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1 RAPID ASSESSMENT OF THE TECHNICAL SUPPORT NETWORK PROVIDED BY THE WORLD HEALTH ORGANIZATION TO THE REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME IN INDIA August 2016 This publication was produced for review by the United States Agency for International Development. It was prepared by Raj Mohan Singh, Health Finance and Governance Project, and Kenneth G. Castro through the Intergovernmental Personnel Act (IPA) agreement between USAID and Rollins School of Public Health, Emory University.

2 The Health Finance and Governance Project USAID s Health Finance and Governance (HFG) project helps to improve health in developing countries by expanding people s access to health care. Led by Abt Associates, the project team works with partner countries to increase their domestic resources for health, manage those precious resources more effectively, and make wise purchasing decisions. The five-year, $209 million global project is intended to increase the use of both primary and priority health services, including HIV and AIDS, tuberculosis, malaria, and reproductive health services. Designed to fundamentally strengthen health systems, HFG supports countries as they navigate the economic transitions needed to achieve universal health care. August 2016 Cooperative Agreement No: AID-OAA-A Submitted to: Neeta Rao, Project Management Specialist Strategic Information and Policy Health Office USAID/India Recommended Citation: Singh, Raj Mohan and Kenneth G. Castro. August Rapid Assessment of the Technical Support Network Provided by the World Health Organization to the Revised National Tuberculosis Control Programme in India. Health Finance & Governance Project, Abt Associates Inc., Bethesda, MD. Abt Associates Inc Montgomery Avenue, Suite 800 North Bethesda, Maryland T: F: Avenir Health Broad Branch Associates Development Alternatives Inc. (DAI) Johns Hopkins Bloomberg School of Public Health (JHSPH) Results for Development Institute (R4D) RTI International Training Resources Group, Inc. (TRG)

3 RAPID ASSESSMENT OF THE TECHNICAL SUPPORT NETWORK PROVIDED BY THE WORLD HEALTH ORGANIZATION TO THE REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME IN INDIA DISCLAIMER The authors views expressed in this report do not necessarily reflect the views of the United States Agency for International Development, the United States Government, or Rollins School of Public Health, Emory University.

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5 CONTENTS Acronyms... iii Acknowledgments...v Executive Summary... vii 1. Introduction Background Context of the Assessment WHO s TSN Technical Assistance to RNTCP Assessment of WHO s TA to the RNTCP through the TSN Methodology Desk Review of Key Documents Key Informant Interviews with Stakeholders Self-administered Online Survey Questionnaire for TSN Consultants Focus Group Discussions Case Study Analytical Methods Limitations of the Rapid Assessment Key Findings Performance of TSN Consultants against the Current ToRs Scale of TSN TA Provision by the TSN Accomplishments of TSN Perceived Strengths and Attributes of TSN Perceived Challenges and Weaknesses in TSN Future of TA through TSN Case Study: Illustrating the Contribution of WHO-RNTCP TSN Conclusion and Recommendations Proposed Recommendations Scenarios for Future Consideration Next Steps...21 Annex A. Scope of Work for the Rapid Assessment List of Tables List of Figures Annex B: List of Key Informants Annex C. Self-administered Questionnaire for TSN Consultants Annex D. Structured Questionnaire for Focus Group Discussions Annex E. Main Findings: Evaluation of Tuberculosis Program in India (USAID 2011) Annex F. List of Peer-Reviewed Articles Published by TSN Since Annex F. References Table ES-1. Proposed Recommendations... ix Table 1. Key Sources of Information for the Rapid Assessment...7 Table 2. Focus Areas for India s Investment Package in the Global Plan to End TB Figure 1. WHO s Technical Assistance to RNTCP through the TSN...5 i

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7 ACRONYMS BMGF CBNAAT CDC CTD DDG DFID DOTS DTO Global Fund GoI HoD ICMR IVRS JMM M&E MDR-TB M/XDR TB NACO NFM NGO NPO NPSP NSP PMDS PMDT PPM RNTCP SDGs SSA STCI STDC STO TA TB TOG Bill and Melinda Gates Foundation Cartridge-Based Nucleic Acid Amplification Test (Xpert MTB/RIF) United States Centers for Disease Control and Prevention Central TB Division (India) Deputy Director General Department for International Development (United Kingdom) Directly Observed Therapy, Short Course District Tuberculosis Officer The Global Fund to Fight AIDS, Tuberculosis and Malaria Government of India Head of Department (in Medical Colleges) Indian Council for Medical Research Interactive Voice Response System Joint Monitoring Mission Monitoring and Evaluation Multidrug Resistant Tuberculosis Multi/Extensively Drug Resistant Tuberculosis National AIDS Control Organisation (India) New Funding Model Nongovernmental Organization National Professional Officer (WHO) National Polio Surveillance Programme National Strategic Plan Performance Management Development System Programmatic Management of Drug-Resistant Tuberculosis Public-Private Mix Revised National Tuberculosis Control Programme United Nations Sustainable Development Goals Special Services Agreement Standards for TB Care in India State Training and Demonstration Centre State Tuberculosis Officer Technical Assistance Tuberculosis Technical and Operational Guidelines iii

8 ToR TSN UATBC USAID WCO-India WHO XDR-TB Terms of Reference Technical Support Network Universal Access to Tuberculosis Care United States Agency for International Development World Health Organization Country Office for India World Health Organization Extensively Drug-resistant Tuberculosis iv

9 ACKNOWLEDGMENTS This rapid assessment was made possible by the support of the United States Agency for International Development s (USAID) Health Finance and Governance (HFG) Project. Abt Associates, which implements the HFG project in India, supported the services of Dr. Raj Mohan Singh, the senior public health consultant commissioned for the assessment. The second principal contributor, Professor Kenneth G. Castro, Senior TB Technical Advisor to USAID, Global Heath Bureau, Infectious Diseases Division, Washington, DC, was supported under an existing Intergovernmental Personnel Act (IPA) agreement between USAID and Rollins School of Public Health, Emory University. We gratefully acknowledge reviews and input by Carlos Avila, Lysander Menezes, Health Finance and Governance Project, Oommen George, and also the support provided by Matthew Bodie with the design, administration, and analysis of the online questionnaire. We are also grateful for the support extended by USAID/India, the World Health Organization (WHO), the Central TB Division (CTD) of the Government of India, State and District TB Officers and their staff, and the consultants working at WHO s Technical Support Network (TSN) for the Revised National Tuberculosis Control Programme (RNTCP). Thanks are also due to the various partner organizations who shared their valuable time and experience and provided insights that were critical to understand the scope of the WHO-RNTCP TSN s support for RNTCP activities in India, the achievements as well as the gaps and challenges faced, and the efforts undertaken to overcome the challenges and to inform the future direction and sustainability of the network. v

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11 EXECUTIVE SUMMARY India has made bold commitments to tuberculosis (TB) elimination, which are reflected in its ambitious goal of universal access to TB care under the National Strategic Plan (NSP) for Tuberculosis Control ( ) and under the international End TB Strategy of the World Health Organization (WHO) and Sustainable Development Goals (SDGs) of the United Nations. Delivering on these ambitious objectives necessitates a renewed look at the technical assistance (TA) architecture that has supported the country s Revised National Tuberculosis Control Programme (RNTCP) and the future of the TA delivery framework to meet emerging needs and priorities. Since 1999, the WHO Country Office for India (WCO-India) has been providing TA to the RNTCP through its Technical Support Network (TSN), which comprises consultants who work in coordination with the central and state governments in India to strengthen RNTCP activities through technical support in planning, training, surveillance, and monitoring and evaluation (M&E). Over the past 17 years, the funding support for the TSN has been provided by external donors, including a World Bank loan to WHO, Canadian International Development Agency (CIDA), U.K. Department for International Development (DFID), USAID, Bill and Melinda Gates Foundation (BMGF), and the Global Fund. This rapid assessment of was undertaken to provide an independent assessment of the perceived value of the WHO-RNTCP TSN and identify the factors affecting its performance as well as to draw forward-looking lessons and make recommendations to inform the other future options for TA activities. The assessment examined the need and scale for TA from the WHO-RNTCP TSN to support TB control activities in India, the performance of TSN consultants against their current terms of reference (ToRs), and their role and usefulness considering the changing context of TB in India. Based on the findings and observations, the assessment team made recommendations for the long-term sustainability of the TSN, the possible modalities for transition, and the future TA needs. Methodology The rapid assessment was carried out during July 1 August 5, 2016, using a mixed-methods approach. It entailed desk analysis of reports, circulars, orders, and other administrative tools related to the WHO-RNTCP TSN; analysis of countrywide data on the TA, based on responses elicited from the consultants within the TSN; field visits and interviews with key informants; reviews of past evaluations; interviews with WHO and RNTCP staff, national program managers, and other key stakeholders; and an in-depth case study. To assess the perceived value of the TSN, the evaluation team relied on information from key informant interviews (KIIs), mostly of persons outside the TSN. TSN consultants were interviewed to gain an understanding of their perspective and practices related to the TORs, priority-setting mechanisms, performance assessments, the role of the outsourced human resources agency, and job satisfaction. The evaluation team comprised two independent consultants (RMS and KGC) who conducted initial planning meetings with WHO, India s Central TB Division (CTD), and USAID/India; prepared an overall framework that was reviewed and approved by the stakeholders; and carried out a series of field visits, focus group discussions with TSN consultants, and standardized key informant interviews in Delhi, Uttar Pradesh, and Maharashtra. This information was complemented by responses from a self-administered questionnaire sent to all TSN consultants, who were asked about the extent to which they follow ToRs, the proportion of time they devote to different activities, and examples of contributions they make outside of their ToR duties. Key Findings The most important finding of the assessment pertains to the crucial role the WHO-RNTCP TSN plays in the planning, implementation, and monitoring of the RNTCP, from the national level to program activities in the field (states and districts). At the time of this assessment, the WHO-RNTCP TSN had 10 national consultants providing support at CTD and 50 consultants working in the field to link the state and district program units with national and international program strategy and operational and technical guidelines. There were 33 vacant consultant positions 25 field medical consultants, 5 regional consultants, and 3 CTD consultants. The network s consultants assigned to field positions have been successful in meeting the various TA needs required for implementation of the strategy to identify and cure persons with TB and for M&E of program vii

