Zika Response in Ecuador and Peru

ZIKA RESPONSE IN ECUADOR AND PERU

Implemented by:

CARE

Cooperative Agreement Number AID-OAA-A-16-00078

Work Plan II Phase, years 2 & 3

Start Date and End Date:

October 1, 2017 to September 30, 2019

TABLE OF CONTENTS

1. TECHNICAL NARRATIVE ...... 3

1.1. Introduction ...... 3

1.2. Project Overview ...... 3

1.3. Project Outcomes, Strategies, Activities and Work plan, Phase I, year 1 ...... 4

1.4. Progress in the development and consolidation of a binational project strategy to strengthen the prevention and control of Zika actions ...... 9

1.5. Relevant context changes ...... 11

1.5.1. Political Context ...... 11

1.5.2. Adverse hydroclimatic events ...... 12

1.6. Key partnerships and alliances ...... 18

1.7. Project Outcomes, Strategies, Activities and Work Plan for Phase II, years 2 and 3 ...... 19

1.8. Zika Work plan - Oct 2017-Sep 2019 ...... 22

1.9. Cost Share ...... 28

2. MEASUREMENT, MONITORING, EVALUATION AND LEARNING PLAN ...... 29

2.1. Data collection ...... 29

2.2. Monitoring and Evaluation Plans ...... 30

2.3. Revised logic model ...... 30

2.4. Indicator Tables ...... 31

3. ENVIRONMENTAL MANAGEMENT & MITIGATION PLAN (EMMP) ...... 38

3.1. Environmental Mitigation and Monitoring Y1 Report: ...... 38

Following the first year the report is presented...... 38

3.2. Years 2 & 3 Environmental Mitigation and Monitoring Plan ...... 43

4. ANNEXES: ...... 48

1. TECHNICAL NARRATIVE

1.1. Introduction

This document serves as the second Operational Plan (OP) of the Zika Response Project in Ecuador and Peru, Cooperative Agreement Number: AID-OAA-A-16-00078. The scope of this OP is from October 1, 2017 to September 30, 2019.

The OP was designed by the teams of CARE Ecuador and CARE Peru considering the guidelines presented by USAID during the conference call held on June 17, 2017. It is organized in the following way: 1. Technical Narrative, includes (1.1) Introduction, (1.2) Project overview (1.3) relevant context changes, (1.4) key partnerships and alliances, (1.5) project outcomes, strategies and activities for Phase II, (1.6) the Work plan; (1.5) management structure; (1.6) cost share and leverage; 2. Measurement, Monitoring, Evaluation and Learning Plan including (2.1) revised logic model and (2.2) M&E plan with data collection and indicator table as well as reporting schedule; and 3. Environmental Management and Mitigation Plan (EMMP).

1.2. Project Overview

Priority areas for implementation will continue to be areas on the tropical coast of Ecuador and Peru where the Aedes aegypti mosquito is widespread, and were affected by an earthquake in 2016 (Provinces of Manabí and Esmeraldas in Ecuador) and by intense rains resulting from the 2017 Coastal Niño Event (Southern Ecuador and Northern Peru), hence undergoing an increased risk for Zika.

CARE will continue working in the achievement of the two key objectives identified at the proposal phase:

1. To increase community, local and national capacities to deliver an efficient and timely response to the Zika virus outbreak and other vector-borne diseases through Disaster Risk Reduction (DRR) and human rights approaches. Our approach relies on CARE’s, sustainable community health systems, and community empowerment. The project will utilize community health agents to strengthen and enable the direct involvement of communities, to prevent the spread of the Zika virus. 2. To enhance regional and national efforts to help decrease the rate of Zika transmission by sharing findings and impact results to influence bi-national policy making. Using a deep and rigorous evidence-based approach of best practices and lessons learned in community mobilization and participation, we will prioritize gender sensitive implementation strategies in diverse social and cultural contexts, increase coordination and planning capacities, refine an accurate monitoring system and develop a communication and dissemination strategy.

Figure 1 Depiction of the Zika Response Project in Peru and Ecuador

1.3. Project Outcomes, Strategies, Activities and Work plan, Phase I, year 1

1.3.1. Best practices in community participation and mobilization on prevention, promotion and practices regarding Zika identified.

Rigorous evidence-based analysis (EBA) and Knowledge, Attitudes and Practices (KAP) studies and documentation of best practices and lessons learned in community mobilization, education, communication and participation in the implementation of community health strategies.

Emphasis was given to the production of quantitative and qualitative data to better understand “soft” strategies related to community mobilization, participation and Community Based Surveillance and vector control. Gender and cultural norms approaches as well as urban/rural scenarios cross cut the selection of identified areas for EBA and KAP studies. EBA information gathering conducted by high level research teams with the participation of MoH, CARE, UNICEF, the academia and other key partners under the scope of national plans and the political leadership of the MoH. Academy will provide support on technical issues and data gathering procedures to complete the EBA and KAP analysis.

