ROUND 8 – Tuberculosisdocs.theglobalfund.org/program-documents/GF_PD_001_e701a...ROUND 8 – Tuberculosis End Project Evaluation and Round-3 BDN TGF grant for TB and Malaria Close

ROUND 8 – Tuberculosis

PROPOSAL FORM – ROUND 8 (SINGLE COUNTRY APPLICANTS)

Applicant Name Pakistan – Country Coordinating Mechanism

Country Pakistan

Income Level (Refer to list of income levels by economy in Annex 1 to the Round 8 Guidelines)

Low Income

Applicant Type CCM

Sub-CCM

Non-CCM

CP_R8_CCM_PKS_T_PF_7Aug08_En Page 1 of 72

PAKISTA

Investing in our future

The Global FundTo Fight AIDS, Tuberculosis and Malaria

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Round 8 Proposal Element(s):

Disease Title

HSS cross-cutting interventions

section (include in one disease only)

HIV1

‘Prevent and halt the HIV epidemic by scaling up comprehensive services to street based IDUs, PLHIV and their families’

Tuberculosis1 Bridging the gap for TB treatment

Malaria

Currency USD or EURO

Deadline for submission of proposals: 12 noon, Local Geneva Time, Tuesday 1 July 2008

1 In contexts where HIV is driving the tuberculosis epidemic, applicants should include relevant HIV/TB collaborative

interventions in the HIV and/or tuberculosis proposals. Different HIV and tuberculosis activities are recommended for different epidemiological situations. For further information: see the ‘WHO Interim policy on collaborative TB/HIV activities’ available at: http://www.who.int/tb/publications/tbhiv_interim_policy/en/


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http://www.who.int/tb/publications/tbhiv_interim_policy/en/



INDEX OF SECTIONS and KEY ATTACHMENTS FOR PROPOSALS '+' = A key attachment to the proposal. These documents must be submitted with the completed Proposal

Form. Other documents may also be attached by an applicant to support their program strategy (or strategies if more than one disease is applied for) and funding requests. Applicants identify these in the 'Checklists' at the end of s.2 and s.5.

1. Funding Summary and Contact Details 2. Applicant Summary (including eligibility) + Attachment C: Membership details of CCMs or Sub-CCMs Complete the following sections for each disease included in Round 8: 3. Proposal Summary 4. Program Description

4B. HSS cross-cutting interventions strategy ** 5. Funding Request

5B. HSS cross-cutting funding details **

** Only to be included in one disease in Round 8. Refer to the Round 8 Guidelines for detailed information.

+ Attachment A: 'Performance Framework' (Indicators and targets) + Attachment B: 'Preliminary List of Pharmaceutical and Health Products' + Detailed Work Plan: Quarterly for years 1 – 2, and annual details for years 3, 4 and 5 + Detailed Budget: Quarterly for years 1 – 2, and annual details for years 3, 4 and 5

IMPORTANT NOTE: Applicants are strongly encouraged to read the Round 8 Guidelines fully before completing a Round 8 proposal. Applicants should continually refer to these Guidelines as they answer each section in the proposal form. All other Round 8 Documents are available here.

A number of recent Global Fund Board decisions have been reflected in the Round 8 Proposal Form. The Round 8 Guidelines explain these decisions in the order they apply to this Proposal Form. Information on these decisions is available at: http://www.theglobalfund.org/en/files/boardmeeting16/GF-BM16-Decisions.pdf. Since Round 7, efforts have been made to simplify the structure and remove duplication in the Round 8 Proposal Form. The Round 8 Guidelines therefore contain the majority of instructions and examples that will assist in the completion of the form.

http://www.theglobalfund.org/en/apply/call8/single/#guidelines


http://www.theglobalfund.org/en/apply/call8/


http://www.theglobalfund.org/en/files/boardmeeting16/GF-BM16-Decisions.pdf



1. FUNDING SUMMARY AND CONTACT DETAILS 1.1. Funding summary

Total funds requested over proposal term (US $)

Disease Year 1

(US $)

Year 2

(US $)

Year 3

(US $)

Year 4

(US $)

Year 5

(US $)

Total

(US $)

HIV 7,936,685 10,700,023 14,182,719 15,124,707 18,274,917 66,219,051

Tuberculosis 4,375,570 5,434,989 5,454,675 5,628,333 5,788,566 26,682,133

Malaria 0 0 0 0 0 0

HSS cross-cutting interventions within [insert name of the one disease which includes s.4B. and s.5B. only if relevant]

0 0 0 0 0 0

Total Round 8 Funding Request : 92,901,184

1.2. Contact details

Primary contact Secondary contact

Name Khushnood Akhtar Lashari Zarina Kausar

Title Federal Secretary Health Senior Project Officer (CCM)

Organization Public Sector, Ministry of Health CCM Pakistan

Mailing address Room No.113, Block-C, Pak Secretariat, Islamabad.

CCM Secretariat

National Institute of Health

National AIDS Control Programme

Chak Shehzad

Islamabad, Pakistan.

Telephone +92 (51) 9211622

+92 (51) 9201782 +92-51-9255367- 8

+92-51-9255242

Fax +92 (51) 9205481 +92-51-9255214

E-mail address [email protected] [email protected]

Alternate e-mail address [email protected] [email protected]


mailto:[email protected]

mailto:[email protected]

ROUND 8 – Tuberculosis 2. APPLICANT SUMMARY (including eligibility)

CCM applicants: Only complete section 2.1. and 2.2. and DELETE sections 2.3. and 2.4. Sub-CCM applicants: Complete sections 2.1. and 2.2. and 2.3. and DELETE section 2.4. Non-CCM applicants: Only complete section 2.4. and DELETE sections 2.1. and 2.2. and 2.3.

IMPORTANT NOTE: Different from Round 7, ′income level′ eligibility is now set out in s.4.5.1 (focus on poor and key affected populations depending on income level), and in s.5.1. (cost sharing). 2.1. Members and operations 2.1.1. Membership summary

Sector Representation Number of members

Academic/educational sector 2

Government 12

Non-government organizations (NGOs)/community-based organizations 4

People living with the diseases 2

People representing key affected populations2Election Process has been

completed on June 20th 2008.

Private sector 2

Faith-based organizations 2

Multilateral and bilateral development partners in country 5

Other (please specify): Observers (non voting) Group of international agencies (UNICEF, CIDA, World Bank, UNODC)

-

Total Number of Members:(Number must equal number of members in 'Attachment C''3) 29

2 Please use the Round 8 Guidelines definition of key affected populations. 3 Attachment C is where the CCM (or Sub-CCM) lists the names and other details of all current members. This

document is a mandatory attachment to an applicant's proposal. It is available at: http://www.theglobalfund.org/documents/rounds/8/AttachmentC_en.xls


http://www.theglobalfund.org/documents/rounds/8/AttachmentC_en.xls


http://www.theglobalfund.org/documents/rounds/8/AttachmentC_en.xls

ROUND 8 – Tuberculosis 2.1.2. Broad and inclusive membership

Since the last time you applied to the Global Fund (and were determined compliant with the minimum requirements):

(a) Have non-government sector members (including any new members since the last application) continued to be transparently selected by their own sector; and (Key Affected Populations Representatives Elections Process – Annexure – CCM – 1)

No Yes

(b) Is there continuing active membership of people living with and/or affected by the diseases. No Yes

2.1.3. Member knowledge and experience in cross-cutting issues

Health Systems Strengthening The Global Fund recognizes that weaknesses in the health system can constrain efforts to respond to the three diseases. We therefore encourage members to involve people (from both the government and non-government) who have a focus on the health system in the work of the CCM or Sub-CCM.

(a) Describe the capacity and experience of the CCM (or Sub-CCM) to consider how health system issues impact programs and outcomes for the three diseases.

The MOH recognizes that the Health System Strengthening (HSS) focus is the urgent need of the hour in order to accelerate the efforts for efficient response towards the three diseases controlling strategies. In this regard, MOH has recently established Health System Strengthening unit. The MOH-HSS unit TORs are to identify the HSS gaps in the overall health sector and to recommend the remedial actions to are to review and identify HSS gaps. Just recently established MOH HSS unit is working in close collaboration with other health sector programmes. EPI programme has taken initiative and have conducted HSS analysis and have identified gaps. MOH initiative of GAVI HSS experience has been found very successful and other programmes are to benefit from this exercise. The capacity building process has been geared up which will ultimately involve health sector and other line ministries and the GOP line departments. The capacity and experience of CCM members towards the HSS is very concise and clear. As it is evident that CCM Pakistan represents key stakeholders with diverse but relevant qualifications and experience for effective strategic guidance in the collective efforts to fight the three diseases. The composition of the CCM (29 total members) includes Chair CCM (Federal Secretary MOH), representatives from the federal government and provincial governments (12), academic and research institutions (2), private sector (2), Vice Chair CCM from Civil Society, NGOs/ Community Based Organizations/Faith Based Organizations (6) Multilateral and Bilateral Agencies (05) Key Affected Communities Representatives (01) is indicative of the broad range of expertise available to the CCM to cater the time to time emerging needs for addressing the impediments including the health system strengthening for attaining the target objectives/goals. CCM members and the programmes representative have attained significant understanding towards the importance of HSS component and how HSS issues impact programmes and outcomes for the three diseases i.e. NACP realized the gap in Procurement of Health items as per the internationally acceptable standards, contracted out a private sector firm which built the federal and provincial programmes capacity in the field of health items procurement. Recently, the national programme HIV/AIDS Control, TB and Malaria has agreed for conducting HSS assessment for three diseases and to submit a comprehensive proposal in GFATM Round-9 so that HSS gaps could be effectively addressed to ensure the desired results to reduce the diseases burden in Pakistan. In addition CCM members from the broad range of the stakeholders also contribute to address the constraints by putting in efforts to accelerate the programme implementation. The monitoring plans of programmes that are in place to ensure that the resources, human and financial, that are allocated are utilized solely to combat the three diseases, HSS is one of its M&E areas. The CCM oversight includes keeping strategic track of progress and challenges including HSS component and offer appropriate recommendations to the PR(s) on improving performance. CCM forms sub committees of the relevant CCM members and assign them various tasks related to TGF grants performance. For example, CCM formed sub committee to sort out the GFATM Round-2 HIV/AIDS grants



End Project Evaluation and Round-3 BDN TGF grant for TB and Malaria Close Out Plan and also the End Project Evaluation to identify transparently most experienced firms/organizations to carry out the End Project Evaluation of TGF grants so that the expected out put could be measured upon the completion of five years grant implementation period. These End Project Evaluations also to identify gaps in health system which will serve as a baseline report to address HSS component and MOH to plan initiatives to resolve them. MOH is focusing to address the HSS gap, thus the Federal and Provincial Governments encourage as a matter of policy the involvement of the Public, Private Sectors and People affected by the three diseases into the CCM forum to ensure priority focus and help develop policies that address social and legal rights of those most affected to encourage the detection rate. The federal and provincial programme managers brings operational management expertise to the CCM forum in areas of implementation including monitoring and evaluation, supply chain issues, service delivery, coordination and also gaps in the health system requiring strengthening. The representatives of the academic and research institutions bring knowledge and expertise based on the latest research conducted in the field to guide prioritization of resource allocations according to the changing and/or emerging trends. The representatives of the NGOs/ Community Based Organizations / Faith Based Organizations besides presenting practical service delivery issues, they also provide insight into issues which also includes HSS relating to social/cultural/religious biases prevalent in society and contribute to policy initiatives to bridge those biases most effectively which also contributes towards TGF grants implementation.



Gender awareness

The Global Fund recognizes that inequality between males and females, and the situation of sexual minorities are important drivers of epidemics, and that experience in programming requires knowledge and skills in:

• methodologies to assess gender differentials in disease burdens and their consequences (including differences between men and women, boys and girls), and in access to and the utilization of prevention, treatment, care and support programs; and

• the factors that make women and girls and sexual minorities vulnerable.

(b) Describe the capacity and experience of the CCM (or Sub-CCM) in gender issues including the number of members with requisite knowledge and skills.

Focusing the factors making women and girls and sexual minorities vulnerable, Gender supportive initiatives are adequately addressed at policy making levels and also by the national programme and the federal ministries. MOH, health sector interventions i.e. National AIDS Control Programme addresses the women, girls and boys and the sexual minorities. Youth groups (Boys and Girls) have been addressed by World Population Fund (WPF) in GFATM Round-2 component of youth groups – Adolescent’s Reproductive Rights at national level. National AIDS Control Programme have always focused sexual minorities, women and girls specially to ensure their access to and the utilization of prevention, treatment, care and support programmes by establishing VCT centers approachable for females in the areas where cultural barriers restrict women’s independent mobility. In addition, for prevention and care, BCC activities disseminated to general populations and 48% of the total population are female in Pakistan. Public Sector representation comprises of 12 members on CCM which includes the member from the Ministry of Women Development (MoWD). The MoWD exclusively deals with women development issues on health and education. In addition MOH Women’s Health Project Unit addresses the Health issues of women on MNCH, adolescent Reproductive Health and their rights and Lady Health Workers force of 400,000 LHWs to increase gender balance in GOP initiatives. Ministry of Education is represented on CCM forum and the Ministry of Education is focusing to enhance literacy rate among women and girls. The most recent example is that the federal and provincial Education porgrammes has approved and executed free education till middle level (1-8th grade) and is providing complete support by providing free syllabus books and no school fee to encourage female and youth enrollment in educational institutions. CCM member representing the Planning Commission of Pakistan has very closely focused the gender development initiatives at national level.

CCM Members representing Multilateral and Bilateral Agencies (05) members and Civil Society Organizations (CSO) are supporting women empowerment initiatives in form of projects i.e. Violence against women, Women empowerment and MCH etc. All aforementioned plans are executed and coordinated by the experienced professionals who are well informed and have rich experience in gender issues. The CCM members representing sectors i.e. Research and Academic Institutions, Private Corporate Sector and People Living with and or Affected by disease also focus the women and girls support initiatives. MOH- NACP in GFATM Round-2 grant has established VCT centers to facilitate HIV+ women in the areas where social and cultural barriers restrict women mobility and access to treatment and Care and Support Centers. Such interventions updated towards the steps taken to address the gender issues at national level. In addition, CCM members representing Civil Society Sector, Multilatera and Bilateral Agencies, Faith Based Organizations are deeply involved for improving the gender balance.

Similarly like CSOs and development partner’s contribution, the initiative taken by the Government of Pakistan by incorporating 33% grass root level legislators (women in decision making) and MoWD’s Project of Women’s Political Participation Project (W3P) a three years project implemented by UNDP and UNOPs in collaboration with the Ministry of Women Development for the capacity building of women legislators. Upon the completion of W3P, the initiative have been kept alive to continue the women empowerment establishing the Women Political School to continue the capacity building process for women in decision making in future and MoWD has established Women Political School for the training of women in decision making.

The sectors represented on CCM are designed in a way to ensure that the CCM can muster the technical expertise on a broad range of issues and can effectively incorporate cross cutting gender issues, the CCM has constituted 3 sub-committees. The sub-committee (technical) consists of experts who provide technical expertise to the CCM on institutional and technical issues. The M&E sub-committee reviews the periodic monitoring reports of the PRs and shares its findings with the CCM. A CCM Core Committee



exists comprising of CCM members representing each sector. The members of the core committee are elected through transparent electoral process fully monitored and documented.

The technical sub-committee consists of 9 members of whom 3 are females with extensive management experience of designing and implementing diverse health related projects with focus on gender. Their inputs are specifically sought to ensure that gender concerns are fully addressed on strategic program implementation issues. Similarly, gender balance is ensured in the M&E sub-committee of the CCM that includes besides representatives of international partners, representatives of civil society. All technical reports to be deliberated upon by the CCM are first reviewed by the relevant sub-committees and gender concerns if any, are highlighted. Though there is scarcity of financial resources but the knowledge and the realization of mobilizing women for economic development is very much there and to promote interventions are taken in to account at various levels of public and private sectors.

Multi-sectoral planning

The Global Fund recognizes that multi-sectoral planning is important to expanding country capacity to respond to the three diseases.

(c) Describe the capacity and experience of the CCM (or Sub-CCM) in multi-sectoral program design.

MOH has been actively involved in the development programmes in partnership with UN missions in Pakistan involving Civil Societies Organizations. But the Country Coordination Mechanism is a uniequ forum that has brought innovative approach towards multi sectoral programme designs. Through the composition of the CCM, it has brought expertise both from the public and private sector in designing and managing health related initiatives. 29 members of the CCM representing Government and Non Government various sectors have contributed in the health sector while designing health projects. CCM Pakistan (multisectoral group) has rich capacity and experience in multi sectoral programme design and have successfully submitted sound proposal and in result have secured TGF grants for HIV/AIDS, TB and Malaria by getting approved GFATM Round-2 (HIV/AIDS, TB & Malaria), Round-3 (TB and Malaria) Round-6(for TB) and Round-7 for Malaria.

We must admint that although an innovative initiative as a pilot project, the formation of CCM in response to the Global Fund requirements in Pakistan but MOH programmes has found the existence of CCM a very useful body which has significantly contributed towards enhancing the capacity building aspects for the programmes while responding to three diseases. The most recent example by experiencing in multi sectoral programme desing is evident from the fact that the National TB Control Programme (MOH), also a CCM member has formulated a TB/HIV multi-sectoral group to address the newly emerging issue of TB/HIV Co infection. The forum meets on quarterly basis and provides inputs to address the cross cutting issues to address the TB/HIV co infection transmission and control strategies effectively. The members of this multi-sectoral group are representing multi dimensional approach. Thus the members of TB/HIV group brings expertise both from the public and private sector in designing and managing health related initiatives members of the CCM from the private sector have worked in the health sector designing health projects.

CCM members representing Public Sector i.e. MOH, Planning Commission of Pakistan and other Federal Ministries as CCM members through CCM forum have realized that private sector participation in development issues actually plays very vital role. Thus Public sector has gained the momentum to prioritize the involvement of Civil Society and Private Sector. The Ministry of Women Development has took the course to involve private sector firms and Civil Society organizations to implement the gender development programmes and this trend is constantly on rise. Similarly MOH other health initiative i.e. MCH or tobacco control programmes etc. are also involving multi sectoral approach (FBOs, CBOs, NGOs and private corporate sector) while designing and implementing programmes for improving health sector in Pakistan. HIV/AIDS, TB and Malaria Control interventions supported by TGF grants are also being implemented by involving multisectoral group (CCM) approach.


ROUND 8 – Tuberculosis 2.2. Eligibility 2.2.1. Application history

'Check' one box in the table below and then follow the further instructions for that box in the right hand column.

Applied for funding in Round 6 and/or Round 7 and was determined as having met the minimum eligibility requirements.

Complete all of sections 2.2.2 to 2.2.8 below.

Last time applied for funding was before Round 6 or was determined non-compliant with the minimum eligibility requirements when last applied.

First, go to ′Attachment D′ to and complete. (Do not complete sections 2.2.2 to 2.2.4)

Then also complete sections 2.2.5 to 2.2.8 below.

2.2.2. Transparent proposal development processes

Refer to the document 'Clarifications on CCM Minimum Requirements' when completing these questions. Documents supporting the information provided below must be submitted with the proposal as clearly named

and numbered annexes. Refer to the ′Checklist′ after s.2.

(a) Describe the process(es) used to invite submissions for possible integration into the proposal from a broad range of stakeholders including civil society and the private sector, and at the national, sub-national and community levels. (If a different process was used for each disease, explain each process.)

A uniform process was used to develop Round-8 proposal and also to invite submission for possible integration into the proposal from a broad range of stakeholders including civil society and private sector and at the national and community level for both TB and HIV/AIDS diseases proposal for GFATM Round-8.

The Global Fund announced the launching of GFATM Round-8 in March 2008. The Global Fund call for inviting proposals was shared with CCM forum. (Annexure –2) Minutes of CCM meeting approving programmes to start the GFATM Round-8 proposal development process.

Step –I:

Upon receiving green signal from multisectoral forum of CCM Pakistan, a meeting of CCM Sub Committee Technical and Sub Committee M&E met to stream line the proposal development process. The CCM sub committees assigned task to CCM Secretariat to prepare draft text for the Expression of Interest for inviting applications for Principal Recipient and the Sub Recipients and to get inputs from the CCM Members. The EOI for the selection of multiple PRs from Public and Private Sector were published in the month of April 2008 where as the EOIs inviting application for the selection of Sub Recipients were published in month of April – May 2008. CCM members provided inputs comments and EOI was finalized for publishing in the nation wide newspapers in national and English languages. (Annexure-3) & EOIs and related correspondence). There was fifteen days margin provided for both EOIs for the submission of the Expression of Interest. The nation wide newspapers in national language (Urdu) and international language (English) are easily accessible for CBOs, NGOs, FBOs, Private Sector and International Development partners in Pakistan. CCM Secretariat received for GFATM Round-8 proposal - multiple PRs (08 for NTP and 11 for HIV/AIDS) (Annexure-4). Similarly CCM Secretariat received EOIs from Sub Recipients (51 for NTP and 95 for HIV/AIDS programme).

Step – II:

CCM sub committee for the selection of PR met and as per the CCM constituted committee’s approved short listing criteria carried out the short listing of PRs. The results of the committee short listing and final recommendation was shared with CCM members. To carry out SRs selection process, CCM Sub Committee for the selection of Sub Recipients (SRs) for GFATM Round-8 proposal for TB and HIV/AIDS carried out the short listing of SRs based on the committee members approved short listing criteria. The committee through a very transparent short listing process recommended 08 SRs for NTP and 33 SRs for HIV/AIDS (Annexure-5).


http://www.theglobalfund.org/documents/rounds/8/AttachmentD_en.doc

http://www.theglobalfund.org/pdf/Clarifications_CCM_Requirements.pdf


Step – III:

In line with the Global Fund guidelines, the CCM Sub Committees recommend and CCM forum reviews and Endorses the committee’s recommended selection of PRs and SRs. CCM meeting was held on May 15, 2008 in which CCM Secretariat described complete process and the lists of selected PRs and SRs. CCM endorsed and approved the process and the selected PRs and SRs. The CCM forum further advised the progammes (NTP and NACP) to further lead the process. Both programmes in consultation with their PRs from the private sector coordinated with the selected SRs. Both PRs, NTP & Green Star, NACP & Nai Zindagi worked out strategy through a consultative process. Both programmes had designed a template and invited concept notes from the selected SRs. SRs submitted the concept notes as per the GFATM Round-8 objectives. The GFATM Round-8 Gap analysis and NTP and NACP objectives for GFATM Round-8 were approved by CCM. Both PRs reviewed the concept notes of SRs. NTP invited concept notes from 08 SRs, only four responded and out of four two SRs concept notes were not relevant to GFATM Round-8 NTP proposal thus only 02 SRs (ASD and PATA) submitted relevant interventions matching the NTP objectives. Whereas, both PRs for GFATM Round-8 proposal of HIV/AIDS selected their own SRs for their relevant objectives. NACP selected SRs for its objective 1 &3 and Nai Zindagi (PR from private sector for HIV/AIDS) selected its own SRs for objective-2.