12 performance. Flexibility to meet these various needs is no doubt enabled by a broad ToR for all TSN consultants supporting RNTCP activities in the field. Each of the 10 TSN consultants performing specialized roles in the CTD have specific ToRs. The findings also attest to the role and usefulness of the TSN, especially in view of the changing context of TB in India. Over the years, the TA provided by TSN consultants has evolved from facilitating TB case detection and treatment done under the RNTCP to addressing more ambitious targets outlined in NSP and supporting the implementation of recent global advances in TB diagnosis and care, which include adoption of rapid TB diagnosis through CBNAAT and evidence-based policy revisions to move to the daily anti-tubercular treatment (ATT) regime. Key informants, including staff from the Government of India (GoI), USAID/India, the Bill and Melinda Gates Foundation/India, The Union/India, PATH/India, the WHO Country Office-India, World Bank/India, STOP TB Partnership, WHO headquarters, Centers for Disease Control and Prevention (CDC) headquarters, and CDC/India, universally perceived the TSN as being crucial to the RNTCP s trajectory and advances in TB prevention and control in India, and expressed doubts whether these accomplishments could have been possible in the absence of TA support provided by the TSN. More specifically, most key informants positively viewed the role that the TSN has played in transfer of technical knowledge and skills to the states. However, this is contrasted with the inability of the national programme both at the central and state level to strengthen its own TA systems, resulting in the perception that the WHO TSN replaces critical government functions. This rapid assessment also threw into sharp focus the uncertainty the TSN has recently experienced regarding its funding sustainability. This has had a detrimental effect on the stability and morale of the TSN consultants. Further, the current limited number of consultants within the TSN only 60 of 93 approved positions are occupied has placed an additional burden on the existing consultants and strained TA functions. Ironically, at a time when the GoI has endorsed the End TB Strategy and SDGs, resources for additional TA do not appear sufficient for the anticipated growing needs and demands. The present resource constraints are artificially imposing a thinking that it is neither ambitious nor proportionate with the requirements to eliminate TB by In view of the expressed needs and perceived future requirements, it is imperative to stabilize and strengthen the TSN and make TA responsive to the emerging TB landscape in India. Recommendations Based on assessment findings and India s TB elimination objectives, the assessment team has proposed recommendations to ensure commensurate commitments and investments. The findings have one clear message: continue to support the TSN with enhanced capacities and resources, including assured funding, to address the emerging priorities in line with national and international commitments to eliminate TB. The present ambivalence and uncertainty about sustainable funding is inconsistent with recent, visible, high -level political commitment to a TB-free India, and threatens both the network and retention of high-quality TA. Ultimately, there is a need to have in place a robust transition plan for TA support, possibly by building the states capacity through third-party expertise. The assessment team has proposed a wide range of specific short-, medium-, and long-term recommendations that are summarized in Table ES-1. Short-term recommendations: Within 1 year Table ES-1. Proposed Recommendations 1. Continue the present TSN network as a strategic investment, which appears feasible under the present GoI agreement with the Global Fund, and secure additional funding support for all 93 approved TSN consultant positions. 2. Move TSN consultants to long-term contracts and retaining the WHO brand; revise and update the ToRs; and continue contracting an outside agency to manage the human resources and financial functions of the TSN until it can be supported by WHO and GoI. 3. Expeditiously develop a country strategy for TA and seek donor coordination with the GoI and WHO in a convening and coordinating role. 4. Develop a time-bound transition plan for TA to meet India s ambitious goal of eliminating TB by Commission a formal value for money assessment of TSN support. viii

13 Medium-term recommendations: Within 3 years 1. Develop a phased transition for scale-up of TA support in line with the NSP , End TB Strategy, and Global Plan to End TB ( ). 2. Diversify the donor base for the TB program and TA, to include additional investments from the GoI and other partners, including the corporate sector. 3. Facilitate greater dissemination of the work of the WHO-RNTCP TSN beyond scientific publications. 4. Enhance the catalytic function of the TSN consultants by building their capacity in communication and other relevant soft skills including consensus-building to effectively engage the private sector. This work should be informed by the various ongoing pilot projects to facilitate universal access to TB care (UATBC) 1. Long-term recommendations: Beyond 3 years 1. Secure sustainable long-term funding for the provision of TA in the context of TB elimination. 2. Increase the investment and ownership of TA support by GOI. 3. Identify and address emerging needs and monitor progress towards TB elimination. Translating the ambitious vision of a TB-free India into reality demands scaled-up TA support, adding new skill sets, improving the capacity to address the rapidly changing landscape (as reflected in the 10 RNTCP thematic areas listed in Box C-1 on page 6), and adapting to address local epidemiologic drivers. The TSN should be considered an integral part of the technical support provided to the RNTCP through the ongoing partnership with WHO at a time when the global community must support India s efforts to eliminate TB. We also recommend three scenario-based settings for future consideration; these are further described in the report. The three scenarios should ideally be informed by the investment package proposed in the Global Plan to End TB ( ) for India (The Paradigm Shift: Global Plan to End TB, ). Next Steps 1. Commission a work group with key stakeholders to develop a costed strategy for TA within the context of an updated NSP for TB, and informed by the investment package included in the Global Plan to End TB ( ) for India. 2. Provide a transition plan for each scenario by relying on existing draft transition plans as starting points. 1 Examples of pilot projects that can inform private sector engagement include Private Provider Interface Agency (PPIA) models in Patna, Mumbai, and Mehsana. ix

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15 1. INTRODUCTION The World Health Organization (WHO) Country Office for India (WCO-India) provides a range of policy inputs and technical assistance to the Government of India s (GoI s) Ministry of Health and Family Welfare (MoHFW). Key among the wide range of health initiatives WCO-India supports is the technical assistance (TA) it provides to the country s Revised National Tuberculosis Control Programme (RNTCP) through the Technical Support Network (TSN). In the 17 years since its inception in 1999, the WHO-RNTCP TSN has sought to strengthen RNTCP activities through technical support in planning, training, surveillance, and monitoring and evaluation (M&E). The present rapid assessment was undertaken to appraise the performance of the existing TSN and the future of the TSN and TA in the context of the WHO s End TB Strategy and the United Nations Sustainable Development Goals (SDGs). The overarching objectives of the rapid assessment were to: 1) provide an independent appraisal of the performance of the WHO-RNTCP TSN and identify factors affecting its performance, and 2) draw forwardlooking lessons and develop recommendations for the future and other options for TA to support subsequent National Strategic Plans (NSPs) for TB control in India. More specifically, the assessment aimed to examine the need and scale for TA from the WHO-RNTCP TSN to support TB control activities in India and the performance of WHO-RNTCP TSN consultants against their current terms of reference (ToRs) and their role and perceived usefulness considering the changing context of TB in India. Based on the findings, the assessment team would recommend improvements to WHO s contract modalities for engaging consultants under the WHO-RNTCP TSN. The rapid assessment was carried out July 1 August 5, 2016 (Annex A). The assessment entailed desk analysis of reports, circulars, orders, and other administrative tools related to the WHO-RNTCP TSN; analysis of countrywide data on the TA, based on responses elicited from TSN consultants; an in-depth case study; field visits and interviews with key informants; reviews of past evaluations; and interviews with WHO and RNTCP staff, national program managers, and other stakeholders. Two experts interviewed key stakeholders at the MoHFW Central TB Division (CTD) and at WCO-India, and they visited the states of Maharashtra and Uttar Pradesh to interview state officials and consultants. Other key informants interviewed included technical partners and stakeholders in India. The preliminary observations and recommendations of the rapid assessment were presented to the key stakeholders on July 29, 2016, at the CTD. This report presents the key assessment findings and insights, which are expected to not only inform the direction of WHO-RNTCP TSN s TA support but also be of value to all stakeholders in the health systems and TB domain in India. 1

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17 2. BACKGROUND India has begun to reverse the TB epidemic, but continues to shoulder an enormous disease burden. The country is home to the highest number of TB cases in the world, accounting for a quarter of the global TB incidence (WHO 2015) and one third of all drug-resistant TB cases. Addressing this unacceptably high disease burden requires the country to scale up various components of its TB services in terms of coverage and quality. Based on the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy, RNTCP was introduced as a pilot in It was launched as a national program in 1997 and scaled up across India in a phased manner, achieving nationwide coverage in March In line with its aim to decrease mortality and morbidity caused by TB and to check the spread of TB, the program has made considerable progress, bringing significant reductions in TB prevalence and mortality in the country. Over the last decade, more than 80 million people have been tested, 15 million TB patients detected and treated, and millions of lives saved by the RNTCP s efforts (Report of the Joint TB Monitoring Mission 2015). In accordance with the current NSP for Tuberculosis Control , the RNTCP aims for universal access to quality diagnosis and treatment for all TB patients. India has also endorsed the SDGs and the global End TB Strategy that calls for a world free of TB. Accordingly, RNTCP s Vision 2020 is to significantly reduce the TB burden in India by ensuring universal access to quality TB care as stipulated in the Standards for TB Care in India (STCI; WCO- India 2014). Despite these efforts and achievements, TB remains an enormous public health problem in India. The 2014 incidence of TB was conservatively estimated at 2.2 million cases per year (95% confidence interval [CI] million) and TB prevalence at 2.6 million cases (95% CI million) per year (WHO 2015). According to the WHO estimates generated from limited community-based mortality surveys, there were an estimated 230,000 deaths from TB. At least 1 million TB cases have been estimated to remain either undiagnosed or are diagnosed and managed outside the RNTCP with uncertain quality and efficacy of treatment. In 2015 the RNTCP was only able to diagnose and treat around 25,000 cases of multidrug resistant TB (MDR-TB) out of an estimated 100,000 cases that emerged in the country that year (CTD 2016). In this context, it should be added here that to further enhance TB care, the RNTCP recently procured 500 Xpert MTB/RIF machines to support India s effort to achieve universal rapid diagnosis and drug susceptibility testing (DST) and inform DST-guided treatment to improve outcomes for persons afflicted with multi/extensively drug resistant TB (M/XDR-TB). The RNTCP has also revised its standard treatment policy and is working on the roll-out of a daily antitubercular treatment (ATT) regimen for treatment of persons newly diagnosed with drug sensitive TB in 104 districts in five states (information shared by key informants during interviews). Implementation of the daily regimen would seek to ensure optimum dosage and reduced pill burden for patients, and is expected to improve treatment outcomes and reduce the emergence of drug resistance due to treatment interruptions. 3

18 As the RNTCP develops the systems and strategies to achieve the ambitious national goal of ending TB by 2035, it requires additional technical support at all levels. Currently, the WHO-RNTCP TSN is authorized for a network of 93 consultants, of which 75 positions are for field medical consultants, 13 for national consultants located at the CTD, and 5 consultants at the regional level. The present assessment aimed to appraise the performance of the WHO-RNTCP TSN, looking in particular at the role of consultants against the current ToRs and their role and perceived usefulness in the changing context of TB in India. The findings of the assessment are meant to inform possible reforms to strengthen RNTCP efforts to control TB in India. 4

