UPPERNILE CDTI PROJECT

UPPERNILE CDTI PROJECT

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COUNTRY/NOTF: South Sudan Proiect Name: Upper Nile

Approval vear:2003 Launchins _vear

z

2006

PERIOD:FROM: JANUARY TO DECEMBER 2OO8

(MONTH/rEAR)

(

MONTTT/rEAR)

Proiectyearof thisreport: (circleone) 1 2(3) 4 5 6 7 8 9 ¹⁰

Date submitted:

^28th

_July 20Ag NGDO partner:

Chirstoffel Blinden Mission

WHO/APOC, 15 November 2006

-)

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 3L .Iuly for September TCC meeting

AFRICAN PROGRAMME FOR

ONCHOCERCTASTS CONTROL ^(APOC)

I

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: Southern Sudan

National Coordinator ^{Name: Dr}

Signature

Date:24th July 2009

APOC Technical Advisor

:

Lazants Nweke Signature:

.

Date: 23rdJuly, 2009

NGDO Representative Name: Fasil

C Signature

Date:

23'd

July,2OOg

This report has been prepared by Name

:

Chuol Both

Designationl

^Project Coordinating offi cer

Signature

Date

z}'h J

2009

Christo Luga

Table of contents

ACRONYMS VI

DEFINITIONS VII

_i

FOLLOW

T]P

ON TCC RECOMMENDATIONS

1

EXECUTIVE SI.JMMARY

²

SECTION

1:

BACKGROIIND INFORMATION

4

1.1.

^GBNBRaT rNFoRMATroN...

1.1.1

Description of the

project

(brieJly)...

1.1.2.

Partnership

1.2.

Popur-RrroN...

SECTION 2: IMPLEMENTATION OF CDTI

9

2.I. Tnnplnn

oF ACTryrrrES

2.2. Aovocncy

4 4 6 8

2.6.1 Treatment

figures

2.6.2 What are the causes of absenteeism? ...

2.6.3

Wat

are the reasons

for

^refusals?,

2.6.4

BrieJly descrifie

all

lcnown and verified serious adverse events (SAEs) that ...

2.6.5. Trend of treatment achievement

from

^CDTI

^project

^{inception to the} current year

2.7

.

ORopRtrtc, sroRAGE AND DELTvERy oF TvERMECTIN

2.8. Col,nruNIry

sELF-MoNIToRING aNo SrerrHoLDERS

Mprrnro..

2.9 SwpRvrsroN 2.9.1

2.3.

2.4.

2.5.

2.6.

3.r.

3.2.

3.3.

3.4.

9

MosLzerloN,

SENSITzATIoN AND IIEALTH EDUCATIoN gF AT RrsK coMMUNITIES 12

Corrnvrrxruy

DrvoLVEMENT... ...I4

CapRcny

BUrLDrNG... ...

t7

...

l9

EqunwNr

Fn.IeNcIAL CoNTRIBUTIoNS oF T}IE PARTNERS AND CoMMUMTIES.

Orrmn FoRMS oF coMMUNTT suppoRT...

E>cBNotruRr PER ACTTvITy

ll

19 22 22 22 '24 26 27 28 28 28 29 29 29 Provide

aflow

chart of supervision hierarchy..

2.9.2.

What were the main issues identified during supervision? ...

2.9.3.

Was a supervision checklist used?

2.9.4.

What were the outcomes at each level of CDTI implementation supervision?

2.9.5.

^Was feedback given to ^the person or groups supervised?...

2.9.6.

^How was ^the feedback ^used to improve the overall performance of the project?

29

SECTION 3:

SUPPORT

TO CDTI

29

29 30 30

3l

SECTION 4: SUSTAINABILITY OF CDTI

32

4.L. INrrRNar;

rNDEpEr$DENr flARrrcpAToRy MoMToRrNc; EveLuarroN... ...32

4.1.1

^Was

Monitorihg/evalitation carried

out

during

the reporting

period? (tick

_any of the

following

^which are applicable)

4.1.2.

^What were the recommendations?

4.1.3.

^How have they been implemented? ...

4.2.

SusranrABlI-rry oFrRoJECTS: rLAN AND sET TARGETS (MANDAToRv AT Yn 3)....

4.2.1.

4.2.2.

Planning at

all

relevant levels...

32 32 32 32 32 32 Funds.... 32

4.2.3

Transport(replacement andmaintenance) 4.2.5, To what extent has the

plan

been implemented....