Simultaneous Process of Submission For Possible Integration in the proposal from by a broad range of stakeholders including civil society and the private sector, and at the national and community levels:

In addition to the aforementioned process, following exercises were also carried out to ensure maximum possible integration in the proposal form by a broad rang of stakeholders.

a) GFATM Round- and Gap Analysis Exercise: In order identify financial and programmatic gaps for GFATM Round-8 proposals, programmes carried out various activities in consultation with provincial programmes, multisectoral development partners, Civil Society and Provincial Programmes Implementing partners /stakeholders. Details of NTP activities conducted to conclude Gap analysis exercise (Annexure-6) and Gap analysis Exercise conducted by NACP for GFATM Round-8 (Annexure-8) are attached. The gaps analysis was presented to CCM for review and to endorse the priority areas to be focused for GFATM Round-8 proposal (Annexure-8).

Inputs by a Broad Range of Stakeholders for GFATM Round-8 HIV/AIDS Proposal:

NACP started the process of consultation for GFATM Round-8 in January by forming two major groups. One was a lager advisor groups comprising of provincial level stakeholders, UN System and Bilateral development partners. The Advisory group consisted of over 40 members representing multistakeholders, PLWHA and Civil Society sectors. The second group called Technical Working Group (TWG) comprising of non CCM members from international organizations i.e. World Bank, Bilateral Agencies etc. TWG was formulated to closely focus the objectives, rational and to ensure there is no duplication of resources programmed by other in country development partners, by public sector and proposed for TGF grants in GFATM Round-8. The TWG met frequently and took way forward to summarize the recommendations to the national level consultant to formulate the first draft of the proposal. Minutes of meetings are attached (Annexure-9-NACP) & (Annexure-10-NTP) to support the aforementioned process.

Integration of Invited Submission for Round-8 Proposal:

A uniform strategy was adopted to ensure maximum integration of submissions in to Round-8 proposal for TB and HIV/AIDS. Upon the final selection of SRs by the CCM committee, the rest was a programme lead process. National AIDS Control Programme and National TB Control Programme sent out a template to 33 SRs for NACP and 8 SRs for TB proposal. Out of 33, 27 SRs submitted proposal for HIV/AIDS and out of 8 SRS for TB only 4 submitted proposals in response to proposal templates which were sent to all SRs. The template had clearly mentioned the Round-8 objectives for HIV/AIDS and TB proposal for Round-8. NTP and NACP formed committees to evaluate in line with the set forth evaluation criteria for each proposal submitted by SRs. Upon completion of SRs proposal evaluation. Consultative meetings were organized by NTP and NACP to discuss and agree on technical and financial modalities related to the Round-8 proposal of HIV/AIDS and TB. NACP categorized the SRs proposals based on the strength of the proposal and selected SRs and also recommended SSRs. SSRs were informed that their involvement in HIV/AIDs programme implementation upon the SRs preference whether SRs select the organizations categorized as SSRs. A consultative process was exercised to integrate submissions in Round-8 proposal by NACP and NTP. In addition, NACP and NTP shared the drafts of proposal with multi stakeholders for inputs and comments which were also incorporated to ensure a consultative participatory approach while preparing the Round-8 proposals for HIV/AIDS and TB.



(b) Describe the process(es) used to transparently review the submissions received for possible integration into this proposal. (If a different process was used for each disease, explain each process.)

The list of selected SRs was shared with the National Programme Managers NACP and NTP to further carry out a programme lead consultative process (both PRs to work together) to finally conclude the quality proposals submitted by the selected SRs. A proposal submission template (CCM Annexure 11 – SR Proposal Submission Template) was shared with the selected SRs by the CCM sub committee on May 16, 2008 that included specific guidance on how to submit the technical and financial proposals. The selected SRs were requested to submit detailed technical and financial proposals by May 26, 2008 with the guidance to focus on two key objectives already approved by the CCM as part of the strategic framework developed through a participatory process. Based on a short listed criteria, both PRs (NACP & NTP) evaluated through a transparent process (Annexure 12 – NTP and NACP evidence of process and activities conducted).The potential SRs selected by both PRs of NTP and NACP invited them and conducted meetings to ensure effective interactive process of fine tuning their proposals thus maintaining strategic focus on the two key objectives of the Round 8 proposal and ensuring that the potential SRs fit into the overall implementation strategy of ensuring coverage of services to the critical mass of IDUs, their families, and care and treatment support to PLHIVs in the districts not covered under the PC-I and to fill NTP’s gap for drugs and Supply Management in GFATM Round-8 also not covered by PC-I in next five years. NACP and NTP organized consultative meetings with the SRs to discus the financial and technical proposals submitted by the SRs and integrated the strategies proposed by the selected SRs in the proposal forms. The first draft of the GFATM Round-8 proposals for HIV/AIDS and NTP were shared electronically and hard copies of the initial draft of proposal was sent via courier to CCM and non CCM members for initial inputs. To strengthen the process, the Chair CCM approved a meeting which was held in which CCM Core Committee Members, Non CCM members and Other People from the Civil Society participated. The potential PRs (NACP) and NTP presented the proposals. All the participants discussed and provided feed back and comments for the both proposals. The comments/feed back was recorded by the programmes. (evidence/minutes of meeting are attached to support the initiatives. (Annexure-13). An other meeting of TWG held in NACP to further discuss and to provide input to HIV/AIDS proposal. (Annexure – 14).

(c) Describe the process(es) used to ensure the input of people and stakeholders other than CCM (or Sub-CCM) members in the proposal development process. (If a different process was used for each disease, explain each process.)

CCM Pakistan organized one day workshop in which different groups Non-CCM Members, PLWHA group, National and International level Civil Society Organizations, UN and bilateral Agencies and Provincial programmes representatives were invited. The purpose of the one day workshop was to share the GFATM Round-8 proposals out line for NTP and NACP strategies to ensure inputs by the wide range of stakeholders for the GFATM Round-8 proposals priority areas. (Annexure – 15). The Technical Working Group and the larger Advisory Group included besides professionals, members of the civil society and representatives of those most affected by the disease to review the recommendations of the Technical Working Group. The entire proposal development process was documented that included a series of Technical Working Group and Advisory Group meetings to define the gaps and identify specific areas of focus. A constant feedbacks process had been practiced soliciting inputs from members of the two committees regarding their concerns and recommendations to draft components of the proposal. Detailed presentations were made rationalizing the choice of the key focus areas and the service delivery areas. The advisory group consisted of members representing civil society organizations, people living with HIV/AIS, representatives from bilateral and multilateral international development organizations, and key program staff members.

Each Provincial Program Manager representing the Provincial AIDS Control Programs were encouraged to brief and share with civil society organizations in their respective provinces the status of the proposal



development process and seek feedback on key elements of the proposal. Written feedbacks were encouraged and received from a range of stakeholders including representatives of bilateral and multilateral development partners about the strategic framework developed by the National Consultant.

In addition, to strengthen the process, the Chair CCM approved a meeting which was held in which Non CCM members and Other People from the Civil Society participated. The potential PRs (NACP) and NTP presented the proposals. All the participants discussed and provided feed back and comments for the both proposals. The comments/feed back was recorded by the programmes. (evidence/minutes of meeting are attached to support the initiatives. (Annexure-16).

(d) Attach a signed and dated version of the minutes of the meeting(s) at which the members decided on the elements to be included in the proposal for all diseases applied for. (CCM Meeting held on May 15, 2008)

Annexure – 17

2.2.3. Processes to oversee program implementation

(a) Describe the process(es) used by the CCM (or Sub-CCM) to oversee program implementation.

To ensure effective oversight, CCM Pakistan has formed its sub committees i.e. monitoring and technical. The CCM sub committee technical complement the technical aspects related to TGF grants ranging from gender to health systems strengthening. The CCM sub-committee M&E consists of experts who provide technical expertise to the CCM on institutional and technical issues related to the grant performance. The M&E sub-committee reviews the periodic monitoring reports of the PRs and shares its findings with the CCM. The CCM forms other task oriented temporary committees to provide technical support to the CCM. The sub-committees are assigned specific tasks and report back to the CCM for final approval. CCM Pakistan Sub Committee M&E’s members are WHO, DFID (as Chair of M&E), UNAIDS, Civil Society Members of CCM, People Living with and or affected by disease and the Programme Managers NACP, NTP and Malaria. There are approved TORs for the CCM Sub Committee M&E. The CCM Sub Committee M&E performs oversight role over the Grants Implementation and PR performance. The rational for providing oversight is to facilitate speedy implementation process of the TGF grants. A): The process exercised by the CCM to oversee programme implementation is very transparent and effective. PR office prepares quarterly progress reports for TGF grants with CCM. CCM Secretariat shares quarterly reports (financial and programmatic) with all CCM members. CCM Sub Committee members review the quarterly progress reports. Incase there is any reporting of below targeted expected output in the respective quarter, it is notified to CCM. The Chair CCM being the Secretary Health directly notices the reason for causing low achievement of targets. The impediment is immediately addressed and the concerned department is immediately approached. B): In order to review PRs performance and the programme implementation status, CCM Sub Committee M&E calls for meeting in which PRs are required to present their performance and the level of progress achieved. During these meetings, PRs also present their constraints/impediments for which CCM Chair issue instructions to facilitate the process. (Annexure – 18). Minutes of M&E Committee and facilitation extended by CCM to PR private sector addressing their concerns. C): In case TGF writes to PR and CCM and reports their concerns over the grants performance in as reported by the LFA to the Global Fund on the PRs quarterly progress reports. In case there is any performance related issue and the Global Fund advices about the Time Bound Actions, then CCM reverts to the PR office and asks PR to respond to performance concerns raised by TGF and what remedial actions will be taken by the PR to address TGF issues. In addition, the CCM forum also identify the areas of support required to meet the time bound actions and concerned sector/department is immediately reached.(Annexure – 19). D): CCM members representing on CCM i.e. Planning Commission of Pakistan has its own M&E component to monitor health projects in Pakistan and while conducting routine M&E TGF grants monitoring is also part of this activity. The programme managers who are also CCM members, when their respective programmes conduct M&E of the TGF grants and in case of any matter related to the TGF grant implementation, the concerns are raised at CCM forum during CCM meetings and are adequately addressed. The subject of M&E is given very close attention to ensure a vigilant oversight over TGF grants and the PRs.



(b) Describe the process(es) used to ensure the input of stakeholders other than CCM (or Sub-CCM) members in the ongoing oversight of program implementation.

To ensure effective oversight, and in puts of stakeholders other than CCM in the ongoing oversight of programme implementation of TGF grants. While the monitoring and technical sub-committees complement the technical expertise of the CCM and bridge incase of any gaps, by including in the sub-committees professionals with expertise ranging from gender to health systems strengthening. The sub-committee (technical) consists of experts from stakeholders M&E experts team in form of input or by assigning to oversee TGF programmes while conducting their routine M&E activities and to share information with the member representing on CCM. CCM observer group members i.e. World Bank, UN agencies etc. the PRs quarterly progress reports are also shared with them. In addition, they also attend CCM meetings in which M&E related matters are discussed and the members other than CCM attending the forum meeting do share their comments and also support for M&E initiatives. (Annexure – 20) (minutes of CCM meeting showing attendance of Non CCM members). CCM also involve experts other than CCM members while forming the other task oriented temporary committees to provide technical support to the CCM. The sub-committees are assigned specific tasks and report back to the CCM for final approval i.e. CCM temporary committees to short list PRs for GFATM Round-8. (Annexure – 21).

2.2.4. Processes to select Principal Recipients

The Global Fund recommends that applicants select both government and non-government sector Principal Recipients to manage program implementation. Refer to the Round 8 Guidelines for further explanation of the principles. .

(a) Describe the process used to make a transparent and documented selection of each of the Principal Recipient(s) nominated in this proposal. (If a different process was used for each disease, explain each process.)

CCM Pakistan applied the similar process to make a transparent and documented selection of each of the Principal Recipient (s) nominated in this proposal for HIV/AIDS and TB proposals. CCM Pakistan supports dual financing mechanism / multiple PRs approach. In order to ensure transparency in the PR selection process, the process of PRs selection started in February 2008. CCM meetings held on February 2008 and on March 05, 2008 approved the PRs selection process. (Annexure-22). CCM focused on the aspect of access of CCM advertisement of inviting applications of PRs from public and private sectors, the members of the CCM sub committee Technical and M&E met on 8th February 2008 and on 20th March 2008 also discussed the draft of EOI, PR short listing criteria. The CCM sub committee M&E and Technical CCM formed a PR evaluation committee consisting of individuals with multi-sectoral experience. The EOI was drafted and circulated to all members of the CCM. After the approval of the EOI notice by the CCM it was published in all the leading newspapers of the country in national language Urdu and English to ensure access to a wide range of NGOs, CBO, Stakeholders and Multilateral/Bilateral Development Partners (CCM Annexure 23– PR EOI Notice). A minimum of 15 days period was provided to interested organizations for submitting EOIs. A total of 19 EOIs were received for for PRs from public and private sectors as per the deadline set for the receipt of EOIs. The CCM Secretariat prepared a list of organizations that had submitted EOIs for PRs for the respective TGF Round-8. CCM committee members evaluated the EOIs based on the evaluation criteria (CCM Annexure 24 – PR Evaluation Criteria). To avoid potential conflict of interest, the short-listing criteria was only shared the evaluation committee members who were not interested t submit EOIs. NTP, NACP and other members of CCM sub committee M&E and Technical did not participate the final meeting held on March 20, 2008 at WHO in which PRs short listing criteria and scores allocation was finalized.(Annexure-24-a). The PR evaluation committee members approved by CCM evaluated as per the CCM approved evaluation criteria and prepared its recommendations for the CCM. On May 15, 2008 CCM forum endorsed the process of PR selection and the PRs from public and private sector for HIV/AIDS and TB proposals for Round-8. The Evaluation Committee’s recommended one PR from the public sector and one from the non-governmental sector which was endorsed by the CCM in its meeting held on May 15, 2008 (CCM Annexure 25 – CCM Minutes of the Meeting).





(b) Attach the signed and dated minutes of the meeting(s) at which the members decided on the Principal Recipient(s) for each disease. (Annexure 26)

2.2.5. Principal Recipient(s)

Name Disease Sector**

National AIDS Control Programme HIV & AIDS Public Sector

Nai Zindagi HIV & AIDS Non Government Sector

National TB Control Programme Tuberculosis PR - Public Sector

Green Star Social Marketing Int. (GSSM) Tuberculosis PR – Non Government Sector

[use "Tab" key to add extra rows if needed]

** Choose a 'sector' from the possible options that are included in this Proposal Form at s.2.1.1. 2.2.6. Non-implementation of dual track financing

Provide an explanation below if at least one government sector and one non-government sector Principal Recipient have not been nominated for each disease in this proposal.

Not Applicable

2.2.7. Managing conflicts of interest

Yes provide details below (a) Are the Chair and/or Vice-Chair of the CCM (or Sub-CCM) from the

same entity as any of the nominated Principal Recipient(s) for any of the diseases in this proposal? No

go to s.2.2.8.

(b) If yes, attach the plan for the management of actual and potential conflicts of interest.

Yes [Annexure No.27)]

2.2.8. Proposal endorsement by members

Attachment C – Membership information and Signatures

Has 'Attachment C' been completed with the signatures of all members of the CCM (or Sub-CCM)? Yes

ROUND 8 – Tuberculosis Section Document description Annex Number

2.2.2 Call for proposal Annex 2

2.2.2 EOIs for PRs Annex 3

2.2.2 Response to EOIs for PRs Annex 4

2.2.2 List of SRs Annex 5

2.2.2 Gap Analysis TB Annex 6

2.2.2 Gap Analysis HIV Annex 7

2.2.2 Endorsement by CCM Annex 8

2.2.2 Minutes Annex 9 & 10

2.2.2 (b) Proposal template Annex 11

2.2.2 (b) Selection Process Annex 12

2.2.2 (b) Feedback Annex 13

2.2.2 (b) TWG meeting Annex 14

2.2.2 (c) Priority Areas identification Annex 15

2.2.2 (c) Minutes Annex 16

2.2.3 (a) Minutes Annex 17, 18, 19, 20 & 21

2.2.3 (a) Approval of Selection Annex 22

2.2.3 (a) PR EOI Notice Annex 23

2.2.3 (a) PR Evaluation criteria Annex 24

2.2.3 (a) CCM Minutes Meeting Annex 25

[use “Tab” key to add extra rows if needed]


ROUND 8 – Tuberculosis List of Abbreviations and Acronyms used by the Applicant

Acronym/ Abbreviation

HIV

Meaning

AIDS AJK ANC ART ARV BCC BOE BTA CBO CCM CPR CSW DIC DOTS EHACP ESW FSW GDP GOP HAART HASP HBV HCV HIV IBBS IDU IEC LHW LSBC M&E MDG MONC MOE MOF MOH MOL MOM MOPD MOPW MSM MSW MTCT MTR

Acquired Immunodeficiency Syndrome Azad Jammu and Kashmir Ante-natal Care Antiretroviral therapy Antiretroviral (medicines) Behaviour change communication Bureau of Emigration and Overseas Employment Blood Transfusion Authority Community-based organization Country coordinating mechanism Contraceptive prevalence rate Commercial sex worker Drop in center Directly observed treatment short-course Enhanced HIV/AIDS Control Programme Eunuch sex worker Female sex worker Gross domestic product Government of Pakistan Highly active antiretroviral therapy HIV/AIDS Surveillance Programme Hepatitis B Virus Hepatitis C Virus Human immunodeficiency virus Integrated behavioural and biological surveillance Injecting drug user Information, education and communication Lady Health worker Life skills-based curriculum Monitoring and evaluation Millennium Development Goal Ministry of Narcotics Control Ministry of Education Ministry of Finance Ministry of Health Ministry of Labour, Manpower and Overseas Pakistanis Men on the move Ministry of Planning and Development Ministry of Population Welfare Men who have sex with men Male sex worker Mother to child transmission Mid-term review


ROUND 8 – Tuberculosis MWRA NACP NGO NHAP NIH NIPS NSEP NSF NWFP OI OPD PACP PEP PHC PIP PLHIV PMTCT PPP RH RSA RTI SDP UN UNAIDS UNGASS USAID WHO

Married women of reproductive age National AIDS Control Programme Non-governmental organization National HIV/AIDS Policy National Institute of Health National Institute of Population Studies Needle syringe exchange programme National Strategic Framework North West Frontier Province Opportunistic infection Out-patient department Provincial AIDS Control Programme Post exposure prophylaxis Primary health care Programme implementation plan People living with HIV (now the preferred alternative to PLWHA) Prevention of mother to child transmission Public-private partnership Reproductive health Rapid situation assessment Reproductive tract infection Service delivery package United Nations United Nations Programme on HIV/AIDS United Nations General Assembly’s Special Session on HIV and AIDS United States Agency for International Development World Health Organization


ROUND 8 – Tuberculosis Acronyms/ abbreviations for TB ASD Association for Social Development BHU Basic Health Unit CHO Community Health Officer DC Diagnosis Center DM Drug management DOT Directly observed treatment DOTS Internationally recommended control strategy for tuberculosis DMIS Drug management Information system DTC District TB coordinator E Ethambutol EDO Executive District Officer EML Essential medicines list FDC Fixed-dose combination TB drugs GDF Global Drug Facility GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GS Green star social marketing H Isoniazid IACC Inter Agency Coordination Committee MOH Ministry of Health MSH Management Science for Healthy NTP National tuberculosis control programme PATA Pakistan Anti-Tuberculosis Association PHD Provincial Health Departments PPC Provincial procurement committee PPM Public-private mix PTB Pulmonary tuberculosis PTP Provincial TB Control Programme PR Principal Recipient R Rifampicin RHC Rural Health Centers S Streptomycin SOP Standard operation procedure SR Sub recipients SS+ Sputum smear-positive SS- Sputum smear-negative TB Tuberculosis TC Treatment center USP United States Pharmacopeia WHO World Health Organization Z Pyrazinamide


ROUND 8 – Tuberculosis 3. PROPOSAL SUMMARY

Duration of Proposal Planned Start Date To

Month and year: (up to 5 years)

July 2009 June 2014

Consolidation of grants

Yes (go first to (b) below)

(a) Does the CCM (or Sub-CCM) wish to consolidate any existing tuberculosis Global Fund grant(s) with the Round 8 tuberculosis proposal?

X No (go to s.3.3. below)

‘Consolidation’ refers to the situation where multiple grants can be combined to form one grant. Under Global Fund policy, this is possible if the same Principal Recipient (‘PR’) is already managing at least one grant for the same disease. A proposal with more than one nominated PR may seek to consolidate part of the Round 8 proposal.

More detailed information on grant consolidation (including analysis of some of the benefits and areas to consider is available at: http://www.theglobalfund.org/en/apply/call8/other/#5

(b) If yes, which grants are planned to be consolidated with the Round 8 proposal after Board approval? (List the relevant grant number(s))

Alignment of planning and fiscal cycles

Describe how the start date: (a) contributes to alignment with the national planning, budgeting and fiscal cycle; and/or (b) in grant consolidation cases, increases alignment of planning, implementation and reporting efforts.

The proposed start date of July 2009 corresponds with: the start of the country’s fiscal cycle (July-June); the National Tuberculosis Programme’s (NTP) quarterly reporting schedule; and, the quarterly reporting schedule for the majority of the proposed Principal Recipients’ (NTP and Greenstar) external donors and partners, including JICA and USAID. The budget cycle for the Round 6 Tuberculosis award, for which the NTP is a co-PR, runs from November through October; however, the NTP does not envisage that this will impede the implementation of the proposed activities under Round 8. By corresponding with the majority of budgeting and programmatic reporting responsibilities, a July 1 start date will help ensure the consistency of data and budgeting by the Principal Recipients and reduce programmatic delays.

Program-based approach for Tuberculosis

X Yes. Answer s.3.4.2 3.4.1. Does planning and funding for the country's response to tuberculosis occur through a program-based approach?

No. Go to s.3.5.

Yes Complete s.5.5 as an additional section to explain the financial operations of the common funding mechanism.

3.4.2. If yes, does this proposal plan for some or all of the requested funding to be paid into a common-funding mechanism to support that approach?

No. Do not complete s.5.5


http://www.theglobalfund.org/en/apply/call8/other/#5



Summary of Round 8 Tuberculosis Proposal

Provide a summary of the tuberculosis proposal described in detail in section 4. Prepare after completing s.4.

