Western Equatoria CDTI Project annual project technical report submitted to Technical Consultative Committee (TCC): January to December 2008

II I I I I wEsr EQUATORIA(WEQ) CDTI PROJECT ORIGINAL : English ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) DEADLINE FOR SUBMIS SION: To APOC Management by 31 January for March TCC meeting To APOC Management by 31 July for September TCC meeting AFzuCAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) RECTJ LE 0 t AiJli 2uL.J APOC/DlR VgD *ilip I IO li I nDi ts ilnlErrneHen Terbrrt I( 8d'.t. COLINTRYAIOTF : SOUTHERN SUDAN Project Name: WEQ CDTI PROJECT Approval year: 2003 Launching year: 2004 Reporting Period(Month/Year): From: January To December 2008 Projectyearofthisreport: (circleone) I 2 3 (4) 5 6 7 8 9 10 Date submitte d: 27th July 2OO9 NGDO partner: Christoffel Blinden Mission CE/ EPI Btrn C.9\ co? cf,ofo 12 i;r tb 1 WHO/APOC, 24 November 2004 ANNUAL PROJECT TECHNICAL REPORT' TO IECI TNICAI- CONSULTATTVE COMMITTEE. (TCC) ENDORSEMENT Please confirtt you have read this report by signing in the appropriate space. OFFICERS to sign the rt: Countr;,:Southern Sudan National Cloordinator Narne: Dr Mounir tuga Signature: . I Date: 21" July 20 APOC Technical Advisor: Lazarvs Nw'eke Signature NGDO Representativc This reptrrt has been preparcd by Name :David Bido Designation : Prdect coordinating officer Signature: ,+if.;. Date: 146 J 2009 Date: I 8th .lu ly 200c) Narrre: Fasil Chane AMSrgnafure: ry Date: 18'h July 2009 z_ I Table of contents Acronyms. Def,rnitions FOLLOW UP ON TCC RECOMMENDATIONS Executive Summary SECTION 1 : Background information.......... 1.1. General information 1.1.1 Description of the project (briefly).. 1.1.2. Partnership 1.2. Population SECTION 2: Implementation of CDTI 2.1. Timeline of activities................ 2.2. Advocacy. 2.3. Mobilization, sensitization and health education of at risk communities .... Signet non d6fini. 5 2.4. Community involvement........... 2.5. Capacity building 2.6. Treatments 2.6.1. Treatmentfigures Erreur Erreur Erreur Erreur ...6 9 ! Signet non d6fini. ! Signet non d6fini. ! Signet non d6fini. ! Signet non d6fini. 2.6.2 What are the causes of absenteeism? 2.6.3 What are the reasons for refusals?................ ................26 2.6.4 Briefly describe all known and verified serious adverse events (SAEs) that...26 2.6.5. Trend of treatment achievement from CDTI project inception to the current year28 2.7. Ordering, storage and delivery of ivermectin............. ..........29 2.8 Community self-monitoring and Stakeholders Meeting 30 2.9. Supervision.... Provide a flow chart of supervision hierarchy... What were the main issues identified during supervision?................... 2.9.3. Was a supervision checklist used? . Erreur ! Signet non d6fini. What were the outcomes at each level of CDTI implementation supervision? 32 Was feedback given to the person or groups supervised?................................32 How was the feedback used to improve the overall performance of the project? 32 SECTION 3: Support to CDTI 32 3.1. Equipment 3.2. Financial contributions of the partners and communities 3.3. Other forms of community support 3.4. Expenditure per activity .............. 2.9.t. 2.9.2. 2.9.4 2.9.5 2.9.6 ...31 ...31 ...31 ..32 34 34 35 36SECTION 4: Sustainability of CDTI ...... J WHO/APOC, 24 November 2004 ,...7 4.1. Internal; independent participatory monitoring; Evaluation............ ...... 36 4.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable)........... ............36 4.1.2. What were the recorlmendations? .............36 4.1.3. How have they been implemented?............ ..................36 4.2. Sustainability of projects: plan and set targets (mandatory at..................................36 Yr3). 4.2 4.2 4.2 4.2 4.2 4.3. 4.3 1. Planning at all relevant levels.... 2. Funds 3 Transport (replacement and maintenance) 4. Other resources.. 5. To what extent has the plan been implemented . Integration l. Ivermectin delivery mechanisms........................ 36 36 36 36 36 36 37 37 374.3.2. Training... 4.3.3. Joint supervision and monitoring with other programs.. ................37 4.3.4. Release of funds for project activities ... Erreur ! Signet non d6fini. 4.3.5. Is CDTI included in the PHC budget?............... ...........37 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements?...... .........37 4.3.7. Describe others issues considered in the integration of CDTI. ......37 4.4. Operational research............ ..................37 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. .........37 4.4.2. How were the results applied in the project? ...'........... 38 SECTION 5: Strengths, weaknesses, challenges, and opportunities ............. ........38 SECTION 6: Unique features of the project/other matters ..40 4 WHO/APOC, 24 November 2004 Acronyms APOC African Programme for Onchocerciasis Control ATO Annual Treatment Objective ATrO Annual Training Obj ective CBO Community-Based Organization CDD Community-Directed Distributor CDTI Community-Directed Treatment with Ivermectin CSM Community Self-Monitoring LGA Local Government Area MOH Ministry of Health NGDO Non-Governmental Development Organization NGO Non-Govemmental Organ ization NOTF National Onchocerciasis Task Force OV Onchocerca volvulus PHC Primary health care PHCC Primary Health Care Centre PHCU Primary Health Care Unit RAPLOA Rapid Procedure for loa loa REMO Rapid Epidemiological Mapping of Onchocerciasis SAE Severe adverse event SHM Stakeholders meeting SSOTF Southern Sudan Onchocerciasis Task Force TA Technical Advisor TCC Technical Consultative Committee (APOC scientific advisory group) TOT Trainer of trainers LTNICEF United Nations Children's Fund UTG Ultimate Treatment Goal wHo World Health Organization 5 WHO/APOC, 24 November 