REPORT OF ATTACHMENT (ASSIGNMENT)

IN NATIONAL TUBERCULOSIS CONTROL

PROGRAMME, AFGHANISTAN

By:

Dr Khwaja Mir Islam Saeed

Training & Capacity Building Manager at Afghan Public Health Institute
Ministry of Public Health, Afghanistan
Fellow of FELTP 3rd Cohort, National Institute of Health, Pakistan

April-May 2010

TABLE OF CONTENT
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Field Epidemiology and Laboratory Training Program, Attachment Report
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PREFACE................................................................................................................4
INTRODUCTION......................................................................................................5
Background:.......................................................................................................5
National Tuberculosis Control Program..............................................................5
METHODOLOGY.....................................................................................................6
Attachment Objective:.......................................................................................6
Planned Activities:..............................................................................................7
Proceedings:....................................................................................................... 7
RESULTS................................................................................................................8
Morning reports:.................................................................................................8
National TB task force meetings........................................................................8
Quarterly Review Meetings................................................................................9
Global Fund Round 8 Coordination Meetings...................................................10
Review of Polices, Strategies and other Documents........................................11
National tuberculosis strategic plan (2009-2013).........................................11
Guideline for TB control Program in Afghanistan..........................................11
Lab guideline for control of tuberculosis.......................................................12
Human Resource Development Strategic Plan (2010-2014)........................12
Other documents..........................................................................................12
Management of Tuberculosis: Training for Health Facility Staff ...................13
Visiting Departments.......................................................................................13
Surveillance, Monitoring and Evaluation Department..................................13
Laboratory and External Quality Assurance Department.............................14
Drug Management Department....................................................................14
Research Department...................................................................................15
Advocacy, Communication and Social Mobilization Department..................15
New Initiative Department............................................................................15
Training Department.....................................................................................16
Administrative Department...........................................................................16
Presentations provided/Attended.....................................................................16
Prevalence of TB infection in Kabul Prison....................................................16
Evaluation of Public Health Surveillance System..........................................16
Evaluation of TB Surveillance System...........................................................17
TB lectures for new graduate doctors...........................................................17
SWOT Analysis.................................................................................................17
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 Strength........................................................................................................17
Weaknesses .................................................................................................18
Opportunities................................................................................................18
Threats.......................................................................................................... 18
CONCLUSION.......................................................................................................19
RECOMMENDATIONS ..........................................................................................19

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PREFACE
The Field Epidemiology and Laboratory Training Program (FELTP) model has
been applied successfully in countries throughout the world. It has been started
in Pakistan since 2006 and it is planned to be started in Afghanistan very soon.
Field Epidemiology Training Program is a competency-based training and
service programs in applied epidemiology and public health that build public
health systems capacity in the countries in which they are implemented. In most
programs at least 75% of the training period is devoted to practicing
epidemiology in the field under the guidance of a mentor. The program aims to
support the strengthening of the public health system and to improve capacity in
applied epidemiology, public health surveillance and response, and public
health laboratories. While in class, fellows take courses in epidemiology,
communications, economics, and management and other main disciplines while
in the field, they conduct epidemiologic investigations and field surveys,
evaluate surveillance systems, perform disease control and prevention
measures, report their findings to decision-makers and policy-makers, and train
other health workers.
After establishment the program enrolled three cohorts from which the first one
is graduated and the other two are continuing their studies and assignment in
the program.
Being FELTP fellow of 3rd cohort, we are assigned, as attachment, to work in
national control programs in order to apply the knowledge and skills gained in
first five month contact sessions and at the same time become familiar with
public health approaches and activities used in the field. Ministry of Public
Health in Afghanistan is focusing on tuberculosis (TB) as main public health
problem and National TB control Program in coordination with other
stakeholders is the responsible for all issues regarding TB in the country.
Realizing the importance of TB as a main challenge in Afghanistan, I selected
this program as a place of my attachment. A specific Terms of Reference which
was developed by management were used as a reference for performing of
activities during assignment.