Progress Year 1: 4

Evidence based analysis (EBA) on vector control strategies and activities for vector control focused on community members (at the household and municipal levels), their roles, the follow-up and surveillance systems on key prevention practices served to assess the efficiency of vector control practices by local health services, local governments and community agents regarding key activities for early action; while the EBA on community surveillance focused on the role and performance of community health agents, primary level health care providers and other agents accountable for community based surveillance. Reiterative EBA studies to validate change and learning will continue in Years 2 and 3.

 Ecuador carried out studies 1) On best practices of ZIKA management and control of disease transmission; 2) On best practices in ZIKA community surveillance systems and vector control and proposal adapted to the context of the disease in Ecuador. The identification of best practices is done through documentary review (national or other country experiences), and field visits through the KAP or EBA studies. The experience and the results of its implementation are documented, obtaining a group of proposals that have been shown to contribute to reduce the risk of transmission of vector-borne diseases with community participation.  Peru established an Alliance with organizations from the Civil Society, the Ministry of Health and PAHO, to convene the identification and presentation of best practices for which it carried out the competition called: "Best Practices Prize in Prevention and Control of Zika." In order to align the documentation of the applications with the project objectives regarding evidence- based analyses (EBA) of community surveillance and vector control systems, the following categories were established:

o Citizen and Community Participation in Vector Control. o Cooperation between Public Agencies in Surveillance and Control.

This action identified 23 good practices, the 15 most cost-effective and replicable were prioritized by the Jury for its dissemination. (Annex 4.2).

National baseline knowledge, attitudes and practices (KAP) studies to identify individual and collective knowledge, attitudes and practices, regarding dengue and chikungunya prevention campaigns, perception of Zika risks and recognition of Zika signs and symptoms. This qualitative research included information on measures adopted at household level, knowledge and practices related to family health care. Results from these studies will be used to influence the Zika campaign to have more targeted messages, segmented by audience and to focus efforts on the greatest gaps in knowledge, attitudes and practices as it pertains to Zika prevention and risk of congenital Zika syndrome. Findings will be shared with relevant stakeholders.

 Ecuador carried out a study on Individual and Collective Knowledge, Attitudes and Practices on the prevention and control of Zika, through surveys and focus groups of the beneficiary

groups prioritized in the project, it also includes the development of an adapted communication strategy: Social and culturally adapted for work in schools.  Peru developed a theoretical model for the prevention of the Zika virus based on a Communicational Assessment, an ethnographical study carried out in two intervention regions: Piura and Chiclayo, using the methodology of Design Thinking. The household survey conducted in Chiclayo helped gather information on project indicators.  The results of EBA and KAP evaluations were reviewed by C4D specialists from both countries for the development of binational communication guidelines.

1.3.2. Immediate testing of best practices and lessons learned from EBA and KAP on Zika prevention in priority risk areas.

Based on the findings of EBA and KAP studies, effective vector control strategies, communication messages and community surveillance activities were identified and validated in priority risk areas. These were implemented and adapted to target audiences (family level and local authorities / leaders)

Progress Year 1:

Ecuador:

 Based on the results of the EBA and KAP studies, in Ecuador, technical guides for surveillance and community control are being developed for work at municipal, community and household level. In addition, the technical standards of PAHO/WHO, CDC, and MoH have been considered. These documents will be validated at the local level through technical meetings with municipal delegates and other project authorities and partners.  Universities in the provinces of Manabí and El Oro have been contacted to link undergraduate students of the health/communication/social careers to support actions at the targeted territories for better vector control, provide information to the population, detection of probable/suspicious cases at the household level and generation of knowledge and development of joint advocacy actions for the prevention of Zika.  Community mingas (collective activities) have been held in 4 of 10 cantons selected in the project, to communicate to the community, municipality and the health ministry to raise awareness, provide information, training and other articulated work at the community level to improve the environment and vector control, including the final disposal of trash.

Peru:

 Six protocols Aedes Aegypti control and Zika prevention were developed after successful tests in the north of the country (Sechura province, Piura region). Technical validation of these protocols was carried out with the participation of MINSA, MINEDU, Municipalities and USAID staff. (Annex 4.3)

 Training of health and education personnel in intervention areas in the new protocols.  Validation of key messages to promote prevention of Zika in women of childbearing age and / or pregnant women.  Validation of key messages to promote the involvement of youth of both sexes as community health agents.  Collection of information on health facilities with clinical guidelines and guidance services for the control and prevention of Zika (WHO).

1.3.3. MoH monitoring system includes a friendly feedback system for local governments and community use to enable a continuous gathering and analysis of best practices at community level.

