North Gondar CDTI annual project technical report submitted to Technical Consultative Committee (TCC): January 2010 to December 2010

.L The Federal Democratic Republic of Ethiopia Ministry of Health ir I i COUNTRY/NOTF: ETHIOPIA Proiect Name: North Gondar Approval vear: 2002 Launchinq vear: 2003 Re portins Period : From J a.p g ary.?.9L8... To;....... p..e..qgm hS f. ?9.1Q v Date submitted : 15 January 2011 NGDO partner: The Carter Center ANNUAT PROJECT TECHNICAL REPORT SUBMITTED TO TECHNTCAL CONSULTATTVE COMMTTTEE (TCC) DEADTINE FOR SUBMISSION: To APOC Management by 31 Januarv for March TCC meeting To APOC Management by 31 Julv for September TCC meeting At" :l'l,ss [0"1,*r'[) **r",-d / -r**l ' on ,"**l,.*{.li**.- t/ r,\! / r':,i ifl''ilru,ci*:n i ;o, ]iSrR , i n u*'"" I \9 AFRTCAN PROGRAMME FOR ONCHOCERCTASTS CONTROL (APOC) a i I ,I /DtOC I I AP WHO/APOC, January 20ll t-. ANNUAT PROJECT TECHNICAT REPORT TO TECHNTCAL CONSULTATTVE COM MTTTEE (rCC) ENDORSEMENT Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the report: Country: Ethropra Tizita Flaiiu Gudeta (Dr') \J "ttr'H-n*Te Gebre (PhD) 1,.,,,. ";,v'ipEor'rt t{'le (:j Df hD} I,.,, rc"\''r5eo.uouniryReoressnlafiru' .'!-,!!Y NGDO Representative Name: ,:::.:::ttt::.r.a.;.ii:::i.....i;:ii.,.....::r. Thrs report has been prepared by Name ...........W.qfkfi..M.gla.t.t,.Ng..T.t Designation' Zone Onchocerctasls Coordinator Srgnature. Date ... January 201,1, .. ...... Nattonal Coordrnator Name: ..,.P.0ts0.,+,[i*Jiu^:Ir;r...1'...,.: :..:n ar;slri ] ,.., \sig".i*qi* g\::D-."*il6,{ :' " '..' 'r}.-.. Dt ""rrr ,($is' 'i"\'.,Date:........... ^if 'r,'\il, / . ' '|r Zonal oncho Coordinator Name: worku Mulat ii ,' I - i ' \-r.. .-r : ,lSignature: \, !- lt WHO/APOC, Januarl' 201 III Table of contents Acronyms Defrnitions FOLLOW UP ON TCC RECOMMENDATIONS 3 Executrve Summary.. 5 MAP OF NORTH GONDAR . 6 SECTION 1:Background rnformation.,......,.. . 9 1 2 15 16 L.L 1..2 SECTION 2: lmplementatron of 21,. TIMELINE OF ACTIVITIES 2,2. ADVOCACY. GtrurnnL TNFoRMATToN PoPULAroN....... 9 12 14 14 15 28 28 2 3. MosrLrznrrol, sENSrrzATroN 2.4. CoMMUNTl-yTNVOLVEMENT... AND HEALTH EDUCATION OF AT RISK COMMUNITIES ,., 2.5. CRpncrrv BUTLD|NG ... .. - . 11 2.6. TREATMENTS. .......19 2 7 . ORorRrruc, sroRAGE AND DELtvERy oF tvERMECTtN .. ... ..24 2.8, CouIvIuruIry SELF-MONITORING AND STAKEHOLDERS METTIruC .. .,.25 2.9. SupEnvrsroru . .. . .26 SECTION 3:Support to CDTI .. .27 3.1 EQutprr,trrur ""27 3,2. FITnT.ICInT CONTRIBUTIONS OF THE PARTNERS AND COMMUNITIES . 3,3. OrHrR rORvS OF COMMUNITY SUPPORT 3.4 EXPENDITURE PER ACTIVITY ,29 SECTION 4: Sustarnability of CDTI .30 4.L. INTERNAL; TNDEPENDENT PARTICIPATORY MoNlroRlNG, EVALUATIoN . .30 4.2. lNrEGRATroN. ..31 SECTION 5:strengths, weaknesses, challenges, and opportunrtres..... ..32 III WHO/APOC, Januarl 20l I Acronyms APOC ATO ATrO CBO CDD CDTI CSM HEP HEW LGA MOH NGDO NGO NOTF PHC REMO SAE 5HM TCC TCC_E ror U NICEF UTG WHO ZHD Afrrcan Programme for Onchocerciasis Control Annual Treatment Objective Annual Trarning Objective Communrty-Based Organizatron Community-Drrected Drstributor Community-Drrected Treatment with lvermectrn Communrty Self-Monrtorrng Health Extensron Program Health Extensron Worker Local Government Area Mrnistry of Health Non-Governmental Development Organization Non-Governmental Organizatton National Onchocercrasis Task Force Primary health care Raprd Epidemiologrcal Mapprng of Onchocercrasis Severe adverse event Stakeholders meetrng Technrcal Consultatrve Commrttee (APOC screntrftc advtsory group) The Carter Centre Ethropta Trarner of trainers Unrted Natrons Chrldren's Fund Ultrmate Treatment Goal World Health Organrzatron Zone Health Department WHO/APOC, Januari' 20 I I Definitions (r) (r') (irr) (v) (ur) (rv) Ultimate Treatment Goal_I_UI€I calculated as the maxrmum number of people to be Total populatron: the total populatron lrvrng rn meso/hyper-endemrc communrties withrn the proJect area (based on REMO and census takrng) Eligrble populatron: calculated as 84% of the total populatron rn meso/hyper- endemrc communrties in the prolect area. Annual Treatment Obtective: (ATO): the estimated number of persons lrvrng rn meso/hyper-endemrc areas that a CDTI project rntends to treat with rvermectrn rn a given year treated annually rn meso/hyper endemic areas wrthin the prolect area, ultimately to be reached when the project has reached full geographrc coverage (normally the prolect should be expected to reach the UTG at the end of the 3'd year of the prolect) Therapeutrc coverage: number of people treated rn a grven year over the total population (thrs should be expressed as a percentage). Geographical coverage: number of communrttes treated in a grven year over the total number of meso/hyper-endemic communitres as rdentifred by REMO rn the project area (thrs should be expressed as a percentage). (vrr) lnteqratron: delivering additional health interventrons (i.e. vrtamrn A supplements, albendazole for LF, screening for cataract, etc.) through CDTI (using the same systems, training, supervision and personnel) rn order to maximise cost- effectiveness and empower communrtres to solve more of therr health problems. Thrs does not include activities or interventions carrred out by community