Metekel annual project technical report submitted to Technical Consultative Committee (TCC): January 2009 to December 2009

COUNTRY/NOTF: ETHIOPIA Proiect Name: Metekel Approval vear: 2003 Launetrtng yeat:2004 Reportinq Period: From: JanUary..?40.9...... To,l.....PeSS.mhgr.?00.9..........(MonthNepr)., (MonthNear) Pr"i""tr"rr"f th (CirCieone) 1 2 3 4 qJ 7 8 9 10 Date submitted : January 2010 NGDO partner: The Carter Center The Federal Democratic Republic of Ethiopia Ministry of Health ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNTCAL CONSULTATTVE COMMITTEE (TCC) DEADLINE FOR SUBMISSION: To APOC Management by LLelgg.Et for March TCC meeting To APOC Management by 31 Julv for September TCC meeting AFRTCAN PROGRAMME FOR ONGHOCERCIASIS CONTROL (APOC) For .Acfisu fot !O 14,L 40, AAi J Apuc / trrit WHO/APOC, December 2009 fD Fq bdomofion ro.A\R RECU tE 2 s lat, zoro Tr_ (9v ANNUAL PROJECT TECHNICAL REPORT TO TECHNTCAL CONSULTATIVE COIUtUITTEE (TCC) ENDORSEMENT PIease confirm you have read this report by signing in the appropriate space. OFFICERS to sign the report: Country: Ethiopia NationalCoordinator Name:................. Siqnature: Date: Zonal Onch o Coord i nator N am e : ..... S.r.YA[e.m.f iK.[f .Hjka........ Signature: Date: .. NGDO Representative Name: .....A.hate.TiJah.U.n. Signature: Date: . This report has been prepared by Name : ....S.t:.Y..a.Le.m.fiKe.f.HiK.a...... Designation: Zone onchocerciasis Coordinator Signature: ... .. Date January 2010 WHO/APOC, December 2009 I Table of contents Acronyms. Definitions. FOLLOW UP ON TCC RECOMMENDATIONS......... Executive Summary.. SECI/ON 1 : Background information ......... 1.1. GrruERnlrNFoRMATtoN............... 1.2. PoPUlATroN............... SECI/ON 2: lmplementation of CDTI..... 2.1 TTMELTNE oF ACTTVTIES .... ......... 2.2. Aovocncv 2,3. MOAITIZATION, SENSITIZATION AND HEALTH EDUCATION OF AT RISK COMMUNITIES 2.4. Cour'aurutrv |NVoLVEMENT............. 2.5. CRpncttvBUtLDtNG... 2.6. Tnrnrueruts............... 2.7. OnorRIr.IO, STORAGE AND DELIVERY OF IVERMECTIN 2.8. CoIuIuuruIry SELF-MONITORING AND STAKEHOLDERS METTINO... 2.9. SupeRvrsroN............... SECI/ON 3: Support to CDTI 3.1. Eoutpuerur 3.2. FIunruc|nI CONTRIBUTIONS OF THE PARTNERS AND COMMUNITIES............. 3.3. OrHrn FoRMS oF coMMUNtrY suPPoRT............... 3.4. EXPTNOITURE PER ACTIVITY SECI/ON 4: Sustainability of CDT|......... 4.1. lrurERlrRt; TNDEpENDENT PARTtctPAToRY MoNlroRlNG; Evn1unrtoN.................. 4.2. 1rurEcRRrroN.............. SECI/ON 5: Strengths, weaknesses, challenges, and opportunities............... 1 2 3 5 7 7 WHO/APOC, December 2009 Acronyms APOC ATO ATrO CBO CDD CDTI CSM HEW LGA MOH NGDO NGO NOTF PHC REMO SAE SHM African Programme for Onchocerciasis Control Annual Treatment Objective Annual Training Objective Commu nity-Based Organization Community-Directed Distributor Com m u n ity-D i rected Treatment with lvermecti n Commu n ity Self-Monitori ng Health Extension Workers Local Government Area Ministry of Health Non-Governmental 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 Zone Health DePartment TCC TOT UNICEF UTG WHO ZHD WHO/APOC, December 2009 Definitions (i) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking). ( ii) Eliqible oulation: calculated as 84o/o of the total population in meso/hyper-endemic communities in the project area (iii) 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 expected to reach the UTG at the end of the 3'o year of the project). (v) Therapeutic coveraqe: number of people treated in a given year over the total population (this should be expressed as a percentage). (vi) Geoqraphical coveraqe: 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) lnteqration: delivering additional health interventions (i.e. vitamin A supplements, albendazole for LF, screening for cataract, etc.) through CDTI (using the same systems, training, supervision and personnel) in order to maximize 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) Sustainabilitv: CDTI activities in an area are sustainable when they continue to function effectively for the foreseeable future, with high treatment coverage, integrated into the available healthcare service, with strong community ownership, using resources mobilized by the community and the government. (ix) Commun itv self-monitorin o (CSM): The process by which the community is empowered to oversee and monitor the performance of CDTI (or any community-based health intervention programme), with a view to ensuring that the programme is being executed in the way intended. lt encourages the community to take full responsibility of ivermectin distribution and make appropriate modifications when necessary. WHO/APOC, December 2009 FOLLOW UP ON TCC RECOMMENDATIONS TCC session 28th #ot Recomme ndation in the Report TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT USE ONLY Diversify channels used for sensitization, mobilization and health education The project couldn't go further beyond using distributing leaflets, population gatherings because of budget constraints and unavailability of local radio station Address problems late submission of reports and arrange for, and take advantages of regular review meetings at all levels to obtain reports. With