Report of mission to the Southern Sudan: 21 February-4 March 2008

REPORT OF MISSION TO THE SOUTHERN SUDAN BY Dr Nomo rlAounkoilo WHO| APOC Chief Epidemiologist ond Vector eliminotion Unit APOC Heodguorters, Ouogodougou lAr Lozorus Nweke WHO| APOC Temporory odvisor Enugu/A nombro/Ebonyi CDTI The Carler Center, Enugu - Nigerio 21 FEBRUARY-4 MARCH 2OO8 Bahr Al Unily i!t'pJ6t BalY A!Geal Jorylei' sd VWst Bahr El Ghazal Project ,i.., East Bahr El Gazal East Equatoria WEst Equatoria ' , .' Upper Nile Sates and delincatlon of CDTI projects, Southern Sudan East Equatoria ..ry', TABLE OF CONTENTS Toble of Contents Abbreviotions/ Acronyms ilt tvAcknowledgement 1.O Bockground of the ltAission 1 1.1 About the CDTT Projects ond Its Scope in the Southern Sudon .........1 t.? Prof ile of Southern Sudan ...2 1.3 Objectives of the Mission ?.O Methods of Tockling Eoch Objective 3 3.O The Mission Processes 4 2 3.1. Arrivol In Noirobi on ZLst Februory 2008 .... 3.2. Meeting of the Mission with the 55OTF Coordinotor at WHO Southern Sudon Office in Noirobi on22"d Februory 2OO8 3.3. Meettng of the Mission with the CBM country representotive at the Oncho Secretoriot, Rumbek in Lakes Stote on the 25 February 2008 3.4. Visit by the Mission to WHO Of ficer in Rumbek on ?6rh Februory 2008 9 3.5. Field Visit to West Eguotorio CDTI Project sites on 27 February 2008......... 3.6. Meeting of the Mission with Mvolo community members ond CDTI on ?7 Februory 2008 ........ ..................12 3.7. Briefings on the f ield visit situotion/meeting of the Mission with 55OTF (Coordinotor ond CBM country reptesentotive) on 28th Februory 2008 ...-....13 3.8. Meeting with the WHO Representotive in the Southern Sudon on 4 Morch 2008 .....................14 .6 10 4 1 4.O. Constroints/Chollenges 5.O. Conclusion 6.O. Woy Forword ond Recommendotions 7.O. Development of Plon of Action Appendix 1: Schedule/itinerory of the Mission from?t Februory to 7 Morch, 2008 ... Appendix 2: The Mission Teom ond Persons met during the exercise 15 t6 t6 17 ..18 19 11 APOC CBM CDD CDTI c5A GOSs JAF MOH MOU N6DO oLs ONCHO PCO REMO 'PLA/ M 5sOTF TCC USAID wHo ABBREVIATIONS/ ACRONYAIIS African Progromme for Onchocerciosis Control Christofell Blindness Mission Community Directed Distributor (of fvermectin) Community Directed Treotment with fvermectin Committee of Sponsoring Agencies Government Of Southern Sudon Joint Action Forum Ministry of Health Memorondum Of Understonding Non-Governmentol Development Organisotion Operotion Lif eline Sudon Onchocerciosis Project Coordinoting Of ficer Ropid Epidemiologicol Mopping for Onchocerciasis Sudonese P eople' s Li berotion A rmylMov ement Southern Sudan Onchocerciosis Tosk Force Techn icql Consu ltotiv e Committ ee United Stotes Agency for fnternotionol Development World Heolth Orgonisotion 111 ACKNOWLED6EA,\ENT The Mission wishes to thonk the Manogement of APOC for supporting the exercise os well os oll thosewho contributed to the successfui occomplishment of the tosk especially: ' The Director of APOC - Dr. Uche V. Amozigo for outhorizingthe Mission. . The WHO Representotive of Southern Sudon - Dr. Abdullohi Ahmed ond his stoff in both Nqirobi, Lokichoggio ond Rumbek for supporting the Mission. . The coordinotor of Southern Sudon Onchocerciosis Tosk Force(SSOTF) - Dr. Sampson Bobo for being there with the Mission ond oll his supports particulorly on opprovol of one housing oportment for the WHO/APOC technicol odvisor ossigned to Southern Sudan. . The WHO/ APOC odministrotion ond Finonce Assistont - Mrs Agnes Wonyoike for excellent ond guick coordinotion of octivities especiolly flight bookings, pass permits, vehicle ond hotel orrongments, . The director of public heolth of Lokes Stote for offering to include WHO/ APOC technicol odvisor in his teom for integrotion of octivities. . The CBM country representotive - Mr Fosil Chane for his kind supports ond useful deliberotions with the Mission. . The Bohr el Ghazal CDTI project coordinating officer, the Mvolo county supervisor, frontline health workers, CDDs ond community members f or giving the Mission useful informotion ond their keen porticipotions. 1V I.O BACKGROUND OF THE 'I,IISSION 1.1 About the CDTI projects ond its scope in the southern Sudon The CDTI projects in the Southern Sudon commenced in 2005 following the first letter of agreement between APOC ond the Southern Sudon Onchocerciosis Tosk Force (55OTF) signed in 2004. fn the Southern Sudon, there are f ive CDTI projects estoblished in f ive out of the ten stotes. When the CDTT projects were eloboroted Southern Sudon hod only two odministrotive levels (Regions ond Counties). Since the peace agreement, Southern Sudon hos three odministrotive levels: regions,stotes ond counties.These CDTI projects are Eost Bohr el Ghazol, West Bohr el Ghozal, Eost Eguotorio, West Equotorio ond Upper Nile. They were estoblished bosed on the onchocerciosis prevolence patterns os obtoined from the result of Rapid Epidemiologicol Mopping of Onchocerciosis (REMO) conducted in the Southern Sudon in Morch 2003. The Southern Sudon Onchocerciosis Tosk Force (55OTF) wos formed in October 2O0O but become operotionol in July 2002 Each of thefive CDTI projects is