Jordan R10 Proposal Single 3-5 TB en Version 1 August 2010

8/2/2019 Jordan R10 Proposal Single 3-5 TB en Version 1 August 2010

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ROUND 10 Tuberculosis

3. PROPOSAL SUMMARY

3.1Transition to a singlestream of funding

(a) Select only one of the threeoptions:

Option 1: Transition to a single stream of funding by submittinga consolidated disease proposal

go to section 3.1 (b)

Relevant sections are marked in RED throughout theproposal form

Option 2: Transition to a single stream of funding during grantnegotiation

go to section 3.1 (b)


Option 3: No transition to a single stream of funding in Round 10


(b) For options 1 or2, list the grant numbers.

insert relevant grant numbers

3.2 Duration of Proposal Planned Start Date To

Month and year: 1 July 2011 1 July 2016

3.3 Alignment to in-country cycles

Describe:

(a) how the proposal duration was selected in section 3.2 and how it contributes to alignment with thenational fiscal cycle(s), programmatic reporting, or in-country program reviews; and

(b) the systems in place for regular national program reviews and evaluations (including Operations andImplementation research).

(a) The current proposal envisages starting the activities on 1 July 2011 and after when theround five proposal ends. The national TB control programme reports her annualactivities by end April of each year to the Ministry of Health. The planning of the National

The Global Fund Round 10 Proposal Form Single: Sections 3-5 Tuberculosis 1

PROPOSAL FORM ROUND 10SINGLE COUNTRY APPLICANT

SECTIONS 3-5: Tuberculosis


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Revenue and Expenditure Budget starts in the middle of the year. Starting the new grantby July would permit the programme finalize its annual report and progress report of theround five and prepare adequately for launching the round 10 activities.

(b) National Program is reviewed externally by WHO EMRO every five years. On a quarterly

basis, NTP supervises the program through governorate TB coordinators. Annual internal

review of the programme is conducted by NTP and CCM representatives. PR informs CCMmembers on achievements and challenges of the programme on a quarterly basis. Withthe support of WHO EMRO and international experts operational research studies(Research and Training in Tropical Diseases: TDR) are being conducted on TB amongmigrants and TB in the poverty pockets. Preliminary results of these studies have helpedNTP develop this proposal so that the vulnerable population may receive improvedservices.

3.4 Summary of Round 10 Proposal

Provide a summary of the tuberculosis proposal.

The objectives and activities of the current proposal are in line with the national TBstrategic plan to control TB 2011-2015 (annex1). Proposed activities are complementing theinterventions funded by the Ministry of Health and implemented by the national TB controlprogram. The National TB Control Program under GFATM round five grant has improved TBcontrol particularly in major cities and most rural areas, however experience in

implementing the round five grant has shown that there are significant gaps in terms ofquality of services for the most vulnerable groups of patients particularly the non- Jordanian

nationals (about one fifth of residents of Jordan). There are barriers surrounding access toand use of services for some of the most vulnerable population particularly the labor

migrants (from high incidence countries), the refugees and the very poor in remote ruralareas. The current proposal will improve detection, treatment and care for these vulnerablepopulations.

With its dual track nature, tThe current proposal envisages wider involvement of civilsociety and communities with strong component of community system strengthening andemphasizes on introducing and monitoring the progress towards implementing patient-

centered approaches. The proposed activities are built up on the lessons learned fromimplementation of the round five grant which comes to an end in June 2011. The pilotproject on Practical Approaches to Lung health (PAL) under round five will be scaled up andfollowed up with strengthened supervision, monitoring and evaluation. The proposalempowers communities affected by TB particularly women and youth association to improvesocial awareness and combat stigma. The latter will be conducted with increasing the

capacity of and empowering NGOs and community members who will work in proximity tothe vulnerable population. Jordanian Anti-TB Association with long history of involvement in

TB control will be empowered to assist with social awareness and providing services torefugees. NGOs will be involved in social mobilization, provision of DOT and home visit to

eligible patients. Based on the result of study of NTP which is under publication, labormigrants are prone to developing TB since they often come from high TB incidence countriesand are often lost to follow-up mainly because they are not aware of their rights andresponsibilities. Language and cultural barriers play an important role. Peer educators frommigrant communities will be trained and supported to overcome these barriers.

The proposal envisages establishing pilot collaboration with private sector and

factories to strengthening TB services in workplace for early detection and management ofTB among vulnerable groups.

The proposal continues and expands the round five MDR-TB activities with thesupport of GLC mechanism and under WHO technical assistance. NTP will work with Annoor

Sanatarium (FBO) to improve quality of and access to MDR-TB services including:improving

infection control measures, strengthening ambulatory DOT, providing quality-assuredsecond line drugs to all MDR-TB patients. The proposal continues and expands the roundfive MDR-TB activities with the support of GLC mechanism and under WHO technical



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assistance. The capacity of National Mycobacteriology Reference Laboratory will beimproved to address the increasing need for quality assured timely diagnosis of drugresistant TB including improved biosafety measures and molecular tests for timely detectionof drug resistant TB.

The lessons learnedresults of an operational research have have shown it is

important to improveaddress the cross border TB control to ensure appropriate care. In aninnovative intervention and with involvement of International Organization for Migration(IOM), civil society representatives and other national and international partners, theproposal is ensuring timely diagnosis of TB and continuity of treatment (throughcare) acrossthe borders.

The pilot project on Practical Approaches to Lung health (PAL) under round five willbe scaled up and followed up with strengthened supervision, monitoring and evaluation.

With the support of round five During R5 grant, NTP implemented PAL in 200 PHCunits out of existingabout 700 units. Under the current proposal, NTP now will scale up PAL

to provide nationwide coverage toof all PHC units and ensure a robust follow up system.

NTP will ensure fFurther advocacy ting for PAL implementation and raisingawareness among all stakeholders and decision makers ais aan initial necessary step toimprove cross-cutting approach and full understanding and ownership of PAL. Theis

advocacy meetings will should include representatives of MOH, NTP, local health directoriesof all governorates, members of national PAL working group, United Nations Relief and

Working Agency for Palestine Refugees in Near East, (UNRWA),, key staff involved in healthmanagement information system (HMIS), essential drug list and Integrated management ofChildhood Illnesses (IMCI). The meeting group is expected to nominate 8 personnel thatconstitute the PAL planning group responsible for of a PAL expansion. This group isresponsible for elaborating a draft ofA national working group will develop a strategicnational expansion plan of PAL. In addition, this meeting should also nominate theoperationalization group of national strategic PAL expansion plan, a group which isresponsible for producing specific implementation and training plan specifying roles and

responsibilities of local district level including supervision of PAL relevant qualityimplementation. This also encompasses the widely agreed introduction of PAL indicators and

the harmonization of PAL relevant R&Rrecording and reporting with the existing HMIS.(health management and information system).

After the national strategic PAL expansion plan has been developed andoperationalized, the Participants of advocacy meeting should endorse it.

To help ensure high quality PAL implementation, supervisory teams should will be trainedand enabled.be guaranteed. Travel allowances for depending on the average distancetraveled and the frequency of supervisory visits are also important to ensure maintenanceof these supervisory visits.

Members of the national working group plus representatives of academia, Jordanian thoracicassociation, army, primary health care, pediatricians, and health safety directorate of MOHwill work on updating the current national PAL guideline, the training materials andproduction of posters that can help using the guideline in PHC units.

For control of patients with bronchial asthma and COPD, some equipment are needed to bepresent at the level of the PHC units and referral TB chest units. NTP, intend to provide2000 peak flow meters for PHC units and 12 spirometers to every TB chest unit in everygovernorate as a referral centers.

A team of trainers will be prepared;, this will include 12 members from the chest NTPcenters at governorate level, 12 heads of health governorate directorates or their

appointees, plus 12 heads of comprehensive health centers of different governorates. Thisteam of trainers will engage in cascade training as outlined in the operationalized national

PAL expansion plan. It is intended that training session would cover 1000 physicians of allPHC and partners., e.g. UNRWA, over three years Participants will receive updatedguidelines, wall display posters and peak flow meters. VAN WILL ADD IN ACTIVITIES THE



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GUIDELINES FOR NURSES AND HOSPITALS.

The objectives of the proposal are to improve quality of TB care for the most vulnerablepopulation particularly the non-Jordanian nationals, to scale up MDR-TB management, control and carecontrol and strengthen health system response to TB Control.

