East Bahr El Ghazal CDTI annual technical report to Technical Consultative Committee(TCC) : January to December 2010

EAST BAHR EL GHAZAL (EBEG) CDTI PROJECT whoebesproi ail.com Proiect Name: East Bahr El Ghazal CDTI COUNTRYAIOTF: Republic of South Sudan Lauuehrnetealz 2004Approvahear: 2003 From: January 2010 (Month{944) To: December 2010 ( Month/Year) Reportins Period: APOCfundinsvear: I 2 3 4 5 (6) 7 8 9 l0 1l 12 13 APOC Proiect implementation vear report: I 2345(6)78910111213 Date submitted:M Partners:- Ministry of Health - African Programme for Onchocerciasis Control (APOC) - Mectizan Donation Program (MDP) - Christoffel Blinden Mission - 1,476 communities ORIGINAL :Enelish ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) DEADLINE FOR SUBMISSION: To APOC Management by 31 Januarv for March TCC meeting To APOC Management by 31 Julv for September TCC meeting AFRICAN PROGRAMME FOR ONCHOCERCTASIS CONTROL (APOC) .-t l I ANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) ENDORSEMENT Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the report: Country: Republic of South Sudan National Coordinator: Dr. Lucia William Kur Signature Date:........./July l20l I Zonal Oncho Coordinator: Abraham Chol Manyiel Signature Date:......../July 120 I I NGDO Representative: Fasil Chane Signature Date:......../July l20l I This report was prepared by: Abraham Chol Manyiel Designation: Project Coordinating Officer Signature: .. Date:........./Jul 2 011 I Table of contents ACRONYMS 5 DEFINITIONS.......... FOLLOW UP ON TCC RECOMMENDATIONS EXECUTIVE SUMMARY............ SECTION 1: BACKGROUND INFORMATION........ 1.1. GeNpnal rNFoRMATroN..................... 1.1.1 Description of the project (briefly) 1.1.2. Partnership.... 1.2. Popur-erroN........... 6 7 9 10 10 t1 l3 SECTION 2: IMPLEMENTATION OF CDTI........ 15 2.1. TruslrNp oF AcrIvruES .............. ...................... 15 2.2. Aovocecv .................. 16 2.3. Mos[TzaTIoN, SENSITIZATIoN AND HEALTH EDUCATION OF AT RISK COMMUUITIPS I6 2.4. CoUULwTTYTNVoLVEMENT 2.5. CapacnvBUrLDrNG............ 2.6. TR-perupNTS....................... 2.6.1. Treatmentfigures....... 2.6.2 What are the causes of absenteeism? ........... ............... .. 23 2.6.3 What are the reosons for refusals?................. ................ 23 2.6.4 Briefly describe all lcnown and verified serious adverse events (SAE| that ....... 23 2.6.5. Trend of treatment achievement from CDTI project inception to the current year 252.7. ORopnTNc, SToRAGE AND DELIVERY OF IVERMECTIN ....,,,,,,,26 2.8. Couvrnrrrv sELF-MoNTToRINGAND STAKEHoLDERS MppuNc ............27 2.9. SuppnvrsroN..... 29 3.1. 3.2. 3.3. 3.4. 17 l8 2t 21 30 3l 35 35 2.9.1. 2.9.2. 2.9.3. 2.9.4. 2.9.s. 2.9.6. Provide a/low chart of supervision hierorchy. .......... 29 Whot were the main issues identified during supervision? .............................. 29 Was a supervision checklist used? ..........29 What were the outcomes at each level of CDTI implementation supervision? 29 'tlasfeedback given to the person or groups supervised? ............. 30 How was the feedback used to improve the overall performance of the project? 30 EqumueNr SECTION 3: SUPPORT TO CDTI 30 FTuaNcIaT- CoNTRIBUTIONS OF THE PARTNERS AND COMMI.]NITIES.... OrHpn FoRMS oF coMMUNrry suPPoRT ExppNoITuRE PER ACTIVITY SECTION 4: SUSTAINABILITY OF CDTI..... 35 4.1. INrenNar-; TNDEpENDENT pARTICIpAToRy MoNIToRINc; Eva1uauoN.................... 35 4.1.1 Has the project ever been evaluated/monitored? (Tick any of the following which are applicable) ........... ....... 35 4.1.2. What were the recommendations? .......... 35 4.1.3. How have they been implemented? .............. .............. -35 4.2. Susran{asrI-rry oF eRoJECTS: eLAN AND sET TARGETS (MANDAToRv AT................ 35 J Yn 3) ...................35 4.2.1. Planning at all relevant levels..... .'.......... 36 4.2.2. Funds........ ......... 36 4.2.3 Transport (replacement ond maintenance) .................... 36 4.2.4. Other resources .......---.......... 36 4.2.5. To what extent has the plan been implemented.......... ..........-----.... 36 4.3. INtpcRauoN .............36 4.3.1. Ivermectin delivery mechanisms................ ................ 36 4.3.2. Training.... 4.3.3. Joint supervision and monitoring with other programs............ 4.3.4. Release of funds for proiect activities 4.3.5. Is CDTI included in the PHC budget? 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. Wat have been the achievements?.............. .................. 36 4.3.7. Describe others issues considered in the integration of CDTI. ....................... 37 4.4. OpenarIoNAL RESEARCH ................... 40 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. '..... 40 4.4.2. How were the results applied in the project?............. ----............... 40 SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES' AND OPPORTUNITIES ,.................. 40 SECTION 6: UNIQUE FEATURES OF THE PROJECT/OTHER MATTERS 4 e Acronyms APOC ATO ATrO CBO CDD CDTI CSM LGA MOH NGDO NGO NOTF PHC REMO SAE SHM TCC TOT UNICEF UTG wHo African Programme for Onchocerciasis Control Annual Treatment Obj ective Annual Training Objective Community-Based Organization Community-Directed D i stributor Community-Directed Treatment with Ivermectin Community Self-Monitoring Local Government Area Ministry of Health Non-Govemmental Development Organization Non-Governmental Organization National Onchocerciasis Task Force Primary health care Rapid Epidemiological Mapping of Onchocerciasis Severe adverse event Stakeholders meeting Technical Consultative Committee (APOC scientific advisory group) Trainer of trainers United Nations Children's Fund Ultimate Treatment Goal World Health Organization 5 Definitions (i) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking) (ii) Eligible