North Gondar CDTI annual project technical report submitted to Technical Consultative Committee (TTC) : January 2013 to 31st December 2013

t The Federal Democratic Republic of Ethiopia Ministry of Health ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) DEADLINE FOR SUBMTSSION: To APOC Management by 31 January for March TCC meeting To APOC Management by 31 Julv for September TCC meeting AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) 'l I e COUNTRY/NOTF: ETHIOPIA Proiect Name North Gondar Launching year: 2003Approval year:2002 Reportins Period F ro m : Ja.n.u a.ry. ?.0.1.3.......... To ;.... Dese.nflhe.r..2 0.1-3......(Month/Year) ( Month/Year) Proiect year of this repoft! (circleone) I 2 3 4 5 6 7 8 9 10(, Date submitted: 30 December 2013 NGDO partner: The Carter Center \9 I ANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSTILTATIVE COMMITTEE (TCC) ENDORSEME,NT Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the report: a Country Ethiapiq National Coordinator Name: Mr. Oumer Shafi Signature: _ Date: Zonal Oncho Coordinator Name:- Worku Mulatu Workie Signature:_ Date: NGDO Representative Name: _Dr. Zerthun Tadesse Signature Date: This report has been prepared by Name :- Worku Mulatu - Designation : Zone Onchoierciasis Coordinator Signature Date ll Table of Contents Acronyms. Definitions Executive Summary.. SECTION I : Background information.......... SECTION 2: Implementation of CDTI 2.1. Timeline of activities Advocacy... 2.3. Mobilization, sensitization and health education of at risk communities........................ 2.4. Communityinvolvement 2.6. Treatments 2.6.L. Treatmentfigures 2.6.2 What are the causes of absenteeism? ........... 2.6.3 What are the reasons for refusals? 2.6.4 Briefly describe all known and verified serious adverse events (SAEs) that........... 2.6.5. Trend of treatment achievement from CDTI project inception to the current year 2.7 . Ordering, storage and delivery of ivermectin................. 2.8. Community self-monitoring and Stakeholders Meeting.... 2.9. Supervision 2.9.L. Provide a flow chart of supervision hierarchy. 2.9.3. Was a supervision checklist used? Yes 2.9.5. Was feedback given to the person or groups supervised? Yes............. 2.9.6. How was the feedback used to improve the overall performance of the project? SECTION 3: Support to CDTI 3.1. Equipment.. 3.2. Financial contributions of the partners and communities............. 3.3. Other forms of community support 3.4. Expenditure per activity. SECTION 4: Sustainability of CDTI.............. 4.1. Internal; independent participatory monitoring; Evaluation.. 4.L.1, Was Monitoring/evaluation carried out during the reporting period?.... 4.7.2. . What were the recommendations? 4.2. Sustainability of projects: plan and set targets (mandatory at Yr 3)....... 4.2.7. Planning at all relevant levels 4.2.2. Funds 4.2.3 Transport(replacementandmaintenance) 4.2.4. Other resources -... To what extent has the plan been imp|emented................. iii .v vi .l .J ,7 ,7 7 8 , 20 20 ............20 ,,..,,......2L .......,,..,21 ...,,,..',..21 ..........,,21 ...,....,...21 .,........,.21 ,.,,....,...2L4.2.5 t7 20 4.3.7. lvermectin delivery mechanisms ...............22 4.3.3. Joint supervision and monitoring with other programs.... ...............22 4.3.4. Release of funds for project activities .........22 4.3.5. ls CDTI included in the PHC budget? ........22 4.3.6. Describe other health programs that are using the CDTI structure and how this was 4.3.7 . Describe others issues considered in the integration of CDT|............ ..................23 4.4.1,. Summarize in not more than one half of a page the operational research undertaken in the project area within the reporting period. ..................23 4.4.2. How were the results applied in the project?................ ..................23 SECTION 5: Strengths, w'ealutesses, challenges, and opportunities.............. .................23 SECTION 6: Unique l-eatures of the project/other matters ........24 a lv Acronyms APOC ATO ATrO CBO CDD CDTI CSM LGA MOH NGDO NGO NOTF PHC REMO SAE SHM TCC TOT UNICEF UTG wHo TCCE UNICECO African Programme for Onchocerciasis Control Annual Treatment Obj ective Annual Training Objective Community-Based Organization Community-Directed Distributor Community-Directed Treatment with Ivermectin Community Self-Monitoring Local Govemment Area Ministry of Health Non-Governmental Development Organization Non-Govemm ental Organ ization National Onchocerciasis Task Force Primary health care Rapid Epidemiological Mapping of Onchocerciasis Severe adverse event Stakeholders meeting Technical Consultative Committee (APOC scientific advisory group) Trainer of trainers United Nations Children's Fund Ultimate Treatment Goal World Health Organization The Carter center Ethiopia United Nations Culture and Economic Commission V Definitions (i) Total population: the totalpopulation living in meso/hyper-endemic communities within the project area (based on REMO and census taking). (i i) Eligible population: calculated as 84o/o of the total population in meso/hyper-endemic communities in the project area. (iii) Annqal Treatment Obiective (ATO): the estimated number of persons living in meso/hyper-endemic areas that a CDTI project intends to treat with ivermectin in a given year. (iv) Ultimate Treatment Goal (UTG): calculated as the maximum number of people to be treated annually in meso/hyper endemic areas within the project area. ultimately to be reached when the project has reached full geographic coverage (normally the project should be expected to reach the UTG at the end of the 3'd year of the project). (v) Therapeutic coverage: number of people treated in a given year over the total population (this should be expressed as a percentage). (vi) Geographical coverage: number of communities treated in a