The main service delivery areas are:

Community System Strengthening (CSS), Advocacy, Communication and Social Mobilization(ACSM), MDR-TB, TB infection control, TB in children, Improving diagnosis, TB in workplace

The main outputs of the programme will be:

Please note that aAlthough the number of patients ese numbers may seem small littlecomparing with other high TB burden countries prevalence countries, however thehumanitarian and public health impacts of proposed interventions are noteworthy for Jordan

with its relatively small size and population and restricted resources.The main outputs of theprogram will be: considering the size of the country and vulnerability of these population,

impact of the current proposal will be significant from humanitarian and public health point

of view:200 migrant TB patients will receive continuum of care per year,PAL will be expanded to all primary health care centers and its monitoring process will bere-enforced.

20 X/MDR-TB patients receive adequate treatment per year with the support ofFaith-based organization Annoor Sanitarium and NTP

200 eligible patients particularly from poor urban and south Jordan will benefit frompatients support to complete their treatment successfully.

Four Community-based organizations will be strengthened and enabled to contributein fighting stigma, improve adherence and implement patient-centered approach.

150 TB/MDR-TB patients will be provided continuums of care across the borders untilthe national program of corresponding countries are taking care of them.

Three pilot models of private-public partnership for TB in workplace are will bedeveloped and tested and successful model(s) of TB in workplace is/arewill be

expanded to 15 more factories.

30 Media representatives will be trained on TB information, education andcommunication.

4. PROGRAM DESCRIPTION

4.1 National programDescribe:

(a) current tuberculosis national prevention, treatment, and care and support strategies;(b) how these strategies respond comprehensively to current epidemiological situation in the country; and(c) the improved tuberculosis outcomes expected from implementation of these strategies.

(a) The National TB Control Strategic Plan has been drafted in 2009 and finalized in aworkshop organized by WHO EMRO in Cairo in May 2010. The strategic plan coversthe period 2010-2015. The overall goal is to decrease the burden of Tuberculosis.The goal is in line with the Global Plan to Stop TB 2011-2015, to achieve the Stop TBPartnership and the MDG targets of halving TB prevalence and deaths compared with

1990 levels by 2015 and to have halted and begun to reverse the incidence of TB by2015 by ensuring access to quality diagnosis and treatment for all, respectively. Theobjectives of the strategic plan are: 1) Pursuing, optimizing and sustaining qualityDOTS, 2) Adapting DOTS to respond to TB-HIV, MDR-TB, and other special



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challenges, 3) engaging all care providers, 4) empowering patients and communities,5) enabling and promoting operational research and 6) strengthening health systemresponse to TB.

(b) Jordanian national TB control strategy address the challenges of TB control in a

comprehensive manner with improving national partnership and intersectoral

collaboration. However there are lack of funds to involve civil society, strengthencommunity system and fulfill adequate advocacy, communication and socialmobilization.

(c) Under the national strategic plan the following outcomes are foreseen: improved andmaintaining treatment success for sputum smear positive patients (at least 90%),

new sputum smear positive TB case detection (above 95%) by 2012, diagnose atleast 85% of estimated MDR-TB cases and treat at least 70% of them successfully.

TWO PAGE MAXIMUM

4.2 Epidemiological profile of target populations

(a) Describe the current epidemiological profile of the target populations, and how this profile is changingwith respect to tuberculosis.

Dr Nadia please add some line from the latest annual or quarterly reports thanks.

ONE PAGE MAXIMUM

(b) Do the activities in the proposal target:

Whole country Specific geographic region(s) Specific population group(s)

Paste map here if relevant (see Guidelines)

(c) Size of population group(s)

If national data is disaggregated differently then type over the categories proposed

Population Groups Population Size Source of Data Year of Estimate

Total country population (allages) 5850000

Jordan Department ofStatistics, Statistical Yearbook2008

2008

Females > 25 years

1162440Jordan Department ofStatistics, Statistical Yearbook2008

2008

Females 20 24 years298420


2008

Females 15 19 years311890


2008

Males > 25 years 1242500 Jordan Department of Statistics, Statistical Yearbook

2008



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(c) Size of population group(s)

If national data is disaggregated differently then type over the categories proposed

Population Groups Population Size Source of Data Year of Estimate

2008

Males 20 24 years321100


2008

Males 15 19 years330440


2008

Females 0 14 years 1062250 Jordan Department ofStatistics, Statistical Yearbook2008

2008

Males 0 14 years 1120960 Jordan Department ofStatistics, Statistical Yearbook2008

2008

Other: labour migrants 303325 Ministry of Labour, 2008 use "Tab" key toadd extra rows ifneeded

(d) Tuberculosis epidemiology of target population(s)

Indicators(see the footnote under this table for the

references)

Number or rate or percentage[Calculation] or

(reference)Bestestimate

Lowestimate

Highestimate

TB estimates, 2008 (available on http://www.who.int/entity/tb/dots/table4_2_2_gfatm.xls)

a Estimated number of new TB cases (all forms) 441 (1)

Male 0-14 (5.4% of total number) 24

Female 0-14 (6.5% of total number) 29

b Estimated number of new TB cases (all forms)per 100 000 population

7[a/population*100

000]

c Estimated number of new smear-positive

cases

135 (1)

d Estimated number of new smear-positivecases per 100 000 population

2[c/population*100

000]

e Estimated prevalence of TB cases (all forms) 534 (1)

f Estimated prevalence of TB cases (all forms)per 100 000 population

9[e/population*100

000]

g Estimated number of deaths due to TB (allforms) among HIV-negative people

46 (1)

h Estimated number of deaths due to TB (allforms) among HIV-negative people per 100 000population

1 [g/population*100000]

i Estimated number of HIV-positive new TBcases (all forms)

0 (1)

j Estimated number of HIV-positive new TB 0 [i/population*100

http://www.who.int/entity/tb/dots/table4_2_2_gfatm.xlshttp://www.who.int/entity/tb/dots/table4_2_2_gfatm.xls


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cases (all forms) per 100 000 population 000]

k1 Estimated % of MDR-TB among new TB cases 5.4% 2.5% 11.3% (2)

k2 Estimated % of MDR-TB among previouslytreated TB cases

40.0% 24.6% 57.7% (2)

Indicators

(see the footnote under this table for thereferences)

Number or rate or percentage

[Calculation] or(reference)Best

estimateLow

estimateHigh

estimate

TB notifications, 2008

l1 Number of new TB cases (ss+, ss-/unknown,extra pulmonary) notified in 2008

337 (including 101 TB amongforeigners) (plus 140 TB cases amongmigrants who preferred to return to

their home countries)

(3)

l2 Number of new TB cases (ss+, ss-, extrapulmonary) and retreatment TB cases(relapse, after failure, after default, other)notified in 2008

356 (3)

m Number of new TB cases (all forms) notifiedper 100 000 population

5.74 [l1/population*100000]

n % of estimated new TB cases (all forms)notified

337/441=76,1%

76,1% [l1/a*100]

o Number of new smear-positive TB casesnotified

104 (3)

Male 0-14 0

Male, 15-44 26

Male, 45 and more 23

Female 0-14 0

Female 15-44 41

Female, 45 and more 14

p Number of new smear-positive TB casesnotified per 100 000 population

1.7[o/population*100

000]

q % of estimated new smear-positive TB casesnotified - Case detection rate of new smearpositive TB

104/135=77% [o/c*100]

r Number of TB cases all forms (new andretreatment) that were tested for HIV 337

(3)

s % of TB cases all forms (new and retreatment)that were tested for HIV

100% [r/l2*100]

t Number of notified TB cases all forms (new

and retreatment cases) that were found orknown to be HIV-positive

0 (3)

u % of all estimated HIV-positive TB cases thatwere found or known to be HIV-positive - casedetection of HIV+ TB

0% [t/i*100]

v Number of notified HIV-positive TB cases (newand retreatment) started or continued on CPT

0% (3)

w % of all notified HIV-positive TB cases (newand retreatment) started or continued on CPT

0% [v/t*100]

x Number of notified HIV-positive TB cases newand retreatment) started or continued on ART

0% (3)

y % of all notified HIV-positive TB cases (newand retreatment) started or continued on ART 0% [x/t*100]

z Number of TB cases (new and retreatment) 62 (3)