regard to timely reporting, improvement has been shown this year compared to the previous distribution period. However, post distribution review meetings haven't held at all levels because of budget constraint. Retain CDDs on documentation and procedure for delivering health education lmproved Encourage selection of community based supervisors in difficult to reach villages ln most and such hard to reach areas, health extension workers are taking the role of communitY based supervisors and promising result is being attained. Building up on existing good structures on integration The CDTI activity is continuing well with other health programs such as malaria, Enhanced outreach strategy for EPI< deworming, and Vitamin A supplementation. Take advantage of high communitY awareness on the improvement of the drug to improve on therapeutic coverage by reducing the number of refusals and absentees The therapeutic coverage of this year is same as the previous Year (71Yo) which below the cut off point. The number of persons who failed to take their drug was high. However data were not available indicating the exact number of absentees and refusals. The project will attempt to know the reasons for high number of untreated persons by using the new form, hence helPs to determine the cause of low coverage. Conduct monitoring and evaluation and prepare sustainability Plan The project had facilitated sustainability evaluation and plan has been made already. WHO/APOC, December 2009 Executive Summary The project named "Metekel Zone Community Directed Treatment with lvermectin" (CDTI) is funded by the African Program for Onchocerciasis Control (APOC) and its partner The Carter Center and is being implemented by the FMoH, Regional Health Bureau and line authorities. Metekel zone is located in the North-west part of Ethiopia. Metekel is one of the three zones in Benshangul Gumuz people's Regional State. There are 4 CDTI project woredas namely Dangur, Pawi, Guba and Mandura. The CDTI woredas are further divided into 82 kebeles and a total of 290 villages/ communities are available under these kebeles. The 2009 census result revealed that there were 147,524 inhabitants in the CDTI woredas. During the treatment period, a total of 104,363 persons have received lvermectin. This makes a therapeutic coverage of 71% while the geographical coverage persists 100%. The following table depicts the treatment history of the project. 1. Overview of the population The total population of the zone is estimated at294,369 in 2009. Majority of the people exist by subsistence agriculture, involving farming and herding which occur all year round. The fertile nature of the land makes the zone in general and the CDTI woredas in particular a potential area for large-scale agricultural work. Owing to this fact, settlers and day laborers visit the area every year. Some communities have nomadic nature. 2. Training data Prior to launching the 2009 distribution, training was given to health staff representing woreda health offices and selected health facilities. Cascade trainings had also been given to CDDs and community supervisors. ln general, 116 health workers (includes health YEAR Total population endemic areas Annual Treatment Obiective Number of persons treated Therapeutic coverage ATO covera ge UTG Coverage 2004 120,234 100,997 65,914 55 65 65 2005 2006 118,421 99,474 79,113 67 80 80 2007 140,182 117,753 99,660 71 85 85 2008 142,056 119,327 100,149 71 84 84 2009 147,524 123,920 104.363 71 84 84 WHO/APOC, December 2009 extension workers), 1404 CDDs and 202 community supervisors have got the training. Majority of the trainees have received it more than one times and the training was organized in one session for both new and repeat ones. This was done for the purpose of sharing experiences among participants. 3. Challenges and how they were overcome The challenge in connection with this year CDTI was late arrival of lvermectin from the center. This posed difficulties to get some mobile communities at their temporary places. As a result, a significant number of persons disallowed from getting the service. Because of underdeveloped infrastructure (road and telecommunication) compounded by old vehicles, made reaching communities difficult to assist CDDs and community supervisors. ln some communities, there were illiterate CDDs who couldn't able to properly record. Deployment of HEWs assigned as community supervisors was the measure taken to maintain service delivery to maximum level. Students handled those problems associated with illiteracy. Opportunities: The Health Extension Program (HEP) creates a fertile ground to smoothly run the distribution. Health Extension workers who are females and working based in kebeles supported CDDs during the entire distribution time. The ever-increasing need of beneficiaries towards the drug and the willingness of CDDs to serve their own communities are opportunities to conduct mass drug administration with little input from the government offices. WHO/APOC, December 2009 SECTION 1: Background information 1.1. General information Description of the Project Metekel zone is located in the North-west part of Ethiopia. Metekel is one of the three zones in Benshangul Gumuz people's