PROJECT AXXES
Final Report
(September 2006 - September 2010)
Integrated Health Services Project (Project AXxes)
USAID Cooperative Agreement No: 623-A-00-06-00058-00
Democratic Republic of Congo
50 1960-2010
Advancing Health. Saving Lives. 50 Years.
with implementing partners:
TABLE OF CONTENTS
ABBREVIATIONS ...... iv
EXECUTIVE SUMMARY ...... 1
I. Component A: Increased Quality of Care ...... 4 A.1 Increased Access and Quality of Care ...... 4 A.2 Family Planning and SGBV Services ...... 8 A.3 Improved Maternal Health and Newborn Services ...... 12 A.4 Improved Child Health Services ...... 16 A.5 Reduced malaria in target population ...... 20 A.6 Improve TB detection and treatment ...... 22 A.7 Improved HIV/AIDS Prevention ...... 24
II. Components B and C: Health Systems Strengthening ...... 26 B.1 Development of the Health Zone ...... 26 B.2 Development in the sector of pharmaceutical supply and usage ...... 27 B.3 Development (Reform) of financing health ...... 27 B.4 Development of human resources in health ...... 27 B.5 Reinforcement of the Health Management Information System (HMIS) ...... 29 B.6 Reinforcement of governance and leadership ...... 30 B.7 Reinforcement partnerships and utilization of small grants ...... 31 B.8 Capacity in surveillance and response to epidemics ...... 32
III. Consortium and Project Management ...... 33 C.1 Implementing Partners ...... 33 C.2 Technical Consultants ...... 33 C.3 Procurement ...... 34 C.4 Cost Share ...... 34 C.5 Operational Research ...... 34 C.6 Environmental Mitigation and Monitoring (EMM) ...... 35
IV. Lessons Learned during the AXxes Project...... 36
ANNEXES
Annex 1: Project AXxes Success Stories Annex 2: Project Indicators (by project year) Annex 3: Health Facilities Rehabilitation Annex 4: Procurement and Shipment of Commodities Annex 5: Material and Equipment Distribution by Health Zone Annex 6: Operational Research Study on Uptake of PMTCT Services
ABBREVIATIONS
AIDS Acquired Immune Deficiency Syndrome AC Animateur Communautaire ACT Artemisinin-Based Combination Therapy AMTSL Active Management of the Third Stage of Labor ANC Antenatal care BASICS Basic Support for Institutionalizing Child Survival BCC Behavior Change Communication BCZS Bureau Central de la Zone de Santé (Health Zone Central Office) BDOM Bureau Diocésain des Œuvres Médicales CCIA Coordination Committee inter agency CCIH Christian Connection for International Health CDR Centrale de Distribution Régionale CDT Centre de dépistage et traitement C-IMCI Community-Based Integrated Management of Childhood Illnesses CODESA Comité de Développement et Santé COSA Comité de Santé COP Chief of Party CPON Post-Natal Consultation CRS Catholic Relief Services CSOs Civil Society Organizations CYP Couple Years of Protection DCIP Dépistage et Conseils Initiés par le Prestataire DHIS District Health Information System DOCS Doctors on Call for Service (a.k.a. DOCS HEAL Africa) DPT Diphtheria Polio Tetanus DMO District medical office DOTS Directly Observed Treatment Strategy DQS Data Quality Surveillance DRC Democratic Republic of Congo (also DR Congo) ECC The Protestant Church of Congo ECZ Health management team of health zone EPI Expanded Program on Immunization FBO Faith-Based Organizations FP Family Planning GBV Gender Based Violence GAVI Global Alliance for Vaccines and Immunizations GESIS Gestion du Système d‟Information Sanitaire GHC Global Health Conference HC Health Center HGR General Reference Hospital Hôpital Général de Référence HISP Health Information System Program HIS Health Information System HIV Human Immunodeficiency Virus HKI Helen Keller International HZ & HZMT Health Zone and Health Zone Management Team ICC Interagency Coordination Committee IMA IMA World Health (Interchurch Medical Assistance Inc.) IMCI Integrated Management of Childhood Illness (PCIME in French) IPT Intermittent Preventive Treatment IPS Inspection Provinciale de la santé (Provincial Health Office) IRM Innovative Resources Management ITNs Insecticide Treated Mosquito Nets IUD Intra Uterine Device JHU Johns Hopkins University KPC Knowledge Practice Comportment LLIN Long-Lasting Insecticidal Nets (also known as ITNs) LQAS Lot Quality Assurance Sampling MCZ Heath Zone Medical (Medecin chef de Zone) MID Médecin Inspecteur de district M&E Monitoring and Evaluation MAO Méthode d'Auto-Observation (natural FP method) MAMA Méthode d'Allaitement Maternelle et Aménorrhée (natural FP method) MOH Ministry of Health MSH Management Sciences for Health NGO Non-Governmental Organizations OMS Organization Mondiale de la Santé ORT Oral Rehydration Therapy OFDA Office of Foreign Disaster Assistance PCIME Integrated Management of Childhood Illnesses (IMCI in English) PEV Programme Elargie de Vaccination (EPI in English) PMA Paquet Minimum d‟Activité (Minimum Package of Assistance) PMP Performance Monitoring Plan PMTCT Prevention of Mother-to-Child Transmission of HIV PNLMD Programme National de Lutte contre les maladies diarrhéiques PNLS Programme National de Lutte contre le SIDA (National AIDS Program) PNLT Programme National de Lutte contre la Tuberculose (TB National Program) PNTS Programme National de Transfusion Sanguine (National Blood Safety Program) PNLP Programme National de la lutte contre le Paludisme PNSR Programme National de la Santé de la Reproduction POPPHI Prevention of Postpartum Hemorrhage Initiative PRONANUT National Program for Nutrition RECO Relay Communautaire (Community Relays) RHS Reproductive Health Services SEA Superviseur en Eau et Assainissement SOW Scope of Work SPHK School of Public Health School of Kinshasa STI Sexually Transmitted Infections SANRU Health Development Program based on the SANRU I, III & III projects SNIS Système National d‟Information Sanitaire (National Health Information System) TA Technical Assistance TB Tuberculosis TOT Training of trainers UNC University of North Carolina UNICEF United Nations Children's Fund UNFPA United Nations Fund for Population Activities VCT Voluntary Counseling and Testing VFR Vaginal fistula repair WHO World Health Organization WRC World Relief Corporation WVI World Vision International EXECUTIVE SUMMARY
The Integrated Health Services Project (Project AXxes) was a four-year $60 million dollar USAID- financed primary health care project designed to revitalize select health zones across the DRC. The main goal of AXxes was to provide integrated development assistance for primary health care health systems strengthening based on the “global assistance” strategy of the Ministry of Health.
1. Selection of Health Zones
The project initially assisted 60 health zones from among a list of 80-90 priority zones selected by USAID in the Kasai, South Kivu, and Maniema provinces and listed in the RFA in May 2006. That number was later revised to 57 health zones post-award following the discovery of significant assistance by a European donor in some of the selected areas and departure of one of the original implementing partners (Merlin). See the annex for a detailed list of the final 57 zones.
2. History of Assistance
The project underwent several revisions in its four year history: 25 Sep ‟06: Signature of Cooperative Agreement (CA) for 40M USD. 30 Sep ‟07: Revision of Cooperative Agreement to include PMTCT increasing CA to 42M USD. 27 Oct ‟09: Revision of Cooperative Agreement w/one year extension increasing CA to 60M USD. 29 Oct ‟10: No Cost Extension of three months until 30 Jan 2011.
3. Implementing, Technical, and Collaborating Partners
IMA World Health, the prime agent, managed a consortium of three Implementing partners and eight Technical Assistants to achieve project objectives. Three international implementing partners were chosen based on their past history of health zone assistance and development work in the DRC and were assigned HZs in clusters (by province) based on their past work, current facilities, and the presence of national partners.
These were:
Eglise du Christ au Congo (SANRU) - 12 HZs in East & West Kasais - 9 HZs in Katanga
Catholic Relief Services (CRS) - 21 HZs in South Kivu
World Vision International (WVI) - 7 HZs in South Kivu - 8 HZs in S. Katanga
Six Technical Partners were chosen based on their proven accomplishments in strategic areas and familiarity with the unique challenges and constraints of working in the DRC. These were:
Helen Keller International (HKI): Micronutrient (Vitamin A and Zinc) support Johns Hopkins University (JHU): Health Information System data base for the MOH Health Information System Program (HISP): DHIS (collection and analysis of HZ data) Management for Science Health (MSH-SPS): Oversight of Pharmacy depots and drug purchasing/credits Dr. Lauren Blum: Care Seeking Behavior and Operational Research Dr. Frank Baer: Program design, assessment, and evaluation
In addition the project collaborated with and benefited from four USAID provided technical partners. These were:
C-Change: Community mobilization for change and increased uptake of FP Safe Blood for Africa: Provides HIV test kits for the transfusion package PROVIC: Technical assistance in PMTCT BASICS and MCHIP: Newborn and Maternal Health, Implementation of Community Care Sites TB UNION and TB CAP: TA for the TB diagnosis and treatment
4. Scope of Assistance
Project AXxes provides health zone development assistance through three major components:
Component A: Increase access to, quality of, and demand for multi-sectoral, integrated PHC; Component B: Increased capacity of the health zone and the referral system; and Component C: Increased capacity of national health programs and provincial and district offices
5. Focus of Assistance and Concentration
Approximately 2/3 of the health zones at project inception were nonfunctional or had limited services by conventional definition of a functional health zone. The project‟s assistance to 57 health zones therefore focused foremost on the MOH priority package of PHC interventions. This included reinforcement of vaccination services, provision of pharmaceuticals and supplies to hospitals and health centers, delivery of a full complement of maternal and child health services including family planning, and newborn and postpartum care. In addition, vitamin A and Zinc supplementation along with newer protocols such as TPI and GATPA were instituted project- wide.
All zones received training and were equipped in the prevention of HIV/AIDS and STIs, malaria diagnosis and updated treatment and management of re-emerging diseases such as tuberculosis and regular surveilance of epidemics. Significant resources were committed to the elaboration of water and sanitation systems and rehabiliation of health facilities. The project established or revamped 137 PMTCT clinics to include updated WHO protocols such as triple ARV therapy. Support systems on
2 the national, provincial, and health zone level included planning and management, health facility rehabilitation, training and supervision, supply line and cost recovery, and information and surveillance systems.
A summary of key Project Accomplishments across the four project years includes:
1) Rehabilitation of 217 health facilities and construction of 130 facility incinerators 2) Cumulative training of more than 33,000 health workers at all levels 3) Attainment of a 44% curative care utilization rate (up from < 30% in year one) 4) 1,276 fistulas repaired in projects years two, three and four 5) More than 1,000,000 antenatal visits (331,649 in year four versus 189,632 in year one) 6) 661,839 pregnant women received Intermittent Preventive Treatment for malaria (212,896 in year four vs. 112,511 in year one) 7) Distribution of more than 1 million ITNs through prenatal and growth monitoring clinics 8) 618,500 women received assisted delivery with Active Management of the Third Stage of Labor(AMSTL) protocol (282,948 in year four vs. 7,094 in year one) 9) Integration of SGBV interventions into the package of primary health care activities in health facilities throughout all 57 supported health zones 10) 849,306 new acceptors of a new method in family planning (283,166 in year four vs. 26,074 in year one) 11) More than 200,000 pregnant women received HIV counseling in 137 PMTCT clinics 12) Prevention of HIV mother-to-child transmission in 983 HIV + women 13) 13,555 partners/husbands of pregnant women received HIV counseling and testing and received results (7,783 in year four versus zero in year one) 14) 818,368 children vaccinated for measles (251,343 in year 4 vs. 123,638 in year one) 15) Detection of 37,823 cases of Tuberculosis 16) 310 community care sites established and functioning at year‟s end vs. 25 in year three (the first year of that initiative) 17) Construction of 629 spring caps, 196 facility latrines and 6,313 community latrines. 18) Procurement, importation, and delivery of more than 100 air and sea freight shipments via Kinshasa, Bukavu and Lumbumbashi.
3 I. COMPONENT A: INCREASED QUALITY OF CARE
A.1 INCREASED ACCESS AND QUALITY OF CARE
Overall Objective and Indicators Utilization of Curative Services
A key Project AXxes objective was to increase utilization of health care facilities, or the percent of the population that visits a center once a year. This was particularly challenging in the context of transitioning from a relief mode (which existed in the majority of conflict zones) to a developmental mode of assistance.
Key interventions implemented over the life of the project to improve the curative care utilization rate included retention and training of personnel, provision of much needed diagnostic and treatment equipment, continued supply of essential medicine, rehabilitation of structures, and establishing a reasonable and fixed tariff system. The significant subsequent progress throughout the project life is shown in the graphs at right and below. Key strategies are explained in the following narrative.
Utilization of Care
At the outset of the project, many health zones (particularly in South Kivu) were providing free or heavily subsidized health care to the population through relief-oriented NGOs such as Malteser, MSF, and IRC. It is well known that access rates approach 80-90% when there is no or minimal cost for care, and then plummet when health care is based on market rates. Project AXxes had the unique challenge of Utilization of Care by Project Year transitioning over 20 health zones from relief mode to development mode while maintaining utilization rates. The average rate for utilization of care in the DRC was 15% at project inception (World Bank report 2005). AXxes set a project objective of 35%. As can be seen in the “Utilization of Curative Services” graph above, that rate fell sharply upon curtailment of relief services from European NGOs then increased as USAID-funded services were established and health systems were strengthened, including referrals systems. This Project AXxes achievement was highlighted in a USAID news story, “USAID Assistance Reduces Maternal and Infant Mortality in the DRC” (see box story on next page).
The objective of 35% was surpassed in year four and maintained above 40% through project completion. This was higher than at the onset when relief care was prominent in AXxes areas—a key achievement of the project! A number of co-factors discussed below contributed to this achievement.
4 Drug Credit System
The hallmark of health zone development is a reliable and sustainable supply-chain of pharmaceutical products. In line with the MOH system of CDRs (regional pharmacy depots) the project created or reinforced five CDRs and supplied them with over 5M USD of pharmaceutical products over the project life. The depots in turn served all 57 health zones based on a line of credit system. Recipient institutions were required to return a percentage of their proceeds from patient care back to the CDRs; these monies were in turn used to place new orders.
This revolving system of supply, serving, payment, and re-supply was functioning in all five depots at project‟s end. Contributing to the success of this system was the engagement of MSH-SPS, which was contracted to assist with ordering, drug management at the CDR level, and oversight of the drug credit system. In addition, IMA procured and imported during this four year period over 100 shipments of pharmaceutical products and delivered them through a complex system of rail, boat, truck, and barges with implication of local partners and project oversight; a significant accomplishment in supplying vital products to a population of over 8 million persons.
A significant strength of Project AXxes was the procurement, importation, and delivery of commodities. We believe the relative investments made in commodity purchases (~ 6M per year) compared to other projects provided a significant edge to Project AXxes and was the „fuel‟ behind nearly 90% of our indicators. Training, equipping, program design, and facility rehabilitation are critical factors; but without commodities such as A Logistical Success Story drugs, test-kits, gloves and syringes, services cannot be rendered in the quality or quantity desired.
A common weakness of the system was the ability and willingness of health zones to reinvest 20% of the proceeds from patient care (and related pharmaceutical use) back into the CDRs for purchase of medicine. Some were very collaborative and invested more than expected, but many re-invested far less than the required 20%. In year four the project pro-actively enforced this co-payment by deducting the 20% from operating subsidies and placing a global drug order in the 3rd quarter which has been For the full story see Annex 1 distributed to health zones.
5 A significant weakness of Project AXxes at the start and finish of the project was the delay in pharmaceutical procurement; a delay in large part caused by the constraints and time involved in securing waivers. USAID shares this responsibility with IMA. In year one, there was significant criticism of the project for late-start up and implementation due in large part to absence of commodities. It took over six months to secure the initial drug waiver and two to three months for international procurement and container delivery to the DRC.
Activities progressed once drugs were in the system, but project managers needed to keep a close eye and pulse on drug supplies. Project AXxes contracted MSH-SPS to monitor both drug use & supply and work with regional depots and coordinators to put together drug orders. Their role was critical and extremely useful.
In year four we had the same issue. With less than four weeks before project closure in August 2009, USAID informed IMA of a one year 20M USD cost extension based in large part on a favorable mid- term evaluation done by USAID. The project, which was running at full speed, would have approximately six months left of commodities to maintain program activities. A waiver request was drawn up and submitted within one week of notification of the cost-extension, but approval took more than six months—at which point the project, taxed by the creation of community care and other sites and increased activities, was running low on commodities.
The process, as we understand it, was held up largely by USAID-NBO. Legal counsel of NBO had issues with our list of essential drugs even though they were identical to the previous two years. The project responded to each request for clarification, writing lengthy explanations and having the MOH affirm the need for each drug, but it often took weeks before we had a response to our answers. It was the most frustrating and trying part of the year. The waiver finally came on March 1st, over six months after request. Knowing it can take four to six months to bring commodities to their final destination, MSH-SPS worked with project staff in creating a series of urgent air shipments to cover gaps, yet incurred over $100,000 in excess transport costs. Given the sheer weight of the orders (newborn kits, antenatal kits, maternal-child kits, health center commodity kits, vaccination kits, essential medicine, ITNs, and diagnostics) the final containers are arriving literally at project end. This resulted in multiple stock outs, but thanks to strategic redeployment and borrowing of commodities, the project continued to increase overall performance.
The silver lining to the late arrival of commodities is that IHP project will start off with 2M USD of commodities. In addition, IMA was also asked by PMI to manage the importation of nearly 100 tons of malaria drugs, tests, and nets in the final two months of the project—all of which have been turned over to the new project. While it is unusual for any new project to have that level of start-up support, we are pleased with the level of assistance lent to the new recipient, especially knowing our common goal of delivering vital and quality services to a population of over 13 million persons in need.
Rehabilitation of Health Facilities
The table at right summarizes the significant achievement in Health Facility Rehabilitations rehabilitating 217 health centers during the four-year project life. Implementing Health center Key strategies that led to success in this activity included asking Partner Rehabilitations health zones to prioritize sites for rehabilitation, engaging CRS 83 community health boards (CODESA) in the elaboration and ECC 67 follow through of such projects, and using competent local contractors paid according to a set timeline of objectives. Some WV 67 of the results, as exemplified by the following pictures, have TOTAL 217 been no less than spectacular.
Other rehabilitation work, including capping of water springs, installation of cisterns, construction of latrines and incinerators, is highlighted in the WATSAN section of this report.
6
Nguba HC Fungurume HZ before and after rehabilitation
Buziba in Mwenga HZ, South Kivu
Challenges included supplying remote sites with A Solar Lighting Success Story durable material such as roofing and cement and maintaining construction during periods of conflict. However, the significant physical improvements to facilities, including expansion, lighting, security, reception, and space, made a notable difference in the population‟s access and ownership of local care, and was a significant accomplishment.
Equipping of health care facilities
At the onset of the project a „needs assessment‟ was done in every health zone to determine the availability of hospital and health center equipment such as delivery tables, operating room Read the full story in Annex 1 equipment, health center diagnostic/treatment material, cold chain, bicycles, motorcycles, and communication equipment. In years one and two,
7 significant container orders of such durable equipment was procured for these facilities, particularly for solar lighting and refrigeration.
Quality of Care Studies
IMA contracted Dr. Lauren Blum, a medical anthropologist to design and carry out several studies related to care seeking behavior. One study looked at care-seeking behavior and barriers to care for sick children in two different provinces (see table below). Another study, in conjunction with the project‟s reproductive health program, examined social and economic factors associated with the development of fistulas and care seeking behavior. Highlights of these studies are noted in the operational research section of this report. Copies of these studies and results are posted on the project website: http://sanru.org/projects/axxes_reports.htm.
Household Decision-Making for Care Seeking
Decision Made by: South Kivu Kolwezi Mother 34% 14% Father 6% 6% Father and Mother 37% 60% Other 23% 20%
C-Change
In year four of the project, USAID commissioned C-Change (Communication for Change) to work with project personnel in select zones to increase community awareness and uptake of family planning services. During that period, C-Change worked in 8 health zones in the Kasai and Katanga provinces focusing on family planning and four health zones in South Kivu. This resulted in a significant increase in counseling for family planning in the pilot health zones in the last six months. We anticipate that this will to a parallel increase in family planning acceptance which unfortunately was not seen during this reporting period.
A.2 FAMILY PLANNING AND SGBV SERVICES
Overall Objective and Progress
The provision of high quality, integrated and accessible family planning services was another key objective of Project AXxes. Family planning (FP) interventions in Project AXxes are focused on promoting birth spacing and avoiding unwanted pregnancies to improve maternal health and child wellbeing. Targeted interventions focus on service delivery for women (provision of a full complement of family planning methods, training of clinical providers, and increasing accessibility at the community level) as well as promoting family planning and helping communities understand the value of family planning as a component of good health. SGBV interventions are focused on the recognition of gender-related issues in the DRC, and prevention of gender-based violence.
Couple Year Protection Rate
The CYP evolution is among the most dramatic graphs in this report; but the reader should be aware that part of the exponential increase in these Family Planning graphs is related to reinforcing the use of natural methods and improved reporting of all methods. In particular, two methods (MAMA and MAO) account for more than 50% of the increase; but even with these removed, the project exceeded
8 its target in CYP rates. Moreover, the inclusion of MAMA and MAO in both counseling and reporting serve to introduce the important concept of family planning and to integrate reproductive health care services at the facility level.
Nearly every woman is counseled on MAMA postpartum, and then at her six month visit she is Couple Year Protection given options for other methods of family planning—a normal step from natural to modern methods. Other methods which increased the CYP and will sustain it for the future dependent on commodity flow (a historic hurdle in the DRC) include condoms, cycle beads, Depo-Provera, pills, and surgical methods. It has been the project‟s guiding principle to provide counseling on all methods and provide the method of choice to each client.
Aside from an assured supply chain, another challenge in this context has been cultural pressures ascribing worth to number of children and a history of needing partner consent for family planning. With work by trained counselors, relays, C-change, and the new DRC constitution, such age-old biases are breaking down. This should pave the way for higher and sustained CYP rates in the future. This groundbreaking work and elevation of CYP from nearly zero to 90,000 per quarter is regardless of methods; a phenomenal accomplishment of Project AXxes.
New Acceptors New Family Planning Acceptors The rate of new acceptors refers to the number of new FP acceptors in USG- supported family planning clinics. This number has increased steadily from Q1 to Q16 as seen in the graph at right. During the introduction of random data quality audits (year two) by partners and health zones alike to verify data and check outliers, a problem with methodology was detected in South Kivu which when corrected gave the readjustment in Q11 with subsequent return to a normal growth curve. Successful strategies that have contributed to the growth of this indicator include:
1. Quarterly review sessions in clusters with all family planning workers and HZ authorities to discuss methods and validate data 2. Implication of Community Relays in the promotion of family planning on a village level 3. The design and printing of family planning promotional tools such as pamphlets and flipcharts 4. The integration of family planning into community care sites and continued supply chain from USAID in modern contraceptives.
9 Challenges will be not only maintaining that system but also improving purchasing power and social marketing of such commodities in non-urban settings.
Fistula Care
A significant contribution of the AXxes project to reproductive health was raising the awareness of fistula incidence in the DRC and working to both prevent and treat this disabling problem. The majority of fistulas in the DRC are obstetrical-related, despite the horrific press coverage and attention given to traumatic fistula development in Eastern DRC.
Activities undertaken related to fistula prevention and care included:
1. Increased training in assisted births and established protocols for transfer 2. Creation and support of both mobile and hospital-based fistula repair teams 3. Research on co-morbid factors associated with fistula development and subsequent obstacles to care 4. Partnership with EngenderHealth and co-sponsorship of two national conferences in raising the awareness and creating strategies to address this problem.
Although AXxes is pleased with the number of fistula cases repaired in four years and that the project was the third largest source of fistula repair in the DRC after Panzi Hospital (Bukavu) and Heal Africa (Goma), we recognize that these numbers are just the tip of the iceberg; much work remains to be done. A significant accomplishment of Project AXxes was not only in work performed, but also in awareness raised, stakeholders engaged, and prevention methods instituted.
Summary of Fistulas Repairs (Project Year 2 to Year 4)
Year Year Year Year Districts/Provinces Sites Total 1 2 3 4 Haut Lomami HGR Kabongo (Mobile Clinic) 41 29 126 196
South Kivu HGRs Panzi & Kaziba (HGR based) 247 234 163 644
Sankuru HGRs Lodja & Kole (Mobile Clinic) 1 122 116 239
Kolwezi Kolwezi (Mobile Clinic) 18 66 84
Kananga HGR Tshikaji (HGR based) in fistulascare 51 57 108
Mbuji Mayi HGR Dibindi (HGR based) 3 2 5
Total Trainingof doctors and nurses 361 442 473 1,276
During the first year, Project AXxes supported the training of doctors and nurses in surgical fistula repairs at training facilities such as IMCK and Panzi Hospital. By year two, FVV repairs were being done in outlying facilities such as Ibanda, Shabunda, Kabongo, and Dibindi hospitals. The project noted, however, a high turnover rate of those trained who gravitated toward better paying positions in urban settings and even outside DRC. Midway through the project we changed our focus to creating and supporting mobile clinics, which served the dual purpose of meeting critical needs while training personnel at visited facilities.
10 Gender awareness and prevention (SGBV)
The aim of SGBV interventions in Project AXxes was to identify and overcome the negative social attitudes toward women as related to incidents of gender-based violence and other acts of discrimination and bias, including forced or early marriage, missed opportunities (e.g. schooling), limited choices in reproductive health, coerced sexual encounters, and teenage pregnancy. Key strategies involved community-based activities such as sponsorship of focus groups, women‟s forums, community leader workshops, and school and youth groups aimed at uncovering and addressing the issue of gender bias and its negative social impact.
The project supported local NGOS including FODESA and Olami Center to:
1. Promote the active participation of women in health center management 2. Train hundreds of community and institutional leaders 3. Work with law enforcement personnel in promoting gender rights.
Radio messages and printed material (including over 10,000 calendars) were other methods used to mitigate the harmful attitudes of gender bias and discrimination. The picture below was featured on the 2009 SANRU Calendar and funded by Project AXxes.
The 2009 SANRU Calendar Featured a Theme on Gender-Awareness
The larger impact of Project AXxes has been the successful integration of SGBV interventions into the package of primary health care activities in health facilities in its 57 supported health zones aimed at the detection of harmful behavior and attitudes as well as the promotion of community-wide behavioral change.
11 A.3 IMPROVED MATERNAL HEALTH AND NEWBORN SERVICES
Objectives and Progress
Comprehensive and quality maternal and newborn care were key objectives in the AXxes project. Targeted interventions include Birth Preparedness and Maternity Services (ANC, Assisted Birth AMSTL, CPON) and New Born Essential Care (New Born Resuscitation Care and Antibiotics). As previously discussed, fistula prevention and care were other components of the maternal package. Evolution of these services, key strategies, and challenges are discussed below.
