The Federal Democratic Republic of Ethiopia Ministry of Health COUNTRY/NOTF: ETHIOPIA Proiect Name: North Gondar Approval vear:2002 Launching vear: 2003 Reportinq Period: From: Ja.nUa.ry..?90.9.... To.l......Pe.S.e.m.hgr.?0.Q.9..........(Monthl/ear) (Month/Year) Proiectvearofthisreport: (circleone) I 2 3 4 5 6V/8 I 10 Date submitted : 20 January 2010 NGDO partner: The Carter Center v@r ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATTVE COMMTTTEE (TCC) DEADLINE FOR SUBMISSION: To APOC Management by 31 Januarv for @[ TCC meeting To APOC Management by 3f Julv for September TCC meeting AFRTCAN PROGRAMME FOR ONGHOCERCIASIS CONTROL (APOC) soi t \ I / DIR ir hr*n To biR WHO/APOC, October 2009 I I I I I For A& slt.tL" inq-) *,'.- ANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) ENDORSEMENT Please confirm you have read this report by signing in the appropriate space. OFFIGERS to sign the report: NGDO Representative II WHO/APOC. October 2009 Country: Ethiooia National Coordinator Zo na I O ncho Coord i n ato r N ame : ..... Y.Lhl.el.P.aSneW Signature: ..,,..j-.' I -._ Date: ...... ! """""""f'.: :l _ '-_ it f, ., I I i This report has been prepared I i ! ! i ! i Designation'. Zone Onchocerciasis Coordinator Table of contents Acronyms. ...................... 1 Definitions. ; FOLLOW UP ON TCC RECOMMENDATIONS .................3 Executive Summary ........5 MAP OF NORTH GONDAR ............6 SECTION 1: Background information........... .....................9 1.1. 1.2. SECTION 2: lmplementation of CDT|..... ........14 2.1. TTMEL|NE oF ACTtvtIES............. ............14 2.2. AovocRcv .. .. 15 2.3. MoatLtzArtoN, sENStlzATtoN AND HEALTH EDUCATToN oF AT RtsK coMMUNtIES 15 2.4. CouvruNrry INVoLVEMENT............. .................... 16 2.5. CRpRctty BUILDING.... ......17 2.6. Tnrnruerurs............... ....20 2.7. ORDERING, SToRAGE AND DELIVERY oF IVERMECTIN .............24 2.8. Courlrlururry sELF-MoNtroRtNG RNo STRxeHoLDERS MEerrruc ...............25 2.9. SupenvrsroN............... ....26 SECTION 3: Support to CDTI ........27 3.1 . Eourprrrerur ....27 3.2. FtNerucrRt coNTRtBUTtoNS oF THE pARTNERS AND coMMUNtlES............. ...............29 3.3. OruEn FoRMS oF coMMUNtrysuppoRT............... ...............29 3.4. ExperuottuRE pER AcTlvtry .............. 30 SECTION 4: Sustainability of CDT1......... ........ 30 4.1. lrurenxRt; TNDEeENDENT pARTtctpAToRy MoNtroRtNc; Eve1un1oN....................... 30 4.2. 1rurecRnrroN............... ... ...........31 SECTION 5: Strengths, weaknesses, challenges, and opportunities ............ ..... 33 WHO/APOC, October 2009 Acronyms APOC African Programme for Onchocerciasis Control ATO AnnualTreatment Objective ATrO AnnualTraining Objective CBO Community-Based Organization CDD Community-Directed Distributor CDTI Community-Directed Treatment with lvermectin CSM Community Self-Monitoring HEP Health Extension Program HEW Health Extension Worker LGA Local Government Area MOH Ministry of Health NGDO Non-Governmental Development Organization NGO Non-Governmental Organization NOTF National Onchocerciasis Task Force PHC Primary health care REMO Rapid Epidemiological Mapping of Onchocerciasis SAE Severe adverse event SHM Stakeholders meeting TCC Technical Consultative Committee (APOC scientific advisory group) TCC-E The Carter Centre Ethiopia TOT Trainer of trainers UNICEF United Nations Children's Fund UTG Ultimate Treatment Goal WHO World Health Organization ZHD Zone Health Department WHO/APOC, October 2009 Definitions (i) (i i) ( iii) (v) (vi) (iv) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking). Elioible oopulation: calculated as 84o/o of the total population in meso/hyper- endemic communities in the project area. Annual 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. 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). Therapeutic coveraqe: number of people treated in a given year over the total population (this should be expressed as a percentage). Geoqraphical coveraoe: 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). lnteqration: 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. (vii) (ix) (viii) Sustainabilitv: 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 mobilized by the community and the government. Communitv self-monitorino (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. lt encourages the community to take full responsibility of ivermectin distribution and make appropriate modifications when necessary. WHO/APOC, October2009 FOLLOW UP ON TCC RECOMMENDATIONS TCC session 28th #ot Recom mendati on in the Report TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT USE ONLY Carry out Stn year Sustainability evaluation The project is ready to facilitate the Sth year sustainability evaluation if APOC is ready to carry out. Address the issue of high wastage of drugs, high refusals and high absenteeism Wastage is reduced compared to the previous year due to the efforts made by HEWs The number refusals increases yearly because of unknown reasons. However the reasons for absentees