drstrrbutors outsrde of CDTI. (vrir) Sustarnabrlitv CDTI activrtres rn an area are sustainable when they contrnue to functron effectlvely for the foreseeable future, wrth high treatment coverage, rntegrated into the available healthcare servrce, wtth strong communtty ownershrp, using resources mobrlized by the communrty and the government. (rx) Communrtv self-monitonnq (CSM): The process by whrch the communrty ls empowered to oversee and monrtor the performance of CDTI (or any communtty- based health tntervention programme), with a vrew to ensuring that the programme rs being executed in the way rntended. lt encourages the communrty to take full responsrbility of ivermectrn distributron and make appropnate modrfrcations when neceSsary. WHOiAPOC, Januarl, 20 1 I FOLLOW UP ON TCC RECOMMENDATIONS The project is well integrated into the government health system and is achieving good geographic and therapeutic coverage. However, the therapeutic coverage has never reached 80%, the new APOC target. The CDD to population ratio has exceeded the target. Other strong areas of the project are sensitisation and mobilisation of the communities, supervision and human resource capacity building. Challenges include; delay in release of funds, high refusals, absenteeism and drug wastage. flof Recomm endation in the Report TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT USE ONLY Report related Provide missrng rnformation on integratron Complete tables 2 and 4 lnclude reasons for and outcome of advocacy Comment on progress of rmplementatron of the Sustalnabrlity Plan. The program rs berng run integrated with malarra and other related activitres. lt rs rndrcated rn the report Data for table 2 and 4 are not avarlable at pro1ect level The project has passed wrthout conducting the 5th year sustainabrlrty evaluatron. We belreve that, the initatrve should ' come from APOC WHO/APOC, January 201I Project related Complete implementation of TCC 28 recommendations lmprove the female CDD ratio Aim for a therapeutic coverage of > 80% Attend to operational issues of high refusals, absenteeism and high drug wastage (NOTF to investigate high drug wastage which ls common in several projects) Explore with the Regronal Health Bureau and NGDO ways of rmproving disbursement of funds to the projects. WHO/APOC, January 20 I I Executive Summary Simrlar to other proJects, the North Gondar Community Directed Treatment with lvermectrn (CDTI) rs funded by the Afrrcan Program for Onchocerciasis Control (APOC) and its partner The Carter Centre The rmplementers are the FMoH, Regional Health Bureau and its lrne offices such as zone health department, the woreda health offrces and health facrlrties. Above all the CDDs and communrty supervtsors are the key actors of the program, North Gondar is located in the Northwest of the country. The total populatron of the zone ts estrmated at 3,160,570 in 2010.The are 23 woredas/ districts in the entrre zone. CDTI has been operational rn frve woredas. There are 76 kebeles and 863 communrtres in CDTI project woredas. The 2010 communrty based census result revealsthat 283,773 people are lrvrng in Onchocercrasrs endemic communrties. Varrous acttvtttes such as advocacy meetrngs, TOT, health workers and CDDs trainrngs, communtty mobtltzatron, recruitment of new CDDs have been carrred out pnor to the commencement of drug admrnrstratton. Accordingly, officials from zone and Woreda administration offrces have been advocated. Total of 17 health workers (2 from ZHD, 15 from 5 Woreda health offices) have received a two days trarnrng using the trainrng manual prepared by The Carter Canter with an addrtional day dedrcated for Woreda based mrcro plan. These rn turn have organized trainings at therr respective Woreda and reached 193 HEWs/HWs and 25 Woreda health office management staff. Trarned HEWs/HWs have given trarning to 3391 CDDs. The trarning was organized in two sessrons, (half a day for malaria and another half day for Oncho). Both new and old CDDs were trained together for the purpose of sharing expenence, The CDD to population ratio for the entrre proJect was 1:83. The proportion of females CDDs remarns low (8%) and which gives a male to female ratro of 11:1. Durrng the treatment period, all communrtres have been accessed to attain the annual treatment oblective whrch rs 238,369 people. However, only 215, 632 persons have recerved Mectizan makrng 90 % and 76% of ATO coverage and therapeutic coverage respectrvely. Relatrvely, low therapeutic coveraBe rs reported from Metema and Mrerab Armachiho woredas; 7O%o and 72%o respectively. Both absentees and refusals make 11% of the total population. More than half (56%) of non treated eligrble persons were documented as refusals. WHO/APOC, January 20 I I The following table depicts the treatment hrstory of the project YEAR Total population endemic areas Annual Treatment Objective Number of persons treated Therapeutic coverage ATO coverag e UTG 2003 1.26,806 1.0'J.,445 86,428 68 85 81 2004 235,71.2 t97,998 180,054 76 91 91 200s 234,O54 195,605 183,945 l9 94 94 2006 249,345 1.99,476 L82,329 73 91 91 2007 302,604 254,187 2t1.,953 70 83 83 2008 282,046 236978 21.O.604 75 89 89 2009 280,2s9 224,207 215,805 17 96 96 2010 283,713 238,359 21.5,632 