 Early initiation of the renovation work
and unforeseen expenses.
 Strict monitoring by the PR throughout
Untimely
completion
of
 In the case of insufficient funds, reallocation
renovation work may cause
will be considered within the current grant
subsequent
delays
with
enrolment of MDR-TB cases.
Logistical
and
safety 
Comply
with
considerations
for
UNDSS security arrangements
implementation of activities 
Contract
security
e.g. - slide collection and
services for physical security.
transportation, home visits, 
Obtain
security
and active case findings
clearances for internal travel
among IDPs. Risks include:

Conduct
conflict
 Potential risk of injury or
assessment as part of selection of districts
death to project staff and 
Contract external
contractors
organizations where required
 Delayed or rescheduled
activities
 Lack
of
security
in
provinces and districts in
which UNDP-JHRA will
carry out programming. This
impedes
project
implementation and impacts
the ability to monitor
activities through field
Standard Concept Note Template
10 March 2014│ 61
assessment.
Leadership
and
organisational
change
among GoA and partners,
caused
by
political
campaigning, Presidential and
PC elections, and subsequent
appointments
Weak capacity of national
Sub-recipients
(SRs)
to
comply with GFATM
reporting requirements
PR’s capacity to ensure
adequate coverage with
monitoring visits (e.g. to
remote areas, given safety
considerations)
for
supervisory and verification
purposes
Support organizational and individual capacity
development for sub national partners and a broad
range of technical specialist and tashkeel personnel,
to minimize the impact.
The following factors are considered for risk
mitigation:

Coordination
mechanism between co-PRs, through proposed
PMU structure

Robust
capacity
assessment process and contracting process

UNDP’s
strong
experience with management of SRs, including the
development of an SR Management Manual,
trainings, and a robust audit process

Develop
and
implement SR Institutional Development and
Capacity Building plans
The grant budget provides for monitoring staff.
There will be strong coordination of monitoring
between PR, other UNDP programmes, and other
donors. The MoPH and UNDP have agreed to have
one monitoring plan for all grants, to ensure synergy
and efficiency.
A plan to ensure monitoring visits to remote and
priority areas will be completed.
CORE TABLES, CCM ELIGIBILITY AND ENDORSEMENT OF THE CONCEPT NOTE
Before submitting the concept note, ensure that all the core tables, CCM eligibility and
endorsement of the concept note shown below have been filled in using the online grant
management platform or, in exceptional cases, attached to the application using the offline
templates provided. These documents can only be submitted by email if the applicant
receives Secretariat permission to do so.
☐
Table 1: Financial Gap Analysis and Counterpart Financing Table
Standard Concept Note Template
10 March 2014│ 62
☐
Table 2: Programmatic Gap Table(s)
☐
Table 3: Modular Template
☐
Table 4: List of Abbreviations and Annexes
☐
CCM Eligibility Requirements
☐
CCM Endorsement of Concept Note
Standard Concept Note Template
10 March 2014│ 63
ANNEX 1: ACRONYMS
ACSM
BHC
BPHS
BRAC
CHC
CHW
DH
DMIS
DOTS
DST
EPHS
EPI
EQA
HF
HIS
HMIS
HIS
HSS
IDP
IMCI
IPT
JICA
M&E
MDR-TB
MOPH
NACP
NRL
NTP
OPD
PPM
R4
R8
R10
REACH
RMNCH
SHC
SS+
TB
TBIS
TST
UN
UNCHR
USAID
VCT
WHO
Advocacy, communication and social mobilization
Basic health center
Basic package of health services
Bangladesh Rural Advancement Committee
Comprehensive health center
Community health worker
District hospital
Drug information system
Directly observed treatment, short course
Drug susceptibility testing
Essential package of health services
Expanded program for immunization
External quality assurance
Health facility
Health information system
Health management information system
Health Information System
Health system strengthening
Internally displaced person
Integrated management of childhood illness
Isoniazid preventive therapy
Japan International Cooperation Agency
Monitoring and evaluation
Multi-drug resistance tuberculosis
Ministry of Public Health
National AIDS Control Program
National Reference Laboratory
National Tuberculosis Program
Out-patient department
Public private mix
Round 4
Round 8
Round 10
Rural Expansion of Afghanistan’s Community-based Healthcare
Reproductive, maternal, newborn, and child health
Sub–health center
Sputum smear positive
Tuberculosis
TB information system
Tuberculin skin testing
United Nations
United Nations High Commissioner for Refugees
United States Agency for International Development
Voluntary counseling and testing
World Health Organization
Standard Concept Note Template
10 March 2014│ 64
UNDP
United Nations Development Program
Standard Concept Note Template
10 March 2014│ 65
ANNEX 2: REFERENCE LIST
NTP, National Strategic Plan 2014-2018
Detail budget plan of Concept note
TB Epi Assessment report ,2013
Assessment report of Key Affected Population (KAP) and People Living With Diseases
(PLWD)
Standard Concept Note Template
10 March 2014│ 66