2004 Definitions (D 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 mesoftryper-endemic areas that a CDTI project intends to treat with ivermectin in a given year. (iv) Ultimate Treatment Goal (UTG): calculated as the maximum number of people to be treated annually in meso/hyper endemic areas within the project area, ultimately to be reached when the project has reached full geographic coverage (normally the project should be expected to reach the UTG at the end of the 3'd year 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) Geographical coverage: number of communities treated in a given year over the total number of meso/hyper-endemic conununities 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 conununities to solve more of their health problems. This does not include activities or interventions carried out by community distributors outside of CDTI. (viii) Sustainability: CDTI activities in an area are sustainable when they continue to function effectively for the foreseeable future, with high treatment coverage, integrated into the available healthcare service, with strong community ownership, using resources mobilised by the community and the government. (ix) Community self-monitoring (CSM): The process by which the community is empowered to oversee and monitor the performance of CDTI (or any community-based health intervention prograrnme), 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. 6 WHO/APOC, 24 November 2004 FOLLOW UP ON TCC RECOMMENDATIONS Using the table below, fill in the recommendations of the last TCC on the project and describe how they have been addressed. TCC session 28 7 Number of Recomme ndation in the Report TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT USE ONLY I The project should conduct census The project has stated this in 2008 but lacked registration books in many villages. There is plan to provide all the targeted villages with household registers to enable CDDs conduct the census in2009 2 Effort should be made to increase the participation of female community members in CDTI activities In 2008, there was improvement in the female participation as evidenced in the number female CDDs that participated in mectizan di stribution. The project will continue to stress on more female community member participation. 3 Increase the number of CDDs The project in 2008 increased CDD number to 600 from 480 in 2007 ard there is plan for further future increase. 4 The usage of Tablets should be properly monitored In addition to adherence to close monitoring of tablets dosage, CDDs and Health staff are to be reminded the importance of this during the refresher training on the use of household register and height stick for giving correct dose. 5 Efforts should be made to improve the treatment coverage with the special attention to the maridi and mundri communities, which The low treatment coverage in both Mundri and Maridi is traceable to security problem. The project will consult all WHO/APOC, 24 November 2004 have the lowest therapeutic coverage 55o/o and 37o/o respectively relevant authorities in Maridi and Mundri counties to provide security during treatment and also community members are to be mobilized to overcome the security threat.. Develop e a sustainability plan Since the project is in year four of APOC phase fund, after evaluation at its flfth year, the sustainability plan would be developed. (Please add more rows if necessary) 8 WHO/APOC, 24 November 2004 Executive Summary This is the fourth year report of West Equatoria CDTI project covering CDTI activities implemented from January to December 2008 The project has a total of population at risk of 506,847 with425,75l and 361,889 people being the project Ultimate Treatment Goal and Annual Treatment Objective respectively in 5 counties. The project line listed CDTI 683 villages with 600 being targeted in 2008. Data on the number of health staff involved in CDTI shows that only 9l(12.7%) persons were involved in CDTI activities out of 716 available health staff in the project areas. The project treated a total of 303,829 persons in 540 communities. The project geographic coverage and therapeutic coverage were 79.1% and 59.9oh respectively. Similarly UTG and ATO achieved were 74.1% and 84.0%o. There is an improvement over 2007 though still below APOC standard. Population movement remains constant. There is great number of Congolese refugees who fled from the attacks of Ugandan rebels (LRA) into Sudan. Also there are internal displaced persons in all the project areas. This has affected the implementation of the CDTI activities especially in Mundri and Mardi. Household registration has not been conducted well because people are moving from place to place. Training was conducted at all level. Of 724 CDDs targeted, 600 CDDs (52.9%) attended basic and refresher training. Of CDDs trained, 145(24.1%) were females while l0l(14.8%) out of 683 villages have female CDDs. The project trained 9l(65.8%) out of 746 targeted health workers. The Ratio of CDDS to the CDTI population is 1:845 people .Therefore the project is planning to train more CDDs in the next treatment round for effective implementation The project has faced the below challenges CDTI is considered as a vertical programme: The project has made a lot of emphasis to explain APOC philosophy on CDTI implementation. Delay in disbursement of Funds: This is big issue regarding staff and activities. Most of the staff have joined other sections but the project managed to encourage and contain the available staff to hold on. Mass treatment campaign: The CDTI strategy is acceptable but the mass campaign should be organized like other community programmes. Integration of CDTI: The PCO met the MOH and put more efforts on the issue of integration of the project staff