is population movement as result of late distribution schedule. lmprove on CDTI documentation Documentation remains a problem especially at woreda and front line health facility (Health Center) level. The main cause is frequent turnover of staffers and poor handover of documents. lncrease female participation Attempts have been made to recruit female CDDs. However, their number is not as expected though few females have engaged this year. WHO/APOC, October 2009 4 Executive Summary North Gondar Community Directed Treatment with lvermectin (CDTI) is funded by the African Program for Onchocerciasis Control (APOC) and its partner The Carter Centre. The direct implementers are the FMoH, Regional Health Bureau, Zone Health Department and above all the four CDTI woredas. North Gondar is located in the Northwest of the country. The total population of the zone is estimated al3,1O7 ,738 (Central Statistics Agency).The are 23 woredas/ districts in the entire zone. CDTI was initially commenced in two woredas which expanded to Tach Armachiho woreda a year later. Currently, there are five CDTI project woredas. A total o'f 75 kebeles and 848 villages/communities reported to be available in five CDTI project woredas. The 2009 community based census result reveals a total population of 280,259, living in both meso and hyper endemic communities. The Annual Treatment Objective was 224.207, which is the same as UTG. ln 2009, all communities are reached and 215,805 persons have received lvermectin. This makes a 77% therapeutic coverage. Therapeutic coverage varies slightly among woredas. The following table depicts the treatment history of the project 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 91 91 2005 234,054 196,605 183,945 79 94 94 2006 249,345 199,476 182,329 73 91 91 2007 302,604 254,187 211,953 70 83 83 2008 282,046 23691 I 210.604 75 89 89 2009 280,259 224,207 215,805 77 96 96 WHO/APOC, October 2009 Map of North Gondar Zone by Woreda and Kebele in 2008 lJgend Rmd! worcdl Eoauat EcerawJratmfluama ETehmt -Lakele - Allwttprroads(Agphalt)E ldrailay E Debart I GmdarTom @ Qum Xu,bdArmadrho - Alt reatErrmds(GrmI) E Aefa E Oeuarttom B GmtarZm E Tadl amadrtu E$td Beles -Drlmatsrcads D8ey€da Eoembrya XJammon Etatara lv$s€nExeteoBortary Dctrrtga Eeaggebs Elsytunafilp I'l N.B: Readers are kindly requested to take West Armachiho and Merab Aramchiho as one woreda. The report writer used both names interchangeably at different times. 6WHO/APOC, October 2009 1. Overview of the population The total population of the North Gondar zone is estimated at 3,107,738 (Central Statistics Agency). There are 23 administrative woredas in the entire zone. CDTI was initially begun in Metema and Quara woredas which had been expanded to Tach Armachiho woreda a year later. Presently, there are five CDTI project woredas namely Metema, Quara Tach Armachiho, Gendawuha and West Armachiho (the later are spited from Metema and Tach Armachiho woredas respectively). ln previously submitted activity repoft, one can see one additional woreda called G/wuha. Ihis is a newly splitted woreda from Metema. ln this report, all activities are reported under Metema woreda. Every year, a number of people flow to these places from the highlands of the country for temporary work (on average for a period of four months: May to September). Others move to these areas by themselves or by the help of the regional government to settle permanently. When the temperature becomes hot (peak time between February and April), they leave the area and go back to their previous places of residence. The seasonal movement of these people influences the population size at different treatment periods. Above all, it affects the therapeutic coverage when the interval between census and lvermectin distribution is long. 2. Training data As usual, TOT and Micro planning session was organized for woreda management staff and selected FLHFs health Workers. Woreda heads, Oncho focal persons and Health Centre heads were the ones representing the respective organizations. The training was held in the zone capital and facilitated by ZHD, RHB and TCC. Three days was allocated for both TOT and Micro planning. During the two days training: Epidemiology, treatment, APOC philosophy, Sustainability Community Self Monitoring, Key malaria and Onco messages, integrated activity of Oncho with malaria and other health activities were thoroughly discussed. The final day was devoted to prepare worda level CDTI micro plan. Trainers were regional focal person, TCC staff (from Bahir Dar and Addis Ababa office) and zone focal person. Forty two persons have attended the training of whom 35 (84Yo) were new for CDTI. Woreda level training had been organized and reported that a total of 241 health workers have received the training. Similarly,3856 CDDs and 719 Community Supervisors received the training. WHO/APOC, October2009 3. Ghallenges and how they were overcome. The main challenge we encountered was the failure of woredas to commence CDTI activities