Impact Application 4K3E-DJU6-KT
Developing comprehensive eye health care services in rural regions of SNNPR, Southern Ethiopia. Developing comprehensive eye health care… - 4K3E-DJU6-KT
Eligibility
1.1 Are you a registered not-for-profit organisation?
Yes
1.2 Which country are you registered in?
1.3 In which country will your project be implemented?
Ethiopia
1.4 Is your project between 3 to 5 years in duration?
Yes
1.5 Do you have less than GBP 10 million annual turnover for the past 3 years?
Yes
1.6 Does total DFID funding from grants over the last 3 years represent less than 40% of your income over the same period?
Yes
1.7 Will you provide 25% of your proposed project funds as match funding?
Yes
1.8 Can you confirm that you are NOT a governmental or an inter-governmental organisation?
Yes
1.9 Can you confirm that your organisation does not:
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Yes
1.10 Do you currently hold 0, 1 or 2 live Impact grants from UK Aid Direct?
Yes
1.11 Do you currently hold 0 or 1 live Community Partnership grants from UK Aid Direct?
Yes
1.12 Does your organisation or your family of organisations hold 0, 1, 2, 3, 4 or 5 live grants from UK Aid Direct?
Yes
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Introduction
2.1 What is the name of your project?
Developing comprehensive eye health care services in rural regions of SNNPR, Southern Ethiopia.
2.2 Please describe your proposed project.
In Ethiopia many people suffer needlessly from blindness which is preventable or treatable simply because they are poor. The project will reduce the prevalence of avoidable blindness and visual impairment within the Gedeo zone and Amaro and Burji Woredas of SNNPR, Southern Ethiopia. We will achieve this by developing eye care services that are comprehensive and accessible to all. We will strengthen local health systems by building the capacity of human resources, increasing the technical ability of local health centres, supplying equipment and provisions, creating a grassroots community referral network and using the WHO SAFE strategy to eliminate trachoma. Thus Orbis will ensure no one suffers needlessly from avoidable blindness.
2.3 What is the proposed duration of your project (in months)?
60
2.4 Do you hold any other funding from DFID?
Yes
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Organisation Details
3.1 Please enter the details of your organisation and those of your implementing partners and matched funding partners.
ORBIS CHARITABLE TRUST
Grant Holder - GB-CHC-1061352
Registered Address: 124-128 City Road, London, EC1V 2NJ, United Kingdom (Great Britain)
Postal Address: (As above)
ORBIS ETHIOPIA
Implementing Partner - ET-MFA-Charity Society Agency #1063
Registered Address: 3rd Floor, Rebecca Building, Haile Gebreselassie Ave., 22 Mazoria Yeka Sub-City, Kebele 11/12,, Addis Ababa, Ethiopia
Postal Address: (As above)
ORBIS INTERNATIONAL
Implementing Partner - US-DOS-The State of New York #257683
Registered Address: 520 8th Avenue, 12th Floor, New York, NY 10018, United States
Postal Address: (As above)
LAVELLE FUND FOR THE BLIND INC
Matched Funding Partner - US-DOS-tba
Registered Address: SUITE 1905, 307 WEST 38TH STREET, New York City, New York State, 10018, United States
Postal Address: (As above)
3.2 Please provide details of the primary contact for this application.
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orbis.cjauregui
3.3 Please provide details of a secondary contact for this application.
3.4 Please upload your Organisational Strategy (i.e. your organisation's strategic plan or equivalent.)
Current Strategy Files
❍ XLSX ❍ Aid Direct Eth Theory Of Change 130417 January 25, 2017 28 Kb ❍ PDF ❍ Oi Strategic Plan April 2015 April 13, 2017 320 Kb
3.5 Please upload your organogram.
Current Organogram Files
❍ DOC ❍ Emea Organisation Chart March 2017 April 10, 2017 320 Kb
3.6 Please upload the following fiduciary documents:
Current Fiduciary Files
❍ PDF ❍ Referees April 18, 2017 29 Kb ❍ PDF ❍ Companies House And Charity Commission Registration Documents April 10, 2017 7.7 Mb ❍ PDF ❍ Engie Electricity Bill April 10, 2017 350 Kb ❍ PDF
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❍ Barclays Good Standing Letter April 10, 2017 210 Kb
3.7 Which Global Goal is your primary focus?
3. Good health & wellbeing
3.8 Which Global Goal is your secondary focus?
1. No poverty
3.9 What is the geographic coverage of your organisation?
● East Asia
● South America
● South Asia
● South East Asia
● Sub-Saharan Africa
3.10 Within the regions you have identified above which countries do you work in?
East Asia
● China ● Hong Kong (Special Administrative Region of China) ● Mongolia
South America
● Peru
South Asia
● Bangladesh ● India ● Nepal
South East Asia
● Indonesia
Sub-Saharan Africa
● Cameroon ● Ethiopia ● Ghana
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● Malawi ● Rwanda ● South Africa (zuid Afrika) ● Tanzania ● Uganda ● Zambia
3.11 How would you describe your organisation?
● International NGO
3.12 How would you describe your organisation in terms of its core business?
● Service delivery
3.13 Are you applying on behalf of a consortium?
No
3.13.1What are the names of the other organisations in your consortium?
3.14 Whether in a consortium or not please provide a list of your proposed implementation partners.
ORBIS Ethiopia Gedeo, Amaro & Burji Zonal and Woreda Health Offices Gedeo, Amaro & Burji Zonal and Woreda Finance Offices Gedeo, Amaro & Burji Zonal and Woreda Education Offices
3.15 Please provide a list of acronyms.
TT - Trachoma Trichiasis IAPB – International Agency for the Prevention of Blindness SNNPR – South Nations, Nationalities and People’s Region WHO – World Health Organization SAFE – Surgery, Antibiotics, Facial Cleanliness and Environmental Improvement MDA – Mass Drug Administration GTMP – Global Trachoma Mapping Project KAT – Kembata-Tembaro TF - trachomatous inflammation-follicular PECU – Primary Eye Care Unit WASH – Water, sanitation and hygiene HEWs – Health Extension Workers RHB – Regional Health Bureau ZHD – Zonal Health Department RBFED – Regional Bureau of Finance and Economic Development WHA – World Health Assembly
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3.16 If you wish to add more acronyms, please enter them here.
TT: Trachomatous Trichiasis BCC: Behavioural Change and Communication CLTSH: Community Lead Total Sanitation and Hygiene DQA: Data Quality Assessment FMOH: Federal Ministry of Health HDA: Health Development Army HReH: Human Resource for Eye Health IEC: Information Education Communication IECW: Integrated Eye Care Worker KAP: Knowledge Attitude Practice MOU: Memorandum of Understanding NA: Not Available/Not Applicable OPD: Outpatient Department PPP: Purchasing Power Parity PRECOG: Prospective Review of Early Cataract Outcomes and Grading study PWD: People with Disabilities PWOD: People without Disabilities RE: Refractive Error SECU: Secondary Eye Care Unit TBD: To Be Determined TEO: Tetracycline Eye Ointment TF: Trachomatous Inflammation Follicular TIS: Trachoma Impact Survey TOT: Training of Trainers TT: Trachomatous Trichiasis UIG: Universal Intervention Goal WrHO: Woreda Health Office
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Proposed Project
4.1 Please tick all the DFID strategic objectives that your project addresses
● Promoting global prosperity
● Tackling extreme poverty and helping the world’s most vulnerable
4.2 In which region(s) will your project be implemented?
● Sub-Saharan Africa
4.3 Which country/countries will your proposed project be implemented?
Sub-Saharan Africa
● Ethiopia
4.4 What regions will the intervention cover within the country or countries of implementation?
The six woredas of Gedeo zone plus Amaro and Burji special woredas in nearby Segen zone. All are in SNNPR, the third largest administrative region of Ethiopia, with approximately 20% of the country's population and 10% of the total area. Gedeo is the next priority zone for the SNNPR regional health bureau, given its trachoma burden. Amaro and Burji were chosen as they have very high TF prevalence and border Gamo Gofa zone, where significant trachoma control programmes are underway.