given year over the total number of meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage). (vii) Integration: delivering additional health interventions (i.e. vitamin A supplements, albendazole for LF, screening for cataract, etc.) through CDTI (using the same systems, training, supervision and personnel) in order to maximise cost-effectiveness and empower communities to solve more of their health problems. This does not include activities or interventions carried out by community distributors outside of CDTI. (viii) Sustainability: CDTI activities in an area are sustainable when they continue to function effectively for the foreseeable future, with high treatment coverage, integrated into the available healthcare service, with strong community ownership, using resources mobilised by the community and the government. (ix) Community self-monitoring (CSM): The process by which the community is empowered to oversee and monitor the performance of CDTI (or any community-based health intervention programme), with a view to ensuring that the programme is being executed in the way intended. It encourages the community to take full responsibility of ivermectin distribution and make appropriate modifications when necessary. vl Executive Summary 1. Backgrqund or! treatment and population data North Gondar is situated in North West of Amhara region and it is one of the I 1 zones with largest land mass share. North Gondar CDTI is the collaborative initiative of APOC, MOH and the non- governmental development partner, TCCE. It is implemented with full support of local govemment and participation of local communities. On the basis of REMO five woredas of the zone have been identified as onchocerciasis endemic and CDTI program is initiated in these areas in 2003. Moreover, evidence from REMO conducted more recently in 2011 has also shown the endemicity of the disease in two additional woredas (Chilga and Tegede) of the zone. On the basis of these findings mass drug administration with ivermectin has been underway in these two additional woredas since 2012. Thus at present the total number of woredas unde(aking CDTI in North Gondar project zone are seven. . Treatment in the old CDTI woredas is administered annually and it is administered semi-annually in the two newly identified woredas. The following table depicts the treatment history of annual treatment woredas in North Gondar zone YEAR Total population endemic areas Annual Treatment Objective Number of persons treated Therapeutic coverage ATO covera ge UTG 2003 126,806 101,445 86,428 68 85 81 2004 235,712 197,998 180,054 76 9r 9l 2005 234,054 196,605 183,945 79 94 94 2006 249 , aJ45 199,476 182J29 73 9l 9l 2007 302,604 254,187 211,953 70 83 83 2008 282,046 236918 210.604 75 89 89 2009 280,259 224,207 215,805 77 96 96 2010 283,773 238,369 215,632 76 90 90 20ll 304737 255,979 2t3ss6 70.1 83.4 83.4 2012 502924 422456 403787 80 96 96 2013 547920 460253 453135 82.7 98.5 98.5 Woreda Year Round(Year) Total Population ATO Persons treated Therapeutic coverage UTG coverage Chilga Round 1 (2012) 119929 l 00740 94892 79.1 94 Round I (2013) I 3 8839 lr6625 1 13066 8l .4 97 2 Round 2 (2013) 139646 117303 114108 81.7 97.3 Tegede Round 1 (2012) 11449 60017 50270 70.4 84 Round 1 (2013) 14891 62908 62343 83.2 99 1 Round 2 (2013) 78336 65802 64076 8l .8 91.4 623090 52339s 498755 80 The following table depicts the treatment history of biannual treatment woredas in N.Gondar zone *ATO - Annual treatment objective +UTG - Ultimate treatment goal Among the major activities accomplished in 2013 are zone level TOT that has been cascaded to woreda and community level. Furthermore, Health development army formation, women development team restructuring together with the existing 2 HEWs in each kebele and the revised volunteer policy were the opportunities exploited to strengthen the performance. The main achievements of the year includes: 100olo geographic coverage and improved therapeutic coverage (83%) than ever before, improved female participation and appropriate integration of PHC programs with CDTI. In the reporting year in North Gondar zone taskforce for Onch/LF was strengthened in all CDTI woredas. Delay in Mectizan arrival was the challenges encountered in the reporting period. Integrated intensive joint supportive supervision was done. The fertile ground laid in the previous year was instrumental for the success gained. Background on population ltoveule4]t$. The communities in the CDTI areas are mainly settled farmers, government employees and daily workers. However, in areas like Metema (bordering Sudan) due to the existence of large scale cotton and oil seed farms there is large movement of people that are attracted to these areas. The indigenous ethnic groups are Amhara, Agew and Gumuz which occupy the entire CDTI Woredas living harmoniously with their fellow brothers of other ethnic groups like Tigray and Kimant. 2 1 Trainins data In 2013, new and refresher trainings were carried out in all the CDTI woredas. Accordingly 410 health workers including HEWs and 6349 CDDs selected by the communities from 1291 villages were trained. Challenses and how thev were overcome Challenges: . Lale arrival of Mectizan . Increased CDD dropout . High turnover of health workers (woreda CDTI coordinators) 0pportunities The presence of Health development army (HDA), mainly Women and 2HEWs at kebele level Solutions sought . Immediate drug dispatch as of its arrival to woredas and villages was taken as remedy to lately arriving Mectizan . Mass Mectizan treatment in 2013 was conducted in harvesting season for which reason some of the CDDs had left their villages for farming that they could not serve their communities. Selection of CDDs to replace the dropout was the remedy used. . Training offered to the newly assigned CDTI coordinators. SECTION l: Background