Antenatal Care (ANC) Utilisation of Prenatal Clinics
Improvement and support of antenatal care services has been one of the pillars of the AXxes project‟s preventive health services, along with vaccination and well child care. Prenatal clinics in DRC traditionally have a high attendance rate, but women typically come late (in the third trimester) and interventions have been limited to weight and blood pressure checks. The project position has been that prenatal visits are not charged for individually, but rather their global costs are integrated into standard delivery fees. Further, the project provides to women—without supplemental costs—important amenities such as SP for malaria prevention in the second and third trimesters, mebendazole, tetanus vaccination, multivitamins with folic acid throughout pregnancy, and LLINs.
ANC clinics provide the first setting for family planning counseling, and by project‟s end 137 Prenatal Clinic Attendance by Project Year of these clinics had comprehensive PMTCT services. In addition, community relays and health leaders with project support used communication and other tools (counseling cards, CPN cards and flipcharts) to encourage and document early and regular attendance at such clinics. Consequently, ANC rates rapidly reached 100% and were even attracting clients from outside the health zone to USAID- supported facilities—a unique accomplishment of Project AXxes.
Assisted Delivery
A significant challenge and accomplishment of the AXxes project was to ensure that women had assisted delivery by trained personnel in equipped centers. Births unattended by trained and unequipped personnel are associated with significant maternal and fetal mortality and morbidity secondary to problems such as unrecognized
12 dystocia, obstetrical hemorrhage, toxemia, tetanus, and sepsis. At project inception the global rate of assisted deliveries hovered below 60%; at project‟s end a rate of nearly 90% was achieved. A multiplicity of factors contributed to this achievement, including capacity building of healthcare workers, significant investments in rehabilitation of maternities, and the procurement of equipment, delivery tables, lighting, and commodities. There is no parameter in the national reporting system (SNIS) to accurately record past and present maternal and fetal mortality—a weakness that should be overcome in the next phase by working with the MOH to develop community-based registers of births and deaths. Though such results are currently immeasurable, we believe that lives saved through such interventions are significant and sustainable.
Assisted Deliveries: Coverage by Project Quarter Assisted Deliveries: Numbers by Project Year
Active Management of the Third Stage of Labor (AMTSL)
The AMTSL or GATPA protocol refers to the active management of labor and delivery and includes the use of empiric oxytocin injection to stimulate uterine contractions and avoid postpartum hemorrhage, a leading cause of maternal death in developing nations. Like assisted deliveries above, this intervention was rapidly undertaken by supported facilities and became the standard of care for not only AXxes but other health zones as well (where the rate is notably lower).
Contributing factors to this success have been:
1. Capacity building of healthcare workers and their supervision 2. Successful adaption of national data recording and collection sheets 3. Adequate supply of oxytocin in all the health zones 4. Posting of the GATPA (AMTSL) protocol and instructions for prevention of postpartum hemorrhage in all birthing centers.
13 The project target that 100% of assisted births follow the AMSTL protocol was intermittently hampered by stock-outs of Oxytocin—a commodity that is temperature and time sensitive. The project made herculean efforts to maintain this stock, including installation of solar refrigerators throughout health zones and even emergency procurement of a $40,000 order when there was a temporary product recall due to production concerns. This is one indicator that is strongly dependent on outside assistance and merits ongoing support and maintenance.
AMSTL: Coverage by Project Quarter AMSTL: Numbers by Project Year
Post-Natal Care Visits by Project Year Post-Natal Consultations (CPON)
CPON, or postnatal care, involves comprehensive postpartum care during the first 72 hours post birth. Aside from important monitoring of the health of mother and child, CPON visits are essential for teaching and counseling in practices such as exclusive breastfeeding, nutrition, hygiene, and family planning. The project has met and exceeded targets in this endeavor. Women who have facility-based and assisted births benefit from this important intervention. A continued challenge is the non- integration of this activity into the national reporting system (SNIS) and the need to extrapolate data from other birth-related activities.
14 Newborn Care (and integrated care of mother and Newborn Care by Project Year child)
Integrated care activities for the mother and newborn are important project components that were successfully introduced in the latter half of the project and well integrated by project end. The project, along with MCHIP and the MOH, laid the groundwork for essential care of newborn and mother in 2007 with the “Specific Working Group” on 18 July 2007 and a “Consensus Workshop” in October 2007.
Aside from the adoption of strategies to support and monitor the health of mother and newborn (SNME) a number of modules were designed, printed, and distributed. These included a Reference Manual, Facilitator‟s Guide, Participant Workbook, Clinic Registers, and Guide for Trainers of Community Relays.
The purchase of mannequins, durable equipment and training of provincial and district wide teams with TA from BASICS and MCHIP allowed for the rapid uptake and dissemination of these important protocols. By project end, strategies for the care of newborns (including provision of hundreds of newborn resuscitation kits) and integrated care of mother and child were instituted in all 57 health zones—a significant achievement of Project AXxes.
NB Care & Monitoring Training by MCHIP and AXxes in WV-assisted HZs, Kolwezi district (March 2010)
15 A.4 IMPROVED CHILD HEALTH SERVICES
Objectives and Progress
The objectives of the Child Health Services component of Project AXxes include the reinforcement of routine vaccination services including Data Quality Surveillance (DQS), application of C-IMCI strategies for child pneumonia and diarrhea, support of child nutrition strategies, implementation of community care sites to increase access to care, and support of clean water and hygiene programs. Malaria prevention and cure is discussed in the next section.
Immunization: DPT3 EPI Coverage by Project Quarter
Project AXxes utilized the "RED Approach" (Reach Every District) in its strategies to reinforce child vaccination including planning and resource management, reaching all populations (including those with difficult access), monitoring, supervision, and strengthening links with the community. The project used DPT3 (the national marker) to gauge success of overall vaccination.
As can be seen in the graph at right, vaccination rates climbed quickly to the target of 92% by the third quarter of year one and remained nearly at 100% throughout the project. Low points were attributed to a national health worker strike (Q10) and periodic stock-outs of vaccine. The project overcame challenges by reinforcing the cold chain (petrol subsidies, spare parts, and purchase of over 100 solar refrigerator units), emphasizing strategic planning, taking possession of vaccine at the national level (PEV) and ensuring its transport to regional areas, and promotion of mini and acceleration campaigns.
IMA was instrumental in receiving and distributing donations of more than 2 million syringes from Becton Dickenson (see box story below). When such support is available, attaining rates near 100% is readily achievable.
Routine Data Quality Audit
As part of monitoring the quality of immunization data, AXxes, with support from MCHIP, reinforced the concept of DQS to verify vaccination numbers. Such tools were already being used to verify other interventions such as family planning (CYP) and malaria (TPI).
See Annex for the full story 16 At the health zone level DQS was used to compare EPI Numbers by Project Year recorded versus actual levels by randomly selecting health centers. This verification process yielded „ratios‟ between verified data and reported data. A ratio below 100% indicates an over-reporting rate whereas ratios above 100% reflect an under-reporting rate.
By convention, ratios between 90% and 110% are felt to be indicative of accurate reporting (less margin of error). Audits being done in the latter half of year four were showing results in the 90%-110% range (over and under reporting within limits) which is an affirmation of both good data collection and reporting. It was noteworthy that many HZs by year four were beginning to take ownership of DQS. For individual health zones to have a tested and feasible way to verify data is an important accomplishment of project AXxes.
Clinic-IMCI (Correct treatment of children)
Project AXxes supported both components of IMCI as strategies to address the high burden of under-five morbidity and mortality:
(1) Clinic-Based Integrated Management of Childhood Illnesses (IMCI), or integrated protocols to assess and treat children at health facilities for common diseases (also referred to as the Minimum Package of Activities (PMA) that each functional health facility is expected to provide for children).
(2) C-IMCI, or integrated frameworks for the organization and promotion of community level health activities, which include work done by the Community Relays, Institutional Relays, CODESAs and Community Care sites. The project objective was that 80% of ill children who attend health centers are treated according to such protocols. USAID Investing In People indicators were used to establish and follow the 80% target by following two key childhood illnesses: pneumonia and diarrhea. Using standard formulas (population x 20% x access to curative care) benchmarks were established for the project. In year four, this would mean that 397,000 would present for treatment for each disease. The project nearly attained that benchmark (97%) for childhood pneumonia but not for diarrhea (80%). While it is possible that the true incidence of diarrheal diseases is less than pneumonia, the fact that over 900 health facilities have the training, equipment, and drugs to treat these conditions, as well as the fact that 80-90% of targeted children are brought into treatment, is a significant success and accomplishment.
Pneumonia and Diarrhea: New cases of project year 1 – 4
Disease Year 1 Year 2 Year 3 Year 4 Pneumonia (IRA) 41,923 283,046 365,061 365,312 Diarrhea 33,555 147,187 287,011 249,954
Community Care Sites
One of the recommendations of the mid-project evaluation was to increase access to care by increasing the number of service sites. At the end of year three, Project AXxes partnered with MCHIP and PNLMD to a.) create community care sites where routine childhood diseases such as malaria and other infections could be treated, and b.) further increase uptake of family planning services. Within a
17 15-18 month period, 364 sites were identified and 310 of these sites were staffed, supplied, and operational; and lent a significant increase in service and care. Follow up supervision and monitoring visits by MCHIP and PNLMD continued throughout year four, ensuring correct use of protocols and appropriate data recording. The sites received significant assistance in terms of training, commodities, and oversight (BCZS) by Project AXxes and had a significant impact on access to care by project‟s end—an important and notable success.
Cumulative Number of Fully Functional Community Care Sites year 3-4 CRS ECC WV TOTAL
Yr Q Q Q Q Yr Q Q Q Q Yr3 Q13 Q14 Q15 Q16 Yr3 Q13 Q14 Q15 Q16 3 13 14 15 16 3 13 14 15 16 Identified 72 72 72 72 72 108 180 215 215 215 60 60 77 77 77 240 312 364 364 364 Sites No. of sites 35 37 37 62 72 108 108 147 147 177 54 58 58 70 70 197 203 242 310 340 implemented Sites certified or 25 32 32 60 70 108 108 147 147 177 42 48 49 61 63 175 188 228 268 310 operational
Nutrition (Zn and Vitamin A campaign and routine)
Vitamin A Project AXxes, along with technical advisor Helen A Vitamin A Success Story Keller International, in collaboration with PRONANUT, ensured the roll-out of an annual Vitamin A campaign in every health zone. They also pioneered the use of routine Vitamin A in child care clinics. During the project, over 6 million children (under age five) in project-supported zones received a dose of Vitamin A during such campaigns. By project end, Vitamin A supplementation (according to MOH/WHO protocol) was widely instituted in all centers served by Project AXxes. Such accomplishments required not only timely and constant provision of pharmaceutical product but also both training of health care workers and awareness creation programs carried out by
Community Relays. By project end, both activities achieved high levels of coverage and success—a For the full story see Annex 1 cross-cutting accomplishment of Project AXxes.
Zinc Though approved by WHO, the use of adjuvant zinc in the treatment of diarrhea was neither an established protocol in the DRC nor a practice seen in many facilities. As with Vitamin A, the project, in consultation with HKI and PNLMD, first instituted pilot programs then mass roll-out of zinc in all 929 supported facilities. Zinc became the standard of care when treating diarrheal diseases in children not only in AXxes supported facilities but also across the nation, due in large part to the success in Project AXxes—an accomplishment that has ramifications well beyond project boundaries.
Water and Sanitation
The objectives of the WATSAN component of Project AXxes were to increase the number of persons with access to both improved drinking water and sanitation facilities. Project AXxes accomplished
18 this by working with health zone officials to identify A Water and Sanitation Success Story strategic sites for rehabilitation (spring capping), installation of cisterns and collection systems, and construction of incinerators in selected facilities. Similarly, each health zone identified both community and facility-based sites for construction of latrines.
All such projects required the initiation and planning of local authorities, contribution of local resources, and training in the maintenance and care of such structures. Engaging community stakeholders in finding practical, cost-effective means to provide access to potable water and sanitation engenders local ownership and continuity of such strategies, which need not depend on outside support to meet water and sanitation needs for the For the full story see Annex 1 millions of inhabitants of the project‟s target area.
Summary table of WATSAN achievements (Y1-Y4)
Indicators Total Water Springs Capped 629 Health center latrines constructed 196 Community latrines constructed 6,133 Rain-Water Catchment Cisterns installed 116 Hospital & health center Incinerators constructed 130 Clean villages certified 41
19 A.5 REDUCED MALARIA IN TARGET POPULATION
Overall Objective and Progress
The malaria component of Project AXxes was based on a two prong strategy:
1. Improve malaria treatment at health centers and reference hospitals 2. Improve and promote malaria prevention through IPT and LLINs.
The treatment objective is that 80% of children with fever will be treated promptly and correctly. The prevention objective in years one through three was that 80% of pregnant women receive IPT during ANC visits as well as 60% coverage of LLINs for pregnant women. In the fourth year, the project objective in relation to TPI was maintained at 80%, while LLINs would be provided to all women attending antenatal care clinics.
Long-Lasting Insecticidal Nets (LLINs)
Project AXxes distributed more than one A Malaria Success Story million LLINs to pregnant women and children under five through established prenatal and well child clinics. Of that number, 235,000 nets were provided by USAID/JSI. In addition, 60,000 were given to other projects for distribution (40,000 to Global Fund/ECC and 20,000 to MSH/LMS) for the same purposes.
The presence of LLINs served as a positive incentive for antenatal consultations of pregnant women (ANC) and children (CPS) increasing attendance at both clinics. In the Read the full story in Annex 1 few health zones where Global Fund or other projects provided nets, Project AXxes collaborated with them so that such nets from other donors could be used for other purposes such as school children and social marketing campaigns.
While antenatal clinics had a near 100% coverage rate, the need for LLINS community-wide will continue to be enormous. The challenge with the upcoming PMI initiative and scale up from Global Fund and other donors will be to ensure synergy and coordination so that all vulnerable persons will be served—an endeavor that led to successful net distribution and coverage rates during the four year AXxes program.
Procurement of LLINs by Project Year
Procuring Agent Year 1 Year 2 Year 3 Year 4 Totals IMA 180,000 180,000 180,000 324,100 864,100 JSI 0 0 0 235,000 235,000 180,000 180,000 180,000 559,100 1,099,100
Intermittent preventive Treatment in pregnancy (IPTp)
Intermittent Preventive Treatment in Pregnancy (IPTP) involves the administration of two series of prophylactic doses of SP sulphadoxine - phrementhamine (SP) to pregnant women in order to reduce
20 the adverse consequences of malaria during pregnancy. Project AXxes considers this Malaria Prevention during Pre-Natal Clinics indicator attained only if women receive both doses starting at 16 weeks (second and third trimesters) during pregnancy consistent with WHO guidelines for this method.
As can be seen in the chart at right, there has been a progressive increase in this indicator from year one to year four, culminating in a 71% coverage rate— compared to a national average of 5% (EDS 2007) and the national objective of 50% (PNLP).
The challenges for maintaining this intervention include a regular supply of SP in antenatal clinics and an onset of prenatal care by 16 weeks gestation. The project experienced particular challenges when SP was part of the national treatment protocol and doses were sequestered from (free) prenatal clinics to (fee for service) curative care during stock-outs. This indicator is commodity- sensitive and will depend on a continual source of SP to be provided without added charge to the prenatal package.
A second challenge is that the initial (16 week) dose is dependent on women presenting early in the second trimester for antenatal care. Many women, particularly those who are multiparous, present in the latter stages of pregnancy. Such women typically can receive only one dose, which is insufficient to meet the WHO criteria for this indicator. The importance of starting antenatal care early in the second trimester and receiving full treatment (vitamins and mebendazole) and early protection from malaria (nets and TPI) needs to be reinforced in the promotion of antenatal care by Community Relays.
Number Receiving IPT Number of LLINs distributed by Year
21 Correct care of malaria and use of ACTs
The national protocol for initial treatment of presumptive and uncomplicated malaria changed midway through the project from SP to ACTs. Project AXxes worked aggressively to rapidly integrate this policy in hundreds of hospitals and clinics. This change of policy required training and briefing health care workers, informing community and institutional relays in the importance of health center based treatment (as opposed to self-treatment), and providing a new therapy for adults and children.
Early challenges were the reluctance of providers and patients to adopt a new therapy, and concerns over potential drug side effects. In fact, the first drug order of ~130,000 cures risked expiring due to underutilization. The project campaigned heavily for the use of this drug and cut its relative price (line of credit price) in half and in the end directed CDRs to serve all health facilities regardless of orders. This forward pressure on prescribers caused increased utilization and then near stock-out as uptake escalated.
By the latter part of year four, the number of children treated for malaria surpassed the target of 115,000 by nearly 100% (the actual number of children treated has surpassed 200,000 on average over the past three quarters). Given the increased uptake of ACTs and significantly higher utilization rate, it is estimated that the year four stock will be depleted by the end of the calendar year. As this report is being written, the planned delivery of 3.7 million cures, provided by PMI and imported with assistance from Project AXxes, is a timely contribution and will ensure such treatment levels into the near future—a success story founded on work done by Project AXxes and its collaborators.
A.6 IMPROVE TB DETECTION AND TREATMENT
Overall Objective and Progress
The objectives and indicators of the AXxes project in reference to TB were to detect at least 85% and cure at least 75% of cases. Support to health zones included training, supervision, and supply of TB medicine and diagnostic supplies to diagnostic and treatment centers as well as support of DOTS and community-based prevention. Results achieved over the four year period are given in the following tables:
TB Detection Globale (Q6-Q16) TB Detection by Partner (Q6-Q16)
22 TB Detection
It was estimated that 12,401 persons in the 57 AXxes-assisted HZs would have Tuberculosis (of which 10,635 are in non-hyperendemic areas). The previous charts showed how detection rates soared in years two and three when the project reinforced established detection centers (CDTs) in hyper- endemic areas in Kasai and Katanga Provinces by providing microscopes, training, lab materials, and support of clinics and supervision. The detection numbers were so high that USAID provided the project technical assistance (TB Cap and TB Union) to confirm such numbers and later ensure appropriate follow up and treatment measures.
These high numbers were in contrast to South Kivu province, which throughout the project had detection numbers far below the national average. Reasons hypothesized for such low numbers included issues of security and access; however, other project interventions such as vaccination and family planning implemented in the same area did not suffer the same low numbers. Again USAID provided technical assistance, including a team from USAID Washington, to look at not only CDTs in the South Kivu area but also the geographical scope of TB incidence. They noted that neighboring Rwanda and Burundi, for instance, had significantly lower national prevalence rates of TB (~70 per 100,000) vs. DRC‟s (150 per 100,000), yet South Kivu Province has the same characteristic climate, landscape, and population. If regional incidence numbers were applied, the detection rates in South Kivu would in fact be normal. Such conjoint work with both PNLT and USAID technical advisors helped to explain sizeable variances in rates and to establish benchmarks based on realistic and attainable numbers. The ultimate normalization of detection rates in Katanga province (see chart) is a direct result of hundreds of patients put on treatment—some who had been on waiting lists for years. The subsequent decrease in the hyper-endemicity in Katanga is a notable achievement and success story of Project AXxes.
TB Treatment A TB Success Story The objectives for treatment of TB were to support DOTS and community-based prevention as well as monitoring, evaluation, and reporting.
Specifically, the program supported:
1. The national TB program (PNLT) utilizing component B funding to enable effective monitoring and supervision of CDTs by government health authorities 2. Local health zone doctors and nurses (BCZS and Health Centers) by way of transport (motorcycles) and operation subsides 3. Community mobilizers through training, provision of materials (registers, posters, For the full story see Annex 1 pamphlets), and transport from village to village with bicycles.
The project also transported at significant expense medicine and reagents from ports of entry (Kinshasa and Lubumbashi) to health zones and treatment centers in hyper-endemic areas. These efforts eliminated the backlog of hundreds of patients waiting for treatment, leading to dramatic treatment successes and normalization of incidence. This is a notable and hopefully lasting contribution of Project AXxes.
23 A.7 IMPROVED HIV/AIDS PREVENTION
Objectives and Progress
The project objectives for HIV/Aids component included blood security (100% of transfused blood is tested against HIV) and the establishment of integrated, quality, and MOH-approved PMTCT services for pregnant women.
Blood security
The project objective was that 100% of transfused blood be tested for HIV. As one can see from the table below, this objective was met. Given the national seroprevalence rate for HIV (4%) one could surmise that 1,431 cases of transfusion-related HIV were avoided by this intervention—largely children, who are the most common recipients of transfused blood.
HIV Testing of Blood for Transfusions
Y1 Y2 Y3 Y4 Total
Blood Tested against HIV 20,267 22,349 28,776 35,777 107,169 Blood Transfused 20,539 22,387 28,780 35,777 107,483 Percentages 98.7% 99.8% 100% 100% 99.7%
Mid-project USAID provided a technical assistant, Safe Blood for Africa, to work alongside AXxes in ensuring safe transfusion of blood. Curiously, HIV testing that had been done successfully by the AXxes consortium during SANRU III and AXxes (2000-2008) was taken out of our intervention packet and given to Safe Blood. While it was a potential cost savings for our project to not have to purchase HIV testing, Abbott Pharmaceuticals was already providing HIV test kits at a significantly reduced price to IMA. Further, having two NGOs providing essential components of the same package (transfusion kit) caused irregular calendars of supply, redundant transport, and sometimes challenges in reporting.
PMTCT Indicators Project AXxes continued to provide all the other components in the transfusion package (ABO, RPR, and Hepatitis B) as well as bags and reagents for blood taking and blood giving. Safe Blood for Africa played a key role in training of laboratory technicians, supervision, and printing of material. Redundant efforts or not, the fact that nearly 100% of all transfusions were tested for HIV—resulting in over 1,400 lives saved—is a success story of Project AXxes and its partnership with Safe Blood.
PMTCT
Project AXxes established and/or supported 137 PMTCT sites during project years two, three and four. Established sites offered counseling and screening to nearly 90,000 women annually by year four. All sites provided ARV prophylaxis to sero-positive mothers and their babies as well as the
24 provision of HIV basic care (cotrimoxazole, A PMTCT Success Story multivitamins) and referral to HIV clinical services where available. HIV testing was also offered to spouses of women who visited the prenatal clinic. Though the uptake of testing by spouses was timid in year two (only 554 accepted), by year three over 5,000 accepted and by year four over 8,000 accepted.
ARV interventions included the use of mono therapy (NVP) in 71 select sites and triple therapy (NVP, 3TC, AZT) in 66 sites, as adopted by the national plan as optimum strategy mid-way through the project. It is also noteworthy that AXxes worked with the PNLS in the establishment and adoption of the new protocol. Moreover, IMA leveraged significant assistance from For the full story see Annex 1 corporate donors such as Abbott, AIDS-Relief, and AXIOS International, which donated most of the materials for HIV testing and treatment. PMTCT by Project Year
Challenges confronted in PMTCT early in the program were significant difference in the numbers of those counseled and those who accepted testing (quality of counseling) as well as the difference between those tested and those who received test results in a timely manner (quality of testing). The project utilized both operational research methods (see success stories) and formative supervision to address these problems. A comparative study between weaker performing and stronger performing centers revealed several statistically significant variables which, when applied throughout the program, helped to close the gap in these differences and caused a significant increase in performance (see graph).
Nbr of Women Counseled Nbr of CPN Clients Counseled Nbr of Men Counseled
25 II. COMPONENTS B AND C: HEALTH SYSTEMS STRENGTHENING
As noted in the executive summary, the three components of Project AXxes were:
(A) Provision of health care services, (B) Capacity of health zone management, and (C) Capacity of regional and national health authorities.
Through technical, logistical, managerial, and financial support, components B and C provided essential elements of Health Systems Strengthening summarized in this section through the following:
Development of health zones Development of human resources Development of supply chain Reinforcement of health information services Governance Leadership Leveraging of community and local organizations.
B.1 DEVELOPMENT OF THE HEALTH ZONE
One of the principle objectives of Project AXxes was to reinforce the development or functional capacity of 57 health zones. The efforts resulted in the following:
1. The establishment of a health zone team working with a common vision to develop their zone. The BCZS (health zone team) received training and support with the objective to meet regularly and develop strategies and make decisions enabling them to confront and solve problems inherent in their zones.
2. Improvement of the quality of care at the level of both hospitals and clinics was made possible by training and reinforcing the capacity of tens of thousands of health care workers to use and follow appropriate protocols. New procedures which were implemented by the project included AMSTL to prevent postpartum hemorrhage, integrated care of mother and child, zinc as adjuvant treatment for diarrhea in children, ACTs as drug of first choice in malaria, and transition to triple ARV therapy. These innovative techniques, along with the provision of essential medicines and equipment, helped to significantly improve the quality of care.
3. Improvement in access to care. In the goal to increase access to care for isolated populations (especially children under 5) Project AXxes worked alongside the MOH in the planning, installation, and monitoring of community care sites. In the course of 18 months, 310 community care sites were established and have contributed significantly to increasing health services to women and children including family planning (pilot experiences).
4. Community Participation. The project worked with health zone teams to increase the participation of the community in all aspects of the program. Health committees of health facilities were re- established and made functional. The Project set targets and objectives for both gender balance and regular meetings of the health zone Administrative Counsels, HZ Management Committees, and local Health Committees. Community participation became particularly important in rolling out activities such as water and sanitation programs in which communities were required to make durable contributions. This resulted in 629 water sources rehabilitated, 41 clean villages, and 6,133 community latrines installed. Community mobilizers (on average 150 per health zone) were trained and equipped with flip-charts, message boards, and bicycles in the goal to promote sound
26 health practices and encourage participation in preventive services such as CPN, PMTCT, CPS and Family Planning.
B.2 DEVELOPMENT IN THE SECTOR OF PHARMACEUTICAL SUPPLY AND USAGE
Project AXxes contributed to the national goals to establish and reinforce a central system of pharmaceutical supply and procurement of quality essential medicine. Project AXxes worked with three CDRs (Kananga, Kamina and Mbuji Mayi) and three private depots (Lodja, Kolwezi and Bukavu) to provide essential medicine for project-supported health zones with funding in excess of 4.5M USD. The depots of Lodja and Kolwezi created by the project are now proposed by the MOH to officially become CDRs. The project assisted as well in the training, equipping, and monitoring of CDR staff as well as contributing to operating costs by paying fees associated with the storage and distribution of project-purchased medicine to project facilities. At the end of the project, IMA will have left a stock of medicine (aligned to drug credits) and kits and commodities with a combined value in excess 2M USD to continue essential health services.
B.3 DEVELOPMENT (REFORM) OF FINANCING HEALTH
Project AXxes provided an assistance of approximately $1.50 per population/per year in 57 health zones. The project worked with health zone and government authorities to institute a fixed tariff system providing care at a cost affordable to the local population, but sufficient to stimulate development and continuity of care. Training was also provided in health systems management and financial practices. In addition, the project provided material such as IT equipment, software, ledgers, registers, and office supplies as essential components in fostering autonomy and management of facilities. The project was unable to pay „primes‟ or „performance based contracts‟ due to donor guidelines. The project encouraged a tarification by illness episode as the mechanism for cost recovery to support the health facility operations.
