ANNUAL REPORT ON THE TB ROUND 6 GRANT - …raa.ro/oldfg/ · ANNUAL REPORT ON THE TB ROUND 6 GRANT ... Development of the Data Management System for Programmatic and Financial Management

ANNUAL REPORT TBS ROUND 6 GRANT

Submission date: December 12, 2008

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ANNUAL REPORT ON THE TB

ROUND 6 GRANT

Principal Recipient:

Romanian Angel Appeal Foundation

The Report reflects the status of implementation within the first

year of the TB Round 6 Grant

(October 1st 2007 – September 30th 2008)



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Contents

Abbreviations: 3

1. Background and Summary 4

2. Sub-recipients 6

2.1 Evaluation of Sub-recipient organizations, Capacity Building and Technical Assistance 8

3. Development of the Data Management System for Programmatic and Financial Management 9

4. Ensuring the quality of program interventions 13

5. Financial & Procurement Considerations 15

5.1. Summary of received and disbursed funds: 15

5.2. Summary of Expended Funds 19

5.3. PROCUREMENT 20

6. Challenges being faced 21

7. Overall progress of the program 22

7.1. HUMAN RESOURCES DEVELOPMENT FOR TB CONTROL 23

7.2. ADDRESSING TB CONTROL AMONG HOMELESS CHILDREN AND YOUNGSTERS 26

7.3. IEC-FROM NATIONAL STRATEGY TO COMMUNITY INTERVENTIONS 30

7.4. ADDRESSING TB CONTROL AMONG PRISONERS 33

7.5. SCALE-UP MDR-TB THROUGH DOTS-PLUS PROJECT 35

7.6. INTRODUCING PAL STRATEGY 37

7.7. OPERATIONAL RESEARCH IN TB CONTROL 39

7.8. INTRODUCING ACSM 41

8. Advocacy for Sustainability 44

Increasing the Program’s visibility 44

9. Securing the co-funding from the State budget for VAT 45

10. Summary of Key partnerships in reaching Program’s goals: 48



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Abbreviations:

ACSM Advocacy, Communication and Social Mobilisation

CHPS / CPSS Center for Health Policies and Services (CHPS)

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria

M&E Monitoring and Evaluation

MDR-TB Multi Drug Resistant Tuberculosis

MEF Ministry of Economy and Finance

MOH Ministry of Public Health

NAP / ANP National Administration of Penitentiaries

PAL Practical Approach to Lung Health

PPM Public-Private Mix Partnership

PR Principal Recipient

RAA Romanian Angel Appeal Foundation

SLD-DRS Second line drugs-drug resistance survey

SR / SRs Sub-recipient / Sub-recipients

TB Tuberculosis

VAT Value-Added Tax

CHPS Center for Health Polices and Services

NCSMF National Centre for Studies in Family Medicine

GARD Global Alliance against Chronic Respiratory Diseases, a WHO initiative

PHC Primary health care

CRD Chronic respiratory diseases

COPD Chronic obstructive pulmonary disease

DOW Doctors of the World

WTBD World TB Day

NSPHSM National School for Public Health and Health Services Management

NTP National TB Control Programme

IDA International Dispensary Association

GLC Green Light Committee

WTBD World TB Day



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1. Background and Summary

Despite the recent efforts, including implementation of Global Fund-supported programs,

tuberculosis (TB) remains a serious public health issue in Romania. While epidemiological data

demonstrates a decline in overall incidence, TB remains widely spread throughout the country.

In particular, nineteen counties, which comprise 9,462,757 persons (44% of the country

population), reported TB rates exceeding national average of 126.5 per 100,000. In 2005, these

counties experienced case rates ranging from 134.7 to a high of 203.2 per 100,000.

At the date of proposal submission, Romania was ranked 42 out of 211 World Health

Organization (WHO) reporting nations based on 2004 data. Within the WHO Euro region,

Romania reported the second-highest TB incidence preceded only by Kazakhstan.

Romania’s TB caseload is concentrated among the nation’s most vulnerable population defined

as having the lowest income, highest unemployment, and low educational achievement.

Another priority area for TB is the prison population. TB incidence amongst inmates was

reported as being 10 times the general population, while multi-drug resistant TB (MDR-TB)

(new cases) in prisons were 4.3% compared to 2.9% of the total country.

While the government of Romania provides for free diagnostic and treatment services, there

exist a number of critical gaps and uncovered areas including human resource development,

patient support and outreach services, program management and operational research. In

addition, Romania requires support to address and standardize treatment services within the

large private-sector.

Finally, given the large population of MDR-TB patients (an average of 1,000 new patients each

year), Romania needs to implement a DOTS Plus program.

Goal:

The overall goal of the Program is to reduce the burden of TB in Romania.

The achievement of the Program goal will be pursued through six objectives:

The first objective is to provide high-quality TB diagnosis and patient-centered care through

training of public and private-sector providers;

The second objective is to protect poor and vulnerable populations from TB through targeted

education and adherence interventions;

The third objective is to scale up MDR TB control through the implementation of DOTS Plus;



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The fourth objective is to expand capacity of the National Target Program (NTP) to manage and

coordinate national and local TB control activities through health systems strengthening and

increase political commitment;

The fifth objective is to develop community support and political commitment for TB control;

and

The sixth objective is to ensure the efficient and effective implementation of the Program

funded under the GFATM Round 6 Grant.

Target Group/Beneficiaries:

• TB patients

• Rural communities

• Roma population

• Homeless

• Low-income population groups

• Prison population

• Medical and laboratory staff involved in TB control activities

• Primary healthcare providers

• Population at large

Strategies:

Romania has proposed a supportive and comprehensive strategy to scale up and sustain recent

achievements and to reduce TB transmission, including national TB DOTS coverage, over 2007-

2011. Services and activities will address national needs, and will consist of policy development,

strategic planning, delivery of standardized training, and targeted interventions such as

education and treatment incentives, as well as implementation of DOTS Plus. In addition, the

Program will address innovation through implementation of operational research and

introducing PAL strategy via measures to better coordinate health care for patients (referral,

notification, and discharge planning) and through new Advocacy, Communication, and Social

Mobilization (ACSM) activities.

Planned Activities:

The Program will address vulnerable populations and the public health workforce through the

following interventions:

• Provide and augment TB services to rural communities, Roma, homeless, and prison

inmate populations

• Improve evaluation and treatment of contacts of TB cases, develop a national health

education strategy for vulnerable populations and educational materials, and

implement health education activities

• Contribute to health systems strengthening through a human resource development

(HRD) initiative to train staff working in TB units and laboratories, particularly in areas

such as program management, epidemiology, surveillance, and financial management.



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In addition, Romania will implement innovative programs in line with the new STOP TB Strategy

that will engage the private-sector, via a public-private mix (PPM) program, and contribute to

health system strengthening by fostering operational research and Practical Approach to Lung

Health (PAL) strategies.

The PPM program will scale up training of family physicians to provide quality-assured

TB care and adhere to international and NTP standards. Further, Romania will implement

targeted advocacy, communication, and social mobilization (ACSM) activities to generate

political commitment and community participation in TB control. The ACSM activities will also

improve treatment adherence practices by educating vulnerable populations and reducing

stigma.

Finally, Romania will address the challenge of MDR by implementation of DOTS Plus project.

2. Sub-recipients

The sub-recipients of the TB Grant have been selected according to the Country Coordination

Mechanism’s Selection Methodology, within one round of selection organized by RAA during

14th

February 2007 (Call opening) – 27th

April 2007 (Selection closing date).

The total number of Sub-recipients sub-contracted by RAA Foundation is of 7 legal entities, out

of which (see full list of SR on the next page):

• Non-Governmental Organizations: 4

• Governmental Institutions: 3

Of the selected SRs, 4 have been also sub-recipients of the Round 2 GFATM.

