Federal Democratic Republic of Ethiopia

Ministry of Health
USAID
FROM THE AMERICAN PEOPLE

STATEMENT OF PARTNERSHIP
BETWEEN
THE FEDERAL MINISTRY OF HEALTH OF THE FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA
AND THE UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT
FOR
TUBERCULOSIS ELIMINATION IN ETHIOPIA

The purpose of this Statement of Partnership ("SP") is to establish an alignment between the
Federal Ministry of Health {FMOH) of the Government of Ethiopia (GOE) and the United States
Agency for International Development {USAID) in Ethiopia (the "Parties") to jointly reaffirm our
respective commitments to combating tuberculosis (TB) in Ethiopia, and to align expectations
related to a joint approach to achieve the objectives and targets to which Ethiopia is
committed.

This SP reflects the intended cooperation between the Parties. It is issued in accordance with
the USAID/Ethiopia Country Development Cooperation Strategy (CDCS) and in support of the
health sector under the Development Objectives Assistance Agreement (DOAG) entered into
between USAID and the GOE's Ministry of Finance and Economic Development (MOFED) on
June 19, 2012.

Through this SP, the Parties aim to provide an implementation framework within which they
will work towards their shared commitment and to describe the process by which the
interventions implemented under this SP will be established.

The SP further describes the approaches that USAID is committed to support, subject to
availability of funds, with particular emphasis in strengthening Ethiopia's journey to self­
reliance, via technical and operational assistance to the FMOH's National TB Program (NTP).
USAID anticipates providing support primarily through its TB business model, "Global
Accelerator to End TB" {Accelerator) activities, which would be the guiding platform for USAID's
engagement under this SP. As part of the broader TB portfolio, with programming to advance
both the commitment and capacity themes of the Accelerator, USAID activities are likely to
include the secondment of highly skilled TB technical experts to NTP under the Sustaining
Technical and Analytic Resources (STAR) project, TB technical support under the Eliminate TB
from Ethiopia (ETBE) project, and support to local organizations under the Local Organizations
Network {LON) project.

The approaches and commitments described herein are in addition to and complmient support
to the TB program provided through other national-level health systems strengthening
activities, private sector engagement activities, and other USG initiatives (such as the
President's Emergency Plan for AIDS Relief (PEPFAR)), that provide system building and
technical support to the NTP for improved TB control.

I. Background

TB context in Ethiopia

Over the past decades, Ethiopia has made significant improvements in expanding universal
health coverage and hence, the health of its population. With an extensively decentralized
service delivery and relatively autonomous regions, the Regional Bureaus, Zonal Departments
and woreda offices are empowered to administer health and social services.

Ethiopia has met most of the Millennium Development Goals for the health sector, including
the 2015 TB targets to halve prevalence, and to reduce incidence and mortality. According to
the National TB Program Report and 2018 WHO TB report, 90% of new DS-TB cases enrolled in
2016 and 70% of MOR/RR-TB cases enrolled in 2014/15 have successfully completed their
treatment which is above the global average. TB/HIV collaborative activities have been well
implemented in Ethiopia with 89% of TB patients accessing HIV testing and approximately 95%
of HIV patients accessing TB screening.

However, Ethiopia continues to be among the 30 highest burden countries for TB, multidrug­
resistant TB (MOR TB) and TB/HIV, with TB incidence and mortality of drug-sensitive TB (DS-TB)
estimated to be 164 and 24 per 100,000 populations, respectively. Estimating the TB
prevalence and analyzing the results of the recently conducted Drug Resistance Survey (DRS) in
Ethiopia is a key priority to determine the actual magnitude and trend of the disease burden.

The 2018 UN High Level Meeting (UNHLM) on TB saw increased commitments by member
states to reach all people by closing the gaps on TB diagnosis, treatment and prevention. These
include commitments to successfully treat 40 million people with TB from 2018 to 2022,
including 3.5 million children, and 1.5 million people with drug-resistant TB including 115,000
children. Member states agree that to achieve these targets, there is a need to: transform the
TB response to be equitable, rights-based and people centered; develop essential new tools to
end TB; invest the funds necessary to end TB; and commit to decisive and accountable
leadership at national and global levels. Ethiopia joined the global commitment to end TB by
participating in the 2018 UNHLM, and is currently in the process of developing a national
roadmap to achieve the goal of ending TB by 2030.