B.4 DEVELOPMENT OF HUMAN RESOURCES IN HEALTH
The increase in capacity of health care workers by didactic and participatory training had a significant role in the increase of quality of care and the attainment of health service related indicators. During the four years of the project, over 33,000 persons (health care personnel in the national, provincial, health zone, facility, and community levels) were trained in the various components of primary and preventative health care. This extensive training, involving several key persons per center permitted the functioning of facilities and continued service provision despite episodes of staff turnover seen often in the context of DRC where health care workers are minimally paid. In addition, the project supported MPH studies for five health zone medical directors.
One of the significant achievements of the project was in transitioning new and non-functional health zones such as Mpokolo, Kayamba, and Pania-Mutombo into autonomous, operational, and highly functional zones by project end.
27 Project AXxes Cumulative Training by Project Year Over 33,000 persons trained
28 B.5 REINFORCEMENT OF THE HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS)
Components B and C involved increasing the capacity of national health programs at health zone, district and central levels. Part of that capacity entails the ability to collect, analyze, and use health data collected from Congo‟s 515 health zones and more than 10,000 health institutions. All institutions report monthly using standardized monthly paper forms. Health zones compile a monthly paper report or SNIS (National Health Information System) which passes through various levels and is sent to Kinshasa as hard copies. The process is cumbersome and slow, and the data difficult to critique, analyze, and process.
Project AXxes focused on improving data collection, verification, and transmission at the health zone level through support from the Health Information System Program (HISP) from South Africa and reinforced data collection and analysis at the central (MOH) levels through support from Department of Informatics of Johns Hopkins University.
At the beginning of the project, the MOH had HISP Platform for data-entry contracted with European donors the installation of an electronic data collection system (GESIS) to replace the paper-based and cumbersome SNIS system. Project AXxes as an integrated program invested resources in years one and two to adopt this system, purchasing computers and modems for all health zones and investing in software installation and training of personnel. Unfortunately the GESIS program was never adopted nationally and restrictions within GESIS made it impossible to make modifications in format to allow the addition of new zones, new districts, changes in population, or evolving indicators and targets.
A HMIS Success Story The MOH had its own challenges with GESIS and with perceived abandonment by the MOH and a continued need to capitalize on the training in electronic data transmission, the project contracted HISP in South Africa to transition our data collection program to DHIS (Data Health Information System) software which has had significant success in contextually similar countries such as Tanzania, South Sudan, Liberia, Malawai, Namibia, Nigeria, Kenya, and South Africa. The MOH was involved in this transition and readily adopted the system, asking Project AXxes to install and adopt it province-wide in South Kivu where For the full story see Annex 1 it has been made operational.
Aside from health zone transmission, partners and regional coordination offices have been reporting electronically to project headquarters in Kinshasa since year one with an access-based data entry system (Katele-lite). This data forms the basis of all Project AXxes quarterly reports with charts and graphs, as shown in this report, generated using Tableau software.
A phase II of this work (planned IHP extension) would entail sending monthly drug and health data reports by phone modems using EDGE technology direct from the health zones to coordination units. This work was to be done in collaboration with Health Information System Program (HISP) and JHU
29 and is still primed to go forward. The essential hardware equipment including new laptops, modems, and solar-based energy supply is all in place to facilitate this continuing work.
With technical assistance from the Department of Informatics of Johns Hopkins University, Project AXxes worked with the Ministry of Health to make the very important transition from a paper to electronic database system. The Project provided and installed high capacity Dell Edge servers, desktops, laptops, LCD projectors, and wireless networking equipment in the Ministry of Health.
AXxes personnel and the team from Johns Hopkins provided training of personnel from key departments of the Health Ministry. This allowed ministry personnel to analyze data, track changes, monitor progress, compare trends at the health zone, district, and provincial level, as well as chart out and put into graphic form the various results.
Training of project (left) and MOH staff (right) in DHIS (Kinshasa, May 2010)
B.6 REINFORCEMENT OF GOVERNANCE AND LEADERSHIP
Under the Component C of Project AXxes, a new approach to central assistance was undertaken. This first involved training health authorities in strategies of leadership and management.
The project also played a key role supporting the organization and facilitation of workshops by various MOH divisions, including PNLS, PNLP, PNLMP and PNSR. The results from those workshops resulted in the adoption of several new protocols and health strategies which were implemented by Project AXxes as part of project Component A, e.g., PMTCT, integrated care of mother and child, AMSTL, TPI, Zinc, and Vitamin A. Many of these interventions were first implemented in AXxes-assisted health zones before becoming the national standards.
On a provincial level, the project supported the supervision and monitoring efforts of government health authorities encouraging a partnership in the evaluation of project objectives and indicators. Challenges with Component C were that the government often perceived Project AXxes as a donor- type agency and often approached the project to fund activities such as transport, communication, workshops, commodity dispatching, and other needs which were not specifically related to project objectives.
30 B.7 REINFORCEMENT PARTNERSHIPS AND UTILIZATION OF SMALL GRANTS
The project supported select local NGOs by providing small grants to enable them to develop their capacity for certain key interventions which are highlighted below:
Small Grant Total Province Area of Intervention Recipient Funding Community-based nutritional care focusing on pro- AFIA KATANGA active interventions in the health regions of $46,184 Kasulo/Kolwezi KASAI Community awareness of SGBV and prevention and FODESA $44,999 ORIENTAL reduction of sexual violence in the Lodja HZ Reinforcement of the fight against HIV/AIDS in mining HALT SIDA SUD KIVU $47,630 zones of Kamituga, Kitutu & Twangiza in SKivu Community-based nutritional care focusing on pro- VAS SUD KIVU active interventions in the health regions of Kalonge in $44,904 S. Kivu Total $183,717
The following are highlights of accomplishments of each NGO:
AFIA Organized a zone wide campaign which A Promising Partners Success Story identified 240 children at risk Organized four community focus groups Held 24 nutrition conferences Worked with 240 families to improve nutritional practices.
FODESA Disseminated new laws regarding sexual violence (DRC) Promoted and supported literacy programs Sensitized key leaders and groups on the prevalence and prevention of SGBV Disseminated of radio messages to For the full story is Annex 1 100,000.
HALT SIDA Revitalization of three youth clubs on prevention of HIV/Aids Meetings with religious leaders on disseminating messages about HIV Organized coffee shop meetings, video groups and forums Supplied two youth groups with AV equipment for promotional work Produced and disseminated of pamphlets on HIV/Aids Sponsored radio messages in Bukavu Distributed of condoms Established VCT testing at their Bukavu office.
VAS Organized village-wide nutritional assessments, identifying 100 cases of malnutrition Organized 18 nutritional sessions to change of knowledge and practices Promoted income generating activities in key areas with community involvement and benefit. Clinical improvement (nutritional) in 95 of 100 children inscribed into program.
31 B.8 CAPACITY IN SURVEILLANCE AND RESPONSE TO EPIDEMICS
Surveillance of epidemics and transmissible diseases was An Ebola Success Story an ongoing component of Project AXxes and comprised a key component of the health zone support budget every year. Project AXxes worked with other partners and especially government authorities in monitoring, reporting, and responding to epidemics and outbreaks such as polio, measles, typhoid, rabies, cholera, and hemorrhagic fever.
Intervention included training healthcare workers in principles of epidemic surveillance and reporting. SNIS reports, which form the basis of documentation, were updated, printed, and given to all centers. A needs assessment identified health zones without radio or HF For the full story see Annex 1 communication, etc. were given HF radios or updated antennas and power systems based on needs. A Cholera Success Story During outbreaks, the project both supplied technical personnel, medicine, protection gear, funds for transport and communication, and physically delivered samples and supplies, in each case working with appropriate MOH personnel and other international organizations such as UNICEF, WHO, CDC, and Red Cross.
The project also intervened in disasters and crises such as the gasoline explosion in Senge, which severely burned 289 victims, many who lost their lives. In each case, natural disaster or epidemic, Project AXxes was often the first responder and communicator to both
USAID and the MOH and facilitated and built upon For the full story see Annex 1 international aid and relief.
Transport of aquatabs and chlorine during the Project AXxes supplied hospital medicine and 2010 Katanga cholera outbreak supplies during the Senge Crisis.
32 III. CONSORTIUM AND PROJECT MANAGEMENT
C.1 IMPLEMENTING PARTNERS
Project AXxes was implemented by three NGOs with Imple- Nbr a long history of delivering primary health care menting Province District services in rural DRC through local partnerships: Partner HZs Bukavu 7 Catholic Relief Services (CRS) CRS South Kivu Center 7 World Vision International (WVI) West 7 The Protestant Church of Congo (ECC) World South Kivu North 7 Vision Katanga Kolwezi 8 Each implementing partner maintained regional Kasai Oriental Lodja 4 coordination offices, staffed by project personnel and ECC Kasai Occid. Kasais 8 Katanga H-Lomani 9 responsible for implementing and monitoring all Total 57 project activities as well as receiving and delivering commodities.
C.2 TECHNICAL PARTNERS
In addition, IMA contracted with a number of technical consultation organizations to provide Project AXxes works with technical assistance and oversight in specific areas, including:
• Helen Keller (HKI): Micronutrient (Vitamin K and Zinc) support Procurement Number of • JHU: HIS (health information system) data base for DRC‟s MOH Category Shipments (component C) Medicines 59 Nets 20 • HISP: DHIC (collection and analysis of health zone data Lab & Tests 18 (component B) PMTCT 14 • MSH-SPS: Oversight of Pharmacy depots and drug CPN 7 purchasing/credits GIK & Misc 7 • MCHIP: Newborn and community care sites (Dr. Indira and Solar 7 Shushelea) Computer 6 EPI 6 • Baertracks: Consortium management, reporting, and compliance Surgical 6 • Dr. Lauren Blum: Quality Care and Care Seeking Behavior Equipment 5 VehiclesKits 4 • Engender health: Monitoring and establishment of fistula care and Family 3 programs PlanniTotalng 162 • C-Change: Community mobilization for change and increased uptake of FP • Safe Blood for Africa: Provides HIV test kits for the transfusion package • PROVIC: technical assistance in PMTCT
Technical support and summaries from each partner are found in the various reports. In brief, the combined expertise and support from these partners had a significant effect in the design, implementation, and monitoring of USAID- and project-proscribed indicators and results.
33 C.3 PROCUREMENT
162 shipments procured and shipped by IMA
The procurement of essential commodities, both medicines Number of Shipments by Project Year and equipment, constitutes the lifeblood of an “Appui Global” project to support and sustain health zone development. IMA‟s coordination of this key project component has included the ordering, importation, and distribution of 162 shipments of commodities brought in by air or sea/train via Matadi/Kinshasa, Bukavu and Lubumbashi. That equals an average of 5.5 shipments per month, including medicines, equipment kits, testing materials, solar refrigeration, computers, and vehicles. The table at right shows the number of orders/shipments for each procurement category per year (sea freight and air freight).
C.4 COST SHARE
$6.5 million in cost sharing
The AXxes consortium had a significant cost-share A Developmental Success Story to the project. Upwards of 6.5M USD worth of cost share was recorded by the end of the project, well surpassing amounts proposed in the original cooperative agreement.
Cost share included personnel, services, and commodities. Specific items included the permanent expatriate staff to the project (Chief of Party, Grants Manager, and Technical Advisor) whose salaries were provided by their host faith-based organizations, HIV test kits and ARV for the 137 PMTCT sites (Abbot, Direct Relief, and AXIOS), Zinc and Vitamin A from IDA, and multiple container and air freight shipments of essential medicine and other pharmaceutical products from US-based companies such as Pfizer, Merck, Johnson & Johnson, and GSK. The level of involvement For the full story see Annex 1 from both faith-based and charitable donors, as well as corporate donors, was significant and distinguished the AXxes project in both its level of cost- leveraging and wide US stakeholder involvement in its health care relief and development endeavors.
C.5 OPERATIONAL RESEARCH
With a service population of over 8 million persons and cross cutting interventions involving many segments of primary care, Project AXxes provided an optimum setting to do observational (non-trial) research on methodologies, protocols, and commonly encountered problems. During the course of four years, research and studies were conducted on topics including:
Health Seeking Behavior (cultural trends)
34 Access to Care (barriers to project-supported care) PMTCT (evaluation of low vs. high performing sites) C-Section Rates (geographic variation in rates) Fistula Care (common factors in fistula victims) TPI (evaluating reasons for low second trimester uptake) Hyperendemicity of Tuberculosis at Malemba Nkulu (verification and determinants)
Some of these studies were contracted out to Operational Research on PMPTC Compliance research teams (Dr. Lauren Blum), and those involving patient records or interviews obtained ethical reviews and concurrence from Kinshasa‟s school of public health. Retrospective data analysis, such as evaluation of high and low performing PMTCT sites (see map), underwent conventional statistical analysis to explain variances and support hypotheses.
In all instances, results obtained from these studies were discussed with both the project and USAID health teams, and the lessons learned were incorporated into ongoing work. For instance, three statistically pertinent factors that increased PMTCT uptake were incorporated in all 137 sites (See PMTCT Success Story on page 24). Reasons for low attendance in first trimester prenatal care (TPI) were discussed with community RECOS to change communication messages and enhance uptake of services. Variances in reproductive health (and low C-section and high fistula rate) had more to do with geography than quality of care, and the reasons why patients avoided hospitals when their children were sick and why women with fistulas hid their conditions were documented and shared in the hope of building a better program. Research for the sake of change and improved care was another significant accomplishment of Project AXxes. Copies of these studies are posted on the project website at http://sanru.org/projects/axxes_reports.htm.
C.6 ENVIRONMENTAL MITIGATION AND MONITORING (EMM)
Project AXxes monitored approximately 40 environmentally related variables each quarter as part of Environmental Mitigation & Monitoring (EMM) and reported on them each quarter since year two. Project AXxes, following a debriefing by USAID-ENCAP in Kinshasa that provided USAID implementing partners with Environmentally-Sound Design and Management (ESDM) skills, worked closely with the Ministry of Health (10th direction) in establishing and printing waste management plans for all health facilities in the DRC. Early support to the MOH 10th division included funding EMM-related workshops, printing posters, pamphlets, and protocols, and holding district-based cluster meetings with regional authorities and health zone partners in the adoption and implementation of waste management plans.
Subsequent to this ground work the AXxes M&E team, in consultation with USAID, prepared a project specific Evaluation, Monitoring and Mitigations Plan to follow up on activities classified as negative determination by the Initial Environmental Examination (IEE). This action plan addressed weaknesses observed in the reporting checklist especially by:
35 1. Helping HZs to have written plans and procedures on medical waste management utilizing universal precaution, 2. Training staff to improve practices and protection, and 3. Improving waste handling, treatment, and storage practices.
Since year three AXxes has been monitoring the implementation of this plan, which has been widely adopted in all zones as can be seen by the chart below. In addition, the project funded the construction of 130 incinerators, purchased waste receptacles and storage bags, and provided sharp containers for syringes and medical instruments on a regular basis. Such intervention has distinguished the USAID- supported AXxes zones as innovators and leaders in waste management and environmental surveillance. The table below shows the continuing improvement across the board in all EMM reporting categories since inception.
Environmental Mitigation and Monitoring by Project Quarter Elements/Actions Cumulative Q9 Q10 Q11 Q12 Q13 Q14 Q15 Q16 1) Written plans and procedures 11% 23% 25% 68% 60% 55% 70% 77% 2) Staff Training, Practices, and Protection 28% 42% 49% 72% 77% 70% 78% 82% 3) Handling and Storage Practices 13% 23% 23% 39% 50% 51% 60% 74% 4) Treatment Practices 19% 31% 32% 43% 49% 50% 71% 78% 5) Construction-Related Aspects 100% 100% 100% 100% 100% 100% 100% 100% 6) Water and Sanitation 94% 94% 94% 97% 94% 94% 96% 96% Overall Compliance 44% 52% 54% 70% 72% 70% 79% 84%
IV. LESSONS LEARNED DURING THE AXXES PROJECT
Toward the end of four-year program, the project COP team convened regional meetings with principal project stakeholders, including health zone medical directors, district and regional medical officers and project regional coordinators to discuss strengths, weakness, and lessons-learned gleaned from four years of implementing Project AXxes. Salient points raised in these sessions are summarized below:
1. The definition of a standardized and realistic assistance package for health zone development in terms of training, medicines, supplies, and equipment was critical to ensuring that the majority of project assistance reached the health zone level. 2. A consensus agreement among the consortium partners to adhere to a few basic Partnering Principles with regards the provision of assistance to health zones created a smooth platform for the management of a rather complex consortium of partners. 3. Project AXxes demonstrated that with the right kind of health zone assistance package, pragmatic project leadership, and an excellent collaboration of implementing partners, MOH authorities, and health zone personnel, it is possible to revitalize health care services even in nonfunctional health zones. 4. The management of Project AXxes as a horizontal platform for the integration and coordination of technical interventions from multiple and vertical funding streams demonstrates the value and effectiveness of a health systems strengthening approach. 5. The project COP team showed that while geography and inaccessibility are major obstacles to commodity-sensitive primary health care programs, they can be overcome by a practical knowledge of logistical networks coupled with the decentralized supply lines and coordination.
36 6. The technical involvement and financial support of local health authorities, both at the district and regional level, distinguished Project AXxes from other projects and contributed to the success and continuity of key activities. 7. The implication of the district medical authorities in the management and use of pharmaceutical products at the regional distribution centers was a sound management decision that reinforced the functionality of that work. 8. The practical clustering of health zone support by districts, e.g., Kolwezi, Haut Lomani and South Kivu, created a positive collaboration with district medical authorities to strategically reinforce supervision and support as part of Component C. 9. The involvement of Ministry of Health experts in the roll-out of technical interventions ensured adherence with newly implemented national protocols and also developed the capacity of those personnel as training experts. 10. The practice of on-site supervision and follow up by trainers for new interventions improved the service quality and coverage. 11. The holding of regular meetings with healthcare workers to discuss experiences and challenges in regard to new interventions, e.g., PMTCT, Newborn Care and Community-Based Care, improved the overall quality of services rendered. 12. Advanced planning by technical persons with community members and health zone teams for facility rehabilitation projects improved expectations and reinforced a sense of ownership and responsibility at the local level. 13. The emphasis on family planning messages that focused on „spacing births‟ rather than „avoiding births‟ were well received at the community level and ensured a higher uptake of services and greater acceptability by couples. 14. Supervision and support visits which emphasized that family planning was part of the Minimum Package of Activities were important in underscoring the importance of family planning as part of primary health care. 15. The project assurance that supplies and tools for collecting data were available at all levels improved the quality of data recording and ensured better data management of health information. 16. The availability of quality essential medicines and integration of pharmaceutical products into the fixed tariff system led to an increase in the utilization of care. 17. Any delay in acquisition of certain essential medicines can have an immediate and strong negative impact on healthcare and service utilization. 18. The improvement of health coverage with the establishment of community care sites permitted communities distant from health facilities to have access to care and significantly increased their health care utilization. 19. The availability of medicine and Long-Lasting Insecticidal Nets at prenatal clinics improved the level of activities and uptake of services. 20. The support of immunization activities with the installation of solar refrigerators, subsidies for kerosene, and support of mini campaigns permitted an increased and sustained performance for this important intervention.
37
PROJECT AXXES
Final Report
ANNEXES
(September 2006 - September 2010)
Integrated Health Services Project (Project AXxes)
USAID Cooperative Agreement No: 623-A-00-06-00058-00
Democratic Republic of Congo
50 1960-2010
Advancing Health. Saving Lives. 50 Years.
with implementing partners:
TABLE OF CONTENTS FOR ANNEXES
ANNEX 1: PROJECT AXXES SUCCESS STORIES
Month/ Project Success Story Topic Page Year Quarter 10-Sep USAID USAID Assistance Reduces Maternal and Infant Mortality in the DRC 1 07-Oct Q04 Outstanding Coverage of Vitamin A: A Life Saving Work 2 07-Jan Q05 Saying ―NO‖ to Cholera 3 08-Apr Q06 Opening the door to Primary Health Care in Kolwezi Health District 4 08-Jul Q07 WV AXxes Integration into Roll Back Malaria Program in Kolwezi District 5 08-Jul Q07 Promising Partner's Grant 6 08-Oct Q08 Scaling up PMTCT Services in Resource-Challenged Areas 7 08-Oct Q08 Kavumu Community Benefits From a Clean Maternity 8 08-Oct Q08 Upgrading the National Health Information System 9 09-Jan Q09 A Monumental Donation of Syringes 10 09-Jan Q09 AXxes Promptly Responds to Ebola (Again) 11 09-Apr Q10 77 Containers Cleared (and Counting) 12 09-Apr Q10 Overcoming Obstacles so 1500 can Overcome TB 13 09-Apr Q10 A Great Leap Forward in TB Detection in Katana HZ of S. Kivu 14 09-Jul Q11 Project AXxes and UNICEF combine forces for WatSan 15 09-Jul Q11 Achieving 95% Vitamin A Coverage 16 09-Oct Q12 To Vaccinate is to Love 17 09-Oct Q12 AFIA Women Improve Child Feeding Practices 18 09-Oct Q12 Tragic Hope: The Story of Naomi 19 10-Jan Q13 The Life-Giving "Ruvima" Water Source 20 10-Apr Q14 Harmonizing Humanitarian and Developmental Assistance 21 10-Jul Q15 Improving Compliance for PMTCT Testing 22 10-Jul Q15 Referral to the Hospital Saved My Life! 23 10-Oct Q16 Lighting Up Quality Health Care in South Kivu 24
ANNEX 2: PROJECT INDICATORS (By Project Year) 25
ANNEX 3: HEALTH FACILITIES REHABILITATION 28
ANNEX 4: PROCUREMENT AND SHIPMENT OF COMMODITIES 34
ANNEX 5: MATERIAL AND EQUIPMENT DISTRIBUTION BY HEALTH ZONE 39 OPERATIONAL RESEARCH STUDY ON UPTAKE OF PMTCT ANNEX 6: SERVICES 47
USAID/DRC NEWS September 2010
In the Field
Inside this issue: Over the past four years, Project AXxes has increased access to health In the Field 1-2 care facilities and has pro- vided essential drugs, CARPE Corner 2 regular training, supervi- sion of activities, tools, equipment and medical USAID Assistance Reduces supplies to government
Maternal and Infant health care facilities. Photo: ProjectAXxes Mortality in the DRC “The nurse advised me to come to the center any- Until 1990, the DRC’s health system time if I was not feeling was known for its network of clinics and well,” said Ilunga. “When high quality of physicians and primary I started feeling contrac- Ilunga and her twin babies at the postnatal clinic at Mwangeji care. Today, the country’s lack of infra- tions, labor was at first hospital, Katanga, DRC structure and fragile public health care normal but then stopped. system has resulted in many public health The nurse checked me and said it was not AXxes provides integrated primary health challenges, including deteriorated mater- a good sign. She referred me to Mwangeji systems strengthening based on the nal and infant health. hospital where they discovered that the “Appui Global” strategy of the DRC The utilization rate of health services is position of the babies was abnormal,” Ministry of Health. very low, with estimates that 70 percent said Ilunga adding “I had complications The program is implemented by Inter- of the population has little or no access to but quick referral to the hospital saved church Medical Assistance Inc. (IMA) as primary health care. my life and the life of my unborn twin prime recipient and three sub partners: USAID/DRC’s flagship primary health babies.” World Vision (WV), the Protestant care program, Project AXxes, increases Ilunga delivered a girl and a boy. “If Church of Congo (ECC) and Catholic the population’s use of primary health there had been no referral, childbirth Relief Services (CRS).■ care services and products in 57 of the would have been difficult for me. The DRC’s 515 Health Zones. The program health center staff referral to the hospital also improves the quality of available ser- saved my life,” she said. vices and products, as well as strengthen- Project AXxes is reducing maternal ing the capacity of health clinics and and infant mortality through high impact health care workers to deliver the services. interventions for antenatal care and close “This was my first pregnancy. When I follow-up with skilled birth attendants. first arrived at the health center, I was The program also provides important also vaccinated. The next visit I was told messages on birth preparedness, recogni- that I was pregnant with twins,” said tion of danger signs, and safe birthing as Ilunga Ngoie, 28, who began attending well as education on nutrition, breast- antenatal care when she was 22 weeks feeding, use of mosquito nets, family pregnant at the Manika Reference Health planning and prevention of HIV/AIDS. center in Katanga province. The four-year, $60 million Project See page 2 to read more about Project AXxes A - 1
Outstanding Coverage of Vitamin A: A Life Saving Work
In 1990, the World Children Summit set an objective to eliminate Vitamin A deficiencies by 2000. In 1994, WHO integrated Vitamin A supplementation as part of an Expanded Programme for Immunization (EPI). Vitamin A is an important micronutrient required for proper growth and protection against infections. It is therefore an important element for reducing infant and child mortality. Vitamin A can also be found in food such as milk, eggs, fish, liver, carrots, vegetables, palm oil and other fruits. DRC is blessed with a variety of foods, but because of poor methods of cooking and storage, the majority of this nutrient is destroyed during food preparation and cooking. Therefore, Vitamin A deficiency is a serious public health problem in the country. A 7 month infant receiving 2 drops of Vitamin A. Vitamin A supplementation combined with mebendazole administration was launched in DRC in 2001. This year the campaign was planned in May 2007. The objective was to reach 100% of children from 6 to 59 months with Vitamin A. In Kolwezi District, where AXxes is implementing an integrated health project under USAID funding, the coverage has increased tremendously this year. One hundred and four percent (104%) of children between 6 and 59 months have received drops of Vitamin A compared to 90.7% of the last campaign carried out in November 2007. ―This coverage is special for the Provincial Health Inspection of Katanga‖, said Nyembo Michel, the PRONANUT Coordinator in Katanga Province.
The campaign organized by PRONANUT, a Ministry of Health body dealing with nutrition, was funded mainly by UNICEF and HKI in collaboration with other partners including World Vision, Medicin du Monde, Association pour la Sante Familial, WHO, and MSF. This The Vitamin A campaign launching year, the preparation for the campaign was well organized. The main ceremony: the team. problems that were identified in the last campaign were addressed. Several meetings were held by the vaccination coordination board for putting up a plan of action to be supported by all partners. Transportation of vaccination materials was timely and communication improved. World Vision AXxes provided transportation in Kolwezi District and organized the mass media using radios and IEC materials.
A - 2
Saying “NO” to Cholera
Successful prevention measures IN SOUTH KIVU, DR CONGO, cholera occurs frequently – too frequently. In 2006, three outbreaks occurred, resulting in 2,778 cases reduce the cholera incidence for and 24 deaths. Orphans and Vulnerable Children (OVC) and Persons vulnerable populations in South Living With HIV/AIDS (PLWHA) are particularly susceptible to Kivu, DR Congo cholera due to their precarious health and socio-economic conditions. Therefore, when the third, and most serious, cholera outbreak of 2006 was declared, USAID took action through its existing projects and partners to protect these vulnerable populations.
In this case, the collaborating projects were the AMITIE project to combat HIV/AIDS, the AXxes project to rebuild health zone capacity for primary health care interventions, and PSI. Together they planned and implemented emergency actions to prevent new cases of cholera via community education and targeted water-chlorination activities, especially for OVCs and PLWHAs.