composed of one or more stotes. For instonce, Eost Equatoria CDTT project covers Centrol ond western port of East Eguotorio stotes; West Eguotorio CDTI covers only West Eguotorio stote; Eost Bohr el Ghazal CDTI project is mode up of port of Western Eguotoria neor Rumbek, Lakes ond Worob stotes; ond West Eguotoria CDTI project comprises port of Worab ond ports of North Bohr el Ghazal ond West Bohr el Ghozol (See Mop). Monogement of APOC hos hod series of missions to the Southern Sudqn in the ef f orts to ensure the implementotion of CDTI octivities giventhe conf lict situotion over there for yeors. Availoble records show thot APOC Monogement hod undertaken more thon four Missions to the Southern Sudon in the past. The conf lict in the oreos oven the years hos stolled both infrostructurol developments ond provision of heolth intervention progrommes including ivermectin distribution ocross thefive CDTT projects within theten stotes. The treatment with ivermectin hos therefore met with chollenges in this areo. It wos the expectotion of APOC thot these projects become olive to implementing the distribution of mectizon. It becomes most compelling in the context of APOC phosing out ond exit strotegy ond the opprovol of the committee of sponsoring Agencies (csA) endorsed by the Joint Action Forum (JAF) to provide more support to post conf lict countries. The Mission hod briefing in Ouogodougou on l6-L9 Februory 2008 with the APOC Director. The Objectives of the Missionwere to ossess the need of technicol support to 55OTF ond to conduct ropid evoluotion of CDTI implementotion in Southern 5udon. I 1.2 Peofile of Southern Sudon Southern Sudon is mode up of threeregions, which ore divided into ten stotes, counties ond Bomo of o lower level. The three regions with their respective stotes ore Eguotorio (Centrol Eguotorio, Eost Eguotorio, ond West Equotorio), Bohr el Ghozol (North Bohr ol Ghazal, West Bohr ol Ghazal, Lokes, ond Worob), ond Upper Nile (Jonglei, Unity, ond Upper Nile). Southern Sudon borders Ethiopio to the eost, Kenyo, Ugondo, ond the Democrotic Republic of the Congo to the south, ond the Centrol African Republic to the west. Southern Sudon, olso known os New Sudon, hos nearly oll of its odministrotive of fices in Juba, the capitol, which is olso the lorgest city, bosed on populotion estimotes. It is estimqted thqt the Southern Sudon has o populotion of oround 15 million. This figure will be updoted by April 2008 census which will take of return of refugees. This region hos been negatively aff ected by wors for more thon 21 yeors, resulting in serious neglect,lock of infrostructure development, ond mojor destruction ond displocement. More thon 2 million people hove died, ond more thon 4 million qre internolly disploced or hove become ref ugees os o result of the civil wor ond wor- reloted impocts. The Comprehensive Peace Agreement signed on Jonuary 9,2OO5 in Noivosho, Kenyo with the SPLA/M, tentotively bringing on end to the Second Sudonese Civil Wor. 1 .3 Objectives of the Mission (1) To ossess the perf ormonce of CDTI projects in the Southern Sudon with emphosis on community involvement ond implementotion of the process of CDTT. (?) To identify oreos f or strengthening copocity of notionols on eff ective implementotion ond monagement of projects.(3) To develop with the Southern Sudqn Onchocerciosis Tosk Force (55OTF) o plon of oction for improving geogrophicol ond therapeutic coverage.(4) To introduce o Technicol Advisor to the Southern Sudon CDTI projects, Mr Lozarus Nweke, selected by the SSOTF. 2 2.O ,IAETHODS OF TACKIJN6 EACH OBJECTIVE Design opprooches - Consultotive meetings ond discussions with 55OTF coordinotor, WHO of f icers,WHO/ APOC odministrotive ond f inonce Assistont, MOH of f iciols ond N6DO (CBM) to determinethe situotion of support to CDTf ot eoch level. - Meeting with stotes CDTI project coordinoting officers, copturing problem oreos. Ascertoin vehicle ovoilobility , office equipment ond drug availobility ond new APOC treotment forms. Stotus of Data monogers ot this level, number of stoff ovailoble ond shoring of counties to stote teom members. Reports ovoiloble or otherwise ond why. Number of ovoiloble CDDs versus totol populotion ond census update. Obiective t Undertoke visits of selected treotment sites including the counties, heolth focilities ond communities. Visit ot community level will exqmine vorious processes of CDTI which are selecting of CDDs, troining of CDDs, drug distribution and reporting bock. fnterviews of some community members on how they feel obout the distribution ond support to CDDs etc. Chains of drug collection ond odeguocy of mectizqn toblets. Looking ot both geographicol ond theropeutic coverage in selected treotment sites. Oblective 2 Try to find out number of troined ond knowledgeable 55OTF staff ,PCOs qnd other stoff , county supervisors, heolth focility stoff ond CDDs ovoiloble, their odeguocy or otherwise. Ability ond copobility of PCOs ond county supervisors in monaging projects in both stote ond county levels respectively. Objective 3 fnitiation of the 55OTF plon of oction to oddress issue of both geographicol ond theropeutic coveroge, sustoinobility of CDTI. Completion of REMO ond Roploa. Review of 2008 plon of oction. Needs of each of the 5 CDTI projects to be incorporoted in the plon ond woys to reinf orce the coordinating role of 55OTF secretoriat. 