information 1.1. General information Description of the project The North Gondar CDTI is situated in North Gondar zone, North West of Amhara region. Amhara region is one of the biggest r6gions in the country with diversity of cultures and features of early civilization in the country and in the continent as well. North Gondar is one of the largest zones in Amhara region and is sub-divided in to 23woredas that further sub divided in to 577 small administrative units called kebeles. CDTI has been initiated in 2003 in five woredas of the zone identified as onchocerciasis endemic and later expanded to include two newly identified endemic woredas in 2012. While the old woredas implement annual mass treatment the new woredas are undertaking semi-annual treatment. Thus in the year 2013 two rounds of ivermectin treatment has been carried out in the newly identified woredas. All the CDTI woredas of the zone have similar ecological conditions with the jungle and fast running big rivers creating suitable habitats for the black flies. The temperature ranges between l7 C' - 44 C". The fertile land in the areas have attracted investors for large scale private farms which in turn contributed to large influx of migrant population into these areas as a labor force. Out of the seven CDTI districts four share borders with Sudan where there is movement of people related J^ with business. Settlement program of the government to ensure food security at family level is one of the important programs in these woredas increasing the influx of people to these areas.. In general, the CDTI woredas are given more attention by the government for their endemicity of tropical diseases including malaria, onchocerciasis, lymphatic filariasis, leishmaniasis and others. !.f (.1-)'l'l rvrn'ctic;r:; The onchocerciasis endemic woredas u,hich were five since the launch in 2003 with the inclusion of the two new woredas reached seven in 2012. In the year 2013 CDTI program has been implemented in all the seven rvoredas with 127 kebeles and its 1291 villages. The community based development teams comprising 20-30 HHs are playing a pivotal role in the community participation of disease prevention and control theme. According to the updated register the total population living in the CDTI woredas reaches 547,920 making its annual treatment objective 460,253. All woreda capitals have all weather roads while efforts are underway in all woredas to make the inter- village accessibility for better technical support and program monitoring. A total of 453,135 people were treated in 2013 ( therapeutic coverage of 82.7Yo and ATO 98.5%). Compared with the previous years promising improvement was seen in terms of geographic coverage (100%) and improved therapeutic coverage. Efforts made to increase the therapeutic coverage have brought remarkable changes but about 3.5%o of untreated from eligible are not undermined. However, uninterrupted planed health education is the sought solution for better service consumption. In this regard HEWs and CDDs are doing their best to ensure the creation of awareness at household level in their respective villages. Health care deliverv svstem There are three hospitals, 726Health Centres artd 567 health posts in the zone. One health centre is set up to serve 25,000 population and one health post to 5,000 persons. Both health Centre and health posts are called Primary Health Care Unit (PHCU). Ninety seven percent of the population is believed to have access to primary health care. About 1,063 HEWs are currently deployed in the health posts to provide basic family based health services. In general there are 808 different types of health workers in all CDTI Woredas. 4 Table 1: Number of health staff involved in CDTI District Number of health staff involved in CDTI activities Total Number of health staff in the entire project area Br Number of health staff involved in CDTI B2 Percentage BfBzlBr * 100 Quara 1,45 78 54 Gendawuha 27 t9 70.4 Tach Arma 133 73 55 West Arm 66 44 66.7 Metema 135 73 54 Chilga 206 92 44.7 Tegede 96 54 56.3 Zone Summary 808 433 53.6 |.'2.1 Partnership The CDTI program is implemented with collaboration of bilateral support from WHO/APOC and development partner, The Carter Centre and local govemment (zone health department, woreda administration and health offices). The zone health department and woreda health offices have assigned CDTI program coordinators responsible to support, follow, monitor, collect and compile reports. Moreover, CDTI is integrated with other health programs where officers at zone and woreda health offices are empowered to provide coordinated support to the program other than CDTI coordinators. On the other hand the health extension workers and health workers in charge of health facilities and CDDs at community level were at forehead of the spear in fighting the disease. They have been playing role in conveying key onchocerciasis control messages, community level supportive supervision, collecting, compiling and submitting reports to their respective higher levels. The program has been implemented with full support of local government and participation of the affected communities 5 Population ofNumber of com munities/villages in Total in meso/hype r-endemic zoIIe A6: Aa* A5 Ultimat e treatme nt Goal (urG) Hyper endem ic zone in the projec t area Az Total in meso/hype r-endemic zone A3: A.7* At Meso- endem ic zone in the projec t area Ar Hyper endem ic zone in the projec t area A5 CDTI Districts in the entire project area Total populati on in the entire project area Meso- endem ic zone in the projec t area Ar NA 999447 8353 s99447 NA NA 202 NAQuara NA 8745 7346 NA NA 26 NAGendawu ha 8745 92587 77773 NA 314 NA NATach Arma 92587 NA 27551 56 NA NA 32799 West Arm 32199 NA NA 84514166 NA NA 100612100612 NA NAMetema NA 138839 662s1lNA NA 332 NAChilga 1 38839 7489r 62908195 NA NATegede 74891 NA NA 4602s3 1291 NA NA 547920 Zone Summery 547920 NA NA 1.2. Population Table 2: Communities and population at risk in the entire project area whether they are treated or not the Was a census for the project done during the reporting period? Yes / No If No, what is the source of the data in the table above? + Source : National census CDD Other source, specify Year If you are using the term community or village, define what constitutes the community or village. This will help understand the profile of the project area. The term community or village in this case is on the average composed of 20-30 neighboring households. 