Evaluation Report
for
National TB Programme, Iraq
Covering the period of
2008 - 2011
Evaluation conducted from
14th April to 24th May, 2012
1
TABLE OF CONTENTS
Executive Summary .......................................................................................................................................................5
Introduction .................................................................................................................................................................13
Implementation and Key Findings ...............................................................................................................................26
Coordination and Operational Issues ..........................................................................................................................55
Equity Assessment .......................................................................................................................................................64
Monitoring and Evaluation ..........................................................................................................................................84
Value for Money ..........................................................................................................................................................90
Summary ....................................................................................................................................................................103
Recommendations .....................................................................................................................................................129
Annexure ...................................................................................................................................................................140
Annexure I .................................................................................................................................................................140
Profile of the Evaluation Team ..................................................................................................................................140
Annexure II ................................................................................................................................................................142
References: ................................................................................................................................................................142
Annexure III ...............................................................................................................................................................144
Guidelines for Undertaking Supportive Evaluation ...................................................................................................144
Annexure IV ...............................................................................................................................................................147
Evaluation Work Plan ................................................................................................................................................147
Annexure V ................................................................................................................................................................149
Field Visit Profile ........................................................................................................................................................149
2
List of Acronyms / Abbreviations used
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
ACSM
ARTI
ATT
CAT
CBI
CBR
CCM
CDR
CHW
CP
DoH
DOT
DOTS
DRS
DST
ENRS
EPTB
EQA
GDF
GoI
GTBC
GFATM
GLC
HE
HHC
IATA
IDP
IEC
IMC
IP
LT
M&E
MoH
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
Advocacy, Communication and Social Mobilization
Annual Risk of Tuberculosis Infection
Anti Tuberculosis Treatment
Category
Community Based Initiative
Crude Birth Rate
Country Coordination Mechanism
Case Detection Rate
Community Health Worker
Continuation Phase
Department of Health
Directly Observed Treatment
Directly Observed Treatment – Short Course Chemotherapy
Drug Resistance Surveillance
Drug Susceptibility Testing
Electronic Nominal Registration System
Extra Pulmonary Tuberculosis
External Quality Assurance
Global Drug Facility
Government of Iraq
Governorate TB coordinator
Global Fund for Aids TB and Malaria
Green Light Committee
Health Education
Household contacts
Iraqi Anti – TB Association
Internally Displaced Persons
Information, Education, Communication
International Medical Corps
Intensive Phase
Laboratory Technician
Monitoring and Evaluation
Ministry of Health
3
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
NGO
NRL
NSP
NSPCDR
NTI
NTP
PHC
PHCC
PMDT
PP
PPM
PR
PTB
RBM
RCDC
SDA
SNRL
SOP
SR
SS
SSF
STS
TB
TBMU
TCDR
TOR
TSR
UNDP
WHO
WHV
WTBD
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
Non Governmental Organization
National Reference Laboratory
New Smear Positive
New Smear Positive case detection rate
National TB Institute
National TB Programme
Primary Health Care
Primary Health Care Center
Programme Management of Drug Resistant TB
Private Practitioner
Public Private mix
Principal Recipient
Pulmonary TB cases
Result Based Management
Respiratory and Chest Disease Clinic
Service Delivery Area
Super National Ref Lab
Standard Operating Procedure
Sub – recipient
Sputum Smear
Single Stream Funding
Stop TB Strategy
Tuberculosis
TB Management Unit
Total Case Detection Rate
Terms of Reference
Treatment Success Rate
United Nations Development Programme
World Health Organization
Women Health Volunteer
World TB day
4
EXECUTIVE SUMMARY
Objectives of the Programme; Magnitude of the Problem; GFATM Implementation Methodology; Expenditure
Profile; NTP Infrastructure; Equity; TB in Prisons; Performance of NTP; Comments on Case Detection and
Treatment Outcomes; MDR-TB; Involvement of Medical Schools; Banning Sale of anti-TB drugs in Private
Sector; ACSM; Monitoring and Evaluation; Drug Procurement, Quality Control and Distribution
Objectives of the Programme
While, vision, goals and TB control strategy of Iraq are based on Stop TB Strategy, following two
objectives constituted R9 GFTAM approved proposal which is now being implemented through
“Single Stream Funding” (SSF) containing left over grant of R6 and grant of R9:

Objective 1: Increase the case detection rate of sputum smear positive TB cases from 43%
to at least 70% by 2014 and maintain high treatment outcome at least at 85% among
detected cases

Objective 2: Ensure universal access to diagnosis, treatment and care for Drug Resistant TB
(DR-TB).
Magnitude of the Problem
Capture / recapture study conducted by WHO in 2011 estimated an incidence rate of 45 /
100,000 population against 2010 WHO estimated incidence rate of 64 / 100,000. However, the
estimated incidence of capture / recapture study may need to be loaded because 4.5 million
population in IDP’s and Marshlands hardly had any access to health services during the period
of study.
5
GFATM Implementation Methodology
Consequent to R9 GFATM support two overlapping grants were consolidated to US$ 18,270,970
from 1st Oct, 2010 to 31st Dec, 2012. A budget of US$ 3,499,027 amounting to more than 19% of
total budget has been allocated to grant management by PR and SR.


The United Nations Development Programme (UNDP) PR: overall program
management, procurement of health equipment, supplies, pharmaceuticals and non
health items.
World Health Organization (WHO) SR: management of technical component. As the sub
Recipient monitoring and supervision of 4 SSR’s.
Expenditure Profile
Out of a total approved outlay, US$ 8,827,115 (48.3%) were allocated to UNDP and 9,443,855
(51.7%) to WHO. Till Dec, 2011, WHO spent 27.6% of its allocation, while UNDP 44%. In view of
low expenditure, revised budget of US$ 16,972,440 reallocated with US$ 10,221,664 (60.2%) to
UNDP and 6,750,777 (39.8%) to WHO. UNDP and WHO combined have been able to spend in 18
months less than 50% of the original total allocations.
NTP Infrastructure
Each of the 18 governorates has a RCDC which in turn are supported by 117 TBMU’s at District
level. RCDC’s and TBMU’s are the focal points of TB services at governorate and District levels
respectively. Services at peripheral level are provided through 2331 PHCC’s. By December,
2011, 211 TB diagnostic and 1093 drug delivery outlets are providing services.
Equity
Equity is a major issue in Iraq as 23.5% of Iraqi population currently lives under the poverty line.
R9 GFATM proposal has initiated building of systems ensuring equity of services to all
populations. To “reach the unreached” following four NGO’s have been contracted as SSR:

The Iraqi Anti – TB Association (IATA) is providing services to 2.8 million IDP’s. Mapping of
IDP camps, collective settlements and all other areas with a high IDP concentration has
been completed. Procurement of two equipped mobile clinics to serve 5 disconnected
geographic areas with 1 million IDP population is yet to materialize thereby practically
smothering the whole initiative.
6
Proposed initiative of assigning the contact tracing to an NGO is neither sustainable nor
operationally feasible and technically sound. Contact tracing need to be undertaken as a
part of composite DOTS strategy.

The International Medical Corps (IMC): IMC shall create cluster of 54 master trainers, 3 in
each governorate for conducting intensified training for different category of staff. One
RCDC in each governorate will be designated and equipped as a training centre. During
2011, 3427 health professional (more than 132% of stipulated targets) have been trained in
DOTS and 545 staff in recording and reporting systems, ENRS and project management.

AMAR International Charitable Foundation is supporting the program in TB care for 1.2
million Marshlands Population inhabitating Muthenna, Basrah and Thi-Qar governorates.
Number of PHCC’s in these three Southern governorates of Iraq has increased from 95 in
2010 to 174 in 2011.Till now WHV’s have sensitized 54,434 families on fight against TB.
Number of families visited as a tool to measure effectiveness of the interventions needs to
be replaced by outcome indicators like families committed to support TB patients /
identifying TB patients.

Premiere Urgence (PU) is supporting the grants in the “Engagement of non-NTP Public and
private sectors in TB control program” which comprises of 289 public; 81 private hospitals;
and an unorganized and disconnected network of around 4,000 private practitioners.
Systematic and sustained coordination amongst organized and unorganized, formal and
informal-TB care providers is essential to improve access to TB care; and to move towards
and beyond 70% case detection for universal access to quality assured TB care. The
challenge is to address the lack of trust and enthusiasm to engage with each other for a
common cause. The policy and guidelines including referral system need to be developed in
consultation with non-NTP partners. Partnership needs to be built on a relation of mutual
respect and trust and projected as a “win-win initiative” for all. PPM focal person should
also be assigned at governorate and District levels.
7
TB in Prisons
There are 64 prisons in Iraq with an average of 50,000 inmates. Detection of 31 new TB cases
from screening of 15,000 prisoners indicates 4 times higher TB incidence amongst inmates.
Treatment outcome of this cohort has been excellent as 29 out of 31 cases completed
treatment. An important contributor to this outstanding outcome is strict adoption of DOT as
has been observed in Al-Rahmania juvenile prison. Since more than 1730 prison administrative
and health staff has been trained, implementation of DOTS as standard of TB care in a phased
manner in all the prisons should be initiated.
Performance of NTP
From 2009 till Q-1-2012, a total of 31,267 cases have been detected, out of which 34.6% are
sputum smear negative pulmonary TB cases. EPTB constitute a disproportionately high
proportion of 30.8% in a low HIV prevalence State like Iraq. Generic guidelines for diagnosing
common type of EPTB cases need to be formulated with emphasis on laboratory confirmation
of the diagnosis as far as possible. There is a great variation in performance between different
governorates and possibly Districts within the governorate.
Comments on Case Detection and Treatment Outcomes
During Q-1/2012, Thi-Qar as the best performer with 49% NSP CDR shows that Iraq is miles
away from achieving its CDR target of 70% by 2014. The programme urgently needs to
consolidate its key function of removing infectious TB patients from the pool of prevalent TB
cases transmitting tuberculosis. Team noted some degree of complacency in the efforts to
expand case-finding to reach undetected cases as is reflected from the declining national NSP
case detection rate which is 37% in Q-1/12 against 46% in 2009 and 38% in 2011.
The most immediate requirement for NTP, Iraq is to re-emphasize adopting DOTS as its “policy
strategy” for TB control with dedicated commitment for its comprehensive implementation at
all levels which requires extensive advocacy by all concerned with a lead from WHO. Likes of
Doctor in Erbil governorate who refuses to accept DOTS, LT in Erbil City Center who refuses to
perform his duty of sputum examination on account of a self created danger of getting TB while
performing his duties or the administrator of Koya District Hospital not wanting DOTS or a
Doctor at Baghdad who reportedly got himself transferred from MDR-TB laboratory for fear of
contracting TB may need to be administratively dealt with.
8
Cough symptomatics screening should be conducted at the registration desk or at the patient
waiting area, which beyond fast-tracking sputum examination shall limit the possibility of
nosocomial transmission to other OPD attendants and health facility staff. Sputum not done
cases as numbers and as percentage of pulmonary TB cases is showing an increasing trend
which needs to be arrested. Except for small children, diagnostic sputum examination must be
undertaken on all pulmonary TB suspects as has been done in Sulaymania, Muthenna and
Ninewa governorates in 2011 and many others even in 2010 and Q-1/2012.
Large number of sputum positive patients is not getting their sputum examined at the
completion of treatment. One of the important reasons is non adoption of DOT which till now
has been relegated a backseat. “Training of treatment supporters” is the only ACSM activity
with Zero budgetary allocations. In some governorates the patients are dispensed TB medicines
through a pigeon hole under the window after the patient speaks through a microphone. There
is no concept of using community members or cured TB patients as DOT provider. A patient centered adherence strategy, including supported treatment agreeable to the patient is the bet
for successful treatment completion and for limiting development of drug resistance.
MDR-TB
MDR - TB among new cases in Iraq is estimated to be 3% and amongst re-treatment cases 38 %.
NRL has met the bench mark by passing the panel test on culture and DST conducted by SNRL,
Egypt. Annual quality certification through panel testing for NRL by SNRL and for private
laboratory in Erbil needs to be ensured. Four laboratories at governorate RCDC’s in Basrah,
Najaf, Babylon and Ninewa equipped with culture examination have been established at
intermediate level and staff trained accordingly. 50 cases of MDR - TB were enrolled in 2011 on
ambulatory regimen out of which 25-44 years age group account for 70.5% of these cases. As
on May, 2012, three died, 1 defaulted and 46 are continuing MDR – TB treatment and 31 have
converted in culture examination.
MDR-TB is a man-made phenomena and the only way to contain MDR - TB is to stop producing
it. Governorate wise treatment outcome of NSP and all sputum smear positive cases of the
cohort from 2009 to Q-1/2011 show that against 5.5% default rate observed on the cumulative
treatment outcome of NSP cases in Iraq, Baghdad accounted for 11% default rate and for all
sputum smear positives during the same period, the figures are 6.5% for Iraq and 12.9% for
Baghdad. Similar pattern is observed in the notification of retreatment cases from 2009 to Q1/2012. Furthermore, out of 50 MDR-TB cases on treatment, 49 are Cat II failure. Cohort of
2010 shows 36% cure rate amongst all Cat II in Iraq against 29% in Baghdad; for 2009 cohort, it
9
is 57% for Iraq and 39% in Baghdad and for Q-1/11 the same is 41% for Iraq and 28% for
Baghdad. As a consequence to this performance, 44% of 50 MDR-TB cases on treatment are
from Baghdad. Unless urgent comprehensive interventions are made, Baghdad will continue to
be the “capital” of MDR-TB.
Objective two of R9 approved proposal is “Ensure universal access to diagnosis, treatment and
care for drug resistant TB (DR-TB)” when NSP CDR of the country is less than 50%. In ideal
circumstances, the objective of universal access to DOTS should precede and receive priority
over universal access to MDR-TB. This requires intensive efforts by NTP, WHO and UNDP as
with only one year left, out of US$ 13,362,502 earmarked for DOTS related activities, a mere
41.7% amounting to US$ 5,575,949 has been spent. Increased CDR and successful treatment of
detected cases beyond reducing TB transmission in health care settings; will also set up a
system of diagnosis and successful management of TB cases within the existing health care
infrastructure which would subsequently be used for MDR - TB.
Involvement of Medical Schools
Though attempts are being made to introduce DOTS in curriculum of 23 medical, 23 nursing
and 5 pharmaceutical schools in 18 governorates, the first step needs to be to promote
adoption of DOTS by medical schools including the teaching hospitals attached to them. A core
group of senior medical school teachers should be constituted to design a road map for
involvement of medical schools in DOTS. The first evidence of their acceptance of DOTS would
be its adoption in their clinical practice at teaching hospitals.
Banning Sale of anti-TB drugs in Private Sector
Government of Iraq has taken a landmark initiative in banning the sale and storage of anti TB
drugs in the private pharmacies from 2011. Coordinated efforts need to be made amongst NTP
and drugs department on a war footing for effective implementation of this ban order.
ACSM
During visit to the different governorates, the team had mixed experiences in this important
area with one commonality of lack of bill boards / hoardings at the health facilities along with
other mass media approaches. This is well supported by the fact that out of budgeted US$
122,500 for health information dissemination, not even a penny has been spent in last 15
months of implementation of the grant.
10
National Health Communication Strategy needs to be formulated and reflected at governorate
and District levels. NTP should set the ways in which TB patients both cured and current,
communities especially the poor, health care providers and governorates can work as partners
and enhance the effectiveness of health services in general and TB care in particular. NTP
should be made a people’s movement encouraging convergent action on awareness creation
on case detection and treatment completion by formal and informal groups at village, PHCC,
District, governorate and central level. This will create demand for TB services which will be a
step towards much needed social marketing of DOTS at governorate, District and village levels.
Monitoring and Evaluation
National M&E plan for 2013 – 2015 covers all aspects of NTP performance in Iraq. An Electronic
Nominal Registration System (ENRS) established in 2008 as a pilot step in 7 governorates is
reportedly being extended to the remaining 11 governorates. During field visits by the
evaluation team, data collection and maintenance of TB registers at District and governorate
level appeared to be complete and reflect the reality except a few exceptions. Old sputum
examination forms being used indicated three sputum specimens while, only two specimens
are now being collected and examined. This not only created confusion amongst patients but
also affected the creditability of the programme.
Key supervisory positions at District and governorate levels demonstrate limited insight and
capacity to conduct evidence-based problem-solving at District and governorate levels for
which NTP needs to undertake their capacity building to translate data into an effective
programme action. Internal systems for monitoring and supervision in Erbil though in place
lacked commitment to and quality of monitoring was weak. There was no feedback and
supervisory meeting discussions lacked instructive information to enhance performance. There
was no mechanism for documenting corrective actions to ensure accountability.
Performance indicators being target-oriented and primarily focused on detection and
treatment outcome of NSP cases (70/85 by 2014) need transition to analysis of trends in key
process and outcome indicators at District and governorate levels. Governorate level
committees to develop appropriate process indicators for local planning and monitoring to
augment national targets should be established. Entire process of supervisions needs to be
reviewed tailoring it with need more than routine and supervision should not be a mere “visit”
or “policy”. Mechanism to evaluate the outcome of the visit should be well defined in terms of
outcome indicators.
11
Central level needs to comprehensively analyze governorate wise performance every quarter
through the quarterly report. Highlights of these findings along with specific advice for
performance enhancement should be sent in a time bound manner to all governorates. Based
on quarterly reports, central level should compile a one pager “newsletter” giving governoratewise 3-4 key performance indicators and circulated to all concerned.
Drug Procurement, Quality Control and Distribution
Procurement of drugs should ideally be contracted to an independent procurement agency
away from all direct and indirect influences. Overseeing distribution of stocks upto governorate
level should be the responsibility of NTP and distribution to TBMU’s / PHCC’s should be the
governorate’s responsibility. An independent agency different from procurement agency
should be hired to ensure quality of drugs starting from their arrival in the country till such time
they are consumed by the patient. National ware house should ensure that supplies with less
than 9/10 of shelf life are not accepted in the country. The present system of procurement of
Rifampicin with 2-3 years shelf life should be changed to procurement of Rifampicin with only 5
years shelf life.
12
INTRODUCTION
Geographic and Socio Demographic Profile; Global Fund Support; Health Care Systems Infrastructure;
Organizational Structure of TB Programme; Disease Burden; Objectives of NTP, Iraq; Objectives spelt out in R-9
GFATM proposal; Summary of Programme Performance; Methodology Adopted for Evaluation (Overview of
Evaluation Methodology and Strategy, Evaluation Team); Work plan and Report; Limitations
Geographic and Socio Demographic Profile
Iraq is spread in an area of 435, 052 square kilometers with an estimated population of 32.33
million (2009), 67% of which lives in urban areas. Population growth rate is 3.4% and Crude
Birth Rate (CBR) 37.5%. Total fertility rate per woman is 5.0 (2008). Country is administratively
divided in 18 governorates with varying population ranging from 500,000 to 7,000,0003. The
country has 124 Districts with an average population of 200,000 to 300,000. Currently
Kurdistan is the only legally defined Region within Iraq; and Duhok, Sulaymania and Erbil
governorates are within the region of Iraqi Kurdistan.
Over the past twenty years, almost 1/3 of Primary Health Care Centers (PHCC) have been
afflicted with direct impact on population health coverage and utility. Some health facilities
were looted in the aftermath of the war and are yet to be fully functional. Age group pyramid of
the population resembles post war conditions; balanced population at the younger age group
and severely male deficient in 40-45 year age group. Only 2.8 % of the population is aged 65
years and above (2009). As a result of the war, Iraq has been experiencing very high population
movements. Human resources deteriorated to the extent that out of 34,000 physicians
registered with Iraqi Medical Association in 1990’s, by 2005 there were only 18,126 physicians
in Iraq9. It is estimated that 1.8 million Iraqis had been displaced to neighboring countries and
1.6 million internally with nearly 100,000 Iraqis fleeing to Syria and Jordan every month2.
Vulnerability of the general population during 2008 showed that 82% of households were not
connected to the electricity grid; 11% of households relied on water from stream/well/tank and
33% Districts deprived from access to water. Poverty is wide spread and equity is a major issue
in Iraq as 23.5% of Iraqi population currently lives under the poverty line and spending less than
US$ 2 per day despite, the relatively high income of the country.
13
From 2007 onwards, general security situation in Iraq has been gradually improving. Poverty
reduction is a national priority for Iraq, and TB control is an integral part of poverty reduction
activities. TB being a disease of poverty; more than 80% of cases occur among economically
productive age groups of 15-54 years in the community. Addressing TB and ensuring cure for all
those suffering from TB and their family members is thus an important step in poverty
reduction in Iraq26.
During the end of 1990, TB case notification rate increased to 120-130/100,000 population
which came down to 40/100,000 after the war in 2003. TB surveillance in Iraq had been weak
for many years following sanctions imposed in 1990. DOTS strategy adopted in 1998 in Iraq was
extended to fully cover 15 governorates Respiratory and Chest Disease Clinics and partially in
three Northern governorates26 in 2000; was available in at least one clinic in each of the 18
governorates and declared “universal coverage of DOTS in Iraq” regardless of the extent of
accessibility of the services to the population5, 3. From the start of the war in 2003, there was no
contact with the Northern governorates until communications were resumed in 2008 27.
Because of political situation, DOTS in Kurdistan region was fully introduced in 2008. In
subsequent years, district TB management units (TBMU) and Primary Health Care (PHC)
network were gradually established, enabling progress towards the goal of universal access to
health care.
Global Fund Support
UNDP and GFATM signed grant agreement number IRQ-607-G01-T effective 15th November,
2007 till 30th September, 2011 with total amount of US$ 14,500,157 of which US$ 11,445,495
were disbursed by GFATM to UNDP by 1st October, 2010 under R6 support of GFATM.
Consequent to UNDP Iraq again being nominated as PR for the TB grant approved to Iraq under
R9 support of GFATM, the two overlapping grants were consolidated as single stream funding
(SSF) and signed by the new grant agreement in October 2010. Currently UNDP is functioning as
the sole PR and WHO as the sole SR. Four NGO’s have been contracted as SSR for
implementation of GFATM Round 9 TB Grant activities in the Service Delivery Area on
“Engagement of the non-NTP public private sectors in the TB Control Programme”. They are
working on “Engagement of the non – NTP private and public sectors in the TB Control
Program”; “Human Resources Development in TB”; “Interventions among high risk group
population: TB care for the Marshland Population” and; “TB care for Internally Displaced
Population” and Ensure proper investigation and care for TB contacts”.
14
Health Care Systems Infrastructure
The Ministry of Health (MoH) is the public provider of health care services in Iraq. There is a
Directorate of Genearl Health (DGoH) in each of the 18 governorates which are further divided
into 124 health districts for administrative purposes. Each district covers on an average 200,000
– 300,000 populations. Out of a total of 2331 PHC centers in the country16, 1025 are designated
as PHC main centers (Category- A) delivering comprehensive primary health care services; 15
PHC main centers which (Category - B) in addition to comprehensive primary health care
service provide training to medical and paramedical professionals; 145 PHC main centers
(Category - C) render primary health care, maternity and emergency services and 1146 PHC sub
centers (Category - D) deliver MCH and immunization services as well as simple curative
services. However, the services provided are not consistent among all PHCC’s due to differences
in availability of equipment and human resources. While, main PHCC’s have at least 1 doctor,
the sub-centres only employ paramedical staff27.
In each district, on an average, there are 5-10 PHC centers, each serving a population ranging
from 10,000 – 45,000. Out of a total of 370 hospitals, 289 are public hospitals and the rest (81)
are private hospitals. However, none of these hospitals is presently involved in DOTS services
except for referral of TB suspects and patients to PHCCs providing DOTS Services. In addition
there are 23 medical, 23 nursing and 5 pharmaceutical schools. Although more than 8,000
NGOs are working in Iraq but their experience in provision of health care is limited. About 4,000
Private Practitioners (PPs) who are members of Iraqi Medical Association are a part of an
unorganized and disconnected private health care system. Outside the NTP, private and public
provisions of health care co-exist in Iraq, with variable referral and notification of TB patients to
NTP.
Organizational Structure of TB Programme
Government of Iraq considering TB as a major public health problem declared it as an
emergency in Iraq26 consequent to which TB control programme is placed high in the national
health agenda. Overall responsibility for TB control rests on the Ministry of Health (MoH). NTP
has 913 staff members: 112 on the central level, and 381 and 430 on the intermediate
(governorate) and peripheral (District) levels respectively. Achieving the MDG’s is a national
priority and NTP has adapted the TB related goals in MDG26. The health system in Iraq is
composed of two main sectors; public and private. In public sector, National TB Programme
(NTP) is the technical core for TB control, and is responsible for formulation of policy and
strategy, coordination with partners, planning, implementation and monitoring of TB control
activities. NTP office in Baghdad headed by the Programme Manager has two broad functions
viz. clinical and public health. The clinical responsibilities are delivered through Chest and
15
Respiratory Diseases specialized center which includes an outpatient consulting clinical section
comprising of ten Doctors and supported by National Reference Laboratory (NRL) and
Radiology and Ultrasound sections. Maintaining consistency with Stop TB Strategy approach, it
is proposed to create a section exclusively dealing with PAL within NTP which is a welcome
initiative. Beyond implementation of NTP, public health activities are supported by two
specialist Doctors in prisons with dedicated focal points for IDP’s, PPM, ACSM, MDR-TB, M&E,
HIV, OR and Marshlands. National warehouse unit responsible for drug management is staffed
by two pharmacists and one pharmacist assistant.
16
NTP ORGANOGRAM
17
Disease Burden
Based on current epidemiological situation, Iraq ranks 44 out of 212 countries and territories by
estimated number of TB cases on the global level and is considered among 9 high TB burden
countries in Eastern Mediterranean Region (EMR) contributing to 3 % of its total cases5. TB
program of Iraq was launched in 1989. DOTS strategy adopted in 1998 in Iraq was extended to
fully cover 15 governorates Respiratory and Chest Disease Clinics (RCDC) and partially in three
northern governorates26 in 2000; was available in at least one clinic in each of the 18
governorate’s, and declared “universal coverage of DOTS in Iraq” regardless of the extent of
accessibility of the services to the population5, 3. However, because of political situation, DOTS
in Kurdistan region was fully introduced in 2008.
In the absence of any proper survey, there have been varying estimates on TB load of the
country. In R9 GFATM proposal, 16,000 people are reported to be suffering from TB every
year3. WHO estimated 19,000 TB cases in Iraq in 2008 increasing to 20,000 incident cases in
2010 (range 17,000 – 24,000) with incidence rate of 64/100,000 and prevalence of 117/100,000
population8. 5 Tuberculin surveys have been conducted (last in 2000) to assess the ARTI 2.
Constrains of ARTI in estimating TB burden are apparent in view of adoption of TB treatment
globally for decades and prevalence of HIV globally. Capture / recapture study to determine
2011 TB burden in Iraq undertaken by WHO estimated 14,563 incident TB cases translating into
a TB incidence rate of 45/100,000 population7. An important precondition of “almost all cases
have access to health services”23 for the validity of capture / recapture data results is not met in
Iraq because more than 4.5 million population living in IDP’s and Marshlands hardly had any
access to health services in 2011 – when capture / recapture study was conducted. Based on
available estimates, Iraq in 2005, had a case detection rate of less than 50% which meets the
criteria laid down in Group 1 of the criteria used for selecting countries to become a candidate
for implementing prevalence surveys for the period up to 201523, but Iraq is not amongst 21
countries identified by WHO for the purpose and the present security situation is not conducive
for undertaking prevalence survey. To settle the dust on account of different varying estimates
and to arrive at a reliable estimated disease burden which is of paramount epidemiological
importance and forms the foundation of assessing the programme performance, it is high time
that NTP Iraq undertakes the disease burden assessment using available estimates through a
group of trained epidemiologists supported by statisticians. In the circumstances, for this
report, all figures relating to disease burden in Iraq are based on WHO estimates of 2010.
18
Objectives of NTP, Iraq

Ensure access to diagnosis, treatment and cure for each TB patient;

Enhance services to ensure high quality DOTS in Iraq;

Ensure greater access to TB care for poor and vulnerable populations in Iraq: e.q. poor
urban slum populations, prisoners, populations in conflict areas, marshlands and
internally displaced populations;

Protect vulnerable populations from TB, TB/HIV and MDR-TB
Objectives spelt out in R-9 GFATM proposal

Objective 1: Increase the case detection rate of sputum smear positive TB cases from
43% to at least 70% by 2014 and maintain high treatment outcome at least at 85%
among detected cases

