Tanzania Work Plan FY 2018 Project Year 7

October 2017–September 2018

ENVISION is a global project led by RTI International in partnership with CBM International, The Carter Center, Fred Hollows Foundation, Helen Keller International, IMA World Health, Light for the World, Sightsavers, and World Vision. ENVISION is funded by the US Agency for International Development under cooperative agreement No. AID-OAA-A-11-00048. The period of performance for ENVISION is September 30, 2011, through September 30, 2019.

The author’s views expressed in this publication do not necessarily reflect the views of the US Agency for International Development or the United States Government.

ENVISION Project Overview

The US Agency for International Development (USAID)’s ENVISION project (2011–2019) is designed to support the vision of the World Health Organization (WHO) and its member states by targeting the control and elimination of seven neglected tropical diseases (NTDs), including lymphatic filariasis (LF), onchocerciasis (OV), schistosomiasis (SCH), three soil-transmitted helminths (STH; roundworm, whipworm, and hookworm), and trachoma. ENVISION’s goal is to strengthen NTD programming at global and country levels and support ministries of health (MOHs) to achieve their NTD control and elimination goals. At the global level, ENVISION—in close coordination and collaboration with WHO, USAID, and other stakeholders—contributes to several technical areas in support of global NTD control and elimination goals, including the following: • Drug and diagnostics procurement, where global donation programs are unavailable • Capacity strengthening • Management and implementation of ENVISION’s Technical Assistance Facility (TAF) • Disease mapping • NTD policy and technical guideline development • NTD monitoring and evaluation (M&E). At the country level, ENVISION provides support to national NTD programs by providing strategic technical and financial assistance for a comprehensive package of NTD interventions, including the following: • Strategic annual and multi-year planning • Advocacy • Social mobilization and health education • Capacity strengthening • Baseline disease mapping • Preventive chemotherapy (PC) or mass drug administration (MDA) • Drug and commodity supply management and procurement • Program supervision • M&E, including disease-specific assessments (DSAs) and surveillance. In , ENVISION project activities are implemented by IMA World Health (IMA).

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TABLE OF CONTENTS ENVISION Project Overview ...... ii TABLE OF TABLES ...... iv TABLE OF FIGURES ...... iv ACRONYMS LIST ...... v COUNTRY OVERVIEW ...... 7 1) General Country Background ...... 7 a) Administrative Structure ...... 7 b) NTD Implementing Partners and Collaborators ...... 8 2) National NTD Program Overview ...... 12 a) Lymphatic Filariasis ...... 12 b) Trachoma ...... 15 c) Onchocerciasis ...... 16 d) Schistosomiasis ...... 18 e) Soil transmitted Helminths ...... 19 3) Snapshot of NTD Status in Country ...... 21 PLANNED ACTIVITIES ...... 22 1) NTD Program Capacity Strengthening ...... 22 a) Strategic Capacity Strengthening Strategy ...... 22 b) Capacity Strengthening Objectives and Interventions ...... 22 c) Monitoring and Evaluating Proposed Capacity Strengthening Interventions ...... 24 2) Project Assistance ...... 26 a) Strategic Planning ...... 26 b) NTD Secretariat ...... 27 c) Building Advocacy for a Sustainable National NTD Program ...... 27 d) Mapping ...... 28 e) MDA Coverage ...... 28 f) Social Mobilization to Enable NTD Program Activities ...... 30 g) Training ...... 33 h) Drug and Commodity Supply Management and Procurement ...... 34 i) Supervision for MDA ...... 35 j) M&E ...... 36 k) Supervision for M&E and DSAs ...... 37 l) Dossier Development ...... 38 APPENDIX 1: Work Plan Timeline...... 39

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APPENDIX 2. Table of USAID-supported Regions and Districts for MDA in FY18 -MDA ...... 41 APPENDIX 3. Table of USAID-supported Regions and Districts for DSAs in FY18 ...... 45

TABLE OF TABLES

Table 1: Non-ENVISION NTD partners working in country, donor support, and summarized activities..10 Table 2: Snapshot of the expected status of the NTD program in Tanzania as of September 30, 2017..21 Table 3: Measuring progress of capacity strengthening…… ...... 24 Table 4: Project assistance for capacity strengthening ...... 24 Table 5: USAID-supported districts and estimated target populations for MDA in FY18 ...... 29 Table 6: Social mobilization/communication activities and materials checklist for NTD work planning..31 Table 7: Planned DSAs for FY18, by disease ...... 37

TABLE OF FIGURES Figure 1: MOHCDGEC leadership and governance levels ...... 7

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ACRONYMS LIST AFRO Africa Region Office, WHO ALB Albendazole APOC African Programme for Onchocerciasis Control CCHP Comprehensive Council Health Plan CDC U.S. Centers for Disease Control CDD Community Drug Distributor CDTI Community-Directed Treatment with Ivermectin CHMT Council (or District) Health Management Team CNTD Centre for Neglected Tropical Diseases DC District Council DED District Executive Director DEO District Education Officer DFID UK Department for International Development DMO District Medical Officer DSA Disease-Specific Assessment EPIRF WHO Epidemiological Data Reporting Form EU Evaluation Unit FLHF Frontline Health Facility FLHW Frontline Health Worker CTND Filariasis Programmes Support Unit (Liverpool School of Tropical Medicine) FTS Filariasis Test Strips FY Fiscal Year GAELF Global Alliance for the Elimination of Lymphatic Filariasis GoT Government of Tanzania GTMP Global Trachoma Mapping Project HKI Helen Keller International ICT Immunochromatographic Test IEC Information, Education, and Communication ITI International Trachoma Initiative IVM Ivermectin JRSM Joint Request for Selected Medicines KCCO Kilimanjaro Centre for Community Ophthalmology LF Lymphatic Filariasis M&E Monitoring and Evaluation MC Municipal Council MDA Mass Drug Administration MOHCDGEC Ministry of Health, Community Development, Gender, Elderly and Children MMDP Morbidity Management and Disability Prevention Program MSD Medical Stores Department NBS National Bureau of Statistics NGO Nongovernmental Organization NIMR National Institute for Medical Research NTD Neglected Tropical Disease OV Onchocerciasis PC Preventive Chemotherapy PCR Polymerase Chain Reaction

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PMO-RALG President’s Office–Regional Administration and Local Government PZQ Praziquantel QEDJT Queen Elizabeth Diamond Jubilee Trust RDT Rapid Diagnostic Test REMO Rapid Epidemiological Mapping of Onchocerciasis RHMT Regional Health Management Team RPRG Regional Programme Review Group SAC School-Age Children SAE Serious Adverse Event SAFE Surgery–Antibiotics–Face cleanliness–Environmental improvements SCH Schistosomiasis SCI Schistosomiasis Control Initiative STH Soil-Transmitted Helminth STTA Short Term Technical Assistance TAF Technical Assistance Facility TAS Transmission Assessment Survey TEMF Trachoma Elimination Monitoring Form TF Trachomatous Inflammation–Follicular TFDA Tanzania Food and Drug Administration TFGH Task Force for Global Health TIPAC Tool for Integrated Planning and Costing TIS Trachoma Impact Survey TOEAC Tanzania Onchocerciasis Elimination Expert Advisory Committee TOT Training of Trainers TT Trachomatous Trichiasis TWG Technical Working Group TZNTDCP Tanzania NTD Control Program USAID United States Agency for International Development WHO World Health Organization ZTH Zithromax

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COUNTRY OVERVIEW

1) General Country Background

a) Administrative Structure

Tanzania is divided into 31 regions, 5 of which make up the semi-autonomous islands of which have a different government structure. Mainland Tanzania has 26 regions with 185 administrative councils. These districts are subdivided into divisions, wards, and villages, which are further subdivided into hamlets. Each village and ward has a chairperson and executive officer, and each hamlet has a chairperson. District councils (DCs) are the governing body at the district level and are headed by district executive directors (DEDs). These local government councils have substantial decision-making power for planning, budgeting, and implementation of policy and development matters. Elective representation levels begin at the villages, moving upward to wards and then districts, which are the primary units responsible for public service delivery, including primary health care. The Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC)—formerly known as the Ministry of Health and Social Welfare—guides policy development, strategic planning, resource mobilization, quality control, and evaluation and provides guidelines to regions and districts on the overall direction of health program implementation and service delivery throughout Tanzania. Service delivery, leadership, and governance are decentralized, with key roles and responsibility divided among four levels (Figure 1). Regional Health Management Teams (RHMTs) interpret policy and provide overall technical supportive supervision to the respective Council (or District) Health Management Teams (CHMTs) of that region. The CHMTs develop health plans and budgets as well as implement, monitor, and evaluate the impact of these plans. The district level is where the national plan execution and coordination occur. The lowest level of the health system is the community. Activities incorporated into the CHMT health plans are derived from community needs identified through community (village) health committees. The national health budget is developed annually based on comprehensive Figure 1: MOHCDGEC leadership and council health plans (CCHPs). The governance levels MOHCDGEC and the President’s Office– Regional Administration and Local MOHCDGEC Government (PMO-RALG) provide inputs Policy and Policy Guidelines Development, Strategic Planning, Resource Mobilization on prioritization and guidelines for the development of CCHPs. CCHPs are Regional Health Management Team Policy Translation and Supportive Supervision funded through district basket funding, which is made up of funds from the District Health Management Team MOHCDGEC, PMO-RALG, Ministry of Planning and Implementation of Strategic Plans Finance, and domestic and international development partners. Many district Community (Village) Health Committee councils also have activity-specific Health Services Demand Generation and Utilization funding from various other sources that does not flow through the established government mechanism. The Tanzania Neglected Tropical Disease (NTD) Control Program (TZNTDCP) is under the MOHCDGEC’s Office of the Chief Medical Officer, Directorate of Preventative Services, and is housed at the Tanzania National Institute for Medical Research (NIMR). At the central level, there is a national NTD Program

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Coordinator and four program officers who are paid for by the MOHCDGEC. NIMR also pays for five support staff to help in the implementation of NTD activities. The NTD Program Coordinator is assisted by the NTD Secretariat for overall program coordination and management. Several partners support the NTD Secretariat by providing technical and management resources to work on a secondment basis with the MOHCDGEC. ENVISION has seconded five officers to the Secretariat, namely, a senior technical advisor for monitoring and evaluation (M&E), two M&E program officers, a drug logistics officer, and a finance/administrative officer; the Centre for Neglected Tropical Diseases (CNTD) of the Liverpool School of Tropical Medicine (formerly the Filariasis Programmes Support Unit [FPSU]) funds a database manager; and Sightsavers, through Helen Keller International (HKI), funds a program officer who manages the UK Department for International Development (DFID) SAFE activities (Surgery–Antibiotics– Face cleanliness–Environmental improvement) from the NTD Secretariat side and works closely with the Trachoma Focal Point. The NTD control program is largely integrated into the existing primary health care system. The NTD program works through the RHMTs, CHMTs, and local communities to plan and implement NTD control activities and is led by national, regional, and district coordinators at each respective level. At the district level, there are cascade leaders and zonal managers who provide the frontline health workers (FLHWs) with supportive supervision and aid in data collection. At the community level, community drug distributors (CDDs) are trained to distribute medicines to the household level and report accordingly. On average, one FLHW is responsible for supervising 15 to 20 CDDs. For school-based interventions, mainly targeting soil-transmitted helminths (STH) and schistosomiasis (SCH), primary school teachers help distribute the medicines and report to the health facilities.

Redistricting Since 2010, redistricting has increased—from 132 districts in 2010 to 166 by August 2015. In fiscal year 2017 (FY17), an additional 20 districts were created, increasing the total number of districts to 186. There is no anticipated redistricting for FY18. However, Tanganyika DC in has fallen under DC and Mpimbwa DC administration, and thus, officially, the full district count for Tanzania goes from 186 to 185. The redistricting aims to bring social and economic services closer to underserved areas of bigger districts, which has presented challenges for the program in using data across the years, as well as for planning and human resources allocation. First, newly formed districts commonly take quite a long time to set up the key infrastructure, including staff with technical expertise necessary to become fully functional and support the health system in these new districts. Second, the process further weakens the already weak systems in the “original” districts because some of the key personnel, such as district medical officers (DMOs) and district education officers (DEOs) are transferred to take roles in the new districts without any replacements being assigned in the districts that they leave. Third, some of the previously established lead NTD personnel are given roles outside of NTD programming, resulting in a big loss to the TZNTDCP, which invested in these persons in terms of training and acquired experience.

b) NTD Implementing Partners and Collaborators

NTD control and elimination activities in Tanzania are supported by many partners (Table 1). The MOHCDGEC provides funding for the TZNTDCP staff mentioned above as well as salaries for all MOHCDGEC-linked staff working in the NTD program from regional to district levels. Also, the MOHCDGEC provides vehicles at the district and regional levels for implementation and supervision of activities. As described below, the US Agency for International Development (USAID) has provided funding for NTD programming in Tanzania since 2010 through the NTD Control Program (2010–2011)

