1 Terms of Reference Kazakhstan Health Review of TB Control Program Objectives 1. In the context of the ongoing policy dialogue and collaboration between the World Bank and the Government of Kazakhstan in the health sector to develop further sector work, a review of the TB Services will be carried out. The objective of this analysis is to assess the relevance of these services to contribute to contain the TB epidemics and provide policy makers with analysis for informed decision making on the allocation of scarce public sector resources. Specifically, the Accounting Office would like to have additional information about best practices elsewhere in the world, and the quality and cost-effectiveness of the Kazakh TB program, to ensure that the allocated public resources are well spent. 2. The review will focus on the following aspects: (i) Assess potential resource shortages in provision of TB services. Actual, planned and necessary human, technical and financial resources invested on those services will be reviewed and estimated. The review will compare these investments with those made in countries that have been successful at containing the spread of TB (e.g., China, Peru). (ii) Assess appropriateness of diagnosis and treatment practices followed by TB services. The review will compare these practices with evidence-based practices recommended by international organizations such as WHO, and followed up in countries that have been able to contain the spread of TB, such as China and Peru. (iii) Assess efficiency and quality of TB services. The review will assess coverage, financial and geographic access, notification and cure rates, and compare these with outputs of similar services in countries that have been able to contain the spread of TB. (iv) Assess potential epidemiological impact, and economic benefits and financial sustainability of investments on TB services. Background 3. As the economic situation in Kazakhstan has improved, the Government has been reducing its borrowing from the Bank and other lenders. At the same time, the Government recognizes the value of international knowledge and assistance and has developed with the Bank a system to co-finance economic and sector work in key areas. The Government has requested assistance in three areas of the health sector, specifically
2 recommendations on the medical insurance system, development of public health reform and TB/AIDS control. Each of these areas are important for the development of the health sector in Kazakhstan at this time. In most cases the Government has been considering the issues for some time but does not have a clear view of the right path to move forward. The Government has requested assistance in reviewing the HIV/AIDS, STIs and TB programs. 4. Kazakhstan bears one of the greatest burdens of TB in the Central Asian region: at the end of 2001 there were 48,701 registered cases with active TB. Between 1990 and 2001, notified rates of new TB cases and deaths in Kazakhstan increased 2.4 times. Following the successful implementation of the DOTS strategy on a nationwide scale since 1998, the treatment success rate increased to 83% in 1999 and 2000, and the TB death rate declined 36% by 2001. Growth rate of new TB cases slowed down significantly during the last two years, although the rate reported in 2001 remained the highest in the Region. USAID/CDC estimate that the implementation of the DOTS strategy in Kazakhstan saved approximately 13,000 lives during the period 1998-2001. 5. Due to overcrowding and poor ventilation and nutrition in the prisons, TB notification and death rates were noticeably higher in the prison sector: 30 and 9 times, respectively, than among the civilian population. However these figures represent a significant improvement since 1997. Notification and death rates in the prisons declined 61% and 85%, respectively. The Ministry of Justice, which administrates the prisons, interprets such a positive change as the result of the implementation of the DOTS approach in the prison system. 6. While Kazakhstan has successfully introduced and is currently implementing the DOTS strategy, multi-drug-resistant tuberculosis (MDRTB) remains of great public health concern. Although it is quite difficult to determine the average national rate of MDRTB, as there has not been any national epidemiological study, the average national rate is estimated to be around 10 percent of all MT+ cases. 7. Government commitment to TB control is high. This is demonstrated by the following: Kazakhstan has a National TB control program based on the WHO recommended TB control strategy (DOTS) adjusted to Kazakhstan conditions, which covers the entire population; In 2002, US$ 8 million of the national budget was spent on procurement of first and second line TB drugs; Procurement of TB drugs is centralized at the national level; and There is no shortage of first line drugs across the whole country: needs for first line TB drugs are identified at six month intervals by monitoring the stock of drugs in each facility through a nationwide computerized TB surveillance system. 8. The DOTS strategy was successfully expanded to the entire country by 2000. The GoK has allocated funds for regular monitoring of DOTS implementation. However, an
3 issue of concern is the efficiency of the utilization of available resources and donor funding. Although the Kazakhstan NTP claims adherence to the DOTS strategy, including passive case detection by sputum microscopy, X-ray mass screening is still applied as evidenced by hard data, for TB case finding in the country: about two thirds of the entire adult population was screened, and over 5 million MMRs were performed in 2001, i.e. 517 MMRs per TB case detected actively; and 30 digital fluorography machines were procured in 2001. With similar treatment success rates in Kazakhstan and Kyrgyzstan, average length of in-hospital stay per patient treated is noticeably higher in Kazakhstan than in Kyrgystan: 92 and 74 days, respectively. The rapid expansion of the MDRTB treatment program without appropriate training, laboratory capacity for drug susceptibility testing and quality DOTS implementation in Kazakhstan is another issue of concern 9. In 2001, the Government and donors and donors allocated $32 million to TB diagnosis and treatment, and 2002, $8 million to the procurement of first-line and secondline TB drugs. This means that Kazakhstan spends about $640 per TB patient each year, which is three times as much as it is used on cost estimates of TB programs that follow the DOTS approach; and $160 per patient per years for pharmaceuticals. Of the $200 per patient per year that a DOTS program may cost, $50 would be for procurement of firstline drugs. 