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received diagnostic DST

aa Number of multi-drug resistant TB (MDR-TB)cases notified among new and re-treatmentcases

6 (3)

Treatment outcome, 2007

ab Number of new smear-positive casesregistered for treatment in 2007

109 (3)

ac Number of new smear-positive cases notifiedin 2007

109 (3)

ad % of all notified new smear-positive TB casesthat were registered for treatment

100% [ab/ac*100]

ae Number of new smear-positive TB cases thatwere successfully treated (2007 cohort)

94 (3)

af % of all new smear-positive TB casesregistered for treatment that weresuccessfully treated (2007 cohort)

94/109= 86.2% [ae/ab*100]

ag Number of new smear positive TB cases thatfailed their treatment 0 (3)

ah % of all new smear-positive TB casesregistered for treatment who failed theirtreatment (2007 cohort)

0% [ag/ab*100]

ai Number of new smear positive TB cases whodied while on TB treatment

5 (3)

aj % of all new smear-positive TB casesregistered for treatment who died while on TBtreatment (2007 cohort)

5/109=4.5% [ai/ab*100]

ak Number of new smear positive TB cases whodefaulted

10 (3)

al % of all new smear-positive TB casesregistered for treatment who defaulted (2007cohort)

10/109=9% [ak/ab*100]

Other: specify use "Tab" key to add extra rowsif needed

1. Global tuberculosis control: a short update to the 2009 report. WHO/HTM/TB/2009.426

2. Multidrug and extrensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response.WHO/HTM/TB/2010.3 See Annex 6: Estimates of MDR-TB, by WHO region, 20083. Data from country TB routine recording and reporting system.

4.3 Major constraints and gaps in disease, health, and community systems

4.3.1 Tuberculosis program

Describe:

(a) the main weaknesses in the implementation of current tuberculosis strategies;(b) existing gaps and inequities in the delivery of services to target populations; and(c) how these weaknesses affect achievement of planned national tuberculosis outcomes.

The National TB control progamme with the support of GFATM round five grant hasmade considerable improvement in TB control and DOTS implementation in Jordan(improved TB case detection and sustaining treatment outcome among Jordanian nationals),however there are significant gaps and constraints for which involvement of civil society andother stakeholders are crucial to provide equitable access to quality services and improve

care for the most vulnerable populations particularly non Jordanians.;



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(a)The main weaknesses of implementation of current tuberculosis strategiesare:

1. Improvements of health services have not been associated with improved access tocare for migrants. Interventions have not been fully tapered to patients needs. The

limited ACSM activities have not yet so far resulted in comprehending and addressing

the barriers to use services by migrants

2. The results of KAP survey that NTP conducted in 2007 by involving 275 patientsdiagnosed with TB in rural areas and poor urban showed that there are serious

barriers for patients to go through daily direct observation of treatment in healthcare facilities. These barriers are mainly stigma, physical burden to refer to services

on a daily basis, family responsibilities to take care of the children at home bymothers and fear of losing the work. The survey tried to look into the percentage ofpatients who were not ensuring compliance to treatment (not taking medication for 7or more consecutive days). While default rate (being lost to follow-up for more thantwo months) is9% among Jordanian nationals, this rate varies in urban and ruralareas. In some rural areas default rate is as high as ???. According to the results of

this survey, 36.4% of the patients were non-compliant and the highest number ofsuch patients was from south Jordan. Many of the knowledge and behavior aspects

including perceived stigma, long duration of treatment, being busy, living far awayfrom facility and fear of losing job were among the causes of this non-compliance

reported by the patients.

3. Up to now, tuberculosis infection control measures have been largely neglected, this

is largely due to low suspicion of TB among patients with respiratory symptoms andlack of know-how on how to decrease the risk of nosocomial transmission of TB. A

survey conducted in 2006 and repeated in 2007 showed xx% of health care staffhave turned PPD skin positive. This means infection control needs to be addressed.

4. In the last three years on average 21% of peripheral laboratories have failed to showsatisfactory results for TB microscopic examination on the external quality assurance.

This has been resulted mainly from high turnover of staff. During the last threeyears, seven out of existing 13 peripheral laboratories have changed their staff

responsible for direct sputum microscopy. The Programme has trained staff howeverthe staff need time to improve their skills.

5. Capacity of National Reference Laboratory in timely and accurate diagnosis of drugresistant TB, particularly among migrant population is limited. In the last three

years, the efforts of NRL to contact a supranational reference laboratory and beexternally quality assessed have not led to any result. The main problem has been

mentioned by SNRL were lack of funding and unavailability of specimen. The NRL isfunctioning without external quality assessment by any SNRL.

6. Health care staff of prisons is not fully aware of how to diagnose and/or treat TB.

Existing gaps and inequities in the delivery of services to target populations

1. There are estimated 1.5 million migrants with limited access to TB care due to lack ofawareness, stigma, and lack of ability of services to reach out to these groups of

population. According to the latest census, there were 303,325 officially registeredlabor migrants including about 60,000 house-maids (mainly from Indonesia, SriLanka and The Philippines) with average annual turnover of 40%. The Ministry ofHealth provides free of charge services to migrants and they are screened on entry;however follow-up screening and provision of treatment for detected TB patients arelargely lacking for several reasons namely the fear of being deported and stigmaassociated with TB, lack of awareness of migrants on their rights and responsibilitiesand psychosocial and cultural/language barriers. For this reason, treatment outcome

among non Jordanian residents is strikingly low. Due to high mobility of thesepopulation and based on agreement with WHO EMRO, NTP enters these patients in a

separate register. In 2007, 313 sputum smear positive patients were detected



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among 390,618 migrants, however only 91 of them are evaluated for treatment, therest were lost to follow-up, either have returned to their home country or can not beidentified to ensure treatment. Although this number seems small, howevercomparing with the number of TB cases among Jordanian during the same period(244 TB cases) and small population, this considers an important portion. In 2006

treatment success rate for new sputum smear positive for Jordanians was 85,7%while the rate is 32% for non Jordanians, In 2007 92,7% for Jordanian and 65,3%and in 2008 this indicator for was 93% for Jordanians and for non-Jordanians 64%.

There are more than 200 large factories in Jordan mostly preparing men suits withlabour migrant mainly from Asia (more than 500 workers mainly from high TBincidence countries). TB in work place does not exist and once diagnosed with TBafter a short intensive phase treatment, these workers are often sent back to theirhome countries by the recruiting companies.

2. There are indications that drug resistant TB is becoming a growing problem among

migrants (numbers??). With security problem in the neighboring countries (Iraq andPalestine) and importance of providing care for patients irrespective of theirnationality, religious or ethnic background, Jordan needs consolidated actions to

improve services and access of services for refugees and migrants. Annoorsanitarium a Christian Faith-based organization is providing care for MDR-TB patientsunder GLC monitoring and financial support of round five for procurement of secondline drugs, with round five GFATM proposal ending in June 2011, there is a need forcontinuous procurement of quality assured concessionally-priced second line drugs

through GLC. Technical assistance of WHO/GLC is needed to ensure moving fromproject and hospital based approach to a programmatic approach of management of

drug resistant TB.

3. There is a need for strengthening cross border TB control with communicationsystem between NTPs and involving other stakeholders particularly the IOM to assistwith linking the moving population to NTPs and civil society for improved TB

diagnosis and care among people coming in from Iraq who have to live in

overcrowded camps. Collaboration with UNRWA (The United Nations Relief andWorks Agency for Palestine Refugees in the Near East) needs to be expanded tocater for the Palestinian refugees.

How these weaknesses affect achievement of planned national tuberculosisoutcomes.

Poor treatment success among non Jordanian nationals, whether these patients arereturned back to their home country or are residing in Jordan and avoiding referring tohealth centers for the fear of being deported will lead to TB transmission in the communitiesand continued reservoir of TB. Should NTP include the non Jordanians in her national

register, treatment outcome would substantially decrease. With almost 200 TB patientstravelling back to their home countries without adequate treatment or infection control

measures in international airports, transit zones and airplanes, in addition to huge physical,financial and mental burden to patients and their families, is a threat to international public

health. Should some of these patients opt to stay in the country, inadequate or self-administered treatment may lead to development of drug resistant TB.

Poor TB infection control measures will lead to staff being infected and ultimatelydevelop the disease (as the result of NTP operational research in 2007 showed that xxx

number of staff were infected in one year period).