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INTRODUCTION

Background:
Tuberculosis is a chronic disease which is caused by Mycobacterium
tuberculosis and remains a major cause of morbidity and mortality and a
significant public health issue worldwide. The global incidence of TB is
136/100,000 population at an average. This represents a total of 8.8 million new
patients and 1.6 millions deaths due to TB every year. According to WHO
estimates one infectious source would transmit infection by Mycobacterium
tuberculosis to 20 others during an average of two years before death or self
cure. Thus, it is very important to find TB patients as early as possible and treat
properly.
Afghanistan is the second highest TB-burdened country in the Eastern
Mediterranean Region and one of the 22 highest TB-burdened countries in the
world, with an estimated incidence of new sputum smear positive (TB SS+)
pulmonary tuberculosis, 76 per 100,000 population per year and all TB cases at
168/ 100,000 population per year. This means an annual incidence of 46000 for
all TB cases and 21,000 for TB SS+ (WHO, Report 2009, Global Tuberculosis
Control). An unusual predominance of TB in women persists. In the past for
many years, women comprised 68% of TB SS+ cases in Afghanistan. These
data clearly indicates that TB control is one of major problems in public health of
Afghanistan to be solved urgently.
The overall health status of Afghanistan demonstrates slow, but steady
improvement of the health care system. With infant mortality of 129/1000, under
five mortality of 191/1000 and maternal mortality of 1600/100000, the country is
focusing on a Basic Package of Health Services (BPHS). It was developed in
early 2003 and revised in 2005, based on disease burden and a primary health
care approach.

National Tuberculosis Control Program

The National Tuberculosis Control Program (NTP) was established in 1954 by
the Ministry of Health, with financial support from the World Health Organization
(WHO). The mission of the NTP is to reduce the impact of TB as a public health
problem in the country. Since 2002, under the new Afghan government, the

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NTP has taken major steps to improve its managerial and technical capacity as
well as in securing external technical assistance and resources in order to
implement the DOTS strategy.
The MoPH has developed a new organizational chart that places the NTP
Directorate of communicable disease and under the General Directorate of
Preventive medicine. Basically, eight regional TB coordinators are responsible
for overseeing TB control in the country with 34 provincial TB coordinators who
oversee TB control in the provinces under the supervision of the Provincial
Health Directorates. For laboratory activities, NTP also recruited regional and
provincial laboratory supervisors and developed their capacity.
The estimated population that has access to DOTS facilities in Afghanistan has
steadily increased up to 97% by the end of 2007. However, this is a generous
estimate of population coverage; it assumes the whole population of a district is
physically covered, even if only one health facility in a district provides DOTS,
regardless of the actual number of people that have access to that facility.
The total number of health facilities utilizing DOTS has increased from 36
(representing 3.5% of the total) in 2001, to 991 (90%) by the end of 2007 and
1031 facilities in 2008. Referral of TB cases for diagnosis and treatment is
common amongst the BPHS and the EPHS as well as in the private and public
sectors.

METHODOLOGY
At the end of five month first contact sessions I was attached to National TB
control Program for one month. With a letter introducing me to NTP, I started to
work there at 18/04/2010 and ended my assignment on 27/05/2010. NTP is
located at west of Kabul within the campus of tuberculosis polyclinic. Following
objectives were observed in this assignment.

Attachment Objective:
• Expose FELTP fellows to the planning and execution of national TB
control program focusing on activities prevention and control of TB as
priority public health problem
• Assist the national TB control program in strengthening respective
surveillance component
• Identify and implement collaborative projects with the technical
assistance from Center of Disease Control and prevention (CDC), Atlanta
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Planned Activities:
I was supposed to be attached with NTP on full time basis for a month from 5th
April to 7th May 2010. During the period of my attachment I was assigned to
work under the direct supervision of the national TB program manager but
would also required attending weekly de-briefing session with FELTP faculty on
every Friday. In case of need I was supposed to be deputed for outbreak
investigation on the request of surveillance department Afghan public health
institute. For best utilization we were proposed to be involved in the following
program activities.
• Disease surveillance activities particularly assisting the concerned staff in
data compilation, analysis and interpretation.
• Participation as observer in the routine meetings aimed at review of
activities/ progress, planning, development of guidelines, SOPs etc.
• Development of action plans, planning and budgeting of various program
activities, rapid assessments.
• Writing various program reports and prepare presentations.
• Evaluation of surveillance arrangements, if required.
• Development of study protocols and other projects proposals particularly
those requiring technical assistance from FELTP office and CDC, Atlanta.