In support of the objectives of TB National Strategic Plan to support TB control in Pakistan, the National Tuberculosis Programme (NTP) and Greenstar Social Marketing (Greenstar) propose a multi-dimensional 5-year program to procure essential anti-tuberculosis drugs and strengthen the drug management system for TB. The procurement of the requested drugs and the strengthening of the drug management system is essential to prevent a critical shortage of anti-TB drugs, to support the successful implementation of the Global Fund Round 6 award and support the TB Programme’s continued progress towards the global Stop TB target of 85% treatment success. In the last 3 years, TB case finding has increased dramatically which has increased the demand for anti-tuberculosis drugs. This increased demand has reduced the NTP national buffer stock, increased the need for drugs at the provincial level, and strained the current drug management system. This program will build on the existing constructive partnership between the NTP and Greenstar to engage both public and private sector partners in improving TB drug management systems. The program designed, summarized in the table below, capitalizes on the comparative advantage and core competencies of the two proposed PRs, NTP and Greenstar, to: achieve high impact; improve absorption capacity; and, effectively engage both the public and private sectors in appropriate TB drug management through the public sector district led implementation model. The scope of the program will be nationwide. The direct beneficiaries will be the national health system and the public and private providers engaged in TB control, and the indirect beneficiaries will be notified TB patients. Goal: Reduce morbidity and mortality due to TB (reduce burden of disease due to TB)

Outcome Indicator:

Treatment success rate of 85%

Objectives: 1. Pursue high quality DOTS expansion and enhancement 2. Health systems strengthening (HSS)

SDA 1.1: Procurement and supply management: Procurement, storage and distribution of first line anti-TB drugs (PR: NTP for activities 1.1.1, 1.1.2 and 1.1.3.1 Greenstar for activity 1.1.3.2) SDA 1.2: Human resources development: Training providers in anti-TB drug management(PR: Greenstar) SDA 1.3: Management and Supervision: Improving strategic coordination for regulation of quality anti-TB drugs (PR: NTP for activity 1.3.1, Greenstar for activity 1.3.2)

Service Delivery Areas (SDA):

SDA 2.1: HSS: Incorporating TB DMIS into national, integrated DMIS (PR: Greenstar)

The proposed dual track financing co-Principle Recipients (PRs) will be NTP and Greenstar Social Marketing. The identified sub-Recipients (SRs) will be the Association for Social Development (ASD) and the Pakistan Anti-Tuberculosis Association (PATA).

The proposed SDAs directly respond to the TRP comments from Round 7 that suggested that a revised proposal should provide innovative solutions for clearly integrating systems for TB drug management and distribution to the national system, and engage the private sector in appropriate anti-TB drug management. To address the TRP comments, the scope of the proposed program has been increased to include partners from the private and NGO sectors and new activities such as expanded drug distribution, training and increasing drug regulation in the private sector have been added to create a more comprehensive, health systems strengthening oriented program.

ROUND 8 – Tuberculosis 2. PROGRAM DESCRIPTION

National programme and strategy

(a) Briefly summarize: the current tuberculosis national programme or strategy; how the strategy responds comprehensively to current epidemiological situation in the country; and the improved tuberculosis outcomes expected from implementation of this programme or strategy.

The overall goal of TB control in Pakistan is to reduce morbidity, mortality and transmission of TB disease, and to prevent the emergence of multi-drug resistant (MDR) TB. In response to increasing TB incidence, the Government of Pakistan declared TB a national public health emergency in 2001 (Islamabad Declaration 2001) and placed a high priority on TB control in the National Health Policy of 2001. The Government confirmed its strong commitment to TB control in the Medium Term Development Framework (MTDF) 2005-2010, the national framework used to guide national annual budget contributions necessary for achieving the country’s Millennium Development Goals. The NTP National Strategic Plan (2005-2010) articulates a clear “road map” for achieving the global Stop TB targets of 70% case detection and 85% treatment success, and 100% DOTS coverage at all public health centers. To achieve these goals, strategic plan prioritizes eight programmatic objectives and corresponding key activities:

o Context-adapted staff training; o Functioning laboratory network; o Availability of quality drugs; o Surveillance, monitoring and evaluation; o Intra and inter-sectoral partnerships; o Programme based research and development; o Public-private partnership development; and o Behavior change communication and social mobilization.

To achieve these objectives, Pakistan has assumed a decentralized approach to TB control that integrates TB control activities with the primary health care system through the four Provincial Health Departments (PHD). This system is separated into three distinct levels: central; provincial; and district. At the central level, the NTP provides strategic guidance, spearheads new initiatives, and provides routine and emergency program support services (such as anti-TB drug procurement). At the provincial level, the PHD budgets for and manages the implementation of TB services within that province. At the district level, district authorities are the primary interlocutor with the health facilities in their respective districts. The NTP also supports several public private partnerships, including the Greenstar Network, to engage private health care providers in TB care. Additional efforts to support TB control include the administration of BCG to all infants through the Expanded Program for Immunization (EPI) and recommending isoniazid prophylaxis (IPT) for all children of TB infected mothers or primary care takers. This decentralized and integrated approach is designed to engage all health care providers and health systems levels in TB control to improve equitable distribution of quality TB services for all Pakistani communities. TB control activities are currently supported by a number of donors, including the Government of Pakistan, GTZ, KfW, JICA, DfID, FIDELIS (The Union), and the Global Fund (Rounds 3 and 6). The Inter-agency Coordination Committee (IACC) was established to limit programmatic overlap between activities. The IACC has been very successful in promoting coordination and preventing duplication of efforts. By following the current strategy the NTP has made significant gains in TB control, achieving 100% DOTS coverage in 2005. According to the 2008 Global TB Control Report, Pakistan has the eighth highest TB incidence in the world (181/100,000 population). The proportion of TB patients is steadily decreasing (6% in 2006) and treatment success rates among new sputum smear positive patients are increasing (83% in 2006). Community awareness campaigns combined with increased access to TB services in the public and private sectors have most likely led to the marked increase in case detection from 33% in 2004 to 59% in 2006. As case detection rates continue to increase, it will be essential that the country maintain a sufficient and well managed supply of TB drugs to ensure that treatment success rates continue to reach for and hopefully exceed the Stop TB treatment success rate target of 85%.


ROUND 8 – Tuberculosis (b) From the list below, attach* only those documents that are directly relevant to the focus of this

proposal (or, *identify the specific Annex number from a Round 7 proposal when the document was last submitted, and the Global Fund will obtain this document from our Round 7 files).

Also identify the specific page(s) (in these documents) that support the descriptions in s.4.1. above.

Document Proposal Annex Number Page References

National Health Sector Development/Strategic Plan -

X National Tuberculosis Control Mid Term Strategy or Plan I

X National Tuberculosis Guidelines (medical) II

Important sub-sector policies that are relevant to the proposal (e.g., national or sub-national human resources policy, or norms and standards)

-

X Most recent annual reports, monitoring mission reports or reviews, including any epidemiology report directly relevant to the proposal

III

X National Monitoring and Evaluation Plan (health sector, disease specific or other) -

National policies to achieve gender equality in regard to the provision of tuberculosis diagnosis, treatment, and care and support services to all people in need of services

_

Epidemiological Background

4.2.1. Geographic reach of this proposal

(a) Do the activities target:

X Whole country

Specific Region(s)

**If so, insert a map to show where

Specific population groups **If so, insert a map to show where these groups are if they are in a specific area of the country

** Paste map here if relevant


r

r

r


(b) Size of population group(s) targeted in Round 8

Population Groups Population Size Source of Data Year of Estimate

Total country population (all ages) 162 m

Pakistan Population Data Sheet 2001 (National Institute of Population Studies)

2008

Women > 25 years 46.3 m


2008

Women 19 – 24 years 16.7 m


2008

Women 15 – 18 years Not available


2008

Men > 25 years 46.3 m


2008

Men 19 – 24 years 18.3 m


2008

Men 15 – 18 years Not available


2008

Girls 0 – 14 years 26.9 m


2008

Boys 0 – 14 years 28.7 m


2008

Other **: **Refer to the Round 8 Guidelines

for other possible groups

Clarified Section 4.2.2

4.2.2 Tuberculosis epidemiology of target population(s)

Population Groups Number Source of Data Year of Estimate

Estimated tuberculosis patients - shown as number per 100,000 population (all ages)

181 WHO Global TB Control Annual Report 2008

2008

(2006 cohort)

Female tuberculosis patients > 25 years Not available

Female tuberculosis patients 19 – Not available






24 years

Female tuberculosis patients 15 – 18 years Not available

Male tuberculosis patients > 25 years Not available

Male tuberculosis patients 19 – 24 years Not available

Male tuberculosis patients 15 – 18 years Not available

Notified Tuberculosis patients all forms (shown as number per 100,000 population)

142 NTP Data 2007

Tuberculosis patients all forms tested for HIV (rate among notified Not available No policy for counseling and

testing TB patients for HIV

Estimated number new smear-positive tuberculosis patients (rate per 100,000 habitants)

82 WHO Global TB Control Annual Report 2008

2008

(2006 cohort)

Notified new smear-positive tuberculosis patients (rate per 100,000 habitants)

54 NTP Data 2007

Case detection rate of new smear-positive cases 69% NTP Data 2007

Estimated number of multi-drug resistant cases of tuberculosis 6000 WHO Global TB Control Annual

Report 2008 2008

(2006 cohort)

Notified number of multi-drug resistant cases bacteriologically confirmed

Not available

Treatment success rate of new smear-positive cases 83% WHO Global TB Control Annual

Report 2008 2008

(2006 cohort)

Defaulter and transfer rate of new smear-positive cases 6% NTP Data 2007

Estimated number of girl (0 – 14 years) sputum smear tuberculosis patients

2606 NTP Data 2007

Notified number of girl (0 – 14 years) sputum smear positive tuberculosis patients

2443 NTP Data 2007

Estimated number of boy (0-14 years) sputum smear positive

1085 NTP Data 2007





tuberculosis patients

Notified number of boy (0 – 14 years) tuberculosis patients all forms

1017 NTP Data 2007

Other**: **Refer to the Round 8 Guidelines for other possible groups

4.3. Major constraints and gaps (For the questions below, consider government, non-government and community level weaknesses and gaps, and also any key affected populations4 who may have disproportionately low access to tuberculosis diagnosis, treatment, and care and support services, including women, girls, and sexual minorities.)

4.3.1. Tuberculosis program Describe: • the main weaknesses in the implementation of current tuberculosis program or strategy; • how these weaknesses affect achievement of planned national tuberculosis outcomes; and • existing gaps in the delivery of services to target populations. While the NTP and its collaborating partners have made significant gains in TB control, weaknesses and gaps still need to be addressed. The 2007 Joint Review of Pakistan TB Control, carried out by the MOH Pakistan, GDF, GTZ, JICA and WHO (Annex III), highlighted both the successes and the continuing challenges to achieving the international STOP TB targets for case detection and treatment success. Successes include: more than doubling case detection since 2004; increased central, provincial and district level government political and financial support; increased resources and logistics support within the public sector; improved laboratory network capacity; and the introduction of innovative public private mix approaches through partners like the Gulab Devi Hospital in Lahore and Greenstar Social Marketing. Despite these advancements, case detection continues to fall short of the global targets and leaving over 120,000 TB patients un-identified and without treatment. The key weaknesses highlighted in the report were: weak drug procurement and management systems; limited capacity of the National Reference Laboratory due to on-going renovations; and low case detection. The report offered these recommendations to address these weaknesses: • Improve drug management supply systems and procurement to ensure a regular supply of high-

quality anti-TB drugs (including monitoring and/or regulating the sale of TB drugs in the private sector);

• Increase human capacity at the NTP and ensure continued financial commitment from the national and provincial governments;

• Scale-up public-private mix (PPM) initiatives and quality case management by private providers; • Strengthen laboratory capacity and networks; • Improve suspect, case and contact management in the public and private sectors; and, • Improve monitoring and evaluation and TB surveillance (including a prevalence survey). Of these challenges, the NTP has identified improving drug procurement and management as the most urgent and critical gap to be addressed by this proposal. This decision was informed by the findings of the Joint Review cited above and an external gap analysis by Management Sciences for Health (MSH) in 2007 (Annex IV), and the impending threat of anti-TB drug shortages and stock-outs if funding for anti-TB drugs is not secured. The Joint Review and MSH gap analyses reports concluded that the rapid increase in case detection rates have dramatically increased the demand for anti-TB drugs and subsequently

4 Please refer back to the definition in s.2 and found in the Round 8 Guidelines.




ROUND 8 – Tuberculosis diminished the availability of high-quality anti-TB drugs available in the public sector, including the NTP buffer stock. The initial NTP buffer stock, financed by the GDF (2003-2006) was rapidly depleted in 2006 by increased case detection and subsequent demand for public sector anti-TB drugs. Unless Pakistan is able to secure funding for the anti-TB drugs requested in this proposal, the country will face a critical stock-out of drugs, which will significantly impede the implementation of the Global Fund Round 6 award and potentially led to the interrupted anti-TB treatment of thousands of Pakistanis in need. To support the appropriate procurement and distribution of the requested life-saving anti-TB drugs, it is essential to strengthen Pakistan’s drug management system. Drug management system gaps were identified by the Joint Review, the MSH report, and the internal NTP Round 7 gap analysis (Annex V, including: limited appropriate storage capacity for anti-TB drugs at the national and provincial levels; limited capacity for distribution of drugs between provincial and district level facilities; availability of questionable quality anti-TB drugs available in the private sector; and, antiquated and inadequate drug management information system (DMIS). Unless these gaps are addressed immediately, there is a palpable risk that the country might not be able to provide an uninterrupted supply of quality drugs to TB patients, threatening the country’s marked advances towards achieving the global target of 85% treatment success and increasing the risk of MDR, and the successful implementation of Round 6. The funding need for drug procurement and improved drug management is critical. This proposal is a resubmission of Pakistan’s Round 7 TB proposal which was not accepted. Pakistan subsequently received an emergency GDF grant of $3.7 million to ensure drug stocks through 2009; however, no alternative long-term funding solution has yet been identified. Filling this gap and strengthening drug management will lay the foundation for the successful design and implementation of Pakistan’s planned Round 9 proposal focusing on scaling up PPM initiatives.

4.3.2. Health System Describe the main weaknesses of and/or gaps in the health system that affect tuberculosis outcomes. The description can include discussion of: • issues that are common to HIV, tuberculosis and malaria programming and service delivery; and • issues that are relevant to the health system and tuberculosis outcomes (e.g.: PAL services), but

perhaps not also malaria and tuberculosis programming and service delivery. The growing burden of communicable diseases has stretched the health system’s ability to provide equitable access to high quality health services to all Pakistanis. Currently, communicable diseases account for 40% of the total national burden of disease (BOD). The most common communicable diseases include: diarrheal diseases; acute respiratory infections; malaria; tuberculosis, hepatitis B and C; and, other preventable childhood diseases. HIV prevalence among the general population is less than 1%. The country is divided into four provinces (Baluchistan, Punjab, Sindh, and the North West Frontier Province (NWFP)). Punjab and Sindh provinces are the most densely populated, representing 81% of the country’s total population. Nationally, approximately 67% of the population lives in rural areas and 33% live in urban areas (Federal Bureau of Statistics, Pakistan). MOH national health programs, including the NTP, are decentralized at the provincial and district levels and integrated into the public primary health care system. In general, the public health system is challenged by issues of equity, effectiveness and efficiency. Public resources are not always equitably allocated, either to populations most in need, such as poor communities, or the greatest health need or disease burden in that locality. Like many other developing countries, Pakistan has insufficient public sector human resources to meet the needs of its population. Services in urban areas are mostly provided by the private sector, while public and NGO services have greater coverage in rural areas. The private sector plays a key role in TB service delivery, as more than 75% of the population first seeks care in the private sector; however, service provision by the private sector is largely unregulated. In the public sector facility network includes: 924 hospitals; 4,712 dispensaries, 5,336 Basic Health Units (BHU); 560 Rural Health Centers (RHC), 906 Maternal and Child Health Centers (MCH); 288 TB Centers (TBC). In the private sector, there are approximately 42,700 registered private facilities providing care and treatment, 69% of which are clinics and drug shops, plus 550 private hospitals. There are 117,973 doctors registered with the Pakistan Medical and Dental Counsel, including many doctors who work in both the public and private sectors simultaneously. The STOP TB partnership has recognized that private health care providers can contribute significantly to TB control if they are integrated into the DOTS




strategy. International studies prove that without engaging private providers, poor quality and sometimes harmful care by untrained private providers will continue. Other analyses have found some evidence that well-managed networks of private providers can offer a service that has a positive impact on the quality of the public sector. Engagement of private providers can extend the reach TB services, especially to rural and underserved populations. Bureaucratic drug procurement procedures, insufficient drug storage capacity and weak drug management information systems (DMIS) are significant challenges for the NTP and wider health system. Standard procurement procedures and standardized specifications for anti-TB drugs need to be developed to reduce procurement delays and prevent stock-outs. Additional efforts also need to be made to regulate the availability of first line anti-TB drugs of questionable quality that are available on the open market. Available NTP and PHD drug storage facilities need to be upgraded, so that they NTP national buffer stock can be appropriately housed at the national level and so that integrated PHD drug warehouses have sufficient space to appropriately store anti-TB drug supplies until they are dispatched to the provinces. A computerized DMIS system also needs to be developed and implemented to correctly track drug inventory and quantify drug needs. The revised DMIS system needs to be able to track drugs procured by the NTP at central level or the PHDs at provincial level, to the provincial warehouses, to the district warehouses, to the health facility and service providers, and then to the patient. This system should also be able to include information from private providers and be linked with NTP monitoring and evaluation systems to verify drug usage against the number of notified TB patients. It is also essential that the DMIS be integrated and complement the DMIS system used by the PHD to track drugs and health commodities; therefore, preventing the establishment of a vertical TB DMIS system.

4.3.3. Efforts to resolve health system weaknesses and gaps Describe what is being done, and by whom, to respond to health system weaknesses and gaps that affect tuberculosis outcomes.

MOH recognizes the weaknesses within the health system and is taking action. To address equity issues, MOH has revised the existing health policy to focus public resources on the poor by increasing access to public sector services in rural and informal urban areas or slums. It is also redistributing human and financial resources to community level service delivery points with the hopes of reaching more vulnerable populations, including women and children under the age of 5. In addition, MOH is mobilizing national and international resources to develop and implement efficient and effective disease surveillance systems to help identify health needs and guide resource allocation. This includes funding from USAID through TBCAP to implement a national TB prevalence survey in 2009. MOH also performs a strong stewardship and coordination role at the federal level, giving strategic guidance to the provinces and coordinating donor investments across the health system. It achieves this through developing guidelines, such as the National Health Policy (2001) and the MTDF 2005-2010, as well as facilitating interagency meetings between the national programs and the PHDs.

MOH also recognizes the strong presence of the private sector and actively supports public private partnership (PPP)/public private mix (PPM) activities for TB and other health needs like reproductive health. TB PPM activities are supported through Greenstar in GF Round 3 and Mercy Corps in Round 6 advocacy, communication and social mobilization (ACSM) activities.

Initial efforts to address health systems weaknesses regarding drug management are also being addressed. USAID is currently funding Abt Associates to develop a comprehensive drug management system for essential health commodities and contraceptives. In addition, JICA is providing funding to develop guidelines for TB drug specifications and procurement. Additional funding is needed for both of these efforts to ensure that TB is adequately integrated into the national DMIS system and to further develop the guidelines into policy, provide training and support enforcement of the policy.

ROUND 8 – Tuberculosis 4.4. Round 8 Priorities

Complete the tables below on a program coverage basis (and not financial data) for three to six areas identified by the applicant as priority interventions for this proposal. Ensure that the choice of priorities is consistent with the current tuberculosis epidemiology and identified weaknesses and gaps from s.4.2.2 and 4.3. Note: All health systems strengthening needs that are most effectively responded to on an tuberculosis disease program basis, and which are important areas of work in this

proposal, should also be included here.

Priority No: 1 Historical Current Country targets

Intervention To ensure an uninterrupted, regular supply of quality drugs 2006 2007 2008 2009 2010 2011 2012 2013

A: Country target (from annual plans where these exist) 179,780 234,100 242,793 495,298 252,602 257,654 262,807 268,063

B: Extent of need already planned to be met under other programs 179,780 234,100 271,463 437,389 154,138 148,403 151,629 151,629

C: Expected annual gap in achieving plans 0 0 -28670 57,909 98,464 109,251 111,178 116,434

D: Round 8 proposal contribution to total need (e.g., can be equal to or less than full gap) 57,909 98,464 109,251 111,178 116,434 *Numbers included in table indicate patient courses of anti-TB drugs (Category 1 and 2). *2009 includes additional patient courses to fulfill national buffer stock.