Regional State. Gilgel-Beless is the capital of the zone where the zonal onchocerciasis control coordination office is based. The zone is divided administratively into seven woredas and 127 kebeles known as the lowest administrative units of the government structure. The zone has a total surface area of 259,932 km landmass. The climate of the zone is classified as tropical. There are two distinct seasons i.e rainy and cool weather from June - October and hot and dry weather from November to May. The temperature ranges from 25 co - 42 co . The topography of the land is classified as 82o/o low land, 10% semi highland and 8% highland. The total population of the zone was estimated at 294,369 in 2009. Majority of the people exist by subsistence agriculture, involving farming and herding which occur all year round in the project area. The fertile nature of the land is preferred for large-scale agricultural work and settlement. Due to this fact, a number of persons move to permanently settle or to work as day laborer yearly. Some communities were identified as nomad. ln consequence, the likelihood of missing them is high if distribution period is delayed beyond February. There is one zonal hospital, seven health centers and ninety-one health posts making the potential health service coverage 93 o/o. The health posts and health centers are the ones providing primary health service to the community. Health posts are closer to the community (mostly available at kebele level) and run by HEWs, who have received a one year training on preventive methods of communicable diseases and treating minor ailments including uncomplicated malaria. Health centers are staffed by health officers and nurses and are responsible to give basic health services. 1.1.1 CDTI woredas Beginning from 2004, Metekel CDTI project is being implemented in four woredas namely, Dangur, Pawi, Guba and Mandura. Unfortunately, the 2nd round was not effective due to administrative problems. There were 82 kebeles and 290 villages targeted for mass drug administration with the drug lvermectin. There is an increase trend in the number of villages from previous years. WHO/APOC, December 2009 ln terms of infrastructure (road, telephone), they have low coverage. The problem is dominant with in the woredas and making access kebeles and villages difficult. The 2009 census update revealed a total population of 147,524. The Annual Treatment Objective was 118,019. And a total of 104,363 persons were treated with lvermectin which makes a therapeutic coverage of 71o/o and ATO coverage of 88%. The geographical coverage persists 100%. Table 1: Number of health staff involved in CDTI District 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 B3=B2l 81 *1 00 Dangur 83 24 28 Pawi 78 49 63 Guba 27 21 78 Mandura 57 22 39 Total 245 116 47 1.1.2. Partnership The CDTI activities are being implemented with the financial, logistics and technical support from WHO/APOC, The Carter Center and above all by the full commitment CDDs and affected communities. The health staff and other sector offices have contributed much in transportation of drugs and supplies, providing training halls, training implementers and by coordinating the overall CDTI activities especially during the entire mass drug administration period. However, the leadership and monitoring role of task forces at different levels were very minimal compared to the previous era. This was partly due to the combined effect of frequent turnover/assignment change of task forces and failure to re-establish or enhance task forces by respective woreda health offices WHO/APOC, December 2009 ON Lo q) o C) o (, o IJ og o CL o E'c o o ot c CL o =.; .9 q, E')g 't o .E tr E tr o(, o -a, olz =o. u, oocr ooi; (!l -co !(f, oo O Y^,tr6 -o-ocE"h .EUEE .f oo =rutra F(t) =u)6(U OO+to oo '= E'lE =ttrotr 9cLJrO o!lo c'd E =Xo) *or I ; '6 o o-o ooL f oa L o _c o oo o o5oc oo (tr c .9 (5 = o"oLL =Goo@> c.. o o -o(5 o -o(u o .C,! .c (U (u E o o oo f oo o .a (5 l- =oz = oz \ a o c\.Eo .E o o- cT)C E o o- o o -c (,) E L)! oc o! o o '6' o- os L orF o)oc oo (U a G B (U oQ -e-SL$sgr Gh so ss (U(U EOol-p) a.o oS -o.\(Eco .t\iB(/)- 3E o6 oct'=x trq) fic 0)'o bE3AaoS*Ac) ESEh .S q) (ES =o a6ESo-:o)gE orIa6 ooI.p<s!. o- tsEq.P) 38,o=a-= =otro\(E Ee BE E8!o' 3h. >. 0)g* EEG=()b ilo) OEta(U5Q Eo L o o_ o)c Eo o- oL o -c o)C .E f! oc L o E o G oL oL(o q) c Loc ot 3 .E o (E o o o CL o c o o -g .s tz ah .E o c o .E(! f, o- o o_ Ec(! o o o'= +.f(Etr =trcL6oo(L N o olfi -F * i() o p' a. o o o tr o s =cL o o. oFf OE E Pt E qo lr)oo @(o o) $lo lif o) o,r C! N F- N(a oN o)(f) Nr k) +s t! 6 i = t.g '- >rtr O gEE F E $$N ros t-$lr)s CDs (f) NlOs r oo(f, @ (f) {(\t ro t sE 5Ets{ o t-slo$ CDs o o tfIot o)t 6:i Hgt s qooyNq \tsNlos o (f) c{ rO$ oo (f) @ (f, @o@ o) .E o o E"g oo c =tr E o o o oII E] =lz1 N +* lt G) IOLE .= &s E5E;oo . o!ttrtr vr- o,v orr) t- r r o C'I(\ N Pt _ O.o nl ssiEe "!, +'trtro.- o CD\t o o o)t 6 Ei ggt s qootsNO srr o oro F- r o)fi,(\ o(Etr.= O .9EEE ox EE"g.E.g Es aoo-trF CL.= CL \t$Nlo$ F-!t rotf CD$ (f, N ro$r oo(oo(f) rt(\t roNt o oo(U 'r.= o otrGi5ox '- !9 i[ i\+, O O.