East Wollega CDTI annual project technical report submitted to Technical Consultative Committee (TCC): January 2011 to December 2011

COUNTRY/I.{OTF: Proiect Name: East Wollega Approval year: Launchins year: 2005 Reporting Period From January 20ll to December 20ll(Monthpz"lp; ( Month./Year) APOC fundine vear: (circle one) I 2 3 4 5 7 8910111213 A r e one 123456 7 910111213 Date submitted Partners: Ministry of Health African Programme for Onchocerciasis Control (APOC) Mectizan Donation Program (MDP) <enter the name(s) of supporting NGDO(s)> <enter the number of communities> communities The Federal Democratic Republic of Ethiopia Ministry of Health ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) DEADLINE FOR SUBMISSION: i To APOC Management by 31 Januarv for March TCC meeting : To APOC Management by 31 Julv for September TCC meeting AFRICANPROGRAMME FOR ONCHOCERCTASTS CONTROL (APOC) --,**sa , i ;t -4'*xt { I i I ! i I i i I I nt ril,iqe t tl i : iPfu ,'i].i hfi;rr.'."$t AAI I .tj Ai i€. '"' tr, R. IS *I I j t Ij { iI t , ."I .' , -; ''-.'\ 4 p ri ,fl WHO/APOC, 14 September 2009 ! .i : , It ? r t : I -I ANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) ENDORSEMENT Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the report: Country: Ethiopia National Coordinator Name: Mihret Hiluf Signature Datel Zonal Oncho Coordinator Name: ...Ato Insermu Jaldu Signature Date NGDO Representative Name: Ato Dubiwak Gemeda Signature Date: This report has been prepared by Name :Ato Dubiwak gemeda Designation Signature : ... Date I ll WHO/APOC, 14 September 2009 I : I I I ! I ! ! i I I : ! i i i I i I I : I I i I I I ,N'd\\c'T ANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) ENDORSEMENT Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the reporf: Country: Ethiopia National Coordinator Name: Mihret Hiluf Signature : . . . r.ff..Y3.,L*,.,*.n Date. .....1-s}'n".)PflV.' .. Zonal Oncho Coordinator Name: . . . Ato Insermu Illihdt Hiluf Nigrrule (RN, BSc, tfI'H) Hc:ith Ploruof ion and Ft"''' .:1.::. F -"trsi,aln DlrccFr :t' a/c / r;irf t\ I ! t t. 'i I I : ! : t 'I 'l I I I : I t ! ! I I I ! I t i I I : I : : I : I i I I \) I Signahue.... Date: t( .+ Tf"' -5r .\ l. ,(. t) G .:L 4.., NG Ve Name: Dr. Zerhun Tadesse k ,t- '?.: I rC | - is+i. Signature, 3::.t+{ Date: ol*-[kt] ThiS report by Name :Ato Dubiwak gemeda Designation Signature : Date , ttti' I I I lt WHO/APOC, l4 September 2009 '-"-l Table of contents ACRONYMS....... .....v DEFINITIONS VI FOLLOW UP ON TCC RECOMMENDATIONS 7 EXECUTIVE SUMMARY ......... ....8 SECTION l: BACKGROUND INFORMATION........ ...................1 l.l. GpNpRar- rNFoRMATroN................ .....................11.1.1 Description of the project (briefly) ................ I1.1.2. Partnership . Error! Bookmark not de/ined.1.2. Popu1arroN............... .....................3 SECTION 2: IMPLEMENTATION OF CDTI... ERROR! BOOKMARK NOT DEFINED. 2.1. Tlvprtxp oF ACTrvtrrES ...............2.2. Aovocacy 2.3 Mogtl.tzerloN, SENSITIZATIoN AND HEALTH EDUCATIoN oF AT RISK coMMUNITIES .. 6 2.4 Couuuxry TNVoLVEMENT. CapacmyBUILDrNG TnrarupNrs....................... . Treatmentfigures......... 2.5 lIthat are the couses of absenteeism?.... Wat are the reasons for refusals? ....... Briefly describe all known and verified serious adverse events (SAEs) that Tre nd of tre ot me nt ac h i ev e me nt fro m CDTI project inception to the current year I42.7. ORoERtNc, sroRAGE AND DELTvERv oF IVERMECTIN .. t52.8. CouuuNny sELF-MoNrrozuNGAND STAKEHoLDERS Mrsrruc t62.9. SuppRvrsroN t62.9.1. Provide aflow chart of supervision l72.9.2. Ilhat were the main issues ide nt ifi e d dur ing supe rv i s i o n? t72.9.3. Was o supervision checklis 't used? l72.9.4. V[hat were the outcomes ot each level of CDTI implementation supervision? l72.9.5. l{as feedback given to the person or groups supervised? l72.9.6. How was the feedback used to improve the overall performance of the project?I7 SECTION 3: SUPPORT TO CDTI 3.1. EeurpvpNr. 3.2. FruaNcral coNTRTBUTIoNS oF THE pARTNERS AND coMMUNITrES... 3.3 OrupR FoRMS oF coMMUMTy suppoRT.3.4. ExpeNorruRE pER AcTrvrry SECTION 4: SUSTAINABILITY oF CDTI.. Ennon! BooruaRr xor DEFINED. .............6 2.6. 2.6. t 2.6.2 2.6.3 2.6.4 2.6.5. 4.1. INrenNal; INDEpENDENT pARTICTpAToRy MoNIToRTNc; EvalunuoN............. 4.1 . I Has the proiect ever been evaluated/monitored? (fick any of the folowing are applicable) ........... 4.1.2. Wat were the recommendations? which 4. 1.3 4.2. I Yn 3) ... . How have they been implemented?....... SustalNaalLrry oF pRoJECTS: pLAN AND sET TARGETS (MANDAToRy AT .... 2 ,,23 ..23 ..23 ..24 ..24 WHO/APOC, l4 September 2009 t7 l8 23 23 23 ill 4.2.1. Planning at all relevant levels 4.2.2. Funds........ 4.2.3 Transport (replacement and maintenance) 4.2.4. Otherresources... 4.2.5. To what extent has the plan been implemented 4.3. INrecRerroN............... 4.3.1. Ivermectin delivery mechanisms 4.3.2. Troining ; ; ;,: ; i u;;,,;, i ;;,,; ;; ;;; d,n,: ;. Error! Bookmark not de/ined. Error! Bookmark not defined. 26 26 26 26 26 26 26 4.3.3. 4.3.4. 4.3.5. Joint supervision and monitoringwith other programs Release offunds for project activities Is CDTI included in the PHC budget? 4.3.6. Describe other heolth programmes that are using the CDTI structure and how this wos achieved. What have been the achievements? ............. ..................27 4.3.7. Describe others issues considered in the integration of CDTI. .....27 4.4. OppnarroNAl RESEARCH.. ..................30 4.4.1. Summarize in not more than one half of a page the operationol research undertoken in the project orea within the reporting period........ .................. 30 4.4.2. How were the results applied in the project? ............. ..................30 SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, AI\D OPPORTUNITIES....... 