6 SECTION 2: Implementation of CDTI 2.1. l-irnclinc ul'actir iticr Table 3: Timeline of activities for the areas treated in the current year - Comments The CDTI activities performed in20l3 were as indicated in the above time table. However, due to the late arrival of Mectizan, there was time gap between drug distribution and training. Where as, in the two new CDTI woredas the biannual treatment has begun as per to the time table. Adl'ocacv State the number of Policy/decision makers mobilized at each relevant level during the current year; the reason(s) for undertaking the advocacy and the outcome. Describe difficulties/ constraints being faced and suggestions on how to improve advocacy. An advocacy meeting was conducted at zone, woreda and community level with focus of CDTI philosophy popularization, increasing CDD number, including CDTI program in the supportive supervision checklist and strengthening task forces at all levels. 7 District/ LGA Mobilization of communities Training Census/Updat e Drug distribution Supervision Start ing mont h Compl etion month Start irrg mont h Compl etion month Start ing mont h Compl etion month Start ing mont h Compl etion month Start irrg mont h Compl etion month Metema Augus t2013 October 2013 June 20t3 July 20t3 July 2013 July 2013 Sep 2013 Oct 2013 Augus t 2013 Oct 2013 Quara Augus t2013 October 2013 June 2013 July 2013 July 2013 July 2013 Sep 2013 Oct 2013 Augus t 2013 Oct 2013 Tach armachiho Augus t 20t3 October 2013 June 2013 July 2013 July 2013 July 2013 sep 2013 Oct 2013 Augus t2013 Oct 2013 West Armachih o Augus t2013 October 2013 Jun 20t3 July 2013 July 2013 July 2013 Sep 2013 Oct 2013 Augus t2013 Oct 2013 Gendawuh a June 2013 August 2013 Jun 2013 July 2013 July 20t3 July 2013 Augus t 2013 August 2013 June 2013 August 2013 Chilga Augus t2013 October 2013 June 2013 July 2013 July 2013 July 20r3 Sep.2 013 Oct.20l3 Augus t2013 Oct.20l3 Tegede Augus t2013 October 2013 June 2013 July 2013 July 20t3 July 2013 Sep.2 013 Oct.20l3 Augus t2013 Oct.20l3 2.1. N,lobiliz:rtion, scrrsitiz-ation urr<l lre:rllh crlrrr:alion ol'al risk crlntntttltitics Following woreda level training, community mobilization and sensitizatton of community leaders were done soon. Health education manuals were distributed to all CDDs and community supervisors. Different types of posters were distributed to each village and posted at different places. More Flip charts were given to HEWs to be used as health education guide. Community mobilization and sensitization was done at each village using all opportunities; like social and religious gatherings including market places by HWs. FIEWs and CDDs. The community elders and the community administration as rvell as the community at large were the key players in facilitating the CDTI activities (selecting CDDs. fixing the Mectizan distribution dates and sites). l. t. t'r;ttrtt;trrtilr inr tllr e tiltlll 4: Communities in the CDTI 'lease add more rows neces,c Number of communities /villages with female CDDs 18.2 54 N.B: NA = data not available. 8 Number of CDDs and the communities involved Number of communities/villages with communitY members as supervisors Percenta Bll: Bro/Ba*10 0 ge Number of communiti es with female CDDs Bro Total Bg= B7+Bg Male CDDs Bt Female CDDs Bs Percenta ge B6: BJ Bn *100 Total no. communiti es in the entire project area Ba Number with communit v members as supervisor s Bsloistrictlt G4 i836 1510t227 2833163202Quara 3l8 52 t691t76226 t6Gendawuha 57 545 976431l8314 57Tach Arma 30 277 3891t22256 t2West Arm 76t26 648 I 10946155166 91Metema 45150 13311062 21500332Chilga 4485 1 056663 3930019sTegede 492 38 65464073 2473202591291Total Comment on: The number of female CDDs is much lower than males because women who are able to write & read also low in the villages. But remarkable improvement is attained in the report period in increasing female CDDs' numbers. - Attendance of female members of the community at health education meetings Female participation is the center of focus in all community based services in the country. The female participation is ensured through female development team; under which I to 5 formations is an active unit. This formal channel was used conveniently to convey CDTI messages and health education among the members of female community. Improved female CDD number is an evidence of addressing females. Conversely, relentless efforts are continued to ensure female participation on primary health care activities. In general, how do you rate the participation of female members of the community meetings when CDTI issues are being discussed (attendance, participation in the discussion etc). - Even though women are given more chance to participate in all important decision making meetings, their number is still low compared with men. Women's association is formed at each village and more women participation in every developmental activity has increased. Moreover, a woman development teams with its 1 to 5 structure was the instrument used in the country to raise their limitless involvement particularly in CDTI programs. However, due to cultural barriers their attendance, participation and involvement in discussion are