4.5 Describe the process of preparing this project proposal.
The original UK Aid Direct Concept Note was based on an existing project in Gurage zone that is supported by the Federal Ministry of Health (FMOH), the SNNPR regional health bureau (RHB) and the zonal Health, Education and Finance and Economic Development departments. It will be no surprise that a key lesson from other similar Orbis projects in SNNPR is that the involvement of all relevant government stakeholders during the initial planning process (and the ongoing monitoring and evaluation) helped to improve their sense of ownership and the integration of eye health into the existing health care system. So for this project proposal, the SNNPR regional health and finance bureaus were contacted and our plans explained. They gave their support for a comprehensive eye care project, particularly as this was in line with their need to intervene in zones and districts in the region with high trachoma prevalence in order to achieve the national TT clearance initiative and the GET2020 targets. In addition, we were able to meet with the Gedeo zone health, education and finance departments for one day to discuss the need for an eye care service in the zone and our plans to provide it. The officials provided valuable inputs and feedback, such as identifying the main problems of the
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community and the barriers this project might encounter during implementation. They also highlighted that eye health care was almost non-existent in the target project areas - there are no eye health care professionals or eye health care units providing a service to the community. As there is no current eye care service in the zone, the support from zonal and regional authorities for our proposed project is very strong. Given the relatively short window to develop this project proposal, it has not been possible to directly consult the communities. However, from our interventions in neighbouring zones, it is clear that the eye health service need of the communities is significant. This is reflected in health review meetings conducted at community, district, zone and regional level for our other projects. Referrals from Gedeo, Amaro and Burji to neighbouring Orbis supported projects have been increasing recently. The total population figure for the project locations (1.27m) in the Concept Note was based on the latest official figures. For the Proposal, we have scaled it back to the figure (1.14m) from the 2013 Global Trachoma Mapping Project – as it is this robust ‘baseline’ on which we have based our figure for the Ultimate Intervention Goal. The budget total has increased from GBP1.99m in the Concept Note, to GBP2.2m in the Proposal. This is due to a thorough review of the costs of operating in this remote area (requiring the addition of a second vehicle, for instance), the costs of comprehensively addressing the very poor TF and TT indicators & the addition of M&E staff and activities to meet the M&E standards required by UK Aid Direct.
4.6 What lessons have you drawn on (from your own and others’ past experience) in designing this project?
The project is based on a comprehensive rural eye health care project delivered by Orbis in Gurage zone over the past 6 years, where eye care services were almost non-existent. Also Orbis, as a key member of ICTC, has been active in developing preferred practices for trachoma elimination, from our experience of delivering the globally recommended SAFE approach over the past 4 years. To highlight 5 key areas of learning from Gurage and other similar Orbis projects: i) Involvement of local government from the start is crucial, especially when introducing a new element of health care – one that may not be seen as a priority, as eye conditions are not killer diseases. Developing trust, creating demand and buy-in by the government has been key and leads to: a. a sense of ownership b. enhanced input into project activities, such as supportive supervision and outreach c. strengthened integration and sustainability of eye health in an existing health care system ii) Given the novelty of eye care, a key challenge has been to promote eye health to the community. Through awareness activities and primary eye care training for community volunteers, we increased uptake of eye care services. Particularly effective activities have been radio broadcasts in local languages and ‘word of mouth’ from HEWs. Messages have included announcement of outreach dates and services, as well as pre-MDA messages. iii) To address the huge need for refraction services, we trained teachers to identify students with refractive error and refer them to optometrists for further assessment and treatment. Selected Integrated Eye Care Workers (IECW) were trained in basic refraction and given refraction sets, to provide a more advanced level of community screening. As the health system lacked capacity to supply eye glasses, Orbis established an optical workshop in Gamo Gofa zone in partnership with Brien Holden Vision Institute. Infrastructure was refurbished, equipment
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supplied and training provided. The workshop is run by the zonal health department as an income-generating activity. iv) The quality of TT surgery has much improved over the last 3 years, reducing high rates of recurrence. Key lessons learned are: a. Training nurses to perform surgery, given the lack of qualified surgeons b. Using HEAD START simulation training package to improve surgical skills. Orbis has been at the forefront of this invention, which has been adopted by the international trachoma community. c. Implementing WHO certification process for TT surgeons d. Enhancing self-assessment for TT surgeons e. Performing surgical audit of around 10% randomly selected patients 3-6 months after surgery, to verify quality of surgery v) Whilst WHO minimum MDA coverage is 80% of the population, Orbis has regularly targeted and achieved 95% by intense awareness raising in the community, by censuses to check the official population figures and by sampling the population afterwards.
4.7 What is the context in which your proposed project will work?
The project area will be the Gedeo zone and Amaro and Burji Woredas, SNNPR. Cut off from urban areas, the population of the project area is underserved and denied basic health services including eye care. In the project area approximately 1.3 million people, the majority of whom live in rural areas (with a TF prevalence of between 14 and 46%), a very painful blinding eye condition but for which there exists an effective treatment. Other leading causes of avoidable blindness are cataract and refractive errors. With adequate trained and skilled personnel and the right medical products and technologies we can make sure these diseases are treated and sight restored. We aim to eliminate trachoma as a public health problem in the region.
4.8 Please provide a more in-depth explanation of the context in which your proposed project will work.
According to the 2006 National Survey on Blindness, Low Vision and Trachoma, prevalence of blindness and low vision was 0.7% and 2.0% respectively in Ethiopia. It is a reasonable assumption that this is reflected in SNNPR, meaning that over 131,000 people are blind and over 374,000 have low vision. The national survey identified cataract as the leading cause of blindness and low vision, followed by trachoma and uncorrected refractive error. All these conditions have relatively straightforward and effective treatments. People are going blind in SNNPR simply due to a lack of eye care services. In Ethiopia, eye care services are underdeveloped relative to other health services. The government has recognized blindness as one of the country’s major health problems, but has allocated insufficient resources to address it. This is changing slowly, because of the scale of other health challenges and the low base from which eye care services start. However, increased government attention is shown by – a national plan is awaiting ratification by parliament; eye care workers have been included for the first time in the national Human Resources for Health plan; the government supports an ambitious national initiative to clear all TT cases by the end of 2017. But neither Gedeo, Amaro nor Burji have primary or secondary eye care facilities in the government health system, nor through any NGO. Currently individuals have to travel outside the zone to get services or end up unnecessarily blind or vision impaired. In
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1998, the World Health Assembly adopted resolution 51.11 that calls for the elimination of trachoma by the year 2020. The WHO-led Global Alliance for the Elimination of Trachoma by 2020 (GET 2020), of which Orbis is a partner, brings together all governments of trachoma endemic countries, bilateral donors, NGOs and academic institutions. The WHO has defined the validation of elimination of trachoma as: 1. a prevalence of trachomatous trichiasis (TT) “unknown to the health system” of less than 1 case per 1,000 total population 2. a prevalence of trachomatous inflammation-follicular (TF) in children aged between 1–9 years of less than 5%, in each formerly endemic district. Trachoma is endemic in Ethiopia and it currently has the largest global burden of active trachoma (TF) that mainly affects children and blinding trachoma (the final stage of the disease: TT) that affects 4 times more women than men. With DFID’s support, the Global Trachoma Mapping Project was launched to address one of the major barriers in the elimination of trachoma - knowing where to intervene. In 2013, surveys were conducted in all districts of SNNPR. Both TF and TT were found to be far above WHO limits (see Appendix 1 data table), warranting rapid intervention through the implementation of the SAFE strategy. The data indicated an Ultimate Intervention Goal of 5,652 people (the number needing surgery, to reach a prevalence of TT below 1 per 1,000 in the total population).
4.9 Please explain who else works in this context (other organisations, government, UN agencies) and how your project adds value to what is already being done.
In Ethiopia nationally, several INGOs support the government’s efforts to implement national and regional eye care plans - FHF (Fred Hollows Foundation), CBM (Christian Blind Mission), International Trachoma Initiative (ITI), The Carter Center (TCC), Lions Club and Light for the World. There are also indigenous NGOs such as Grarbet Tehadiso Mahber working in the field of eye care. Orbis, ITI and TCC work intensively on trachoma control, whilst others work on cataract. DFID and UNICEF are the major supporters of Water Sanitation and Hygiene (WASH) programmes - and DFID is a major contributor to the ‘One WASH’ government-led initiative. In SNNPR, Orbis is the only INGO working in eye care. In Gedeo and Segen zones, UNICEF and WHO work in the health sector (mainly on Maternal and Child Health) and the World Bank is supporting interventions of the ‘One WASH’ initiative (based on high level WASH indicators, 68 districts were selected out 154 in SNNPR for inclusion in ‘One WASH’. Five of these districts are included in the proposed project area). For trachoma globally, WHO is taking the lead through the GET 2020 Alliance. All MOH from endemic countries, bilateral donors, NGOs and academic institutions are part of the Alliance, setting the global direction of the elimination programme. The Ethiopian FMOH has prioritized the elimination of trachoma through the Minister’s initiative on eliminating trichiasis, through which it has pledged to eliminate the TT backlog by the end of 2017 and has budgeted close to USD2m in 2017 for activities to scale up TT surgery in the country. In Ethiopia, bilateral donors that are investing in the elimination of trachoma are DFID, Irish Aid and USAID. The DFID SAFE trachoma control programme, led by Sightsavers International and implemented in Ethiopia by Orbis, the Fred Hollows Foundation, Light for the World and The Carter Center, has spearheaded the scale-up of the elimination of blinding trachoma in Ethiopia. Orbis is the Coordinating Partner for Ethiopia and the Implementing Partner for SNNPR, where the project covers 3 zones. USAID is supporting, through their
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Envision project (led by RTI), the MDA in Amhara, Oromia and Tigray regions, and through the MMDP Project (led by HKI and implemented in Ethiopia through RTI, FHF and LftW) provision of TT surgery in Oromia and Tigray regions. The International Trachoma Initiative is coordinating the Zithromax donation from Pfizer. So the added value of this Orbis project is in extending eye care (and trachoma control in particular) into further zones and woredas in Ethiopia and helping move towards a position where trachoma has been eliminated as a public health problem.