3 3.O The lAission Processes 3.1. Arrival in Nairobi on 21st February 2@8 The Mission, comprising two Persons, orrived Noirobi , capitol of Kenyo onZl"t Februory 2OO8 from Ouogodougou vio Coted'fvoire. The Mission wos met on arrivol by the WHO/ APOC odministrotive ond f inonce qssistont , Mrs Agnes Wonyoike. 3.2. ltleeting of the tlhission with the SSOTF coordinator at WHO Soufhern Sudan office in Ndirobi on 2?d Februory 2008 At the meeting, the 55OTF coordinotor Dr Bobo oddressed the following issues; 1. Bockground of the Southern Sudon ond the CDTI projects. The informotion provided by him ot the meeting was used to build the bockground in this report. This ronges from odministrotive structures to displocement os well as CDTI structure, terroin problem ond vostness of lond in the Southern 5udan. 2. Problems facing/needs of the projects include a) Humon resources: He exploined thot the projects ore continuolly losing stoff to other N6Os ond UN ogencies due to poor payment. For instonce, UN agencies poy o driver $800 plus other benef its but the CDTI project driver collects $150. The situotion in the Southern Sudon hos given rise to open competition which nobody con control. b) APOC Manogement not releosing funds on time: The top-ups the stoff orereceivingarevery irregulor ond when they ore not released for up to 3 months, they get ogitated. As of dote solaries is not being poid by government. Second instollment of 2OO7 opproved budget by APOC is yet to be releosed.He expressed displeosure over not releosing f und f rom APOC Trust Fund. c) High cost of living and occommodotion: In Jubo and Rumbek, there is very serious shortoge of occommodotion, which result in high living ond occommodotion cost. A tent costs os much os U5$200 - US$250 o night in Jubo ond between U5$100 ond U5$150 in Rumbek. A bottle (smoll) of woter cost U5$5 in Jubo ond U5$4 in Rumbek. d) Woter: fn Rumbek , there is woter scorcity. e) CDD troining: This is done bit by bit. All hove not received training due to due to budget line drosticolly scole down by APOC Monogement. f) APOC generotor not onymore efficient ond lock of resource to contribute to fuel cost stroining. 4 3. Construction of a new office for SSOTF ond plon for VSAT instollation: The office ot Rumbek in Lokes stote hos been rebuilt and furnished by USAID. The Eost Bohr el Ghozal CDTI Project is olso locoted here.There is now on orrongement to provide VSAT in the Ministry of heolth, the project ond the secretoriot. 4. Ministry of heolth: There is o shortoge of expertise, solories areyet to be poid. At the meeting, APOC delegotion highlighted the following points by o) Trocing the history of formotion of notionol Oncho Tosk Force in the Southern Sudan. b) fndicoting thot Oncho is public heolth problem in the Southern Sudon ond should be oddressed properly. c) fntroducing Mr Lozorus Nweke as WHO/ APOC technicol odvisor to the 55OTF. Dr Bobo welcomed him ond informed him of the situation in the Southern Sudon. And thot he is looking forward to the technicol Advisor's working with them ond ploy his role. d) Stoting thot APOC will phose out in 2015 ond theref ore urgent actions ore needed in Southern Sudan to drive ond estoblish f unctionol CDTT projects bef ore APOC closes. Hence the need f or a technicql odvisor whose role will be to support the 55OTF under supervision ond guidonce of the 55OTF coordinator in CDTf implementotion. At the end of the meeting, it wos ogreed thot . All should meet ot Rumbek, Southern Sudon on 25th Februory 2008. . The Mission should leove Noirobi for Lokichoggio on the 24th February 2008 ond sleep ot Lokichoggio comp Operotion Lif eline Sudon (OLS). . Mrs. Agnes should orronge oll plones, comp bookings, f light authorizotions, ond Lqzorus's poss permit to Southern Sudon. . Working ogendo be drown os contoined in oppendix 1. 5 3.3. iheeting of the tlLission with the CBtll country represenfative at fhe oncho Secrefariat, Rumbek in Lokes sfafe on fhe 25 February 2OO8 The porticiponts broinstormed ond generated the following information Dr Nomo's briefings dwelt on the following points to improve on theropeutic ond geogrophicol coveroge rates. document of o. Extension of APOC to 2015. b. Support troining of CDTf personnel including copocity building. c. Financing other heolth interventions such os moloria,Vit A, Polio erodicotion ond lymphotic f iloriosis in the f ramework of co-implementotion. support (?Ots APOC will exit from countries). cotch up in CDTf implementotion conseguent of yeors of conf licts. Sudon ond what eoch portner should do. implementotion of CDTI in post conf lict countries. Southern Sudan. He is to work in colloborotion with the SSOTF secretariot under the f ist supervision of Notionol coordinotor in troining personnel ond implementing CDTI strotegy to moke o difference in the neor future. project oreqs, ond os regords office, whot con we do by woy of improving the communicotion with APOC. 6 The CBlrt country representotive, Mr Fosil welcomed the Mission ond