Screening methods for industrial and domestic workers coming from other countriesare not satisfactory leading to diagnosis of TB in them only when they have landed inJordan. The health facilities make maximum efforts to treat these patients but many a times

these patients are sent back to their country of origin by their employers. This can result in

loss to the follow-up and an inadequate contact management.Low performance of one fifth of peripheral laboratories can lead to under-diagnosis of

TB and continuous transmission of the disease in the society. There is a need to strengthen



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on-site supervision by NRL.

4.3.2 Health Systems

Describe the main weaknesses of and/or gaps in health systems that affect tuberculosis outcomes.

Lack of continuum of care for migrants diagnosed with TB is a major weakness ofhealth system. The practical Approaches to Lung Health has started officially in 2006 after afeasibility study 190 physicians were trained, however there have not been supervisoryvisits planned. just limited to few health services. The PAL monitoring has not been includedin the reporting system.

Despite decrease of TB among general population, latent TB infection and active TB isbeing reported among health care staff particularly in services where TB is not suspected.Up to now no infection control risk assessment has been conducted, staff is not trained onTB-IC, effective use of natural ventilation and personal protection equipment (respirators)are not introduced. Limited education on cough etiquette is provided to patients. TBinfection control is one of the areas which needs improvement both in terms of laboratory

biosafety and development of facility standard operating procedures as well measures todecrease the risk of TB infection in health care services, particularly in Annoor Sanitariumwhere MDR-TB, potentially XDR-TB and at time drug sensitive TB patients are admitted

together.

4.3.3 Community Systems

Describe the main weaknesses of and/or gaps in community systems that affect tuberculosis outcomes.

Stigma is a major barrier in involving communities in TB control. The results of KAPsurvey that NTP conducted in 2007 by involving 275 patients diagnosed with TB showed

that 36.4% of the patients interrupted their treatment for 7 or more consecutive days and

the highest number of such patients was from south Jordan. Many of the knowledge andbehavior aspects including perceived stigma, long duration of treatment, being busy, livingfar away from facility and fear of losing job were among the causes of this non-compliancereported by the patients.

There are no community activities among migrants and refugees. The communities

of migrants are by large under-powered and self-restricted due to their fear of beingdeported. TB among these groups continues to flare-up after their arrival most probably dueto stress of new environment and their wish to save all their incomes for their families andsaving on housing and food costs. These individuals do not get any specific communitysupport.

4.3.4 Efforts to resolve weaknesses and gapsDescribe what is being done, and by whom, to respond to health and community system weaknesses andgaps that affect tuberculosis outcomes, as outlined in sections 4.3.2 and 4.3.3.

PAL is being piloted. Round five proposal has helped improving TB infection controlin the national reference laboratory.

In order to destigmatise TB, a celebrity is recruited as a TB Ambassador is recruited.In collaboration with WHO EMRO and STOP TB, a high level visit of President GoergioSampaio was arranged to sustain commitment to TB control despite financial restrictions ofthe government. ACSM activities are conducted but with limited resources.

In response to poor performance of some peripheral laboratories conducting direct

sputum smear microscopy, the programme has introduced parallel preparation and readingof sputum samples at NRL at the same time in the low performance centers. The lessonslearned shows that at least two training courses shall be organized per year to address the



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high turnover of staff.

The programme has translated in Arabic and distributed the patient charter to

highlight patients right and responsibilities.

4.4 Proposal strategy

Complete this version of section 4.4.1 if the applicant selected option 2 or 3 in section 3.1 ofthe Proposal Form

Option 2 = Transition to a single stream of funding during grant negotiationOption 3 = No transition to a single stream of funding in Round 10

4.4.1 Interventions

This section should be completed in parallel with the Performance Framework and detailed budgetand work plan

Describe the objectives, service delivery areas (SDA), and activities of the proposal. The descriptionmust be organized in that exact order and the numbering system must match the PerformanceFramework, detailed budget and work plan.

The description must identify:(a) who will implement each area of activity (e.g. Principal Recipient, Sub-recipient or other

implementer); and(b) the targeted population(s).

The proposal is structured in three objectives in line with StopTB strategy and The NationalTB Control Strategic Plan 2007-2011

Objective 1: To ensure quality DOTS for the mostvulnerable population particularly the non-Jordanianresidents

Vulnerable populations in Jordan are mainly immigrants including refugees and labormigrants, nomads and people living in poor urban and remote rural areas. There are about

1.5 million immigrants in Jordan (one in every fifth resident). Activities under this objectivewill supplement the services provided by the Ministry of health and will improve accessibilityand acceptability of services for the most vulnerable populations particularly the non-Jordanian nationals who are the most vulnerable population and face multiple barriers toaccess and use services. The proposed activities will be mainly implemented mainly by civil

society, NGOs, communities and NTP partners who have proximity to the population. Indesigning the community system strengthening (CSS) and patient-centered approaches, thelatest guidelines of GFATM, WHO and UNAIDS have been used to classify the SDAs with

inputs of NGOs and migrants.

SDA 1.1 Community System Strengthening: Human resources (skillsbuilding for service delivery, advocacy and leadership)

Target population: Migrant population, people living below poverty line, women andyouth

Indicators:



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Principle activities:

Activity 1.1.1 Conduct quality of care workshops with patients and communitiesrepresentatives - NTP, JATA and representatives of migrants, patients and/or ex-TBs andcommunities will take part in round table consultation meetings under a national committee

to discuss patient-centered approaches, patient default prevention and tracing mechanismand adapt the models of TB care in Jordan.

Activity 1.1.2 Conduct training of TB health educators who are targeting women,nomads, rural areas and poor urban JATA will train six health educators embedded inwomens groups, Youth NGOs and faith-based organizations to conduct TB health educationamong women, rural areas and poor urban to fight stigma and improve case detection andreferrals.

SDA1.2 Community System Strengthening: Community basedactivities and services delivery, use, quality

Target population: Migrant population, people living below poverty line, othervulnerable population including single mothers

Indicators:


Activity 1.2.1 Develop peer support network for migrant communities JATA willidentify and train five migrant peer- supporters per year. Peer supporters conduct monthly lectures anddistribute TB health education materials in their respective communities to combat stigma and promotepatients right. Their main task is to be focal contact for migrants particularly housemaids.

Activity 1.2.2 Provide Direct Observation of Treatment (DOT) via community

treatment supporters JATA will contract four NGOs to improve DOT with patient-centeredapproaches including home visits and/or DOT by treatment supporters for eligible patients (singlemothers, disabled patients, nomads and migrants with difficulty to access health care services; 200 peryear) in poor urban, remote rural and migrant communities.

Activity 1.2.3 Provide food supplements as an incentives and reimbursement oftravel expenses as enablers for most vulnerable patients JATA will identify eligiblepatients based on an already-developed national selection criteria (annex XX) of the social status

(including low income, unemployment, single mothers, migrants and patients from rural remote areas)and provide them with incentives and enablers to improve their adherence to treatment. To confirm the

social status, a social nurse will visit patients domicile. JATA will provide food supplements (35 USD permonth) and reimbursement of patients transport cost of 15 USD per month (200 socially eligible

patients per year).

SDA: 1.3 Advocacy, Communication and Social Mobilization

Target population: general population, policy makers, migrants

Indicators:


Activity 1.3.1 Conduct training for mass media on TB control NTP in collaboration withthe communication department of Ministry of Health will organize Media training workshops (Yrs 2 and4) for media representatives in order to educate them on the current TB issues and provide them withup-to-date TB resource kits.

Activity 1.3.2 Produce and distribute TB information and education materials Anational working group (NTP, NGOs, IOM and JATA) will develop and distribute TB health educationmaterials in different languages to increase knowledge among refugee and cross border populations and



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other population groups in the year one. Information and education materials will include 1000 flipcharts and 50,000 posters to be distributed through NGO partner networks. Additionally, 1000 footballswill also be purchased and branded with TB control messages to be disseminated through youthassociations, schools, rural communities and migrant worker groups.

SDA 1.4 Community System Strengthening: Monitoring anddocumentation of community and government interventions

Target population: Communities affected by TB

Indicators:


Activity 1.4.1 Monitoring implementation of Community System Strengtheningactivities A subgroup appointed by CCM with representatives of CBO, FBO and PR will oversightimplementation of community system strengthening activities. The subgroup will conduct desk review ofthe implementation reports and conduct quarterly site visits. The subgroup will report back their findings

and recommendations to CCM Oversight Committee.