TB technical and programmatic management gaps and needs

Despite the significant progress in reducing TB incidence and mortality as well as enhancing
program management capacity, the low case notification rate of TB and DR-TB cases remains a
primary challenge. With the current disease burden estimates, nearly 30% of TB patieqts and
70% of DR-TB patients are missed. The critical challenges in program implementation that
contribute to low case finding require new innovative approaches and strong resource
mobilization, including domestic funding, to achieve the ambitious End TB targets through
development of sustainable health systems.

Overall, there are always areas for improvement in performance with the existing resources,
but the TB program in Ethiopia may have reached fundamental limits in some areas due to
financial constraints. Based on the 2018 Global WHO TB report, Ethiopia's NTP has
approximately a 56 percent funding gap which is consistently similar every year. The funding
level for implementation phase 2 (IP-2) of Global Fund's new funding model of has shown a 37
percent decrease and only 11% of needed TB resources come from domestic funding. With the
consistently lower domestic financial commitment, a decreasing funding level from the
traditional donors and with the existing funding gap, it will be difficult for the NTP and sub­
national programs to achieve the End TB milestones and objectives set for 2020 and 2025
respectively.

USAID contribution to TB care and prevention

Fighting TB is a top priority for the United States Government and the Government of Ethiopia.
USAID TB funds are a significant percentage of TB support in Ethiopia, almost equaling the
amount of funds from Global Fund. Thus, a proportion of the USAID funding may have to go
towards implementation. But, with no major expansion of Global Fund or USAID resources
expected, this will not be enough for future service expansion. Without a focus of some of
USAID Ethiopia's TB support on domestic resource mobilization, the necessary expansion in
funding is unlikely to occur - this explains the inclusion of domestic resource mobilization in the
objectives below, which also supports the commitment goals of the Global TB Accelerator.

USAID has been a leader in the global fight against TB for over two decades and supports anti­
TB efforts in more than 50 countries. In Ethiopia, USAID has provided and continues to provide
extensive support through multiple projects to build technical and programmatic capacity.
USAID's the "Global Accelerator to End Tuberculosis," will catalyze investments across multiple
countries and sectors to end the epidemic while building self-reliance. This is a change in
approach to ensure USAID is fighting to end TB effectively and efficiently.

II. Purpose
The purpose of this SP is to establish an alignment between the Parties to jointly reaffirm our
respective commitments to combating TB in Ethiopia, and to align expectations related to a
joint approach to achieve the objectives and targets to which Ethiopia is committed.

This SP describes the respective roles and responsibilities that each Party will assume toward
the achievement of this purpose, subject to the availability of funds and each Party's applicable
laws and regulations. In particular, the Parties agree that the targets and objectives towards
combating TB in Ethiopia will be achieved only by accelerating implementation of the national
strategy and by speeding up the current pace of implementation. Therefore, the Parties will
work toward scaling up the implementation of highly effective, strategic interventions,
including in the areas of service delivery, policy development and implementation, leadership,
supervision, supply chain logistics, operational research, improved data for decision making and
robust monitoring and evaluation systems that contribute to detecting and diagnosing TB,
reducing the TB and TB/HIV burden, and ending the spread of MDR-TB.

This SP further describes the approaches that USAID is committed to support, subject to
availability of funds, via technical and operational assistance to the FMOH's NTP and related
divisions and Ministries, including the possible secondment of two or more highly skilled TB
technical experts to National (FMOH) and selected sub-national TB programs (Regional Health
Bureaus (RHBs)). This SP defines the process, objectives, and approaches for FMOH and USAID's
joint commitment to combating TB in Ethiopia.

Ill. SHARED OBJECTIVES OF THE PARTIES AND KEY TECHNICAL AREAS

The Parties are committed to working together in a joint approach to achieve the Sustainable
Development Goals target to End TB through achievement of the following objectives by 2030:
• Increase treatment coverage to 90%

• Sustain the success rate of drug sensitive TB treatment at 90%

• Improve the number of patients with MOR-TB put on treatment to 100% of all MDR-
TB diagnosed

• Increase the success rate of MDR-TB treatment to 90% of all MOR-TB put on treatment

• Increase the proportion of TB patients with documented HIV status to 100%

• Increase the proportion of co-infected TB-HIV patients enrolled on ARV treatment to

100%

• Increase the proportion of TB patients diagnosed with rapid molecular diagnostics to