ROUND 8 – Tuberculosis 4.5. Implementation strategy

4.5.1. Round 8 interventions Explain: (i) who will be undertaking each area of activity (which Principal Recipient, which Sub-Recipient or other implementer); and (ii) the targeted population(s). Ensure that the explanation follows the order of each objective, program work area (or, "service delivery area (SDA)"), and indicator in the 'Performance Framework' (Attachment A). The Global Fund recommends that the work plan and budget follow this same order. Where there are planned activities that benefit the health system that can easily be included in the tuberculosis program description (because they predominantly contribute to tuberculosis outcomes), include them in this section only of the Round 8 proposal. In support of the objectives of TB National Strategic Plan to support TB control in Pakistan, the National Tuberculosis Programme (NTP) and Greenstar Social Marketing (Greenstar) propose a multi-dimensional 5-year program to procure essential anti-tuberculosis drugs and strengthen the drug management system for TB. The procurement of the requested drugs and the strengthening of the drug management system is essential to prevent a critical shortage of anti-TB drugs, to support the successful implementation of the Global Fund Round 6 award and support the TB Programme’s continued progress towards the global Stop TB target of 85% treatment success. In the last 3 years, TB case finding has increased dramatically which has increased the demand for anti-tuberculosis drugs. This increased demand has reduced the NTP national buffer stock, increased the need for drugs at the provincial level, and strained the current drug management system. This program will build on the existing constructive partnership between the NTP and Greenstar to engage both public and private sector partners in improving TB drug management systems. The program designed, summarized in the table below, capitalizes on the comparative advantage and core competencies of the two proposed PRs, NTP and Greenstar, to: achieve high impact; improve absorption capacity; and, effectively engage both the public and private sectors in appropriate TB drug management through the public sector district led implementation model. The scope of the program will be nationwide. The direct beneficiaries will be the national health system and the public and private providers engaged in TB control, and the indirect beneficiaries will be notified TB patients. Goal: Reduce morbidity and mortality due to TB (reduce burden of disease due to TB)

Outcome Indicator:

Treatment success rate of 85%

Objectives: 1. Pursue high quality DOTS expansion and enhancement 2. Health systems strengthening (HSS)

SDA 1.1: Procurement and supply management: Procurement, storage and distribution of first line anti-TB drugs (PR: NTP for activities 1.1.1, 1.1.2 and 1.1.3.1 Greenstar for activity 1.1.3.2) SDA 1.2: Human resources development: Training providers in anti-TB drug management(PR: Greenstar) SDA 1.3: Management and Supervision: Improving strategic coordination for regulation of quality anti-TB drugs (PR: NTP for activity 1.3.1, Greenstar for activity 1.3.2)

Service Delivery Areas (SDA):

SDA 2.1: HSS: Incorporating TB DMIS into national, integrated DMIS (PR: Greenstar)

NTP will be PR for SDAs 1.1 and 1.3, with Greenstar as a implementing PR for Activities 1.1.3.2 and 1.3.2. Greenstar will be PR for SDAs 1.2 and 2.1, and will be supported by the Association for Social Development (ASD) and The Pakistan Anti-Tuberculosis Association (PATA) as SRs for Activity 1.2.4. Each SDA will be managed by one PR only to safeguard against any conflicts of interest. For the activities that Greenstar will be SR to the NTP, Greenstar will report to the NTP and the NTP be will be responsible for reporting on the activity indicators listed on Attachment A. At no time will a PR, either NTP or Greenstar, be a SR to itself if it is also PR for that specific SDA. Instead both the NTP and Greenstar will be implementing PRs for the SDAs assigned in the table above. As an implementing PR, the PR will have management, financial and oversight


ROUND 8 – Tuberculosis responsibilities as well as implementing responsibilities as well as implementing specific activities included under the SDA. Designating both NTP and Greenstar as implementing PRs addresses any concerns about potential conflicts of interest that may arise from having a SR and a PR being the same organization on the same SDA. SDAs and activities that will be implemented to achieve the above objectives are detailed below. (Detailed work plan is annexed at VI). Objective 1: Pursue high quality DOTS expansion and enhancement SDA 1.1: Procurement and supply management: Procurement, storage and distribution of anti-TB drugs (PR: NTP for activities 1.1.1, 1.1.2 and 1.1.3.1 Greenstar for activity 1.1.3.2) The NTP will be PR for this SDA as the procurement of anti-TB drugs to be distributed through the district led implementation model is the role of the NTP under the National Strategic Plan for TB. Activity 1.1.1: 1st line Category 1 and 2 anti-TB drug procurement (Partner responsible: NTP as an implementing PR) Over five years, the NTP (PR) will procure 493,236 1st-line drug anti-TB patient courses (451,523 Category 1; and, 41,713 Category 2). This total amount represents a total annual contribution of 30% of Category 1 and Category 2 drugs supplied by the NTP for distribution through the respective Provincial Health Departments to the districts, as well as the 30% of Category 1 and 2 drugs needed to increase the national buffer stock from 70 to 100% as per WHO and The Union guidelines. The table below illustrates the current quantified need for TB drugs, the existing amount available through other resources, and the difference needed to fill the gap. The drugs requested in this Round 8 proposal will fill this gap.

Need 2009 2010 2011 2012 2013 Total

Total Estimated Cases 495,298 252,602 257,654 262,807 268,063 1,536,424

Cat 1 445,768 227,342 231,889 236,526 241,257 1,382,782

Cat 2 49,530 25,260 25,765 26,281 26,806 153,642

Cat 1 $ Amount $11,144,200 $5,683,550 $5,797,225 $5,913,150 $6,031,425 $34,569,550

Cat 2 $ Amount $2,575,560 $1,313,520 $1,339,780 $1,366,612 $1,393,912 $7,989,384

Total $ Amount Needed $13,719,760 $6,997,070 $7,137,005 $7,279,762 $7,425,337 $42,558,934

Available 2009 2010 2011 2012 2013 Total

Cat 1 390,459 137,600 132,480 135,360 135,360 931,259

Cat 2 46,930 16,538 15,923 16,269 16,269 111,929

Cat 1 $ Amount $9,761,475 $3,440,000 $3,312,000 $3,384,000 $3,384,000 $23,281,475

Cat 2 $ Amount $2,440,360 $859,976 $827,996 $845,988 $845,988 $5,820,308

Total available $12,201,835 $4,299,976 $4,139,996 $4,229,988 $4,229,988 $29,101,783

Gap 2009 2010 2011 2012 2013 Total

Cat 1 55,309 89,742 99,409 101,166 105,897 451,523

Cat 2 2,600 8,722 9,842 10,012 10,537 41,713

Cat 1 $ Amount $1,382,725 $2,243,550 $2,485,225 $2,529,150 $2,647,425 $11,288,075

Cat 2 $ Amount $135,200 $453,544 $511,784 $520,624 $547,924 $2,169,076

Total $ Amount Needed $1,517,925 $2,697,094 $2,997,009 $3,049,774 $3,195,349 $13,457,151

Total Courses Needed 57,909 98,464 109,251 111,178 116,434 493,236


ROUND 8 – Tuberculosis Assumptions: *Based on 80% case detection rate (all forms); based on consumption and morbidity *Estimated cost of Category 1 patient course: $25 (per GDF pricing) *Estimated cost of Category 2 patient course: $52 (per GDF pricing) *Year 1 (2009) includes 100% buffer stock for total estimated cases (all forms) *Complete information concerning source of available drugs included in Annex VII. The annual supply of TB drugs procured by the NTP, with support from Round 8, will be distributed to each Provincial Health Department (PHD) according to the need communicated by the respective PHDs to the NTP. The initial shipment will first arrive at the NTP central warehouse and recorded. The requisite amount of stock will then be delivered to the PHD integrated warehouse, which is used for all essential health drugs, where the anti-TB drugs will be recorded and stored until they are distributed to either district warehouses; or, if the provincial, regional and/or district warehouses are housed together, directly to health facilities. District warehouses that receive drugs from the provincial warehouses will then distribute the drugs accordingly to health facilities through the integrated, district led implementation model. Drug inventory will be shifted to the provinces based on a “pull” drug management system described under Activity 2.1 below. This program will also pilot a new initiative to allow non-public sector providers to access drugs from the district warehouses through Greenstar, under the condition that any anti-TB drugs received from the NTP must be given to the patient free of charge (for more details see Activity 1.1.3 below). The flow chart below illustrates the proposed planned flow of drugs.

The buffer stock procured by the NTP will be recorded and stored at the NTP’s central warehouse, currently under construction at the Ralwalpindi Chest Diseases Hospital (Maternal and Child Health Center). As needed by the provinces, the buffer stock will be distributed to the integrated Provincial Warehouses, where all the essential drugs required by the PHDs for all health needs are stored not only TB drugs. To prevent expiry of the buffer stock, the buffer stock will be rotated into circulation at the provincial level on a “first in, first out” basis with new anti-TB drugs as they are procured on an annual basis. The total buffer stock amount will however remain at 100% unless the buffer stock is needed to fill an unexpected gap at provincial level. To ensure that the management of the anti-TB drugs is integrated with the management of TB and other essential drugs at the provincial level, the drugs stored in the central warehouse will be managed/monitored by a TB drug management information system (DMIS) and procedures that complement and are compatible with the DMIS used at the provincial level. This will prevent the establishment of vertical system for TB. 1.1.2 Warehouse refurbishment at central, provincial and district level for the appropriate drug storage (Partner Responsible: NTP as an implementing PR) 1.1.2.1 Provincial and district warehouse refurbishment: The NTP will improve the storage capacity for TB

drugs at the integrated PHD warehouses and district warehouses. A need assessment will be done to identify the requirements of refurbishment at provincial and district level. The Provincial Warehouses are integrated, storing all the essential health drugs procured by the province, including TB drugs. According to the MSH gap analysis report (Annex IV), while most provincial and district warehouses have sufficient storage space there is a common need to upgrade these facilities to ensure the proper storage of TB and other drugs. The suggested upgrades include improved ventilation, temperature control systems, and additional shelving/partitioning to store drugs in a more organized manner. According to the MSH report, most of district warehouses do not have separate storage areas for TB drugs. Therefore, the NTP will lead the refurbishment of all public sector integrated provincial and district warehouses. Each warehouse will be upgraded so that it meets the minimum “drug storage standards” indicated in the revised guidelines for TB drug management (see Activity 1.2 for more details). The NTP will upgrade: 4 Provincial/ Regional Warehouses and 44

Integrated Provincial

Warehouses

Integrated District

Warehouses Health

Facilities

Patients

Private and NGO providers

(Greenstar)

NTP


ROUND 8 – Tuberculosis district warehouses in Year 1 and 3 Provincial/ Regional Warehouses and 90 district warehouses in Year 2.

1.1.2.2 At central level, the NTP does not currently have a warehouse to store the buffer stock or the drugs

that the NTP procures for the provinces. A central warehouse is needed to store the buffer stock at national level so that it can be dispatched efficiently and effectively by the NTP to any province or region in need of additional drugs. If the buffer stock was stored at the provincial level, the response time to a stock-out in another province would be slowed because an inter-provincial transfer of drug stocks would need to be negotiated and approved before the transfer could be initiated. This is a key weakness identified in the MSH report. A central warehouse is currently under construction at the Ralwalpindi Chest Disease Hospital; however, it will not be completed until 2010-2011. Therefore, the NTP proposes to lease an appropriate warehouse until the central warehouse is completed, and has included warehouse rental costs in the NTP PR budget.

1.1.3 Distribution of 1st line anti-TB drugs to public sector and participating non-public sector providers (Partner responsible: NTP as an implementing PR for Activity 1.1.3.1; Greenstar as an implementing PR for Activity 1.1.3.2) Once the anti-TB drugs are procured, they will need to be distributed from the NTP through the PHD to districts then to health facilities, which ultimately provide the drugs to notified TB patients. Under this activity, NTP, Greenstar and PATA will work together to ensure that these high-quality drugs reach as many participating public and private sector providers as possible. 1.1.3.1 Public sector distribution: The NTP (implementing PR) will be responsible for distributing drugs to

the public sector Provincial Warehouses. NTP will also purchase 5 loader vehicles (trucks) to transport the drugs from the provincial warehouses to district warehouses on a regularly scheduled basis. These trucks will be procured by NTP as PR and then seconded to the provinces to support the integration of TB drug delivery into the integrated health system at provincial level. As part of their routine supportive supervision visits, District TB Coordinators (DTC) will be responsible for liaising with public health facilities to ensure that health facilities submit drug orders and receive stock on a timely basis, and that patients are receiving the appropriate drugs for the entirety of their treatment in accordance with national guidelines. During these visits, DTC will also responsible for monitoring that the storage of TB and other drugs at the health facility are in line with national drug storage protocols. They will also be responsible for ensuring that the orders for the facilities within their catchment area are properly entered into the DMIS for submission to the Provincial level. Distribution of anti-TB drugs to public sector health facilities will be nationwide for the entirety of the program. The indicator used to measure performance for this activity will be the number (%) of public sector health units that report a stock-out or interrupted supply of anti-TB drugs to patients during the respective reporting period.

1.1.3.2 Private sector distribution: Greenstar (implementing PR) will be responsible for distributing drugs to identified, high-performing private providers in the Greenstar network (supported by GF Round 3). Greenstar Community Health Officers (CHOs) will perform tasks similar to their public sector counterparts, the DTCs, as described in the paragraph above to ensure proper drug management by providers and use of anti-TB drugs by notified and enrolled patients. In addition, CHOs will also monitor providers to ensure that any TB drugs procured through this mechanism are provided to the patient free of charge. Greenstar will develop procedures for enforcing this policy. The respective Greenstar district office will then be responsible for collecting, collating, and submitting a consolidated order for drugs to the DTC using the new drug management information system (DMIS) used by the PHD (please see SDA 2.1 below), the districts and NTP. Greenstar will be responsible for collecting the ordered drugs from the appropriate district warehouse and distributing them to the correct participating provider. Greenstar anticipates that 1,000 Greenstar network providers, who are already providing high quality DOTS with support from Round 3, in 5 municipalities (Lahore, Karachi, Ralwalpindi, Peshawar, Quetta) will receive anti-TB drugs through this mechanism. This activity will be an initial step to engage and integrate qualified private sector providers in the district led public private mix model for drug management and distribution. Once the systems for distributing drugs from the public sector to private providers through the district led model is established, it is anticipated that more private providers will be able to access drugs through this mechanism, either independently and/or through Greenstar.


ROUND 8 – Tuberculosis SDA 1.2: Human resources development: Training of public and private sector providers in anti-TB drug management (Principle Recipient: Greenstar) Greenstar has been selected as PR for this activity because of Greenstar’s proven capacity in developing and delivering high-quality training to health providers and its strong practical experience in logistics management. Under this SDA, Greenstar (PR) will develop a comprehensive training program to train public and private sector providers based on the new national TB drug management policy guidelines and regulatory frameworks, and the TB DMIS (described below in SDA 2.1). NTP, with support from JICA, is currently developing the national policy guidelines as a consolidated set of national guidelines for anti-TB drug procurement and management do not currently exist in Pakistan. The lack of national guidelines with clear specifications and weak regulatory frameworks for approved anti-TB drugs facilitates the availability of drugs of questionable quality in the public sector and on the open market. For example, the National Hospital Formulary and Essential Drug List (EDL) does not include all of the internationally and nationally approved 1st and 2nd line anti-TB drugs, making it difficult for PHDs to know which anti-TB drugs are the most appropriate for their needs. The final guidelines will include sections on: 1st and 2nd line anti-TB drug specifications; procurement best practices; a list of pre-qualified manufacturers; regulatory frameworks for bio-viability and quality assurance; inventory and storage standards; drug distribution procedures and standards; and, the general operational framework of the TB DMIS and how it is integrated into the national DMIS system for all health commodities. Once these guidelines are developed an approved (expected before July 2009), Greenstar will develop complementary operational guidelines to provide practical advice for public and private health workers on how to put the national guidelines into practice. After the development of the operational guidelines, Greenstar will develop a comprehensive training program for the public and private sectors in the national guidelines, operational guidelines and how to implement the integrated TB DMIS system described below under SDA 2.1. As much as possible, Greenstar will coordinate with partners to ensure that the curriculum developed and trainings delivered optimize synergies and minimize overlap. Greenstar will be an implementing PR for this SDA and be supported by 2 SRs, the Association for Social Development (ASD) and the Pakistan Anti-Tuberculosis Association (PATA), for Activity 1.2.4.1). Specific activities for this SDA will include: 1.2.1 Operational guideline development: Greenstar (PR) will develop practical operational guidelines – a

“user’s guide” – for the national policy guidelines as described above. Greenstar will develop the operational guidelines and print them for dissemination by the end of Year 1.

1.2.2 Curriculum development: Greenstar (PR) will develop a comprehensive training curriculum including a facilitator’s manual, a participant’s manual, a training of trainers (TOT) manual, and a series of practical classroom training tools. Greenstar will finalize the training materials once the national guidelines (SDA 1.2) are complete and approved by the Government (planned for the end of Year 1).

1.2.3 Implementing TOT: Greenstar (PR) will implement a series of TOT training workshops using the curriculum developed (Activity 1.2.2). Greenstar will implement 1 TOT workshops for the public sector (NTP and Provincial TB Control Programme (PTP)), and 1 TOT workshop for partners working with the private and non-public sector providers (Greenstar, PATA and ASD). Twenty participants will attend each training. A refresher TOT will be held annually and Greenstar training coordinators will follow-up with TOT participants once per quarter for continued mentoring and on-the-job support. In Year 2, 3 trainings will be held and 60 providers trained. In Years 3-5, this target will increase cumulatively as a new cohort of providers is trained and cohorts of providers previously trained receive annual refresher trainings. At the end of Year 5, a cumulative total of 400 master trainers will be trained and 20 TOT trainings will be delivered.

1.2.4 Public sector training: Using the TOT curriculum, Greenstar (PR) will train DTCs, National Program Officers, and Provincial TB Control Program staff (including store keepers) (200 total), to become district level trainers and experts on the revised guidelines and new DMIS system. A total of 10 TOTs will be rolled out in Year 2 to train the proposed 200 district level personnel. Greenstar training coordinators will follow-up with TOT participants once per quarter for continued mentoring and on-the-job support.

1.2.4.1: Facility level personnel training: ASD (SR) and PATA (SR), under Greenstar as PR, supported by the district level master trainers (Activity 1.2.4 above), will train 5580 public and private-not-for profit facility level staff at diagnostic centers (DC). ASD will train DC staff in 50 districts, PATA will train DC staff in 50 districts. The remaining districts will be trained by Greenstar


ROUND 8 – Tuberculosis master trainers or another SR to be identified during implementation (budget currently included in the Greenstar PR budget). To support facility staff to implement the lessons learned at the trainings, both ASD and PATA will provide ongoing “on-the-job” mentoring to ensure good drug management and appropriate use of the drugs by the patients.

1.2.5 Private sector training: Greenstar (PR) will be responsible for training private sector network providers on the national TB drug management policy guidelines, operational guidelines and DMIS. Greenstar Community Health Officers (CHO) will also be trained in how to incorporate monitoring of effective drug systems management and mentoring into their monthly supportive supervision visits with network providers. Greenstar will implement 100 trainings in 40 districts, and implement 3 trainings for 30 CHOs to support these providers with on-going on-the-job training and mentoring to ensure the proper implementation of the guidelines and the use of drugs by patients treated by the participating private providers.

SDA 1.3: Management and Supervision: Improving strategic coordination for regulation of quality anti-TB drugs (Partner responsible: NTP as an implementing PR for Activity 1.3.1; Greenstar as an implementing PR for Activity 1.3.2) One of the key concerns raised by the Joint Review, MSH report and the TRP Round 7 comments was the concern about the availability on the open market of 1st line anti-TB drugs of questionable quality and bio-viability. While the policy guidelines for TB drug procurement and drug management (see description under SDA 1.2 for more details) will provide a framework for improving the regulation of anti-TB drugs available in the public and private sectors, specific operational tools will be developed through the following activities to assist in enforcing the implementation of the guidelines. Activity 1.3.1 Development and facilitation of a multi-sectoral committee for appropriate TB drug

management and regulation: The NTP will lead the formation and coordination of a multi-sectoral committee to engage public and private stakeholders and provide strategic guidance on how to implement and enforce the national policy for TB drug management. The committee will include representatives from: NTP, MOH, PDH, the government drug regulatory authority, pharmaceutical manufacturers (international and national), WHO/GDF, the Pakistan Medical Association, private providers, and communities affected by TB disease/TB patients, among others. The committee will meet once per quarter.

Activity 1.3.2 Developing and promoting a “seal of quality” for high-quality anti-TB drugs available in the public and private sectors: In collaboration with the NTP (PR), Greenstar will develop a “seal of quality” logo to be displayed on the outer packaging of all anti-TB drugs that meet the bio-viability and quality assurance standards set out in the revised national policy guidelines. All qualified drugs will be authorized to be “branded” with the logo, whether they are intended for public sector distribution or sale in the private sector. The development and branding of TB drugs with a “seal of quality” has benefits at the government level, for providers, and for TB patients and communities. At the government level, the “seal of quality” presents a mechanism through which the government can start to regulate the private sector, a key intervention in preventing MDR and increasing treatment success, by outwardly identifying which drugs are high-quality and approved government regimens. For drug manufacturers, authorization to use the seal will be a reward for their diligence in maintaining consistently high standards in their manufacturing processes and compliance with national anti-TB drug regulations. For private providers, including pharmacists, they will have confidence that the drugs that they are providing to the patients are of high-quality. Private providers are concerned about providing high standards of care, both for their professional satisfaction and because a provider who is known for curing people in the community is the provider who has more clients. For the patients and communities, they will now have an easy to use way of knowing if their drugs are real and safe, giving them a greater confidence in the drugs and care they receive from providers distributing the branded drugs in their communities. While Greenstar will develop the seal, the logo will be registered to the NTP and the Government of Pakistan. Greenstar will develop the seal in Year 1, and once the seal is registered, will present this to the NTP and the National Coordination Committee for TB Drug Management (see Activity 1.3.1). The benefits highlighted above can only be achieved if the “seal of quality” is supported by a dynamic advocacy and communication campaign. To promote the seal, the NTP will mobilize funds from its Round 6 ACSM activities to reach out to


ROUND 8 – Tuberculosis manufacturers, providers and communities to promote awareness of the seal.

Objective 2: Health systems strengthening (HSS) (Principle Recipient: Greenstar) SDA 2.1: HSS: Incorporating TB DMIS into national, integrated DMIS Partner Responsible: Greenstar as an implementing PR This SDA closely linked and integral to the SDAs listed above under Objective 1; however, it has been included under a separate Objective in this proposal to reflect the Stop TB Planning Framework which clearly recommends that management information systems be included under a separate objective dedicated to health systems strengthening. 2.1.1 Development and integration of DMIS system for TB: Greenstar (PR) will collaborate with Abt

Associates, who have received a grant from USAID to develop a national, integrated logistics management information systems (LMIS), to integrate TB DMIS needs and concerns into this health system wide DMIS for all essential drugs and contraceptives managed by the public sector from the provincial level to the health facility. The LMIS component of the Abt Associates' Strengthening Health Systems project in Pakistan is working with both the MOH and the Ministry of Population Welfare (MOPW) to develop compatible LMIS software to link the ministries’ logistics management information systems of contraceptives and essential drugs, including TB drugs. The project will also provide some necessary equipment and provide support to upgrade drug storage facilities at the district level in 20 districts. Technical assistance is being provided by LMI and Uti. The electronic and paper-based TB DMIS system developed under this activity will complement the LMIS developed for drug management at the provincial level and reflect the system described in the National Policy Guidelines for TB Drug Management (described above under 1.2). This complementary TB DMIS will extend the scope, using the same format of the national LMIS, to manage inventory at the central NTP warehouse, including the national buffer stock, and quantification for the NTP annual contribution to the PHD anti-TB drug supply. The TB DMIS will also capture data concerning private providers who are receiving anti-TB drugs from NTP through Greenstar (Activities 1.1.3.2). By capturing this data, NTP will be able to include the drugs needed by these private providers in their annual quantification and procurement of anti-TB drugs. This will help the NTP respond in time and appropriately to rising demand from non-public sector providers and to reduce the risk of stock-outs due to increased case finding. The TB DMIS will be developed in Years 1 and 2. Once the TB DMIS, is developed and the NTP trained in its use, the implementation of the DMIS will be the responsiblitity of the NTP; however, Greenstar will continue to provide on-going technical support for the maintainence of the DMIS.

The SDAs and activities detailed above are in line with the objectives and the priorities set out by the National Strategic Plan for TB and the objectives of the Stop TB Strategy. The indicators listed above are ambitious but specific, measurable, achievable and time-bound (please see Attachment A for further details concerning specific indicators, and Annex VI for the work plan). The implementation of this proposed program will contribute to Pakistan’s progress towards achieving an 85% treatment success rate. It also increases the capacity of the public and private sector to provide quality TB drugs to existing and future TB patients identified through increased case finding. Finally, this program and proposed activities will help overcome specific drug management challenges in the implementation of GF Round 6 activities and help to prepare the country for a planned scale up of PPM initiatives in all 4 provinces to be proposed in Round 9.