Objective 2: Ensure universal access to diagnosis, treatment and care for Drug Resistant
TB (DR-TB).
19
Summary of Programme Performance
Out of a total of 9,668 cases
detected in Iraq during 2009, NSP
constitute 34.6%; sputum smear
negative 24.6% and EPTB 30%.
Sputum not done cases constituted
4.4% of PTB cases. Baghdad
accounted for 94 (32.4%) out of a
total of 290 sputum not done cases.
A total of 8,917 new TB cases were
detected out of which 3,347 were
NSP
cases4.
In
2009,
11
governorates had a total case
detection rate of > 70% and 9
governorates had NSP case detection rate of > 50%. Overall treatment success rate in 2009
cohort has been 89.4% with a default rate of 6%. Death rate has been around 2.8%.
NSP (3,618) accounted for 35.8%; pulmonary sputum smear negative (2,317) for 23% and EPTB
(3,009) for 29.8% of total TB cases (10,097) detected in Iraq during 2010. As compared to 2009,
total case detection in 2010 has shown a marginal increase of 4.4%; NSP cases by 8.1% and;
EPTB cases by 3.6%. However, total case detection rate of 69% is 2% less than 2009, NSP case
detection rate has remained constant at 46%. Number of governorates with > 70% TCDR have
reduced from 11 in 2009 to 9 in 2010 and those with > 50% of NSP case detection rate have
remained constant at 9. Sputum smear not done cases increased by 29.6% as compared to
2009 and accounted for 5.5% of the total pulmonary TB cases notified. Out of 10,097 registered
cases in 2010 only 9,955 have been evaluated. Overall success rate has been 89%, death rate
3.2% and default rate 6.2%. Erbil governorate has the lowest success rate of 71% and
Sulaymania (97%), Ninewa
(98%) and Diala (99%) the
highest.
During 2011, a total of 9,168
TB cases were detected in
Iraq indicating a total case
20
detection rate of new cases as 47% and NSP case detection rate of 38%. Out of a total of 6,211
pulmonary TB cases, no diagnostic sputum examination was undertaken on 364 (6.1%) cases
which increased by 0.6% when compared to 2010. Total and NSP case detection rate has
continued to fall and stood at 61% and 38% respectively. Number of governorates with > 70%
TCDR reduced from 9 in 2010 to 5 and those with > 50% has come down to 3 as compared to 9
in 2010. In spite of Iraq being a low HIV prevalence country, EP cases accounted for 32.3% of
total cases. Out of a total of 820 NSP registered cases in Q-1/2011, 686 had been cured giving a
cure rate of 83.6% and treatment completion rate of 5.4%. Death rate has been 2.8%; default
rate 5% and failure rate as 2.8%. Diala governorate has demonstrated an excellent performance
with 100% cure rate.
The pattern of overall case detection in Q-1/2012 continues to be the same as in previous years
in so much so that NSP cases constitute 33.7%; sputum smear negative s 21.9%; and EPTB cases
32.4% of the 2,334 total cases detected. Case detection rate of all forms of new cases is 48%
and that of NSP cases 39%. Percentage of sputum not done cases amongst PTB cases increased
from 6.1% in 2011 to 6.8% in Q-1/2012. TCDR has continued to fall and during this quarter it
stood at 59% as compared to 71% in 2009. Similar is the status of NSP case detection rate which
has shown a decline of 9% from 46% reported in 2009. Number of governorates with > 70%
total case detection rate has come down from 11 in 2009 to 4 in Q-1/2012. There is not even a
single governorate in Q-1/2012 in which NSP case detection rate is > 50%.
From the last more than 3 years, Baghdad has consistently been contributing 1 out of every 4
cases being detected in Iraq. Baghdad also has a dubious distinction of being a governorate
where %age of sputum not done amongst all PTB cases notified has been gradually increasing.
In 2009, it was 5.8% which rose to 7.3% in 2010 to 7.5% in 2011 and to 7.9% in Q-1/2012. The
corresponding figures for this important indicator (of the use of sputum microscopy as the
primary diagnostic tool in pulmonary TB suspects) at the central level have also been increasing
over the years and have been 4.4%, 5.5%, 6.1% and 6.8% respectively from 2009 to Q-1/2012.
In fact, in most of the governorates, a similar situation is observed. In many countries including
India, there is no column of “smear not done” in the case notification forms / reports and even
in children below 10 years who cannot bring out sputum, gastric lavage is undertaken to make
sputum smear.
Since the start of Round 6
TB grant in 2008, in the past
four years 36,253 TB cases
have been detected, which
21
included 13,174 new sputum smear positive TB cases. Out of these NSP cases, 11,725 have
been successfully treated preventing more than 0.1 million infections to occur. Access to
diagnostic services has improved through the expansion of quality assured laboratory network
from 17 in 2008 to 211 laboratories by the end of 2011. But still more microscopy centers need
to be established to reach WHO recommended target of at least one microscopy centre for
every 100,000 population. There is ongoing expansion of DOTS within the primary health care.
By the end of 2011, 1093 health facilities were providing DOTS services supported by 630
registered medical professionals. To ensure comprehensive quality DOTS services, 3427 health
professionals including Doctors, nurses, paramedical staff and prison health staff have been
trained in TB control and DOTS, laboratory diagnostics of TB, and on TB drug procurement and
supply management. NTP surveillance system has been strengthened through the routine use
of the ERNS, introducing a web-based TB surveillance program in pilot sites, and implementing
regular supervisory visits to all sites.
Methodology Adopted for Evaluation
Overview of Evaluation Methodology and Strategy
Evaluation of National TB Program (2008 – 2010) including implementation of the Global Fund
to fight AIDS, TB and Malaria (GFATM) TB grants in Iraq has been undertaken by an evaluation
team led by an international TB expert and supported by five Iraq based national experts whose
profile is attached as Annex I. It is learnt that, present programme review is the first
independent review of NTP, Iraq. After an initial desk review and reference to the suggested
analytical framework, the first activity undertaken was a meeting of all stake holders and
consultants at Erbil on 19th April, 2012. Due to non availability of visa, the team leader missed
this important pre – field visit meeting.
Key objective of the evaluation are:




Current progress toward goals and objectives of the NTP under GFATM round 6 and
round 9 proposals
Progress made in achieving impact/outcome targets included in the Performance
Frameworks of GFATM round 6 and round 9 proposals
Current methods of data collection and data sources used by NTP and other
stakeholders (consistency with the M&E framework and the international guidelines);
Management and Partnership:
22


 Assess current implementation arrangements of the GFATM grants and TB program
in Iraq in general
 CCM governance and oversight to the program
Equity assessment: measure the effectiveness and efficiency of prevention activities
among vulnerable groups by the project against the project targets and indicators.
Value for money: evaluate whether the maximum efficiency and effectiveness are
obtained with the resources available.
The evaluation followed two tracks – the first track relating to desk review of different
documents and the other track involved field visits to TB clinics as well as meetings and
discussions with large project stakeholders in Iraq to assess progress against goals, M&E,
management, collaborations, partnerships, equity assessment, value for money and project
success.
A desk review of the relevant documentation provided by UNDP was undertaken by the team
leader, the important ones amongst them being listed at Annexure II. Dr. Mohammed Mudawi
and his team on 22nd April, 2012 briefed the team leader on the functioning of NTP in Iraq;
constitution of the evaluation team along with brief profile of the team members and the TOR
of the evaluation mission. Before travelling to Erbil on 3rd May, 2012, and subsequently after
Erbil visit, meetings with Dr. Sevil Huseynova and her team of WHO, Amman were productive
which gave detailed insight into major activities of NTP and the initiatives being implemented
by four SSR’s. On account of security concerns, the team leader could not undertake any
meetings with MoH officials, civil society organization and international donors but had
detailed personal interaction with M&E officer of NTP and NTP manager through video
conference. While pursuing the available documentation, the team leader fished out more
documentation from UNDP and WHO during his continued desk review at Amman from 13 th to
24th May, 2012.
With a view to ensure comprehensibility and possible uniformity in evaluation methodology
and assessment during field visits of team members, and consistency with UNDP’s evaluation
policy, the team leader developed guidelines for undertaking supportive evaluation contained
in a structured schedule to be used (Annex III) as a tool for undertaking supportive evaluation
which were explained to the team through a video conference on 26th April, 2012 which was
also attended by NTP Manager. Language problem necessitated explaining finalities in Arabic.
Each team member was requested to field test the instrument independently in at least one
facility for assessing its operational feasibility. They were also requested to undertake SWOT
analysis of NTP, Iraq for getting inputs for formulation of recommendations. Though some of
the team members e-mailed evaluation friendly stature of the tool, but a meaningful discussion
could be held only on 10th May, 2012, when all the team members met at Chwarchra Hotel in
23
Erbil for the first time. The team members till then had not comprehensively visited any of the
health facilities providing TB care. The guidelines for undertaking supportive evaluation were
reaffirmed and they were advised to use them as a guiding tool of comprehensibility in all their
field assessments.
Because of security concerns, team leader had to restrict his field evaluation visits to only Erbil
where he personally visited the programme implementation outlets, met with project staff and
collected data through observation and personal interactions. Visit to Erbil and its health
facilities were well facilitated by M&E officer of NTP with his valuable contributions of
programme related national data. Most of the field work had to be undertaken by the Iraqi
national experts in Iraq including Kurdistan Regional governorates (KRG). National consultants
visited health facilities in Baghdad, Duhok, Najaf, and Basrah governorates; prison at Baghdad
and IMC – an NGO. Profile of field visits by the team members is at Annexure V. The evaluation
has thus been carried out using the desk review, field visits to health facilities, consultations
with project partners and beneficiaries and other key stakeholders.
The team leader thereafter drafted a comprehensive evaluation report of NTP which included
field specific inputs incorporating what all was seen and heard from the staff to improve
performance supplemented with derivations derived from the desk review of the
documentation including programme related reports and returns. This formed an insight into
the implementation status of existing NTP polices and guidelines and what should now be done
formed a set of recommendations all aiming to improve program performances targeting
achievement of NTP objective of 70/85 by 2014 and universal access to diagnosis, treatment
and care for DR-TB.
Evaluation Team
Evaluation team is composed of an international consultant as team leader and five Iraq based
national consultants whose brief profile is attached as Annexure I. National consultants had the
overall obligation of meeting with GFATM project beneficiaries and other stakeholders and
conducting field visits in the southern, central and northern regions of Iraq. Because of the
restricted field visits of the international consultant due to security concerns, work of the
national consultants has been critical to the strength of the evaluation as they were tasked with
conducting the field visits to different health centers, patient houses, prisons, internally
displaced population (IDPs) and Marshland along with documenting the opinions of most
stakeholders through different meetings with NTP, Country Coordination Mechanism and
implementing NGOs. Responsibility of the team leader beyond desk review and visit to health
facilities in Erbil has been to synthesize all information gathered by the national consultants,
24
conduct its analysis in the broader context of considering all information sources and write the
evaluation report.
Work plan and Report
The work plan is attached as Annexure IV.
The report contains detailed findings in key areas and recommendations of the evaluation
team.
Limitations
The evaluation process and collection of data was affected by limitations of the International
Consultant’s movement in Iraq, lack of adequate opportunity of training of the national
consultants and almost nil interaction with the senior officials of the concerned GoI
functionaries. The International Consultant could manage to make visit to only Erbil, KRG for
personal interaction and field observations.
25
IMPLEMENTATION AND KEY FINDINGS
Vision, Goals and TB Control Strategy – Iraq (Vision, Goal, Objectives, Targets, Components of the strategy);
Organizational Structure of TB Programme; Sputum Microscopy Network; Drug Delivery Outlets; Programme
Performance (Case detection during 2009, 2010, 2011, Q-1/2012, Treatment Outcome of Cohort of 2009, 2010,
Q-1/2011, Performance Analysis); Recommendations; Drug Procurement, Quality Control and Distribution
(Recommendations); MDR-TB (Recommendations); Operational Research
Vision, Goals and TB Control Strategy – Iraq
Vision :
A TB-free country, with elimination of the disease as a public health problem by
2050
Goal
:
To reduce dramatically the country burden of TB by 2015, in line with the MDG’s
and Stop TB partnership targets
Objectives:

Ensure access to diagnosis, treatment and cure for each TB patient;

Enhance services to ensure high quality DOTS in Iraq;

Ensure greater access to TB care for poor and vulnerable populations in Iraq: e.q. poor
urban slum populations, prisoners, populations in conflict areas, marshlands and
internally displaced populations;

Protect vulnerable populations from TB, TB/HIV and MDR-TB
26
Targets:
MDG 6, Target 8: Halt and begin to reverse the incidence of TB by 2015.
Epidemiological targets linked to MDGs:
1. Achieve detection of 70% of infectious TB cases and cure at least 85% of those cases by
2014
2. Reduce the prevalence of and deaths due to TB by 50% by 2015 with 1990 as baseline.
Components of the strategy:
1. Pursuing, quality DOTS expansion and enhancement






DOTS expansion
Political commitment
Capacity building
Drug management
Strengthening of laboratory system
Monitoring and Evaluation (M&E) and impact measurement
2. Addressing TB/HIV, MDR-TB and other special challenges by scaling up TB/HIV joint
activities, Programme Management of Drug Resistant TB (PMDT), and other relevant
approaches;