afterword responded by roising the following issues. Portners: CBM is ploying o major role, followed by APOC qnd MOH lost with no budget ond no releose. Humon resources: There ore o lot of positions in the 55OTF letter of ogreement but pockoge is low hence occounting for loss of stoff to others thereby resulting to 9op in humon resources ond thus provided. The Toble below shows stoff ot SSOTF level ond their stotus Copacity of stoff : Stqff ore not ovoilqble ond those avoiloble hove low guolif icotions ond educotion. All stotes' project coordinating off icers ore not oll that guolified to be in those positions. No solory from the ministry of heolth to stoff . This hos remoined o problem getting to three yeors now. There is not yet o notionol budget. Top-up from APOC: The top-up from APOC connot sustqin the stoff os no solary comes from the ministry. Even the Top-up hos not been poid to stoff for 6 months now. Turn over or ottrition: stoff desert the project ? or 3 months ofter troining due to poor solory. fn Southern Sudan, there are o lot of UN ogencies thot poy very well. No. of supervisory centers: There is plon to increqse the current number of supervisory centers ocross the 5 projects to cover the ten stotes in the Southern Sudon. I I 7 S/N Position of Stoff ot SSOTF No. of stoff I Notionol coordinotor 1 2 Deputy Notionol coordinotor 1 3 Administrotion ond f inonce off icer 0 4 Driver I 5 Assistont driver 1 6 Rodial operotor 1 7 security 1 8 bookkeeper 0 9 secretary 0 10 Doto monoger 0 Period of mectizon distribution: This varies from project to project occording to the dry seoson , e.g. Upper Nile f rom Sept to Dec. Review meeting ond troining: The project normolly holds review meeting in Jonuory eoch yeor with oll projects before conducting troining loter in Jonuory - Februory. Up till now thesetwo octivities have not been performed due to no release of fund from APOC. Rebuilding of Oncho office by USAID. The 55OTF office situoted in the ministry of heolth premises at Rumbek in Lokes stote hos been rebuilt ond furnished by USAID under the leodership of 5SOTF coordinotor. New APOC doto collection forms: These forms ore yet to be introduced to most CDDs qnd heolth workers. Lozorus commented on the some issues roised - Clorif ication on the line of reporting of CDTT octivities f rom the stote to community level in the Southern Sudon: This wos provided beginning from stote, County, Heolth focility/Poyom, ond Boma - Community. Sometimes Bomo is skipped. - Need to line-list oll communities occording to heolth focilities, counties ond stotes for better dato monogement. - More informotion on the projects os provided below s/N CDTI projectlyeor of commencement Locotion No of stoff No. of supervisory centres No. of counties 1 Eost Bohr el Ghozol/2OO4 Rumbek 7 4 4 2 West Bohr el Ghozal/2006 Wou 7 10 10 3 Eost Eguotorio/2006 Yei 7 7 7 4 West Equotorio/2OO4 Yombo 7 5 5 5 Upper Nile/2006 Akobo 7 6 6 6 Notionol ssorF/2000 Rumbek 7 32 32 8 HTGHIJGHT OF ISSUES DISCUSSED * New direction of APOC betore exiting in 2Ol5 os contoined in the strotegic orientotion document. * Deployment ond copocity building of WHO/ APOC Technicol Advisor to the Southern Sudon CDTI project. * NGDO concerns over providing the need of the technicol odvisor in terms of trovels to project locotions os well os APOC's opplying the OLS rules of gronting stqff leave after six weeks to him and general living conditions in Rumbek. * Humon resources: profile of stoff ond capocity ot both notionol 55OTF secretoriot ond five stotes CDTI projects. * Review of packoge of certain categorres of stoff on full time within the notionol secretoriot f or APOC support. * Review of opproved 2008 plan of oction porticulorly os it concerns vehicle/eguipment where no money wos opprovedby APOC to cover mointenon ce, f ueling ond runnin g cost , training/ educotion ond trovel cost where little wos opproved for SSOTF secretoriot. * Deloy in releosing the remoining top-ups f or 2OO7 which omounts to $78 ,784 , representi ng 23% of the totol opproved budget * Eguipment: Photocopier ond oir conditioner to be provided. + Remo ond Roploo to be completed /ref ined in October 2008 * Period of mectizan distribution: This depends on diff erent project but within two periods of Jon - Jun ond Sept - Dec. * Dote for submission of TCC report: In July ogoinst TCC meeting in September. * coverage:2oo7 Theropeutic coverage was 35.75% while the Geographic coverage wos indeterminote os the number of totol CDTI villoges wos not ovoiloble due to the prevailing situotion in the Southern Sudon. + Quontity of mectizan toblets required for 2008 is 7,140,000 3.4. Visit fo WHO office n Punbek on 26th February ZOOa The Mission poid o courtesy visit to WHo office where they met with Dr Joyoprokosh Voliokorleri. After o formql introduction, the Mission informed him thot they ore in Rumbek plonning ond discussing with MOH off iciols on cDTr strotegies. The Mission further informed him thqt Apoc would be phosing out in 2015 ond thot Southern Sudon needed to reoch certoin level with other countries in Af rico. This is the reoson for hoving o technical 9 Advisor who would ossist the 55OTF in troining people ot eoch level ond implementing other CDTI octivities. He wos told thot the technicol qdvisor would from to time brief him on whot is going on. fn his response,he thonked the Mission for coming ond expressed the hope to hove o good working relotionship with the technicol odvisor when would f inolly come to be port of efforts to deol with the heolth situotions in the Southern Sudon. 