76 90 90 WHO/APOC, January 201I Map of North Gondar Zone by Woreda and Kebele in 2008 (- ",i,/' --\ (\rt -r/- Legmd Roads woredas D ualar f] Genda vt4.fraTrynf] Melema E Tehml Lake Tam - All wearhe ilo ads lAsphan) [-] Adi a rkay L] D€ bark D Gondar Town f] Ouara -- - Wlsl tumchho -AllweatherroadslcEvel) rJAbfa [ ]D"unlo* DGmdarZura i,]Tehamachrhf]wesl&le$ oryweath€rrcads E8€yeda Eoem!rya ffiJanamore ETakusa Iwogen nKeFteEomdary L]Ctrrtga f]EalEeteseELay,l,tachho WHO/APOC, January 201I L. Overview of the population The total population of the North Gondar Zone is projected at 3,160,570 rn 2010. There are 23 administratrve Woredas in the zone. Masstreatment wrth Mectizan ls operational in frve woredas. Less than L0% of the zone population lrve rn the five Woredas. Every year especially durrng cultivation and harvest time, a number of people visrt these places for temporary agrrcultural work. 2. Training data The Carter Centre has made avarlable trarnrng modules for trainers, health workers and CDD's gurde to each CDD. Besides, gurdelines were distributed to zone and Woreda officrals Training of trarners for Zone and Woreda management staff was given usrng the modules. Woreda health offrce heads, Oncho focal persons and malaria focal persons (three from each Woreda) have parttcipated rn the three days trainrng and plannrng session. ln general, 17 TOT partrcipants have attended the sessron. Training was given byTCC staff and ZHD focal person. Each Woreda health offrce has given training to HEWs and other health workers assrgned in the perrphery. From all Woredas, a total of 193 (24 woreda health offrce management staff, 169 HEWs/HWs) were trained for two days All Woreda level trarnrngs are supervrsed by The Carter Centre and ZHD employees to ensure the qualrty of the trainings Similarly, HEWs/HWs have given trarnrng to 3391 CDDs. The trarnrng was organized rn two separate sessions, (half for malana and the other half for Onchocerciasis). Both new and old CDDs were trarned together for the purpose of sharing experience. Care and utrlizatron of LLIN, rmmedtate treatment seeking when a famrly member is sick of malaria, complrance of treatment, Onchocerciasrs and the tmportance of the treatment, recordrng and reporting, preparatron of measunng strck and takrng herght were the toprcs addressed. The Carter Center, ZHD and Woreda health office staffs have supervrsed selected CCD's trainrng. Allthe 3991 CCDs make the CDD to population ratro for the entrre project to be L 83 The proportron of females CDDs remarns low (8%) and whrch gtves a male to female ratro of 11:1. 3. Challenges and how they were overcome. Late arrival of the drug was one of the problems the Woreda health offrces faced. As a result, dlstrrbution of drug was extended untrl June and even.luly rn some communrtres. This has caused poor follow up, absenteeism, engagement of distrrbuters in farm work and delay rn collecttng report from communities. The overlapprng of the drstributron time wrth the natronal electron schedule was another problem the project faced. ln consequence, it was impossrble to get the full support of vartous leaders and decision makers at all levels. WHO/APOC, January 201I Efforts have been made to sensitize community members durrng communtty gatherings organized for government agenda. Opportunities: The presence of HEWs at Kebele level can be taken as an opportunrty. This is because they are basically working at therr Kebele and have a chance to closely and frequently support CDDs and community supervisors. SECTION 1: Background information 1.1. General information Description of the project The project "North Gondar CDTI" is located rn North Gondar Zone one of the 11 Zones in Amhara Regronal State. lt located rn the northwest part of the regron and covers an area of 48,621, km2. lt rs bordering Tigray Regron rn the North, Sudan in the west, Metekel and Awi Zones rn Southwest, South Gondar zone rn the South, and partly with Waghrmera zone in the East. The total populatron of the zone is estrmated at 3,160,570. The overwhelming malonty (80%) of the populatron lives in rural areas where as the remainng20% lives rn urban and semr-urban areas, The average populatron density rs 60 per km2 whereas the average household srze rs 4 3. Administratrvely, it is divided rn to 23 Woredas and 577 Kebeles. There are three hosprtals,82 Health Centres and 451 health posts wrth a health centre set up to serve 25,000 population and a health post to 5000 persons. Both health Centre and health posts are called Prrmary Health Care Unit (PHCU). Nrnety seven percent of the populatron rs believed to have access to pnmary health care About 1067 HEWs are currently deployed in the health posts to provrde basic famrly based health services. All the CDTI Woredas resemble each other by their topography, weather conditron, drsease pattern, natural resource and other factors. The climate of the CDTI Woredas rs categorrzed as troprcal Srmilar to others, there are two seasons r.e. the rarny and cool weather from June - October and the hot and dry weather from November to May. The temperature ranges between 17 Ce - 44 Cs. The marn source of income rs mrxed agriculture (farmrng and herdrng) followed by trade. During the wet season, a