4.10 What is your strategy to address the contextual needs?
Orbis has used the WHO Health Systems Framework as a guide for project strategy: Capacity building: The project will work within the existing health system, providing training and support for health and non-health personnel on all aspects needed to deliver quality eye care. Medical Products & Technologies: We will provide all equipment and consumables needed (and training where necessary) to deliver comprehensive quality eye care. Outreach: The project will create a community referral network, and carry out awareness raising in the form of a behaviour change campaign to increase demand for eye care and establish good eye health practices. SAFE strategy: Orbis will use the WHO SAFE strategy to eliminate trachoma as a public health problem.
4.11 Please provide more detail on your strategy to address the contextual needs.
The project will develop quality comprehensive rural eye care at primary and secondary levels, integrated into the existing health system and accessible to all. 1. Capacity Building Equip current staff for an eye care role: • 20 Nurses and 606 HEWs/HDAs will be trained to identify and refer RE, TT and cataract cases upwards for successful case management. Over 200 teachers will be trained to identify and refer RE cases. All will be sensitised to the issues of women, girls and PWD, to help ensure vulnerable groups are included. • Almost 900 HEWs, HDAs, woreda and zonal officials will be supported to own and lead MDA campaigns. • Leadership training and involvement in planning, monitoring and evaluation will equip 80 local officials to sustain eye care service delivery to the communities. 2. Medical Products & Technologies Provision of equipment and consumables to set up 20 PECUs and one SECU (from year 2). This will include refraction sets, TT surgery kits and related anaesthetics, topical and oral antibiotics for MDA for the PECUs – and cataract surgery equipment for the SECU. 3. Outreach In partnership with zonal officials, create a behaviour change campaign to establish good personal eye health practices and increase demand for eye care. Including radio broadcasts in local languages, dissemination of eye health learning materials, establishing eye health clubs in schools and engaging influential community and religious leaders – all to create demand for the new service. A community referral network will be created, so patients can be identified at primary level and referred upwards for treatment at secondary or tertiary level. This will help to reach the most vulnerable – women, girls and PWD. Patients will be encouraged to make follow-up visits for the best possible outcomes. Outreach will also be used in MDA campaigns. A one-off population census will be undertaken and house-to-house sampling will check
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coverage after each campaign. 4. SAFE Strategy The WHO SAFE strategy will be used to address blinding trachoma. Over 400 Community Case Finders will be trained to screen and identify trachoma cases. 20 nurses (IECWs – one per PECU) will be trained and equipped with 3 TT kits each, to provide surgery to 5,652 patients. Children and adults will receive Zithromax or TEO, as per WHO guidance that areas with TF of between 10%- 30% require at least 3 rounds of MDA (6 woredas – Kochere, Gedeb, Yergachefe, Bule, Dilla Zuria, Wenago) and those with TF >30% require at least 5 rounds (2 woredas – Amaro and Burji). MDA will be conducted every 10/11 months so that Trachoma Impact Surveys can reassess the TF and TT prevalence before the end of the project. The SAFE strategy F & E components will be implemented in partnership with 2 local WASH actors in the ‘One WASH’ programme. Orbis will focus on behavioural change, with IEC to communicate key messages. Partners will focus on revitalisation of existing water infrastructure.
4.12 How do you know this is the right response to the need? What other strategies did you consider?
Orbis has worked in the eye care sector for 44 years and in Ethiopia since 1996. We know this is the right response as it is the one we have applied successfully to other zones in Ethiopia with similar needs. We know that provision of effective and accessible eye health care services is the key for effectively controlling avoidable blindness and visual impairment. There is a logic in integrating eye care within the existing health system, because a number of risk factors for blindness or low vision (e.g. diabetes mellitus, smoking, premature birth, rubella, vitamin A deficiency) can be addressed through general health services. The Ethiopian FMOH has urged NGOs to ensure that comprehensive eye care is included during the training of the health care workers in MDA and TT services. A vertical trachoma programme would have less likelihood of succeeding and providing long term access to care for those that may still develop TT after the intervention has ended. Our approach is supported by the key findings of the 2016 external evaluation of the Orbis trachoma project in Gamo Gofa zone. Key strengths were noted as: • “Strong alignment with and leadership from the Ethiopia Government Primary Health Care to deliver plans and systems”; • “Strong international and national policy environment, targets for and guidance on trachoma elimination”; • “Strong Government and civil society partnerships, where Orbis Ethiopia is clearly valued and trusted”; • “Commitment and retention of skilled Orbis Ethiopia staff”. The evaluation made a number of recommendations relevant to the proposed intervention in Gedeo, Amaro and Burji: 1. “Orbis should remain active in trachoma control and continue to provide and support services within the current geography in order to achieve trachoma elimination”; 2. “Orbis should continue to work with local partners, especially government, to ensure that trachoma is integrated into a comprehensive approach to eye health care”; 3. “Orbis should consider expansion of the trachoma elimination catchment in order to meet more of the unmet needs of the considerable un/under-served parts of SNNPR”; [hence this proposal for work in new areas] 4. “Orbis should strengthen F&E aspects of SAFE and consider adopting a different approach to F&E where the focus is more on advocacy and coordination, than direct implementation with or without partners [Orbis will work with two WASH actors to ensure they are addressing needs in project areas, with a focus on both infrastructure and behaviours that break the cycle of trachoma
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transmission]”; 5. “In planning for a next phase, Orbis Ethiopia should consider the introduction of a Comprehensive Eye Health Care programme (introducing cataract and refractive error management) [this proposal is for comprehensive rural eye health care in line with the recommendation]”
4.13 How does your project fit with the UK Aid Direct theory of change?
Orbis will contribute to delivering prosperity for the population within the project area. This will be delivered by focusing on two main approaches. First, Orbis will create and increase access and supply to basic services, by establishing quality eye care services at primary and secondary levels which are accessible to all. Second, the project will seek to build positive health seeking behaviour and practices so that people seek eye care services when needed, and the population follows improved sanitation and facial cleanliness practices to prevent the spread of trachoma. Also, the project will be accompanied by an M&E strategy, which Orbis will use to share learning in order to promote improved delivery of interventions.
4.14 Please detail a recent example that demonstrates your organisation’s track record and capability in engaging in and contributing to bringing about a similar type of change in the past five years.
Our recent comprehensive eye care programmes in nearby Zones highlights our track record and capability to bring about a similar change in another area. Our work in the KAT zone highlights the effectiveness of SAFE interventions implemented by Orbis since 2013. Surveys in 2016 showed that blinding stage trachoma had reduced to <5% (from 40%) in children aged 1-9 in 5 of 8 woredas. Moreover, in Gamo Gofa zone, a 2016 independent evaluation of our work found similar results. It highlighted that the reason for the project’s success was its ability to engage beneficiaries in project design and implementation. The evaluation also recommended that for effective trachoma control, the project area in this proposal should be our next focus.
4.15 What is the value added of your organisation in delivering the proposed intervention? What is your organisation’s track record in delivering similar interventions in similar contexts for a similar cost?