3.5. Field visif to l0/est Equotoria CDTT project sites on 27 February 2OO8 The Mission wos occomponied by the project coordinotor of Eqst Bohr El Ghazal who orrong ed the f ield visit to Mvolo County in the Western Eguotorio. At Mvolo heolth centre : On orrivol, the heolth plonning officer in the heolth center, Mr Williom Dolli received the team ond after o formol introduction, the Mission exploined the objectives of the visit, which wereto ossess the performonce of CDTI project ond whot is on ground for oncho control os well os woys to strengthen the copocity on oncho control throughout Southern Sudon in general including introducing Lozorus selected by the 55OTF Headguorter qs the Person to work with them for the next two yeors by Dr. Nomo. The Mission further expressed its reodiness to work on other heolth progrommes such os molorio, schistosomiosis, guineo worm ond other neglected tropicol diseoses. Mr Dolli quickly replied thot April - November used to be o diff icult time for the people of Mvolo os biting black f lies ond mosguitoes ore in obundonce resulting to high prevolence of malorio ond elephontiosis in the community. Mvolo community is sotisf ied with oncho control ond people skin conditions are being improved, however they complained obout molorio ond elephontiosis which connot betreoted. The Mission exploined thot elephantiasis is now possible to treot with combinotion of olbendozole ond mectizan. Mectizon movement: Mr Williom Dolly correctly described the process of mectizon distribution to community members.He exploined thot he hos been in OV activities especiolly in porticipoting in the troining of CDDs for yeors now. He exploined thot the heolth center distributes the mectizon every yeor to CDDs who in turn treot community members with it. On how they collect drug he soid thot the county supervisor collects from the stote qnd then distributes them to oll heolth centers in the county. Mectizon storoge: fu\ectizon toblets ore stored ot the heolth centers from there they ore collected by CDDs or occosionolly by Boma supervisors for their CDDs. l/tobilizotion: On the system of mobilizotion, it wos leornt thot key community leoders ore olwoys mobilized. These ore chiefs, Poyom odministrotors, church leoders ond the schools. 10 Troining, troining moteriols ond tronsport: Mr Dolli soid thot troining of CDDs is corried out before eoch distribution ot the heolth center. Troining moteriols included monuol for CDD troining plus incentives in form of mosguito nets, blankets, smoll bogs for corrying mectizon ond tolly sheets(treotment forms) by CDD ond roincoqt. He described tronsport as o problem in the oreo and thot motorcycle for the county supervisor has been off-rood since 2005. Number of stoff lhealth centers: A totol of ten health focilities ore ovoilable in Mvolo County. These ore Mvolo ,Yeri, Bogori , Bohr el Gigirididi, Kulu, Lomu, Combi, Lali, Domeri, Lesi ond Dori. Mvolo health center hqs 16 staff. At Domeri the Mission met with the Countv suoervisor: The county supervisor, Mr Wisley Bcourt hos been in Oncho progromme for o long time. He is troined ond knowledgeable obout the diseose ond mectizan distribution mechonism. He is olso the progromme coordinator of a locol NGDO, SIDF. He is doubling for oncho ond SIDF works. He recounted his experiences ond post works on Oncho ond below ore the issues he provided informotion on during the meeting with the Mission. Number of Poyom in Mvolo County: Seven Poyoms ore in Mvolo County nomely, Mvolo, Yeri,Lesi, Dori, Boggori, Borigrindiond Kokori. This hos o relotionship with heolth focility os one Payom cqn hqve one or heolth focilities. Oncho Endemicity in ltAvolo County: This County is highly endemic for oncho. The result of REMO exercise shows thot the prevolence rate wos 93%. Number of ovoiloble CDDs, troining ond storoge: Mvolo County os o whole hos 203 CDDs out of which 50 fresh CDDs ond onother 50 old CDDs were trained ond retroined respectively in yeor 2007. Troining took ploce at county heolth office under thetrees.2-3 doys ore used in troining the CDDs depending on whether they are new or old. The mectizon tablets which qre stored in the heolth county of fice ore distributed to CDDs immediotely after the troining octivity. Solories ond Top-ups: Salories hove not been paid by the ministry of heolth to heqlth workers in the ten counties in West Eguotorio since the peace ogreement wos signed in 2005. On the issue of top-up, the County supervisor is the only one receiving top-up of $120 in Mvolo county ond the lost he wos poid wos Moy 2007. The county supervisor requested for upword review of the Top- up given the prevoiling situotion ond the cost of lif e. On whether ony treotment ond Number of treoted communities in ?