as per the set schedule. This was also due to the coincidence of other competing priorities. The other major problem was lack of transportation facilities due to shortage of cars and motorbikes. ln few villages, village registers were missing. Attempts have been made to finalize census updating and lvermectin supply in short time by deploying additional staff who were able to facilitate community mobilization and assist CDDs and community supervisors. Rental cars, borrowing from other governmental organizations and using public transport were alternatives used to tackle transport shortage. Walking on foot was opted in places where there are no road accesses. However, it is believed that most difficult areas haven't been properly assessed. For the missing registers, new registers have been used. Opportunities: The Health Extension Program is an opportunity. The program is run by HEWs who are basically trained to offer community based health service. These workers played a role in training CDDs, providing technical assistance and collecting and reporting activities. WHO/APOC, October 2009 SECTION 1: Background information 1.1. General information Description of the project The project "North Gondar CDTI' is located in North Gondar.'North Gondar zone is the largest of zones in Amhara Regional State. lt located in the northwest part of the Amhara National Regional State. lt covers an area of 48621km2. lt is boarding with Tigray Region in the North, Sudan in the west, Metekel and Awi Zones in Southwest, South Gondar zone in the South, and partly with Waghimera zone in East. Based on the 2007 population and housing census figure, the total population of the zone is estimated at 3,107,738 in 2009 (Central Statistics Agency). This figure is smaller than the 2008 population figure. The overwhelming majority (80%) of the population lives in rural areas where as the remaining 20% lives in urban and semi-urban areas. The rate of natural increase is 1.7% per annum. The average population density is 60 per km2 whereas the average household size is 4.3. Administratively, it is divided in to 23 woredas and 577 kebeles. There are three hospitals, 72 Health Centres and 449 health posts. One health centre is set up to serve 25,000 population and one health post to 5000 persons. Both health Centre and health posts are called Primary Health Care Unit (PHCU). ln consequence, the potential health service coverage for primary health services reaches 96%. !n principle, each health post should be at least staffed by two HEWs. Overall, there are 1067 HEWs indicating the presence of three HEWs in some health posts. All the CDTI woredas resemble by their topography, weather condition, disease pattern, natural resource and other factors. The climate of the CDTI woredas is categorized as tropical. Similar to others, there are two season i.e rainy and cool weather from June - October and hot and dry weather from November to May. The temperature ranges between 17 Co - 44 Co. The main source of income is mixed agriculture (farming and herding) followed by trade. Every time, many people move to these places for temporary work (on average for a period of four months: May to September) and many others to settle permanently. When the temperature becomes hot (peak time between February and April), they leave the area back WHO/APOC, October 2009 9 to their previous residents. The seasonal movement of the people influences the population size at different times. 1.2 CDTI woredas Two CDTI woredas have all weather road access while the rest two dry weather road until the capital. lnter-kebele road networking is underdeveloped in all of them. Tach Armachiho Metema and Gendawuha woredas have both Landline and Mobile telephone access. Electrification is also available in these areas. ln relative term, West Armachiho is the difficult woreda among others. The CDTI project is being implemented in five woredas. ln 2009, all the 75 kebeles and the 848 villages or communities have been reached for treatment. The number of villages is reduced by 56 from previous years. Based on the assessment made by ZHD, previously there were inconsistencies on the definition of villages among CDTI woredas especially in Quara woreda. When woredas strictly follow the definition and started to report by villages, discrepancies noticed. The total population of the project area was found to be 280,259. Both the Annual Treatment Objective (ATO) UTG was 224,207 . lnline with this, a total of 215.805 persons were treated with lvermectin. This makes a therapeutic coverage of 77o/o. The geographical coverage persists as 100%. Table 1: Number of health staff involved in CDTI 10 District Number of health staff involved in CDTI activities. Total Number of health staff in the entire project area B1 Number of health staff involved in CDTI B2 Percentage Bg=Bzl Br *1 00 Metema 135 64 47 Quara 88 79 90 Tach armachiho 96 70 73 West Armachiho 37 28 76 Total 356 241 68 WHO/APOC, October 2009 1.2.1 Partnership The CDTI is being implemented with the financial, logistics and technical support from WHO/APOC, The Carter Centre and above all by the involvement of affected communities in the five CDTI woredas. The Zonal Administrative Council and the respective Woreda Councils provide guidance and leadership for the effective mobilization of communities. The Zone Health Department, Woreda Health Offices, The FLHFs, get involved in facilitating and monitoring the overall CDTI activities. 