population: calculated as 84oh of the total population in meso/hyper- endemic communities in the project area. (i ii) Annual Treatment Obiective : (ATO): the estimated number of persons living in meso/hyper-endemic areas that a CDTI project intends to treat with ivermectin in a given year. (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 expecied to reach the UTGat ihe end of the 3'd year of the project). (v) Therapeutic coverage: number of people treated in a given year over the total population (this should be expressed as a percentage). (vi) Geographical coverage: number of communities treated in a given year over the total number of meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage). (vii) Inteqration: delivering additional health interventions (i.e. vitamin A supplements, albendazole for LF, screening for cataract, etc.) through CDTI (using the same systems, training, supervision and personnel) in order to maximise cost-effectiveness and empower communities to solve more of their health problems. This does not include activities or interventions carried out by community distributors outside of CDTI. (viii) Sustainability: CDTI activities in an area are sustainable when they continue to function effectively for the foreseeable future, with high treatment coverage, integrated into the available healthcare service, with strong community ownership, using resources mobilised by the community and the government. (ix) Community self-monitorine (CSM): The process by which the community is empowered to oversee and monitor the performance of CDTI (or any community-based health intervention programme), with a view to ensuring that the programme is being executed in the way intended. It encourages the community to take full responsibility of ivermectin distribution and make appropriate modifications when necessary. 6 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 _32 Number of Recommenda tion in the Report TCC RECOMMENDATION S ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT USE ONLY Report related (i) The Report must be endorsed by all partners as required This has been done (ii) Indicate the source of population figures This has been done. Population figures are derived from annual projections of population growth of the REMO and WHO needs assessment population figures. (iii) Table 3 population census data are not clear. It is indicated that an update of the census was not carried out and yet dates are provided. Correction has been made to the population census table (2 not 3). The population figures are projected using an annual population growth rate of 2.9%. The base figures are those from a harmonised figure used in 2004 for the REMO and WHO needs assessment. Project related (i) Submit a research proposal on CDD attrition as recommended by TCC29 This is still work in progress with the SSOTF and hopefully a proposal will be submitted next review meeting. (i i) Attract more NGDO partners E.g. from Sight Savers, Carter Centre, World Vision This is being done in collaboration with the SSOTF Merlin has expressed interest in doing communication and advocacy work. (iii) Train all existing health staffin CDTI Currently on-going. The challenge is that there is also a high tumover of staff working in the NGO-supported health facilities and also the amount of funding available has also been a major limitation. (iv) Train more females as CDDs and as Community Affempts are being made to have this done despite the 7 Supervisors social-cultural challenges associated with having females actively participating in work outside their homes. ( ) Investigate the lower. coverage rate ofTonj county and take corrective action The reason was a combination ofinsecurity and the fact that Tonj county was/is under the jurisdiction of a different local government authority; causing supervision being a challenge. The County is now under Warrap state, in West Bahr El Ghazal CDTI project. (vi) Seek for creative ways of reaching pastoralist communities E.g. mobile CDDs, collaboration with health facilities in areas they migrate to This is being considered for the current treatment cycle. (vii) Continue improving geographical coverage to reach l00o/o and therapeutic coverage to reach 80%o, as required by APOC The project will continue aiming at achieving these coverage rates despites a fall in coverage rates recognized this year. (viii) Conduct a year 5 sustainability evaluation This was done outside this report's timeframe (May/June 2011) (ix) Fill the two vacant post of County Oncho Supervisors This has been done. 8 Executive Summary This report covers the activities that were implemented by East Bahr El Ghazal CDTI project from January 2010 to December 2Ol0; which was the 6'n year of APOC funding. Support was also received from CBM, an Intemational NGDO in close collaboration with the South Sudan Onchocerciasis Task Force. The project covered a total population of 550,325 people. The population of the project area was less than that reported in 2009 by 211,592 people because 3 counties that were previously covered were administratively shifted to Warrap state. Tonj East, Tonj North and Tonj West counties were moved to Warrap state in West Bahr El Ghazal CDTI. The project had a UTG of 462,273 and an ATO of 408,293 during this reporting period. I , 123 communities out of I ,47 6 were treated covering a population of 323,680, thus achieving a geographic coverage of 760/o and a therapeutic coverage of 59%o. The coverage rates reported are lower than those of the previous year because there were two major incidences of inter-tribal/clan conflicts that arose from competition for grazing fields and water sources resulting in population displacements that coincided with the mectizan distribution cycle in this reporting period. In addition was also compromised by lack of a functional vehicle for the most part of 2010. A total number of 2,567 CDDs were available for CDTI work and of these, I ,761 had been newly trained. 