80%

• Increase the coverage of TB preventive therapy (TPT) to 90% of PLHIV and of children
under-five years who are contacts of TB patients

To achieve these objectives, The Parties agree to jointly address the following key technical
areas that are critical to ending TB in Ethiopia:

1. Strengthening the TB program leadership in districts, including the ability to disseminate

and monitor best practices

2. Increasing client access to adequate and high quality TB services

3. Addressing risk factors for TB

4
 4. Strengthening partnership and the cross-sectoral response to TB, including a
coordinated effort on district planning and financing for TB, through a TB coordination
forum

5. Increasing the strength and self-reliance of the community contribution to the TB

control program

6. Strengthening the public health function in TB (required to improve notification, tracing

loss-to-follow-up (LTFU), contact investigation, etc) to adequately support both public
and private facilities

7. Increasing the dete�tion and cure of MOR-TB, including greater use of a rapid test for
MOR-TB such as GeneXpert

8. Strengthening the management of the TB program.

9. Improving the quality of TB program monitoring and evaluation including data quality
improvement, performance review and use of data for decision making and
programming

It is understood that specific approaches outlined above may be altered based on new
evidence, and that they will assist in reaching the national priorities. With this understanding
and flexibility in mind, the Parties nevertheless agree to make a good faith effort to jointly
address these key technical areas that are critical to ending TB in Ethiopia.

IV. ROLES AND RESPONSIBILITIES

A. Ministry of Health, National TB Program

In support of the joint commitment to achieving the objectives outlined above, FMOH is
committed to:

l. Including the commitments and targets agreed to at the High Level Meeting on TB at the
United Nations General Assembly in September 2018 in the revision of the National
Strategic Plan (NSP) 2013-2020 and the subsequent NSP for the period of 2020-2025;
2. Convening, participating in and documenting a joint Annual Roadmap process between
FMOH, all other relevant partners, and USAIO, to assess results and to agree to
interventions by the government and USAIO-funded activities on an annual basis;
3. Ensuring the adoption of relevant national guidelines and policies in implementing the TB
program at all levels;
4. Ensuring an uninterrupted supply of quality assured TB drugs and commodities;
 5. Continuing to build the capacity of the program for effective and transparent use of data
for performance monitoring and evaluation, including domestic support for a strong
system of cascading supervision and quality monitoring;
6. Ensuring sufficient work space and logistics to host USAIO-seconded TB Advisors;
7. Ensuring sufficient and sustainable financing for quality and cost-effective TB services
towards achieving universal health coverage;
8. Periodically reviewing and analyzing routine TB data with the assistance of USAIO-funded
Advisors in a timely manner;
9. Convening a bi-annual meeting to jointly review performance data, technical reports and
accountability records with USAID for activities that involve USAID commodities or
technical assistance; and
10. Convening a high level End TB partnership that will establish and monitor a Multi-sectoral
Accountability Framework for TB involving all key stakeholders, including the private
sector.

B. USAID

In support of the joint commitment to achieving the objectives outlined above, and subject to
the availability of funding, USAID is committed to:

1. Participating in a joint annual Roadmap planning process between MoH, all other
relevant partners, and USAID, to assess results and to agree to interventions by
government and USAID-funded activities on an annual basis;
2. Providing technical assistance as identified in the joint Annual Roadmap to strengthen
capacity and achieve results;
3. Seconding TB experts to key roles within the MOH and RHBs to serve as TB Advisors for
the National TB program and Regional TB programs;
4. Assisting with the improvement of monitoring and evaluation systems and with the
quality of data collection and analysis;
s. Closely working with its implementing partners to establish and maintain good
coordination with MOH in term of project planning, implementation and submission of
reports on project progress, challenges, and results; and
6. Supplying MOH with available equipment and supplies from existing USAIO
implementing partners.