@7: A lot of people were treated ocross oll 7 Poyams in over 200 communities with on estimoted totol populotion of 111,000 persons. Response to treotment by community members. The county supervisor reported thot there is rush for mectizon treotment in Mvolo county. People are willing to tqke the drugs qnd some ore now hoving 'good'skin and 'good' sight. Incentives: The county received in2007 some items such os 30 T- shirts (but these went to Bomo odministrotors),45 bogs for CDDs ond blonkets. 11 Supervision ond motorcycle/bicycles: Supervision hos been hompered due to non functionol motorcycle. ft wos understood thot one motorbike was provided since the inception ond o lot of money hod been spent in the efforts to get it bock on the road but to no avoil. The motorbike is porked in the 55OTF secretoriot of Rumbek. The two bicycles ollocoted to the county were looted during tribe conf licts. Additionol public heolth chollenge: Nodding diseose is o concern to the county os well as lymphatic f iloriosis ond molorio ond con be found in mony ports of the county especiolly Mvolo, Domeri, Yeri etc. Reguests: The progromme county officer requested side effect drugs, Motorcycle ,bicycles,increase in top-up, payment of heolth workers solories os well os the outstonding top-ups The Mission's Comments The Mission proised the efforts of the county supervisor ond assured him thot the issues he raised would be oddressed.The Mission olso informed him of the plon to secute the speciol country initiotive to support troining more CDDs ond heolth workers for improvement of geographic ond theropeutic coverage. 3.6. tl,leeting of the rltlission wifh l|volo community members and CDDs on 27 February ?OOa A group of community members numbering l? were met in the village squore. One of them o teacher nomed Mr Gobriel Sebit wos interviewed. He provided bosic information concerning the menoce of biting block f lies ond mosguitoes in the community. He said thot bite of block f lies is very painful ond more intense during the roiny seoson. The octivities such os hunting, f ishing ond forming by Mvolo people exposed them to the bite of both block flies ond mosguitoes Mectizon intoke hos helped in reducing the problem ossocioted with OV. The Mission told them thot mosguito control would be embarked on with the help of PCO ond the technical odvisor APOC is deploying to them. Treatment with mectizon is very populor in this community os oll thot were asked whether token mectizon, the response wos tO}% positive evento the point of indicoting the number of toblets token with their f ingers without being osked. The community hqs three CDDs nomely Froncis Dolo, Jocob Hobbos ond Jocob Camis. However, it wos only Jocob Comis thot wos present. He soid he is willing to continue distributing the mectizon to help his people. He soid thot his problem is monoging side eff ect ond tronsport when trying to cover more locotions. On the number of persons treoted in 2OO7, he quoted 700 persons but could not produce his treotment notebook which he cloimed wos in his house. But whot is very interesting ond encouroging is high level of qwqreness, enthusiosm ond response to treotment with ivermectin in this community. According to the CDD, it tokes 7 days to complete distribution ond the time of distribution is both morning ond evening but vorying f rom household to t2 household. Regording incentives, he expressed the need of books, roincoots ond bednets. 3.7. Briefings on fhe field visit situation/meefing of The l4ission with SSOTF (coordinator dnd CBtl,l country representafive) on 28h Februory 2OO8 All met ot the SSOTF secretoriat f or briefing ond discussions. The Mission expressed pleosure over the level of work in Mvolo county especiolly community members' enthusiasm ond respond to treotment ond thus commended the coordinotors ond their teom for their efforts. The coordinotors ond the state CDTI project coordinoting officer for Eost Bohr el Ghazal however retorted thot the situotion in Mvolo County is o speciol cose ond mony other oreqs ore guite contrary. The PCO recounted how some communify members were ref using mectizon treotment in some oreos in the stote. Other motters discussed centered on 1. Census, which Dr Bobo soid would hold in April 2008 ond this would give informotion on updoting the populotion ot high risk. 2. REMO and RAPLOA. This would be completed in Oct- Dec 2008 due to census slated for April plus the foct thot on integrated diseose workshop would toke ploce during this period in Southern Sudon. Dr Nomo soid that no technicol ossistont would be sent ond thot Dr Babo, Fosil ond Lozorus wete enough to hondle the exercises including other olreody troined people on thqt. 3. Additionol qdministrotive structure. Administrotive levels weretwo before such os region ond county but now three nomely region, stote ond county. Forecosting whot would hoppen to oll oreas thot were not occessible during the REMO exercise,the present ten stotes hove to be covered within the five CDTI projects ond foilure to get ot oll the ten stotes meons hoving f oci of infection. 4. Building of Oncho of f ice. Need for solor energy os on olternotive powe? supply, internet service to moke communicotion eosy and procuring eguipment such os oir- conditioners, fons etc. However there is plon occording to Dr Boba to hove VSAT in the building. 