for smooth running of CDTI. a a o a 9 WHO/APOC, 24 November 2004 SECTION 1: Background information 1.1. General information 1.1.1 Description of the project (briefly) Geographical location, topography, climate The West Equatoria CDTI project is located between latitude 4.0 - 6.5 degrees and longitude 26-31 degrees in the South-western region of south Sudan. The project office is situated in Yambio town in West Equatoria state. The state is bounded on the North by Lakes, Warrap and Unity states, on the East by Central and East Equatoria states. South and West parts share intemational boundaries with Central African Republic (CAR) and Democratic Republic of Congo (DRC) respectively. The project consists of five counties namely; Tambura, Ezo, Yambio, Maridi and Mundri. The Nile River traverses the Equatoria region dividing it into Eastem and Western Equatoria. The topography of the state is ironstone plateau with complex basement. The project area transects two hydro-topographical zones of the Nile and Congo watershed, which is characterized by fast-flowing rivers e.g. Yei, Yale, Bahr-Naam, Era, Maridi, Lesi, Sue, YubulRingasi/ Ibba, Biki, Mbungu and Duma. All rivers drain northeast to the Jur and east to Bahr el Jebel, which form a confluence at the White Nile. It is precisely because of climatic and topographic conditions that the disease prevalence rates are so high, as the black fly thrives in such environment. The vegetation of the areas is mainly guinea savannah with woodland derived from rain forests to the south. Population: activities, Cultures, language The total population at risk of being infected of onchocerciasis was 506,847 people. The people who emigrated or internally displaced persons are retuming homes and this exerts increase in the overall population of the state. Prior to the war, the majority of the inhabitants of West Equatoria were settled agriculturalists in the communities practicing subsistence farming. Current settlement patterns have been impacted by prolonged conflict. In 2008, people were unable to carry out their farming and other occupation as a result of both internal and external conflicts. The population is dispersed with seasonal farmsteads. West Equatoria also still accommodates lnternally Displaced Persons [IDP] and refugees from DRC and CAR. The languages spoken by the people of West Equatoria are Balanda, Zande, Moru, Baka, and Morukodo. The Zande is the dominant ethnic group. Communication system (road, Accessibility to the state is via North West Uganda although the road infrastructure is worn out. It is also accessible by air from Juba, capital of Southern Sudan and Lokichokio in northern Kenya. Within the state, there are occasional internal flights between the counties. There is also a road network to all counties. These roads are in a poor state except the one within Yambio. These roads are however relatively good compared to those found in most southem Sudan location and are passable throughout the year mainly because of the free draining laterite soil. There is a road connection to Uganda through Maridi, Yei and Kaya. This road is responsible for the improvement of trading activities in the area. The roads are not tarred seasonal and prone to flooding during the rainy seasonal. And there are communication network available using Gemtal, Sudan and Zain companies as well as internet system through WHO. 10 WHOiAPOC, 24 November 2004 Administrative structure There are three tiers of administrative levels; the State, the county and the payam. The state forms the first level of administration followed by the counties, payam and Bomas. The project has five counties and 683 communities. Those five counties have been split to 10 counties with one county under East Bahr el Ghazal project. Health systems &health care delivery @rovide the number of health posts / centers in the project area if the information is available). West Equatoria state has i56 PHCUs, 36 PHCCs and 5 rural hospitals namely Yambio, Lui, Tambura, Nzara and Maridi hospitals. The specialized treatment center for sleeping sickness is situated in Yambio hospital which is supported by Medicine Sans Frontiers (MSF), Belgium Number of health staff in project area and number of health staff involved in CDTI activities The total number of health facility staff available in the project area was 716 with only 9l(12.71%) involved in CDTI as indicated in the table below. This is an improvement over 2007 where the figures were not at all available. Table 1: Number of health staff involved in CDTI (Please add more rows if necessary) District/LGA 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 Bz Percentage B3:B2l Br + 100 Tambura 65 15 23.08 Ezo 66 19 28.79 Yambio 272 22 8.09 Maridi lr8 t6 13.56 Mundri 195 19 9.74 Total 716 91 t2.71 l1 WHO/APOC, 24 Novemb er 2004 1.1.2. Partnership Indicate the partners involved in project implementation at all levels [MoH, NGDOs (nationaliinternational), communitie s, lo cal or ganizations, etc. ] Describe overall working relationship among partners, clearly indicating specific areas of project activities (planning, supervision, advocacy, planning, mobilization, etc) where all partners are involved. State plans, if any, to mobilize the state/region/district/LGA decision-makers, NGDOs, NGOs, CBOs, to assist in CDTI implementation. Indicate the partners involved in project implementation at all levels [MoH, NGDOs (nationaUinternational), communities, local organizations, etc.] In West Equatoria CDTI project, the partners involved are the health services (the state ministry of health, county health department and primary health care centers/units); Communities which include the payams, Bomas and 683 villages; CBM and WHO/APOC Describe overall working relationship among partners, clearly