Proceedings:
Following main activities were conducted during one month attachment in
national tuberculosis control program.
• Participation in morning report on Saturday and Mondays
• Attending in TB task force meetings which was held weekly at
Wednesdays
• Participation in provincial quarterly review meeting for medical doctors
• & lab technicians
• Participation in Global Fund Round 8 coordination meetings
• Reviewing policies, strategies, guidelines, and training materials
• Discussion of main activities with respect to each department with head
and staff of departments at NTP
• Presenting the study on” prevalence and risk factors associated with
Mycobacterium tuberculosis among prisoners in Kabul Central Prison” at
national TB task force
• Presenting the evaluation of TB surveillance system in Afghanistan at
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 national TB task force
• Participation in half day session on tuberculosis for new gradate doctors
• Direct observation of activities which was done during attachment at NTP

RESULTS
After leaving FELTP office with the aim of attachment to national TB control
program in Kabul, Afghanistan, FELTP and APHI at Ministry of Public Health
developed a letter and send to NTP showing our assignment based on pre-
determined TOR. The letter was a bit delayed and I started to work in NTP on
April 18th, 2010. Taking into consider the planned activities some actual
activities were performed during attachment. Brief description of those activites
is explained below.

Morning reports:
It is one of the important meetings which are secluded for Saturday and
Mondays each week. Mostly the internal issues regarding the program are
discussed in this meeting. That issue which is not resolved in this meeting is
shifted to TB task force meetings. In the meetings that I have attended following
mains issues were discussed.
• Final draft of national TB guideline in Afghanistan
• Supervision and monitoring of activities in the field
• Delay in supervisory and salary payment
• Issues regarding Drug Resistance Survey
• Expediting the process of quarterly data collection and analysis
• Community workshops and IEC material for health centers
• Picture book of world TB day from all provinces
• Human Resource Development strategy
• Shortage and procurement of TB drugs to health centers
• Issues regarding Round 10 Global Fund
• Training plans
• Communication and its importance in NTP

National TB task force meetings

This is a very fundamental decision making body regarding tuberculosis control
and prevention in Afghanistan which is held on Wednesdays every week. All
stakeholders including donors, non-governmental organizations (NGOs) and

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government staff are participating in this official forum. Controversial issues are
put as agenda for this task force to find a better and joint solution for it. In task
forces that I attended was very interactive ones in which WHO, NTP, TB CAP,
NTP were participating. Here are some main issues which were discussed in
these task forces.
• Financial support and medical doctors who working in National TB
Institute in Kabul
• Perdiem policy for supervisory and monitoring visits which is performed
by NTP staff to provincial levels
• IEC material and TV sports regarding tuberculosis
• Human Resource Strategic Plan for TB in Afghanistan
• Lac of lab technicians regarding microscopy in health centers
• Advocacy, communication and social mobilization (ACSM) issues and its
approval by MoPH
• Integration and modification of TB registers in health centers
• Training of health staff and conduction of quarterly review meetings in
low secure provinces including Kandahar, Zabul and Urozgan.
• Translation of NTP guidelines into local language
• Presentations on TB infection in Central Prison, Evaluation of TB
surveillance system and first draft of HRD strategy