= o. Lf o)c([ o t(o& (E -of o oLfEc(5 F oF ls there any other information of interest about the population in the project area? lf so, include it here. As it is mentioned above in the population profile, some of the people in project woredas are settlers/seasonal workers coming from highland areas of the country. These highlanders usually leave the area when they finalize harvest their crops usually after February. This causes variation of population figure at different treatment year and inconsistency of therapeutic coverage. WHO/APOC, December 2009 tr .9 .9, E oo t, .9- EE cLoEEo- (u (u (U ogf - 9-c k9 soL(5 = o (5 = .Co (5 -coL o tr o .o .9,!, E,lf o EE cLo EEo-o6 (U ocf - ED- E9 a- EoL o = -coLo .c.oL(5 -co G o (E 'rEo :) o otr oo EcEFotr 5(,E EoL(5 EoL(E EoL(U :Lo- E". 'Ee H9 a- -(5 aL -oo LL -([ :fL -o o) TL a. o JLooIL Z"([ JLo o LL E,lc (E Ll- o o= -o.6 EEo o,o L o -o E oooo Ct)o L o -o E c)o o)o o,o Lo -o E oo oo ct)o oo E oo oo ED- ke O)o L o -oo() o o)o Lo -oo oo o)o L o -oo() o o)o L o) -oo() o rFoo -oo.E (lt=Ntr == -OEgE .9- EE cLo EEo-C)- o,oi ofc(o - CDo .(5 5c([ a CDo -(U lc o - ct)o b([ 5c(! - E,). 'li eE9 CDo z-(5 ac(! - O)o a"(5)tr(! - o)o a G =c o - o)o a(E fE(E oJDo o i5 Lf o)c(U o =otL (! _o :,(9 oLf1'tr(! = o\ N () -o oo C) IJ O - o.{ oH o o (U !o o =o E o c) c .o (5 .g E o oo .Y(u o =o(U =(U oE L o E o ! oLo o E L o- o -c aPc o E E oo I L(5 q) c o L Jo o .E E o (E oL a(u E(5 oE L o o o := o(tr o o .gT E tr c"it ol -ol(6l r-l tro o lF o tr o +,(EZo68 oE CLE :o oe.i Ez9oE FolIJ -U, e.i 2.2. Advocacy State the number of policy/decision makers mobilized at each relevant level during the current year; the reason(s) for undertaking the advocacy and the outcome. Describe difficulties/ constraints being faced and suggestions on how to improve advocacy. A number of advocacy meetings have been undertaken at woreda level for woreda cabinets, and kebele leaders. These in turn have mobilized religious and community leaders. However, the number of persons addressed in this area was not properly documented. When ever possible, the zone health department and woreda health offices believe to undertake advocacy on yearly basis. The rationale is to keep maintaining the support of decision makers notably in the phase of frequent leader's turnover. The difficulties associated with advocacy were to get these decision makers at a time. Using local media perhaps help reaching all stakeholders due to its wider area coverage on top of the efforts being made. 2.3. Mobilization, sensitization and health education of at risk communities There had been a number of people's conferences in many places that were meant to address governmental agendas. Woreda health offices and FLHF staff have used the opportunity to mobilize the community. However, it was difficult to mobilize pastoralist and other mobile communities. Approaches such as health facility based education and individual education during home visit by HEW have been used to bring a synergetic effect. Obviously following their sensitization/training, CDDs have taken part in community sensitization. WHO/APOC, 24 November 2003 $ N r() -o () o z .f N () o r TJ > =Lf E E oo o)c .E =! c .9 (5 o_ '6 E(tr o_ .c L o o -o oL o =@o oo q) (U E o {jo(tr E J(E .E .c E o(tr 3 EoC o o_o oE >goo -c -o 6E _cE3> .e=(EEO-c :0bEoQoLl-6 -oE ?lEP 8b?E6xuI -L6ov.Ei6n .a;P Iolr-c oiu CO (,, ooc(5 1'c o u(! Eooofo .9,E o)c '6 -o oL(E o ofa .a Fo() c o -c =o(,) C oo E =c :f E E oo o -c o oLo -o E o E o(! Eo o E o G o-() E(o-io() OO LF v=g; C, O' l()o .:2>E oc) -o _c ==o.Eg _-o(E'{=LC6oo_ L'^- o .:Jo)E -(tr:o- =cf, E Eoo .c ooc o)ooL o- .E o -c E G o-LICf oo of E .= o E .eE p38;cOLYOoC)E Ju '6o '=E ooEo) Eb a2CE .-L 5.eEc c'-OEoc)oc 2.EEO- E6F u, -o(5-3kgt) e.e(trl C'F =EEoo5;6-ooo _EegEoc)EE oooo EeEaC6g;(tr0, o.=(5(DEE o(5tL O) oE' c o o E tr o (E(, =E o E =Go .c +, G .E c E o(, oE o o ott E o E -9G Eo o o .. (, ctro(u -!lCtroo E< o(Jr !o o 5 o oE o s ,r, Gi .o ooo o G e i art o i o tJ o oa o at E G U, t4 oo o s ar,i o\ o o EE G o t4 Go s troo o .= tr o (E CL o E(! CL oo .E E E oo + -g .ct(E F tr o E o o .E .E E E o o aN o o cDg \g' oO .9o .= c)!otrG CEbeoE 3'= o .Cl Efz oo ru I- dE d' o E')(! c o o o o. o o E tflbE6f 'E o5=E - Ee o o z z z z z o(, .E J E E o o o5Elr>(!y oco'-o o o ott E Jz @ d! + F m il tr! E oF rr)$N @ rr)(o Ns (f)N CO @ t @ 9aqo tsofo o(o o, N N rO Fo oooo -9G = 1r) @ t-(o rr) o(a @(o a)tN .E =E E o o Eo .=L]E E'EE"O se>oioO(! Plt LOJOEctr66Eo o o! E ,z oo llr do- @ o E')(! tr oo o o- o,@ oo (o o) r()(o t o f aH e ?'=- p B T E.g'EEEEP =ooiioe6 (o(o o(o @$ s ro N trl .= 0.8 e Etr ='j: (uE55H E ET A6eo $ F.