indicating specific areas of project activities (planning, supervision, advocacy, mobilization, etc) where all partners are involved. The working relationship among partners can be described to be cordial and strong. Prior to training, planning was done together with all partners especially NGDO, SSOTF and APOC and the outcomes later were translated to other levels and the communities where mobilization and distribution of mectizat were carried out by communities through their CDDs. The project in conjunction with NGDO/SSOTF carried out advocacy with a view to attract govemment and community supports. Supervision was not jointly carried out due to difficulty in organizing this activity. Furthermore, the project has maintained a strong partnership with the affected communities. CDTI programs are based on the principle of community participation and encourage community members to take an active involvement in both the planning and distribution of Ivermectin. State plans if any to mobilize the state/regionidistrictllGA decision-makers, NGDOs, NGOs, CBOs, to assist in CDTI implementation. The project has planned to intensifu advocacy to all the decision /Policy makers at the state and county level aimed at getting the OV staff fully integrated and absorbed into the health system as well as deploying more health staff to the project office and also improving on government counterpart contribution. Also, there is plan to approach NGDO to define their financial contribution to the project. Other local CBOs are to be involved in the project at county and community to assist in mobilization in order to improve the treatment coverage t2 WHO/APOC, 24 November 2004 O C.l ! 0) -o E 6) o z .d- ol O o o. o ca C)kd €o(.) 'a k C) o Lr O. o t d t)tr o p. o a F C) bod tro oo o P a/) o ch oo Cd o rE o C) bo Cd l< o >. oo Lr(.) o bo U) o) Lr Cd o +{ tr) N I ca I Lrd C) c/) t/)(.)tr C)th oL C) X C) o zH E (d r!& ,; ooq U) do *< o(A l-< C) o t-.1 c-.Q(.) r\ >V o -od (.) -o cd o dEo) OJEo. qi 6)Oc) LHao rr(s9z .e8! 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Timeline of activities Fill in table 3, timeline of activities for areas treated in current year, indicating when the key activities were implemented by the month they began and the month they ended. l5 WHO/APOC, 24 November 2004 sOON ()s o o z + c.l (J o o > \o (h l+{qr o >. Cd() o () o E(d ,ir I o E 0) o bo lro C)o(d €(.) o € () op (.) (d o (d O. U) 0) (n> E.'UPai(.)d(E th =(.),x -cvH >.Lr(c U) ar)() oo qi ah oL c)L o € (d o) U) CB C) A k () >' C)LrL o() tr €() I 0)k c/)(c C)k(d o L € th o o cd(g o C) (.) A t- c.; o -odF o U) Lo a eEgott \ro H()p C)o() lr 0.) -o () o C) o Lrq) -o () oo t-.1 !o oo 0) o L<o -o () o C) 3o -q ho ah oo ar', bo ./) bo (r') oo P(h bo o k (/) E b0 e o qE o.oEE Oa(Jo H(.) -o E() oo lr(l) c)oo t-.1 F<() -o C)o 0) t-1 !o -o C)oo t-.1 t< C) -o E 0)o() t-.1 oo- L^(u: c/)oo anbo U)oo U)bo chbo 0) (d o v) U) (.) U ots o.otrtrOt\JO bo- H99Fr (.) € oz 0) o o z o o € oz o o o z () o Po z o0 kF t)= o.o HH l,/ o >. b >. Ff l- >. fa oo- LA €>< >. z x cd z z x(d >rCB z (rr O<n aC) o.= eLiftl- N= 5troo = (.)z 9EQO \JO tra li tra LiP. Lq a0- 9LiH9PH(n- okCd ot-<(g oLr(dz ol-{(s =a oL(B z oFl o lr U) o (dL (gF oNH o .o A crt Ld z lr ) z 2.2. Advocacy State the number of policy/decision makers mobilized at each relevunt level during the current year; the reason(s) for undertaking the advocacy and the outcome. Describe dfficulties/constraints beingfaced and suggestions on how to improve advocacy Number of policy/decision makers mobilized At the state level, three officials were mobilized and these are the acting director General and the director for preventive and curative medicine in the state ministry of Health and the state SRRC director. At county level, 9 county administrators and 6 county medical officers of Health and the State paramount chief were mobilized. At payam and community level, 353 stakeholders and community leaders attended mobilization and sensitization workshop in the 5 counties ofthe project area. The reason for undertaking the advocacy was to attract support, create awareness and involvement of all for participation in CDTI activities as well as beefing up security in treatment areas especially in Mundri and Maridi counties. The outcome was positive impact on the treatment activities especially in security and community selection of more CDDs and higher treatment coverage. The constraints include security problem that led to repeated visits, fuel problem and inadequate availability of advocacy tools like T-shirts and calendars for top government functionaries. Suggestions on how to improve advocacy 1. Involment of security personnel during advocacy. 2. Joint advocacy with key stakeholders and other influential groups. 3. Involving School teachers, church leaders and other important community social groups. 4. Increase in fund for advocacy to facilitate fueling of vehicle and motorcycles. 5. Production and distribution of T-shirts and calendars to enhance advocacy and increase in awareness. 