4.3

INrecnRuoN

...

4.3.1.

Ivermectin delivery mechanisms...

4.3.2.

Training....

4.3.3.

^Joint supervision and monitoring with other

4.3.4.

^Release _{of funds}

_for

project activities

4.3.5. Is

CDTI included in the PHC budget? ...

4.3.6.

Describe other health programmes that are this was achieved. Whai have lieen the achievements?

proSrams

using the CDTI structure and how 33

4.3.7.

^{Describe othei's} issui's considered in the integration of

CDTI.

^{... 33}

4.4. OpEnerroNAL

RESEAR4H...

^...33

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, OPPORTI.JNITIES

33

33

CHALLENGES, AND SECTION 6: IINIQLJE FEATLIRES

OF

THE PROJECT/OTHER MATTERS34

...33

)

V WHO/APOC, 15 November 2006

Acron yms/Abbrevi ations

apOC'ii.,.'

;-;

African Programme for Onchocerciasis Control

, ,:affilPirrr_

AT9Sd+;:t:.

^Annual Treatment Obiective r,ffinf'.f..rnr*,=

')ATrOl',*r'];';''' Annual Training Objective

cno J:r:#i

Community-Based organization CBM'

CDD

i.::

Chirstoffel Blinden Mission

,,=

Community-DirectedDistributor

Cnfl,,',1itfiH

Community-Directed Treatment with Ivermectin

q@]

_:

jiji

County Health Depa{ment

CH.Wj.,,;:i#

Community Health Workers COS':i:,.'i.ffi

i

Counw OV Supervisor

CPA

:ffi a;-pfh"*i""

^{Peace Agreement}

Self-

CSOs i:i:' Civil Society Orgdnisatioris DRQ _.--

u1pi.

Democratic Republic of Congo

iJsr"''..'lil

Government of south sudan

IECs

,

-.r

Informatiory Education and Communication IDPs:':,:'..

':'"

Intemally Displaced People

LGA '."'.;' i.;, 1-o"^Govemment

,1,: Ministry of Health Non-Govemmental

Non-Govemmental Organization National Onchocerciasis Task Force PCo ^''.

PHC . :-)i::1;:i

Project Coordination Offiber Primary Health Care

pHic.i-$

pHcu

i'-t

Primary Health Care Center Primary Health Care Unit

POS ^-'

^'

'

_Payam OV Supervisor REMO

SAE

of Onchocerciasis Severe adverse event

,'

Sudan Relief and Commission

Tgc:Tfiflli

^Technical Consultative Cdmmittee(APOC scientific advisory group)

toT"j.ff{ ^r'\-[

Trainer of traineri

-U-NICEF; ^I

ll

:'

Ut itud Nations Children's Fund UrC. _;::.lilrl ^',11 Ultimate Treatment Goal

WHO-i":,**:i

World Health Organization

I sliil4";:,''

.:,ii:

stakeholders meeting

a

Definitions

(i)

Total population: the total population

living in

meso/hyper-endemic communities within the project area (based on REMO and census taking).

Eligible

population: calculated as 84Vo

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 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'd

year of the project).

(v) TheraBeutic 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/ltyper-endemic communities as identified

by

REMO

in

the project area (this should be expressed as a percentage).

(vii)

Inteeration: 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 emppwer communities

to

solve more

of

their health problems.

This

does no1

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 pversee and monitor the performance of CDTI (or any community- based health interventipn 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.

(ii)

vtl

^{WHO/APOC, 15} November 2006

li

. FOLLOW

UP ON

TqC RECOMMENDATIONS

.t

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-

Number

ot

Recommendation in the Report

TCC

RECOMMENDATIONS

ACTIONS

TAKEN BY THE PROJECT

FOR TCC/APOC

MGT ASE ONLY

Report-related: ¹ Include comments, from TCC in ^the first ^part

of

the report and respond to them

accordingly

There was

^no

comment

from

TCC in the first report.

)

_{Provide an} explanation as

to why the project vehicle has not been purchased

I

have no information

on why it ^was

^not

purchased

in

^2007,

However,

at

the end

of 2008, it

^was

purchased and would be handed over to the proiect in 2009.

3 Redefine "community"

-

the

current

definition

^is insufficient

People

living in

^the

same place with ^same

culture

^and

homogeneous language.