TB/HIV joint activities
PMDT
TB among the poor and other vulnerable groups
3. Contributing to health system strengthening
Improving quality and efficiency of general services in respiratory illnesses using the
Practical Approach to Lung Health (PAL)
27
4. Engaging all care providers, public, non-governmental and private, by scaling up publicprivate mix (PPM) approaches to ensure adherence to the International Standards of TB
Care (ISTC), with a focus on the providers of the poorest and implementing Public-Private
Mix approaches
5. Empowering patients and communities by scaling up community TB care and creating
demand through context-specific advocacy, communication and social mobilization;
IEC/BCC for patient empowerment, community involvement; and Community Health
Worker (CHW) training for community-based DOTS
6. Enabling and promoting operational research to improve programme performance.
Developing a national framework for operational research and building local capacity to
undertake the same.
Organizational Structure of TB Programme
Government of Iraq considering TB as a major public health problem declared it as an
emergency in Iraq26 and TB control programme is placed high in the national health agenda.
Achieving the MDG’s is a national priority which has been reiterated by the Government. NTP
has adapted the TB related goal stipulated in MDG’s26. The health system in Iraq is composed of
two main sectors; public and private. In public sector, the main health care provider is MoH.
Overall responsibility for TB control rests with the Ministry of Health (MoH). Within the MoH,
National TB Programme (NTP) is the technical core for TB control, and is responsible for
formulation of policy and strategy, coordination with partners, planning, implementation and
monitoring of TB control activities. NTP office in Baghdad headed by the Programme Manager
has two broad functions viz. clinical and public health. The clinical responsibilities are delivered
through Chest and Respiratory Diseases specialized center which includes an outpatient
consulting clinical section comprising of ten Doctors and supported by National Reference
Laboratory (NRL) and Radiology and Ultrasound sections. In pursuing STS, NTP Iraq aims among
others to contribute to national and local health systems strengthening. These efforts aim at
providing equitable access to quality health services by all people. Innovations have included
emerging partnership with non NTP public and private sector, special efforts for IDP’s and
Marshland population. Maintaining consistency with Stop TB Strategy approach, it is proposed
to create a section exclusively dealing with PAL within NTP which is a welcome initiative.
28
Beyond implementation of NTP, public health activities are supported by two specialist Doctors
in prisons with dedicated focal points for IDP’s, PPM, ACSM, MDR-TB, M&E, HIV, OR and
Marshlands. National warehouse unit responsible for drug management is staffed by two
pharmacists and one pharmacist assistant.
Organizational structure of NTP is based on four levels:
1. NTI at Baghdad is apex TB institution of the country looking after quality implementation of
National TB control program activities which include capacity building, quality assurance of
comprehensive TB services at intermediate and peripheral levels and conduct operational
research. Quality assurance of diagnosis is maintained by national reference laboratory
(NRL) - wing of NTI. The laboratory at NTI also provides quality assured smear microscopy.
Out of total NTP staff strength of 913, 112 are placed at Central level. National TB Institute
(NTI) or Respiratory and Chest Disease Institute at national level in Baghdad is responsible
for training of staff, overall programme strategy development, and implementation of the
national plan and supervision of activities of 18 Respiratory and Chest Disease Clinics (RCDC)
and all other TB related activities in the governorates. NTP at Central level has an
independent M&E unit. Training unit assesses training needs, develops training plans and
organizes trainings for NTP. OR unit conducts relevant research and national surveys.
2. At intermediate level, each governorates headed by GTBC has one governorate Respiratory
and Chest Disease Clinic. One RCDC also functions at NTI thus making a total of 19 RCDC’s in
the country. Nineteen clinics provide quality assured direct smear examination and provide
treatment to patients or refer them to the District TB Management Unit (TBMU) nearest to
their house for treatment / follow up. GTBC is responsible for collection of TB data in the
governorate at intermediate level from all its TBMU’s for onward transmission on quarterly
basis to M&E unit at Central level. A total of 381 staff members support NTP at 18 RCDC’s.
3. There are 124 health Districts in Iraq. In each of these Districts (presently in 117 Districts)
the main Primary Health Care Center has a TB Management Unit (TBMU) headed by a
District TB Coordinator. Out of these 117 TBMUs, till December, 2011, only 85 provide
microscopy services to diagnose TB cases12. TBMU ensures TB diagnosis, monitor treatment
intake of TB patients, and referral of TB patients for treatment intake to the PHCC’s nearest
to the residence of the patient. TBMUs also have TB register and reporting facilities. District
29
TB coordinator is responsible for collection of TB data in the District for quarterly
submission to the governorate TB coordinator (GTBC). There are 430 staff members at the
peripheral level.
4. Network of 2331 Primary Health Care Centers (PHCCs) having different range of services
provides graded health care services to 32.3 million Iraqis.
Sputum Microscopy Network
During 2009, diagnostic service outlets increased from 68 to 128 by establishing 59 new
laboratories in clinics and one in Karch TB center in Baghdad. Currently only 10 PHCCs are
involved in sputum examination. In addition to 85 microscopy centers functioning from
TBMU’s, one at NTI, 18 in governorate clinics, 10 in PHCC’s, 5 in prisons, 92 quality assured
direct smear examination outlets have been established through PPM partnership making a
total of 211 functional sputum microscopy units till the end of 2011 which is almost doubling
diagnostic outlets from 200912. Diagnosis of TB patients is currently limited to the National
Reference Laboratory, and the Respiratory and Chest Disease Clinic in Baghdad; Respiratory and
Chest Disease Clinics in the 18 governorates of Iraq; and District PHCC’s (TBMU’s) at the
peripheral level.
Till date, there is one laboratory for 150,000 population against a WHO recommended norm of
at least 1 laboratory for every Distribution of Microscopic Diagnostic centers by Governorates by 31st Dec, 2011
100,000 population. Through the Governorate Governorate TBMUs PHCC Prison Hospitals
Total
2
14
5
5
14
40
implementation of GFATM SSF Baghdad
1
4
5
0
10
20
grant, the network of laboratories Al-Anbar
1
9
0
0
9
19
is targeted to be increased to 321 Nineawa
Basra
1
4
0
0
12
17
quality assured laboratories by the
Wasit
1
6
0
0
6
13
end of 201527. During the
Babel
1
4
0
0
8
13
expansion, access to high quality TB
Dieyla
1
2
0
0
10
13
diagnostic laboratory services will SalahEldin
1
8
0
0
2
11
be ensured to entire population of Thiqar
1
4
0
0
5
10
Iraq, particularly taking into Duhok
1
7
0
0
1
9
consideration geographical areas Erbil
1
7
0
0
0
8
1
5
0
0
1
7
with limited access during the Sulimaniyah
1
3
0
0
2
6
expansion. Based on PPM-DOTS Karbala
Kirkuk
1
2
0
0
3
6
which NTP is implementing, it is
Diwania
1
1
0
0
4
6
Missan
1
3
0
0
1
5
Najaf
1
1
0
0
3
5 30
Muthana
1
1
0
0
1
3
Total
19
85
10
5
92
211
envisioned that private laboratories will be included in the laboratory quality assurance system,
and will be provided with laboratory guidelines and laboratory staff will receive training. The
progress in this area has been slow which is supported by the fact till 2011, only 40% of budget
allocation of US$ 7,482,351 on “expansion of quality assured TB diagnostic and treatment
services” has been spent. Non accessibility of diagnostic services is an important reason for low
case detection rate. Till such time additional microscopy facilities are established,
transportation of smear slides from the PHCC’s to the microscopy center would be a low cost
high gain initiative. Five established laboratories in the prisons whose laboratory technicians
have been trained need to be made functional delivering composite DOTS services at the
earliest possible.
To ensure quality assurance of microscopy services, the National Reference Laboratory in
Baghdad conducted panel testing for 18 intermediate laboratories, which in turn conducted
panel testing for 203 peripheral laboratories14. Currently existing External Quality Assurance
(EQA) System (supervision, panel testing, and training) between the National Reference
Laboratory and the 18 governorate Respiratory and Chest Disease Clinics and to peripheral
laboratories is proposed to be further enhanced. Human capacity in the laboratory has been
developed through provision of training on direct sputum microscopy for 491 LT’s till Q-1/2012.
In addition, 14 laboratory experts have been trained in Egypt in EQA and 16 Bacteriologists
were trained for DST at Milan21.
Drug Delivery Outlets
In northern governorates, 67 new health care facilities (Erbil 21, Suleymaniyya 25 and Dohuk
21) have been established for providing drug delivery services and 2 of them in Suleymaniyya
have TB diagnostic laboratories4. IMC and Iraqi Anti TB Association expanded their services to
10 additional PHC’s in Al-Anbar governorate and 5 PHC’s, 3 private and 3 public hospitals in Al –
Kadikia District4. To ensure comprehensive quality DOTS services, 3427 other health
professionals including Doctors, nurses, paramedical staff and prison health staff have been
trained till 2011. A total of 1093 PHCC’s and 630 registered medical practitioners are providing
treatment services. In the next three years, NTP plans to expand treatment services through all
2331 PHCC’s27 which is also envisaged in R9 GFATM support.
PHCC’s functioning as microscopy centers; provide laboratory support by undertaking sputum
microscopy and drug distribution. However, irrespective of patient being diagnosed/ registered
in any facility within the governorate, he is referred to the PHCC nearest to his house for taking
his treatment and his drugs and patient treatment card in an indigenized plastic pouch with his
31
name and TB No. written on it is delivered to the referred center. During transit some patients
are lost as has been TB No 124/11 at Nazder Bammery PHC. Three such centers where patients
are referred for treatment were visited by the team leader in Erbil and found low commitment
of the health workers for the TB programme. In charge of PHCC’s was not aware of the status of
the patients referred for DOT. Communication between referring and referred center was
limited only to supply of drugs. There was no system of default retrieval. In fact in all the cases,
the evaluation team found that the health worker was not even aware that the patient had
defaulted. Expired drugs were lying in the plastic pouch of the patient with evident danger of
their use. Referral system between PHCC’s is rudimentary and needs to be streamlined.
Programme Performance
During 2000-2003 there was a steady increase in the number of notified cases, which was
interrupted during 2003 – 2007 due to internal conflict. Subsequent improvement in the
security situation supported with R6 support of GFATM, resulted in improvement of case
notification. Since the start of GFATM R6 TB grant in 2008, in the past four years, 36,253 TB
cases have been detected out of which 13,174 were new sputum smear positive TB cases and
11,725 of them have been successfully treated.
Case detection during 2009
Out of a total of 9,668 cases detected in Iraq during 2009, NSP constitute 34.6%; sputum smear
negative 24.6% and EPTB 30%. Sputum not done cases constituted 4.4% of PTB cases. A total of
8,917 new TB cases were detected out of which 3,347 were NSP cases4. Case detection rate of
all forms of new cases has been 54% and that of NSP cases 46%. CDR of sputum smear positive
cases in 2009 increased by 8% from 38% in 2007 and all TB cases increased by 10% to 55% with
varying performance in different governorates. Eleven governorates had a total case detection
rate of > 70% and 9 governorates had NSP case detection rate of > 50%. Baghdad accounted for
94 (32.4%) out of a total of 290 sputum not done cases. Amongst all governorates, Baghdad
detected highest number of NSP (856), sputum smear negative (425) and EPTB (755) cases
accounting for 25.6%, 17.9% and 26% respectively of type wise total cases detected in Iraq in
2009. At the same time, Erbil was the lowest contributor in NSP cases (47); Duhok (51) in
pulmonary sputum smear negatives and Kerkuk (63) in EPTB cases accounting for 1.4%, 2.2%
and 2.2% respectively of total type wise cases detected. It is good to note that about 40%
governorates (Sulaymania, Erbil, Selah-Aldin, Muthenna, Kerkuk, Diala, Diwanyiah) have
reported less than 30% of their total case detection as EPTB cases. Remaining 11 governorates,
32
particularly Anbar which reported 39.9% of its total notified cases as EPTB should follow the
best practices of good performing governorates in this area.
Out of a total case detection of 2,420 in Baghdad in 2009, NSP cases accounted for 35.4%;
sputum smear negatives 17.6% and EPTB cases 31.2%. Sputum not done cases accounted for
5.8% of all pulmonary TB cases in this governorate. NSP case detection in Sulaymania (45%),
Najaf (44.4%), Kerbela (42.5%), Babil (40.6%), Diala (43.1%), Misan (40.1%) governorates has
been good (%ages in parenthesis indicate NSP as %age of total case detection in the respective
governorates) and needs to be maintained. NSP cases in Erbil, Muthenna and Duhok
governorates account for 13.8%, 19.5% and 27.6% respectively of the total case detection of
their respective governorates. These three governorates need to ensure active searching of
chest symptomatic amongst all passively reporting patients to the outdoor facilities of all health
services outlets within the governorate, irrespective of their ownership. They also need to
ensure that all chest symptomatic are well demonstrated the method of bringing out quality
sputum; following the diagnostic algorithm stipulated by NTP by all health facilities; and regular
monitoring of laboratory quality control. They should also learn from the good practices of the
well performing governorates by field visits and also during interactive sessions of the quarterly
review meetings. Pulmonary sputum smear negatives in Erbil (51.2%) and Muthenna (46.3%) is
on a very high side particularly in low HIV prevalence country. These two governorates should
analyze District wise data and identify poor performing Districts, undertake supportive
monitoring visits, analyze the reasons for such a performance and facilitate remedial action.
From the last more than 3 years,
Baghdad has consistently been
contributing 1 out of every 4 cases
being detected in Iraq. On the
other hand, Baghdad has also a
dubious distinction of being a
governorate where %age of
sputum not done amongst all PTB
cases notified has been gradually
increasing. In 2009, it was 5.8%
which rose to 7.3% in 2010 to
7.5% in 2011 and to 7.9% in Q1/2012. The corresponding figures
33
at the central level have also been increasing over the years and are 4.4%, 5.5%, 6.1% and 6.8%
from 2009 to Q-1/2012. In fact, in most of the governorates, a similar situation is observed
which is an area of serious concern. In a good performing programme, except for small children
who cannot bring out sputum, all PTB suspects must undergo sputum examination. In many
countries including India, there is no column of “smear not done” in the case notification
forms/ reports and even in children below 10 years who cannot bring out sputum, gastric
lavage is done. Such a column is an invitation to health professionals to start ATT on clinical
diagnosis or diagnosis based on X-ray. In any case, this column should not be bracketed with
sputum smear negative cases as in some cases, if sputum examination is done, it may be
positive. If at all a column of “smear examination not done” needs to be kept, it should be a
separate column.
Case detection during 2010
NSP (3,618) accounted for
35.8%; pulmonary sputum
smear negative (2,317) for 23%
and EPTB (3,009) for 29.8% of
total TB cases (10,097) detected
in Iraq during 2010. Case
detection rate for new cases of
all forms has been 53% and NSP
case detection rate as 46%. As
compared to 2009, total case
detection in 2010 has shown a
marginal increase of 4.4%; NSP
cases by 8.1% and; EPTB cases
by 3.6%. NSP case detection
rate has remained constant at
46%. Number of governorates with > 70% TCDR have reduced from 11 in 2009 to 9 in 2010 and
those with > 50% of NSP case detection rate have remained constant at 9. Pulmonary sputum
smear negative cases remained almost constant. Sputum smear not done cases increased by
29.6% from the previous year and accounted for 5.5% of the total pulmonary TB cases notified.
Baghdad accounted for 24.2% of total case detection of Iraq; 24.4% of NSP case detection;
16.1% of Pulmonary sputum smear negative cases and 23.6% extra pulmonary of total cases
detected in Iraq. Out of the total 2,440 TB cases detected in Baghdad, NSP constituted 36.2%,
sputum smear negative 15.3% and EPTB 29.1%. Diagnostic sputum examination was not done
34
on 6.9% of PTB cases initiated on treatment in 2010 in Baghdad. Duhok detected the lowest
number of total TB (218) and EP (64) cases; Muthena the lowest number of NSP cases (61); and
Najaf the lowest number of sputum smear negative cases (27). It is interesting to note that ThiQar contributed 6.9% and Muthenna around 2.4% and Duhok around 2.2% to total case
detection of the country both in 2009 and 2010.
NSP cases constituted 47.3% of its total case detection in Diala and 45.9% in Najaf
governorates. In Sulaymania, Selah-Aldin, Misan and Ninewa governorates, NSP cases
accounted for more than 40% of total case detection. Sputum smear negative cases in Baghdad,
Basrah, Misan, Babil, Anbar, Thi-Qar, Wasidit, Diala and Najaf governorates accounted for less
than 25% of total case detection in their respective governorates. Sputum smear negative cases
accounted for 42.5% in Erbil; 45.6% in Kerkuk; and 41.2% in Muthenna of their respective total
case detection which is an area of concern. Sputum smear negative cases also account for high
%age of total cases detected in the governorates of Suleymania, Duhok, Selah-Aldin, Diwanyiah
and Ninewa. A high %age of sputum smear negative cases in a low HIV prevalence country calls
for quality control of laboratory including ensuring good quality of sputum specimen. Since
diagnosis by X-ray picks up a large number of false +ve cases, all pulmonary TB suspects with
negative sputum should be treated for 10 days on antibiotics before undertaking X-ray for
diagnostic purposes. In fact, one of the specialists in RCDC, Erbil does not practice DOTS and
initiates treatment after X-ray only. It is good to note that, in Sulaymania, Ninewa and Anbar
governorates diagnostic sputum smear examination had been undertaken on all pulmonary TB
suspects.
EPTB cases constituted 17.6% of total case detection in Diala and 19.6 % in Kerkuk. However, in
Babil and Anbar, proportion of EPTB cases to total cases detected in the governorate has been
alarmingly high at more than 40% calling for further analysis of the reasons for the same. Case
fatality is known to be higher in people living with HIV and having smear-negative pulmonary /
extrapulmonary TB. In all the governorates, with a high incidence of EPTB, all cases should
invariably be tested for HIV. All such cases who are found to be suffering from both pulmonary
and EP tuberculosis should always be classified as pulmonary TB cases.
35
Case detection during 2011
During 2011 in Iraq, a total of 9,168 TB cases were detected indicating a total case detection
rate of new cases of all forms as 47% and NSP case detection rate of 38%. NSP constituted
33.4% and sputum smear negative pulmonary TB cases 22.9%. Out of a total of 6,211
pulmonary TB cases, no diagnostic sputum examination was undertaken on 364 (6.1%) cases
which increased by 0.6% when compared to 2010. Thi-Qar (20), Baghdad (18), Wasidit (11),
Basrah (8) and Diala governorates constitute 65 out of 83 sputum not done cases reported in Q1/11. Total case detection in 2011 decreased by 9.2%; NSP cases by 15.5%; and pulmonary
sputum smear negative cases by 9.4%. Total and NSP case detection rate has continued to fall
and stood at 61% and 38% respectively. Number of governorates with > 70% TCDR reduced
from 9 in 2010 to 5 and those with > 50% case detection rate amongst new sputum smear
positive has come down to 3 as compared to 9 in 2010. Analyzing the reasons for the decline in
case detection in 2011, revealed that all passively reporting adult new OPD patients are not
being actively screened for 2 weeks cough which is supported by the fact that suspects
identified are much less than the anticipated at least 2% of the general OPD attendance. In
addition, complacency seems to be playing its part in this decline and needs to be arrested
immediately. Special efforts by Central level need to be made for consistently low performing
governorates and governorates need to make special efforts for consistently low performing
Districts. Supportive assessment and advisory visits with hand holding would be productive in
much needed improvement in programme performance. Baghdad detected highest number of
NSP cases (782), highest number of sputum smear –ve (335) and highest number of EP cases
(787), while, Misan detected lowest number of total cases (212), Duhok lowest number of NSP
cases (57), Najaf lowest number of pulmonary sputum smear –ve cases (26) and Selah-Aldin
lowest number of EP cases (72). In terms of %age, Baghdad accounted for 25.2% of total case
detection in Iraq during 2011, NSP accounted for 25.6%, sputum smear negative for 16% and EP
for 26.6% of total cases detected in Iraq. Amongst PTB cases, sputum not done accounted for
23.9% of cases in Baghdad.
In spite of Iraq being a low HIV
prevalence country, EP cases
accounting for 32.3% of total cases
is a matter of concern requiring an
in-depth analysis. EPTB normally
constitutes about 15-20% of all
36
cases of TB in immunocompetent patients30. While Babil and Anbar governorates reported
more than 40%; Najaf, Thi-Qar, Kerbela and Misan governorates reported more than 35% of
their total case detection as EPTB cases. In Diala, Kerkuk and Wasidit governorates, EP cases
accounted for less than 25% of their total case detection. Lymph nodes are the commonest site
of involvement in EPTB followed by pleural effusion and virtually every site of the body can be
affected. NTP needs to formulate guidelines promoting diagnosis of EPTB at the common sites,
keeping in mind that clinical presentation of EPTB is atypical in certain situation; tissue samples
for diagnostic confirmation can sometimes be difficult to procure and the conventional
diagnostic methods have a poor yield. Emphasis should be placed on laboratory confirmation of
diagnosis as far as possible. Diagnosis should be based on at least one specimen with confirmed
M. Tuberculosis or histological/strong clinical evidence consistent with active EPTB, followed by
decision of the clinician to treat with full course of anti tubercular treatment25. Empirical
treatment should not be encouraged. All EPTB cases should also be asked about the history of
cough. If EPTB case has cough of even less than 2 weeks duration, his sputum examination
should also be undertaken. In case the sputum is positive, such a patient should be classified as
smear +ve PTB and not as EPTB.
Out of 234 total cases detected by Selah-Aldin governorate, NSP constituted 47.4%, while in
both Diala and Babil governorates, NSP constituted around 44% of total case detection. Erbil
reported a low of less than 17% of their total case detection as NSP cases, while in Duhok, 1 out
of every 4 detected TB cases has been a NSP case. Both Erbil and Duhok governorates need to
pay special emphasis on actively searching of all chest symptomatic amongst all passively
reporting patients in outdoor facilities of all NTP and non- NTP public and private health
facilities in the governorate; using sputum microscopy as primary diagnostic tool in pulmonary
TB suspects; demonstrate to all PTB suspects the correct method of bringing out quality sputum
sample; and quality control of sputum microscopy.
It is good to note that Sulaymania, Muthenna and Ninewa governorates undertook diagnostic
sputum examination in 100% of their PTB cases. In Diwanyiah, Anbar and Kerbala, sputum not
done constituted less than 2% of all pulmonary TB cases initiated on treatment. Except for
children who are not able to produce sputum, as a matter of rule, all PTB suspects must
mandatorily undergo sputum examination.
37
Case detection during Q1/2012
The pattern of overall case
detection in Q-1/2012 continues
TB Case Notification during Q1-2012
to be the same as in previous
years in so much so that NSP
cases constitute 33.7%; sputum
smear negative 21.9%; and EPTB
cases 32.4% of the 2,334 total
cases detected. Case detection rate of all forms of new cases is 46% and that of NSP cases 37%.
Extrapolating Q-1/2012 case detection to one year, it is observed that total and NSP case
detection show a marginal increase while sputum smear negative pulmonary TB cases remain
almost constant when compared to 2011. However, the %age of sputum not done cases
amongst PTB cases increased from 6.1% in 2011 to 6.8% in Q-1/2012. Similar is the status of
NSP case detection rate which has shown a decline of 9% from 46% reported in 2009. Similarly,
governorates with > 70% total case detection rate have come down from 11 in 2009 to 4. There
is not even a single governorate in Q-1/2012 in which NSP case detection rate is > 50%.
Baghdad continues to contribute highest number of all form of TB cases and accounts for 24.7%
of NSP cases; 26.9% of EPTB cases and 16.2% of sputum smear negative cases amongst total
case detection in Iraq during Q-1/2012. Basrah needs to step up NSP case detection and reduce
number of “sputum not done” cases (10% of PTB notifications) which by itself will enhance NSP
case detection rate. Erbil, Duhok, and Diwanyiah governorates need to enhance their NSP case
detection rate. Duhok governorate is the lowest contributor to the country’s NSP, EP and total
case detection; and Najaf in pulmonary sputum smear negatives for Q-1/2012.
NSP cases constitute 41.7% in Diala; 41.3% in Kerkuk; and 39.3% in Basrah amongst total cases
detected in their respective governorates. NSP cases account for 1 out of every 5 cases
detected in Duhok which needs to ensure strict implementation of NTP Iraq’s prescribed
diagnostic algorithm; every PTB suspect should be demonstrated the correct procedure of
sputum sample production and quality monitoring of all sputum microscopy laboratories in the
governorate with emphasis on poor performing TBMU’s. Foregoing observations are well
supported by the fact that in Duhok governorate, sputum smear negative pulmonary TB
constitute 32.7% of total case detection and sputum smear not done in more than 15% of PTB
cases detected in the governorate.
38
Notified New Cases All forms by Governorates in Q1-2012
Anbar, Najaf, Misan, and Babil governorates reported more than 40% of their total cases
detected as EPTB cases. Sputum not done constituted 16.4% of PTB cases notified in Erbil. On
the contrary it is good to note that diagnostic sputum smear examination was undertaken for
all pulmonary TB cases notified in the governorates of Muthenna, Kerkuk and Sulaymania
during Q-1/2012.
Anbar (50%); Najaf (46.3%); Babil (46.9%); Missan (40%); Thi-Qar (38.5%) are the governorates
reporting very high %age of EP cases. While Central level should prioritize strict monitoring of
these governorates, the governorates by themselves monitor the performance of poor
performing Districts and ensure that patients are initiated on treatment only after laboratory
confirmation and not merely on clinical suspicion.
Treatment Outcome of Cohort of 2009
Out of 9,668 cases detected in 2009, overall treatment success rate has been 89.4% with a
default rate of 6%. Death rate has been around 2.8%. While Misan, Ninewa, Suleymania,
Muthenna, Dewaniya and Diala governorates demonstrate a success rate of 96% and above,
39
Erbil governorate has a treatment success rate of 66% and default rate of 26.5%. Baghdad also
showed a high default rate of 11.8%. Babil has shown high death rate of 7.5%.
Out of 3347 NSP cases registered in 2009, 2674 (79.9%) were cured and 324 (9.7%) completed
treatment with a default rate of 5.7%. Death rate has been 2.3%. Out of all the governorates,
Baghdad had the lowest cure rate (56%) and treatment success rate (82%) amongst NSP cases
and the highest completion (25.4%) and default (11.6%) rates. Duhok (24.6%) and Erbil (23.4%)
also had a high treatment completion rate indicating that large number of patients do not come
for giving sputum on completion of treatment. Field visits have shown that patients during CP
are given medicines for one month and even the relatives are also given drugs almost on
regular basis. In fact, health professionals are very liberal in giving drugs to anybody who comes
and for any duration of treatment patient / attendant wants.
Pulmonary sputum smear negative cases have shown a treatment completion rate of 88.9%
and a death rate of 3.4%. Erbil continues to have the lowest TSR of 61% and a default rate of
28.2%. One of the important reasons for high default rate in Erbil is because of use of X-ray as
primary diagnostic tool as a result of which non TB patients initiated on treatment stop taking
treatment after some time and add up to the list of defaulters. The evaluation team came
across one such female patient who even informed the staff that she has discontinued the
treatment as she is not a case of TB and has unnecessarily been put on anti TB treatment. In a
low HIV prevalence country like Iraq, death rate amongst smear negatives more than NSP’s is a
situation requiring detailed investigation. A treatment completion rate of 91% has been
observed amongst 2,904 EPTB cases with 2.9% death rate and 5.3% default rate. Here also, Erbil
has shown the lowest treatment completion rate (64%) and the highest default rate 28.6%.
However, death rate has been highest in Babil (7.9%) followed by Nejef (6.9%) and Baghdad
(3.4%). In all areas with high death rate amongst EPTB cases, in addition to early diagnosis, DOT
at least during IP and evaluation for co morbid conditions including HIV are essentialities.
40
Governorate wise Success & Default rates comparison between cohort Y.2009 & 2010
Cure rate amongst Cat II cases has been 57% and treatment success rate 84%. Completion rate
of 27% does not speak well about the quality of programme implementation.
Treatment Outcome of Cohort of 2010
During 2010, out of 10,097 registered cases only 9,955 have been evaluated. The fate of
remaining 142 cases is not documented which is in violation of the cardinal principles of DOTS
strategy which envisages that each and every case registered in TB register must be accounted
for. Overall success rate has been 89%. Erbil governorate which has the lowest success rate of
71% needs to learn from successful experiences of Diala (99%), Ninewa (98%) and Suleymania
(97%). Over all death rates for the country is 3.2% and default rate 6.2%. Using cured patients
and community members as treatment supporters will certainly reduce the default rate.
Out of a total of 3618 NSP cases initiated on treatment, 2906 have been cured giving a cure rate
of 80.3% and a completion rate of 8.6%. Performance of Erbil and Baghdad has been poor, with
Baghdad showing a cure rate of 59.9%, treatment completion rate of 23% and default rate of
10.9%; and Erbil showing a cure rate of 44.8%, treatment completion rate of 26.9% and default
rate of 23.9%. High treatment completion and default rates indicate poor rapport between the
41
patients and health providers indicating that DOT is not happening and default retrieval
mechanism is not operational. In fact, both these facts were seen in all the five health facilities
visited in Erbil and now they are being corroborated by the results. Both the governorates need
to learn from successful experiences of Ninewa and Muthenna which have demonstrated a cure
rate of 95%.
Success rate amongst EPTB cases has been 91% with Erbil at the bottom with 71% success rate
and 29.4% of cases defaulting. 376 “Sputum not done cases” have shown a treatment
completion rate of 88.7%, default rate of 7.7% and death rate of less than 3%. Here also Erbil
has the lowest treatment completion rate of 62% with a very high default rate of 34.6%.
Diagnostic algorithm needs to be religiously followed in Erbil.
Cure rate amongst Cat II cases has been at dismally low rate of 36% while success rate is 76%
which is because of issuing of drugs for longer period. “Cure rate is the critical indicator of the
quality of the programme” needs to be adopted by NTP. Default rate of 10.4% is high and needs
to be reduced.
Treatment Outcome of Cohort of Q-1/2011
During Q-1/2011, out of a total of 820 NSP registered cases, 686 had been cured giving a cure
rate of 83.6% and treatment completion rate of 5.4% amalgamating to 89% treatment success
rate. Death rate has been 2.8%; default rate 5% and failure rate as 2.8%. Diala governorate has
demonstrated an excellent performance with 100% cure rate amongst its 53 NSP cases. In fact,
Baghdad with 68% cure rate and Nejef with 64% cure rate has brought down the country’s cure
rate amongst the cohort of Q-1/2011. One of the important observed reason for low cure rate
and high completion rate has been issuing of drugs even to the relatives of the patient and that
too for long durations. In Baghdad, completion rate of more than 15%; default rate of 9.3%; and
failure rate of 5.9% point towards poor DOT. A regular DOT builds a rapport between the health
provider and the patient which by itself reduces default. To facilitate easy access to the
patients, the concept of community DOT providers and specially cured patients as DOT
providers should be promoted. In fact, anybody can be DOT provider as long as he is willing, is
acceptable to the patient and answerable to the health system. Each center should display a list
of DOT providers and every patient at the start of treatment is provided an opportunity to
42
identify his own DOT provider. In Nejef, though numbers are small, death rate of 14.3% is high
and needs to be investigated. Important reasons for high death rate within Iraq context which
need to be addressed include low community awareness leading to patient delay in reporting to
health facilities, non enforcement of DOT and high tobacco consumption. Efforts need to be
made to sensitize the community on signs and symptoms of TB so that patients do not report to
the health facility in late moribund stage; DOT should be adopted and all TB patients who are
smokers should be regularly counseled to quit smoking and tobacco education should become
a part of TB education. HIV should be ruled out in all high risk cases.
Comprehensively treatment outcome of NSP cases is good and it appears to have the potential
of further improvements by promoting DOT at all health facilities resulting in rapport building
between the patient and the health provider; and discontinuing issue of drugs for more than
one week; and use of cured patients and community members as DOT providers.
Out of 556 sputum smear negative pulmonary TB cases, 500 completed their treatment giving a
treatment completion rate of 89.9%. Default rate of 6.7% can further be reduced by promoting
community and cured TB patients as DOT providers. Treatment completion rate of 90.9%
amongst 694 EPTB cases notified during Q-1/2011 is an indicator of good performance and
needs to be maintained, except Erbil where treatment success rate of 75% needs to be
improved. Overall treatment outcome of “smear not done cases” has been 89% (Erbil needs to
improve from 57%) and should be maintained.
During Q-1/2011, 2330 detected TB cases had a treatment success rate of 88% with Thi-Qar
(98%) and Suleymania (98%), Ninewa (97%), Dewaniya, Diala, Muthenna (96%). During the
same quarter, Cat II cases had a poor cure rate of 41% with success rate of 71% and default rate
of 16.4%. Low cure rate appears to be due to issue of medicines for longer duration and high
default rate probably because of DOT not happening.
43
Performance Analysis
Over the years, NTP has established an effective multi tier TB control setup with over 900 staff
members. Cure rate amongst NSP cases has been consistently good. Increasing TB diagnostic
service outlets for sputum smear microscopy by 25% in 2011 as compared to 2010 and 1093
PHCC’s providing treatment services is a commendable job. For improved quality of services,
during 2011, 1596 health workers have been provided fresher and refresher training on TB
control and DOTS.
During Q-1/2012, Thi-Qar as the best performer with 49% NSP CDR shows that Iraq is miles
away from its CDR target of achieving detection of 70% of infectious TB cases by 2014. Team
noted some degree of complacency in the efforts to expand case-finding to reach undetected
cases as is reflected from the declining NSP case detection rate which is 37% in Q-1/12 against
46% in 2009 and 38% in 2011. Major public and private hospitals are not systematically
involved nor there is a defined referral policy. Such a performance throughout the country is a
matter of concern. The programme urgently needs to consolidate its key function of removing
infectious TB patients from the pool of prevalent TB cases transmitting tuberculosis. Cure rate
of infectious retreatment cases has been considerably less. Inadequate case holding of
retreatment cases is well reflected by a high default rate of 16.4% in Q-1/2011 cohort.
Emphasis needs to be made to use cure rate as quality treatment indicator. Beyond local and
focal initiatives, more inputs at national level in the form of training, supportive educative and
facilitatory supervision with hand holding support and adaption of DOT is required. The most
immediate requirement for the country is to re-emphasize adopting DOTS as its “policy
strategy” for TB control with dedicated commitment for its comprehensive implementation at
all levels which requires extensive advocacy by all concerned with a lead from WHO. Likes of
Doctor in Erbil governorate who refuses to accept DOTS, LT in Erbil City Center who refuses to
perform his duty of sputum examination on account of a self created danger of getting TB while
performing his duties or the administrator of Koya District Hospital not wanting DOTS or a
Doctor at Baghdad who reportedly got himself transferred from MDR-TB laboratory for fear of
contracting TB may need to be administratively dealt with. Such a situation in one of the States
of India during early days of its DOTS implementation resulted in skyrocketing performance
after stringent administrative measures.
Cough symptomatics screening should be conducted at the registration desk or at the patient
waiting area, which will help in fast-tracking sputum examination as well as limiting the
possibility of nosocomial transmission to other OPD attendants and health facility staff. To
reduce sputum not done cases amongst pulmonary TB suspects, training especially of Doctors
44
need to focus on sputum microscopy as the gold standard for diagnosis of PTB and X-ray chest,
a sensitive tool of diagnosing PTB picking up to 70% false positive cases. Importance and
reliability of sputum microscopy also needs to be marketed to the community for their
acceptance. Majority of sputum negative PTB suspects are not given 2 weeks of antibiotics and
are directly X-rayed on the basis of which diagnosis is made and treatment initiated. For this
reason, TB No. 5/12 of Erbil governorate RCDC who was placed on anti TB treatment as Cat I
without sputum examination defaulted before the end of IP and told the staff of the clinic that
she has stopped treatment because she was not suffering from TB and was unnecessarily
placed on anti TB treatment by the RCDC. Such cases beyond other aspects undermine the
professional credibility of the organization. Detailed analysis may reveal more cases similar to
TB No. 5/12 for which a cocktail of advocacy, technical update and administrative directions for
the Doctors appears to be the answer.
Large number of sputum positive patients are not getting their sputum examined at the
completion of the treatment because DOT is not being adopted as a result of which rapport
between patient and health worker is not built. Lack of governmental commitment to promote
DOT is well supported by “Zero” budgetary allocations to “training of treatment supporters”.
There is no concept of using community members or cured TB patients as DOT provider.
Thomas R. Frieden, presently Director CDC Atlanta and Prof. John A. Sbarbro wrote in IJTLD
“……….if a programme is unable to establish a patient – friendly option for treatment
observation – observation that is acceptable, accessible and convenient to the patient and
accountable to the health system – then the programme is doing a serious disservice to the
patient………”33. The concept that anybody and everybody can be used as DOT provider needs
to be promoted amongst the NTP and the community and the patient given choice to select
his/her own DOT provider for which every facility should prepare and display the list of willing
DOT providers. DOT beyond direct observation is facilitation of drug intake aiming at a rapport /
bond building between the providers and the patient thereby promoting treatment and other
advice adherence. The original proposal of training 10,000 treatment supporters per year needs
to be revived. Budgeting this activity will have no problem as after 18 months of
implementation only 18.9% of ASCM budgetary allocations have been spent. In practice, the
patients are dispensed TB medicines through a pigeon hole under the window after the patient
speaks through a microphone. Shockingly, absence of microphones was one of the major
grievances of Erbil’s City Center Clinic. In routine, one week drugs are dispensed during IP and 2
weeks during CP. Pharmacist / health workers are very liberal in giving drugs for longer period.
Son of TB No. 6/12 at Erbil governorate RCDC informed that he has been mostly collecting the
drugs for his mother without any objection from the pharmacy. A patient - centered adherence
45
strategy, including supported treatment agreeable to the patient is the bet for successful
treatment completion and for limiting the development of drug resistance.
Central level needs to comprehensively analyze governorate wise performance every quarter
through a time bound quarterly report. The analysis should include number of suspects
registered vis-à-vis new adult OPD attendance of all NTP and non NTP health facilities to
monitor adequate screening of new patients coming to all health facilities (at least 2% should
be chest symptomatic); undertaking of sputum microscopy for diagnostic purposes vis-à-vis
suspects registered in the suspect register and number found to be sputum positive and those
registered in TB register calling for recall of initial defaulters; number initiated on treatment visà-vis all cases registered in TB register; identifying and tracing initial defaulters; pattern of
categorization to see if it fits into the country’s case detection pattern; to verify if all
categorized patients have been initiated on treatment; compare the consistency of cohort
undergoing sputum conversion with the corresponding cohort of case detection; and the cohort
on which treatment outcome has been reported is consistent in terms of number and type of
disease recorded in the quarter 12-15 months back. Highlights of these findings along with
specific advice for performance enhancement should be sent in time bound manner to all
governorates demonstrating equal importance for both receipt of report and giving feedback.
Sending feedback should invariably be followed by the quarterly review participatory meeting
where beyond updating governorate wise performance and action taken report on the
suggestions given in the feedback, inter governorate performance should be discussed and
specific advice on addressing deficiencies provided. Review meeting should also be utilized for
experience sharing among the governorates.
Central level should compile and circulate one pager quarterly performance report of key
indicators to all concerned in Iraq and KRG. This activity should also be replicated every quarter
at District and TBMU level. This will help in identifying poor performing areas which pull down
the comprehensive performance of their respective governorate / District. In all identified poor
performing areas, monitoring activities need to be intensified for field assessments of deficient
performers and to address them by giving need based hands on training.
At the time of categorization, the process of detailed history of past anti TB treatment should
include suggestive question like – did you get daily injections for 1 – 2 months or did your urine
ever become orange while taking treatment etc. Generic guidelines for diagnosing common
46
type of EPTB cases need to be formulated where in emphasis should be laid on laboratory
confirmation of the diagnosis as far as possible. Large number of EP cases in a low HIV
prevalence country would require adherence to formulated diagnostic guidelines.
Technical support from external consultants with experience of running successful TB
programmes would improve programme performance.
Recommendations – Implementation and Key Findings
1. NTP needs to re-emphasize adopting DOTS in its “policy strategy” for TB control supported
with extensive advocacy lead by WHO
2. Develop and implement systems for active identification and fast tracking of TB suspects in
outpatient departments with the involvement of paramedical workers at the registration
counter / the first point of contact
3. All public and private hospitals should be systematically involved in DOTS and a well defined
referral policy formulated and implemented
4. Microscopy center and DOT centers must be established in all teaching hospitals attached
to medical colleges
5. Promote sputum microscopy as the primary diagnostic tool in pulmonary TB suspects with
X-ray chest as a supporting tool
6. NTP should prioritize consolidating its key function of removing infectious TB patients from
the pool of prevalent TB cases transmitting tuberculosis
7. A patient – centered adherence strategy, including facilitated treatment agreeable to the
patient should be adopted at all service outlets. DOT must be the standard of care
8. Cure rate should be used as an index of quality implementation of treatment amongst all
smear positive cases
9. Quarterly comprehensive feedback by the central level to the governorates should be
adopted as a policy procedure to be also followed by the governorates in respect of TBMU’s
in their jurisdiction
10. DOT should be adopted by all facilities as a facilitatory intervention; community including
cured TB patients should be promoted as DOT providers; and patients need to be treated as
VIP of the programme. Recruited DOT providers should be trained.
47
Drug Procurement, Quality Control and Distribution
First line NTP drugs for the last three years are being procured through GDF grant or procured
by GFATM grant. KIMEDIA has been responsible for receiving, storage and distribution of drugs2
and in its current capacity is not able to ensure timely delivery of drugs even for existing limited
number of facilities implementing DOTS. During field visits, drug shortages have been observed
and reported from many governorates. Government has well realized that in the absence of
adequate capacity, even if Iraq has a regular supply of drugs, it would not be able to maintain
much needed un-interrupted drug supply for TB patients. With proposed rapid expansion of TB
programme network, the Government is committed to build local drug management capacity
including drug store/warehouse staff, develop drug management policies, guidelines and
computerized drug information system. In this context, 140 staff from PHCC’s, drug managers,
logistic officers from NTP has been trained till Q-1/201221.
Because of its multifaceted responsibilities, NTP should not be burdened with drug
procurement so that programme efficiency is not adversely affected. Experience shows that in
the field of drug procurement, NTP should restrict its role to drug specification formulation,
calculation of quantity and distribution within the country. Procurement of drugs should ideally
be contracted to an independent procurement agency away from all direct and indirect
influences. For the time being, “Fund in Trust” mechanism between MoH and WHO – Iraq
Office has been developed for 2012 through which MoH will finance for the procurement of
first line anti TB drugs and WHO shall carry out the procurement. Presumptive actions including
initiation of the process of procuring customs duty exemption from the Government within the
lead time of procurement to ensure supplies are not held up at the customs should be taken.
Overseeing distribution of stocks up to governorate level should be the responsibility of NTP
and distribution to TBMU’s / PHCC’s should be the governorate’s responsibility. NTP should
support governorates in capacity building and logistic support for drug storage at governorate
level and distribution at peripheral level. National ware house unit which presently has 2
pharmacists and one pharmacist assistant should be strengthened.
An independent agency different from procurement agency should be hired to ensure quality of
drugs at different stages; starting from procurement to entry into the country; during storage at
48
different levels and till such time they are consumed by the patient. For an effective quality
control, randomized quality testing at all levels need to be undertaken. To avoid situations like
TB No. 133/10 at Mohammad Bajilin Center in Erbil where patient was initiated on treatment
with three months of shelf life of Pyrazinamide, the national ware house should ensure that
supplies with less than 9/10 of shelf life are not accepted in the country. In fact, the total
consignment should be split in two installments which would give an enhanced shelf life. The
present system of procurement of Rifampicin with 2-3 years shelf life should be changed to
procurement of Rifampicin with only 5 years shelf life both in loose drugs and FDC’s. Regular
monitoring of drug consumption/stock at all peripheral outlets to ensure optimum stocks
consistent with consumption pattern of the health services outlet and immediate removal of
any expired drugs from the health facility would be important responsibilities of the National
warehouse.
Recommendations – Drug Procurement
1.
2.
3.
4.
NTP should not be burdened with the responsibility of drugs procurement
Rifampicin both loose or in FDC’s should be purchased with only 5 years shelf life
Drugs with only 9/10 shelf life available should be accepted at country level
No expired drug should be allowed to be stored in health facilities and certainly not with the
drugs being used.
MDR-TB
Estimated number of MDR - TB cases in Iraq is 988 out of which 719 are smear positives3.
However, as per WHO, number of confirmed cases of MDR - TB in Iraq are 1108. Percentage of
MDR - TB among new cases in Iraq is estimated to be 3% and amongst re-treatment cases 38 %.
In the absence of any DRS, the real magnitude of MDR - TB is not known, and hence a need to
conduct DRS in Iraq.
GLC has now approved the existence of the functioning system of programmatic management
of drug resistant TB (PMDT) in Iraq. Implementation of the PMDT relies heavily on quality
49
assured laboratory services and only NRL has met the bench mark by passing the panel test on
culture and DST conducted by SNRL, Egypt. One private laboratory in Erbil is also providing DST
services. Annual quality certification through panel testing for NRL by SNRL and for private
laboratory in Erbil needs to be ensured.
In 2011, the case finding approach for MDR-TB cases was limited to provision of culture and
DST services to all retreatment cases, MDR-TB contacts of TB patients and HIV positive TB
patients. For the diagnosis of MDR-TB cases, a system for case finding needs to be established
which will require at least 950 culture and DST tests to be performed to identify MDR-TB cases.
This envisaged quality system in laboratories and transportation of samples to RCDC’s at
Basrah, Najaf, Babylon and Ninewa is yet to be established. Because of unavailability of the
hospitals during 2011, 50 cases of MDR - TB were enrolled on ambulatory regimen. Age/ sex
distribution of the cases show that of 25-44 years age group account for 70.5% of these MDRTB cases; 30 are males, 20 females. As on May, 2012, 46 are continuing on treatment out of
which 31 converted in culture examination. These patients reportedly received food and
transportation allowance of 60 US$ per month during July – December, 2011. The ENRS for
MDR-TB patients has been established as a part of routine reporting.
Second cohort of 65 MDR-TB patients identified by the end of 2011, could not be initiated on
treatment because of non availability of SLDs. Two amongst these 65 MDR-TB patients have
already died14. It is good to note that in 2011, 400 treatment supporters received training on
MDR-TB patient support. Doctors providing care to MDR-TB patients were trained on MDR-TB
case management and NTP staff trained on PMDT and on MDR-TB recording and reporting.
MDR-TB management guidelines, treatment guidelines including educational material for
patients and communities have been reportedly formulated. An ex-army hospital in the city of
Sulaymania in the Kurdistan Autonomous Region is being rehabilitated to become the National
MDR-TB Hospital in Iraq with a capacity of 30 beds. Another 12 bedded hospital in Baghdad has
also been reportedly rehabilitated for the purpose. Efforts should be made to ensure that these
two hospitals are fully functional soon to take more serious amongst the second cohort of
waiting MDR-TB cases.
It is re-enforced that MDR-TB is a man-made phenomena and the only way to contain MDR - TB
is to stop producing it. This is amply proved by the fact 44% of 51 MDR-TB cases on treatment
are from Baghdad. A detailed analysis of governorate wise treatment outcome of NSP and all
50
sputum smear positive cases of the cohort from 2009 to Q-1/2011 show that against 5.5%
default rate observed on the cumulative treatment outcome of NSP cases in Iraq, Baghdad
accounted for 11% default rate and
for all sputum smear positives during
the same period, the figures are 6.5%
for Iraq and 12.9% for Baghdad.
Similar pattern is observed in the
notification of retreatment cases
from 2009 to Q-1/2012. Furthermore,
out of 51 MDR-TB cases on
treatment, 50 are Cat II failure. This is
again supported by the data which
shows 36% cure rate amongst all Cat
II in Iraq against 29% in Baghdad
amongst cohort of 2010 and for 2009
cohort, it is 57% for Iraq and 39% in
Baghdad and for Q-1/11 the same is
41% for Iraq and 28% for Baghdad. It
is in this context that using cure rate
as an index of quality implementation of treatment inputs is being advocated. Unless urgent
interventions are taken to improve treatment outcome, Baghdad will continue to be the
“capital” of MDR-TB.
PMDT is a complex intervention requiring collaboration and cross –referral between designated
laboratories, referral hospitals and all levels of NTP down to PHCCs. Global experience shows
requirement of sufficient number of motivated and qualified human resources in PMDT
machinery. Irrespective of availability of drugs, equipment and technical assistance for MDR –
TB management, NTP authorities need to ensure appropriate staffing to use those facilities
which would require major political and administrative commitment at all levels. Hopefully
developed plan for infection control includes airborne infection control guidelines to be
implemented in laboratories and health facilities serving MDR - TB suspects and patients and
they need to be piloted and implemented. To benefit from the global experience in up-scaling
MDR - TB services, involvement of GLC and GDF in technical assistance and programme
monitoring must be undertaken on a continuing basis.
51
Four laboratories at governorate RCDC’s in Basrah, Najaf, Babylon and Ninewa equipped with
culture examination have been established at intermediate level and staff trained accordingly.
A system needs to be developed for transportation of samples from the peripheral laboratories
to the four proposed culture laboratories at governorate respiratory and chest disease clinics.
Quality assurance is also required to be applied in each level of laboratory services. At the same
time knowledge, experience and skills of NTP staff needs to be strengthened in MDR - TB
specific component.
Objective two of R9 approved proposal is “Ensure universal access to diagnosis, treatment and
care for drug resistant TB (DR-TB)” when NSP CDR of the country is less than 50%.
Corresponding objective in the same R9 approved proposal is “increase CDR of sputum smear
positive from 43% to at least 70% by 2014 and maintain high treatment outcome at least at
85% among detected cases”. It is good that the country has maintained 85% TSR since long but
Iraq is miles away from universal access to DOTS. In technically ideal circumstances, the
objective of universal access to DOTS should precede and receive priority over universal access
to MDR-TB. This requires intensive efforts by NTP, WHO and UNDP as with only one year left,
out of US$ 13,362,502 earmarked for DOTS related activities, a mere 41.7% amounting to US$
5,575,949 has been spent. Increased CDR and successful treatment of detected cases will
reduce TB transmission in health care settings. This will not only benefit masses but will also set
up a system of diagnosis and successful management of TB cases within the existing health care
infrastructure which would subsequently be used for MDR - TB.
Recommendations – MDR-TB
1. Universal access to DOTS should precede and receive priority over universal access to MDRTB, which will help set up a system of diagnosis and successful management of TB cases
within the existing health care infrastructure which would subsequently be used for MDRTB
2. Programme urgently needs to consolidate its key function of removing infectious TB
patients from the pool of prevalent TB cases transmitting tuberculosis
3. Annual quality certification through panel testing for NRL by SNRL and for private laboratory
in Erbil needs to be ensured
52
4. An independent procurement agency should be hired for procurement of anti TB drugs
including second line drugs and their distribution responsibility within the country should be
discharged by NTP
5. A separate independent quality control agency should be hired to ensure quality of drugs at
all levels from the time of arrival in Iraq till their consumption by the patients
6. To benefit from the global experience in up-scaling MDR - TB services, involvement of GLC
and GDF in technical assistance and programme monitoring must be undertaken on a
continuing basis
7. Intensified efforts need to be made to make two MDR-TB hospitals functional at the earliest
8. Monitor and address the anticipated emergence and spread of resistance to second line
drugs
9. To design and establish a comprehensive laboratory network clearly outlining the role and
responsibilities to start with at most populated and high risk governorates.
Operational Research
Mid Term Strategy for National TB Control Programme in 2009-2011 had laid down well defined
targets in relation to Operational Research but none of the stipulated targets could be
achieved. National M&E Plan (2010-2015) has also identified some of the Operational Research
studies to be conducted each year.
NTP has established an Operational Research Board that engages academic institutions,
research centers, universities and civil society to TB related operational research (OR). In the
first meeting of OR Board held in August, 2011, a 14 member committee for TB OR has been
established. Medical colleges and other TB related institutions should also be made a part of OR
policy for which OR capacity building workshops for program managers and other institutional
partners should be undertaken. Around 40 staff has been trained in OR.
It is felt that proposal dealing with ground realities and field challenges should be prioritized.
OR should basically aim to generate more information and evidence to effect necessary
changes in policies and management practices of NTP to make TB control more effective and
sustainable. As a first step, National guidelines for OR need to be developed. Research findings
should get translated into improved policies and procedures.
53
Awareness and preparedness needs to be created both at central / governorate levels. A full
time expert for OR capacity building should be engaged who should assist the governorates to
formulate and undertake at least one significant OR activity annually under central leadership.
Beyond already accepted proposals, the evaluation team considers following as some of the
critical research activities for the NTP to be completed within next 3 years:
1. Health seeking behaviors and reasons for TB diagnostic delay in vulnerable populations
including IDP’s, marshlands and urban slum dwellers
2. Understand the reasons for large number of “sputum not done cases” initiated on
treatment and find out the possible solutions which could be implemented ensuring
that every suspect of PTB undergoes the prescribed diagnostic algorithm
3. Understand the reasons for diagnosed infectious TB patients not bringing their close
contacts for evaluations and suggest methods ensuring 100% screening of contacts of all
infectious cases diagnosed in NTP Iraq
4. Create a website for NTP Iraq which in addition to the program updates should include a
list of approved proposals for OR; the sites at which they are being carried out; and the
summary outcomes of completed studies so that OR activities can be disseminated
irrespective of the success or failure of the researcher in getting the research published
in a peer – review journal. The study protocol itself should also be placed in the website
so that other sites using the same protocol can carry out similar studies if necessary.
This will enhance participations in OR studies
5. In collaboration with other programmes/initiatives, conduct research to understand and
address the role of social and clinical risk factors for TB, including malnutrition, smoking,
diabetes and indoor air pollution.
54
Coordination and Operational Issues
GFATM support; NGO’s functioning as SSR (The Iraqi Anti – TB Association, The International Medical Corps,
AMAR International Charitable Foundation, Premiere Urgence); Involvement of Medical Schools; Ensuring
community participation including cured patients; HIV – TB Management; Recommendations
NTP, though a composite programme has a large number of components which are
interdependent on each other and require well knit coordinated efforts to make NTP a success.
Coordination and operational issues therefore, have been dealt at all appropriate places within
various chapters of the report. For this chapter, major coordination and operational issues have
been dealt in the following five areas:
1.
2.
3.
4.
GFATM support
NGO’s functioning as SSR
Involvement of Medical Schools
Ensuring community participation including cured patients
5. HIV – TB Management
Global Fund Support
Overall goal of this grant is to drastically reduce by 2015 the burden of TB in Iraq, particularly
amongst the poor and vulnerable population, in line with MDG’s and Stop TB Targets. UNDP
and GFATM signed grant agreement number IRQ-607-G01-T effective 15th November, 2007 till
30th September, 2011 with total amount of US$ 14,500,157 of which US$ 11,445,495 were
disbursed by GFATM to UNDP by 1st October, 2010 under R6 support of GFATM. UNDP Iraq has
also been nominated as PR for the TB grant approved to Iraq under R9 support of GFATM. The
GFATM modified their funding architecture through consolidation of two overlapping grants for
the same disease component. Hence, in October 2010, UNDP and the GFATM have signed a
consolidated grant agreement for US$ 18,270,970, merging the balance of grant agreement
number IRQ-607-G01-T and the new grant approved under R9 as single stream funding (SSF).
Consequent to consolidation of the two grants, the first grant activities were closed by 30th
55
September, 2010 and new consolidated grant activities started from 1st October, 2010 till 31st
December, 2012. Both R6 and R9 grants, strongly build on the strategic objectives of the Iraqi
national TB control midterm strategy, 2009-2011. GFATM R9 grant reflects and details the Iraqi
National TB Control programmes vision with regard to TB control efforts in Iraq in 2010-2015.
Current implementation modality and consequent coordination and operational issues of
UNDP, which is primarily an administrative body, as a sole PR and WHO – a technical agency as
a sole SR are summarized below along with its five partners comprising of 4 NGO’s and NTP.
The four NGO’s after signing an MOU with WHO, a SR, are now working in specified areas as
SSR.