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and ENVISION (2011 to date). Both efforts have been managed by RTI International centrally and IMA World Health in country. USAID also provided funding for the African Program for Onchocerciasis Control (APOC) to implement an integrated NTD program in six regions (Ruvuma, Mbeya, Iringa, Njombe, Tanga, and Morogoro) from 2009–2015. APOC supported pre- and post-mass drug administration (MDA) activities as well as M&E activities (such as funding for onchocerciasis [OV] epidemiological and entomological surveys and pre-transmission assessment surveys [pre-TASs]). APOC ended in December 2015, and ENVISION took on the programmatic support in these six OV-endemic regions in FY16. DFID funds several partners to support the TZNTDCP. DFID funding to the TZNTDCP through CTND supports community-based lymphatic filariasis (LF) MDA in six districts of the Region. In FY17, CTND funding included training, community mobilization, MDA, and data collection. In addition, CTND has also established lymphedema care and hydrocele surgeries in the three districts where they completed the LF morbidity mapping. They have provided funding and technical assistance to complete more than 700 surgeries to date. CTND has also worked closely with the TZNTDCP to develop a national morbidity management and disability prevention (MMDP) program strategy and framework for scaling up MMDP activities across the country. As noted above, CTND also employs a database manager seconded to the NTD Secretariat. For FY18, CTND plans to continue to provide funds for MDA in the Dar es Salaam Region, as well as pre-TAS and TAS1 for the six districts of the Dar es Salaam Region. In addition, CTND plans to provide funding for hydrocelectomies for more than 1,000 additional patients. DFID funds the Schistosomiasis Control Initiative (SCI) to address SCH and STH. SCI has supported school- based MDA in the Lake Zone regions (, , , Mara, and Shinyanga) and Dar es Salaam Region. In FY18, SCI will continue to provide funding to TZNTDCP to support praziquantel (PZQ) and albendazole (ALB) school-based MDA in the five Lake Zone regions and Dar es Salaam, as well as transition of (6 districts) from ENVISION. SCI is also in discussion with the TZNTDCP to finalize arrangements for the transition of school-based MDA from ENVISION in Geita and Kilimanjaro regions in FY19. In addition, SCI will fund SCH/STH sentinel site assessments across Kagera, Mwanza, Shinyanga, Mara, and Kigoma. SCI also procures PZQ for areas where it operates. For several years, World Vision International provided approximately 4 million PZQ tablets, which were used in Dar es Salaam school-based MDA. However, the supply ended in 2016, and there has been no further information on whether it will continue to supply PZQ going forward. DFID also funds a five-year SAFE project through Sightsavers. The project has worked on the “S” (surgery) component of the SAFE strategy since July 2014, with linkages to other partners and sectors for other components. The project works to support national-level trachoma surgery planning and coordination through its Tanzania coordinating partner, HKI. DFID also supports partners to carry out trachomatous trichiasis (TT) surgeries, with activities in regions distributed as follows: IMA supports surgeries in Mtwara; Sightsavers in Pwani; and Kilimanjaro Centre for Community Ophthalmology (KCCO) in Arusha and Manyara. The Queen Elizabeth Diamond Jubilee Trust (QEDJT) is funding a three-year project (April 1, 2016–March 31, 2019) to expand SAFE efforts. Currently, QEDJT funding supports partners to carry out TT surgeries, with activities in regions distributed as follows: Sightsavers in Lindi, Kongwa Trachoma Project in Dodoma, and KCCO in Arusha. DFID/SAFE is also funding the facial cleanliness (“F”) and environmental improvement (“E”) components of the SAFE strategy. Simavi receives funding for and HKI for Arusha and Pwani regions. DFID plans to conduct more TT-only surveys in districts where needed and to be determined for FY18, but funds are limited.

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Sightsavers/Tanzania has focused on eye care, education, and rehabilitation services. It has provided training and funding for eye examinations and implements the “S,” “F,” and “E” components of the SAFE strategy in two districts in the Morogoro and Ruvuma regions. Furthermore, as noted above, Sightsavers seconds a program officer to the NTD Secretariat. It has also provided TT surgeries in Tanga and Ruvuma, in addition to , where it works under the DFID SAFE project. KCCO as mentioned above works under DFID/SAFE and QEDJT, in Arusha and Manyara regions. KCCO also supports research projects for trachoma, including treatment for endemic villages in the Siha District in the . The Kongwa Trachoma Project receives funding from the International Trachoma Initiative (ITI) to conduct bacteriological trachoma infection research in children and tracks antibodies formation in another cohort of children. The research is focused in a few selected villages of Dodoma Region. ITI first funded Zithromax® (ZTH) MDA campaigns until its funding priorities changed and ENVISION took over Zithromax distribution in 2014. ITI also works closely with the TZNTDCP to prepare its ZTH applications for submission to the Trachoma Expert Committee, and it assists with drug shipping and clearance. Furthermore, ITI funded the Trachoma Action Plan workshop in FY17 and continues to provide some funding for cross-border meetings. The End Neglected Tropical Diseases (END) Fund has been working on and off in Tanzania for several years, and it receives all of its funding from private donors (individuals or corporations, etc.). The END Fund has been providing support for TT surgeries in Tanga and , as well as some funding for hydrocelectomies in . In FY18, the END Fund plans to continue support in the same regions, as well as expand hydrocelectomies to . The END Fund’s priority area for Tanzania is morbidity management. Statoil is an international offshore oil company based in Mtwara, southern Tanzania. As part of its corporate social responsibility, it supports hydrocelectomies in . In 2015, Statoil supported 103 hydrocelectomies at Mikindani Town Council (TC), and it has pledged to support 100 hydrocele surgeries in Mtwara DC for FY17. In addition, it has conducted a follow-up health economic assessment of its beneficiaries. Finally, CBM International has also provided funding for TT surgeries periodically throughout the country.

Table 1: Non-ENVISION NTD partners working in country, donor support, and summarized activities Is USAID Other donors providing NTD supporting these financial support partners/ Partner Location Activities to this partner? activities? CBM Country office in Dar es Provision of some TT No Other International Salaam surgeries HKI Manyara, Singida, and TT surgery coordination; No DFID/SAFE and Tabora regions as well potential funding for “F” QEDJT as coordinating partner and “E” components of for DFID/SAFE and SAFE strategy QEDJT-funded regions (Pwani, Lindi, Mtwara,

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Is USAID Other donors providing NTD supporting these financial support partners/ Partner Location Activities to this partner? activities? Arusha, Manyara, and Dodoma)

IMA World Mtwara Region TT surgery No DFID/SAFE Health Center for Dar es Salaam, and Funding for MDA and No DFID; other Neglected other regions covered M&E in Dar es Salaam; Tropical Diseases periodically through seconded database (CNTD) TAS and other research manager to NTD efforts Secretariat; hydrocelectomy Sightsavers Morogoro, Pwani, Focused on eye care- No DFID/SAFE, DFID, Lindi, and Ruvuma related activities, and QEDJT regions including trachoma control; support mainly for TT surgeries; seconded program officer to NTD Secretariat SCI Kagera, Kigoma, Mara, School-based MDA for No DFID Mwanza, Shinyanga, SCH/STH; various Dar es Salaam, and studies Simiyu KCCO Kilimanjaro Region TT surgeries; research No DFID/SAFE and and treatment of high- QEDJT prevalence villages in Siha District Kongwa Dodoma TT surgeries, research No DFID and QEDJT Trachoma Project and technical assistance in Kongwa DC and MDA in Chamwino ITI Trachoma-endemic Supply Zithromax® (ZTH) No Pfizer districts

Statoil Mtwara Hydrocele surgery (100 No None surgeries planned for FY18) END Fund Tanga, Tabora Hydrocele surgery No None

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2) National NTD Program Overview

Several NTDs are endemic in Tanzania, the five most common being LF, OV, SCH, STH, and trachoma. A large portion of the population is at risk of co-infection of two or more of these diseases. The overall TZNTDCP goals for elimination and control are as follows: 1. Continue to implement a modified community-directed treatment with ivermectin (CDTI) approach to community MDA in targeted regions. Ivermectin (IVM), ALB, and ZTH will be distributed using a modified CDTI approach 1 that relies on active community participation with supervision from the TZNTDCP, focusing on empowering communities to take responsibility in MDA activities. This includes advocacy for more MDA activities to be funded by regions and districts, which is increasingly important because donor resources are changing. 2. Sustain the national geographic coverage achieved through phased expansion. The TZNTDCP started in FY09 in six regions, then expanded in FY10 to seven additional regions, and in FY11 to two additional regions. In 2013, TZNTDCP expanded further to Dar es Salaam and Mwanza regions; in 2014 into four additional regions; and in 2015 expanded to Kigoma, Shinyanga, Kagera, and Mara regions to cover all 26 regions of Mainland Tanzania. During this expansion, the national NTD Secretariat has gained knowledge and experience in coordination and implementation of an integrated NTD program. 3. Expand MMDP efforts. Currently, MMDP activities such as TT and hydrocele surgery are being supported by partners, including Sightsavers International, IMA, CTND, CTND, HKI, END Fund and Statoil. The TZNTDCP would like to expand MMDP activities to reach hydrocele and lymphedema patients in Dar es Salaam, but also the large numbers of cases in Tanga, Mtwara, Pwania, and Lindi regions, which are believed to have the majority of hydrocele and lymphedema cases. Additional activities include training, hydrocelectomy, and lymphedema management—the TZNTDCP is seeking partner support to fund these activities.

a) Lymphatic Filariasis

By August 1, 2017, Tanzania has been able to stop LF MDA in 74 districts, and anticipates reaching the national elimination goal (elimination of LF by 2020) early, stopping MDA in all districts in FY19. In FY17, the country also experienced new redistricting where, of the total 185 districts, 64 are regarded as non- endemic, and only 120 were ever endemic. Of the 120 endemic districts, 73 (61%) had reached the criteria for stopping MDA, and only 47 districts required MDA in FY17. The scale down of MDA is based on rigorous disease monitoring carried out by the program. LF mapping in Tanzania was carried out from 1999 to 2004, and the results showed that LF was endemic in all districts in the country. Mapping data indicated high endemicity in the coastal regions and lower levels further inland. Accordingly, the national strategy was to start MDA campaigns in areas with high endemicity first and then progressively add regions further inland.

1 In traditional CDTI, the community determines everything related to the MDA (i.e., when, where, and by whom). In the modified approach, some aspects are determined by the Ministry of Health at the central level to ensure harmonization across the entire country. In Tanzania, the TZNTDCP determines when drugs and funds will be available and determines a national MDA schedule. In traditional CDTI, different communities within a region/district may choose different dates to suit their specific local conditions; in Tanzania, TZNTDCP plans a schedule so that all districts in an entire region conduct MDA at the same time.

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MDA began in 2000 in districts along the coast where prevalence at the time of mapping was very high; however, treatment was at times interrupted due to lack of funding support. Since regular funding support was initiated by USAID (through ENVISION and APOC) and DFID (through CNTD), MDA campaigns have been an annual feature of the TZNTDCP. The LF MDA package in Tanzania includes IVM and ALB and is distributed once a year. This IVM+ALB package is distributed house to house in all endemic communities by CDDs.

Remapping In 2012, CNTD funded a TAS in , even though treatment with IVM+ALB had never been initiated in the region. Results indicated there was no ongoing transmission. Following consultation with the World Health Organization (WHO)’s Africa Regional Office (AFRO) Regional Programme Review Group (RPRG), the TZNTDCP decided to remap the 63 districts where MDA had not yet started, including those in Mwanza Region, with funding from ENVISION and the Task Force for Global Health (TFGH). Results indicated that all 63 districts were below the MDA threshold. This reduced the number of LF- endemic districts from 185 to 120 in 2015.

LF MDA In FY17, MDA was conducted in all 41 ENVISION-supported districts, targeting 7,850,199 people. Of these, 7,688,853 people were treated, with 97.9% program coverage and 82.15% epidemiological coverage. In this MDA round, all districts (i.e., 100%) met epidemiological coverage targets. As the program approaches the 2020 elimination target date, concerted efforts are directed toward providing quality MDA in the remaining districts, with adequate epidemiological coverage. It is projected that only 28 districts (22 ENVISION funded) will need LF MDA in the October 2017 round and only 13 (ENVISION) in the August 2018 round . This will mark significant steps toward the 2020 goals. Optimal coverage is one of the factors that will propel the program to LF elimination. The program has carefully planned the August 2018 MDA to be implemented 10 months after the October 2017 MDA (refer to a detailed justification in the MDA section). This will help streamline MDA rounds back to the original schedule, which was disrupted in 2014 following integration of IVM+ALB with the national immunization campaign. It is thus expected that in FY19, the remaining 10 districts will be due for a pre- TAS and subsequently pass TAS1, and by 2020, all districts will have proceeded to the surveillance phase.