11WHO/APOC, October 2009 NN kop o (-) o O o o. soH L(I, o) ; =oo o_ an oo f oo L o -c o c.. l(l)1 o -oIH E\J(5tvl olEI =lLI(El fl(5l Eol of -caPcbg oo(I,)oV,EozEPO .og(50 EU) oz oz \ ah' G) c-.Eo L o o_ o)c E o o- oL o .C o)c L)E oE oE o o 'a o_ o L oF ofac o)o (tr o(U 3 Soo Q' a. q) o \oo\ E hD o o b o o $ ot-f, o oo e o bo oo a-xo oa b\ o q () o) 0 o. o 5 (u \o -o o,q o oo o a_ Q U)o o) o) c Eo oGo (t) o o(l) Q' a. o co =bo C) oo lq)lololrlo IGItr lrt-l(U leI(!l*l()lo l'6-lls la.(I) ! } U)$ eo o Q)b o o) a- so u) o (E c (U Eo$(I) q)a o o o_o o a. o oa E .\ x(E E o u) a Eo $\() Go ll ol- D Eo .E o o_ o)c Eo o_q) L o -c o)c .E =E voc L o !o eo oL oL o o -ce L c) -c os 3 ooL(E I(J o 'd L CL oL y tr o oE, I .E .Yo L Po c o (!) o- o o- Ec(5 o o v arC fl=(Et =Eo.ooo o. NI ol "i €lFFI o tr o g f CL o o- OE -E EE OEE O F =Eo 3 c,(0 o o) rOt\f G' .o(o(o ro N(9 NN oNttNN o + il o itr 8..9 €f E Rl- lrt L 'oq,E rf rot- @o $t-o(o o, NN@ or- O)o o)_ r\N C') rOol ooN -, .9 tr !:.: $gfiEHs< I I I I ! og $6'E:6gtPE <= ooyNcL I I I I .= oo E) s oo .E E E o o o o .Ct E =z N +_ II roLE .s &R EEE;oo .o!, trELo F-o (f) o) o) rr(f) r(o G't@ 0)eEO -O.oiNo'drE(E 1.=_ 9E diEEGE, {"trE o I I t ,r9E6'E= EgtEq i oogNcL I t OGtr.: o .9E EE 9EE =E.qgEsaoo-iF EL.= CL $lo$_ @@ sl- o_ (f) o) NN @ ot- o)o ct) F-N o)loNd ooN o oo(g 'E.=O -,Lotr(Ei5 ox96&.-i-r +, OHt-O.= cL (U Eo o (E L o) o os -c.oo EL Eo(UF oS .Co([ E at 0) = FoF lf 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 is a structure composed of 30 - 50 nearby households that are under the control of one developmental team. A developmental team can be explained as farmers selected among these households who are exemplary in many developmental activities. The number of households under their control is determined by their geographical vicinity. ls there any other information of interest about the population in the project area? lf so, include it here. Because of periodic restructuring by the government, the number of villages varies from time to time. Compared to last year census, there was evidence of a 22, 345 (7%) population reduction while in reality more people is expected. Migration of settlers could be the possible explanation, but demands further investigation. WHO/APOC, October 2009 13 +tr .9 .9 E o CL o tr o o: ELo EEo (5 tz 3 -o)1-9 o Y 3trcD -s9 :L o_ Y =oo) '(') I c)Ef -v 3 oO) -(a9 ED EEE9 a o, -Y9 ==oO- o)o -Y =L:cO- CD -Y93EqO- o, -yO =;s(5 tr o)lt L q !, E') J o Eo-c gCLtrEtroo6Eo O) lz9 -(U o, -y9 tr(5 o,Y9 =EoO- O)ofzBg C-(a- ED Ee.H9 o O) f<9BE oO- O)o -Y}E cQ- o) _Y9 =EoO- o):<OB; o(E o GE' o.D o otr oo EEcLoEE oo6 O)fz93E PO- O) rz9BE Pq o) -Y93E 90- o) -yO3; o(5 ED EEke AL o)o .Y}E o) -Y9BE 90_ o)o .)z}E o)yP -(5 E"tr tr .E F o EEcLoEE o(J ct)I Eg co o, vOE: CD9 vEE9C(U o)bo BE -c. (U 9-tr EEE9 U'b o)I -!z -cBe o(E o,9 -yCBgp(E o)9 -Y.g3g o(U bg -Y .BEE(E oo o o.= G= .NE tttroo =c, EEcLoEE oo5 o) -y9 -(U o)o -Y =L:cO- o)o -:z}E cO- tso -Y3E oO- ED 'i= cE9 OE o)o =Ec(U o)I -Y-3E E(U o,I -Y -c =ge(5 o,be v-CEg o(U oJEo ..2o (5 Eo o = (5 L G =a os -co(5 EL(E Eo([F os l-o(U EL al, o = F oF o\ N L c)p o o () Pr (J a c o E E oo I L(u o tr(, LL J o oe .= !, o (E oL+, o(E oL IU =oA&l-l I()r- EOb oXlo.o .E.9.E E.Z6ox(EEG=Oi-\.r;oo EO.=L .=o$iE.E z'EFOFc,irFolfliEl(/)NFI 2.2. Advocacy State the number of policy/decision makers mobilized at each retevant levet 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. Woreda health offices reported that advocacy meetings have been undertaken at woreda capital level for woreda council and officials from other government sectors. However; it is noticed that it was hardly done at sub- woreda and kebele level. Community mobilization was mainly relied on CDDs, supervisors and FLHF health workers notably HEWs. Nevertheless, data were not available on the number of persons participated. It is crystal clear that, advocacy meetings are crucial for any community based intervention. ln situation when there is frequent transfer of decision makers, routine advocacies to these groups would help to bring their attention and consequently support. The problem in relation to conducting advocacy was the engagement of these people by other activities. Since Woreda health office heads are members of the woreda council, they ought to use all the opportunities to advocate decision members. lnviting these people (woreda administrators) to chair the monitoring meeting would help to get their active involvement. Enhancing and/or re-establishing Woreda and kebele level taskforces is also an approach to get the full commitment and support of decision makers. The problem associated with taskforce is lack of continuity/sustainability when members are changed. 