SDA 1.5 Cross border TB care

Target population: Migrant population, asylum seekers, refugees

Indicators:


International Organization of Migration (IOM) is dealing with pre-entry screening of migrants, refugeesand asylum seekers. Once in Jordan, Iraqi refugees and asylum seekers are receiving services from IOM

clinic. Labor migrants with TB may be returned home by the company recruiting them. Under SDAs 1.1,1.2 and 1.3, the program attempts to provide care and support for these patients until they fully

recover, however some patients may opt to return to their home country while on TB treatment. Thesepatients need to have immediate access to treatment and care across the borders. Previous NTP efforts

to reach other countries NTP for transfer of patients have not resulted in any feedback from countriesreceiving patients. As the result NTP has created a separate register for temporary residents. Under this

SDA, the program will work with IOM as a sub-recipient to ensure continuity of care for patients acrossthe borders using IOM offices in different countries and regions. IOM has offices in Iraq as well as high

TB incidence countries the patients are coming from and therefore will expand its services to providecontinuation of care to TB patients internationally (150 estimated TB patients per year).

Activity 1.5.1Train IOM clinicians NTP will train five staff of IOM clinics in Jordan to transferTB suspects to NTP and follow their treatment if residing in Jordan in year 1 and year 3.

Activity 1.5.2Strengthen cross border referral system NTP and IOM will prepare referral

and transfer forms for TB patients and ensuring treatment outcomes are reported back to NTP Jordan inyear 1.

Activity 1.5.3 Contract IOM to deliver services to migrants IOM will ensure effectivehealth pre-screening of labor migrants (including TB screening) through appointed healthcenters in home country of migrants, provide DOT for asylum seekers and Iraqi refugees

with TB in Jordan and ensure transfer of data if patients are transferred to their homecountry: (60,000 USD per year from every 1 onwards).

SDA 1.6 TB laboratory network

Target population: TB suspects, TB patients

Indicators:



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Activity 1.6.1 Improve external quality control assurance of direct microscopy TBlaboratories in the periphery and laboratories in refugee camps and IOM will sendrandomlyselected slides to NRL for double checking of slides and quality control (according to WHO

EQA system) on a quarterly basis (transport cost of 1000 USD per year).Activity 1.6.2 Conduct supportive supervisory visits to peripheral laboratories NRLwill conduct supervisory visits to peripheral laboratories on a quarterly basis to conduct onthe job training of staff and improve the quality of direct sputum examination.

Objective 2: To scale up MDR-TB management, control andcare

Under this objective, NTP in collaboration with Annoor sanitarium will scale-up national MDR-TBresponse and provide treatment and care for all MDR-TB patients who are residents of Jordanirrespective of their ethnic, race, religion or nationality. Annoor Sanitarium is a Faith-based organizationwho has been providing treatment and care for patients with TB and respiratory diseases in the past fourdecades. The center has a bilateral partnership agreement with NTP and provides care for MDR-TBpatients under the GLC agreement. Under round 10 proposal, the support to procure second line drugsfrom GLC/GDF will be continued and with WHO technical assistance, NTP will scale up programmaticmanagement of MDR-TB with providing ambulatory treatment of patients. The capacity of NationalMycobacteriology Reference Laboratory will be improved to timely detect drug resistance for all residents

of Jordan.

SDA 2.1 Improving diagnosis

Target population: TB and MDR-TB suspects

Indicators:


Activity 2.1.1Establish external quality assessment NTP will establish an external qualityassurance system for mycobacteriology services by NRL with panel testing of SNRL on an annual basis.

Activity 2.1.2 Improve infection control in NRL The program will refurbish the NRL toimprove TB infection control. (procurement of two class II laminar Biosafety cabinets (18,000 USD),maintenance of biosafety cabinets (4000 USD every other year), four Ultra-Violet Germicidal Irradiation

(UVGIs) (4x680 USD), physical separation of clean and dirty zones and negative pressure ventilation(60,000 USD) in year 1.

Activity 2.1.3 Transport safely sputum samples from peripheries NTP will arrange safetransport of sputum samples for culture and DST from district laboratories, refugee camps and workplaces every quarter from year 1 onwards (1000 USD per year).

Activity 2.1.4Train NRL staff on liquid culture Three NRL staff will be trained at SNRL onliquid culture/DST in year II and year IV.

Activity 2.1.5 Procure laboratory equipment and supply for liquid culture PR willprocure MGIT equipment for liquid culture and supplies for 120 tests per year from 2011 onwards.

Activity 2.1.5 Establish Drug susceptibility testing to second line drugs NRL in closecollaboration with SNRL will introduce drug susceptibility testing to second line anti-TB drugs from 2013onwards.

Activity 2.1.6Provide external technical assistance An external laboratory consultant willvisit NRL and provide technical assistance on an annual basis.

SDA 2.2 Provision of quality assured second line drugs

Target population: MDR-TB patients



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Indicators:


Activity 2.2.1 Procure second line drugs PR will procure second line drugs from GLC/GDF

mechanism for 20 X/MDR-TB patients per year.

SDA 2.3 Programmatic management of Drug resistant TB

Target population: MDR-TB suspects, MDR-TB patients

Indicators:


Activity 2.3.1 Provide external technical assistance PR will ensure technical assistancefrom WHO/GLC appointed expert on annual basis (one visit per year).

Activity 2.3.2Develop Standard Operating Procedures for MDR-TB case managementIn consultation with WHO, GLC and Annoor Sanitarium, NTP will finalize standard operating procedurefor ambulatory care for MDR-TB patients in year 1.

Activity 2.3.3 Train staff responsible for ambulatory care of MDR-TB patients NTPwill train 15 staff of MDR-TB ambulatory units per year on case holding, side effect management andfollow-up of MDR-TB patients.

Objective 3: To improve health system response to TBcontrol

SDA 3.1 TB in workplace

Target population: Workers working in manufacturing factories (mainly labor

migrants from high TB incidence countries)

Indicators:


Activity 3.1.1 Map the potential sites for TB in workplace NTP and governorate TBcoordinators will map the factories with more than 500 workers where mainly labor migrants areworking in year two. The mapping exercise includes the following variables: number of workers,percentage of labor migrants, health care and health insurance status of workers and identify contact

persons in each workplace. (2000 USD per governorate).

Activity 3.1.2 Study visit to successful models of TB in workplace Three staff (NTP andJATA) will participate in a study visit to a country with successful models of TB in workplace year 1.

Activity 3.1.3 Develop feasible model of TB in workplace A working group from NTP, NGOand private sector responsible for workplace will establish a model of collaboration (modus operandi) in

year 2.

Activity 3.1.4 Train TB in workplace Focal Persons In collaboration with the private sector,JATA, NTP and IOM will select and train TB focal persons in each workplace (three people in eachworkplace) in year 2.

Activity 3.1.5Conduct TB health education campaigns in workplace TB Focal Personsin workplace in collaboration with the private sector will conduct TB health education campaigns with

emphasis on early referral of TB suspects, importance of timely start of treatment and full treatment ofpatients on a quarterly basis. TB focal persons will provide TB patients with patients charter,

emphasizing on their right and responsibilities regardless of race, ethnic group, nationality or



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background.

Activity 3.1.6 Establish DOT in workplace or via appointed private sector Incollaboration with three major workplaces, NTP will pilot directly-observed treatment of workers with TBincluding the labor migrants in the year 2. Treatment will be provided by the private sector appointed by

the factory or the trained focal person on a home-based care.

Activity 3.1.7 Assess the pilot DOT in workplace A team of national and internationalconsultants will assess the pilot models of TB in workplace in year 3.

Activity 3.1.8 Organize national orientation workshop NTP will organize a nationalorientation workshop to share the results of TB in work place pilot implementation with other factorymanagers in year 3.

Activity 3.1.9Expand TB in workplace model NTP will expand the model of TB in workplaceto 15 more factories from year 3 to 5.

SDA 3.2 TB in Children

Target population: children (below 12 years old)

Indicators:


Using the existing national team on Integrated Management of Childhood Illnesses (IMCI), the GFATM

project will include TB in the curriculum and train the trainers.