Quarterly Review Meetings

NTP has planned separate quarterly review meetings at provincial and regional
level and main issue emerging from these meetings is discussed in national
review meetings. Data collection, refining and feedback is done in these
meetings along with sharing of experiences, challenges and solutions. Some
technical training sessions are also included in these review meetings. In
meetings that I attended following issues were discussed.
• Ensuring of quality on lab microscopy with respect to Microscope, lab
technicians and staining
• Sample (sputum) quantity, its content and proper staining
• Random collection of slides (20) from each health centers which is
supported by lab facility in order to recheck by national reference
laboratory
• Discussion regarding high false positive (HFP), high false negative(HFN),
low false positive (LFP) and low false negative(LFN)
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 • Discussion regarding AFB staining and labeling of smears
• Technical discussion about smear pattern, thickness and evenness
• Collection of quarterly lab reports from health facilities
• Collection of quarterly data regarding case detection and treatment
• TB Case detection and treatment and comparison of actual figures with
targets set by NTP
• Register of tuberculosis for suspects, contacts, treatment and lab
examinations
• Challenges of lab technicians regarding referring of suspects for sputum
examinations
• Shortage of streptomycin as a main drug for treatment of category II TB
patients
• Poor supply, supervision and monitoring of activities
• Providing presentations regarding SOPs and IEC material
• Motivation and commitment of staff in order to eliminate TB as a public
health problem in Afghanistan

Global Fund Round 8 Coordination Meetings

It was a meeting which was conducted every Wednesday prior to task force
meeting from 9:30 to 10:30. Stakeholders involved in global fund round 8 were
participating in these meetings and it was particularly focused on indicators
which are set for TB in global fund proposal. Following main issue were
discussed during these meetings in which I attended.
• Urgent supply of streptomycin to provinces
• Conduction of provincial quarterly meetings in southern provinces
• Delays in sending of quarterly reports by less secure provinces
• Overseas training ( SAARC) for TB technical staff
• Delay of supervisory and salary payment by donors
• Inclusion of nomads in TB registers as a requirement of global fund
proposal ( indicator)
• Drug resistant survey as a pilot in six provinces
• Teachers and schools students orientation of tuberculosis and
distribution of notebooks with messages of TB for primary students
• Contact screening

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Review of Polices, Strategies and other Documents
In last five years a set of documents have been developed and still in progress
by NTP and its supported stakeholders. Following are some main documents
which are reviewed during attachment taking into consider the time constraint.

National tuberculosis strategic plan (2009-2013)

It envisions a TB free country, with elimination of the disease as a public health
problem by 2050. The main goal is to reduce dramatically the country burden of
TB by 2013, in line with the Millennium Development Goals (MDGs) and Stop
TB partnership targets. It is based on last strategic plan (2006-2010) which is
focusing on main actions which is enshrined in stop TB strategy.
• Pursue quality DOTS expansion and enhancement
• Adapting DOTS to respond to TB/HIV, MDR-TB and other challenges
• Contributing to health system strengthening
• Engaging all care providers
• Empower patients and communities
• Enable and promote research

Guideline for TB control Program in Afghanistan

It is a document which guide all public health providers and clinicians how to
manage tuberculosis in the country. As a reference book it is newly developed
and NTP is trying to translate it in local language and distribute it to all TB
treatment centers to be used. Following are main issue which is discussed the
guidelines.
• Tuberculosis and its overall control
• National TB control Program
• TB case detection and diagnosis
• Role of laboratory in TB control
• Treatment of tuberculosis
• Prevention of tuberculosis
• Recording and reporting system of tuberculosis control program
• Monitoring and evaluation
• Human resource development
• Community involvement
• New initiatives in tuberculosis control
• Infection control
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Lab guideline for control of tuberculosis
This guideline is developed for initial and refresher training of lab technicians
and their daily use. It starts with description of tuberculosis and modes of
transmission and afterwards continues with organization of lab activities prior to
sputum collection and examination. Smear microscopy procedures and quality
assessment system is the other main portion of this guideline. Assessment and
feedback to lab technicians is the last parts of this module. It is very useful
which facilitates daily affairs of lab staff al local levels.