still less than that of men. Incentives provided by communities for the CDDs Previously CDDs were participating in community based campaigns and paid perdiem. The FMoH has launched new policy for volunteer service in 2012. The core of the policy says every member of the community is responsible to participate in any preventive and control aspects of health and it is forbidden by law paying perdiem or any incentives for activities carried out at community level. Every family is responsible to produce its own health as part of its subsistence. This goes friendly with CDTI philosophy. Hence, no incentives requested or provided for CDDs in the reporting period. Is attrition a problem for the project? If yes, how is it addressed? - Attrition of CDDs is a problem for North Gondar project area. Attrition is common especially among settlement community. Replacement is the means to handle this issue. Moreover, increasing the number of CDDs to serve small HHs is instrumental to avoid volunteer fatigue. Otherwise, attrition is unavoidable problem for the project because experienced CDDs are leaving the service. 9 WHO/APOC, 24 November 2004 2.5. Capacity building - Describe the adequacy of available knowledgeable manpower at all levels. Zone level TOT and woreda level trainings were offered every year before conducting mectizan mass treatment. The training is cascaded to community level each year. This is the only remedy to overcome frequent transfers and dropouts. CDTI coordinators from zone, woreda and project advisors from TCCE supported Mectizan distribution to augment lack of trained human resource. Table 5: Training at the different levels of CDTI implementation (Please add more rou's if necessary) * 'New', 'Refr' : If detail not available, provide the corresponding total only. Make sure that there is no double counting. District/ LGA Number of Districts/ staff trained Number of Health center/post staff trained Number of other trainers of trainees ( TOTs) ATr o cr Ne w c2 Re fr Cj Tot Cq= Cz+ c3 ATr o Cs Ne w Ca Re f, Tot Cr= Cr+ CtC ATr o Cq Ne Re f, ct Tot. Crr: Cro* c,, w c1 0 I AT rO C,, Quara 27 0 27 27 5l 0 5 1 5 I 2 0 2 2 I I 5 0 1 8 5 132 i l5l 5: 0 Gendawu ha 9 0 9 9 8 0 8 8 2 0 2 2 t6 9 53i 116i 169 Tach Arma ll 0 1l 1 I 62 0 62 62 2 0 2 2 97 6 51 7t 4591 976 West Arm 11 0 11 33 0 i33i33 2 0: 2i 2 38 9 I 2 0 269 389 Metema 14 0 i 14", t4 59 0 is9is9 2 0 2 2 1l09 2 17 1109892 Chilga t2 0 i12i t2 75 0 75 75 2 0 2 2 13 37 1 9 2 114 5 133 7 Tegede 8 0 8 8 46 0 46 46 2 0 2 2 10 56 I 7 3 i 10s883i 6 Total 92 0 92 92 334 33 33 0 4 4 l4 0 I 4 1 4 65 46 14 57 350 89 654 6 100'h Achievement l0 0 Achievement I00 100 "/o Achievement I00 100 "/" Achievement r00 o//o 10 Numher of CDDs trained Ct, Ne ll, Tot Cre= Crr* Crs Refr Cts 1l Trainees Type of training CD Ds Other Community members e.g Community supervisors Health Workers (FLHF) MOH staff or Other Politic al Leader S Others (specif v) Program management How to conduct Health education Management of SAEs CSM SHM Data collection Data analysis Report writing Others (specify) Table 6: Type of training undertaken (fick the boxes where specific training u'as carried oul during the reporting period) Any other comments o CSM and SHM encouragingly improved 2.6. Treatrnents 2.6.7. Treatment figures If the project is not achieving 100% geographical coverage and a minimum of 65Yo therapeutic coverage or the coverage rate is fluctuating, state the reasons and the plans being made to remedy this. The project has achieved 100% geographic with average 82.7% therapeutic coverage in2013 ll WHO/APOC, 24 November 2004 Distric t lLGA Communities/Villages Population Num ber of absen tees Num ber of perso NS who refus ed the treat ment Nu mbe rof SAE s Numbe rof serious adverse events (SAEs) referre d to the health post4ro spital Total# of commu nities/ villages in the meso/h yper- endemi c areas Dr Annu al Treat ment Objec tive D2 Number of communities /villages treated D3 Geogra phical coverag e (%) Dr: Dt/ Dr * 100 Total populat ion of the meso/h yper- endemi c areas Ds Annu al Treat ment Objec tive D6 Nu mbe rof pers ons treat ed D7 Therap eutic covera ge (%) Da: Dt/ Ds* l0 0 Quara 202 202 202 100 99447 8353 5 823 03 82.7 L47t 224 0 0 Genda wuha 26 26 26 314 100 8745 7346 748 J 85.6 240 0 0 0 0 0 Tach Arma 314 314 100 92587 7711 3 147 27 80.7 706 1s0 West Arm 56 56 56 100 32799 2755 1 279 59 8s.3 276 136 0 0 Metem a 166 166 166 100 100612 845 I 4 852 54 84.7 1448 373 0 0 Chilga 332 332 332 100 I 38839 tt66 25 l13 066 81.4 4448 0 0 0 Teged e 195 l9s 195 100 74891 6290 8 623 43 83.2 7!28 9 274 0 0 Total t29t l29t t29l 100 547920 4602 53 453 135 82.7 7987 8 1757 0 0 Table 7: Treatment and SAEs by district/LGA in all areas at risk (Please qdd more rows if necessary) Formula for computing therapeutic and geoqraphical coverage Therapeutic coverage rate (%) within the project area (%) %UTG achieved Geographical coverage rate : Number oles(%) Total number of meso/hyper-endemic communities as identified by REMO in the project area ATO coverage rate Number of people treated x 100 Number of people treated x 100 Total population living in meso/hyper-endemic communities Annual Treatment Objective N@ Total number of people to be treated in meso/hyper- endemic areas within the project area (UTG) 2.6.2 Whart are the causes of absenteeistn? The coincidence of the distribution time with harvesting time and failure to retrieve absentees and failure to go repeatedly to look absentees at their home can explain the causes of absenteeism. Majority (94 %) of them were from four woredas (Quara,Metama, Chilga and Tegede). However, t2 the number of absentees reduced by two fold in 20l3compared to the year2012 whereas refusals reduced by 96% in relation to the previous year. 2.6.3 What are the reasolrs for refusals? Town dwellers are mostly registered as refusals for they think that the disease does not exist in towns and they don't trust CDDs to receive mectizan other than health workers. This shows that proper awareness creation is needed in towns. Among persons who failed to collect their medication , | .8 oA and 0.2%o were absentees and refusals respectively. The reason for not accepting the service is not well known and demands further study. But most people living in towns are from non onchoendemic areas. 