2.3. Mobilization, sensitization and health education of at risk communities Woredas followed different approaches of SmoB of communities. Some woredas have addressed the issue during community conferences (when communities gather to discuss various development agendas). Others gave health messages during house to house visit through HEWs and CDDs. All have intensified facility-based education for out patients during distribution time. Community gatherings (Sundays' and holydays' church) were used to mobilize the community at large. . WHO/APOC, October 2009 l5 ooo .go EC) =str(ECEbeo 3'=oo -ct oEE" =(Ez oo rr I- F{, od'eIo o E,,(! =o() o o- I I I I = E -srrrE(E S Z 5 H .i5 E€Oz g = z z z z z o5E (6y otro o5E hc TEtrO =oz @o +No iloo E o oN roo(o of.-f.- o@N (.o l., @(Y) @o oagotro ,i(r o, oO) N of.- (\t (Y) *{ Fgg o o lorlf)r o)s@ orN €t@ao Eo EB E'EC"O(UcL E8 +. arl =EEFO6E:to.= o)IlEEE =ozo oo ll* ot oo sgl o cD(E tr o(, o o. o,t\ $rr) Ns (o N l(,q, 548 e.t'E 2AE ET'E dEEEE =ooTZ E 6 N$N @o(f) o)Nr o)(f) ct tr C,EEEtr=E G ?EYTE=o!t@:tror.9 .v=EO FL-jeL 5cL o t-o (f) o, o, r r r(f) GIto oJ o ,.2o (5 E o o = (5 Lof o os -co o EL I -co(5F os .Co([ EL qt o = E oF s N () -o 0) oz <1- al O o o. ,-\ > \o q, aG G G o s o oi G Gt il(t = a = Eoq(/) oo Q)\\ (/) =o\ q) l! o L bB a o u) o 0) E troo o € .E cya oatrE.soog8 CO o g .- L=3E EC LEoooosr olaElNFI
Comment on: - Attendance of female members of the community at health education meetings. No data. - ln general, how do you rate the participation of female members of the community meetings when CDTI issues are being discuses (attendance, participation in the discussion etc). lncentives provided by communities for the CDDs. ln all CDTI woredas, there is no any form of material/cash incentive. Some CDDs are allowed to participate in other health programs such as EOS. Polio campaigns and Zithromax@ mass administration for trachoma - Attrition of CDDs. - ls attrition a problem for the project? lf yes, how is it addressed? CDD's attrition rate was hardly documented. But, there is a belief that if community members leave the area, attrition is very likely. - Other issues 2.5. Capacity 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 knowledgeable manpower was available or if staffs are frequently transfened during the course of the campaign). During the distribution period, there was adequate and knowledgeable health staff. As a - means to ensure the availability of adequate and knowledgeable manpower, project woredas provide trainings for a number of health workers and management staff. ln reality, the ' probability of staff transfer during the course of the campaign is low and was not manifested in this treatment period. Narrowing the interval between training and distribution time is commonly done. The other opportunity is the low transfer rate of HEWs which minimizes the threat. t7 WHO/APOC, September 2009 !, o c, (E ooo o o olt E =z Et!+6Y@t-Pctdo oN 1r,o @ ot-N o@N $ CO r @ roo(v) (o C" tr o E o .9 o s *ro&d c{o)o) o)(oNr (orrr) sto N o) a, i\Pd o)oN (o(f)(f) (os lotto) aoid oN (r)(o @ loN@ r (f, (f) oNot o o .=o .EFtso Ov5ooo sO(, .=LGEiEO z Eu+ *.NOedd.: N (o N olt (tG' o Eo .g o s .8ts&d (f) O) N r lr) ro =o *d @ N @N to d N Nr N @ (r) t Eo =!Etg OE L(E oo r8E-B2€ o(, Eootd v(o O)F* of.- @N $$t toq, t tr o E o .g o s &d s (o(o N(o (o N rEo' (aN (f)r @ (oro oLOFO o o o o (E o ol. lh(ri ECLoEE o'E OY ,lt E z gJLT F(J Ed tr o E o .9 o s *d oLF(J oJ o .9,o (U E o o = GL([ =o os -co -(5()F(5E os -co(E E(U L = !(UoOEJ-EP85oNO FoF o\ cn (.) -o 0) o.oa t) - o E > o\ lp IElf,lol: l-olf,lotbloIC lu, l0lo)lct*l$l-c l! ls) lf,lqlo lr<I(U t> Il5IEo (E o b) c b eo a-q g oo o (Db e a. qt a(EtsG o o (E oE lL Eog -= o =+ E(o u) U) ooo qtp p o L Eb o o u) o ea c o .E (5 E o E o o_ .E F-oo o o o -c) c oLo rL E oE o(,) .Cc '(5 LF lbr ol -ol(El FI Table 6: Type of training undertaken (Tick the boxes where specific training was carried out during the reporting period) - Any other comments The concept of CSM was in the main agenda when training and social mobilizations were given at various levels. Efforts are being exerted to help community own the activities. However, reports indicate that community participation/ownership is still not satisfactory. 2.6. Treatments 2.6.1. Treatment figures - lf the project is not achieving 10Oo/o geographical coverage and a minimum of 650/o therapeutic coverage or the coverage rate is fluctuating, state the reasons and the plans being made to remedy this. The project keeps maintaining a 10Qo/o geographic coverage and a TCR of >65%. CDTI woredas also keep maintaining the minimum project indicator. However, the level of achievement hasn't been monitored by villages. This might indicate different pictures (TCR) among kebeles or villages. Trainees Type of training CDDs Other Community members e.g. Community supervisors Health Workers (FLHF) MOH staff or Other Politic al Leade rs Others (specif v) Program management How to conduct Health education Management of SAEs CSM SHM Data collection Data analysis Report writing Others (specify) sustainability WHO/APOC, October 2009 20 N b .9 E '6- EfEE€E 2@ t e g o o o o o OUr(^gGEb E E oErii;Ef;UH6 o o o o o bsEbEE)6zi6 |r) rf) @(o @lo NN c\l (olo (o @ ro(a @ofi)@ h9.Eo €bE€ggfi-c2 8- 5 E ts @ r lr) rr) r (osN$ s@f.