Human Resource Development Strategic Plan (2010-2014)

A group of technical staff from NTP supporting by an international expert
developed and finalized the first draft of this strategy. Fortunately during my
attachment I had a chance to participate in the meeting when it was presented
to the stakeholders at NTP. Strategy is budgeted for five years and action plan
for first year is also developed. Following strategic interventions were suggested
in this strategy.
• Action field: policies and strategies
• Action field: NTP leadership for human resource development
• Action field: financing of human resource development /NTP HRM
• Action field: education at NTP
• Action field: partnership for NTP
• Action field: human resource management for NTP

Other documents
There are some other documents which is developed in NTP and due to
limitation of time I was not able to review them in detail. Some of these
documents are listed here.
• Advocacy, Communication and Social Mobilization Strategy
• Monitoring and Evaluation Strategic Plan
• Public Private Partnership Strategy
• TB/HIV guidelines
• TBIS guidelines
• Terms of References
• Standard Operating Procedures

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Management of Tuberculosis: Training for Health Facility Staff
It is a training package for facility staff which is prepared based on WHO
document (treatment of tuberculosis: guideline for national programs, 3rd edition
2003). Training department at NTP is using this package for national and
refresher trainings. Following are the main modules.
• Introduction
• Case Detection
• Treat TB Patients
• Inform Patients about TB
• Identify and Supervise Community TB Treatment Supporters
• Manage Drug and Supply for TB
• Ensure Continuation of TB Treatment
• Monitor TB Case Detection and Treatment
• Field Exercise: observe TB Management
• Reference Booklet

Visiting Departments
During attachment I had a chance to visit each department and discuss their
routine activities they were conducting. The staff including head of department
was interviewed in which success stories along with challenges discussed.
Following are the main activities they were conducting and the points I
discussed with them.

Surveillance, Monitoring and Evaluation Department

This department is responsible for overall case recording and reporting of TB
cases. They are managing supervisory and monitoring visits. They are
collecting, compiling and analyzing of quarterly reports to calculate indicators
regarding case detection, treatment outcome and AFB conversion. They have
developed the first draft of NTP national M&E plan and consolidate M&E
framework. They are busy with TB information system (TBIS) pilot and soon it
will be established at NTP. They are revising the reporting forms timely and
submit the report to EMRO online to be uploaded in global report. They are
providing annual reports. The main forms which is used form data recording and
reporting which is used by the program is listed here.
• TB01- Treatment Card
• TB02- Identity Card
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 • TB03- Health facility TB Registers
• TB04- Lab Registers
• TB05- Request for Sputum Microscopy Exam Form
• TB06- Request for Culture/Susceptibility Form
• TB07- Referral/Transfer Form
• TB08- Lab Quarterly Report
• TB09- Health Facility Quarterly Report for case detection
• TB10-Smear Sputum Conversion Quarterly Report
• TB11-Treatment Outcome Quarterly Report
• TB12- Requests for Drug and Lab Supplies and Reagents
• TB13- Suspect Register
Data is collected quarterly but it is analyzed in detail (indicators calculation)
annually and annual report is produced and published.

Laboratory and External Quality Assurance Department

They have developed a lab network consists of national reference laboratory in
Kabul, six regional laboratories and almost 600 field laboratories. Quality
assurance for sputum smear microscopy is their high priority and it is supported
by JICA. Using lab supervisors at regional and provincial levels, they are
conducting supervisory visits in order to check the quality and provide on spot
guidance for technicians. They are conducting quarterly review meetings at
regional and provincial levels. In these meetings they provide technical
assistance and collect quarterly data on lab and compile sliders for cross
checking. In addition they are providing trainings sessions for lab technician
regularly based on their action plans. The other main activity at central level is
TB culture and drug sensitivity test.

Drug Management Department

This department is trying to ensure uninterrupted supply of anti-TB drugs and
medical supplies to health facilities in all regions and provinces. WHO and GDF
are the main donors in this regard. Head of drug department is trained in TB
drug management organized by WHO EMRO in Egypt and other trainings in
Kabul. They have calculated drug and medical supplies which is requirement for
all health facilities in a year. They are distributing drugs and medical supplies
according to their plan. Supervisory visits and monitoring covers the issue of
drug and medical supplies as well. Module for TB drugs and logistic system is
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developed and approved by MoPH.