number of migrant workers and nomadrc people travel to these Woredas for temporary work, lnflux of people also occurs in accordance with the government plan to ensure food security 1.2 CDTI Woredas Mass drug adminrstration with mectizan is operational in five Woredas, T6 Kkebeles and the 863 communitres. Updated vrllage register Indicates that there are 283,773 people livrng rn these Woredas. The annual treatment objective was set as 238,369 people; by takrng 84%of the total populatron as elrgrble for treatment. WHO/APOC, January 201I l0 At present, all CDTI Woredas have all weather road access from the Zone capital. lnter-kebele road networking is still underdeveloped in the majority of the Kebeles. Three Woredas have better access in telecommunication and internet. The problem of telecommunrcation is not yet solved in Quara and Mierab Armachiho woredas. Of the total populatron, 215632 176%) recewed the drug and L2% didn'l receive it due to absenteersm and unwrllrngness to take the medicatron. The rest were not elrgible for treatment Geographically, all vrllages have been reached for treatment, but many absentees were documented. lnapproprrateness of distrrbutron trme contrrbutes for increased number of absentees. Table 1: Number of health staff involved in CDTI Distrrct Number of health staff involved rn CDTI acttvtttes. Total Number of health staff in the entire project area Bl Number of health staff involved in CDTI B2 Percentage Bz=Bzl B1 *100 Metema 60 40 6l Genda woha 6 6 100 Quara 92 61. 66 Tach armachrho 91 58 64 Mierab Armachrho 37 28 t6 Total 286 193 61 L.2.L Partnership The CDTI rs berng implemented wrth the frnancral, logrstrcs and technrcal support from WHO/APOC, The Carter Centre and the Zone and Woreda. ln addition the Zone and Woreda admtnrstratton offices also provide guidance and leadershrp for the effective mobtltzatron of communttles. The Zone Health Department, Woreda Health Offices, The FLHFs, get involved rn factlrtating and monttortng the overall CDTI actrvitres. Health workers rn charge of health facilitres and CDDs have played a paramount role in provrdrng the drug to beneficiarres, providing key malaria and onchocerctasis messages, monitorlng actlvltles and submittrng reports to the next level. llWllO/APOC. January 201 I c\ ^l>. d1 tra (, o o I (o OJ ; 'tU 0) o_ d f o 0'Jr o o)>oO^ o- rcv c.) -oo 0.)E E G ro.^ 9:le?p0J o,o oJc:e atPO(! aZ C,"5qr eg =GO _C. U-\ 3 dz =* tr a!)s 3 ! AJ o oq) L-qr9asa OQ \o-tP !.:.tro JqJ ohEi"oaJ ut ,9 \\ o'O qJ qr Sqr, --cl\!l =-ttolirr IF-t3) IYel h{l YCzQU B( e^ :'bH.E I\UI -carl\QIUXISqrlE3 |q'Bl I\f,1 = o \l o€l I c!lcHlo.Yq!PyU^ Oar= u-cX\! !--esqShg otro.o>- qrOF q:oO".oPEqqcr- t-b PL)FqrO -ou:Ee=tr€lca--o trPa.r\o,c: =ootqr!io)vi-u ts,J\*\o P!: U*!s0 huoo; hqJ-E ieOoq )i''l ! q OqJoJQ.-U ttiG tha-6Xqrro ! .9 o CL oD .= o CL o o ooc '= l! o o ! o t! o o) (E oE o ! (u ! 3(! o (! Io o CL OJ C o o ! .E .Y (! c o g f CL o CL E'E(u OJ oc SE4tr, cL= ^9;e oir ol -: -ol(El Ll o c o ! =CL o CL OEEE. OEE8 55g rO @ € or ul Fl Flrlofn (n @(Yt u)r\ rrl(rl 1.c) €(D Ol @(o Ol ro(Yl @(n N ,O . E.E d -V Sgbrr cc\LO ro O) a! N cO a{ cn(I) m a! cO O)d Or @ rl o_ F- F- l'rO a! oo' (n NF rYi @N og ,.9 1EL-6iE; E d -trE'=ooYNO z z z z Z IEe3(U+L E(o ccPse;3 <oc'=q^vox: z z z z z .= o oos '5 .92 tr f E E o I o o -o E :, z + I o9q ON(U'= -0,tr! cEo oF r-. t--(\ (Orn OlO)d z roo co Lr)N m(O @ .9EoflortY .EY(! LLqr'-tJ< .. o, o) oJ:o *H eI z z z Z z .. e 3 ,'.=i:OF6?.LP6iee<;T'd,ozctr'=ooY N^ z z z z oco6O)L .= L tllEEt 6 rP IFcL-yCL rn O) c{ r-l l-- co(\ ro(O co a! cn OI O) co Fi o. r.- 1... I-\o a! oo- NN ft1 coN OJFltEo .Eo9ttr q,!9 .24oo ot9(l) (o E o o o =-c(.)(! E -o(o ,9 o o f o o E(J (E E L s oF (o s o B GE 0)(9 J F oF 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 communrty or village is a structure composed of 30 - 50 households that are under the control of one developmental team. A developmental team can be explarned as farmers selected among these households who are exemplary in many developmental activrties. The number of households under their control rs determined by their geographical vicinrty. ls there any other information of interest about the population in the project area? lf so, include it here. No comment WIIO/APOC. January 201 I l3 $=al 5 =a - o C I C .F loo -LLn 6F !o o!qlaJLU!c .cJ LL o)0l>F >! oc OJ OJ -.c -cl9! ro: +OoJ x€u* oJ a.)3[ ;Ud-c or9 I eCtr- oi L: qJ ooPCrc p!h9 6= ^,Ef cu-OLJ o U0J 4 0.Jbj-9 >C5rO u-x bog6 G :bB o:.c;i-oi!3= l-o/o-o)+f Xo >!?dO>TEc;lrc(u boO!d -Ufu= -:OLUooc NLUug +@eUS so?o; -v P9E LU :rcFior CqlGo:^ _o UJ0]!6to-o l>0ril--c :26PL=bno-c3.- P o(gE9-trY14+oJY =oorF aB E Ec.yboO=Lrc!urc- ,F6> L ro C) P o L L J I o) ! v ; oP(u(u L P q(o o, Lt! o,FE OP(J-L Ib- 6cxio, 9.- u.LI6>.4y.-vsE9(ul! -5FEO;orq .L F.-:E9 N.: FF4oml:-(ul -lB-i*llrlNFI o 't o CL f c o o? CLOEE olJ OJc f 0)C = o)c f (u c EO .=vPEheE rU f -o3- ro f 3- ro f, L _o o.) ;-LL (D =o I g .9 f lt .9!, 00 o tr o qJE cLOEE o(J OJc :l o)E f Oc l o)c f, qo uCE9 (o (o (o (o o(, ! o-l G) I c o oz. cLoEE oI = o- = o_ =o : o_ o! .:PPCE9 = o- = o- =o =o_ oo (! F c o .E E,oE cLoEE ou s.() (D .CU ro s ro E(J (o oo vCE9 E.