Evaluation of DRTB Intervention in Baghdad, Iraq

• Starting date: November 2021, if feasible ,or later as per mutual agreement
• Duration: Final report to be submitted by latest March, 2022 (to be adjusted according to the starting date)
• Period to evaluate:2018-2021
• Requirements: Interested applicants with the right profile/s should submit 1) A proposal describing how to carry out this evaluation (including budget in a separate file), 2) a CV, and 3) a written sample from previous work
• Deadline: No later than 2359hrs CET on Oct 21, 2021
• Send application to: [email protected] with subject line “BATBE”
• Other: ▪ Obtaining a visa and access to the project may be a challenge for all nationalities. As a result, the evaluator/evaluation team must take into account the question of access to the field for the sake of the data collection phase. ▪ Evaluator/s visiting from other countries will be expected to stay in quarantine upon entering the country and a factor to consider. ▪ This ToR is downloadable here.

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BACKGROUND

Incidence of TB in Iraq is estimated at 41/100.000 population (WHO data for 2019), translating into 14,000-18,000 new TB cases/year. Prevalence of rifampicin resistant (RR) forms are estimated at 6.1% among new and 24% among retreatment cases, while MDR at 1.1% among new and 19% among retreatment cases (DRS National Survey 2013-2015), with more than 400 RR/MDR incident cases estimated each year.

In August 2018, MSF initiated two interventions in Sadr City. Sadr City is a densely populated suburb of Baghdad. It was originally built as a social housing project in 1957 to accommodate farmers who were migrating towards the capital city. With a population of approximately 3.5 million, the city offers a limited health infrastructure that does not respond to current needs, including access to water and health care. Unemployment is thought to be about 70%. Living conditions in Sadr City are conducive to TB transmission. A significant proportion of MDRTB patients detected in 2017 in the country were from Sadr City.

The first intervention focused on supporting the Emergency Department (ED) of MoH Imam Ali Hospital. It ended in June 2019. The second one focused on supporting DRTB management. It is scheduled to be completed at the end of 2021. Both interventions were managed and coordinated by a common single team set-up in Baghdad.

Regarding DRTB, project design has evolved significantly during its project course, in response to challenges faced by MSF team and changes in the context:
▪ The initial strategy (as defined in 2017) aimed at reducing mortality and morbidity due to DRTB at Sadr City through the support of DRTB care. The specific objective was defined as Sadr City population making use of good quality, comprehensive medical services and adherence support for DRTB patients. Project ambitions included increasing DRTB detection and improving the management of DRTB diagnosed cases. The introduction of new, shorter oral regimens for MDR/XDR patients (under a pilot study), together with a decentralization of services towards lower levels of care were at the core of these ambitions. Ad-hoc programmatic support to National TB Program (NTP) was also considered as an element of the intervention. The intervention was projected for 2 or 3 years.
▪ In 2019, following to the release of WHO new regimen and the decision by National TB Program (NTP) to refuse pilot study proposed by MSF, the project strategy was reviewed. Overall objective aimed at reducing mortality and mobility due to MRTB in Iraq by improving DRTB diagnosis and clinical management. Specific objective was to support the Iraq National TB Program (NTP) in the implementation of strengthened TB/DRTB case finding strategies, and in the programmatic management of DRTB, including roll out of new WHO recommended regimens for DRTB, with a patient-centered approach. Support to NTP on IPC, pharmacy management and decentralization of services were also included as key elements of the project. This package was designed as four years project.
▪ One year later (2020), considering new financial constraints at OCB, the project timeframe was reviewed, and it was decided to close the project at the end of 2021. Given this new timeframe, the project decided to limit its support to the Iraq National TB Program (NTP) in the transition of injectable-free WHO-recommended oral DRTB treatment. Project component of decentralization of services was maintained. However, other previous project components such as case finding, IPC and pharmacy management were no longer supported.

In terms of project activities, MSF has been principally involved in the following:
▪ provision of technical advice to NTP (DRTB protocol, and DRTB committee);
procurement and donation of supplies (ie, GenXpert machine and cartridges, laboratory reagents including first- and second-line drug reagents for drug susceptibility testing (LPA), and drugs for DRTB treatment including new drugs bedaquiline and delamanid);
▪ capacity building and on-site training on diagnosis and clinical management of patients to NTP MDs and to laboratory staff from National Reference Laboratory in Baghdad and from the chest and respiratory clinic in Rusafa;
▪ advocacy to promote policy change in the management of DRTB, including technical contribution to the revision of the national TB/DRTB guidelines and collaboration with other key partners involved in TB/DRTB (i.e. IOM).

