Identifier
Created
Classification
Origin
05AMMAN7237
2005-09-11 08:22:00
UNCLASSIFIED//FOR OFFICIAL USE ONLY
Embassy Amman
Cable title:  

(U) Jordan Response - Global Fund Parallel Review

Tags:  TBIO EAGR JO 
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110822Z Sep 05
UNCLAS SECTION 01 OF 03 AMMAN 007237 

SIPDIS

STATE for S/GAC - Mamacos, Carson, Mikus
STATE pass USAID for GH/MMiller
HHS for OSOPHS - WSteiger

SENSITIVE

E.O. 12958: N/A
TAGS: TBIO EAGR JO
SUBJECT: (U) Jordan Response - Global Fund Parallel Review
Process for Round Five Projects

Ref: A) State 153140 B) 09/06/2005 Whittlesey-Mamacos email

UNCLAS SECTION 01 OF 03 AMMAN 007237

SIPDIS

STATE for S/GAC - Mamacos, Carson, Mikus
STATE pass USAID for GH/MMiller
HHS for OSOPHS - WSteiger

SENSITIVE

E.O. 12958: N/A
TAGS: TBIO EAGR JO
SUBJECT: (U) Jordan Response - Global Fund Parallel Review
Process for Round Five Projects

Ref: A) State 153140 B) 09/06/2005 Whittlesey-Mamacos email


1. (U) Summary: Text below is post's response to ref A
request for an evaluation of Jordan's Round Five proposal on
tuberculosis control to the Global Fund To Fight AIDS, TB
and Malaria, emailed to S/GAC ref B.


2. (SBU) Begin text:
Country: Jordan
Region: Middle East and North Africa
Title: Strengthening and Support National TB Program
Jordan


A. Proposing Group:
--------------
National Country Coordinating Mechanism (CCM)

Amount: USD 2,782,864
(Year 1 ($533,800) plus Year 2 ($539,064) = $1,072,864)


B. Overall comments and recommendations for U.S. delegation
position:
-------------- --------------

The aim of Jordan's TB program is to reduce TB morbidity and
mortality. The main objectives are:
-- To improve TB care and treatment among vulnerable groups,
specifically the poor, refugees, immigrant, and mobile
populations.
-- Establish and upgrade nine service delivery points among
refugees, and poor areas and two mobile care points of
delivery.
-- To implement DOTS plus (Directly Observed Treatment,
Short course) through a global initiative the Green Light
Committee (GLC) in the Amman reference hospital and one
clinic for ambulatory care and drug-resistant surveillance
(DRS).
-- To strengthen TB managerial capacity through partnership
development, lab strengthening, computerized monitoring and
evaluation (M&E) and the Practical Approach on Lung Health
(PAL) strategy

Jordan's TB program (NTP) is vertical in nature, is managed
in Amman, and is the sole provider of total TB care
throughout the country. The overall goal of the program is
to reduce morbidity and mortality due to TB and to reduce
multi-drug resistant (MDR) TB in Jordan.

The NTP operates at three levels:
-- Central Level: Ministry of Health's (MOH) Chest Disease
Directorate is responsible for the national TB program and
coordinates and supervises all TB control activities. It
also supplies the chest clinics with requisite drugs,
supplies, reagents, etc.
-- Regional Level: 12 TB diagnostic centers throughout the
country.
-- District Level: the TB program is partially integrated

with the Primary Health Centers/Clinics (PHC) to adopt the
DOTS strategy.

Areas of Success
--------------
The Executive Summary states (Section 2.1.4): The NTP has
been in operation since early 1973 and has achieved a good
deal of success. Examples of activities that have been
implemented which have resulted in achieving success in
different components are:
-- The NTP/MOH provides free anti-TB drugs to all diagnosed
patients (Jordanians and foreigners) and free screening of
all contacts.
-- The NTP achieved more than an 80% success rate among
newly discovered cases, but this rate is lower than 30%
among treatment and multi-drug resistant (MDR) cases. Low
success with MDR indicates the need to develop a strategy to
treat MDR cases.

Areas for improvement
--------------
While the NTP provides a few types of training courses, it
believes it important to increase the administrative,
management and technical skills of the central and
intermediate program staff.

Surveillance through central and district levels needs to be
improved and upgraded by introducing appropriate Management
Information Systems (MIS) and other data systems (electronic
registration and website).

The NTP needs to strengthen and intensify public awareness
of TB through a variety of approaches and ensuring health
education for the patient and adherence to treatment.

The NTP wishes to develop national and international
institutional collaboration to conduct operations research.
Mobile units are needed to survey vulnerable groups and hard
to reach populations.

The central and provincial laboratories need to be upgraded
and staffed with highly qualified technical personnel and
modern equipment.