- o,s oro t- o C')N (9 J (, .t2o L) o)c(E o = (u o- G -of(, (o LfEc(E E oF lncentives provided by communities for the CDDs. No any form of incentive given to CDDs by the communities Attrition of CDDs: !s attrition a problem for the project? !f yes, how is it addressed? CDD attrition is common among mobile communities. ln areas where villagers permanently live, there have been CDDs working since the beginning of CDTI Recruiting new volunteers to replace them address the problem. Other issues 2.5. Capacity building - Describe the adequacy of available knowledgeable manpower at all levels - Where frequent transfers of trained staff occur, state what the project is doing, or intends to do, to remedy the situation. (The most importantissue to describe is what measures were taken to ensure adequate CDTI implementation where not enough knowledgeable manpower was available or if staffs are frequently transferred during the course of the campaign). It is believed that knowledgeable staffs are available in each worda .ln general, frequent transfer of trained staff and change in assignment due to periodic government's reform remains a problem in the entire region. The region in general is deprived in many aspects and a result staff transfer is occurs frequently. The problem varies from woreda to woreda. ln some woreda health offices and FLHFs there were trained staff and CDTI focal persons working up to 4 years. Every year, the Zone Health Department and The Carter Center plan to provide training to all staff as a means to maintain the availability of knowledgeable staff at all levels. ln line with this, one day training has been given to woreda management staff, FLHF health workers and HEWs. WHO/APOC, 24 November 2004 t N () .o a) z $N U o G q q t- (/) oao E G eoto =\oo oa\ a U) U) :E(E o r<(u q)E a G o. O) .= c g o (u 't cttrO$ o- a-Q-:-(EF- ERQvox*oBSQo\E*op EE resba-Qo 9S JcbQ> 68 9ohe\o5a E,s(U-obq3 =e c; oo o) a oE o q Qq) o E U) o\(U 5 o G o O) Eso a-(r) o\ oo o ob's Q a. qt a(E\ E G o $ oE tog =0)z ; E$qq q) oq) $- (/) =e o o EbB G o) U) Gq) E C .o (o #C o E o o- E troo o o o o c o o € o (5 tf) .CC '(! LF rbt ol -ol(5l FI T'oc (E ooo o o olt E =z 3EttO Ed; ir *d rr)$N lr)NN oN @ rr) @ (oo CO l{) l.r)(r) @ c{ 1r)(o (a(o (e F.(f) (o(o N !tot !t ro o) o|ot oo A tr o E o .g (J s82ko o lo(o[o \t o(f) olo @ o o .=oGFEO o-Eooo *Ob.= stll .t:Eb z :EnO E.i .=o &d Io *d o o o o o o o o o o o o o o o o o E o .g o soeF o o o o o !, o *, (EGE0)s -(Eoo $[E- 2P oo s8tF() No o \q)q i 0)z $N @ (o O)s tt N r.c)N N (o 1.c) NN F lr) (0 |r)(o ro ooi tr o Eo .9 o soeF o o)$ o rr) tto G o o o htl69 i5'= o+, o .ct E3z Erci F o'+-Fo o o \ oq =oe tr o E o .9 (J s oQF o o .t2o L =o,C(5 o '= (5 o- G -o =o (5 L)Ec(E J F oF Type of training CDDs Other Community members Community supervisors Health Workers (FLHF) MOH staff or Other Politic al Leade rS Others (specif v) Program manage ment How to conduct Health education Management of SAEs CSM SHM Data collection Data analysis Report writing Others (specify) Table 6: Type of training undertaken(iicX the boxei where specific training was carried out during the reporting period) - Any other comments All actors have been briefed on the concept of community Self Monitoring (CSM). However, it was noticed that the system was not fully implemented in all CDTI woredas. The good thing is that most supervisors were HEWs (believed to be representatives of the community) have involved in monitoring the overall activities. 2.6. Treatments 2.6.1. Treatment figures lf the project is not achieving looo/o geographical coverage and a minimum of 65% therapeutic coverage or the coverage rate is fluctuating, state the reasons and the plans being made to remedY this. ln this treatment period, all the fourworedas maintained 100% geographic coverage and a therapeutic coverage ol71o/o. However, Dangur woreda couldn't attain more than 66%. The therapeutic coverage of this year is consistent with the previous one. The possible explanation is the mobile nature of the community and associated with untimely lvermectin delivery. ln order to prevent the situation from happening, distribution time shouldn't coincide with harvest time (in this case the zone is ready to adhere with this schedule provided that the drug is available before June). During the annual review and planning meeting (meant for the whole health programs) wordas were strongly encouraged to maintain their coverage and exert efforts to increase yearly to 80% level WHOiAPOC, 24 November 2004 .f, ct Lo -o C) o z$N L,, o lTr > 5 t o (, E o G E o .e. (4.g.s ssoo>c 'BI G! -o -(, .:oEE 9 o-l E E.'q ': 5Xi !,t't E3 * Ct3 =be su .g ho-E xrot$sr d.bo O'rrg :Itr ssO 'S*r [3r Ol\S F?$ s:T PH .9 EEH bsi$rss*I E$> tro\ coo 'ioI BpE Hi .s t* s r$ o o\E B[o os a. Q-1 \ S-'o oEb bFa a= s :gB SPE Eg; E!Ci EG o o.9f Et n rrfe eRt- FO b e€ * s#EE€s5@* E 8v-^Z_ L# g o o o o o 9 qe. eGEE I9 q, EH2- gR do o o o o o bs Et f; r)6zii I I I I I g* E eE,E- E"osEEtg' I I I I I C .o (5 =o- oL oo *oo il\dd &P(E{JL-;.b= 9 (,5 -c. oFo (o(o (f)F- (or.- Nt- l'- FoE* HEto!r(gr 6E z. o-f o)$@ o)N oNo(0 (f) O)t- o)o r 1r) |r) F*N e:'(o fi,to @o co f E ?iEE-6fP I s$N rO$ Nlo$ o) .t (f) N ros oo(f) @(a $N ro t oo J-b 9.s sBtEE* $sN ros t- rOs o)s (f, N ro$ oo(f) @(f) tNloi-t o o o) _([ = a .o) .=Cf E Eoo o irB io 'E o)o- o)(E- (5a b,lI b:e oooo oo oo oo oo oo o b= E- E =g*btr>g): EE' st- ct$ orf) t- o ol(\ No (Ec 'E q L 'td6E.6 orEE 6 sr- o)s oro t- o C')N E= .E * .e * Em 9eE tE ua .:<tr S o cGF8 >: E o st- o,s orO 1.- r o o)N .o< E9o\ Lfq c([ o = (U(L (5 -of o (E Lfoc(E EoF E aqq q) oq) h (/)i e eo E! o q)q o o) ts .Yo L (5 o(U c)L o o .c (9 o L .9.E -o a TJJ a EC(U c o E (o o F F* o -o(u 2.6.2 What are the causes of absenteeism? It is unfortunate that the number of refusals and absentees was not documented. Woreda health offices failed to use the new form. ln general, a total of 43161 persons didn't receive their drug relatively high number in Dangur. Taking the findings of the recent suitability evaluation and our previous observation in to account, the reason for not taking the drug could be due to absenteeism. As repeatedly stated, untimely delivery of service is believed to be the prime factor for high number of untreated persons. ln order to avoid such gaps, the zone health department will make use of the new form for the upcoming round. 