30 SECTION 6: UNIQUE FEATURES OF THE PROJECT/OTHER MATTERS...........31 lv WHO/APOC, 14 September 2009 Acronyms APOC ATO ATrO CBO CDD CDTI CSM LGA MOH NGDO NGO NOTF PHC REMO SAE SHM TCC TOT UNICEF UTG wHo African Programme for Onchocerciasis Control Annual Treatment Objective Annual Training Objective Community-Based Organization Community-Directed Distributor Community-Directed Treatment with lvermectin Community Self-Monitoring Local Govemment Area Ministry of Health Non-Governmental Development Organization Non-Governmental Organ ization National Onchocerciasis Task Force Primary health care Rapid Epidemiological Mapping of Onchocerciasis Severe adverse event Stakeholders meeting Technical Consultative Commiffee (ApOC scientific advisory group) Trainer of trainers United Nations Children's Fund Ultimate Treatment Goal World Health Organization V .} WHO/APOC, 14 September 2009 Definitions (i) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking). (ii) Eligible population: calculated as 84%o of the total population in meso/hyper- endemic communities in the project area. (iii) Annual Treatment Objective: (ATO): the estimated number of persons living in mesolhyper-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 mesoftryper endemic areas within the project area, ultimately to be reached when the project has reached ful1 geographic coverage (normally the project should Ue explctld to reach the UTG at the end of the 3'd year ofthe project). (v) Therapeutic coverage: number of people treated in a given year over the total population (this should be expressed as a percentage). (vi) GeoEraphical 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 govemment. (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 WHO/APOC, l4 September 2009 FOLLOW UP ON TGC REGOMMENDATIONS Using the table below, fill in the recommendations of the last TCC on the project and describe how they have been addressed. TCC session I WHO/APOC, 14 September 20097 Number of Recommendation in the Report TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT ASE ONLY The report should be rewritten to provide missing information on advocacy The given recommendation is accomplished. The level of implementation of post sustainability plan and other missing information in the report should bg provided Post sustainability plan and other missing information is provided (Please add more rows if necessary) Executive Summary Onchocerciasis used to be an important public health problem in east Wollega with 1,254,974 people at risk, and many suffering from debilitating skin disease, terrible itching out of which 868,680 are in CDTI districts and 390,294 are in non CDTI. Therefore, CDTI project was launched in 2005 with the aim of eliminating the disease from the zone. East Wollega is one of thelTth zones of Oromia Regional State located in the Western part of the region. It is divided into l7 districts out of which nine of them are CDTI districts. The CDTI districts are sub- divided in to 159 kebeles / sub- districV and the Kebeles are further sub- divided into 3546 communities/ villages/.The villages are affanged in such away that they can consist 30 to 40 households. The total population of the zone is 1,254,974. On the other hand, Bako Tibe district which is located in west Shewa zone and included into East Wollega CDTI project has the total population of 113,407 .lt is subdivided into 31 kebeles/sub-districts/ with 753 communities/village/.Thus, the total population of East Wollega CDTI project is 869,620 including the population of Bako Tibe district. Similarly, the total village of the project is 4299. The ATO, and people treated were 712,318 and 717,348 respectively. On the other hand, about 1521272 people were not treated among refusal and absenteeism were 917821 6oh/ and 2414061 160/ol respectively. The number of absenteeism is greater than ever due to the movement of the community for farming. In some districts, the people move from highland to low land within the districts for farming during Mectizan distribution and CDDs are among the movers. Before conducting training at all level training need assessment was conducted to prioritize what skills should be learned. As usual the training was given at zone and districts level for 179 new and refreshed 661 health workers. Likewise, 161 new and 11,282 CDDs were trained/ retrained. On the training, district focal persons and all health center staff were participated. The training was given on how to prepare plan at their level, the need of int.g.ating Onchocerciasis with other programs, how to conduct Community Self Monitoring /CSMi, the importance of supervision, community mobilization and document management. In addition, the role of community leaders in the implementation of the project and methodology of CDD training were included in the training. On the other hand 400,907 male and 417,273 females were mobilized while 689,911 people have got health education. Each Health Center is responsible to supervise and support five satellite health posts in their catchments areas. The lack of transportation facility for program officer and the delay of Mectizan release from the donor were the main challenges. However, the challenges were overcome by finding other altematives. It is planned to expand the project to West, East, Horo-Guduru Wollegs and West -Sh.*u new districts in seven, five, one and two districts respectively. Action plan was prepared for each zone and submitted to MOH. On the hand, there is a plan to conduct final REMO refinement in East, West, Horo-guduru Wollega and West Shewa to cover the rest of the districts that are at risk of the disease. 