10. The increasing funding that is allocated from the state budget to the TB program has become a concern to the Kazakhstan Accounting Chamber, which would be interested in having the program reviewed, including an expenditures and costeffectiveness study. However, more funding would be needed for expansion of DOTS in prisons and introduction of DOTS Plus in the civilian sector. Based on a TB prevalence of 153 per 100,000 population in 2000, an average national rate of MDRTB 10% among MT+ would suggest that Kazakhstan has about 2,300 MDRTB patients. MDRTB treatment costs about US$5,000 per patient in Kazakhstan, which require about US$ 11.5 million annually if all MDRTB patients were treated. Scope of work 11. The content in this area would be analytical in nature and would result in written studies following reviews of the TB program. These reviews will look at both the services carried out by MoH s and also those in prisons. This work will be coordinated with the Tb Institute, WHO and USAID-funded programs implemented by CDC and Project Hope. The Consultant will carry out the following scope of work for each of the studies included under this TOR: Assess potential resource shortages in provision of TB services (i) Assess actual, planned and necessary human resources, including medical and non-medical outreach workers, physicians, nurses and other staff; (ii) Assess actual, planned and necessary technical resources, including existence of approved protocols of care, microscopes, supplies and TB pharmaceuticals;
4 (iii) Assess actual, planned and necessary public financial resources, as budgeted and as available to pay for staff salaries and incentives for TB workers, and procure supplies, pharmaceuticals and diagnostic equipment. Assess appropriateness of diagnosis and treatment of TB (i) Assess implementation of DOTS as compared with WHO recommendations including surveillance, training, laboratories and supervision; (ii) Assess implementation of DOTS Plus as compared with WHO and Green Light Committee recommendations Assess efficiency and quality of TB control Program (i) Assess coverage of, and access of groups of TB patients to TB services providing DOTS; (ii) Assess utilization and efficiency of TB services; and (iii) Assess quality of those services by cure rates and decrease in mortality rates. Assess potential economic benefits and financial sustainability of investments on TB control Program (i) Assess cost-benefits and cost-effectiveness of the TB Program; (ii) Assess affordability of providing free diagnosis and treatment of TB and MDRTB. Expected Deliverables and Reporting 12. The Consultant will submit and discuss with the Ministry of Health, the Accounting Chamber of Kazakhstan and the World Bank in workshops in Kazakhstan the following reports: (i) Design of 4 studies by January 31, 2003; (ii) Draft study reports by April 30, 2003; (iii) Final study reports by May 30, 2003; (iv) Recommendations for policy and resource allocation by May 30, 2003. 13. All information generated by the Consultant as a direct result of this contract will be provided to the client in electronic or hard copy. The products presented will be the exclusive property of the client and cannot be used by the Consultant without the exclusive written consent of the client. All documents should be presented in electronic format using Microsoft Office products (Word, Excel, Power Point, and Access) version 97 or above and in hard copy (2 copies). Consultant Qualifications
5 14. A team of local and foreign experts will carry out the assignment. The team will have skills in public health and health economics with at least 5 years experience. In addition, the consultants will have the following skills: Experience in health services review; Experience in health expenditures review, and financial and economic analysis; Experience of TB programs and research; Excellent verbal and written ability in English; Preferably Russian and/or Kazakh language skills; Experience in working in the FSU and with the World Bank (sector work and/or operations). 15. The Consultant will provide the following background information: (i) Personal Curriculum Vitae for all key members and proposed staff; (ii) References; (iii) Description of similar works and experience in FSU countries; and (iv) Detailed project proposal that meets the requirements of the present Request for Proposal. Duration of services 16. The proposed consultancy would have an estimated duration of 3-person months. Payment of services 17. This assignment has the following payment schedule: Product Payment Upon signature of the contract and approval of a work plan 15 % Studies design 15% Draft study reports 20% Final study reports 25% Recommendations for policy and resource allocation 25% 18. Distribution of costs over international and Bank staff, and national consultants is estimated as 80/20.
6 Variables for cost-benefit analysis Type Variables Name Sociodemographic Total population Population (rank ages, sex, region) Economically Active Population (EAP) Participation rates of EAP (% in labor force) Growth rates of population (% annual) Life Expectancy (at birth) Target populations of the project (characteristics) Source Statistics and Census Institution, Social Security Institution, Ministry of Work, Ministry of Health Health Number of Live births Morbidity rates by main causes Mortality rates by main causes Number of deaths by rank ages (main causes) Average age of death (main causes of mortality) Infant Mortality Rates Maternal Mortality Rates Intrahospitalary Mortality Rates Hospital Acquired Infections Rates Discharges costs Average bed day Costs Consultation Costs Average Lenght of Stay (ALOS) Inpatient Days Bed days Inpatients affected by project Outpatients affected by project Admissions (or impact expected on admissions) Number of beds Ministry of Health, Statistics and Census Institution, Social Security Institution Economic TB GDP (nominal, real, growth rates) GDP per capita Exchange Rates (last 5 years and projected 5 years) Consumer Price Index (last 5 years and projected 5 years) Implicit GDP deflactor (last 5 years and projected 5 years) Inflation rates (last 5 years and projected 5 years) Health Public-Private-Local-Regional-Total Expenditures Hospital-Clinics Expenditures (Budget by categories) Minimum Salaries TB prevalence Ministry of Economy, Central Bank, Statistics and Census Institution, Ministry of Health, Ministry of Work
7 TB notification rate TB Mortality rate TB number of deaths Mean age of death TB number of cases (by age) TB drugs costs (average) Medical atention cost of a TB patient Ministry of Health, Statistics and Census Institution, WHO