19 3. CONTEXT OF THE ASSESSMENT 3.1 WHO s TSN Technical Assistance to RNTCP Starting in 1999 and working in coordination with the central and state governments in India, WHO hired, trained, and deployed local technical consultants to support central, state, and local governments in RNTCP activities (WHO 2010). The TA architecture of the TSN comprising these RNTCP consultants, referred to as the WHO-RNTCP TSN consultants, is funded by WHO via donor support. The funding in the past came exclusively from the Canadian International Development Agency (CIDA), United States Agency for International Development (USAID), and U.K. Department for International Development (DFID), and more recently through the Global Fund and supplemented by Bill and Melinda Gates Foundation (BMGF) for providing TA to private sector engagement projects. At present, about one half of the funds for the network is provided by the Global Fund grant under the New Funding Model (NFM); this agreement ends December The WHO-RNTCP TSN provides technical support to the RNTCP through a central team at WCO-India (Figure 1). The team comprises a Medical Officer-TB (MO-TB), National Professional Officer-TB (NPO-TB), NPO-Drug Resistant TB (DR-TB), and NPO-Laboratories. A network of technical consultants is based at the CTD and in states to provide TA to central, state, and district program management units. Figure 1. WHO s Technical Assistance to RNTCP through the TSN Seen in terms of levels, the first tier of WHO TA to the RNTCP is provided by a core advisory team at the national level. This team consists of two groups of technical advisors: 1) WHO staff serving as technical domain experts for RNTCP and project leaders for a comprehensive series of support activities and 2) specific national officers recruited as WHO staff to support the highest-priority areas of work, such as DR-TB or TB laboratories. The second tier of WHO TA is provided by national consultants embedded in the CTD. The third tier of WHO TA is provided through field consultants at state and district levels. At present, the WHO-RNTCP TSN has 10 national consultants providing support at the CTD and 50 consultants working in the field to link the state and district program units with national and international program strategy and operational and technical guidelines. There are 33 vacant consultant positions 25 field medical consultants, 5 regional consultants, and 3 CTD consultants. Existing consultants support the center and the states with strategic planning, M&E, capacity building, advocacy, and operational research. TSN administrative and financial management is outsourced to a private agency, IPE Global, which provides basic 5

20 Box C-1. RNTCP Thematic Areas 2 1. Pediatric TB 6. New drugs 2. M/XDRTB 7. Active case finding 3. HIV-TB, diabetes, and co-morbidities 8. Private sector engagement 4. Special populations 9. E-surveillance 5. Lab expansion 10. Research staff management, payroll, travel, and other services. This support enables the consultants to effectively carry out project activities. 3.2 Assessment of WHO s TA to the RNTCP through the TSN With the RNTCP seeking the more ambitious goal of universal access, as reflected in NSP , WHO pursuing the End TB Strategy, and SDGs, complemented by the Stop TB Partnership s Global Plan to End TB, , there is a need to enhance TA to help India achieve its ambitious objectives and targets. Potential TA funders and managers also need to further understand the performance of the existing TSN and the unmet TA needs in order to make informed recommendations for meeting anticipated future needs. In 2011, USAID/India contracted Social Impact, Inc. to conduct an evaluation of the support that WHO provided WHO to the RNTCP. The evaluation report states the objectives of the evaluation as: 1) to determine the impact of WHO support, relative to the stated objectives and achievements, and 2) to provide suitable recommendations for future direction and priorities (USAID 2011). This comprehensive evaluation included an assessment of the WHO-RNTCP TSN consultants, focusing on their ToRs, selection criteria for the consultants, the role and impact of the TSN at national and state levels, monitoring and supervision of technical support activities, impact and changes, transfer of knowledge and skills, supervision, and future direction. The evaluation s main findings pertaining to the impact of WHO s consultant network are presented in Box 1. The need for the present (2016) assessment reflects significant shifts over time; in 2011, the RNTCP s main goal was TB control, with a focus on achieving the global targets of 70 percent case detection and 85 percent cure rates. In 2016, its goals are guided by NSP , and subsequent GoI commitment to the End TB Strategy resolution adopted by the World Health Assembly in 2014, that is, to the ambitious and specific agreed-upon plan to end TB by In recent years, India s TA requirements have, thus, reflected rapid global policy developments in the fight against TB, and manifested by ten priority thematic areas. The significant movement toward elimination will require commensurate quality and quantity of TA support. 2 2 The list of RNTCP priority thematic areas is derived from a desk review of Joint Monitoring Mission reports, TB India (2015) report, and the National Strategic Plan for TB Control ( ). 6

21 4. METHODOLOGY This rapid assessment used a mixed-methods approach that triangulated desk review of existing documents and qualitative and quantitative data collected from interviews and questionnaires (see Table 1). The assessment team worked mostly in Delhi, and also undertook field visits to Uttar Pradesh (UP) and Maharashtra, to assess the TA provided in diverse contexts of perceived relatively weak health systems (UP) and relatively developed health systems (Maharashtra). The assessment focused on the TA provided by WHO- RNTCP TSN consultants since the last evaluation (2011). Table 1. Key Sources of Information for the Rapid Assessment Survey Activity Data Analysis Desk Review Field Visit Sample Team Leader Survey Stakeholder Survey Interviews Focus Group Discussions Source of information Country- and state-level data, data from the self-administered questionnaire for TSN consultants on the FluidSurveys platform TORs of consultants, report of past evaluation of the consultants network, RNTCP annual reports, JMM reports Purposive sample of 2 states 1. Uttar Pradesh a large EAG state with weak health systems and poor health outcomes including RNTCP. 2. Maharashtra A large developed state with better systems and program outcomes. Offers scope to understand the TA associated with getting private sector participate in a national programme. Guided survey (using a standard questionnaire) of NPOs and relevant at WCO and CTD Guided survey (using a standard questionnaire) of STOs, DTOs, and other stakeholders at the state and national level WHO staff/management, consultants, government officials, donors, other stakeholders Team leaders, consultants at CTD and states 4.1 Desk Review of Key Documents The desk review of key documents by the assessment team included Joint Monitoring Mission (JMM) reports (2012, 2015); the aforementioned comprehensive evaluation of WHO support to India s TB control program (2011), commissioned by USAID/India; a RNTCP annual report (2015); and ToRs of WHO-RNTCP TSN consultants. 4.2 Key Informant Interviews with Stakeholders Another important source of information were the key informant interviews (Annex B) with staff from the CTD, the GoI, USAID/India, BMGF/India, The Union/India, PATH/India, WCO-India, World Bank/India, STOP TB Partnership, WHO headquarters, Centers for Disease Control and Prevention (CDC) headquarters, and CDC/India. The key informants from the government included State and District TB Officers (STOs and DTOs), other program managers, and heads of departments in medical colleges. A short (five-question) interviewer-administered questionnaire was used with this purposive sample of key informants and stakeholders/partners who interact with the WHO-RNTCP TSN or are beneficiaries of its TA. This 7

22 questionnaire assessed the perceived strengths, weaknesses, gaps, and challenges, and elicited recommendations for future TA support in India. The assessment examined WHO s strategic approach to TA at the national and state levels, and the performance of the TSN based on the available ToRs. Focus areas for exploration during field visits were selected in consultation with key stakeholders in three pre-evaluation consultations. The selected areas were those that had received significant WHO TA in the previous five years and offered opportunities for learning. The selected focus areas related to: i. Strategic planning ii. iii. iv. Country/state demand and ownership Purposes of TA Sources, levels, and adequacy of TA financing3 v. Role and impact of outsourced agency s business processes vi. vii. viii. ix. Extent of decentralization of TA project administration to executing agencies Use of consultant resources Internal and external coordination Sustainability of TSN and TA outputs and outcomes 4.3 Self-administered Online Survey Questionnaire for TSN Consultants The assessment also included a self-administered online survey questionnaire using FluidSurveys (Annex C) to ascertain from existing TSN consultants the contributions of the WHO-RNTCP TSN as reflected in the existing ToRs and to elicit recommendations for revisions to the ToRs. The self-administered questionnaire was supplemented by interviewer-administered questionnaires to elicit qualitative responses through individual interviews with all TSN consultants working at the CTD, UP, Goa, Kerala, and Maharashtra. These in-person interviews reviewed how the TSN followed guidelines, procedural requirements, and due diligence for RNTCP-related TA in project planning and implementation support, including capacity building, monitoring, mentoring, and evidence building at both national and state levels. 4.4 Focus Group Discussions Focus group discussions (Annex D) were conducted with groups of consultants in both UP and Maharashtra and at the central level (CTD) to elicit their understanding of the TA provided by the TSN and the future TA requirements of the TB control program, as well as to ascertain their job satisfaction. 4.5 Case Study The assessment team also developed a case study to illustrate the value addition made by the TSN in recent years. The thematic focus of the case study was the contributions of TA to resource mobilization, innovation, and to knowledge in the field of TB prevention and care. 4.6 Analytical Methods The assessment employed analytical methods, including: 1) review of the perspectives elicited from guided interviews, grouped by both principal contributors into common themes; 2) computerized text analysis of online responses to identify patterns and themes in the online responses of TSN consultants; and 3) frequency distributions of quantitative online responses. 3 Not investigated thoroughly as it was beyond the scope of this study. However, high-level information was gleaned from key stakeholders, including CTD, WHO, USAID, and World Bank, and was used for discussions and recommendations. 8

23 4.7 Limitations of the Rapid Assessment Quantifying and isolating the impact of WHO-RNTCP TSN s TA is challenging. Each TSN intervention produces results, but the overall RNTCP impacts materialize from cumulative interventions and projects jointly undertaken by the government and other development and technical partners. This assessment only attempted to ascertain the contributions made by the TSN to the overall success against TB in India, not to attribute isolated impacts to the TSN. The assessment design had a limited scope, focused on eliciting candid perspectives from TSN consultants and other key informants about the perceived strengths, weaknesses, challenges, and future options for TA. These perspectives were accepted at face value and no independent efforts were undertaken to validate them. In addition, the evaluation was not a performance assessment. Two states were purposefully selected in consultation with stakeholders to reflect perceived weak and developed health systems, but they are not necessarily representative of all states in India. The review of ToRs was not an independent assessment of TA performance. The evaluation did not assess TA funding details, but instead relied on reports by some key informants about the general sources of funding and estimates of the amounts required to support the existing WHO-RNTCP TSN. 9