The added value of Orbis delivering this intervention is twofold. Firstly, it replicates tried and tested approaches that we currently implement and that deliver results. Secondly, it builds on existing strong working relationships that we have developed with the Federal Ministry of Health and SNNPR regional health bureau. Over 5 years, the proposed project will develop a comprehensive rural eye health care service for approximately 1.1 million people at a cost of GBP2.2 million. Given that Gedeo is a more remote zone and that Ethiopian inflation has historically been high, this compares well with the similar Gurage zone project, which over 5 years has reached 0.8 million people with a budget of just over GBP1 million. The Orbis project in Gurage produced the following
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results: • Over 3,500 adult surgeries completed • Over 71,000 children screened • Over 582,000 adult medical/optical treatments carried out • Almost 520,000 child medical/optical treatments carried out • 68% of the trachoma surgery target achieved in just 18 months through the trachoma clearance initiative – very focused attention on TT surgery delivered rapid, good quality results In addition, Trachoma Impact Surveys conducted in similar Orbis projects in other zones of SNNPR have shown positive results in reducing the burden of blinding trachoma. It has been eliminated as a public health problem in 16 of 70 woredas that we have worked in or currently work. We anticipate a further 12 may reach this stage during 2017 after the results of 20 new surveys are known. Through a sub-contract from Sightsavers International, Orbis acts as the national coordinating partner in the DFID SAFE trachoma control programme - and the implementing partner for Hadiya and Sidama zones and Yem special woreda. As a result, we have experience of and the coordination/logistic systems to successfully deliver MDA campaigns to up to 1.75 million people at a time, significantly higher than the maximum size anticipated for this proposed project. Given the impact on the project budget of MDA campaigns, it is notable that Orbis achieves a unit cost comparable with the International Coalition for Trachoma Control (ICTC) preferred practice figure of USD0.25 (~GBP0.20). Similarly, our trachoma surgery unit cost is comparable with the ICTC preferred practice figure of USD40 (~GBP32). The partnership with FMOH and SNNPR health, education and finance bureaus has been in place since 1999. Together, we have developed and delivered high quality comprehensive eye health care projects across SNNPR that have been in line with the Ethiopian government strategy of Health Extension Programme (HEP) and Health Development Army programme (HDA). The FMOH and regional government want Orbis support and leadership for eye health care in Gedeo, Amaro and Burji and will support the start of project activities as quickly as possible.
4.16 If your organisation has not delivered this type of intervention before, what learning/evidence underpins your proposal?
n/a
4.17 What would a UK Aid Direct grant enable you to do that you aren’t currently doing?
Orbis is working in 11 zones and special woredas of SNNPR. The remaining 10 have a TF prevalence that indicates a need to urgently intervene with multi-year programmes to ensure that Ethiopia can make significant strides towards being declared free of blinding trachoma as a public health problem by 2020 (see Appendix 2 SNNPR map). Multi-annual funding on the scale of a UK Aid Direct grant is not readily available from other donors. So this proposal is an opportunity for Orbis to replicate its comprehensive rural eye care work in one zone and 2 woredas identified as priorities by government, with sufficient time to eliminate trachoma as a public health problem amongst a further 1.1m people by the end of the 5-year project. A recent Irish Aid evaluation of a similar Orbis project (focused on elimination of blinding trachoma in Gamo Gofa zone) recommended expanding interventions to the adjacent Segen zone, which includes Amaro and Burji. Over several years the FMOH and RHB have urged Orbis to lead the development of eye health care services in SNNPR. Our
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proposed project responds to this recommendation and this urging. Trachoma disproportionately affects women, children and the poor. Poor communities are less likely to have access to clean water and improved sanitation, the use of which helps prevent transmission of trachoma. In a largely rural region, the SNNPR population is already marginalised. So women and PWD targeted by this project are double-marginalised and comprise the ‘most vulnerable’ that UK Aid Direct wishes to reach. In line with the government’s initiative to reach mothers and children at household and community level, the assignment of HEWs within the community will provide house-to-house eye health education. Health and WASH facilities will be modified to accommodate the need of those who are disabled. As necessary, transport service will be arranged to improve access for eye care services by PWDs. We will raise awareness of disability by inclusion in the planned eye health worker training packages. Our current work in Ethiopia involves comprehensive rural eye care and trachoma control projects that are having a demonstrable impact on eye health. But without a specific focus on disability, gender or social inclusion, we cannot be sure that our projects reach the most vulnerable and disadvantaged people. The focus of UK Aid Direct on disability and gender prompts the need to explicitly consider and include these issues in our project design - and offers us an opportunity to develop in this area. As part of this project, we will need to undertake research or evaluation to check what we are achieving. But once we have proven that our interventions work, we will be able to apply them to current and future projects, thus enhancing our impact on beneficiaries. In addition, we believe this project would add value to DFID’s huge portfolio of investment towards the target of eliminating NTDs in Ethiopia and globally.
4.18 Which of the following UK Aid Direct approaches will your proposed project contribute to?
● Improve access, supply and quality of basic services
● Show positive behaviour change in targeted groups as a result of the interventions
4.19 Please explain your rationale for choosing the three (maximum) UK Aid Direct approaches you will take; how will they help you to achieve your programme goals and why are they needed?
Orbis has chosen two of the UK Aid Direct approaches, which will help us achieve our goal of reducing avoidable blindness by acting on both the supply and demand side of eye health care: 1. Improve access, supply and quality of basic services A key problem is the lack of eye care knowledge, skills and equipment in the existing health system, as well as inadequate water and sanitation facilities. The project will work to ensure: • An appropriate quality of eye care service, so that treatment outcomes are good and the population develops confidence in the service • An appropriate supply, so that eye health care is available when needed • Appropriate levels of access, by ensuring that eye care is available in accessible locations and that barriers to access by the most vulnerable members of the population are overcome • Appropriate WASH facilities, through two WASH partners Another key problem in this context is access by the most marginalised – women, children and PWD. We are not sufficiently familiar with the cultural and practical issues that make these groups
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especially vulnerable to eye disease and less likely to be able to access treatment. Through community consultations at the start of the project, we will sensitively explore the barriers to access for these groups, as understanding and addressing them is necessary to help us achieve the project goal. This approach will help Orbis achieve all three of our stated Outputs (1. Improved quality and availability of primary and secondary eye health care services; 2. Improved access to eye health care services; 3. Improved access to quality WASH systems). 2. Show positive behaviour change in targeted groups as a result of the interventions Behaviour change amongst the beneficiary population is essential if the project is to have optimum benefit, including by breaking down barriers to access by women and girls. Through the first approach, the project will create greater availability of eye health care services. To take full advantage, through the use of promotional materials and communication we need to assist the population to adopt new health-seeking behaviours so they can: • Recognise eye conditions that can be treated clinically • Understand the benefits of modern medicine • Be aware of where to go to get treatment and of the services on offer • Be prepared to invest time and resources into seeking treatment • Recognise and act on the disproportionate impact of eye conditions on women, children and PWD • Recognise the vectors of trachoma infection and take active steps to improve environmental conditions and hygiene behaviours in their communities This will all require significant awareness-raising and support for behaviour change amongst the community – which will take time. This approach will help Orbis to achieve Output 3. Improved access to quality WASH systems.
4.20 Please number and list any references you have used in your proposal.
In Section 6.7 the figures have been obtained from: Rural - NATIONAL DEMOGRAPHIC AND HEALTH SURVEY 2016 Extreme Poor - ETHIOPIA POVERTY ASSESSMENT, WORLD BANK 2015 PWD - ETHIOPIAN PROFILE ON DISABILITY, JICA 2002
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Monitoring and Evaluation
5.1 What is your proposed approach to monitoring? What methodologies, tools and approaches will you use? How will you measure change? Who will be involved? What training is required for partners to monitor and evaluate the project?
Orbis routinely monitors and evaluates projects, to provide internal and external stakeholders with timely and accurate data to inform programme decision-making, while building local capacity for effective M&E. Our approach is to prepare a Project Monitoring Plan (PMP) during the first 3 months of a project. This PMP finalises data collection and reporting processes, quality control measures, M&E staffing and training needs for partner and project staff. For this project, we can anticipate the following approaches: Data collection and results reporting: Woreda health offices will compile monthly reports with HMIS data, disaggregated by age and gender. Typically they will indicate progress towards outcomes, highlight key performance outputs, identify problems in implementation and propose corrective actions. Key eye care performance indicators (e.g. # TT surgeries, # cataract surgeries, # screenings and examinations) will be analysed to identify trends. Orbis will validate these reports. Data quality control: Orbis will assess the quality of reported data from HMIS. WHO’s Data Quality Assurance tool for NTD Programmes will be used. Monitoring visits: Orbis will conduct quarterly joint supportive supervision visits to project sites with zonal and/or woreda officials. The visits will focus on identifying successes and challenges in implementation, sharing/documenting best practices, verifying progress reports, reviewing financial documents, conducting data quality checks and mentoring health staff on M&E (rather than formal training). They will also examine the status of donated equipment and compliance with Orbis and donor policies. Measurement of change: Orbis will conduct a Rapid Assessment of Avoidable Blindness (RAAB) at the beginning of the project to provide a baseline and at the end to measure change. We will reassess TF and TT prevalence by conducting Trachoma Impact Surveys (TIS) and KAP surveys in six districts in year 4 and two districts in year 5 - monitoring the reduction in cases of trachoma until it is no longer a public health problem. Behaviour change indicators to be measured will include facial cleanliness of children age 1-9, latrine utilization by residents of the project area and household waste disposal practices. We will also aim to undertake measures such as Focus Group Discussions amongst women, children and PWDs to determine if they are accessing eye care services. Project review and evaluations: Annual planning/review meetings will involve local officials and the community. Progress relative to targets will be examined, achievement gaps identified and an action plan developed to address the gaps. The project will have a mid- term review and a final evaluation, with the latter containing key informant interviews and Focus Group Discussions conducted by an independent consultant. The government requires that both must involve key stakeholders from the regional health, education and finance bureaus.