Activity 3.2.1 Include TB in Integrated Management of Childhood Illnesses NTP willinclude TB in the curriculum of Integrated Management of Childhood Illnesses (IMCI) and adapt thenecessary recording and reporting forms and monitor the referral of TB suspects (latent TB and activeTB) from NTP and non NTP treatment providersin year 2.

Activity 3.2.2Train national IMCI trainers NTP will train national IMCI trainers (11 trainers)

and four trainers from UNRWA in year 2.Activity 3.2.3 Train health care providers on TB in children Trainers will conduct two-daytraining courses of staff of public health care units (150 staff per year) from year 2 onwards.

Activity 3.2.4 Monitor progress of improved TB case detection and management

among children NTP will conduct quarterly follow-up supervisory visits to primary health carecenters and UNRWA from year 2 onwards.

SDA 3.3 Practical Approaches to Lung Health

Target population: Individuals above five years of age with respiratory symptoms

Indicators: number of primary health care facilities with at least one physician trained in PAL over

total number of PHC facilities in Jordan TO ADD HERE (VAN AND NADIA)


NTP will scale up PAL started under round 5 and ensure a robust follow up system.

Activity 3.3.1. A national awareness and advocacy and expansion planning one daymeeting Participants: representatives: (2) form MOH, (2) from NTP, (12) from governorate healthdirectorates, (12) from supervisory officers from health directorates, members of national PAL workinggroup, (1) representative from UNWRA, (1) from Health Management Information System (HMIS), (1)from responsible from pharmaceuticals and one from IMCI. (Year 1, Q1). The outcome of this meeting isnomination of the PAL planning group and operationalization group.

Activity 3.3.2 meetings of PAL planning group Group is composed of 8 members asnominated by the meeting under 3.3.1. Meetings should hold three times, two meetings in two months.

The outcome should be an elaborated draft of a strategic national expansion PAL (end of Q1 beginning



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Q2 of first year).

Activity 3.3.3 National meeting to operationalize and discuss the draft of strategic

PAL expansion plan Participants: (2) from NTP, (2) from MOH, (12) TB governorates coordinatorsand (12) primary health care appointees (appointed by the head of the general directorate, as in 3.3.1).The outcome will be a specific implementation and training plan specifying roles and responsibilities of

local district level including supervision of PAL relevant quality implementation. This also encompassesthe widely agreed introduction of pal indicators and the harmonization of pal relevant R&R with theexisting HMIS (health management and information system). To help ensure high quality PALimplementation, travel allowances for supervisory teams should be guaranteed. The actual allowancedepends on the average distance traveled and the frequency of supervisory visits (Q2 of first year).

Activity 3.3.4 national PAL expansion plan endorsement meeting: Participants:representatives: (2) form MOH, (2) from NTP, (12) from health directories, (12) fromsupervisory officers from health directories, members of national PAL working group, (1)representative from UNWRA, (1) from HMIS, (1) from essential drug list and one from IMCI.

One-day meeting in Q3 of year one to endorse the operationalized plan.

Activity 3.2. Updating the PAL national guideline, the PAL training materials anddeveloping PAL posters

Members of the national working group plus representatives of: academia, Jordanian

thoracic association, army, primary health care, pediatricians, health safety directorate ofMOH (year 1 Q3, after endorsement of the expansion plan see, activity 3.3.4)

To consider external TA for 3.2 activity

Activity 3.2.1 printing the updated PAL guideline in sufficient number (2000 copies,end of Q3 and beginning of Q4, year 1).

Activity 3.2.2 printing of PAL posters in sufficient number (1000 copies, end of Q3 and

beginning of Q4, year 1)

Activity 3.2.3 procuring PAL equipment: peak flow meters (2000), spirometers (12), to

cover primary health facilities with peak flow meters and TB centers with spirometers. (Q1,year1).

Activity 3.3

PAL training

i. Trainer of trainers: training of additional trainers conducted by theNTP: 12 from the chest NTP centers at governorate level, 12 heads ofhealth governorate directorates or their appointees, plus 12 heads ofcomprehensive health centers of different governorates. (one sessionin Q4 year1 and the second session in Q1 year2).

ii. Cascade training by trainers (continuation of 3.3.1) as outlined innational PAL expansion plan (endorsed under activity 3.3.4). To train1000 physicians in three years (years 2 to year 4 inclusive).Participants will receive updated guidelines, wall display posters andpeak flow meters, which were developed under activities 3.2.1 to3.2.3.

Activity 3.3.1 Conduct supervisory visits NTP will conduct supportive supervisoryvisits to centers to monitor the progress of implementation on a quarterly basis.

Activity 3.3.2 Improve recording and reporting system NTP will integrate the PALrecording and reporting to the national health information system in year I.



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Activity 3.3.3 Train newly recruited staff NTP trainers and Chest Physician associationwill train other physicians to scale up PAL (120 staff per year).

SDA 3.4 TB in prisons

Target population: prisoners

Indicators:


Activity 3.4.1Introduce TB health education materials for prisoners NTP incollaboration with the Ministry of Interior will develop and distribute health education materials forprisoners.

Activity 3.4.2 Train health care staff and wardens Every year NTP will train 10 prisonhealth staff on TB infection control, early referral of TB suspects, sputum collection andDirect Observation of Treatment every year and train 20 wardens per year on TB infectioncontrol and communication skills with patients.

Activity 3.4.2Conduct supervisory visits NTP will conduct supportive supervisory visitsto prisons to monitor the progress of implementation on a quarterly basis.

SDA 3.5 TB Infection control

Target population: General population, health care staff, prisoners and prisonwardens

Indicators:


Under this SDA, the program will introduce modern infection control policies and practices,the latest WHO and CDC guidelines will be used.

Activity 3.4.1Develop National guidelines on TB Infection control A national workinggroup will develop national guidelines for TB-IC for Jordan based on the 2009 WHOguidelines in the year I.

Activity 3.4.2Establish TB surveillance among health care staff NTP will introducesurveillance of TB among health care workers from year I onwards.

Activity 3.4.3Train staff on TB-IC WHO will conduct training of three national trainers

on TB-IC, trainers will train 2 staff per governorate on TB-IC risk assessment and differentlevels of TB-IC from year II onwards

Activity 3.4.4 Conduct facility TB-IC risk assessments governorate TB coordinatorswill conduct facility TB-IC risk assessment in their respective governorates from year II

onwards and recommend measures to decrease the risk of TB infection in health carefacilities.

Activity 3.4.5 Procure TB-IC related equipment and supplies PR will procureequipment to measure airflow and air changes per hour and 20 shielded UVGI (14 for TBcenters+ 6 for MDR-TB patient facility Annoor), respirators (N95 or FFPII certified, 3respirators per staff working with TB patients per month) and qualitative respiratory fit

testing kit (five) in year I and III.

Complete this version of section 4.4.1(a) (b) and (c) if the applicant selected option 1 in section3.1 of the Proposal Form

Option 1 = Transition to a single stream of funding by submitting a consolidated disease proposal



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4.4.1 Interventions

This section should be completed in parallel with the Consolidated Performance Framework anddetailed budget and work plan

(a) Overview of programmatic activities

Describe the objectives, service delivery areas (SDA), and activities of the consolidated diseaseapplication. The description must be organized in that exact order and the numbering system mustmatch the Consolidated Performance Framework, detailed budget and work plan.

The narrative description of the Round 10 interventions should reflect all objectives, service deliveryareas (SDAs), and activities in the Round 10 consolidated disease proposal, but distinguish between whatprogramming is being continued from existing grants versus new programming for Round 10.

The description must identify:(1) who will implement each area of activity (e.g. Principal Recipient, Sub-recipient or other

implementer);(2) the targeted population(s);

(3) what changes in implementation and/or the targeted population(s) have occurred, if any, for thoseelements which are from existing grants and continuing in this consolidated disease proposal;(4) any links between the existing grant activities to be continued in the consolidated disease proposal,

as these activities previously existed in separate grants;(5) any links between the proposed activities and existing Global Fund grants for other diseases or HSS;

and(6) how duplication will be avoided if there are linkages identified in points (4) and (5) above.

FOUR - EIGHT PAGE MAXIMUM

(b) Changes to existing SDAs, programmatic activities, indicators and targets

In the table below, list the SDAs and activities of existing grants consolidated within the Round 10consolidated disease proposal. Explain whether each SDA and activity from an existing grant will beincluded in the Round 10 consolidated disease proposal by indicating an increase in scale, decrease inscale, continuation without change, or discontinuation. Provide justification for any proposed changes ordiscontinuation.