4.5.2. Re-submission of Round 7 (or Round 6) proposal not recommended by the TRP If relevant, describe adjustments made to the implementation plans and activities to take into account each of the 'weaknesses' identified in the 'TRP Review Form' in Round 7 (or, Round 6, if that was the last application applied for and not recommended for funding).

This proposal is a resubmission of a Round 7 proposal, which was graded as a Category 3. The current proposal has been revised to address the TRP comments from Round 7 listed below: TRP Comment 1: There is inadequate description of the present drug management system or on how drugs received from the GDF were distributed in the country. The distribution chain from the moment of procurement to the peripheral level and finally the patient is unclear. Response: In Pakistan, the NTP (central level) and the Provincial Health Department share the


ROUND 8 – Tuberculosis responsibility for the procurement and management of TB drugs. Through government resources, the NTP and the Provincial Health Departments procure approximately 50% of the TB drug needs for the country. These drugs are then distributed to regional and/or district warehouses, where they are then distributed to public diagnostic and treatment centers through the district led implementation model. The NTP procures the remaining 50% of TB drugs, using donor and/or government funding, which are then sent to the respective Provincial Health Department integrated provincial level warehouses to be distributed by the Provincial Health Department. The NTP is also responsible for storing and managing the buffer stock at central level. Please see the drug distribution flow chart and description under Activity 1.1.1 in Section 4.5.1 above for further description. Please see the chart under TRP Comment 7 below for a summary of the current status of available drugs and funding source. TRP Comment 2: The proposed drug management system to be created seems to be a vertical system to manage only tuberculosis drugs without referring to possibilities of linkages and shares with the overall national drug management system. Response: Activities 1.1.2 and 2.1.1 directly respond to this comment. While the TB Programme, like other national programs of the MOH, is vertical at the national level it is fully integrated into the primary health care system from the provincial level, through the district and up to service delivery to the patient. The buffer stock will be procured, inventoried and stored by the NTP at the national/central level to allow the NTP to dispatch any necessary amount to a province or district in need without having to negotiate a “loan” of TB drugs between provinces. The limitation of bureaucracy allows NTP to respond very quickly to stock-outs, wherever they might occur. As indicated in SDA 2.1, the proposed TB DMIS system will be designed to complement the planned national drug management system. The national system will serve as the basis and template for the TB DMIS, to ensure the smooth transfer of data and information between the two systems. In figurative terms, the TB DMIS will be an additional software package for the national DMIS that includes special tools that the NTP will need to improve its strategic guidance and management decisions concerning TB drug management in the country. TRP Comment 3: According to the recent country program review carried out in April 2007 by WHO EMRO, there are concerns related to: 1) the procurement process (“is often tedious which could result in drug shortages”); 2) to the availability on the market (over the counter) of first line drugs of uncertain quality; 3) to the quality of drugs being procured with the government budget; 4) storage facilities; and 5) buffer stock management. These aspects are not addressed in the proposal. Response: The listed concerns have been addressed by: 1. Procurement process: The development of the new drug management guidelines (Activity 1.1.3) will set

out clear procedures and drug specifications for TB drugs that seek to reduce delays in public drug procurement.

2. Availability of uncertain quality drugs in the private sector: The activities set out under SDA 1.3 Activity 1.3.2, the development of the “seal of quality” and related advocacy activities, address this concern.

3. Quality of drugs: Please see response 1 above. 4. Storage facilities: Activity 1.2.1 and 1.2.2 directly address this concern. 5. Buffer stock management: Activity 1.1.2 addresses this concern. TRP Comment 4: In spite of having a good tuberculosis public private component in the NTP, the availability of drugs and drug management in the private sector is not described. Response: Greenstar Social Marketing has been included in this revised proposal as civil society dual track financing PR and will be responsible for implementing activities that engage the private sector in drug distribution, operational guideline curriculum development, training, drug management, and advocacy. Please see the SDAs described under Objective 1 in Section 4.5.1 above. TRP Comment 5: The rationale behind procurement of the 100% buffer stock for all Category 1 and 2 patients in spite of the fact that the proposal requests drugs for only 48% of the patients is not given. Response: This comment has been clarified in the description under Activity 1.1.1. In this proposal, the NTP is requesting funds for 30% of the total buffer stock needed as 70% has already been procured with funding from the Japanese Government. The combination of the 30% buffer stock requested and the 70% currently available will increase the total buffer stock available to 100% of the total amount of Category 1 and 2 drug stocks needed for the country. A buffer stock representing 100% of the country’s total anti-TB drug need is recommended by both WHO and The Union. TRP Comment 6: The lack of clear inventory records of current stocks including drugs recently delivered by


ROUND 8 – Tuberculosis the GDF and drugs to be procured by KfW in NWFP, and ambiguity of the buffer makes the justification for the drug shortage unconvincing. Response: The table below depicts the projected need, availability and anticipated gap of anti-TB drugs. In addition, please see the response to TRP Comments 1 and 5 above, and Activity 1.1.1 in Section 4.5.1. (Please note that 2008 is included in the table but not the final total calculated; only 2009-2013 is included.)

2009 2010 2011 2012 2013 Total Estimated # of cases 309,561 315,752 322,067 328,509 335,079

Case Detection Rate (all forms)

80% 80% 80% 80% 80%

# of Cases (all forms) 247,649 252,602 257,654 262,807 268,063 1,288,774

# of CAT 1 patients (90% of all cases)

222,884 227,342 231,888 236,526 241,257 1,159,897

# of CAT 2 patients (10% of all cases)

24,765 25,260 25,765 26,281 26,806 128,877

Cost of Cat 1 Drugs Needed

5,572,098 5,683,540 5,797,211 5,913,155 6,031,418 28,997,423

Cost of Cat 2 Drugs Needed

1,287,774 1,313,529 1,339,800 1,366,596 1,393,928 6,701,627

Cost of 1st Line Drugs Needed

6,859,872 6,997,069 7,137,011 7,279,751 7,425,346 35,699,049

Buffer Stock (100%) 6,859,872 - - - - 6,859,872 Cost of Total Need ($M) 13.71 6.99 7.13 7.27 7.42 42.55 Funds Available: Govt of Pakistan ($M)

2.97 3.29 4.14 4.23 4.23 18.86

Funds Available: GTZ, NWFP only ($M)

0.99 1.01 - - - 2.00

Funds Available: Govt of Japan ($M)

8.24 - - - - 8.24

Funds Available: GDF Emergency Grant ($M)

- - - - - -

Total Funds Available ($M)

12.20 4.30 4.14 4.23 4.23 29.10

Total Funds Needed ($M)

1.51 2.69 2.99 3.04 3.19 13.45 *Complete information concerning source of available drugs included in Annex VII.

4.5.3. Lessons learned from implementation experience How do the implementation plans and activities described in 4.5.1 above draw on lessons learned from program implementation (whether Global Fund grants or otherwise)?

NTP, Greenstar, ASD and PATA have all been involved in the implementation of Global Fund grants in Pakistan. NTP is a SR under TB Round 2 and 3, and is PR for the current TB Round 6 grant. Greenstar is a SR for TB Round 3 and Malaria Round 2. Both ASD and PATA are SRs on TB Round 2 and 6. Greenstar also receives technical assistance from its international technical partner, Population Services International (PSI). PSI has served or is currently serving as PR on 8 grants in 5 countries respectively, all of which are A rated. PSI country programs and local affiliates, including Greenstar, serve as SRs on more than 52 grants in 28 countries. This combined experience in implementing Global Fund grants, and familiarity with Global Fund procedures, provide the proposed PRs and SRs will a strong comparative advantage to implement the proposed program with minimal programmatic delays.

A key lesson learned by the partners in implementing donor funding programs is that communication is integral to the successful implementation of any collaborative program. It is also essential for partners to understand and agree to the specific roles and responsibilities of each partner from the outset of the program. Therefore, Greenstar will organize three different types of regular meetings. First, an annual coordination meeting will be held to bring all the implementing partners together to discuss roles and responsibilities, reporting procedures, and draft any necessary program documentation, such as annual


ROUND 8 – Tuberculosis reports and/or work plans. Second, regularly quarterly meetings will be held with all partners to review progress, address challenges to implementation and confirm activities and deliverables expected in the upcoming quarter. Third, PR action meetings will be scheduled on an ad-hoc basis to address any program management issues or concerns, such as SR/PR performance or unexpected changes in the operating environment, as they arise. These meetings will facilitate strong communication, improve coordination, and promote transparency between the partners. Costs for these meetings are included in the Greenstar PR budget.

Central activities in the proposed program are the procurement of anti-TB drugs and equipment to support the appropriate management and distribution of these drugs. NTP and Greenstar both have significant experience in procuring health commodities in accordance with Global Fund rules and regulations, including transparent tendering and supplier selection. Greenstar and PSI both have written standard operating procedures for procurement. To ensure accordance with Global Fund procurment procedures, both NTP and Greenstar will have included personnel dedicated to logistics and procurement, who will ensure the proper procurement and monitoring of distribution of all pharmaceuticals and equipment procured through the program.

Other key lessons learned from previous Global Fund grant implementation experience are the importance of strong financial and data management systems, and the importance of the professional relationship between the PRs and the local fund agent (LFA). Each PR must have a clear and robust financial management and accounting system in place to monitor the expenditure of the grant funds, and to monitor the appropriate expenditure of funds by the selected SRs. Both NTP and Greenstar have experience in managing large grants from multiple donors simultaneously, and have strong systems and procedures in place to properly monitor the expenditure of funds. At the first annual meeting (see above), the PRs will share the SRs their expectations for financial accounting and reporting, and specify an agreed reporting schedule. Program data management is also very important, and both PRs already have existing and strong monitoring and evaluation (M&E) systems to capture the necessary indicators proposed for this program. At the first annual meeting, the PRs and SRs will work together to work out systems to capture the data required by the proposal, and that complement and build on their existing M&E systems. Strong data quality and financial management will be essential to supporting a positive relationship between the LFA and the PRs. After the first annual meeting with the SRs, the PRs will meet with the LFA to review the performance framework and expectations together to develop consensus as to what each indicator means and the specific activities and budget inputs are necessary to achieve the indicator. This transparent and open communication between the PRs and the LFA will assist in the smooth implementation of the regularly scheduled LFA performance audits of grant activities.

4.5.4. Enhancing social and gender equality Explain how the overall strategy of this proposal will contribute to achieving equality in your country in respect of the provision of access to high quality, affordable and locally available tuberculosis diagnosis treatment and care and support services.

(If certain population groups face barriers to access, such as women and girls, adolescents, sexual minorities and other key affected populations, ensure that your explanation disaggregates the response between these key population groups).

In Pakistan, men and women are almost equally affected by tuberculosis. During the last 5 years, 51% of new sputum smear positive cases were men and 49% were women. Men and women of economically productive age (16-49) represent the most frequently notified age group (Annual Report NTP). Approximately two thirds of the population lives in rural areas and the remaining one third in urban areas.

To promote equity to access to TB services, including among women, children and rural populations, the Government of Pakistan has adopted a decentralized approach that integrates TB into the primary health care. Under this model, TB services are integrated into the primary package of care delivered at the district health facility level. For a woman living in a rural community, this means that when she seeks care for respiratory systems at a public sector diagnostic center she can be screened, tested and if infected with active TB disease able to access treatment at the same health center where she would take her child to be immunized, including the BCG vaccination.

To expand the coverage of services to underserved populations, the Ministry of Health has supported a variety of public private mix (PPM) initiatives to engage private providers in delivering high quality TB


ROUND 8 – Tuberculosis diagnostic and treatment services (supported by GF Round 3). To ensure that cost is not a barrier to proper use of TB drugs, TB treatment available through public sector sites and official PPM initiatives are available free of charge (Greenstar activities under GF Round 3). The government is also supporting a variety of advocacy, communication and social mobilization (ACSM) activities to promote community awareness about TB symptoms and active health seeking behavior for TB (supported by GF Round 3 and 6).

These activities have had a significant impact in reducing gender or socio-economic discrimination towards access to high-quality TB services. The activities proposed in Round 8 will build on these efforts to improve the management and distribution of high quality TB drugs to communities in need. By strengthening drug management systems for TB, including operational guidelines for high quality TB drug management and training of health care workers, will strengthen the public and private sectors’ abilities to provide patients with uninterrupted access to TB treatment. By procuring high quality TB drugs through the NTP and distributing these drugs through the public and private sectors, this proposal promotes the use of appropriate TB treatment to continue the country’s progress towards 85% treatment success. Finally, using social marketing techniques to promote the availability of high quality drugs in the public and private sectors will contribute to regulating the quality of drugs available in the market and limiting a potential driver of drug resistance. This program proposes key steps to improve the equitable and enhanced availability of high-quality anti-TB drugs for all communities in Pakistan.

4.5.5 Strategy to mitigate initial unintended consequences If this proposal (in s.4.5.1.) includes activities that provide a disease-specific response to health system weaknesses that have an impact on outcomes for the disease, explain:

the factors considered when deciding to proceed with the request on a disease specific basis; and

the country's proposed strategy for mitigating any potentially disruptive consequences from a disease-specific approach.

While this program proposes is a disease specific approach, it has been designed to integrate with the primary health care services delivered through the district led approach. For example, the development of the TB DMIS will be developed to complement and be compatible with the larger national logistics management system for essential health drugs – so that the MIS for TB is linked with the MIS used by the wider health system. Also, the training provided to the public and private sector on appropriate drug management will include information on best practices for drug management and storage, such as appropriate storage conditions and keeping accurate and up-to-date inventory cards, that can be applied to all pharmaceutical drug management not only TB drugs.

An unintended consequence of this program would be that by improving drug management systems, potential errors in the current quantification of anti-TB drugs could be revealed. For example, improved storage practices could reduce wastage and reduce the number of courses needed at district or provincial level. Alternatively, increased community awareness and demand for high-quality drugs from the public sector and participating private providers could increase case detection rates and the increase the amount of drugs that need to be procured from the amount proposed in Section 4.4. In addition, the results of the TB prevalence survey planned for 2009 could change the quantification of TB drugs needed in the country. Should such unintended consequences occur, the country will need to re-evaluate the situation and the PRs will work together with the Global Fund to find an appropriate solution.


ROUND 8 – Tuberculosis 4.6. Links to other interventions and programs

4.6.1. Other Global Fund grant(s) Describe any link between the focus of this proposal and the activities under any existing Global Fund grant. (e.g., this proposal requests support for a scale up of ARV treatment and an existing grant provides support for service delivery initiatives to ensure that the treatment can be delivered).

Proposals should clearly explain if this proposal requests support for the same interventions that are already planned under an existing grant or approved Round 7 proposal, and how there is no duplication. Also, it is important to comment on the reason for implementation delays in existing Global Fund grants, and what is being done to resolve these issues so that they do not also affect implementation of this proposal.

Pakistan has received 3 Global Fund grants for TB: Rounds 2, 3 and 6. The main programmatic priorities of these approved programs are: Round 2:

• Strengthen the 2-way referral of complicated adult and pediatric TB suspects between primary health care (PHC) treatment centers and district hospitals

• Implement a behavior change communication (BCC) strategy • Expand TB DOTS coverage to an additional 20million Pakistanis through public private

partnerships (NGO model) by 2004

Round 3: • Use a social marketing approach to increase access and knowledge of high quality TB DOTS

information, testing and treatment through a private sector clinic franchise network • Develop and implement an interactive community mobilization strategy, in partnership with

NGO/CBO networks and public sector facilities

Round 6: • Strengthen the laboratory network and external quality assurance (EQA) activities • Pilot MDR management and TB/HIV activities • Engage tertiary care hospitals in DOTS services • Human resource development for the NTP • ACSM

Round 2 will end in December 2008, and Round 3 will end in March 2009. Round 6, for which NTP is a PR, is on-going and engages a variety of partners in TB control. Drug management systems’ strengthening has not yet been addressed by a previous Global Fund award; even though it has been identified as a key weakness and gap in the country (please see Annexes III, IV, and VII for gap analyses reports). Drug procurement has typically been supported by grants from the Global Drug Facility and other external donors; however, funding from the GDF ended in 2006 except for an emergency grant in 2008, and all other planned donor funding for drug procurement will end in 2009-2010. If Pakistan does not receive funding to procure these life saving drugs and to improve the drug management system, to support the proper procurement, storage and distribution of those drugs, Pakistan will face a critical stock-out of life saving anti-TB drugs. The activities proposed will support the implementation of the activities included in Round 6. For example, as Round 6 activities increase demand for TB services and case detection rates there will be an increased need for quality anti-TB drugs from public sector diagnostic centers, tertiary care hospitals and private providers. In addition, Pakistan plans to scale-up PPM initiatives in the near future, for which the existence of a strong drug management system and uninterrupted supply of quality anti-TB drugs for both the public and private sectors will be an important foundational building block. Finally, the activities proposed under SDA 3.1 will be linked with the current ACSM activities supported by Round 6, to ensure complementarity, capitalize on synergies, and maximize output while minimizing overlap. Pakistan’s success in achieving its deliverables for Round 6, its National Strategic Plan and the Stop TB global targets are dependent on securing funding to procure and properly manage high-quality anti-TB drugs.


ROUND 8 – Tuberculosis 4.6.2. Links to non-Global Fund sourced support

Describe any link between this proposal and the activities that are supported through non-Global Fund sources (summarizing the main achievements planned from that funding over the same term as this proposal).

Proposals should clearly explain if this proposal requests support for interventions that are new and/or complement existing interventions already planned through other funding sources.

This program will directly link with 3 non-Global Fund supported programs: 1) the development of the national policy guidelines for TB drug procurement and management supported by JICA; 2) the development of an integrated logistics management information system (MIS) for all essential health drugs and contraceptives supported by USAID; and, 3) the USAID supported TB prevalence survey planned for 2009. The proposed activities build on these activities, providing additionality not duplication. SDA 1.2 will use the national policy guidelines developed by NTP with support from JICA, to develop practical operational guidelines for TB drug procurement and management. These guidelines will also guide the development of a comprehensive curriculum and training program for both the public and private sector in how to implement the national policy guidelines and associated drug MIS (DMIS). SDA 2.1 will deliver a TB DMIS designed to complement the national, integrated DMIS being developed for the primary health care system at the provincial/district level. By using compatible data systems and requirements, the data collected through the national DMIS will directly link to the data analyzed by the TB DMIS which will then be used to guide NTP management decisions, such as how many courses of anti-TB drugs need to be procured to meet national demand and maintain a buffer stock that reflects 100% of the national demand. Finally, the results from the planned TB prevalence survey could change the assumptions used in this proposal to quantify the amount of anti-TB drugs needed through 2013, requiring a revision to the amount of drugs to meet 100% of the country’s need for anti-TB drugs.

Two deliverables of this program (SDA 1.2 and 2.1) are dependent on the successful and timely completion of these non-Global Fund activities. The delay in completion of either of these projects (the guidelines are expected by July 2009 and the DMIS by the end of 2009) could delay the implementation of SDA 1.2 and 2.1. Any changes in the assumed TB prevalence, identified by the USAID funded TB prevalence survey planned for 2009, could increase or decreased the total need for anti-TB drugs currently quantified in this proposal. The PRs for Round 8 will work closely with these two other projects to be aware of any delays and develop a plan of action to respond accordingly.

4.6.3. Partnerships with the private sector

(a) The private sector may be co-investing in the activities in this proposal, or participating in a way that contributes to outcomes (even if not a specific activity), if so, summarize the main contributions anticipated over the proposal term, and how these contributions are important to the achievement of the planned outcomes and outputs.

(Refer to the Round 8 Guidelines for a definition of Private Sector and some examples of the types of financial and non-financial contributions from the Private Sector in the framework of a co-investment partnership.)

While the private sector will not be a direct contributor to implementing the proposed program, the proposed activities will engage the private sector in strengthening drug management for TB control. Drugs procured through this proposal will also be distributed, through the district led implementation model, to private providers through the Greenstar network. The numbers of patients treated through PPM initiatives like Greenstar have also been included in the national quantification for TB drugs. In addition, participating private providers will also receive training in the new TB DMIS and national DMIS system, and ongoing mentoring from Greenstar will ensure that the drugs provided through the Greenstar network are provided for free and are used correctly by the patient. The social marketing of a “seal of quality” for all anti-TB drugs that meet the bio-viability requirements set by the national drug regulatory authority and the NTP will also be a means of engaging the private sector in regulating the control of anti-TB drugs of questionable quality available on the open market.



ROUND 8 – Tuberculosis (b) Identify in the table below the annual amount of the anticipated contribution from this private sector

partnership. (For non-financial contributions, please attempt to provide a monetary value if possible, and at a minimum, a description of that contribution.)

Population relevant to Private Sector co-investment (All or part, and which part, of proposal's

targeted population group(s)?) n/a

Contribution Value (in USD or EURO) Refer to the Round 8 Guidelines for examples

Organization Name

Contribution Description

(in words) Year 1 Year 2 Year 3 Year 4 Year 5 Total

[ use “Tab” key to add extra rows if needed]

The section 4.6.3 is not applicable.


ROUND 8 – Tuberculosis 4.7. Program Sustainability

4.7.1. Strengthening capacity and processes to achieve improved tuberculosis outcomes The Global Fund recognizes that the relative capacity of government and non-government sector organizations (including community-based organizations), can be a significant constraint on the ability to reach and provide services to people (e.g., home-based care, outreach contact, orphan care, etc.).

Describe how this proposal contributes to overall strengthening and/or further development of public, private and community institutions and systems to ensure improved tuberculosis service delivery and outcomes. Refer to country evaluation reviews, if available.

The proposed program strengthens the drug management capacity of the public, public-not-for profit (community based organizations), and the private sector involved in TB control. A secure and uninterrupted supply of high-quality anti-TB drugs supported by a strong, integrated drug management system that engages both public and private sector providers will support Pakistan to achieve its goals in TB control. This proposed drug management system is integrated into the national drug management system at provincial level, and provides capacity building and infrastructure improvements to the provinces for drug management and distribution. By engaging the private sector with training and high quality drugs (through Greenstar), this program supports the NTPs efforts to improve TB services delivered in the private sector through public private partnerships. The program design also includes training and training master trainers from the public, private, and private not for profit (NGOs/CBOs) in appropriate TB drug management. This helps build the capacity of the health system to provide high-quality TB treatment and maintain progress towards the target of 85% treatment success. Both of the proposed PRs, NTP and Greenstar, have the capacity to achieve these goals. NTP, as an SR for Rounds 2 and 3 and PR for 6, has progressively built its capacity in program management and developing strong systems for collaborating well with partners from both PHD, private-not-for profit (NGO), and private sectors. Greenstar has strong implementation capacity and a proven track record of improving the capacity of the private sector to provide high-quality DOTS services. Greenstar and its international technical partner PSI have strong Global Fund experience and community systems strengthening; skills that will enable it to build the capacity of the included SR and private providers trained by this program. Both the NTP and Greenstar have the current skilled human resources capacity to roll-out the proposed program. For example, the NTP Drug Management System (DMS) Unit currently includes a trained DMS Coordinator, Procure and Supply Management Officer, a data expert, and a Monitoring and Evaluation officer. Similarly, Greenstar currently employs highly skilled staff in drug management information systems, drug distribution and TB services training. Both organizations have well developed monitoring and evaluation systems for monitoring program performance. Greenstar will train all identified SRs in appropriate monitoring and evaluation systems and improving financial management for donor funded programs. The activities proposed in this program will strengthen the drug management system, which once established and effectively implemented by NTP and the PHD should lead to the effective and efficient management of TB drugs over the long term.