4 Although there was no treatment in Kurmok, the team claims that all ^the orugs were

used

but it is not

clear

what

happened

to

^the

drugs that were meant for this site

Drugs -. we

^are

receiving have

not been enough. So the

ones meant

for

Kumok was

shared among Lador, Akobo and Pochalla counties

when reaching

the

Kurmok

county was

not

possible

due

to

flood

as accessing

it by

both land and air was impossible at the time.

5 Fully complete the table on financial expenditure to facilitate a calculation of ^the cost

per treatment

I don't

^have

information

on

^other financial expenses on

work support

items

because they

^are

purchased by SSOTF

without

providing

projects with

^the

detailed amount.

Project-related: ¹ Step up advocacy; the current levels are too low to facilitate a deeper

This

was

a

problem

of

accessibility and lack

of

vehicle which

understanding

of the CDTI approach and ownership by the policy makers and communities in general;

we hope to address in 2009 as soon as we get our vehicle

2 Increase the

communities superusors

number

of

-

with

:

The ^project

^has

planned

to

^increase

the number of

community

with supervisors in 2009

j

_Increase

the

number

of

CDDs to reduce the ratio per population

This has

^been

discussed

with

^the

Technical

Advisor and we are going to increase

it with

the fund availability 4 Increase the propcirtion

of

female

CDDs

^I

^More will be

^female selected in^CDDs

2009 through

more community

enlightenment.

5 Initiate training activities on CSM

This

will

be initiated

in

2009 but we need support from APOC.

6

Conduct

operational

research on

^social

structuresJ returnees

J

Issue of

^dperation

research

is not

too relevant

now as

we are

still

laying good

CDTI

foundation in communities. May be

in

future this

will

be

done with

^the

assistance of

Technical Advisor.

(Please add more rows

if

necessary)

2 WHO/APOC, 15 November 2006

t

o

Executive Summary

This is the report of

CDTI

activities implemented by Upper

Nile CDTI

project, Southern Sudan from January to December 2008. The project is in its

third

year of APOC funding phase. The project is also being supported by

CBM,

an International NGDO coordinating

CDTI

in collaboration

with

Southern Sudan Onchocerciasis Task Force.

The project has a

CDTI

total population

of

482,155 persons, UTG of 405,010 persons and an

ATO of

243,006 persons during the reporting period.

It

is made up of 6 counties and 3180 communities. Data on the number of health staff involved

in CDTI

shows that297(35.37o) persons were involved

in CDTI

activities out

of

842 avallable health staff

in

the project areas.

On treatment,

only

1720 communitiJs were treated and thus

giving

a geographic coverage

of 54.I7o. A

total

of

185,462 persons received mectizan treatment during the period under

review.

This treatment figure represents a therapeutic coverage,

UTG

coverage and

ATO

coverage

of

38.597o, 45.8%o and76.37o respectively

in

2008.

Population movements are mainly attributed to those

still

returning from internal displacement

following

years of conflicts and floods devastation.

On

training,

381(63.5) CDDs were trained out

of

annual training objective

of

600. The population/CDD trained was

in

a ratio

of

1CDD

to

L265 population

in

2008 and this is higher than

in

2007. This implied that CDDs are under heavy workload which the project

will

squarely addressed

in

2009.. The number of health staff was 173( out of 492 targeted persons.

The project had a

lot

of challenges as stated below:

o

Inclusion of

CDTI

staff in the nominal role of the

MOH:

This was discussed

with

the authority but there is hope of their absorption over time. However, only county supervisor was absorbed.

o

Getting the drugs and other training materials before the onset of rainy season: This is

still

^a problem and the project would want

airlifting

of materials before setting in

of

rains.

o

Inadequate number

oflCDD{

This was addressed through training CDDs and meeting

with

community members but

still

this was not enough given the population/CDD ratio

of

L265:

I.

o

Lack

ofproper

household census registration: The project has not been able to deal

with

this but as things change later and

availability

of registers, this

activity will

be performed.

o

Lack

of

the project vehicle: The pouched vehicle

in

2008 has not been released to project.

o

Maintaining a good record of

CDTI

activities is a problem.

