Term of Reference International MDR – TB Expert

International Multi-Drugs Resistance Tuberculosis (MDR-TB) Expert to support MDR-TB Unit in the National TB Program (NTP) in Iraq Project title: Duty station: Travel: Estimate starting date: Duration of the assignment:

Support to National TB and HIV/AIDS Control Programs Baghdad or Erbil - Iraq Travel to Baghdad or Erbil, travel to Basrah might be required July 2016 60 working days spread over the period of July -September 2016

A. Project Description TB is a major public health problem in Iraq. The Government of Iraq has given priority to Tuberculosis (TB) control. However, after the occupation and deteriorated security situation, the infrastructure and human capacity to effectively provide TB care were seriously damaged. As a matter of fact, notifications of TB cases continuously decreased. This changed in the last years and National TB Program (NTP) / Ministry of Health (MoH) started revitalizing TB control with support from partners like the Global Fund to fight AIDS, TB and Malaria (GFATM) and the United Nations Development Programme (UNDP). The GFATM R6 and R9 TB grant with UNDP as the Principles Recipient (PR) of the grant supported the delivery of services for quality DOTS TB care for poor and vulnerable populations, expansion of DOTS and increasing NTP’s management capacity in order to reduce the country burden of TB in Iraq in accordance with the National Strategic Plane to Control TB in Iraq for the period of 2015 -2019 that has set five objectives: 1. Objective 1: To increase case detection to at least 70% or more of new and relapse cases and treatment success of drug-susceptible case to 85% or more by 2019 2. Objective 2: To increase case detection of MDR-TB cases among notified (pulmonary) TB cases to 100% and treat successfully at least 70% by 2019 3. Objective 3: To provide TB control services to at least 75% of the populations belonging to vulnerable groups by 2019, which include children, IDPs, refugees, marshland populations, prisoners and people with TB/HIV 4. Objective 4: To strengthen and enhance monitoring and evaluation and operational research by 2017 and beyond 5. Objective 5: To strengthen and maintain efficient and effective program management by 2017 and beyond UNDP is committed to support the NTP to bridge all the gaps in fighting TB emphasizing the adaptation to local requirements and performance expectation and that the individual skills can be changed by following series of systematic steps that will stimulate the strength of the work and improve the outcome which will be reflected on the program achievements.

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Term of Reference International MDR – TB Expert B. Multi-Drugs Resistance Status in Iraq The number of patients diagnosed with MDR-TB has been in decline over the last 4 years and the number of MDR-TB patients diagnosed in 2014 was 66 patients out of which have been enrolled in treatment. The management of DR-TB patients including confirmation of diagnosis, treatment and follow up is currently centralized and conducted in Baghdad. Despite that an old hospital was renovated to be as the MDR – TB Specialized Hospital in Sulaimaniya Governorate which will be the main center for the admission – if indicated - and management of MDR-TB patients in Iraq, but due to TB stigma resulted from false believes the locals opposite the opening of the hospital and demanded its closure, currently MoH is working to establish MDR-TB hospital In Basrah Governorate and a specialized department in one of the hospitals in Baghdad. In the term of capacity development; physicians and treatment supporters had been trained on MDR-TB management. Treatment success was only 60% in the 2011 cohort, but this is above the global average of 48%. MDR-TB recording and reporting of adverse events is undermined by lack of important diagnostic aids such as audiometry. In order to encourage and improve the adherence of MDR-TB patients to the treatment; monthly 60 USD was received by each patient through the GFATM funds as a support for the transportation and food costs but this was stopped since 2014 due to financial issues. In the National TB Control Strategic plan for Iraq 2015 – 2019; Objective 2 “To increase case detection of MDR-TB cases among notified (pulmonary) TB cases to 100% and treat successfully at least 70% by 2019” was set to address MDR-TB in Iraq through implementing effective steps to expand the use of GeneXpert to become the first-line diagnostic, initially among suspects in five pilot governorates, and if this is successful to expand across Iraq – to improve the sensitivity of diagnosis; increase MDR-TB case detection to all notified cases using GeneXpert and provide prompt treatment to all those diagnosed; expand culture facilities by 6 laboratories of which 3 will develop drug susceptibility testing capability. Testing of patients for drug resistance will additionally be expanded to all failures, re-treatment cases, contacts of MDRTB cases, and TB/HIV cases (in line with existing policy which has been so far not implemented fully) and in line with WHO recommendations, Category II regimens will be phased out and replaced by individual DST and administration of an individualized regimen. While waiting for DST results, an empirical regimen will be devised based on the DRS results that will shortly become available. Until then the Category II regimen can continue to be used until individual results are available. In order to have a more precise overview for drug resistant TB epidemiology in Iraq and measure the prevalence of drug resistance among new and previously treated smear positive PTB cases in Iraq; a Drug Resistance Survey (DRS) that included 1110 SS+PTB patients including 987 new patients and 167 retreatment cases was conducted and the recently released report has suggested that the final estimate for MDR-TB prevalence among SS+PTB cases was 1.1% in new cases and 19.7% in retreated cases (Table 6). And the proportion of susceptible patients is 71.3% in new cases and 52.9% in retreated cases. The proportion for INH resistance in new & retreated cases was 7.6% & 27.9% respectively while the proportion for RR in new and retreated cases was 5.9% & 24.3% respectively, these results implies that more focus and efforts should be directed towards the management of MDR-TB in Iraq. C. Objectives of the Service The procurement of international expertise aims at providing in-depth analysis of existing MDR-TB Program in Iraq. Thus identifying and assessing knowledge and professional gaps which should be addressed through technical support and capacity building interventions in different areas. IRQ10-IC-153/16 – International Multi-Drugs Resistance Tuberculosis (MDR-TB) Expert