114 health staff and Payam Supervisors were available for CDTI work and of these 51 were newly trained. The major challenges faced by the project during the reporting period were: o Repeated inter-tribal/clan conflicts that arose from competition for grazing fields and water sources resulting in population displacements and thus affecting the access to the populace for mectizan distribution. . The project also lacked a functional vehicle for the most part of 2010 and thus hampering monitoring and supervision of CDTI activities. o Attrition of health staff in the frontline health facilities has affected the supervisory base at the Payam, Boma and community levels. 9 SECTION 1: Background information 1.1. General information Geographical location, topography, climate The East Bahr El Ghazal CDTI project is located between latitudes 5.5oN and 8.0oN and longitudes 28.5'E and 3l.5oE and has its project office with the premises of the State Ministry of Health in Rumbek town, Lakes State. The project area is bordered to the North by Unity state, to the South by Westem and Central Equatoria states, to the East by Western Equatoria state and to the West by West Bahr el Ghazal state. The landscape of the project area is mainly made up of flat savannah grasslands that is prone to flooding in the wet seasons especially in the eastern parts. The soil type is mainly the clay type and it rests on a stone plateau in most parts of the project area. The rainfall ranges from 750mm - l200mm and the climatic condition varies a wet season to medium wet seasons and prolonged dry seasons. Population: activities, cultures, language The dominant ethnic group are the Dinka who are agro- pastoralists whereas the minority Jur Bel are agriculturalists. Conflicts arising from the differing lifestyles of the pastoralists and agriculturalists have led to repeated flaring up of conflicts. The languages spoken are Dinka Agar (the majority), Jur Bel, Bongo, and Juba Arabic. Kiswahili is now also spoken mainly by retumees that lived in the East African countries as refugees during the prolonged war times and also by the traders. Communication systems The roads in the project area are not in good condition due to lack of routine maintenance work and the impact of heavy rainfall and floods. The roads mainly lead to Yirol, and Cueibet counties and are all seasonal. Some places like Awerial and Maper counties have never had a proper road link and they can only be accessed in the dry seasons. The project area can be accessed by air and there are airstrips in Yirol and Rumbek counties. The Rumbek airstrip is one of the busiest in Southern Sudan and the WFP flights and other private airlines make use of it on a regular basis. A number of mobile telephone companies like Gemtel, Mobitel, MTN and Zain provide services in the project area. The other means of communications is by satellites phones and long range HF radio; these are used mainly to communicate to places like Awerial, Thiet, Makuac and Maper or any other place that does not have a mobile telephone communication network. Ad ministration structure The administrative structure of the East Bahr El Ghazal project is according to the Government of Southern Sudan structures. The State forms the highest level of administration followed by the Counties, Payams and Bomas. States are administered through Governors, Counties by County Commissioners, and Payams by Payam Administrators, and Bomas by Boma councils. Health system & health care delivery The project area is served with a total of 107 health facilities that are broken down as 73 Primary Heath Care Units (PHCUs), 29 Primary Health Care Centres (PHCCs), 4 rural hospitals and one state hospital. The state hospital is located in Rumbek town. The rural and 10 state hospitals are referral facilities for the Primary Health Care Centres (PHCCs). The Primary Health care system still experiences shortage of qualified manpower. However, there is a drive to have health staff recruited and posted in these rural health facilities and hopes are high that the staffing situation will improve in the coming months/years. Number of health staff in project area and number of health staff involved in CDTI activities A total of 1,197 health staff existed in the projectarea, of which ll2 (9.4%) were involved in CDTI as shown in the Table below. }!!g-l: Number of health staff involved in CDTI County Number of health staff involved in CDTI activities. Total Number of health staff in the entire project area Br Number of health staff involved in CDTI Bz Percentage BrBzlBr *100 Cueibet 214 28 t3.t% Rumbek Centre 188 l0 5.3% Rumbek East 173 t2 69% Rumbek North 176 l0 5.7% Wulu 155 10 65% YirolEast 105 14 13.3 Yirol West 97 t4 14.4 YiroliAwerial 89 t4 15.7 Total 1,197 tt2 9.4. Note that new counties were curved from old counties by the local administrative authority, thereby doubling the total number of counties in the project area. 1.1.2. Partnership Indicate the partners involved in project implementation at all levels The partners involved in CDTI activities in the project area were the 1,476 communities situated in 8 counties, health care service providers at the national, state, county and health facility levels, NGDO - CBM and APOC/WHO. Describe overall working relationship among partners, clearly indicating specific areas of project activities The overallworking relationship among partners was cordial since all worked towards ensuring that mectizan got to targetted communities. Before the commencement of mectizan distribution, partners engaged in planning, advocacy and mobilization both with the local communities and authorities. While distribution of mectizan was on-going, supervisory visits were carried out by partners to ensure success of the project activities. 