LF M&E LF disease-specific monitoring is an ongoing process, and various districts are at different stages of LF elimination. The district is the implementation unit and would typically be monitored at baseline, midterm, and after five MDA rounds. Routine impact assessments and progress monitoring through sentinel and spot-check sites at midterm (i.e., at completion of three rounds of MDA) or pre-TAS (after five rounds of MDA) have been implemented if funds are available. To determine TAS eligibility, the post-fifth-round sentinel and spot-check site assessments are conducted in every district in accordance with WHO guidelines. This strategy has allowed Tanzania to monitor programmatic progress as well as to present clear data about TAS eligibility for decision making by the program and the RPRG. To ensure strong program monitoring and to gather data for decision making toward LF elimination, the TZNTDCP’s long-term strategy has been to establish two integrated sentinel sites in each new region when treatment starts, to monitor the impact of LF MDA rounds over time and make informed decisions about when to stop MDA. The TZNTDCP recommends that wherever possible, any parasitological sentinel/spot-check site assessment should be integrated and include samples from three NTDs—LF, STH, and SCH. When determining where to establish new sentinel and spot-check sites, the TZNTDCP

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uses the disease-specific WHO Guidelines. 2 For LF in each implementation unit, the TZNTDCP selects one village as the sentinel site and one as a spot-check site. Criteria for village selection include (1) stable population, (2) approximately 500 inhabitants or more, and (3) known high LF endemicity or expected low coverage. Within the site, 250–300 individuals ages five years and older are tested for circulating filarial antigen (CFA). For STH and SCH sites, the TZNTDCP selects two schools in known high- transmission zones and in similar ecological zones. In each school, 50 pupils in Standard (Grade) 3 are examined; techniques used include Kato Katz, urine filtration, and anthropometric measurement. The TZNDTCP conducted TAS1 in 27 districts in July 2016. Based on preliminary field results, of the 27 districts, 25 districts achieved criteria for stopping LF MDA. One evaluation unit (EU) consisting of two districts (Chemba and Kondoa DC) did not pass TAS1. In FY17, Kondoa DC split into two districts (Kondoa DC and Kondoa TC), and thus MDA took place in three districts—Chemba, Kondoa TC, and Kondoa DC— in FY17. Based on the FY16 TAS results (the most recent available), thus far 73 of the 120 LF-endemic districts have met the stopping MDA criteria, and thus 61% of endemic no longer require treatment. Overall, using the FY17 redistricting as a baseline, only 47 districts needed LF MDA in FY17, 41 of which will be treated with ENVISION support and 6 with CNTD support. In FY17, LF TAS2 was conducted in six districts, and all reported CFA levels <2%, signaling sustained interruption of transmission in Newala DC, Newala TC, Mkuranga, Lushoto, Bumbuli, and . ENVISION provided support for five districts and TFGH supported one district (Muheza). The TAS2 in Muheza, Lushoto, and Bumbuli were integrated with OV monitoring, thus providing useful disease prevalence data for the program that was presented to the Tanzania OV Elimination Expert Advisory Committee (TOEAC) for strategic planning and decision making during the February 2017 meeting. Furthermore, 30 districts are scheduled for a pre-TAS in July 2017. Of these, it is expected that 24 EUs will be formed for TAS1 in August 2017 in Manyara, Tabora, and Morogoro regions. In , in the nine districts, the TOEAC advised to integrate the TAS1 surveys with OV monitoring using the experience and lessons learned from the previous integrated surveys. The TZNTDCP has received approval from the TFGH for “F-TAS" (integrated LF/OV TAS) in one district. The program is currently seeking funding for OV monitoring activities in the remaining eight districts. In FY18, the MOH plans to conduct TAS in a total of 78 districts. There will be 19 TAS1: 6 will be supported by CNTD (Dar es Salaam Region) and 13 TAS1 will be supported by ENVISION. ENVISION will also support 59 TAS2 districts. Among the TAS1 districts are Kondoa TC, Kondoa DC, and Chemba DC, which failed a TAS1 in 2015. Prior to TAS1, all 19 districts will undergo a pre-TAS (pre-re-TAS in the case of Kondoa TC, Kondoa DC, and Chemba DC) to determine if they meet the CFA levels of 2% or less. The 59 districts eligible for TAS2 in FY18 signify a great step in LF elimination efforts in Tanzania. These districts are in the formerly APOC-supported regions of Ruvuma, Mbeya, Iringa, Njombe, and Iringa.

MMDP Tanzania has assessed LF morbidity in the Dar es Salaam Region with funding and technical assistance from CNTD. Unfortunately, funding has not been available for LF morbidity burden assessments in the rest of the country. As discussed above, CNTD provided funds and technical assistance for LF morbidity mapping. Volunteers were used to collect information house to house via a questionnaire, using mobile

2 WHO, Global Programme to Eliminate Lymphatic Filariasis. (2012). Monitoring and epidemiological assessment of mass drug administration in the global program to eliminate lymphatic filariasis: A manual for national elimination programs . Geneva. WHO.

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data collection devices. An estimated total of 6,000 patients have been identified. CNTD supported hydrocelectomy for 1,000 patients in 2016 and an additional 500 patients in 2017 in Dar es Salaam via routine hospital-based surgeries and special hydrocelectomy camps in Dar es Salaam. IMA received funding from the Izumi Foundation for hydrocele surgeries in the Mtwara and Lindi regions. The project subsidized surgeries for 1,320 men suffering from hydrocele before the project ended in 2016.

History of USAID Support In FY10, under the NTD Control Program, USAID started supporting LF MDA (IVM+ALB) in seven regions (Mtwara, Lindi, Coast, Dodoma, Singida, Rukwa, and Katavi), and in FY11 under ENVISION, two additional regions (Tabora and Manyara). In FY16, ENVISION began funding IVM+ALB MDA in addition to school-based PZQ+ALB MDA in the six OV-endemic regions previously supported by APOC. Under ENVISION, integrated LF/STH/SCH sentinel and spot-check site assessments as well as pre-TAS and TAS were also carried out. In FY15, in collaboration with TFGH, ENVISION supported LF remapping efforts for 63 districts where no LF MDA had been initiated.

b) Trachoma

The TZNTDCP’s goal is to eliminate blinding trachoma in Tanzania by 2020. Mapping for trachoma was completed in 2014, with ENVISION providing funding and technical assistance for grader and enumerator training through our role in the Global Trachoma Mapping Project (GTMP). Through inclusion of Tanzania in the GTMP and electronic data capture during baseline and impact surveys, mapping speed and quality were improved significantly. Based on baseline surveys, a total of 61 districts were trachoma endemic with >5% trachomatous inflammation–follicular (TF) prevalence. Following redistricting, the total number of districts estimated to have TF prevalence rates of ≥5% is 71. By the end of FY15, all districts that require MDA were receiving treatment, thus achieving 100% geographical coverage. As the program interventions took place, some districts achieved TF prevalence rates below 5%, thus achieving the criteria for stopping MDA. In FY17, only 18 endemic districts (25%) needed MDA. To eliminate blindness resulting from trachoma, the SAFE strategy must be implemented for one to five years in districts determined to be endemic (depending on baseline prevalence) before impact surveys are conducted. The TZNTDCP carried out trachoma impact surveys (TISs) in 2009, and then annually since 2012 in various districts. By the beginning of FY17, 53 endemic districts (75%) have reached the criteria for stopping MDA for trachoma (<5% TF). Of the 18 endemic districts where MDA is ongoing in FY17, 6 districts are not yet eligible for TIS; 5 districts had a TIS that resulted in TF prevalence rates of 5%–9.9% and were eligible for one additional MDA round; and 7 had TF prevalence rates of ≥10% following TIS, requiring three more MDA rounds. By the end of FY17, the TZNTDCP will have completed TIS in nine districts. Tropical Data recently updated the protocol for trachoma surveys. The new protocol requires countries to split districts into EUs of no more than 250,000 population. Since Tanzania has some very populous districts, the nine districts above were split into 12 EUs. Of these, one district, Misungwi, was mapped in 2013 using the GTMP methodology and originally classified as not endemic (TF<5%). A later review of the GTMP data resulted in recategorizing the district as having a TF prevalence >5%. The district was not treated but since more than three years have passed, it was surveyed in late FY17 and had TF prevalence <1%. The remaining 8 districts where TIS was completed were eligible for TAS after the minimum rounds of treatment. Preliminary data indicate that 7 of 8 districts had TF <5% and Kalambo DC has TF of >5% but <10% and will require one more round of treatment.

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Twenty districts will have pre-validation surveillance surveys in August 2017, and those districts will be split into 20 EUs Preliminary results indicate of that of the 20 districts, 18 had TF <5% and two had TF >5% and <10%. ENVISION and the MOH are consulting with the WHO to determine next steps for these districts. In FY18, a total of 14 districts will continue MDA: • 6 districts that are not yet eligible for TIS • 6 that had TF prevalence rates ≥5% after failing a TIS in previous years • 2 that had TF prevalence ≥5% after failing a TSS in FY17. In FY18, trachoma surveillance surveys (TSS) are planned in 20 districts (20 EUs) and TIS in 10 districts (12 EUs). Among the 10 districts to undergo TIS, 6 will be eligible for their first impact survey, 3 will be eligible for repeat TIS after MDA, and one will be eligible for TIS following failure of TSS and one round of treatment. Previous experience suggests at least 2 districts surveyed in FY17 will have a prevalence rate of 5%–10%. Looking at the current trend, the TZNTDCP is on track for meeting trachoma 2020 elimination goals. The last two trachoma-endemic districts to undergo TIS will be Kiteto and Simanjiro in FY19. In addition, there is much effort by the TZNTDCP with support from the SAFE/DFID and QEDJT projects (described in the Partner Support section) to reach the ultimate intervention goals for TT surgery. These projects cover Lindi, Mtwara, Dodoma, Arusha, Manyara, and Pwani regions. Through these combined efforts, the TZNTDCP anticipates the TT surgery backlog to be cleared in these regions. However, there is a substantial TT burden in 16 districts that do not have support for TT management; these districts require TT-only surveys to inform planning for TT surgery services.

c) Onchocerciasis

The TZNTDCP’s goal is to eliminate OV by 2025 in line with WHO targets, and as guided by the new WHO guidelines for OV elimination. OV is endemic in 7 foci across 28 districts in 6 regions: Mbeya, Morogoro, Njombe, Ruvuma, Iringa, and Tanga. The CDTI program was launched by APOC in Tanzania in 1997. The 7 CDTI foci, comprising 21 districts, were treated with APOC support through a phased scale-up approach: Tanga, Tukuyu, Ruvuma, Tunduru, Mahenge, Kilosa, and Morogoro. By 2009 when three additional districts (Ludewa, Mufindi, and Njombe) were included, the TZNTDCP had moved to an integrated MDA approach and treated all districts in the six regions with IVM+ALB with funding from APOC and, later, ENVISION. Due to redistricting, the number of OV-endemic districts has increased from 23 in FY16 to 28 in FY17; a new region, Songwe, was established in 2016, thus increasing the number of OV-endemic regions from six to seven in FY17. All OV-endemic districts are co-endemic for LF, and since 2009, these districts have received IVM+ALB through annual community-based MDA. From 2009 to 2015, APOC supported OV activities with USAID funding. By FY16, all districts had received 10 to 16 rounds of IVM MDA with effective coverage. In FY16, ENVISION started supporting training, pre-MDA, and MDA in the OV-endemic regions. Under APOC support, nine districts in Tanga and Mbeya regions had conducted Phase 1b epidemiological evaluation in 2012 and showed 0% Onchocerca volvulus microfilaremia. However, these districts never had an entomological assessment to ascertain OV prevalence in the vector, S imulium spp. In February 2017, the TZNTDCP had its second meeting of its national elimination committee, the TOEAC. The committee reviewed the progress of the OV program and December 2016 and January 2017 OV elimination surveys, and provided recommendations on the way forward in several key areas related

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to OV elimination. Of note, the TOEAC will advise on next steps for OV treatment (e.g., continued treatment on annual basis, alternate treatment strategy, or stopping MDA) based on the results of any monitoring and mapping activities. Further, the TOEAC recommended that the MOHCDGEC develop a budget and plan for upcoming activities (e.g., monitoring, epidemiological evaluations, entomological evaluations, elimination mapping, MDA), to source necessary funds from the government and other national and international partners. The TOEAC also recommended that the MOHCDGEC develop an OV flag to provide a quick way of identifying the situation in each focus/district and to help with advocacy efforts. The next meeting is planned for February 2018.

OV MDA In FY17, the program stopped LF MDA in 33 districts across the OV-endemic regions; however, 28 of those districts will continue with district-wide IVM+ALB MDA due to co-endemicity with OV and STH. Due to OV and LF co-endemicity, the TOEAC recommended to continue with MDA until the evaluations for stopping OV MDA can be carried out. However, the program has received limited support so far for epidemiological and entomological evaluations, which are the WHO prerequisites for a decision to stop MDA. Thus, district-wide IVM+ALB MDA rounds will continue in the 18 LF/OV co-endemic districts. Because MDA was delayed until August in FY17 in three districts of Morogoro region, 25 districts will have MDA in October 2017 and 28 districts are planned for August 2018.

OV M&E The TZNTDCP, with guidance from the TOEAC and funding from ENVISION, implemented its first OV epidemiological assessment survey in Tukuyu focus (Ileje, Rungwe, , and Kyela districts) in December 2016. A total of 3,198 children, 6–9 years of age, were assessed and 1 (0.03%) was positive (as measured using an OV16 rapid diagnostic test [RDT]). This is a good indicator of progress toward elimination. However, WHO requires definitive results from OV16 enzyme-linked immunosorbent assay (ELISA) analysis for a decision to stop MDA. TFGH has agreed to fund the analysis of the dried blood spot samples in 2017. When the results are available, the program will present them to the TOEAC for review and guidance. It is hoped the Tukuyu focus will meet the WHO MDA stopping criteria. Other OV monitoring surveys were conducted with ENVISION funding in Tunduru and Tanga foci in January and February 2017. Tunduru’s OV16 RDT positivity rate was at 0.4% in the general population (5 years and above). OV16 RDT positivity was 0% and 0.06% in children 6–9 years old in Bumbuli and Lushoto districts, respectively. The Lushoto and Bumbuli OV monitoring surveys were nested in the LF TAS2 and were carried out among primary school pupils in Grades 1, 2, 3, and 4, representing age groups 6–9 years old. In FY18, due to lack of data for decision making in OV elimination, it is proposed that nine districts eligible for TAS 2 also conduct OV monitoring. They include districts in (Mbinga DC, Nyasa DC, Madaba DC, Songea DC, Songea Municipal Council [MC], Namtumbo), (Mufindi DC) and in (Ludewa DC and Njombe DC). WHO recommends monitoring OV endemicity after every 4 to 5 years of MDA to determine if a district is ready for stop MDA epidemiological and entomological evaluations. In FY16 and FY17, upon review of available prevalence data, the TOEAC recommended that the Tanzania program routinely collect prevalence data to inform decision making. It was noted in particular that Ruvuma has completed 18 years of MDA (1999–2016), with only 1 Phase 1a epidemiological assessment, which reported 3.4% microfilaremia. This was based on skin-snip microscopy and nodule palpation techniques that are no longer recommended in the new WHO guidelines. Results from these assessments will help inform the TOEAC to provide useful guidance to the program and the MOHCDGEC.