The CCM Secretariat activities corresponding to the TB Grant have been sub-contracted

through UNDP to the Romanian HIV/AIDS Centre (The Romanian HIV/AIDS Centre is currently

operating as joint project between UNDP and National Infectious Diseases Institute “M. Bals”).

At the date of submission of this report (December 2008), the number of sub-contracted

projects under the TB grant is 16 (see full list of SRs and number of projects sub-contracted in

Table 1 next page).



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Table 1: List of TB Grant Sub-Recipients, Number of Projects Sub-contracted, Date of signing the sub-

grant-agreement and Project Title

No. Sub-recipient

Number of

projects

sub-

contracted

Sub-Grant agreement number /date of signing,

Project code & Project title

1

Center for

Policies and

Health Services

6

TB 3505i / 18.12.2007

O1 SDA1 I1 - Strengthening the Private -Public Mix in TB Control

O2 SDA2 I1 - Behavior Change Communication in TB Control – From A

National Strategy to Local Interventions

O4 SDA1 I1 - Increasing the Management Knowledge and Skills of the

Medical Staff from the TB Control Network

O4 SDA2 I1 - PAL Implementation Strategy

O4 SDA3 I1 - Operational Research regarding TB control in Romania

O5 SDA2 I1 - Mass Media Support in Behavior Change

Communication Campaigns (BCC)

2

“Save the

Children”s

Romania

Foundation

3

TB 181i / 28.01.2008

O2 SDA1 I2 - Psycho-social support for street children and youngsters

at risk or having TB

O2 SDA2 I2 - Prevention of TB transmission among street children

and youngsters, throughout health education

O2 SDA3 I2 - Timely identification for effective treatment of the TB

street children and youngsters

3

National

Penitenciary

Administration

2

TB 1222 I / 09.07.2008

O2 S2 I3 - Health education sessions for prisoners

O2 S4 I3 - Implementation of the National TB Program in Prisons

4

"Marius Nasta"

National

Pneumology

Institute

1

TB 463 I / 27.02.2008

O3 SDA1 I5 - Scale- up MDR-TB control through implementation of

the DOTS-Plus project

5

National Centre

for Studies in

Family Medicine

1 TB 605 I / 11.03.2008

O4 SDA2 I6 - Pilot Implementation of PAL strategy

6

National School

of Public Health

Service

Management

2

TB 97 I / 17.01.2008

O5 SDA1 I4 - Elaboration of an Advocacy, Communication and Social

Mobilization Strategy related to TB

O5 SDA2 I4 - Training of journalists in order to reflect TB problem in

mass media

7 Romanian Red

Cross Society 1

TB 1877 I / 09.10.2008 (Sub-grant agreement in preparation during

the last month of the programmatic Y1)

O2 SDA1 I7 - Increase TB patients compliance to treatment through

incentives distribution



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2.1 Evaluation of Sub-recipient organizations, Capacity Building and Technical

Assistance

Prior to sub-contracting the selected SR, RAA conducted an in-depth evaluation process aimed

on revealing the selected SRs capacity to implement the projects, their strengths and

weaknesses and the need of capacity-building and technical support.

The evaluation was structured on three major areas:

• Institutional and Programmatic capacity

• Financial and Procurement capacity and

• Monitoring and Evaluation.

Specific evaluation methodology including evaluation instruments have been developed by RAA

Foundation.

The GFATM M&E Systems Strengthening Tool served as basis for RAA Foundation in designing

the evaluation methodology for the SRs. RAA focused on the assessment of the data-collection

and reporting systems per SR including their ability to report accurate, valid and quality data

related to implementation.

On the financial and procurement assessment side, the evaluation included the assessment of

accounting procedures, the capacity of SR to absorb the new activities, the manner in which all

supporting documents are kept; the experience of SR to implement procurement procedures,

management of inventory and stocks, stocking capacity of each SRs, the experience in

developing financial reports according with funders requirements, the proof of previous audit

reports, evaluation of the budgets proposed, etc.

The information gathered during the evaluation process has served as a basis for establishing

the agenda of the capacity-building M&E workshops as well as for the training on financial

management provided by RAA to the sub-recipient organizations (see Table 2).

Besides capacity building events such as trainings and workshops, technical assistance was

provided by RAA Foundation to all SRs in the form of desk analysis followed by written

feedback, ad-hoc or solicited meetings followed in most occasions by project technical

assistance visits.



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Table 2:

Summary of Capacity Building and Technical Assistance Activities Provided to SRs during the first 12

programmatic months

Type of activity

Number of

Sub-recipients

Number of

Sessions

M&E seminar

Topics:

• Principles in Monitoring and Evaluation of the TB Program

• Programmatic reporting of the TB Projects, On-line Technical

Reporting

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1

Financial & procurement seminar

Topics:

• Financial reporting principles and tools

• Introducing the web-based financial and procurement

reporting system

7

1

Technical Assistance events

provided by PR at SRs request

or resulted from PR’s assessment of SR’s capacity

5

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3. Development of the Data Management System for Programmatic

and Financial Management

During the first three months of the TB grant implementation, RAA Foundation developed a

tailored on-line system for collecting and reporting the programmatic and financial data

provided by SRs.



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The web-based reporting system was structured in three major chapters:

- Financial reporting

- Procurement reporting

- Programmatic (M&E) reporting

The system can be accessed by every SR (using a password and a username), and reflects the

main programmatic and financial data for all the SR’s projects.

The reports can be aggregated quarterly and annually, by indicator, by project or SR.

At any point in time, the reports show what has been achieved, against what target and what is

left to be achieved during the next quarters.

Access to the reporting system is restricted to SR, in order to respect confidentiality of

information. Each user has the possibility to work on and visualize only the information related

to his/her organization. The members of the PR team have the possibility to visualize all the

information uploaded by the SRs. Each individual SR can create a data base with relevant

information about contracts signed with their service providers: name of the provider, type of

contract, duration, starting date and finish date, amount of the contract, installments. This way

all the contracts can be followed up in a rapid manner. The disbursements to SRs under the TB

Grant are made based on the financial and procurement reports, as well as on the M&E report.

The financial report is structured as follows:

• Income received in the reporting quarter (disbursement received from PR), including

balance account and exchange rate

• Expenditure made during the reporting quarter, structured on budgetary lines:

human resources (consultancy and personnel); non-health goods and equipment;

infrastructure; trainings; commodities and products (medical products and medical

equipment); drugs; M&E visits; other meetings, visits, conferences; IEC materials;

administrative costs; audit; incentives; protocol; bank charges; other costs

• Personnel costs are automatically completed by the system, this report allowed to

have representative pictures of salary levels, including taxes.

• VAT report, automatically completed by the system, structured on VAT categories:

services, utilities, non-health products, medical equipment, health products, drugs

• M&E financial reports, automatically completed by the system, show the percentage

of expenditure , from the total expenditure, allocated for M&E activities

• Cumulative reports permit to compare level of expenditure with budget and funds

received from the PR. This report show figures from the reporting period and

cumulative up to date.



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• Explicative reports, show differences between budget and expenditure for the

reporting period and also cumulative and explain deviation from the budget

• Interest reported, show the bank interest received

• Closing balance, show deviation, if any, between real balance account (cash and

bank) and balance account calculated by the reporting system

• Disbursement represents the installment request. The amount for next installment

to be received by SR is calculated with the following formula:

[Outstanding obligation + planned expenditure] – [Initial balance account + installment

received + interest (cumulative) - expenditure]



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The procurement report is also automatically filled in by the system. The procurement report is

structured as follows:

• Buildings

• Medical products

• Medical equipment

• Non-health goods

• Services

• Drugs

• Consultancy

The M&E web-based report reflects the quarterly situation of the indicators mentioned in

every SR’s M&E plan (key and additional indicators), as well as the quarterly status of the

activities mentioned in the SR’s work plan (e.g. activity totally achieved, partially achieved,

achieved in advance etc.).