1l State plans, if any, to mobilize the state/region/districttLGA decision-makers, NGDOs, NGOs, CBOs, to participate in implementation of CDTI activities. During the reporting period, the project managed to meet with the state ministry of health officials from Lakes states. These officials were the Director-General and the Director of Public Health. 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E C) q(.) a 0.) -o Eq) q() a 0.) -o 0) a o) U) L o) C) a. 0)a .He1itr a!: a bo 0 b0 0 a0 0 b0 0 b0 0 b0 a b0 a bo aa 6lt-F o =oEE Q at bo 0 b0 0 o0 0 ho 0 b0 0 o0 0 bI) o bo) H= .E: >. >, >' >, >, >' E, >. -q) s= ooE9a EE Q h oo 0 o0 0 bo 0 bo 0 bo (, bo 0) o0 o bo H= tiE €!: x x >' >' Q (.) -o o Q ()9 C) O& c) .o & cr) E] ll(.) ,.o ii o z J 0) -o ah(s E] o U)q) B o (! L C) 4 o!r lr) o o z I .r) c) U ,- o q) LL (J q) e c!q)L rr) c! 6)L 6l q) L u2e c) 6t q) 6) F ('ll ol -alGIFI o o # a-#(, IE IF o o E o E a-F F N -FA -(,) (E o o 6l o) Q) - N z o -t-r(J ria 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. At the Lakes state level, the Director-General and the Director of PHC were met by the APOC TA and the PCO and the need to integrate CDTI activities into the mainstream primary health system and absorption of CDTI staff was discussed. The officials expressed the willingness to have all staff integrated but cited budgetary constraints that they were experiencing at the time. County Health Department Officers were met and they also pledged to provide support as required especially in facilitating the process of having FLHF staff getting involved in the implementation of CDTI activities as opposed to having only the Payam Supervisors participating in CDTI activities. Most Payams Administrators and Boma Secretaries that were met pledged their support to ensure improvement in community support to CDTI implementation. Describe difficulties/constraints being faced and suggestions on how to improve advocacy The major constraint is the ability of the state and county authorities to implement the desired measures suggested during the advocacy meetings. The willingness is there but there is limited flexibility in apportioning budget lines to ably contribute to the implementation of CDTI activities. The decentralization of planning, budgeting and implementation of social services is still at its very early stages; the predominant top-bottom approach limits flexibility or inclusion of priorities of the end-user of the public health delivery system. In order to improve advocacy, the still existing top-bottom approach could be taken advantage of and if advocacy is done at a high level of the central government ministry of health, then funding can be allocated to CDTI activities. 2.3. Mobilization, sensitization and health education of at risk communities The use of media and/or other local systems to disseminate information o The FM Radio in Rumbek town was used to convey messages to the wider community on the need of taking the mectizan annually. A series of talk shows were held at which the project coordinating officer was periodically hosted to talk about Onchocerciasis control in the project area. o The base radio (long-range radio calls) at the MOH Rumbek was used to communicate to county and payam supervisors and also with the different counties. o Information during home visits at community level and also at communal gatherings like at places of worship and market places. Types of IEC materials used The IEC materials used during the reporting period by the project were posters, flipcharts and T-shirts. Mobilization and health education of communities including women and minorities Mass community mobilisation and education was carried out in the project areas before Mectizan distribution and also during the distribution to create awareness about treatment and 16 also mobilisation for increased community participation in the project activities. Community leaders were contacted to arrange for the meetings with community members at the times that were convenient for the communities. During the health education sessions, messages such as how one gets onchocerciasis, disease symptoms, eligibility criteria for treatment, management of side effects and dosage required were mentioned. Health education was conducted in all the counties in the project area and attendance included men, women, young and the elderly members of the community. Response of target communities/villages Community members' response to the health education was that there were relatively high numbers reached during the Mectizan distribution in the areas that were affected by inter-clan clashes. Accomplishments o There were less refusals and absentees as compared to 2009. o Managed to have communities select CDDs to participate in the mectizan distribution. Suggest ways to improve mobilization and sensitization of the target communities o More women will continuously be encouraged to actively get involved in Mectizan distribution as CDDs. o Advocacy to communities and their leaders will continue so that they gradually fully own and participate in project activities. . There is need for more health education sessions at the community level especially in the areas where insecurity disrupted CDTI activities. . More pictorial Information, Education and communication (IEC) materials like T- shirts, caps and posters should be made available to the target communities. 