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d) Schistosomiasis

SCH was mapped in 2004 through blood-in-urine questionnaires administered to SAC in all districts. Results indicated a high prevalence (≥30%) in 13 districts and a moderate prevalence (>1 and <30%) in 153 districts. It is important to note that this questionnaire provides information about Schistosoma haematobium , but does not provide a baseline profile of S. mansoni . Of the 185 districts that are endemic, 15 are treated annually (high prevalence) and 119 biannually (moderate prevalence) through ENVISION and 51 treated biannually by SCI; other districts are covered by SCI. SCH control efforts target school-age children (SAC) who are enrolled in primary schools as well as the ones who are not enrolled. The TZNTDCP reviewed mapping and sentinel site data to determine a more optimal treatment strategy going forward. The information was presented at the Annual Joint Planning Meeting in June 2017 and provided information down to the ward level. This initial review included analysis of mapping and sentinel and spot-check site data on S. haematobium and S. mansoni , in order to update district and ward endemicity data and shape the treatment strategy. Currently, all districts are either treated annually or biennially, and high-risk adults are not treated. This analysis helped identify which districts can be treated less frequently (twice during a child’s school years) and those where a high prevalence in identified foci/communities require treating high-risk adults with PZQ as per WHO protocol for SCH control. SCI is looking into purchasing PZQ for treatment of high-risk adults. Until the new strategy is formally adopted (perhaps before the end of FY17 in SCI-supported areas), the TZNTDCP has been advised to continue to distribute PZQ with ALB in a separate school-based distribution. In districts where community MDA campaigns with IVM and ALB take place, PZQ+ALB will be distributed six months after the community MDA. In districts where there is no community distribution with IVM+ALB, PZQ+ALB will be distributed through school-based MDA campaigns. Currently, 18 districts require annual treatment with PZQ, and 167 districts are treated every other year with PZQ. In off years, districts in the latter category are treated with ALB only. In FY17, all districts having reported data have achieved the treatment target, except one split district, where baseline data are yet to be verified and because the population estimate has not yet been agreed upon. Generally, the program is constantly working to address coverage issues with SCH due to poor denominator estimations. The denominator includes enrolled SAC, who are found in school and can be easily verified, and non-enrolled SAC, who are difficult to enumerate. So the program relies mostly on national population census data to estimate these figures and triangulate them with reported total SAC from the district MDA report. When districts split, it takes times for both parties (parent and new districts) to properly estimate/adjust the number of SAC, thus potentially impacting the coverage being reported. In FY17, SAC estimation considered split districts, and the TZNTDCP triangulated this with available reported data. In the past, treatment coverage has been low in most regions, in part due to overestimation of the denominator as described below in the STH section. The SAC population was previously estimated using a blanket percentage projected from the national population census provided by the National Bureau of Statistics (NBS). As noted in the STH section, district-specific proportions have been applied to estimating SAC, and the TZNTDCP will use these estimations going forward. The TZNTDCP has learned from the coverage and Knowledge, Attitudes, and Practices studies that the primary inhibitor to taking PZQ during MDA is fear of adverse events (AEs). This has led to parents not allowing their children to attend school during MDA days. The program has worked on targeted social mobilization strategies that involve school management committees and parent associations to respond to these myths and attract increased MDA participation. Furthermore, the program requires that a meal be eaten before PZQ MDA in schools. Teachers work with parents to collect food and prepare a meal for

ENVISION FY18 PY7 Tanzania Work Plan 18

all SAC taking PZQ during an MDA. The program has not had any serious adverse events (SAEs) reported from PZQ in years, and in 2016/17, no SAE was reported. The provision of food during PZQ school MDA has been successful because of the involvement of both regional and district political, education, and health leaders during regional advocacy meetings. Mobilization of schoolchildren and their parents, as well as resources to provide meals to children on the day of MDA, are key to success. It is a practice that the food must be cooked at the schools, and eating is directly observed by the teachers. The district education officers are involved in all NTD planning and review meetings and are members of the district NTD team. The district education officer mobilizes school heads, NTD representative teachers, and school committee members to ensure food is provided during school MDA. In addition, the school committee and school head also issue letters of information or make announcements in the community to ask parents to contribute food and other resources toward the preparation of food for MDA. The re-categorization of SCH endemicity that will inform the new treatment strategy will also help improve coverage because efforts will be more focused toward areas with the highest need. The program has learned that where the disease is highly endemic, and the communities vividly see SCH morbidity, MDA uptake is very high and communities even request PZQ. USAID started funding community-based MDA (IVM+ALB) and school-based MDA (PZQ+ALB) in FY10 under the NTD Control Program in seven regions (Mtwara, Lindi, Coast, Dodoma, Singida, Rukwa, and Katavi), and in FY11 under ENVISION in two additional regions (Tabora and Manyara), for a total of nine regions. In FY16, ENVISION began supporting IVM+ALB MDA in addition to school-based PZQ+ALB MDA in the six OV-endemic regions previously supported by APOC. ENVISION has also supported integrated LF/STH/SCH sentinel and spot-check site assessments.

e) Soil transmitted Helminths

STH is believed to be endemic throughout Tanzania, although baseline mapping of STH has not taken place. In 2004, the MOHCDGEC conducted a desk review of hospital and health facility records. At the time, all regions were found to require some level of STH intervention per WHO guidelines (for this reason, Table 2 does not represent this as a mapping gap). Control efforts for STH through the TZNTDCP target primary school SAC ages 7–13 years, who are the group with the greatest risk of STH infection. Preschool children (1–6 years of age) are treated through the Vitamin A/deworming program run by the Reproductive and Child Health Section of the MOHCDGEC. The main intervention for SAC is MDA with ALB—implemented by trained school teachers supported by health personnel, which is complemented by school health education and environmental sanitation. In FY17, 100% of the country was reached with at least one round of STH treatment, with support to the MOHCDGEC provided by ENVISION, SCI, and CTND. In districts that are non-endemic for LF and those that have passed TAS, the TZNTCP conducted school-based ALB or ALB+PZQ MDA (depending on SCH treatment protocol). In districts that are still LF- or OV-endemic, the TZNTDCP conducts school-based MDA with ALB or ALB+PZQ and a second round of MDA through community distribution of IVM+ALB. In the past, coverage rates for SAC have been low, and while there are various reasons (by district), the main contributing factor across all the districts until FY15 was the challenge of correctly estimating the number of SAC. In FY15, following concerns about high estimates of the SAC population by the national NTD Secretariat, a data review was conducted. With the aid of the 2012 National Population Census report (which is disaggregated by age and gender) released by the NBS in 2013, school-age categories were determined. The national policy states that primary-level education is for children ages 7 years and older and runs from Grade 1 to 7. NBS estimates that the age range for SAC is 7–13 years of age. Upon a review of the 2012 census report, this corresponds to a national average of 19.1% of the total population. However, this proportion differs from district to district. Thus, a district-specific proportion

ENVISION FY18 PY7 Tanzania Work Plan 19

of SAC was determined and applied accordingly—these proportions range from 12.3% to 22.7%. These estimates are as realistic as any the TZNTDCP can currently obtain. The newer estimates have been applied and used in estimating MDA needs and targets from FY15 to date and will continue to be used in the future. As stated above, USAID started funding community-based MDA (IVM+ALB) and school-based MDA (PZQ+ALB) in FY10 under the NTD Control Program in seven regions (Mtwara, Lindi, Coast, Dodoma, Singida, Rukwa, and Katavi), and in FY11 under ENVISION in two additional regions (Tabora and Manyara), for a total of nine regions. In FY16, ENVISION began supporting IVM+ALB MDA in addition to school-based PZQ+ALB MDA in the six OV-endemic regions previously supported by APOC. Integrated LF/STH/SCH sentinel and spot-check site assessments as well as integrated TAS were also supported. In FY18, the TZNTDCP, with ENVISION funding and IMA’s technical assistance and supervision, will continue deworming for SAC in 134 districts. As described above in the NTD Partners section, SCI will fund MDA in districts of the Simiyu Region, with Geita and Kilimanjaro to be added in SCI’s 2018 planning cycle.

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3) Snapshot of NTD Status in Country

Table 2: Snapshot of the expected status of the NTD program in Tanzania as of September 30, 2017

Columns C+D+E=B for each Columns F+G+H=C for each disease disease* MDA GAP MDA MAPPING GAP DETERMINATION DSA NEEDS a DETERMINATION ACHIEVEMENT A B C D E F G H I No. of districts No. of districts Expected receiving MDA as of expected to be No. of 09/30/17 in need of districts Total No. of No. of No. of MDA at any where No. of districts districts districts No. of districts level: MDA not criteria for Disease Districts classified classified in need requiring DSA as yet started, or stopping in as as non- of initial of 09/30/17 USAID- has district-level Tanzania endemic endemic mapping Others funded prematurely MDA have stopped as of been met as 09/30/17 of 09/30/17 Pre-TAS: 13 TAS1: 19 *** LF 120 65 0 47 ** 6 0 73 TAS2: 59 TAS3: 0 Elimination Mapping: 12 OV 28 158 0 28 0 0 0 185 * OV monitoring: 9 Entomology: 4 SCH 185 0 0 134 51 0 0 SSA ǂ: 13 (integrated with STH 185 0 0 134 51 0 0 LF pre-TAS) TIS: 10 Trachoma 71 + 114 0 18 0 0 53 ++ TSS: 20 *In FY18, the total number of districts has changed from 186 to 185 because Tanganyika DC has been reverted to the two councils of Mpanda DC and Mpimbwe DC. **Note that in FY17 30 districts were eligible for pre-TAS and 21 are eligible for TAS 1 as of August 31, 2017. TAS 1 is planned for September 2017. ***Includes 13 districts supported by ENVISION and 6 districts supported by CNTD. ǂ SSA = Sentinel Site Assessment +71 endemic >5% TF. Five districts were 5%–9.9% at baseline (Rombo DC, Mvomero DC, Morogoro DC, Singida MC, and Misungwi DC) . ++ The TZNTDCP just received TIS and TSS results incdicating that 8 of 9 districts passed TIS and 18 of 20 districts passed TSS. This is in addition to the 53 districts, for a total of 59 districts that have reached the stopping MDA criteria (53+8-2).

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PLANNED ACTIVITIES

1) NTD Program Capacity Strengthening

a) Strategic Capacity Strengthening Strategy

ENVISION and the NTD Secretariat together have identified the following priorities for capacity strengthening to ensure the continued success of efforts to address NTDs in Tanzania: • Identify and apply for new funding sources and platforms to sustain STH and SCH control, and OV elimination as well as trachoma and LF morbidity activities. • Raise the visibility of the NTD sector and achievements (with a focus on ENVISION contributions). • Continue to build the NTD management and M&E capacity of MOHCDGEC staff at national, regional, and district levels and strengthen the culture of data use for project management and decision making.

b) Capacity Strengthening Objectives and Interventions

Objective 1: Identify and apply for new funding sources and platforms to sustain OV, STH, and SCH control, and OV elimination as well as trachoma and LF morbidity activities Interventions 1: Establish a working group to implement recommendations of resource mobilization plan : As part of the FY17 capacity strengthening strategy, ENVISION supported the TZNTDCP with funding for the development of a resource mobilization plan with the objective to map the domestic funding ecosystem in Tanzania. In FY18, the TZNTDCP and IMA will establish an advocacy team to implement the recommendations from the resource mobilization plan. The team will be composed of private sector representatives, NTD program officers, and selected regional representatives who will be working hand in hand with government officials to bring more resources for NTD activities to sustain the gains made by ENVISION and other partners. In addition, they will work with NTD-endemic district officials to ensure funds are allocated in CCHPs for NTD activities and provide support to the districts to mobilize their own internal resources for NTD activities. This technical working group (TWG) should only require level of effort (LOE). Interventions 2: District-level advocacy and awareness-raising for NTD activities, and budget allocation in the CCHPs : In FY18, the resource mobilization TWG will lead meetings for all 19 regions to advocate for more resources and the inclusion of NTD activities in CCHPs and budgets. The team will discuss the history of USAID support and highlight progress of achievements, opportunities, and programmatic needs. Interventions 3: Transition plan for ENVISION-supported seconded staff : The NTD Secretariat relies on a total of nine seconded staff funded by ENVISION (5), CTND (1), SCI (1), and Sightsavers/HKI (2). As part of the transition process for the staff supported by ENVISION, two junior seconded M&E Officer positions will be phased out in FY18 (April 2018). As part of the transition process of the two junior associates, ENVISION will work with the NTDCP to ensure their responsibilities are adequately documented in anticipation that someone from MOHCGEC will be hired to take over their responsibilities. ENVISION will also work closely with the NTD Secretariat and other partners to develop a transition plan for the remaining ENVISION staff seconded to the TZNTDCP (Finance/Administrative Officer, Senior Technical Advisor for M&E, and Drug Logistics Officer). The objective is to ensure that a succession plan is in place

