UPPERNILE CDTI PROJECT

UPPERNILE CDTI PROJECT

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ORIGINAL:

English

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ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO

TECHNICAL CONSULTATIVE COMMITTEE

DEADLINE FOR SUBMISSION:

To APOC Management by 31 January for March TCC meeting To APOC Management by 31 Julv for September TCC meeting

,1, t/

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AFRICAN PROGRAMME FOR

ONCHOCERCTASTS CONTROL ^(APOC)

Proiect Name: Upper Nile COUNTRY/NOTF: South Sudan

Approval _vear: 2003 Launching year: ₂₀₀₆

:FRoM! JANUARY TO DECEMBER 2008

(

MONTH/YEAR) (MONTH/rEAR)

Proiectyearofthisreport: (circleone) | 2(3) 4 5 6 7 8 9

¹⁰

Date submitted:

28th

July ^2oog NGDO partner:

Chirstoffel Blinden Mission

WHO/APOC, 15 November 2006 , ,J.

,.I{

I

ANMIAL ^PROJECI' TECHNICAL RDPORT TO

TECHM C]AL CONSULTATIVE COMMITTEtr (TCC)

ENDORSEMEI{T

Please conlirm you have read this report by signing in the appropriate space.

OF'FICE

RS to sign

the report:

Country: Southem Sudan

National Coordinator

Name:

Dr

Christo

L

uga Signature:

Date:24'r' July 2009

A

POC Technical Advisor :

LazarusNrveke Siguaturc

Date: 23rd

July,

2009

NGDO Representatire

Name: Fasil Signature:

Date: 23'd

July,2009 This report has been prepared by Nune

: Chuol

Both

Designation: Project Co

Signature:

,..

Date

20'I Jrtl-)'

olficer

JI

o

Table of contents

ACRONYMS V DEFINITIONS VI

FOLLOW

UP

ON TCC RECOMMENDATIONS

1

EXECUTIVE SUMMARY

²

SECTION

1:

BACKGROUND INFORMATION

4

l.l.

GENeRel rNFoRMATIoN...

1.1.1 Desuiption

of the

project

(briefly)

1.1.2.

Partnership....

1.2. PopulnrroN...

2.1

SECTION 2: IMPLEMENTATION

OF

CDTI

⁹

.

^{TruelrNE oF ACTrvrrrES}

4 4 6

8

...9 ... l1 2.2.

2.3.

2.4.

2.5.

Apvocecy

Moett.tzertoN,

sENSITIZATIoN AND HEALTH EDUCATIoN oF AT RrsK

coMMtxlrtes

12

CoNavu{rry INVoLVEMENT... ...I4

Cepecrry

BUTLDTNG..

t6

2.6.

TRearveNTS...

2.6.1.

Treatmentfigures...

2.6.2

^What are the causes of absenteeismT

2.6.3

^What are the reasons

for

refusals?....

.18

.18

.21

2.6.4

BrieJly describe

all htown

and verified serious adverse events (SAEs) that ... .21

2l

2.6.5. Trend of treatment achievementfrom CDTI

project

inception to the current

year2j

2.7.

ORonRrNc, sroRAGE AND DELIVERv oF IVERMECTIN

2.8. Couuuqrry

sELF-MoNrroRrNG aNo SIRTeHoLDERS

MpprrNc

2.9 SuppRvrsroN

Provide

aJlow

chart of supervision hierarchy.

Wat

were the main issues identified during supervision?

Was a supervision checklist used?

2.9.4. Wat

were the outcomes at each level of

CDTI

implementation supervision? 27

2.9.5.

^Was feedbock given to ^the person or groups supervised?... 27

2.9.6.

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

27

SECTION 3: SUPPORT TO CDTI

28 2.9.1

2.9.2 2.9.3

24 25 26 26 26 27

3.1 3.2

EqurvENr

FnqeNcter. coNTRIBUTIoNS oF THE pARTNERS AND coMMLNITIES...

3.3. ^Oruen

^{FoRMS oF} coMMLrNrry suppoRT....

3.4.

ExpeNorruRE ^pER

AcTrvrry

28 29 29 29

SECTION 4: SUSTAINABILITY

OF

CDTI

³¹

4.1. INreRNel;

TNDEIENDENT pARTrcrpAToRy MoNrroRrNc; Eve1uerroN...

3l

4.1.1

^Was

Monitoring/evaluation

caruied out

during

the reporting

period?