2.4. Gommunity involvement }[!g1: Communities participation in the CDTI Coun8 - LGA Number of communities/villages with community members as supervisors Number of CDDs and the communities involved Number of communities /villages with female CDDs Total no. communities in the entire project area Br Number with community members as supervisors B( Percentage Bo= BJ B. *100 Male CDDs B7 Female CDDs B. Total Bo= Bz*Br Number of communities with female CDDs Brn Percentage Brt= Brr,/Ba*100 Cueibet' 435 257 59. r 715 60 775 28 6.4 Rumbek Centre 156 79 50. l 294 t4 308 6 3.9 Rumbek East 176 83 47.2 479 29 508 9 5.1 Rumbek North 74 32 43.2 212 15 227 5 6.8 Wullu 63 JI 58.7 183 25 208 8 12.7 Yirol East - 228 123 54.0 352 48 400 27 11.8 Yirol West 286 138 48.3 390 40 430 25 8.7 Yirol/Awerialt 58 3l 53.4 440 40 480 5 8.6 Total 1,476 780 52.9 3,065 271 3,336 113 7.7 t7 Comment on: Attendance of female members of the community at health education meetings The attendance is still low but is gradually increasing. In general, how do you rate the participation of female members of the community meetings when CDTI issues are being discusses The participation has increased at meetings almost half of the participants are females and they participate in the discussions. Incentives provided by communities for the CDDs Communities do not provide any incentive. Attrition of CDDs. Is attrition a problem for the project? If yes, how is it addressed? Yes, it is still a problem. It is addressed by continuously talking to the community about the CDTI philosophy and also by asking the communities to select more CDDs for training. Other issues - None 2.5. Gapacity building Describe the adequacy of available knowledgeable manpower at all levels. The staff situation is better than it was in 2009. All counties now have county OV supervisors The staffs at the frontline health facilities/payam supervisors have been trained in CDTI. The number of knowledgeable CDDs at the community level is also gradually increasing. Where frequent transfers of trained staff occur, state what the project is doing, or intends to do, to remedy the situation. The project did not experience frequent stafftransfers l8 o\ 0a o o p s a o o bo i- \ p a. qr'{ B s co oo \a) c.t oo oo cn a.t ootr) c.l o ol a.) c\l r-\o ra 6l \0 a \o r-- +.= qv 6 ,: + .U ir *o ra) o \o 00 o.l 00 ra) $+ o\ ral c.t € a € s in :. c) {) q) (, sc.l \o ao o\ €$ e- c.l \o $ o.l t-- ra) €$ cn (\l €\\o ra o G rn Q q) z I FU \o(\ t(a (?) 6l \l t+ s cn ra) o.l c.t $ c-r s t $ $ + a * S.itv o -= +Ll, = F: ev r lr) (n = q) q) o I .\ s raao)q) .= '.r2' 6t FrLh !- Fi o: o!) ,o L6liDL z Q rat Ir) tr- + (-- t'- $ F- CI \o ra U Q .l: E.'l + *. * o\ oocl o\ \ oi \o (n ra) ral r- s r- tr) c.l €\o c) q) o) I .\ s\\o € Uk' (--a.) c.lco la) C.l la) s 0) cEL !s E3 tr>- 22 q)(, c.l c.l N c.l c.l c.I N ci \o \o il I i z U + U 6 F A< c.l (\ c..l c.l c.l ol c.l (\ c.I c.l c.l \o 6t .A a) Fl9e9C) l- .=;!u a q)E z I cl N al c.l c.l rh d rI] ,lz C) .o & o z .V(.)s & an rI] L ah C) o (! L c) oL Fl t't Fr () q) q) I s -o .\ j q o -o 0)() .v0)., =o&Q q) o F U U) q) 0) q) L .e q) 6t a! 6llrF ral ol -al6lFI Table 6: Type of training undertaken Any other comments - None Trainees Type of training CDDs Other Community members e.g Community supervisors Health Workers (FLHF stafO MOH staff or Other Political Leaders Others - County OV Supervisors Program management How to conduct Health education Management of SAEs CSM SHM Data collection Data analvsis Report writing Others (specify) 20 2.6. Treatments 2.6.1. Treatment figures If the project is not achieving l00oh geographical coverage and a minimum of 65"h therapeutic coverage or the coverage rate is fluctuating, state the reasons and the plans being made to remedy this. The reasons for not reaching the above coverage include: o Insecurity, some communities were displaced by inter-clan/tribal conflicts that occurred twice in 2010. . Lack of the project vehicle affected the capacity for the project coordinating officer to conduct supervision activities in the project area. o Most of the distribution again took place in the rainy season thus affecting capability to access some communities. The plans being made to remedy the above challenges: . APOC management approved the purchase of a new project car and procurement process is in its final stages and the vehicle is expected to be received in August 201r. o Continued efforts will be made to target key CDTI activities like distribution for the dry season. o The project hopes that there will be less conflicts in future, but in the unfortunate situation of them occurring, then the project considers reaching out to the population wherever they will have moved to provide their annual mectizan treatment. 2t NN € tq q ! L\ s st Oo\ a U q. L !O !!6 \ !{ E$\{ qq 's -\s\i! 6!sf <a:H = e\; E.siE h.S E9 dF!ABDYL ii q oY",E € OT66US -:\u = o.r:g o :EE' e 9 f t.EI U-tr \ - \s;\'tdai : E 9<i >o=L\ ? E 9srE E e!.E E re q-siE E EPSo ! <\so^,E a\'=E5t= >!Ei-lE h{ 5! xl E EU; 9Ul o cJi o 6t = -: E e.glE BEoa-l o :6'l or ) iil E ot ot g E i =lqEliel.=l; fE:l : El &:li:l; : i " Elg;lE ElSEl"$t$Eddol= =lE ol= olat - \sTEs El€ElE;"1: {E itl El E 6l - 61 5 6l '-F.;S3l3E:lE €tE 3!; S b, -l bl = ol tr ol ,- ol F !? 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Fe €\o t7) 6l(.) r- € oo c.l C.l 6 q(\ ato\N c'l $ r a N +\oq +$ c.t o\vI +$ $ ao c'I$ a -- ai:q Ebe3 0.!z tr-\o \O- \o \o$$ * (.l o\N € = Eo = 6.: 1Qs' l-v c.t a.l co aa aa oo\i ...l r*\o \o^ \o\o F-\o \O^ € c.t r-\o \o^ \o c..l €6c\ \o \o N <+ t- ta) \O^ aa o\ tr- oo o\lr) 00^ r- $r- c.) raN ra rA ) c Qo;'i_giH r:;->;o -v 5G 9: E -^^oLd' =- o o c.) aa + c.)\o ca \o oo o\\o r- tr- s\o r-. € .9o aU = d^ :v oo\toZ- i;a o ll * ^rx oo oo \o F- € ao\o co+ (') N 't*!> uuo= 3EE zEs a oo\o a.t ao c.l ao $F- \otn \or- +t-- a.)\o a c..l c.l \o 00N € \ot- = :o 6 0.= j a-o' FL' =l \ot- = an+ \o \o t-- $r- c-t\o € o.l(\ \ococ.l € U)() bo oo E o(, rr E!.;.