ENVISION FY18 PY7 Tanzania Work Plan 22

for transfer of critical skills and expertise. ENVISION, with support from USAID/Washington, will also continue to engage and advocate with the MOHCDGEC leadership and the GoT to absorb some of the seconded staff into their payroll. Objective 2: Raising the visibility of the NTDs Intervention 1: Launching of updated NTD Master Plan and NTD Learning Day : In FY18, the TZNTDCP will initiate and operationalize an advocacy activity targeting political leaders in higher government positions in the three key ministries participating in NTD control and elimination. The ministries include the MOHCDGEC, the Ministry of Local Government and Regional Administration, and the Ministry of Education. The updated NTD Master Plan (2017–2022) will be introduced and officially launched, and the NTD Secretariat will highlight achievements made due to ENVISION and other partner funding. The event will attract press participation, which will help elevate advocacy efforts for increasing GoT contributions down to the community level. Another awareness-raising activity will be the NTD Learning Day, which will highlight NTD activities and achievements and include representatives from the national donor community who might not be familiar with NTD control and elimination activities. The purpose of the NTD Learning Day will be to increase the TZNTDCP visibility to the Government, recognize ENVISION and other donors, and obtain buy-in for extra domestic resources mobilization and sustainability to support the continuation of SCH/STH MDA and other activities. Intervention 2: Revitalization of the NGDO NTD Coalition . The IMA Country Director has played a key role in staff supervision, activity oversight, and budget and financial management of ENVISION funds. In FY18, the Country Director will continue to focus on these oversight and quality control areas, as well as play an integral role in carrying out the capacity strengthening and advocacy activities outlined in the work plan. These efforts will be focused on raising the profile of the ENVISION project. The Country Director will also take a lead role in re-establishing the NTD NGO Coalition. This will entail working with relevant stakeholders to develop the terms of reference, identify interested parties, and eventually nominate and elect leadership of the network. Primary goals of the network will be to harmonize the multiple donor-funded interventions to streamline initiatives; coordinate with other health/water, sanitation, and hygiene programs; raise the profile of the NTD sector; improve value for money; and advocate for resources for the sustainability of NTD efforts in Tanzania. Objective 3: Strengthen the NTD management and M&E capacity of MOHCDGEC staff at national, regional, and district levels Intervention 1: NTD Toolbox orientation for national NTD staff : In FY18, ENVISION will promote and integrate the use of the ENVISION NTD Toolbox as a key resource to build the capacity of the national NTD program. The NTD Toolbox, which can be found on the ENVISION website (http://www.ntdenvision.org/toolbox ), is a user-friendly, one-stop shop for a variety of print, video, and web-based resources about the four phases of NTD programs: planning, management, M&E, and assessment. ENVISION and the TZNTDCP will be promoting the NTD Toolbox in meetings, workshops, and other interactions with stakeholders as one of the best one-stop shops for NTD technical and programmatic resources. Objective 4: Support for LF and trachoma dossier development Intervention 1: Short-term technical assistance (STTA) for LF and trachoma dossier development : In FY18, ENVISION will support the TZNTDCP to continue moving forward with the first stages of LF and trachoma dossier development. ENVISION will hire a local consultant who will work with the TZNTDCP to analyze the existing data collected for the trachoma dossier and begin drafting a narrative. For the LF dossier, IMA HQ will provide STTA and will assist in creating the framework for data collection, analysis, and a plan for development of the dossier. The goal of this support is to enable the TZNTDCP to manage

ENVISION FY18 PY7 Tanzania Work Plan 23

the compiling of the dossier components all the way through to submission to WHO. In addition, a local consultant will assist with data collection and drafting of the narrative.

c) Monitoring and Evaluating Proposed Capacity Strengthening Interventions

To ensure continual monitoring of capacity strengthening efforts, ENVISION staff will continue to meet regularly with the TZNTDCP and discuss capacity strengthening progress and needs in key technical, managerial, financial, and operational areas. ENVISION will also liaise with other relevant government stakeholders, including the Department of Preventative Services and NIMR. These meetings will serve as a platform to regularly monitor and assess proposed capacity strengthening interventions mentioned above. The Annual Joint Planning Meeting, TWGs, and other meetings described under Strategic Planning will also be an opportunity for ENVISION and the TZNTDCP to more broadly discuss capacity strengthening needs and opportunities with Tanzania’s NTD partners and donors (please reference Table 1).

Table 3: Measuring progress of capacity strengthening Objectives Indicator Identify and apply for new funding sources and platforms to sustain OV, STH, and SCH control, Number of new partnerships (domestic and international) and OV elimination as well as trachoma and LF and additional sources of funding identified morbidity activities • Number of ENVISION supported staff absorbed into Raising the visibility of the NTDs government payroll • Percentage increase of GoT budget allocated for NTDs. Strengthen the NTD management and M&E Percentage of NTD endemic districts meeting coverage capacity of MOHCDGEC staff at national, regional, targets and district levels

Table 4: Project assistance for capacity strengthening How these activities will help to Project Capacity strengthening interventions/activities correct needs identified in situation assistance area above 1. Annual Joint Planning Meeting Opportunity for local and international 2. Disease-specific TWG meetings disease-specific experts to lead and promote discussions to address disease- 3. TOEAC meeting specific issues that might otherwise be Strategic Planning lost in the framework of integration. The meetings provide a space to review and discuss disease-specific data to inform programmatic decision making and short- and long-term strategic planning. 1. The Tool for Integrated Planning and Costing TIPAC identifies funding gaps, which (TIPAC) is updated regularly and presented help stakeholders choose priority areas NTD Secretariat annually to partners to plan activities and identify of interest for support. gaps.

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How these activities will help to Project Capacity strengthening interventions/activities correct needs identified in situation assistance area above 1. The TZNTDCP is prioritizing the development of a Promoting achievements; strengthening sustainable strategy to increase domestic government ownership, advocacy, Building Advocacy resources and local financing toward direct coordination, and partnership for a Sustainable implementation of NTD activities. National NTD 2. NTD Master Plan launch and NTD Learning Day Planning for results, resource Program mobilization, and financial sustainability 3. NGO NTD Coalition 4. Transition plan for seconded staff Social 1. Continue to implement Behavior Change Strengthen the social mobilization skills Mobilization to Communication (BCC) strategy for Nomadic for implementing activities for hard to Enable NTD communities reach communities. Program Activities 1. Using Supply Chain Management Booklets The training has helped pharmacists developed through ENVISION, the TZNTDCP has train lower cadres on management of Drug Supply and trained most district pharmacists and regional NTD medicines and help them Commodity pharmacists on management of NTD medicines understand standard operating Management and from the date of arrival at their storage facilities, procedures for handling NTD medicines, Procurement distribution, reverse logistics, etc. quantification (which reduces medicine waste due to expiry), management of SAEs, etc. 1. Provide focused supervision efforts during Supportive supervision enhances skills of trainings for FLHWs, CDDs, and teachers. FLHWs, CDDS and personnel from the Supervision for 2. Strengthen monitoring mechanisms during DHMTs through coaching and MDA supportive supervision (e.g., supervision mentoring. checklists). 1. Initiate the process for the development of LF The dossier process is expected to Dossier dossier. strengthen the documentation skills of the NTDCP Development 2. Continue to analyze data and preparation of trachoma dossier document

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2) Project Assistance

In Tanzania, ENVISION’s lead implementer, IMA, follows the lead and programmatic guidance of the national TZNTDCP and NTD Secretariat throughout all of its work. In FY18, IMA will continue to support the MOHCDGEC and TZNTDCP to implement NTD control activities in line with the Tanzania NTD Master Plan (formerly 2012–2017), which is in the process of being updated to cover 2017 to 2022. The NTD Secretariat will continue taking the lead in initiating, planning, implementing, and monitoring planned activities. ENVISION/IMA will provide technical guidance, project management, and operational support to the national NTD Secretariat at the district, regional, and national levels. Proposed activities outlined are expected to contribute to ENVISION objectives in support of the national program: • Technical assistance and funding for NTD control and elimination activities • Capacity development for NTD control and elimination • Improved M&E for NTD program activities. As part of the SCH transition activities in FY18, six districts in Simiyu Region will be transitioned to SCI support for treatment. This includes four districts requiring SCH/STH treatment and two requiring STH- only treatment in FY18. The remaining 12 districts in (6 districts) and Kilimanjaro Region (6 districts) will be transitioned in FY19. In FY18, ENVISION will continue providing funding and technical assistance to the TZNTDCP for the 19 regions—Lindi, Mtwara, Pwani, Manyara, Dodoma, Singida, Tabora, Rukwa, Katavi, Geita, Arusha, Kilimanjaro, Tanga, Morogoro, Iringa, Njombe, Ruvuma, Songwe, and Mbeya—and the associated 135 districts covered in FY17. ENVISION will also support school-based distribution of PZQ+ALB in all 135 districts and LF and/or OV community-based distribution of IVM+ALB in 42 districts. In addition, ZTH community-based distribution will be carried out in 12 districts.

a) Strategic Planning

Planned Activities for FY18 Activity 1: Regional and district review/planning meetings : In FY18, ENVISION, will continue to support and fund the annual regional and district review/planning meetings lead by the TZNTDCP. These meetings will take place in October 2017 for 43 districts that will conduct community-based IVM/ALB MDA and 9 districts that will conduct ZTH MDA, as well as in January/February 2018 for the 135 districts conducting PZQ and ALB school-based MDA. IMA staff, in partnership with the national NTD Secretariat members, will facilitate the regional meetings. District-level meetings will be led by the regional NTD coordinators. Regional and district meetings will be held in the 135 districts and 19 regions supported by ENVISION. These meetings focus on the review of previous MDA activities and lessons learned to develop and inform plans in line with the national NTD plan for upcoming MDA-related activities. These meetings are an important opportunity for the exchange of feedback to the regional and district levels on activities that work well and areas of challenges. MDA coverage information is reviewed and discussed, which helps to inform any needed changes or additions to activities for the upcoming year. Each district and region submits a table of activities with budgets for approval by RTI, IMA, and the TZNTDCP. Activity 2: Disease-specific TWG meetings : In FY18, ENVISION and the TZNTDCP will continue to organize and facilitate disease-specific TWG meetings (for LF/OV, STH/SCH, and trachoma) to allow for and promote discussions to address disease-specific issues that might otherwise be lost in the

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framework of integration. The NTD Secretariat will present data for review and discussion, and this will drive planning and decision making. These TWGs will meet in FY18, and ENVISION, in collaboration with the national NTD Secretariat, will organize and participate in discussions in these meetings. ENVISION will support one meeting for each TWG (two meeting days total for the three meetings) during the third quarter (the TWG meetings will take place the same week as the Annual Joint Planning Meeting). Activity 3: Annual Joint Planning Meeting : To ensure that the MOHCDGEC can better lead the coordination of local and international NTD partners in Tanzania, as well as avoid duplication and increase harmonization of efforts among partners, ENVISION will provide funds and help in organizing an Annual Joint Planning Meeting for local and international stakeholders in FY18. This meeting is led by the NTD Secretariat, and CTND and SCI will also provide some funding support. It is critical for the MOHCDGEC to consider differing fiscal years and planning cycles when planning with all partners and donors and establishing how best to plan activities. Each year, the TIPAC is used to plan activities and identify gaps. In addition to partner presentations, the NTD Secretariat presents activities that were completed, highlighting success and challenges. The meeting promotes active discussion on issues of MDA coverage, data quality, and regional- and district-level concerns. As in previous years, the disease- specific TWG meetings will be held the day before the Annual Joint Planning Meeting to take advantage of partner organization representatives who will be in Tanzania to attend both sets of meetings. Activity 4: Tanzania OV Expert Committee meeting : Tanzania moved forward with establishing an OV expert committee in FY16—the TOEAC. In FY18, the TZNTDCP plans to conduct one TOEAC meeting to plan OV efforts in the country. Representatives from USAID, IMA, RTI, AFRO/RPRG, END Fund, the Centers for Disease Control and Prevention (CDC), and others will be invited to attend this meeting. ENVISION funds the participation of RTI and IMA staff from headquarters and in-country staff. The meeting will provide a platform for reviewing new OV data and formalizing a plan for the way forward for the TZNTDCP. Goals of the meeting include reviewing the elimination strategy, deciding on stopping MDA in specific foci/districts, and determining actions for any remaining areas of unknown endemicity. One issue for OV assessments required to date has been donor commitments, and it is hoped that donor representative involvement in country-led discussions will assist in defining a realistic strategy for Tanzania to meet the OV targets for elimination, as per WHO guidelines.

b) NTD Secretariat

Activities for FY18 Activity 1: Administrative and Transport Support to NTD Secretariat : As in previous years, all NTD partners contribute some funds for the general functioning of the NTD Secretariat. In FY18, ENVISION funding will continue to provide administrative and operational support to the national NTD Secretariat, including stationery and other office supplies, and communication costs, including telephone and email/Internet services. Transportation assistance includes the provision of fuel and vehicle maintenance to support the NTD Secretariat with supervisory activities and some general operations.

c) Building Advocacy for a Sustainable National NTD Program

Activities for FY18 Activity 1: Regional and district-level advocacy and resource mobilization : For ensuring sustainability of ENVISION achievements, the TZNTDCP and ENVISION plan to establish a resource mobilization team that will be composed of TZNTDCP staff and selected regional representatives. In FY18, the team will lead meetings in 6 of the 19 regions selected on the basis of need to increase more resources and the