(tick _any of

thefollowingwhichare applicable)... ...3l

4.1.2.

^Whatwere the

recommendations?

...31

4.1.3.

^{How have} they been implemented?

...

...

3t

4.2.

SusrRrNeerI-rry oF eRoJECTS: ILAN AND sET TARGETS (MANDAToRv AT...

3l

...

3l Yn

3)

111 WHO/APOC, l5 November 2006

4.2.1.

^{Planning at}

^all

^relevant

levels...

...31

4.2.2.

^Funds

...

... 31

4.2.3

^Transport (replacement and

maintenance) .

... 31

4.2.4.

^Other

resources

^...

^3l 4.2.5.

^{To what} extent has the

plan

been

implemented...

... 31

4.3. INrpcneuoN...

^...32

4.3.1.

Ivermectin delivery

mechanism,s...

... 32

4.3.2. Training....

...32

4.3.3.

^Jotnt supervision ond

monitoringwith

other

programs...

...32

4.3.4.

^Release

offundsfor ^project activities

^...32

4.3.5.

^Is

^CDTI

included in the PHC budget?

...

... 32

4.3.6.

Describe other health programmes that are using the CDTI structure and how this was

achieved.

What have been the

achievements?...

... 32

4.3.7.

^Describe others issues considered in the integration of

CDTI.

^{... 32}

4.4. OpnnarroNAl

RESEARCH

^...32

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.

... 32

4.4.2.

^How were the results applied in the

project?...

... 32

SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, AND

OPPORTUNITIES

33

SECTION 6: UNIQUE FEATURES

OF

THE PROJECT/OTHER MATTERS33

lv

^WHO/APOC, 15 November 2006

Acronyms/Abbreviations

'

African Programme for Onchocerciasis Control Annual Treatment ve

ATrO Annual Training Objective a

A

CBO Based

Chirstoffel Blinden Mission CDD

CDTI CHD

Directed Distributor

Community-Directed Treatment with Ivermectin Health

CHWs, Community Health Workers OV Su

Comprehensive Peace Agreement CPA

CSM CSOs DRC

Self-

Civil Society Organisations Democratic Republic of Congo GoSS

,

Government of South Sudan

Education and Communication Internally Displaced People

Local Govemment Ministry of Health Non-Governmental

Non-Governmental Organization

"

_National Onchocerciasis Task Force

PCO

^Project Coordination Officer

PHC _lii;

^:

li

Primary Health Care

FHE;ffiHilJf

PHbu;'l'_fiT$i

Primary Health Care Center Primary Health Care Unit

POS :'r'$; Puyurn OV Supervisor

REMO of Onchocerciasis

SAE ^':1" Severe adverse event SHM I:,'i

:''l

stakeholders meeting

SRRC Sudan Relief and Rehabilitation Commission Technical Consultative scientific Trainer of trainers

United Nations Children's Fund Ultimate Treatment Goal World Health Organization

V WHO/APOC, 15 November 2006

o

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 84Yo

of the total

population

in

meso/hyper- endemic communities in the project area.

(i

ii)

Annual Treatment Qbiective

(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

(JTG):

calculated as the maximum number of people to

be treated annually in

meso/hyper endemic areas

within the project

^area,

ultimately to

be reached when the project has reached

full

geographic coverage (normally the project should be expected

to

reach the UTG at the end

of

the 3'd

year

ofthe

project).

(v) Therapeutic coverage: number

of

people treated

in a

given year over the total population (this should be expressed as a percentage).

(vi)

Geographical coverage: number

of

communities treated

in

a given year over the total number

of

meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage).

(vii)

Integration: delivering additional health interventions (i.e. vitamin

A

supplements, albendazole

for LF,

screening

for

cataract, etc.) through

CDTI

(using the same

systems,

training,

supervision

and

personnel)

in order to ^maximise

^cost-

effectiveness and empower communities

to

solve more

of

their health problems.

This

does

not include activities or

interventions

carried out by

community distributors outside of CDTL

(viii)

Sustainability:

CDTI

activities

in

an area are sustainable when they continue to

function effectively for the

foreseeable

future, with high

treatment coverage, integrated into the available healthcare service,

with

strong community ownership, using resources mobilised by the community and the government.

(ix)

Community self-monitoring

(CSM):

The process

by which the

community is empowered to oversee and monitor the performance of CDTI (or any community- based health intervention 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.

vl

^{WHO/APOC, I 5} November 2006

FOLLOW

UP ON TCC

RECOMMENDATIONS

Using the table below,

fill in

the recommendations of the last TCC on the project and describe how they have been addressed.