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The reporting web-based system is accessible on the web-page created by RAA for the HIV/AIDS and TB

Programs funded under the Round 6 ( www.globalfund.ro ).

4. Ensuring the quality of program interventions

Due to ISO 9001:2001 certification on quality management, one of the characteristics of RAA’s

management of the Round 6 program is the preoccupation not only for the achievement of the

key indicators, but also for the quality of interventions.

For the grant implementation RAA developed a Manual of Operations that mentions the quality

principles to which RAA is committed and describes the implementation procedures and

instruments related to all the major implementation areas: monitoring and evaluation, financial

and procurement and communication.



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In line with the Manual of Operations, the PR is engaged in the following types of activities, to

ensure the quality of interventions:

• Perform monitoring visits at the sites of the projects contracted by the SRs. During the

first 12 months of the program, the PR team monitored the programmatic performance

of 15 TB projects, during 17 field visits and 7 technical assistance meetings; the financial

and procurement progress was monitored for 3 projects during 1 field visits.

• Issue specific recommendations for the SRs following all the monitoring visits; most of

the recommendations were related to the need of improving or adjusting to the

requirements from the Manual of Operations the data collection and reporting system,

the methods for delivering the services, manner in which cash accounting is kept and

recommendations related to financial and procurement report.

• Analyze the quarterly narrative reports of the SRs and provide feed-back and

recommendations on the quality of the report, as well as on the quality of activities

described.

• Supervise the changes recommended to the SRs following the monitoring visits and

the report analysis. Since every recommendation is followed by a plan and a deadline,

the PR has the chance of checking if and when the recommendation is respected by the

SR.

• Promote partnership and collaboration among SRs providing similar or complementary

services, also promoting the need to use standardized methods and instruments when

delivering services to the same category of beneficiaries.

• Check and approve all the informative materials produced by the SRs under the grant.

The PR gives feed-back to regarding the content and the format of the materials, in line

with the Manual of Operations.

• Revise of the SRs implementation plans. After the first 12 months of implementation,

the program results (collected through the narrative reports and the monitoring visits)

were analyzed by the M&E TB and financial teams. In order to overcome the problems

or delays identified, the PR proposed the SRs a revised implementation plans. Each plan

revises either programmatic issues (e.g. redistribution of targets, improvements in the

method of service delivery, reporting practices) or/a financial and procurement issues.



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Based on the above-described actions the PR manages:

• To get timely information of the main issues with which the SRs are confronted in the

field;

• To discuss with the SRs and identify solutions to the problems

• To monitor the problem solving process and intervene, whenever necessary.

5. Financial & Procurement Considerations

5.1. Summary of received and disbursed funds:

The total budget contracted with GFATM for the first year of the program implementation

(1 October 2007 – 30 September 2008) is 1,903,099 Euro, structured as follows:

OBJECTIVE

Budget contracted

with the GFATM for

the first year of the

Program

OBJECTIVE 1:

Provide high-quality TB diagnosis and patient-centered care

through training of public and private-sector providers

99,750 €

OBJECTIVE 2:

Protect poor and vulnerable populations from TB through

targeted education and adherence interventions

871,962 €

OBJECTIVE 3:

Scale up MDR TB control by implementation of DOTS plus 211,354 €

OBJECTIVE 4:

Expand capacity of the NTP to manage and coordinate national

and local TB control activities through health systems

strengthening and increase political commitment

467,471 €

OBJECTIVE 5:

Develop community support and political commitment for TB

control

101,727 €

OBJECTIVE 6:

Program management 150,835 €



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From the total budget contracted with GFATM, RAA received an amount of 2,246,849 Euro

(including the 564,350 Euro buffer, but excluding the amount of 77,287 Euros for MDR-TB

drugs, wrongly budgeted in the first year of activities) and disbursed to SR the amount of

1,461,382 Euro (including one month buffer), out of which the SR’s and PR expenditure was

865,263 Euro.

OBJECTIVE

Budget contracted

with the GFATM for

the first year of the

Program

(1 October 2007 -

31 September 2008)

Amount

disbursed by

GFATM:

2,246,849Euro

(including one

quarter buffer)

Amount

disbursed to SRs

(including 1

month buffer) Expenditure

Objective 1 99,750 € 217,553 € 111,566 € 68,927 €

Objective 2 871,962 € 973,844 € 713,521 € 305,555 €

Objective 3 211,354 € 152,280 € 58,959 € 50,293 €

Objective 4 467,471 € 541,792 € 358,059 € 244,508 €

Objective 5 101,727 € 178,558 € 113,597 € 90,300 €

Objective 6 150,835 € 182,822 € 105,680 € 105,680 €

TOTAL 1,903,099 € 2,246,849 € 1,461,382 € 865,263 €



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The distribution by objectives of the amount disbursed by GFATM for the first year of program

implementation (including one quarter buffer) is presented in the table below:

OBJECTIVE Amount disbursed by

GFATM

OBJECTIVE 1: Provide high-quality TB diagnosis and patient-

centered care through training of public and private-sector

providers

217,553 €

OBJECTIVE 2: Protect poor and vulnerable populations from TB

through targeted education and adherence interventions 973,844 €

OBJECTIVE 3: Scale up MDR TB control by implementation of

DOTS plus 152,280 €

OBJECTIVE 4: Expand capacity of the NTP to manage and

coordinate national and local TB control activities through

health systems strengthening and increase political

commitment

541,792 €

OBJECTIVE 5: Develop community support and political

commitment for TB control 178,558 €

OBJECTIVE 6: Program management 182,822 €



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From the total amount budgeted for the first year of the Program implementation, the PR

disbursed to SRs 77% funds, representing 1,461,382 Euro (including one month buffer):

OBJECTIVE Amount

disbursed to SRs

OBJECTIVE 1: Provide high-quality TB diagnosis and patient-centered care

through training of public and private-sector providers 111,566 €

OBJECTIVE 2: Protect poor and vulnerable populations from TB through

targeted education and adherence interventions 713,521 €

OBJECTIVE 3: Scale up MDR TB control by implementation of DOTS plus 58,959 €

OBJECTIVE 4: Expand capacity of the NTP to manage and coordinate

national and local TB control activities through health systems

strengthening and increase political commitment

358,059 €

OBJECTIVE 5: Develop community support and political commitment for TB

control 113,597 €




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5.2. Summary of Expended Funds

From the total amount received from GFATM for the first year of implementation (the amount

of 1,825,812 Euro – buffer not included), 47% were spent by SR and PR. Expenditure

distribution by objectives is:

OBJECTIVE Expenditure

OBJECTIVE 1: Provide high-quality TB diagnosis and patient-centered care through

training of public and private-sector providers 68,927 €

OBJECTIVE 2: Protect poor and vulnerable populations from TB through targeted

education and adherence interventions 305,555 €

OBJECTIVE 3: Scale up MDR TB control by implementation of DOTS plus 50,293 €

OBJECTIVE 4: Expand capacity of the NTP to manage and coordinate national and

local TB control activities through health systems strengthening and increase

political commitment

244,508 €

OBJECTIVE 5: Develop community support and political commitment for TB

control 90,300 €




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During the first year of implementation PR disbursed to SR 77% from the total contracted

budget, out of which expenditures represent 59%. Program expenditure represents 46% from

the total budget contracted with GFATM. All variances between budget and expenditure are

explained in the Annex 1 - Enhanced Financial Report.

5.3. PROCUREMENT

The assessment of PR's capacity in Procurement and Supply Management was made by Dr. Gabor

Szalay, Pharmacist Independent Specialist/Consultant, Health Procurement & Supply Chain

Management and Global Fund.

During the assessment visit, Dr. Szalay visited the MDR-TB centre from Bisericani and the warehouse for

MDR-TB drugs in Bucharest, in order to verify chain supply, quality management of drugs, storage

conditions, distribution etc.