(-) ro E(J ro s. ro -c(J ro Oo c.9o.: PL(El lltroo o O, -= cLoEE oI L rc f _o qJ L ro l _o q.) LL rU =o 0.,u L ro l _o OJ I u0 vCb9 rof _o C) II ro) _o 0) I ru f _o o I (o l _o o LL (9 J u i5 (g E (U OJ (o rc o o _c E L)(E E G EU ro F E -cU(g E 0l B 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. Special emphasrs was given to advocate key stakeholders who extst at various levels. Zone health department management staff and Zone and woreda admrnistratrons had been debrrefed by a team composed of The Carter Centre and Zone health department focal person. Leaflets were prepared and drstributed and flags to be placed in front of tables were prepared and drstrrbuted. ln general, 23 Zone and Woreda officials were mobilrzed. The presence of newly assrgned offrcrals was the reason for conducting the activity. Followrng the advocacy meetings, leaders at Zone and Woreda levels have communrcated therr subordrnates through letter and other channel Nonetheless, the support from Kebele chiefs was minrmal. Efforts need to done be to be reach kebele chrefs Woreda health offices have to made efforts to approach to draw the attentron of leaders at kebele level. 2.3. Mobilization, sensitization and health education of at risk communities Mobilizatrons and education was mainly done by HEWs and CDDs. CDDs were provrded with Flrp chart (one for two CDDs). HEWs educate durrng therr home to home vrstt and CDDs dunng census updating and the time of drug distrrbution. WI IO/APOC. January 201I l5 o b0 s o6 .go .:(Jtr q', al!trc tro,oso? :; olt E z oo E{ll *J{ I co o oo o tr o(, o CL 3Eg8 h'Fo;5PF EEECDiE:9.p B z z Z Z z z o -C T,PO, E! 6Co3.u oc LJOF -o=5Ez @ + co I co E oF r @ N N O) 01 N @d (o mr Fl or ft1fn CO oqotoo(Jr (o(O rnr-l (o a\J\o od gt(O(\l cotBz(J c\lr'- D-t'\d corod @strn af)(OH Nt\F{fn fs333'> -.- B. >oBH 't-g '= o, =-otrL =oEE9> o'E LflOE!LFEio ZtJ ooFI l|* co co co (u uo(! o IL o o- oI o(-o m @ .'l r\.1 $$H F(O o co rt) fiSs3'E s gI Ei; d"5EE3 zeEo ro co i T'- r-- a! <f, cO rO(o co O) O) oo (o co P .U .=o .v,t'A OUL c.!oro coo-<LLdl tuoEtFEo oo,9-C v (O r) rooco rnc! ft1(D @ (, J (J i5 rc E q) 0) o € _cU rc E _o(! I ro old o € .CU rc E -cU roF o c o B o -o c OJ(, E oF fcO N u _o E o CZ cl a o- C = \o q; a o B o o c B BB tt q e di a E oqq qJq q, c ,\ 6] o\ AJ\ o tr\ !! B q) i4 o q,, a. _ troI c,) u .; o =jjE3 LO9E oq >B cq o P F-Etr!ou(J {r olq*l NFI Comment on: - Attendance of female members of the community at health education meetings. No document - ln general, how do you rate the participation of female members of the community meetings when CDTl issues are being discuses (attendance, participation in the discussion etc) The partropation of females in general rs minimal, but progress rs seen from trme to trme. lncentives provided by communities for the CDDs. No any form of incentive from the community - Attrition of CDDs. - ls attrition a problem for the project? lf yes, how is it addressed? - Attritron ts common especrally among settlement communrty. Replacement rs the means to handle thrs rssue. Some CDDs and supervisors are not willrng to contrnue related to absence of tncenttve or recognitron. By consrderrng thrs problem, The Carter Centre has provrded ballpotnt for each CDD and Certrfrcate. Except in Metema, the rest Woredas have offered the Certflcate to CDDs and communrty supervrsors during post campaign kebele level review meetings. 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 . lThe most importont issue to describe is whot meosures were token to ensure odequote CDTI implementation where not enough knowledgeoble monpower wos ovoiloble or if stoffs ore frequently tronsferred during the course of the compoignl. As much as possrble, the malorrty of the health workers who were expected to involve rn the program have been trarned on integrated rmplementatron of malarra and Onchocerciasts. The trarning was grven using modules prepared byThe Carter Centre. Suffrcient copies of the modules are drstributed to each trainee. t7 WFIO/APOC. September 2009 ilI H+(J: ]= :\t rOid bq T' oc '6 oo L.' o olt E a z O) 6J(D ri o)f\(O ri O rO l-- ri Cll 'od I o rl(o o r{(o o F{ O'|fo m to otdfn rn or Fl @ ot cq, E o .9c I Nl.\ol-r ri rn l--d rft l'- rl c! O) ri o Fi(D o (n(n <l T(!ll I P '9' S&'G o o L^ l!L!bgFo- +6 cf) cO a! cO co o c! a\ o cn r! H cO r- r{ rn Fl (\l <l O) 0) E o .9 ! I s cf) ]o :\t o LOF(J 6S O.= .(o oilt E f z O cO cn rO m ca €ri (!lrIi5 d +-F(J *\OJ LJt 9\r llolLF(J o CL o 9,t B -c .:v(E(Oe Os (! oo olt E) z O <l O o os (O d rO o co(O co r/) @ rn o (O rO @ c{ @N o a\l cO (O rO o, O O o o or tr o E o .9 ! I x 6,,(J6.i+^F(J 5,jq ,j I i OJ e o F ! o c '6 (o (Jf icL i5 o o -ct E f z rn rn o Ol o) o f-- l-- o c! N o H o d O u) N tft IN o (o N o) E O) .9 I s r) oH l-. ln co cOcO (9 .c i5 (! E G' G) o d o E -c.U rg E To(o F o io o E(o G -co B '9 .gPOrtr ., G;o- ^ O)iio J FoF c.CC cl o o o- Otn a o oT : ! oU qJ a o! o qJ qJ o qJ 0J .Y o i o Or ! o a_ qJ qJs qJ o a- qJ a o o o o AJ ! S- qJq i AJ =* E B q, u qJ tr .\ i o OJ o tr B! tr OJ o OJ a. c o (! c(u Eg CL .E tro(J o E o o) o =E o (! @ .E .s ag F rh ol -ololFI @ or-.@N c! o) r_t rr)(O <l co o ro rn d @n O rn O (Y) O) H on o) r-t o ut F{ AJ Table 6: Type of training undertaken (Tick the boxes where specific troining wos carried out during the reporting period) - Any other comments ln all Woredas, the parttctpation of the community in planning and monitoring of activrties was almost absent. 