CRS, the implementing partner for AXxes in South Kivu, and AMITIE coordinated their interventions and resources which included: Collaboration between USAID-funded Mobilized 56 Red Cross chlorinators to19 strategically-selected projects AMITE and AXxes, in water distribution points to treat water and to educate the collaboration with PSI, promoted community on cholera prevention. cholera prevention and distributed Printed and distributed (in French and Swahili) 8,000 ―Key water purification treatments. This Cholera Prevention Messages‖ via AMITIE‘s network of volunteers to the general public and to the targeted population of helped to reduce the incidence of OVCs and PLWHAs. cholera by 61%, especially among the vulnerable population of OVCs and Trained and mobilized AMITIE Home Volunteers, in collaboration with PSI, to distribute packets of ―PUR‖, a water PLWHAs. purification treatment, to PLWHA and OVC beneficiaries.
Within a few days the collaboration between AMITIE, AXxes, and PSI were protecting water drawn by the population and had distributed sufficient quantities of ―PUR‖ so that every PLWHA could purify a 10-day supply of drinking water.
The results were impressive. In the health zone of Kadutu, the center of the epidemic, CRS AXxes recorded only seven cases of cholera following these jointly implemented activities. That works out to a cholera incidence among the AMITIE-served population of .29% which is 61% lower than the while the .75% rate in the general population.
A - 3
Opening the door to Primary Health Care in Kolwezi Health District
Kolwezi Health District is located, in the North-West of Katanga Province, in the Democratic Republic of Congo. The population estimated at 647 688 majority being Mine workers. During the Mobutu era, Kolwezi was popularly known as ‗Poumon du Zaire‘, meaning the lung of Zaire, (former DR Congo) because of its capacity to produce Copper and Cobalt at that time.
Before 1998, health care was provided by Gecamine and SNCC (a rail road company). Employees were treated for free but other people were obliged to pay. Catholic and Protestant mission organizations were also active in providing health care in rural areas.
The District experienced two wars; the eight day war (in 1977) and the six-day war, which destroyed most of the well defined infrastructure including health facilities. In addition, as a result of poor investment and neglect by the Government, health services have become non-existent and morale and motivation among health workers have deteriorated. The state is incapable of ensuring the application of any minimum standards in the existing services. Where services are functioning they depend heavily on user fees and external funding from missions, donors and NGOs particularly from UNICEF, UNFPA, Global Assistance for Vaccination and Immunization (GAVI), GTZ and Damien Foundation. However, assistance provided has been partial and often vertical covering certain areas yet failing to address health care holistically.
Faced by this difficult situation, the only hope was to find a partner who would provide health care assistance as a total package “Appui Global”. Project AXxes is an integrated health program funded by USAID and adopts the National Health Care Policy through the Ministry of Health. AXxes will run for three years from September 2006 and is implemented by four partners including ECC, World Vision, CRS and Merlin in Eastern and Southern Congo.
Access to health services is perhaps one of the most important issues facing Congolese people. Conservative estimates of health facilities coverage show that 37 percent of the population, or approximately 18.5 million people, have no access to any kind of health care. Through the practical interventions implemented by this three-year project, it is hoped that the PHC infrastructure will be restored and health care services rendered to the groups that need them most and at an affordable cost. Doctor Leon Manda, the District Medical Officer in Kolwezi could not hide his joy at the beginning of project activities by WV in his area, as he commented that, “I have been the MID for this District for almost ten years. All this time my dream has been to see someone intervening in Appui global. I am proud and ready to go for retirement now because this dream has come true. Our health personnel have begun an intensive training which I believe that coupled with supply of medicines and equipment we will ensure quality services in the days to come.
A - 4
WV AXxes Integration into Roll Back Malaria Program in Kolwezi District
According to WHO, malaria is the leading cause of death of children under the age of five in Africa. It is estimated that 3,000 children under the age of five years fall victim to malaria each day. Malaria also affects pregnant women who are particularly vulnerable. The disease also takes an economic toll because of reduced productivity. Malaria is a significant threat in DRC where the most aggressive species, Plasmodium Falciparum is endemic and a significant cause of morbidity and mortality.
As a strategy to respond to this challenge, World Health Organization and other UN agencies introduced the Roll Back Malaria (RBM) program in 1998 with the goal of halving the global burden of malaria by 2010. LLINs at WV AXxes Depot in Kolwezi before distribution in Health Zones Kolwezi District, like many other areas in the developing world, has a high incidence of Malaria. It is located in the southeastern part of the Democratic Republic of Congo (DRC) in Katanga Provice. The population is estimated at approximately 750,000. Kolwezi District has eight Health Zones, two urban and six rural, all supported by Project AXxes.
In Kolwezi District, almost 85% of transfusions in children under 5 years and 40% of miscarriages are due to malaria (National Malaria Control Program Report, 2007). RBM control strategy includes effective treatment of malaria, use of Insecticide Treated bed Nets (ITNs), implementation of vector control activities and use of preventive treatment (TPI) for pregnant women. Before AXxes project Mujinga Ilunga, a mother of three began its work in the area, RBM activities concentrated on treatment children under five was thankful to only. There were no partners to support other activities especially Project AXxes for providing her with distribution of ITNs. 4 LLINs for herself and the children. As a result of AXxes interventions, all of the RBM components have “Before we started using LLINs, I been reinforced including use of ITNS where WV AXxes has was always seen in this health center distributed more than 47,000 LLINs for pregnant women and children (Kinsanfu) almost every other week under five years since project inception. because my children were getting fever from malaria,” she said. ―Since September 2007, we have noticed that malaria episodes in children are decreasing‖ said the Medical Doctor in charge of Dilala Health Zone, DR. Ngoy Peke Josee. Thank you Project AXxes!
A - 5
Promising Partners’ Grant
To paraphrase the team leader of the USAID health team in DRC, ―Some of the best development ideas spring up not in Washington or Kinshasa but in the areas where they are most needed.‖ One of the components of Project AXxes, ‗The Promising Partners‘ Grant‘ (PPG) was designed to foster and develop just that.
This past quarter a number of proposals were submitted to Project AXxes. Ideas ranged from focusing on low risk (as opposed to high risk) persons in mining areas of DRC where the seroprevalence of HIV/AIDS is the highest in the country and low risk students become high risk workers. Another group wanted to establish community-run micro-enterprises aside health clinics with cooperative management. One NGO sought to form clubs bringing together parents, students, and teachers to bring to light the problem of sexual harassment of female students; others addressed the issue of girls becoming mothers or prostitutes. In another region where sexual assault is prevalent, a group wanted to ensure that victims of rape come forward and that perpetrators were prosecuted. Their appeal for funding was based on the premise that many rural areas don‘t recognize sexual assault as a crime. A program in Katanga Province recognizing that malnutrition is both a socio-economic and health phenomenon sought to identify high risk families and screen children based on risk factors, intervening before the vicious cycle of malnutrition started.
The PPG program seeks to not only foster ideas, but to train and support grass root NGOs to implement them. After a process of submissions and screenings several NGO representatives were invited The AXxes „Promising Partners‟ to Kinshasa where Project AXxes staff worked with them in developing proposals, procedures, and protocols. A two-tiered training Grant‟ not only fosters innovative process involved writing skills, budget establishment, creation of ideas, but also builds the capacity indicators, and modalities to monitor and measure progress. of grass root NGOs to develop, manage and monitor sustainable Four new grants, ranging from $25,000 to $30,000, were selected this health projects within their quarter for funding and submitted to the USAID for approval. Project communities. AXxes believes that the success in these endeavors will be twofold: First, through the delivery of health and development services to communities in need; and second, by fostering local ideas and grass roots organizations that not only give credence to local initiatives but also represent hope for sustainability in development, long after Project AXxes has fulfilled its objectives.
A - 6
Scaling up PMTCT Services in Resource- Challenged Areas
During project years one and two, Project AXxes initiated PMTCT programs in almost 120 sites across DR Congo. At each health center women seen in antenatal clinics are screened for HIV and, if positive, offered potentially life-saving mono-therapy treatment (NVP) for their babies.
This has been a herculean task in a country where women are able to contribute less than 0.50 USD for prenatal care. According to governmental Ministry of Health standards routine prenatal modalities should include provision of iron and folate, de-worming, malaria prophylaxis (TPI), supply of LLTNs, as well as mono- therapy ARV for PMTCT. Now that standard is being raised to include triple-Rx PMTCT!
Thanks to support from USAID, Project AXxes zones have and will be able to maintain all MOH standards and recommendations for antenatal care while also keeping access fees low and utilization rates Project AXxes PMTCT Coordinator high (antenatal care access rates in supported zones this year averaged over 94%). Dr Marie Claude Mbuyi (right) and
CRS HIV Program Manager, Dr. In what will be phased-in activities, Project AXxes is transitioning Nicole Shabani (left) discuss PMTCT sites from single to triple regimen ARV therapy. AXxes modalities of triple Rx PMTCT with partner Catholic Relief Services recently brought in a consultant to technical advisors at a training look at the feasibility of transitioning CRS service sites. In September conference in Jos, Nigeria (Sept 08) 2008, with technical assistance from CRS, Project AXxes consortium members traveled to Nigeria for practical training in PMTCT comprehensive approach and triple-Rx.
As this report is being written, as many as 45 sites in South Kivu province are being transitioned to triple Rx. AXxes partner ECC has followed the lead and has hired technical coordinators in larger urban health zones, e.g., Lodja, Kananga, and Dibindi, who will undergo intensive PMTCT triple-Rx training and in turn transition an additional 20 sites in the Kasai Province in early 2009.
Commodities are being ordered, persons trained, protocols printed, and eventually more lives saved by the latest of international protocols—even in resource poor areas of the Democratic Republic of Congo—thanks to support from the American People and USAID!
A - 7
Kavumu Community Benefits from a Clean Maternity
Kavumu maternity and Miti Murhesa Health zone started in early 2005 due the restructuring of the pediatric rooms in Miti former Katana Health zone to becoming the Northern South Kivu District, in Murhesa Health Zone November 2003. At that time, population was approximately 151,175 rehabilitated by World Vision inhabitants. The population density is more or less 250 hab. /km². After a Project AXxes population count in September 2007 and further update in 2008, it came to approximately 165,711 inhabitants.
In 1989, Kavumu community built a two-room structure as health facilities. One room was used for hospitalization and another for maternity. It is worth mentioning that at this particular time the population size was approximately 5,000. The Health Zone is currently working out with 16 health centers, one hospital and one pediatrician hospital. Among these health facilities, Kavumu RHC is the biggest within Miti Murhesa HZ with approximately 32,363 inhabitants, i.e. 20% of the total size of population with an average of 200 delivery cases per month.
After noticing that it was not easy for people from the neighborhood to access Kavumu Referral Health center, in 1997 Kavumu community decided to build a more or less 12/8 metres room for postpartum. When AXxes started in 2006, the people at the grassroots level expressed the need for widening the maternity because pregnant women were giving birth in very pathetic conditions. Sometimes there were 2-3 deliveries on a single bed. The room was unclean and crowded. Pediatric was facing a similar challenge with two to three children sleeping on a single bed. However, with support and funding USAID, World Vision AXxes in collaboration with Miti Murhesa Above, Mwamini and Furaha, Health Zone succeeded in expanding the three-room structure in order to delivered on a single bed are seen better meet the needs of the population. The rooms were also equipped with with their children and below titular nurse in the new maternity. necessary equipment. The center is now spacious, clean, and pleasant. Kavumu community members are endlessly thankful to USAID funded program for these great achievements.
“Now I am very happy since each labor case is handled individually in [its] own bed. Mother can now rest in a clean room and this will help not only in avoiding infections but also hygienic conditions are sound…” claimed Mr Passy MUHOGERHA, Kavumu RHC Titular Nurse.
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Upgrading the National Health Information System
‗Component C‘ of Project AXxes calls for the increased the capacity of national health programs and provincial/district offices. Part of that capacity entails the ability to collect, analyze, and use vital health data, which in this case comes from over 500 health zones comprising five times that number of districts and 20 times that number of health institutions—all reporting on standardized monthly forms culminating in a paper-based data system that has become simply too large and too bulky to manage.
This past quarter, with technical assistance from the Department of Informatics at Johns Hopkins University, Project AXxes with support from USAID is helping the Ministry of Health make the important transition from a paper to electronic database system.
At the initiation ceremony where high capacity Dell Edge servers, desktops, laptops, LCD projectors, and wireless networking equipment were given to the Ministry of Health, the Secretary General underlined the importance of Project AXxes in supporting the work of the Ministry of Health.
The following day the team from Johns Hopkins, with support from project personnel, started a month-long series of training personnel from various departments of the Health Ministry (4th, 5th, PNSR, etc). After completing a week-long training seminar using the Johns Above: General Secretary of Health Hopkins installed dashboard system called Tableau, Mr. Patrick (DRC) Dr Miakala inspecting IT Mayuba, a statistician from the 5th direction (office of planning and equipment furnished by Project AXxes. research) stated ‗This is fantastic….we not only have the tools to create a national database and national health information system (server and desktops) but have the software as well (Tableau) to Below: JHU Technical Advisor, Dr. analyze disease trends district-by-district, week-by-week and Nkossi and ProjectAXxes M&E Officer Dr. Katele train health personnel in the respond proactively rather than after the fact to epidemics in our use of a database dashboard. country. Thank you Project AXxes for bringing us to this point!
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A Monumental Donation of Syringes
Project AXxes, thanks to some astute leveraging by IMA World Health, received a donation this quarter of 1,200,000 syringes. The solo-shot syringes were donated by BD Medical (Becton, Dickinson and Company) to IMA in support of their internatonal health programs. IMA decided to allocate this grcious donation to the Project AXxes to supplement its vaccination and curative care program.
The 1.2 million syringes filled a 40-foot container. Transportaion and importation were accomplished with assistance from the US Embassy and USAID. These syringes have been earmarked by IMA for Project AXxes-assisted health zones and are now being distributed to health zones through the three implementing partners, Catholic Relief Services Project AXxes Depot Manager, Mme (CRS), World Vision International (WVI), and the Protestant Church of Bero, inspects the shipment of donated Congo (ECC). syringes received by IMA from BD Medical (Becton, Dickinson and We have discussed this donation with the national vaccination program Company). (PEV). Since the supply of syringes for vaccination purposes from UNICEF is expected to continue, Project AXxes will prioritze use of the BD syringes for non-vaccination programs such as treatment of malaria and respiratory illnesses; obstetrical uses for Oxytocin injections; and screening and laboratory purposes, e.g., HIV, blood transfusions, and other lab testing.
The autobloquant features of these 2cc syringes and needles will ensure one-time use. This will help to avoid the transmission of blood borne diseases and infection.
This donation is a good example of IMA‘s ability to leverage donations from the corporate partners with whom it has many years of collaboration. The value of this shipment of syringes is in excess of $500,000, and provides an excellent complementary and supplementary assistance that that provided by USAID.
This monumental gift of syringes is timely, strategic, and will be put to significant use in helping to improve the quality of services and prevent diseases in Project AXxes supported facilities.
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AXxes Promptly Responds to Ebola (Again)
In November 2008, AXxes project personnel were alerted to an outbreak of hemorrhagic fever in the health zone of Mweka in Kasai-Occidental. AXxes supports four health zones in the same province, of which Bulape is a neighboring health zone to Mweka.
The index case for the outbreak was reported to be an 18 year old woman who died from hemorrhage shortly after child birth. Her baby subsequently died along with nine family members who assisted at her burial. A total of 49 clinical cases of hemorrhagic fever and 15 deaths have since been reported. Samples sent to the reference laboratory in Gabon confirmed Ebola as the etiologic agent.
AXxes personnel in Kinshasa and Kananga maintained daily contact with Above: Treating a patient of suspected medical authorities. One suspect case was identified in the AXxes-assisted Ebola Virus in isolation with material reference hospital in Tshikaji. That individual died from fever and provided by USAID and Project AXxes hemorrhage within 24 hours of hospitalization. (Bulape ZSR Oct 07)
Below: Kampangu Health Center/Ground Project AXxes was prepared with materials strategically located to assist in Zero (Mweka ZSR) site of Ebola Epicenter the response to this outbreak. AXxes immediately moved assistance from in 2007 outbreak. Bulape to Mweka health zone, e.g., 40 protection kits, 100 bottles of chlorine, and 100 masks with face visors. AXxes Kinshasa shipped additional materials to the Kasai Coordination office for at-risk health personnel. This included 50 personal protection units, 50 kilogram drum of chlorine powder, a chlorine industrial sprayer, and antibiotics (6000 ciprofloxin) due to past history of concurrent febrile diarrhea epidemic.
AXxes also helped distribute CDC training materials to at-risk health facilities, and provided other support materials that included IV fluids, rehydration fluids, gloves, gowns, masks, standard WHO essential medicines and other hospital supplies.
No further cases have been reported in AXxes-assisted health zones or in Photos by Bill Clemmer, Project AXxes case-to-case transmission as frequently occurs in outbreaks, such as the Kikwit outbreak of 1995 or the Mweka outbreak of 2007. The success of this story is that through a combination of preparedness, training, and prompt availability of isolation and protection materials, AXxes was able to contribute to preventing further spread of this highly infectious disease.
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77 Containers Cleared (and Counting)
A key objective of Project AXxes is to increase access to, demand for, and quality of health care services. This has included training more than 23,000 health care workers and rehabilitating some 200 health facilities. It has also included providing commodities to 57 health zones in some of the most rural and isolated areas of DRC. The challenges are daunting -- reams of custom regulations, lack of roads, weak bridges, areas of insecurity, and much more.
We are pleased, therefore, to report that the 77th AXxes container recently cleared customs. The average container includes 15 tons of commodities valued at $100,000. This translates to more than 100 tons of supplies/equipment with a total value $7,000,000. And those figures do not include the 30+ air freight shipments of cold storage meds and IT equipment.
AXxes commodities include WHO essential meds from Copenhagen, insecticide treated nets from South East Asia, solar freezers from Hungary, solar panels and batteries from California, cycle beads from Hong Kong, birthing tables from Belgium, and much more. Some containers also include donated commodities and equipment that IMA World Health has leveraged from corporate partners, such as the donation of syringes that was reported in the previous quarterly report.
This massive effort is made possible due to strong collaboration and assistance from USAID and the American Embassy which works with our full-time logistics staff in obtaining duty free exoneration and priority importation and clearance in ports, some of which have had containers backed up for over 12 months and into a country which has no functioning railway or national highway system.
To facilitate importation and to reduce costs, Project AXxes imports products through three ports of entry (Matadi, Goma, and Lubumbashi) where containers arrive by sea from the United States and Europe or overland from Tanzania, Uganda, Zambia, and even South Africa.
Map and photos by SANRU
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Overcoming Obstacles so 1500 can Overcome TB
Tuberculosis is a resurgent and growing epidemic in parts of DRC. Last year an alarming number of cases were detected in a cluster of AXxes- assisted health zones in remote central Katanga province (see map). With support provided by Project AXxes, several thousand were screened and over 1,500 were found to be positive for TB. Unfortunately, none had access to treatment.
In coordinating respective roles with other partners, the mandate of Project AXxes is to reinforce the diagnostic and treatment capability of rural treatment centers (not write protocols or provide medicines). However in this case, and with USAID encouragement, we traversed traditional stakeholder spheres of influence and combined forces with the national program to tackle the hyper-endemic spread of this life threatening and highly communicable disease.
Project AXxes organized after-hour workshops to help the National TB program (PNT) finalize a revised DOTS protocol (PATI-4) and then printed and distributed over 1,000 protocol manuals. With TB-Union and personnel from PNT, Project AXxes organized field training for health care providers in updated protocols. We purchased diagnostic equipment, motorcycles, and bicycles to permit health workers to travel within their health zones. AXxes logistics specialists literally sat in government offices waiting for long promised medicine and then air-freighted five tons of pharmaceuticals to staging areas in Lubumbashi. We then chartered single engine planes from Missionary Aviation Fellowship (MAF) to ferry hundreds of cartons of medicine and equipment into rarely-used grass and dirt-packed airstrips in the remotely located health zones.
Above: AXxes Logistics Officer Alan Kamba The results have been well worth the effort. A recent e-mail from the AXxes checking inventory in Lubumbashi regional coordination office announced that, "La mise en traitement des Below: Loading a MAF plane in Lubumbashi malades tuberculeux grâce à la présence des médicaments présents dans les Zones de Santé; 100% des malades en attente sont sous traitement à ce jour", i.e., All 1,582 persons who screened positive for TB are today on treatment… thanks in large part to Project AXxes and USAID!
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A Great Leap Forward in TB Detection in Katana Health Zone of South Kivu
South Kivu province has one of the lowest TB detection rates in DR It is possible Congo. Katana health zone (HZ), located 52 kms north of Bukavu, is to change for the better. among the 34 health zones comprising South Kivu. It covers 400 km² -- Dr. Gilbert Mungugu and serves 162,000 inhabitants. Katana is also one of Congo's oldest HZs, and helped to establish the system of decentralized health zones.
In 2008, Katana had three TB Detection and Treatment Health Centers (CSDT) but with weak demand for TB examinations. In 2008, the TB Coordination Program with assistance from World Vision confirmed a low detection rate of 30%. However, with AXxes assistance the health zone authorities used TB International day (April 24, 2008) to sensitize the population on this important topic.
Three large assemblies were held for community leaders, including village chiefs, opinion, youth and religious leaders, respected women, Traditional Birth Attendants (TBAs), health development committee members, and community relays. The meetings stressed how Leprosy and Tuberculosis Supervisor, Dr. communities can prevent TB and encourage prompt treatment when Gilbert Mungugu, of Katana Health Zone. necessary.
The community leaders were encouraged to become channels of information for their respective communities. Some leaders used church services to talk about TB, others raised these issues during local meetings or through peer to peer talks. This strategy was The low rate of Tuberculosis detection coupled with assistance from Project AXxes and other partners to has been remedied in Katana health train staff, equip key facilities with microscopes and reagents, and to zones, thanks to the USAID-funded ensure regular supervision. AXxes project, implemented by World Vision in South Kivu. Key Health Care One year later, the health zone is reporting a significant increase in Providers and the Community are the TB detection rate from 30% to 87%. This translates to 212 new happy to report increased detection in cases of Pulmonary Tuberculosis identified by positive check through the hope of eradicating this deathful Microscopy out of an estimated 244 patients expected in 2008. illness. Katana health zone is indebted for the assistance from Project AXxes and USAID to strengthen healthcare in Katana and in the entire province. Positive lessons learned from these achievements are now being replicated in other health zones.
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Project AXxes and UNICEF combine forces for WatSan
In September 2007 Project AXxes received an $860,000 grant from UNICEF for Water and Sanitation (WatSan) interventions. With these additional resources AXxes was able to mount a campaign to increase community awareness for WatSan in 320 high-risk communities across 16 health zones.
The program embraced a multitude of activities, including training WatSan engineers and supervisors; promoting basic hygiene messages, e.g., unclean water as a vector of disease; creating hundreds of village- based WatSan committees; and recognizing the achievements of Clean Villages.
Among the many diverse achievements of this initiative were:
5,092 Latrines installed; 110 Water Sources constructed; 2,000 Community Relays trained; 16 WatSan supervisors and community mobilizes trained; 117 villages adopting the PHAST approach; and 11 "Village Assaini.‖
The addition of an expanded WatSan initiative to AXxes was due in part to the ability of Project AXxes to manage multiple and supplemental funding streams. Add-on funding to AXxes has included interventions for PMTCT (USAID), EPI (GAVI), and WatSan (UNICEF). This provides not only a time-effective and cost-efficient promotion of an important activity, but also increases and promotes the synergy of interventions at the community level.
Project AXxes has provided an ideal platform for UNICEF to finance WatSan interventions that are making an indelible and lasting contribution to health practices in rural communities; notably creating community awareness of the importance of clean water supplies and hygienic practices as well as implement practical modalities of disease prevention and health promotion.
Photos by Project AXxes by Project Photos
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Achieving 95% Vitamin A Coverage
Helen Keller International (HKI) is a technical assistance partner to Project AXxes for the introduction and use of micronutrients such as Zinc and Vitamin A. One of HKI's roles is to collaborate with the national program (PRONANUT) on behalf of Project AXxes to organize an integrated mass distribution campaign for Vitamin A distribution and treatment of Soil Transmitted Helminthes (aka de-worming).
Preparation for this integrated campaign was finalized during the last quarter with micro-planning workshops in all AXxes-supported health zones and during regional coordination meetings in all provinces. Due in large part to planning and co-financing by USAID/AXxes, the campaign was successfully completed in all AXxes-supported 57 health zones. These health zones have a total population of more than 8 million and a targeted population of 1.3 million children (6-59 months).
Preliminary results from the campaign indicate that on average, over 95% of all targeted children received both Vitamin A supplementation and Mebendazole for deworming!
Below: Dr Miakala mia Ndolo, HKI also took advantage of the contact with nurses from nearly 2,000 Secretary General MOH launches the supported health clinics to distribute flip charts and Behavioral Change Vitamin A Campaign in Mbuji Mayi, Communication (BCC) materials regarding the correct use of rehydration Kasaï Oriental, April 6, 2009. solutions (SRO) and Zinc. These are essential adjuvants for the management of diarrheal illnesses, a major cause of pediatric mortality in DRC. These BCC materials were printed in local languages and distributed to all USAID/AXxes supported health facilities.
It is noteworthy that this one coordinated campaign in 57 AXxes- supported health zones is equivalent to organizing and achieving national campaigns for several West African countries. Such planning, coordination, financing, partnership with the MOH, and results are characteristic of the work which Project AXxes has been able to attain through dedicated partners such as HKI, a strong working relationship with the Ministry of Health, and support from the American People under the auspices of USAID.
Photos by Project AXxes
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To Vaccinate is to Love
A key objective of Project AXxes, USAID, and the Ministry of Health
(MOH) is to increase vaccination coverage in children under five in our
target population of 8 million persons. However, a MOH survey
conducted near the start of Project AXxes showed sobering results.
Nationwide only 31% of children under the age of two had completed
their primary vaccination series (BCG, Measles, and DPT). And an
alarming 18% of all children never received a single vaccine!
Addressing that problem has required a team effort of major players
such as USAID, UNICEF, and the Ministry of Health to address
Above: Dr. Bill Clemmer, AXxes COP problems of supply, access, cold chain, and materials. Those efforts have
with team members brought vaccination rates as high as 80%-90% in recent months. One of Below: Dr Leon Kintaudi, SANRU the newer contributors to this initiative is Becton Dickenson (BD), a Program Director with Michelle Russell, well-known international supplier of vaccination syringes. For a second Health Officer, USAID. time in 12 months BD has made a significant contribution (and
difference).
This past quarter we received a combined BD-USAID gift of more than
two million vaccination syringes earmarked for vaccinating a generation
of children in the DRC. Delegations from the Ministry of Health,
international NGOs, donors, and partners came out to celebrate both the
significance of this gift and the hope that it provides for lives saved.
The true success in this story has been the joining of committed partners
such as BD, MOH, UNICEF, USAID, and Project AXxes to ensure that
every child will have an opportunity to be vaccinated so that preventable
diseases such as tetanus, measles and polio will be a phenomenon of the
past and their eradication a model for the future.