A primary interest of the NTP is continuing medical
education (CME) for its physicians and researchers.
Constraints:
--------------
With the above as background, it should be noted that the
leadership and staff of the NTP are enthusiastic, committed,
and have a strong work ethic. However, the TB Department in
Amman that manages the vertical NTP for the entire country
is experiencing the following constraints:
-- Heavy workload; i.e., 1,800 cases per day of foreigners
alone (e.g., construction workers, etc.)
-- Lack of modern equipment to handle the increasing
workload
-- No computerized MIS system, data base, or trained data
entry staff (currently rely on manual log book)
-- Less than optimal patient flow through the facility
-- Less than optimal patient confidentiality and privacy
-- Less than optimal case detection
-- Linkages and collaboration with other public health
sectors (i.e., HIV/AIDS) needs to be expanded/strengthened
to achieve NTP objectives and provide better services

Recommendations:
--------------
To address these constraints and strengthen and expand the
NTP, post recommends that the TB proposal be approved for an
initial two year period on condition that the following
issues are addressed over that timeframe:
-- Targeted technical assistance be included in the proposal
or provided by the Government of Jordan (GOJ) or, in the
short term, by donors (NOTE: USAID/Jordan has no funds for
such technical assistance except as noted in footnote **
below.)
-- Develop the 10-year strategic plan for TB control (pp. 36-
79 and 55-79 of the proposal),with technical assistance, if
necessary. It would be ideal if this strategic plan were
developed in the same way that Jordan's HIV/AIDS strategy
was developed. (See footnotes * and **.)
-- A robust, results-oriented Monitoring and Evaluation Plan
(M&E) be developed similar to that developed for HIV/AIDS.
Without an improved MIS/database, reliable and credible
reporting on indicators will not be possible.)
-- Develop a comprehensive plan for reaching vulnerable
groups
-- Develop a comprehensive list of sub-recipients and
network for TB information and services


C. Comments on Technical Review Panel (TRP) review
(especially disagreements/omissions)
-------------- --------------

-- Post disagrees with the TRP statement that the Amman TB
facility is "a health center of excellence" since it needs a
great deal of upgrading and modernization to make it a true
center of excellence.

-- Regarding the strengths outlined by the TRP:
(1) Bullet 1: post agrees that the proposal is relatively
comprehensive and includes rational objectives and
activities that address essential components of the TB
control program (i.e., migrants, DOTS plus, laboratory
strengthening, etc.).
(2) Bullet 2: there is a very high level of political
commitment for TB control by the GOJ and the MOH, including
financial support from the government;
(3) Bullet 3: there is partnership with NGOs and UN Relief
and Works Agency (UNRWA). But as stated above, the network
of organizations capable of TB work should be expanded; and
(4) Bullet 4: post disagrees with the TRP's assessment that
this is a fully "successful TB program." While it has
achieved a great deal since its inception, it still has a
long way to go to be a truly successful TB program,
especially in light of the programmatic constraints noted
above.
-- Regarding the weaknesses outlined by the TRP:
(1) Bullet 1: post believes, is addressed above;
(2) Bullet 2: additional approaches on mortality and/or
disease prevalence surveys could be addressed in Jordan by
exploring existing mechanisms or surveillance systems;
(3) Bullet 3: post agrees that including the HIV prevalence
survey among TB cases within the HIV/AIDS M&E matrix makes
good sense.

-- Costs: Unfortunately, post could not open the budget
attachment related to the costs cited in the TRP document.
This issue was discussed with a local colleague familiar
with the budgeting process who explained that the cost
examples outlined in the TRP review are reasonable and based
on WHO's current practices and costs in country. However,
these costs do not include technical assistance which, when
added, would increase these types of costs dramatically.


D. Other public health or scientific considerations
(appropriateness, coverage, capacity issues, feasibility,
monitoring):
-------------- --------------
Post believes that this has been addressed above.


E. Coordination with other partners (including potential
duplication):
-------------- --------------
Stronger coordination with the HIV/AIDS program in
particular would benefit the TB program. Similarly, further
collaboration with other local partner organizations capable
of TB work should be explored under the 10-year Strategic
Plan for TB Control.


F. Political considerations:
--------------
Jordan accords a high level of political commitment to TB
control including government financial support and
additional staff required to implement the proposal.


G. Additional comments:
--------------
N/A


H. Embassy point of contact:
--------------
David L. Piet, Team Leader, Population and Family Health,
USAID/Jordan
Email: dpiet@usaid.gov Phone: 962-6-590-6622

Footnotes :

* The TB section of the proposal was authored by senior
officials of the TB Department, NTP/MOH, with assistance
from the WHO's Eastern Mediterranean Region (WHO/EMRO).
Thus, the TB proposal is rather general and lacks specifics
that should be addressed during the first two years. The
HIV/AIDS section of the proposal, by contrast, was
strategically and comprehensively developed with the
assistance of an international expert working in close
collaboration the National AIDS Program (NAP),the CCM, and
a wide array of public-private-NGO-donor experts.

** While USAID/Jordan does not have the funding resources
necessary to provide technical assistance to the NTP,
USAID's Family Health International (FHI/Jordan) is willing
and able to provide limited technical assistance to the NTP
to strengthen the linkage between the NTP and the HIV/AIDS
programs. However, the NTP will need specialized technical
assistance to increase its effectiveness.

HALE