4.7.2. Alignment with broader developmental frameworks

Describe how this proposal’s strategy integrates within broader developmental frameworks such as Poverty Reduction Strategies, the Highly-Indebted Poor Country (HIPC) initiative, the Millennium Development Goals, an existing national health sector development plan, and other important initiatives, such as the 'Global Plan to Stop Tuberculosis 2006-2015' for HIV/TB collaborative activities. In Pakistan, TB is the leading infectious cause of adult mortality (approximately 5% of the adult burden of disease). Consequently, a series of coordinated interventions promoting TB control must be implemented simultaneously for Pakistan to achieve the second target of Millennium Development Goal (MDG) 6 of reversing the spread of major diseases by 2015. As previously discussed, the Government of Pakistan has declared TB a National Emergency (24 March 2001) and has prioritized TB control activities in the National Health Policy 2001. TB is also prioritized in other non-health specific development frameworks in Pakistan. Pakistan’s broad


ROUND 8 – Tuberculosis development agenda has been defined in the “Poverty Reduction Strategy Paper for Pakistan - Accelerating Economic Growth and Reducing Poverty: The Road Ahead”. It outlays a comprehensive development agenda across all sectors with special emphasis on poverty reduction and social sector development. The Poverty Reduction Strategy Paper (PRSP) envisages increased financing and enhanced efficiency in the health sector through organizational and management reforms. On the programmatic aspects the focus is on control of communicable diseases (especially TB, malaria, HIV/AIDS, Hepatitis B, and cluster of immunizable childhood diseases), reproductive health, child health and nutrition. The linkages between TB and poverty are well documented, and both the PRSP and the TB National Strategic Plan stress the importance of ensuring equitable access to TB services for all Pakistanis, especially the poor. In response to these strategies, the all drugs procured by this program will be distributed for free, either through free public sector diagnostic and treatment sites or qualified Greenstar private providers. This will limit the risk of interrupted use of anti-TB by patients seeking care in the public sector or through Greenstar providers because of the patient’s inability to afford high-quality anti-TB drugs.

4.8. Measuring impact

4.8.1. Impact Measurement Systems Describe the strengths and weaknesses of in-country systems used to track or monitor achievements towards national tuberculosis outcomes and measuring impact. Where one exists, refer to a recent national or external evaluation of the IMS in your description. Global targets to reduce the epidemiological burden of TB have been set for 2015 within the context of the MDGs and by the WHO Stop TB Partnership. The NTP measures progress towards these targets through routine monitoring of case notification and treatment outcomes, and evaluation of the impact of TB control on incidence, prevalence and mortality using routine surveillance data. NTP is planning to conduct a national disease prevalence survey in 2009. This survey will produce credible national and sub national assessments of TB prevalence and progress towards the 2015 impact targets. The last disease prevalence survey was conducted in 1984. NTP is also planning to conduct population-based mortality surveys, through verbal autopsy, to measure the impact of the interventions indirectly. According to WHO annual reports, Pakistan’s TB prevalence is decreasing. These estimates are based on routine surveillance data; however, the prevalence survey will provide more reliable data. The National TB control Program is committed to effectively contain this major Public health problem and to improve the quality of services. Thus for effective implementation of DOTS, and maintaining the quality of services monitoring and supervision has been given priority by the program. NTP Pakistan has developed a unique system of Monitoring and supervision at all levels. Monitoring and evaluation is conducted at three levels i.e District, Provincial and National levels. TB Program is integrated with Primary health Care (PHC) at the district level. In each district there is a designated District TB Coordinator responsible for onsite supervision and smooth implementation of TB DOTS. He is responsible for monitoring of all health facilities in his district and report to Executive District Officer Health (EDO). Executive District Officer Health (EDO) and District Health officer also monitor TB control activities in the district during their routine visits. The Provincial TB Control Program is also responsible for carrying out supervision through Program Officers and Medical officers. At the Federal level Technical unit in NTP is responsible for the monitoring and evaluation. Desk monitoring is a regular on going feature of this unit. National Manager is regularly updated on the reports. Reports are shared with WHO and other donors/ bilateral and implementing partners on quarterly basis. NTP recruited National Program Officers, with the support of WHO/ USAID, at regional level responsible for four to five districts each. The NPOs play a critical role in supporting District Tuberculosis Coordinators (DTCs) in monitoring the activities being carried out in the field through the District and Tehsil Health Teams and providing Technical assistance to Districts and provincial TB Control Program. NTP technical Unit monitors the performance of NPOs. The monthly and quarterly reports submitted by the NPOs are scrutinized regularly and accordingly feedback on action at various levels is verified.


ROUND 8 – Tuberculosis Greenstar has developed a standardized monitoring and evaluation (M&E) system for all its health interventions. Greenstar implements a wide range of innovative M&E approaches within that framework with the goal of supporting quality in health care delivery and enabling evidence-based programmatic decision-making to improve the performance of its interventions. Performance indicators focus on the effectiveness of interventions in changing preventive behaviors, equity of use across socio-economic quintile, and the efficiency and cost-effectiveness of interventions in terms of the unit cost of delivering and producing outputs. Greenstar’s monitoring and evaluation efforts rely heavily on the use of methods and tools that designed to improve evidence-based decision making as well as the measurement of impact associated with the project’s various interventions and activities. All of Greenstar’s activities include comprehensive Performance Monitoring and Evaluation Plans, which are designed to ensure: • The provision of key data periodically to project managers so that decisions are based on evidence

and adapted to evolving situations; and • The frequent tracking of the performance of activities against project objectives and indicators. Greenstar adheres to Global Fund reporting guidelines, as well as internal MIS reporting structures, to enable effective program management and strategic decision-making by all key stakeholders. Greenstar submits Progress Update reports to the PR on a quarterly and annual basis. In addition to these reporting mechanisms, Greenstar will prepare internal reports on a monthly basis to assist programmatic decision-making, including field reports, financial reports, MIS reporting against program deliverables and targets, procurement and shipping reports and monthly progress update reports from sub recipients and partners. Greenstar’s management information system (MIS) monitors program inputs, such as number of providers trained on TB DOTS, number of neighborhood meetings conducted and number of participants, as well as outputs, such as number of TB cases detected, number of patients treated. The system is flexible and can be updated to record data from quality monitoring forms and provide summary reports on quality of service indicators agreed upon by managers. Greenstar’s managers review and analyze the data on a monthly basis to determine priority areas of focus at the national and regional level, and make recommendations for any needed changes to improve quality and service delivery. To complement reporting, managers of all departments, regions, and zones conduct spot supervisory visits to provide on-site job training and feedback to their staff. Greenstar routinely shares results of project progress with its partner organizations and stakeholders. Progress reports are circulated and meetings held to report key findings and lessons learned. With support from Round 3, the NTP has been able to use the current M&E system to capture data from select private sector providers through the Greenstar network. Like public sector diagnostic and treatment units, Greenstar provider sentinel sites keep detailed daily records to measure the impact of Greenstar’s private sector provider network on TB case detection and treatment outcomes. Greenstar also routinely collects data from cross-sections of populations at risk for adverse health outcomes to measure the impact of TB programs, and conducts audits of TB facilities and activities in different geographic areas to measure coverage, quality of coverage, access and equity to access. Provider Sentinel Sites Greenstar provides incentives for selected providers to serve as sentinel sites for the collection of data related to TB program. Sentinel providers will keep detailed daily records including the number of TB patients seen, the number of patients treated, number of discontinuers, etc. Records will be collected monthly and analyzed to gain a better understanding of Greenstar’s provider network impact. TRaC Survey With technical assistance from PSI, Greenstar recently implemented an innovative new research methodology called TRaC (Tracking Results Continuously) into its program. TRaC surveys serve as a tool to inform program managers by routinely collecting data from cross-sections of populations at risk for adverse health outcomes and to provide actionable evidence for social marketing decision-making as well as helping to measure the impact of project interventions and activities. Measuring Product and Service Coverage Greenstar will apply a PSI research methodology called MAP (Measuring Access and Performance) to


ROUND 8 – Tuberculosis measure specific objectives indicators relating to the coverage, quality of coverage, access and equity of access to products and services throughout Pakistan. MAP applies lot quality assurance sampling techniques to select randomly a small number of geographic areas in which an audit of facilities and activities is conducted relative to standards set by managers. Those standards are set to reflect how end-users seek product and services in different settings. MAP uses geographic information systems to measure access and equity of access.

4.8.2. Avoiding parallel reporting To what extent do the monitoring and evaluation ('M&E') arrangements in this proposal (at the PR, Sub-Recipient, and community implementation levels) use existing reporting frameworks and systems (including reporting channels and cycles, and/or indicator selection)?

A supervision, monitoring and surveillance unit (technical unit) exists at the national level. WHO supports TB control in Pakistan through National Program Officers (NPO) with a public health background, based at regional level to provide technical assistance to the Provincial TB Control Programs and Districts. The technical units at central and provincial levels and the TB coordinator at district levels are responsible for monitoring and evaluation. The broad areas related to TB control program to be monitored include: program indicators; logistics and quality control. Program implementation and performance will be monitored through existing scheduled analysis of routine surveillance data, supervisory visits, review meetings at various levels and periodic in-depth internal evaluations. Measurable indicators for quality control, program outcomes and operational effectiveness will be the basis for program monitoring. An annual program performance report is published by NTP and widely disseminated, and it is available on website www.ntp.gov.pk. In order to facilitate the receipt of DOTS DATA from the periphery up to the Central level timely and regularly, quarterly surveillance meetings are held at District, Provincial and National levels. (intra-district meeting, inter-district and Inter-provincial meeting). The meetings are arranged in a cascade fashion starting from the District, Province, and to the National level. The objectives of these meetings are to ensure timely submission of data, analysis of DOTS data and discussing and solving issues and problems in DOTS implementation.

Intra district meeting is arranged at district level and diagnostic canter staff (Doctor, paramedic and laboratory technician) attends this meeting. Along with the quarterly reports (TB 07, TB 08, TB 09), they bring the TB register (TB03) and laboratory register (TB 04) for data validation and compilation. The health facility (Diagnostic centres) data is validated, collected, compiled and analyzed at district level and reports are generated with the technical assistance of National Program Officers. The reports are evaluated at provincial level with the assistance technical experts. The inter-district meetings held at provincial level are meant to evaluate the performance of the district teams, to develop strategies to address the bottle necks and planning for the forthcoming quarter. All district TB coordinator and EDO health attend this meeting. District data is compiled in these meetings. The inter-provincial meeting held at federal level is designed primarily to evaluate the overall performance of the programme. These meetings are held regularly on quarterly basis and all provincial program, National Program Officers and representative of partners attend this meeting. 4.8.3. Strengthening monitoring and evaluation systems What improvements to the M&E systems in the country (including those of the Principal Recipients and Sub-Recipients) are included in this proposal to overcome gaps and/or strengthen reporting into the national impact measurement systems framework?

The Global Fund recommends that 5% to 10% of a proposal's total budget is allocated to M&E activities, in order to strengthen existing M&E systems.

In regards to the overall regular supervision of routine TB case management in the public sector, the NTP is currently implementing the supervision and monitoring module (see Annex VIII) nationwide as per the national guidelines. The successful completion of this training should improve the quality of data captured at public sector TB diagnostic and treatment centers. NTP has been effectively managing drugs procured through financial support from GDF, GTZ, the Government of Japan and the Government of Pakistan (PC1); however, weaknesses in the current drug


http://www.ntp.gov.pk/

ROUND 8 – Tuberculosis management system, identified in the Joint Review and MSH reports, have been identified as critical gaps that could impede the successful implementation of the Round 6 activities. Some of these weaknesses include lengthy and bureaucratic procedures for drug procurement and a lack of clear operational procedures for TB drug management at provincial and district warehouses. Through activities proposed under Objectives 1 and 2 in Section 4.5.1 above, the existing M&E for drug management will be reviewed and revised based on the national policy guidelines currently being revised by the NTP with support from JICA. The development and implementation of an efficient and effective electronic and paper based drug management information system (DMIS) (Objective 2: SDA 2.1 detailed above), that complements the national logistics MIS, will: 1) improve the capacity of both public and private sector providers to accurately and appropriately record and report essential data concerning drug inventory that can be easily shared with the NTP and the PHDs; and 2) improve the ability of the NTP and PHDs to appropriately quantify, procure and distribute high-quality anti-TB drugs to public sector facilities and participating private providers. To achieve this Greenstar will develop an effective and efficient TB DMIS that integrates with the national logistical MIS currently being developed by Abt Associates with support from USAID. After the system is developed, Greensar, ASD and PATA will train public sector and participating private sector Greenstar providers in the new DMIS for TB. The effective implementation of this proposed health system strengthening SDA will improve the capacity of the NTP, both as PR and as steward of anti-TB drug procurement in Pakistan, to ensure an uninterrupted supply of quality anti-TB drugs to notified patients and reach Pakistan’s targets for 85% treatment success.

4.9. Implementation capacity

4.9.1 Principal Recipient(s) Describe the respective technical, managerial and financial capacities of each Principal Recipient to manage and oversee implementation of the program (or their proportion, as relevant). In the description, discuss any anticipated barriers to strong performance, referring to any pre-existing assessments of the Principal Recipient(s) other than 'Global Fund Grant Performance Reports'. Plans to address capacity needs should be described in s.4.9.6 below, and included (as relevant) in the work plan and budget.

PR 1 National TB Control Program

Address Plot No 61, I-10/3, Industrial Area, Islamabad, Pakistan NTP is a legal entity in Ministry of Health, Government of Pakistan. NTP has been successfully planning, managing and implementing the program activities in public sector as well as bilateral and multilateral partners funded projects. The government has accorded high priority to TB control in its National Health Policy of 2001. Moreover, TB has been declared as National emergency (Islamabad Declaration). Pakistan and DOTS has been adopted as National strategy for TB control program. National TB Control program has a variety of highly qualified professionals (including TB, public health and financial management expertise) working under an efficient organizational structure. The organization has a well established net work extending from national to provincial and district levels. NTP is responsible for implementation of various national and international projects. The efforts made by the program for expansion and implementation of TB DOTS are being evaluated for National and International missions regularly. These findings of mission has led to remarkable improvement in the capacity and functioning of the program. The program has clearly defined roles of National TB Control Program, Provincial TB Control Programs and districts for DOTS implementation. NTP has an established net work of infrastructure having managerial capacity to successfully implement the program in Public sector. The program is already carrying out the DOTS implantation in public sector and providing technical assistance for implementation of Quality assurance program in laboratory network, ACSM and PPM throughout the country. A panel of technical experts is available and they are already providing technical assistance to the provincial programs and other implementing partners including SRs of GF grant in Round-2 3 and 6. To manage extensive activities and huge amount of budgets and procurements a complete management unit with dedicated staff to deal with procurement and supply management will be established. NTP is the implementing agency for many National and International projects. It has been successful in


ROUND 8 – Tuberculosis procurement planning, processing bids and purchasing as well as logistical support right down to the operational sites. NTP has proven capacity in Financial Budget planning, control and monitoring, financial recording and reporting both of public sector funds and arrangements with partner NGOs and Public-Private Partnerships. Based on the strengths, NTP was recommended by CCM and agreed by LFA and TGF to be the PR in Round 2 whereas in Round 6 NTP is the approved PR. National TB Control Programme headed by National Manager has got the following units:

1. Management unit 2. Planning and development 3. Research unit 4. Finance unit 5. Administrative & Accounts unit 6. IT & Data unit 7. Monitoring & Supervision unit 8. Reference Laboratories 9. TB. HIV and MDR TB Unit

NTP have a well established Finance Unit, headed by Finance Manager. This unit is providing services to NTP and related projects. This unit assists NTP in preparation of budgets, proposals and plans. They provide assistance and guidance to the other technical staff on financial monitoring techniques and tools. Interpretation of various financial reports, development of financial procedures and schedules provincial and field officers. The major projects looked after by the unit include USAID, FIDELIS, CIDA, JPRM and Global fund. NTP through its proven financial management capacity has been successful in the implementation of several projects e.g. Government and donor funded. For detail please see section 5.1. Partnership has been playing a critical role in TB control efforts in Pakistan. Increasing number of national partners, both in public and private, have worked together for TB control. This include NGOs working in many different areas of TB control such as TB care for vulnerable populations, refugees and poor, social mobilization for TB control, operational research and public private mix approach of health care delivery. Moreover, private sector such as private medical schools and private health care providers are coming on board. Equally important is the increasing number of international partners including donors, and bilateral and multilateral agencies. The Inter-agency coordination committee (IACC) comprising of the local and international partners, donors and bilateral agencies has been very effective to bring and coordinate support from international partners, holds meetings on quarterly basis to avoid duplications of services and optimal use of support.

PR 2 Greenstar Social Marketing Pakistan (Guarantee) Limited

Address 21 C, Zamzama Commercial Lane No. 5, Phase V, DHA, Karachi 75600 Greenstar has seventeen years of experience managing large-scale, multi-faceted projects in Pakistan. Greenstar, with technical assistance from PSI, has obtained numerous multi-million dollar contracts directly from numerous donors including Global Fund, USAID, KfW, UNFPA, DFID, foundations and other international, and as a subcontractor to other organizations. As a result, Greenstar has become experienced in donor policies and procedures and has a proven record of establishing management and financial systems honed to respond to project and contract requirements. Greenstar also has significant experience in developing formal relationships and signing contracts with organizations and individuals to assist in the design, implementation or evaluation of a number of project activities. Agreements delineate each party's responsibilities, describe the nature and timing of any deliverable outputs, and establish financial arrangements necessary. Greenstar’s management systems in all technical and crosscutting functional areas operate in compliance with Global Fund principles and guidelines. Monitoring of all activities is being done by using Greenstar’s MIS system which is Oracle based online application allowing data being entered at the source. The MIS system has various modules linked to each other allowing for accurate and speedy report generation. For instance, because inventory and purchase module is interlinked with sales and distribution module, anytime when there is sales recorded, inventory levels are reflected accordingly. Although Greenstar is most often recognized for its success as a direct implementer of programs, the


ROUND 8 – Tuberculosis organization also has significant experience collaborating on large-scale projects with multiple partners including: local and international NGOs, small businesses, private health care providers and public sector organizations. When working with local counterparts, Greenstar works to strengthen the capacity of its partners to continue project activities and inspire independent initiatives in the long-term. Greenstar considers private sector collaboration to be an essential element to the sustainability and effectiveness of social marketing programs. Greenstar uses private sector techniques to maximize efficiency and speed and to increase coverage of socially-marketed health products in a sustainable way. The relationships between Greenstar and private sector partners are mutually beneficial; partners have the opportunity to grow their businesses, client bases and profit margins, while high quality and affordable Greenstar products and services are delivered to target populations quickly, in all corners of the country. Greenstar in Pakistan and PSI globally has extensive experience in and existing capacity for routine financial management of large scale health programs, operating in accordance with international standards and Global Fund principles for transparency, timeliness, inclusive decision-making and effective oversight. Greenstar utilizes in-country technical advisory services of PSI as required, and has direct access to other PSI global resources. PSI, a non-profit organization incorporated in 1970, combines entrepreneurial spirit with social mission to encourage healthy behavior and improve public health worldwide. Working in more than 65 countries, PSI delivers affordable and accessible health products and services to low-income and vulnerable populations, and produces and disseminates innovative, culturally appropriate behavior change communications. PSI uses commercial marketing techniques to harness the power of markets to create equity and access to quality and affordable health products and services. PSI’s primary interventions concern: HIV/STI prevention, HIV counseling and testing (CT), family planning, malaria, diarrheal disease, maternal and child health, and tuberculosis (TB). Globally, PSI has considerable experience successfully implementing Global Fund programs in all three disease areas as a Principal Recipient (PR), a Sub-Recipient (SR), and in supporting the Country Coordinating Mechanism (CCM) as a full member or as a technical advisor. Greenstar has extensive experience in and existing capacity for routine financial management of large-scale health programs, operating in accordance with international standards and Global Fund principles for transparency, timeliness, inclusive decision-making and effective oversight. Greenstar’s financial management system enables to disburse funds to sub-recipients and suppliers in a timely, transparent and accountable manner. Greenstar’s financial management system is subject to local and international standards and oversight in order to ensure timeliness, transparency and accountability in all dealings with sub recipients and suppliers. Greenstar’s current operations under the family planning program funded by USAID, KfW, and UNFPA are subject to such standards, including external auditing. Greenstar is also subject under Round-3 TB program to ongoing coordination with and oversight by the Global Fund’s Office of Principal Recipient represented by NACP and Local Fund Agent (LFA) to ensure compliance with GFATM financial guidelines. Greenstar is able to prepare regular and reliable financial statements, and safeguard the donors’ assets. For this, Greenstar operates Oracle based standardized online financial management and accounting systems, which have been specifically designed to enable accurate internal monthly reporting and review, as well as regular and reliable reporting to donors. These systems were established by Greenstar recently due to the urgency to have the necessary reporting systems in place to meet the financial reporting requirements of its donors as well as to enhance operational and financial efficiency. Greenstar finance and control systems allow it to custom design financial and asset management reports as per each donor’s needs. Greenstar also has a variety of systems in place for safeguarding its assets following international best practices, including procedures for asset coding, competitive bidding, corporate insurance policies, asset lists. Greenstar’s financial statements and accounting procedures are subject to internal audits on a regular basis, and external audits annually by major global accounting firms. Audited financial statements are made available on an annual basis. In addition, Greenstar’s sister company PSI employs financial analysts, procurement specialists, and contracts specialists that review Greenstar’s finance, contracts, and procurement documents to ensure compliance with its financial, contracts, procurement operating systems. In addition to this, PSI conducts regular internal assessments that include field visits by global accounting and financial management specialists, providing another layer of oversight and accountability. Finally, under the Global Fund, Greenstar as an SR is subject to ongoing operational PR/LFA overview,


ROUND 8 – Tuberculosis and supports the Global Fund principles of transparency by making internal financial statements and reports fully available to the PR and LFA on a regular basis.

PR 3 [Name]

Address [street address]

[Description] Copy and paste tables above if more than three Principal Recipients 4.9.2 Sub-Recipients

X Yes (a) Will sub-recipients be involved in program implementation?

No (b) If no, why not?