The banner shown at top left says it all: "Thank you BD and USAID for
this gift of two million auto-block syringes for the secure vaccination of
our children. Thank you Ministry of Health for the importation and
proper use of these syringes. To Vaccinate is to Love!"
Palettes of some of the two million syringes provided by Becton Dickenson and USAID.
Photos by Project AXxes
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AFIA Women Improve Child Feeding Practices
In Kolwezi health zone chronic malnutrition for under-five children is especially high in the Kasulo health area. The AFIA project (meaning "Health" in Swahili), in collaboration with World Vision International and Project AXxes, promotes community-based nutrition using the positive deviancy Hearth model. AFIA also encourages exclusive breastfeeding, safe feeding practices and complementary feeding. Mothers and caretakers learn from each other about care and feeding practices.
In conjunction Project AXxes, AFIA also integrates sessions in growth monitoring promotion, safe motherhood, HIV/AIDS, birth spacing, raising awareness of family planning methods and distribution of contraceptives. Members of AFIA have become important channels of Above: Mama Katiye, second from information to their villages, peers, partners and other family members. right, and her baby girl, Bwake. One AFIA member, Mama Katiye, provides this testimony:
Poor health for my children was partly contributed by poor feeding Below: Mothers of AFIA practices. Before I joined AFIA PD hearth sessions, our main meal at home was Bugali (maize meal) taken with sombe or lengalenga (cassava leaves or amaranthus) and sometimes bitoyo (dried fish). I will let my children eat in one pot except for my small baby who is still breastfeeding. After joining hearth sessions I learned that the way I cook my food can help to preserve important nutrients. I now also know that it is important to add some ingredients in order to not only make it tasty but nutritious. We still eat the same type of food as before but our meals are now enriched with ground nuts, soya flour and the usual palm oil. I also make sure that I do not overcook vegetables. My small children eat in a separate pot from older siblings and I see that my children grow up healthy day by day.
Photos by Project AXxes The Kasulo area is also surrounded by copper mining with many people concentrating on non-agricultural commerce rather than farming. AFIA encourages members to raise family income through nutrition-related income generating activities and gardening. Clementine Shimili, age 38 and with 8 children, is a food vendor. She sells cooked food and flour (mixture of maize and soya flour) outside her house, and says:
I thank God that I can feed my family through this work. I am widowed but I can still make some small money to pay for the house, health care and school. I also use part of the food I prepare for sale to feed my children.
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Tragic Hope: The Story of Naomi
Thousands of women and young girls suffer from fistulas in DR Congo. A fistula is caused by obstructed labor (dystocia) or sexual violence (rape and trauma). They cause involuntary loss of urine (incontinence) or stool and severe social stigma and distress. Many fistulas can be prevented through appropriate obstetrical care and repaired through delicate and lengthy surgical procedures.
Project AXxes has trained physicians and nurses to treat and manage fistulas in regional hospitals. The project has also worked with health centers and communities to create an awareness of this condition and need for early recognition, appropriate management, and referral. In the process we have encountered stories that are both tragic and hopeful.
One such story is that of Naomi (not her real name). Naomi was married off at age fourteen by her uncle who was offered a dowry. Six months later she was pregnant. Her husband was unwilling to send her for prenatal care at the local clinic, and sent her to her own village near the end of her pregnancy. When her labor pains commenced, her cousin walked her to the thatched hut of a traditional birth attendant rather to the health center. Naomi spent four agonizing days in labor. She was told to push, and had others sit on her abdomen. Eventually it was determined that the baby had died, and on the 5th day she was put astride a bicycle and pushed to the hospital where the dead child was removed by c-section. Above: A resident physician receiving Unfortunately Naomi‘s troubles did not end there. obstetrical training at a Project AXxes- assisted regional hospital After a long hospital stay, prolonged by having no one to pay her bill, Naomi walked back to her husband's village. However, she now had a sizeable fistula and was incontinent of urine. She smelled chronically and could not keep her bedding Below: The first fistula repair in or clothes clean. Her husband banished her back to her home village where she Lodja General Reference Hospital was grudgingly taken in.
For the next eight years Naomi was a pariah in her own village. She survived in a tiny dwelling by fixing clothes with a sewing machine her grandmother gave her. One day she heard on the radio that a team of doctors supported by the USAID- funded Project AXxes would be coming to a nearby hospital to treat women with fistulas. She decided to sell her precious sewing machine in order to have money to support her during what she perceived would be a long and expensive hospital stay.
The happy and hopeful ending to this story is that Naomi's fistula was successfully repaired, and she received the operation free of charge. During her lengthy Photos by Project AXxes hospital stay she was fed and tended by empathetic and caring health workers. Naomi is now physically healed and back in her home village. She has found someone who has asked her to marry. She is back sewing clothes, with the hope that she‘ll be soon be making clothing for her own family and children.
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The Life-Giving "Ruvima" Water Source
Kalonge health zone (HZ) in the northern part of South Kivu province includes 17 health areas. It is assisted by Project AXxes with WVI as implementing partner. The HZ has no central water distribution system. The population collects waters from rivers or water sources. From time to time rainwater is also used for cleaning needs, but not for drinking or cooking.
Bumoga health area of Kalonge HZ has a population of 6,093. Water has been a real burden for women and children as they were obliged to walk 5 to 7 km to the neighboring health area of Chifunzi for clean drinking water. In Bumoga, there was a unused source because its Hortense BORA collects potable water water was known to be harmful. It was called ―Mulambi‖ which from the restored Ruvima source. means ―death‖ in the local language. The Bumoga water committee
believed and hoped that one day Mulambi spring could be properly Photo by WVI restored and protected.
Bumoga community with Project With community encouragement, ―Mulambi‖ water source was AXxes assistance changed their selected by the HZ management team and WVI to be restored with polluted Mulambi (Death) water Project AXxes funding. Over a period of weeks, the spring was cleaned out, filled with rock, covered, and sealed with a cement wall source into a life-giving crystal and outflow pipes. Project AXxes provided technical guidance and clear “Ruvima” (Life) source. materials while the community provided labor, sand, and gravel. The community was highly motivated as they participated in hoeing the site, bringing stones, hauling sacs of cement and other materials down the ravine to the source. sure management and sustainability. Now that crystal clear, potable water flows from it, the water source is no longer called ―Mulambi‖ (Death), but ―Ruvima‖ (Life). The Bumoga source is one of more than 300 sources that have been restored or capped by Project AXxes.
The Bumoga population now smiles as they draw the Life-giving water from the Ruvima source. They are thankful to USAID and Project AXxes program for this assistance. Mrs. Hortence BORA, a beneficiary community member reports that ―Since AXxes rehabilitated the water source, I now have more time to devote to taking care of my new born twins because I‘m no longer obliged to fetch water far from my house.‖
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Harmonizing Humanitarian and Developmental Assistance
The Health Zone of Kalehe was created in October 2004 from Katana Health Zone. At that time it lacked a hospital infrastructure, a Health Zone Management Team, and effective community participation. It was also an area that had been destabilized by the years of Civil War.
The International Rescue Committee (IRC) began assisting Kalehe health zone in early 2006 with humanitarian funding from OFDA. Subsequently USAID opted to also assist this health zone with development funding through Project AXxes with IMA World Health (prime) and World Vision International (implementing partner). At that time there was some concern if dual assistance (humanitarian and developmental) could be harmonized within the same health zone.
The WVI and IRC teams worked closely with the Health Zone Management A Focus Group on Family Planning Team to harmonize interventions and to avoid duplication. A population census (above) is animated by Community and baseline assessment was jointly conducted in 2007 with support from the Relays (below) trained by Project District, South Kivu IPS and other local partners/stakeholders. These studies provided both population (137,967 persons) and baseline data on health services capacity (very sparse). Faced with a new health zone and significant service challenges, the two USAID partners (IRC and AXxes) worked out a division of strategies.
IMA/AXxes focused on primary and preventative health care interventions such as reinforcing prenatal and maternal health services, vaccination and cold chain support, and establishing family planning and PMTCT service sites. IRC focused on curative care, payment of HZ personnel, and building/rehabilitation of structures. Both groups undertook extensive training and supervision support.
Through the combined support from IRC and WVI, health centers are able to provide quality and integrated health services to then entire population while strengthening linkages between local and district medical authorities. Community Relays volunteers have been reactivated and the Health Zone Management Team has been empowered to plan and support all primary health care activities.
The medical director of Kalehe Health Zone, Dr. Ngaboyeka summarized the collaboration by saying “The synergy of action of the two [partners] encouraged me to stay in the health zone as I have seen this zone growing up day after day. My hope is to have this support to an extent where the zone is stabilized and there is more of the development outlook in the region. On my own behalf and on behalf of my team and our people, please convey our gratitude and thank you to USAID and the American people."
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Improving Compliance for PMTCT Testing
More than 100,000 pregnant women receive HIV counseling each year at PMTCT sites supported by Project AXxes. The services include HIV counseling and testing, and for those who are positive, the provision of free treatment. It was noted that up to 30% of pregnant women deferred that potentially life-saving testing and treatment. We asked ourselves, why?
It is known that some women refuse testing due because of fear of needles, stigmatization, and inconvenience. However, those factors would be expected to occur across all PMTCT sites. PMTCT supervisors noted that 21 of 130 clinics had acceptance rates for treatment of 97% or greater while 23 clinics had rates 55% or lower. Was the problem site-specific?
To study this problem, and more importantly to improve compliance in the lower performing sites, Project AXxes undertook a comparative study of the ‗top 20‘ and ‗bottom 20‘ sites to investigate factors related to compliance with testing and treatment.
Three variables were found to have a strong positive influence on compliance: 1) Existence of a private counseling area; 2) HIV testing done as a routine ‗opt out‘ procedure; and 3) HIV testing available during all clinic days.
These findings suggested that improvements in confidential counseling, opt-out testing, and offering of testing outside of PMTCT clinic days might significantly improve uptake of PMTCT services in low performing sites. During the past three months PMTCT coordinators gave special attention to the lower performing sites to ensure that all three factors were applied.
The results show significant improvement in uptake of services. In the past quarter changes in the cohort of 20 low performing sites increased the proportion of women who accepted testing from 70% to 89%, and those who received counseling, testing and results from 63% to 86% (see chart at left).
Thanks to this very practical research agenda, and the prompt application of research findings, more than 700 additional pregnant women were tested and received test results during the past three months at AXxes-assisted PMTCT sites.
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Referral to the hospital saved my life!
Ilunga Ngoie, 28, began attending antenatal care at the Manika Reference Health Center when she was 22 weeks pregnant. She completed the usual examinations, screening and assessments to ensure that her health and the health of the unborn child were good. She also participated in education sessions geared towards promoting health, self-care and birth preparedness.
“This was my first pregnancy. When I first arrived at the health center, I was also vaccinated. The next visit I was told that I had twins. The nurse advised me to come to the center anytime if I was not feeling well. Since I live far from the center, I discussed this with my husband and we decided that I should move in with my mother- in- law who lives just next to the health center. Ilunga and her twin babies during postnatal clinic at Mwangeji Hospital. Project AXxes is reducing maternal and infant mortality through high impact interventions for antenatal care, and with close follow-up with skilled birth attendants. The availability and correct use of iron, Fansidar, mosquito nets, vaccines (tetanus txxoid), oxytocin, Active Management of the Third Stage of Labor (AMTSL), partographs and antibiotics are all part of that approach. Important messages on birth preparedness, recognition of danger signs, and safe birthing are also provided as well as basic education on nutrition, breastfeeding, use of mosquito nets, family planning and prevention of HIV/AIDS.
When I started feeling contractions, labor was at first normal but then stopped. The nurse checked me and said it was not a good sign. She referred me to Mwangeji hospital where they discovered that the position of the babies was abnormal. The midwives used several obstetric maneuvers which enable me to deliver normally.”
Manika Health Center and Mwangeji Reference Hospital are located in semi-urban Manika health zone. Project AXxes has increased accessibility to these Government-owned facilities. They are now stocked with essential drugs, receive regular training and supervision, and have the tools, equipment and medical supplies that they need.
I had complications but quick referral to the hospital saved my life and the life of my unborn twin babies. I am very happy to have twins, a girl and a boy. I thank the nurse who referred me to the hospital. If there was no reference, childbirth would have been difficult for me. The health center staff referral to the hospital saved my life!
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Lighting Up Quality Health Care in South Kivu Bitale health center of is located 20 km from the Central Bureau of Bunyakiri health zone in the northern part South Kivu Province, an area of continuing insecurity and internal conflict. Bitale serves a population of more than 6,000 including approximately 1250 women of reproductive age. WVI is the implementing partner for Project AXxes in this area of S. Kivu.
Prior to Project AXxes, health services operated in an emergency mode to provide basic medical care with little investment in health infrastructure. Inadequate working tools, a chronic lack of medicines and insufficient training also contributed to poor health care. However, as regional stability has improved, Project AXxes, funded by USAID, has been able to assist in shifting from humanitarian to development approaches with by providing significant health strengthening assistance. This has included increasing Bitale Health Center Before accessibility to quality health care with synergy of health interventions, provision of essential drugs, equipment, training, supervision and improved and After Solar Lighting management.
Bitale is one of five health centers in Bunyakiri HZ that received solar panels to provide lighting for their maternities. The maternity in Bitale, and many other health centers in AXxes-assisted health zones, were also rehabilitated and equipped with delivery beds, working tools and skilled midwives.
During the past four years Project AXxes has funded more than 500 solar lighting systems (fixed and portable) and 207 solar refrigerators. These efforts have significantly improved the health care conditions and outcomes for the populations served.
Mimi Mapendo, the midwife nurse at Bitale health center, has nicely summarized the situation with this statement:
―The solar panel provided by AXxes for our maternity is making my work easy and pleasant. Before this donation, we had difficulties in taking care of pregnant women correctly especially during delivery at night. Both simple and complicated cases were difficult to handle. Care of the newborn and the mother was compromised because of darkness or poor lighting from kerosene candle that we used. Thank you to the project and to the donor, USAID for this support. I am motivated to do this work because it is contributing immensely in the reduction of child and maternal deaths particularly deaths related to child birth.”
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ANNEX 2: PROJECT INDICATORS (By Project Year)
Quartely Population Year 4 Targets COVERAGE % FAMILY PLANNING FORMULA Targets concerned Achieved % Number Number Q1 Q2 Q3 Q4 TOTAL % 1. Couple years of protection (CYP) for FP USG-supported Workplan 90,000 22,500 43887 56,576 81,087 101,398 282,948 314% programs * 1a. Couple years of protection (CYP) after exclusion of Workplan 90,000 22,500 14,913 17,197 29,028 36,432 97,570 108% MAMA and MAO for FP USG-supported programs * 2.Number of new FP Acceptors in USG supported family (pop)(.21) 1,736,259 20% 347,252 86,813 59,381 62,655 79,574 85,148 286,758 16.5% 83% planning clinics ** 2b.Number of new FP Acceptors of modern method in (pop)(.21) 1,736,259 20% 347,252 86,813 42,754 43,856 51,918 52,341 190,869 11.0% 55% USG supported family planning clinics 3. Number of USG-assisted services delivery points Total H.C 929 100% 929 929 845 894 894 894 894 96% providing FP counseling or services*
Quartely Population Year 4 Targets COVERAGE % MALARIA FORMULA Targets concerned Achieved % Number Number Q1 Q2 Q3 Q4 TOTAL % 0 0 1. Number of ITNs distributed that were purchased or pop (0.04) *ANC 304,259 92% 279,918 69,980 ITN in ITN in 394,250 499100 499,100 164% 100% subsidized with USG support * (Cumulative) coverage the pipe the pipe 2. Percent of pregnant women in targeted health zones pop (0.04) *ANC 304,259 86% 260,141 65,035 50,213 49,052 55,621 58,010 212,896 70% 82% received IPT* coverage 3. Number of children under five with malaria treated 578,753 80% 463,002 115,751 ND 202,570 210,643 196,084 609,297 105% 132% correctly following the national protocol**
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Quartely Population Year 4 Targets COVERAGE % MATERNAL CHILD FORMULA Targets concerned Achieved % Number Number Q1 Q2 Q3 Q4 TOTAL % 1. Number of antenatal care (ANC) visits by skilled pop (0.04) 330,716 92% 304,259 76,065 78,002 80,125 84,115 89,145 331,387 100% 109% providers from USG-assisted facilities* 2. Number of deliveries with a skilled birth pop (0.04) 330,716 75% 248,037 62,009 59,858 59,000 70,210 72,800 261,868 79% 106% attendant(SBA) in USG- assisted programs* 3. Number of women receiving Active Management of the pop (0.04) * assited Third Stage of Labor(AMSTL) through USG-supported 248,037 100% 248,037 62,009 58,785 57,413 68,059 66,210 250,467 101% 101% birth programs*
4. Number of postpartum newborn visits within 3 days of pop (0.04) * assited 248,037 100% 248,037 62,009 59,858 59,000 70,210 72,800 261,868 106% 106% birth in USG-assisted programs* birth
5. Number of newborns receiving essential newborn care pop (0.04) * assited 248,037 100% 248,037 62,009 58,037 58,357 68,786 71,026 256,206 103% 103% through USG-supported programs* birth
6. Number of newborns receiving antibiotic treatment for infection from appropriate health workers through USG- (pop)(0.04) (.05) 16,536 90% 14,882 3,721 3,479 1,867 3,127 2,729 11,202 68% 75% supported programs* 7. Number cases of child pneumonia treated with (pop)(.20)(Rate of use antibiotics by trained facility or community health 496,074 80% 396,859 99,215 95,810 83,615 96,746 89,141 365,312 92% for Curative Services) workers in USG-supported programs*