- (.o N$t Eo (U =o_ o(L 8-Po <gc.rij,1.1\O eEEoU dd!Foo (ot- (oF- tr)@ (ot- No b ? E -oxos€EOlNGr 6Ez. o- s(o rt-(o r- o, O)r- @ o@(f)o(o s(o c!oN l(,o c,l(, $t @o =c)(tr(t).4 f E6 =6.o at(o o (D !li,s$ @ rll,(0(0lo (\t c,NN oNtNN ,.:-b PoEE.P =E 3 APAEEEH O9oou tr s ro s_ @ @ tNo- (f) CD c!N@ ot- CDo o)_ NN o) l(, C\t o oo(\t (r, q) o) -o E .1, o .E) E Eo() Eo)o- et c,!o(Urr\oBseE 3dIoooo() oo oo r oo r oo r oo X'{=av'=o) €E+fi d28BE t-o(f) o) CD (o oot oo NoEgE$o No(o o)o, r(o (f) ootc, b'E .E * .., EEEE,eEd,gsd F-o(o ct) o, r r r(f, (a G'tG' fr9o\ (5 E Q) o oL(U) o os -co -c(UocotF(E o5 -coo E .o =f E ot- o\ oN Ho .o o o O o r o E(U U) u) o)o o (, =e eo bE o o(r) (U o E. .Y U' L G U'(I, oL o (! .c (, J fJ .E .u,E -o U, IU a Ec G c o E (E oLF NI ol -ol(5l FI ITlol- l3lc lol I-r.lo t;lo I3lolc l=lol-l=lol- lq, IEloItr 14. l3lflo- loloIolol-lq,lolr lo lor lolo l6l-lorlolo o-JPd(o oi sg 3gv6'v6.qr- ooP69aiEE(D-qd o illl -.|Eo6i8P 35!l- v a)o)i5' (o oo- o)d EES E5EEU'IE.e r Ir<,. rir { {ooss9.gd (5 -ili g. \='SE= sss 8.o:rlA.E Est t(qq q Poo{; ;qiooEoOsr ! ----o-oolrrt= 3q S'g+ =.qiar8ts ;iq 6!.\.OSr S0to =ti g ;\ o *r={9o*4.EHO\:3Q.6 6'o:ts BVt:lo)$=. 6ooix ilUO0)otnes. IsB=H=HS' !Bi G.a.d oBE gEa t0rOitoa5$FriE B6E EC- s${\AtciE o)tq!r5 -6 =$\Q ioS5cioE; S9(Do\:6$8 sOO "rt s' -*Ao'd{ E.Eil 5g.ss ;t= 3t= dli B li913 Rl+ gB gl.,trq -rq =E EleiE $E ili aE tlilElilgla:lilrh 5h $til d, l:rls ls glE 3lsE 6'l+ XiD 3la 6o- =- tPr i5 al8. gr :[ E(,Jlo3q El6 6':'). EOYO.n=T$3o@- =o-o_=qe6 =t*@q&+ ooqf, =1 ilgro9. =o)foo=+EJgEg$ocro olBd*iD o)dCo) -{I o rJ o -c) oo og (DI b.Joo\o NJ N.) 2.6.2 What are the causes of absenteeism? Over 8.5% of eligible persons were absent during distribution. The highest figure reported from Metema and Tach Armachiho woredas. lnappropriateness of distribution time was reported as one of the reasons. However, in scattered communities, CDDs have failed to carry out repeat visit to retrieve absentees. 2.6.3 What are the causes for refusals? A significant number of persons (5.5%o) refused to take the drug. lt would be ideal if is explored formally. However, it is routinely reported that majority of refusals are urban residents by considering themselves as low risk. 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. ln 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 23 WHO/APOC, 24 November 2004 vo N C) () oz s(\ 1,, - P. > !f, C\ os o)gH Jo O @ o) tifo) o, (r)@ o)@ @o) C .o o f o_ o o_ o)(EoUi:-ll-Ok I oa f uii." .ouJ ro @ o) so) o) (f)@ o)@ (oo) g8,oE€$8 ,ihEitr8ur @(o (or.- o)t- (f)t- of.- rr)t- t.-N @ u.l E e EE H* _LbE 2 0-P @N s_(o @ $loo o@ ro$ o) co @ O)N co N@r (f,lo O)- N so(o o N roo @_ ro N ts uJ cc)E P; =coLPEg6= los n o @ o) o) 1- o) 1r)o @_(o O) (ot- n o) o) r F-@ s rON @ o)(o(r) N t-o ry$N c{ clpo =3o*Ealyo-csofir@P*EEEHlu (oo@ @N c{ r- r.c)(a N $loo s(r, N los (f, o,sN !to @- No(o @so N@N o) r.r)N o@N oo o) _([ o .g .=cf E E o() o)o E' - , -tkEoE "TuiloouJ oo r oo oo oo oo oo oo og)oPgEoS,j,tliE=-e Y- ur os oo oo oo oo- oo oor b =o rr -O==.rrO:5>::A =trYa(J) -o.9": o (f)(o(o s r CD \t o) s r ct s o) so o, @s@ UJ co f E.ijF6.o F\J (f)(o (f) s o, s r O) s r O) $ o) so CD @s@ bgrb.o= q o:+r-==5EE EEg;gHUit-E(UoO' g= E $ o, s r o) rt o) $ o, s r o, !to o) @s@ E. IIJ (f,ooN rtooN rf)ooN (oooN F-ooN @oo e{ ct)ooN -o c o I G Jg Go o c')(! L o o(, oFD G .E t- oHEg) .= tsoOtr5(, =Eotuoogrt5Eu- oti.E:6E .Eg3E-O.EoOo L v g_b-+, !OOEe3!gOYt\lE.ERIE=d ^buNl;El sE HI !EEI 8E.al 'sgocL .aE.gLUHX"EE;9EhbHraoo?EL=3;Eg(.,Z(gEu€OFtrLForl o "i*l IqtlsNFI o. 2.7. Ordering, storage and delivery of ivermectin Mectizan@ ordered/applied for by - (p/ease tick the appropriate answer) MOH V WHOtr UNICEFE NGDOM Other (please specify): Mectizan@ delivered by - (p/ease tick the appropriate answer) MOH g WHO E UNICEF f] NGDOM Other (please specify). Please describe how Mectizan@ is ordered and how it gets to the communities Based on the plan made at zone level, request submitted to FMoH. All the processes of verification and custom clearing is routinely done by NOTF. On arrival, the drug temporarily stored in FMoH warehouse and from which ZHD notified to collect. This year, The Carter Centre and RHB have facilitated the shipment from Addis to Zone level. Each woreda have collected their amount by themselves. Ways of distribution from woreda onwards vary from area to area. Some transported until FLHFs level and others left it for FLHFs to collect from woreda. The commonest means is using both alternatives. Either community supervisors or CDDs have collected form health facilities. How are the remaining lvermectin tablets collected and where are they kept? The