The proposed changes should be clearly and systematically reflected in the Consolidated Performance Framework

Round #

Service

DeliveryArea(SDA

)

Activity

Proposed

changeJustification for change

useTabkeytoaddextra

rows



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(c) Changes to existing impact or outcome indicators and targets

Describe any major changes in indicators and targets that may have occurred due to theprogramming described above in sections (a) and (b) and that is supported by the ConsolidatedPerformance Framework. In particular, if there has been discontinuation or change in indicatorsor if targets have been changed between previous grants and the Round 10 proposal, describe

why this has occurred.

ONE PAGE MAXIMUM

4.4.2 Addressing weaknesses from a previous category 3 proposal

If relevant describe how the weaknesses identified in the TRP Review Form of a previouscategory 3 proposal have been addressed.

TWO PAGE MAXIMUM

4.4.3 Lessons learned from implementation experience

How do the implementation plans and activities described in 4.4.1 above draw on lessons learned fromprogram implementation (from either Global Fund financed or non-Global Fund financed programs)?

Implementation of round five grant has shown that there is a need for a sound cross border TB control.For the GLC cohort of 2007, out of 19 MDR-TB cases among non nationals, 5 are said they moved back totheir own countries and three are lost to follow-up in Jordan, this shows that MDR-TB management shallbe accompanied with a strong cross border collaboration with NTPs, civil societies and organizationsinvolved in TB care in home countries of migrants, otherwise NTP efforts will be lost.

The principal experience has a track record experience in implementing GFATM proposal withtransparent and efficient manner.

Lessons learned from GFATM round five has shown that NTP and the Ministry of Health can notaddress the complex problem of TB in Jordan by themselves, there is a need for involvement ofcivil society and strengthening community system.

The lessons learned has shown that provision of services, does not mean that the populationparticularly the most vulnerable ones would necessarily use the services. In order to improveaccessibility, acceptability and equity, patients perspectives and key elements of support andcare need to be taken into account in the planning and provision of services.

In addition strong TB control for only Jordanian nationals shall not be a reason for complacency.For humanitarian reasons as well as public health reasons, TB control among migrants and refugeesneed to be improved with involving representatives of these communities.

4.4.4 Enhancing TB/HIV collaborative activitiesDescribe:(a) how the proposal will contribute to strengthening TB/HIV collaborative activities; and(b) the collaboration between the National TB program and the HIV services of your country.

TB and HIV programmes are functioning in close collaboration. All TB patients are offeredHIV testing and counseling in the last three years no HIV positive case among TB patients

have been found. Active TB case finding is in place among PLWH.

4.4.5 Enhancing social and gender equality

Using specific references to objectives, SDAs, and activities included in section 4.4.1, explain how the

Under the SDA number xxx, Women Education council will be further involved to mobilize



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Only complete section 4.4.7 if the applicant selected Option 2 or 3 in section 3.1 of the ProposalForm, DO NOT COMPLETE section 4.4.7 if the applicant selected Option 1 in section 3.1 of theProposal Form

Option 1 = Transition to a single stream of funding by submitting a consolidated disease proposalOption 2 = Transition to a single stream of funding during grant negotiation

Option 3 = No transition to a single stream of funding in Round 10

4.4.8 Links to non-Global Fund resources

Describe whether the Round 10 interventions (e.g. goals, objectives, SDAs, and activities) listed insection 4.4.1 have linkages to programs financed through non-Global Fund resources. If such linkagesexist, list the non-Global Fund financed programs and their activities, and explain how the proposalcomplements those programs and activities. In addition, explain how the Round 10 interventions do not

duplicate existing programs and activities supported by non-Global Fund resources.

The activities under this proposal are not funded by other non-Global Fund resources. The activities of thecurrent proposal are complementary to improve care.

The Global Fund Round 10 Proposal Form Single: Sections 3-5 Tuberculosis

4.4.7 Links to other Global Fund resources

Describe in the table below the linkages between this Round 10 proposal and existing Global Fundresources. It is important to list the SDAs and activities as outlined in the current proposal in the lefthand column, add a description as to how they relate to previous grants in the middle two columns, andthen outline how the Round 10 proposal specifically addresses this in the right-hand column.

Key SDA and activity as proposed in theRound 10 proposal

Existing grants

Round 10 Proposal

Round five [insert Round #]

1. SDA

1.1 ActivityPAL Expansion of PAL

1.2 Activity

2. SDA

2.1 ActivityMDR-TB Programmatic

management of drugresistantTB

3. SDA

3.1 ActivityACSM Expansion of ACSM

3.2 Activity

use Tab key to add extra rows

23


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4.4.9 Strategy to mitigate unintended consequences of additional program support on healthsystems

Describe:

(a) the potential risks and unintended consequences on health systems that may result from the

implementation of the proposal; and(b) the proposed strategy for mitigating these potentially disruptive consequences.

(a) Home based care if not carefully planned may weaken the status of health care services and patientsacceptability of the existing ambulatory health structure.

(b) The activities under this proposal have been planned in such a way to provide a sound balance ofhome-based care and use of ambulatory services by patients. Only eligible patients are provided withhome based care.

4.5 Program Sustainability

4.5.1 Strengthening capacity and processes in tuberculosis service delivery to achieveimproved health and social outcomes

Describe how the proposal contributes to overall strengthening and/or further development of public,private and community institutions and systems to ensure improved tuberculosis service delivery andoutcomes.

If available, refer to country evaluation reviews

Support explanation with excerpts from documents that the country has adopted, identifying the source, such as a NationalDisease Strategy

The National TB strategic plan (annex 1) provides evidence on the Ministry of Health and NTPs vision onsustainability of activities.R10 proposal will strengthen the capacity of the programme to address the

challenges with training of staff, updating pre-service and in-service training curricula.

4.5.2 Alignment with broader developmental frameworks

Describe how the proposals strategy aligns with broader developmental frameworks such as:

Poverty Reduction Strategies;

The Highly-Indebted Poor Country (HIPC) initiative;

The Millennium Development Goals; An existing national health sector development plan;

Any other important initiatives.

ONE PAGE MAXIMUM

4.5.3 Improving value for money

Explain how the program that the proposal contributes to represents good value for money. Specifically,given the context of the epidemic in the country and the definition of value for money provided in theGuidelines, describe how the key interventions in the proposal represent the best balance of costs andeffectiveness, with consideration to the desired achievement of both short and long term impacts.

Cost-effective interventions are planned to provide best value for money in this proposal. Thoughsome of the interventions are expensive (such as treatment of MDR TB) they can be considered efficient

in a longer term, since will contribute to preventing spread of drug resistant TB forms.The interventions outlined in this proposal imply comprehensive approach in TB control aiming to

reduce burden of disease. It is deemed that this approach will contribute to longer-term effects of the



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program to be implemented at the national level.

ONE PAGE MAXIMUM



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4.6 Monitoring and Evaluation System

4.6.1 Impactand outcomemeasurement systems

Describe the impact and outcome measurement systems, including strengths and weaknesses, used to measure achievements of the program at impact andoutcome level.

Conducting TB prevalence survey study to measure impact of interventions would be very costly and therefore the National TB Control Program will useepidemiological data and recording and reporting to measure the trend in TB notification and TB mortality as proxies for impact. Concerning the outcomes,these data are readily available with number of TB patients identified and number of patients who will be successfully treated. The major weakness ofimpact measurement is those service deliveries considering non Jordanians, as NTP data recording and reporting has not been developed to capture them.NTP will improve its recording and reporting to ensure outcome indicators among all groups of patients including migrants may be captured. ONE PAGEMAXIMUM

4.6.2 Impact and outcome measurement

(a) Has impact and/or outcomedata been collected in the last2 years?

Yes

answer section4.6.2 (b)

No

go to section4.6.2 (c)

(b) What was the source(s) ofthe measurement?

insert source(large scale surveys,demographic surveillance, vital registrationsystems, other)

(c) It is important to guarantee that there are systems in place to measure all impact and outcome indicators in the performance framework. In order todo this, fill in the table below, fully describing all planned surveys, surveillance activities and routine data collection in country used to measureimpact and outcome indicators relevant to the proposal. Add rows as needed.