2.3. Mobilization, sensitization and health education of at risk communities Provide information on: The use of media and/or other local systems to disseminate information The project made use of FM Mira Sudan which came into being during the reporting year for information disseminating. Other local systems were announcements in churches, schools and through community meetings. Mobilization and health education of communities including women and minorities This was conducted in many communities with involvement and inclusion of women and the minorities. During which time community participation in CDTI was stressed and health education regarding those who should take the drugs and those to be excluded were all explained. The need to select and support CDDs was also discussed. The level of disease l7 WHO/APOC, 24 November 2004 situation in the project was elucidated and also long term treatment with mectizan was mentioned. Those already blinded by the disease were encouraged to take treatment to avoid endangering other through assuming source of infection. Response of target communities/villages Communities with cases of blindness and stigmatization due to OV knew the impact of mectizan. Eligible groups are demanding treatment dose to even for twice a year all in bid to prevent blindness. Accomplishments . Communities believed Mectizan treats Onchocerciasis and thus many participated.. . People with minor reaction believed it is a good sign of medicine working. . Communities knew the direct and indirect impact of Onchocerciasis disease. o There is high demand of Mectizan consumption by the community. o The communities have strong opinion to be involved in Mectizan distribution Suggest ways to improve mobilization and sensitization of the target communities o Community leaders' workshop should be conduced to bring OV to the attention of general public. o The Health worker at frontline health facilities should be OV supervisors. . Community members who are participating in CDTI activities must understand their role. o Training for more CDDs, Health workers, and Payam and Boma focal persons is needed for better mobilization and health education coverage. . Enough Funds is to be allocated for mobilization and sensitization. o Media announcement should be encouraged to spread information on OV disease. o Incentives should be given to CDDs and Health workers to motivate them during the mass treatment. o IEC materials are to be distributed and displayed in the targets. o Mothers' awareness is essential for creating awareness in the community. . A[1 Health staff should be trained at all level. 18 WHO/APOC, 24 November 2004 Ezo ambio 2.4. Communityinvolvement Table 4: Communities participation in the CDTI (Please add more rows if necessary) Comment on: Attendance of female members of the communify at health education meeting There is improvement in attendance of female members in the community health meeting. 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?) Women participation is still low. However they are coming -up with a decision of being acknowledged to share in meetings. Incentives provided by communities for the CDDs In this reporting period, no monetary incentive by community was provided to the CDDs During the training they assist the CDDs Attrition of CDDs: Is attrition a problem for the project? If yes, how is it addressed? Yes, attrition of CDDs is still a problem. Some CDDs still feel they have to be paid and therefore have refused to work voluntary and project is making effort in convincing communities of their roles in providing CDDs some incentives. Other issues No other issues DistricI/LGA Number of communities/villages with community members as supervisors Number of CDDs and the communities involved Number of communities ivillages with female CDDs Total no. communiti es in the entire project atea Ba Number with community members as supervisors B5 Percenta ge B6: Bs/ Bq * 100 Male CDDs Bz Female CDDs Bg Total Bs: B7+Bg Number of communitie s with female CDDs Bro Percentage Blr: B1e/Bat 100 Tambura 72 53 70.6% 81 30 I I I t7 22.6% 92 82 86.3% 9l 2l tt2 l5 t6.3% 253 220 869% 105 3l 136 28 tt% Maridi 109 85 77.9% 87 26 113 20 18.3% Mundri 157 100 63.6% 9t 37 r28 2T 133% Total 683 540 79.r% 455 t4s 600 1 0 1 14.8% 19 WHO/APOC, 24 November 2004 2.5. Capacity building Describe the adequacy of available knowledgeable manpower at all levels. There is no adequate knowledgeable manpower at all level. At the state level, there deficient staff as well as assistant project coordinating officer. At county level, the available knowledgeable staff is still low following additional four new county supervisors in Nagero, Zara,Ibba and East Mundri counties. As a measure to improve on this, the project is planning to work in collaboration with all the government departments through involving them in the activities. 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 staff are frequently transferred during the course of the camp There is no transfer of staff in the project area. Most of the CDTI implementers are selected from their own locality and not staff of MOH. 20 WHO/APOC, 24 November 2003 c.lOoN L 0) -o () o z$ c..l O o o. o N rh C) v) a. 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U) r\)cxc) L.;ES (t o l-<(.) .oF z Q + alO () dO $O (d €oF ,ts o& Boz lri tr) o\ cA c.l € o () C) o -oo\ dokF C.I \o *l o k V) a (g H s tr dF oNH o -o E CO L Cg z t{ z -l F oF Table 6: Type of training undertaken (Tick the boxes where specific training was carried out during the reporting period) Any other comments No 2.6. Treatments 2.6.1. Treatment figures If the project is not achieving l00o/" geographical coverage and a minimum of 65'/o therapeutic coverage or the coverage rate is fluctuating, state the reasons and the plans being made to remedy this. The reasons are: . Insecurity caused by Ugandan rebels in the entire project area. o CDTI staff are not included in the nominal role of Ministry of Health with exception of the PCo o Inadequate manpower for the implementation of activities. o Poor motivation to CDDs and payam supervisors. o Timeline activities is not being followed due to delay of funds Trainees Type of training CDDs Other Community members e.g Community supervisors Health Workers (frontline health facilities) MOH staff or Other Political Leaders Others(specif v) Program management ./ How to conduct Health education Management of SAEs CSM SHM Data collection { ./ Data analysis Report writing { Others (specify) 22 WHO/APOC, 24 November 2003 Plans to remedy this are: o Ministry of Health should integrate CDTI into existing PHC system o Appraisal and motivation to all staff is of great necessity. 