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In the first year of the programme no centralized procurement was conducted. However the PR has

provided technical assistance to all Sub-Recipients contracted, but especially to the Centre for Health

Policies and Services (CHPH), Save the Children Romania and PIU-TB - National Administration of

Penitentiaries. The topics were concerned mostly with the procurement of consultancy services, IEC

materials, IT equipment, and incentives.

The MDR-TB drugs can be procured only after the approval of GLC for 320 additional Romanian patients’

enrolment. This approval was received in September 2008 and during the next period the final

documents and order will be prepared and submitted to IDA.

6. Challenges being faced

During the first 12 months of the grant, the implementation faced three main challenges, one

of them affected the whole management process, and the others were related to particular

areas of implementation:

• Although some important steps have been achieved as a result of RAA interventions at

the Ministry of Finance and Ministry of Public Health, the VAT co-funding for GFATM

Grants was legally solved by the Government through the issue of a Governmental

Ordinance only at the end of September 2008, meaning at the very end of the first year

of implementation of the TB Grant.

• Multiple changes at the management level of National Administration of Penitentiaries

(NAP) occurred in during June – March 2007 have prevented RAA to properly negotiate

and sign the sub-grant agreement with this SR until July 2008, causing a serious delay in

implementation of TB prevention activities in prisons, fortunately overcame by an

exemplary mobilization of the NAP-PMU coordinator (Dr. Lucia Mihailescu) supported

by the newly appointed NAP management team (especially the General Manager - Mr.

Ioan Bala).

• An important challenge not yet solved was and still is the Second Line anti TB Drugs- Drug

Resistance Survey (SLD-DRS) Protocol. NTP started a retrospective study without the

approval from RAA or WHO on the 1st

of August. Although it was discussed and finally

agreed to implement the SLD-DRS in a prospective manner and to have a WHO technical

assistance Mission for this during December, the NTP Manager cancelled the WHO Mission

in December due to very busy agenda, and also denied any possibility of financial support



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for the SLD-DRS from NTP in the situation of financial crisis, the insurance of drugs for TB

patients being a priority in front of any other activity such as the SLD-DRS.

7. Overall progress of the program

The first semester of the TB Grant was featured by thorough revision of the annexes of the

selected SR; evaluation of SRs and preparatory work such as delivery by the PR of technical

assistance sessions for SR as well as numerous approaches of the national stakeholders for

issuing the legal basis for the reimbursement of VAT value for the procurement of goods and

services from the GFATM HIV and TB grants.

The quality of the SR’s applications / project documents was not always corresponding to the

PRs / GFATM requirements. The negotiations with institutional SRs such as Institute M. Nasta

proved less smoother and longer than planed and therefore the revision of project plans,

budgets and negotiations took sometimes 2 months (i.e. CHPS), 4 months (Institute M. Nasta),

etc. Besides, similar as for the HIV grant, multiple negotiations with various changing

management teams of the National Administration of Penitentiaries (which formally deciding to

enter into negotiations with RAA only in February 2008) have had an unwanted impact on the

overall performance of the first semester of the R6 TB Grant.

The late start of most activities impacted the achievement of indicators during the first

semester as follows:

• 6 indicators (43%) have been underachieved

• 2 indicators (14%) have been overachieved.

Other 6 indicators (43%) are associated with activities that are planned to start either in Q4 or

(mainly) in year 2.

The second semester of the TB grant was featured on one hand by the PRs efforts to put on

track the implementation by concluding the sub-grant-agreement with the National

Administration of Penitentiaries and by working with SRs to achieve the desired project results.

A lot of lobby activity was also performed by the PR's team to convince the Ministry of Health

to issue the Government Ordinance regarding the funding for VAT for goods and serviced

procured under the Round 6 grants.



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Technical assistance was also offered by the PR to majority of SRs (including M. Nasta Institute,

Center for Health Policies and Services, National School of Public Health and Health

Management) in order to increase the quality of services delivered.

However, even with a good mobilization of the majority of SRs, the late start of some activities

such as those in penitentiaries affected the overall implementation of the grant during the

second semester as follows:

• out of 14 indicators 3 indicators (21 % ) have been substantially met,

• 2 indicators (14%)have been partially met

• 4 indicators (29%) have been overachieved

• 1 indicator (7%) has been underachieved

• 1 indicator (7%) has not been achieved (SLD-DRS).

Other 3 indicators (21%) are associated with activities that are planned to start in the second

programmatic year.

However, despite all the difficulties, we believe that the greatest achievements are:

• We managed to cover all the program areas and specific activities;

• All implementers (SRs) have been adequately monitored and evaluated and received

technical assistance from the PR to adequately improve their work plans in order to

increase the quality of interventions and accelerate implementation.

The existing monitoring and evaluation reports indicate (with minor exceptions) that the

implementation is now on track and there are great chances (with one exception - SLD-DRS of

Marius Nasta Institute) that the key indicators will be recovered during the second year of the

program.

7.1. HUMAN RESOURCES DEVELOPMENT FOR TB CONTROL

Addressing both training of family doctors and training of staff from the TB network for

improving coordination of health services and care between primary providers and the TB

network and development of managerial capacity of the medical staff from the TB network.

2 Projects are implemented by CHPS under objective 1, SDA1: TB: PPM (Public Private Mix), and

objective 4, SDA1: Supportive environment: Human Resources.

Development of public-private partnership (PPP or PPM) in TB Control is a continuous challenge

in the ongoing health care system reform.



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The aim of this project is to train at least 1,000 family doctors in TB and TB control activities, to

improve collaboration of primary health care providers and TB network through some outreach

activities and local workshops at county/regional level with participation of representatives of

main stakeholders involved in TB control activities.

During the 1st

year of implementation after a meta analysis study of the PPP performed in

collaboration with DOW. The representatives of DOW were active in Romania till April 2006;

they implemented a USAID child survival grant on TB control in Romania during 3 years in

collaboration with NTP and participated in elaboration of some GFATM projects for the 6th

Round. This is the reason why they were able to provide their support and technical assistance

as they are aware about the situation of TB and NTP in Romania.

The study report was used along the first year of the grant implementation in the revision

process of the Implementation norms of the NTP required by the Ministry of Public Health

(MoH); some of the recommendations were included in the last version of the norms, revised

on the request of the Ministry of Public health. These norms define the legal framework for the

involvement of the primary health care providers and TB network units/staff in the TB control

activities.

Based on the revised NTP implementation norms and the previous experience in the country

gained during the training of over 4,000 family doctors in the project implemented in 2nd

Round GFATM Grant, the training curricula for the family doctors was revised;

26 trainers were trained for providing the training sessions for family doctors using the new

curricula and new training materials which are planned to be organized starting with 2nd

year of

project implementation.

Cover page of the Participant’s Manual

for the family doctors training



25

Training of staff from TB network for development of the managerial skills aims at consolidating

the TB control planning at national level. The implementation and monitoring capacity by

increasing the level of knowledge and managerial and communication skills of the medical staff

active in the TB control network is implemented by CHPS under Objective 4, SDA1: Supportive

environment: Human Resources.

Based on a training needs assessment study for the medical staff from the NTP network carried-

out during Q2 in selected locations throughout the country (quantitative and qualitative data

was collected and analyzed by specialized consultants) during Q3 of implementation were

elaborated 5 training modules and course curricula and other training materials for the

residential training courses and during Q4 were elaborated the 2 modules for distance learning.

The 5 modules for residential training are covering the following areas: 1. General

management, 2. Quality management, 3. Project and financial management, 4. Communication

and advocacy; 5. Tuberculosis surveillance and informational system.

600 copies of a manual containing all 5 training modules have been printed.

124 persons have been trained in residential system in September during the Summer School

“Development of Respiratory Diseases prevention and Control Capacity”, organized by CHPS at

“Marius Nasta” Institute during 15th

-19th

of September 2008.