8 WHO/APOC, l4 SePtember 2009 SEGTION {: Background information 1 1 General information 1.1.1 Description of the project (briefly) a East Wollega is located in the Western part of Oromia Regional State. It shares boundaries with West Shewa and Jimma zones in the East, West Wollega in the West, Horo Guduru zone and Amahara Regional State in the South and Ilubabbora zone in North West. All are CDTI project zones except Horo- Guduru. The total land area of the zone is about 21,980 million squire kilometers. The zone has a diverse topographic feature that ranges from 500 to 2,600. There are three climatic zones Low, Middle and high land with temperature ranging between 22 to 28 Co .The zones is divided into 17 districts out of which 9 of thern are hyper and meso-endemic areas. The districts are again sub-divided into 159 kebeles/ the lowest administrative unit/. There are four big rivers in the zone, namely Gibe which is between West Showa and East Wollega zones, Didesa, Anger and Uke. The zone has many other small rivers and streams that drain into the basin. East Wollega is home for diversified people with multi cultural and multi- lingual richness. Over five ethnic groups and languages are believed to exist in the zone. Some of them came from different regional States and zones of Oromia Regional State in the last three decades for resettlement. Christianity and Islam are the two major religions. Out of the total population about 85% live in rural areas, largely depending on subsistence farming. Male to female sex ratio is I to 1.1. Women in the reproductive age group I 15-49/ constitute 22.9% of the total population. Infant / < I yearl, under-five and under 15 years children, account for 2.62Yo, l4.76yo and 45.42o/o of the total population respectively. There are 30 Health centers, and 190 Health posts with 812 health personnel of all categories. The available information indicate that the majority of public health problems of the zone include among others, malaria, tuberculosis, HIV/AIDS, child health illness and reproductive health problems. Similarly, parasitic infections and other vector - borne diseases like Onchocerciasis are among the serious public health problems in the zone. All districts have all weather roads except most health facilities. Besides high health service coverage, now the zone is experiencing another opportunity such as Balanced Scorecard /BSC/ that enhances the quality and speedy health service provision in the zone. It is also a tool of strategic plan and management that tracks performance against the plan and mission of the ministry of health. This also helps the implementation of oncocerciasis control program in the zone. t WHO/APOC, l4 September 2009I Table l: Number of health staff involved in CDTI (Please add more rows if necessary) Number of health staff involved in CDTI activities. Total Number of health staff in the entire project erea Br Number of health staffinvolved in CDTI B2 Percentage B.=Br/B, *Ifi) Guto Gida 83 75 90 Diga 9I 88 97 Leka Dulech 81 77 95 Sibu Sire {s 88 99 Wama Hagalo 68 68 r00 Boneya Boshe 48 48 t00 Jimma Arjo 77 77 100 Sasiga lt2 100 89 Wayu Tuka 65 65 r00 Bako Tibe 122 lll 9t Total 836 797 96 1.1.2. Partnership As usual the partners involved in the project implementation for the year were APOC, Light for the world, Merk Co. the Carter Center Ethiopia, MOH, district administration office and communities at large. Thus, there is good working relationship among the partners in exchanging information and performing certain tasks to ensure their involvement. The Carter Center Ethiopia, MOH, WHO/APOCi and Light for the World have participated in conducting training and review meeting. In addition, the ministry of health and Light for the World has cooperated in preparing action plan for 2012, in conducting supervision, advocacy and social mobilization. There is plan to mobilize decision makers from the districts and community leaders from the lower level especially in new districts where REMO was conducted in 2010. The attendance and participation of females in decision making is still low. Because, females stay at home taking care of their children and cattle and cook food. So far no incentive was provided by the community for CDDs. Since the attrition of CDDs is insignificant it is not a problem for the project. Even if it occurs it is possible to select the new ones and train to replace the missing ones. 2 WHO/APOC, l4 September 2009 o\ O c..t 0) .o (.) o.() a =t p '\\\p I I $L q) .a o E Sss8 x-'5U\ta. --u:\ .Y\cl o'\r.\B up .s ,\ -tSs bo'B*PiBq)!* tBs r\qr< L\ $q, i:\ h()snsp 5\ s.Y EHtr* sdBr$-:\g -dt -. q) s'\ ts-EN\ b*' -o: s\\s '-L E3 qJ.{.Y crs dqoBU -- bo .:=)\ lud t\S v1 L q)L -;l ! TJ o Lo o. oo Eo o. 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C) L € t,)(t') Eo L) CB U) 63 B -7 o c.. oC) r) -o(u I -ocdl;l -ql €l .El €l dlE-l o=E tt)(H c)oo 9.t E (,(Boz .38 E:3 Ed6> d z ilt o\ c.l 0.) o o. 0) a t Q o a. > O ao L3 o a0E,E aE o. o L th a0 L a o rE Q bI) boEE (!: 6)c q) Ea o o q)I .)= oo \JO 6, 2 boEE liEi9 o. a0 E] fitl -l o a5 EE(J o L z a0EE 1iE hd k of! - q,) .i'E s= oo!l c.)2 o o.=EEc(J co 2 a0at I'E o. j I tr U) a !0! G bo H o C) H (B&oJ o a -o c/) ag bo (! d > ot o xoco ra o a 6t oo( U) c,li F (.) -oi: o .v G, c0 F] F oF lr) a\ r-. %q q) U v1: L \ o t q) U L(!(l) >. C)Lt- o o o 0)L th(o 0.) (0 C) L ,o (r') C) o(n (H o q) o F ".ir6)l -ol(gl FI o .gIar a-t, o G|F o og -o E F a!F N Fo o 5 o tr .9# G{J tr o Eg c! aaN z o IF o luo an c o) oU I+ 2.2. Advocacy 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. Advocacy was conducted at sub-district level for community leaders and Managers. 2.3. Mobilization, sensitization and health education was conducted for a risk Gommunities, Thus, 4OO,9O7 male and 4171273 females were mobilized while 689191{ people have got health education. -Mass media can be used, but APOC did not allocate the expense in the budget ltems. - Mobilization and sensitization of the target communities can be improved by involving community leaders, managers, religious leaders, CBOs and others. 