2.6. Treatments 2.5.1. Treatment figures - lf the project is not achieving 7OO% geographical coverage and a minimum of 65%6 therapeutic coverage or the coverage rate is fluctuating, state the reasons and the plans being made to remedy this. All of them have attatne d 1.00% geographrc coverage and more than 65% therapeuttc coverage Trai nees Type of trarnrng CDDs Other Communrty members e.g. Community supervrsors Hea lth Workers (FLHF) MOH staff or Other Polrtrcal Leaders Others (specify) Program management How to conduct Health education Management of SAEs CSM SHM Data collectron Data analysrs Report wfltrng Others (specify) sustainability WFIO/APOC, January 201 I l9 O(-.l 9Po;:'aErET P- cr'.9at, =irr-cOaLPO O o o o o o orgYq ^JY'Pq =so;CL!, fc)-O?.tr1 ZOEUV o o o O o o gO OCJ -olE-06o 1q2S 6 O) rO r-l O) mo Fl(o Fl @ ri c! rn r-. co o(O a! co @lrl @t{ L6c a;u0)!69H0.,EEo!^i=,-c = b rb 3zo-;:i o @ Lr) @ sf O)N c! cOo(O rns a! !n o) c\t r.o a\,1r\ <l Fl c o , rc =o o o- fO, oo!OS.e fl o , *\3b*yeoo*_ -coOFL) r-t N cO N cON o@ r-.l-- (o N o g6 oJsY. -oo,YFb!,4rc :LJO'i Zo-P !n Fi slo LA cflos(.o a! rn @Ot |-.. N aOs (O |-\ O)N(o IN(n ro rn Fl N o ,G, ruo.a)iuEEq FIJ (O @ co O) lJ) dr)O co co @ cO !Or\ 6 O)(os(o $ ol co(o O)(o(n @ rn t! I OL -uuo=-q F:YCro o- 6i o.rOrOC cO O) a! r-l N cO a! cr)(D c! rO O)d O) @ o. NN I-\o a! oo- tY)F F\ di6N 0) b.0(g t 0.) , c f E E o L) eOJOFoDo : (s ?.{F-b6.rr *- Yfo-Yu\\(9cO oo d oo rl Oo d oo Orl oo Fl ==6ULO- LcboYqlay!E=io5l->0.) =c\J66PZUqr F- l-.N \o Ln O) Ol (o O cO rn c! (r1 1l) co o orgoc.a -PPO ii_o -Fo |-\ l-- c! (-o LN O) O) r-l \o r) N fn(o @ :;-3&eYEloo,>E-+?i:rJ-oro T F: E BE H OS b> - v 'uart r-. l--N (D L.) Olil (O o co r) a\l (r) ro @ 9<!(, o'\ o E 0.) o) -c. =TH9E (orcld IiU _o utoL (D -c B G c 0.)(9 t oF c al a'6 = cd U o o -]. e. B qJ I qJ b] o q, o !! B AJ o AJ a. (! ro o (o (o e 19 J .9 .9 ! -o llj ttl :c, l! c o E (g q) F nf orl -oll!lFI c\ = cl d a Cd \,o o f la B +t OJ 'd'\ .4.EP0r= trqJq, .Ci :Eo U.g .S tP -Ba-E P3H ibT iHsg\ .=BTSErn oJf!! dboq, T :Etr !,f qr! ss.\L€ :a.tr9qros ssh. .:e Ffi ols : BHsr\o:o {v!a,YtqtrolE *EBSa. .c Pil EqroJqrQ.a !\ 0r\5 .rOOE 8f, * EiA9 -\trorO*O'! Eh. .Etrar -9){\\! Broi .s-oEi ss 0roJO$ 8':B. r.sr. bs 4., qJ Oaaus sE\\ !EA0r:tr !-LOFtirtr.=o * Ig'qit=e eetrtr! ,,,,3P Pts <5P o L- ru-Jo)-LG o 0,) L UG0iP _d3OL ojo_O LL(ooJo- -cUPo, ocE Yo.! z.oJg-r=? _>6Li(q -O) -!r-O(g5.=c:qE- occ 'EOJ(U =EE caqOJ EGI-E33_ -Eu^r=\F 5l ; ?,:dl !or *xl EE =.--l oordl eci.=l u- -oqul Eo.,gLI^,P >pl:(o or €xll Eot ot I ol oEAq)Ol ol P al u Il f, :l , !l -3;lE;l+ol2oloUl . )J - o.,l E AIEl" :l: EIS El81, L =' "' bl O il gvl;:lqo,l ' =l E -el -. -el 3-E E El b 3 s EE0.rl Eol Lorl !:o)l016UlcolEq9 *ol = *"1 f *"1 g tl fblf bl) ;l= bl= =l:116=lE=15 0'J Yro LoJ 0.)oD o.0 (gG-Li: oJ 0J OJ>!o[!cou:oJu-oJ> ,, o oO oJY^U^O^= 6-0>@ oGOrneiouts;oO-);o.)F-: old(6tLl oJl >l olUI EI .91 -cl oJ olLlM ol ol dd EI(El ul elrl orl ol olLl oJl -clvlg fl ol EI ol :l el -l3l EILl olsl 2.6.2 What are the causes of absenteeism? Many absentees are reported this year with the malority (82%) being from two Woredas (Metama and Mierab Armachiho). The corncidence of the drstrrbution trme with cultivation time and failure to retneve absentees/lack of frequent visits were the matn reason ln these Woredas. 2.6.3 What are the causes for refusals? Among persons who failed to collect their medication,45% were refusals. The reason for not acceptrng the service is not well known and demands further study. 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 lnformation 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 22 WHO/APOC. Januari' 201 I =oN a cd Q o o f co(.-l q) oo(,IE^F6S o(J r-{ co r-l O) $O) r{O) rn@ O)co (oo) oO) c o 'n (o l oL oo!o - o) o\ .a '- * ol!() lJ) @ r{ O) +Ol t+ O) cn @, O)@ (D O) OO) fq)oo!o 0.)2. @;ouJi-ur co\o \oF- O)rr cor-- o|-\ rnN l--l-- (gr\ lrJ o6LCX33XEb9loP z @ c! -+- (O co <f rn o_ o@ Fl tn or co co Fl o) C{ co ^i@ ri ro r,) 01 d d a! sloq o d c! rno co- rn r+ a\ c! co(O ui d c! tr, eil oo)>?trULe CG=4(l)-o rJ) $- dOri co O)ol r* O) LA O(O d O) rl (o t-- n ot O) t'- co r-l + u) C! 00 rl o)d cr) a! l--o N +N a! O)(o co @ cON coJOo: : ;a,)>-F0 .lj.otSdP@ Fo-b;c(oOGrO, tr (o o co- (O c! rl (\ \ rn co c! slnO +fo c! rn$d'l o) sl a{ slO(o- c\ o m r!) sl o_ c! co N q) rn 6ld @ a\l co l-rl-- cO co c\ AJ bo ro ; ,OJ =cl E E o(J ooooOP:r\-qkgd,i,.c{ oulU oO oO oo d oo oOri oO d Oo oo r{ a0J ^ ooo o=g:luJur* .,!2a63- o st Oo d oo F{ oo d OOt oo r-l Oo OO .=b, ;L(o-! ;!:o to:<-or(gu -tui9 zooJi U; cO(o Irl $d Ot $ d O) sl d O) $O O) co @ .o\o @ UJ rA GGJ.a ?trtJLe co= o cf) rO cn $ O) s d Ot s Fl O) sf o) $O O) @ @ cn(O oo 5o\66:i(lJ o.0r!-a: L-_ PT(u9LOCuogr(UFCGUE O-C: ov <l rl o) $ r-l O) sl O) $rl Ol s $O O) oo cO ro(o 00 U cOooN sloO(^.l rnoOr! (! oor! NooC! cooo c! O)oo C! o do a! -q c .9y s f .u(o I o oo(! L o oI(, Ff (u '; oLP(,(Eoc trsoOEIoo:, o 'c,;E .35q ; a.Y.ro;9or co.= .Yooou..=EilE .eYo.tL9 dr-IE UoJ) 9' B orl : : r.ol :6o11Foo-lo-rnl(J ;l NlFEI 3Eol hESl Eo>c,E!l 'a ar@L <bnCL oluo, rg 5:8 iC!(I)cYFotrE6)3E Phon;EOA9v -(!