Since 2018, close to 100 MDs from the MoH have been trained by, or with, the support of MSF. After the introduction of oral regimen in the country, NTP has enrolled 49 patients within this regimen in Baghdad and 98 at national level. A patient education and counselling package (including food basket and transport reimbursement for eligible patients) was integrated in DRTB care. NTP initiated decentralization of DRTB treatment in Basra CRDC in 2020.

REASON FOR EVALUATION/RATIONALE

Since 2003, there have been projects that MSF sought to implement which have not lived up to initial expectations including OCB projects. In addition, the experience of MSF working on TB in Iraq is limited, especially when compared to other contexts (such as Southern African or Central Asia). Therefore, this project represents an opportunity for MSF to reflect and learn about its strategies and ways of working in Iraq in general, and more specifically, with respect to TB.

OVERALL OBJECTIVE AND INTENDED USE

OVERALL OBJECTIVE. To assess the relevance, appropriateness, effectiveness, and connectedness of MSF DRTB intervention in Baghdad (2018-2021); and to identify the key lessons learnt.
INTENDED USE. The evaluation is aimed primarily at contributing to MSF-OCB conversations about strategic and programmatic approaches and practices most appropriate in Iraq, in general and with respect to TB.

SPECIFIC OBJECTIVES

EQ 1: How relevant has the MSF DRTB Intervention in Bagdad been?
▪ What needs did the intervention aim to address and how were they identified and selected?
▪ Did the intervention respond to the expressed needs and demands of the different stakeholders?
▪ Were there other TB or DRTB related needs that could have been addressed by the MSF intervention?

EQ 2: To what extent has the DRTB Intervention in Baghdad been appropriate to the TB needs and Iraqi context?
▪ Do the intervention objectives correspond to the identified needs?
▪ Was the MSF overall strategy appropriate in order to achieve its objectives?
▪ To what extent was the intervention appropriate according to the main stakeholders?
▪ Did the strategy take into consideration changes in the environment in a timely manner?
▪ What amendment may have been necessary to better embed the DRTB intervention in this specific context?

EQ 3: To what extent has the DRTB intervention been effective in achieving its objectives?
▪ To what extent have the expected objectives been achieved?
▪ What were the main enabling and challenging factors for achievement and not achievement of the objectives?
▪ How did the project respond to the identified challenges?
▪ Did the MSF intervention create any unintended effect?
▪ What could have been done to make the intervention more effective?

EQ 4: How connected has the MSF DRTB intervention been in the context?
▪ What local capacities and resources were identified? How did the project connect with these?
▪ To what extent was the MSF way of working effective in attracting and working with different partners as a mean to achieve objective?
▪ To what extent was the intervention embedded in the local health system, overall national strategy and building on existing capacity?
▪ What problems can be identified for the continuity of the intervention objectives, and how have they been taken in consideration by MSF?

EXPECTED DELIVERABLES**1. Inception Report**

As per SEU standards, after conducting initial document review and preliminary interviews. It will include a detailed evaluation proposal, including methodology.
2. Draft Evaluation Report
As per SEU standards. It will answer to the evaluation questions and will include conclusions, lessons learned and recommendations.
3. Working Session
With the attendance of commissioner and consultation group members. As part of the report writing process, the evaluator will present the findings, collect attendances´ feedbacks and will facilitate discussion on lessons learned.
4. Final Evaluation Report
After addressing feedbacks received during the working session and written inputs.
5. Other dissemination deliverables
They may include, among others, the presentation of evaluation findings to the MSF-OCB staff. A more detailed proposal will be defined as part of the Inception Report.

TOOLS AND METHODOLOGY PROPOSED

In addition to the initial evaluation proposal submitted as a part of the application (see requirement chapter), a detailed evaluation protocol should be prepared by the evaluators during the inception phase. It will include a detailed explanation of proposed methods and its justification based on validated theory/-ies. It will be reviewed and validated as a part of the inception phase in coordination with the SEU.

RECOMMENDED DOCUMENTATION

▪ MSF project/related documents (i.e. project proposals, logframes, monthly and annual reports, field visit reports)
▪ National and regional documentation (Iraq TB and DRTB health national policies)
▪ External scientific literature and documentation of similar experiences

PROFILE/REQUIREMENTS FOR EVALUATOR(S)**▪ REQUIREMENTS:**

o Proven competencies in evaluation (minimum 5 years)
o Experience in TB and DRTB programming (minimum 5 years), including national level
o Formal background/studies on Public Heath, International Humanitarian, or similar
o Experience in Middle East
o Language requirements: English (Fluent)

▪ ASSETS:
o Language: Arabic
o Understanding of Middle East and Iraq context