2.4. Gommunity involvement Table 4: Communities participation in the CDTI (Please add more rows if necessary) 23 7.7 6 Number of communities/villages with community members as supenisors Number of CDDs and the communities involved Number of communities /villages with female CDDs Total no. communities in the entirc project area B. Number with community members es supervisors B< Percentrge Bo= B./ B. *100 Male CDDs Bz Female CDDs Bs Total Bo= Bz*Br Number of communities with femele CDDs Bro Perccntage Bu= Brr/B.*100 Guto Gida 489 489 100 1332 214 1546 t02 2t Diga 4ll 4ll 100 648 42 690 22 5 Leka Dulech 376 376 100 976 275 t25l 88 Sibu Sire 578 578 100 t260 93 l 353 45 Wama Hagalo 269 269 100 626 2 628 I 0.3 Boneya Boshe 250 250 100 472 3 475 I 0.3 Jimma Arjo 422 422 r00 t454 239 1693 89 2t Sasiga 404 404 r00 1049 52 I l0l l2 3 Wayu Tuka 347 34'7 100 986 263 1249 65 t8 Bako Tibe 753 753 100 1271 25 t296 6 0.7 Total 4,299 4,299 100 10074 1208 ll,2E2 431 100 WHO/APOC, 14 September 2009 Comment on: - Attendance of female members of the community at health education meetings - In general, how do you rate the participation of female members of the community meetings when CDTI issues are being discusses (attendance, participation in the discussion etc). - Incentives provided by communities for the CDDs - Attrition of CDDs. Is attrition a problem for the project? If yes, how is it addressed? - Other issues -Attendance of female members in health education meeting is low when compared to males. On the other hand, attendance and participation of female members during discussion of CDTI issues is also minimal. - Even though trial was made still there is no incentives provided by the Communities for the CDDs, that is why there is attrition which was addressed By training and replacing by the new once. 2.5. Gapaclty building - Describe the adequacy of available knowledgeable manpower at all levels - Where frequent transfers of trained staff occur, state what the project is doing, or intends to do, to remedy the situation. (The most important issue to describe is what measures were taken to ensure adequate CDTI implementation where not enough lmowledgeable manpower was avoilable or if staff are frequently transferred during the course of the campaign). Training is given for all categories of health personnel every year at all level. Thus, there is no shortage of knowledgeable manpower. However, frequent transfer of trained staff is occurring any time, especially head health districts and Oncho Focal persons. On the other hand, during the course of the campaign some health workers are leaving to attend summer course. Besides, zone and districts Oncho. Focal persons engage in malaria control activities. However, there is an opportunity in using Health Center staffs that are available all the time in their catchments areas. It is believed that Health Center staffs can solve many problems by supporting health extension workers and CDDs. Due to delay in receivin g mectizan from abroad every year the campaign is carried out in the winter when health workers attend summer course and the community and CDDs are engage in farming. 'I WHO/APOC, l4 September 20097 r,o 6l 0 e e(J q) € z .i LV: .U .s .:tv ir ev \o+ \o o\s o\\o \o a.l N co a.) c.l 6N\o \o r-. =l t t N \o o\\o o\ =cl o\6l c..l a.l \o ot \o o\ o{ N6cl t\a \o Aq) Eq) (J .) s U o F \o F- c.l $\o \o\o o\\o \oc.l \o o\N rai-! o a) (u .=c6t t< r- Fro): oq)|FP LF €)L z 6 .i t bu= tsO r:zv N\o F-$ r- <f al+ € @ ooa <+ <t o\F- F-\o a.l oo oos e.l a.t\o l+ € c.l r- \o o\ € c{ ?al F-t- o\a|a ? € a(l) o q) \0 U O\o \o o, F- F- N 6o\ \oo\rr E(l) -4 =c!ettt- f;E Eg -rEtr> 2E €)I E,'l? S-\ .yv U @\o r- € rr\o .+ F- @ N F- ca oo oo €I sl o\ c.l \o F- sf + oo o\ \or- t{6l 00 00r- raor- Nt ra \o a) a) iU \o U a\o @ Dr F- € s \o @ @ raorr 6l 0 at ItI 8e()() iic o q)E z .? E.'l +F-d U o< = o\ a \o c-l o\ oo 00 \o sl' (\ c.l * 6 6\ 6l Eoa o tl) s UYF @ a \o =f + r.) ()J 0 6! o 6bo oo o(! -va o ch -o rr') (€ hod 6 H o o ca 6 o ca o 6l d UD 6t(n lz F x s, > o €F IZ(! EA Fl F oF o\ N o .o E o o.oO sf (.) > oo $ €I € I (! I s o c o 60 ttI * F o o I t o o_ 6B i o t\ \ :. = A qq a)Q\J q i r. uL -: q) 4Bq) s o (0 tro C) o tr F oU tH at) 0) o oL _o!# o (d bo tr r! F ,iit ol -ot(dl t-l Table 6: Type of training undertaken (Iick the boxes where specific training was carried out during the reporting period) - Any other comments Since the above listed training topics do not addressing all CDTI activities, management functions such as planning and supervision were included. 7 WHO/APOC, l4 September 20099 Trainees Type of training CDDs Other Community members e.g Community supervisors Health Workers (frontline health facilities) MOH staff or Other Political Leaders Others(speci&) Program management { { How to conduct Health education ./ Management ofSAEs { { CSM { { .i SHM { { { { local NGOS Data collection ./ { { Data analysis ,v Report writing { ./ ^/ Others (specifu) o\a e.t o -o E 6) o.oa $ q)() q) 4: oL s.)r. o t q) Fa \) &tr) L ad U) Cd C) r<(! (! 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Eso c:A o*d rr Erq N6o { F: o\ r 8 @- r o\ 6 ll rd^- E .9o -o- !EF5 6Da uoo o o ts.u .-g.t [i rQ -8 5 SH =E>!zd o o\ €+ * \ot- 6t- o\\o c.r a.l a.lNI + + r\ -l r- o\g\ .lt a =od O.= aQo c 6.: ,'l I -o' Fv o\ oo + t \ot- €F- o\\o N o N ai o^tt ta = t-. -f r o\ o\N i o\ €$ -t \or oor\ o\\oN a.l a16lt + + F-+ c- o\ o\6l = V)o b0 cO cno tr) tr o(J >9 ' 8a o:J i oo5-x! = E;i.gxg EgES- . 8= E E (g ! € b0 H oo H (6 .voI o c/) -otn (g h! > (! >roOEc6oo ca ca cl E 6l BI 6l O Cgv F >r Cd o -o F li o t] F oF .9<;v o\ a] (.) -o E() o.() U)\t (J <o $ E $ g 3-EEO!'(oYSii 5E 'ad\EE.HSI€-aBA.E'aX.g o F lsf = E $ s € a .= 'a: .=>,=:tE : r.:r.; B HIE;Es$aor- hF-o =b.eXsEEE;SaE I €'-r=$E ? 5 r.E3 € t Xte 'E Es $E o, E -4. € b € =I E B E FE ;Ig E f; ISE Et'E f $ ti e sE $l ?