For the continuation of the training sessions in residential system during year 2 at regional level

in order to reach the 300 persons trained target, 14 trainers with management training

experience in collaboration with CHPS training centers network from the Iasi, Timisoara and

Cluj-Napoca CHPS were trained.

Residential training session for

development the managerial

capacity of the staff form the TB

network during the Summer

School, 15-19 September 2008,

at Marius Nasta Institute.



26

The 2 modules for distance learning trainings, available on www.e-sanatatepublica.ro are

dedicated to 1. Project management and 2. TB surveillance and information system.

Distance learning courses in management did not start in Q4 as planned; distance education

needs to obtain accreditation from the Romanian College of Physicians within a partnership

with a university. The accreditation was obtained in November 2008.

All modules are adapted to TB control programme.

7.2. ADDRESSING TB CONTROL AMONG HOMELESS CHILDREN AND

YOUNGSTERS

3 projects are implemented by Save the Children Romania Organization (SC) under objective 2:

SDA1: Social assistance and psychological counseling, SDA2: Prevention: BCC - community

outreach and SDA3: Timely detection and quality treatment of cases.

This is the first time in TB Control activities in Romania that the homeless children and

youngsters are addressed in a systematic approach.

The activities of the 3 projects are very much connected, being implemented by the same

persons in Bucharest and 3 branches of the organization located in Timisoara, Iasi and Craiova,

all big cities with important number of target group beneficiaries.

At the beginning of the project there were trained 20 persons from the staff working in the

management of project in TB control and then 81 persons to implement the outreach activities

Screen-shots of distance learning training (e-learning) in management for the TB network

staff



27

were trained in TB Control and in specific approach of the target group beneficiaries: social

workers psychologists, educators, medical professional, teachers and even policemen,

according to the special designed curricula. Also 44 peers were identified and trained aiming at

getting some support at community level, mostly for treatment monitoring.

18 partnerships were concluded between Save the children Romania and its branches with local

institutions and organizations such as local social services directions, medical units, etc, in order

to ensure collaboration and support for project activities.

The activities have been carried on within 33 locations. The identification of new locations is a

continuous process.



28

The interventions were performed on different levels:

• First activity performed by the social assistants and the project staff when approaching

the homeless vulnerable community was to evaluate the situation of the

community/individual; they made the so called social inquiry at each community level;

the purpose was to identify the members of the community, their urgent and

important needs, and then to proceed to the IEC for TB and identification of TB

suspects. There were performed 98 social inquiries at community level.

• Organization of ad-hoc meeting with the beneficiaries and providing IEC sessions using

IEC materials, and mostly discussions; 639 persons were reached vs. a 500 previewed

target.

• 180 TB suspects were identified and referred to medical services; 63 were diagnosed

with TB and put on anti-TB treatment; among them 33 were smear positive TB cases.

The TB patients were monitored after the release from TB hospitals. 14 already

complete their treatment; 3 moved to other known locations and 4 were simply lost.

• For all 180 TB suspects individualized intervention plan for social support, medical

support and counseling was provided. They also received food packages, hygiene kits,

clothes or any other important and urgent needs that were identified, for each

individual; beside the GFATM funds there were used also funds from the organization

"Save the Children Romania". Beside the items mentioned before the beneficiaries

received professional counseling, in order to go to a school or to find a job, they were

referred to school, or to the educational centers of Save the Children, in order to

receive certain education. For some of them approached to get ID papers were done,

or to support them in any urgent need identified, such the payment of the rent.



29

• 50 TB patients were psychological evaluated and 47 were also counseled in order to

increase awareness about the importance of completing the TB treatment.

A KAP survey on 400 homeless persons regarding TB was done based on a detailed

questionnaire and the final report was printed in 600 copies.

Challenges:

• The beneficiaries’ attitudes and behaviours oriented to satisfy their basic needs (food,

shelter and clothes) determine a lack of concern about long term needs. Thus, they are

not very much concerned about their health.

• The lack of the specialized juridical services that can intervene in emergency situations

of child abuse or neglect in order to take measures of special protection (when the

social assistance and child protection departments cannot decide)

Success stories and lessons learned:

As a consequence of the interventions made by the implementation team, within the targeted

communities there has been an increased responsibility of some of the benefficiaries regarding

their attitude towards health, fact that made them undergo periodical visits to the medical

units.

Apart from the TB suspects that have been identified, the access to medical and social services

of other disadvantaged persons from the project implementation areas has also been

facilitated.

The conclusion of partnerships with relevant social assistance institutions and their interest in

the current project put the basis for creation of local networks aiming at informing the

beneficiaries of social programs about TB, to identify TB suspects among them and to offer

social support for maintaining the adherence of the TB treatment.



30

The direct example of persons from their communities that have been suffered from TB and

have been healed is the most relevant method to present the information on the importance of

the correct and complete treatment.

Using, in collaboration, the adequate instruments for the social cases, within multi- disciplinary

and inter-institutional teams, and the supplementary services provided by the program

partners ensures the complementarities and the diversification of the programs;

Involving the parents and children as partners, not only as beficiaries of the interevention is

very important.

Future plans:

• Continuing to offer material support and other social services for the beneficiaries in

order to satisfy their basic needs

• Collaborating with social assistance and child protection departments in order to take

measures of special protection for children abused or neglected by their parents (in the

situations in which they can decide)

• A closer collaboration with the network of sanitary mediators and with other

institutions, such as Proximity and Community Police

7.3. IEC-FROM NATIONAL STRATEGY TO COMMUNITY INTERVENTIONS

The project is implemented by CHPS, under objective 2, SDA2: BCC - Community Outreach.

The aim of the project is to develop a national strategy for IEC in TB Control as recommended

by the WHO Programme Review Mission performed in April 2005 and to implement IEC

activities in vulnerable remote, isolated communities, poor communities, roma population and

also IEC activities for the TB patients.

In order to establish a baseline for knowledge, attitudes and practices of the general population

regarding TB for the elaboration of the national IEC strategy and to assess the effectiveness of

the activities planned to be implemented by the end of 1st phase of the grant implementation a

number of 20 questions regarding TB were introduced in the annual inquiry of the general

population regarding heath and health care performed by CHPS.

There were analyzed all KAP survey studies on TB control performed in Romania during last

years, with various funding sources: 2 in the penitentiary system, 1 in the general population, 1



31

performed among vulnerable groups (roma, prisoners, poor, TB patients and their family

members), 1 performed for the 15-25 age group, the report performed during Round 2 of

GFATM project among the professionals from TB network. Also other important documents

were analyzed (NTP Review report, National strategy for TB Control), etc. Based on these 2

reports the national strategy for IEC in TB Control was elaborated, printed and distributed at

national level in 500 copies. It has been presented to an important audience during the

"Summer School organized during Q4.The document is a comprehensive one, it includes the

communication with mass media strategy and also an implementation plan. It was approved as

a strategic document by the MoH. Representatives of all institutions and organizations involved

in TB control participated in working group meetings and provided feedback on the strategy.

6,898 persons during 63 caravans in 152 vulnerable communities were reached with IEC

activities. Each caravan consisted in 2-3 IEC sessions in different communities. The session are

previously announced, 30-35 persons participate in each session. Beside IEC materials

distribution, a video film specially elaborated for this activity is projected and discussion on TB

symptoms, diagnosis, treatment and policies are carried on with the community members.



32

A notice for active involvement of medical student’s organization from Bucharest in IEC

activities mainly on the occasion of WTBD: distribution of IEC materials and discussions persons

from the general population.

Before WTBD, a contest was launched for medical students and TB patients and former TB

patients for writing a story related on TB. 43 students and 39 TB patients or former TB patients

from the whole country participated to this contest. The winners have been announced during

the press conference organized on WTB and the diplomas and prizes were handed by the

Ministry of Health.