8. Number of cases of child diarrhea treated in USAID- (pop)(.20)(Rate of use 496,074 80% 396,859 99,215 80,625 47,250 62,481 59,598 249,954 50% 63% Assisted programs * for Curative Services)
9. Number of children less than 12 months of age who (pop)(.0.349) 288,550 90% 259,695 64,924 74,052 63,692 28,079 76,682 242,505 84% 93% received DPT3 from USG-supported programs* 10. Number of chidren less than 12 months of age who (pop)(.0.349) 288,550 90% 259,695 64,924 66,213 59,531 61,056 69,536 256,336 89% 99% recived vaccin for measles
11. Number of children under 5 years of age who received No No (pop)(.18) 1,488,222 95% 1,413,811 1,413,811 1,431,725 1,431,615 1,431,670 96% 101% vitamin A from USG-supported programs* Campaign Campaign
12. Number of pregnant women received VAT 2+ from pop (0.04) *ANC 304,259 90% 273,833 68,458 64,204 61,655 64,624 73,045 263,528 87% 96% USG- supported programs coverage 13. Rate of use of health services * Pop Total 8267899 35% 2,893,765 723,441 750,467 797,186 908,310 932,802 3,388,765 41% 117%
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Quartely Population Year 4 Targets COVERAGE % TB FORMULA Targets concerned Achieved % Number Number Q1 Q2 Q3 Q4 Number % 1. Case notification rate in new sputum smear positive pop*.0015 12,402 95% 11,782 2,945 2580 2,546 2,551 2,052 9,729 78% 83% pulmonary TB cases in USG-supported areas* 1a. Case notification rate in new sputum smear positive pulmonary TB cases in USG-supported areas without HZs pop*.0015 10,635 85% 9,040 2,260 1534 1,674 1,706 1401 6,315 59% 70% with high detection rate* 2. Percent/ Number of sputum smear positive pulmonary TB patients that were cured and co;pleted treatment under 11782 75% 8836 2,209 2736 2984 USG-funded DOTS*
Quartely Population Year 4 Targets COVERAGE % PMTCT FORMULA Targets concerned Achieved % Number Number Q1 Q2 Q3 Q4 TOTAL % 1.Number of Pregnant women seen for ANC in PMTCT (pop /57)*0.04* Nbr 69,624 100% 69,624 17,406 20,785 23,194 22,765 22,338 89,082 128% 128% facilities * HZ* % Pop Covered Nber of women seen 2.Number of pregnant women receiving HIV counseling for ANC in PMTCT 69,624 100% 69,624 17,406 22,198 21,103 22,816 21,522 87,639 126% 126% *** facilities *100% Nber of women 3.Number of pregnant women receiving HIV counseling receiving HIV 69,624 75% 52,218 13,055 17,923 16,625 21,243 20,425 76,216 109% 146% and testing *** counseling *0.75 4.Number of pregnant women receiving HIV counseling Nber of women tested 52,218 100% 52,218 13,055 17,630 16,321 20,885 20,255 75,091 144% 144% and testing; and receiving test results* * 100% Nber of women tested 5.Number of pregnant women who tested positive* 627 100.0% 627 157 194 147 170 148 659 105.2% 105% * 1.6% 6.Number of pregnant women tested HIV positive who Nber of women tested 627 100% 627 157 176 141 165 103 585 93% 93% receive test result* * 1.6% 7.Number of PMTCT health facilities offering PMTCT See Work Plan 130 130 137 137 137 137 130 100% 100% services* Nber of women tested 8.Number of pregnant women provided with a complete HIV positive delivered 626.6197137 100% 626.619714 157 119 98 93 103 413 66% 66% course of antiretroviral prophylaxis for PMTCT* in maternity 9.Number of newborns who received a complete course of Nber of women tested 595 95% 566 142 90 65 59 59 273 46% 48% antiretroviral prophylaxis* ** HIV positive* 95% 10.Number of partners/husbands of pregnant women who Number of pregnant 10,444 100% 10,444 2,611 1,527 1,285 2,141 2,830 7,783 75% 75% receive HIV coun-seling and testing and receive results* women tested * 20% 11.Number of women receiving CTX and MVI post Nber of women tested 627 100% 627 157 252 147 135 222 756 121% 121% counseling* HIV positive* 100% Nber of women tested 12.Number of newborns receiving CTX and MVI * HIV positive* 95% 595.288728 100% 595 149 103 44 31 25 203 34% 34% (Surviving babies)
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ANNEX 3: HEALTH FACILITIES REHABILITATION
Nbr Provence Health Zone Partner Structure Name 1 S. Kivu Bagira CRS CS Cigurhi 2 S. Kivu Bagira CRS HGR BagiraMaternite 3 S. Kivu Bagira CRS CS LUMU 4 S. Kivu HautsPlateaux CRS CS Mugogo 5 S. Kivu HautsPlateaux CRS CS Kitoga 6 S. Kivu HautsPlateaux CRS CS Masango 7 S. Kivu HautsPlateaux CRS CS Murungu 8 S. Kivu Ibanda CRS CS Ch CEPAC maternité 9 S. Kivu Ibanda CRS CS Ceca Nguba 10 S. Kivu Ibanda CRS CS Croix rouge Nguba 11 S. Kivu Ibanda CRS CS CH CAHI, matérnité 12 S. Kivu Ibanda CRS CS MuhunguEtat 13 S. Kivu Kadutu CRS CS Nyamululagira 14 S. Kivu Kadutu CRS CS CecaMweze 15 S. Kivu Kadutu CRS CS CiririMaternite 16 S. Kivu Kadutu CRS CS Neema 17 S. Kivu Kadutu CRS CS Nyamugo 18 S. Kivu Kalole CRS CS Itula 19 S. Kivu Kalole CRS CS Lukumba 20 S. Kivu Kalole CRS CS Kalabula 21 S. Kivu Kalole CRS Maternité KYAKOMBE 22 S. Kivu Kamituga CRS HGR PediatrieUrgences 23 S. Kivu Kamituga CRS CS KeleSidem 24 S. Kivu Kamituga CRS CS Kimbaguiste 25 S. Kivu Kaniola CRS CS Cagala 26 S. Kivu Kaniola CRS CS Murhali 27 S. Kivu Kaniola CRS CS Budodo 28 S. Kivu Kaziba CRS CS Mushenji 29 S. Kivu Kaziba CRS CS Kafinjo 30 S. Kivu Kaziba CRS CS Buzonga 31 S. Kivu Kaziba CRS CS Ngali 32 S. Kivu Kaziba CRS Maternité HGR Kaziba 33 S. Kivu Kitutu CRS CS Kakenenge 34 S. Kivu Kitutu CRS HGR Kitutu 35 S. Kivu Kitutu CRS CS CobaderMitobo 36 S. Kivu Kitutu CRS CS ESPOIR 37 S. Kivu Lemera CRS HGR Bloc Echo/Radiographie 38 S. Kivu Lemera CRS CS Kagaragara 39 S. Kivu Lemera CRS CS Narunanga 40 S. Kivu Lemera CRS CS Luvungi II 41 S. Kivu Lemera CRS CS Lubarika Nbr Provence Health Zone Partner Structure Name 42 S. Kivu Lulingu CRS CS Milenda 43 S. Kivu Lulingu CRS Maternité Tshonka 44 S. Kivu Mubumbano CRS CS HGR Maternite 45 S. Kivu Mubumbano CRS CS Cihusi 46 S. Kivu Mubumbano CRS CS IRONGO 47 S. Kivu Mubumbano CRS CS Ibula 48 S. Kivu Mulungu CRS CS LUMU 49 S. Kivu Mulungu CRS CRS MULINDWA 50 S. Kivu Mulungu CRS CRS CEPAC 51 S. Kivu Mwana CRS CS Buhamba 52 S. Kivu Mwana CRS CS Kakwende 53 S. Kivu Mwana CRS CS Kashadu 54 S. Kivu Mwana CRS CS Lurhala 55 S. Kivu Mwenga CRS CS Sungwe 56 S. Kivu Mwenga CRS CS Iganda 57 S. Kivu Mwenga CRS CS BUZIBA 58 S. Kivu Nundu CRS CS MaterniteSwima 59 S. Kivu Nundu CRS CS Kaboke II 60 S. Kivu Nundu CRS CS LusendaMaternité 61 S. Kivu Nundu CRS Maternité ABEKA 62 S. Kivu Nyangezi CRS HGR Nyangezi 63 S. Kivu Nyangezi CRS CS Kamanyola 64 S. Kivu Nyangezi CRS CS Kahinga 65 S. Kivu Nyangezi CRS Maternité Mazigiro 66 S. Kivu Nyangezi CRS CS Kamisimbi 67 S. Kivu Ruzizi CRS CS SangeEtat 68 S. Kivu Ruzizi CRS CS MutaruleMaternite 69 S. Kivu Ruzizi CRS CS SangeEtatMaternite 70 S. Kivu Ruzizi CRS CS CH Kiliba 71 S. Kivu Shabunda CRS CS Miswaki 72 S. Kivu Shabunda CRS CS Kassa 73 S. Kivu Uvira CRS CS Kavimvira 74 S. Kivu Uvira CRS CS KalunduEtat 75 S. Kivu Uvira CRS CS KalunduCepac 76 S. Kivu Uvira CRS CS BatimentMaternité HGR 77 S. Kivu Uvira CRS CS CS Kilomoni 78 S. Kivu Walungu CRS CS Walungu 79 S. Kivu Walungu CRS CS Lurhala 80 S. Kivu Walungu CRS CS Ikoma 81 S. Kivu Walungu CRS CS CRS Kidodobo 82 S. Kivu Walungu CRS CS Rushindye 83 S. Kivu Walungu CRS Maternité Mwendo A - 29
Nbr Provence Health Zone Partner Structure Name 84 KOR Bibanga ECC HGR Pavillonmaternité 85 KOR Bibanga ECC CS Lukangu 86 KOR Bibanga ECC CS Viens et vois 87 KOR Bibanga ECC HGR PavillonHopital 88 KOR Bibanga ECC CS Manja 89 KOR Bibanga ECC CS Maternité de Tshibila Dibindi / 90 KOR Dibindi ECC HGR PavillonsHopital 91 KOR Lodja ECC HGR Batiment 92 KOR Lodja ECC CS Elonge 93 KOR Lusambo ECC HGR Maternité 94 KOR Lusambo ECC CSM Tshileta 95 KOR Mpokolo ECC CSR/HGR Pavillonmaternité 96 KOR Mpokolo ECC CSR/HGR Pavillonmaternité 97 KOR Mpokolo ECC CHR/HGR Pavillon BC 98 KOR Omendjadi ECC HGR/CHR Hiambe 99 KOR Omendjadi ECC Maternité Lokavukavu 100 KOR Omendjadi ECC CS Akongedowo 101 KOR PaniaMutombo ECC HGR/CHR PavillonHôpital 102 KOR PaniaMutombo ECC BCZ BCZ 103 KOR VangaKete ECC Maternité Utshudi 104 KOR VangaKete ECC CS Asuku 105 KOC Bulape ECC HGR Pavillonmaternité 106 KOC Bulape ECC CS Yolo 107 KOC Bulape ECC CS Mbelo 108 KOC Bulape ECC CS MpataMbamba 109 KOC Bulape ECC CS Ingongo 110 KOC Lubondai ECC HGR Pavillonmaternité 111 KOC Lubondai ECC CS Dibwedieto 112 KOC Lubondai ECC CS Katambwe 113 KOC Lubondai ECC CS Minkulumbu 114 KOC Lubondai ECC CS Lubondai II 115 KOC Lubondaie ECC CS Maternité de Kaponde 116 KOC Mutoto ECC HGR Pavillonmaternité 117 KOC Tshikaji ECC HGR PavillonMatern/pédiatrie 118 KOC Tshikaji ECC CS MamuMwilu 119 KOC Tshikaji ECC CS Mbumba 120 KOC Tshikaji ECC CS Katumba 121 KOC Tshikaji ECC CS Salongo 122 Katanga Kabongo ECC HGR Batiment 123 Katanga Kabongo ECC CS Lenge I 124 Katanga Kabongo ECC CS Lwakidi
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Nbr Provence Health Zone Partner Structure Name 125 Katanga Kabongo ECC CS Maternité de Lenge 126 Katanga Kayamba ECC Maternité Kamayi 127 Katanga Kayamba ECC CSR Kamayi 128 Katanga Kinkondja ECC CS Kipamba II 129 Katanga Kinkondja ECC CS Masangu 130 Katanga Kinkondja ECC CS Kibila 131 Katanga Kinkondja ECC CS Mangi II 132 Katanga Kitenge ECC HGR BâtimentPéd. + Mat. 133 Katanga Lwamba ECC CS Kabumbulu 134 Katanga Lwamba ECC CS MbanzaMbuyu 135 Katanga Malemba Nkulu ECC CS Mat. de Kametemete 136 Katanga Malemba-Nkulu ECC HGR 3 bâtiments 137 Katanga Malemba-Nkulu ECC CS Kabozya 138 Katanga Malemba-Nkulu ECC CS MutomboLupichi 139 Katanga Malemba-Nkulu ECC CS Songwe 140 Katanga Malemba-Nkulu ECC CS Kabwe Mulongo 141 Katanga Mukanga ECC HGR Pavillonmaternité 142 Katanga Mukanga ECC CS Mukanga II 143 Katanga Mukanga ECC CS Lupandilu 144 Katanga Mulongo ECC CSR Kabamba 145 Katanga Mulongo ECC CS Ngoya 146 Katanga Mulongo ECC CS Mpemba 147 Katanga Mulongo ECC CS Bukena 148 Katanga Songa ECC HGR Pavillonmaternité 149 Katanga Songa ECC CS Samba 150 Katanga Songa ECC CS Maternité de Samba 151 Katanga Bunkeya WVI CS Tondo 152 Katanga Bunkeya WVI CS Kikobe 153 Katanga Bunkeya WVI CS Kateba 154 Katanga Dilala WVI CS Kapata 155 Katanga Dilala WVI CS Noah 156 Katanga Dilala WVI CS Kolwezi 157 Katanga Dilala WVI CS Musonoi 158 Katanga Dilala WVI CS Luilu 159 Katanga Fungurume WVI CS Kando 160 Katanga Fungurume WVI CSR Dipeta 161 Katanga Fungurume WVI CS Box PMTCT Neema 162 Katanga Fungurume WVI pharmacy fungurume pharmacy 163 Katanga Fungurume WVI CS Nguba 164 Katanga Kanzenze WVI CS Musokatanda 165 Katanga Kanzenze WVI CS Kamoa 166 Katanga Kanzenze WVI CSR Walemba A - 31
Nbr Provence Health Zone Partner Structure Name 167 Katanga Kanzenze WVI CS Wakipindji 168 Katanga Lualaba WVI CS Mushima 169 Katanga Lualaba WVI CS Pwene 170 Katanga Lualaba WVI CS Manga Manga 171 Katanga Lualaba WVI CS Pwibwe 172 Katanga Lualaba WVI CS Mupandja 173 Katanga Lubudi WVI HGR Maternite 174 Katanga Lubudi WVI CS Lubudi 175 Katanga Lubudi WVI CS Mbebe 176 Katanga Lubudi WVI CS Mutobwe 177 Katanga Manika WVI CS Kasulo 178 Katanga Manika WVI CSR Manikapavillonmaternite 179 Katanga Manika WVI CS Manika Marche 180 Katanga Mustatsha WVI CS Tshinaweji 181 Katanga Mustatsha WVI CS Kayembe 182 Katanga Mutshatsha WVI CSR Maisha 183 Katanga Mutshatsha WVI CS Yanva 184 S. Kivu Kalonge WVI CS Bumoga 185 S. Kivu Kalonge WVI CS Mule 186 S. Kivu Bunyakiri WVI CS Makuta 187 S. Kivu Bunyakiri WVI CS Bagana 188 S. Kivu Bunyakiri WVI CS Hombo 189 S. Kivu Bunyakiri WVI HGR Maternite 190 S. Kivu Bunyakiri WVI CS Lwana 191 S. Kivu Bunyakiri WVI CSR Bitale 192 S. Kivu Idjwi WVI CS Kihumba 193 S. Kivu Idjwi WVI CS Nyakalengwa 194 S. Kivu Idjwi WVI HGR Monvu(Maternite) 195 S. Kivu Idjwi WVI CS Mishimbwe 196 S. Kivu Idjwi WVI CS Mafula 197 S. Kivu Kalehe WVI CS Ishovu 198 S. Kivu Kalehe WVI CS Chofi 199 S. Kivu Kalehe WVI HGR Maternite+Pre Partum: 200 S. Kivu Kalehe WVI CSR Bushushu 201 S. Kivu Kalehe WVI CS Lushebere 202 S. Kivu Kalehe WVI CS Nyabibwe 203 S. Kivu Kalonge WVI CS Mutale 204 S. Kivu Kalonge WVI HGR Maternite+PTME 205 S. Kivu Kalonge WVI CS Cholobera 206 S. Kivu Katana WVI CS Lugendo 207 S. Kivu Katana WVI CSR Birava 208 S. Kivu Katana WVI CSR Ihimbi A - 32
Nbr Provence Health Zone Partner Structure Name 209 S. Kivu Katana WVI HGR Maternite 210 S. Kivu Katana WVI CS Kabushwa 211 S. Kivu Minova WVI CS Nyamasasa 212 S. Kivu Minova WVI CS Bulenga 213 S. Kivu Minova WVI CSR Kalungu 214 S. Kivu Minova WVI CS Muchibwe 215 S. Kivu Miti-Murhesa WVI CSR Kavumu 216 S. Kivu Miti-Murhesa WVI CH Murhesa 217 S. Kivu Miti-Murhesa WVI CS Buhandahanda
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ANNEX 4: PROCUREMENT AND SHIPMENT OF COMMODITIES
No Year Category Description Arrival Vendor How Clearing Agent Date 1 2007 Computer IT Equipment Kinshasa IMA Air Freight 4/9/2007
2 2007 EPI FrigoSibir Kinshasa WEM Sea Freight Sosar 6/10/2007 3 2007 Surgical Tables Opération&Lampesscyalitiques Kinshasa WEM Sea Freight DHL 7/26/2007 4 2007 Vehicles Cars(10 + 01) Kinshasa WEM Sea Freight Comexas/Sosar 8/12/2007 5 2007 Computer GIK 1:Ordinateurs, solar batteries, GIK Meds Kinshasa IMA Sea Freight Agetraf 6/30/2007 6 2007 Solar GIK 2:Solar systems Kinshasa IMA Sea Freight Agetraf 7/25/2007 7 2007 CPN Table gyneco,Vaccine carrier (Unicef) Kinshasa UNICEF Sea Freight Agetraf 7/8/2007 8 2007 CPN Table examine (Unicef) Kinshasa UNICEF Sea Freight Agetraf 7/16/2007 9 2007 Lab & Tests ARI Timer Kinshasa UNICEF Air Freight Agetraf 6/10/2007 10 2007 Lab & Tests Blood test kit + RPR tests Kinshasa IDA Air Freight Agetraf 6/17/2007 11 2007 Medicines Medicines (SP,Mebendazole,Fer..) airfreight Kinshasa IDA Air Freight Agetraf 7/15/2007 12 2007 Lab & Tests HIV tests determine(16000)depot Kinshasa IDA Air Freight Agetraf 04/19/2007 13 2007 Lab & Tests HIV tests determine (64,000) Kinshasa IDA Air Freight Sosar 9/23/2007 14 2007 Equipment Kits Mini Kits/Gloves/Chirurgical sets Kinshasa IDA Sea Freight Gecotrans 8/8/2007 15 2007 Medicines Medicines for dépôts (+/-50% of order) Lubumbashi IDA Sea Freight Gecotrans 9/7/2007 16 2007 Medicines MedicinesKnga,Klzi,Kma&Kowzi for Dépôt BUKAVU(+/ - 35% of Kinshasa IDA Sea Freight Agetraf 9/1/2007 17 2007 Nets Nets (30000order) pour ECC) Kinshasa Vestergaard Sea Freight Gecotrans 8/1/2007 18 2007 Nets Nets (120000 pr Bukavu) Bukavu Vestergaard Sea Freight Agetraf 8/8/2007 19 2007 Nets Nets (30000 L'shi ) Lubumbashi Vestergaard Sea Freight Agetraf 8/1/2007 20 2007 Solar Solar Refrigerator Kiinshasa Sundanzer Sea Freight Sosar Aug-10 21 2007 Family Planning Cycle beads Kinshasa Cycle Technology Sea Freight Agetraf Apr-10 22 2007 PMTCT PMTCT commodities1(cotrimoxazole, Kinshasa IDA Air Freight DHL 11/26/2007 23 2007 PMTCT PMTCT commodities2nultivits) + Tshikapa Kinshasa IDA Air Freight GTM 1/21/2008 24 2007 GIK & Misc GIK3: supplementarybaptists commodities Kinshasa IMA Sea Freight GTM 1/18/2008 25 2007 Lab & Tests GIK4:lab kits, microscopes, furniture; Kinshasa IMA Sea Freight GTM 1/11/2008 26 2007 Medicines Medicines for computersBUKAVU (Year1 part2) Kinshasa IDA Air Freight Gecotrans 1/17/2008 27 2007 Medicines Medicines to Kinshasa for ECC&WVI Ktga Lubumbashi IDA Sea Freight Gecotrans 1/18/2008 28 2007 Nets Nets(to Kinshasa(Year1 for part2)ECC Kasai &Ktga) Lubumbashi Sea Freight Gecotrans 6/5/2007
29 2007 Nets Nets(to BUKAVU for CRS & WVI) Bukavu Sea Freight Gecotrans 6/5/2007
30 2007 Nets Nets(to Lubumbashi for WVI & ECC Ktga) Lubumbashi Sea Freight GTS 6/5/2007
31 2008 GIK & Misc GIK5: divers IMA/PCUSA Kinshasa IMA Sea Freight GTN 5/15/2008 32 2008 Lab & Tests HIV tests determine (Abbott) secutrans Kinshasa Abbott Air Freight USAID 4/30/2008 33 2008 Computer IT Equipment & others Kinshasa Various Air Freight SOSAR 4/29/2008 34 2008 CPN Autoclave/Sterilizer ASCO Kinshasa ASCO Sea Freight GTM 6/15/2008 No Year Category Description Arrival Vendor How Clearing Agent Date 35 2008 CPN Tables examination,obstetrical Kinshasa ASCO Sea Freight Gecotrans 10/17/2008 36 2008 Solar Freezers(72) Kinshasa New England Sea Freight Sosar 6/15/2008 37 2008 Medicines SP/Oxytocine/Vitamine A/New born Kit… Kinshasa Kinshasa Air Freight Sosar 8/4/2008 38 2008 Medicines Medicines Y2(po 40063&po40137) IDA Bukavu IDA Sea Freight Gecotrans 6/15/2008 39 2008 Medicines Medicines Y2(andBukavu Y1P2) IDA Kinshasa Kinshasa IDA Sea Freight Sosar 6/15/2008 40 2008 Medicines Medicines Y2 (cpd, gloves, medicines) Kinshasa IDA Sea Freight 6/15/2008
41 2008 Medicines Medicines(diazepan, phenobarbital) depots Y1 Kinshasa IDA Air Freight Sosar 7/15/2008 42 2008 Medicines Medicines: ACTs Kinshasa IDA Air Freight Sosar 7/28/2008 43 2008 Medicines Medicine oxytocine Kinshasa IDA Air Freight Sosar 7/31/2008 44 2008 Medicines Medicines: Sulfadoxinepyr Kinshasa IDA Air Freight Sosar 7/18/2008 45 2008 GIK & Misc GIK 6 Kinshasa IMA Sea Freight GTM 8/15/2008 46 2008 Family Planning Cycles beads Kinshasa Cycle Technology Sea Freight Gecotrans 7/2/2008 47 2008 EPI Seringues AB Kinshasa BD Sea Freight Agetraf 5/19/2008 48 2008 CPN Simulators/New born Kinshasa Childbirth Graphic Air Freight Sosar 8/2/2008 49 2008 Medicines Medicines Y2/MP Kinshasa MP Sea Freight Gecotrans 10/20/2008 50 2008 Medicines Medicines Y2/MP Bukavu MP Sea Freight Sosar 10/20/2008 51 2008 Medicines Medicines Y2/MP Lubumbashi MP Sea Freight Gecotrans 10/20/2008 52 2008 Medicines Medicines Y2/MP(narcotics) Kinshasa MP Air Freight Sosar 10/15/2008 53 2008 Lab & Tests Blood giving set with airlet and needle Kinshasa IDA Air Freight AGETRAF 8/30/2008 54 2008 EPI Syringes BD Kinshasa BD Intl Sea Freight GTS 9/1/2008 55 2008 Medicines Medicines(ketamine/depot Bukavu), 93 colis Kinshasa IDA Air Freight SOSAR 10/10/2008 56 2008 Lab & Tests CPD-a-bag for blood taking Kinshasa IDA Sea Freight GECOTRANS 10/15/2008 57 2008 Medicines Medicines(insuline/kolwezi,kananga,bukavu), Kinshasa IDA Air Freight SOSAR 11/17/2008 58 2008 Medicines Medicines(insuline/Kamina,Kananga),3 colis 3 colis Kinshasa IDA Air Freight SOSAR 12/1/2008 59 2008 PMTCT Pmtct commodities per agency per cluster,126 Kinshasa IDA Air Freight SOSAR 12/4/2008 60 2009 Medicines ARVscolis Kinshasa IDA Air Freight SOSAR 1/5/2009 61 2009 Nets Nets year 3/Bukavu,62500pcs Bukavu VESTEGAARD Sea Freight GECOTRANS 1/15/2009 62 2009 Nets Nets year 3/Lubumbashi,60000pcs Lubumbashi VESTEGAARD Sea Freight GECOTRANS 1/15/2009 63 2009 Nets Nets year 3/Kinshasa, 30000pcs Kinshasa VESTEGAARD Sea Freight GECOTRANS 1/15/2009 64 2009 Nets Nets year3/Bukavu,27500pcs Bukavu VESTEGAARD Sea Freight GECOTRANS 1/21/2009 65 2009 Family Planning Cycles beads Year 3 Kinshasa VESTEGAARD Sea Freight SOSAR 1/27/2009 66 2009 Medicines Oxytocin for Bukavu Kinshasa IDA Air Freight SOSAR 1/29/2009 67 2009 Solar GIK 7:solar system/batteries, vehicle… Kinshasa IMA Sea Freight GECOTRANS 1/31/2009 68 2009 Medicines Medicines Year 3/IDA Lubumbashi Lubumbashi IDA Sea Freight GECOTRANS 1/31/2009 69 2009 Medicines Medicines Year 3/IDA, Cotripmtct, blood Bukavu IDA Sea Freight GECOTRANS 1/31/2009 70 2009 Medicines Cotrimoxazole…/PMTCTgiving set Kinshasa Kinshasa IDA Air Freight SOSAR 2/4/2009 A - 35
No Year Category Description Arrival Vendor How Clearing Agent Date 71 2009 Surgical Gauze/Glove/Fistula kit Kinshasa IDA Sea Freight GECOTRANS 2/15/2009 72 2009 Medicines Medicines Year 3/IDA, Cotripmtct, blood Kinshasa IDA Sea Freight GECOTRANS 2/15/2009 73 2009 PMTCT Hiv Doublegiving check+transfusion set Kinshasa kit mod2 Kinshasa IDA Air Freight SOSAR
74 2009 Medicines Methylergometrine/Year3 Kinshasa Mission Pharma Air Freight DHL 3/9/2009 75 2009 Medicines Medicines(supplemental order) Kinshasa IDA Air Freight SOSAR 3/15/2009 76 2009 Medicines Methylergometrine/Year3 Kinshasa Mission Pharma Air Freight DHL 3/15/2009 77 2009 Medicines Oxytocine Kinshasa Mission Pharma Air Freight DHL 3/24/2009 78 2009 Medicines Medicines/cotripmtct(129 COLIS) Lubumbashi IDA Sea Freight AGETRAF 3/26/2009 79 2009 Medicines Medicines/Acts Year 3 Kinshasa IDA Sea Freight GTS 3/31/2009 80 2009 Medicines Medicines/transfusion kits mo2/medic an3 kga- Kinshasa IDA Sea Freight AGETRAF 4/6/2009 81 2009 Medicines Medicineslodja Year 3 MP Kinshasa Mission Pharma Sea Freight COMEXAS 5/5/2009 82 2009 Medicines Medicines Year 3 MP Lubumbashi Mission Pharma Sea Freight COMEXAS 5/5/2009 83 2009 Medicines Medicines Year 3 MP Bukavu Mission Pharma Sea Freight GECOTRANS 5/5/2009 84 2009 Solar GIK8:Watt solar lantern, Tasok, Baptist Kinshasa Sea Freight GECOTRANS 6/10/2009