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inclusion of NTD activities in CCHPs and budgets. The team will discuss the history of USAID support and highlight achievements made. Political and government leaders will understand that to sustain the achievements made, district councils must find ways to provide more resources. Activity 2: Launching of updated NTD Master Plan : In FY18, the TZNTDCP will initiate and operationalize an advocacy activity targeting political leaders in higher government positions in the three key ministries participating in NTD control and elimination. The updated NTD Master Plan (2017–2022) will be introduced and officially launched, and the NTD Secretariat will highlight achievements made due to ENVISION and other partner funding. The event will attract press participation, which will help elevate advocacy efforts for increasing GoT contributions down to the community level. Activity 3: NTD Learning Day : The NTD Learning Day activity will highlight NTD activities and achievements to date. The event will include represetatives from the following groups: national budget authorities; key ministries and departments; local donor community; internatonal donor community and diplomatic community; as well as implementing partner NGOs and donors. The purpose of the NTD Learning Day will be to include representatives from groups who might not be familiar with NTD control and elimination activities, and to increase the TZNTDCP visibility to the government highlighting contributions from ENVISION and other donors. The goal is to create awareness about NTDs, achievements, recruit new partners and obtain buy-in for increased domestic and international resources to support the sustainability of the NTD activities beyond the end of ENVISION project. Activity 4: NGDO NTD Coalition coordination meetings : In FY18, IMA will lead two quarterly meetings of a coalition of NDGO and other NTD stakeholders for the purpose of raising the profile of the NTD donor community to the Government and leveraging resources for NTDs.

d) Mapping

All trachoma mapping for Tanzania has been completed, and LF remapping was completed in FY15. SCH was mapped in 2004 through blood-in-urine questionnaires administered to schoolchildren in all districts. STH is considered endemic throughout Tanzania, although baseline mapping of STH has not taken place. In addition, all OV meso- and hyper-endemic mapping has been completed. In the six OV-endemic regions, the following districts may benefit from OV elimination mapping to establish infection levels: Liwale (first mapped in 1997), Songea MC and Mufindi DC (mapped under Rapid Epidemiological Mapping of Onchocerciasis [REMO] in 2006), Njombe DC (mapped under REMO in 2006), Kilolo (borders Kilosa DC, which is hyper-endemic), and Makete (borders Ludewa, also hyper- endemic). In addition, the following districts need to be checked for OV endemicity because they share borders with endemic countries: Karagwe and Ngara districts, which border Burundi and Uganda; Kyela, which borders Malawi; Nyasa and Mbinga, which border ; and Newala and Tandahimba, which border Mozambique. Tanzania looks forward to clarification of the best way to proceed with mapping. As noted in the Strategic Planning section, ENVISION will continue to support the TZNTDCP to convene the TOEAC, which can advise whether and how to proceed with remapping in these areas. No ENVISION funding is requested for this activity in FY18.

e) MDA Coverage

In view of the 2020 elimination goals for LF and trachoma and the need to ensure each MDA has the strongest possible epidemiological coverage, the TZNTDCP has proposed to all partners to conduct FY18 MDA as follows:

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Table 5: USAID-supported districts and estimated target populations for MDA in FY18 Number Number of of Total # of rounds of Distribution districts eligible people NTD Age groups targeted distribution platform(s) to be to be targeted annually treated in FY18 in FY18 LF all at-risk people ≥5 Community-based 1 22* 3,239,513 (October 2017 MDA) years in a district (IVM+ALB)

OV all at-risk people ≥5 Community-based 1 25 4,395,152 (October 2017 MDA) years in a district (IVM+ALB) Community-based STH all at-risk people ≥5 1 (ALB as part of 41 6,306,592 (October 2017 MDA) years in a district IVM+ALB) Trachoma all at-risk people ≥6 Community-based 1 11 2,2,204,560 (October 2017 MDA) months in a district (ZITH)

SAC only, enrolled and SCH Annual or School-based non-enrolled in primary 65 2,800,979 (February 2018 MDA) skipped year (PZQ) schools SAC only, enrolled and STH School-based non-enrolled in primary 1 135 6,038,533 (February 2018 MDA) (ALB) schools

LF all at-risk people ≥5 Community-based 1 13* 2,522,176 (August 2018 MDA) years in a district (IVM+ALB) OV all at-risk people ≥5 Community-based 1 28* 5,030,435 (August 2018 MDA) years in a district (IVM+ALB) Community-based STH all at-risk people ≥5 1 (ALB as part of 36 7,757,948 (August 2018 MDA) years in a district IVM+ALB) Trachoma all at-risk people ≥6 Community-based 1 7 1,564,993 (August 2018 MDA) months in a district (ZITH) *There are six (6) districts which will have LF and OV MDA (Morogoro region: Gairo DC, Ifakara DC, Morogoro DC, and Mvomero DC; and Tanga region: Korogwe DC and Mkinga DC) in October 2017, and 5 districts in August 2018 (the same districts listed above, minus Korogwe DC.).

Activities for FY18 Location in budget: MDA Coverage Activity 1: Purchase of replacement measuring papers for PZQ : ENVISION will fund the purchase of measuring papers for PZQ, which are budgeted at a 30% replacement rate due to increased enrollment of SAC (attributed to the free education policy introduced in 2017). Activity 2: Production and replacement of school and household registers: For MDA data collection, the TZNTDCP uses school and household registers. School registers are budgeted at a 30% replacement rate. For household registers, replacement is budgeted for 20% across the ENVISION-supported districts.

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Activity 3: Printing of summary data form : ENVISION will fund the printing of replacement summary data forms for all 19 regions, and 135 districts, budgeted at 50%. These summary forms are used to aggregate data from the service delivery point to the district and from districts to region. Activity 4: Transportation of MDA supplies : In FY18, ENVISION will fund the transport of replacement MDA supplies and summary data forms from the central level to regions and districts. Activity 5: MDA : In FY18, ENVISION will provide funding for drug distribution, which includes payments to FLHWs, teachers, and CDDs for community-based and school-based MDAs.

f) Social Mobilization to Enable NTD Program Activities

Activities for FY18 Activity 1: Production of integrated IEC materials : To continue to improve community-level NTD knowledge and coverage rates, ENVISION will fund the production of integrated IEC materials for both school- and community-based MDA campaigns in ENVISION-supported areas. Activity 2: Airing of radio and TV spots at national, regional, and district levels: ENVISION, in collaboration with the NTD Secretariat, will provide funds to air radio and TV spots at national, regional, and district levels. These programs will be aired through different national and local radio stations for all 19 ENVISION-supported regions and 135 districts. Activity 3: Delivery of IEC materials : After materials have been produced, ENVISION will fund the delivery of the IEC materials to regions and districts. ENVISION will also fund district distribution of the materials to the facility, school, and household levels. Posters are hung in schools, ward offices, and health facilities, and banners are placed in strategic locations advertising the MDA efforts. Flyers/fact sheets and brochures are also produced and delivered. Flyers, fact sheets, and brochures are given to teachers, school boards, health workers, and community leaders for distribution to parents and students prior to school-based MDA. IEC materials and messages provide information on the MDA logistics as well as basic NTD education and drug information. These materials are typically in Kiswahili. Activity 4: Social mobilization activities in 5 nomadic districts : To improve social mobilization approaches, in FY17 the TZNTDCP, with the support of the BCC consultant, gathered all existing information on coverage surveys, IEC materials, and research recommendations and synthesized and highlighted key information, which was used to develop communication strategies aligned with nomadic/pastoralist culture and settings. The consultant worked with the Health Education and Promotion Unit of the MOHCDGEC to develop an NTD social mobilization strategy and materials for the following: training community mobilizers as change agents; organizing school competition games and essay writing, using folk media groups; carrying out meetings with key community leaders in the Maasai, Sonjo, and Barabaig communities, which have strong cultural traditions; and organizing community- accepted events such as barbecue days. These events will continue to be used as platforms for lobbying and obtaining community acceptance of NTD activities to pass on knowledge of NTD and MDA. The target districts are Longido, Monduli, and Ngorongoro districts in the and Kiteto, Simanjiro, and Hanang districts in the . These districts are almost entirely nomadic, and the whole population is at risk. The outcome of these efforts will be evaluated periodically by the NTD Secretariat. In FY18, more resources will be needed to continue the scale up implementation of the BCC strategy in the targeted districts of Longido, Monduli and Ngorongoro in Arusha Region and Kiteto and Simanjiro in Manyara Region.

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Table 6: Social mobilization/communication activities and materials checklist for NTD work planning

Has this Where/when will Key Target material/message Category IEC strategy they be Frequency messages population or approach been distributed? evaluated? MDA Inform the SAC and the Banners, • Banners hung in • Banners posted Messages have participation community entire population posters, and main crossroads 4 for duration of been evaluated about the in the community brochures weeks before MDA over the years by MDA dates (except pregnant MDA • Posters used the NTD Secretariat and locations women and • Posters used throughout and partners, and in the children under 2 during community mobilization and they have commune years old) sensitization during MDA requested feedback meetings starting from communities from 8 weeks during coverage before MDA surveys and • Brochures and supervision visits. flyers given to CDDs, FLHWs, and teachers for distribution to target audiences before MDA Treatment SAC and the Radio and TV • Radio and TV • Radio and TV Messages have been medications entire population spots spots aired spots: aired 4–6 evaluated over the are free and in the community starting from times per day years by the NTD safe; they one month Secretariat and come from the before MDA partners, and they best have requested laboratories feedback from overseas. communities during coverage surveys and supervision visits. If sometimes SAC and the Posters, • Posters, flyers, Posters hung in Messages have been you entire population flyers, and brochures schools and in evaluated over the experience in the community brochures distributed and community years by the NTD side effects, (except pregnant used 2 weeks– locations with Secretariat and this is a sign women and one month in traffic partners, and they that the children under 2 advance of MDA have requested MDA medicine is years old) feedback from participation working, and communities during we have drugs coverage surveys and to handle supervision visits. these side effects. If you SAC and the Radio and TV • Radio and TV • Radio and TV Messages have been experience entire population spots spots aired spots: aired 4–6 evaluated over the side effects, in the community starting from one times per day years by the NTD this is a sign (except pregnant month before Secretariat and that the women and MDA except in partners, and they medicine is children under 2 the west, where have requested working, and years old) spots are aired feedback from we have drugs three months in communities during to handle advance of MDA coverage surveys and these side supervision visits. effects.

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Has this Where/when will Key Target material/message Category IEC strategy they be Frequency messages population or approach been distributed? evaluated? Disease The drugs are SAC and the Posters, flyers • Posters • Posters hung in Messages have been prevention preventative entire population and, distributed to schools and in evaluated over the and curative in the community brochures FLHWs, teachers, community years by the NTD for NTDs; the (except pregnant and CDDs and locations with Secretariat and earlier you women and used 2 weeks– traffic partners, and they take the children under 2 one month in have requested medications, years old) advance of MDA feedback from the better. communities during coverage surveys and supervision visits. Disease The drugs are SAC and the Radio and TV • Radio and TV • Radio and TV Messages have been prevention preventative entire population spots spots aired spots: aired 4– evaluated over the and curative in the community starting from one 6 times per day years by the NTD for NTDs; the (except pregnant month before Secretariat and earlier you women and MDA, except in partners, and they take the children under 2 the west, where have requested medications, years old) and spots are aired • Community feedback from the better. community three months in meetings held communities during leaders advance of MDA prior to pre- coverage surveys and • Community MDA activities supervision visits. meetings Disease The drugs are SAC and the Community Megaphones Community Messages have been prevention preventative entire population public address distributed to locations with evaluated over the and curative in the community systems FLHWs, teachers heavy traffic years by the NTD for NTDs; the (except pregnant and CDDs and used Secretariat and earlier you women and 2 weeks–one month partners, and they take the children under 2 in advance of MDA have requested medications, years old) feedback from the better. communities during coverage surveys and supervision visits. Nomadic/ NTDs are Children, youth, 1. Community Group discussion At every Messages will be pastoral- caused by adults (both men leaders and mentoring and community evaluated by the NTD specific social transmissible and women) 2. Health coaching meeting, Secretariat and mobilization organisms, workers Reproductive and partners, and they strategy which can be 3. School Child Health (RCH) have requested prevented and teachers’ fora clinics, and in feedback from treated by schools communities. FY17 is modern the first year this medicines. updated strategy is Increase Community Media Schools, public At every being implemented. perception of leaders; parents/ (print and places, local radio community risk and guardians, electronic), stations meeting, RCH increased self- teachers clinic, and in efficacy to Policymakers school councilors’ prevent monthly meetings infections Health RCH clinic day workers Messages Community Media Schools, public At every targeting leaders; parents/ (print and places, local radio community cultural and guardians, electronic), stations meeting, RCH community teachers clinic, and in behavior or Policymakers schools

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Has this Where/when will Key Target material/message Category IEC strategy they be Frequency messages population or approach been distributed? evaluated? practices Traditional associated Health festivals with NTD workers Councilors’ transmission monthly meetings RCH clinic day Messages Parents of school Creation of Households and Variable targeting children Community peers cultural and Ambassadors community School pupils behavior or properly practices trained and associated equipped to with NTD speak to transmission peers, parents, etc. Water and Traditional Demonstration During traditional Scheduled sanitation leaders of correct barbeques/ according to improvements hygiene ceremonies discretion of the and practices practices, elders Fliers, posters, brochures

g) Training

Activity 1: Refresher training of trainers (TOT) : As part of the annual MDA training, ENVISION staff and the NTD Secretariat will facilitate MDA TOTs for district and regional NTD coordinators. In the current 19 regions and 135 districts where ENVISION will be implementing activities, each region will have a one- day refresher TOT. All region and district teams received a refresher training in FY17. Because the TZNTDCP is moving toward implementing more M&E activities in these regions, these refresher TOTs will emphasize M&E activities that will be conducted in the districts, and the role the district and regional NTD coordinators will play in managing them. Training will center on the requirements for a successful MDA, particularly training and supervision of lower level health care personnel and teachers, as well as MDA data review and reporting. In refresher trainings, MDA coverage will be a major focus; a key role for NTD coordinators is ensuring that lower level health care staff (i.e., regional/district NTD teams and FLHWs) and teachers are well-versed in MDA procedures through the cascade trainings. As in years past, there is a discussion of past MDA coverage, and participants are taught how to analyze multi- year treatment for their area. In addition, these TOTs will highlight ways to advocate for more NTD activities to be covered under CCHP funding and creative ways that regions and districts can use existing platforms for social mobilization and training. Activity 2: Accountants’ refresher training : To ensure that ENVISION funds are managed per USAID, RTI, and IMA requirements, ENVISION will conduct refresher finance training for a select number of district and regional accountants managing ENVISION funds. Furthermore, ENVISION accountants will provide onsite mentorship to all accountants as they visit these districts for supportive supervision. At the training, ENVISION will also provide accountants who are new to ENVISION a simple guidance manual that highlights key compliance issues. In addition, these trainings will highlight ways to advocate for