In order to increase TB patients’ awareness and compliance to treatment another set of

interventions have been carried on. There have been procured 223 TV and DVD-players, vs. 200

planned for the TB units in order to provide continuously information regarding TB to the TB

patients and the persons referred to TB units, using specific health education materials

(another video film); 4,000 posters for TB patients, 10,000 brochures for TB patients were

multiplied and distributed in all TB units.

Distribution of IEC materials by the

Medical Students’ Organisation



33

7.4. ADDRESSING TB CONTROL AMONG PRISONERS

Another vulnerable group for TB control addressed with IEC interventions is the prisoners, as a

continuation of the activities initiated under the 2nd

GFATM Round Grant.

The project is implemented by the National Administration of Penitentiaries under Objective

2, SDA 2: Prevention: BCC - community outreach, and SDA 4: Supportive environment: Human

Resources.

Health education sessions for prisoners continued during the 6th

Round GFTAM timeframe

even the sub-grant agreement with the NAP was concluded very late (9th

of July 2008).

The health education sessions were held by the 264 educators trained during 2nd

Round GFATM

Grant reaching 3,855 prisoners from 1st

of January till 30th

of September 2008, vs. a 5,280

target.

During the 6th

Round additional 396 health educators will be trained and the health education

sessions will be improved/extended by introducing e-learning for the prisoners in all

penitentiaries from the country: computers with internet access and video projectors will be

procured and distributed during the 2nd

year of implementation, when the e-learning platform

and special designed materials will be developed.

Another important activity is the revision of the National TB Control in Penitentiaries (NTPP)

which will be revised according to the new NTP implementation norms.

Educational kits and other printed materials containing information about TB will be printed

and distributed in all penitentiaries. Some will be used as incentives for the prisoners and for

the educators.



34

All printed materials have been procured till 30th

of September 2008.

Supervision visits in all penitentiaries for monitoring the implementation of NTP and also

health education sessions will be performed yearly. By 30th

of September 11 visits have been

performed (out of a total target of 88 by the end of 30th

of September 2009).

On this occasion training of staff from all penitentiaries in infection control measures for TB will

be performed; during the 11 visits, 136 staff persons have been trained.

Also a Manual for infection control for TB in the penitentiary system will be elaborated.



35

7.5. SCALE-UP MDR-TB THROUGH DOTS-PLUS PROJECT

Project implemented under objective 3, SDA1: Scale up MDR TB control by the implementation

of DOTS plus, by the “Marius Nasta” Institute for Lung Diseases.

Addressing MDR-TB is one of the most challenging issues in TB Control. The project started

during Round 2 GFATM Grant. Starting with 2004, Romania implemented the DOTS- Plus

project. Approval from Green Light Committee (GLC) was received for two 200 MDR-TB cohorts

(400 MDR- TB patients in total, till 2008). These patients have been evaluated and treated

according to the Romanian MDR- TB case management guidelines and also in line with the

WHO recommendation in 2 MDR- TB centers (Bucharest-“M.Nasta” Institute and Bisericani; a

total of 130 beds) with 2nd

line anti-TB drugs procured from International Dispensary

Association (IDA), the provider agreed by the GLC and GFATM. Among the drugs used for the

treatment of these patients is Capreomycine as well as PAS, both not registered in Romania and

therefore not being used in the country during last 30 years.

The treatment outcomes for the first cohort are comparable with those registered in other

DOTS-Plus projects; for the 2nd

cohort the final evaluation is not yet available.

Evaluation and follow-up is ensured by 2 Commissions functioning in each MDR- TB center.

A GLC Evaluation Mission was carried on during March 2008; important recommendations for

MDR-TB case management at country level, not only those insured with drugs from the GFATM

project, were provided and included into the new NTP Implementation Norms released as an

order of the Ministry of Health in November 2008.

GLC Monitoring visit at

Bisericani MDR-TB Center,

March 2008.



36

In October 2008 the approval for the extension of the DOTS-Plus project cohort was received

from GLC for 320 MDR-TB patients. Their enrollment will start in February-March 2009. Funds

are insured for 160 MDR-TB patients under the GFATM project implemented in the 1st

phase of

the GFATM Grant. Approaches for insuring funds from NTP for a larger number of MDR-TB

patients were done and will be restarted as soon as the new team will be appointed at the

Ministry of Health (general elections took place on the 30th

of November 2008).

A contract for custom clearance, storage and distribution for 2nd

line anti-TB drugs procured

from IDA was concluded with the National Company UNIFARM, insuring services by end of 1st

phase of Grant implementation (30th

of September 2009).

SLD-DRS is planned to be carried-on, in collaboration with the National TB Control Programme.

First discussions on the survey have been carried out during the 5th

Balkan Meeting for TB

control held in 3rd

-5th

May in Banya Luka, Bosnia Hertzegovina, with the WHO experts.

Based on the discussions and taking into account the resources available, a first draft of the

SLD-DRS protocol was submitted by the SR during end of June 2008. An improved English

version was submitted to WHO for comments and approval by end of July. Main feature of this

protocol is to retest 269 strains isolated in the 2nd

half of year 2007 from MDR-TB patients from

the 2 MDR-TB centers and in Cluj - Napoca reference laboratory, using the proportion method.

Even the protocol was not approved either by the WHO experts or RAA, NTP started the

implementation of the survey using NTP resources on the 1st

of August 2008.

RAA representative did not agree with this feature of the survey and proposed another protocol

outline for the survey from a prospective approach. This approach would have ensured the

representativeness of the samples and also the follow-up for the 1st

line anti-TB drugs survey

performed in 2003-2004.

Technical assistance from WHO to support this activity was asked, however the Mission that

supposed to take place in December was declined for the time being.

By the time of the submission of this report, the retrospective study is ongoing with technical

and financial the support of NTP.

The MDR-TB patients’ guide was elaborated and multiplied in 800 copies. 200 were distributed

in Bucharest; the remaining copies will be distributed as the new DOTS-Plus cohort will start the

enrollment. The content of the guide is focused on the management of treatment side-effects

and management of possible crisis moments that might appear during the treatment.



37

7.6. INTRODUCING PAL STRATEGY

The Practical Approach to Lung Health (PAL) Strategy, part of the new STOP TB strategy for TB

Control launched in 2006 represents an integrated approach for treating respiratory diseases at

PHC level, and to manage non-tuberculosis respiratory conditions related to TB.

The project is implemented in partnership by CHPS and NCSMF under objective 4, SDA2: PAL

strategy implementation.

WHO technical assistance was previewed both for development of the national strategy for PAL

and for elaboration of the implementation guidelines; the Mission was carried out during

March 2008, and a follow-up during November 2008.

At the beginning of the project, 3 persons participated in the WHO training workshop held in

Bischkek, Kyrgystan, during February 2008; these persons became the core of the Working

Group established for implementation of this project.

The most important and difficult issue was to establish a national steering committee for PAL

strategy implementation aimed at ensuring political commitment and ownership of this project.

The involvement and partnership with the professional society of pneumology proved to be a

winning strategy for reaching the promotion of this concept among all the stakeholders and

Cover of the MDR-

TB patients’ guide.



38

integrating PAL within the activities that address the chronic respiratory diseases (CRD) in our

country (i.e. GARD).

The steps to be undertaken for implementation of PAL strategy and the status as for December

2008 are shown in the figure below:

PRACTICAL APPROACH TO LUNG HEALTH (PAL)

Adopting the strategy ay country level

The National Health

Authority express the

interest Preliminary assessment

of the existing conditions

needed for adopting the

strategy Establish a national

technical working

group (TGW)

TWG elaborates the

national guidelines

for implementation of

PAL

TWG elaborate the

training program

for implementation

Initial assessment

(baseline) of the

respiratory case

management National Guidelines

validated in the same

locations Impact study of

PAL

implementation

Development of the

implementation and

extension Plan of

PAL

The Plan is adopted by

the National Health

Authority

�

�

�

First meeting of the

Steering Committee

on PAL strategy

implementation

under the lead of the

Ministry of Public

Health Secretary of

State, Mircea Manuc



39

The prevalence study about the respiratory chronic disease in Romania, initially not previewed

was carried on and results were released during the press conference held on the 19th

of

November on the occasion of COPD international day.