Research Department
This department is responsible for management and conduction of operational
researches regarding tuberculosis. According to research department the report
of study on knowledge, attitude and practice of sub urban population in Kabul
about TB is published. They have undertaken a project in collaboration with
SAARC to assess the HIV testing acceptability by TB patients. The analysis is in
progress and final report is awaited. They have investigated the role of private
pharmacies in treatment of TB patients in the central region and it is under
analysis by EMRO WHO. There are some projects granted by TDR,
EMRO/WHO and some other projects which are submitted; they are busy with
its management. Drug Resistant Survey is another main project which is going
on now as a pilot in five provinces in the country. Some departments including
lab department is involved in this important study.

Advocacy, Communication and Social Mobilization Department

The department has developed ACSM strategy to be finalized by MoPH.
Development of website is a practical measure for awareness through reflection
of news, reports, and photo galleries. They have developed some important IEC
materials for patients and their families, for health staff and general community.
There are some billboards and TV stop which is developed and used by this
department. They are conducting some orientation workshops for community
influential, religious leaders, teachers which have been very useful. In 2010,
they celebrated the world TB day in big functions and a picture book from this
gathering is under process to be published soon. They have developed the
STOP TB partnership which is supported by WHO and MoPH.

New Initiative Department

It is a new but active department within NTP and any issue which is new in
control of tuberculosis is managed by this department. They have developed
TB/HIV guidelines to be distributed to all health facilities. They are busy with
management of TB in prisons, Internally Displaced Populations (IDP) and
refugees. In addition department is trying to involve private sector by a pilot
project and they are also with management of TB in cross border areas.
Recently they have received fund for an important project on TB.

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Training Department
It is a department which is involved in development of human resource for TB
control program. They have developed the first draft of strategic plan of human
resources for TB (2010-2014) to be approved by MoPH. Different sorts of
trainings is managed and conducted by this department in order to ensure
delivery of quality health TB care. They are responsible for conduction of
quarterly review meetings and awareness workshops. It’s in phase of transiting
to human resource development department.

Administrative Department
It is a department which is managing all managerial and correspondence
issues. Financial management, accounting, logistic and services, filing and
transportation is the responsibilities of this department.

Presentations provided/Attended
Taking the benefit of opportunity during attachment period at NTP, I provided
three presentations which were related to TB in national TB task forces. They
were welcomed by task force members and a question and answer sessions
was conducted at the end of each presentations. Following are the main points
of these presentations.

Prevalence of TB infection in Kabul Prison

As a requirement of MSc these at Aga Khan University, I completed one study
on prevalence and risk factors associated with TB infection among prisoners in
Kabul Central Prison ( Puli-Charkhi). Prevalence of TB infections was 55.7 %
and risk factors such as age, weight, monthly income prior to imprisonment,
duration of incarceration, area of accommodation per prisoner, personal
hygiene, content of food (meat and bean), low grade fever and night sweat were
associated with TST positivity. At the end of presentation the final report of
thesis was submitted to NTP which was received by worm welcomes. They
considered this study an important point for further study regarding TB in
prisons in Afghanistan.

Evaluation of Public Health Surveillance System

A framework for evaluation of public health surveillance system has been
developed by CDC which is very useful for evaluation of public health

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surveillance systems. As have evaluated TB surveillance system, therefore, I
considered it very useful to present and orient task force members about steps
and attributes of surveillance system which is developed and explained by
CDC. They were very interested and the copy of presentation and guideline of
CDC was circulated later after presentation.

Evaluation of TB Surveillance System

As a requirement of FELTP program I had evaluated TB surveillance system in
the country in which HMIS and NTP was discussed. Both systems were
evaluated matching the attributes such as simplicity, flexibility, Acceptability,
data quality, sensitivity, positive predictive value, timeliness, representativeness,
and stability. They agreed with the evaluation scoring and welcomed the
recommendation which was provided to them. During Q&A session they
emphasized to strengthen recording and reporting, analysis and feedback along
with fully functional TB database.