* ?r : Ets 5l ; El $ rln :l; s l_=g $Ig ElE fiI{ HIE i $i tl il€ EI; il€ d? * Ss$ :t 3 :tE :tr ?tE i E,s sl €l; €l; #lE #l; s r f El zt1 zt1 zti zt1 i $i .el s iEEl 'l -s -s$|, , ,r r EtEbr $ $sEt e tF$ s1 E E SrS =l rr bI)dr s E - S iSA E P g '!, i s.. 5I T A E H E I"q fl *s as f,s E 3 S$Er ts E ! F f tEEl E H' z , s oE €l F d ? s \ SS 2.6.2 What are the causes of absenteeism? As usual, every year the community moves from one place to another for farming. 2.6.3 What are the reasons for refusals? *Considering them selves as free from the disease. 2.6.4 Briefly describe all known and verified serious adverse events (SAEs) that occurred during the reporting period and provide (in table 8) the required information when available. * No case was reported . Parasitologist trained? No o Existence of microscope? [t is available in some health facilities . Has the project reported all SAEs to Mectizan Donation Program (MDP)? Please tick one. {E No ! Yes In case the project did not have any cases of serious adverse events (SAE) during this reporting period, please tick in the box. No SAE case to report t2 WHO/APOC, l4 September 2009 o\ c.l ro -o o o.o c/) sl (J(J 0. o > ao ! 0) L oq C)Lr q) d B (l)(n do oz U'o oz\ o' .o \ -uv) t : !) \ o \: B ci s o o. bI) E o o.o o bo E !o E ooo 6 q.l (/) t^ C) o 0.)th Lo E o o o(h q< o U) C) ah(d(-) ool Iol -ol cdlFI o oo :: A90= -Y>: <.E 5 Aa - doy.5 E !G:GOb fiEgqJ U'6 o.9E2 3F" (J O- =o9E *E ag d.9ot € d6 o.2= iq E E= A€EE !o =Ed:! o! ct 6bD (ql -hJd -c o.NE€ 8i O=LSZ o a. U) t=a -xEo =o Hod =o .N .E{rE: 5S y o o P.s =h0ao xo U) o 6I) I * (, o\ c.l Lo -o E C) o.oa$ \J o B \f o d n gD C o = C o C E E ! C U Io C o o o € FD I I d o Ar L G c) c)t-t- q) 0) o :.iiasEiE.S (.) i()$ t- .= F}F8 trgOc&E!'e o 0)E o9(,,€ 6 oEl 501cr 3lg.al EqPoHEB q)E rrEFs .r;P \o !q .gNF o,l d d FI a@ o oO !J 6 N 6 6 O6 O N t tro a) OJ ot o.t t rt i t.5rd r.l o 9 S:aF 06\ -o I d 6 oa O No $ t ll * t{ grl f.l os o o 9 8. E F r r r r N N a ri !o o o oq o o3 E z \o6 N N €\o6r N" a r 8- \o\o\o =Er @$ F- a- hl =o?E> =troed=i O3' FU d \o€ \o N r o\O. 6\ N € \o I r € rt: € o\ € F- 9 .,3E Eg = o t+d AE€:A ._'E€6 Eg F r \o € N ri r \o c.l N €r 6 a € Iq @ N o\ 00 H td il f.l o e s:;F 06\ -o a o 6 o, g No <1, 9s, I -*8o,,-f Fo:e)rd Idtj B O I g E E E Oo t{ E9 - 3 5 P€E C= O =Et.!,ao a o\N IN^ EN" o,6N^ o\o\ .l <t EI :o do= CEY J o0' FU o\aC\ :f a6N. o6N. 6oNN o\ o\c{\t a, !"E eq= XiJo >! L TEE:o E E:E . EE EEc o\6d^ 6 o\N. :f o\6 .{\' o\ o\ct o\ o\6I sf &66 666 EN N 9! N N oN N E N ro N @ N o.aoN N e.l 2.7. Ordering, storage and delivery of ivermecti Mectizan@ ordered/applied for by - Qtlease tick the oppropriate answer) MOH tr WHO! IJI\I"ICEFtr Other (please speciff): Mectizan@ delivered by - Qtlease tick the oppropriate answer) MOH tr WHO f] T]NICEF f] NGDON NGDOtr Other (please speciff): Please describe how Mectizan@ is ordered and how it gets to the communities Every year the ministry of health orders mectizan according to ATO of the project zones. When it arrives from abroadthe ministry of health receives and distributes to the project zones based on the process of drugs supply system. In turn, the zones distribute to their respective CDTI districts, where it is distributed to health facilities following drug procurements system of the country. Then the health facilities give to the representatives of the community or CDDs according to the number of their target groups to be treated. At the health facility level sine there is no formal format the informal one is produced on which the community or CDDs sign when they collect the drug from the health facility. The near by health facility collects the remaining Ivermectin tabs from the community and takes to the districts pharmacy unite where it can be stored. At the health facility level the balance of the drug is checked in order to avoid wastage. At the district level the drug is stored in drug store until it will be given to health facilities. It is stored according to the rule and regulation of drug store system. First come first out drug system is used at all level. Table l0: Mectizan@ Inventory (Please add more rows if necessary) How are the remaining ivermectin tablets collected and where are they kept? rL WHO/APOC, l4 September 2009 State /District ILGA Number of Mectizano tablets In stock from previous year Requested Received Used Lost Waste d Expired Remai ning Guto Gida 0 200,000 198,377 0 lt87 0 436 Diga 0 176,000 174,576 0 tt2 0 t3t2 Leka Dulech s62 I 87,500 184,150 0 1428 0 2,484 Sibu Sire lll 281,000 278,473 0 l14l 0 t497 Wama Hagalo 0 I 30,500 129,851 0 424 0 225 Boneya Boshe 0 I 35,000 134,708 0 292 0 0 Jimma Arjo 0 205,000 204,688 0 312 0 0 Sasiga 354 I r90,000 t93,157 0 384 0 0 Wayu Tuka 0 l 65000 164,539 0 46t 0 0 Bako Tibe 23,919 242,500 264,487 0 618 0 l3 l4 TOTAL 28,133 1,912,500 l,g27,006 0 63s9 0 7268 l5 CDDs give back to the health posts. Health posts to district health offices where is kept and used for the next year. List and briefly describe the activities under ivermectin delivery that are being carried out by health care personnel in the project area. Identifu gaps for training Prepare training proposal train health personnel atzone and district level Train CDDs and community supervisors conduct mobilization, sensitization advocacy and health education assist CDDs and community supervisors in Census up dating Check the amount and collect the over Ieft Mectizan from community supervisors and CDDs. distribution of the drug conduct intensive supervision before, during and after distribution collect, analyze and send a report to the concerned bodies conduct meeting with stakeholders carry out CSM conduct review meeting at all level 2.8. Gommunity self-monitoring and Stakeholders Meeting Has any training (of trainers) for community self-monitoring been done in the project area? Table I l: Community self-monitoring and Stakeholders Meeting (Add rows if needed) District/ LGA Total # of communities/villages in the entire project area No of Communities that carried out self