The Romanian strategy for PAL implementation is finalized, and the implementation guidelines

are almost finalized. The documents were evaluated by the last WHO technical assistance as at

good quality level and elaborated at recommended speed; however refinement is essential for

their finalization before any testing or training; in the meantime the training materials are

developed as well.

The training of 94 family doctors for the initial assessment of the respiratory case management

was performed in November 2008. The results of this initial assessment, performed also in

November, will be available during January 2009. These family doctors from 2 counties (Calarasi

and Dolj) will also participate in the implementation of PAL as a pilot in Romania.

Main issue to be solved: the nomination of a focal point (a person) for PAL development and

PAL process within a relevant structure and approved by MoH.

Also some changes in the implementation plan were suggested by the WHO technical

assistance Mission; these changes will be done during the 2nd

year of the project

implementation.

7.7. OPERATIONAL RESEARCH IN TB CONTROL

One of the important issues raised by the new STOP TB Strategy for TB control released by

WHO in 2006 is the use of Operational research for improving TB control at country/regional

level. The project is implemented by CHPS under objective 4, SDA3: Information system &

operational research.

During the first year of project implementation by CHPS the framework for implementation was

created and a thorough evaluation of the challenges and opportunities of research in lung

diseases and TB control field in Romania have been assessed in collaboration with “Marius

Nasta” Institute.

The activities undertaken proved the difficulty of the scientific community in the lung diseases

and TB control field in communicating the results of its activity as well as the lack of

collaboration and common strategy in the field of research that could lead to accomplishment

of a single goal of advancing research in this field in Romania. As such the research activities



40

undertaken, even if relevant for other professionals too are not known and frequently

duplication activities aroused.

The analysis report on OR situation in TB control in Romania was done with technical assistance

from DOW; it needed several requests in order to obtain some valuable information to make

the report.

During the Summer School held in September 2008, a training in OR principles and

methodology was carried on with technical assistance from DOW for 21 persons from TB

network. Main outline of the training sessions: 1st

day: what is OR, which is the role of the

manager in OR, problems and solutions identification types of OR studies and examples, the OR

studies design; 2nd

day: OR models (exercises), how to implement an OR study, the research

budget, elaboration of a funding application, critical analysis of the scientific research.

Consensus workshop organized with the participation of the international partner and also

representative from WHO Geneva and all the pneumology university clinics in Romania

catalyzed fruitful discussions among the representatives of university pnenumology clinics all

over Romania and created the premises for a further successful project implementation,

through activities in line with the identified and perceived needs of the population.

The Final Agenda of the

Summer School held

between 15-th-19th

of

September 2008.



41

The OR implementation plan was presented to the participants and gain the support of all its

intended stakeholders and beneficiaries.

An important lesson learned was the need for involving the leadership figures in the activities

from the beginning and the importance of the professional society in catalyzing the process of

information sharing.

During 2nd

year of implementation there will be selected for funding some of the OR proposal

that were already submitted as letters of intent. The authors will be trained in preparing the

detailed project proposals and best projects will be funded under the grant. Results will be

disseminated.

2 persons participated to a training workshop for use the EpiData Software in OR in TB control,

in Chisinau, during April 2008.

The WHO Programme Review Mission was asked in September 2008, and it is planned to take

place during March 2009.

7.8. INTRODUCING ACSM

The new Stop TB Strategy identifies implementation of an Advocacy, Communication and Social

Mobilization (ACSM) plan as an essential component in TB control. ACSM activities aim to

create demand, spur health seeking behavior and combat stigma. Till now many of the global

ACSM activities focused enough successfully on mobilizing resources and consolidating the

political and governmental engagement. The project responded to an acute need for intensified

communication efforts and generates an increased commitment from civil society in TB control

and elimination.

Consensus workshop on

OR with participation of

relevant stakeholders



42

Activities are implemented under the objective 5, SDA1: Empower people, ACSM, by NSPHSM,

and SDA2: Prevention: BCC - mass media, by CHPS in collaboration with NSPHSM.

Elaboration of the national ACSM strategy will be done based on a meta analysis report of

systematic review of documents, studies reports available at international level and on a needs

assessment analysis report for TB patients’ needs performed in a pilot county (Maramures)

using a detailed questionnaire applied to a representative number of TB patients under TB

treatment (133 out of about 500 registered annually) during 2 months. The meta analysis

report is available, while the report of the TB Patients’ needs is still pending.

The activities at county level are coordinated by the NTP local coordinator with the help of 5 TB

patients’ advocates, TB patients and former TB patients with good communication skills and

willing to share their experience and to participate in ACSM activities.

During 2nd

-4th

of July 2008, a three days workshop was organized in Baia Mare, the capital city

of the pilot county Maramures with the participation of 50 representatives of county and local

authorities, public health authority, TB network, laboratories, TB patients’ advocates,

journalists, touching issues on advocacy, development of skills for communication with mass-

media, communication with vulnerable groups, community support networks, fundraising

campaigns, the role of DOT supporter, etc.

The event had significant impact on local written media; we mention headlines like “Physicians

are seeking for treatment strategies for TB patients”.

As a first step in elaboration the national ACSM strategy in TB Control a workshop with

participation of main stakeholders involved in TB control activities was organized during June

2008. It is worth to mention the active participation with important ideas (such as introducing

the incentives for TB patients in the budget of local communities, for all TB patients, at country

level) and willing to help of the representatives of Ministry of Internal Affair and Administrative

Reform and Ministry of Labor and Social Protection.

A detailed analysis of the participants’ workshop evaluation questionnaires was done by the SR

(NSPHSM).

During the 2nd

year of implementation the strategy will be finalized, launched in a national

conference and a list of legislative proposals will be provided to the legislative body.

CHPS elaborated a communication strategy with mass media that underlines the most efficient

channels to communicate to journalists the TB issues. This strategy has been included in the

overall BCC/IEC strategy for TB prevention and control developed in the “Communication for



43

Behavior Change in TB Control – from National Strategy to Local Interventions” project

implemented by CHPS and assumed by MoPH. The strategy benefited from an international

expert input and has been revised thoroughly based on feedback from journalists, MoPH,

StopTB Partnership members, communication and public health specialists, and TB medical

specialists.

The communication with mass-media and a constant and accurate reflection of TB in mass-

media is the aim of several activities/interventions:

• Training of journalists in “How to write about TB”, based on training materials

elaborated with international technical assistance; 39 journalists out of 80 previewed to

be trained by the end of year 2 of implementation, participated in 2 training sessions,

one at central level, organized by CHPS in collaboration with NSPHSM (Bucharest) and

one at regional level, organized by CHPS (Iasi) with the important contribution of the

international consultant, Prof. Dr. Lee Reichmann.

• Quarterly electronic newsletter released for over 160 persons; 1st

in Q3 and the 2nd

in

Q4. (See www.tbnews.ro website).

• Media events organized on the occasion of WTBD: press conference, talk-shows, etc.

• Contest for best article about TB in mass-media, for written and audio-video sections

Training session with

journalists held in Iasi.



44

There is a continuous process of monitoring the mass media, both audio-video and written

components by professionals. Reports on news and articles related to TB subject are provided.

8. Advocacy for Sustainability

One of PRs role is to increase the visibility of program’s activities and results with the purpose

of raising awareness among national stakeholders and ensuring the TB program’s sustainability

from domestic funds.