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25 5. KEY FINDINGS The rapid assessment focused on appraising the TA provided through the WHO-RNTCP TSN, aiming in particular to review its perceived performance, gaps and challenges, and accomplishments, and to offer recommendations for the TSN and future TA. A total of 58 (97 percent) of the current 60 TSN consultants completed the self-administered online questionnaire. The findings reported below reflect the responses to this questionnaire as well as the information collected during three focus group discussions and 72 in-person interviews with TSN consultants and key informants. Seventy-two (90 percent) of the 80 key informants approached were interviewed. Structured survey questionnaires were administered by to three key informants who could not be reached in person. Non-respondents were unavailable or away on annual leave. The findings provided the assessment team with an improved understanding on the aspects mentioned above. For added clarity, the assessment team classified the key findings under seven major headings: 1) performance of TSN consultants against the current ToRs, 2) scale of TSN, 3) TA provision by TSN, 4) accomplishments of TSN, 5) perceived strengths and attributes of TSN, 6) perceived challenges and weaknesses/gaps in TSN, and 7) future of TA through TSN. The key findings are presented below in greater detail. 5.1 Performance of TSN Consultants against the Current ToRs The interviewed WHO-RNTCP TSN consultants were 83 percent male, and 17 percent female. These consultants had worked in the TSN for a range of 1.5 to 16.1 years, with an average of 7.2 years and median of 7 years. In addition, 57 percent of the consultants had been in the TSN for more than 5 years. We estimate that TSN consultants now provide approximately 388 person-years of direct TA services at a cost of approximately US$5 million/year. This total cost is externally financed from 2011 until September 2015 partly by USAID and since 2014 partly by the Global Fund (until 2017), with supplemental funds by BMGF during for pilot projects supported by the TSN. The recent uncertainty experienced by the TSN regarding its funding sustainability has had detrimental effects on the network consultants stability and morale. Remarkably, the lower than approved number of TSN consultants have taken on added workload to continue delivering on the ToRs. The assessment closely examined the existing ToRs for the TSN consultants. The main findings in this area are presented under relevant subheadings: ToR Content i. The ToRs are valued by the consultants as guides to help in the organization of their efforts and activities for the year. ii. Written ToRs exist for all TSN consultants. The ToR for consultants in the fields is generic and guided by NSP

26 iii. iv. There are 10 specific ToRs for each of the TSN consultants located in the CTD. These ToRs are based on several thematic areas of technical responsibility to address needs related to electronic surveillance for TB cases, M&E, standards for the care of TB patients, childhood TB, TB-associated co-morbid conditions (such as HIV and diabetes mellitus), public-private partnerships, community mobilization, diagnosis and management of DR-TB, laboratory diagnostic capacity, and airborne infection control. The ToRs mention all the priority areas of RNTCP s NSP , thereby enabling flexibility in the provision of TA in the field ToR Implementation i. The ToRs have not been officially revised since However, in the online survey, 94 percent of the TSN consultants agreed or strongly agreed that the ToRs address the program priorities of RNTCP. ii. iii. iv. The ToRs guided the achievement of the consultants roles as these were used to set their annual plans, priorities, and actions as detailed in the Performance Management Development System (PMDS). In fact, 79 percent of the TSN consultants agreed or strongly agreed that their performance and achievements are influenced by the ToRs. The ToR for field consultants is very broad and risks not all components being implemented. Nevertheless, the ToR was not perceived to hamper the role of the consultants. Over 95 percent of the TSN consultants' roles at the state and district levels are multiple and include the following 10 functions in support of: 1. Preparation of strategic/action plans 2. Preparation of annual project implementation plans (PIPs) 3. Surveillance data management and/or electronic transmission 4. M&E of program outcomes 5. Preparation of reports/feedback to the national level on RNTCP performance 6. Supervision of local staff 7. Public-private mix (PPM) 8. HIV-TB activities 9. Programmatic Management of DR-TB (PMDT) activities 10. Childhood TB activities v. On average, 65 percent of the consultants time was spent in: field activities at the state/district/subdistrict/institutional levels (25 percent); training and capacity building interventions (20 percent); and M&E, electronic reporting, and validating information (20 percent). vi. In the survey, 50 percent of the TSN consultants reported deviations from agreed-upon annual activity plan, with the most common reason for deviation being policy changes or the need to address reassigned program priorities (63 percent). 12

27 5.1.3 Support in executing ToR and professional growth i. The TSN consultants are technically supervised by the NPO-TB. Based on the in-depth interviews with consultants, it is evident that they are given adequate support for executing their ToRs as well as provided opportunities for professional growth. ii. iii. iv. The TSN consultants were supported for professional growth, with 79 percent reporting having received support (mostly through professional training). Sixty-six percent of the consultants who reported having received support mentioned they had attended trainings/workshops/courses/meetings. An additional 24 percent said they were given support on operational research (18 percent) or provided opportunities to give presentations at national and international conferences, made possible through travel support (6 percent). Fifty-nine (98 percent) of the 60 TSN consultants are medical doctors with post-graduation in public health/concerned specialties and have at least two years of experience. They are hired at a salary scale equivalent to that of a national professional in the UN salary scale. The consultants are also provided with telecommunication facilities and travel support to enable fulfillment of their activities. This package is deemed attractive and appears to have contributed to the recruitment and retention of high-quality consultants in the TSN. Since 2008 WHO has outsourced the administrative and financial management of the TSN to a human resources (HR) agency. Both self-administered online questionnaires and supplemental indepth interviews revealed that the outsourcing of the TSN s administrative/finance functions to a third-party HR management agency had not adversely impacted the work of TSN consultants. In fact, 82 percent of the consultants reported being either satisfied or very satisfied with the services of the outsourced agency; 86 percent had not experienced delays in salaries or travel claims due to the business processes of the outsourced agency. The desk review and some KIIs revealed that the present funding uncertainty has resulted in the need for the WHO to enter into quarterly contracts with the HR agency. This, in turn, has resulted in consultants being issued time-limited (3 months) contracts since April 2015 onwards. Until 2008, the WHO-RNTCP TSN consultants were hired under the Special Services Agreement (SSA) mechanism of WHO, which provided the TSN with WHO affiliation, helpful in opening doors with senior officials. In more recent years, the hiring mechanism has changed to contracts through other outsourced agencies. In contrast, the WCO-India continues to rely mostly on SSA mechanism for hiring its Surveillance Medical Officer (SMO) National Polio Surveillance Programme (NPSP) network. All TSN consultants who have been in the network for several years favored the SSA mechanism. However, during this assessment, we learned that the WHO is moving away from reliance on the SSA mechanism and is instead using alternative approaches. 5.2 Scale of TSN There is a shortfall of consultants in the WHO-RNTCP TSN. Only 60 (65 percent) of the 93 consultant positions are filled at present; 33 positions are vacant. This situation is mostly due a funding gap. Although the TA functions do not appear to have been notably compromised, there is severe strain on the reduced number of consultants to fulfill the expectations of the state/district health authorities. The strain is primarily manifested in a compromised ability to conduct frequent field monitoring visits. 5.3 TA Provision by the TSN The rapid assessment provided rich insights on the TA provision and the areas on which the TSN currently provides TA to RNTCP activities. Universally, the TSN was perceived as being crucial to the RNTCP s trajectory of advances in TB prevention and control in India. In addition, most key informants acknowledged that these accomplishments would have not been possible in the absence of TA support provided by the TSN. More specifically, key informants positively viewed the role that the TSN has played in the RNTCP in the expansion, consolidation, and introduction of new interventions or operational research. However, this perspective was contrasted by key informants observations that the inability of the national programme both at the central and state level to strengthen its own systems for TA results in the perception that the WHO- RNTCP TSN replaces many critical government functions. 13

28 5.3.1 Prioritization and allocation of TA i. The strategy for prioritizing and allocating the provision of TA is guided by NSP and, recently, by the STCI. Key informants mentioned that a revision of the TA strategy is planned to address the heightened need for implementing the End TB Strategy. ii. iii. The TA activities seemed to be driven, in large part, by national program priorities and directions of NSP The latest initiatives of PMDT and CBNAAT expansion emerged as important drivers of recent TA activities. Most consultants described determining the TA needs through a consultative process with various stakeholders (primarily the program managers at the national/state/district levels), field assessments and evaluations, and gap analysis using program indicators Process of TA delivery i. Twenty-two percent of the TSN consultants noted the focus on guidelines and infrastructure as being a key aspect in their transferring of skills to ensure sustainability of their interventions. ii. iii. iv. Most TSN consultants stated that there is no explicit mechanism on how transfer of knowledge is to take place. However, in practice the transfer of knowledge routinely takes place, primarily through training sessions and training of trainers (ToT), and is understood as a key function of the TSN consultants. STOs, and in some states higher officials, relied heavily on the TSN consultants and delegated various responsibilities to them. Some consultants reported being deeply involved in providing administrative support. A discussion with stakeholders revealed that lack of capacity, vacancies, frequent staff turnover, and lethargic processes at the state offices led to support being required from consultants to address the gap functions; this support was often perceived as necessary to get things moving or completed. Three key informants expressed their view that sometimes achievement of a task came from being agreeable to government counterparts, who could then start relying on the consultants for work other than that stated in the ToR. 14

29 5.3.3 Monitoring progress and evaluating impact i. The supervisor (NPO-TB) consistently assessed the results expressed in the ToRs. Regular and frequent interaction, apart from the structured bi-annual/annual performance evaluation by the supervisor, provided the consultants direction and course correction. Ninety-five percent of the survey respondents indicated receiving mentoring, oversight, and supportive supervision more frequently and at least twice a year. ii. The impact of TA provided by the TSN was evaluated most commonly through the PMDS (31 percent), performance indicators (24 percent), and quarterly/semi-annual meetings (24 percent). iii. iv. More than 96 percent of the TSN consultants reported a high level of satisfaction with being a part of the network. The TSN consultant workforce appeared to be nurtured and managed well by the WHO-RNTCP leadership, as reflected in the interviews with consultants, frequent monitoring and oversight, evident dedication, high-level TA with subject-matter skills, and job satisfaction. 5.4 Accomplishments of TSN i. The assessment investigated the extent to which TSN generated knowledge products or contributed to knowledge management within RNTCP. Respondents of the online questionnaire universally (100 percent) reported transfer of knowledge and skills to the states. The majority of the knowledge transfer was being achieved through capacity building, technical analysis, and onsite support. In addition, TA knowledge products were generated, including publications, workshops, training courses and manuals, conferences, study tours, technology (such as information technology [IT]-enabled projects), and reports. The most common knowledge products were specific technical reports or publications, which included manuals, guidelines, and scientific communications published in journals. Notably, 93 scientific communications had been published since 2013 (Annex E). RNTCP guidelines were developed by active contribution of TSN consultants. STCI, revised Technical and Operational Guidelines (TOG), NIKSHAY, training materials, and M&E tools are additional examples of the knowledge products facilitated by the TSN. ii. iii. Over the years, the TSN has built technical capacity nationally and globally. In addition to providing technical support to TB activities in India, many of the TSN alumni are shaping global health response as part of teams at WHO headquarters, the Global Fund, STOP TB, UNAIDS, USAID, The Union, PATH, CDC, and other technical or development agencies. Key informants commonly stated that TSN consultants play a crucial role in high-level advocacy with decision makers, including in different ministries, to mobilize additional resources for TB control as well as to tap resources by developing proposals for additional funding from national and international agencies. Examples of success in this area include: 1) funding from the Local Self Government Department for nutritional support for TB patients in Kerala, 2) financial support for TB patients from the Department of Social Justice and Empowerment in Gujarat, 3) special funding for conducting state representative TB prevalence survey from the annual development plan of the Government of Gujarat, and 4) TB REACH grant for developing an IT platform to capture missing cases and reduce delay in diagnosis and treatment initiation (see Box 2 Case Study). 15