X 1 – 6

7 – 20

21 – 50 (c) If yes, how many sub-recipients will be involved?

more than 50 X Yes [ Annex IX] (d) Are the sub-recipients already identified?

(If yes, attach a list of sub-recipients, including details of the 'sector' they represent, and the primary area(s) of their work over the proposal term.) No

(e) If yes, comment on the relative proportion of work to be undertaken by the various sub-recipients.

If the private sector and/or civil society are not involved, or substantially involved, in program delivery at the sub-recipient level, please explain why.

As PR for SDA 1.2, Greenstar will be supported by two civil society SRs: the Association for Social Development (ASD) and the Pakistan Anti-Tuberculosis Association (PATA). These SRs were chosen by the NTP and Greenstar through a transparent selection process. The inclusion of these SRs will extend the geographic scope of the proposed program to train public sector key personnel in the new drug management operational guidelines and DMIS. The role of Greenstar, ASD and PATA significantly increase the role of civil society and the private sector in TB drug management systems strengthening. Specific roles and responsibilities for ASD and PATA are outlined below: Association for Social Development (ASD) Training of health personnel: ASD, in partnership with NTP, Greenstar and other partners, will carry out trainings of healthcare personnel on drug supply & drug management. This will include:

• A two-day national level training event (for master trainers) will be arranged for programme managers/staff.

• Two–day provincial level events will be arranged for provincial and regional level managers.

• Two-day event will be arranged for personnel from 50 district health offices. Five persons from each district will participate.

• Two-day event will be arranged for doctors from diagnostic centre. Two doctors from each of 536 diagnostic centers will be trained


ROUND 8 – Tuberculosis • Two-day event will be arranged for paramedics from diagnostic centre. Two paramedics from

each of 536 diagnostic centers will be trained.

• One-day event will be arranged for treatment centre staff. One staff members from each of 2400 treatment centers will be trained.

• One-day event will be arranged for 500 personnel from private clinic/hospitals in 36 of the 50 districts. Only those clinics/hospitals will be offered the training who has already been participating in the NTP PPM initiative in each respective district.

• At least one designated district health office staff from each of the 50 selected districts, plus 10% staff attrition (assumed) from year 2 onwards, will be enabled for computer-based inventory management including estimating the requirements, initiating the procurement/ demand process, storage and distribution, record maintenance and analysis etc.

Pakistan Anti-TB Association (PATA) As an SR, the Pakistan Anit-TB will offer its inputs to train private providers in 50 districts for strengthening the private sector capacity to manage drugs at national, provincial, district and facility levels. The enhanced drug management system would help improving the quality of care in the private sector facilities in these districts. The main set of success indicators would be availability and quality of anti-TB drugs, through enhanced capacity/practice to plan, procure, store, distribute, and quality control. This health services strengthening would in turn lead to improved utilization of services and better treatment outcomes in these districts. The final selection of main indicators (inputs, process, outputs and outcome) and procedures/tools for monitoring these indicators will be made in consultation with the NTP and other implementing partners. PATA proposes to undertake the following activities in 50 selected districts, where PATA is already operational:

• Training of managerial Staff • Training of store Keepers • Training of staff in charge of facilities • Training of private providers • Training on Monitoring & Evaluation • Trainings will focus on storage standards including logistic and inventory management system,

refurbishment of drug ware houses maintaining optimal temperature, humidity, illumination and space conditions

• Standard Distribution and transportation arrangements from national to provincial and from provincial to district/peripheral ware houses

• Capacity building of technical staff on rational usage as per NTP/WHO guidelines In addition to being PR, Greenstar will also be a SR to NTP (PR) under SDA 1.1 and 1.3 (please see Section 4.5.1 above for details). NTP has identified Greenstar as the most appropriate SR to effectively implement these activities. At no time is Greenstar SR to itself as PR.

4.9.3. Pre-identified sub-recipients Describe the past implementation experience of key sub-recipients. Also identify any challenges for sub-recipients that could affect performance, and what is planned to mitigate these challenges. Association for Social Development (ASD) A National Council, with nine credible senior members, steers the Association working. The Association has four main functional units i.e. administration and finance unit, policy and research unit, programme development and technical support unit, and field operations and implementation support unit. Each unit


ROUND 8 – Tuberculosis has a Lead professional and a team of professionals, associate professionals, fellows and support staff. The Chief Coordinating Professional, reporting to the Chairman, coordinates the overall functioning of the four units in the Association. Since 1994, the Association for Social Development (ASD) has been working with national, provincial and district level health programmes (including TB, Malaria, HIV/AIDS, Nutrition) to develop a systematic process for building public sector capacity to design, plan, implement, monitor and evaluate context sensitive interventions, including public private partnership models. The specific examples of programme development through systematic four-stage process includes: public-private partnership development for disease control interventions, hospital DOTS linkage development, TB-HIV co-infection, external quality assurance of TB and malaria microscopy, syndromic management of STI through public health facilities etc. This fourteen years experience of working, as a technical partner, has helped the Association staff to achieve the required understanding and skills, refine the processes, as well as establish credentials and recognition for working as a long-term and able technical partner of the programmes. The Association also has an access to in-country and overseas teaching, research and development institutions as well as a pool of professionals with a wide range of expertise in programme development, management, research, and social sciences including economics and anthropology. The extensive development and implementation support experience with national and provincial TB control programmes, as well as an in-depth understanding of the other ongoing initiatives of the programme and its partners gives Association an advantage to effectively harmonize the drug management capacity enhancement process with the rest of the programme activities. The Association has developed arrangements/ SOPs for managing project resources as well as monitor performance according to international acceptable standards. The Association has an experience of working with a wide range of development partners including DFID (UK), World Bank, WHO, CIDA-IUATLD, GTZ, UNDP, Medical Research Council (UK). The Association also has an in-depth understanding of the Global Fund policies, operations and tools. The accounts are regularly audited, on annual basis, by a reputable chartered accountant firm. The Association has valuable experience of working with district health offices to strengthen the public sector delivery and management of disease control interventions including DOTS, RBM and STIs. The Association, in partnership with the provincial disease control programmes, has actively been involved in planning, implementing, monitoring and scaling-up various disease control interventions in more than twenty-five districts of Punjab, NWFP and Balochistan (Sindh to start in July 2008). This continued presence as a technical partner in provinces and districts, with a wide range of ongoing interventions, gives Association the confidence and competitive edge for taking this new initiative (i.e. drug management capacity enhancement) to public sector programmes, and selected districts and its facilities. In many of these districts, the Association has also been engaged in advocacy, communication and social mobilization (ACSM) activities for enhanced disease control. This further enables the Association to take the consumer perspective into consideration, while developing operations for delivery and management of care. The Association is very well placed to, work in partnership with the programme and districts, develop an effective and replicable drug management capacity enhancement package. The proposed exercise would supplement the ongoing programme efforts to enhance the quality of DOTS implementation. Some of the specific ongoing interventions are as under:

• District enabling to implement DOTS in 16 districts of Punjab. This include: district plans, staff training, material supplement, facility & district level monitoring, & external quality assurance.

• Enabling district and tehsil level public hospitals in 12 districts to implement DOTS, as per national protocols. The ASD facilitated the hospital staff to put in place the key arrangements/ practices.

• Enabling 22 teaching hospitals in Punjab/NWFP to operationalize core DOTS, TB-HIV co-infection and childhood TB interventions. The inputs include development and implementation support.


ROUND 8 – Tuberculosis Pakistan Anti-TB Association (PATA) Pakistan Anti TB Association (PATA) is a single object non-profit / non-governmental and registered community based organization having international and national references. PATA is an active member of IUATLD. Its component associations are providing services to TB patients in all the provinces of Pakistan having their Provincial Head Quarters at Lahore, Karachi, Peshawar and Quetta. These associations are maintaining more than 100 diagnostic centers throughout the country where free TB diagnostic and treatment facilities are provided with the help of more than 10000 community volunteers. PATA has a panel of chest specialists of country’s top TB and Chest specialists on board. PATA has enhanced its capacity in detection of TB cases through strengthened sputum microscopy and service delivery for TB patients through GFATM R-2 project. But the gaps in Drug Management System and managerial capacity for implementing DMS still remain as the biggest gap in PATA TB services. To strengthen the Drug Management System and capacity enhancement at NGO health outlets/Service Delivery Points through public private partnership with Pakistan Anti TB Association. Pakistan Anti TB Association is an implementing partner for WHO recommended DOTS strategy and is providing standard diagnostic and treatment facilities through its country-wide network of diagnostic and treatment centres. At present PATA has managerial, technical and financial capacity for implementing DOTS strategy except for Drug Management System (DMS). For carrying out the round 8 proposal PATA will require one full time Project Coordinator at central level and five regional coordinators in the field. Project coordinator and regional coordinators will work in close liaison with NTP, PTPs, DTCs and NPOs of WHO. This arrangement will also ensure coordination with PR. Through capacity enhancement and strengthening of DMS the objective of implement a standard DMS cycle will be achieved. Greenstar Please see the capacity statement for Greenstar as PR for details concerning Greenstar’s implementation capacity (Section 2).

4.9.5. Coordination between implementers Describe how coordination will occur between multiple Principal Recipients, and then between the Principal Recipient(s) and key sub-recipients to ensure timely and transparent program performance.

Comment on factors such as:

• How Principal Recipients will interact where their work is linked (e.g., a government Principal Recipient is responsible for procurement of pharmaceutical and/or health products, and a non-government Principal Recipient is responsible for service delivery to, for example, hard to reach groups through non-public systems); and

• The extent to which partners will support program implementation (e.g., by providing management or technical assistance in addition to any assistance requested to be funded through this proposal, if relevant).

In the proposed program, the NTP (the government PR) is responsible for procurement of high quality anti-TB drugs and then distributing them through the PHD’s integrated warehouse and distribution system; however, as highlighted by the TRP’s 4th Comment from the Round 7 proposal, this distribution system should be expanded to engage private providers through the district led implementation model. Therefore, Greenstar has been selected as a SR to the NTP for SDA 1.1 to distribute high quality anti-TB drugs to private providers through its existing private provider network which is supported by Round 3. This activity not only builds on the activities from previous Global Fund Rounds, but will also strengthen the district led implementation model to operationalize and test a mechanism for distributing public sector drugs to the private sector to increase access to TB care through the private sector and attempt to regulate the quality of drugs available to patients being treated by private providers.

Communication and coordination between partners is integral to the successful implementation of any collaborative program. It is essential for partners to understand and agree to the specific roles and responsibilities of each partner from the outset of the program. Therefore, Greenstar (as PR) will


ROUND 8 – Tuberculosis organize three different types of regular meetings. First, an annual coordination meeting will be held to bring all the implementing partners together to discuss roles and responsibilities, reporting procedures, and draft any necessary program documentation, such as annual reports and/or work plans. At the first annual meeting, the PRs will share the SRs their expectations for financial accounting and reporting, and specify an agreed reporting schedule. Program data management is also very important, and both PRs already have existing and strong monitoring and evaluation (M&E) systems to capture the necessary indicators proposed for this program. At the first annual meeting, the PRs and SRs will work together to work out systems to capture the data required by the proposal, and that complement and build on their existing M&E systems. Second, regularly quarterly meetings will be held with all partners to review progress, address challenges to implementation and confirm activities and deliverables expected in the upcoming quarter. Third, PR action meetings will be scheduled on an ad-hoc basis to address any program management issues or concerns, such as SR/PR performance or unexpected changes in the operating environment, as they arise. These meetings will facilitate strong communication, improve coordination, and promote transparency between the partners. Costs for these meetings are included in the Greenstar PR budget.

4.9.6. Strengthening implementation capacity The Global Fund encourages in-country efforts to strengthen government, non-government and community-based implementation capacity.

If this proposal is requesting funding for management and/ or technical assistance to ensure strong program performance, summarize:

(a) the assistance that is planned;**

(b) the process used to identify needs within the various sectors;

(c) how the assistance will be obtained on competitive, transparent terms; and

(d) the process that will be used to evaluate the effectiveness of that assistance, and make adjustments to maintain a high standard of support.

** (e.g., where the applicant has nominated a second Principal Recipient which requires capacity development to fulfill its role; or where community systems strengthening is identified as a "gap" in achieving national targets, and organizational/management assistance is required to support increased service delivery.)

Technical and management assistance for drug systems management strengthening will be provided by Greenstar and its international technical partner, Population Services International (PSI). The assistance planned is detailed in SDAs 1.2 and 2.1 in Section 4.5.1 above. The need for this technical assistance was identified by the Joint Review Report (Annex III), the MSH Report (Annex IV), and the NTP Round 7 Gap Analysis (Annex V). Greenstar was selected by the CCM to deliver this assistance in its capacity as PR for drug systems management strengthening activities. Greenstar was selected by the CCM to be PR and provide this specific technical and management support to the NTP through an open and transparent selection process as described in Sections 1 and 2 of this proposal. The effectiveness of the assistance provided by Greenstar will be evaluated by its ability to achieve the deliverables outlined for Greenstar in Attachment A. Throughout the implementation of the proposed activities, Greenstar will work closely with the NTP to build the NTP’s capacity in drug systems management, as the NTP will ultimately be responsible for managing and directing the implementation of the TB DMIS developed by Greenstar under SDA 2.1 and the monitoring the performance of public sector warehouses and treatment facilities in implementing the TB drug management operational guidelines developed by Greenstar under SDA 1.2.



4.10. Management of pharmaceutical and health products 4.10.1. Scope of Round 8 proposal

No Go to s.4B if relevant, or direct to s.5. Does this proposal seek funding for any

pharmaceutical and/or health products? X Yes

Continue on to answer s.4.10.2.

4.10.2. Table of roles and responsibilities

Provide as complete details as possible. (e.g., the Ministry of Health may be the organization responsible for the ‘Coordination’ activity, and their ‘role’ is Principal Recipient in this proposal). If a function will be outsourced, identify this in the second column and provide the name of the planned outsourced provider.

Activity

Which organizations and/or departments are responsible for this function? (Identify if Ministry of Health, or Department of Disease Control, or Ministry of Finance, or non-governmental partner, or technical partner.)

In this proposal what is the role of the organization responsible for this function? (Identify if Principal Recipient, sub-recipient, Procurement Agent, Storage Agent, Supply Management Agent, etc.)

Does this proposal request funding for additional staff or technical assistance

Procurement policies & systems MOH PR (NTP)

X Yes

No

Intellectual property rights MOH PR (NTP) Yes

X No

Quality assurance and quality control

MOH – through Drug Regulatory Board PR (NTP) Yes

X No

Management and coordination More details required in s.4.10.3.

MOH- NTP, PTP, District Govt. PR (NTP)

X Yes

No

Product selection

NTP for ATT drugs, Provincial Health Departments for drugs at Provincial level.

PR (NTP) Yes

X No

Management Information Systems (MIS) Greenstar Greenstar (PR)

X Yes

No

Forecasting NTP/ PTP Public Sector NTP (PR) Private Sector Green Star PR) and SRs

X Yes

No

Procurement and planning National TB Control Program MoH PR (NTP)

X Yes

No

Storage and inventory management More details required in s.4.10.4

MoH – NTP, PTP, District Govt

Public Sector NTP (PR)

Private Sector Green Star PR) and SRs

X Yes

No

Distribution to other stores and end-users More details required in s.4.10.4

MoH – NTP, PTP, District Govt

Public Sector NTP (PR)

Private Sector Green Star

X Yes

No


ROUND 8 – Tuberculosis PR) and SRs

Ensuring rational use and patient safety (pharmacovigilance)

National TB Control program Public Sector NTP (PR)

Private Sector Green Star PR) and SRs

X Yes

No

4.10.3. Past management experience

What is the past experience of each organization that will manage the process of procuring, storing and overseeing distribution of pharmaceutical and health products?

Organization Name PR, sub-

recipient, or agent?

Total value procured during last financial year

(Same currency as on cover of proposal)

National TB Control Program PR US$2.82 million

Greenstar Social Marketing PR US$ 544,845

[use the "Tab" key to add extra rows if more than four organizations will be involved in the management of this work]

4.10.4. Alignment with existing systems Describe the extent to which this proposal uses existing country systems for the management of the additional pharmaceutical and health product activities that are planned, including pharmacovigilance systems. If existing systems are not used, explain why. The drug management system in the country in fully integrated and at provincial and district level, there is common drug stores that maintain and distribute supplies. Therefore, strengthening of drug management for TB drugs through the proposed TB DMIS which is compatible with the national logistics DMIS will strengthen overall drug management system in the country. NTP will use existing human resource, available with the provinces and districts for the drugs management at provincial and district level. NTP is supplying TB drugs to the provinces and then from provinces drugs are supplied to the districts. The districts are the main implementing unit in TB Program and privates sector should access drugs directly from the districts. While no stock outs have been observed in the past at central or peripheral levels (WHO report 2008), the gap analyses (the Joint Review and MSH Reports mentioned previously) identified that without strengthening of the current drug management system stock-outs could occur in future, especially as demand for TB drugs through the district led implementation model increases. Therefore, this pharmaceutical management system will be strengthened with the support of the Round 8 and provincial and district level staff and participating Greenstar private providers will be trained for the overall drugs management system. The Project will strengthen the present drug management system at all levels to ensure optimal utilization of drugs by establishing a dedicated drug management unit in NTP at central level, and developing and implementing drug management plan, developing guidelines through international and national technical assistance. This system will complement the national integrated logistics DMIS being developed for essential drugs and contraceptives by Abt Associates with support from USAID. Greenstar will develop trainings based on the national policy for TB drug management and corresponding operational guidelines, which will then be delivered to both public and private sector providers. This proposal will strengthen existing management systems and not create a new or vertical system.


ROUND 8 – Tuberculosis 4.10.5. Storage and distribution systems

National medical stores or equivalent

Sub-contracted national organization(s) (specify)

Sub-contracted international organization(s) (specify)

(a) Which organization(s) have primary responsibility to provide storage and distribution services under this proposal? X Other: National TB Control Program (PR) will be primarily

responsible for storage and distribution in public sector and Greenstar (PR) will be primarily responsible for storage and distribution in private sector of drugs received from the public sector through the district led implementation model. (specify)

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

NTP would be responsible for drug supply and storage in the Public Sector. All provinces and districts have drugs stores and TB drugs are also stored in same integrated drug stores in public sector health facilities. The storage capacity is generally sufficient to store the required amount of TB drugs at provincial and district levels. To strengthen drug management and logistic management, it is proposed that each province and district should have the store/warehouse refurbished to bring at par with WHO standards. As MOH do not have integrated drugs store at National level, drugs management is vertical at National level and NTP needs a central warehouse to store the drugs and buffer stock. Current storage capacity is limited and new building of NTP, with store, is under construction in Chest Diseases Hospital Rawalpindi. Greenstar currently operates 44 warehouses (1 central, 3 regional and 40 zonal) serving 104 districts throughout Pakistan. Greenstar has been distributing commodities through these warehouses on pre-defined Standard Operating Procedures and has requisite warehousing and human resource capacity, needing no additional infra-structure for storage of Anti-TB drugs under the current proposed Round. (c) For distribution partners, what is each organization's current distribution capacity for

pharmaceutical and health products? If this proposal represents a significant change in the volume of products to be distributed or the area(s) where distribution will occur, estimate the relative change in percent, and explain what plans are in place to ensure increased capacity.

Anti-TB drugs procured by NTP are distributed based on the case notification, consumption and stock position. NTP distributes drugs to the provinces and drugs are stored in the provincial drug stores, with the drugs procured through the provincial resources. From the provinces, the drugs are distributed to the districts and stored in the district drug stores. From the district store, the drugs are distributed to the health facilities. Through this proposal the availability of drugs will be ensured at each current distribution point. The existing drug distribution and information system will be strengthened with provision of vehicles for distribution from provinces to districts and providing training in Drug management and information system. Greenstar has one of the largest distribution systems in Pakistan, reaching over 20,000 pharmacies a100,000 general stores throughout the country. Greenstar has over a 100 sub-distributors throughout tcountry, who have staff dedicated exclusively to the distribution of Greenstar products. A total of over 2sales staff are employed for the distribution effort of 14 Greenstar products. Greenstar complies with the Global Fund’s Procurement and Supply principles for the procurement of drugs, operating a competitive selection process among manufacturers approved by World Health Organization (WHO) and following the standardized written procurement policy established with assistance by PSI’s International Procurement Department. To ensure the timely delivery of high-quality products to end-users, Greenstar monitors the performance of its distribution networks through monthly


r

r

r

ROUND 8 – Tuberculosis reports, as well as randomized field visits at regular intervals to assess the status of product distribution activities.

4.10.6. Pharmaceutical and health products for initial two years

Complete 'Attachment B-Tuberculosis' to this Proposal Form, to list all of the pharmaceutical and health products that are requested to be funded through this proposal.

Also include the expected costs per unit, and information on the existing 'Standard Treatment Guidelines ('STGs'). However, if the pharmaceutical products included in ‘Attachment B-Tuberculosis’ are not included in the current national, institutional or World Health Organization STGs, or Essential Medicines Lists ('EMLs'), describe below the STGs that are planned to be utilized, and the rationale for their use.

Pharmaceutical products, which will be procured through this proposal, are included in the current national and World Health Organization Essential Medicines Lists ('EMLs'). All drugs will be procured through the Global Drug Facility (GDF) to ensure the quality and bioavailability. The unit cost calculated in the Attachment B is based on patient courses. Category 1 = 25 USD (RHZE 2 months, EH 6 months) Category 2 = 52 USD (RHZES 2 months, RHZE 1 month, RHE 5 months)


ROUND 8 – Tuberculosis 4.10.7. Multi-drug-resistant tuberculosis

Yes In the budget, include USD 50,000 per year over the full proposal term to contribute to the costs of Green Light Committee Secretariat support services. Is the provision of treatment of multi-drug-

resistant tuberculosis included in this tuberculosis proposal?

No

Do not include these costs

4B. PROGRAM DESCRIPTION – HSS CROSS-CUTTING INTERVENTIONS

Optional section for applicants SECTION 4B CAN ONLY BE INCLUDED IN ONE DISEASE IN ROUND 8 and only if:

The applicant has identified gaps and constraints in the health system that have an impact on HIV, tuberculosis and malaria outcomes;

The interventions required to respond to these gaps and constraints are 'cross-cutting' and benefit more than one of the three diseases (and perhaps also benefit other health outcomes); and

Section 4B is not also included in the HIV or malaria proposal Read the Round 8 Guidelines to consider including HSS cross-cutting interventions. 'Section 4B' can be downloaded from the Global Fund's website here if the applicant intends to apply for 'Health systems strengthening cross-cutting interventions' ('HSS cross-cutting interventions').



http://www.theglobalfund.org/documents/rounds/8/ProposalForm_HSS_4B_en.doc

ROUND 8 – Tuberculosis 5. FUNDING REQUEST 5.1. Financial gap analysis - Tuberculosis Clarified Table 5.1 1

Summary Information provided in the table below should be explained further in sections 5.1.1 – 5.1.3 below.