Data Source FundingYears of Implementation Impact/Outcome Indicators

relevant to the proposal to bemeasured by data source

2011 2012 2013 2014 2015

Source 1(large scale surveys,

demographic surveillance, vitalregistration systems, other)

Total cost

Secured funding amount and funding source

Funding gap

Round 10 funding request for Source 1



Total cost


Funding gap




Total cost


Funding gap




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4.6.3 Links with the National M&E System

(a) Describe how the monitoring and evaluation (M&E) arrangements in the proposal (at the PrincipalRecipient, Sub-recipient, and other levels) use existing national indicators, data collection tools andreporting systems including reporting channels and cycles.

The key indicators and their definitions are selected from the internationally approved lists andsources developed by WHO and Stop TB Partnership. In particular, Monitoring and Evaluation Toolkit forHIV/AIDS, Tuberculosis and Malaria (Interagency guidelines, Second Edition, January 2006) was used asreference. Output and process indicators were developed in line with the Service Delivery Area andActivities included in the proposals Workplan.

The selected indicators are among those which are used routinely by the National program. NTPand JATA will be responsible for monitoring and evaluation of the Round 10 project. The M&E team willwork closely with National TB Control Program, National Health Information Service and other nationaland international counterparts. ONE PAGE MAXIMUM

(b) Are all of the M&E arrangements planned for the proposal

using the national M&E system?

Yes

go to section4.6.4

No

continue tosection 4.6.3 (c)

(c) If no, explain why not and list any service delivery areas (SDAs) and/or activities that will not bemonitored through the national M&E system.

ONE PAGE MAXIMUM

4.6.4 Strengthening monitoring and evaluation systems

(a) Has a multi-stakeholder national M&E assessment been

recently conducted (in last 2 years)?

Yes

continue tosection 4.6.4 (b)

No

go to section 4.7

(b) If yes, has a costed M&E action plan been developed orupdated to include identified M&E strengthening measures?

Yes

continue tosection 4.6.4 (c)

No

go to section 4.7

(c) Describe whether the proposal is requesting funding for any M&E strengthening measures. Thesestrengthening measures may have been identified through a national M&E assessment or any otherrelevant evaluation or review process.

HALF PAGE MAXIMUM



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associated with TB

IOM TB control among migrants, TB health education among migrants

Annor Sanitarium a Christian charity foundation has been supporting treatment of patients withMDR-TB for the last decade. The current proposal envisage supporting them for MDR-TBmanagement.

(f) If the private sector and/or civil society are not involved as Sub-recipients in implementation, oronly involved in a limited way, explain why.

Chest Disease Society in training activities and guidelines development (Childhood TB guidelines)

Faculty of Medicine in Amman and Erbid in operational research

4.7.3 Sub-recipients to be identified

Describe:

(a) why some or all of the Sub-recipients are not already identified; and

(b) the transparent, time-bound process that the Principal Recipient(s) will use to select Sub-recipientsand not delay program performance.

ONE PAGE MAXIMUM

4.7.4 Coordination between or among implementers

Describe:

(a) how coordination will occur between multiple Principal Recipients if there is more than onenominated Principal Recipient for the proposal; and

(b) how coordination will occur between each nominated Principal Recipient and its respective Sub-

recipient to ensure timely and transparent program performance.

(a) MOH and JATA as two principle recipient will meet on a monthly basis and more often ifneeded to ensure coordination of activities. Both MOH and JATA are members of CCM. The CCM willmonitor the project progress to ensure that the activities are carried out according to the workplan andindicators of programmatic and financial performance are accomplished. It will make the key financialand programmatic decisions and will have the responsibility to address the main problems and challengesrelated to the project.

(b) Each of PRs have direct contact with their subrecepients. Since the tasks of each PR isdifferent coordination among stakeholders are quite straightforward. In addition a quarterly meeting ofall SRs and PRs will be held to discuss implementation progress (just a day before CCM meeting).The CCMmeetings will be convened quarterly or more often as necessary. Technical working groups for each

component will work with the stakeholders between the CCM meetings and prepare the documentation tobe endorsed by the CCM. The CCM and the Ministry of Health will carry out the role of coordination withother programmes and development initiatives. The CCM will ensure practical coordination andcollaboration with all local partners involved.

TWO PAGE MAXIMUM

4.7.5 Strengthening implementation capacity

(a) The applicant is encouraged to include a funding request for management and/or technical assistanceto achieve strengthened capacity and high quality services, supported by a summary of a technicalassistance (TA) plan based on the indicative percentage range in the Guidelines. In the table belowprovide a summary of the TA plan.

Refer to the Strengthening Implementation Capacity information note for further background and detail

http://www.theglobalfund.org/documents/rounds/10/R10_InfoNote_TA_en.pdfhttp://www.theglobalfund.org/documents/rounds/10/R10_InfoNote_TA_en.pdf


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Managementand/or technicalassistance need

Management and/ortechnical assistanceactivity

Intended beneficiary ofmanagement and/ortechnical assistance

Estimatedtimeline

Estimated cost

same asproposal currency

add extra rowsas needed

(b) Describe the process used to identify the assistance needs listed in the above table.

HALF PAGE MAXIMUM

(c) If no request for management and/or technical assistance is included in the proposal, provide ajustification below. Or, if the funding request is outside the indicative percentage range, provide ajustification below.

HALF PAGE MAXIMUM

4.8 Pharmaceutical and Other Health Products

4.8.1 Scope of Round 10 proposal

Does the proposal seek funding for any pharmaceuticaland/or health products?

Yes go to section 4.8.2

No skip the remainder of section 4.8

4.8.2 Table of roles and responsibilities

Function

Name of theorganization(s)

responsible for thisfunction

Role of theorganization(s)

responsible for thisfunction

Does theproposalrequest

fundingfor

additional staff

ortechnica

lassistanc

e?

indicateYes or No

Procurementpolicies, systems,

and planning



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4.8.2 Table of roles and responsibilities

Intellectualpropertyregulations

Quality assurance

and quality control

Management andcoordination more detailsrequired in section4.8.3

Product selection

ManagementInformationSystems (MIS)

Forecasting

Storage andinventorymanagement more detailsrequired in section4.8.4

Distribution toother stores andend-users more detailsrequired in section4.8.4

Ensuring rationaluse and patientsafety

Pharmacovigilance

Drug resistanceSurveillance



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4.8.3 Past management experience

Describe the past experience of each organization that will be involved in managing pharmaceutical andother health products.

Organization name Short description of management experience

Total value procuredduring

last financial year same currency as proposal

use the Tab key to add extrarows

4.8.4 Alignment with existing systems

1.1.1 Describe how the proposal uses existing country systems for the management of the additionalpharmaceutical and health product activities that are planned, including pharmacovigilance and drugresistance surveillance systems. If existing systems are not used, explain why.

ONE PAGE MAXIMUM

4.8.5 Storage and distribution systems

(a) Whichorganization(s) have primaryresponsibility to provide

storage and distributionservices under the proposal?

tick thecorresponding boxes to theright and enter the name ofthe organization(s)

National medical stores or equivalent

specify

Sub-contracted national organization(s)

specify

Sub-contracted international organization(s)

specify

Other:

specify

(b) For storage partners, what is each organization's current storage capacity forpharmaceutical and health products? If the proposal represents a significant change in the volumeof products to be stored, estimate the relative change in percent, and explain what plans are inplace to ensure increased capacity.

The Ministry of Health is responsible for customs clearance, storage and inventory management ofdrugs and other health commodities and products within the National TB Program, including those to besupplied with the Global Fund support. The procedure of airport storage, customs clearance and pickupby the NTP CO has been functioning properly.

ONE PAGE MAXIMUM

(c) For distribution partners, what is each organization's current distribution capacity forpharmaceutical and health products? If the proposal represents a significant change in the volumeof products to be distributed or the area(s) where distribution will occur, estimate the relativechange in percent, and explain what plans are in place to ensure increased capacity.

The NTP has established reliable practices of distribution of drugs and other health products to allTB service facilities. Drugs and supplies are dispensed to the service delivery sites including the

penitentiary system on a quarterly based on the peripheral stock monitoring data. All treatment deliverysites use standard drug management and stock monitoring documentation according to DOTS.

The Global Fund Round 10 Proposal Form Single: Sections 3-5 Tu

Documents

Jordan R10 Proposal Single 3-5 TB en Version 1 August 2010