30 Box 2. Case Study: TSN Helps Andhra Pradesh Mobilize Funds for an Innovative Solution to Reach Missing TB Cases Along the diagnosis to treatment initiation pathway for TB, there are gaps that can result in loss of patients. RNTCP reports record information only for cases registered for treatment, and diagnosed TB cases that are not registered on treatment are left unreported. This has been an inherent weakness of the program since it began, and the problem was not being addressed systematically. The development of the IT-enabled Electronic Surveillance and Management of Drug Resistant Tuberculosis (E- SMARTS) platform paved the way for the TSN consultants at State TB Cell, Andhra Pradesh, to use the existing capabilities of E-SMARTS to develop a way to specifically address the longstanding problem of missing TB cases. The TSN consultants role in this project was to identify the problem, formulate the project proposal without any external support, and compete globally to garner support for the innovation. RNTCP Andhra Pradesh proposed a technological solution, the e-lab register, to provide real-time feedback on referred cases while tracking the diagnosed TB cases to initiate treatment. The project proposal was awarded a full grant under the Wave 4 TB REACH funding in 2014 to implement the e-lab register in 50 Basic Management Units. The proposed project was the only one under the Wave 4 grant to secure initial funding of US$1 million. The key features of this project to develop the e-lab register included: 1) Devising an electronic lab register (e-lab register) similar to the paper-based lab register 2) Sending SMS/voice calls at various points along the diagnostic pathway to track patients so that they are not missed but instead complete their diagnosis and start early treatment 3) Linking the entire electronic database to the E-SMARTS web server In line with the project objectives, web and mobile versions of the e-lab register were developed. Sputum testing microscopy centers were provided with computers, and an SMS and Interactive Voice Response System (IVRS) gateway was set up with pre-recorded messages and SMS templates, which could be deployed at specific points in the diagnostic algorithm. Both the e-lab register application and the SMS/IVRS gateway were linked with a server, which could automatically update the e-lab register, send auto SMS/IVRS, complete backend functions, and produce graphs and charts, etc. These multiple, linked technologies enabled lab technicians to record all the details and real-time test results of presumptive TB cases who attended the 275 microscopy centers in Andhra Pradesh, covering a population of ~50 million. Details of all presumptive TB cases attending these microscopy centers are now being entered into the e-lab register application on a real-time basis by trained lab technicians. The server connected to the application sends auto SMS/voice calls to track patients at defined points in time. The project has achieved significant outcomes. Six out of 13 districts in the state have implemented this project, leading to data digitization of 65,953 presumptive TB cases. A significant 7,240 TB cases have been diagnosed, out of which 6,740 patients have been put on treatment; 498 TB cases have been tracked (from initial loss to follow-up); and 2,362 pediatric presumptive TB cases have been detected. The number of repeat sputum examinations has also recorded a 39 percent increase to 1,566. Importantly, random surveys have demonstrated patient satisfaction with the intervention. As a health care provider put it: They are pleased because it instructed them clearly on what to do and they felt cared for by the health system. 16

31 5.5 Perceived Strengths and Attributes of TSN The perceived strengths and attributes of TSN, as stated by respondents, include: i. Has an independent, passionate, dedicated workforce with credible technical voice ii. iii. iv. Serves as catalyst, helping to get things moving quickly Reduces the risk in program activities and improves quality by ensuring: 1. Effective implementation 2. Veracity of surveillance and monitoring 3. Relatively rapid transition to new systems Is flexible and adaptable to meet emerging needs v. Provides high-quality information/feedback/inputs/program knowledge on planning, M&E, and data analysis vi. vii. viii. ix. Enhances the uptake and efficacy of evidence-based policy decisions Facilitates rapid communication between all levels Serves as a repository of institutional knowledge Enables better access to administrators at all levels 5.6 Perceived Challenges and Weaknesses in TSN The perceived challenges and weaknesses/gaps in the TSN, as stated by respondents, include: i. Limited number of consultants to effectively engage the private sector, address other priority thematic areas (all key for universal access to TB care [UATBC]), and carry out frequent monitoring visits to the field ii. iii. iv. Work done in relative isolation, which limits learning from experiences gained in maternal and child health, polio, and other health programs Limited-time contracts (three months) with outsourced agency, risking the ability to recruit and retain a trained and experienced workforce Limited technical and managerial capacity of state/district program managers in many states due to frequent transfers and existing vacancies, etc.; this results in a deficient support system for effective implementation of TA in those states v. New GoI policy of mandatory three-year term for consultants, risking experience drain 5.7 Future of TA through TSN i. The provision of TA was found to be closely related to the extent of development of health systems; for it to be of high quality and limited to its core business (ToR of the TSN) requires a concurrent improvement in the health infrastructure and systems at national and state levels. 17

32 ii. iii. iv. A majority of the key informants voiced the need for infusion of new funding from the GoI and consideration for pooling, or better coordination of diverse donor resources. Potential options for new funding/contracting mechanisms included: a. Paying for the services of the TSN: considering its capacity to provide independent TA, major donors could utilize the existing TSN for their projects and pay for its services b. Affiliating the TSN with an Indian organization such as the All India Institute of Medical Science, the Indian Council of Medical Research, or other reputable in-country organizations c. WHO to seek new funding sources The close working relationship of the TSN with the RNTCP was highlighted as a key strength. However, the evident strength of the TSN consultants embedded within RNTCP and working in close collaboration with CTD was contrasted by few opinions citing the relative independence of the polio network and its effectiveness in reaching out to senior officials in state administration, which is perceived to have contributed to program effectiveness. Many key informants highlighted the need for massive investments and mobilization of skilled human resources, including TSN consultants, to hasten progress from the current 2 percent decrease in TB incidence to the 17 percent decrease required for achieving elimination of TB by Case Study: Illustrating the Contribution of WHO-RNTCP TSN The assessment team developed a case study to illustrate the value addition made by the WHO-RNTCP TSN in recent years. The case study, presented in Box 2, describes how the TSN support helped the southern Indian state of Andhra Pradesh to mobilize additional funds for an innovative ehealth and mhealth solution to track missing TB cases. 18

33 6. CONCLUSION AND RECOMMENDATIONS This rapid assessment, facilitated by the USAID-funded HFG project, has provided valuable insights that can inform the direction and future course of the WHO-RNTCP TSN and the TA it provides. Findings point out areas of strength as well as gaps that need to be addressed, and the likely solutions to address these gaps. This chapter presents recommendations based on the main findings. The recommendations also seek to respond to key questions about strategic alignment, management processes, sustainability, and future of TSN and TA, and are provided primarily to improve areas where the TA made limited progress and to inform key measures for the future. It will be crucial for the GoI, WHO, and other stakeholders, including funders, to seriously and expeditiously consider and plan for how to proceed with the TA in the short-, medium-, and long-term. The present ambivalence and uncertainty about sustainable funding is inconsistent with recent, visible, high-level political commitment to a TB-free India, and poses considerable threat to the network and retention of high-quality TA. The TSN should be considered an integral part of the technical support provided to the RNTCP through the ongoing partnership with WHO at a time when the global community must support India s efforts to eliminate TB. Ironically, the WHO- RNTCP TSN reflects important, in-country capacity building that could serve as a TA model to other countries. The recommendations below support the RNTCP s goal of eliminating TB from India through commensurate commitments and investments. They are grouped as short-, medium-, and long-term activities, and are followed by three scenario-based settings for consideration. 6.1 Proposed Recommendations Short-term Recommendations (within 1 year) First, to prevent the high risk of disastrous consequences in the absence of continued support for TSN, continue the present TSN network as a strategic investment until assured and sustainable funding can be secured. This appears feasible under the present agreement with the Global Fund to provide most of the presently needed resources for TSN until Second, immediately consider moving TSN consultants to long-term contracts and retaining the WHO brand in addition to supporting and nurturing the highly skilled and credible workforce. This will avoid the risk of the brain drain that comes with short-term (three-month) contracts. The TSN s present contributions are attributed to the high level of dedication of TSN consultants, but the present situation is untenable. While revising the contracts, it would be opportune to also address the need for revising the ToRs, considering the End TB Strategy, the RNTCP s revision of its technical and operational guidelines, and the need for focused attention on newer initiatives and scale-up of interventions, resulting from a rapidly evolving body of knowledge. 19

34 Third, secure additional funding support to promptly fill all 93 approved TSN consultant positions (that is, recruit and hire skilled professionals for the 33 vacant positions). Additional fund-raising efforts should be promptly undertaken, such as exploring the feasibility of obtaining augmented funds from the GoI and applying for supplementary funds from the Global Fund and the World Bank. In this context, we suggest deliberate and bold investments in TA, as required for results; the TSN must be viewed from the perspective of justified TA needs in a setting where annually only about US$5 million (2.5 percent) are presently invested to provide TA for effective deployment of the more than US$200 million spent on TB in India. Fourth, expeditiously work to develop a country strategy for TA to meet India s TB elimination needs, and seek donor coordination with GoI and WHO in a convening and coordinating role. This will help optimize investments to address areas of unmet needs and avoid or minimize duplication of efforts and investments. Fifth, secure sustainable long-term funding for the provision of TA in the context of TB elimination. The GoI should increase its investment and ownership of TA support. In addition, it is important to consider the development of a time-bound transition plan for TA to meet India s ambitious goal of eliminating TB by The national TB program must develop a 3-year and 10-year plan with all stakeholders, including donors; this plan should include a TA component that would ensure longterm funding for the network. This should also include a rigorous assessment of staffing needs to achieve the desired results. Sixth, commission a formal value for money assessment of TSN support; this unique model for TB TA in India could inform other countries. Medium-term Recommendations (within 3 years) First, develop a phased transition for scale up of TA support, possibly by building the states capacity through third-party expertise. This transition plan should be framed within an updated NSP for achieving TB elimination. Second, diversify the donor base for the TB program and the TA, to include additional investments from the GoI and other partners, including the corporate sector. Third, the national TB programme to underake governance reforms to strengthen weak health systems to benefit TA for TB and other health sectors. Fourth, equip the TSN consultants with added skills on communications and relevant soft skills including consensus- building to more effectively engage the private sector, which are perceived as key to the success of UATBC. Fifth, design and implement actions to disseminate and communicate the work of the WHO-RNTCP TSN beyond scientific publications. Examples include policy briefs and reports for decision makers within the MoHFW and other related ministries. Long-term Recommendations (beyond 3 years) i. First, secure sustainable long-term funding for the provision of TA in the context of TB elimination. ii. iii. Second, the GoI should increase its investment and ownership of TA support. Third, identify and address emerging needs and monitor progress towards TB elimination, as done in other successful disease eradication campaigns such as small pox and polio. In summary, India s ambitious vision for TB elimination must become a reality through a scaled-up approach, adding new skill sets, improving the capacity to address rapidly changing landscape (as reflected in the 10 priority thematic areas of the RNTCP), and adapting to address local epidemiologic drivers. 6.2 Scenarios for Future Consideration Three scenarios for future consideration are: Scenario 1: Both the GoI and partners provide bold and sustained commitments to additional investments in the health sector and TB program in particular to attain the ambitious goals and coordinated efforts to meet the multiplicity of needs and avoid duplication. 20