remaining drugs were collected by CDDs/ Supervisors along with their report. Front line health facilities in turn returned to woreda health offices where temporarily stored until the next distribution. Table 10: Mectizan@ lnventory (Please add more rows if necessary) DistricULGA Number of Mectizan' tablets E o) o o)uou E o) ooot 9otd8 >(tr9EL-o Eo oo _9 (E E oF Eo U'l @oJ Eo .o(o E EoL 'o- x UI o) .c .E(E E ot Metema 218500 1 51 500 48500 200000 164762 0 2830 0 32408 Quara 235000 1 70000 36000 206000 1 83991 0 877 0 21132 West Armachiho 80000 59000 45000 104000 62625 0 2015 0 39360 Tach Armachiho 233500 162500 't 1500 174000 151448 0 1753 0 20799 Total 767000 543000 141000 684000 562826 0 7475 0 1 13699 25 WHO/APOC, 24 November 2004 List and briefly describe the activities under lvermectin delivery that are being carried out by health care personnel in the project area. . Determine the amount of Drug . Collection of lvermectin from the Woreda health office . Distribution of lvermectin to CDDs . Give training to community supervisors and CDDs . Facilitate recruiting new CDDs and community supervisors ' Conduct supervision, monitor and manage minor side effects . Collect all records and compile reports and submit to woreda health offlces ' Collect the reaming drugs, temporally store and finally transport to the centre - Any other comments: no 2.8. Community self-monitoring and Stakeholders Meeting Has any training (of trainers) for community self-monitoring done in the project area? Community Self Monitoring (CSM) was given during zone level TOT. lt was part of the training agenda. CSM was also inculcated in woreda level trainings, but cascading it to community level is not promising. lf so, When? The training was given during zone level TOT that was conducted from 9-11 March 2009. Table '1 1: Community self-monitoring and Stakeholders meeting (Add rows if needed) 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. DistricU LGA Total# of communities/villages in the entire project area No of Communities that carried out self monitoring (CSM) No of Communities that conducted stakeholders meeting (sHM) Metema 307 NA NA Quara 199 NA NA Tach Armachiho 311 NA NA W. Armachiho 31 NA NA TOTAL 848 NA NA WHO/APOC, October 2009 26 Data on the number of communities that have undertaken CSM from project woredas hence difficult to measure the outcome 2.9. Supervision 2.9.1. Provide a flow chart of supervision hierarchy. ZHD & TCC-E) Woreda Health office ) Health Facility ) Community supervisors ) CDDs 2.9.2. What were the main issues identified during supervision? . Variation in definition of communities /villages resulted in reduction of the number of communities from previous years . Missing community registration book in some communities . Low involvement of female CDDs the majority of woredas. . Poor documentation (failure to fill the fields) . Failure to audit available LLINs 2.9.3. Was a supervision checklist used? Yes 2.9.3. What were the outcomes at each leve! of CDTI implementation supervision? Above all, CDDs and community supervisors showed their interest when team members physically appeared at villages. lt is believed that the supervision helped them continue as a CDD and community supervisors. On the other hand, it improved the quality of service. Nevertheless, supervision was limited to few villages because of time constraint and road access. 2.9.5. Was feedback given to the person or groups supervised? Yes All the findings have been communicated to those who deserved. lmmediate suggestions were given to distributors and health workers. 2.9.6. How was the feedback used to improve the overall performance of the project? Besides to the coverage, improvements have been noticed on appropriate handling of records and drugs, minimizing absentees and refusals and willingness of CDDs to deliver the service yearly. However, this doesn't mean the situation works in all communities. Communities that are not visited might not have similar courage. WHO/APOC, October 2009 27 SECTION 3: Support to CDT! 3.1. Equipment Table 12: Status of equipment (Please add more rows if necessary) .ConOition of ihe equipment (F=Functional, CNFR=Currently non-functional but repairable, WO=Written off). APOC and TCC donated car and motorbikes are almost giving up functioning. Regarding vehicles, the CDTI activities are entirely running by cars, motorbikes and equipment supplied from other sources. Since, the CDTI activities are highly integrated into the general health delivery system, utilizing these materials is not a problem at present. Problem occurs whenever there are other activities at time and when they get old. Therefore the need to replace old car, motorbikes and other relevant equipment is mandatory. How does the project intend to maintain and replace existing equipment and other materials? Maintenance of cars and motorbikes is mostly done when broken. There is no scheduled maintenance. Replacement of written off cars and motorbikes is not easy at woreda and Source Type