5.2 How will you measure disability within your project?
Disability is both a cause and consequence of poverty. In societies where increasing education, skills development and civil engagement have brought growing prosperity and fuller participation, people with
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disabilities are being left behind. Globally, over 400 million disabled people live below the poverty line. People with disabilities are often significantly poorer and less likely to attend school. Once a child’s eyesight starts to deteriorate, if left undiagnosed and untreated the child is at significant risk of dropping out of school. This reduces the likelihood of that child securing employment or a livelihood. This project specifically aims to prevent and/or cure avoidable blindness – and thus one form of disability. There are three main challenges with establishing a disability baseline in this project. Firstly, official figures by zone are not available; secondly, the most up-to-date source we have is the ‘Ethiopian Profile on Disability, JICA 2002’ that quotes figures for SNNPR, from which we have interpolated to get figures for the project areas; thirdly, the JICA data quoted in section 6.5 includes ‘Partial’ and ‘Total’ blindness as disabilities, but the estimates for SNNPR are very different to those we provide in section 4.8 based on the 2006 National Survey on Blindness, Low Vision and Trachoma. A new national blindness survey is planned for 2018 and we will encourage the inclusion of measurement of disability. But we cannot be sure that the data will be available at zonal or woreda level and so, during the life of this project, we only expect to be able to measure absolute numbers and not change. Neither the health system, nor Orbis, are used to measuring disability. So we will start the project by exploring the issue sensitively with the communities and with local NGOs that specialise in disability issues. Following that, we will conduct a ‘Rapid Assessment of Avoidable Blindness’ that will include the Washington Group Short Set of Questions on Disability. The RAAB will also incorporate relevant questions regarding accessibility of health services – and will give us a much better picture of the number of PWDs and their ability to access health services. In the logframe, we have included a number of project indicators that will be disaggregated by disability (and age and gender): • Number of screenings carried out • Percentage of referrals acted upon • Number of pairs of eye glasses provided • Number of cataract surgeries performed • Cataract surgical outcome/quality • Number of TT surgeries performed The project will revise HMIS, registers and monthly reporting formats to capture these indicators – and will sensitise the health staff who will be recording data, so they are aware of how to identify and classify disability. The final RAAB and the TIS in years 4 and 5 will allow us to identify and record the impact of the project activities on PWD, including the effectiveness of our efforts to overcome barriers to access.
5.3 Please explain the budget allocated to M&E. Please ensure there is provision for baseline, on-going data collection and an end of project independent evaluation.
The project allocates adequate budget for the following M&E related activities: • RAAB at the beginning (baseline) and end of project • Printing and distribution of M&E tools, e.g., TT register, cataract register, OPD register, refraction services register, MDA register, monthly reporting forms, referral cards/slips • Regular data collection from respective district health offices by field coordinators • Annual planning/review meetings • Monthly technical support to primary and secondary eye care units by field coordinators • 3 month post op cataract visual outcome follow-up • WHO cataract surgical audit • Trachoma Impact Surveys (TIS) and KAP surveys in six districts in year 4 and in two districts in year 5. TIS are carried out by independent consultants using WHO-recommended methodology. They will include TT surgery quality assessments (as a more regular
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level of assessment cannot be achieved within the project budget envelope). • Quarterly supportive supervision visits to project sites jointly with zonal and/or respective woreda health officials • MDA census. MDA coverage supervision within two weeks of MDA (through random household checks) • Regular data quality assessment (using the WHO DQA tool for NTD Programmes) and TT verification in 10 PECUs per year • Mid-term and final project evaluation involving regional stakeholders, with the latter led by an independent consultant • Dissemination of survey reports and learnings from evaluations to relevant stakeholders Overall, just OVER 10% of the project budget is apportioned for M&E. The major items are: • TIS/KAP GBP86,000 • Routine M&E activities GBP53,000 • Quarterly/annual review and planning meetings GBP44,000 • RAAB GBP18,000 • End of project evaluation GBP20,000
5.4 What mechanisms will be in place to capture feedback from stakeholders and beneficiaries and feed it back into the system? How will you be able to adapt and respond flexibly to changes in context?
There are several routes, both informal and formal, for Orbis to capture feedback and feed it back into the system. Informally, Orbis will be open to feedback from government officials, eye health care providers, community health workers (HEWs and HDAs) during every training programme, joint supportive supervision visit and follow-up visits to project sites. In addition, whilst conducting TT and cataract verification programmes (with representatives from the zone, respective woreda health offices and health facilities) Orbis will use the opportunity to obtain feedback from beneficiaries as the verification is carried out by moving from house-to- house to visit those who have received TT and cataract surgery. Formally, we will use the annual review meetings to capture feedback from the national, regional and woreda officials. The Mid-Term Review and End of Project evaluation will actively seek and assess feedback from partners and beneficiaries. Orbis will use the finding and recommendations for improvement of the current project (in the former case) or design of future projects (in the latter case). Orbis will enable and encourage feedback from beneficiaries through the following mechanisms: • Focus group discussions during quarterly annual review meetings and surveys • Regular Key Informant Interviews and one-on-one interviews • Involve beneficiaries through interactive radio conversations • Community/beneficiary suggestions and comments will be collected through suggestion boxes placed at eye care units and selected schools • Opening an SMS channel for those who have access to mobile phone technology to share their views and thoughts. There may be more we can learn from the Beneficiary Feedback Mechanism pilot conducted by Amref Health Africa in nearby Konso, particularly about how to close the feedback loop where beneficiaries are geographically dispersed. With a dedicated project team (Zonal Field Coordinator, Project Manager and M&E Officer) based in the field and in close contact with the local officials, we have a good structure to be able to hear, understand and adapt/respond to feedback.
5.5 Please explain how the learning from this project will be incorporated into your organisation and disseminated, and to whom this information will be targeted.
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The key successes and areas for improvement of the project will be analysed and shared with Orbis Ethiopia country management to be replicated in other existing projects or to be used for future programming, as appropriate. Where appropriate to the project and context, it will be shared across the global Orbis network. The Mid-Term Review and End of Project evaluation are an ideal time to consolidate, review and share this learning. We anticipate that routine learning will include: • Trachoma Impact Surveys will be shared with other DFID SAFE partners through the Orbis role as Coordinating Partner for the DFID SAFE programme, published nationally and shared at international conferences. TIS results will be forwarded to the FMOH who are responsible for reporting to WHO on progress towards elimination of trachoma. Each SAFE implementing partner has a slightly different approach to screening, case-finding and MDA campaigns – and so Orbis data can be compared with other implementing partners to judge the effectiveness of each approach. • The project approach to the supply of eye glasses may contribute important learning for Orbis on meeting refractive error needs in the population. It would be too early to establish a workshop in Gedeo, so we plan to part-source frames and lenses from the Gamo Gofa optical workshop. Orbis will assess the extent to which using an optical workshop in a neighbouring zone helps ensure consistent and timely supply of eye glasses – and what factors determine the capacity of a workshop to meet demand. • Learning how to undertake surgical outcome monitoring more effectively/consistently. • Further learning on how to determine when to stop, when the final few TT cases to meet the UIG prove difficult to locate in the extensive rural area of SNNPR. The particular opportunity from this project is to learn more about new approaches to identifying and removing barriers to access for the most marginalised in this context – women and PWD. Globally Orbis has a focus on women, as it is on women that the main blindness burden falls. But we have not systematically explored techniques to ensure we reach the most marginalised. We will consult local NGOs that specialise in gender and disability issues, to understand barriers and ways to overcome them – before verifying them with the communities in culturally sensitive ways. We will then measure the effectiveness of these approaches and learn what works and what doesn’t – useful information for all our Ethiopia projects.