monitorins (CSM) No of Communities that conducted stakeholders meeting (SHM) Guto Gida 489 None None Diga 4tt None None Leka Dulech 376 None None Sibu Sire 578 None None Wama Hagalo 269 None None Boneya Boshe 2s0 None None Jimma Arjo 422 None None Sasiga 404 None None Wayu Tuka 347 None None Bako Tibe 753 None None TOTAL 4,299 none none 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. CSM is not carried out because, all Heath extension workers were engaged in other programs. abov6 all,It requiers long time and huge money. l6 WHO/APOC, l4 September 2009 2.9. Supervision 2.9.1. Provide a flow chart of supervision hierarchy. NTOF--TROTF ---ZOTF-+WOTF---rHealth facility Comm unity Supervises --+ CDDs 2.9.2. What were the main issues identified during supervision? Poor census updating loose of supervision from health facilities to villages poor record keeping staff turn over o a a a 2.9.3. Was a supervision checldist used? Yes 2.9.4. What were the outcomes at each level of CDTI implementation supervision? . The knowledge and skill of the supervisee is increased o Problems were solved to some extent. o CDTI activities were improved 2.9.5. 2.9.6. How was the feedback used to improve the overall performance of the project? As it is mentioned above the supervisee have learned from their mistakes, and their knowledge and skill have increased. As a result, all CDTI activities were improved and therapeutic coverage was increased L3 WHO/APOC, l4 September 2009 Was feedback given to the person or groups supervised? Yes o t7 SECTION 3: Support to GDTI Status of add more rows nece, +Condition of the equipment (F:Functional, CNFR:Currently non-functional but repairable, WO:Written off). How does the project intend to maintain and replace existing equipment and other materials? Both vehicles and Motor bicycles are maintained by zone health department. 3.2. Financial contributions of the partners and communities -Fill tables l3a, l3b and l3c -If there are problems with release of counterpart funds, how were they addressed? Every year APOC is very late in releasing fund and there is problem in utilizing and liquidating timely. For instance the project did not receive the second phase l30yol till now but the calendar year is almost over. Additional comments As the project is expanding, the amount of fund released from NGDOs is getting less APOC MOH DISTRICT/ LGA NGDO OthersSource Type of equipment No Condltion No Condrtion No Condrtron No Condrtion No Condrtron l. Vehicle 2 function 2. Motor cycle(s) 4 ll 3. Computer(s) I It 4. Printer(s) I il 5. Photocopier (s) I not functioning 6. Fax Machine(s) I not functioning. 7. Others a) b) c) l8 WHO/APOC, l4 September 2009 o\ c.l q) -o o o U) !+ Q(J 0rf< > o\ o,o 1O, ct,tL x-o,EE .9; 6 .E! E, I : ol tro o' C'Io o. E cr, o,>t 6,6i o, cio Erol o,q; (El =t -;r I .91 lt 'Et oi EI c G, E o o,G G E so 5{l s ta E (l o T 6 o,o o, 'o' :9! ;cj ,.6 ;o. t\: o rcC'I .=I '=l l!l G,' .\r c'to ,E ,fB]R!!r :,9!,5; E E jil _,cE3 EEE9 3;E .i-: € Gos o o G t4 coto x(, G o o ! 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O'o.. c r34e, o 'ES o 6OtE "'Jt z III I I I I I € io E og, g .9 E! :g(, E oE E. IIJ -, Ot oo cl-(, z I I I (o @@(o (o(.o 00@ Nt art oF-o\r oF F-'<ci oNto o F-$@ c) €{- G'$t !,o e .lt o tSE o r.r)s @lr)t- @ (o o ol(, olooioC.)ls i I I ooo o, ooo(D oo@ .i' rO to- N (olr) F- rr) iolo ico oo@ lo(o od6 ,Ol(oi oi@i I I !t o{t-t oo(v) o6t @lot- @ @o o,o Oro'i, ooo O) ooo(n oi oi()i olN; (o ,oi -ili i ii o rolo il oo cO oo@ @ o) @- ro co oi6)i(o; oi co! t-lo or- I I l N'lr)o I I Nloo N roo ro t ii 0 o .E ,9o oc ol ] EI ol lri .d, I G,I t'." o o o .E" .E irol= o o ..! .E -o '''aal t '.€ .o .E /o .tr rr, s t) t !,o o C'E o c\ a.t o C)l- (h cd c) k € o oz G o ,I r ,ll l o,;10, , Orai'Xe,O, c. -, .^, oi Hr .9' Hi2.o';: =oE ='ao3l (/) I'llr 69.,di -, At,6 i I o, ciO, Or oa (I)! >lE,(E E,(D o.a' sl oi E. o; Ei8i> Ei E c .9 ,o .9,o c o oct o) - t0 o o o Qo E G o o o o o trr a! G E E G oo Io ri I I I ; i ,l I I I II o' or 9ic'El 96 =Ep g c o, a' e o)oJa - o G5 G tlJ .! o i o o) v , lo,,} i ;t,€ ; Ei3'OrI oi oI oIo, ' cic .E'E , 'd, d, ,od) OI OI1cl ctri =r'= .S, E.E .sr i r:$, ' .,' ., i I ilc'o i(u ,q >- Hi 6O: E6l =ii oEl 0) <i x .t. o .9 G .N lr, I ota ,, *l(.) iG,:ool>I E.E s:E EEFiE STEHEs>;(/) -9 E -,^i t- IIJ(, o =o (! th o -o L o (! o (d ?, I ?a q) clF I 3.3. Other forms of community support Describe (indicate forms of in-kind contributions of communities if any) No any form of contribution. 3.4. Expenditure per activity Indicate in table 13, 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 17.75 USA Any comments or explanations? SEGTION 4: Sustainability of GDTI 4.1. lnternall independent participatory monitoring; Evaruation 4.1.1 Has the project ever been evaluated/monitored? (Tick any of the following which are applicable) Year I Participatory Independent monitoring Mid Term Sustainability Evaluation a/_ 5 year Sustainability Evaluation Internal Monitoring by NOTF Other Evaluation by other partners 4.1.2. What were the recommendations? Zone level Develop a short and long term CDTI sustainability plan with cost reduction and containment strategies. Putting in place proper documentation of past and present CDTI information like treatment reports, supervisory visits, letters of agreement, government contribution records etc. Put in place documentary evidence to show how effectively CDTI is implemented in integration with other health activities. Ensure that the zone provide effective leadership for the project by having enough trained personnel that can support the implementation of CDTI activities. The zone government should fund CDTI activity by increasing its budgetary allocations and ensure timely releases for its implementation. The LGA plan should be reviewed along with relevant partners in order to address areas of weakness and the evaluation recommendation. r6 