of equipment APOC MOH ** DISTRICT NGDO ZHD No. Condit ion No Condit ion No Condit ion No Condit ion No Condit ion All kinds of cars 1 WO 4 F 3 F Motor cycles 6 NF 12 F 3 NF 2 F Desk top computer 1 NF 5 F 10 F LaserJet printer 1 F 5 F 10 F Photocopier 1 NF 3 F 1 F Fax machine 1 CNFR 1 F 1 F Overhead projector 1 F 1 F LCD 1 F 1 F Megaphones 2 F TV 1 F 1 F VCR 1 F 1 F Generator 3 F 2 F 1 F WHO/APOC, October 2009 28 zone level. Zone and woreda health offices expect from FMoH or RHB. However there is possibility to purchase some office equipment by woreda health offices and ZHD. 3.2. Financial contributions of the partners and communities Table 13: Financial contributions by all partners for the last three years - lf there are problems with release of counterpart funds, how were they addressed? With regard to APOC fund, there was a delay in releasing from the Regional Health Bureau due to superfluous bureaucracy.'series of discussions have been made to get funds released. The Carter Center fund was also not available during distribution time, which made operation difficult. - Additional comments Unfortunately, project woredas failed to report how much money the government contributed this year. Actually, it is difficult to quantify all government's contribution in monetary forms, it is obviously understood that its input is enormous. The indirect program costs would definitely out weigh the direct financial contributions for the effective implementation and sustainability of this project. 3.3. Other forms of community support 29 Contributor (2007) (2008) (200e) TOTAL Cash Budgete d (us$) TOTAL Cash Releas ed (us$) TOTAL Cash Budgeted (us$) TOTAL Cash Release d (us$) TOTAL Cash Budget ed (us$) TOTAL Cash Released (us$) MOH (Central + State) MOH (District + zone) 4,683 4,683 NA NA NA NA Local NGDO(s) ( if any) 0 0 NA NA 0 0 NGDO partner (TCC) 8,1 15 8,1 15 NA NA 15,000 't4242.86 Communities 0 0 0 0 0 0 APOC Trust Fund 2,375 2,375 NA NA 8175 4640 TOTAL 15,173 15,173 NA NA 23175 18882.86 WHO/APOC, October 2009 - Describe (indicate forms of in-kind contributions of communities if any) No any form of suPPort 3.4. Expenditure Per activitY - lndicate 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. lndicate exchange rate used here l USD = 1 1.00 Table 14: lndicate how much the project spent for each activity listed below during the reporting period Activity Expenditur e ($ us) Source(s) of funding OrG OetiArV from NOTF HQ area to central collection point of community fvf oUlfEition ind hea[h;ducation of communitres 0 0 2100 APOC Training of CDDs 0 0 Training of health staff at all levels 12570 APOC+ NDGO Supervising CDDs and distribution 200.46 APOC+ NDGO lnternal monitoring of CDTI activities 5094.4 APOC+NDGO Advocacy visits to health and political authorities IEC materials Summary (reporting) forms for treatment Vehicles/ Motorcycles/ bicycles maintenance Office Equipment (e.g computers, printers etc) Others, Staff Salaries TOTAL 19964.87 Total number of persons treated WHO/APOC, October 2009 30 SECTION 4: Sustainability of GDTI 4.1. lnternal; independent participatory monitoring; Evaluation 4.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable) No Year 1 Participatory lndependent monitoring Mid Term Sustainability Evaluation 5 year Sustainability Evaluation lnternal Monitoring by NOTF Other Evaluation by other partners 4.1.2. What were the recommendations? 4.1.3. How have they been implemented? 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? . What arrangements have been made to sustain CDTI after APOC funding ceases in terms ot? 3lWHO/APOC, October 2009 4.2.1. Planning at all relevant levels 4.2.2. Funds 4.2.3 Transport(replacementand maintenance) 4.2.4. Other resources 4.2.5. To what extent has the plan been implemented 4.3. lntegration Ouline the extent of integration of CDTI into the PHC structure and the plans for complete integration: 4.3.1. lvermectindeliverymechanisms 4.3.2. Training : 4.3.3. Joint supervision and monitoring with other programs 4.3.4. Release of funds for proiect activities 4.3.5. ts CDTI included in the PHG budget? 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? 4.3.7. Describe others issues considered in the integration of CDTI. 4.4. Operational research p t WHO/APOC, October 2009 32 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. NONE 4.4.2. How were the results applied in the project? SECTION 5: Strengths, weaknesses, challenges, and opportunities ' Strengths: The 2009 performance is satisfactory , Weaknesses: l.Delayed lvermectin return from some communities in T/Aramchiho woreda 2. Missing community registers 3. Lack of supportive supervision from RHB and ZHD Challenges: 1. Frequent staffs transfer, 2. Poor road and telephone access in west Aramchiho and Quara woreda, 3. Presence of other competing priorities during distribution time, and security problem in west Aramchiho Opportunities: The health extension program SECTION 6: Unique features of the projecUother matters a WHO/APOC, October 2009 JJ