- -Q.2 a X on = 9o,5E 3 -E ES€:{ HA t==>oo '6> E L c) L -(6 rI F F () -o C) U ,y3e =o)&O &(.) =(!ds J<os-C EL .od,z 0(! r! L 0o oL Ib< 4 ri o!i Q 2.6 What are the causes of absenteeism? o Population displacements due to conflicts. o Movement associated with nomadic culture of the cattle keepers. . Travel for different reasons out of the community. 2.7 What are the reasons for refusals? Knowledge/sensitization gaps especially among persons that did not attend the health education sessions Individuals that have no clinical/physical manifestations of disease think there is no reason as to why they should take medication. Perceived fear of the side effects of the medication. a a a 2.6 Briefly describe all known and verified serious adverse events (SAEs) that occurred during the reporting period and provide (in table 8) the required information when available. o None were reported. Parasitologist trained? No Existence of microscope? No Has the project reported all SAEs to Mectizan Donation Program (MDPX Please tick one. Not applicable ENo +IYes 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 x 23 oao9 o;o 4 t= z ;Po8E.= c €6J(\,oia i= E ai);FCr! 6'5 z oQ.2 e^OE9ao =Al, o. z O+ q9 ^ a.= tr)o-c tr&34 z rG(k;(,- o.9t6o tr tr= daAoOEEd z o o2=b()'=== :E (, Xu d-cGi z (E €-g9P'E; =.o.= ogEb*€ L-6-giZ z o o. a z 0) 0)o6)+ l-l o z =() .N*gE;A>; z o o50s6.J =bo?o z xo ru z C) bo z * 1 U) + c.l U o'\g \q)q ,( L o o0 L aq) 6) AD q) LL (.) a Gt rY ,A= 7a <Ela4 ;,i o- >q)ob0r> .1, - c)Y>a) !, 9? .9';h o.r Qh^ lH (r3Oo U)-oo- ,)0-(9(€tJ5 6la ol -ol6tlFI q) oo E $s/o Q c.t o\ cl(n N aor .'') \o .') aa F- n$ co t-- o CB o o (.1 lI] rL ri o9Sa - o6\ -o o c! \o c'l c.t r,- \o o\ oq c{ o\ q \o oo ..] l'- a.t o\F- rI] 9l tl El o !o =oLO d^OE\o(! glo- ooEOF cn o\ v? (\ .o6\ cn a- v? \o q f,- o\ ET ,o o6 ,o6!4oEtr z?oo. c.) \n oo \o o\ al € e.l $ F- cn\ o\\o+ c.)\o t'-(n o\$ $ o €\o^ c.t c.l co t1 :o? 6.2 < 9€'FL,) r- t'-\o N r- t-\o al \o s 00 c.l$ oo o\N \o a.l € o^ c.l\o\o * a.) ca r c.t o\ c-l oo s Gh ^.rd: qe - *dQ.i o ho . ' d. 3s o c.l o\ € F-F- oclq €r-r- c.t o\ €r- tr- ra) ooc{ t--N o\ tr) ooc\ r- c.l o\ F- o\ \o t-. cl aa () bo(n () oQ ll * r.l td o ^ bI)9 e6 - oo\ < >v 'o o € € c.i c- \\o oo o\ oe oo c- n o\ \o F- 'EoQ $= $ssgOoEl q \o r cl c.)$ oq \o =q cn\o -q oo cr n 00 € \o c- f.l o'i qbEbE = E-a!1700 oo c.t ca cns o\ \o c.t\o F. o\ \o caF. c.l N Ll =ad o.a 10s' FV t'-+ \o c.l r- c.l r- C.l o\ \o tr- =f bnd =o;J.rd :-.4 o q I + oE >,:: Oa.46aFr tr q 9! to a o\\o\o oo ca (n o.i ca\oq \o F-$- s c-l al \o c.l r-o N € c.t o\ c.l at rn c.l L Gq) c)trrr 6t =9)?H rB L llAu)is .Er E o!tr q, ==: e x.eB i xE '= : dori tr cnEo n L F-5E( c\6l-Sr.{> 'A t-t \o O - Ll $eL, 6ll .. rrt El gcyE Et e)Fe -91 :Dt 6rl :'-E 3 E"9 .ol 'e.=E t E: e)L:G '= 9 =tr? e EEE E UEi 6t FEE e 5c) L!-.- a\t9€tr () E-^ijEr= -Ell --g; E E5trL=40I :tEF ?I ';, .?r; +l 2iq A -Egci irl F<= 2.7. Ordering, storage and delivery of ivermectin Mectizan@ ordered/applied for by tr NGDO Other (please specify): Mectizan@ delivered by *.*--E Other (please specify) wHo Please describe how Mectizan@ is ordered and how it gets to the communities o Information on consumption levels and balances of mectizan available at the community level is provided to the Project Coordinating Officer (PCO) by the Payam and County Supervisors. o The PCO compiles all the received data for the project and then submits it to the SSOTF secretariat. Information received details the total population in the project area, amount of mectizan distributed, amounts wasted and the stock balances remaining after the distribution cycle. o SSOTF compiles this data as part of the country information and then prepares the next year's drug order for submission to MDP' o MDP reviews application, approves and forwards the application to MERCK and a notification of the approval is sent to the SSOTF. o At a later stage, the consignment of mectizan is shipped to South Sudan and it is received by WHO Country Office staff. . In conformity with the data that had earlier been received from the Project Coordinating Officer, requests for mectizan for the year, and the SSOTF approves the request and supplies the corresponding amounts of mectizan to the project. o At project level, each county supervisor collects the mectizan from the project office and then notifies all Payam Supervisors of the mectizan availability for collection. . The Payam Supervisors on collection notify and invite Boma Supervisors to collect supplies for their corresponding communities' . The Boma Supervisors, some of who are CDDS share this information with other CDDs and the communities. . The community members then decide on the time for the mectizan distribution to the rest of the community members. @JLQ: Mectizan@ Inventory tr LGA County Number of Mectizan @ tablets In stock from previous year Requested Received Used Lost Wasted Expired Remai ning Cueibet 0 310.000 310,000 308.657 39 0 0 1 )3 04 Rumbek Centre 0 80.s00 80.500 80,430 70 0 0 0 Rumbek East 0 200.000 200.000 199962 38 0 0 0 Rumbek North 0 86,000 86.000 85,945 55 0 0 0 Wulu 0 80.000 80,000 79,946 54 0 0 0 Yirol East 0 170,000 170,000 169,970 30 0 .0 0 26 Yirol West 0 165,000 165,000 164,989 1l 0 0 0 Yirol/Aweri al 6,879 126,500 126,500 129,906 15 0 0 3,458 TOTAL 6,879 1,218,000 1.21E.000 1,219,805 312 0 0 4,762 How are the remaining ivermectin tablets collected and where are they kept? Whenever there are balances of ivermectin tablets, the CDDs are charged with the responsibility of submitting them to the health facility staff so that they are stored in preparation for the next treatment cycle. The amounts of stock of medicines that remain are communicated to the Project Coordinating Officer through the reports from the Payam Supervisors through County OV Supervisors. This information is then communicated by the Project Coordinating