The United Nations Development Programme (UNDP) PR: overall program
management, procurement of health equipment, supplies, pharmaceuticals and non
health items.
World Health Organization (WHO) SR: management of technical component. Hold the
sub Recipient Role in this grant. Monitoring and supervision of 4 SSR’s.
4 NGO’s (SSRs): Implementation of GFATM R9 TB Grant in the service delivery area on
“Engagement of the non-NTP public and private sectors in the TB control programme”.
56
Implementation Modality of the GFATM R9 TB Grant
Primary Recipient
(UNDP)
Sub Recipient
(WHO)
NTP
Strengthening,
the lab network,
M&E, TB
surveillance,
MDR-TB, drug
management,
OR
IMC-SSR
AMAR-SSR
IATA-SSR
PUAMI- SSR
Training of PHC
staff
Marshland
population/
Community
outreach
Working with
IDPs and TB
contact tracing
PPM-DOTS
(Courtesy: WHO)
Presently all these four NGO’s submit not only their technical reports but also financial reports
to WHO, who then forwards them to UNDP. WHO as SR is also the supervisory authority of all
these SSR’s. This arrangement requires WHO to spend a lot of its time on administrative and
financial matters at the cost of technical responsibilities. It would be more appropriate if WHO
as a matter of policy limits its role only to technical issues. UNDP as PR should undertake the
responsibility of all GFATM related administrative and financial matters. By this arrangement,
expertise of both the agencies will be gainfully utilized in their specialized areas. National TB
Programme (NTP) being the coordinator of entire NTP activities in Iraq should continue to work
in close collaboration with WHO in technical matters and UNDP in all administrative and
financial matters.
57
NGO’s functioning as SSR
 The Iraqi Anti – TB Association (IATA) is a charity, medical, social and educational society
established in 1994. Its 610 members comprise of 45% as medical doctors, 10%
paramedicals, 15% lawyers/academics, 10% administrators, and 5% media workers. This
NGO is supporting NTP Iraq in the area of “TB care for Internally Displaced Population and
ensure proper investigation and care for TB contacts”.
With reference to TB care for Internally Displaced Population, non procurement of mobile
van has hindered the implementation of not only the planned activities but the initiative as
a whole. Fifty thousand units of health educational materials have not been distributed.
This material also includes calendars which have already lost more than 50% of their shelf
life. There is still limited availability and accessibility of PHC services. Non availability of TB
care services for IDP’s at camp level necessitated three indentified TB suspects to be
referred to one of the TB management clinic outside the camp.
It is good to note that an SOP imbibing contact investigation, monitoring procedures and
pediatric TB management guidelines have been formulated. Going by the present plan of
enrolling 20 Districts every year in contact investigations, it will take more than six years to
cover the country which can be ill afforded. The proposed initiative of assigning the contact
tracing to an NGO is neither sustainable nor operationally feasible and technically sound.
Being a part of comprehensive DOTS strategy, contact tracing should not be taken in
isolation of DOTS. Contact tracings among extra pulmonary cases are almost a wasteful
expenditure of resources. Efforts need to be concentrated on contact tracings of infectious
cases.

The International Medical Corps (IMC): Beyond mass exodus of health professionals, there
has been huge brain drain evidenced by availability of 18,126 physicians in 2005 against
34,000 registered with Iraqi Medical Association in 1990’s. Production of new cadres has
also been affected by damage to medical schools and migration of teaching staff. The inservice and refresher trainings have also been affected by lack of professional development
programmes. These factors collectively affected the accessibility and quality of health
services including TB control. Cognizant of wide gaps in human resources and undertaking
capacity building in a systematic manner, the responsibility of training various cadres of
health workers has been entrusted to International Medical Corps (IMC) which is a global,
humanitarian, non-profit organization dedicated to saving lives and relieving sufferings
58
through health care training, health system strengthening, advocacy and education,
capacity-building, community development, and managing emergency relief programs. IMC
has been operational in Iraq since 2003 with full time staff of more than 200 persons. This
NGO is supporting the program in the area of “Human Resources Development in TB
Control”.
To start with, IMC shall conduct courses for TOT to create cluster of 54 master trainers, 3 in
each governorate for conducting intensified training for different category of staff in PHC
Centers. One PHCC in each governorate will be designated as a training centre and
adequately equipped with training equipment and other necessities for providing DOTS
related training to medical and paramedical staff of all health facilities including medical
schools. During 2011, 3427 health professional (more than 132% of stipulated targets)
comprising of Doctors, nurses, paramedical staff and prisons health staff have been trained
in DOTS and 545 staff in recording and reporting systems, ENRS and project management 12.
The challenge now is to properly, adequately and gainfully utilize the cadre of trained
personnel.
 AMAR International Charitable Foundation: is an international charitable foundation that is
supporting the program in the area of “Interventions among high risk group population: TB
care for Marshlands Population”
Number of PHCC’s in three Southern governorates of marshlands of Iraq has increased from
95 in 2010 to 174 in 2011. WHV’s are required to regularly visit families to educate them on
fight against TB. Number of families visited as a tool to measure effectiveness of the
interventions needs to be replaced by outcome indicators like families committed to
support TB patients / identifying TB patients. All the reports to be submitted by AMAR
should be on quarterly basis. Two employees from London helping to administer the project
appear to be a wasteful expenditure.
 Premiere Urgence (PU): is an international entity that is supporting the grants in the
“Engagement of non-NTP Public and private sectors in TB control program”.
Need for coordinated approach amongst all social service sectors – public and private to
create an epidemiological impact on Tuberculosis control has been globally recognized. An
unknown, but considerable, proportion of TB patients are treated outside of NTP, either by
private practitioners or by public health staff prescribing drugs of unknown quality, for use
59
in non – standardized regimens, and with no mechanism for reporting, adequate
supervision and follow up of treatment in place. Even with the availability of public health
services, the role and involvement of private health sector cannot be undermined. Non NTP
public and private sector in Iraq comprises of 289 public and 81 private hospitals mostly
located in Baghdad. There is an unorganized and disconnected network of around 4,000
private practitioners operating through their clinics in the afternoon and public clinics at
PHC center in the forenoon nationwide, and small private hospitals mostly located in
Baghdad providing general health services to the population. There are no official and
formal mechanisms for public-private collaboration and partnership. Coordinated and
concerted efforts with all potential partners are essentially required to ensure availability of
ISTC to all those who need it.
PPM-DOTS country assessment carried out in 2009 revealed limited knowledge within NTP
to engage non-NTP public and private sectors, lack of knowledge on DOTS within the nonNTP sectors and a lack of mechanism and legislation within MoH to engage non-NTP sectors
in NTP3. Even capture / recapture study has shown that 14% of TB suspects in the non-NTP
sector in Iraq is not referred to the NTP and treated in the facility7. Systematic and
sustained coordination amongst these both organized and unorganized, formal and
informal-TB care providers is essential to improve access to TB care; and to move towards
and beyond 70% case detection for universal access to quality assured TB care by adopting
ISTC.
The challenge is to address the lack of trust and enthusiasm to engage with each other for a
common cause. Partnership policy and strategy between NTP and non-NTP health facilities
in adopting DOTS needs to be formulated and operationalized. The policy and guidelines
need to be developed in consultation with non-NTP partners. Partnership needs to be built
on a relation of mutual respect and trust and projected as a “win-win initiative” for all. NTP
may consider empowering intermediary organizations like Iraqi Medical Association to scale
up PPM, while strengthening programme capacity at the Central and governorate levels to
undertake a stewardship role for PPM development. This activity till date has not been
accorded its due importance as even after 15 months of implementation only 15% budget
has been spent on “engagement of non-NTP private and public sectors”.
NTP needs to take a lead role in comprehensive monitoring and coordination of the
activities of these 4 NGO’s. Looking at the nature of responsibility in IDP’s and Marshland,
the implementing agencies need hand holding of NTP for implementing the planned
activities. Learning from the implementation experience and need assessment, more
60
activities could be planned as till December, 2011, only 6% of budgeted amount of US$
1,692,357 has been spent.
Involvement of Medical Schools
There are 23 Medical schools, 23 Nursing schools and 5 Pharmacy schools in Iraq. It is good to
note that NTP has taken initiative to introduce DOTS in the teaching curriculum of Medical
schools. However, in the first instance, the NTP needs to convince teachers of medical schools
about the effectiveness of DOTS strategy for which they need to be sensitized. Thereafter, a
core group of senior medical school teachers should be constituted to design a road map for
involvement of medical schools in DOTS. The first evidence of their acceptance of DOTS would
be its adoption in their clinical practice at teaching hospitals. The Government has broken the
ice by appointing a focal point in all the teaching hospitals. The urgent need is formulation and
operationalization of the policy of involvement of referral hospitals in adoption of DOTS. All
operation related logistics – both consumables and non-consumables need to be made
available. Coordination mechanism between NTP and the hospitals in terms of referral of
suspects, delivery of laboratory results, initiation of treatments, etc. need to be formalized and
adopted.
Government of Iraq has done a commendable act of banning the sale and storage of anti TB
drugs in the private pharmacies from 2011. However, the evaluation team during a visit to 18
pharmacies in Erbil found that most of the anti TB drugs are freely available. It is well known
that weak implementation of ban order leads to proliferation of the use of non standard
combination of “whatever, whichever, wherever and whenever” drugs available which
becomes the churning source of MDR-TB. Coordinated efforts need to be made amongst NTP
and drugs department on a war footing for effective implementation of the ban order
pertaining to storage and sale of anti TB drugs in the private sector.
61
Ensuring Community Participation Including Cured Patients
First step in ensuring community participation and social mobilization is formulation of National
Health Communication Strategy. Reflection of the formulated strategy at governorate and
District levels is an important coordination and operational issue for which advocacy also needs
to be undertaken in a coordinated manner with all concerned to influence policy changes and
sustain political and financial commitment. Subsequently, a working partnership needs to be
established between the health sector and the community – the local population, especially the
poor as they are more commonly the victims of TB, and TB patients both current and cured. To
make NTP a people’s movement encouraging convergent actions, coordinated approach needs
to be adopted between the health sector and community at all levels including PHCC. NTP
needs a coordinated action to actively engage political leaders, the NGO’s and non –
programme providers to come on board. This will promote social marketing of DOTS at Central,
governorate, District and village levels. Social mobilization needs active coordination with
political leaders, community leaders including cured patients on achieving universal awareness
of the right to, and availability of, free TB treatment and care at a convenient place. NTP needs
to set the ways in which patients, communities, health care providers and governorates can
work as partners and enhance the effectiveness of TB care. In fact a cured patient is the most
effective coordinator for marketing these concepts to the society in general and TB
suspect/patients in particular and should be utilized in the programme.
HIV-TB Management
Out of 2258 TB cases tested for HIV, only one was found to be HIV positive32. Low HIV
prevalence in Iraq does not call for complacency because it is at high risk for development of an
HIV epidemic due to changes in risk factors, presence of military troops from different
nationalities, opening of country borders, influx of large number of foreigners and increased
possibilities of drug abuse. TB cards should indicate the status of HIV testing which is more or
less a neglected area. Peer education needs to be used to identify the affected population
particularly amongst marginalized groups including prisoners and a comprehensive package
provided. Districts / governorates with disproportionately high incidence of smear negative
pulmonary TB / EPTB and those with high case fatality rate amongst TB patients, particularly
pulmonary sputum smear negatives need to consider HIV as one of the important possible
reasons.
62
Recommendations
1. WHO should fully dedicate its role to technical activities
2. While UNDP should procure mobile vans without any further delay, management
techniques like PERT and CPM should be used for all procurements to avoid similar future
delays
3. Contact tracing should be undertaken as an integral part of DOTS strategy to be
implemented by the health workers in a proactive manner
4. Formulation of the partnership policy and strategy between NTP and non-NTP health
facilities in adopting DOTS
5. Formulation of National Health Communication Strategy and its reflection at governorate
and District levels
6. Efforts to promote adoption of DOTS in clinical practice of the teachers of medical schools
should precede initiatives for inclusion of DOTS in the teaching curriculum of medical
schools.
63
EQUITY ASSESSMENT
Interventions amongst high risk and vulnerable population (TB care for Internally Displaced Population, The
Marshlands of Iraq, TB Care in Prisons, Investigation and care for TB contacts); HIV and TB; Gender Bias: Equity;
Quarterly Review Meeting – A tool to reduce inequity; ACSM and Stigma reduction – Interventions; Existing
Health Services Situation – Unfriendly to Equity; Recommendations
War in Iraq during 2003 – 2007 resulted in considerable damage to health infrastructure and
manpower, resulting in disruption of health care services to majority of the population. Equity
is a major issue in Iraq as 23.5% of Iraqi population currently lives under the poverty line and
spending less than US$ 2 per day, despite the relatively high income of the country.
Tuberculosis is a disease of poverty. In Iraq, with marked social and economic disparities, poor
and deprived populations are not only disproportionately affected by disease and death but
also have to face greater barriers to access health care services. Like many other countries with
similar socio economic status, a comparison of basic health indicators according to social class
and geography would show that the health indicators of the general population are better than
those living in IDP’s and Marshlands of Iraq. The success of any initiative in general and
treatment / policy making in particular lies in its accessibility to maximum number of people
across the barrier of economy, gender, culture, place of residence, etc.
With generally improving security coupled with financial support from R6 GFATM, the health
sector in general and TB programme in particular started improving evidenced by an increasing
case detection rate of all TB cases by 10% to 54% in 2009 as compared to 2007. R6 of GFATM26
targeted increasing case detection from 20% to 30% in two years while maintaining treatment
success at 85%; made inroads into some vulnerable and neglected areas; supported delivery of
services for quality DOTS for poor and susceptible populations through expansion of DOTS into
the 3 northern governorates; and increasing NTP’s management capacity. However the support
was not adequate to chiefly address the concerns of high risk and vulnerable populations like
prisoners, IDP’s, the marshland and the families and individuals in contact with infectious TB
cases.
Having realized the urgent need to provide dedicated care for TB patients in such areas, all
these socially, ethically, morally and medically prioritized areas have not only being adequately
addressed by R9 GFATM proposal but envisaged interventions have been well knit into grants
work plan, budget and monitoring frame work. Wherever possible, quantifiable targets have
also been laid down to effectively monitor the performance and measure the achievements in
the key areas. In all proposed initiatives, country level assessment of inequities and barriers in
64
reaching the marginalized population is the first step of the drawn up strategy. Overall aim is to
promote universal access to ISTC and PMDT especially to all those who are most in need of it
irrespective of their geographical location or other variables. In fact, the initiatives contained in
R9 GFATM support no longer aim at providing adhoc interventions to vulnerable and high risk
population but are a step towards building of systems to make these services at par with those
for the general population.
Interventions amongst high risk and vulnerable population
TB care for Internally Displaced Population:
Iraq is one amongst the three largest IDP’s holding countries24. Delivery of quality DOTS TB care
to 0.6 million poor and vulnerable populations; expansion of DOTS into 3 northern
governorates; and increasing NTP management capacity through R6 grant resulted in improving
notification of smear positive cases from 2950 in 2007 to 3150 in 2008 thereby increasing CDR
from 37% in 2007 to 43% in 2008.
Despite the increase in CDR, Iraq lags behind the global targets and MDG’s primarily because of
its slow pace of increasing case detection. Cognizant of the service gaps and the coverage of
fragmented population within this vulnerable group, interventions enhancing and
strengthening DOTS services to 2.8 million IDP’s, have been designed to address the gaps and
provide comprehensive coverage of the entire IDP population under the umbrella of “TB care
for Internally Displaced Population”. The project has been contracted to IATA which has the
experience of working in the field of charity, medical and social society for the last 68 years.
Presently it has 610 members, of which 45% are medical doctors, 10% paramedicals and 5%
media workers. The contractual period with IATA is from 1st April, 2011 to 31st December, 2012
with a total amount of US$ 153,407.
As a first step, precise magnitude and location of the IDP camps, collective settlements and
poor areas with high IDP concentration have been mapped in 2011 through collaborative
efforts of IATA, NTP and Ministry of Displaced Population. Total number of displaced families
has mounted to 212,063. Health needs assessment with a special focus on overall situation of
TB amongst IDP with addressing the gaps in the delivery of TB care services have been initiated
through 4 IDP camps – one each in Diwanyiah, Basrah, Kerkuk and Sulaymania provinces where
in population for each camp was ranging from 500 – 2,000. Poverty and overcrowding in most
65
of these camps are favorable grounds for TB transmission. Precise service delivery for special TB
care has been scheduled to be provided through:
1. Strengthening of existing health care centers and providers for providing DOTS – An
approach to Basic TB Control in those areas
2. Development and printing of Health Education material
3. Training of selected IDP’s as community health workers (CHW’s) on TB control
4. Organization of community events
5. To serve 1 million IDP’s living in 5 disconnected geographical areas having largest group
of IDP population in Wasidt, Najaf, Kerbela, Diwanyiah, Selah-Aldin through two
specially designed mobile clinics equipped with microscopy infrastructure and trained
staff on provision of quality DOTS
6. Training at the beginning of the project and refresher training of 15 mobile health clinic
staff every two years
7. Movie theaters will be included into the mobile clinics to provide culturally appropriate
and locally and focally tailored awareness to the population.
Drugs for identified TB cases shall be arranged by IATA through NTP and an identified
treatment supporter from within the patient’s community will be provided DOTS related
training. Till date, procurement of mobile clinics has not been effected resulting in delay in
initiating the training of 400 community health volunteers and training of mobile health clinic
staff. Fifteen community events per quarter to be provided through mobile clinics have also not
been organized. Health education materials have been developed and more than 50,000 units
printed. Materials include health messages in the form of calendars; books and leaflets
containing relevant information about the disease, its prevention and management. The
materials need to be distributed without any further delay as beyond other reasons; calendars
have already lost more than 50% of their shelf life.
66
Current activities at the
camp level are focused on
Notification of NSP and Total TB cases in IDP's
IEC aiming to raise
2009
2010
2011
Q-1/2012
awareness amongst IDP’s. Governorate
NSP Total NSP Total NSP Total NSP Total
Key findings as after Q1/12 included limited Basrah
238
618 220
685
219
657
66
168
availability
and
158
442 176
449
145
457
25
98
accessibility
of
PHC Diwaniyah
services
and
non Kerkuk
113
320 116
388
101
313
31
75
availability of TB care
Sulaymania
248
551 224
531
188
503
46
134
services for IDP’s at camp
level necessitating the IDP’s to seek treatment elsewhere. Three TB suspects detected during
the visits had to be referred to receive proper management in one of the TB management
clinics outside the camp21, 24. Raising awareness without availability of services becomes
counterproductive and leads to credibility erosion of the system. Because of security
constraints, the four IDP camps at Basrah, Diwanyiah, Kerkuk and Sulaymania could not be
visited by the team and therefore, impact of interventions has been attempted through
comparison of NSP case detection. A comparison of NSP case detection in these 4 governorates
from 2009 till Q-1/12 does not indicate any change which is not surprising as hardly any specific
activity among the planned interventions have been undertaken. Even otherwise, it takes some
time for the interventions to become productive and produce visible and quantifiable results.
At the present stage, the initiatives need to be strengthened and more importantly
implemented.
Implementation of the interventions planned will make inroads into till now neglected
community who will now be able to benefit from DOTS – An approach to Basic TB Control.
Treatment supporter for identified TB patients from within the patient’s community would not
only reduce default, but would be a step towards social mobilization and against stigma. The
initiative will be a milestone towards community ownership and promoting equity. However, at
this stage, non procurement of mobile vans has hindered the implementation of not only the
planned activities but the initiative as a whole warranting immediate action for procuring
mobile vans particularly, when only less than 30% of the life of contractual period with IATA is
left.
67
The Marshlands of Iraq:
The Marshlands of Iraq is the largest wet land in the Middle East and stretching over three
southern governorates of Misan, Thi-Qar, and Basrah. As a consequence of marsh drainage and
destruction, the largely displaced and widely persecuted 1.5 million marsh dwellers had been
suffering from absence of basic facilities including DOTS – An approach to Basic TB Control.
AMAR charitable foundation is an international charitable foundation and has specialized in
providing services to marshland population since long. They have been engaged for the
purpose of “reaching the unreached in the Marshland of Iraq” for TB control in collaboration
with NTP for a consideration of US$ 98,341. The contract duration is from 1st April, 2011 to 31st
December, 2012. The NTP will be implementing planned activities and will be responsible for:



Establishment of TB diagnostic and treatment units in the marshland’s PHCC’s through
provision of necessary equipment and training of staff;
Establishment of a proper recording and reporting system;
Ensuring timely delivery of NTP drugs.
AMAR will be responsible for:




Training of 160 community health volunteers every year
Organization of TB-related community events every quarter in each district.
Developing and printing of HE material
For making the interventions effective, regular supervision of the activities will also be
undertaken.
68
Number of PHCC’s in the three southern governorates has significantly increased from 95 in
2010 to 174 in 2011. All the three
Comparison of NSP case detection in Marshland
Marshland
governorates
have
Governorates
benefitted from the increase in number
of PHCC’s as evidenced by increase in
NSP Case detection
Basrah from 45 in 2010 to 103 in 2011,
Year
Basrah
Thi-Qar
Misan
in Thi-Qar from 33 to 45 and in Misan
from 17 to 26. During 2011, regular
2009
238
200
108
monthly
trainings
have
been
undertaken in each of the 3 Marshland
2010
220
237
126
governorates for 160 WHV’s who are
2011
219
197
67
assigned a set number of families to
visit regularly to educate them on basic
Q.1/ 2012
66
58
22
principles of preventive health care
including the fight against TB and promoting services of PHCC’s. Starting from Q-2/2011 to Q1/2012, the WHV’s have visited 54,434 families. During Q-1/2012, 15 community events
covering 550 populations have been organized. For effective monitoring, 24 supervisory visits22
have been undertaken to these 3 governorates.
Keeping the performance focus on outputs like the number of families visited is not an ideal
tool to measure effectiveness of the interventions. Outcome like families committed to support
TB patients / identifying TB patients is the ultimate product which matters. Similarly
undertaking of training of 160 women health volunteers every year and organization of TB –
related community events are outputs. Consequent to this training, numbers of community
health volunteers functioning as DOT providers or identifying TB suspects in the community
should be treated as the outcomes which should be used for impact assessment of
interventions and need to remain at focus on all levels. This would remain true for all scheduled
activities including community related events. Because of security constraints, only one
marshland in Bahle of Basrah governorate could be visited by the team and hence, the
effectiveness of the foregoing interventions has been attempted through the trend of NSP
cases detection for the last three years and comparison between 2011 and Q-1/2012
extrapolated to a year.
NSP CDR in Basrah has been almost constant from 2009 to 2011; and in Thi-Qar and Misan it did
not follow any definite pattern during the same period. The trend shown in the first quarter of
2012 seems to be encouraging. NTP should hasten to further strengthen the TB diagnostic and
treatment capacity in the marshlands’ PHCC’s with reliable and comprehensive recording and
reporting system. In the quarterly reports to be submitted by AMAR to WHO, on the number of
69
TB cases detected amongst marshland population “per year” may be changed to “per quarter”
which will not only ensure improved monitoring and feedback but would be consistent with
quarterly cohort reporting. Further the quarterly feedback provides more opportunities for
corrections and performance improvements.
In addition to using 12 employees in Iraq to coordinate and run the project on ground, 2 other
employees are reportedly helping to administer the project from London. For the type of
activities AMAR has been entrusted with, any expenditure on “advisors from London” would be
an infructuous expenditure for the initiative and the money saved should be better utilized.
Though initiating new activities in the neglected area is a welcome step but some of the
planned activities which have been delayed should now be implemented at the earliest.
TB Care in Prisons:
There are 64 prisons in Iraq with an average of 50,000 inmates. At present, there is limited data
on the number of TB patients amongst prisoners; however, anecdotal evidence indicates that
TB is highly prevalent amongst prisoners in Iraq, like many other countries in the world 26.
Prisons are the most conducive settings for the spread of TB and prisoners are amongst the
high risk population, well demonstrated by the fact that 31 new TB cases were detected in the
4th quarter of 2008 from screening of 15,000 prisoners in 10 prisons of Iraq indicating that TB
incidence amongst inmates is 4 times higher than among general population (224/100,000
population in prisons vs 56/100,000 in general population). Treatment outcome of this cohort
of Q-4/2008 (verbally reported by NTP) has been very favorable (93.6% completed treatment)
as 29 out of 31 cases completed treatment and the remaining 2 (6.5%) died. This excellent
outcome is probably due to strict adoption of DOT as has been observed by national team at
Al-Rahmania juvenile prison. Prisoners being a captive population, such favorable outcome are
not impossible as effectiveness of DOTS strategy has been well established. During 2011, 47 TB
cases have reportedly been detected (verbal communication) from prisons of 7 governorates.
Ministry of health being responsible for prison health services, NTP is collaborating with 64
prisons in the provision of DOTS services and has done well in establishing 5 laboratories for
providing quality microcopy in the prisons of Baghdad. Although staff has been trained and
logistics including microscopes supplied, but still the TB suspects in these prisons are being
referred to the TB centers outside the prisons for diagnosis for the reasons not known. It will
be useful if the prisons, at least those 5 where the laboratories have already been established
immediately start functioning as a TBMU which will be convenient to the inmates as well as to
70
the respective prison staff; data management, reporting and monitoring would be
operationally convenient; and experiences learnt can be used while expanding to other prisons.
Till Q-1/2012, 1731 prison administrative and health staff has been trained on DOTS 21. A study
to assess structure, administrative context and TB epidemiology situation initiated; the
developed study protocol for prison assessment has been revised and sampling decided. All
necessary tools are reportedly ready for use and security clearance awaited. In WHO annual
progress report 201114, it has been stated that “the study may proceed in early 2012” and till
July, 2012, the same has not commenced. The evaluation team felt that “structure and
administrative context of the prisons” is well known to the Ministry of Health who has already
been working in the prisons. While administrative bottlenecks on account of security concerns
are well appreciated by the team, but it should be noted that the health staff of Ministry of
Health working in the prisons has already gone through all the mandatory security and
administrative essentials of working in these high security areas. The team observed 29 health
staff including 3 Doctors, 5 Dentists, one LT in the clinic inside Al-Rahmania juvenile prison
which after training has the potential of adopting DOTS. The evaluation team further felt that
service delivery to this socially, epidemiologically, ethically, vulnerable and neglected
population should not be neglected for undertaking epidemiological assessment particularly
when the same can be undertaken simultaneously with service delivery which is a public health
concern. The need is for one trained laboratory technician (if the same is already not available);
a corner in the existing laboratory nearer to the window (hopefully would be ventilated,
otherwise at some other place); and provision of good quality microscope with other logistics.
In addition to promoting equity amongst the high risk and underserved population, the
initiative will enhance much needed case detection in this high incidence area and going by the
example of treatment success of 93.6% will also enhance the country’s treatment outcome.
While providing DOTS – An approach to Basic TB Control in the prisons should not be
undermined, at the same time risks of treatment completion particularly amongst the under
trial prisoners is an important visualized constraint and should not be lost sight of. While in
case of convicts, tenure of imprisonment could be a guiding factor for treatment initiation and
monitoring of treatment completion, in case of under trials who commonly get bailed out
without any notice, maintenance of comprehensive contact details of the prisoners initiated on
treatment and a good referral system would need to be essential prerequisites of a sound TB
programme in prisons.
71
Investigation and care for TB contacts:
About 1/3rd contacts of an infectious TB case will get infected out of which 5-10% will develop
TB in their lifetime which would work out to 2% of contacts developing TB. These estimates
were correlated by household contact investigation of infectious TB cases carried out in Iraq in
200810.
TB contact tracing of infectious cases and their management by and large is being undertaken
in a passive and unsystematic manner leaving a gap in the diagnosis and treatment of possible
TB patients thereby missing a major opportunity for improving case detection. Even pediatric
contacts of sputum smear positives are not systematically evaluated3, 5. Health professionals do
not seem to have been adequately sensitized on the importance of this component of TB
control. It has been observed during evaluation in Erbil, that neither any patient brings his
contacts for evaluation nor the health professionals are serious about it. The contacts are
brought to health facility only when they start suffering from TB. This is well demonstrated by
TB No. 15/2012 - a Category II diagnosed and under treatment at Erbil governorate RCDC. This
patient was diagnosed as sputum negative in 2008; initiated on treatment; thereafter defaulted
and became positive; accordingly treated and completed treatment; relapsed for which he is
now being treated. A perusal of patient treatment card reveals that he has not brought his
contacts including 2 children of less than 5 years for evaluation. Incidentally father of this
patient was also under treatment at the same center for sputum positive TB and no contacts
were brought to the center for screening till his sister developed sputum positive TB and
treated at this very centre and during her treatment also no contacts were brought till TB No.
15/2012 developed TB. This is further supported by the fact that more than 100 TB cards of
sputum positives from 5 different service outlets examined by the team in Erbil governorate
had a blank contact examination column. However, in some areas, like in Al-Kadhmia District
Unit contacts of infectious cases were being given INH prophylaxis.
At central level, quarterly and yearly report on household contact management being produced
indicates that beyond contacts of sputum smear positives, contacts of sputum smear negatives
and extra pulmonary cases are also being registered and evaluated. Normally, contacts of only
infectious cases are evaluated as sputum smear –ve cases do not discharge mycobacterium in a
72
concentration essential for spread of disease. (Sputum sample needs to have 10,000
mycobacteria / ml so that 100 field examinations of sputum smear measuring 3 X 2 cms could
show at least 1 bacterium.) However, close and long contact of household members with these
cases could justify screening of contacts of smear negatives with a cost of inconvenience to the
patients and a burden on the public system. Evaluation team is of the opinion that screening of
contacts of infectious cases should be prioritized and there is no justification for the screening
of extra pulmonary cases.
Since, total number of HHC registered according to index patients of smear +ves, smear –ves
and extra pulmonary as well as HHC under 5 years of age remain the same in the report of all
the 4 quarters of 2011, therefore, the same has not been considered. A perusal of HHC
management in 2010 reveals that for every registered sputum smear +ve case, 4.1 contacts
have been screened which is almost 50% of the average family size of Iraq. It is surprising to
see that 0.91% of the screened contacts of sputum smear negative cases have been identified
as sputum smear +ves while, the corresponding figure for the screened contacts of sputum
smear positives is 0.59%. Beyond other factors, quality of sputum microscopy should also be an
area of concern. During 2011, 3557 sputum positive (3059 NSP) cases were detected through
NTP Iraq. Assuming a family size of 7, about 25,000 contacts are required to be screened in a
year. Extrapolating the survey findings, about 500 cases could be detected amongst household
contacts. In 2011, 261 household contacts were diagnosed as TB out of which 81 were NSP and
during Q-1/2012, out of 61 household contacts diagnosed with TB, 33 were NSP cases. It
appears that these cases have been detected through evaluation of contacts and the system
needs further strengthening. Though TB affects all social strata, it is more common amongst
poor population. This intervention will enable to identify, diagnose and treat the silent, poor
and helpless suffering contacts of infectious TB cases. Increased and timely case detection
supplemented with effective treatment will also reduce the risk of TB transmission in
community settings. To sum up, there is an urgent need to strengthen systematic contact
investigation and management of infectious cases.
To improve performance in this area an MOU has been signed between WHO and IATA. An SOP
has been formulated through consultative meetings, imbibing definition of TB index case and
contact, procedures to be adopted in investigating TB contacts and monitoring system to
follow contact investigation activities. Pediatric TB management guidelines incorporating
standardized diagnostic algorithm and contact tracing have been finalized in consultation with
Iraqi Pediatric Association. Ten PHCC’s have already been identified to pilot test the initiative in
73
2012 and based on the evaluation results of pilot sites, the initiative is proposed to be
expanded in a phased manner during which every year, 20 districts have been targeted to be
enrolled to contact investigation activities. Going by the present plan, it will take more than 6
years to cover the country which can be ill afforded.
The proposed initiative of assigning the contact tracing activities to an NGO is neither
sustainable nor operationally feasible and technically sound. Being a part of comprehensive
DOTS strategy, this activity should not be taken in isolation of DOTS and needs to be
expeditiously implemented to ensure country vide coverage by 2015 to support achieving Stop
TB targets and MDG’s. Addition of contact tracing to the programme activities shall increase TB
case detection and prevent emergence of TB cases in people most at risk. Health workers
should follow the contacts at the house for which they should be provided logistic support.
During the contact tracing visit, defaulters in the neighborhood could also be retrieved. Since
the risk for infection and disease is particularly high among close contacts of persons having TB,
the contacts should usually be identified within 3 days and examined within 7 days after
identification of the infectious patient28. Once effectively implemented, the intervention will
increase timely case detection amongst the contacts which will also reduce the risk of TB
transmission in household and community settings.
HIV and TB:
Out of 2258 TB cases tested for HIV, only one was found to be positive 32. Though Iraq is a low
HIV prevalence State but this does not call for complacency because of high risk for
development of HIV epidemic due to changes in risk factors. The NTP policy of July, 2008,
requiring all TB cases reporting to governorate Chest Clinics to be screened for HIV has been
changed to screening of only Cat II and MDR-TB cases. Erbil RCDC reported perennial shortage
of HIV testing kits as a result of which TB patients are “referred” to the nearest HIV testing
center for which no records are maintained nor there is a system of receiving the reports. In an
examination of about 100 patient treatment cards, not even one of them carried the HIV
status. Effective and functional collaboration needs to be formulated between AIDS and TB
programme at all levels—starting from Central to TBMU level.
Marginalized population including prisoners being a high risk HIV group should be especially
cared for. Peer education should be used to detect affected populations, build bridges and
provide a comprehensive package for identified population. Districts / governorates with
disproportionately high incidence of smear negative pulmonary TB / EPTB and those with high
74
case fatality rate amongst TB patients, particularly sputum smear negative, need to consider
HIV as one of the important possible reasons.
Gender Bias: Equity
All TB cases distribution by gender in 2010 and 2011 is almost similar in pattern with slight
male predominance in case
detection.
Notified
NSP
cases/100,000 population in
Notified NSP cases per 100,000 population, 2011 – age and sex
2011 was marginally higher
amongst females up to 24 years
age group. To some extent, this
case notification pattern is an
evidence against the prevalence
of stigma as this age group being
the customary marriageable age
for females is most sensitive to
externalities. However, beyond
24 years age group, prevalence
of TB amongst females has been
comparatively low when compared to their male counterparts which are not much different
from global scenario.
All TB cases distribution per gender in Y.2010
Age and sex distribution of
TB cases in 2011 shows a
marked decrease (38.5%) in
case detection amongst
females in 25 – 54 years age
group.
Although
epidemiology
of
low
prevalence of TB amongst
females
is
not
well
understood but a decrease of
38.5% beyond other factors
75
could be the result of the cocktail of poverty, social customs, poor education, inaccessibility
of services and stigma. In 65+ age group, notified NSP cases/100,000 population amongst
males have almost doubled when compared to females. In a patriarchal society, in this age
group females remain at a disadvantageous position because of social mores and poverty.
However, a comparison of percentage of gender wise total cases shows that by and large,
male female ratio in case detection is consistent with the standard pattern and female cases
have marginally improved from 47% in 2010 to 49% in 2011. During the same period, in
Najaf
governorate,
notified cases amongst
All TB cases distribution per gender in Y.2011
females improved from
38% to 45%.
In our considered view,
the overall male female
distribution of cases in
Iraq is not significantly
skewed against females.
More use of women
health volunteers as in
Marshlands
and
including females in the
TB patient’s clubs would further improve case detection and treatment completion amongst
females.
Quarterly Review Meeting – A tool to reduce inequity
At the national level, the mechanism for data collection, reporting and monitoring is strong and
well appreciated; however, the follow up for corrective action by the present four member
team at M&E surveillance section is weak. Quarterly reports from the governorate need to be
analyzed for all performance indicators and specific time bound feedback given to improve
performance for which M&E section at central level needs to be strengthened to follow up on
corrective actions. Presently RCDC at governorate acts a post office for collecting quarterly
reports from the District TBMU’s; compiling and sending them to central level. On the proposed
pattern of central level, they also need to analyze District wise data and give time bound
76
feedback containing technical inputs for improvement. Directorate at governorate level is well
versed with geographic and socio economic population profile being catered to by TBMU and
the PHCC’s and the precise location of the public sector health services outlets vis-à-vis the
unreached, vulnerable, poor population including slum dwellers. A TBMU wise performance
analysis of their quarterly report, monitoring their quantifiable indicators pertaining to delivery
of DOTS including CDR and TSR followed by a face to face discussion during quarterly review
meetings would also throw some light on accessibility and quality of services being rendered to
neglected groups of population based on which local and focal interventions to improve the
situation can be made.
ACSM and Stigma reduction – Interventions
KAP studies conducted in two districts during 2008 revealed poor community knowledge on TB
which has adverse effects on their health seeking behavior particularly when TB is highly
stigmatized in Iraq3. KAP study in the three Northern governorates has been finalized, and
preparations for carrying out KAP study in the remaining 15 governorates in 2012 are ongoing.
Out of 8,000 NGOs, only 4 NGOs viz. IATA, IMC, AMAR and PU-AMI are actively involved in
DOTS. Involvement of private sector is in its infancy. Initiatives undertaken for formulation of
National COMBI Plan for action and undertaking of 101 community events are the other two
major achievements of 2011 in the field of ACSM.
National Health Communication Strategy needs to be formulated and reflected at governorate
and District levels. The twin initiatives of rapid scale up of ACSM activities to improve TB
awareness in the community and to reduce the stigma need to be prioritized. NTP should set
the ways in which patients, communities, health care providers and governorates can work as
partners and enhance the effectiveness of health services in general and TB care in particular.
Civil society needs to be engaged for promoting the concept of empowering patients and
communities to play a leading role in TB control. NTP needs to actively engage political leaders,
the community and non – programme providers to come on board. Advocacy needs to be
undertaken to influence policy changes and sustain political and financial commitment. This
includes advocacy to those in position of influence; communication with community so that
they know, trust and are ready to avail free TB diagnosis and care; and communication with
patients during diagnosis and entire duration of this lengthy treatment (against present system
of dispensing drugs through a pigeon hole under the window and talking to the patient through
a microphone); and mobilization of communities to demand, use and lend support to NTP, Iraq.
Social mobilization activities need to concentrate on achieving universal awareness of the right
to, and availability of, free TB treatment and care at a convenient place. A working partnership
77
should be established between the health sector and the community – the local population,
especially the poor, and TB patients both current and cured and NTP should be made a people’s
movement encouraging convergent action on awareness creation on case detection and
treatment completion by formal and informal groups at village, PHCC, District, governorate and
central level. This will create demand for TB services which will be a step towards social
marketing of DOTS which needs to be undertaken at central, governorate and District levels. A
cured patient is usually a willing and an effective communicator and can wield significant
influence in the community.
During visit to the different governorates, the team had mixed experiences in this important
area with one commonality of lack of bill boards / hoardings at the health facilities along with
other mass media approaches. This is well supported by the fact that out of a budget of US$
122,500 till 31st Dec, 2011, not even a penny has been spent. While, some stray HE activities
were observed in health facilities of Duhok governorate, Sumail and some other Districts, no TB
related IEC activities were found in all the health facilities visited in Erbil except two mutilated
banners of World TB Day 2010 and 2011 at the Erbil governorate RCDC. Some patients
interviewed in Erbil did not even know the total duration of treatment that they were required
to take, while in Duhok governorate patients were reportedly aware of it. Awareness on
contact examination was also a mixed bag. Out of more than 100 patients in Erbil, not even one
brought the contacts for assessment. Low priority to IEC activities appears to be an important
deterrent in enhancing community knowledge on TB which has been found deficient by even
KAP studies.
It is encouraging to note that community empowerment is being ensured through community
events in line with DOTS expansion through the PHCC’s and organization of events at the
National level. Two community events in TB control per year in each District being undertaken
by central level have been undertaken only in 8 governorates because of security reasons.
Decentralization of such activities to governorate / District level would promote timely holding
of events with minimum security concerns and would build IEC capacity and promote
ownership of the programme at governorate and District levels. This will also provide an
opportunity to the ACSM focal point from central level to effectively plan and monitor
activities. Strengthening the PHC’s system through community based initiative (CBI) has been
introduced under SPHC Project. National Stop TB Partnership under the umbrella of Regional
and Global Stop TB Partnership is scheduled for launching in near future, to advocate for
improved TB care and to facilitate availability of all technical commitments. A number of
78
workshops have been held to develop COMBI Plan and final product needs to be prioritized. For
monitoring and evaluation of ASCM activities, focus at all levels should change from present
system of monitoring outputs like number of community meetings held to monitoring
outcomes like communities committed to and supporting patients.
Social stigma against TB still prevails in Iraq in spite of implementing DOTS in 15 governorates
for more than 10 years. Stigma and discrimination does remain an important factor in being a
barrier to case detection and treatment adherence and the same appears to have been
worsened by the behavior and attitude of the staff / system. Evaluation team in Erbil saw
health workers going around the health facilities with mask and TB patients being heard in the
pharmacy through microphone and; drugs being dispensed through a small pigeon hole below
the window in both Erbil and Duhok governorates are some of the observed examples.
One of the senior Doctor in Erbil told the team leader of the evaluation team:
“_________But, more important than stigma is discrimination of patients by community,
especially health care providers. And this has more effect on patient’s compliance with therapy
than the stigma itself. Because when a patient is seeing that a health care provider is avoiding
him or her, he will become reluctant to obey their recommendations. And subsequently, he or
she will refuse to bring family members for testing and so. ________________we feel strongly
that cause of defaults is related to discrimination more than stigma.”
TB number 6/12 at Erbil governorate was visited by some members of the evaluation team
accompanied by the facility In charge on 6th May, 2012. The patient had given wrong address in
the TB card apparently to mask identification but correct telephone number lead the team to
her house. The treatment given to the visiting team at the patient’s house at Erbil, Najaf and
Basrah governorates strengthens the belief that stigma barrier can be demolished through
demonstrated concern for the patient. The health facility staff should try to break the barrier by
demonstrating a caring attitude to the patients and treating them like a VIP of the programme.
Starting a “Cured TB patient Club” at the governorate level demonstrating normal life being led
by cured TB patients will go a long way in reducing stigma. Cured patients should be
encouraged for disseminating their success stories in the community meetings and through
electronic media which is a hot favorite of Iraqi households. Although TB affects all, it is well
known that poor are afflicted more. Development of brotherhood feeling amongst fellow TB
79
patients most of which are poor could thus be used as a tool to promote equity. In the initial
stages, some difficulty may be encountered in recruiting female cured patients to this club but
a beginning could be made by recruiting older females who would be important opinion makers
in the community. With success of “Cured TB patients Club”, the initiative subsequently should
be extended to TBMU level. Local religious and political leaders could be another group of
important opinion leaders.
Cured patients would be successful DOT providers as they have felt the pain as a patient and
have waded through the constraints of NTP. Anybody and everybody can be a DOT provider
(after a short sensitization) provided he is agreeable for the same, is acceptable to the patient
and answerable to the health system. List of available DOT providers comprising of cured
patients and other willing community members should be prominently displayed in every
health facility and the patient provided with an opportunity to choose his own DOT provider.
This will not only reduce stigma but would also be a step towards most cost effective
decentralized DOT services taking them to the door steps of the community, which would also
reduce default rate and promote treatment completion.
Existing Health Services Situation – Unfriendly to Equity
In a study of the expenditure analysis of proposed BHSP services in Iraq carried out by MOH
with technical support of WHO, it was found that the highest share of direct cost is absorbed by
the curative care and emergency services which are delivered through major hospitals mostly
concentrated in big cities thereby primarily benefiting the rich and affluent strata of the society.
This skewed allocation of resources in favour of curative and emergency services located in big
cities provides disproportionally enhanced job opportunities to the health professionals’
particularly skilled and highly skilled leading to exodus of medical/paramedical personnel to big
cities leading to skewed availability of technical manpower for the poor.
80
A perusal of the table indicating distribution of key health manpower in Iraq shows that key
functionaries
are
Distribution of technical manpower – Iraq
concentrated in more
affluent governorates.
Deployment Pattern
Category of
National
Iraq has an average of No manpower
Average
Higher
Value
Lower
Value
2.2
specialist/10,000
populations, against 3.9
Missan
3.5
in Erbil and 1.1 in 1
Physician
7.5/10,000
Erbil
10.5
Diyala
4.3
Misan, Diyala and Thi –
Thi-Qar
4.4
Qar. While there are
35.7
Missan
1.1
pharmacists/10,000
Average
2
2.2/10,000
Erbil
3.9
Diyala
1.1
specialist
population in Erbil, the
Thi-Qar
1.1
national average is
16.7%/10,000
Basrah
0.5
population
and
at
Thi-Qar
0.6
Misan the figure is 3
Dentists
1.7/10,000
Baghdad
3
Missan
0.8
astronomically low at
5.4.
Muthanna
0.8
Dohuk
0.7
Pharmacists
1.9/10,000
Karbala
3
Sulimaniyah
0.7
The distribution of 4
Primary Health Care
Missan
0.8
Centers
is
also
Salah Aldin
4.6
inequitable
as
the 5
Nurses
14/10,000
Diwaniya 25.4
Sulimaniyah
7.5
population per health
centre ranges from
Missan
5.4
6
Paramedics
16.7/10,000
Erbil
35.7
3,700 in Sulaymania
Anbar
8.4
governorate to 41,478
in Baghdad. Half of the health centers have a physician while the other half is covered by
paramedical staff. This distribution leads to inequitable allocation of resources amongst various
health care service outlets with minimum allocation to main PHC and the least to sub-centers
which are the hub of providing comprehensive services for the poor who live in rural areas and
urban slums. C and D category of PHCC’s are located at the peripheral level and cater to rural
population which by and large is poor. These PHCC’s even do not provide sputum examination
services. Coming to higher facilities require spending extra resources by poor patients which
they can ill afford. Due to resource constraints, the governorate is not able to establish sputum
81
microscopy services at all these peripheral levels. Sputum smear transportation in such
circumstances could be a cost effective feasible equity promoting intervention. To facilitate all
TB cases in getting their treatment, community members including cured TB patients should be
motivated to function as DOT provider which beyond facilitating decentralized treatment would
be an important stigma reducing tool with no additional cost. Another way to address this
imbalance for the purpose of TB care and to ensure at least some semblance of equity, it is
essential to involve all non NTP Public and private health care institutions in partnering in the
delivery of DOTS – An Approach to Basic TB Control to all those clients who need it.
Notifications of detected TB cases by Referral in Iraq during Q1-2012
Pulmonary (SS+)
Referral
Pulmo.(SS-) New
New Previously treated (SS+) New New
Total
Total
Total Total Total (SS-) Total
Previously cat.2 cat.1,2 New
(SS+) relapse failure default (SS-) (ND) (EP)
Self
Other
treated
(SS+)
(SS+)
(SS-) (ND)
TB
Cat.1 Cat.2 (ND) (EP) Cases
352
40
17
4
221
49
207
33
61
413
829
94
270
477
923
2
0
0
0
3
1
3
0
0
2
9
0
4
7
9
Public
214
25
3
1
140
23
226
23
29
243
603
52
163
389
655
Private
203
15
0
1
143
29
316
16
16
219
691
32
172
488
723
Other
19
0
0
0
0
0
4
1
0
1
2
0
0
1
2
790
80
20
6
507
102
756
73
106
896
2155
179
Community
Total
609 1365 2334
Efforts of NTP in this direction have started yielding results. In 2010, non NTP public and private
sector combined accounted for 59.5% of total notified cases in Iraq and almost the same %age
has been maintained in 2011 and 1st quarter of 2012. Contribution of this sector in detecting
NSP cases has been around 52% during the same period. Sputum smear negative, sputum not
done and extra pulmonary group of cases referred by non NTP public and private sector
constituted 66.9% of their total cases in 2010; 64.8% in 2011 and 63.6% in 1st quarter of 2012
calling for sensitization of this sector on adopting diagnostic algorithm. While a total of 911
private practitioners are reportedly collaborating with NTP in 2011, precise number of
collaborating non NTP hospitals is not known. Rizgary Teaching Hospital which has about 100
Doctors and is attached to Medical University Hawleir, also known as College of Medicine, Erbil,
has appointed a TB focal point in April, 2012. No awareness programme and DOTS training has
82
still been undertaken as a result of which only few Doctors refer the suspects to governorate
RCDC without any organized referral system and at governorate level there is no system of a
feed back to the referring practitioner. Even no suspect register was being maintained. There is
an urgent need for systematic involvement of all non NTP public and private sector hospitals in
the DOTS programme. Such an initiative will not only increase case detection rate but would
also be a step towards promoting equity.
Recommendations
1. Availability and accessibility of PHC services in IDP’s need to be improved
2. Procurement of mobile vans which is fulcrum of service delivery in most IDP’s should be
ensured without any further delay
3. Indicators for assessment of Marshland activities should be changed to outcome
interventions
4. Expenditure on advisors from London by AMAR should be gainfully utilized on other
activities
5. Arrangements should be made to initiate diagnostic and treatment facilities in 5 prisons
where training of key staff has already been undertaken
6. Contact tracing should be operationalized as a part of DOTS strategy and should
immediately cover all 117 TBMU’s
7. “TB patients clubs” with female participation should be encouraged
8. National Health Communication Strategy should be formulated at central level in
consultation with stakeholders and reflected at governorate and District levels
9. Community and cured TB patients should be promoted for social marketing of DOTS
10. IEC activities should be enhanced
11. Transportation of sputum slides should be adopted at Group C and D PHCC’s.
83
MONITORING AND EVALUATION
Monitoring and evaluation (M&E) is the collective use of social science and epidemiological
research methods to assess and eventually improve the implementation of programmes.
Monitoring is a routine tracking of programme using input, process, and outcome data that are
collected on a regular and ongoing basis. Data generated by the reporting system is essential
for evidence based policy decisions and is the vehicle for programme evaluation and
performance monitoring. A good M&E system needs to ensure most efficient use of resources
and guides data collection and analysis to increase consistency25. The scale and increased
complexities of TB programme coupled with stake of Government and donors has enhanced
the need for data to inform decision makers and demonstrate progress towards MDG’s29. NTP
Iraq needs strengthened M&E system to report accurate, timely and comparable data that can
be used to strengthen the programme and continue getting financial support from the donors;
and also to give a time bound regular performance based feedback to the governorates.
National TB Control Programme – Iraq has developed a compact National M&E plan27 (20132015) which has enlisted a set of indicators on the impact / outcome as well as on output and
process levels comprehensively covering all aspects of NTP performance in Iraq. TB data is
recorded at all TB service delivery outlets using standardized templates and collection tools
which ensures uniformity facilitating compilation and analysis. Data collected from service
delivery outlets at the peripheral level health facilities flows to District level where it is verified
and compiled for onward transmission to the governorate where the data from all Districts
within the governorate is aggregated and transmitted to central level who shares the
comprehensive data with all stakeholders and MOH. Governorate and District TB coordinators
are responsible for regular and timely collection and verification of data within their
geographical mandate. Each TBMU has one designated District TB coordinator responsible for
M&E who also verifies the accuracy of data through triangulation of registers with standardized
recording tools during quarterly supervisory visits to peripheral PHCC’s providing DOTS. At
intermediate level, governorate TB coordinator checks on completeness and accuracy of data
through random cross checking of registers. He is also responsible for carrying out same
supervisory procedures at the prisons located within the respective governorate. M&E unit at
Central level collects all data from the 18 governorates’ GTBC’s and is responsible for storage,
compilation and analysis of the data to produce strategic information and reports. The M&E
surveillance unit also consolidates data on supervisory visits into a GFATM specific quarterly
reporting tool. Central M&E surveillance unit sends all epidemiological data on TB to National
Health Information Management Unit at the MOH as well as to WHO and UNDP.
84
TB surveillance in Iraq had been weak for many years following sanction imposed in 199027.
Presently, the NTP Central M&E Unit consists of 4 sub units who overview data storage,
processing, analysis, and transforming TB data into information products.

The Central M&E Surveillance Unit has the responsibility of overseeing recording and
reporting of data, and the maintenance of the Electronic Nominal Registration System
which till December, 2011 is operating in 118 Districts. The team consists of 1 community
medicine specialist and 3 statisticians

The Central M&E Supervisory Unit is responsible for overseeing and following up on all
supervisory visits, overseeing M&E activities, timely collection of data, and improving data
quality assurance mechanism. More than 720 supervisory visits have been conducted in Q4/2011. The team consists of 1 community medicine specialist, 1 general practitioner, and 2
statisticians

The Central M&E Training Unit is responsible for assessing training needs, developing
training plans, and organizing M&E trainings for NTP staff members

The Central Operations Research Unit consists of 1 community medicine specialist who is
responsible for identifying research needs and for initiating and following up on conduction
of research and data collection activities, including national surveys
Storage of data pertaining to NTP Iraq at the peripheral level until 2008 was exclusively paper
based. UNDP country office in Iraq has reportedly contracted to build an online countrywide
information management system for NTP Iraq which will allow to better track and monitor
progress towards strategic objectives of National TB control strategy. It is envisioned that
eventually the database will collect data down
to the peripheral level and that Districts will
be equipped with proper equipment, internet
connectivity, and human capacity to enter
data directly into the database. The evaluation
team feels that, envisaged up gradation of
M&E system will comprehensively improve
efficiency of NTP, Iraq.
During field visits by the evaluation team, data
collection and maintenance of TB registers at
85
Use of old forms
District and governorate level appeared to be complete and reflect the reality, with a few
exceptions. Absence of contact information of infectious cases, HIV testing status and marking
of drugs issued on patient cards were notable deficiencies at almost all visited facilities. All
treatment outcome reports should ensure that while calculating “cure rate” the denominator
needs to be only sputum positive cases registered during the quarter/year. Due to shortage of
stationery, old forms and registers were being used in some governorates. In fact, old sputum
examination forms being used indicated three sputum specimens while, as per WHO guidelines
(2010), only two specimens are now required to be collected and examined in settings where a
well – functioning EQA system exists, the workload is very high, and human resources are
limited. Even NTP, Iraq has also recommended examination of two sputum specimens. This not
only created confusion amongst patients but also affected the credibility of the programme. As
part of the GFATM approved work plan, WHO should ensure printing of NTP stationery without
any further delay.
“Sputum not done” cases should not be registered under the pulmonary sputum smear
negative cases. In a
well
performing
programme,
except
for small children,
sputum examination
should be undertaken
on all pulmonary TB
suspects. Sulaymania,
Muthenna
and
Ninewa governorates
in
2011
have
undertaken diagnostic
sputum examination
on all their pulmonary
TB
notifications.
Similar notifications
have also been made
by Muthenna, Kerkuk
and
Sulaymania
governorates in Q-1/2012, Ninewa, Anbar and Sulaymania governorates in 2010 and Anbar and
Kerbela governorates in 2009. If at all the column of sputum not done is to be retained, it
should be a separate column. The programme should develop a vision of dispensing away with
86
this column and practice of not undertaking sputum examination in all pulmonary TB suspects
in foreseeable future.
Internal systems for monitoring and supervision in Erbil though in place lacked commitment to
and quality of monitoring was weak. There was no feedback and supervisory meeting
discussions lacked instructive information to enhance performance. There was no mechanism
for documenting corrective actions to ensure accountability.
Despite noteworthy performance in generating and disseminating a large volume of
programme data, from an operational perspective, the NTP reporting system is not utilized for
relevant programme action and planning. Key supervisory positions at District and governorate
levels demonstrate limited insight and capacity to conduct evidence-based problem-solving at
District and governorate levels. NTP needs to invest further in capacity building of District and
governorate managers to perform evidence-based problem-solving and translate data into an
effective programme action. This will require education and training on how to conduct and
interpret basic epidemiological analyses with special emphasis on how to translate findings into
public health practice for which sufficient funds are also available.
Performance indicators are target-oriented and primarily focus on detection and treatment
outcome of NSP cases (70/85 by 2014), without due attention to programme management,
case-finding processes and case-holding processes. Central level should challenge well
performing governorates to set more appropriate goals based on local trends in performance.
While the verticality of the information system has yielded some advantage for NTP, there is
very limited engagement with the larger health system in public sector like 289 public hospitals
including teaching hospitals and prisons and in private sector for the collection of relevant
performance based indicators. Transition from target-focused monitoring of performance to
analysis of trends in key process and outcome indicators at District and governorate levels
needs to be made in order to improve performance. Governorate level committees to develop
appropriate process indicators for local planning and monitoring to augment national targets
should be established.
Supervisory visits cover all NTP related areas and are carried out regularly from the central to
the intermediate (governorate), intermediate to peripheral (district), and from peripheral to
other PHCC’s of the district. In addition, on the intermediate level, the governorate TB
coordinator carries out regular supervisory visits to prisons included in the DOTS program
within the respective governorate. Supervisory visits through different levels are presently
being carried out by a team to crosscheck and verify completeness, accuracy and consistency of
data in reports against actual registers and also to monitor the quality of laboratory and
treatment services. Outcome of 720 supervisory visits conducted in Q-4/2011 is not well
87
understood nor the process of arriving at the decision of visiting a particular governorate. Entire
process of supervisions needs to be reviewed tailoring it with need more than routine. Low
performing governorates should be prioritized for supervision which should not be a mere
“visit” or “policy”. Supervision has to be a blend of education, coordination, facilitation,
guidance and motivation comprehensively aiming at performance enhancement. Mechanism to
evaluate the outcome of the visit should be well defined in terms of outcome indicators. The
composition of supervisory team should be need and issue based and correlated with
performance. Treatment outcome of cohort of Q-1/2011 shows 68% cure rate and more than
9% default rate in Baghdad and 64% cure rate in Nejef with 14.3% death rate, both of which
have brought down, the country’s treatment outcome of NSP cases. As a part of recommended
monitoring strategy, central level should prioritize monitoring visit to both these governorates
to find out and address the reasons for this poor performance. Similarly, these two
governorates should analyze TBMU-wise treatment outcome data, identify and visit low
performing TBMU’s for addressing the identified deficiencies. All these activities should be
replicated by TBMU at the poor performing service delivery outlets within their respective
District. NTP should develop and distribute a standardized supervisory site-visit report that
includes both qualitative and quantitative variables and ample space for comment, in order to
document corrective actions as well as successful completion.
At the Central level, the mechanism for data reporting and monitoring is strong and well
appreciated; however, the follow up for corrective action by the present four people team at
central M&E surveillance unit is weak. Quarterly reports from the governorate need to be
analyzed in respect of all performance indicators; good and poor performing governorates and
areas identified; reasons for poor performance assessed and specific time bound email based
constructive and suggestive feedback given to improve the weak areas. These detailed
comments subsequently should form an important agenda item for discussion during the
quarterly review meetings. Based on quarterly reports, Central level should bring out a
quarterly one pager “newsletter” giving governorate-wise 3-4 key performance indicators
which should be circulated to all concerned including senior officers in MOH. Low performing
units should be marked red. This will bring an atmosphere of appreciation for good performers
and concern for poor performers who will make all attempts to get rid from the red mark in a
publicly circulated document.
For undertaking the recommended initiatives, M&E surveillance unit at central level needs to
be adequately strengthened. Incidentally only 27% of budgeted amount of US$ 1,236,039 for
88
M&E has been spent in 15 months of implementation of SSF while Erbil governorate could not
undertake any monitoring visits during 2011 on account of non availability of funds.
Presently RCDC at governorate functions like a post office for collecting and compiling quarterly
reports from the Districts; and sending them to central level. Directorate at governorate level is
well versed with geographic and socio economic population profile being catered to by TBMU
and the PHCC’s and the precise location of the public sector health services outlets vis-à-vis the
unreached, vulnerable, poor population including those living in slums. A TBMU wise
performance analysis of the quarterly report, monitoring their quantifiable indicators pertaining
to delivery of DOTS including CDR and TSR followed by a face to face discussion during quarterly
review meetings beyond improving performance would also throw some light on accessibility
and quality of services being rendered to neglected groups of population based on which local
and focal interventions to improve the situation should be made. On the proposed pattern of
central level, the governorates also need to analyze District wise data and give time bound
feedback to Districts containing technical inputs for improvement. Governorates on the pattern
of central level should also prepare and circulate a quarterly one pager “newsletter” in respect
of their Districts.
Recommendations
1. WHO and NTP should ensure availability of all NTP forms and registers at TBMU level
2. Based on quarterly report analysis, central level should send time bound comprehensive
comments on the performance with specific advice on improving the weak areas.
Similar action should be taken at governorate level
3. Central level should set an example for the governorates by immediately undertaking
publication and circulation of “quarterly TB newsletter”
4. Importance of sputum microscopy as primary diagnostic tool in all pulmonary TB
suspects should form a part of all trainings and an integral part of monitoring visits
5. NTP should initiate transition from target-focused monitoring of performance to
analysis of trends in key process and outcome indicators at District and governorate
levels
6. Capacity building at governorate and District level to perform evidence-based problemsolving and translating data into an effective programme action
7. NTP reporting system should be used for governorate and District level performance
related planning and programme action
8. All columns of treatment card should always remain updated and the same should be
verified during the supervisory visits.
89
VALUE FOR MONEY
Introduction; Round 6: Analysis by objectives; Single Stream Funding (SSF): Analysis by objective and service
delivery areas; Combined analysis by Cost category for both R6 and SSF grants; Government of Iraq
Contributions; Recommended areas for addressing the ineffectiveness; Disclaimer
Introduction:
UNDP Iraq and the GAFTM signed grant agreement number IRQ-607-G01-T effective 15th
November, 2007 till 30th September, 2011 with total amount of US$ 14,500,157 of which US$
11,445,495 was disbursed by the GFATM to UNDP by 1st October, 2010. UNDP Iraq has also
been nominated as Principle Recipient (PR) for the TB grant approved to Iraq under R9 of
GFATM. In October 2010, UNDP and the GAFTM has signed a consolidated grant agreement,
merging the remaining activities of grant agreement number IRQ-607-G01-T and the new grant
approved under R9. The consolidated grant first implementation period is from 1 st October,
2010 to 31st December, 2012. The second implementation period will be from Jan, 2013 to
September, 2015 pending the GFATM approval.
This value for money analysis is based on two main sources of information:

Enhance Financial Reports (EFR) that were submitted by the PR to GFATM for both R6 and
the SSF grants

Information gathered from NTP about the government contribution to NTP including salary
and operational costs.
90
Round 6: Analysis by objectives:
R6 grant implementation started in January 2008. There were four objectives under R6 as
described hereafter. By 30th September, 2010, the total reported expenditure to the Global
Fund was US$ 7,843,865.
The first objective was to "Enhance services to ensure quality DOTS in Iraq" which aimed at
supporting revitalization of TB care network in Iraq damaged under complex emergency. Main
activities were to: revitalize and expand the network of quality assured microscopy
laboratories; enhancing the network of treatment supporters and treatment supervision;
effective drug supply and management system; enhance the monitoring and evaluation system;
strengthen health system by rehabilitating peripheral TB facilities; and strengthen collaboration
with non NTP public and private health sector.
The second objective was to "Address TB care for poor and vulnerable populations" aimed at
ensuring greater access to TB care for poor and vulnerable populations including populations in
poor urban slum areas (1.2 million); prisoners; and populations in conflict areas and internally
displaced population (0.6 million).
The third objective was to "Expand DOTS in 3 northern governorates" having a population of 4.1
million. Main activities included advocacy; establishing a network of diagnostic laboratories
with a system of quality assurance; scaling up the use of standardized treatment; ensuring
regular supply of quality assured TB drugs; and installing effective monitoring and evaluation
system.
The fourth objective was "Improved project management capacity at national level" aimed at
strengthening overall technical and management capacity of NTP at the national level to
address TB care effectively and to ensure successful implementation of the Project. Main
activities include: improving the capacity of the existing staff; recruiting additional national and
international staff to support the NTP; procurement of basic equipments; and conducting
operational research to assess the impact of the Project.
91
Budget and expenditure of R6 by Objectives with Overhead WHO & UNDP
In US$
Objectives
Budget
Expenditure
% of Total
Expenditure
Objective 1: Enhance services to ensure quality
DOTS in Iraq
5,643,753 (54%*)
4,253,671 (75.4%*)
54.2%
Objective 2: Address TB care for poor and
vulnerable populations
621,192 (5.9%*)
385,806 (62.1%*)
4.9%
Objective 3: Expand DOTS in 3 northern
governorates
660,452 (6.3%*)
288,082 (43.6%*)
3.7%
Objective 4: Improved project management
capacity at national level
1,518,950 (14.5%*)
1,172,938 (77.2%*)
15.0%
WHO & UNDP Overhead fees & other
administrative cost
2,012,565 (19.3%*)
1,743,368 (86.6%*)
22.2%
Total
10,456,912
7,843,865
100%
* Figure in parenthesis under budget indicates %age of total budget and under expenditure
indicates %age of objective specific budget spent
Findings:
1. Objective on enhancing services
to ensure quality DOTS in Iraq
accounts for 54% of the total
budget amounting to US$
10,456,912. From 2009-2010, the
diagnostic
service
outlets
increased from 68 to 191 and
treatment centers to 600.
Beyond other staff, more than
1,100 treatment supporters and
300 laboratory technicians were
92
trained. Implementation of the activities enhancing services to ensure quality DOTS in Iraq
contained in six SDA’s accounted for an expenditure of US$ 4,253,671, which is more than
75% of the allocated budget and 54.2% of the total expenditure. NTP received first line anti
TB drugs through the grants from the GDF. During 2009-2010, 19,765 TB cases were
detected out of which, 17,468 were successfully treated giving a treatment success rate of
88.4%. This intervention averted more than 4,300 estimated deaths and prevented 0.18
million estimated TB infections.
In the absence of SMART objectives in R6 proposal, this intervention could be assessed as
an effective intervention in terms of value for money.
2. The activities included in objective 2 on addressing TB care for poor and vulnerable
populations in Iraq include
strengthening PHC capacity to
provide TB DOTS and increasing
awareness through community
based initiatives. IMC and IATA
expanded their services in AlAnbar governorate and AlKadimia District. Some inroads
were also made in reaching 0.6
million population of IDP’s. The
objective
was
budgeted
disproportionately low at 5.9% of the total budget. Even with this low budget, the
expenditure has been 62.1% of the budgeted amount.
3. Although Objective No. 3, covered expansion of DOTS in 3 governorates accounting for
12.7% of Iraq’s population but were allocated only 6.3% of the total budget. In addition to
some trainings and supervisory visits, 67 new facilities as treatment centers and 2
microscopy centers were established in the 3 governorates. In spite of low budget
allocation, only 43.6% of the allocated budget was spent.
4. The fourth objective beyond improving the capacity of existing staff, envisaged recruiting
additional national and international staff. However, most of the expenditures has been
incurred in attending meetings and workshops. More than 77% of allocated budget for this
objective was spent because most of the meetings and workshops involved foreign travel.
Looking at the pattern of expenditures vis-à-vis the spelt objective, in terms of value for
money in grant management, the interventions made cannot be considered as effective
interventions.
93
Single Stream Funding (SSF): Analysis by objective and service delivery areas
The SSF grant implementation started in October 2010. The grant has the following two
objectives; Objective 1 "Increase the Case Detection Rate of sputum smear positive TB cases
from 43% to at least 70% by 2014 and maintain high treatment outcome among detected
cases" and Objective 2 "Ensure universal access to diagnosis, treatment and care for DrugResistant TB (DR-TB)".
As of 31st December, 2011, US$ 6,483,379 was spent (42.4%) out of the total budget of US$
15,290,665. Additional US$ 5.4 million was obligated mainly for procurement of health
products and equipments.
Cumulative Budget and expenditure by objectives of SSF grant as of 31 st Dec, 2011
Objectives
Budget
Expenditure
Expenditure &
Commitments
commitments
Expended &
commitments
from Budget %
Objective 1 13,362,503
5,575,949
4,706,274
10,282,223
77%
Objective 2 1,928,162
907,429
700,106
1,607,535
83%
Total
6,483,379
5,406,380
11,889,759
78%
15,290,665
Key activities under the first objective are: expansion of quality assured TB diagnostic
laboratories so as to have 1 laboratory per 100.000 population and 1922 PHCC facilities
providing treatment services; introduction of DOTS services into Primary Health Care Centers;
interventions among high risk population groups such as prisoners, Marshland populations,
IDPs and TB contacts; engagement of the non-NTP private and public sectors in TB care; and
improvement in targeted operations research capacity within the Program. Therefore activities
were grouped under the five SDAs below:
94
Budget and expenditure by SDA’s for objective 1 of SSF grant as of 31st Dec, 2011
In US$
Service Delivery Area
Budget
Expenditure
% of Total
Expenditure
SDA 1.5: Grant management by PR & SR
3,499,027
(26.2%*)
2,328,177
(66.5%*)
41.8%
SDA 1.1: Expansion of quality assured TB
diagnostic and treatment services
7,482,351
(56%*)
2,972,657
(39.7%*)
53.3%
SDA 1.4: Operations Research (including
Impact measurement)
345,783
(2.6%*)
115,468
(33.4%*)
2%
SDA 1.3: Engagement of the non-NTP
private and public sectors
342,984
(2.6%*)
51,988
(15.2%*)
0.9%
SDA 1.2: Interventions among high risk
population groups
1,692,357
(12.7%*)
107,659
(6.4%*)
1.9%
Total
13,362,502
5,575,949
* Figure in parenthesis under budget indicates %age of total budget and under expenditure
indicates %age of allocated budget spent
The second objective is to expand MDR-TB care in line with the targets set in the “Beijing Call
95
for Action”. Key activities are designed to establish an effective, responsive and sustainable
system of detection, treatment and care of DR-TB cases as an integrated component of TB care
in Iraq. Activities are in line with WHO recommended Programmatic Management of DrugResistant TB and grouped in six SDA’s below:
Budget and expenditure by SDA’s for objective 2 of SSF grant as of 31st Dec, 2011
In US$
Service Delivery Area
% of Total
Expenditure
Budget
Expenditure
SDA 2.1: Diagnosis of DR-TB
797,681 (41.4%*)
660,631 (82.8%*)
72.8%
SDA 2.4: Monitoring and Evaluation of
MDR-TB program
78,800 (4.1%*)
50,000 (63.5%*)
7.6%
SDA 2.2: MDR-TB specific human
resources development
101,836 (5.3%*)
52,583 (51.6%*)
5.8%
SDA 2.6: SR Grant management
119,519 (6.2%*)
40,118 (33.6%*)
4.4%
SDA 2.3: MDR-TB Drug management
331,670 (17.2%*)
86,549 (26.1%*)
9.5%
SDA 2.5: MDR-TB case management
498,657 (25.9%*)
17,549 (3.5%*)
1.9%
Total
1,928,163
907,430
* Figure in parenthesis under budget indicates %age of total budget for each of SDA’s and under
expenditure indicates %age of allocated budget spent
96
Findings:
1. For Objective 1; the highest utilization rate was for SDA 1.5: "Grant management by PR &
SR" with 66.5% expenditure rate and more than 41% of total expenditure and the lowest
performing SDA is SDA 1.2: “Interventions among high risk population groups” with only
6.4% expenditure rate accounting for 19% of total expenditure. This has been primarily
because of practically non start of activities in IDP’s; poor inroads into prisons; and
insignificant progress in contact tracings. Not much headway has been made in engagement
of non NTP private and public sectors as a result of which only 15.2% of the allocated
budget has been spent which accounts for a mere 0.9% of total expenditure.
2. For Objective 2; the highest utilization rate was for SDA 2.1: "Diagnosis of DR-TB" with
82.8% expenditure rate and the lowest performing SDA is SDA 2.5: "MDR-TB case
management" with only 3.5% expenditure rate which is well understandable because first
cohort of 50 cases was initiated on treatment in August, 2011 out of which, 31 have already
converted sputum negative and treatment outcome would be available by mid 2013.
97
Combined analysis by Cost category for both R6 and SSF grants:
This section is prepared to look at the combined expenses versus the budget of the two grants.
Cumulative category wise budget & expenditure - R6 & SSF grants (Jan, 2008 - 31st Dec, 2011)
Cumulative Period R6 & R9
#
Category
Cumulative
Budget in US$
Cumulative
Expenditure in US$
% R6 & R9
Expenditure
Vs. Budget
1
Overheads
2,916,190
2,386,035
82%
2
Other ( NGO contracts)
291,860
223,459
77%
3
Technical Assistance
1,115,870
831,318
74%
4
Human Resources
1,574,960
1,099,694
70%
5
Medicines & Pharmaceutical
1,592,095
1,002,662
63%
6
Infrastructure & Other Equipment
5,030,718
3,165,307
63%
7
Planning & Administration
2,162,667
1,284,306
59%
8
Training
3,333,450
1,754,730
53%
9
Health Products & Equipment
5,073,061
1,893,444
37%
10
Monitoring & Evaluation
1,994,217
604,892
30%
11
Communication Materials
513,457
79,441
15%
12
Living Support to Clients
149,030
1,955
1%
25,747,576
14,327,244
100%
TOTAL
Findings:
1. There were hardly any expenses by end of Dec 2011 under the “Living Support to Clients”
although the ambulatory MDR treatment started with the first cohort of 50 MDR in August,
2011.
2. For the entire period of 4 years (2008-2011); expenditure on Communication Materials
account only for 15% of approved budget under this budget category.
98
3. Budget for Planning & Administration and Overheads accounts for US$ 5 million (20% of the
total approved budget for 2008-2011) and combined expenditure for these two categories
account for US$ 3.67 million which represent 25.6% of the total cumulative expenses.
4. An important activity like training of treatment supporters which has been budgeted at Zero
needs to be appropriately budgeted
5. Monitoring and evaluation accounted for only 4.2% of the cumulative expenditure and 30%
of the budgeted amount requiring strengthening of this activity
6. With only 9 months of the validity of the agreement left, UNDP and WHO combined have
been able to spend less than 50% of the original total allocations in 18 months showing
gross under spending by both which in effect is an indicator of delay in implementation of
the planned activities.
Government of Iraq Contributions
i.
NTP Staff Cost:
Staff cost is estimated to be US$ 5,395,160 annually.
Annual salaries of NTP at central level are US$ 1,196,160. There are 112 Staff members who
receive an average monthly salary of US$ 890. A total staff of 442 at governorate level
accounts for US$ 9,500 as the average annual cost.
ii.
Operational Cost:
 Electricity and Fuel
Annual operational cost on account of electricity and fuel are estimated to be US$ 101,400.
99
On average the electricity and fuel cost monthly in 18 GTC is US$ 125 (18*125*12 months =
27,000) and 124 DTC that will pay US$ 50 monthly (124*50*12months = 74,400).
iii.
Rehabilitation Cost
In 2010 the MoH shared the cost of US$ 40,000 for rehabilitating Erbil TB clinic in Erbil
governorate.
Global Fund vs Iraq Government expenditure for the TB program
Year
Total Global Fund Expenditures
in US$
Iraq Government Estimated
Expenditures on TB in US$
2008
2,133,534
5,496,560
2009
3,304,920
5,496,560
2010
3,030,564
5,536,560
2011
5,612,503
5,496,561
100
Cumulative Budget R6: By Objectives with Overhead WHO & UNDP
As indicated in the chart given above, the Government was actually contributing more than the
global fund for the period from 2008-2010 while in 2011 the government of Iraq and the Global
Fund have similar expenditures. It is worth mentioning that the government of Iraq is intending
to increase its contribution to the program starting 2012. Government of Iraq will purchase
through WHO the first line anti TB drugs with domestic resources while the GFATM resources
will be used for procurement of the Second Line Drugs (SLDs).
Findings:
1. The Iraqi Government has actually been contributing more than the global fund for the
period from 2008-2010 while in 2011 the government of Iraq and the Global Fund have
similar expenditures
2. Support of global fund has been an additionality
3. While, there is evidence to the fact that government of Iraq is intending to increase its
contribution to the program starting 2012, the prospect of sustainability of the program
beyond 2015 when support through SSF ends is not very clear.
101
Recommended areas for addressing the ineffectiveness:






Budget allocations need to be made for training of DOT supporters
Contact tracing need not be contracted out
Relook at the expenditures on UNDP and WHO offices in Amman
Very high charges on overheads and planning and administration
Expenditure of London based staff for advising on Marshlands appears infructuous
Expenditure on foreign travels may be restricted.
Disclaimer
“Value for money” being a matter of perception, is not an appropriate scientific parameter for
assessing the benefits accruing out of the investments made. Even result oriented indicator like
cost benefit analysis has some limitations in its application to TB programme. It is not easy to
accrue value for the death. Similarly, increasing awareness and social mobilizations are long
term investments where gains accrue after a long time but for a long term making cost
assessment difficult.
102
SUMMARY
Introduction; Evaluation Team; Objectives of the Programme; Magnitude of the Problem; GFATM
Implementation Methodology; Expenditure Profile; NTP Infrastructure; Equity; TB in Prisons; Performance of
NTP; Case detection during 2009 – Q-1/2012; Treatment Outcome of Cohort of 2009 – Q-1/2011; Comments on
Case Detection and Treatment Outcomes; MDR-TB; Involvement of Medical Schools; Banning Sale of anti-TB
drugs in Private Sector; TB – HIV; ACSM; Stigma and Discrimination; Monitoring and Evaluation; Drug
Procurement, Quality Control and Distribution; Operational Research
Introduction
Based on current epidemiological situation, Iraq ranks 44 out of 212 countries and territories by
estimated number of TB cases on the global level and is considered among 9 high TB burden
countries in Eastern Mediterranean Region (EMR) contributing to 3 % of its total cases5. TB
program of Iraq was launched in 1989. DOTS strategy adopted in 1998 in Iraq was extended in
2000 to fully cover 15 governorates Respiratory and Chest Disease Clinics (RCDC) and partially
in three northern governorates26; was available in at least one clinic in each of the 18
governorate’s, and declared “universal coverage of DOTS in Iraq” regardless of the extent of
accessibility of the services to the population5, 3. However, because of political situation, DOTS
in Kurdistan region was fully introduced in 2008.
The health system in Iraq is composed of two main sectors; public and private. In public sector,
National TB Programme (NTP) is the technical core for TB control, and is responsible for policy
and strategy formulation, coordination with partners, planning, implementation and
monitoring of TB control activities.
103
Evaluation Team
After more than 3 years of implementation of GFATM supported initiatives in TB control, CCM –
Iraq and NTP, Iraq decided to have a joint external review mission to have inputs from external
experts on the progress in the TB control programme in the country. Evaluation team is
composed of an international consultant as team leader and five Iraq based national
consultants. National consultants had the overall obligation of meeting with GFATM project
beneficiaries and other stakeholders and conducting field visits in the southern, central and
northern regions of Iraq. Responsibility of the team leader beyond desk review and visit to
health facilities in Erbil has been to synthesize all information gathered by the national
consultants, conduct its analysis in the broader context of considering all information sources
and write the evaluation report.
Objectives of the Programme
While, vision, goals and TB control strategy of Iraq are based on Stop TB strategy, following two
objectives constituted the R9 GFTAM approved proposal which is now being implemented
through “Single Stream Funding” (SSF) along with R6 remaining support:

Objective 1: Increase the case detection rate of sputum smear positive TB cases from 43%
to at least 70% by 2014 and maintain high treatment outcome at least at 85% among
detected cases

Objective 2: Ensure universal access to diagnosis, treatment and care for Drug Resistant TB
(DR-TB).
104
Magnitude of the Problem
Capture / recapture study conducted by WHO in 2011 estimated 14,563 incident cases with an
incidence rate of 45 / 100,000 population against 2010 WHO estimates of 20,000 incident cases
with incidence rate of 64 / 100,000 population. However, the estimated incidence of capture /
recapture study may need to be loaded because 4.5 million population in IDP’s and Marshlands
hardly had any access to health services during the period of study.
GFATM Implementation Methodology
Iraq has received GFATM support for R6 and R9. Pertaining to R6 GFATM support, UNDP and
GFATM signed a grant agreement for US$ 14,500,157 effective 15th Nov, 2007 till 30th Sept,
2011. Consequent to R9 GFATM support with UNDP, continuing as PR, and WHO as SR, two
overlapping grants were consolidated to US$ 18,270,970 from 1st Oct, 2010 to 31st Dec, 2012. A
budget of US$ 3,499,027 amounting to more than 19% of total budget has been allocated to
grant management by PR and SR.



The United Nations Development Programme (UNDP) PR: overall program
management, procurement of health equipment, supplies, pharmaceuticals and non
health items.
World Health Organization (WHO) SR: management of technical component. Hold the
sub Recipient Role in this grant. Monitoring and supervision of 4 SSR’s.
4 NGO’s (SSRs): Implementation of GFATM R9 TB Grant in the service delivery area on
“Engagement of the non-NTP public and private sectors in the TB control programme”.
105
Expenditure Profile
Out of a total approved outlay of US$ 18,270,970, US$ 8,827,115 (48.3%) were allocated to
UNDP and 9,443,855 (51.7%) to WHO. Till Dec, 2011, out of a total expenditure of US$
6,484,880, WHO spent US$ 2,603,214 accounting for 40.1% of total expenditure and 27.6% of
its allocation, while UNDP spent US$ 3,881,666 constituting 59.9% of the total expenditure and
44% of its allocation. Keeping in view the low expenditure, the revised budget of US$
16,972,440 reallocated with US$ 10,221,664 (60.2%) to UNDP and 6,750,777 (39.8%) to WHO.
Till 31st March, 2012, UNDP has spent 50.1% and WHO 50.9% of their revised allocations.
NTP Infrastructure
By 2011, more than 900 staff members are working in the three tier organizational structure of
NTP, Iraq out of which 381 support NTP at 18 RCDC’s – one in each of 18 governorates which in
turn are being supported by 117 TBMU’s at District level. RCDC’s and TBMU’s are the focal
points of TB services at governorate and District levels respectively. Increasing TB diagnostic
service outlets for sputum smear microscopy to 211 in 2011 which is almost doubling from
2009 and 1093 PHCC’s providing treatment services is a commendable job. For enhancing
performance quality, 1596 health workers have been provided fresher and refresher training on
TB control and DOTS during 2011.
106
Equity
Equity is a major issue in Iraq as 23.5% of Iraqi population currently lives under the poverty line
and spending less than US$ 2 per day, despite the relatively high income of the country. R6 of
GFATM initiated penetration into some vulnerable and neglected areas and supported delivery
of quality DOTS through expansion into 3 northern governorates. These efforts resulted in
improving notification of smear positive cases in the country from 2950 in 2007 to 3150 in 2008
thereby increasing CDR from 37% in 2007 to 43% in 2008. Having realized the urgent need to
provide dedicated care for TB patients in such areas, all these socially, ethically, morally and
medically prioritized areas have not only being adequately addressed by R9 GFATM proposal
but envisaged interventions have been well knit into grants work plan, budget and monitoring
frame work. R9 GFATM support no longer aim at providing adhoc interventions to vulnerable
and high risk population but has taken the initiative towards building of systems ensuring
equity of services to all populations. To reach the unreached populations following four NGO’s
have been contracted as SSR:

The Iraqi Anti – TB Association (IATA): IATA has been contracted for providing services to
2.8 million IDP’s living in poor slums, IDP camps and collective settlements which do not
have access to ISTC10; ensure proper investigation and care for TB contacts. As a first step,
the initiative in 2011 has concluded mapping of IDP camps, collective settlements and all
other areas with a high IDP concentration14. The total number of displaced families has
mounted to 212,063. Health need assessment with a special focus on overall situation of TB
amongst IDP with addressing the gaps and in the delivery of TB case services has been
initiated through 4 IDP camps – one each in Dewaniyah, Basrah, Kerkuk and Sulamaniyah
provinces. Two well equipped mobile clinics to serve 5 disconnected geographic areas
having around 1 million of IDP population will be established. Drugs for identified TB cases
shall be arranged by IATA through NTP and a treatment supporter within the patient
community will be trained for providing support to the patient.
Non procurement of mobile van has hindered the implementation of not only the planned
activities but more or less the initiative as a whole. Health education material which also
included calendars have also not been distributed even when more than 50% of their shelf
life has expired.
The evaluation team is of the opinion that, the proposed initiative of assigning the contact
tracing to an NGO is neither sustainable nor operationally feasible and technically sound.
Contact tracing should be undertaken as a part of composite DOTS strategy.
107

The International Medical Corps (IMC): To start with, IMC shall conduct courses for TOT to
create cluster of 54 master trainers, 3 in each governorate for conducting intensified
training for different category of staff in PHC Centers. One PHCC in each governorate will be
designated as a training centre and adequately equipped with training equipment and other
necessities for providing DOTS related training to medical and paramedical staff of all health
facilities including medical schools. During 2011, 3427 health professional (more than 132%
of stipulated targets) comprising of Doctors, nurses, paramedical staff and prisons health
staff have been trained in DOTS and 545 staff in recording and reporting systems, ENRS and
project management12. The challenge now is to properly, adequately and gainfully utilize
the cadre of trained personnel.

AMAR International Charitable Foundation: is supporting the program in the area of
“Interventions among high risk group population: TB care for Marshlands Population”
(around 1.2 million) inhabitating Muthenna, Basrah and Thi-Qar governorates in Southern
Iraq. Number of PHCC’s in three Southern governorates of marshlands of Iraq have
increased from 95 in 2010 to 174 in 2011. WHV’s are required to regularly visit families to
educate them on fight against TB and have visited 54,434 families in one year. Number of
families visited as a tool to measure effectiveness of the interventions needs to be replaced
by outcome indicators like families committed to support TB patients / identifying TB
patients. Case detection trend shown in Q-1/2012 seems to be encouraging.
Two employees from London helping to administer the project appears to be a wasteful
expenditure.