2.6..7 l3riefly rlc.scribc'all knor.vn:rnrl verified scr-ious atlvcrse evcnts (SAlrs) that Occurred during the reporting period and provide (in table 8) the required Information when available. - Serious adverse effects (SAEs) were not observed during 2013 Mectizan distribution period In case the project did not have any cases of serious adverse events (SAE) during this reporting period, please tick in the box. No SAE case to report l3 O N L C) -o E 0) o z $N (-) o o- o 0) oo9 Ea - >i: U co o\ so\ o. c.)co o\oo \oo, oo\ r;@ \o o\ -t 00 o\ o o 0lADQ9 E e rt>= - q) o\ -itd *J > VE _ r -o r,(, co o\ $o\ o\ coco o\@ \oo\ o\ n € \o c<; o, ll *6€ rI] li ri (, =oo0) 6^(aL.o6 0)o\l- >vq)o E(JF @\o \otr- c- caF- F- r- r-r- \or- ;r- O@ \ c.l oo ri L E-:3Etr:(! Zr- oo eln\o oo $ @ $o\ 00 (\ c\ oo N $O9 (-.l oo a'l (-I 6 ri N \or)q} N r- @ c- $ C' rt, 2s? 5.. iE$ sv O @ o\o\ tr- o\ \O^ \o o\ (-rq o\ o\ r- oo + N oo o\ \o co ol r-ocl $NN o\\c) o oo co C.l o\r-o: N \o N a.l co N w IEL;€: *E r ." :J!Eoc)r-ii 3.ElE r-o aia) H \o @ cl c.l \ c.) c! .f, + N wdI o\vN $o \O^ a.lO c.) \o .f o- C.l ooC\ o\ c.I oo N co F- t-- ca @(\ r- cer- s art s(\ o\N ar o\F-$ oq) UT(! a 4) oQ q $t-B5 O O o o oO OO nr- o\ O E .9c, = -EEo =oSs-I *F 6 N ,_T._i ;o I --: q)v El t OO O o O OO v,] r- o\ O o q 0) u0 6! l-lrT3E O:5 {ri =tr1-z= co\o c.t $ o\ s o' $ o, t o\ $ o\ co$ oo c.)\o @ F-- oo c.l coN o\c.l f.l !or " 6.a EEB co co $ o\ s o\ $ $ o\ s o\ oo$ oo cn\o @ o\\o € O o\ a.l o\N o0)tEOLs L3r-= tcio..5 !I.[ B.I.-.G99JE -E.E E EF = q)! -Y 6) I s o\ $ o, s o\ s o\ o\ $o o\ oos oo c.)\o oo o\\o oo O o\ c.l o\N il f.l co o(\l so N |r) o o.l \ooO a.l rro N 00oo a.l o\o c{ o o c.l o c.l e.l o c.l c.) o c{ *(r a d (.) 6 C) q) bo e( q) I Fp cE fr cg tr o 0) q) (t) cg() l. oo q) 0) an raU) ol \os q) L I 0) oL o) l- -o 3F q) q) 6l(J r5 q) q) 6lq) er q) = t- U o) d(dotr (u nEC, c) '!i o.l o.= =ebo- c) -E:-riFLa,o F(d =oJO>'Lplk(dl Ptl oJ oltrElr3ti51 '=o!ooU(g c) oo tr! i(66J th r/tr oE Eis = .o)PE t o.1tn ol ,i 5l :(glNFI 2.7. Ordcring, storagc lnd tlcliver)' of ivcrntccfitt Mectizan@ ordered/applied for by - Qtlease tick the appropriate answer) MOH M WHOtr UNICEFE NGDC Other (please specify) Mectizan@ delivered by - Qtlease tick the appropriate answer) MOH M WHOtr UNICETtr NGDC Other (please specify) Please describe how Mectizan@ is ordered and how it gets to the communities The NOTF requests for Mectizan from MDP. After the drug reaches the country it follows the existing drug and other medical equipment delivery regulation system of FMoH. The drug is stored in MOH warehouse from which the project receives. This year, The Carter Centre has facilitated the shipment from Addis to Zone level and woredas as of its arrival to avoid further delay. It is from the Woreda, the Health Extension Workers get the drug and distribute to the CDDs based on census of each village and the CDDs to the community based on their height measurement. Table 10: Mectizan@ Inventory (Please odd more rows if necessary) Lost Wasted ExpiredRemaining from the previous year (2012) Requested Received (available) Used District/LGA 0 216 01 8886 26t000 279886 232774Quara 082846 0 82846 21360 0 r23Gendawuha 216851 0 864 0I 55459 248500 403959 0 20 09347 90500 99847 79681 0 3746 063 198 300000 363 198 243406Metema 0360000 467633 30800 I 0 1450Chilga 107633 59 0210000 2s4003 I 8588 1 0Tegede 44003 1951372 1287954 0 6538 0Total 481372 r470000 Tach \rmachiho West Arm Number of Mectizaoo tabl"tt How are the remaining ivermectin tablets collected and where are they kept? At the end of the treatment period, the CDDs return the remaining drug to their collection centers (HPs). The HEWs return the tablets to HCs and the HCs to the Woreda health office. Hence, the remaining Ivermectin is kept at the Woreda level. Remaining 46836 61363 t86244 20146 116046 ls8l82 68063 6s6880 l5 List and briefly describe the activities under Ivermectin delivery that are being carried out by health care personnel in the project area. . Training of trainers at zone level from onchoendemic woredas, mostly 2 participants, head of woreda health office and woreda CDTI coordinator from each woreda. . Training of health workers, community supervisors and CDDs on handling, distribution, maintaining stock balances, recording and reporting . Collection of Ivermectin from the Woreda level . Distribution of Ivermectin to community supervisors and CDDs . Supervision . Taking care of Ivermectin . Recording and reporting of data . Collect the remaining Ivermectine from the supervisors and CDDs and return to the Woreda. . Post Mectizan distribution review meeting at community and woreda level 2.8. Conrtrtuttit1 sclf-lnolriloring antl Sf:tkcholders N'Ieeting Has any training (of trainers) for community self-monitoring been done in the project area? No If so,When? o Training of trainers was not carried out for community self-monitoring separately, it was integrated with woreda level MDA training. Table I l: Community self-monitoring and Stakeholders Meeting (Add rows if needed) Gendawuha Tach Armachiho West Arm Metema c.!ilea Tegede 26 3t4 s6 166 aa^)3L 9 48 14 28 38 NA NA NA NA NA No of Communities that conducted stakeholders meeting (sHM) Total # of communities/villages in the entire project area No of Communities that carried out self monitoring (CSM) District/ LGA NA202 36Quara 195 t6 t9 NA Describe how the results of the community