All

county and payam supervisorslhealth were reminded of the importance of this and the project anticipate improvement

in

the future as they have noted their mistakes and need to keep good records.

o

Lack of Community self monitoring activity: The project has not introduced this but this

will

be accommodated

in

2009.

o

More improvement

in

Health education and community participation especially women: Women participation was

initially

poor but the project's

effort

improved this year and

it

was

fair

as earlier reported.

o

Release of the fund in rainy season by APOC,

it

affect the project activities (treatment and training and data collection etc).

o

Non

availability

of

work

support items for two years (2007- 2008),:

It

demoralizes the CDDs and Payam supervisonto carry out the activities properly. SSOTF should please

quickly

address this as

I

have previously complained on this matter.

o

o SECTION

l:

Background information 1.L. General

information

1.1.1 Description of

the

project (briefly)

Geographical location, tofography,, climate

P o pulat io n : act iv it ie s, c ultu re s, lang uage Communication systems ⁽ roads... ) Administration structure

Health system & health care delivery @rovide the number of health posts/tenters in the project area if ^the

info rmat i on i s ava ilabl e ).

Number of health staff in project area and number of health staff involved in CDTI activities.

-

Geographical location, topography, climate

Upper

Nile CDTI

project

is

located between latitude 5oand

ll"and

between longitude

of

29"

and 35o.

It

is situated on the North

of

Southern Sudan and bordering Ethiopia.

Lying

across its base or South is Jonglei state'and strbtching towards the West is North Sudan.

The project

is

made up

of two

Statds (Jonglei _and Upper

Nile)

and

six

counties. The Project has its

Office

at the County Health Department building

in

Akobo.

The Upper Nile CDTI project lies in 3

ecological zones.

The

western

part is flood

prone zones, the Eastern part being Sudan savannah on

clay

and Guinea savannah, the eastern part along Ethiopian border is

hilly

area. The eastern part is a continuation of the Ethiopian plateau

with

fast

flowing

rivers and streams and hence suitable sites

for

Similium vector breeding. The Boma plateau to the south

is

mountainous and volcanic

in origin..

The Pochalla,

Akobo

and Rahad rivers drain the Upper

Nile

region.

The

rainy

season begins

in May

and ends

in

October. The

dry

season

is from

November to

April.

The

farming

activities start

with

the onset

of

the rains. The

farming

season lasts

from May to

September.

The length of the growing

seasons

varies ftom 7 -9 ^{months in}

^the

highlands.

The

area has an annual

rainfall of 800-

1000

millimeters or

more

in

the Sudan- savannah, guinea -savannah ^and the Boma

plateau.

Flooding

is

common

in

the

flood

prone areas due

to

the fast

flowing rivers from

the Ethiopian highlands.

The

Boma highlands are characteized

by medium wet

seasons

that

are

cool

and

rainfall

varies

from

1000

to

600 millimeters. During the dry season, the main subsistence

dctivity

is fishing.

Population : activitie s, culturg s,

hn[uog,

The total population at -

risk,of

On6tocerciasis infection

is

482,115.

With

the returnees from Kenya, Ethiopia, Uganda and North Sudan and other population movement out of Upper

Nile,

there was

fluctuation in

the at-risk population

in

this report. The demographic description

of

the population

is still

obscure

with

the census

which

the project

did not

conduct across all areas

during

the reporting period. The Upper

Nile CDTI

^project area

is

home

to Nuer

^(Lou Nuer, Jikany Nuer, Gajak Nuer and Gaguang Nuer),

Murle,

Anyuak and

Dinka.

Nuer is the dominat ethinic group

The activities

of majority of

the people

in

Upper

Nile

are subsistence farming, Cattle keeping, hunting and fishing. There were no internal or ^external conflicts

in

2008 and this stability has accounted for free movement for pedple to engage

in

those activities.

4 Communication system

(road...)

{i WHO/APOC, 15 November 2006

Accessibility to

Upper

Nile

region

is

through Ethiopia, Juba and Rumbek

in

Southern Sudan by air

in

rainy season and by land

in.dry

season.

In

rainy season,

only

the county headquarters and surrounding villages could be accessed. WFP

flights

operate

in

the region and facilitate movement

of health workers in different parts of the region,

especially

in rainy

and dry season.

The

road infrastructure

is very poor

and some

villages

are

not

accessible

during

the rainy season that

is

usually

in May,

June,

July,

August, September and

October.

^Movement and accessibility are

much

easier

during the dry

season,

which

lasts

from

November

to

May, hence

the

need

for

mectizan

distribution during this period. CDTI activities in the

project areas require the use of

4WD

vehiclos, motorcycles, motor boat, bicycles and canoes.