85 2009 Equipment Kits New born kit/Lodja suppl Kinshasa IDA Sea Freight GTS 6/12/2009 86 2009 EPI Syringes BD Kinshasa Becton Dickinson Sea Freight SOSAR 7/24/2009 87 2009 Lab & Tests Tests HIV determine Abbott Kinshasa InternationalABBOT Air Freight DHL 8/4/2009 88 2009 Lab & Tests Tests HIV determine IDA (50x100tests) Kinshasa IDA Air Freight DHL 8/5/2009 89 2009 Medicines Medicines( supplemental order) Kinshasa IDA Air Freight SOSAR 8/20/2009 90 2009 PMTCT Double Check Gold HIV Tests Kinshasa IDA Air Freight SOSAR 8/20/2009 91 2009 PMTCT ARVs(pmtct) Kinshasa IDA Air Freight DHL 9/5/2010 92 2009 Medicines Quinine di HCI, Oxytocyn, HIV Rapid Test Kinshasa IDA Air Freight SOSAR 9/7/2009 93 2009 Medicines Medicines(pentazocine,diazepan,phenobarbital)Unigold Kinshasa IDA Air Freight SOSAR 9/7/2009 94 2009 PMTCT Double CheckY3 Gold HIV Tests Kinshasa IDA Air Freight SOSAR 9/7/2009 95 2009 Medicines Meds for Kamina, Kolwezi, Lodja, Bukavu, Kinshasa IDA Air Freight SOSAR 10/14/2009 96 2009 Medicines Quinine di HCI, Oxytocyn,Kananga HIV Rapid Test Kinshasa IDA Air Freight SOSAR 10/14/2009 97 2009 Medicines Meds: Quinine sulphate,Unigold Vitamin A 200 & 100 Kinshasa IDA Air Freight GTM 10/22/2009 98 2009 Medicines Meds for Kamina, Kolwezi, Lodja, Bukavu, Kinshasa IDA Air Freight SOSAR 10/22/2009 99 2009 Lab & Tests Rpr welcomeKananga syfacard -r 8E58-01 Kinshasa IDA Air Freight SOSAR 11/20/2009 100 2009 Medicines Meds: Quinine sulphate, Vitamin A 200 & 100 Kinshasa IDA Air Freight GTM 11/20/2009 101 2009 Lab & Tests Rpr welcome syfacard-r 8E58-01 Kinshasa IDA Air Freight DHL 12/9/2009 102 2009 PMTCT Viramune&Baxa Dispensers Kinshasa BohringerIngel. Air Freight DHL 12/9/2009 103 2009 Lab & Tests Determine HIV 1/2 Test Kit (100 tests) Kinshasa ABBOT Air Freight DHL 12/17/2009 104 2009 Medicines Medicine:insulineisophane/an2 (Klzi, Kga, Kinshasa IDA Air Freight SOSAR 12/17/2009 105 2009 PMTCT Viramune&BaxaBkvu) Dispensers Kinshasa BohringerIngel. Air Freight DHL 12/17/2009 106 2010 PMTCT ARVs for Bukavu, Mbuji-mayi, and Kananga Kinshasa IDA Air Freight SOSAR 1/4/2010 A - 36
No Year Category Description Arrival Vendor How Clearing Agent Date 107 2010 PMTCT Determine HIV 1/2 Test Kit (100 tests) Kinshasa ABBOT Air Freight DHL 1/4/2010 108 2010 Nets Mosquito nets for Kinshasa Kinshasa Sumitomo Sea Freight COMEXAS 1/13/2010 109 2010 PMTCT ARVs for Bukavu, Mbuji-mayi, and Kananga Kinshasa IDA Air Freight SOSAR 1/13/2010 110 2010 Nets Mosquito nets for Bukavu Bukavu Sumitomo Sea Freight 4/6/2010
111 2010 Nets Mosquito nets for Lubumbashi Lubumbashi Sumitomo Sea Freight 3/25/2010
112 2010 Nets Permanets (mosquito nets for Kinshasa) Kinshasa VESTEGAARD Sea Freight GTS 3/25/2010 113 2010 Nets Permanets (mosquito nets for Bukavu) Bukavu VESTEGAARD Sea Freight GECOTRANS 3/24/2010 114 2010 Nets Permanets (mosquito nets for Bukavu) Bukavu VESTEGAARD Sea Freight GECOTRANS 4/6/2010 115 2010 Nets Permanets (mosquito nets for Lubumzbashi) Lubumbashi VESTEGAARD Sea Freight GECOTRANS 3/24/2010 116 2010 Computer IT Equipment & others Kinshasa IMA Air Freight GTS 3/25/2010 117 2010 PMTCT PMTCT Products for BKV, KNG, MJM, Kinshasa IDA Air Freight SOSAR 2/8/2010 118 2010 Computer IT EquipmentKMN, L'SH & others Kinshasa IMA Air Freight GTS 2/8/2010 119 2010 Lab & Tests Transfusion Kits 1 & 2 (IMA) Kinshasa IDA Air Freight SOSAR 2/17/2010 120 2010 PMTCT PMTCT Products for BKV, KNGA, MJM, Kinshasa IDA Air Freight SOSAR 2/17/2010 121 2010 Solar SolarKMNA, Refrigerators L'SHI Kinshasa IMA Sea Freight SOSAR 2/23/2010 122 2010 Lab & Tests Transfusion Kits 1 & 2 (IMA) Kinshasa IDA Sea Freight SOSAR 2/23/2010 123 2010 Surgical Hospital Mini Kits (IMA) Kinshasa IMA Sea Freight GTS 3/8/2010 124 2010 Solar Solar Refrigerators Kinshasa IMA Sea Freight SOSAR 3/8/2010 125 2010 Vehicles Toyota Land Cruiser Bukavu Toyota Burundi Sea Freight GECOTRANS 4/22/2010 126 2010 Surgical Hospital Mini Kits (IMA) Kinshasa IMA Sea Freight GTS 4/22/2010 127 2010 Surgical Hospital gloves/gauze kit (IMA) Kinshasa IDA Sea Freight GTS 4/22/2010 128 2010 Surgical Hospital gloves/gauze kit (IMA) Kinshasa IDA Sea Freight GTS 7/30/2010 129 2010 Vehicles Toyota Land Cruiser Lubumbashi AGRIEX Sea Freight 4/15/2010
130 2010 GIK & Misc Air Freight Order 1 Kinshasa IDA Air Freight SOSAR 7/30/2010 131 2010 GIK & Misc Donated medical supplies and equipment Kinshasa IMA Sea Freight SOSAR 4/15/2010 132 2010 GIK & Misc Donated medical supplies and equipment Kinshasa IMA Sea Freight GECOTRANS 5/20/2010 133 2010 Equipment Kits New Born Kit & medical supplies and Kinshasa IDA Sea Freight GTS 5/30/2010 134 2010 Lab & Tests CPNequipment Tests Kinshasa MP Air Freight SOSAR 6/1/2010 135 2010 Medicines ACTs Kinshasa MP Air Freight OPTIMUM 6/1/2010 136 2010 Medicines Narcotics and keep cool from Demark Kinshasa MP Air Freight NA 6/3/2010 137 2010 Medicines Supplementary Medicine Order Kinshasa IDA Air Freight NA 8/30/2010 138 2010 Medicines Narcotics 2nd lot Kinshasa 0 Air Freight SOSAR 8/30/2010 139 2010 Medicines MP Narcotics 2nd Lot Kinshasa Mission Pharma Sea Freight SOSAR 8/12/2010 140 2010 Lab & Tests Determine HIV ½ Test Kits Kinshasa ABBOT Air Freight SOSAR 8/18/2010 141 2010 Medicines Essential Medicine (year four) Kinshasa IMA Air Freight GTS 8/23/2010 142 2010 Medicines Essential Medicine (year four) Kinshasa Sea Freight SOSAR 8/23/2010
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No Year Category Description Arrival Vendor How Clearing Agent Date 143 2010 Vehicles Car Kinshasa IMA Sea Freight GECOTRANS 8/27/2010 144 2010 Medicines Essential Medicine (year four) Kinshasa Mission Pharma Sea Freight COMEXAS 9/13/2010 145 2010 EPI BD auto-bloquant vaccine syringes Kinshasa BD Sea Freight GTS 9/10/2010 146 2010 Medicines Essential Medicine (year four) Bukavu Mission Pharma Sea Freight GECOTRANS 9/10/2010 147 2010 Medicines Essential Medicine (year four) Lubumbashi Mission Pharma Sea Freight GECOTRANS 9/13/2010 148 2010 Lab & Tests Determine HIV ½ Test Kits Kinshasa Direct Relief Air Freight SOSAR 9/16/2010 149 2010 Computer IT Supplies (via Pakistan) Kinshasa IMA Air Freight GTS 9/17/2010 150 2010 EPI BD auto-bloquant vaccine syringes Kinshasa BD Sea Freight GTS 10/7/2010 151 2010 Equipment Kits CPN Kits Kinshasa Mission Pharma Sea Freight GECOTRANS 12/28/2010 152 2010 Equipment Kits CPN Kits Bukavu Mission Pharma Sea Freight GECOTRANS 12/28/2010 153 2010 Medicines Residual Essential Medicine Order Bukavu Mission Pharma Air Freight SOSAR 10/19/2010 154 2010 Medicines Medicines(IDA:S82275-D) Bukavu Kinshasa IDA Sea Freight GTM 9/16/2010 155 2010 GIK & Misc Donated medical supplies and equipment Kinshasa IMA Sea Freight SOSAR 10/24/2010 156 2010 Medicines Essential Medicine (year four) Kinshasa Mission Pharma Air Freight GTS 10/26/2010 157 2010 Medicines 2 cartons from Pakistan Kinshasa IMA Air Freight GTS 10/7/2010 158 2010 CPN CPN year 4 Bukavu Mission Pharma Sea Freight GECOTRANS 11/23/2010 159 2010 CPN CPN Kin &Lushi Kinshasa Mission Pharma Sea Freight GECOTRANS 11/28/2010 160 2010 Nets ITNs Bukavu JSI Sea Freight AGETRAF 11/22/2010 161 2010 Nets ITNs Lubumbashi JSI Sea Freight MANICA 11/27/2010 162 2010 Nets ITNs Kinshasa JSI Sea Freight COMEXAS 12/15/2010
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ANNEX 5: MATERIAL AND EQUIPMENT DISTRIBUTION (By Health Zone)
Matériels/Equipements SNIS/GSIS
Generator Bicycle bord Hors Kit informatique(ec Radio plus HF access. SNISCS SNISBCZ SNIS HGR Ordinogramme A,B,C de Fiches référence Registre Consultations Curatives Calendriers Axxes de Fiches 07 Monitorage Region Health Zone CS Moto S. Kivu Kadutu 11 5 1 7 0 1 0 1526 143 66 16 3331 27 143 50 S. Kivu Mwana 19 5 1 3 0 2 0 1956 140 60 24 3261 23 377 95 S. Kivu Nyangezi 10 5 1 5 0 2 0 1,339 143 60 15 2,164 14 235 73 S. Kivu Kaziba 15 5 1 5 0 2 0 2,190 140 60 20 4,204 21 363 109 S. Kivu Walungu 11 5 1 17 0 2 0 3,093 140 60 16 5,787 44 501 148 S. Kivu Kaniola 7 4 1 5 0 2 0 1775 140 60 12 3335 29 302 66 S. Kivu Mubumbano 10 5 1 3 0 2 0 1876 140 60 15 2942 37 400 104 S. Kivu Kamituga 20 5 1 15 0 2 1 2701 140 62 25 3466 42 367 206 S. Kivu Mwenga 22 5 1 17 0 2 1 2038 140 62 27 3848 25 333 194 S. Kivu Uvira 25 4 1 22 0 2 0 2,552 140 60 30 4,310 39 341 197 S. Kivu Bijombo 10 5 1 15 0 2 1 2770 140 62 15 4473 49 265 92 S. Kivu Nundu 15 5 1 33 0 2 1 2922 140 62 20 5,757 64 371 139 S. Kivu Lemera 20 6 1 21 0 2 1 2340 140 60 25 4555 45 357 109 S. Kivu Ruzizi 15 5 1 20 0 2 0 1775 140 60 20 2,822 33 292 84 S. Kivu Ibanda 8 5 1 13 0 1 0 2101 143 60 13 1774 31 156 55 S. Kivu Bagira 22 5 1 9 0 1 0 1164 143 60 27 2523 19 105 36 S. Kivu Kitutu 26 5 2 6 0 2 1 2771 130 50 31 2043 43 431 150 S. Kivu Lulingu 15 4 1 0 0 2 1 2454 131 50 20 4167 45 407 141 S. Kivu Kalole 15 5 1 10 0 2 1 3077 128 50 20 2121 47 500 173 S. Kivu Shabunda 21 4 1 7 0 2 1 2425 131 50 26 1954 39 388 134 S. Kivu Mulungu 22 4 1 7 0 2 1 2252 131 50 27 2049 42 412 142 Distributed to HZs 101 22 240 0 39 10 47,097 2,903 1,224 444 70,886 758 7,046 2,497 Quantity Received by CRS 101 22 240 0 39 10 47,097 2,903 2,295 444 70886 758 7,886 3,337 Balance 0 0 0 0 0 0 0 0 1071 0 0 0 7886 840 % Distributed 100% 100% 100% 100% 100% 100% 100% 53% 0% 100% 100% 89% 75%
K. Oc. Tshikaji 12 4 0 0 0 2 0 1179 112 128 16 2,500 20 40 K. Oc. Bulape 15 4 1 0 0 2 0 1134 1004 131 18 2,500 20 136 49 K. Oc. Mutoto 13 3 1 0 0 1 0 1000 634 131 0 2,500 20 127 46 K. Oc. Lubondai 19 4 0 8 0 2 0 1794 1043 160 23 3,500 30 182 65 K. Or. Bibanga 14 4 1 15 0 2 0 1404 112 77 19 2,000 28 150 60 K. Or. Mpokolo 15 4 1 15 0 2 0 1702 110 78 17 4,599 30 130 50 K. Or. Dibindi 13 3 0 11 0 1 0 1799 103 92 15 3,000 54 125 40 K. Or. Lodja 22 4 1 22 0 2 0 620 70 79 24 2,500 10 173 77 K. Or. Lusambo 13 4 1 13 1 2 0 1508 102 78 15 2,500 12 125 40 K. Or. Omendjadi 18 4 1 18 0 2 1 505 70 75 20 2,500 12 143 63 K. Or. Pania Mutombo 10 3 1 10 1 2 0 1496 104 78 12 2,500 27 130 50 K. Or. Vanga Kete Ototo 17 4 1 17 0 2 1 670 70 59 19 2,500 12 134 60 Katanga Mulongo 25 3 1 4 1 2 1 748 28 43 17 1389 38 105 40 Katanga Kayamba 20 4 1 0 0 2 1 644 32 45 15 2063 28 85 30 Katanga Lwamba 23 3 1 4 0 2 1 630 32 45 20 2184 19 115 45 Katanga Songa 15 3 1 0 0 2 1 1195 32 45 31 3152 52 180 70 Katanga Malemba Nkulu 7 4 1 4 1 2 0 1743 32 45 20 3917 31 115 45 Katanga Mukanga 13 3 1 29 1 2 0 861 32 45 21 4780 32 120 50 Katanga Kabongo 14 2 0 0 0 1 0 720 32 45 28 5076 44 160 65 Katanga Kitenge 16 2 1 0 0 2 0 976 32 45 21 5153 40 120 45 Katanga Kinkondja 18 3 1 1 2 2 1 1022 32 31 26 5370 44 160 50 Distributed to HZs 72 17 171 7 39 7 23350 3818 1555 397 66,183 603 2715 1080 Quantity Received by ECC 72 17 171 7 39 7 23350 3818 1555 397 66183 603 2825 1080 Balance 0 0 0 0 0 0 0 0 0 0 0 0 110 0 % Distributed 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 96% 100%
Katanga Kanzenze 15 5 1 41 0 2 0 842 106 72 21 2080 100 365 200 Katanga Bunkeya 7 4 1 25 0 2 1 644 64 63 10 2080 71 239 180 Katanga Mutshatsha 13 6 1 37 0 2 1 812 100 63 18 2080 95 365 210 Katanga Lualaba 14 4 1 19 0 2 0 822 94 60 20 2105 91 345 190 Katanga Lubudi 16 6 1 40 0 2 1 722 118 81 22 2580 118 357 190 Katanga Fungurume 11 4 1 20 0 2 0 1068 94 72 17 2605 101 345 190 Katanga Dilala 10 4 0 34 0 2 0 732 88 72 17 2630 98 325 185 Katanga Manika 13 4 0 35 0 2 0 682 61 72 20 2665 106 325 185 S. Kivu Kalonge 15 6 1 16 0 1 1 553 13 13 17 3000 21 612 189 S. Kivu Kalehe 10 4 0 12 0 0 0 534 13 5 23 2833 21 546 172 S. Kivu Minova 10 4 1 8 0 1 1 549 13 5 17 2833 21 630 190 S. Kivu Bunyakiri 23 6 1 12 0 1 1 572 13 5 25 2833 21 779 274 S. Kivu Katana 16 4 0 8 0 0 0 554 13 12 18 2833 21 664 214 S. Kivu Miti 17 4 0 12 0 0 0 553 13 5 18 3500 21 644 210 S. Kivu Idjwi 21 4 1 16 0 1 1 3064 13 5 22 2833 30 752 245 Distributed to HZs 69 10 335 0 20 7 12703 816 605 285 39490 936 7293 3024 Quantity Received by ECC 69 10 335 0 20 7 12703 816 605 285 39490 936 7293 3024 Balance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 % Distributed 100% 100% 100% ##### 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
SECUTRANS/LABO OUTILS GESTION FINANCIERE ET DES MEDICAMENTS
HIVtests Determine secutrans Fiches Techniques Securité tests Blood kits Labo Kit RUMER Cons. Registre HGR Méd/ tech Fiches Méd Gestion CS tech Fiches Méd Gestion HGR tech Fiches Méd Gestion BCZS stock de Fiches Quittancier Journarecettes CS Journal depensesCS Journarecettes BCZS Journal depensesBCZS Journal Ventillation HGR recettes Journal HGR Journal depensesHGR BonsSortie caisse Bonsentrée caisse caisse de Livre 4,917 42 5 2 18 3 28 2 2 4,634 41 5 5 3 3 9 7 3 17 17 12 1,558 27 5 1 11 2 0 2 1 1,541 46 5 6 4 2 10 7 3 12 10 7 2,143 0 4 1 15 1 0 0 0 1,219 38 4 4 3 3 9 7 4 16 14 11 870 0 4 1 31 2 0 0 0 1,426 43 5 5 3 5 12 9 6 25 24 21 1,310 85 4 1 33 3 56 4 4 7,883 72 9 10 6 6 18 14 7 32 29 23 1,465 0 4 1 18 1 0 0 0 1,994 41 5 5 3 3 9 7 3 19 16 13 1,536 0 4 1 20 2 0 0 0 2,013 52 6 7 4 3 12 9 4 20 18 14 2,851 0 5 2 22 2 0 4 0 1,812 58 8 8 6 4 15 11 5 22 164 16 1,490 0 4 1 25 2 0 0 0 1,577 55 7 7 5 4 13 10 5 22 20 17 13,763 58 8 2 23 2 38 3 3 6,015 58 8 9 6 4 16 11 5 26 19 16 700 85 3 1 42 2 56 4 4 6,416 72 8 9 6 6 18 13 6 27 26 23 5,840 81 4 1 32 2 54 4 4 7,286 69 10 9 6 5 17 20 6 30 27 22 2,547 70 4 1 28 2 46 4 4 5,976 67 9 9 6 5 17 13 6 25 23 19 3,170 46 4 1 18 1 31 2 2 4,537 52 7 7 5 3 12 9 4 19 17 13 2,830 58 4 2 22 2 38 3 3 6,836 43 5 5 4 4 7 8 4 28 24 16 1,270 31 4 1 12 1 20 2 2 3,116 32 3 4 2 2 7 5 2 12 10 8 1,310 0 4 1 22 2 0 0 0 1,722 72 9 10 6 6 19 14 7 29 27 24 1,310 77 4 1 24 2 0 0 0 1,971 87 8 9 6 0 17 12 5 27 25 21 1,170 116 4 1 22 2 0 0 0 1,596 87 11 11 7 0 21 18 9 36 35 32 1,040 70 4 1 22 2 0 0 0 1,777 61 8 8 6 50 16 5 5 24 22 19 1,110 30 4 1 22 2 3 0 1 2,673 67 8 9 6 5 17 19 6 24 23 22 54,200 876 90 25 482 40 370 34 30 74,020 1,213 148 156 103 123 291 228 105 492 590 369 54200 876 90 25 482 40 370 34 30 74,020 1,402 150 158 105 123 293 228 106 492 590 369 0 0 0 0 0 0 0 0 0 0 189 2 2 2 0 2 0 1 0 0 0 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 87% 99% 99% 98% 100% 99% 100% 99% 100% 100% 100%
2870 31 1 2 28 1 18 2 2 2350 80 15 15 4 5 5 5 5 161 131 37 2490 41 1 3 28 2 23 2 2 2852 104 11 9 5 5 6 5 5 203 172 27 2050 36 1 5 28 1 20 2 2 2480 71 13 9 4 5 3 5 5 162 128 20 2890 52 1 2 40 2 29 2 2 2303 72 39 38 8 5 10 5 5 96 73 41 2250 16 2 2 69 10 20 2 2 2450 100 27 15 6 2 6 15 10 238 238 95 2040 16 2 2 71 9 23 2 2 2650 84 20 20 6 6 6 11 6 238 238 96 1320 16 3 2 57 8 40 5 1 6650 100 38 38 7 5 7 6 1 238 238 94 770 96 0 2 29 29 32 5 0 8000 123 58 62 5 0 13 9 10 275 376 170 1220 16 2 2 49 8 40 4 2 6650 84 34 34 5 5 5 6 1 238 238 92 720 96 0 2 27 32 40 4 2 10000 118 34 62 4 0 14 8 10 295 319 182 1270 49 2 2 50 8 40 4 4 6650 100 34 34 5 5 5 6 1 243 243 92 510 106 0 2 25 32 31 4 1 8500 78 42 60 5 0 14 8 10 304 330 166 1630 46 1 2 43 5 24 2 2 2260 103 25 16 3 5 5 5 5 99 91 38 590 33 1 2 35 6 20 2 2 3250 91 20 13 3 5 5 5 5 103 73 37 610 35 1 2 31 5 12 2 2 2250 103 23 13 4 5 5 5 5 99 92 39 2490 79 1 4 77 7 43 2 2 2299 117 15 19 4 5 5 5 5 109 121 48 2220 46 1 4 42 5 24 2 2 2250 101 7 16 3 5 5 5 5 98 92 38 1430 46 1 4 43 5 24 2 2 2260 103 13 16 3 5 5 5 5 99 91 40 2670 70 1 2 70 7 38 2 2 2300 112 14 19 3 5 5 5 5 106 112 46 1480 51 1 4 65 7 30 2 2 2270 113 16 19 3 5 5 5 5 107 115 45 2880 66 1 2 56 6 35 2 2 2260 103 18 19 4 5 5 5 5 99 94 41 36400 1043 24 54 963 195 606 56 40 82934 2,060 516 546 94 88 139 134 114 3,610 3,605 1,484 36400 1043 24 54 963 195 606 56 40 82934 2,060 516 546 94 88 139 134 114 3610 3605 1,484 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
1600 20 1 1 20 2 19 2 1 2750 122 30 34 10 5 37 18 22 41 9 18 1550 20 1 1 20 2 19 2 1 2750 96 24 21 10 7 30 15 10 23 5 7 1300 20 2 1 22 1 19 1 1 2750 90 35 29 10 5 27 18 20 35 13 14 1150 20 1 1 20 1 19 1 1 2750 117 28 31 10 8 31 14 19 48 20 21 1330 15 1 1 25 2 18 2 1 2750 81 25 26 12 2 29 17 14 41 20 17 2850 25 1 1 28 2 19 2 1 2750 126 25 30 10 1 39 18 23 38 10 13 1700 25 3 3 25 1 19 1 1 2750 120 31 44 18 2 32 20 18 42 10 18 2050 25 1 2 28 2 19 2 1 2750 153 27 40 12 2 17 20 23 47 25 20 3300 10 4 2 25 2 25 2 2 3000 65 33 47 11 0 21 9 0 18 0 18 3200 10 3 1 25 2 20 2 2 1500 50 22 30 11 0 28 9 0 12 0 12 3000 10 5 1 25 2 20 2 2 3000 60 26 40 11 0 18 9 0 13 0 13 3000 10 4 1 25 2 33 2 2 2000 95 47 65 11 0 24 9 0 16 0 14 2600 10 22 1 25 2 25 2 2 2000 70 33 47 11 0 19 9 0 18 0 18 4300 10 15 1 25 4 25 2 2 1500 70 34 48 10 0 19 9 0 20 0 19 2600 10 7 2 30 2 34 2 2 2000 90 42 58 11 0 22 10 0 23 0 23 35530 240 71 20 368 29 333 27 22 37000 1405 462 590 168 32 393 204 149 435 112 245 35550 240 71 20 368 29 333 27 22 37000 1405 462 590 168 32 393 204 149 435 112 245 20 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
A - 40
Santé de Reproduction et PF
Fiche CPN Fiche (x1000) CPON Fiche (x1000) planing Fiche familial Partogramme (x500) Cons P.F Fiche (1000) Cons Registre P.F(jeu x…flles) RDV Carte ND CPN Regis. CPON Registre Registre Accouchements DepoProvera 7968 2500 7388 603 12 1336 21 19 26 4,280 4861 2500 6434 1164 14 1637 18 18 24 2,925 5314 500 4,755 1,153 11 1,124 9 7 14 3,155 4099 500 6,638 1,365 13 649 19 14 20 3,399 7473 2500 11,936 2,053 23 2,424 24 38 45 5,693 7389 2500 4298 3439 12 1211 26 25 28 3,571 7394 2500 7050 1385 16 1561 29 29 37 4,475 5317 2500 6089 1567 17 1861 43 34 42 5,128 6231 500 8002 2882 29 1899 12 19 26 4,053 9937 2500 9,614 2,187 17 1,861 31 33 39 4,953 6152 2500 7,230 1308 21 2424 37 41 53 3,516 8645 2500 9581 1875 19 2336 39 41 53 4,515 7210 2500 5821 1563 19 2249 35 36 44 4,305 7065 2500 6,072 1330 13 1549 23 26 34 3,600 10734 2500 9115 500+1644 13 1299 26 16 36 4,466 5503 2500 3847 1007 8 949 15 14 18 3,051 4677 0 5736 950+684 21 1,924 23 23 47 3959 6052 2000 7382 1322 19 2,361 27 23 44 4380 4225 0 5568 1502 23 2,361 23 23 52 4642 4833 0 5671 1692 21 1,574 23 23 42 4684 4999 0 5993 1699 21 1,836 23 23 46 5485 136,078 36,000 0 144,220 31,096 362 36,425 526 525 770 88,235 136,078 36,000 0 144,220 31096 362 36425 526 525 770 88,235 0 0 0 0 0 0 0 0 0 0 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
5341 2300 5341 850 20 2800 37 26 28 4670 6994 2550 6994 1300 25 1200 30 26 39 3490 5294 2050 5294 1800 25 1100 29 26 31 3250 6371 3350 6371 1350 36 2000 44 36 40 4960 2550 1800 2300 1300 33 800 30 26 29 1575 2500 1800 4800 3300 29 1700 38 25 41 2255 2500 300 1700 0 18 2500 37 13 13 4525 4150 3410 1600 1850 17 1500 14 14 14 2700 2500 1800 1200 7300 18 2000 15 12 12 1395 4054 3289 1585 3350 15 2000 12 12 12 2175 2500 1800 1200 7300 18 2000 13 12 12 950 3817 3030 1565 1800 15 1500 12 12 11 2000 1445 1563 1500 850 30 500 34 30 34 3650 2475 1527 2379 1350 26 1000 30 25 31 5020 3045 2063 2656 1350 17 1000 21 18 22 5400 4146 2784 3401 2399 51 1400 58 50 57 8140 5416 3759 4106 1350 30 1500 34 30 34 8750 5545 4563 4932 1350 30 2000 34 30 34 10850 6043 4754 5339 1400 44 2000 50 44 51 13050 6078 4768 5160 1400 36 1200 42 36 42 14620 6060 5115 5707 1400 41 1400 45 40 46 12855 88,824 58,375 75,130 44,349 574 33100 659 543 633 116280 88824 58375 75130 44349 574 33100 659 543 633 116280 0 0 0 0 0 0 0 0 0 0 0 100% 100% #DIV/0! 100% 100% 100% 100% 100% 100% 100% 100%
5399 4899 5099 2178 10 0 86 10 30 2375 3974 3474 3774 3200 10 0 43 10 20 1500 4830 4000 4250 2100 10 0 67 10 32 550 5316 4566 5016 3000 10 0 63 10 30 2275 5424 5274 5224 1800 10 0 84 13 40 2125 6747 7394 6344 1800 10 0 78 13 42 2300 6690 5940 5990 1830 10 0 74 13 40 3950 7872 8122 8222 1860 10 0 82 13 40 2575 6500 4000 5750 2517 1 1000 18 53 23 2583 6500 4000 5250 2517 0 1000 18 53 23 2650 7500 4583 5500 2717 1 1000 18 53 23 2944 7000 4253 5003 2770 0 1500 18 53 23 2551 5500 4583 5250 3017 1 1500 18 53 15 2990 5500 4583 7000 3107 0 1000 18 53 21 2766 7500 5000 7500 3608 3 1500 16 54 22 2966 92252 74671 85172 38021 86 8500 701 464 424 37100 92252 74671 85172 38021 86 8500 701 464 424 38100 0 0 0 0 0 0 0 0 0 0 1000 100% 100% #DIV/0! 100% 100% 100% 100% 100% 100% 100% 97% A - 41
Santé de Reproduction et PF
Lo-femenal Ovrette DIU Condoms Condoms Féminin TestsRPR/cpn du Collier Cycle CCVKit DiuKit SP/TPI Mebendazole Fer+Acide folique images à Boites (sr) 4,046 1,840 90 46,534 2,402 36 1,251 1 34000 57000 831000 11 2,396 1,068 57 33,424 1,849 12 1,062 1 1 41000 37000 497000 13 2,098 1,361 48 36,451 1,327 12 1,112 1 37000 33000 468000 10 2,128 1,627 61 40,515 1,539 3 1,264 1 19000 35000 446000 12 2,738 3,112 128 63,343 2,025 12 1,491 1 35000 73000 893000 22 2,338 1,642 81 40,773 1,825 3 1,126 1 1 26000 52000 645000 11 2,655 1,434 83 47,227 2,014 3 1,145 1 1 27000 51000 645000 15 2,936 2,562 87 54,639 2,188 15 1,250 1 1 25000 47000 618000 19 2,976 1,709 72 51,863 2,204 6 1,267 1 1 21000 38000 521000 16 2,637 2,306 124 54,411 2,443 129 1,457 1 1 40000 83000 905000 20 1,732 2,591 75 41,581 1,181 0 1,320 1 1 17000 32000 418000 20 2,519 2,704 112 1,151,512 1,558 63 1,461 1 1 32000 65000 592000 21 2,728 2,450 87 51,286 2,012 12 1,382 1 1 25000 47000 603000 21 3,472 1,706 76 42,742 2,308 27 1,218 1 1 27000 47000 667000 16 3,469 1,750 130 47,140 2,165 28 1,350 41000 92000 1167000 12 2,583 1,395 50 36,207 2,334 9 1,010 1 1 17000 29000 413000 8 2,168 2477 192 44230 2,445 0 1,287 1 1 21000 39000 500000 22 2,662 2598 95 8217 2,019 0 1,537 1 1 25000 47000 608000 20 2,860 2634 77 45336 2,085 0 1,807 1 1 16000 32000 452000 27 2,830 2609 90 46989 2,085 0 1,482 30000 56000 178000 19 2,914 2522 92 40796 811 0 1,173 1 1 24000 43000 575000 20 56,885 44,097 1,907 2,025,216 40,819 370 27,452 18 16 580,000 1035000 12642000 355 56885 44,097 1907 2,025,216 40,819 370 27452 18 16 580,000 1,035,000 12,642,000 357 0 0 0 0 0 0 0 0 0 0 0 0 2 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99%
6300 5300 2 60400 450 5 1000 2 1 5 156 118 26 3100 3100 2 9400 600 5 1235 2 1 5 106 123 24 3100 2500 25 36400 450 5 1155 2 1 5 104 146 24 3600 2900 2 72500 600 5 1610 2 1 7 104 221 29 10200 770 3 27800 1200 6 2100 2 2 15 53 126 7 9800 620 1 71000 1250 6 1825 2 2 14 55 325 8 10400 1010 1 47800 700 2 1555 2 1 2 51 29 6 2600 2600 1 33000 400 6 1540 2 1 36 52 374 10 6700 540 1 20000 400 2 1555 1 1 2 52 13 6 0 0 1 27000 300 0 1260 1 1 31 52 306 5 3700 280 1 16500 400 2 1465 1 1 1 52 10 6 200 0 1 27000 300 0 1200 2 1 30 52 289 9 4250 1725 2 30000 870 16 1100 2 1 32 97 229 17 1750 835 2 18000 920 19 740 1 1 52 74 100 17 2050 955 2 18000 870 20 1000 1 41 71 236 17 2120 850 2 36000 885 25 1660 2 2 38 74 249 20 2585 1015 2 30000 870 28 1070 2 2 49 90 250 17 2100 855 2 39000 870 32 1150 2 2 57 82 280 17 2120 970 3 51000 875 31 1480 2 2 80 69 348 15 2200 1070 2 45000 870 32 1360 1 1 49 89 248 15 2420 1485 3 51000 870 34 1430 2 2 72 88 249 18 81295 29380 61 766800 14950 281 28490 35 28 623 1623 4269 313 81295 29380 61 766800 14950 281 28490 36 28 623 1623 4269 153 0 0 0 0 0 0 0 1 0 0 0 0 -160 100% 100% 100% 100% 100% 100% 100% 97% 100% 100% 100% 100% 205%