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Term of Reference International MDR – TB Expert These interventions will ultimately contribute to a better MDR – TB program management that leads to effective Diagnosis and treatment of MDR – TB patients in Iraq, subsequently increasing case detection among notified (pulmonary) TB cases to 100% and treating successfully at least 70% by 2019. D. Scope of Work Under the overall guidance of the UNDP Global Fund Project Manager and in close collaboration with the NTP – MoH the International Consultant(s) will be responsible for the timely implementation of the following tasks and responsibilities:    

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Provide technical assistance in the development and updating of the DR-TB guidelines, operational and procurement plans. Ensure the appropriateness of budget allocation under the different funding sources. Clearly define the technical support and HR capacity development needs for effective implementation of the MDR-TB component. Advise on concise practical actions required for: a) Addressing the factors leading to the emergence of MDR-TB in Iraq. b) Monitoring the progress of MDR-TB patients’ management (including –but not limited-to) field visits, reports review, and analysis of performance reports) Provide technical support in detailed DR-TB rational treatment design, monitoring and management of adverse effects. Provide specific guidance to the NTP in scaling up the enrollment on MDR-TB treatment through providing technical support in: a) The decentralization of the activities to increase the coverage of the detection/diagnosis. b) The development of a recording and reporting system designed for MDR-TB control that enables performance monitoring and evaluation of treatment outcomes. c) The establishment of MDR-TB related database. Design/adapt the Public Private Mix (PPM) strategy to adequately address DR-TB management. Evaluate the status of the newly established MDR-TB hospitals in Basrah Governorate and MDR-TB Department in Ibn Zuhur Hospital in Baghdad. Provide technical support according to the findings. Deliver training sessions on the Clinical Management of MDR-TB for 20 participants Provide on-the-job training in the diagnosis and management of MDR-TB.

E. Timeframe: The assignment will be 60 working days spread out over the period from July 2016 – September 2016. The International Expert needs to be able to travel within one month once the final approval notification is received from UNDP, this period will be used to finalize the agenda of the mission in coordination with NRL - NTP / MoH and follow up the home-based tasks. F. Duty Station: The tasks carried out by the International consultant shall take place mainly in Baghdad or Erbil, possible travel to Basrah might be required.

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Term of Reference International MDR – TB Expert G. Expected deliverables and outcomes: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Finalized National DR-TB Management Guidelines. National DR-TB Management operational and procurement plans. The action plan for HR capacity development needs to implement effective program. Complete report on the proposed recording and reporting system for MDR-TB data with all its relevant requirements. (including –but not limited to- the design of the system, the reporting forms, periodicity, training requirements…etc.) Detailed Monitoring plan for MDR-TB patients Evaluation Reports for Basrah MDR-TB Hospital and MDR-TB Department in Ibn Zuhur Hospital. Provide training for 20 participants on the Clinical Management of MDR – TB Adapted Public Private Mix (PPM) strategy to address MDR-TB Lead and facilitate the final workshop to discuss the findings, achievements and recommendations of the mission. Final mission report. Deliverables / Outcomes

1 2

3 4 5

6 7 8

9 10

National DR-TB Management Guideline National DR-TB Management operational and procurement plans Monitoring plan fro MDRTB patients

Estimated Duration to Complete 12 Days

Target Due Dates Home-based

Baghdad or Erbil

28 Days

HR needs action plan System and data for recording and reporting for MDR-TB Evaluation for MDR-TB Department in Ibn Zuhur Evaluation for MDR-TB Hospital in Basra Provide Training on the Clinical Management of MDR-TB

Target Due Dates July 2016

Baghdad or Erbil Baghdad or Erbil Baghdad or Erbil

1 day 5 days

2 days

Workshop

2 days

Baghdad

Final Report

10 days

Home-based

UNDP / GFATM Project Manager UNDP / GFATM Project Manager

UNDP / GFATM Project Manager July-August 2016 UNDP / GFATM Project Manager UNDP / GFATM Project Manager UNDP / GFATM Project Manager

Baghdad or Erbil Basrah

Baghdad or Erbil

Review and Approvals Required

UNDP / GFATM Project Manager UNDP / GFATM Project September 2016 Manager

Total Duration

IRQ10-IC-153/16 – International Multi-Drugs Resistance Tuberculosis (MDR-TB) Expert

UNDP / GFATM Project Manager UNDP / GFATM Project Manager 60 days

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Term of Reference International MDR – TB Expert H. Institutional Arrangements: The International Institution/Expert(s) will be working closely/supervised by and reporting to the UNDP/GF project manager. All the deliverables should be cleared by the latter and endorsed by the NTP before they are considered final. Weekly progress-reports will be submitted to the UNDP GF project manager. Any adjustments/modifications in the deliverables and or mission-schedule will be mutually agreed between UNDP and the consultant(s).

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