Premiere Urgence (PU): is supporting the grants in the “Engagement of non-NTP Public and
private sectors in TB control program”. Non NTP public and private sector in Iraq comprises
of 289 public and 81 private hospitals mostly located in Baghdad. There is an unorganized
and disconnected network of around 4,000 private practitioners. There are no official and
formal mechanisms for public-private collaboration and partnership. Systematic and
sustained coordination amongst these both organized and unorganized, formal and
informal-TB care providers is essential to improve access to TB care; and to move towards
and beyond 70% case detection for universal access to quality assured TB care by adopting
ISTC. The challenge is to address the lack of trust and enthusiasm to engage with each other
for a common cause and accordingly formulate and operationalize the partnership policy
and strategy between NTP and non-NTP health facilities in adopting DOTS. The policy and
108
guidelines need to be developed in consultation with non-NTP partners. Beyond designating
a PPM focal person at central level, PPM focal person should also be assigned at
governorate and District levels. Partnership needs to be built on a relation of mutual respect
and trust and projected as a “win-win initiative” for all.
All referred TB suspects/patients by the non NTP public and private sector should be duly
acknowledged by NTP and after diagnosis and/or treatment completion should be referred
back with the result to the referring physician. Even during anti TB treatment, if the patient
develops any other non TB ailment, he/she should be referred back to the private practitioner
for management of that illness episode. NTP needs to remember that the patient in the private
sector is a source of money earning for the private practitioner and in any case, the referring
private Doctor should not get a feeling that his paying patient has been hijacked by NTP.
TB in Prisons
There are 64 prisons in Iraq with an average of 50,000 inmates. Prisons as the most conducive
settings for the spread of TB and prisoners amongst the high risk population is well
demonstrated by detection of 31 new TB cases in Q-4/2008 from screening of 15,000 prisoners
in 10 prisons of Iraq indicating that TB incidence amongst inmates is 4 times higher than among
general population. Treatment outcome of this cohort has been very favorable as 29 out of 31
cases completed treatment and the remaining 2 (6.5%) died. An important contributor to this
excellent outcome is strict adoption of DOT as has been observed in Al-Rahmania juvenile
prison. Till Q-1/2012, 1731 prison administrative and health staff has been trained on DOTS21.
Since, MoH is already working in the prisons, the structure and administrative context of the
prisons is well known to them and they would have also gone through the security and
administrative essentials of working in these high security areas. The evaluation team feels that
service delivery to this epidemiologically significant; vulnerable; and socially neglected
population should not be delayed for undertaking epidemiological assessment particularly
when the same can be undertaken simultaneously with the existing service delivery system.
109
Performance of NTP
From 2009 till Q-1-2012, a
Case Detection Pattern: 2009 - 2012 (Q-1)
total of 31,267 cases have
Year
NSP
Cat II
SSEP
Total
been detected, out of which
34.6% are sputum positives,
2009
3,347*
626
2,376
2,904
9,668
23.4% as sputum smear
(34.6%)
(6.5%)
(24.6%)
(30%)
negative pulmonary TB
2010
3,618
515
2,317
3,009
10,097
cases. EPTB constitute a
disproportionately
high
(35.8%)
(5.1%)
(23%)
(29.8%)
proportion of 30.8% in a low
2011
3,059
498
2,099
2,957
9,168
HIV prevalence State like
(33.4%)
(5.4%)
(22.9%)
(32.3%)
Iraq. Generic guidelines for
diagnosing common type of
Q-1/12
786
106
511
756
2,334
EPTB cases need to be
(33.7%)
(4.5%)
(21.9%)
(32.4%)
formulated with emphasis
10,810
1,745
7,303
9,626
31,267
on laboratory confirmation
of the diagnosis as far as
(34.6%)
(5.6%)
(23.4%)
(30.8%)
possible. It is interesting to
* Figure in parenthesis are %ages of total cases
note
that
the
case
distribution pattern over the years has been almost constant. There is a great variation in
performance between different governorates and possibly Districts within the governorate.
110
Case detection during 2009 – Q-1/2012
2009
Out of a total of 9,668 cases detected in Iraq during 2009, NSP constitute 34.6%; sputum smear
negative 24.6% and EPTB 30%. Sputum not done cases constituted 4.4% of PTB cases. Eleven
governorates had a total case detection rate of > 70% and 9 governorates had NSP case
detection rate of > 50%. Baghdad detected highest number of NSP (856), sputum smear
negative (425) and EPTB (755) cases accounting for 25.6%, 17.9% and 26% respectively of type
wise total cases detected in Iraq in 2009. At the same time, Erbil was the lowest contributor in
NSP cases (47); Duhok (51) in pulmonary sputum smear negatives and Kerkuk (63) in EPTB cases
accounting for 1.4%, 2.2% and 2.2% respectively of total type wise cases detected.
Out of a total case
detection of 2,420 in
Baghdad in 2009, NSP
cases accounted for
35.4%; sputum smear
negatives 17.6% and
EPTB cases 31.2%.
Sputum not done cases
accounted for 5.8% of
all pulmonary TB cases
in this governorate.
From the last more
than 3 years, Baghdad
has consistently been
contributing 1 out of
every 4 cases being
detected in Iraq. On the other hand, Baghdad has also a dubious distinction of being a
governorate where %age of sputum not done amongst all PTB cases notified has been gradually
increasing. In 2009, it was 5.8% which rose to 7.3% in 2010 to 7.5% in 2011 and to 7.9% in Q1/2012. The corresponding figures at the central level have also been increasing over the years
and are 4.4%, 5.5%, 6.1% and 6.8% from 2009 to Q-1/2012. In fact, in most of the governorates,
a similar situation is observed which is an area of serious concern. In a good performing
111
programme, except for small children who cannot bring out sputum, all PTB suspects must
undergo sputum examination.
2010
NSP (3,618) accounted for 35.8%; pulmonary sputum smear negative (2,317) for 23% and EPTB
(3,009) for 29.8% of total TB cases (10,097) detected in Iraq during 2010. Case detection rate
for new cases of all forms has been 53% and NSP case detection rate as 46%. As compared to
2009, total case detection in 2010 has shown a marginal increase of 4.4%; NSP cases by 8.1%
and; EPTB cases by
3.6%.
NSP
case
detection
rate
has
remained constant at
46%.
Number
of
governorates with >
70% TCDR have reduced
from 11 in 2009 to 9 in
2010 and those with >
50% of NSP case
detection rate have
remained constant at 9.
Pulmonary
sputum
smear negative cases
remained
almost
constant. Sputum smear
not done cases increased by 29.6% from the previous year and accounted for 5.5% of the total
pulmonary TB cases notified. Baghdad accounted for 24.2% of total case detection of Iraq;
24.4% of NSP case detection; 16.1% of pulmonary sputum smear negative cases and 23.6%
EPTB cases. Out of the total 2,440 TB cases detected in Baghdad, NSP constituted 36.2%,
sputum smear negative 15.3% and EPTB 29.1%. Diagnostic sputum examination was not done
on 6.9% of PTB cases initiated on treatment in 2010 in Baghdad. Duhok detected the lowest
number of total TB (218) and EP (64) cases; Muthena the lowest number of NSP cases (61); and
Najaf the lowest number of sputum smear negative cases (27). It is interesting to note that ThiQar contributed 6.9% and Muthenna around 2.4% and Duhok around 2.2% to total case
detection of the country both in 2009 and 2010.
112
2011
During 2011 in Iraq, a total of 9,168 TB cases were detected indicating a total case detection
rate of new cases of all forms as 47% and NSP case detection rate of 38%. NSP constituted
33.4% and sputum smear negative pulmonary TB cases 22.9% of total case detection. Out of a
total of 6,211 pulmonary TB cases, no diagnostic sputum examination was undertaken on 364
(6.1%) cases which increased by 0.6% as compared to 2010. Thi-Qar (20), Baghdad (18), Wasidit
(11), Basrah (8) and Diala (8) governorates constitute 65 out of 83 sputum not done cases
reported in Q-1/11. Total case detection in 2011 decreased by 9.2%; NSP cases by 15.5%; and
pulmonary sputum smear negative cases by 9.4%. Total and NSP case detection rate has
continued to fall and stood at 61% and 38% respectively. Number of governorates with > 70%
TCDR reduced from 9 in 2010 to 5 and those with > 50% case detection rate amongst new
sputum smear positive has come down to 3 as compared to 9 in 2010. Analyzing the reasons for
the decline in case detection in 2011, revealed that all passively reporting adult new OPD
patients are not being actively screened for 2 weeks cough which is supported by the fact that
suspects identified are much less than the anticipated at least 2% of the general OPD
attendance. In addition, complacency seems to be playing its part in this decline and needs to
be arrested immediately.
In spite of Iraq being a low HIV prevalence country, EP cases accounting for 32.3% of total cases
is a matter of concern requiring an in-depth analysis. While Babil and Anbar governorates
reported more than 40%; Najaf, Thi-Qar, Kerbela and Misan governorates reported more than
35% of their total case detection as EPTB cases.
It is good to note that Sulaymania, Muthenna and Ninewa governorates undertook diagnostic
sputum examination in 100% of their PTB cases. In Diwanyiah, Anbar and Kerbala, sputum not
done constituted less than 2% of all pulmonary TB cases initiated on treatment. Except for
children who are not able to produce sputum, as a matter of rule, all PTB suspects must
mandatorily undergo sputum examination.
113
Q-1/2012
The pattern of overall case detection in Q-1/2012 continues to be the same as in previous years
in so much so that NSP cases constitute 33.7%; sputum smear negatives 21.9%; and EPTB 32.4%
of the 2,334 total cases detected. Case detection rate of all forms of new cases is 46% and that
of NSP cases 37%. However, the %age of sputum not done cases amongst PTB cases increased
from 6.1% in 2011 to 6.8% in Q-1/2012. Similar is the status of NSP case detection rate which
has shown a decline of 9% from 46% reported in 2009. Similarly, governorates with > 70% total
case detection rate have come down from 11 in 2009 to 4. There is not even a single
governorate in Q-1/2012 in which NSP case detection rate is > 50%. Baghdad continues to
contribute highest number of all form of TB cases and accounts for 24.7% of NSP cases; 26.9%
of EPTB cases and 16.2% of sputum smear negative cases amongst total case detection in Iraq
during Q-1/2012. Basrah needs to step up NSP case detection and reduce number of “sputum
not done” cases (10% of PTB notifications) which by itself will enhance NSP case detection rate.
Erbil, Duhok, and Diwanyiah governorates need to enhance their NSP case detection rate.
Duhok governorate is the lowest contributor to the country’s NSP, EP and total case detection;
and Najaf in pulmonary sputum smear negatives for Q-1/2012.
Anbar, Najaf, Misan, and Babil governorates reported more than 40% of their total cases
detected as EPTB cases. Sputum not done constituted 16.4% of PTB cases notified in Erbil. On
the contrary it is good to note that diagnostic sputum smear examination was undertaken for
all pulmonary TB cases notified in the governorates of Muthenna, Kerkuk and Sulaymania
during Q-1/2012.
114
Treatment Outcome of Cohort of 2009 – Q-1/2011
2009
Out of 9,668 cases
detected in 2009, overall
treatment success rate has
been 89.4% with a default
rate of 6%. Death rate has
been around 2.8%. While
Misan,
Ninewa,
Suleymania,
Muthenna,
Dewaniya
and
Diala
governorates demonstrate
a success rate of 96% and
above, Erbil governorate
has a treatment success
rate of 66% and default
rate of 26.5%. Baghdad
also showed a high default rate of 11.8%. Babil has shown high death rate of 7.5%.
Out of all the governorates, Baghdad had the lowest cure rate (56%) and treatment success rate
(82%) amongst NSP cases and the highest completion (25.4%) and default (11.6%) rates. Duhok
(24.6%) and Erbil (23.4%) also had a high treatment completion rate indicating that large
number of patients do not come for giving sputum on completion of treatment. Field visits have
shown that patients during CP are given medicines for one month and even the relatives are
also given drugs almost on regular basis.
Beyond non adoption of
community DOTS, one of the
important reasons for high
default rate in Erbil is use of
X-ray as primary diagnostic
tool as a result of which non
115
TB patients initiated on treatment stop taking treatment after some time and add up to the list
of defaulters. The evaluation team came across one such female patient who even informed
the staff that she has discontinued the treatment as she is not a case of TB and has
unnecessarily been put on anti TB treatment.
2010
During 2010, out of 10,097 registered cases only 9,955 have been evaluated. Overall success
rate has been 89%. Erbil governorate which has the lowest success rate of 71% needs to learn
from successful experiences of Diala (99%), Ninewa (98%) and Suleymania (97%).
Performance of Erbil and Baghdad has been poor, with Baghdad showing a cure rate of 59.9%,
treatment completion rate of 23% and default rate of 10.9%; and Erbil showing a cure rate of
44.8%, treatment completion rate of 26.9% and default rate of 23.9% amongst NSP cases. High
treatment completion and default rates indicate poor rapport between the patients and health
providers indicating that DOT is not happening and default retrieval mechanism is not
operational.
Cure rate amongst Cat II cases has been at dismally low rate of 36% while success rate is 76%
which is because of issuing of drugs for longer period. “Cure rate is the critical indicator of the
quality of the programme” needs to be adopted by NTP.
Q-1/2011
During Q-1/2011, out of a
total of 820 NSP registered
cases, 686 had been cured
giving a cure rate of 83.6%
and treatment completion
rate
of
5.4%.
Diala
governorate
has
demonstrated an excellent
116
performance with 100% cure rate amongst its 53 NSP cases. In fact, Baghdad with 68% cure
rate and Nejef with 64% cure rate has brought down the country’s cure rate amongst the
cohort of Q-1/2011. One of the important observed reason for low cure rate and high
completion rate has been issuing of drugs even to the relatives of the patient and that too for
long durations. In Nejef, though numbers are small, death rate of 14.3% is high and needs to be
investigated. Important reasons for high death rate within Iraq context which need to be
addressed include low community awareness leading to patient delay in reporting to health
facilities in a moribund stage, non enforcement of DOT and high tobacco consumption.
During Q-1/2011, 2330 detected TB cases had a treatment success rate of 88% with Thi-Qar
(98%) and Suleymania (98%), Ninewa (97%), Dewaniya, Diala, Muthenna (96%). During the
same quarter, Cat II cases had a poor cure rate of 41% with success rate of 71% and default rate
of 16.4%.
Comments on Case Detection and Treatment Outcomes
During Q-1/2012, Thi-Qar as the best performer with 49% NSP CDR shows that Iraq is miles
away from achieving its CDR target of 70% by 2014. The programme urgently needs to
consolidate its key function of removing infectious TB patients from the pool of prevalent TB
cases transmitting tuberculosis. Team noted some degree of complacency in the efforts to
expand case-finding to reach undetected cases as is also reflected from the declining NSP case
detection rate which is 37% in Q-1/12 against 46% in 2009 and 38% in 2011. Such a
performance throughout the country is a matter of concern.
The
most
immediate
requirement for NTP, Iraq is
to re-emphasize adopting
DOTS as its “policy strategy”
for
TB
control
with
dedicated commitment for
its
comprehensive
implementation at all levels
which requires extensive
117
advocacy by all concerned with a lead from WHO. Likes of Doctor in Erbil governorate who
refuses to accept DOTS, LT in Erbil City Center who refuses to perform his duty of sputum
examination on account of a self created danger of getting TB while performing his duties or
the administrator of Koya District Hospital not wanting DOTS or a Doctor at Baghdad who
reportedly got himself transferred from MDR-TB laboratory for fear of contracting TB may need
to be administratively dealt with. Such a situation in one of the States of India during early days
of its DOTS implementation resulted in skyrocketing performance after stringent administrative
measures.
Cough symptomatics screening should be conducted at the registration desk or at the patient
waiting area, which will help in fast-tracking sputum examination as well as limiting the
possibility of nosocomial transmission to other OPD attendants and health facility staff. NonNTP public and private hospitals need to be systematically involved and a referral policy defined
and implemented. Contrary to consistently high cure rate of NSP cases, cure rate of infectious
retreatment cases has been considerably less and stood at 41% with 16.4% default rate
amongst Q-1/2011 cohort. Emphasis need to be made to use cure rate as quality treatment
indicator of infectious cases.
Sputum not done cases as numbers and as percentage of pulmonary TB cases is showing an
increasing trend. In Q-1/12, out of 1505 pulmonary TB cases, no sputum examination was
undertaken on 102 accounting for 6.8% of PTB cases. Sulaymania, Muthenna and Ninewa
governorates in 2011 have undertaken diagnostic sputum examination on all their pulmonary
TB notifications. Similar notifications have also been made by Muthenna, Kerkuk and
Sulaymania governorates in Q-1/2012, Ninewa, Anbar and Sulaymania governorates in 2010
and Anbar and Kerbela governorates in 2009. “Sputum not done” cases should not be
registered under the pulmonary sputum smear negative cases. The programme should develop
a vision of dispensing away with this column and practice of not undertaking sputum
examination in all pulmonary TB suspects in foreseeable future. In this context, training
especially of Doctors need to focus on sputum microscopy as the gold standard for diagnosis of
PTB and X-ray chest as a sensitive tool of diagnosing PTB picking up to 70% false positive cases.
Importance and reliability of sputum microscopy also needs to be marketed to the community
for their acceptance.
118
Large number of sputum positive patients are not getting their sputum examined at the
completion of treatment. Cure rate of Cat II cases amongst Q-1/2011 cohort is 41% against
success rate of 71%. One of the important reasons is non adoption of DOT as a result of which
rapport between patient and health worker is not built. DOT component till now has been
neglected by NTP as “training of treatment supporters” is the only activity in ACSM with Zero
budgetary allocations. In some governorates the patients are dispensed TB medicines through a
pigeon hole under the window after the patient speaks through a microphone. There is no
concept of using community members or cured TB patients as DOT provider. Cured patients
would be successful DOT providers as they have felt the pain as a patient and have waded
through the constraints of NTP. Anybody and everybody can be a DOT provider provided he is
agreeable for the same, is acceptable to the patient and answerable to the health system. A
patient - centered adherence strategy, including supported treatment agreeable to the patient
is the bet for successful treatment completion and for limiting development of drug resistance.
NTP needs to promote the original proposal of training around 10,000 treatment supporters
every year which will yield high programme dividends in reducing default and enhancing
contact tracing. Technical support from external consultants with experience of running
successful TB programmes would improve programme performance.
MDR-TB
As per WHO, number of confirmed cases of MDR - TB in Iraq are 1108. Percentage of MDR - TB
among new cases in Iraq is estimated to be 3% and amongst re-treatment cases 38%. GLC has
now approved the existence of the functioning system of programmatic management of drug
resistant TB (PMDT) in Iraq. NRL has met the bench mark by passing the panel test on culture
and DST conducted by SNRL, Egypt. Annual quality certification through panel testing for NRL by
SNRL and for private laboratory in Erbil needs to be ensured. Four laboratories at governorate
RCDC’s in Basrah, Najaf, Babylon and Ninewa equipped with culture examination have been
established and staff trained.
During 2011, 50 cases of MDR - TB were enrolled on ambulatory regimen. Age sex distribution
of the cases show that of 25-44 years age group account for 70.5% of these MDR-TB cases; 30
are males, 20 females. As on May, 2012, three died, 1 defaulted and 46 are continuing
treatment out of which 31 converted in culture examination.
119
For the diagnosis of MDR-TB cases, a system for case finding needs to be established which will
require at least 950 culture and DST tests to be performed to identify MDR-TB cases. This
envisages quality system in laboratories and transportation of samples to RCDC’s at Basrah,
Najaf, Babylon and Ninewa which is yet to be established. Second cohort of 65 MDR-TB patients
identified by the end of 2011, could not be initiated on treatment because of non availability of
SLDs. Two amongst these 65 MDR-TB patients have already died14. An ex-army hospital in the
city of Sulaymania in the Kurdistan Autonomous Region is being rehabilitated to become the
National MDR-TB Hospital in Iraq with a capacity of 30 beds. Another 12 bedded hospital in
Baghdad has also been reportedly rehabilitated for the purpose.
MDR-TB is a man-made phenomena and the only way to contain MDR - TB is to stop producing
it. This is amply proved by the fact 44% of 50 MDR-TB cases on treatment are from Baghdad. A
detailed analysis of governorate wise treatment outcome of NSP and all sputum smear positive
cases of the cohort from 2009 to Q-1/2011 show that against 5.5% default rate observed on the
cumulative treatment outcome of NSP cases in Iraq, Baghdad accounted for 11% default rate
and for all sputum smear positives during the same period, the figures are 6.5% for Iraq and
12.9% for Baghdad. Similar pattern is observed in the notification of retreatment cases from
2009 to Q-1/2012. Cure rate amongst all Cat II in Iraq is 36% against 29% in Baghdad amongst
cohort of 2010 and for 2009 cohort, it is 57% for Iraq and 39% in Baghdad and for Q-1/11 the
same is 41% for Iraq and 28% for Baghdad. It is in this context that using cure rate as an index of
quality implementation of treatment inputs is being advocated. Unless urgent interventions are
taken to improve treatment outcome, Baghdad will continue to be the “capital” of MDR-TB.
Objective two of R9 approved proposal is “Ensure universal access to diagnosis, treatment and
care for drug resistant TB (DR-TB)” when NSP CDR of the country is less than 50%. It is good that
the country has maintained 85% TSR amongst NSP cases (though low cure rate amongst Cat II
cases) since long but Iraq is miles away from universal access to DOTS. In technically ideal
circumstances, the objective of universal access to DOTS should precede and receive priority
over universal access to MDR-TB. This requires intensive efforts by NTP, WHO and UNDP as
with only one year left, out of US$ 13,362,502 earmarked for DOTS related activities, a mere
41.7% amounting to US$ 5,575,949 has been spent. On the contrary, 83% of the budget of US$
797,681 on the diagnosis of MDR-TB has been spent till 2011. Increased CDR and successful
treatment of detected cases will reduce TB transmission in health care settings. Beyond
benefiting masses, it will also set up a system of diagnosis and successful management of TB
120
cases within the existing health care infrastructure which would subsequently be used for MDR
- TB.
Involvement of Medical Schools
Though attempts are being made to introduce DOTS in curriculum of 23 medical, 23 nursing
and 5 pharmaceutical schools in 18 governorates, the first step needs to be to promote
adoption of DOTS by medical schools including the teaching hospitals attached to them and
advocacy of DOTS by these 3 categories of professional institutions in Iraq. Job responsibilities
of the focal point appointed in teaching hospitals need to be defined. Starting with Doctors,
medical and paramedical staff needs to be trained in their respective field of operation. A core
group of senior medical school teachers should be constituted to design a road map for
involvement of medical schools in DOTS. The first evidence of their acceptance of DOTS would
be its adoption in their clinical practice at teaching hospitals. No doubt that involvement of
medical schools in DOTS is a difficult task but is doable and has been successfully accomplished
in many countries across the globe wherein returns from investments in non programme
providers including medical schools have been proportionate to time, efforts and human and
financial resources expanded.
Banning Sale of anti-TB drugs in Private Sector
Government of Iraq has taken a landmark initiative in banning the sale and storage of anti TB
drugs in the private pharmacies from 2011. However, the evaluation team during a visit to 18
pharmacies in Erbil found that most of the anti TB drugs are freely available. Coordinated
efforts need to be made amongst NTP and drugs department on a war footing for effective
implementation of the ban order pertaining to storage and sale of anti TB drugs in the private
sector.
121
TB – HIV
Out of 2258 TB cases tested for HIV, only one was found to be positive32. Though Iraq is a low
HIV prevalence State but this does not call for complacency because of high risk for
development of HIV epidemic. Marginalized population including prisoners being a high risk HIV
group should be especially cared for. Peer education should be used to detect affected
populations, build bridges and provide a comprehensive package for identified population.
Districts / governorates with disproportionately high incidence of smear negative pulmonary TB
/ EPTB and those with high case fatality rate amongst TB patients, particularly amongst sputum
smear negatives, need to consider HIV as one of the important possible reasons.
ACSM
During visit to the different governorates, the team had mixed experiences in this important
area with one commonality of lack of bill boards / hoardings at the health facilities along with
other mass media approaches. This is well supported by the fact that out of budgeted US$
122,500 for health information dissemination through mass media and print media, not even a
penny has been spent in last 15 months implementation of the grant. While, some HE activities
were observed in health facilities of Duhok governorate, Sumail and some other Districts, no TB
related IEC activities were found in all the health facilities visited in Erbil except two mutilated
banners of World TB Day 2010 and 2011 at the Erbil governorate RCDC. Some patients
interviewed in Erbil did not even know the total duration of treatment that they were required
to take, while in Duhok governorate patients were reportedly aware of it. Awareness on
contact examination was also a mixed bag. Out of more than 100 patients in Erbil, not even one
brought the contacts for assessment. Low priority to IEC activities appears to be an important
deterrent in enhancing community knowledge on TB which has been found deficient by even
KAP studies. This is supported by the fact only US$ 119,725 out of budget allocation of US$
635,304 constituting 18% of budget allocations has been spent on ACSM till December, 2011.
National Health Communication Strategy needs to be formulated and reflected at governorate
and District levels. The twin initiatives of rapid scale up of ACSM activities to improve TB
awareness in the community and to reduce the stigma need to be prioritized. Civil society
needs to be engaged for promoting the concept of empowering patients and communities to
122
play a leading role in TB control. NTP should set the ways in which TB patients both cured and
current, communities especially the poor, health care providers and governorates can work as
partners and enhance the effectiveness of health services in general and TB care in particular. A
cured patient is usually a willing and an effective communicator and can wield significant
influence in the community. NTP should be made a people’s movement encouraging
convergent action on awareness creation on case detection and treatment completion by
formal and informal groups at village, PHCC, District, governorate and central level. This will
create demand for TB services which will be a step towards much needed social marketing of
DOTS at governorate, District and village levels.
Stigma and Discrimination
Stigma and discrimination does remain an important factor in being a barrier to case detection
and treatment adherence and the same appears to have been worsened by the behavior and
attitude of the staff / system. Evaluation team in Erbil saw health workers going around the
health facilities with mask and TB patients being heard in the pharmacy through microphone
and; drugs being dispensed through a small pigeon hole below the window in both Erbil and
Duhok governorates. The treatment given to the evaluation team at the patient’s house at
Erbil, Najaf and Basrah governorates strengthens the belief that stigma barrier can be
demolished through demonstrated concern for the patient. Starting a “Cured TB patient Club”
at the governorate level demonstrating the normal life being led by cured TB patients will go a
long way in reducing stigma. Cured patients should be encouraged for disseminating their
success stories in the community meetings and through electronic media.
One of the senior Doctor in Erbil:
“_________But, more important than stigma is discrimination of patients by community,
especially health care providers. And this has more effect on patient’s compliance with therapy
than the stigma itself. Because when a patient is seeing that a health care provider is avoiding
him or her, he will become reluctant to obey their recommendations. And subsequently, he or
she will refuse to bring family members for testing and so. ________________we feel strongly
that cause of defaults is related to discrimination more than stigma.”
123
Monitoring and Evaluation
National TB Control Programme – Iraq has developed a compact National M&E plan27 for 20132015 covering all aspects of NTP performance in Iraq and has also enlisted a set of indicators on
the impact / outcome as well as on output and process levels. TB data is recorded at all TB
service delivery outlets using standardized templates and collection tools which ensures
uniformity facilitating compilation and analysis. During field visits by the evaluation team, data
collection and maintenance of TB registers at District and governorate level appeared to be
complete and reflect the reality except a few exceptions, the notables being non marking of
contact tracing and drugs issued on the patient treatment card.
Due to shortage of stationery, old forms and registers were being used in some governorates.
In fact, old sputum examination forms being used indicated three sputum specimens which not
only created confusion amongst patients but also affected the creditability of the programme.
Despite noteworthy performance in generating and disseminating a large volume of
programme data, from an operational perspective, the NTP reporting system is not utilized for
relevant programme action and planning. Key supervisory positions at District and governorate
levels demonstrate limited insight and capacity to conduct evidence-based problem-solving at
District and governorate levels. NTP needs to invest further in capacity building to perform
evidence-based problem-solving and translate data into an effective programme action.
Internal systems for monitoring and supervision in Erbil though in place lacked commitment to
and quality of monitoring was weak. There was no feedback and supervisory meeting
discussions lacked instructive information to enhance performance. There was no mechanism
for documenting corrective actions to ensure accountability.
Performance indicators are target-oriented and primarily focus on detection and treatment
outcome of NSP cases (70/85 by 2014), without due attention to programme management,
case-finding and case-holding processes. Transition from target-focused monitoring of
performance to analysis of trends in key process and outcome indicators at District and
governorate levels needs to be made in order to improve performance. Central level should
challenge well performing governorates to set more appropriate goals based on local trends in
performance. There is very limited engagement with the larger health system in public sector
124
like 289 public hospitals including teaching hospitals and prisons and in private sector for the
collection of relevant performance based indicators. Governorate level committees to develop
appropriate process indicators for local planning and monitoring to augment national targets
should be established.
Entire process of supervision needs to be reviewed tailoring it with need more than routine.
Low performing governorates should be prioritized for supervision which should not be a mere
“visit” or “policy”. Supervision has to be a blend of education, coordination, facilitation,
guidance and motivation comprehensively aiming at performance enhancement. Mechanism to
evaluate the outcome of the visit should be well defined in terms of outcome indicators.
Based on quarterly reports, central level should compile, a one pager “newsletter” giving
governorate-wise 3-4 key performance indicators which should be circulated to all concerned in
Iraq and KRG including senior officers in MoH. Low performing units should be marked red. This
will bring an atmosphere of appreciation for good performers and concern for poor performers
who will make all attempts to get rid from the red mark in a publicly circulated document.
Central level needs to comprehensively analyze governorate wise performance every quarter
through the quarterly report. Highlights of these findings along with specific advice for
performance enhancement should be sent in a time bound manner to all governorates. Sending
feedback should invariably be followed by the quarterly review participatory meeting. Review
meeting should also be utilized for experience sharing among the governorates.
Drug Procurement, Quality Control and Distribution
During field visits, drug shortages have been observed and reported from many governorates.
Government has well realized that in the absence of adequate drug management capacity,
even if Iraq has a regular supply of drugs, it would not be able to maintain much needed uninterrupted drug supply for TB patients. With proposed rapid expansion of TB programme
network, the Government is committed to build local drug management capacity.
125
Because of its multifaceted responsibilities, NTP should not be burdened with drug
procurement. Procurement of drugs should be contracted to an independent procurement
agency away from all direct and indirect influences. Overseeing distribution of stocks upto
governorate level should be the responsibility of NTP and distribution to TBMU’s / PHCC’s
should be the governorate’s responsibility. NTP should support governorates in capacity
building and logistic support for drug storage at governorate level and distribution at peripheral
level. National ware house should be strengthened.
An independent agency different from procurement agency should be hired to ensure quality of
drugs at different stages; starting from its arrival in the country till such time they are
consumed by the patient. National ware house should ensure that supplies with less than 9/10
of shelf life are not accepted in the country. In fact, the total consignment should be split in two
installments to get an enhanced shelf life. The present system of procurement of Rifampicin
with 2-3 years shelf life should be changed to procurement of Rifampicin with only 5 years shelf
life.
Operational Research
Mid Term Strategy for National TB Control Programme in 2009-2011 had laid down the
following targets in relation to Operational Research:
1. By mid 2009, a training needs assessment in research will be completed, and focal
persons from MoH, NTP and academic institutions will be enabled to conduct basic
operational research on DOTS strategy
2. By end 2009, an operational research policy and technical guidelines for the health
sector will be endorsed and the NTP research plan for DOTS strategy approved
3. By end 2009, funding for operational research proposals based on NTP research plan
will be secured.
However, none of the above stipulated targets could be achieved.
126
National M&E Plan (2010-2015) indicates following Operational Research studies to be
conducted each year. These studies will be directed towards:
1. Delivery of strategic information that identifies challenges and room for improvement of
the overall and component specific implementation of the TB control program
2. Testing of approaches and provision of solutions to specific challenges / problems at the
national, intermediate and peripheral levels
3. Assessing impact of TB control activities in particular with reference to the MDGs
4. Measuring cost-effectiveness of the program
NTP has established an Operational Research Board. As a first step, National guidelines for OR
need to be developed. Guidelines should include a clear cut process for review and funding. A
full time expert for OR capacity building should be engaged who should assist the governorates
to formulate and undertake at least one significant OR activity annually under central
leadership. Medical colleges and other TB related institutions should also be made a part of OR
policy. OR should basically aim to generate more information and evidence to effect necessary
changes in policies and management practices of NTP to make TB control more effective and
sustainable. While some priorities can be listed by central and the governorate levels keeping in
view that important proposals usually emerge from field units involved in service delivery.
Research findings should get translated into improved policies and procedures.
Beyond the 8 already accepted proposals, the evaluation team considers following as some of
the critical research activities for the NTP to be completed within next 3 years:
1. Health seeking behaviours and reasons for TB diagnostic delay in vulnerable populations
including IDP’s, marshlands and urban slum dwellers
127
2. Understand the reasons for large number of “sputum not done cases” initiated on
treatment and find out the possible solutions which could be implemented ensuring
that every suspect of PTB undergoes the prescribed diagnostic algorithm
3. Understand the reasons for diagnosed infectious TB patients not bringing their close
contacts for evaluations and suggest methods ensuring 100% screening of contacts of all
infectious cases diagnosed in NTP Iraq
4. Create a website for NTP Iraq which in addition to the program updates should include a
list of approved proposals for OR; the sites at which they are being carried out; and the
summary outcomes of completed studies so that OR activities can be disseminated
irrespective of the success or failure of the researcher in getting the research published
in a peer – review journal. The study protocol itself should also be placed in the website
so that other sites using the same protocol can carry out similar studies if necessary.
This will enhance participations in OR studies
5. In collaboration with other programmes / initiatives, conduct research to understand
and address the role of social and clinical risk factors for TB, including malnutrition,
smoking, diabetes and indoor air pollution.
128
RECOMMENDATIONS
Political Commitment and Advocacy; GFATM Implementation Methodology; Value for Money; Case detection;
Facilitate patient in taking treatment; Engaging all providers; TB/HIV Interventions; Equity, Gender and Social
Issues; MDR – TB Management; Infection Control; Drug Regulation, Procurement, Supply, Quality Control and
Distribution; Recording, Reporting, Monitoring, Supervision and Evaluation; Operational Research
The evaluation team proposes that Government of Iraq considers the following main
recommendations for taking forward the next phase of NTP, Iraq. The donor agencies of the
programme may like to refer to these recommendations, as well as the full report in their
respective review missions in the future.
Political Commitment and Advocacy
Low priority to IEC activities appears to be an important deterrent in enhancing community
knowledge on TB which has been found deficient by even KAP studies. This is supported by the
fact that only US$ 119,725 out of budget allocation of US$ 635,304 constituting 18% of budget
allocations have been spent on ACSM till December, 2011. More shockingly, out of US$ 122,500
budgeted for educational activities like mass media and printing of educational material, not
even a penny has been spent.
1. To achieve the targets of 70% of infectious TB case detection and cure at least 85% of those
cases by 2014, the most immediate requirement for the country is to reemphasize adopting
DOTS as its “policy strategy” with extensive advocacy lead by WHO
2. National Health Communication Strategy needs to be formulated at central level in
consultation with stakeholders and reflected at governorate and District levels
3. Social mobilization activities need to concentrate on achieving universal awareness of the
right to, and availability of, free TB treatment and care at a convenient place. This will
create demand for TB services which will be a step towards social marketing of DOTS
129
4. Mass media activities including short movies/messages from celebrities promoting TB
control should be regularly telecast. Potential of cured TB patients particularly females
should be recognized and promoted as one amongst key interventions
5. The concept of IEC being a process – rather than product should be used in development of
IEC strategy for IDP’s and Marshlands
6. NTP should set the ways in which patients, communities, health care providers and
governorates can work as partners making NTP a people’s movement encouraging
convergent action on awareness creation on case detection and treatment completion by
formal and informal groups at village, PHCC, District, governorate and central level
7. Health facilities should break the stigma barrier by treating patients like a VIP of the
programme
8. Cured TB patients’ club demonstrating normal life of cured TB patients at governorate and
TBMU’s level will enhance treatment adherence and reduce stigma
9. Existing 15 pager patient education guide needs to be trimmed promoting its reading by the
patients. As an example following one pager containing well adopted brief and crisp
messages preferably in pictorial form may be considered to be developed in local language:
a. Don’t feel stigmatized for having got TB. TB affects all – rich and poor; affluent and non
affluent alike
b. Any cough of more than 2 weeks could be TB. Get your sputum examined
c. TB is curable; complete prescribed treatment. Don’t make it incurable by interrupting
treatment
d. Follow the advice of your Doctor and get all your contacts examined at the TB clinic
e. All TB related services are available free of cost.
GFATM Implementation Methodology
Amalgamated R6 and R9 GFATM support as SSF for US$ 18,270,970 is being implemented by
UNDP as PR and WHO as SR.
1. The concept of current implementation modality of WHO as sole SR may need to be
relooked to the extent that WHO should confine itself to lead the “technical partner” role.
2. Out of a total expenditure of US$ 7.84 million, WHO and UNDP overhead charges and other
administrative costs account for 22% which needs to be reduced substantially
3. Physical location of PR and SR insulate them from the field operations which are the actual
service delivery outlets. Their functioning from Amman need to be relooked
130
4. Implementation and monitoring of all programme activities need to be assigned to NTP.
Technical aspect of monitoring outcome should be monitored by WHO and administrative
and financial aspects of monitoring by UNDP.
Value for Money
Findings of the evaluation team are well collaborated with the analysis undertaken in “Value for
Money” as well as with the expenditure incurred. Important recommendations emerging
thereof are as follows:
1. During R6 support, more than 75% of the budget had been spent on “enhancing services to
ensure quality DOTS” as a consequence of which 19,765 cases have been detected in 20092010. Evaluation team observed some degree of complacency in efforts to expand case
detection network to reach undetected cases which is well supported by the fact that in SSF
only 39.7% of budget has been spent on “expansion of quality assured TB diagnostic and
treatment services” as a consequence of which NSP case detection rate decreased from
46% in 2010 to 37% in Q-1/2012. Intensive efforts need to be made to fully implement all
nine components of this SDA in letter and spirit in all 18 governorates.
2. ACSM activities in general and IEC activities in particular have been relegated a back seat
and for the entire four year of GFATM support (2008-2011), expenditure on communication
materials has been petty 15% of the allocated budget in this category. Evaluation team did
not notice any mass media activity which is equally well supported by Nil expenditure
against a budget allocation of USD 122,500. In fact, this issue was well highlighted by the
team leader during post field VCT debriefing of NTP, UNDP and WHO. Incidentally, by then
expenditure figures were not made available to the evaluation team. ACSM needs to be
prioritized to get long term dividends.
3. Absence of community based DOTS and DOT is well reflected by low case detection and low
cure rate among CAT II cases. There are no DOT providers from the community including
cured TB patients. All this is supported by Zero budgeting of training of treatment
supporters. This activity being the backbone of DOTS urgently requires appropriate
budgeting and its utilization.
4. An expenditure of US$ 3.7 million on planning, administration and overheads being 25.6%
of total cumulative expenditure needs to be substantially reduced and so is the expenditure
on foreign travels.
131
5. Non procurement of mobile vans has put the entire gamut of activities supporting TB care
for IDP’s in jinx. Comprehensive DOTS services even in just five out of total 64 prisons have
yet not begun. As a consequence of all these, expenditure till 2011 under SDA 1.2
“Interventions among high risk population groups” has been only 6.4% of the budgeted
amount accounting for 1.9% of total expenditure.
Case detection
During Q-1/2012, Thi-Qar as the best performer with 49% NSP CDR shows that Iraq is miles
away from achieving its CDR target of 70% of infectious TB cases by 2014. Team noted some
degree of complacency in the efforts to expand case-finding network to reach undetected cases
which beyond declining case detection is supported by the fact that less than 40% of the
budgeted expenditure of US$ 7,482,351 on “expansion of quality assured TB diagnostic and
treatment services” has been incurred till 2011.
1. NTP should promote in its programme policy the concept of universal access to ISTC. All
public and private hospitals should be systematically involved in DOTS and a well defined
referral policy formulated and implemented
2. Promote sputum microscopy as the primary diagnostic tool in pulmonary TB suspects with
X-ray chest as a supporting tool
3. Screening cough symptomatics should be undertaken at the registration desk or at the
patient waiting area. The symptomatics should be actively searched amongst all patients
attending general health facilities including those owned by non NTP public and private
sectors. Number of identified symptomatics should be correlated and monitored with their
daily adult new patient OPD attendance
4. Proposed initiative of assigning the contact tracing to an NGO is neither sustainable nor
operationally feasible and technically sound. Contact tracing should be undertaken as a part
of composite DOTS strategy
5. To reduce high %age of “sputum not done cases”, except for children, no pulmonary TB
patient should be placed on treatment unless sputum examination has been undertaken
6. Training manuals and modules of all categories of professionals need to be updated
tailoring them with field realities and monitoring outcomes
7. TBMU’s should be established in each of the 124 Districts. Microscopy centers should
immediately cover all TBMU’s. Keeping in view persistently low case detection rate, the
target of opening 321 quality assured TB laboratories by the end of 2015 needs to be
preponed. For difficult and hard to reach areas, norm of 100,000 populations for a
microscopy center should be relaxed ensuring that patient does not lose his day’s wages for
132
getting his sputum examined. Till such time, additional microscopy centers are established,
the PHCC’s should function as sputum collection centers with established working
relationship with the nearest diagnostic center
8. Monitor at TBMU level the trend of TB suspect examination and proportion of initial
defaulters on a quarterly basis in order to promptly identify and pursue opportunities for
improving case finding
9. Laboratory technician should demonstrate to every suspect the correct method of
producing sputum; and complete contact details of all suspects undergoing sputum
examination should be recorded in the laboratory register to facilitate retrieval of initial
defaulters
10. Quality assurance of microscopy laboratory till now a neglected area with 12% of budgeted
expenditure having been spent till Dec, 2011 needs to be strengthened.
Facilitate patient in taking treatment
The country has been maintaining a good cure rate of more than 85% amongst NSP cases.
Strangely, the same for Cat II has been consistently low and stood at 41% in Q-1/2011 cohort.
DOT as treatment facilitation and a patient – provider barrier breaking tool is not being
implemented. Training of treatment supporters is the only ACSM activity which has been
budgeted at Zero.
1. Programme urgently needs to consolidate its key function of removing infectious TB
patients from the pool of prevalent TB cases transmitting tuberculosis
2. A patient – centered adherence strategy, including facilitated treatment agreeable to the
patient should be adopted at all service outlets. DOT must be the standard of care
3. Anybody and everybody can be a DOT provider as long as he/she is willing; is acceptable to
the patient and answerable to the health system should be the norm. Use of cured patients
as DOT provider should be promoted
4. Decentralize DOT for the convenience of TB patients to the level that is feasible for
monitoring and supervision
5. Focus default reduction efforts on smear positive cases and on governorates and within
governorates on Districts and within Districts in the treatment units with high default rates.
133
Engaging all providers
For enhanced case detection; maintaining sustainability; and to create an epidemiological
impact there is an urgent need for coordinated approach amongst all social service sectors –
public and private. None of the 23 medical schools have adopted DOTS in their clinical practice
as a consequence of which patients attending teaching hospitals are not benefitting from DOTS.
There is still a large untapped potential for further action to involve providers not yet linked to
NTP.
1. A task force comprising of senior teachers from medical schools should be constituted at
central level; sensitized about DOTS and assigned the responsibility of drawing a roadmap
for involving medical schools and teaching hospitals in adopting DOTS in their clinical
practice
2. Focal points appointed in all teaching hospitals attached to 23 medical schools should be
trained in DOTS implementation and their responsibilities well defined. An effective two
way referral system between NTP and teaching hospitals should be developed and
operationalized
3. A task force in collaboration with IMA and Iraqi Anti TB Association should be constituted to
guide innovations in scaling up PPM partnership from existing 900 private practitioners and
expanding it to District level and also including related fields like pharmaceutical sector,
traditional healers, management and marketing experts, affected patients and community
representatives
4. Develop a PPM module for the training of non NTP staff that incorporates guiding steps to
adopt DOTS comprehensively or any of its components. Private practitioner should be
offered a cafeteria approach to select his area of partnership
5. Align ACSM and PPM approaches to facilitate inter-provider and patient-provider
communications as well as community involvement to create a demand for access to quality
TB care from both public and private care providers
6. Increase public recognition of collaborating PP’s and other providers by high-level political
leaders and programme staff
7. Beyond the existing PPM focal point at central level, PPM focal points should also be
appointed at governorate and District levels and their capacity developed to undertake PPM
related activities effectively
8. Develop and regularly update mapping or line listing of all providers and referral facilities
134
9. Diagnostic and treatment services in 5 prisons where laboratory technicians have been
trained should be initiated without any further delay.
TB/HIV Interventions
Iraq, though a low HIV prevalence State is at high risk for development of an HIV epidemic and,
therefore, does not warrant complacency at least in strengthening TB-HIV interventions.
1. Effective and functional collaboration needs to be formulated between AIDS and TB
programme at all levels—starting from central to TBMU
2. Marginalized population including prisoners being a high risk HIV group should be especially
cared for. Peer education should be used to detect affected populations, build bridges and
provide a comprehensive package for identified population.
Equity, Gender and Social Issues
Equity is a major issue in Iraq as 23.5% of Iraqi population currently lives under the poverty line
and spending less than US$ 2 per day, despite the relatively high income of the country. It is a
matter of concern that in 15 months of implementation of intervention amongst high risk
population groups, only 6% of allocated US$ 1,692,357 has been spent.
1. Non procurement of mobile vans has practically made the entire initiative for “TB Care for
Internally Displaced Population” defunct. Procurement needs to be ensured without any
further delay
2. To make the diagnostic services accessible to the poor populations served by C and D
categories of PHCC’s, schemes for smear transportation need to be formulated in
consultation with concerned Districts
3. Monitor the outcome of the strategies undertaken for IDP’s and Marshland populations for
modification/continuation
4. Develop strategies to build greater social support systems and linkages with social welfare
schemes, community based organizations and village health committees
5. Starting a “Cured TB patient Club” at the governorate / District level demonstrating the
normal life being led by cured patients will go a long way in reducing stigma. Cured patients
should be used for disseminating their success stories at appropriate platforms including
electronic media
135
6. Although TB affects all, it is well known that poor are afflicted more. Development of
brotherhood amongst fellow TB patients most of which are poor could thus be used as a
tool to promote equity
7. Expenditure being incurred on employees advising on “interventions among high risk
population” from London should be used on some more productive product.
MDR – TB Management
Initiatives on preventing MDR-TB should get precedence over treating MDR-TB. Universal
access to DOTS should precede and receive priority over universal access to MDR-TB.
1. Universal access to DOTS should precede and receive priority over universal access to MDRTB. System of diagnosis and successful management of TB cases within the existing health
care infrastructure thus built should subsequently be used for MDR-TB
2. Ensure that all laboratories responsible for culture and DST for PMDT comply with infection
control guidelines, with focus on laboratories handling MDR –TB suspects and specimens.
Often simple administrative, environmental and respiratory protection is sufficient to
minimize the risk of transmission
3. Comprehensively review bottlenecks experienced during the initial phase of MDR-TB
management, including laboratories, clinical management, logistics and drug supply and
address them carefully while planning further expansion, including development of an
appraisal mechanism and criteria for expansion to new sites
4. Monitor and address the emergence and potential spread of resistance to second line drugs
5. Annual quality certification through panel testing for NRL by SNRL and for private laboratory
in Erbil needs to be ensured
6. To benefit from global experience in up-scaling MDR - TB services, involvement of GLC and
GDF in technical assistance and programme monitoring must be undertaken on a continuing
basis
7. Efforts need to be made in improving cure rate amongst Cat II cases and reducing default
rate particularly amongst all infectious cases.
136
Infection Control