Officer to the SSOTF secretariat. List and briefly describe the activities under ivermectin delivery that are being carried out by health care personnel in the project area. The activities that are carried out by the health care personnel include: o Training for both new and old CDDs within the communities before the mectizan distribution. o Issuing the CDDs with mectizan tablets and collecting the remaining balance from them for inventory and storage at the health centre at the end of distribution cycle. . Conducting community mobilization and health education on OV program. . Facilitating the process of selection of CDDs by the community. o Management of any person with minor or severe adverse side effects reactions and keep records. Any other comments None 2.A. Gommunity self-monitoring and Stakeholders Meeting Has any training (of trainers) for community self-monitoring been done in the project area? No If so, When? N/A @LL: Community self-monitoring and Stakeholders Meeting 0 0 63 0 County - LGA Total # of communities/villages in the entire project area No of Communities that carried out self monitorins (CSM) No of Communities that conducted stakeholders meeting (SHM) Cueibet Rumbek Centre 435 156 0 0 0 0 Rumbek East 176 0 RumbekNorth 74 0 Wullu 0 0Yirol East 228 27 0 Yirol West Yirol/Awerial 286 58 0 0 00 TOTAL 1,476 0 0 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. N/A 28 2.9. Supervision 2.9.1. Provide a flow chart of supervision hierarchy. SSOTF Task Force Project Coordinating Officer / County OV Supervisors I / Payam Superuisors / 7 CDDs / 7 Beneficiary com mun ities Su Reporting 2.9.2. What were the main issues identified during supervision? The main issues found during supervision were that: o Poor recording of the household information in the treatment registers o Some communities had not received treatment o Population updates/census was not done. 2.9.3. Yes 2.9.4. a a a Was a supervision checklist used? What were the outcomes at each level of CDTI implementation supervision? On-job coaching and mentoring was done on how to fill out the household registers and the need of having it done annually. For villages/communities that had not received mectizan, alrangements were made to avail it and it was done. CDDs were asked to have the population figures of their communities updated and the Payam and County Supervisors were tasked with the responsibility of following this up. 29 t 2.9.5. Was feedback given to the person or groups supervised? Yes feedback was given 2.9.6. How was the feedback used to improve the overall performance of the project? o On the job training was given to the staff supervised on how to update the household information, fill the summary forms and tally sheets. o Practical sessions were given to poorly performing individuals and those performing relatively better were also encouraged to coach their colleagues. o Positive peer criticism was also encouraged. SECTION 3: Support to CDTI 3.1. Equipment @-Jl2: Status of equipment *Condition of the equipment (F:Functional, CNFR:Currently non-functional but repairable, WO:Written off). How does the project intend to maintain and replace existing equipment and other materials? With expected integration of the CDTI activities into the government primary health care system, the state MoH will be responsible for maintaining and replacing equipment through the counterpart contribution to the project. This is not yet happening and so in the interim period, support will be requested from the NGDO partner or APOC management. Source Type of equipment APOC MOH DISTRICT/ LGA NGDO Others No Condrtron No Condrtron No Condrtron No Condrtron No Condrtron l. Vehicle 0 NA 0 NA 0 NA 0 NA 0 NA 2. Motor cycle(s) 4 F 0 NA 0 NA 0 NA 0 NA 3. Computer(s) 2 F 0 NA 0 NA 0 NA 0 NA 4. Printer(s) I F 0 NA 0 NA 0 NA 0 NA 5. Photocopier (s) I CNFR 0 NA 0 NA 0 NA 0 NA 6. Fax Machine(s) 0 0 0 NA 0 NA 0 NA 0 NA 7. Others 0 0 0 NA 0 NA 0 NA 0 NA a) b) c) 30 3.2. Financial contributions of the partners and communities Fill tables l3a, 13b and l3c If there are problems with release of counterpart funds, how were they addressed? 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E E gi -L'-A)O Rr .i-Ea+sE (/)l UJ OE .t .,Y J, -l -'d oF oz t o uJ = UJ(, of @ !,\o: GN t4 soto *io oocoo>'EE5 F E q EE E S T E EE E E 5: = So o (l) .El o)Es > I 1'I5E : : : : (E o aI a4 rrcg.sbstsi ,L, Io=r lU8g p E,E, Ecc.OE,EI E99c;; .s o'E'E='3 SiEis,$ gtl -i oj d olidi*ds 5 -=o S: .9 -E.E'E =Hj s E e ?i - 1tFi N (f, 4l c'ji d: d ; () oL cn C) L .o c0 U) -o ! o (! O tri a)(a 6) dF I I I I 3.3. Other forms of community support Describe (indicate forms of in-kind contributions of communities if any) . Meals for CDDs during the distribution of mectizan o Training venues for CDTI trainings . Community mobilisation for CDTI activities 3.4. Expenditure per activity Indicate in table 13, the amount expended during the reporting period for each activity listed Write the amount expended in US dollars using the current United Nations exchange rate to local currency. Indicate exchange rate used here ? Rsd Any comments or explanations? None SECTION 4: Sustainability of CDTI 4.1. lnternal; independent participatory monitoring; Evaluation 4.1.1 Has the project ever been evaluated/monitored? (Tick any of the following which are applicable) In 2009, Independent Participatory Monitoring was carried. The report/results are yet to be received. Year I Participatory Independent monitoring Mid Term Sustainability Evaluation 5 year Sustainability Evaluation Internal Monitoring by NOTF Other Evaluation by other partners 4.1.2. What were the recommendations? Not applicable 4.1.3. How have they been implemented? Not applicable 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?