35 Scenario 2: The GoI increases its investment for TB elimination, and other donor funding remains stable. Scenario 3: The GoI and other in-country resources are mobilized for TB elimination, but reliance on external donor funding support decreases over time. An investment package has been suggested in the Global Plan to End TB ( ) for India. Thirteen elements for this country setting ( Setting 7 ) acknowledge the tremendously high burden of disease, the nature and capacity of the RNTCP, the role of the private sector, and the untapped potential, and should ideally be adapted for each of the three scenarios mentioned above. The investment package for India specifically focuses on the thirteen elements listed in Table 2. Table 2. Focus Areas for India s Investment Package in the Global Plan to End TB Source: The Paradigm Shift: Global Plan to End TB, Next Steps Adequate planning for the above-mentioned three scenarios necessitates the following next steps: 1. Commission a working group with key stakeholders to develop a costed strategy for optimal TA in the context of an updated NSP for TB, and informed by the investment package included in the Global Plan to End TB ( ) for India. 2. Provide a transition plan for each scenario by relying on existing draft transition plans as starting points. 21

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37 ANNEX A. SCOPE OF WORK FOR THE RAPID ASSESSMENT HFG India: Rapid Assessment of the WHO Technical Assistance to RNTCP Consultant Scope of Work Overview: USAID s Health Finance and Governance (HFG) is a five-year, $209 million project to increase the use of priority health services, especially by women, girls, poor and rural populations, in developing countries throughout the world. The project is led by Abt Associates Inc. with core partners including Training Resources Group, Inc., Broad Branch Associates, Development Alternatives Inc. (DAI), Johns Hopkins Bloomberg School of Public Health, Results for Development Institute, and Avenir Health. Background: India has begun to reverse the tuberculosis (TB) epidemic, but an enormous disease burden remains. India has a quarter of the world s TB burden and one third of all drug-resistant TB cases. To address this burden, the country needs to scale up various components of its TB services in terms of both coverage and quality. Priorities for scale up include engagement with the private sector, which caters to at least half of the TB patients in India, rapid scale up of programmatic management of drug resistant TB, ensuring quality of basic TB programming to prevent the emergence of drug resistance, introduction and scaling up newer interventions for preventing catastrophic cost to TB patients and families, design of operational research for better TB control, and better coordination of the efforts of various partners. Since inception, the Revised National Tuberculosis Control Programme (RNTCP) has evaluated over 91 million persons for TB, initiated treatment for over 19 million TB patients, and saved more than 3.5 million lives. In its National Strategic Plan , RNTCP, aims for Universal Access for quality diagnosis and treatment for all TB patients. India has now endorsed the Sustainable Development Goals and global End TB Strategy that calls for a world free of tuberculosis. Accordingly, RNTCP s Vision 2020 is to significantly reduce TB burden in India by ensuring universal access to quality TB care as per Standards for TB Care in India (STCI). Despite these efforts, TB remains an enormous public health problem in India. The 2014 incidence of TB has been conservatively estimated to be 2.2 million cases per year (95% CI million), and the prevalence 2.6 million cases (95% CI million) per year. According to World Health Organization (WHO) estimates generated from limited community-based mortality surveys, there were an estimated 230,000 deaths from TB. At least 1 million TB cases remain either undiagnosed or are diagnosed and managed outside the TB programme with uncertain quality and efficacy of treatment. In 2015 the RNTCP was only able to diagnose and treat around 25,000 cases of MDR TB out of an estimated 100,000 cases that emerged in the country that year. 23

38 To further enhance TB care, RNTCP procured 500 GenXpert machines to support India s effort to achieve universal drug susceptibility testing (DST) and DST-guided treatment for better outcomes for MDR-TB cases. RNTCP plans to roll-out a daily regimen for treatment of new drug sensitive TB cases in 104 districts in five states. The implementation of the daily regimen will ensure optimum dosage and reduced pill burden for patients and is expected to improve treatment outcomes. RNTCP will need technical support at all levels as it seeks to develop the systems and strategies to achieve this ambitious national goal. Currently RNTCP is supported by a network of 95 medical/technical consultants, of which 12 are located at Central TB Division (CTD) and 83 are field medical consultants under the WHO-RNTCP Technical Support Network (WHO-RNTCP-TSN). The WHO, funded by USAID and DFID in the past and now the Global Fund, has led technical support efforts to RNTCP. Technical support has been provided by a central team based in the WHO India Country Office (WCO) consisting of National Professional Officer (NPO)-TB, NPO- DRTB, and NPO-Laboratories, technical consultants based at the Central TB Division, and a network of field-level WHO-RNTCP medical consultants with the job of providing technical assistance to the State and District programme management units. The first plank of WHO technical assistance (TA) to RNTCP is provided by a core advisory team to the national level, which consists of two groups of technical advisors: 1) WHO staff serving as technical domain experts for RNTCP and project leaders for the comprehensive series of support activities, and 2) specific national officers recruited as WHO staff to support the highest-priority areas of work, such as drug resistant TB, drug procurement, or TB laboratories. A WHO project management team supports the technical advisors to effectively carry out project activities, which are dependent on efficient contracting with third parties for research or basic staff management functions. The second plank of WHO TA consists of national consultants embedded in the Central TB Division, Ministry of Health and Family Welfare. This group of consultants has been supported by various agencies since The third plank of WHO technical assistance is the WHO-RNTCP medical consultants at the State and District levels. Approximately 83 consultants link state and district programme units with national and international guidelines. Consultants support states with planning, monitoring, evaluation, capacity building, advocacy with senior state officials, and operational research. With RNTCP seeking the more ambitious goal of Universal Access and WHO pursuing its End TB Strategy, there is a need to adapt the TA to help India achieve its objectives and targets. TA funders and managers need to further understand the performance of the existing TA and the need for additional TA in order to recommend modifications in the future. Scope: HFG India seeks a consultant to assess the performance of the WHO-RNTCP-TSN consultants against their current terms of reference (ToRs), and to assess their role and usefulness considering the changing context of TB in India. The assessment shall also inform possible reforms to this support. Objectives: The objectives of the consultancy are to assess the need and scale for TA for TB control in India through the WHO-RNTCP-TSN, assess the contributions of WHO-RNTCP-TSN as per the existing TORs of the consultants, provide recommendations for any changes in the TORs, and provide recommendations for improvements to WHO s contract modalities for engaging consultants under WHO-RNTCP-TSN 24

39 Consultancy Tasks: Review current and past WHO-RNTCP-TSN consultant TORs Review WHO-RNTCP-TSN current and past strategies Review relevant records, reports, and other necessary documents Conduct interviews with stakeholders including at the Central TB Division (CTD), a sample of State and District TB Officers and other program managers, a sample of Medical consultants both at CTD and field, WHO focal points, civil society organizations, and the private sector. Develop a methodology that includes a multi-site observational component and sufficient sample of consultants and relevant people to be interviewed. Self-questionnaires may be used to reach a larger number of consultants and key persons and assess their perception regarding the changes and improvements that have occurred through this long term TA Draft a written report with the following features: 1. An assessment of the extent to which TORs are followed by Medical Consultants both at CTD and in the field, with reasons for deviations or inability to follow particular TORs. 2. An assessment of the proportion of time devoted by TSN in different activities such as duty travel, training, review meetings, evaluations, workshops etc. (a self-administered checklist may be used for this purpose for quantitative analysis). 3. An assessment of overall value brought by TA to RNTCP, as viewed by the program (standard questionnaires with rating scales may be used). 4. Examples of instances of additional contributions above the TORs such as the addition of new knowledge with observational or actual research findings or contribution to policy changes in the form of supporting evidence or designing conceptual frameworks for policy. 5. Recommendations for the volume and form of future TA and suggestions of changes in TORs for TSN. 6. Brief summary of RNTCP program officers understanding of TA of TSN and future TA requirements for program. 7. An assessment of present WHO arrangement of outsourcing administrative and financial management of the network to an HR agency and recommendations on strengthening the management of the network including alternate contract mechanisms, if any. This may be done through interviews with consultants, WHO officials, CTD officials and other stakeholders. 8. An assessment of long-term sustainability of this network and possible modalities for transition. Deliverables: Preliminary outline of the assessment report including a brief description of the methodology to be used. The outline shall be submitted to HFG by close of business (COB) on July 9, Preliminary presentation of findings including a brief summary of recommendations for the future shall be submitted to HFG by COB on July 30, Final assessment report. The final report shall include all eight features detailed in the Consultancy Tasks section of this document. The final report shall be submitted to HFG by COB August 13, Responses to stakeholder comments on the final report shall be submitted by COB August 19,