5. Plon of Action. Lazorus needs to develop o work plan for providing ossistonce to the 5 CDTI projects ond the 55OTF secretoriot. 5. Humon resources development in order to secure ond troin more people in the projects. 13 7. Logistic ond mointenonce. More motorcycles ond bicycles areneeded including mointenonce of existing project vehicle. 8. fntegration. Additionol fund could be provided for co-implementotion of oncho with other diseoses using the CDTI structure. 9. Speciol Country Initiotive. This would enable for increosing the number of CDDs ond copocity of heolth workers so os to realize CDD/total populotion rotio of 1:100 and this would ultimotely improve geographic ond theropeutic coveroge rotes in Southern Sudon. 10. Nodding disease epidemiology. Some oreos where the disease is prevolent in the Southern Sudon ore port of Jubo, Mvolo, Eost Moduru, Rojo ond Mugi counties An operotionol is needed. 3.8. tl,leeting with the WHO Represenfafive of Southern Sudan on 4 tl\arch 2008 Dr Ahmed Abdullohi received Mr Lazorus Nweke in his office.Hetried to f ind out whot his experience like from the visit to the Southern Sudon ond whether he was in Jubo before proceeding to Rumbek. fn his response, Mr Nweke told him thot the situotion in Rumbek is too chollenging giventheperceived high cost of trovel (oir ond high cost of vehicle fueling on lond, poor roods ond generol ef f ect it would exert on mointenonce of vehicle including humon heolth implicotions ond olso occommodation problem. Dr Abdullohi guickly agreed with him by saying thot logistics alone tokes 80% of the whole fund. On whether he wos in Jubo, Mr Nweke told him it wos on tronsit to Rumbek ond not necessarily being to ony of f lce in Jubo. Dr Abdullohi osked him obout his controct document with regards to the new job. Mr Lozorus showed him APOC invitotion letter to undertoke the foct f inding mission. Dr Abdullohi told Mr Nweke thot he needs to get the detoils so thot EMRO office would be communicoted. He directed thot o copy of theletter of of f er be given to the Administrotive of f icer to enoble her open o f ile f or Mr Nweke. On issue of occommodotion Mr Nweke exploined to him the extent of eff orts so for ond how Dr Bobo hos given consent to ollocoting an oportment in one of the new houses in the ministry ond olso the initiol thought of APOC Director to reoch him concerning building o tent within the WHO premises in Rumbek. Dr Abdullohi described her ideo os perfect. He osked qbout the internet system in the SSOTF heodguorter ond it wos exploined to him thot the ministry wos yet to hove one. He soid their office is ovoiloble for internet system. Dr Abdullohi osked the Administrotive officer to get Ouogo to send the controct document to his office. On when Mr Nweke would be relocoting to Rumbek, he wos told it would be on 25 t4 April ond he osked Mr Nweke to be in their Jubo off ice on his woy to Rumbek for further briefing. 4. O CON5TRAINTS/CHALLENGE5 1. Deloy in releosing fund to pay top-ups to staff and general CDTI operotions by APOC. 2. Ministry of heolth's non poyment of solories to stqff for mony months now. 3. Mectizon tablets areyet to orrive for commencement of 2008 distributionbef ore the onset of roin in Moy. 4. Freguent turnover or high ottrition rote of troined or ovoiloble stoff. 5. General scarce of monpower rn the Southern Sudon CDTT projects. 6. Low pockoge f or CDTI staff ogoinst high pockoge by other UN ogencies in the Southern Sudqn. 7. No record of number of communities treoted ond theref ore colculoting the geographic coveroge wos most chollenging. 8. The project is obviously very for f rom reoching the minimum theropeutic coverage rote of 65% as mony Poyom/heolth focilities/communities ore to yet commence treotment. 9. Report of some people ref using treotment with mectizon due to reoctions ond generol unwillingness. 10. High cost of petroleum product os one drum of fuel costs os much os $3,500. 11. Poor communicotion networks in the Southern Sudon. 12. Logistics in oreo of motorcycles ond bicycles ore inodequote ond some very old motorcycles need replacement. 13. High cost of vehicle mointenonce including motorcycles. 14. Complete lock of ossistont project coordinoting officer ot stote level ond ossistont county supervisor ot county level. 15 5.O CONCLUSTON The CDTI in the Southern Sudon reguires re-lounching with greoter momentum in capocity building ond empowerment of project coordinoting officers to eff ectively mon their respective projects for future sustoinobility. 