WHO/APOC, l4 September 2009 a a a a 23 a District level Recommendations given at this level is almost the same with the zone level except that: The skill of district staff involved in CDTI Implementation need to be built on how to carry out need assessment for training and HSAM. Increase the number of trained personnel available to support CDTI implementation at the district. FLHF level Effort should be intensified by the HFs at ensuring that a detailed copy of the integrated health plan is available at the health posts. Ensure that the documentation of integrated activities is available for effective supervision and monitoring by the higher levels. There should be documentary evidence of the HFs meeting with the Kebele leaders and other key stakeholders. Target supervision on problem areas should be given high priorify by the health staff Record of feed back given based on supervisory visit should be made available at the health p, Training and HSAM should be targeted at areas with need in view of program sustainability Community/ village/ level The option of using old and experienced CDDs to train others should be explored but supervised by the HFs. Mectizan should be requested based upon accurate census data. The community registration book should not contain invalid data like migrated households and died population 4.1.3. How have they been implemented? It was implemented according to the recommendation given by the evaluation team. At the Zone and district level review meeting was conducted to discuses on the issue. Especially On job training was given at FLHF level to act on the recommendation given. 4.2. Sustainability of projects: plan and set targets (mandatory at Yr 3) Was the project evaluated during the reporting period? No_ Was a sustainability plan written? When was the sustainability plan submitted? Submitted in 2009 What arrangements have been made to sustain CDTI after APOC funding ceases in terms of: a a a 24 WHO/APOC, l4 September 2009 a 4.2.1. Planning at all relevant levels The Ethiopian health sector planning process is redesigned under the policy planning monitoring and evaluation lPPll4'Elcore process. Though the PPME is a part of the new Business Process Reengineering / BPR/ the planning process with the principle of "one plan, one Budget and one report" has been exercised for the last two years with the top- down and bottom up approach in order to align priorities and targets while addressing local priorities too. "One plan" is the idea that all the major activities happening at various levels of the health system are included in one joint plan. "one plan" means that all stakeholders (government, donors, NGOs and the community) agree to be part of a brooder sect oral plan. Where as "one budget" ideally means all funding for health activities pooled and channeled through government channels. However, all funds for health activities reflected in one plan and one documented budget, but actually disbursed through separate channels. Therefore, the plan and fund for Onchocerciasis control program can not be excluded. Thus, the arrangements that have been made to sustain CDTI after APOC and other NGDOs funding ceases is as explained above. The vehicle and motorcycles used by the ministry of health at all levels are provided by different donors such as UNICEF, WHO, and others. Therefore, the chance of replacing is low while it can be maintained by zone and district expenses. The human resources required for the realization of the strategy would be fulfilled through basic in-service training activities. The budget for material production, technical support and actual work at community level will be incorporated in the regular budget of districts. So far it is implemented to some extent. The existing Vehicles and Motor cycles and other resources were used for Onchocerciasis control program too. 4.2.2. Funds No budget was allocated for Onchocerciasis control alone, because all health Programs are well integrated and carried out simultaneously including Onchocerciasis control program. Ideally means all funding for health activities Pooled and channeled through govemment channels. However, all funds for health activities reflected in one plan and one documented budget, but actually disbursed through separate channels. 4,2.3 Transport (replacement and maintenance) While there are few Vehicles atZone Health Departments some of the districts have no at all. They have few Motor Cycles which are very old and need Maintenance. Besides, no arrangements made to replace the old with the new once than maintaining. t+ WHO/APOC, l4 September 200925 4.2.4. Other resources/ Human resource is properly utilized by coordinating at all level. 4.2.5. To what extent has the plan been implemented The ptan has been implemented by integrating the Project into the existing heath Programs. 4.3. lntegration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration: CDTI is well integrated with the exisisting health programs of the country in planning, supervision, monitoring and evaluation. 4.3.1. Ivermectin delivery mechanisms The Ivermectin delivery system is very well integrated in to the MOH structure right from the onset. There has been no separate Ivermectin delivery system than following the existing delivery system in the country. When the drug arrive from a broad the project zones are notified to collect from the central point and distribute to the districts and Health facilities from where it is distributed to the communities 4.3.2. Training Every year All health professionals in the entire project area train and retrain on Community Directed Treatment with Ivermecti /CDTII The project is integrated with the Primary Health Care /PHC I particularly to malaria and other vector borne diseases from the beginning. Therefore, CDTI is a part and parcel of the health care delivery system at all level 4.3.3. Joint supervision and monitoring with other programs Primary Health Care activity in the project area are supervised and monitored in an integrated manner, of which Mectizan distribution is one. Supervision check list is developed in such a way that it consists all health programs including Onchocerciasis control program. When returning back from supervision the supervisors discusses on it and send feed back to the districts and health facilities. 