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more NTD activities to be covered under CCHP funding and creative ways that regions and districts can use existing platforms for social mobilization and training. Activity 3: Trachoma graders’ refresher trainings : ENVISION will also work with the TZNTDCP to organize and lead trachoma graders’ refresher training, facilitated by trainers who are already certified through Tropical Data training. This training will target district eye care coordinators who will carry out the impact and surveillance surveys. Because trachoma grading can be highly variable, it is critical to conduct refresher trainings that review techniques and processes for field graders to determine their concordance with more experienced graders. Following super-TOTs (training the trainers of trainers) on Tropical Data in 2016 and 2017, Tanzania now has five grader trainers and four recorder trainers. The trainers of trainers will share their new knowledge and skills during the refresher training, which will be conducted in Dodoma Region—30 graders and 30 recorders will be trained by 6 facilitators. Those who do not pass the grader training will be removed from potential field teams conducting grading and will be assigned alternative roles. Activity 4: Printing of training materials : Each financial year, to ensure proper coordination of training for teachers, FLHWs, and CDDs, the TZNTDCP conducts refresher training and new training for drug distributers and supervisors at different levels using the cascade strategy. In FY18, ENVISION will fund printing of training manuals for CDDs in 55 districts planned for community-based MDA and training manuals for FLHWs and teachers in 135 districts that will be conducting school-based MDA. The printing is budgeted at 20% to replace worn-out or lost manuals. Activity 5: Training activities : ENVISION will also fund the training of district NTD teams. Trainings will be conducted in a cascade fashion, with regional and district NTD coordinators facilitating training for the regional and district NTD teams, which in turn train FLHWs, teachers, and CDDs. FLHWs and CDDs will receive a one-day training before community-based MDA in October 2017 and August 2018. Teachers will receive a one-day refresher training from the district NTD teams prior to the school-based MDA rounds. Teachers will then distribute medicines during the MDA under the supervision of FLHWs and district NTD teams. Teachers In the current 19 regions and 135 districts, the teachers will be the key to strong school-based MDA performance. Teachers will receive a one-day refresher training. The training will be conducted by district NTD teams. Under the previous MDA model, teachers received far less supportive supervision, and refresher trainings were not held each year prior to MDA. FLHWs and CDDs In districts where community-based MDA campaigns for LF and/or trachoma are planned, FLHWs and CDDs will each receive one day of training. Training will focus on key MDA steps, including NTD overview, drugs used for MDA, eligible populations for each drug package, dosing, how to introduce the program, and use of household registers.

h) Drug and Commodity Supply Management and Procurement

Activities for FY18 Activity 1: Drug transportation from the national warehouse to regions: All medicines, after clearance from the port, are stored at MSD and transported to the districts by MSD before MDA activities. However, there can be delays with MSD transport to districts due to late drug arrival in country, changes in MOHCDGEC/TZNTDCP MDA planning, or general timing issues with MSD. Transportation of NTD drugs

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through MSD is usually carried out in coordination with transport of other, non-NTD medicines, and MSD will often wait until the truck is full before shipping. Furthermore, MSD sometimes closes for consecutive weeks to conduct inventory. Both of these issues have led to delays in the transportation and delivery of NTD drugs for MDA. In FY18, if there are delays in transport before MDA activities, ENVISION will provide funds for drug transportation by hiring private transporters to move the drugs to the regions. This will only need to be considered if there are delays in receiving the drugs from outside of Tanzania, or if customs clearance is slow and the drugs are only released two weeks or closer to the MDA campaigns. Activity 2: Transport from region to distribution points (districts) : The transport of medicines from the district to the community is normally conducted by the DMOs using district vehicles. Activity 3: Reverse supply chain : Experience from previous years has shown that after completing MDA in most districts, unused medicines are left in health facilities, sometimes in poor storage conditions. Some of these medicines have long expiry dates, warranting proper storage so that they can be used in future MDA rounds. For example, between 2013 and 2016, ENVISION supported the TZNTDCP to collect and transfer more than 4 million PZQ tabs, more than 1 million ZTH tabs, and more than 25,000 bottles of ZTH powder for oral suspension to other districts. The major challenge has been transportation for district pharmacists to travel to different health facilities and gather all the unused drugs for proper storage at the district health pharmacy. Based on past experience, in FY18 ENVISION will be supporting 15%–18% of the districts for reverse supply chain activities. Activity 4: Pharmacists supervisory visits : In July FY15, the TZNTDCP carried out a regional pharmaceutical supervisors’ training led by the Drug Logistics Officer. Three selected pharmacists from 13 regions were trained on NTD drugs and inventory management; quantification and reporting, including how to complete summary forms at each level (household, register, health center, district, and region); as well as on peer mentorship skills and techniques. Once trained, the pharmacists in each region will form a mentors/supervisors team under the leadership of the Drug Logistics Officer. The regional teams will also select high-performing district-level pharmacists to join the regional team. In FY18, these teams will continue to provide mentorship and supervision in their respective regions. The supervision will be conducted in regions and districts where there are issues.

i) Supervision for MDA

Activities for FY18 Activity 1: Supportive supervision of pre-MDA activities : ENVISION will provide funds for supportive supervision of all MDA-related activities at all levels, from national, regional, and district to health facility and school levels. With ENVISION funding, the TZNTDCP staff will conduct supportive supervision during training and pre-MDA activities, such as community mobilization. TZNTDCP and IMA staff will travel to districts during the training and community mobilization activities in advance of the community-based and school-based MDA campaigns. To maximize staff resources, supportive supervision is carried out in districts with new NTD coordinators, districts where the NTD coordinator has shown weakness in the past, districts where there are challenges from the district leadership, and districts with low coverage in the previous MDA. In these identified districts, TZNTDCP and IMA staff will interact with district staff and FLHWs, providing oversight for activities. District staff will also supervise training and community mobilization activities carried out at the health facility, school, and community levels. Activity 2: Supportive supervision for school- and community-based drug distribution : ENVISION will also provide funding for NTD Secretariat members and ENVISION staff to carry out supportive

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supervision for school- and community-based drug distribution before and during the community- and school-based MDA campaigns. TZNTDCP staff, along with IMA staff, will supervise all activities at regional and district levels and will carry out a spot supervision of the activities implemented at the health facility, school, and community levels. With funding from IMA, district NTD teams will in turn mentor FLHWs on supportive supervision. FLHWs will be trained to provide supportive supervision to CDDs and teachers. Regional teams will provide spot supportive supervision to activities at district, school, health facility, and community levels. Furthermore, there will be regular meetings between ENVISION and NTD Secretariat staff to review each MDA activity (e.g., training, social mobilization, etc.) shortly after that activity’s implementation and explore and mitigate any possible obstacles to the next activities. In addition, funding will be provided for regions and districts to provide supportive supervision during advocacy and community mobilization activities, as well as during drug distribution activities.

j) M&E

FY18 Activities Activity 1. LF pre-TAS : In FY18, the program plans to conduct pre-TAS in 11 districts. The surveys will consist of two villages that will be assessed for CFA among at-risk population ages 5 years and older using FTS. This pre-TAS will enable the program to request RPRG approval for stop-MDA TASs in these districts. The program also coordinates the pre-TAS with STH and SCH assessments. Since these districts will have completed five rounds or more of MDA, the STH/SCH surveys results will inform the SCH/STH treatment strategy. Activity 2. TAS1 : In FY18, it is estimated that 13 districts will be eligible for conducting stop-MDA TAS1. Surveys are planned in 13 districts. Ten districts will have completed five effective rounds of MDA and passed the pre-TAS. Three districts failed a TAS1 in 2015—Chemba DC, Kondoa TC, and Kondoa DC. In these districts, two rounds of MDA have been implemented in FY16 and FY17 and following a re-pre- TAS, eligibility for TAS1 will be re-determined. Activity 3. TAS2: In FY18, the TZNTDCP anticipates that 59 districts are eligible for TAS2, which will be divided into 45 EUs. LF TAS2 is planned in all 59 districts that are in the post-treatment surveillance phase. These districts passed TAS1 in 2015, and from 2016 have been in a post-treatment surveillance phase. They are located in Ruvuma, Mbeya, Iringa, Njombe, Rukwa, Katavi, Ruvuma, Dodoma, and Singida regions. The TAS2 results will be important for the programmatic decision to continue with surveillance; if any of the districts fail to meet the critical cut-off point, then the program will need to restart MDA because transmission could be ongoing. Activity 4. OV monitoring surveys in 17 districts : OV monitoring is planned in 17 districts that have no recent endemicity data and that have completed more than 13 rounds of treatments. These districts include 6 in Ruvuma—Mbinga DC, Nyasa DC, Madaba DC, Songea DC, Songea MC, Namtumbo DC; 2 in Njombe—Ludewa DC and Njombe DC; 1 in Iringa—Mufindi DC; and additional 8 in Morogoro region. The program intends to leverage the LF TAS2 surveys and integrate the OV monitoring in at least two frontline villages in these districts. Results will be reviewed by the TOEAC for review and a recommendation on the full stop-MDA epidemiological assessment. Activity 5. TIS : In FY18, impact surveys are planned for 10 districts. Per Tropical Data guidance, and the need to split districts into 2 EUs if the population is too large, the final number of EUs is estimated to be 12. These include a first TIS in the following: Longido DC, Monduli DC, Ngorongoro DC, Chunya DC, Songwe DC, Liwale DC, Bahi DC, Chemba DC, Ngara DC, and Mpwapwa DC. Due to the large population size of Ngara DC, the district will be split into two EUs and TIS will be carried out in each EU. This is in

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line with Tropical Data recommendations and guidelines about districts with population >250,000. The budget reflects ten districts for TIS, to accommodate Ngara’s two EUs. It is worth noting that Longido DC, Monduli DC, and Ngorongoro DC were mapped in 2004 and had initial prevalence of >50% TF, indicating a need for five consecutive rounds of MDA with effective coverage prior to a TIS. These districts were treated non-consecutively for two to three years prior to FY15, when ENVISION began funding them. Recent surveys in districts with similar ecological and epidemiological characteristics have shown a significant decrease in TF prevalence. As a result, after three rounds of coverage, the MOHCDGEC has determined that TIS is warranted to reassess progress toward the 2020 goals. Results of the TIS will also inform the DFID and QEDJT partners about the status of the TT backlog in these districts, so they can plan for trichiasis surgeries. Activity 6. TSS : In FY18, ENVISION will support 20 districts (20 EUs) for TSS. Due to the population size of Igunga DC, Sumbawanga DC, Morogoro DC, and Mvomero DC, all of which are >250,000, each district will be split into two EUs, in line with Tropical Data recommendations and guidelines. The budget reflects 23 districts for TSS to reflect the number of EUs.

Table 7: Planned DSAs for FY18, by disease

No. of districts No. of EUs No. of endemic Type of Diagnostic method Disease planned for planned for districts assessment (Indicator: Mf, FTS, etc) DSA DSA 11 11 Pre-TAS FTS LF 28 13 13 TAS1 FTS 59 45 TAS2 FTS STH 185 11 11 SS/SC Kato Katz SCH 185 11 11 SS/SC Urine filtration 10 12 TIS Clinical Grading Trachoma 71 20 23 TSS Clinical Grading OV OV 28 17 17 DBS & ELISA Monitoring

k) Supervision for M&E and DSAs

Activities for FY18 Activity 1: Supervision for LF/STH/SCH sentinel and spot check sites : ENVISION will fund supervision costs for LF/SCH/STH sentinel and spot check sites in 11 districts. Activity 2: Supervision for TAS 1 : In FY18, ENVISION will provide funding for supervision during TAS 1 in 13 districts. Activity 3: Supervision for TAS 2 : ENVISION will fund supervision costs for TAS 2 for 59 districts. Activity 4: Supervision for Trachoma Surveys : In FY18 ENVISION will fund supervision costs for 10 TIS and 23 TSS. Please see above under the M&E section for more information. Activity 5: Supervision for OV Monitoring Surveys : ENVISION will support supervision of OV monitoring surveys in 17 planned districts.

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l) Dossier Development

Activities for FY18 Activity 1: Trachoma Dossier Development Meeting : In FY18, ENVISION will fund one trachoma 3-day meeting. In FY17, the TZNTDCP updated the National Trachoma Action Plan with technical support from the Trachoma Technical Working Group and other stakeholders. A draft dossier was produced. However, data from F&E and MDA implementing partners need to be gathered and entered into the trachoma dossier template and the narrative needs to be written to finalize the dossier. In FY18, ENVISION will continue to provide technical support through the Regional Technical Advisor to ensure the F&E data are collected. The 3-day trachoma dossier development meeting will allow for review of the progress reached,data collection and entry, and finalization of the narrative for sharing with key stakeholders for review and comments. Activity 2: LF Dossier Development Meeting : For the case of LF dossier development, in FY17 the LF technical working group developed an action plan to begin the dossier process for Tanzania. In FY18, ENVISION will fund one LF 3-day meeting. ENVISION will provide technical guidance for implementation of the action plan especially the data collection systems, understanding of all the templates and the narrative outline. The three-day meeting for LF dossier development will allow for review of the available data, initiation of data entry and drafting of the narrative section. These efforts will be followed by continuous updating of the data entry dossier template.