self- monitoring and stakeholders meetings have affected project implementation or how they would be utilized during the next treatment cycle. The CSM conducted in some villages of CDTI woredas brought changes on community leaders in supporting the program. The health development army in each village need to conduct CSM in the subsequent rounds of MDA. 2.9. Supcn isiort '2.9.1. Provirle rr f lor.t, r-'lr;tt't ttl .supcl'visioti lticrarcltv. NOTF ) ZOTF) WOTF ) Health Facility ) Community supervisors ) CDDs. Zones and woredas have made supportive supervision to CDDs and HFs What were the main issues identified during supervision? . Lack of proper and continuous supportive supervision at all levels . Poor document and record keeping . The involvement of woreda management staff to support HFs and CDDs was strengthened . MDA period shortened by using CBO, health development army . improvement on register updating and consistency of reporting in the reporting year 2.9.3. Was a supervision checklist used? Yes What were the outcornes at each level of CDTI implernetttation? The ZHD has carried out supportive supervision and that has helped on the improvement of document handling, record keeping, timely report submission, therapeutic coverage and geographic coverage. The strengthened taskforce at all levels was instrumental in shortening MDA duration at community level. 2.9.5. Was feedback given to the pcrson or groups supervised? Yes 2.9.6. Horv was the feedback used to improve the over;rll performance of the proiect? ' Heads of the frontline health facilities and woreda health offices heads are showing more concem to the CDTI program. r Integration of CDTI with the other PHC programs is being implemented at all levels. . Updating of village registers improved . Record keeping and document handling improved . Geographic and therapeutic coverage improved . Community awareness increased t7 SECTION 3: Support to CDTI 3. l. Iir;uiprncnt Table 12: Status of equipmenl (Please add more rov,s if necessary) *Condition of the equipment (F:Functional, CNFR:currently non-functional but repairable, WF:written off). How does the project intend to maintain and replace existing equipment and other materials? The existing equipments are being maintained by the goverlment budget. The project is still looking for replacement of equipments from APOC. F F Source Type of equipment APOC MOH - Zone DISTzuCT NGDO Others No Condition No Conditi on No. Conditi on No. Conditio n No. Conditio n All kinds of cars I F 2 F 3 F WF 2 NF Motor cycles 6 NF t2 F 3 NF 2 F Desk top computer 1 NF 5 NF 10 F LaserJet printer 1 NF 5 F 10 Photocopier I NF J F I Fax machine I CNFR I F I F Overhead projector I F I F LCD I F I F Megaphones 2 F TV I F I F VCR NF I F Generator J NF 2 F I F 18 I Contributor Year 9 (2011) Year 10(2012) Year 11 (2013) TOTAL Cash Budgeted (us$) TOTAL Cash Released (US$) TOTAL Cash Budgete d (us$) TOTAL Cash Released (us$) TOTAL Cash Budgeted (us$:17.29) TOTAL Cash Released (us$:17.29) MOH (Central+ State) MOH (District + zone) 6000 4723.45 3722.8 3722.8 3869 3 869 Local NGDO(s) ( if anv) 0 0 0 0 NGDO partners(TCC) 12000 t1922.98 1,673 1,613 21622 21622 Communities 0 0 0 0 APOC Trust Fund 11888.25 832t.6 t4574.9 14574.9 10018 l00l 8 TOTAL 29888.25 24968.03 19,970.7 19,970.7 3s509 35509 3.2. Financial conlributions of thc ;tartners atttl colnmunitics Table 13: Financial contributions by all partners for the last three years DNA - Data not available - If there are problems with release of counterpart funds, how were they addressed? There is no problem in releasing funds and APOC trust fund was also released at appropriate time in20l3 than ever. - Additional comments The MoH is contributing for mobilizing their staff and other stakeholders, coordinating project activities, storing and distributing Mectizan, providing trainings, covering communication costs, offering office premises for CDTI coordination, managing project funds, providing other logistical support, solicit financial support, record keeping, reporting and providing transportation services, etc. 3.3. Other frrrms of cotnrrttrnih' support - Describe (indicate forms of in-kind contributions of communities if any) The community leaders and leaders of health development army give much time in mobilizing the community during Mectizane treatment periods. t9 .1.{. Iirpcnditurc l)er activitl - Indicate in table 14, the amount expended during the reporting period for each activity listed. Write the amount expended in US dollars using the current United Nations exchange rate to local currency. Indicate exchange rate used here lUSD :16.65 Table 14: Indicate how much the project spent for each activity listed below during the reporting period Activity Expenditure ($ US=16.65) Source(s) of funding NGDO Drug delivery from NOTF HQ area to central collection point of community Mobilization and health education of communities Training of Cads 2000 2718 1019 TCCE APOC APOC of health staff at all levels Supervising CDDs and distribution Internal qqq4qi qg_o_l C D TI acti v i ti e s Advocacy visits to health and political authorities IEC materials Qlatqo rygy qq{p'i,tq!_e _ S forms for treatment Salary offocal persons Vehicles/ Vqlqrtvgl!{ lpvgE -etllqlqqgq-,- Fuel and oil Office Equipment (e.g computers, printers etc) Others 21622 4205 675 156 0 716 0 t2779 804.14 1130.11 0 0 TCCE APOC APOC APOC APOC MOH MOH MOH TOTAL* 47884.25 Cost per treatment for the entire project is 0.087 USD. SECTION 4: Sustainability of CDTI -t.1. Internal; irrtlependent participaton monitoring; Evaluation 4.I.1 Was Monitoring/evaluation carried out during the reporting period? [tick an.y of the following which are applicable) Year I Participatory Independent monitoring / _ mid Term Sustainability Evaluation 5 year Sustainability Evaluation Internal Monitoring by NOTF Other Evaluation by other partners monitoring by The Carter Center Ethiopia 20 4.1,.2. What were the recommendations? We are waiting for the ongoing monitoring results and once we receive the recommendations, we will act accordingly. 