2.6.3 What are the causes for refusals? The reason is described above 2.6.4 Briefly describe all known and verified serious adverse events (SAEs) that occurred during the reporting period and provide (in table 8) the required information when available ln case the project did not have any cases of serious adverse events (SAE) during this reporting period, please tick in the box. No SAE case to report ,/ WHO/APOC, 24 November 2004 $ ON () -o () o z$N L./ L,)A o E > -o o +, -g) o Go o E')g o o(, (9 Ff, (E L(EL(l)0 UG ELE.E:oJo6 o!,5Ee L& .YG yO E $EtlL!9I CL E,EErEEOE qE .FPOt:3ov h H3olrb Fl-l- :(!I F5EI E E EI f;E A.Ea $Er $e ALE UE9Eo5EFE e;ts EfEEgPE gEFEF6'; "i* 3qts NFo. o) roS 5 g,s o o O) o@ @@ @@ a@@ c o .F o o- o o. oll \Oo @- uiu *- IIJ o)OE ,?t- o ox<B <- o t-@ o@ @@ @@ a@@ o tl -O ,3rif, UJ Pg,(5 () !u-bE 05f '?J lolr) r\(o t- or\ t- @ lU E p,oo 6-9!(/)(trEbg z* $ o, ro @ I (f) oir- o(o(o o, o) O)$ oo (f) @(9so N uJ cc)E o.> Ffr E.2 0J.o' F\J ro o)(o_ |r) N (f, r-$- o) O) lr)s @_ N rr)s(o- (f) r $Nlr)t-s 5 &g s;IE5 e, $(f) N oN N s- co (oo@ ot (oloo c.is sNto r-$ o o) o) -g aU' .o =cf E Eoo o ,hD i u.l o)oE -l-- 9 ()S<6 v() olo oo oo oo oo ec E,, s,i,tli o og ur stoto Iolo oo oo oo oo o IIJ;" Er *e |r)$r I O)@N O)@N o,@N o o)N Nlu -cO E 9.EJE() F 6.Sr < E*'Fv lr,s r I o)@N CD @N CD @N o Ct)N pEEfg e' ' 8>= e 1r)$ o,@N O)@N o)@N o o)N t TU sooN toooN (oooN r-ooN @ooN o)ooN I I I I 2.7. Ordering, storage and delivery of ivermectin Mectizan@ ordered/applied for by - (p/ease tick the appropriate answer) MOH g WHOf] UNICEFN NGDO Other (please specify) Mectizan@ delivered by - (please tick the appropiate answer) MOH g WHOf] UNICEFN NGDO tr Other (please specify) please describe how Mectizan@ is ordered and how it gets to the communities Mectizan@ ordering and distribution was done as per the existing government drugs and supplies management system. The Zonal health department submitted a request paper to FMoH the total amount based on the woredas requirement. Shipment of drugs and other supplies from FMoH to zone warehouse was facilitated by the ZHD. Similarly, woreda health offices transported to woreda and some times to health facility levels (depending on the accessibility and availability of vehicles. For most communities, the CDDs or community supervisors collected the drug from the FLHF. Only in a few cases did the FLHF staff deliver the drug to the communities during their visits for other health programme activities. Tabte 10: Mectizan@ lnventory (Please add more rows if necessary) N. B The difference in the remaining against received and used plus wasted is the balance forwarded from the previous round. - How are the remaining lvermectin tablets collected and where are they kept? At the completion of drug distribution, allthe remaining drugs are collected by the help of supervisors and temporally collected at FLHF level. Until now the drug is kept at health post and health centers and only some proportion of the drug stored at woreda warehouse. List and briefly describe the activities under lvermectin delivery that are being carried out by health care personnel in the proiect area. . FLHF responsible staff formally requests the office, in some instances the woreda health office staff (pharmacy technician or person in charge of doing this section) transports to FLHF level when deemed necessary' . Transportation and/or distribution of lvermectin to cDDs DistricULGA l{umber of Mectizan' tablets Requested Received Used Lost Wasted Expired Remai Metekel Zone 320778 320778 296941 0 838 0 26693 WHO/APOC, 24 November 2004 tr . Collect from CDDs or community supervisors and transport to woreda warehouses. . Audit and assess the condition of remaining drug . Facilitate disposal of expiry or damaged drugs - Any other comments 2.8. Gommunity setf-monitoring and Stakeholders Meeting Has any training (of trainers) for community self-monitoring done in the project area? As indicated earlier, training was given to woreda management staff and FLHF health workers (HEWs) on the concept of Community Self Monitoring using APOC guide. lt was part of the training schedule. lf so, When This was given during woreda level training that was conducted days before launching ivermectin distribution. Table 11: 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. ln Metekel CDTI project, practicing CSM by community members is not yet fully implemented. Thus far health workers and HEWs (who are considered as representatives of the communities) have been briefed on the concept of CSM and taught to organize community gatherings so that community members will take part in monitoring CDTI activities. DistricU LGA Total# of communities/villages in the entire project area No of Communitiesthat carried out self monitoring (GSM) No of Communities that conducted stakeholders meeting (sHM) Dangur Pawi Guba 74 49 50 0 0 0 