40 Schedule: The consultancy shall be performed from July 1 August 19, 2016 for a maximum of 35 days. The following deliverables shall be submitted no later than the dates listed below: Deliverable Outline Preliminary Presentation Final Report Comments Addressed Period of Performance; Week Ending: July 9 July 16 July 23 July 30 Aug. 6 Aug. 13 Aug. 19 X X X X Monitoring: The consultant shall provide a weekly update on progress to the COP or other HFG staff member to be named. The consultant shall also be prepared to participate in phone or in-person updates as requested. Desired Qualifications: Expert knowledge of and experience working on tuberculosis control in Asia; specific knowledge of and experience with India s RNTCP and WHO s End TB strategy. Demonstrated experience working with national and international TB stakeholders, including Government of India, Global Fund, and WHO. Demonstrated experience conducting TB-related research in India. Knowledge of program assessment and evaluation methodologies and demonstrated experience assessing and evaluating public health and disease control programs. Strong analytical and interpersonal skills Excellent, articulate and concise writer; capacity to synthesize and present research findings to technical and non-technical audiences Proficient in Word and other software as needed Spoken and written fluency in English; command of Hindi and other Indian languages a plus Highly motivated and organized professional; meets deadlines reliably Ability to work effectively with diverse teams Master s degree in relevant field (e.g., public health); PhD. or professional degree (e.g. medical doctor) preferred Available to begin work promptly in July 2016 Notes: HFG Country Manager shall review and approve deliverables prior to approval of invoice for payment. 26

41 ANNEX B: LIST OF KEY INFORMANTS Position/Organization 1 DDG TB, CTD, GOI Dr Sunil Khaparde 2 Additional DDG, CTD, GOI Dr V Salhotra 3 Additional DDG, CTD, GOI Dr D Gupta 4 Assistant DDG, CTD, GOI Dr Raghu Rao 5 ICMR DG ICMR Dr S Swaminathan Name 6 WHO WR Dr Hendrik Jan Bekedam 7 NPO TB, WHO India Dr A Sreeniwas 8 NPO DRTB, WHO India Dr Mallik Parmar 9 NPO Labs, WHO India Dr Rajani Ramachandran 10 MO TB, WHO India Dr Sundari Mase 11 National Consultants WHO RNTCP TSN 10 based in Delhi 12 Consultants in the States - WHO RNTCP TSN 7 in UP 4 in Maharashtra/1 Goa/1 Kerala 13 CDC Dr Tom Frieden 14 CDC Dr Jacek Skarbinski 15 STOP TB partnership Dr Lucica Dittu 16 STOP TB partnership Dr Suvanand Sahu 17 PATH Dr Shibu Vijayan 18 USAID Mr Xerxes Sidhwa 19 USAID Dr Reuben Swamickan 20 World Bank Mr Jorge Coarasa 21 World Bank Ms Suneeta Pinto 22 BMGF Dr Puneet Deewan 23 The Union Mr Prabodh Bhambal 24 The Union Dr Jamie Tonsing 25 Principal Secretary Health, UP Mr Arvind Kumar 26 MD, NRHM UP Mr Alok Kumar 28 State TB Officer UP Dr R K Naiyer 29 Former State TB officer UP Dr Alok Ranjan 30 STDC Director UP Agra Dr Bhardawaj 31 District TB Officer Kanpur Nagar Dr Anil Kumar Saxena 32 District TB Officers Unnao Dr Rishi Kumar Saxena 33 Private sector Dr Rajendra Prasad 27

42 Position/Organization Name 34 Principal Secretary Health, Maharashtra Ms Sujata Saunik 35 MD, NHM Maharashtra Dr Pradeep Vyas 36 AMC, BMC Ms Kundan 37 Director, Health Services Dr Mohan Jadhav 38 State TB Officer - Maharashtra Dr Sanjay Kamble 38 Executive Health Officer Dr Padmaja Keskar 39 Deputy STO Dr Madhukar Pawar 40 Assistant Director, Health Services Dr Sharad Patil Assistant Director, Health Dr Bhadkumbhe Director STDC Pune Dr Sudhakar More 43 STDC Director Nagpur Dr Nadeem Khan 44 District TB Officers Pune Dr Narendra Thakur 45 District TB Officer Mumbai Dr Daksha Shah 46 DTO Kolhapur Dr Harshla Sdhakar Vedak 47 Medical college - BJ Medical college Dr Anju Kagal 28

43 ANNEX C. SELF-ADMINISTERED QUESTIONNAIRE FOR TSN CONSULTANTS (For the FluidSurveys Questionnaire) 1. Respondent s sex (tick the box) Male Female 2. Indicate the number of years/months that you have worked in RNTCP years months 3. The WHO-RNTCP TSN terms of reference (ToR) for consultants addresses the programme priorities of RNTCP. (Likert scale: 1= strongly disagree, 2 = disagree, 3 = neither disagree nor agree, 4 = agree, 5 = strongly agree) 4. Your performance and achievement as a consultant are influenced by the ToR (Likert scale: strongly disagree to strongly agree) 5. Are there instances of deviation from your agreed-upon annual activity plan? Yes No If yes, briefly provide a maximum of three instances and provide the reasons. 6. Tick all that apply to your role as Ta SN consultant at the state/district 1. Support the preparation of strategic/action plans 2. Support the preparation of annual PIP 3. Surveillance data management and/or electronic transmission 4. Monitoring and evaluation of program outcomes 5. Support preparation of reports/feedback to national level of RNTCP performance 6. Supervision of local staff 7. Support to PPM activities 8. Support to HIV-TB activities 9. Support to PMDT activities 29

44 10. Support to childhood TB activities 11. Support to civil society engagement activities 12. Other If other, please enumerate. 7. Provide an approximate estimate of the proportion (%) of time devoted by you on the following activities, on an average each month: a. Time spent for field activities at state/district/sub-district/institutional level b. Training and other capacity building interventions c. Monitoring, evaluations, electronic reporting, and validating information d. Facilitating coordination among government and NGOs, and liaising with state/district level authorities e. Conducting and/or facilitating operational research 8. How frequently is oversight (monitoring, supervision, mentoring) provided by the programme leadership (WHO supervisor)? Semi-annually Annually More frequently 9. Is the performance of your technical assistance evaluated? Yes No If yes, briefly explain how? 30

45 10. Describe briefly how you determine the technical assistance needs at the state/national level. State Level (for field consultants): National Level (for CTD consultants): 11. Rate your satisfaction with the support provided by the outsourced agency managing your contract in terms of timeliness of salary, reimbursements, and travel arrangements. Very dissatisfied Dissatisfied Neutral Satisfied Very satisfied 12. Did the outsourced TSN managing agency s administrative /finance/office processes contribute to any delays or other problems in implementing your role? Yes No If yes, briefly explain how? 13. Does the TSN transfer knowledge and skills to the States (all relevant institutions) to ensure sustainability of their interventions? Yes No If yes, briefly explain the 3 most important ways in which you have undertaken these in 2015 and Have you received support from WHO for capacity building and professional growth opportunities? Yes No If yes, briefly explain three instances of support received by you. 31

46 15. Briefly describe how you envisage the provision of technical assistance to RNTCP in the future? 16. I have a high level of satisfaction being a part of the TSN network (Likert scale strongly disagree to strongly agree) 32

47 ANNEX D. STRUCTURED QUESTIONNAIRE FOR FOCUS GROUP DISCUSSIONS Future of TSN and TA to RNTCP 1. Do you think there should be a differential role of the consultant in poorly and better performing districts/ states? Please indicate how. 2. Do you think the TORs needs to be changed to reflect the unique characteristics of a particular state? EAG states vs rest of the states. 3. Do you participate in key meetings or events, formal partnerships, conferences, other relevant meetings? Are you able to influence the decisions during the meeting? 4. How does WHO-RNTCP-TSN position itself and its work in partnership with other partners like private sector, UNICEF, BMGF, The Union, etc.? 5. Does the consultant network need to be independent? 6. Is it possible to have a dual line of control for the TA? 7. Will the Government have the capacity to absorb the TA if at all? 8. What in your opinion can be a good model for TA? 33

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49 ANNEX E. MAIN FINDINGS: EVALUATION OF TUBERCULOSIS PROGRAM IN INDIA (USAID 2011) Box 1. Main Findings: Evaluation of Tuberculosis Program in India (USAID 2011) This excerpt is from the executive summary of the evaluation report. The principal factor of DOTS successful implementation in India has been and still is the involvement of WHO-contracted local consultants, who provide technical support at CTD, state and district levels. Indeed, eighty-six field-level consultants are assigned to specific states and work closely with district and state TB officers, enhancing the capacity of district health systems for supervision, monitoring and evaluation; assisting in data management and electronic transmission of the quarterly surveillance data to the national level; and improving record-keeping and monitoring the consistency and accuracy of the quarterly cohort data. Additionally, they provide feedback on RNTCP performance to the national level. Half of the financial support for this network is provided by USAID and half by the United Kingdom Department for International Development (DFID). Since September 2008, the consultants depend administratively on RNTCP only, while the management of the network is outsourced. This change of label is of great concern to the consultants, diminishes the attractiveness of the position, and increases the turnover. The network has contributed significantly to the good performance of RNTCP, and provided an element of stability and continuity within a context of frequently-changing GoI staff at the state level. This network is of low cost, but it produces tremendous benefits for TB control at the state, district and even national levels in India. It is recommended that USAID continue to support this n etwork up to the end of the launching period of RNTCP3 (2017), and, if possible, take over full financial support once DFID withdraws its support in December In order to increase the sustainability of RNTCP performance, a concrete plan to operationalize the transfer of their knowledge and skills to the homologues in the RNTCP system should be prepared by WHO, CTD and the state tuberculosis officers (STOs), detailing precise benchmarks for the transfer. In addition to the eighty-six state-level consultants, ten other consultants provide technical support to the CTD, with thematic responsibilities in the domains of PPM, HIV/TB, HR, advocacy, communication and social mobilization (ACSM), etc. They are one of the pillars of CTD s good performance, but th ey have no real counterparts, which handicaps an eventual exit strategy. Their present job satisfaction is found to be very high, although their career development opportunities are minimal, and the present salary is less attractive than it has been in the past. This network provides excellent value for money. As CTD is moving quickly to take up the RNTCP3 challenges in 2012, the consultants role will become more crucial than it is today, because there is yet no model in the country to reach the ambitious RNTCP3 targets. A case study carried out in East Uttar Pradesh state has learned that the WHO consultants play an important role in correctly performing districts as well as in poorly performing ones: in the latter, the consultants support is crucial to maintaining a minimum level of case finding and case holding services. 35