TB lectures for new graduate doctors

A six week course was handled by APHI in which TB was given priority and two
sessions were allocated to it. In these two sessions the national TB control
program, national strategic plan, stop TB strategy and national TB guideline
particularly case detection and treatment was discussed in open forum.
Fortunately I also participated in these sessions and tool benefit of these
lectures.

SWOT Analysis
During one month of attachment I was able to identify the following strength,
weakness, opportunities and threats for National TB control program in
Afghanistan.

Strength
• Comprehensive structure and position with MoPH
• Qualified and experienced staff at central and provincial levels
• Availability of strategic plan, guidelines and SOPs
• Need based planning and decentralization of trainings
• Expansion of TB management centers (DOTS) in last years
• Quarterly meetings at provincial and regional levels

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• Establishment of TB Database (TBIS)
• Involvement of private sector and public private partnership
• Paying attention to gender and TB, cross border issues and HIV/AIDS, high
risk groups such as refugees, prisoners etc.

Weaknesses
• Delayed recording, reporting and analysis of TB
• Lack of protection fees for lab staff
• Inconsistency in use of calendars at central and community levels
• Inadequate number of microscopes at health facilities
• Proper place for sputum collection, examination and storage
• Availability of water and power at health facilities
• Load of other lab tests than sputum exam in laboratories
• Low refer of suspect by OPD to laboratories
• Lack of capacity and motivation of staff including lab technicians
• Inadequacy in supervision and monitoring
• Shortage and poor supply of drugs and medical supplies
• Improper management and supply of drugs, medical supplies and lab
reagents
• Lack of coordination between NTP and other stakeholders at MoPH at
central and provincial levels

Opportunities
• Political Commitment
• Support of NTP by a group of donors
• Efficiency of services as compare to government by NGOs
• Availability of proper network of regional and provincial TB management
• Launching of global fund round 10
• Vertical program at central and integrated at local levels
• STOP TB strategy

Threats
• Staff turnover at facility levels
• Probability of overlapping among donors in supporting NTP
• Sustainability of program being supported by donors
• Security disturbance in some provinces

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• Unavailability of allocated space and building for NTP

CONCLUSION
Although Afghanistan is one of 22 high burden countries and still tuberculosis is
a critical public health problem, however, as compare to 5 to 10 years earlier
there are much achievement which is credited to NTP. They have developed a
very acceptable structure for NTP at central and provincial levels and qualified
staffs have been recruited for these positions. They have been providing
technical trainings to staff involved in TB control and management. With
technical and financial support of stakeholders they have developed policies,
strategies, guidelines and standard operating procedures at different
department levels. There is a dramatic decline in burden of TB in the country
and all departments are jointly struggling to stop TB as a public health problem
in the country. Efforts regarding data management and epidemiology of
tuberculosis are in progress and I am optimist regarding surveillance of TB in
the country. Establishment of TB database at central level will solve many
challenges of planning, implementation and monitoring of TB related activities.