23 WHO/APOC, 24 November 2004 $OON E a) .o (.) z t(\ o o. o $N ()X> €-gU ts,a o= Oootro5a.d(!() :Lel- li' -8E z< (c o l-r o(.) 'a l-r o. 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CBLro F (/) q) bo(t Lr C) oo CBo q Cd L< oo o o) oo d o ()q dHo oo g oo k ,P (d tr L o trr a?gt.-sf'* EEUE?H.E€=2€E 6 et € E O O Ezi- U) o 0.) 0) U) -od (t-i o k(,)p z tr) C\C\ oo o\ r-$ \os str) tr- -+ bg !8 *.*59VoEE o rta€ E -) d) - .t 6izo.trE N \o .{- ca o d q o Or t6 o sx 0)xbo F-.9 E a6E9o\d)?v l- 9L() yO o\q \o r- \o o\9 r- 1Oo\q \or- scl N\o s\ oo .+ o\q o\tr) r o b 2t *,'.595"HE z Qij ca tr-$ =f,N o\N r-\oN\o(-- + \o N+ o\ o\ C.il oo ca ca € cq) tv:4H9EE-8{t I s o) nN(o sf- -r cf) lo O) o) -fN o Or-(o(o (o (f) (o N o) @ @^ (0 co oEEe$e ua H' s\o\o^ N co rn cac\ $ (\ o\ o\ @ o\ @ o\ (a)\o la) @ t-- .+ oo\i \al (t)() bod U)() () rL>= no"- t-.1 =oo. oo<d- cUaL --i l-t rObD)\ OO\g - B-oo o\9 cAr- o\ oi oo s <? r-@ s od tr- s\ ca\o \oo\ oir- a 'i vtL .'r 6)C) tr oo'o -O. 5 cd C)dHi-PE O EE 3E tr< HF-Ov) o c.) c.)\.) c.loo ONN (r) oo o $ta) N t-l Eg EdE:8,co'=<F 5 r- tnoo $c.l O.+ O\o <*'t c Q t-> A .H A.H = Eu$u;i gu t-C)'4..1t. O ? E H c.lt-- No\ canN o\O t--lr} cftoo\o .9<lr.i;qE< G,t)s E crlF oNH o s E G' E Ld a t<E z -l F oF >.t< Cd U)(h q) o(.) (ri U) olr C)Ho € €d (.) lr)d C) pr J1 U) k (r)(c C)k(t d F.l o L{ U) >. -o U)I! U) E d 0) E (6() L<F t- c)p(!F t O c..l Lo -o C) o z .f, N (J o > lr) C\ 6O L:?dl-r<9q) (-! d96 co 'i. -c c)6 r B'?tr tr Ec'a0JJ .E E€E H Utsh E sHE 9 9E '= -!U -( .??.o. 'F .9 o.r() S (d-c 'F! F-' rv .E !' 'l t =E ^L.E ,- E3 u) E td-C cdCpPg s 8;ru f-i .=1 .h: ; E.Htr q) ",D! H i9b a. gt rH'=..!h t- tiEXn.ircd5 6 :! fr E FBH : -oStr H HPE H €TE .e 6P ^()e.r-5I E E=;{ E 5EP; J. dV)Hq g 3Ei)* x E.E oo. oEt P E.E()lrt-i(Se O.() i () >, u-O .= Hi<'6 E bo ;EgE F :EtrE = 9 E =: o g-ZJ tr 38,Xo(gU ^ Ho- * 0-)(!la>6 eollr.tio P 5E =4io F L'- = trQ tri:U E!PH2V(EF<O)E E E] .q 3 E,E -q C) oEH f E3 7h()vllll(uI - r'rPlvv ,ljq 2.6.2 What are the causes of absenteeism? This is migration of people arising from farming and cattle rearing. 2.6.3 What are the reasons for refusals? Due to previous mectizanreaction and personal desire not take the drug 2.6.4 Briefly describe all known and verified serious adverse events (SAEs) that o occurred during the reporting period and provide (in table 8) the required information when available. No case of SAEs occurred during this reporting period. In case the project did not have any cases of serious adverse events (SAE) during this reporting period, please tick in the box. No SAE case to report 26 WHO/APOC, 24 November 2004 $ O C.I Lq) ,o q) o z vN o o. o r-(\ P () (dq o) qr o Lr()p tr (€ k(I)a It >.ti(s th U) C)o 0.) qi ar) ol-r (.)L o E (c C) r/)d o) o tr 0)q bo k oq (.) t-r (.) bo Lr 0.)kL oo (g ar) IJ] a ar) C) (.) 0) at) l-r() rcd U) o s< o)(r)(ri o U) G)(/) Cd() (; (!) -o CdF Esu 956: <.E E E b0 Po8c .=c .-PAja (B -ilCE.J6 -I 35 .x * E.gglooos) o.2c(hEE i+< Eq)oo. lr .,(d(n+ 0) u)4 h 'u, I 9.0)(re ^.,/ A = Eqr(,o.2 EFo tr i== A#EEE - O.cH'A= >.vn(te o'= (l)=!HF._d-!=- c)o H.E,S 4 CU €,,9 ep'EEE€.5 8;.:o=\< *o-oiiA t/) H oqt >,a i aO -.E H0)=c) €HAdFU)=o # E H''c cd N frE EsOlcS +r o (.)b0tr cg.;i =ooao X 0.)a 0) bo 4A* .f, OON E() .o o o z$ o1 (J o o. o aN sC) bo ,-(BYbi-.>)o Q c.l .+ cn \ o\N c! oo tal q lrl\o n r-- o (d a. o o< II -Oo @idr *- rl] -o o\C) bI) ^dfr C)kts o ooA r- ,r? \o tr) o\ oo 9tr) oo +@ t+ rrl r[ -> rr:' Er )o()bo O. (da(d C) !robE9C -qoFo c.l t c.) \ o\N cl €(r) n rr)(r) q o\tn € fr.l (! o.^ a5g+U)CdEbe .= Q.€z \os rn + oo o\$ \o c\ co ta)\o t--+N nNF- ooN o\N oo co cn r rl] E a.rE 6.2Ztr-ol==() < 9€'FU N$tr) ra) N C\$ ra) rn N cala) €\o(-- N \o ooq c-N c.t o\ € oo^ \o ca LrHQ<.1 EE#$€ unF d6 6 i Cgo o0)aE (r) t-*(rl N <+ tr)\lr) ol$ ta)\tatN$ oot@ \o (a) r-$ oo\i ra) al 6) bod t u)o o(J Oil >= rr: Irl *^ rI] C) effaF Oo\< >v -o o c.l co € n oo tr- ca o\ \n @ oo r- @ +booli=tr^,,-O 3'.U g , s.fr&F()s 7iO- U r! @ crt oo \o+ \ t-* q o\\o o\t-- rl] rd c) (d c.)k th o oo .acd0() A--; €.- E.Ftr o H>)=() -a.da4 <).= $ h No\ o\ c{ tr- oo+ tra) a.l rl] EoE 6.2ItrL) c (!.: <.eA' FV ra) @ \n .+ N co co o\(r) \o )9.'Hqi C)E il 0) E E $EI' -+ O $ $ t-r o\\o ca oo\o &H v oN la) N \o o c.l r-o c.l ooOO6l -th d o 9(d o o O bo/-. cd6L € a) eo €o()7h L{ \J Hrbk od *d liAL 0)Y Pti=d d09Etr(so]JC)tro=0)H#()vv -q()Pci.( o0)9 l-{ (htrddoH() 9L!o3F'RbOSEtEtrt+a o.nPLJ(-) .i P .qEalo'o2Ho..lr, IFl.-O€(nO;\ (d r/.)H9No/-r+ ,l<L tE(sE.E HLr (n9()Ea.ts.* *LHYoa(g 0) =LdHg:ijE6bii(J(+rS!o .5HF q 6J rF9 UEE;F3H{fi€\otr6i o\ ':oZ =()tuFo. 2.7. Ordering, storage and delivery of ivermectin Mectizan@ ordered/applied for by - (please tick the appropriate answer)MOHtr{ WHON LINICEFN NGDO L-]! Other (please specify): Mectizan@ delivered by - (please tick the appropriate answer)MOHtr WHOtr{ UNICEFtr NGDO N Other (please specify) Please describe how Mectizan@ is ordered and how it gets to the communities West Equatoria CDTI project orders and collect Mectizan from the SSOTF office in Rumbek, lakes state to the project coordination office in Yambio. Due to condition of transport, the project coordinating officer distributes the drugs to counties base on the annual treatment objectives of each specific county. At the county the health staf? Payam supervisors collect to the health centres whereby Boma focal persons and CDDs come to collect and distribute to the community. Table l0: Mectizan@ Inventory (Please add more rows if necessary) State/District/LG A Number of Mectizant tablets Number in stock Requested Received Used Person treated Lost Wasted Expired Remaininig Tambura 0 187,000 187000 14t479 47003 0 0 0 45,521 Ezo 0 94,000 94,000 79,779 29,t24 