50 ANNEX F. LIST OF PEER-REVIEWED ARTICLES PUBLISHED BY TSN SINCE Standards for TB Care in India Published Joint Monitoring Mission-TB Published STCI e-tool Kit Published Intensified TB Control in India- TB-Mission 2020 Un-Published Draft Does Alcohol Consumption during Multidrug-resistant Tuberculosis Treatment Affect Outcome? Published Is Screening for Diabetes among Tuberculosis Patients Feasible at the Field Level? Published Feasibility of Decentralised Deployment of Xpert MTB/ RIF Test at Lower Level Published of Health System in India Composite Indicator: New Tool for Monitoring RNTCP Performance in India Published What Are the Reasons for Poor Uptake of HIV Testing among Patients with TB in an Eastern India District? Published 2013 Comparing Same Day Sputum Microscopy with Conventional Sputum 10 Microscopy for the Diagnosis of Tuberculosis Chhattisgarh Published 2013 Tuberculosis Management Practices by Private Practitioners in Andhra Pradesh, 11 India Published 2013 Isoniazid Preventive Treatment in Children in Two Districts of South India: Does 12 Published Practice Follow Policy? 2014 Enhancing TB Case Detection: Experience in Offering Upfront Xpert MTB/RIF 13 Testing to Pediatric Presumptive TB and DR-TB Cases for Early Rapid Diagnosis Published 2014 of Drug Sensitive and Drug Resistant TB Intensified Tuberculosis Case Finding among Malnourished Children in 14 Nutritional Rehabilitation Centres of Karnataka, India: Missed Opportunities Published Use of Xpert MTB to Enhance Case Detection in Pediatric Age Group in India Published Use of Moxifloxacin or Gatifloxacin to Shorten First Line Anti TB Treatment Published 2013 Optimization of Conventional Minimum Inhibitory Concentration Method for 17 Drug Susceptibility Testing of Ethionamide Published Optimization of Proportion Sensitivity Testing Method for Ethionamide Published 2013 A Multi-site Validation in India of the Line Probe Assay for the Rapid Diagnosis of 19 Published Multi-drug Resistant Tuberculosis Directly from Sputum Specimens Guidelines for EQA of Smear Microscopy Update Un-Published Draft Guidelines for Second line DST in RNTCP Update Un-Published Draft EQA for Culture and DST and Molecular DR Tests - RNTCP Un-Published Draft Protocol for Validation of Newer TB Diagnostic Tests Un-Published Final Protocol for Implementation Pilot for Daily Regimen Introduction in India Published Protocol for National Drug Resistance Survey in India Un-Published Final Protocol for Evaluate the Safety and Effectiveness of Bedaquiline in Adults with New Sputum Smear Positive Multi-drug Resistant Pulmonary Tuberculosis: Expanded Access Programme through RNTCP Un-Published Draft Revised National Laboratory Scale up Plan Un-Published Final Guidelines for DST Guided Treatment of All Forms of Drug Resistant TB in India Un-Published Draft National DRS Training Tool Kit and Training Videos Published

51 1 Standards for TB Care in India Published Guidance Document for Use of GeneXpert under RNTCP in India Published PMDT Appraisal Reports of ~520 Districts of India Un-Published Final PMDT Scale Up Forecasting Tool Un-Published Final Revised Partnership Guidelines for RNTCP in India Published 2015 Alarming Levels of Drug-Resistant Tuberculosis in HIV-Infected Patients in 34 Metropolitan Mumbai, India Published 2014 Innovative Social Protection Mechanism for Alleviating Catastrophic Expenses on 35 Published Multi -Drug Resistant Tuberculosis Patients in Chhattisgarh, India 2015 Airborne Infection Control in India: Baseline Assessment in 35 Health Care 36 Facilities Un-Published Final Nationwide Scale-up of Programmatic Management of MDR TB in India Un-Published Draft 2014 Unacceptable Treatment Outcomes among India s Initial Cohorts of MDR TB 38 Programme Published 2015 Alarmingly High Treatment Failures in Non-Rifampicin Mono/poly-drug Resistant 39 TB Cases Managed with Standard First Line Regimen and Resulting Amplification Published 2015 to Rifampicin Resistance in Such Cases in India Certification and Scale-up of Culture and Drug Susceptibility Testing 40 Laboratories for Diagnosis of Mycobacterium Tuberculosis in India: Challenges Un-Published Draft 2014 and Lessons Learnt e-smarts - Electronic Surveillance and Management of Drug Resistant 41 Tuberculosis: An Innovative Approach towards Better Patient Management in India Published Transforming TB Control in Mumbai, India Published 2014 High Relapse among New Smear Positive TB Patients Successfully Treated under 43 published National TB Program: Retrospective Cohort Study from Gujarat, India 2015 Tuberculosis Burden Estimation using Capture Re-capture Study - Sitamarhi, 44 India Published 2014 A Collaborative Initiative between the Private Gene Xpert Sites and the Revised 45 Published National Tuberculosis Control Programme in Bihar State, India 2014 The Impact of e-smarts, a Technological Innovation, on Drug Resistant TB 46 Treatment Pathways in Telangana, India Published 2014 e-health and m-health Solutions for National TB Programmes to Track Missing 47 Cases Published 2014 Recurrence of TB among Cured NSP TB Patients over One Year Follow-up and 48 Published Role in Amplification of Resistance 2014 Does Diagnostic Technology and Travel Distance Reduce Delays in Treatment 49 Initiation of MDRTB Patients in India? Published 2014 Controlling Mumbai s Epidemic of Drug-resistant TB Towards Universal Drug 50 Susceptibility Testing Published Is Lower Body Weight at Initiation of Treatment More Lethal for TB Patients? Published 2014 Finding Missing TB Patients: Impact of a Dedicated Cough Corner in a Busy 52 Out-patient Public Health Setting of Maharashtra, India Published 2014 Confirmatory Culture Results of Patients with Mycobacterium Tuberculosis 53 (MTB) Not Detected on Xpert MTB/RIF with Initial Smear Positive Results in Published 2014 Gujarat, India Drug Susceptibility Pattern among Previously Treated Extra-pulmonary 54 Tuberculosis (EPTB) Patients in Gujarat, India Published 2014 Should India Offer Universal Drug Susceptibility Testing to All Tuberculosis 55 Patients? Published 2014 Qualitative Evaluation of Patient and Provider Reported Determinants of 56 Multidrug Resistant TB Treatment Default in Nagpur, India Published

52 1 Standards for TB Care in India Published Occurrence of Sputum Smear Positive Xpert MTB Negative Cases among Presumptive Multi-drug Resistance Tuberculosis (MDR TB) Patients on XPERT MTB/RIF Assay in Tamil Nadu Recurrence and Death Rate among New Sputum Smears Positive Pulmonary TB Patients at 5 years after Completion of Treatment under Revised National TB Control Programme in Banaskantha District of Gujarat Sputum Collection and Transportation System (SCTS) Improved Case Notification and Reduced Patient Costs in Rural Areas of Gujarat, India Published 2014 Published 2014 Published NIKSHAY Data Entry Speed and Quality of Various Data Entry Operators Un-published-draft Cross-sectional Observational Study of Private Sector TB Diagnostics in India Un-Published Draft 2014 Social Support a Key Factor for Adherence to Multidrug Resistant Tuberculosis 62 Treatment: A Qualitative Study Un-Published Final 2014 Factors Associated with Tuberculosis and Rifampicin-resistant Tuberculosis 63 amongst Symptomatic Patients in India: A Retrospective Analysis Published 2016 Piloting Upfront Xpert MTB/RIF Testing on Various Specimens under 64 Programmatic Conditions for Diagnosis of TB and DR-TB in Paediatric Published 2015 Population The Potential Impact of Up-front Drug Sensitivity Testing on India's Epidemic of 65 Multi-drug Resistant Tuberculosis Published 2015 Has Introduction of Rapid Drug Susceptibility Testing at Diagnosis Impacted 66 Published Treatment Outcomes among Previously Treated Tuberculosis Patients in Gujarat Standards for TB Care in India: A Tool for Universal Access to TB Care Published Public private Mix for TB Care in India: Concept, Evolution, Progress Published 2016 Impact of Nutritional Support to Patients on First Line Anti TB Treatment in 69 India: A Case Control Study Published 2014 Impact of Decentralization of Treatment Services in the Management of Drugresistant TB 70 Published 2014 Strengthening Tuberculosis Notification by Private Sector: A Way Forward for 71 Improving Tuberculosis Care Published 2014 Local Self Government Involvement in TB Care in Kerala - Standards for TB 72 Care in India Published 2014 Scale-up of Facility Integrated Counselling and Testing Centres and PPP ICTCs in 73 Published India -Contribution of HIV Testing in TB Patients Tuberculosis in Homeless Population in Delhi Published Public-private Partnership in Drug Resistant TB: A Model from Nagpur, India Published Perceptions of Private Practitioners on STCI Published Screening for Diabetes Mellitus in TB Patients - How Well are We Doing? Published Guideline for Use of Bedaquiline under PMDT Published Revised Technical and Operational Guidelines for RNTCP Published Guidelines for Surveillance for TB in Health Care Workers Published Guidelines for Management of Adverse Drug Reactions to Anti TB Drugs Published Pediatric TB Guidelines Published Public-Private Partnership in TB and HIV: A Case Study of India Published 2015 SMSs and IVRS Gateways to Quality TB Care and Treatment Adherence in 84 Andhra Pradesh, India Published Systematic Screening of Contacts of DR-TB Patients: Result of a Rapid Survey Published Implementation of Xpert/MTB RIF under India's National TB Control Programm Published

53 1 Standards for TB Care in India Published A Sustainable Model of Private Provider Engagement via e-health and Free Drugs, Mehsana, Gujarat, India Published E/M-health Solution for National TB Programme to Track Missing Cases Published DOTS: Monitoring and Improving TB Medication Adherence using Mobile Phones and Augmented Packaging Published Study of Active Case Finding of Tuberculosis in Prisons Published 2015 Severe Malnutrition Impair Treatment Response among India's Initial MDR-TB 91 Cohorts Published RNTCP Experience in Rolling Out Baseline 2nd line DST in MDR TB Patients Published Factors for Diagnostic Delay in Smear Positive TB Cases in India Published

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55 ANNEX F. REFERENCES Agarwal S.P., and L.S. Chauhan Tuberculosis Control in India. New Delhi, Directorate General of Health Services, Ministry of Health and Family Welfare. India. Central TB Division TB India Revised National TB Control Programme Annual Status Report. Ministry of Health and Family Welfare. India. Frieden T.R., and G.R. Khatri Impact of National Consultants on Successful Expansion of Effective Tuberculosis Control in India. International Journal of Tuberculosis and Lung Disease, 7(9): Report of the Joint TB Monitoring Mission, India, Accessed July Revised National Tuberculosis Control Programme. National Strategic Plan for Tuberculosis Control Accessed July Stop TB Partnership The Paradigm Shift: Global Plan to End TB, Accessed July United States Agency for International Development Evaluation of Tuberculosis Program in India. WHO Report. Accessed July World Health Organization Country Office for India Standards for TB Care in India. Accessed July World Health Organization Global Strategy and Targets for Tuberculosis Prevention, Care and Control After th session, EB134.R4, Agenda item Accessed July World Health Organization A Brief History of Tuberculosis Control in India. Accessed July World Health Organization Global TB Report. Accessed July

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