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APPENDIX 1: Work Plan Timeline

FY18 Activities

Management Support Ongoing Staffing and Country Office Support Project Assistance Strategic Planning Region/District Review and Planning Meetings (IVM + ALB /ZTH MDA and 50 districts) Region/District Review and Planning Meetings (ALB + PZQ/ ALB MDA in 83 districts) Oncho Expert Committee Meeting Technical Working Group Meetings Annual Joint Planning Meeting NTD Secretariat Administrative Support Communications Support Building Advocacy for Sustainable National NTD Program NTD Master Plan Launch and NTD Learning Day (Dodoma) NGDO - NTD Coalition Advocacy for Region/District Resource Mobilization Mapping N/A MDA Coverage MDA Supplies (dosing poles and measuring papers) Production of Registers and Summary Data Forms Region and District Strategic Planning Region and District Social Mobilization Training of Trainers Training of FLHWs Training of Teachers Drug Distribution ALB+PZQ / ALB (135 districts) MDA Registration (census for 50 districts and for 40 districts) Drug Distribution of IVM+ALB (41 districts) Drug Distribution of IVM+ALB (33 districts) Drug Distribution of ZTH (9 districts) Drug Distribution of ZTH (7 districts) MDA Supportive Supervision and M&E Data Collection Social Mobilization to Enable NTD Program Activities Printing/Production Integrated IEC/BCC Materials (Replacement) Airing Radio and Television Spots Cultural appropriate messages/MDA adverts/jingles

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FY18 Activities

Delivery of IEC Materials Training Finance and Accountants Training Training of Trainers for Region NTD Teams Training of District NTD Teams Training of FLHWs Training of CDDS Training of Teachers Drug Supply Management and Procurement Drug Transportation from MSD Dar to Regions Drug Transportation from Regions to Distribution Points Reverse Logistics Supervision for MDA Supportive Supervision for IVM + ALB / ZTH (50 districts) Supportive Supervision for ALB + PZQ / ALB (135 districts) Supportive Supervision for IVM + ALB / ZTH (40 districts) Monitoring and Evaluations Pre-TAS Sentinel/ Spot Check Assessments for LF/STH/SCH (11 districts – including 3 re-pre- TAS) TAS 1 in 13 districts TAS 2 in 59 districts TIS in 10 districts TSS in 20 districts Oncho Monitoring in 17 districts Supervision for Monitoring and Evaluation Supportive Supervision for Pre-TAS Sentinel/ Spot Check Assessments for LF/STH/SCH Supportive Supervision TAS 1 Supportive Supervision TAS 2 in 59 districts Supportive Supervision TIS in 10 districts Supportive Supervision TSS in 20 districts Oncho Monitoring in 17 districts Dossier Development LF and Trachoma Dossier Development meeting STTA TRA Dossier Development Consultant (local) LF Dossier Development Consultant (local)

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APPENDIX 2. Table of USAID-supported Regions and Districts for MDA in FY18 -MDA

Regions District MDA- OCT 2017 MDA- August 2018

LF OV SCH STH TRA LF OV TRA

Totals 135 22 25 65 135 11 13 28 7

1 Arusha Arusha City Council X 2 Arusha Arusha District Council X 3 Arusha Karatu District Council X 4 Arusha Longido District Council X X 5 Arusha Meru District Council X 6 Arusha Monduli District Council X X 7 Arusha Ngorongoro District Council X X 8 Dodoma Bahi District Council X X X 9 Dodoma Chamwino District Council X 10 Dodoma Chemba District Council X X X X 11 Dodoma Dodoma Municipal Council X 12 Dodoma Kondoa District Council X X 13 Dodoma Kondoa Town Council X X 14 Dodoma Kongwa District Council X 15 Dodoma Mpwapwa District Council X X 16 Geita Council X 17 Geita Council X 18 Geita Council X 19 Geita Geita Town Council X 20 Geita Council X 21 Geita Nyang'hwale District Council X 22 Iringa Iringa District Council X X 23 Iringa Iringa Municipal Council X X 24 Iringa Council X X 25 Iringa Mafinga Town Council X X 26 Iringa Mufindi District Council X X X X 27 Kagera Ngara District Council X X X 28 Katavi Mlele District Council X 29 Katavi Council X 30 Katavi Mpanda Municipal Council X 31 Katavi Mpimbwe District Council X 32 Katavi Nsimbo District Council X 33 Kilimanjaro Hai District Council X 34 Kilimanjaro Moshi District Council X 35 Kilimanjaro Moshi Municipal Council X 36 Kilimanjaro Mwanga District Council X 37 Kilimanjaro Rombo District Council X 38 Kilimanjaro Same District Council X 39 Kilimanjaro Siha District Council X 40 Lindi Council X X X

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Regions District MDA- OCT 2017 MDA- August 2018

LF OV SCH STH TRA LF OV TRA 41 Lindi Council X X X 42 Lindi Lindi Municipal Council X X X 43 Lindi Liwale District Council X X 44 Lindi Council X X X X 45 Lindi Council X X X 46 Manyara Babati District Council X 47 Manyara Babati Town Council X 48 Manyara Hanang District Council X 49 Manyara Kiteto District Council X X X 50 Manyara Mbulu District Council X 51 Manyara Mbulu Town Council X 52 Manyara Simanjiro District Council X X X 53 Mbeya Busokelo District Council X X X X 54 Mbeya Council X X X 55 Mbeya Council X X X X 56 Mbeya Council X X 57 Mbeya Mbeya City Council X X 58 Mbeya Council X X 59 Mbeya Council X X X X 60 Morogoro Council X X X X X X 61 Morogoro Ifakara Town Council X X X X X X 62 Morogoro Council X X X X 63 Morogoro Council X X X X 64 Morogoro Council X X X X 65 Morogoro Morogoro District Council X X X X X X 66 Morogoro Morogoro Municipal Council X X X X 67 Morogoro Council X X X X X X 68 Morogoro Council X X X X 69 Mtwara Council X X X 70 Mtwara Masasi Town Council X X 71 Mtwara Council X X Mtwara-Mikindani Municipal 72 Mtwara X X Council 73 Mtwara Nanyamba District Council X X 74 Mtwara Council X X 75 Mtwara Council X 76 Mtwara Newala Town Council X 77 Mtwara Council X 78 Njombe Ludewa District Council X X X X 79 Njombe Makambako Town Council X X 80 Njombe Makete District Council X X 81 Njombe Njombe District Council X X X X 82 Njombe Njombe Town Council X X 83 Njombe Wanging'ombe District Council X X 84 Pwani Bagamoyo District Council X 85 Pwani Chalinze District Council X 86 Pwani Kibaha District Council X X X

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Regions District MDA- OCT 2017 MDA- August 2018

LF OV SCH STH TRA LF OV TRA 87 Pwani Kibaha Town Council X X 88 Pwani Kibiti District Council X 89 Pwani Kisarawe District Council X 90 Pwani Mafia District Council X X X 91 Pwani Mkuranga District Council X 92 Pwani Rufiji District Council X 93 Rukwa Kalambo District Council X X 94 Rukwa Nkasi District Council X X 95 Rukwa Council X 96 Rukwa Sumbawanga Municipal Council X 97 Ruvuma Madaba District Council X X X X 98 Ruvuma Council X X X X 99 Ruvuma Mbinga Town Council X X X X 100 Ruvuma Namtumbo District Council X X X X 101 Ruvuma Nyasa District Council X X X X 102 Ruvuma Songea District Council X X X X 103 Ruvuma Songea Municipal Council X X X X 104 Ruvuma Council X X X X 105 Singida Council X 106 Singida Council X 107 Singida Itigi District Council X 108 Singida District Council X 109 Singida Council X 110 Singida Singida District Council X 111 Singida Singida Municipal Council X 112 Songwe Ileje District Council X X X X 113 Songwe Council X X 114 Songwe Momba District Council X X 115 Songwe Songwe District Council X X X 116 Songwe Tunduma Town Council X X 117 Tabora Council X 118 Tabora Council X X 119 Tabora Council X 120 Tabora Nzega Town Council X 121 Tabora Council X 122 Tabora Tabora Municipal Council X X 123 Tabora Council X X 124 Tabora Council X X 125 Tanga Bumbuli District Council X X X 126 Tanga Council X X 127 Tanga Handeni Town Council X X 128 Tanga Council X X 129 Tanga Council X X X X X 130 Tanga Korogwe Town Council X X X 131 Tanga Council X X X 132 Tanga Mkinga District Council X X X X X X

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Regions District MDA- OCT 2017 MDA- August 2018

LF OV SCH STH TRA LF OV TRA 133 Tanga Council X X X 134 Tanga Council X X X X 135 Tanga Tanga City Council X X X X

Total Count 135 22 25 65 135 11 13 28 7

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APPENDIX 3. Table of USAID-supported Regions and Districts for DSAs in FY18

DSA Regions District LF- LF- LF- SCH- STH- TIS TSS OV SSA TAS1 TAS2 SSA SSA Monitoring

Totals 95 11 13 59 11 11 10 20 17

1 Arusha Longido District Council X 2 Arusha Monduli District Council X 3 Arusha Ngorongoro District Council X 4 Dodoma Bahi District Council X X 5 Dodoma Chamwino District Council X 6 Dodoma Chemba District Council X X X X X 7 Dodoma Dodoma Municipal Council X 8 Dodoma Kondoa District Council X X X X 9 Dodoma Kondoa Town Council X X X X 10 Dodoma Kongwa District Council X 11 Dodoma Mpwapwa District Council X X 12 Iringa Iringa District Council X 13 Iringa Iringa Municipal Council X 14 Iringa Kilolo District Council X 15 Iringa Mafinga Town Council X 16 Iringa Mufindi District Council X X 17 Kagera Ngara District Council X 18 Katavi Mlele District Council X 19 Katavi Mpanda District Council X 20 Katavi Mpanda Municipal Council X 21 Katavi Mpimbwe District Council X 22 Katavi Nsimbo District Council X 23 Kilimanjaro Rombo District Council X 24 Lindi Kilwa District Council X X X X 25 Lindi Lindi District Council X X X X 26 Lindi Lindi Municipal Council X 27 Lindi Liwale District Council X X 28 Lindi Nachingwea District Council X 29 Mbeya Busokelo District Council X 30 Mbeya Chunya District Council X X 31 Mbeya Kyela District Council X 32 Mbeya Mbarali District Council X 33 Mbeya Mbeya City Council X 34 Mbeya Mbeya District Council X 35 Mbeya Rungwe District Council X 36 Morogoro Gairo District Council X 37 Morogoro Ifakara Town Council X 38 Morogoro Kilombero District Council X 39 Morogoro Kilosa District Council X

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DSA Regions District LF- LF- LF- SCH- STH- TIS TSS OV SSA TAS1 TAS2 SSA SSA Monitoring

40 Morogoro Malinyi District Council X 41 Morogoro Morogoro District Council X X 42 Morogoro Morogoro Municipal Council X 43 Morogoro Mvomero District Council X X 44 Mtwara Masasi District Council X X X X X 45 Mtwara Masasi Town Council X 46 Mtwara Mtwara District Council X Mtwara-Mikindani Municipal 47 Mtwara X x Council X X 48 Mtwara Nanyamba District Council X 49 Mtwara Nanyumbu District Council X 50 Mtwara Newala District Council X 51 Mtwara Newala Town Council X 52 Mtwara Tandahimba District Council X 53 Njombe Ludewa District Council X X 54 Njombe Makambako Town Council X 55 Njombe Makete District Council X 56 Njombe Njombe District Council X X 57 Njombe Njombe Town Council X 58 Njombe Wanging'ombe District Council X 59 Pwani Bagamoyo District Council X 60 Pwani Chalinze District Council X 61 Pwani Kibaha District Council X X X X 62 Pwani Kibaha Town Council X 63 Pwani Kibiti District Council X X 64 Pwani Kisarawe District Council X X 65 Pwani Mafia District Council X X X X 66 Pwani Mkuranga District Council X 67 Pwani Rufiji District Council X X 68 Rukwa Kalambo District Council X 69 Rukwa Nkasi District Council X 70 Rukwa Sumbawanga District Council X X 71 Rukwa Sumbawanga Municipal Council X 72 Ruvuma Madaba District Council X X 73 Ruvuma Mbinga District Council X X 74 Ruvuma Mbinga Town Council X 75 Ruvuma Namtumbo District Council X X 76 Ruvuma Nyasa District Council X X 77 Ruvuma Songea District Council X 78 Ruvuma Songea Municipal Council X X 79 Ruvuma Tunduru District Council X 80 Singida Ikungi District Council X 81 Singida Iramba District Council X 82 Singida Itigi District Council X

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DSA Regions District LF- LF- LF- SCH- STH- TIS TSS OV SSA TAS1 TAS2 SSA SSA Monitoring

83 Singida Council X 84 Singida Mkalama District Council X 85 Singida Singida District Council X 86 Singida Singida Municipal Council X X 87 Songwe Ileje District Council X 88 Songwe Mbozi District Council X 89 Songwe Momba District Council X 90 Songwe Songwe District Council X X 91 Songwe Tunduma Town Council X 92 Tabora Igunga District Council X 93 Tanga Korogwe District Council X X X X 94 Tanga Korogwe Town Council X X X X 95 Tanga Tanga City Council X Total Count 95 11 13 59 11 11 10 20 17

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