TCC session

28

Number

of

Recommendalion in the Report

TCC

RECOMMENDATIONS

ACTIONS

TAKEN BY THE PROTECT

FOR TCC/APOC MGT

USE ONLY

Report-related: I 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 *as

noi 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

H:';,j::'T,;".#:

culture

^and

homogeneous language.

4 Although there was no

treatment in Kurmok, the team claims that all the drugs 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 Latjor, 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 ofthe 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: I Step up advocacy

-

^the

current levels are too low to facilitate a deeper

This

was

a

^problem

of

accessibility and lack of vehicle which

WHO/APOC, I 5 November 2006 o

I

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

) Increase

the

number

of

communities

with supervisors

The project

has

planned

to

^increase

the number of

community

^with

supervisors in 2009

3 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 proportion

of

female CDDs

More

female CDDs

will be

selected in

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

structures, returnees

Issue of

^operation

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

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(35.3%) persons were involved

in CDTI

activities out

of

842 available health staff in the project ^areas On treatment,

only

1720 communities were treated and thus

giving

a geographic coverage

of

54.1%.

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

38.59o/o,45.8% and76.3Yo 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 lCDD to

1265 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:

.

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

of

CDDs: This was addressed through training CDDs and meeting

with

community members but

still

this was not enough given the population/CDD ratio

of

1265: ^L

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.

.

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.

.

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.

.

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 supervisor to carry out the activities properly. SSOTF should please

quickly

address this as

I

have previously complained on this matter.

3 WHO/APOC, 15 November 2006

a

o SECTION 1: Background information 1.1. General

information

1.1.1 Description

of the

project (briefly) -

Geographical location, topography, climate

-

Population. activities, cultures, language

-

Communicationsystems (roads...)

-

Administrationstructure

-

Health system & health care delivery (provide the number of health posts/centers in the project area if the idormat ion is availab le).

-

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 5"and

l

loand between longitude

of

29o and 35o.

It

is situated on the North

of

Southem Sudan and bordering Ethiopia.

Lying

across its base or South is Jonglei state and stretching towards the West is

North

Sudan.

The project is made up

of two

States (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 from 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 characterized

by medium wet

seasons

that

are

cool

and

rainfall varies from

1000

to

600 millimeters. During the

dry

season, the main subsistence

activity

is fishing.

Population:

activities, cultures, language

The total population at

- risk of

Onchocerciasis infection is 482,1 15.

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 people to engage in those activities.

4 Communication system (road..

)

WHO/APOC, I 5 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

vehicles, motorcycles, motor boat, bicycles and canoes.

Administration

str ucture

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, Lador, 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

northern sector.

And from

2009,

we would be working in Maban,

Longuchok, and

Maiwut

Counties instead

of Kurmok

and Renk counties in this report. Renk consists

of

Renk, Maban and

Malut

but the project is going to focused

only in

Maban

in2009 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

d

^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

has

a total of

I 12

health facilities comprising 82

Primary Health Care

Units

(PHCUs), 23 Primary 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 229.4% 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,

A total of

297(35.30/o) olut

of

842 health

staff in the project

area

were involved in CDTI activities.

There was also increase

by

158.26% in the health staff involved

in CDTI

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

5 WHO/APOC, 15 November 2006

Table 1 : Number of health staff involved in

CDTI

(Please add more rows

if

necessary)

District/LGA

Number of health staff involved in CDTI activities.

Total Number

of health

staff in

^the

entire project area Br

Number

of

health

staff involved

in CDTI

B2

Percentage

B3:B2lBr ^*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:2. v

28.8 Total o

842 297

35.3

1.1.3. Partnership

Indicate the partners involved in project implementation at

all

levels [MoH, NGDOs (national/intemational), communities, 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.]

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

speciJic areas

of

project

activities

(planning,

supervision, advocacy,

mobilization,

etc) where all partners are involved.

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 d ^{any to mobilize the} state/region/district/LGA

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.

7 WHO/APOC, I 5 November 2006

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a SECTION

2:

Implementation

of CDTI

2.1. Timeline of activities

Fill

in table 3, timeline of activities

for

areqs treated in current year, indicating when the key activities were implemented by the month they began and the month they ended.

9 WHO/APOC, 15 November 2006

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