_No When was the sustainability plan submitted?_No 35 What arrangements have been made to sustain CDTI after APOC funding ceases in terms of: 4.2.1. Planning at all relevant levels - No plans made yet 4.2.2. Funds - No plans made yet 4.2.3 Transport (replacement and maintenance) - No plans made yet 4.2.4. Other resources - No plans made yet 4.2.5. To what extent has the plan been implemented - Not yet applicable 4.3. lntegration 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 used now is that: o WHO delivers the mectizan to the state ministry of health o The state ministry of health is then responsible for releasing the mectizan to the County Health Department stores in the Counties o It from the County Health Departments that they will later be dispatched to frontline health facilities in the Payams. o Most Payams in the project area have health facilities, so there were no instances of having the mectizan kept outside the health facility. 4.3.2. Training: In regards to training there is willingness of other programs to cooperate. These include EPI (Expanded program on Immunization) and GW (Guinea Worm Eradication program). The final implementation needs to be finally planned and executed. 4.3.3. Joint supervision and monitoring with other programs The scheduled supervision visit by other health programs was taken advantage of since the OV vehicle is still out of function. The integration was more on logistics due to a mechanical fault of the far, hopefully more programmatic integration will occur in future. 4.3.4. Release of funds for project activities There were no funds released from the PHC system. 4.3.5. Is CDTI included in the PHC budget? Not yet. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? There are no other health programmes are using the CDTI structure yet. The existent community based health programs are still using their own implementation structure. Explain what are the combinations of interventions co-implemented? There is no clear arrangement for co-implementation yet. 36 4.3.6. How were the interventions implemented? (at the same time?) The interventions are not implemented at the same time. The different programs utilise the same persons in the community to implement the programs. 4.3.7. Describe others issues considered in the integration of CDTI. This is not yet applicable in this project. 37 €an q) o o o o q) z 6 o3 qq) q)tr q o 2 o 4) b0 (! 0 4) 6) z F q 4) o tu Oq) tq 2 q o> -otr z 6 3 oo q)9 o 6) CE ,?O.- -o3Etr Zo Q) eEq) c q) () o0 6 - io E.2 Z q,) () 6) o u0 tE - i.E tr\ >- ti .os o.O os Eg" lH .= x9 >L ,0) a a a a oo o!Qt ->. oH(J 4q) )< + 4 q)\ .a q) ,,.i q q) ca R L I *) L() LL €) - AIi Aoo L,, .E .. IIH Fl(! o-l0)E>' ?-Z u)o L o() l- o €) o) o H 0o() o0 6) o o o I ctt 6 q0 q,) u! o2POtQ 2 o c! o o 0 o o E- LO oo i'E .g oa) ?.t Z oE o E.9 9o =q) EEqo6) ot EO '= >. =iisv) 6) o o o oo 6 o q) o o C) F a O o a a a a q) F o\ c.l q q) a- )<q) q q) .s .{ 4 o q) q) q) no 6)r-J =99ar Lt -gth () H; ODFEO U, L)ro) 8E E9p cr= a0 ?) ai: .oo oyEA AO ,ii g FCB .9 sr lt o)cl -CFF I ! 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 has been done. 4.4.2. How were the results applied in the project? Not applicable. SECTION 5: Strengths, weaknesses, challenges, and opportunities Strengths: o The project has been running for a number of years and it has a number of experienced CDTI staff that can work independently. The support staff is quite good, notably in the finance section. . There is strong collaboration with the health staffs in the front line health facilities that are the mectizan distribution points before it is dispatched to the communities. o The project coordinating office is located within the state ministry of health premises and this eases day-to-day coordination with the government authorities. . There is a very good working relationship between the project staff and the state ministry of health officials. o The counties that are covered under this project are consolidated into one state and this is beneficial in regards to administration issues with the local government authority. Weakness: . High attrition rate of CDDs and FLHF staff. o Poor system of maintenance of equipment especially vehicles and motorbikes. . Slow integration of CDTI staff and activities into the PHC programs. . Poor coordination on the needs of the project with the SSOTF, there has been instances where there was inadequate provision of household registers for the collection of community information. Challenges: . The state of the roads and failure to access beneficiary communities in the wet season. . There is always a potential of insecurity in the area especially in the dry seasons since rival communities fight over grazing and watering places. . The low level of literacy gets reflected in the quality of staff that gets employed especially at the community level. o There is a high level of poverty and deprivation in the wider community and whenever there is some community initiative, the persons involved see it as an opportunity to benefit financially. Opportunities: . There is the presence of other WHO programs that work with community level persons and there could be better performance and thus efficiency as regards human resources at the community level and also in monitoring and supervision of community level activities. 40 t aSECTION 6: Unique features of the project/other matters . The project area is consolidated in one state and thus there are no administrative issues across states. o The project has presence in the state Ministry of Health and this is a very good step towards ownership of the program by the ministry. . The project is also serving a community that is highly prone to inter-tribe and inter-clan conflicts that arises usually from competition of resources to sustain their livelihoods. 4t