l0 0 0 14,211 Yambio 0 22s,000 225,000 222341 76267 0 0 0 2,659 Maridi 0 201,000 201,000 177048 61014 22 0 0 2,3930 Mundri 0 379,000 379,000 291175 90421 89 0 0 87,736 0 l,086,000 1086,000 911,82 2 303,829 t2t 0 0 174,057)TAL How are the remaining ivermectin tablets collected and where are they kept? CDDs send all the remaining tablets to the payam supervisors or health facilities staff who in tum send to county supervisor. It is the county supervisors that keep them at the county offices. List and briefly describe the activities under ivermectin delivery that are being carried out by health care personnel in the project area. * Training of CDDs: Health workers participate in conducting trainings to CDDs at community level: * Data collection: They collect all relevant data on training, mectizan distribution and treatment. * Management of side effects: Health workers are involved in monitoring and management and referral serious adverse events. 29 WHO/APOC, 24 November 2004 * Health Education: Health workers conduct individual, Family and community Health education. Any other comments No 2.8. Community self-monitoring and Stakeholders Meeting Has any training (of trainers) for community self-monitoring been done in the project area? No If so, When? NA 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. Not Applicable District/ 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) Tambura 72 92 0 0 0 Ezo Yambio 0 0253 0 Maridi 109 0 0 Mundri 157 0 0 TOTAL 683 0 0 30 WHO/APOC, 24 November 2004 2.9. 2.9.1 Supervision Provide a flow chart of supervision hierarchy. SSOTF HQ Supervis Reporting 2.9.2. What were the main issues identified during supervision . Some CDDS refused to conduct household registration o Level2 (county Form) not filled accordingly o Inadequate supplies of community summary form (level4). o No motivation to CDDs by the community. . Some CDDSs are not using height stick. o Treatment was not conducted well due to insecurity problem in the whole project area . CDDs found difficulties in filling community summary forms o Some CDDS not using height stick. ,, tr.r, n I r _l i, i_\ 31 WHO/APOC, 24 November 2004 What were the outcomes at each level of CDTI implementation Supervision? The PCO corrected the county supervisors on the mistakes made on level2 forms and the corrections were effected. Also CDDs, Boma and Payam supervisor accepted changes in their weak points and took appropriate corrections to improve in their work. Community members were contacted on the incentive to CDDs and they agreed to look into it. 2.9.3. Was feedback given to the person or groups supervised Yes, it was given 2.9.6. How was the feedback used to improve the overall performance of the project? The feedback provides accuracy in their work which improves performance SECTION 3: Support to CDTI 3.1. Equipment Table l2: Status of equipment (Please add more rows if necessary) *Condition of the equipment (F=Functional, CNFR:currently non-functional but repairable, WO:Written off Source Type of equipment APOC MOH DISTzuCTi LGA NGDO Others No Condit ion No Condit ion No Condit ion No Condit 10n No Condit ion 1. Vehicle 1 CNFR 2. Motor cycle(s) 5 F 3. Computer(s) 1 CNFR 4. Printer(s) 1 F 5. Photocopier (s) 1 F 6. Fax Machine(s) 0 NA 7. Others a) Safe 1 F b) Bicycles t6 F c)Base Radio 1 Not fixed d) Solar Panels 2 F 32 WHO/APOC, 24 November 2004 How does the project intend to maintain and replace existing equipment and other mater At the moment the project cannot maintain and replace the existing equipments .However in the long run the state ministry of Health will take full responsibility of maintaining project assets. 33 WHO/APOC, 24 November 2004 3.2. Financial contributions of the partners and communities Table 13: Financial contributions by all partners for the last three years 3.3. Other forms of community support If there are problems with release of counterpart funds, how were they addressed? Counterpart contribution towards OV is a still a problem as there is no govemment budget in the MOH. Request for provision of counterpart funding to the project will be submitted when the situation normalized in the state. Additional comments No. Describe (indicate forms of in-kind contributions of communities if any) a Provide security to CDDs during distribution. Communities assist in doing announcements Communities identifu and select CDDs and Boma supervisors Communities are planning to initiate income generating activities to support CDDs.. a a a Contributor Year 1 (2006') Year 2 (2007') Year 3 (2008') TOTAL Cash Budgete d (us$) TOTAL Cash Release d (us$) TOTAL Cash Budgete d (us$) TOTAL Cash Release d (us$) TOTAL Cash Budgete d (us$) TOTAL Cash Release d (us$) MOH (Central + Provincial/State) 0 0 0 3000 4200 MOH (District/LGA) 0 0 0 0 0 0 Local NGDO(s) ( if any) 0 0 0 0 0 0 NGDO partner(s) 1 2,1 00 12,100 13,368 13,368 12515 t2515 Others 0 0 0 0 0 0 a) 0 0 0 0 0 0 b) 0 0 0 0 0 0 Communities 0 0 0 0 0 0 APOC Trust Fund 65869.00 25204.00 45875.00 36102.00 71,215.00 50,911.00 TOTAL 77969 37304 59243 49470 86730 67,626 34 WHO/APOC, 24 November 2004 Communities have opinion to recommend the hardworking CDDs who have informal education background to Health trainings e.g. CHW/I,fCHW. Communities also want the CDDs to be recognized in other programmes e.g.