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Results
6.1 Please upload your theory of change
6.2 Please explain the theory of change for your proposed project
This project aims to reduce poverty and vulnerability to disease by developing comprehensive eye care that is accessible to all, reaching the rural poor, children unable to attend school and women, who are four times more likely than men to suffer from trachoma. Our holistic approach is informed by the WHO framework to developing strong health systems, a proven strategic approach which will ensure sustainability. By improving capacity and providing equipment we will increase supply. Through education and behavioural change in the community, we will increase demand. Through SAFE we will increase access to WASH and eliminate trachoma. The impact will be reduced avoidable blindness, a healthier community and increased economic opportunities
6.3 If desired, please upload an updated theory of change.
Current Theories of Change Files
❍ DOCX ❍ Appendix 1 Data Table V180417 April 18, 2017 19 Kb ❍ JPG ❍ Appendix 2 Snnpr Map V120417 April 14, 2017 770 Kb ❍ XLSX ❍ Aid Direct Eth Theory Of Change 130417 April 14, 2017 28 Kb
6.4 Please explain the theory of change for your proposed project in more depth.
We have uploaded a new Theory of Change document, which refines and clarifies the one submitted with the Concept Note. The ‘issue’ remains the same. The ‘inputs’ are similar, but the ‘outputs’ now recognise the difference between availability and accessibility of eye health care services – and the necessity for both to be in place to optimise the impact of the eye health care service. Availability is secured by ensuring trained personnel are in place, eye care units are adequately equipped, quality mechanisms are in place and regional/local government takes increasing ownership of eye care as the project progresses. Accessibility is secured by establishing eye care units in the right locations in existing health units, by raising awareness of eye health care, by establishing school screening programmes, by supporting Mass Drug Administration to the entire population, by establishing and communicating referral pathways & by ensuring barriers to access are overcome. The final ‘output’ recognises the importance of WASH within the delivery of the SAFE strategy, if trachoma is to be eliminated. These ‘outputs’ should lead to a reduction of avoidable blindness and visual
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impairment – and ultimately an impact on poverty reduction as treated people can become more productive or economically active or can pursue an education that will give them options to escape poverty in the future. This will all contribute to reduced poverty and vulnerability to disease in SNNPR.
6.5 Who are your primary beneficiaries?
People with disabilities (PWD) - Under 5 years - Female - 5 - 14 years - Male - 15 - 24 years - 25 - 49 years - 50 - 64 years - Over 65 years Extreme poor - Under 5 years - Female - 5 - 14 years - Male - 15 - 24 years - 25 - 49 years - 50 - 64 years - Over 65 years Rural - Under 5 years - Female - 5 - 14 years - Male - 15 - 24 years - 25 - 49 years - 50 - 64 years - Over 65 years
6.6 What is the total number of primary beneficiaries you intend to reach?
1135062
6.7 Please break down the total number of primary beneficiaries into each population group below:
Rural 1094408 Extreme poor 381770 People with disabilities (PWD) 16543
6.8 Who are your secondary beneficiaries? How many secondary beneficiaries in total will benefit from your project?
Number of People
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2233 - 25 - 49 years - Female - Male
6.9 Please demonstrate how you are identifying and including the most vulnerable and marginalised groups of beneficiaries. How will the project include those with a disability?
From the data we have for the primary beneficiary categories in section 6.5, 35% of the beneficiary population can be identified as most vulnerable and marginalised (PWD and the Extreme Poor). However the situation is more complex than that, particularly in a region like SNNPR that is marginalised due to location and lack of resources. Blindness is both a cause and consequence of poverty. The majority of blind and visually impaired people live below the poverty line, especially if they live in rural rather than urban areas of Ethiopia. Women with visual impairment face double discrimination because of their gender and their disability. Their vulnerability can put them at higher risk of gender-based violence, sexual abuse and neglect. Women with disabilities face significantly more difficulties in accessing health services, education and employment. The 2006 National Survey on Blindness, Low Vision and Trachoma and the 2013 Global Trachoma Mapping Project showed that women and children are disproportionately affected by eye conditions - including trachoma, with which women are up to four times more likely to be affected than men. So gender also is an indicator of vulnerability, with 50% of the population being women. We will identify and include the vulnerable, marginalised and disabled in the following ways: • Working with the communities to identify and target the most vulnerable. • Running behaviour change campaigns through radio and other media to increase understanding of eye disease and knowing where and when to get help. The radio is the best medium to reach women, PWDs and the rural poor as it can broadcast into their homes. • Training trusted primary health workers on eye care - HEWs and HDAs who have in-depth knowledge of their communities and will help address barriers to access at the community level. • By MDA campaigns, through which Orbis regularly achieves a population coverage of up 95% (the WHO recommended minimum is 80%) and which give opportunities to identify people who may have difficulty accessing eye health care services, ensuring no one is left behind with the terrible disease of trachoma. • By working on F and E aspects of SAFE, we will ensure safe water is available locally to the communities most in need, which will also positively impact on the lives of women and girls. • Children will be targeted through school eye clubs discussed in 6.11. Orbis makes a clear distinction between availability of and accessibility to services. Even if health centres, in which eye care units will be established, are in the right areas, they might not be accessible to vulnerable groups like women, children and PWD for reasons including distance, cost of transport and opening hours. After consultation with the communities, we will put in place appropriate measures to improve accessibility, which may include a transport subsidy to and from screening.
6.10 What is the project’s approach to empowerment and gender equality and what are the linkages to DFID’s ‘leave no one behind’ agenda?
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This project is in direct alignment with DFID’s policy to ‘leave no one behind’. The predominantly rural location of Gedeo zone and Amaro and Burji woredas in SNNPR is remote. The population of the project area is 80% pastoralist and lack access to basic health services, including eye care. Access to safe water is low, which helps to explain the high rates of active trachoma - up to 46%. This project will help to bridge the development gap by introducing comprehensive eye care and eliminating painful trachoma. Two key success factors of this project are the empowerment of the community (in order that the impact is sustainable) and a focus on gender (given the disproportionate burden of eye conditions on women and the key role of women in health-seeking behaviour in the household). We will empower the community by giving them the skills and expertise to restore sight. We will equip teachers and HEWs with knowledge of common eye problems and give them the skills to screen for basic eye conditions at primary level. Teachers will be trained and supported to establish school eye health clubs, through which school children will be encouraged to adopt good facial and hand hygiene practices and to take these messages home, to help combat painful trachoma. Community-Led Total Sanitation and Hygiene will be encouraged, thus empowering the community to look after their own sanitation. Many believe that there is no cure for blindness, but our outreach and behaviour change campaign will change this attitude. By treating cataract, trachoma and refractive error, we will restore sight thereby improving health and enabling adults to look after their families and go back to work. It will also allow children to go to school. In addition, the F and E part of the SAFE strategy will introduce safe water and sanitation to the communities most in need. This will be huge empowerment to a community that has thus far been largely excluded from development. To help address the issue of gender equality, the project will target the involvement of both women and men in all awareness raising and health education activities – the women so that they have the knowledge to look after their own eye health, can champion health-seeking behaviour within the family, can continue their household duties and be productive members of their community; the men so that they can understand the new learning of the women and can support their health-seeking actions within the family. The project will also use a range of approaches (such as community conversations, in-depth interviews and Focus Group Discussions) to help ensure the full participation of women and girls - addressing barriers to their participation and meeting their specific needs.