A dminis trati.o n s tru cture

The

administrative structures

in the Upper Nile CDTI project basically divided into

state, county, Payam and Boma. The Boma

is

the lowest

level of

government administration. The state

is

administered

by

Governor, county

by

commissioner, Payams

by

Payam administrator

and Bomas by Boma liberation council. The project covers 6 counties, namely;

Pibor, Pochalla,

Akobo, Latjor, Renk

and

Kurmok (Blue Nile). But it

appears

that Kurmok

falls under

the

government

of National Unity,

therefore

they would be getting

mectizan tablets

from nofthern

sector.

And from

2809,

we would be working in Maban, Longuchok,

and

Maiwut

Counties instead

of

Kurmol( and Renk counties

in

this report. Renk consists

of

Renk, Maban and

Malut

but the project is going to focused

only in

Maban

in

2OO9 by carving

it

out since

it

is the only endemic in Renk region.

Health

system

& health care delivery

^(provide

the number of health

posts/centers

in

the project _area

if

the

information

is available).

The Primary Health Care system has improved

in

the set

up

and

staffing by rolling

them to

MOH nominal roll

instead

of

being paid

by

NGOs..However, there

is

inadequate

of

drugs, equipment, and instruments to carry out the activities in health centers.

The Upper Nile CDTI ^project nal a total of

112

health facilities comprising 82

Primary Health Care

Units

^(PHCUs), 23

Pimary

Health Care Centers (PHCCs) and 7 rural Hospitals based

in

Boma,

Kurmok, Akobo,

Pochalla,

Nasir,

Renk, and

Malut. The

number

of

health

facilities

increased

by

229.47o

over the 2007 figure and this is attributed to a

better information and penetration of the project areas

in

2008.

Number of health staff in project area and number'of health staff involved in CDTI

activities.

I

A total of

297(35.37o) out

of 84}Lealth staff in the project

area

were involved in CDTI

{

activities.

There was also increase

by

158.26Vo in the health staff involved

in CDTI

more than last year when compared. The break down is shown below.

Table

l:

Number of health staff involved in

CDTI

(Please add more rows

if

necessary)

DistricUlGA

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

B*BJ

^{Br {'100}

Akobo 200 48

24

Pochalla 58 56

96.6

Pibor(Boma) 160 46

28.8

Latjor(Sobat) 148 40

27.0

Renk/Maban 130 65

50

Kurmok(Blue Nile) 146 42

t.z.

^P 28.8

Total

-

^{842 297 35.3}

1.1.3. Partnership

-

Indicate the partners invol$ed in ;i project implementation at all levels

[MoH,

^NGDOs

(n ation allinternati onal), co{nmunities, local organizations, 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.l

The partners

involved in CDTI

activities are the communities, health services though weak,

NGDO - ^CBM

^and

WHO/APOC. Also

other

local

NGOs such as

Nile

Hope Development

Forum (NHDF) in Akobo,

International

Medical Corp (IMC) in Akobo, Christian

Mission

Aids (CMA) in Dajor

and

Relief

International

(RI) in

Maban

provide their

^health

staff

to assists

in

training

of

CDDs and also

in

supervision

of

distribution as

well

as dissemination

of

information.

Describe

overall working relationship

among

partners, clearly indicating

speciftc areas

of

proj ect activities

(plnnning,

involved.

superviiion,

advocacy,

mobilization,

etc) where

all partners

are ,tl

Within

the

limited

prevailing atmosphere,

all

the partners are

working cordially

and

trying

to

meet the CDTI

objectives. Operating

in the project

area

is most

challenging

to

^partners.

Partners like communities project office representing health system jointly _carry

_out

community

mobilization,

health education,

training

and mectizan distribution. The project in conjunction

with

SSOTF and NGDO do planning, meetings and advocacy. The project has the worst terrain in Southern Sudan and this hampers

joint

activities implementation.

6 WHO/APOC, 15 November 2006

State plans if any to mobilize the state/regi.on/districtlLGA decision-makers,

NGDOs, NGOs, CBOs,

to

assist

in CDTI

implementation,

The CDTI project

plans

to

advocate and

mobilize

State,

County

and decision makers and NGOs to assist

in

the implementation

of CDTI

activities through

visiting

them. This

will

help to increase the awareness and support

of all

the partners to

CDTI activities.

Also there is plan to continue consulting

with

the

Ministry

of Health through the Director General on the need to have the

CDTI

^{program and,}

staff

integrated

into

the

Ministries of

Health services

of

Upper

Nile

and Jonglei

states.

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