1.2. Sustainability'of proiects: plan and set targets (nurndatrtn' at Yr 3) Was the project evaluated during the reporting period? No Was a sustainability plan written? Yes When was the sustainability ptan submitted? on the 3'd year of the project What arrangements have been made to sustain CDTI after APOC funding ceases in terms ofl 'X,2.',. Pl:rnning at all relevetnI Ievels The CDTI activities are planned integrated with the other PHC programs at all levels. Therefore, the planning processes are carried out through participatory methods, using bottom-up approach and integrated with the basic health services. Resources are used to all health activities on integrated basis. 4.2.2. Funds Funds from the govemment and other donor agencies are utilized on integrated basis for all health programs. 4.2.3 Transport (replacement and maintenance) It is expected that APOC will replace a vehicle and motorcycles by the end of the 10th year. The RHB has allocated one vehicle to Quara Woreda received from other programs to be used for integrated health services. The existing APOC donated vehicle was maintained and is being used for integrated health services. 4.2.4 4.2.5 , Other resources - . To what extent has the plau been implemented The plan is well executed by the support of the government, APOC, The Carter Centre Ethiopia and the community at large. The CDTI activities are mostly incorporated and integrated with other PHC programs, even though support from APOC and The Carter Center Ethiopia is highly demanded. 4.3. Integration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration: The CDTI program is being carried out on integrated basis with the other PHC activities Supportive supervision, monitoring, treatment and evaluation, etc. are integrated. 2l -t,:1. 1. lvertnectin tlelivet'_y nrechanisttts Since the beginning of the program, there is no separate Ivermectin delivery system to the lower level; it follows the existing drug delivery system of the general health service. In other words, Ivermectine delivery is fully integrated into the existing drug delivery system of the country. 4.3.2. Training: CDTI trainings are integrated with the Primary Health Care (PHC) from the beginning at the National, Regional, Zonal, Woreda and HF levels. The Malaria and other Vector born disease section is responsible in taking care of the program at all levels. Therefore, all the staffs of these units have received training on CDTL Training of health work at Front Line Health Facility (FLHF) has been carried out in an integrated manner with other health programs by the concerned professionals from the ZHD, Woreda health office and The Carter Center Ethiopia. Amhara region. 4.:t.:1. f oint .supet'visir.ut and tnottitorittg with other programs As part of the system in the country, all sorts of supportive supervision and monitoring activities of the CDTI program are carried out in an integrated manner with other PHC programs. 4.3.,+. Relcase of furids foi irroiect activities The government, The Carter Center Ethiopia and APOC have released fund for the year 2013 CDTI activities. The government is paying the salary of all focal persons and allocates budget for supervision, fuel, stationary and vehicle maintenance, etc. All health activities are carried out on integrated bases using the allocated budget from the govemment and NGDOs. ,1.3.5. Is CD'l.l inclutled in the PHC budget? CDTI is included in the PHC budget. 4.:1.6. Describe other hcalth programs that are using the CDTI structure and horv this was achicved. What havc been thc achievcl'llents? CDTI structure is being used for malaria prevention, national vaccination programs such as Polio, TT, Measles and EOS. CDDs were contributed during these campaigns and are showing good achdvements. 22 a4.3.7. Describe others issues considered in the integration of CDTI. {.{. Operatiorral rescarch 4.4.1 . Summarize in not more than one half of a page the operational researclr undcrtakcn in thc project area within the relrorting pc,riod. Not done 1..1..'1.. IIou, r,t,r:re rhe results applied in the projcct? SECTION 5: Strengths, weaknesses, challenges, and opportunities Strengths: - 100% geographic coverage - High therapeutic and annual treatment coverage 82J% and 98.4%o respectively Weaknesses: - Continuous and regular Supportive supervision needs to be integrated to health tier system - Proper record keeping and documentation is still a problem in some HFs - Number of Absentees and Refusals is high in some CDTI Woredas Opportunities: o Two Health Extension Workers (Females) deployed at each kebele level for a population of about 5,000 is a good opportunity for effective implementation of CDTI and other PHC activities. o The expansion of the government structure to a village level has made it easy to execute PHC activities to a lower level. o Existence of health development army with friendly principles of CDTI philosophy . Females 'development team is being established and strengthened at each community will give a chance to increase their participation in CDTI activities. Threats (Challenges): . High turnover of health staffs especially at FLHF and woreda levels o Late arrival of Mectizan. 23 SECTION 6: Unique features of the project/other matters North Gondar zone CDTI Woredas is very green, fertile and forests are very attractive too. Its virgin land is producing Cesium, Cotton and Gum which have great share in economical development of the country attracts a large number of daily laborers. The biggest National Park of the country. Alatish Park is also found in Quara CDTI Woreda has great tourist attraction. a ) 24