4.3.4. Release of funds for project activities Always there is a problem in releasing fund on time. It is released late after CDTI activities have been accomplished and time for utilization and liquidation is over. For instance the second installment l3O% /for the reporting period is not released till now, but the calendar year is going to be over. 4.3.5. Is CDTI included in the PHC budget: Yes, it is included but not separate budget for CDTI alone. 26 WHO/APOC, l4 September 2009 4.3.6. 4.3.7. Describe others issues considered in the integration of GDTI. o Plan can be prepared at all level as it is usually done a Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? No one o Fill tables 14 and 15 and provide describe other programmes that are using the cDTl structure and how this was achieved. What have been the achievements? o For each intervention listed in table 15, explain what were the roles played by the CDDs (census, mobilization, distribution, data collection, storage, collection of drugs, referral of SAEs, etc ...)? o Explain what are the combinations of interventions co-implemented? o How were the interventions implemented? (at the same time?) Trial can be made to allocate budget along with malaria and other vector borne disease o As much as possible the existing Vehicles and motor bicycles will be maintaino There is sufficient manpower who can sustain the project. o To some extent the plan can be implemented ( WHO/APOC, l4 September 200927 o\ O c.l (.) -o C) o. c)a + Q B oo c.t %q) B Hq) 5q { q) I\ q) .a q) vq) .j d q) e q) q) ao ts I o +. 6l +J I 0) LLq) |rI ! o U $ -o 6E Fr q) (! o q 4)o o oD z € F a) C! q) lz, a) 6t a, !() q) b0 (! oq q) o !t) z oF o (!l Eofrt () c! 2 aU=u9ozr.9 -otr !r Z (g oF oo 6 E !ufr q) a( 2 E.E 6e -o=EE z6 !() 6t()il E a) q,) a0 (! F 6.9!L 4.2 =Ez r5 Q) (l(u & q) () u! (! Fr ^.=v\ >, :i .os €Sos 6t .: (r,i ES s0 >rLti(D _c .=oUE9E OJ|/)>= a so c(uo6 'EN =t!fEEo, .9 ttOE a o_ co)oz =(q9'u .:'Eaa t!Oo. a oc, cEON =i; €b .ts -ooO)i5E a o c oEJ -o '-6 Ez. o= a P C oF.g 0J= or P+Fca ;l!- -Eo a ,F (E c <oJ cE '= OJE* >6o a a a a a a a a a ooet *E ->. oFe (r) U)(! o oc-99 o= o3 o H.eE.ho.(! HL and Eo an o lr) oa (n FU) oL C) (€ L(! z oL o o lr(! (0 z tro L cd z (n o o Cq F (n o(n (d c,(J ,>' 9ts o\ N 0) -o Eo o C)a <t U h-o o\ o{ q s) B !< a) 5q v) q.) B Q .a B q) q) d q) > s) q) h = q) s\ o'\ss l^ l\' v .\e C)k +lO V) cU bo C') a C) CO o0 ot<q ! C) fi - €) CE t< Go o o €)q) o o ! -v, u0 o o a0 o220 EQ 2 t- oo o o ! tn9 -E E.9 qa) o! ic ! og " E.eEE o (! o q) E =q, -E =a)5EooorU= qCl c, o o t)E oI lF o o o) o - u)o bo .:> =Hso Er q I a o a)t(D o oa t- -C .=otrE 9_d O)q>E a I o cOo6 ENf(! -oE Eo .9 tto-6 a o c o f -o L .2o a o P 5oo coON ';i s €bi:o6A) OL a z J) o c o a -o L P .9o a c o E o bo(! E.e CLL(! oE qFo; -o a .s E(g .: a a a a a a a a a o o o (9a F o 0(! o C)9-uo xo\J() 6 ad d o o. -l o a cl o0 o a o(n Fo o oo d d d oL oo d H(! o L (d z d o od F a c)d d (B O a C) o 4.4. Operational research 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. Not done, because, there was no budget allocated for this purpose. 4.4.2. How were the results applied in the project? SEGTION 5: Strengths, weaknesses, challeng€sr and opportunities Strength Despite excessive meeting, summer course training and work load on the health personnel and lack of incentive for CDDs either from the project or the community the performance was found to be good Weaknesses o Even though, intensive training and supervision were conducted, still there is; o Poor record keeping. o Poor census up dating o Delay in reporting o inability to increase female participation in CDTI and the number of CDDs o Lack of supervision o Lack of preparing integrated plan which includes budget. Challenges During this distribution period, most of the health workers who are trained and have valuable experience in reporting were sent to different colleges for graduate studies. Besides, most of the health staff working in zone health department and districts was engaged in chemical spray to prevent malaria. Above all staff tum over is a big challenge, which harmed the quality of the report and delay in submitting on time. Opportunities . The expansion of health facilities r The number of health extension workers has increased o The need of community is increasing from year to year o the ability of the drug to expel different intestinal parasites o the reduction of mectizan side effect 30 WHO/APOC, l4 September 2009 a bon the other hand, the health policy of the country is developed based on the criticat examination of the nature, magnitude and root causes of the prevaiting health probtems of the country of which onchocerciasis is one. ln addition, there is good relation and support among the partners. ln the reporting period all health center staff was assigned to supervise and support five satettites health posts in their catchments areas. Besides, the zone is experiencing what we call 3rBalanced scorecardtt /Bsc/ that enhances the quality and speedy health service provision in the zone. lt is also a tool of strategic plan and management that tracks performance against the plan and mission of the ministry of heatth. This will help the implementation of cDTl in the entire project zones. sEGTloN 6: Unique features of the projecuother matters what makes this project unique is that it is managed and carried out by the community with out payment. b WHO/APOC, 14 September 2009 I 3l a