(Polio) in order to retain them 3.4. Expenditure per activity Indicate in table i4, 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_ Table 14: Indicate how much the project spent for each activity listed below during the reporting period Any comments or explanations? No. a a Activity Expenditure/ Source - APOC ( usD) Expenditure/ Source - CBM (USD) Drug delivery from NOTF HQ area to central collection point of community Mobilization and health education of communities 3,388.00 9,568.00 353 I Training of CDDs Training of health staff at all levels Supervising CDDs and distribution tt4t 1426 Internal monitoring of CDTI activities Advocacy visits to health and political authorities 1,762.00 IEC materials 13,080.00 4991 Summary (reporting) forms for treatment Vehicles/ Motorcycles/ bicycles maintenance Offrce Equipment G.g gompqtels, printers etc) Others/Plus 4200 USD from MOH only 8,600.00 800.00 17,913.00 t426 TOTAL 55,1 I 1.00 t25ts GRAND TOTAL AMOUNT 67,626 Total number of persons treated 303829 COST PER TREATMENT 4.49 USD 35 WHO/APOC, 24 November 2004 SECTION 4: Sustainability of CDTI 4.1. Internal; independentparticipatorymonitoring; Evaluation 4.t.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable) No_Year I Participatory Independent monitoring No Mid Term Sustainability Evaluation 5 year Sustainability Evaluation No Internal Monitoring by NOTF _No Other Evaluation by other partners 4.1.2. What were the recommendations? NA 4.1.3. How have they been implemented? NA 4.2. Sustainabitity of projects: plan and set targets (mandatory at Yr 3) Was the project evaluated during the reporting period?_No_ Was a sustainability plan written?_N When was the sustainability plan submitted?_NA What arrangements have been made to sustain CDTI after APOC funding ceases in terms of: 4.2.1. Planning at all relevant levels: NA 4.2.2. Funds:NA 4.2.3 Transport (replacement and maintenance): NA 4.2.4. Other resources: NA 4.2.5. To what extent has the plan been implemented: NA 36 WHO/APOC, 24 November 2004 -No- 4.3. Integration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration: 4.3.1. Ivermectin delivery mechanisms The Ivermectin delivery mechanism is not integrated into the primary Health Care structure. Currently,Mectizan@ is delivered by CBIWWHO from Nairobi to the SSOTF head quarters in Rumbek. However the Government of South Sudan is working on the central procurement and supply unit through which all drugs will be supplied to all states. This system will be used to deliver drugs to the project area once they reach the country. 4.3.2. Training The CDTI training has been integrated into the CHW training and refresher courses curriculum of the PHC. In the project implementation, health workers at different categories were trained on CDTI concepts. 4.3.3. Joint super"vision and monitoring with other program Not applicable for now 4.3.4. Release of Funds for project activities No budget and no release for the period to the project in any manner by MOH 4.3.5. Is CDTI included in the PHC budget? No, PHC has no budget for implementing activities. 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? No any programme is using CDTI structure. Neglected tropical disease is planning to use CDTI structure as role model but still not effective. 4.3.7. Describe others issues considered in the integration of CDTI. Nil 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 There is no operational research under taken in the Project within the reporting period. 37 WHO/APOC, 24 November 2004 4.4.2. How were the results applied in the project? Not applicable. SECTION 5: Strengths, weaknesses, challenges, and opportunities List the strengths and weaknesses of CDTI implementation process. Strengths . The project staff have strong will and committed to sustain to the programme. . The ministry of Health is providing necessary support to CDTI implementation. . The MOH absorbed the PCO in the nominal role and planning to integrate the staff at county level. o Communities have positive impacts on the progralnme Weakness o Health workers do not collaborate with CDDs. o CDTI is not integrated at county payam level. . Delay in disbursement of Funds. . No census update in the project area. o lnadequate number of CDDs. . Poor record keeping. o Poor communication facilities o Insecurity remains the major cause of low coverage. List the challenges and indicate how they were addressed. CDTI is considered as a vertical programme: This problem is weakening the activities because of health workers assumed the CDDs and Payam supervisors are getting salaries .The project has made a lot of emphasis to explain APOC philosophy on CDTI implementation. Delay in disbursement of Funds: This is big issue regarding staff and activities. Most of the staff have joined other sections but the project managed to encourage and contain the available staff to hold on. Mass treatment campaign: The CDTI strategy is acceptable but the mass campaign should be organized like other community programmes. Integration of CDTI: The PCO met the MOH and put more efforts on the issue of integration of the project staff for smooth running of CDTI activities. a a a 38 WHO/APOC, 24 November 2004 aa Inadequate CDDs: Selection of CDDs will be done according to the villages and the population they treat to reduce unnecessary demands. Insecurity: This is one problem that only government can solve and not the project. However, the project has made series of complaints to the appropriate authority responsible for security. I 39 WHO/APOC, 24 November 2004 SECTION 6: Unique features of the project/other matters During the period under review, two surveys were carried out in the project namely, REMO/RAPLOA in l1 villages with all the result submitted to technical advisor and the monitoring of treatment coverage limited to 5 villages due to insecurity at the time of the survey couple with the project vehicle problem. The surveys were conducted in November/December and October all 2008 respectively. APOC technical advisor arrived in Southern Sudan in 2008 and he remained a major strength in the project with his high sense of urgency and coordination of CDTI implementation. The project is very grateful to APOC for sending him to Southern Sudan. a 40 WHO/APOC, 24 November 2004