Increasing the Program’s visibility

RAA Foundation is committed to continue its efforts to increase the visibility of the program

and to underline the strategic importance of GFATM funded programs, with the purpose on

ensuring national commitment for continuing funding.

A public Romanian-English web-site www.globalfund.ro was developed in this respect and a bi-

annual electronic newsletter is edited and submitted through the web-site. The web-site

contains a large section dedicated to SRs, with updates, news and success stories from the field,

resources, testimonials and photos illustrating the national effort in the fight against

Tuberculosis supported by the GFATM Grant. Although pretty new (launched in November

2007) the Round 6 web-site managed to gain in short time a significant number of visitors from

Romania and abroad (2,500 – 3,000 unique visitors / month).



45

The first number of the Newsletter – available in Romanian language only – highlighted the

objectives and activities of the TB Round 6 Grant, brought the prevention interventions for

vulnerable groups into the public interest and also brought a tough highlight on the pending of

governmental co-funding for VAT issue.

9. Securing the co-funding from the State budget for VAT

At the time of Round 6 country proposal writing (summer 2006), the procurement of goods and

services purchased from external funds such as the Global Fund, were exempted of VAT and

also the NGOs could recover the VAT value at the end of the fiscal year. As soon as Romania

joined EU, on January 1st

2008, a new Fiscal Code was adopted and the old facilities for NGOs as

the VAT recovery or exemption were excluded.

At the beginning of April 2007, RAA Foundation requested a meeting1 at the Ministry of

Economy and Finance (MEF) in order to evaluate the possibility of re-covering the VAT value for

the Round 6 programs. This meeting was attended by Mrs. Maria Kirova, GFATM Portfolio

Manager, MOH – Round 2 PR and RAA’s representatives. The meeting was moderated by Mr.

Catalin Doica, Secretary of State in MEF. As a result of this meeting, the recommendation made

by Mr. Doica2 was that as long as the GFATM grants are focused on public health issued, the

MOH should be the one to establish the legal framework for obtaining the necessary funds

from the State budget in order to co-fund the VAT for the procurements made by RAA

Foundation as Principal Recipient3.

Based on the principle of transparency and common efforts, in June 2007 RAA, backed up by

CCM members as well as institutions and NGOs involved in implementing programs in HIV/AIDS

and TB field, has submitted a Memorandum4, asking for an effective solution for the VAT co-

funding for the Round 6 GFATM grants.

This Memorandum was sent both to MOH and MEF and copies of the document reached the

Romanian President Secretariat and the Cabinet of Prime Minister, highlighting the main

reasons about the necessity of governmental commitment in implementing and sustaining

prevention and supportive interventions in health priority areas. After a month two official

1 Official letter no 991/23th of March, 2007, sent by RAA to MEF

2 Official letter no 51109 / 26

th of April, 2008 from MEF to RAA Foundation

3 A similar legislative initiative was adopted for the Ministry of Health – as Principal Recipient of the Round 2

GFATM HIV/AIDS and TB Grants. 4Memorandum, reg no 1968 I / 28

th of June, 2007 from RAA and partners, sent to MOH and MEF



46

answers were received: one form MEF5 specifying that the clarification of this issue is MOH’s

responsibility and one from MOH6. The last one mentioned that since this situation (the PR is

an NGO and not a Governmental structure) it is necessary an adjustment of the existing legal

framework. MOH’s solution for the VAT problem was the co-funding with VAT value from the

State budget through MOH, for GF programs financed within Round 6. The framework of this

co-financing should be based on the Governmental Ordinance that can establish the conditions

of co-financing.

In order to elaborate this document, RAA Foundation and MOH had to work together and to

support each other following the legal procedure, so that, the MOH’s answer was followed by

several meetings between RAA and representatives from several Ministerial Departments:

Budgets and External Financing, Integration and European Integration, Legal Assistance, etc.

Putting altogether all the recommendations and suggestions, RAA elaborated a draft of

Governmental Ordinance. The result, including all the documentation (project of Gov.

Ordinance, Note of Foundation) was sent simultaneously to MOH and MEF7, for comments.

Also, a draft of Memorandum of Understanding to be signed between MoH and RAA was sent

by RAA for comments and approval of the Ministry of health. MOH operated several

adjustments within the documents and thanks to the support of Mr. Vlad Iliescu, Secretary of

State at MOH and at that time Chair of CCM, the document obtained by December 2007

approval from all interested departments of the MOH and has been proposed to be sent for

approval by the Government by an emergency procedure.

Unfortunately the beginning of 2008 brought some changes in MOH structure, accordingly to

the national sanitary reform. One of these changes was the replacement of the CCM Chair, so

that Mr. Mircea Manuc, Secretary of State, was appointed as coordinator for GF programs in

Romania and CCM Chair. The new Secretary of State considered that the legal basis regarding

VAT co-funding was not properly documented and therefore asked all the supporting

documentation, from the very beginning, including the GFATM Grant Agreements translated in

Romanian, etc8. The process of clarifying the VAT issue didn’t mark any progress for almost 6

months, from January till June 2008 and although this problem was included by RAA on the

agenda of CCM meeting in March, no progress was mentioned in the absence of MoH’s

support.

5 Letter no 146064/ 2

nd of August, 2007 from MEF to RAA Foundation

6 Letter no EN 7257/27

th of August, 2007 from MOH to RAA Foundation

7 Letter no 3019 I / 30

th of October, 2007

8 Putting the procedure of Ordinance approval on hold, Mr. Manuc invocated the absence of the legal basement

for programs implementation, since the CCM is not a legal entity and there were no updated /new National

HIV/AIDS Strategy and TB Methodological Norms approved by Governmental acts.



47

In June 2008 RAA officially requested a meeting9 with Mr. Eugen Nicolaescu, the Ministry of

Public Health. The meeting was scheduled in July 200810

and was successful, two months and a

half later, the Government of Romania was issuing the Governmental Ordinance addressing the

VAT for the GFATM Grants implementing by RAA Foundation (Government Emergency

Ordinance No. 114/2008 published on “Monitorul Oficial” / Official Gazette issued 29 September

2008).

9 Official request No. 1160 I / 30

th of June, 2008

10 The delegation included a legal expert from a partner law company, RAA’s General Manager and Financial

Manager as well as 2 CCM Members (Executive Director of UNOPA and the Executive Director of the Centre of

Policies and Health Services).



48

10. Summary of Key partnerships in reaching Program’s goals:

Key Partner Contribution to the Program

WHO – Euro

Region Office

• Support in the organization of the SR’s selection (member in the

TB Technical Evaluation Committee)

• Support in the organization of WHO and GLC missions

• Support in negotiations with Institute M. Nasta

• On-going advice for implementation

USAID • Support in the organization of the SR’s selection (member in the


John Snow Inc.

Research and

Training Institute



The National

Agency for Roma

Population



The Resource

Center for Roma

Communities



WHO-STOP TB

Partnership

• Support via GLC in Monitoring the DOTS-Plus project in Romania

• Providing the green light for DOTL-Plus extension request and

assisting in procurement in SLD from IDA.

CCM members

(incl. Ministry of

Public Health)

• Support in the organization of the SR’s selection

• Endorsing the Memorandum re VAT issue and supporting RAA

approach towards Ministry of Health11

• On-going support in solving various bottlenecks in

implementation

11

Special thanks to former CCM Chair - Prof. Vlad Iliescu for his constant support offered during his mandate; also

special thanks to Mr. Eduard Petrescu (UNAIDS), Mr. Iulian Petre (UNOPA) and Dr. Dana Farcasanu (CHPS) for their

active participation to the meetings with the Ministry of Health’s representatives.

ANNUAL REPORT ON THE TB ROUND 6 GRANT - …raa.ro/oldfg/ · ANNUAL REPORT ON THE TB ROUND 6 GRANT ... Development of the Data Management System for Programmatic and Financial Management

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