6.11 Please provide more detail on the three (maximum) UK Aid Direct approaches you will take.
Improve access, supply and quality of basic services: This approach is at the core of the proposed projects design. The project aims to develop quality comprehensive eye care that is accessible to all. Our focus is at the primary and secondary levels as currently no such services exist in the area. It is important to note that the baseline prevalence of TF(within Amaro and Burji woredas) is 46%, the project will deliver five annual rounds of MDA, in order to satisfy the WHO guidelines for tackling trachoma, which indicate that five annual rounds are needed for a prevalence of more than 30%. This is the justification for the five-year duration of the proposed project. We will achieve this through three principle strategies: 1. By building the capacity of key existing health professional staff at the primary level we will integrate eye care within primary health care services. We will train HEWs to identify eye health problems including trachoma and primary care nurses to diagnose and treat
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trachoma at the blinding stage by performing surgery. Thus, the project will secure the accessibility and availability of eye care services within the community; they will also be trained to refer more complicated diseases to the secondary level. We will also train teachers to screen children in schools so that any problems can be picked up early and also referred. In this way we will strengthen referral pathways ensuring the best treatment at the right level. 2. The provision of equipment and supplies will improve the both the efficiency and quality of procedures and also the patient experience at both primary and secondary levels. Orbis will offer training on how to use and maintain the equipment so that both quality and sustainability are ensured. Following the WHO Health Systems Framework, we will also strengthen finance and management systems, data capture and procurement systems. These will all serve to improve the efficiency of patient flow and use of medical products and technologies. By doing so, this will ensure that basic services can be offered and managed in a sustainable fashion. One such example of this can be seen in a similar Orbis programme in Gurage, SNNPR where consumables for all cataract and Trachoma surgeries are now funded by the regional health bureau. The proposed project will attempt to replicate this success by developing our relationship with the regional and zonal health departments, whereby they continue to fund trachoma based activities and comprehensive eye care services beyond the project time frame. 3. The project will use the WHO SAFE strategy for eliminating trachoma and by doing so increase access to basic and quality services. The project will develop the capacity of PECUs to offer TT screening and surgery (4258 surgeries to be performed in order to achieve TT elimination as a public health problem). MDA requires a minimum coverage of 95% which will enable the project to reach those that are most marginalised, for example women and girls, as MDA distributors can go from house-to-house to ensure all are able to access the service. Moreover, utilising HEW within the community provides the project with detailed insight into where these groups can be found and how they should be engaged. MDA will be conducted within eight woredas. As stated, Amaro and Burji woredas require five annual rounds of MDA (with a baseline active trachoma prevalence of 46%), whilst the remaining six woredas, which form the Gedeo Zone, will require 3 annual rounds (baseline prevalence between 14% -18%). Finally, the Ethiopian Government fully supports trachoma elimination strategies, including those of Orbis. With this government buy in at the very top level, the project will successfully and sustainably strengthen the health system. Show positive behaviour change in targeted groups as a result of the interventions: As well as working to increase the supply and level of access to quality eye care services the project will work to increase the demand for services. This will be achieved by using various outreach methods to promote positive health seeking behavioural change. Messages concerning the availability of eye care services, good eye health practices and the importance of seeking care will be communicated via HEWs and local radio in local languages. We have found this to be an effective way of engaging the local community, both in our other Ethiopia programmes and also our initiatives in other countries. Moreover, we will train school teachers to identify and refer school children with potential eye health problems. Teachers will run school eye clubs to promote positive behaviour change amongst children. We have found from previous work that children are able to act as change agents within the community. School clubs also help families to think about eye health, alongside radio and messaging from community leaders. This will help to create a generation and community that is knowledgeable about eye health and where to seek eye care services, promote facial cleanliness and use of improved latrines, as well as reducing the number of blind people and those that are at risk of blindness.
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As part of the SAFE strategy for eliminating trachoma the project will encourage positive behaviour changes in community WASH practices which will help reduce transmission of trachoma. The F and E elements of the strategy will educate communities about the importance of face washing and general best practice for hygiene, such as encouraging use of improved latrines. Trachoma infection is a result of bacteria spread via human contact and by flies which are attracted to open and poor sanitation systems
6.12 Which of the following outcome areas will your project contribute to?
● Immunisation against preventable diseases ● Income generation and poverty reduction ● Access to sanitation ● Access to clean water ● Women and Girls empowerment
6.13 What is your outcome statement?
By the end of this 5-year project, there will be 20 Primary Eye Care Units and one Secondary Eye Care Unit integrated into the existing health system and providing sufficient availability of and access to quality comprehensive eye health care services. This will ultimately lead to a reduction in avoidable blindness and visual impairment, contributing to poverty reduction amongst the 1.1 million marginalised and vulnerable population in Gedeo zone, Amaro and Burji woredas in SNNPR.
6.14 What will the impact of your project be?
This project, through restoring vision and eliminating avoidable blindness in communities, will enable adults to return to work, and children to return to school. Not only does this positively impact the lives of individuals, but also communities. By establishing quality and accessible eye care services, this project contributes to communities breaking the cycle of poverty, in particular where blindness and visual impairment are part of the poverty trap. Furthermore, the impact of this project will advance Ethiopia’s progress towards SDGs 1 and 3. By promoting and creating a quality health service for all, this intervention will enable community members to escape poverty of all forms.
6.15 If your project includes capacity building, empowerment or advocacy aspects, please comment on why they are needed and how they are expected to contribute to change.
Capacity Building From implementing similar projects where self-reliance and sustainability are considered the cornerstones for lasting results, Orbis knows that capacity building of the community to sustain its own good health is important. Without building this local capacity, the project will not be able to meet its goals and objectives. Training existing eye care workers is a sustainable method which is effective, good value for money
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and is sustainable - as it does not create a parallel system and strengthens referral pathways. The project will train and support nurses to deliver primary eye health care services, including TT surgery, and will build the capacity of government health and finance departments to plan, implement, monitor and report on eye health care activities and budgets. Trachoma elimination is a complex public health intervention. In building the capacity of government and communities to plan, implement and review trachoma-related activities, the project will strengthen capacity for delivering other public health projects. The proposed project will build the capacity of community volunteers and teachers to disseminate key health messages to improve community eye health knowledge, as well as to provide basic eye care services where none currently exist. These community health cadres are known to be an effective gateway for dissemination of key project messages to the community. Capacity building also gives these cadres a clear role in community eye health care. With their knowledge of basic eye conditions and referral pathways, they will be empowered to identify and refer people with blindness and visual impairment. Training community cadres in eye health will also mitigate the challenges of maintaining sufficiently high levels of staffing at primary and secondary levels of the health system. Empowerment It is important to address the demand side of the eye care service. By awareness-raising and education, we will empower the local community to take control of their eye health in dispelling myths about eye disease, prevention activities, knowing that treatment is available and knowing when and how to seek it. Strong demand will help the supply side to be sustainable and will develop lasting wellbeing in the community so that people are not unnecessarily blind and being unable to work or attend school.
6.16 Please fill in the draft logframe.
Current Planning Files
❍ XLSX ❍ Aid Direct Eth Logframe 180417 April 13, 2017 37 Kb
6.17 How do the proposed activities achieve overall value for money? Show how the project demonstrates economy, efficiency, effectiveness and equity.
Blindness has a huge public cost and is estimated at 0.5% of GDP per annum in Sub-Saharan countries such as Ethiopia. However, many eye problems can be tackled easily and cheaply. The World Health Assembly states that blindness treatments are among the most cost effective of all health interventions. A study by Aravind Eye Institute in India showed that the average person who regained functional vision through cataract surgery generated 1,500% of the cost of the surgery in increased economic productivity during the first year following surgery. Economy Orbis uses a number of low cost treatment techniques – i) the small incision technique for cataract surgery, specifically designed for use in developing country contexts. Low cost and quick to recover from, as only local anaesthesia is required; ii) adult TT surgery costs USD40 (~GBP32) on average, including consumables and training; iii) MDA costs are kept low as the pharmaceutical company Pfizer provides
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free-of-charge antibiotics. The cost per treatment per person is estimated at USD0.25 (~GBP0.20) with MDA delivered by community volunteers who receive a nominal ‘per diem’. Orbis carries out MDA within 7 projects in SNNPR, covering over 10 million people, which enables economies of scale in our antibiotic distribution chain. Efficiency Orbis will work through the existing health system, being efficient by avoiding duplication. We will train selected community members to carry out screening and detection of eye conditions in their communities. This is an efficient way of reaching maximum numbers given community members are screened where they feel most comfortable by people they trust. Effectiveness In developing countries, investing in preventing blindness and impaired vision can dramatically improve the lives of individuals and their families. With many eye care interventions, the results are almost instantaneous. Adults are able to support their families and children can pursue an education. It is known that a high percentage of children in developing countries with visual impairment do not attend school or drop out. By intervening early, we can prevent potential long term visual impairment and/or blindness, therefore reducing the likelihood of the child entering the poverty trap. Equity SNNPR was chosen because of its poor eye health indicators, as it is one of the poorest and least served areas of Ethiopia and has no eye health programmes. So the project targets marginalised communities who would otherwise have no access to eye health care. Orbis-supported research shows that elderly people, women and rural residents are at a greater risk of low vision and blindness, reflecting the social inequalities in accessing health services in Ethiopia. The project will target all members of the community, including those unable to attend outreach clinics, by working with the community to identify and visit them in their homes.
6.18 Please explain the project's approach to sustainability.
This project will ensure sustainability by working within the existing health system structure, with existing personnel, integrating eye health care. Engaging stakeholders, and building government backing, Orbis will ensure that funding for eye care is available to sustain the implementation of post trachoma elimination activities and continue to provide clinical services. By advocating to government, Orbis will integrate eye care within the health system. The project will utilise recommended strategies. This will ensure sustainability as the project design is focused, and has space for learning to facilitate adaption and better implementation. Best practice and learnings will be shared in order to facilitate project growth and scale up.
6.19 Please elaborate on the project's approach to sustainability. How does your project demonstrate efforts towards achieving social, economic and environmental sustainability?