RECOMMENDATIONS
Taking into consider the period of attachment at NTP following recommendation
is provided for improvement and strengthening of the program.
• National TB control program and TB polyclinic in which TB patients are
coming for treatment are working at the same building. There is a need to
have separate building for each entity. Fund should be raised for
construction of allocated building for NTP.
• A cooperation agreement should be signed among donors that are
supporting NTP. It should cover recurrent expenditure of NTP for which no
one is responsible. It will avoid duplication of financial support and facilitate
managerial and technical issues of the program. Multiple donors are equally
a challenge and opportunity for the program. Their full involvement in all
planning, implementation and evaluation of activities will be a solution.
• Capacity building for proper performance is must of NTP. They should
perform activities independently and sustainability should be guaranteed.
Technical trainings for health staff and lab technicians should be reinforced
and more facilities should be provided for central and provincial staff for
better performances.
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• Multiplicity of data recording, collection and reporting forms is less
acceptable by stakeholders. There is a need to conduct a workshop and
integrate the number of forms, particularly four register at health facilities
should be decreased to one or two registers.
• It is required to develop a proper feedback mechanism in order to rectify the
problems raised at the field. Timely analysis of data and provision of
consistent feedback will improve the performance of the program. How to
provide quarterly feedback is a challenge for technical partners to assist
NTP in this regard.
• Activities in Laboratory department have been conducting a bit in isolation
as compare to other departments, particularly surveillance department.
There is a need to strengthen coordination and integration of activities
among all departments.
• TBIS is an important achievement of the program and it should be
strengthened. Training on data entry, analysis and production of report using
this software is crucial. It will facilitate planning, implementation and
evaluation of activities.
• Protection fee was an incentive which was provided for laboratory and high
risk health workers in Afghanistan. Unfortunately it is not provided anymore
and admin department at NTP should find ways to add it on package of
benefits for those who need it.
• Duality of calendars confuses the staff at central and provincials levels.
Based on HMIS experience the local calendars should be focused and this
issue will not create problem for donors and reporting period should be
developed based on their requirement.
• Research department should investigate the reasons for predominance of
female with respect to proportion of TB cases in the country. Based on
analysis of quarterly or annual data the can generate hypothesis to be tested
regarding TB. They should submit at least five proposals for TDR yearly.
Creation of epidemiology unit under research department will facilitate the
issues.
• Working for high risk groups such as prisoners, IDPs, refugees, MDR and
XDR, and HIV patients have been started and mostly they are at pilot
phases. They are the group who pump the disease to general community.
Specific budgeted action plans should be developed for each group in order
to control the disease among them. Coordination meetings with neighboring
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2010
 countries by mediation of WHO will solve the problem of refuges screening.
• Involvement of private sector is very much important. There is no one at
private sector to examine the sputum of patients for TB diagnosis and
treatment. For the time being we should start from private hospitals and
support them technically to detect and refer the cases. Some sorts of
motivation or incentives should be taken into account by more involvement
of private sector in order to refer the cases to TB to TB treatment centers.
• Management of drug, medical supply and reagents for laboratories is
required to be strengthened. There should be plan of providing such
supplies based on their need and they should be supplied at least for three
month in advance. Shortage of drugs and supplies will jeopardize the fame
of the program.
• Provision of all utilities such as water, gas, power, space and necessary
equipment will facilitate activities and motivate staff. It should be coordinated
with NGOs that are implementing the rule and regulation of MoPH.
• Turn over of staff at local levels have face NTP to a challenge. Motivation
and incentives along with some agreement prior recruitment can decrease
turn over of staff.
• Supervision and monitoring of activities at local levels is a good event which
is common at NTP. Unfortunately it is dependent on incentives and payment
by donors. It should independent of donor support and part of NTP
supported activities.
• Sustainability of current performance when technical and financial support is
withdrawn is a big challenge. Retrospective analysis shows stoppage of
some activities when support is taken out. Technical and financial supporters
of NTP should find a mechanism to solve this problem and ensure
sustainability of program. Slowly and gradually provision of financial
provided by government would be one of solutions.
• Conduction of more awareness campaigns particularly through TV spots will
inform communities regarding the disease and it will increase case
detection, treatment and prevention.
• There is a rapid expansion of TB detection and treatment centers in the
country which is a good sign of improvement. Anyway the issue of quality of
these DOTS center is a question. Particularly the quality of sputum
examination which is done by lab staff and recording and reporting of data is
a real challenge. NTP in cooperation with donors and local NGOs should
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 strengthen the provision of technical trainings and equip them with facilities
which are needed for proper case detection and treatment. DOTS should be
expanded slowly and gradually to all health facilities by strengthening public
private partnership, urban and community based DOTS. Integration of BPHS
and EPHS in the name of Comprehensive Package of Health Services
(CPHS) by MoPH will assist NTP in application of its strategy.
• Security has deteriorated some activities regarding performance of program.
Involvement of local and religious leaders, implementer NGOs, recruitment
of local residential staff, and strengthening community involvement will
facilitate and improvement the program.
• Many guidelines and documents have been developed which is the strength
of the program, but still some are in progress and/or in the phase of
finalization. All departments should make efforts to finalize the documents
and translate it to local language to be useable and accessible by first line
health staff.

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