1800 1600 50 37600 600 1123 2425 1 1 11300 25 787 0 1800 1600 50 31900 700 1273 1905 1 1 8100 25 661 0 1700 1500 50 32900 600 1510 1923 1 2 13600 25 784 1 1800 1600 85 37800 700 1605 2475 1 1 6900 25 584 0 2300 1700 63 38200 900 1758 2980 1 1 11600 25 607 0 2200 2400 105 47900 800 2137 2978 1 1 14800 25 249 1 4300 3600 50 48500 1282 1926 2032 1 2 11700 25 684 0 4100 3600 50 48900 1600 3364 2032 1 1 12000 0 673 1 4042 2642 125 36322 754 1700 2097 1 1 3000 49 144 3772 2936 175 61902 814 1700 2127 1 1 4000 31 87 3800 3100 200 62082 873 1700 2482 1 1 4000 45 119 3762 3990 150 58812 784 1900 2621 1 1 3000 66 99 5292 3800 250 65182 874 2500 2474 1 1 4000 50 104 4050 4450 125 67900 904 2200 3630 1 1 5000 49 122 6530 5410 225 69900 993 1900 2542 1 1 5000 59 118 51248 43928 1753 745800 13178 28296 36723 15 17 118000 524 5822 3 52998 46528 1753 752700 79249 28296 36723 15 17 118000 524 5822 3 1750 2600 0 6900 66071 0 0 0 0 0 0 0 0 97% 94% 100% 99% 17% 100% 100% 100% 100% 100% 100% 100% 100%
A - 42
PALUDISME
Moustiquaires I.I. I.T.N Registre - 5ans I.T.N Registre femmes enceintes Registre Rapport ITN Mensuel image Boite paludisme Registre RapportAnnuel I.T.N Fiches Techniques P.N.L.P. 16,300 16 16 17 27 1 28 9,000 19 19 14 32 1 31 15,500 15 15 15 0 1 0 8,700 18 18 30 0 1 0 20,250 33 33 30 54 1 57 12,250 16 16 18 0 1 0 11,700 22 22 20 0 1 0 12,700 25 25 23 37 1 0 10,000 23 23 24 0 1 0 18,600 25 25 23 37 1 57 7,600 33 33 33 54 1 40 13,900 31 31 32 52 1 0 10,750 30 30 27 45 1 39 13,100 17 17 18 30 1 47 13,300 18 17 23 37 1 39 8,000 12 12 12 20 1 21 15,250 33 33 35 0 1 0 19,200 30 30 30 0 1 0 12,000 40 40 45 0 1 0 12,000 27 27 27 0 1 0 14,500 31 31 32 0 1 3 274,600 514 513 528 425 21 362 390300 514 513 528 425 21 362 115700 0 0 0 0 0 0 70% 100% 100% 100% 100% 100% 100%
3900 46 30 18 24 1 18 4900 42 25 23 27 1 23 4500 41 25 10 20 1 20 6200 46 30 29 33 1 28 7400 40 43 44 10 20 21 6500 37 41 29 23 20 36 5600 64 60 49 40 20 0 5850 78 73 66 44 35 0 5650 63 72 49 40 20 36 4750 71 77 75 50 34 0 4450 65 72 49 40 20 36 4500 83 84 70 56 32 0 6200 40 43 38 25 1 24 2000 39 42 35 22 1 20 2600 37 40 33 13 1 12 3500 29 30 26 44 10 43 5300 15 18 13 25 1 24 4200 24 27 22 25 1 24 7500 26 29 24 38 1 38 5300 29 31 27 30 10 30 5000 32 35 27 34 1 34 105800 947 927 756 663 232 467 105800 947 927 756 663 232 467 0 0 0 0 0 0 0 100% 100% 100% 100% 100% 100% 100%
13500 25 0 20 20 0 19 9600 7 0 7 20 0 20 12200 25 0 20 10 0 20 9400 25 0 20 20 0 19 13700 25 0 20 20 0 23 15100 10 0 10 20 0 19 19800 25 0 20 28 0 20 26400 25 0 20 28 0 22 18450 22 22 21 27 0 24 13100 17 17 15 26 0 18 16100 20 20 16 26 0 18 20140 32 32 28 30 0 31 21790 23 23 20 20 0 23 22904 23 23 20 25 0 23 26402 30 30 27 28 0 31 258586 334 167 284 348 0 330 258586 334 167 284 348 330 A - 43 0 0 0 0 0 0 0 100% 100% 100% 100% 100% #DIV/0! 100%
PEV/CPS
PEV
Registre Form. Form. Registre PEV1 Form. Registre PEV2 Form. Registre PEV3 Form. Registre PEV4 CarnetFiches pointage vacc Registre PEV CPS de Fiches CPS Registre Solar Refrigerator Sundanzer Carrier Vaccine Icepark/Accumu lateur Refrigerator SIBIR 79 3 21 21 64 27 14293 28 3 11 33 3 0 0 0 0 41 17 8259 29 3 19 19 2 0 0 0 0 58 0 7412 15 3 10 23 3 0 0 0 0 117 0 10721 23 2 15 27 3 159 7 41 41 128 54 20210 55 3 11 49 3 0 0 0 0 70 0 10901 31 3 7 25 2 0 0 0 0 0 0 5930 43 3 10 31 2 0 6 0 0 87 0 11952 45 3 20 41 3 0 0 0 0 93 0 9203 31 3 22 44 2 108 5 28 28 87 37 18666 43 4 25 35 3 159 5 41 41 128 54 9193 59 2 17 41 2 152 7 39 39 122 52 15292 57 3 15 35 2 130 4 34 34 105 45 11866 48 3 20 43 1 87 2 23 23 70 30 12115 35 4 15 29 2 108 5 28 28 87 37 20924 32 3 8 29 2 58 2 15 15 47 20 8529 20 3 22 19 2 0 0 0 0 134 0 9449 44 3 26 31 3 0 0 0 0 117 0 11379 42 2 15 31 1 0 0 0 0 175 0 8484 49 2 15 56 2 0 0 0 0 105 0 8450 40 2 21 32 2 27 0 15 11 2 10 11915 43 2 22 31 2 1,067 46 285 281 1,837 383 245,143 812 59 346 704 47 1067 46 285 281 1837 383 245,143 812 59 346 704 47 0 0 0 0 0 0 0 0 0 0 0 0 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
57 4 19 19 28 23 32300 20 2 8 34 1 70 4 19 19 33 28 39300 32 5 8 35 0 62 4 22 22 58 25 40800 15 2 8 34 1 88 4 19 19 54 34 41850 30 3 8 34 0 152 4 11 29 131 51 33735 20 2 5 33 1 66 4 24 22 132 32 84384 22 4 5 32 2 71 11 52 51 144 55 72800 10 1 5 0 1 171 61 22 118 108 105 50350 8 6 5 28 1 136 10 51 49 112 54 23300 7 5 5 8 1 144 20 64 43 70 109 34350 7 8 5 31 1 71 10 51 50 112 54 17300 7 5 5 8 1 139 15 52 51 60 94 37435 7 6 5 22 1 94 5 19 18 72 33 74585 24 4 8 32 0 76 4 16 14 64 37 24871 20 4 8 32 0 77 5 14 13 62 20 31548 12 3 8 32 1 159 5 28 28 115 56 21195 44 4 8 32 0 112 5 19 19 77 33 68010 24 4 8 32 0 45 5 19 19 82 33 57533 24 3 8 21 2 145 5 28 28 116 49 23389 38 4 8 32 0 118 5 23 22 124 40 23428 30 4 8 32 0 150 5 26 25 113 43 68640 34 3 8 32 0 2203 195 598 678 1867 1008 901103 435 82 144 576 14 2203 195 598 678 1867 1008 901103 435 62 144 576 14 0 0 0 0 0 0 0 0 -20 0 0 0 100% 100% 100% 100% 100% 100% 100% 100% 132% 100% 100% 100%
19 3 15 8 20 19 3330 20 3 25 25 0 20 3 15 8 5 19 3330 15 3 25 25 0 20 1 10 8 70 20 3330 15 6 25 25 0 19 3 15 7 70 19 3330 20 4 25 25 0 23 3 15 20 70 15 4330 20 6 15 25 0 19 3 15 7 20 18 4330 20 5 25 25 1 20 4 20 8 70 20 4330 20 1 25 25 0 22 0 20 8 70 20 4330 20 0 25 25 1 77 3 24 25 102 27 3500 30 4 16 64 1 59 3 24 25 102 25 4500 24 3 11 49 1 59 3 24 25 102 24 6000 24 2 15 59 0 87 3 24 25 102 32 3753 30 5 15 93 1 76 3 24 25 102 33 5000 24 3 24 69 2 76 3 23 25 102 26 6000 24 4 18 69 2 86 3 23 25 102 32 5500 40 4 22 89 1 682 41 291 249 1109 349 64893 346 53 311 692 10 682 41 291 249 1109 349 64893 346 53 311 692 10 0 0 0 0 0 0 0 0 0 0 0 0 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% A - 44
EQUIPEMENTS HOPITAUX ET CENTRES DE SANTE
Microscope Microscope HGR CS Microscope HGR Gloves/Gauzes Kit Lighting Solar systemkit Minikit HC Table d'opération HGR Lampe scyalitique de table consultation Table d'accouchement HGR/gyneco Bte d'accouchement HGR HGR laparo Bte Bte Herniorraphie HGR Césarienne Bte HGR Boite Appendicectomi HGR e Kerosene(litre) Autoclave Incinérateur 3 17 4 11 1 2 9 6 2 2 1 1 4320 5 1 3 15 6 13 0 7 4 2 2 2 2 7350 6 1 3 15 6 10 1 1 7 4 2 2 1 0 5050 5 1 3 15 6 12 1 0 7 4 2 2 2 1 7800 6 1 3 18 6 22 2 7 6 2 2 2 1 11910 5 0 3 16 6 12 1 0 7 4 2 2 2 1 5910 6 0 3 16 6 14 1 0 7 4 2 2 2 2 7580 6 1 3 17 6 18 1 0 7 5 3 1 3 2 2 7210 7 0 2 16 7 16 1 1 7 5 3 1 2 2 2 9930 7 0 3 19 6 17 1 0 9 6 2 2 2 2 3600 9 1 3 15 6 20 1 1 8 4 2 1 2 2 2 6780 7 0 2 17 6 21 1 0 7 5 2 2 1 2 8390 7 1 3 16 6 18 1 0 6 5 2 2 1 2 15130 7 0 3 16 6 12 1 1 7 5 2 2 2 2 5720 7 1 3 20 4 12 0 7 5 2 2 1 1 2890 5 0 3 14 4 8 1 7 5 2 2 1 1 4320 6 1 3 16 7 23 1 1 7 5 2 1 2 1 2 6110 7 0 3 17 7 20 1 1 7 4 2 1 2 2 2 6220 6 0 3 16 7 25 1 7 4 2 0 3 2 2 7850 7 0 3 15 7 18 1 1 7 4 2 2 1 0 7030 7 0 3 16 7 21 1 1 7 4 2 1 2 2 2 6940 7 0 0 61 342 126 343 16 14 151 98 44 6 44 34 32 148,040 135 9 0 61 342 126 343 16 14 151 98 44 13 44 34 32 148,040 135 9 0 0 0 0 0 0 0 0 0 0 7 0 0 0 0 0 0 #DIV/0! 100% 100% 100% 100% 100% 100% 100% 100% 100% 46% 100% 100% 100% 100% 100% 100%
4 15 8 16 0 0 11 4 0 1 2 2 2 1000 0 2 4 16 6 20 0 0 11 4 0 0 2 2 2 2000 1 1 4 19 6 17 0 1 11 5 4 1 2 3 2 0 1 1 3 15 6 33 0 2 11 5 2 0 2 1 2 1600 1 1 4 17 7 21 0 0 11 4 2 1 2 2 1 4300 1 0 3 16 6 25 1 1 12 5 4 1 2 3 2 5075 2 1 1 16 5 21 1 1 11 5 0 1 1 1 1 3725 1 0 1 56 9 22 1 1 11 4 1 1 1 1 1 1800 1 1 1 12 6 26 1 1 11 5 1 1 1 1 1 4800 2 1 2 27 10 21 1 1 11 5 0 1 1 2 1 3000 1 0 2 11 6 35 1 1 11 5 1 1 1 1 1 5000 2 1 2 27 9 20 1 1 11 5 0 1 2 2 1 2600 1 1 3 28 8 22 0 0 11 4 3 0 1 1 1 4245 1 0 4 28 8 28 1 1 11 5 3 0 2 2 2 2670 1 0 4 29 7 12 1 0 11 4 3 0 2 3 1 4245 1 0 4 29 8 37 0 1 12 5 4 0 3 2 1 4410 1 0 3 29 8 22 1 1 11 5 4 0 2 3 1 4645 1 0 3 28 7 22 1 1 11 5 3 0 2 3 2 4465 1 0 3 31 8 32 1 1 12 4 3 1 2 2 3 5255 1 1 4 31 8 27 1 1 11 5 3 1 2 3 2 2905 0 1 2 31 7 31 0 0 12 4 3 0 3 2 2 5645 0 0 61 511 153 510 13 16 235 97 44 12 38 42 32 73385 21 12 61 511 154 510 13 16 235 97 44 12 38 42 32 73385 21 12 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 #DIV/0! 100% 100% 99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
A - 45
EQUIPEMENTS HOPITAUX ET CENTRES DE SANTE
Boite Boite pansement ARITimer Labo Kit Stérilisateurs salter Balance aspirateur manuel lampes rechargeables Newborn Kit Manninquin mama Manninquin bebe 12 21 2 0 11 15 13 1 0 13 11 19 2 1 10 13 0 0 1 12 23 42 1 0 22 12 23 2 1 11 16 25 0 1 15 21 29 1 1 19 17 31 1 1 16 22 29 2 1 20 23 42 1 0 20 22 40 1 1 21 21 35 1 0 21 17 23 1 1 16 11 29 1 0 12 9 15 1 1 8 22 44 2 1 22 20 38 1 1 20 27 58 2 1 22 20 35 1 1 19 20 9 1 1 20 374 600 25 15 350 374 600 25 15 350 0 0 0 0 0 10 0 % 100% 100% 100% 100%
21 25 0 0 25 31 1 5 24 27 1 0 33 39 1 5 27 29 1 3 25 29 1 0 23 0 1 0 31 44 1 10 23 0 1 5 28 44 1 12 28 0 1 6 27 44 1 12 25 33 0 23 27 1 10 28 17 1 10 38 58 0 33 33 1 0 29 33 1 10 35 51 1 0 29 41 1 0 34 47 1 0 589 652 18 88 589 652 18 102 0 0 0 0 14 100% 100% #### 100% 86%
67 31 1 18 5 6 31 2 0 57 15 0 9 3 5 34 2 0 15 27 0 17 5 5 34 2 0 66 29 1 17 4 6 34 0 0 210 33 0 14 5 7 30 0 0 220 37 0 13 7 7 34 2 1 211 40 1 26 4 2 31 2 1 216 27 0 23 4 2 31 2 0 30 30 1 14 5 5 15 0 0 27 25 0 9 4 4 12 0 0 28 25 1 13 5 5 15 0 0 32 32 1 20 6 6 18 0 0 32 28 0 15 5 5 15 0 0 30 25 0 14 4 4 12 0 0 33 35 1 18 5 6 18 0 0 1274 439 7 240 71 75 364 12 2 1274 439 7 240 71 75 364 17 8 0 0 0 0 0 0 0 0 5 6 100% 100% 100% 100% 100% 100% 100% 71% 25%
A - 46
ANNEX 6: OPERATIONAL RESEARCH STUDYON UPTAKE OF PMTCT SERVICES
Project AXxes Study on Uptake of PMTCT Services Q14
I. Challenge
The largest growing group of persons with HIV/AIDS is women of reproductive age. The group with the largest mortality rate is offspring of HIV positive mothers. In the past three years, Project AXxes clinics have provided pre-natal counseling to 114,569 pregnant women. Of those, 81,452 (71%) agreed to be tested for HIV and accessed PMTCT services. If almost 30% of pregnant women defer free and potentially life-saving treatment— it begs the question, why?
Intake data from 130 PMTCT clinics in the Democratic Republic of Congo
2007 2008 2009 Total Women who received HIV counseling 5,443 30,236 78,890 114,539 Women who were tested 4,803 20,637 56,012 81,452 Women who were tested (percent) 88% 68% 71% 71% Women who tested positive 68 296 637 1001 Women who tested positive (percent( 1.42% 1.43% 1.14% 1.2%
II. Action
We met with PMTCT supervisors to explore reasons for this coverage gap. In reviewing site-by-site statistics, we noted significant differences between PMTCT sites. Of 130 sites established and supported over the past three years, 21 had uptake rates of 97% or greater (women who were counseled and tested) while 23 had rates 55% or lower (some as low as 9%!).
The map at right displays the geographic distribution and "testing acceptance coverage" by PMTCT site. It appears that a significant variance was not cultural or anthropological but service-point specific. We undertook a study this past quarter (Q14) of these ‗top twenty‘ and ‗bottom twenty‘ sites to investigate common variables.
III. Methodology
The methodology involved a retrospective analysis of the ‗top twenty‘ and ‗bottom twenty‘ performing clinics (those that had a >90% acceptance rate vs. those which had a <50% acceptance rate, as shown below) to examine possible institution-specific co-factors. We wanted to examine institutional or site-specific factors such as level of training of intake workers, amenities for privacy and counseling, same day HIV testing, etc. For obvious reasons (confidentially of testing) we did not interview women who tested positive, nor did we have physical contact with patients. The study had no impact on current access to services. Our intent was to examine
A - 47 trends of past encounters with hope of uncovering ‗best and worst practices‘ to increase our level of service in future quarters.
The Top Twenty and Bottom Twenty Performing PMTCT Clinics
% District Health Zone Site acceptingtesting Haut-Lomami/Katanga MALEMBA NKULU HGR MALEMBA NKULU 9% Haut-Lomami/Katanga MALEMBA NKULU CS KAMETEMETE 15% Haut-Lomami/Katanga MALEMBA NKULU CS KABOZYA 15% SK Ouest/Sud-Kivu SHABUNDA CSR MUNGEMBE 18% Sankuru/Kasai-Oriental LUSAMBO MATERNITE DE LUSAMBO 29% Mbuji-Mayi/Kasai-Or. MPOKOLO CS ANUARITE 31% SK Ouest/Sud-Kivu KAMITUGA HGR KAMITUGA 35% SK Centre/Sud-Kivu MUBUMBANO CSR BURHUZA 41% SK Centre/Sud-Kivu KANIOLA HGR KANIOLA 44% Haut-Lomami/Katanga KITENGE HGR KITENGE 44% Tshilenge/Kasai-Or. BIBANGA CS MATERNITE KATANDA 44% SK Ouest/Sud-Kivu MWANA CH KAKWENDE 46% Tshilenge/Kasai-Or. BIBANGA CS CIBILA 46% SK Ouest/Sud-Kivu KAMITUGA POLY-AFYA 48% Lemera/Sud-Kivu LEMERA CSR LUVUNGI 48% SK Ouest/Sud-Kivu KAMITUGA CS MULAMBULA 49% Sankuru/Kasai-Oriental LUSAMBO CSR INKONGO 50% Mbuji-Mayi/Kasai-Or. MPOKOLO CS BUENA MUNTU 51% Haut-Lomami/Katanga SONGA HGR SONGA 52% Haut-Lomami/Katanga MULONGO HGR MULONGO 53% Bukavu/Sud-Kivu KADUTU CBCA NYAMUGO 53% Sankuru/Kasai-Oriental LUSAMBO CSR BAKUA MBUMBA 54% SK Centre/Sud-Kivu MUBUMBANO HGR MUBUMBANO 55% Kolwezi/Katanga FUNGURUME CSR DIPETA 97% Bukavu/Sud-Kivu KADUTU HS CIRIRI / CS CIRIRI 97% SK Ouest/Sud-Kivu MWANA CSR MULAMBI 97% Lulua/Kasai-Occid. LUBONDAYI HGR LUBONDAYI 98% Kolwezi/Katanga LUALABA CS MUSHIMA 98% Kananga/Kasai-Occid. TSHIKAJI CS ST MARTYRS 98% Lulua/Kasai-Occidental LUBONDAYI CS MIKULUMBU 98% SK Sud/Sud-Kivu UVIRA CSR KAVIMVIRA 99% SK Ouest/Sud-Kivu MWANA HGR IFENDULA 99% SK Sud/Sud-Kivu NUNDU CSR SWIMA 99% Kananga/Kasai-Occid. TSHIKAJI KALEMBA MULUMBA 100% SK Ouest/Sud-Kivu LULINGU CH KATCHUNGU 100% Kolwezi/Katanga BUNKEYA CS NTONDO 100% Tshilenge/Kasai-Or. BIBANGA HGR BIBANGA 100% Kolwezi/Katanga BUNKEYA CS KALUA 100% Mbuji-Mayi/Kasai-Or. DIBINDI CS MULAMI MUIMPE 100% SK Nord/Sud-Kivu IDJWI HGR IDJWI 100% SK Nord/Sud-Kivu MITI MURHESA CSR LWIRO 100% SK Ouest/Sud-Kivu SHABUNDA HGR SHABUNDA 100% Kananga/Kasai-Occid. TSHIKAJI CS TSHIKAJI 100% Kananga/Kasai-Occid. TSHIKAJI CSR NTAMBUE ST BERN 100%
Dr. Judith Brown (cultural anthropologist) and Dr. Richard Brown (HIV care specialist) were asked to help design a questionnaire specifically looking at institutional barriers to care. After revisions and translations, the final document was adopted. Field supervisors from ECC, CRS, and World Vision as well as Project PMTCT A - 48 management personnel visited the above forty sites during regular supervision visits and filled out the questionnaire seeking factors related to staff attitudes and practices and facility performance. A sum score was created for all queried items ranging from 0 to 1, where 0= not exists and 1= exists. The results when compiled and tabulated revealed the following data.
Mean Scores from Forty Questionnaires Received
Top 20 sites Bottom 20 Questions (n=20) sites P Value Q1. At least two health workers know their own HIV status 19 (95%) 16 (80%) 0.151 Q2. At least two health workers are trained in PMTCT 18 (90%) 12 (60%) 0.028 Q3. The presence of at least two trained workers during CPN clinics 13 (65%) 3(15%) 0.001 Q4. Health Care workers trained by the project (AXxes) or MOH (PNLS) 19 (95%) 17(85%) 0.292 Q5. What are the means of HIV transmission known to the health worker 19 (95%) 12(60%) 0.008 Q6.interviewed? Health Care knowledge of how prophylaxis should be given 20(100%) 17(85%) 0.072 Q7. Health Care worker knowledge of when to start prophylaxis 17 (85%) 10(50%) 0.018 Q8. Health care worker knowledge of the four steps in PMTCT (prevention of 14 (70%) 3(15%) 0.000 Q9.transmission, The existence family of planning,a place for PMTCT, confidential and ARVcounseling treatment) 18 (90%) 7(35%) 0.000 Q10. When are antenatal clinics held? (morning or afternoon) 18 (90%) 16(80%) 0.376 Q11. Number of antenatal clinics held per month? (at least four) 18(90%) 14(70%) 0.114 Q12. The presence of a lab technician during antenatal clinics 16(80%) 15(75%) 0.705 Q13. When is HIV testing done? (only during clinics or daily) 19(95%) 9(45%) 0.001 Q14. Where is HIV testing done? (on site or off site) 17(85%) 13(65%) 0.144 Q15. When do test results get communicated? (same day or not) 13(65%) 13(65%) 1.000 Q16. Presence of stock-outs of medicine or tests in the past three months? 13(65%) 7(35%) 0.058 Q17. Is HIV testing presented as a routine procedure in antenatal clinics or opt ini 19(95%) 7(35%) 0.000 Q18. Who does the counseling (nurse or nurse and lay counselors) 14(70%) 7(35%) 0.027 Q19. How is counseling done? (individual or group) 19(95%) 19(95%) 1.000 Q20. Are partners invited to attend the counseling? 12(60%) 9(45%) 0.342 Q21. Is counseling and information offered at all visits? 18(90%) 5(25%) 0.000 Q22. Are there at least four themes of PMTCT discussed during counseling 12(60%) 9(45%) 0.342 (prevention, treatment, pregnancy) Blue = significant at < 0.028
IV. Analysis
An analysis of the twenty top and twenty bottom performing sites was undertaken to investigate such co-factors as related to access to care. Statistical analysis was carried out using SPSS-PC. These analyses included: x2 tests, Pearson‘s correlation, and regression analyses using Anova. The purpose of the analysis was to determine the association with any variables that were statistically significant with institutions reporting a low vs. high uptake of PMTCT services.
This study yielded 10 statistically significant variables associated with acceptance of PMTCT services (in blue above). These 10 variables were analyzed with an ANOVA regression analysis to measure their impact on the dependent variable.
Three independent variables were found to be the key components for a high uptake of PMTCT services. These were all highly significant variables with p values of less than 0.000. Three independent variables were:
Existence of a private counseling box HIV testing done as routine versus ‗opt in‘ HIV testing available during all clinic days. A - 49
V. Explanation of calculations
Initial analysis of data using Pearson‘s coefficient revealed that of the 22 variables, 10 had a significant (P<.05) positive association with strong PMTCT programs. When we performed regression analysis of those 10, three of those variables had a strong influence on high performing PMTCT centers. Significance was carried out to 0.000 with an R-squared of 0.58 (58%) and F of 16.73. These three variables were:
Existence of a private counseling box, with a coefficient of .277 HIV testing done as routine versus ‗opt in‘, with a coefficient of .375 HIV testing available during all clinic days, with a coefficient of .347
Coefficients (a)
Coefficients non Coefficients T Test Significan Model standardized standardized ce B Std Error Beta 1 (constant) -.200 .114 -1.758 .087 Existence of a private .286 .131 .277 2.186 .035 counseling room Routine (opt out) HIV testing .393 .135 .375 2.921 .006 Testing (HIV) performed all .379 .125 .347 3.025 .005 days
a: Dependent Variable
ANOVA(b)
Sum of Average Model Squares ddl Square F Significance 1 Regression 5.829 3 1.943 16.772 .000(a) Residual 4.171 36 .116 Total 10.000 39
a. Predicted Values (constants: HIV testing on all days, private counseling, and routine HIV testing. b. Dependent Variable : level
Other factors not incorporated into the study such as quality of supervision, community or cultural factors, methods of communication, and presence of training could also account for some of the unexplained difference in the rate of acceptance of PMTCT services.
Summary Model
Model R R-squared R-squared adjusted Standard Error 1 .763(a) .583 .548 .340
a. Predicted values (constants), Routine HIV testing, Testing all days, existence of a counseling room.
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VI. Summary
The underling hypothesis of this study was that institutional rather than patient-related factors are principal impediments to care. A minority of women will eschew testing due to personal reasons such as fear of needles, stigmatization, and inconvenience, but such parameters we believe are common across all sites and represent a minority of those who refuse testing and follow-up. Our premise is that institutional factors are more important and indeed the study revealed specific institutional related co-factors statistically associated with high performing clinics. These are:
1. Routine HIV testing of all CPN clients (opt out) 2. Testing available on all clinic days (not just CPN) 3. Existence of a private room for counseling.
Factors that did not make a statistically significant difference were:
1. Knowledge and attitudes of HC workers regarding PMTCT and their own status 2. Time and frequency of PMTCT and antenatal clinics (morning, evening, weekly, etc.) 3. Setting of lab (on site or off site) and same day testing and results 4. Quality of counseling (group vs. individual, spouse invitation, and written literature).
VII. Conclusion
In a setting where PMTCT services are available, 30% of pregnant women did not access care due to unknown barriers. The results of this study underscore significant institutional-related barriers and suggest that key improvements such as confidential counseling, opt-out testing, and offering of testing outside of PMTCT clinic days can significantly improve uptake of PMTCT services. While attention to all factors is important, the project will want to assure compliance to these three in all 135 settings in order to bridge the gap between antenatal and PMTCT services.
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