6.0 WAY FORWARD AND RECOAAAAENDATIONS 1. APOC should consider os o motter of urgency the release of the outstonding top-ups for ?0O7 ond olso to speed up the releose of fund opproved for 2008 to enoble CDTI octivities to commence in the projects z. The 6055 ond the Ministry of heolth to f ind o solution to chronic non- poyment of stoff salories to reduce loss of troined ond knowledgeoble monpower in CDTI project to other ogencies ond thus reduce over dependency on top-ups. 3. APOC is reguested to give speciol considerotion in supporting certoin cotegory of stoff ot the Notionol Oncho Secretoriot as tobulated below s/N Stoff ot 55OTF to be supported by APOC No. of stoff Proposed pockoge Being poid by NGDO & other UN progrommes 1 Administrotion ond finonce officer 0 $1200 - $1500 2 Logistic officer 0 $1000 - $1200 3 Secretory 0 $8oo - $1200 4 Doto manoger 0 $1200 - $1500 4. Troining ond copocity building of oll CDTI stoff at oll levels such os PCOs, county supervisors, heolth focility staff ond CDDs (with a greater focus on the new APOC doto collection forms) should be given top priority for stobilizotion and eff ective functionolity of CDTI in the Southern Sudon. 5. Troining of doto monogers on hondling, hqrmonizotion, storoge ond monqgement of doto using oppropriote computer soft wores ond Apoc dotobose. 6. Providing appropriote troining for f inonciol monogement officer f or ef f ect:e hondling of f inonciol tronsactions ot the notional secretoriot. 7. All projects ot the stqte ond the county levels should hove? ossistonts each f or better monogement ond implementotion of CDTI. 8. Need to review ond omend trovels, troining ond operotron/expenses budget lines in 2008 plon of oction os it concerns 55OTF f or better coordinotion of CDTf octivities implementotion ot the 5 stotes project level. 16 9. The 55OTF project should increose the number of CDD /totol populotion rotio to 1:100 in the 5 stotes CDTI projects by opplying to APOC f or the Speciol Country Initiotive to tockle the issue of low theropeutic ond geogroph ic ol cov eroge rotes. 10. APOC is reguested to consider providing a new generotor of high copocity to 55OTF secretoriot to oct os bockup to the smoll one presently ovoiloble os there is no other olternotive power source in Rumbek. 11. APOC to support census registrotion updote ocross oll 5 CDTf projects to determine the totol populotion ovailable in these oreos. 12. fntensive community mobilizotion ond heolth educotion should be strengthened f or proper institutionalizotion of CDTT strotegy ocross oll projects ond communities in the woke of the returning of refugees. 13. APOC to ensure ovoilobility of one functionol motorcycle to eoch county in the 5 projects ond bicycles to some heolth focility stoff f or ef f ective supervision of CDTI octivities. 14. Community self monitoring ond stokeholders meeting should be exponded to include oll CDTT communities ocross the 5 projects to accelerote complete community ownership of the progromme. 15. More funds should be ollocoted for project vehicles ond motorcycles mqintenonce. 7.O Development of Plon of Action Efforts were made to give direction to development of the plon of oction f or the speciol country initiotive which would enable for high number of CDDs to o populotion rotion of 1:100 to improve geographic ond theropeutic coveroge. fnitial cqll to develop it didn't go down well os 5 projects needed to get their plons to enoble 55OTF office come up with o holistic plan of oction. Funds opproved in 2008 APOC letter of ogreement hos not yet been received. t7 Appendix 1: Schedule/itinerory of the Mission from 21 Februory to 7 Morch, 2008 Doy/Dote Ploce to visit Activity Remork Day l/21Feb Noirobi -Arrivol ond settling down by the mission - Sorting out immigrotion possport issue with AA Doy ?/22Feb. Noirobi -Meeting with SSOTF coordinotor ond Agnes Doy3/23 Feb Noirobi Plonning Day4/?4 Feb Lokichogio Tronsit to Rumbek Doy 5/25 Feb Rumbek / 55OTF office Meeting with the CBM country representotive Day 6/?6 Feb 55OTF office Meeting contd Doy 7/27 Feb Mvolo county Field visit for CDTf performonce Day 8/28 Feb 55OTF office lAeeting with Dr. Bobo, Fosilond MOU presentotion for signing Day 9/29 Feb Rumbek Nairobi Plon of oction development Doy 10-13/1-4 Morch Nairobi Report writing Doy t4/ 5 Monch Ouogo Submission of MOU Days 15 - 22 /6-14 Morch Ouogo Further Briefings, Finolizing ond submission of mission report ond collection of letter ol controct Day ?3/ L4 Morch Logos Deporture Day 24/t5 Morch Enugu Home 18 Appendix 2z The Mission Teom ond Persons met during the exercise s/N Nome Designotion Off iciol locotion Emoil oddress/Phone No 1 Dr Nomo Mounkoila w\o/ APOC cEv Ouogodougou, Burkino Foso nomom@oncho.of ro.who. int ? Mr Lozorus Nweke wHo/ APOC Temporol Advisor Rumbek, Southern Sudon nnabuike .com O7tlt397}8 - Nairobi +23480474710 - Nigerio 3 Dr Sompson Bobo SSOTF Coordinator Jubo MOH, Southern Sudan Somson-bobo@yohoo.com +256477t25799 - Jubo 0722364982 - Noirobi 4 Mrs Agnes Wonyoike wHo/ APOC administrotive ond occounting officer Nqirobi, Kenyo wonyoikeo@ nbo.emro.who. int O7228t6975 - Nairobi 5 Fosil Chone N6DO Coordinotor (cBM ) Rumbek, Southern Sudqn f bchone@yohoo.com +8821643335349 - Sudon +25t911792415 - Addis 6 Chuol Project coordinating officer, Eost Bohr el Ghozol CDTT Rumbek, Southern Sudon 7 Dr.Joyoprokosh Voliokolleri T. WHO Medicol officer, Polio Erodicotion Progrom Rumbek, Southern Sudon Vtdrlp56@yohoo.com 8 Wilsey Bcourt Mvolo County supervisor Sudon Inlond Development (srD), Domeri, Mvolo wis leybcourt@yahoo.com 9 Williom Dolli Mvolo county heolth plonning officer Mvolo heolth centre 10 Jqcob Comis Mvolo CDD ond Bomo supervisor Mvolo viilage, neor heolth center 11 Dr. Ahmed Abdullohi WR Southern Sudan Jubo ohmed@whosom.unon.orq r9