Financial gap analysis (same currency as identified on proposal coversheet) Note Adjust headings (as necessary) in tables from calendar years to financial years (e.g., FY ending 2007; etc) to align with national planning and fiscal periods

Actual Planned Estimated

2006 2007 2008 2009 2010 2011 2012 2013

Tuberculosis program funding needs to deliver comprehensive diagnosis, treatment and care and support services to target populations

Line A Provide annual amounts 21.131

(21,131,000) 29.498*

(29,498,000) 36.718*

(36,718,000) 37.190*

(37,190,000) 38.832*

(38,832,000) 41.609*

(41,609,000) 44.673*

(44,673,000) 47.540*

(47,540,000)

Line A.1 Total need over length of Round 8 Funding Request (combined total need over Round 8 proposal term)

Current and future resources to meet financial need

Domestic source B1: Loans and debt relief (provide name of source )

0 0 0 0 0 0 0 0

Domestic source B2 National funding resources

5.47 (5,470,000)

5.39 (5,390,000)

6.20 (6,200,000)

10.10 (10,100,000)

11.62 (11,620,000)

13.36 (13,360,000)

15.36 (15,360,000)

17.36 (17,360,000)

Domestic source B3 Private Sector contributions (national) 0 0 0 0 0

Total of Line B entries Total current & planned DOMESTIC

(including debt relief) resources:

5.47 (5,470,000)

5.39 (5,390,000)

6.20 (6,200,000)

10.10 (10,100,000)

11.62 (11,620,000)

13.36 (13,360,000)

15.36 (15,360,000)

17.36 (17,360,000)


ROUND 8 – Tuberculosis Financial gap analysis (same currency as identified on proposal coversheet)

Note Adjust headings (as necessary) in tables from calendar years to financial years (e.g., FY ending 2007; etc) to align with national planning and fiscal periods


2006 2007 2008 2009 2010 2011 2012 2013

External source (provide source name)

USAID

2.50 (2,500,000)

1.00 (1,000,000)

1.00 (1,000,000)

0 0 0 0 0


JPRM

0.035 (35,000)

0.100 (100,000)

0.100 (100,000)

0 0 0 0 0


DFID

0.100 (100,000)

0 0 0 0 0 0 0

External source (provide source name) Govt. of Japan (JICA)

0.120 (120,000)

0.125 (125,000)

0.125 (125,000)

0 0 0 0 0


Govt. of Japan (For drugs only) 0 0 0

8.24 (8,240,000)

0 0 0 0


GTZ/ kfw

3.6 (3,600,000)

3.12 (3,120,000)

3.21 (3,210,000)

0 0 0 0 0


Global Drug Facility (GDF) 0 0

3.78 (3,780,000)

0 0 0 0 0

External source C3 Private Sector contributions

(International)

Total of Line C entries Total current & planned EXTERNAL (non-

Global Fund grant) resources:

6.35 (6,350,000)

4.32 (4,320,000)

8.10 (8,100,000)

8.24 (8,240,000)

0 0 0 0


ROUND 8 – Tuberculosis Financial gap analysis (same currency as identified on proposal coversheet)

Note Adjust headings (as necessary) in tables from calendar years to financial years (e.g., FY ending 2007; etc) to align with national planning and fiscal periods


2006 2007 2008 2009 2010 2011 2012 2013

Line D: Annual value of all existing Global Fund grants for same

disease: Include unsigned ‘Phase 2’ amounts as “planned” amounts in

relevant years

2.56 (2,560,000)

14.42 (14,420,000)

13.33 (13,330,000)

10.84 (10,840,000)

11.53 (11,530,000)

11.07 (11,070,000)

0 0

Line E Total current and planned resources (i.e. Line E = Line B total

+ Line C total + Lind D Total)

14.39 (14,390,000)

24.13 (24,130,000)

27.63 (27,630,000)

29.18 (29,180,000)

23.15 (23,150,000)

24.43 (24,430,000)

15.36 (15,360,000)

17.36 (17,360,000)

Calculation of gap in financial resources and summary of total funding requested in Round 8 (to be supported by detailed budget)

Line F Total funding gap (i.e. Line F = Line A – Line E)

6.73 (6,730,000)

5.33 (5,330,000)

9.08 (9,080,000)

8.01 (8,010,000)

15.68 (15,680,000)

17.17 (17,170,000)

29.31 (29,310,000)

30.18 (30,180,000)

Line G = Round 8 tuberculosis funding request (same amount as requested in table 5.3 for this disease)

4.37 (4,370,000)

5.43 (5,430,000)

5.45 (5,450,000)

5.62 (5,620,000)

5.78 (5,780,000)




Part H – 'Cost Sharing' calculation for Lower-middle income and Upper-middle income applicants

In Round 8, the total maximum funding request for tuberculosis in Line G is: (a) For Lower-Middle income countries, an amount that results in the Global Fund's overall contribution (all grants) to the national program reaching not more than 65% of

the national disease program funding needs over the proposal term; and (b) For Upper-Middle income countries, an amount that results in the Global Fund overall contribution (all grants) to the national program reaching not more than 35% of

the national disease program funding needs over the proposal term.

Line H Cost Sharing calculation as a percentage (%) of overall funding from Global Fund

Cost sharing = (Total of Line D entries over 2009-2013 period + Line G Total) X 100 Line A.1

%

ROUND 8 – Tuberculosis 5.1.1. Explanation of financial needs – LINE A in table 5.1

Explain how the annual amounts were:

• developed (e.g., through costed national strategies, a Medium Term Expenditure Framework [MTEF], or other basis); and

• budgeted in a way that ensues that government, non-government and community needs were included to ensure fully implementation of country's tuberculosis program and strategy.

Tuberculosis program funding needs to deliver comprehensive diagnosis, treatment and care and support services to target populations was calculated with an extensive exercise during the Round 7 proposal development. The following steps contributed to the analysis: 1. Quarterly Inter-provincial workshop; 2. MOST for TB Workshop with the support of Management Sciences for Health and USAID; and 3. Two day Workshop on Drug management system – at the primary health care facility, supported by MSH and USAID All Provincial stake holder and partners attended the workshop and participated in this exercise. (Please see Annex V for the detailed report). After the Round 7 proposal was declined, the provincial programs and NTP agreed during the inter-provincial and IACC meetings that the meeting that the gap still needed to be addressed and should be proposed for Global Fund support in Round 8. (Please see Annex XI for details).

5.1.2. Domestic funding – 'LINE B' entries in table 5.1

Explain the processes used in country to:

• prioritize domestic financial contributions to the national tuberculosis program (including HIPC [Heavily Indebted Poor Country] and other debt relief, and grant or loan funds that are contributed through the national budget); and

• ensure that domestic resources are utilized efficiently, transparently and equitably, to help implement treatment, diagnosis, care and support strategy at the national, sub-national and community levels.

NTP holds regular quarterly meetings at Districts, Provincial and National levels to see the latest status of the program activities, to discuss the issues and to facilitate the receipt of DOTS data. The theme of the quarterly meeting conducted in February 2008, was identifying and conducting Programmatic and Financial Gap Analysis for TGF Round 8. The priority areas were identified keeping in view the National Strategy and new Stop TB Strategy Programmatic needs in each priority component of DOTS were listed and resources needed were calculated and the available resources were than deducted to quantify the funding gap. (Please see Annex XI for minutes of the above mentioned inter-provincial meeting.)

5.1.3. External funding excluding Global Fund – 'LINE C' entries in table 5.1

Explain any changes in contributions anticipated over the proposal term (and the reason for any identified reductions in external resources over time). Any current delays in accessing the external funding identified in table 5.1 should be explained (including the reason for the delay, and plans to resolve the issue(s)).

An Inter-Agency Coordination Committee (IACC) was set up in 2001 which meets regularly to discuss the progress and gaps in TB Control activities in the country. The Inter-agency Coordination Committee (IACC) has been very effective to coordinate support from international partners and ensuring to avoid duplications. The purpose of IACC is to share the progress of NTP, issues and future plan, with the partners. After the decline for Round 7, the IACC meeting was convened to see the available funding resources from the partners and donors and to discuss the round 8 proposal with them. Japanese Govt. agreed to provide 8.24 million for drugs. IACC was followed by the Quarterly Inter-provincial workshop in February 2008 and in which gap analysis was completed.




5.2. Detailed Budget Suggested steps in budget completion: 1. Submit a detailed proposal budget in Microsoft Excel format as a clearly numbered annex.

Wherever possible, use the same numbering for budget line items as the program description.

• FOR GUIDANCE ON THE LEVEL OF DETAIL REQUIRED (or to use a template if there is no existing in-country detailed budgeting framework) refer to the budget information available at the following link: http://www.theglobalfund.org/en/apply/call8/single/#budget

2. Ensure the detailed budget is consistent with the detailed workplan of program activities. 3. From that detailed budget, prepare a 'Summary by Objective and Service Delivery Area'

(s.5.3.) 4. From the same detailed budget, prepare a 'Summary by Cost Category' (s.5.4.) 5. Do not include any CCM or Sub-CCM operating costs in Round 8. This support is now available

through a separate application for funding made direct to the Global Fund (and not funded through grant funds). The application is available at: http://www.theglobalfund.org/en/apply/mechanisms/guidelines/

http://www.theglobalfund.org/en/apply/call8/single/#budget

http://www.theglobalfund.org/en/apply/mechanisms/guidelines/

ROUND 8 – Tuberculosis 5.3. Summary of detailed budget by objective and service delivery area

Objective Number

Service delivery area (Use the same numbering as in program description in s.4.5.1.)

Year 1 Year 2 Year 3 Year 4 Year 5 Total

1

SDA 1.1: Procurement and supply management: Procurement, storage and distribution of first line anti-TB drugs (PR: NTP for activities 1.1.1, 1.1.2 and 1.1.3.1 Greenstar for activity 1.1.3.2) $2,783,981 $3,921,521 $4,036,024 $4,186,370 $4,421,148 $19,349,045

1 SDA 1.2: Human resources development: Training providers in anti-TB drug management (PR: Greenstar) $919,054 $1,132,835 $1,122,553 $1,218,021 $1,088,162 $5,480,626

1

SDA 1.3: Management and Supervision: Improving strategic coordination for regulation of quality anti-TB drugs (PR: NTP for activity 1.3.1, Greenstar for activity 1.3.2) $153,279 $43,017 $9,000 $9,000 $9,000 $223,296

2 SDA 2.1: HSS: Incorporating TB DMIS into national, integrated DMIS (PR: Greenstar) $519,256 $337,616 $287,097 $214,942 $270,255 $1,629,166

Round 8 tuberculosis funding request: $4,375,570 $5,434,989 $5,454,675 $5,628,333 $5,788,566 $26,682,133


ROUND 8 – Tuberculosis 5.4. Summary of detailed budget by cost category (Summary information in this table should be further explained in sections 5.4.1 – 5.4.3 below.)

(same currency as on cover sheet of Proposal Form) Avoid using the "other" category unless

necessary – read the Round 8 Guidelines. Year 1 Year 2 Year 3 Year 4 Year 5 Total

Human resources 764,004 916,802 991,606 1,082,752 1,184,213 4,939,377

Technical and Management Assistance 463,179 322,921 132,472 141,490 146,046 1,206,108

Training 186,906 455,002 505,767 564,777 360,896 2,073,348

Health products and health equipment - - - - - -

Pharmaceutical products (medicines) 1,517,925 2,697,094 2,997,009 3,049,774 3,195,349 13,457,151

Procurement and supply management costs 56,620 63,343 69,495 78,705 89,319 357,482

Infrastructure and other equipment 614,655 274,510 10,406 11,447 12,591 923,609

Communication Materials - - - - - -

Monitoring & Evaluation 335,099 199,093 261,648 194,330 286,411 1,276,581

Living Support to Clients/Target Populations - - - - - -

Planning and administration 241,987 315,499 303,346 317,628 332,630 1,511,090

Overheads 193,196 188,726 180,927 185,431 179,110 927,389

Other: (Use to meet national budget planning categories, if required) 2,000 2,000 2,000 2,000 2,000 10,000

Round 8 tuberculosis funding request (Should be the same annual totals as table 5.2) 4,375,570 5,434,989 5,454,675 5,628,333 5,788,566 26,682,133




5.4.1. Overall budget context

Briefly explain any significant variations in cost categories by year, or significant five year totals for those categories.

Main budget category (50%) is for procurement of first line anti TB drugs. For detail see section 4.5.1 and annexure VII. The Human Resources category accounts for 19% of the total programme cost. There will be a need to enhance the human resource capacity of the Greenstar and SR’s activities under this project, which will have intensive human resource requirements. Accordingly, recruitment of new personnel have been included, who will be engaged in all aspects of the programme, including but not limited to, the storage of the TB drugs, their safe distribution to the health care providers the development and implementation of the drug management and information system (DMIS), TOTs, on the job training of health care providers on TB drug management and supervision and monitoring of activities. Training category accounts for 8% of the total programme cost. This mainly includes series of TOTs and training by ASD (SR) and PATA (SR) of 5580 public and private not for profit health care facility level staff at diagnostics center level. Technical and Management Assistance: The high cost in Year 1 as compared to Year 2 is due to consultancy services, which will be procured at the start of the programme for the development of:-

1. User Guides for the National TB Policy Guidelines 2. TOT Training manual and curriculum 3. ‘Seal of Quality” logo 4. The Drug Management Information system (DMIS) 5. Procurement of DMIS software database.

Other main line items included in technical and management assistance include the following (further explanation can be found in section 5.4.3):

• Consultancy services for the development and integration of a Drug Management and Information System (DMIS),

• Development of ‘Seal of Quality’ logo for TB drugs • Preparation of training curriculum and training manuals for the TOT workshops. • Technical assistance (programmatic, contractual, logistical and financial) provided for by PSI.

5.4.2. Human resources In cases where 'human resources' represents an important share of the budget, summarize: (i) the basis for the budget calculation over the initial two years; (ii) the method of calculating the anticipated costs over years three to five; and (iii) to what extent human resources spending will strengthen service delivery. (Useful information to support the assumptions to be set out in the detailed budget includes: a list of the proposed positions that is consistent with assumptions on hours, salary etc included in the detailed budget; and the proportion (in percentage terms) of time that will be allocated to the work under this proposal.

Attach supporting information as a clearly named and numbered annex Most of the activities proposed beyond drug procurement, such as training, developing operational guidelines and developing a TB DMIS, are labor intensive and need skilled staff to implement them. Therefore, human resources costs represent 19% of the total costs. All of the human resources costs needed for this proposal have been included under this line item and have not been included under other line items. For example, the human resources costs for employing the trainers to implement SDA 1.2 are not included under training but are instead included, as per Global Fund guidelines, under the Human Resources line item. For additional details and clarifications, please see the detailed budget narrative included in Annex X and XII.

Human resources will contribute a vital and integral part in the successful implementation of the programme. Community Health Officers (CHO) and their supervisors will play a pivotal role in the distribution of TB drugs in private sector, the implementation of the new TB DMIS, the training of health


ROUND 8 – Tuberculosis care providers on its proper use.

Programme Manager and the Assistant TB manager will be responsible for the day to day operations of the programme, liasioning with NTP and other SR’s including the planning of activities, their implementation and monitoring and supervision of these activities.

Training coordinators will be dedicated to ensure that all the TOTs and other trainings are well planned and coordinated. To coordinate in the development and integration of DMIS and its implementation, MIS coordinator will be 100% dedicated. Fringe benefits are included in the human resources cost . They include mainly statutory contributions, medical and staff welfare benefits which are in compliance with the general Human resource benefits in the country.

5.4.3. Other large expenditure items If other 'cost categories' represent important amounts in the summary in table 5.4, (i) explain the basis for the budget calculation of those amounts. Also explain how this contribution is important to implementation of the national tuberculosis program.

Attach supporting information as a clearly named and numbered annex

HALF PAGE MAXIMUM

Budget for procurement of first line anti TB drugs is 50%. For detail see section 4.5.1 and annexure VII. The amount budgeted for infrastructure refurbishment, vehicles and computers are budgeted as per prevailing market rates and survey. Trainings: This category comprises of 8% of the programme cost. The details are as follows:

• Development of User Guide for the National TB policy Guidelines, development and implementation of TOT training curriculum and manuals as well as its Training of 400 master trainers and 200 District TB coordinators, national programme officers, and provincial TB control staff including store officers

• Training CHOs in order to assure effective TB drug management. • training of 5580 public and private health care facility level staff at diagnostics center.

Technical and management assistance: This category accounts for 5% of the programme cost. The details are as follows:

• Consultancy services for the development and integration of a Drug Management and Information System (DMIS), User Guides for the National TB Policy Guidelines, development of ‘Seal of Quality’ logo for TB drugs and the preparation of training curriculum and training manuals for the TOT workshops – US$717,228.

• PSI staff will be responsible for providing programmatic, contractual, financial and logistical support to the programme. Daily rates for PSI program management and support personnel are an average and used for budgeting purposes. Personnel may change over the life of the project. Only actual costs will be charged to the project and will be based on actual assignments and time spent supporting this project by the programmatic support staff. US$ 416,980

5.5. Funding requests in the context of a common funding mechanism In this section, common funding mechanism refers to situations where all funding is contributed into a common fund for distribution to implementing partners. Do not complete this section if the country pools, for example, procurement efforts, but all other funding is managed separately.


ROUND 8 – Tuberculosis 5.5.1. Operational status of common funding mechanism

Briefly summarize the main features of the common funding mechanism, including the fund's name, objectives, governance structure and key partners.

Attach, as clearly named and numbered annexes to your proposal, the memorandum of understanding, joint Monitoring and Evaluation procedures, the latest annual review, accountability procedures, list of key partners, etc.

5.5.2. Measuring performance How often is program performance measured by the common funding mechanism? Explain whether program performance influences financial contributions to the common fund.

5.5.3 Additionality of Global Fund request Explain how the funding requested in this proposal (if approved) will contribute to the achievement of outputs and outcomes that would not otherwise have been supported by resources currently or planned to be available to the common funding mechanism.

If the focus of the common fund is broader than the tuberculosis program, applicants must explain the process by which they will ensure that funds requested will contribute towards achieving impact on tuberculosis outcomes during the proposal term.

5B. FUNDING REQUEST – HSS CROSS-CUTTING INTERVENTIONS

Applying for funding for HSS cross-cutting interventions is optional in Round 8 SECTION 5B CAN ONLY BE INCLUDED IN ONE DISEASE IN ROUND 8 and only if this disease includes the applicant's programmatic description of HSS cross-cutting interventions in s.4B. Read the Round 8 Guidelines to consider including HSS cross-cutting interventions Down load 'Section 5B' from the Global Fund website here if the applicant intends to apply for 'Health systems strengthening cross-cutting interventions' ('HSS cross-cutting interventions') in Round 8 and has completed section 4B and included that section in the Tuberculosis proposal sections.


http://www.theglobalfund.org/documents/rounds/8/ProposalForm_HSS_5B_en.doc


Section Document description Annex Number

A completed 'Targets and Indicators Table. Attachment A – Tuberculosis

Preliminary List of Pharmaceuticals and Other Health Products Attachment B – Tuberculosis

4.3.1 Gap analysis in DMS – Review report Annexure IV

4.3.1 Round 7 Gap analysis Annexure V

4.5.1 A detailed component Work Plan (quarterly information for the first year and indicative information for the second year). Annexure VI

4.5.1 Drug Need and Gaps Annexure VII

4.8.3 Module for Monitoring and Supervision Annexure VIII

4.9.2 Short listing of SRs Annexure IX

5.4.2 Detailed component Budget/ Human resource cost - NTP Annexure X

5.1.1 Programmatic and Financial Gap analysis Annexure XI

Greenstar Budget and work plan Annexure XII

A copy of the Technical Review Panel (TRP) Review Form for unapproved Round 7 proposal. Annexure XIII

PC-Is Annexure XIV


PakistanTuberculosis

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value Year Source Year 1 Year 2 Year 3 Year 4 Year 584% 2006 R&R TB

system, yearly management report

85% 85% 85% 85% 85%

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Objective Number

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101112131415

Impact and outcome Indicators

Treatment success rate: new smear positive TB cases

Indicator

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Baseline

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outcome

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Program Goal, impact and ouctome indicators

Attachment A - Tuberculosis Performance Framework

Program DetailsCountry:Disease:Proposal ID:

* please specify source of measurement for indicator in case different to baseline source

GoalsReduce morbidity and mortality due to TB (reduce the burden of disease due to TB)

Targets

Objective description

Pursue high quality DOTS expansion and enhancementHealth systems strengthening

Comments*

Comments

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Program Objectives, Service Delivery Areas and Indicators

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CP_R8_CCM_PKS_T_AttA_07Aug08_En 1/2

PakistanTuberculosis

Attachment A - Tuberculosis Performance Framework

Program DetailsCountry:Disease:Proposal ID:

Value Year Source6 months 12 months 18 months 24 months Year 3 Year 4 Year 5

1.0 Procurement and supply management (First line drugs): SDA 1.1

# of TB management units (TBMU) that reported a stock out in first line drugs that resulted in interruption of treatment during the year (% out of all TBMUs)

XX 2008 R&R TB system, quarterly reports

0 0 0 0 0 0 0 N N Y - over program term

NTP

1.0 Procurement and supply management (First line drugs): SDA 1.1

no. of stores refurbished XX 2008 Administrative records

0 4 - provincial/ regional and 44 district stores

7 - provincial/ regional and 89 district stores

7 - provincial/ regional and 134 district stores

0 0 0 Y N Y - over program term

NTP

1.0 Human Resource Development: SDA 1.2

# of health workers trained on TB drug management (%)

0 2008 Training records 0 480 1095 1710 3075 4610 5580 Y N Y - over program term

Greenstar

1.0 Management and Supervision: SDA 1.3

# of coordination meetings held by the TB drug regulation committee

0 2008 Administrative records

1 2 3 4 6 8 10 Y N Y - over program term

NTP Meetings will be held biannualy

2.1 HSS: Information System: SDA 2.1

# of Warehouses that are using the revised DMIS for TB

0 2008 R&R TB system, quarterly reports

0 0 2 3 5 7 8 Y N Y - over program term

Greenstar

Development of operational guidelines and training curriculum will occur in first 6

DTF: Name of PR responsible for implementation

of the corresponding

activity

Baselines included in

targets (Y/N)

DMIS will be developed by Greenstar in Years 1; implementation will begin in Year 2

Indicator Baseline (if applicable)

Comments, methods and

frequency of data collection

Targets for year 1 and year 2 Directly

tied (Y/N)Annual targets for years 3, 4 and 5 Targets

cumulative (Y-over program

term/Y-cumulative

annually/N-not cumulative)

Service Delivery AreaObjective / Indicator Number

(e.g.: 1.1, 1.2)

CP_R8_CCM_PKS_T_AttA_07Aug08_En 2/2