0 0 0 Mandura 117 0 0 TOTAL 290 0 0 WHO/APOC, December 2009 2.9. Supervision 2.9.1. Provide a flow chart of supervision hierarchy. ZHDINGDO) WHO ) Health Facility ) Community supervisors ) CDDs 2.9.2. What were the main issues identified during supervision? . Poor handling of documents. . Delay in returning of drugs by CDDs . Reporting delay form CDDs and FLHFs . . Misallocation of Drug among CDDs . Lack of supporUattention from Keble leaders (in some places) 2.9.3. Was a supervision checklist used? ln most cases Yes, but it was also observed that there were supervisors who didn't use checklist. The tool was not distributed front line health worker for use. 2.9.3. What were the outcomes at each level of CDTI implementation supervision? It is believed that supervision has contributed in correcting some recording and document handling. ln general improvements have been observed following supervision. Supervisions were made mainly in accessible areas. Most remote and hard to reach communities were not assessed. 2.9.5. Was feedback given to the person or groups supervised? yes, but not in written form-. The trend is to disclose the findings during annual review 2.9.6. How was the feedback used to improve the overall performance of the project? We believed that the feedback given and the discussions made during reviewing meeting has added value in improving data quality, reporting, drug balance and other CDTI activities. The feedback received from communities and FLHFs staff also helped zone and woreda management staff to know how we can suPPort them. WHO/APOC, December 2009 SECTION 3: Support to CDTI 3.1. Equipment Table 12: Status of equipmenl (Please add more rows if necessary) *Condition of the equipment (F=Functional, CNFR=currently non-functional but repairable, WO=Written off, NA data not available) APOC donated Vehicle and motorbikes got old and some are irrecoverable. Similarly, other office equipment is getting old which need immediate replacement. The evaluation team members also observed the condition of vehicles and office equipment during Sustainability Evaluation. How does the project intend to maintain and replace existing equipment and other materials? The ZHD and woreda health offices attempt to keep functional the existing vehicles and office equipment through periodic maintenances. Because of the rising maintenance cost and spare parts, it is becoming difficult to maintenance schedule. Replacement of old or written off vehicles doesn't seem feasible at zone level. lnstead ZHD and CDTI woredas have been using other vehicles and equipment meant for other health programs. The zone health department expects APOC and TCC to replace these equipment and materials soon. Source Type of equipment APOC MOH ** DISTRICT NGDO Others No Condit ion No Condit ion No Condit ion No Condit ion No Condit ion Toyota Hilux pickup 1 F (old) 1 F 4 F Motor cycles 6 F NA 3 F Desk top computer 1 F NA LaserJet printer 1 F NA Photocopier 1 F NA Fax machine 1 CNFR NA Overhead projector 1 F NA Megaphones 2 F NA TV 1 F NA VCR 1 F NA Generator 3 F NA 2 F WHO/APOC, December 2009 Contributor Year (2007) Year (2008) Year (2009) TOTAL Cash Budgete d (us$) TOTAL Cash Release d (us$) TOTAL Cash Budgete d (us$) TOTAL Cash Releas ed (us$) TOTAL Cash Budgeted (us$) TOTAL Cash Released (us$) MOH (Central + State) 0 0 MOH (District + zone) 5000 4408.7 Local NGDO(s) (if any) 0 0 NGDO partner (The Carter Center) 7000 6009.5 Communities 0 0 APOC Trust Fund 5651 .1 1 3,740 TOTAL 17651.11 14158.2 3.2. Financial contributions of the partners and communities Table 13: Financial contributions by all partners for the last three years - lf there are problems with release of counterpart funds, how were they addressed? ln most cases, release of APOC fund is slow. Rather the fund from TCC is fast and flexible - Additional comments It is known that most CDTI activities have been carried out integrated with other health programs; however, few CDTI wordas have failed to document the direct government input. This is the weakness of the project and also identified by the evaluation team. 3.3. Other forms of community support - Describe (indicate forms of in-kind contributions of communities if any) Rarely, some community members participate in transportation of lvermectin when asked; otherwise there are no any forms of in- kind support from the communities 3.4. Expenditure per activity lndicate in table 14, the amount expended during the reporting period for each activity listed. Write the amount expended in US dollars using the current United Nations exchange rate to local currency. lndicate exchange rate used here { USD = 11.00 Birr WHO/APOC, December 2009 Activity Expenditure ($ us) Source(s) of funding Drug delivery from FMoH area to central collection point of community Mobilization and health education of communities 1020.00 Zone + Districts APOC 0 APOC+ TCC APOC+TCC APOC 0 TCC ---* Lone Zone +Districts TCC APOC 1210.66 Training of CDDs Training of health staff at all levels lgpervls r ng q D Dq 4q!!9!Ii bu!!g! CDTI activities Adv_o_cagy visits _to h ealth orities IEC materials Summa forms for treatment Vehicles/ b maintenance OJf i ce Eqqr p m 9 !! ( e, g . qg m p!.rtels, jl!4q9j!9) Other miscellaneous