Formulate national guidelines on airborne infection control, pilot test and prioritize their
introduction in MDR-TB care facilities and TB laboratories ensuring that they do not
promote stigma.
Drug Regulation, Procurement, Supply, Quality Control and Distribution
First line NTP drugs for the last three years are being procured through GDF grant or procured
by GFATM grant. KIMEDIA has been responsible for receiving, storage and distribution of drugs 2
and in its current capacity is not able to ensure timely delivery of drugs even for existing limited
number of facilities implementing DOTS.
Government of Iraq has done a commendable act of banning the sale and storage of anti TB
drugs in the private pharmacies from 2011.
1. An independent procurement agency should be hired for procurement of anti TB drugs
including second line drugs. Role of NTP should be limited to formulation of drug
specifications and distribution of drugs from the central to governorate level
2. Quality control of the drugs within the country should be assigned to an independent
agency that should monitor the quality of drugs at different levels of storage till it is
consumed by the patient
3. With the availability of 5 years shelf life of Rifampicin, loose or Rifampicin in FDC’s with 2 –
3 years shelf life should not be purchased
4. Drugs with only 9/10 available shelf life should be accepted at country level
5. No expired drug should be allowed to be stored in health facilities and certainly not with the
drugs being used
6. Efforts need to be made on a war footing for effective implementation of the ban order
pertaining to storage and sale of anti TB drugs in the private sector.
137
Recording, Reporting, Monitoring, Supervision and Evaluation
National TB Control Programme – Iraq has developed a compact National M&E plan27 for 20132015 covering all aspects of NTP performance in Iraq and has also enlisted a set of indicators on
the impact / outcome as well as on output and process levels comprehensively. TB data is
recorded at all TB service delivery outlets using standardized templates and collection tools
which ensures uniformity facilitating compilation and analysis.
1. Present concept of monitoring and evaluation based on number of visits and composition of
monitoring team should be changed to performance based monitoring and supervision
tailoring it with need more than routine and prioritizing low performing governorates. Field
units posing a challenge to the programme should be prioritized for frequent monitoring
visits. Composition of supervisory team should also be need and issue based
2. At the national level, follow up for corrective action needs to be strengthened. Quarterly
reports from the governorate need to be analyzed and specific time bound feedback given
to improve performance for which M&E section at central level needs to be strengthened.
Similar initiative needs to be taken by the governorates in respect of TBMU’s in their
jurisdiction for which they should also be adequately strengthened
3. To improve performance, transition needs to be made from target focused monitoring of
performance to analysis of trends in key processes and outcome indicators at governorate
and District levels
4. Supervisory visits also need to cross check various components of programme performance
data and matching them with interdependent activities so that resultant accurate and
authentic data becomes the basis of evidence based policy decisions and the vehicle for
programme evaluation and performance monitoring
5. Central level should periodically convene, preferably every year, external monitoring of
every governorate with senior officers of other governorates to objectively and
transparently assess the validity and accuracy of collected data and findings should be
shared with all concerned and used for improving performance
6. Capacity of the central, governorate and District managers should be built to interpret basic
epidemiological and operational data and perform evidence based problem solving and also
to translate data into programme action
7. Central level should bring out a quarterly one pager “newsletter” giving governorate-wise 34 key performance indicators which should be circulated to all concerned including senior
officers in MoH. Low performing units should be marked red. This will bring an atmosphere
of appreciation for good performers and concern for poor performers who will make all
attempts to get rid from the red mark in a publicly circulated document
138
8. Monitoring guidelines/manual containing criteria influencing monitoring visits focusing on
assessing activity outcome against the present system of assessing activity output need to
be formulated and printed
9. Central level should challenge well performing governorates to set more appropriate goals
based on local trend in performance.
Operational Research
Operational Research should basically aim to generate more information and evidence to effect
necessary changes in policies and management practices of NTP. Important proposals usually
emerge from field units involved in service delivery.
1. As a first step, national guidelines for OR need to be developed imbibing a clear cut process
for review and funding
2. Medical colleges and other TB related institutions should also be made a part of OR policy
3. A full time expert for OR capacity building should be engaged to assist the governorates to
formulate and undertake at least one significant OR activity annually
4. OR capacity building workshops for program managers and other institutional partners
should be undertaken
5. Regularly update NTP Iraq website which should also include a list of approved proposals
for OR; the sites at which they are being carried out; and the summary outcomes of
completed studies. The study protocol should also be placed on the website providing an
opportunity for multicentre study if necessary.
Evaluation team considers following as some of the critical research activities for the NTP to be
completed within next 3 years:
1. Understand and address the role of social and clinical risk factors for TB, including
malnutrition, smoking, diabetes and indoor air pollution
2. Health seeking behaviors and reasons for TB diagnostic delay in vulnerable populations
including IDP’s, marshlands and urban slum dwellers
3. Understand the reasons for large number of “sputum not done cases” initiated on
treatment and find out the possible implementable solutions
Understand the reasons for infectious TB patients not bringing their contacts for evaluations
and suggest methods ensuring 100% screening of their contacts
139
ANNEXURE
ANNEXURE I
PROFILE OF THE EVALUATION TEAM
Dr. G. R. Khatri
Team Leader
Dr. Khatri is an internationally renowned TB and Tobacco crusader. Dr. Khatri as Programme
Manager of India’s TB Programme, led the team to demonstrate fastest and quality expansion
of TB programme to occur anywhere in the world. In recognition of his services to TB
programme, Dr. Khatri was awarded the Karel Styblo award at Florence, Italy in 2000 and
Princess Chichibu award in Berlin in 2010. Dr. Khatri joined WHO in 2002 and worked for
different countries of SEAR and also at SEARO in New Delhi. As global contracts Director of
FIDELIS, Dr. Khatri was instrumental in providing financial and technical support to 53 projects
in 19 countries. Dr Khatri has been member of the first two TRP’s of GFATM. In his present
position of Senior Public Health Advisor to World Lung Foundation, New York, Dr. Khatri has
been the key technical support for poor African and Asian countries.
Dr. Raid Kadim Al-Saidi
Member
Dr. Saidi is a free lancer management consultant who did his Phd from Romania and has been a
part of monitoring and evaluation programmes of varying social and health activities mostly
supported by international agencies including UNESCO, UNOPS, and UNHCR. Dr. Saidi has also
been a part of data collection and field evaluation team in 6 governorates pertaining to cost
accounting. Under a UNOPS project, Dr Saidi has been responsible for sensitization of more
than 170 opinion leaders in community related social activities.
Dr. Adnan Mohammed Mahmood Al-Jubouri
Member
Dr Jubouri is a Consultant physician and Professor in Faculty of Medicine, University of
Baghdad. Dr. Jubouri is a medical graduate from the University of Iraq and graduated with 4 th
rank amongst 400 students. Dr. Jubouri has to his credit MRCP and FRCP – both from Edinburg.
140
Prof. Jubouri has more than 30 years of teaching experience in the field of medicine and is
credited with a large number of acknowledged publications.
Dr. Khalid I. Nissan Al-Khoury
Member
Dr. Khoury is a public health specialist with Diploma in Public Health from Royal Institute of
Public Health and Hygiene, London and MSc in Community Health from London School of
Hygiene and Tropical Medicine. Dr. Khoury has more than 38 years of wide and varied
experience of working in the Government starting from peripheral level and going up to
Director of an infectious disease hospital. Presently Dr. Khoury is involved in training of health
personnel working in TB programme through IMC, Iraq.
Dr. Kassim Mohammad Sultan
Member
Dr. Kasim after his graduation got his MRCP in 1984 and FRCP from Glasgow in 2005. Dr Kasim
after working in different hospitals of UK has been a consultant physician in Iraq for more than
25 years. He is presently a faculty in the Department of General Medicine and Chest Diseases in
Baghdad Medical College. Dr. Kasim is also a supervisor for post graduate studies in general
medicine and Chest diseases.
Dr. Basil Fawzi Jameel Al – Jassar
Member
Dr Basil is a specialist in Internal Medicine and Respiratory and Chest Diseases and is presently
working as Senior Specialist in Medical City – Baghdad Teaching Hospital. In addition to being a
member of Iraqi Medical Association, Dr. Basil is also a member of Anti – Tuberculosis and
Chest Disease Society, Iraq and Iraqi Cardio Thoracic Society. Dr Basil is involved in clinical
training courses for under graduates and for students of Diploma of Chest Diseases.
141
ANNEXURE II
REFERENCES:
1.
Terms of References - TB Programme Evaluation Team Leader
2.
Mid-term strategy for the National TB Control Program in 2009-2011
3.
Round 9 proposal submitted to GFATM
4.
Annual progress report (January – December, 2009)
5.
The National M&E Plan 2010-2015 / NTP Iraq
6.
Annual progress report (January – December, 2010)
7.
Capture Recapture study to determine the Tuberculosis burden in Iraq
8.
Global TB report – 2011 (WHO)
9.
MOU between the World Health Organization (WHO) and International Medical
Corps (IMC)
10.
MOU between the World Health Organization (WHO) and Iraqi Anti-TB Association
(IATA)
11.
MOU between the World Health Organization (WHO) and AMAR International
Charitable Foundation
12.
Ongoing Progress Update (14) and Disbursement Request (10)
13.
Global Fund Information Note: Opportunities to promote equity (Dec., 2011)
14.
Annual progress report (2011) on implementation of R6 and R9 Single Stream
Funding – TB Control
15.
Health Sector Assessment and Functional Review Report – Iraq
16.
NTP National M&E Plan (2013 – 2015)
17.
Annual TB report (2010) of Erbil Governorate
18.
Annual TB report (2011) of Erbil Governorate
19.
TB report (Q-1/2012) of Erbil Governorate
142
20.
Order issued by Kurdistan Region – Iraq banning the sale of H, R, Z, E and SM by
private sector
21.
Ongoing PU and Disbursement Request – Cycle beginning, 1st March, 2012
22.
AMAR Quarterly Report Summary (Jan - Mar, 2012)
23.
STOP TB policy paper No. 2 – TB Impact Measurement
24.
Health Need Assessment – Presentation during 4th TB Conference on 17th April, 2012
25.
Treatment of Tuberculosis – Guidelines Fourth Edition, World Health Organization
26.
R6 proposal submitted to GFATM
27.
The National TB Control Programme – Iraq; National M&E Plan 2013-2015
28.
MMWR – Recommendations & Reports, CDC, Atlanta – September 8, 1995
29.
Monitoring & Evaluation Tool Kit – Global Fund
30.
Review Article: Extra pulmonary TB, Indian J Medical research, 120, Oct, 2014
31.
Ministry of Health – Iraq, Annual Report
32.
Report on HIV Survey among TB patients from July to December, 2008 in Iraq
33.
Slippery Slope to Sloppy DOTS; IJTLD, 2002.
143
ANNEXURE III
GUIDELINES FOR UNDERTAKING SUPPORTIVE EVALUATION
The evaluation is not a policing activity. It needs to be a supportive initiative. Emphasis needs to
be paid on education, motivation, facilitation and guidance including; “hands on training in the
facilities visited”. As far as possible poor performing/difficult areas should be visited.
A- In the OPD
1. All adult OPD patients been specifically asked about two weeks cough –registration
desk/ health professional
2. Any register of symptomatic identified being maintained
3. Identified symptomatic – how to bring out sputum; no of samples; where to give
sample
4. Categorization; counseling; contacts; follow up of sputum
5. Choice of DOT provider
6. Training of doctors; LT; DOT provider
7. Tally number of symptomatic identified with adult OPD (2%)
8. List of available DOT supporters displayed at the health/ DOT facility
9. Time gap between identification of symptomatic - sputum examination - conveying
result –categorization - initiation of treatment -patient treatment card -patient card recording in TB register
10. Pulmonary sputum negative – antibiotic for 7 days?
11. Total cases; number of sputum positives; sputum negatives; EP; l TAD”, failure and retreatment
12. How many PHCs (A) grade in the area and how many of them have MC services
13. How many PHC’s in the Governorate have DOT service outlets/drug distribution centers
14. Patient’s expedience’s and success stories in their own language
15. Challenges and lessons learnt
B- Laboratory
1.
2.
3.
4.
The sputum cup properly screwed and labeled on side with marking pencil
Spot sample collected on the day of referral
Is the patient given another sputum cup to bring morning sample
Is patient advised how to bring out sputum sample particularly morning sample
144
5. Is laboratory technician picking sputum sample for smearing from thick mucoid portion
of sample
6. Availability of light, uninterrupted water supply and sink in the laboratory
7. LT training status and when trained
8. Grading and physical examination of the sputum recorded in the laboratory register
9. Time gap between receipt of sample and result
10. Mechanism for recording and tracing of initial defaulters
11. Quality control - any record in support
12. Adequate stock of logistics including slides, sputum cups, reagents, marking pencil
13. Functioning binocular microscope
14. Quality of cups and reagents- precipitate in Carbol Fuschin
15. Waste disposal mechanism in laboratory
16. Sample ten sputum positive slides to see the grading
17. Status of ventilation and air borne infection control
C- DOT facility
1. Whether patient is made comfortable; treated with respect and as VIP
2. Whether patient swallows the drugs in front of health worker; given support like water
to swallow drugs
3. Number of patients getting DOT through DOT provider other than health facility
4. Whether treatment card is marked at the same time
5. Number of days drugs are given to the patient in IP / CP?
6. Is patient treatment card arranged as per date of next visit?
7. Any counseling to the patient
8. Patient treatment card – is it fully filled; sputum quality; sputum positive result in red;
weight; contact tracing; categorization; treatment regimen
9. Any advice for follow ups sputum
10. Guidance if sputum not coming near treatment completion
11. Any address verification done before start of treatment
12. Default tracing –how, when and records in patient treatment cards
13. Any shortage of drugs
14. Tallying drug consumption with patients getting treatment
15. Recording of HIV testing on TB patient treatment card
16. CPT to HIV positive TB patient
145
D- Drug store
1.
2.
3.
4.
Shortage
Expired drugs
Storage- working height- combination
FEFO (first expired, first out)
E- Records
1. Compare patients on treatment (IP and CP) in quarter 1/12 from TB register with drugs
consumption
2. TB register – compare with patient treatment card -entry of HIV testing and CPT
3. Compare quarter 1/12 report with corresponding cohort entries in TB register – total
cases; / sputum conversion and treatment outcome
4. Is there any firm date of sending quarterly report and conveying any feedback and how
often is the compliance!
F- NTP
1. In 2011 no. of quarterly reports received/ targeted to receive/timeliness/feed back
2. Monitoring visits undertaken and feed back; any check list
3. Coordination mechanism between four monitoring units of NTP
G- Visit to randomly selected patients house
1. Level of satisfaction
2. Contact verification viz-a viz patient treatment card
3. Drug consumption- Tally with drugs issued and available with patients.
146
ANNEXURE IV
EVALUATION WORK PLAN
Time Period April to June 2012
Task completed
April 15-18
- Desk Review of provided documents
April19 & 20
- Meeting in Erbil with National evaluation team, Iraqi
stakeholders, UNDP, WHO and NGOs to explain the objective
and expected outcome of this evaluation as well as give
extensive presentation on R6/ R9 support and the structure of
entities working under GFATM. Team leader could not attend
as visa was not available
- Prepare evaluation work plan-International Consultant
April 21 – 25
- Visit NTP and CCM- National Consultant
- Team meeting amongst UNDP and international consultant in
Amman with national consultants in Baghdad via VCT to
confirm work plan and share guidelines
April 26– May 2
- Field visits by national consultants
- Meeting WHO team at Amman – International Consultant
- Full team meeting in Erbil
May 3 – 13
- Field visits in Erbil- International Consultant
- Ongoing review- National Consultants
- Meeting with Ministry of Health – National Consultant
May 14 – 18
- Meetings with implementing NGOs – National Consultant
- Meeting with UNDP, WHO - International Consultant
- Debriefing meeting via VCT including UNDP, WHO and
international team leader in Amman with national consultants
and NTP in Baghdad
May 19 to 24
- Field visits to prison and Marshland- National Consultants
- Ongoing review and analysis of findings- International
Consultants
147
May 25 to June 15
- Finalization of Report that outlines recommendations and
lessons learned for UNDP – International Consultant
June 15 – 30
- Revision/endorsement of final report by UNDP and share
with GFATM – International Consultant
148
ANNEXURE V
FIELD VISIT PROFILE
Expert Name
Type of Facility visited
Facility visited
Governorate
Chest Clinic
RCDC
Teaching Hospital
Rizgary
TBMU
City Centre
PHC
Nazdor Bamery
PHC
Bajilin Centre
Prison
Rahmania Juvenile Prison
District
Al-Sadr TDC
District
Al-Kadhmia (visited twice
different dates)
NGO
IMC
PHCC
Khazir
PHCC
Ba’adrah
PHCC
Duban
District
Sumail
TB Clinic
Najaf TB Clinic
Najaf
PHCC
Bahle (Marshland – Almdaina)
Basrah
Dr. Kassim
Mohammad Sultan
PHCC
Sommer
Baghdad
Dr. Basil Fawzi
Jameel Al – Jassar
District
Al-Adil
Baghdad
Dr. G. R. Khatri
Dr. Adnan
Mohammed
Mahmood AlJubouri
Dr. Khalid I. Nissan
Al-Khoury
Dr. Raid Kadim AlSaidi
Erbil
Baghdad
Duhok
149