(!T'oe EL=oF= Fol '; .,: ot 6 "i =l _ENFI CL 2.7. Ordering, storage and delivery of ivermectin Mectizan@ ordered/applied for by - (please tick the opproprnte onswer) MOH g WHO E UNICEF tr NGDOS Other (please specrfy): Mectizan@ delrvered by - (pleose tick the oppropriote onswerl MOH g WHO E UNICEF tr NGDOM Other (please specrfy) Please describe how Mectizan@ is ordered and how it gets to the communities Based on the plan made at Zone level, request rs submitted to FMoH with all the processes of verrfrcation and custom cleanng berng routrnely done by NOTF. On arrlval, the drug rs temporarily stored rn FMoH warehouse from whrch ZHD are notrfred to collect Thrs year, The Carter Centre and RHB have facrlrtated the shipment from Addrs to Zone level. Each Woreda have collected their amount by themselves. Ways of drstributron from Woreda onwards vary from area to area. Some transported until FLHFs level and others left rt for FLHFs to collect from woreda. The commonest means ts ustng both alternatives. Erther communrty supervisors or CDDs have collected form health f a cilrtres. Table 10: Mectizan@ lnventory (Pleose odd more rows if necessory) District/LGA Number of Mectizan' tablets ! 0.) 0.1lq OJ d. ! 0) z 0)U 0.)d !o;dE>o9G A- -O -o - (')g6 |:o ro E 0.)q f q) ! AJ o .B ! 0., aXU o! c E o E QJ d Metema L60600 197500 29072 22651,2 1 16303 0 2782 NA 1.01427 G/woha 18000 9500 6650 16150 15831 0 81 NA 238 Quara 200000 182s00 37 497 2L999l 219322 0 574 NA 101 Mrerab Armachrho 90000 89500 6760 96260 71763 0 1016 NA 23481 Tach Armachrho 170000 1 67500 37L73 204673 lt 1.7 02 0 642 NA 32329 Total 638800 646500 105954 763592 594921 0 5095 NA 1 63576 24 WHO/APOC, Januar.'- 20 ll For Unknown reason, high wastage is reported from Metema woreda How are the remaining lvermectin tablets collected and where are they kept? ln princtple, the remalning drugs should be collected by CDDs/ Supervrsors along wlth therr report. The front lrne health facilitres in turn should return to Woreda health offices where they are temporarily stored untrl the next dtstnbution. List and briefly describe the activities under lvermectin delivery that are being carried out by health care personnel in the project area. . Determrne the amount of Drug . Collection of lvermectin from the Woreda health offrce . Distnbutlon of lvermectrn to CDDs . Give training to communlty supervisors and CDDs - Facrlrtate recruiting new CDDs and communlty supervtsors . Conduct supervisron, monitor and manage mrnor srde effects . Collect all records and compile reports and submit to woreda health offrces . Collect the reaming drugs, temporally store and f rnally 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? All health workers and Woreda management staff have been trained on CSM lf so, When? lt has been given durrng trarnings conducted at drfferent levels. Table 11: Community self-monitoring and Stakeholders meeting lAdd rows if needed) Distnct/ LGA Total # of communrtres/villages rn the entrre project area No of Communrtres that carried out self monitorrng (CSM) No of Communrtres that conducted stakeholders meeung (SHM) Metema Quara Tach Armachiho W. Armachiho G/wor', 277 199 ioo 56 25 NA NA NA NA NA NA NA NA NA NA TOTAL 863 NA NA WHO/APOC, January 201 I 25 Describe how the results of the community self- monitoring and stakeholders meetings have affected proJect implementation or how they would be utilrzed during the next treatment cycle No report on CSM undertakings 2.9. Supervision 2.9.L. Provide a flow chart of supervision hierarchy. ZHD & TCC-E) Woreda Health office ) Health Facility ) Community supervrsors ) CDDs Zones and Woredas have made supportive supervision to CDDs and HFs 2.9.2. What were the main issues identified during supervision? . Most CDDs were well acquarnted with malaria and Onchocerciasrs . There were missrng or damaged village regrsters . The involvement of Woreda management staff to support HFs and CDDs yras very low especially rn Metema . Post campatgn revrew meetrngs not done at Kebele and Woreda levels . Poor documentatron (farlure to frll the fields) . No report on malarra activtttes 2.9.3. Was a supervision checklist used? Yes 2, 9.4. What were the outcomes at each level of CDTI implementation supervision? o CDDs and health workers were motivated by the support o Better performance documented from areas that 8ot support . lmmediate corrective measures were taken 2.9.5. Was feedback given to the person or groups supervised? No written supervision given. 2.9.6. How was the feedback used to improve the overall performance of the project? WHO/APOC, January 201I 26 SECTION 3: Support to CDTI 3.1. Equipment Table 12: Status of equipment (Pleose qdd more rows il necessary) *Condrtron of the equipment (F=Functronal, NF=Non functronal,CNFR=Currently non-functronal but repa i rable., WO=Written off). APOC and TCC donated car and motorbikes are almost grvrng up functionrng. Regardrng vehrcles, the CDTI activities are entirely runnrng by cars, motorbrkes and equrpment supplred from other sources Slnce the CDTI activrtres are hrghly rntegrated into the general health delrvery system, utrlrzrng these materials is not a problem at present. However, problem occurs whenever there are other srmultaneous acttvttles at time and when they get old. Therefore the need to replace old car, motorbikes and other relevant equrpment rs mandatory Source Type of equipment APOC MOH ** DISTRICT NGDO ZHD No. Condrtron No Condition No Condrtron No Condrtron No Conditron' All krnds of cars 1 WO 4 F 3 --- Motor cycles 6 NF L2 F 3 NF 2 F Desk top computer I NF 5 F 10 LaserJet printer 1 F 5 F 10 F Photocopier t NF 3 F 1 F Fax machine L CNFR 1 F 1 t 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, January 201I 2l How does the project intend to maintain and replace existing equipment and other materials? Maintenance of cars and motorbikes is mostly done when broken with no scheduled marntenance. Replacement of written off cars and motorbikes not possible at all. Absence of vehicles rs critically affecting the project actrvities. 