6
V. GENERAL INTENTION OF THE PARTICIPANTS

Jointly, the Parties agree to:

1. Monitor progress, share information, review learnings, and evaluate and report on
progress;
2. Meet on a bi-annual basis, or as needed based on mutual agreement to define the specific
activities to be undertaken and provide the required guidance to the implementing
partners;
3. Jointly plan and organize any launch or dissemination events related to activities mentioned
in Section IV;
4. Participate in a regular (e.g., semi-annual and annual) performance review process;
s. Coordinate with each other on all press releases of public statements regarding partnership
activities under this statement of partnership (). Public communications should recognize
the Parties through appropriate branding in accordance with their respective legal, policy,
and procedural requirements. Each Party intends to communicate publicly the contributions
of the other in articles, media, and publications or other documents as well as hand-outs
and signage at events.
6. The Parties agree to respect one another's confidentiality policies, with the mutual
understanding that the Parties intend to publicize their support and its objectives without
disclosing any confidential or proprietary information of_ the Parties. The Parties will
endeavor to share information on their individual policies, procedures, and requirements
relating to branding, and other communications-related requirements, so that potential
obstacles can be addressed in a timely manner. All communications should be sent to the
Parties at the following addresses:

For USAID/Ethiopia:
U.S. Agency for International Development
U.S. Embassy Entoto Street, P.O. Box 1014
Addis Ababa, Ethiopia
Tel: +251-11-1306600
Attn: Mr Sean Jones, Mission Director, USAID/Ethiopia (sjones@[Link] )

For FMOH Democratic Republic of Ethiopia:

Federal Ministry of Health, Sudan Street, P.O. Box 1234
Addis Ababa, Ethiopia
Tel: +251-11-5534867
Attn: Dr Lia Tadesse, State Minister of Health, Federal Democratic Republic of Ethiopia
([Link]@[Link])

7
VI. TERMS AND CONDITIONS

1. No obligation of funds: This Statement of Partnership does not effectuate an obligation

of funds by any Party. All obligations of funds by USAID to support its undertakings under
this Statement of Partnership are intended to be made in other agreements with USAID
implementing partners by USAID, consistent with U.S. law and regulations, and in
accordance with USAID procurement and other related policies, procedures, and
guidelines.

2. No international status: It is understood by the Parties that this Statement of

Partnership is not an international treaty or international agreement and is not subject to
either the Government of Ethiopia or United States Government's treaty ratification or
other domestic and internal legal procedures for ratification of treaties or international
agreements.

3. Non-binding Statement of Partnership which does not supersede existing

agreements: This Statement of Partnership shall be considered to be a good faith
Statement of Partnership to pursue the goals and objectives identified above for the
benefit of the people of Ethiopia, and is non-binding and not legally enforceable on any
party. The Parties entering into this Statement of Partnership maintain their own
separate and unique missions and mandates and their own accountabilities. This
Statement of Partnership shall not supersede or interfere in any way with other
agreements or contracts entered into by the Parties, either prior to or subsequent to the
signing of the Statement of Partnership.

4. Assistance under the Framework Bilateral: Any assistance provided by USAID in

furtherance of this Statement of Partnership is United States assistance within the
meaning and terms of the ongoing Partnership Agreement for Health signed on June 19,
2012.

s. Duration: This Statement of Partnership is effective upon signature of the Parties, and
will remain in effect until otherwise notified by either Party.

6. Amendments: This Statement of Partnership may be amended or modified in writing by

mutual consent of all Parties, as may be necessary from time to time.
 7. Termination: Each Party may, at its discretion, terminate this Statement of Partnership
by providing all other Parties, in writing, with 60 days' advance notice, a communication
reflecting the intent to terminate the Statement of Partnership.

The Parties, each acting through their duly authorized representatives, have signed this
Statement of Partnership as of this 13th day of September 2019.

Federal Ministry of Health of Ethiopia

� ��
_,,,.+-�United States Agency for
International Development in Ethiopia
� �c.
,(,.--i>VjwA)�
� �
[Link] Tadesse
State Minister of Health Mission Director
Federal Democratic Republic of Ethiopia
• q,�
USAID/Ethiopia

'o.
....

........
'�,
• ,�"

9
Front office Clearance Page

Subject: Non-binding Statement of Partnership, Global Accelerator to End TB

Drafted by:
Yewulsew Kassie Anteneh, Health office

Cleared By:

<b-. Date
Doug Arbuckle, ID Team lead, Health Office ------ j) J.;:;) I )
Rachel Cintron, Office Chief, Health office ___,_l-F--=--_Date 'J /:5 /11
Paul Vaca , Office Chief, Program office
(<.,<.. k Cv n'I. �
--�,c:;...____Date 1l/st/11
�u,RLO �
�--..------ Date 4 j,:,-/l\
J J
Diala Darsney, A/ Deputy Mission Director � Date 1\�\\�
Sean Jones, Mission Director �Date