expenses 0 5876.12 1719.26 140.98 0 750.00 184.00 3204.70 250.13 18.12 TOTAL 14373.97 Total number of persons treated Table 14: lndicate how much the project spent for each activity listed below during the reporting period SECTION 4: Sustainability of CDTI 4.1. lnternal; independent participatory monitoring; Evaluation 4.1.1 Was Monitoring/evaluation carried out during the reporting period? (Tick any of the following which are applicable) Year 1 Partici patory lndependent monitoring Mid term Sustainability Evaluation 5 year Sustainability Evaluation lnternal Monitoring by NOTF Other Evaluation by other partners WHO/APOC, December 2009 4.1.2. What were the recommendations? The zone didn't yet receive evaluation result from APOC. However, the evaluation team has debriefed all stakeholders the main findings and recommendations. Base on this, the following recommendations were given. . Training should be targeted . Government budget should be explicitly spelt out at all levels . lmprove therapeutic coverage to highest level . lmprove documentation of CDTI activities especially at worda level . Mectizan should be available at the appropriate time . The need to plan for vehicle and equipment replacement 4.1.3. How have they been implemented? The ZHD and woreda health offices are prepared to act on some of the recommendations in the coming distribution period. Some recommendations seem difficult to be implemented (such as material replacement) and this demands the involvement of other partners. 4.2. Sustainability of projects: plan and set targets (mandatory at Yr 3) Was the project evaluated during the reporting period? - Was a sustainability plan written? When was the sustainability plan submitted? What arrangements have been made to sustain CDTI after APOC funding ceases in terms of? 4.2.1. 4.2.2. 4.2.3 4.2.4. 4.2.5. Planning at all relevant levels Funds Transport (replacement and maintenance) Other resources To what extent has the plan been implemented 4.3. lntegration Ouline the extent of integration of CDTI into the PHC structure and the plans for complete integration: WHO/APOC, December 2009 4.3.',,. lvermectin delivery mechanisms ln this project, lvermectin delivery mechanism is full integrated into the existing MOH drug procurement and distribution system. Zone health department is responsible to transport lvermectin from FMoH until zone level and respective woreda health offices transport to woreda and when necessary to FLHFs. ln most cases, drug and materials transportation is not done alone. The management staff plans to integrate with other health programs. The nature of lvermectin (its minimum bulk) allows integrating with other activities. 4.3.2. Training : CDTI is integrated with the Primary Health Care (PHC). The government health reform is a fertile ground to carry out activities integrated. The Oncho control program and Malaria control activities run by one person. Blindness prevention section also includes Oncho in its plan. ln most cases, Oncho benefits from Malaria. The intended Onchocerciasis activities are being carried out when ever capacity building and program review sessions is organized for malaria, 4.3.3. Joint supervision and monitoring with other programs The government promotes to execute different and related activities jointly. Activities related CDTI are discussed as other health programs during biannual or annual review meetings. Nevertheless, ZHD encourages FLHFs to undertake separate supervision specific CDTI activities during the time of I vermectin distribution. 4.3.4. Release of funds for project activities Finance management at both zonal and woreda levels is now in a pool system. ln most instances, difficulties appear to have money released on time. 4.3.5. ls GDTI included in the PHC budgetz Yes. As indicated above CDTI is part of Malaria and Other Vector Borne Diseases. One can not find earmarked budget for Oncho specifically. The budget for this section means Oncho is also addressed. 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? ln some malaria endemic villages, CDDS are also trained on malaria preventions (lTNs use). During their mass treatment, they are expected to WHO/APOC, December 2009 disseminate malaria messages. The Health Extension Program benefits from it because the program is entirely community based. 4.3.7. Describe others issues considered in the integration of CDTI. 4.4. Operational research None 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. 4.4.2.How were the results applied in the project? SECTION 5: Strengths, weaknesses, challenges, and opportunities Strengths: . Good TCR and 100% geographical coverage . Willingness of communities and CDDs . Satisfactory result of sustainability evaluation Weaknesses: . Untimely lvermectin delivery resulted in high number of absentees. . Failure to document and present governmental financial expense to the evaluation team. Challenges: Problems related to transportation . Poor infrastructure to reach CDT villages . Vehicles (being old, few in number) . Escalating cost of maintenance and spare parts . Frequent transfer of trained staff . Mobile nature of some communities. SECTION 6: Unique features of the projecuother matters WHO/APOC, December 2009 I t t