3.2. Financial contributions of the partners and communities Table 13: Financial contributions by all partners forthe last three years - lf there are problems with release of counterpart funds, how were they addressed? There rs a trend of delay rn release of AIOC fund. TCC fund rs easy and flexrble to use - Additionalcomments Woreda health offrces and Zone health department have strll problem of putting the government share or contributron explrcrtly. Besrdes, Woreda health offices lack to lrqurdate thetr expenses trmely. Thrs rn turn causes problem to uttlize APOC fund. 3.3. Other forms of community support - Descrrbe (rndicate forms of rn-kind contrlbuttons of communitres if any) No any form of support Contributor (2008) (2ooe) (2010) TOTAL Cash Budgeted (uss) TOTAL Cash Released (uss) TOTAL Cash Budgeted (uss) TOTAL Cash Re leased ( uss) TOTAL Cash Budgeted (uss) TOTAL Cash Released (uss) MOH (Central + State) MOH (Distrrct + zone) NA NA NA NA 6000 47 23.45 Local NGDO(s) ( rf any) NA NA 0 0 NGDO partner (TCC) NA NA 15,000 14242.86 12000 11922.98 Communitres 0 0 0 0 APOC Trust Fund NA NA 8 175 5122 1l-888.25 8321.6 TOTAL NA NA 231t5 19964 86 29888 2s 24968.03 WHO/APOC, January 20 ll 28 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 1USD = 16.50 Table 14: lndicate how much the project spent for each activity listed below during the reporting period Cost per treatment for the entire project is 0.15 USD. SECTION 4: Sustainability of CDTI 4.L. lnternal;independentparticipatorymonitoring;Evaluation 4.L.t Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable) No Year 1 Partrcipatory lndependent monrtonng I Activites Expenditure (s us) Source(s) of funding Drug delivery from FMoH area to central collection point of community 84t.25 GOV & TCC Mobilization and health education of communitres (HSM) 1280.3 1 APOC rrelftgllQqDr n Trarning of health staff at all levels 1.3076 APOC, TCC & GOV qlpgly![g_c_ q o_g_4q ljst ri b u t i o n 4492.3 APOC, TCC & GOV CSM 2590 APOC lnternal monitoring of CDTI activities 634 TCC Advocacy visits to health and political authorities t83 TCC IEC materials 0 Summary (reporting) forms for treatment 0 Vehicles/ Motorcycles/ bicycles maintenance 1.032 GOV Office Equipment (e.9. computers, printers etc) Other miscellaneous expenses 101 138.18 GOV & TCC TOTAL 24968 04 WI'IO/APOC. January 201 I 29 Mrd Term Sustainabilrty Evaluatron 5 year Sustarnability Evaluatron lnternal Monitorrng by NOTF Other Evaluation by other partners 4.L.2. What were the recommendations? 4.L.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 of? 4.2.7. Planning at all relevant levels 4.2.2. Funds 4.2.3 Transport(replacementandmaintenance) a WHO/APOC. January 20ll 30 4.2.4. Other resources 4.2.5. To what extent has the plan been implemented 4.3. lntegration Outline the extent of integration of CDTI into the PHC structure and the plans for complete rntegration: ; - Training : - Mectizan delrvery - Distrrbutron - Supervisron 4.3.1. lvermectindeliverymechanisms Ivermectin deliverv follolvs the exrstrng drug delrvery system of the general health servlce 4.3.2. Training : .Trarnings are rntegrated wrth PHC at all levels 4.3.3. Joint supervision and monitoring with other programs Supportlve supervision and monitoring activrties of the CDTI program were carfled out wrth other PHC programs in an rntegrated manner 4.3.4. Release of funds for project activities .Funds were released for CDTI activities by the government, the Carter Center and APOC. However, APOC part of the budget was released late. 4.3.5. ls CDTI included in the PHC budget? Yes 4.3.5. 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. t I WHO/APOC, January 201I 3l 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. NONE , 4.4.2. How were the results applied in the project? t SECTION 5: Strengths, weaknesses, challenges, and opportunities a : t Strengths: The overall performance can be rate as satrsfactory, but there are areas that need improvement Weaknesses: 1.. Missrng and or damaged village regtsters 2 Lack of supporttve supervtston from woreda health offrce Challenges: o Lack of transportatron . Woreda heads like Metema worda health offrce lack attentron to the program o The coincidence of national electron ttme wtth drstrlbution ttme o Extended distribution trme and unable to get report timely o Unable to find complete report f rom woredas rncluding drug balance Opportunities: The health extenston program SECTION 5: Unique features of the project/other matters WHO/APOC. January 20ll )L