Sustainability is a fundamental characteristic of this project. It is designed to build on existing health infrastructure to result in a trusted and quality eye health care service that is an integral part of the zonal and woreda health system and to eliminate an endemic disease from the population. Social sustainability - Through a reduction in avoidable blindness and visual impairment, this project aims to contribute to improved quality of life for people in the project area unable to pursue an education and those unable to work due to avoidable eye conditions. It will also improve the quality of life for carers, both adults and children, who will be free to pursue
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work, education or leisure. The project will also further demonstrate the success of a comprehensive rural eye health care programme, encouraging further zonal health authorities to prioritise eye health care and to consider the access needs of the most vulnerable. We also expect lasting changes in health-seeking and hygiene behaviour through the awareness of eye health care services and the delivery of community-led total sanitation and hygiene. Economic sustainability - This project aims to correct or avoid blindness and visual impairment in over 600,000 adults and over 530,000 children. The former will be able to re-join productive activities, whilst the latter will be able to pursue an education that will give them the best opportunity of graduating from poverty in the future (in addition to potentially releasing carers into productive activity). Capacity building work with the health facilities will include budget management and financial sustainability, helping them to identify how best to use their limited government funding and, for the SECU, how to develop income-generating activities (such as eye glass sales) in order to continue to deliver a comprehensive eye care service once the project has ended. Environmental sustainability - The project should have a significant positive impact on the environment and disease burden of rural areas. We estimate that 101 kebele (the smallest administrative unit of Ethiopia), or 50% of those in the project area, will become ‘Open Defecation Free’ by the project end and will have better sources of water for face and hand-washing. This will not only reduce the vectors of trachoma infection, but also Soil-transmitted Helminths and a number of other water-borne diseases such as Acute Watery Diarrhoea. External factors affecting the intervention will include the suitability of the terrain for deep pit latrines away from water sources, as well as the availability of groundwater. If groundwater is not consistently available during the year, it may be necessary for communities to innovate with simple domestic rainwater harvesting systems.
6.20 How will you coordinate project implementation with other development actors and ensure no duplication of effort (including with other DFID funded activities)? How will you work with local/national government and private sector providers?
All development actors in Ethiopia must work in coordination with the local and federal government. In addition, by supporting/working through the existing health system, Orbis coordinates particularly strongly with the local government and thus should be aware of any risk of potential duplication. Woreda, zonal and regional government officials, along with associated development partners will be part of the project quarterly and annual progress and planning meetings. This will help to coordinate and maximise our efforts. Supportive supervision visits will be undertaken both with and for the benefit of local officials. There will be no overlap with the DFID SAFE work of Orbis in SNNPR, as it takes place in different zones. A separate project management structure will be put in place for Gedeo, but with clear linkages to cooperate and share learning both ways. Orbis will continue its involvement in national Zithromax planning meetings, to help ensure the antibiotic is available first for priority areas and that any necessary logistical coordination can be put in place. Orbis will seek to ensure that government ‘One WASH’ programme activities will cover 5 of the communities within the project area and will support the hardware component of the project. Orbis will not work on WASH hardware, but will co-ordinate with government and two NGO actors on CLTSH interventions and to promote good
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hygiene practices - face and hand washing, use of improved latrines – that interrupt the transmission of trachoma. In section 4.9, we mentioned the major NGOs working in the area. However, a more in-depth understanding of the eye health NGOs will come from mapping to identify additional suitable partners. During the project, Orbis will continue its regular update meetings with the DFID Ethiopia office as a further opportunity to coordinate, to avoid duplication with existing or proposed interventions and to see opportunities for leveraging our work in the region/country. We do not expect to work with any private sector actors.
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Financial details
7.1 Please complete the workplan and budget.
DFID Funding 1663661 Match Funding 555373 Total Funding 2219034
7.2 Please detail the annual income of your organisation, for the past three years.
Income for 2016 (£) 4758956 Income for 2015 (£) 5741581 Income for 2014 (£) 4713710
7.3 Please upload your three most recent sets of audited accounts
Current Account Files
❍ PDF ❍ Audited Accounts 2013 Orbis Charitable Trust January 30, 2017 460 Kb ❍ PDF ❍ Audited Accounts 2015 Orbis Charitable Trust January 24, 2017 640 Kb ❍ PDF ❍ Audited Accounts 2014 Orbis Charitable Trust January 24, 2017 470 Kb
7.4 Has a Financial Management Assessment (or other due diligence assessment) been completed on your organisation in the past three years by an international donor?
Yes
7.4.1 Would you be willing to share that with UK Aid Direct should your application be successful?
Yes
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Risk
8.1 What are the key risks associated with your proposed project and how will you mitigate against them? Please enter any additional risks that you have considered.
Level Risk descriptions
Extreme Fluctuation in Pound Sterling Sterling has settled since the Brexit vote, but further fluctuations throughout the 5 years of the project are likely and could significantly reduce the local currency value of the grant.
Mitigations Very close monthly monitoring of exchange rates and expenditure, will enable early warning of forex impact on the project. DFID will be consulted if a significant impact on the project is anticipated.
High Availability of Zithromax affecting MDA timing Zithromax supply into Ethiopia is unpredictable and the GoE decides where stocks will be used.
Mitigations Orbis will try to plan MDA campaigns at a point in the DFID financial year, so that delays will not push expenditure into the next year. DFID will be consulted if a significant impact on annual project expenditure is anticipated.
High Unpredictable Ethiopian Inflation Rate The actual Ethiopian inflation rate could outstrip the forecast rate used for the project budget, which is based on official rates.
Mitigations Orbis will actively track Ethiopian inflation and its impact on project costs. Early warning to country management of potential or actual problems. DFID will be consulted if a significant impact on the project is anticipated.
High Changing official population figures affecting MDA planning Whilst estimated population growth is 2.93% per annum, Zithromax is made available based on latest official figures, which may show more or less growth.
Mitigations Orbis will plan and budget for 100% population coverage, so that our typical 95% coverage can be managed within the budget envelope.
Medium Ethiopia civil unrest There is a risk of further civil unrest and government response (e.g. a state of emergency) as in 2016.
Mitigations Regular review of security protocols by the Country Director and HQ; good relationships with authorities; information on security from project areas; insurance in place; clear communication for staff to follow government directives (e.g. on curfews)
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Medium Significant change in planning figures This project has been planned using the latest available figures – from the 2013 GTMP and the 2006 National Blindness survey. A new national survey is planned for 2018 and the results could be significantly different.
Mitigations Orbis will play a major part in the new survey and will be in a good position to have early sight of the new figures for replanning purposes. DFID will be consulted if a significant impact on the project is anticipated.
Medium Government humanitarian responses delay programme activity Drought, crop failure, food shortages and disease outbreaks are a perennial issue in Ethiopia. The government can mobilise any staff to such humanitarian crises.
Mitigations Orbis will monitor the weather, food security situation and disease outbreaks to anticipate possible delays and to inform planning. Higher outputs will be worked for before or after such humanitarian crises.
Medium Government staff attrition Despite formal agreements to retain GoE staff for a reasonable period after training, there is an expected attrition rate from those working in rural areas.
Mitigations Orbis will train higher numbers of staff where possible, in anticipation of attrition. Ensure adequate incentive and retention mechanisms are in place for eye care staff.
Medium Relationship difficulties with GoE departments As this project will and can only be delivered through working with the FMOH and Regional Health Bureau, a breakdown in relationships would have a major impact.
Mitigations Orbis will maintain the existing strong working relationships. MoUs will be in place with all departments, with clear roles and expectations. Senior GoE officials are involved in planning and review meeting and in evaluations.
Medium Fraud in Orbis or government partners Fraud is always a possibility in field work, when many project transactions need to be in cash due to a lack of banking facilities.
Mitigations Robust financial controls; advances only made when needed, to keep amounts small; annual internal & external audits; project accountant works with GoE finance to support strong financial systems; on-the-spot checks of GoE department finances.
Low Insufficient WASH expertise in SNNPR It may not be possible to secure sufficient support from WASH actors.
Mitigations Orbis has an experienced WASH expert in its team and currently works successfully with various WASH actors in other parts of SNNPR – and we will engage with two of them after the proposal process to ensure the support is available if necessary.
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Low Project vehicle breakdown Working in remote rural areas is tough on project vehicles. Vehicle management and regular preventive maintenance is required to prevent breakdown.
Mitigations The project has budgeted for two new vehicles to meet project travel needs and to minimise this risk.
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Summary Budget Total: £2,219,034 Project Funding Expense Year 1 Year 2 Total Staff 0 0 0 Facilities & Equipment 0 0 0 Accomodation & Admin Costs 0 0 0 Technical Assistance 0 0 0 Travel 0 0 0 Core Funding Expense Year 1 Year 2 Total Staff 0 0 0 Facilities & Equipment 0 0 0 Accomodation & Admin Costs 0 0 0 Technical Assistance 0 0 0 Travel 0 0 0
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