Development of a friendly feedback information system for health facilities, local governments and communities for the continuous analysis of relevant information and good practices used by local communities

Progress Year 1:

Ecuador:

 The Ministry of Public Health, has centralized the epidemiological surveillance system. There are no mechanisms of surveillance between MoH and the municipalities. Therefore, it is proposed to develop a Community surveillance system and early warning for Zika prevention, to identify and respond efficiently to alerts, especially concerning community roles in prevention and follow-up of risks at household and neighborhood levels. The local health system will receive the data collected through community surveillance actions. In addition, the information will be shared with the community to enhance their involvement.  For this end, information and work meetings have been held with: the Subsecretaries of Public Health Surveillance, the National Directorate of Strategies for Promotion and Control, the Directorate of Control of Metaxenic Diseases, the Subsecretariat for Health Promotion & Equality, and with the Directorate of International Relations.  In addition, an association with PAHO has been sought to promote joint and articulated work to exchange information, review experiences in other countries and identify joint actions. This alliance aims to strengthen the prevention of Zika and community surveillance systems. This is a strategic alliance and this does not include specific Budget commitment.  Training activities have been conducted for workers in municipalities and organized communities on the importance of coordinated work for the prevention and control of Zika at the community level.

Peru:

 The process of building the community surveillance system (vector control, epidemiological report and case report) is under construction. (Annex 4.4)  The CBSS (Community Based Surveillance System) pilot will be validated in Tumbes. It will come into use in the Phase II of the Project  Training events have been held for health personnel to raise awareness of the impact of Zika with an emphasis on the need to implement community-based strategies for vector control.  Febrile cases and/or patients with symptoms / signs of metaxenic diseases have been identified with the promoters. Adequate public health practices, such as correct water storage, elimination of breeding /hatching sites, among households with children under 3 years of age, have been strengthened with promoters. This is through the use of the community surveillance system, still under construction, for reference and counter- referral, with the participation of community health agents (ACS)  A guideline was developed and validated for the design and adaptation of information management and an early warning system for community health agents.

1.3.4. Communication strategy with unified key messages (segmented by audience and through gender and diversity lens) implemented by all parties and stakeholders

Ensure that key gaps learned from KAP studies are incorporated and adapted into communication strategy through unified key messages that are segmented by audience, not gender biased and focused on key behaviors and practices for Zika prevention.

Progress Year 1:

 In Ecuador, the communication strategy is being developed based on the KAP and EBA studies.  Inter-institutional agreements and support have been established with UNICEF, PAHO and MSP to generate contributions to the KAP studies and inputs for the design of the communication strategy with the approaches: C4D, CCS & C, DRR communication and community participation.  In Peru based on EBA and KAP studies including ethnographic studies, the communication strategy and the material have been constructed according to the audiences, with the participation of 915 people from 4 regions and 11 districts including MINSA, MINEDU, municipalities and community personnel. In August a launch event was held in Piura with the participation of the regions where the project is being developed.  With the findings and results of the KAP and EBA studies, the binational strategic communication meeting with Zika stakeholders was held in Tumbes in August to analyze the results in the two countries and define the guidelines for the development of a binational communication strategy for Prevention and Control of ZIKA.

1.3.5. Scaling up of sustainable policies, strategies, and protocols from the local level to national and binational levels for policy making.

Implement planning at the local level to the national and binational levels for advocacy in Zika prevention and vector control.

Progress Year 1:

 Design an advocacy work plan with identified regional and national government level stake holders.  Provide technical support to better enhance coordination platforms and mechanisms (intersectoral) at the subnational government levels.  Regional learning and information sharing event (to ensure accountability).

Ecuador:  Cooperation agreements have been signed to work on Zika prevention and control and other vector-borne diseases, with all the Municipalities, according to the competencies assigned to them by the National Constitution, which basically relate to provision of basic services of safe water, solid waste management, and habitat improvement.  With the Faculty of Medicine of the Central University of Ecuador, a letter of understanding was signed to develop projects to link with targeted communities. Students carry out field actions in the intervention cantons (Manta and Portoviejo municipalities) to strengthen prevention and control actions and develop evidence from academy.

Peru:  Awareness-raising processes have been developed for local and regional authorities to develop public policies related to the control / prevention of Zika  Training was carried out in the Budgetary Program for Metaxenic Diseases and Disaster Risk Management to incorporate prevention and control actions into the operational plans and budgets of 2018.

1.4.Progress in the development and consolidation of a binational project strategy to strengthen the prevention and control of Zika actions

In Ecuador and Peru, the Zika project has among its main objectives to contribute to the consolidation of a binational and regional strategy aimed at strengthening prevention and control of Zika by strengthening local capacities and community participation in surveillance, prevention & control actions and local capacities, as well as to influence behavior change and adaptation of healthy practices for the prevention and control of Zika. This implies the scaling up (to the national, binational and / or regional levels), actions developed locally, to achieve their incorporation at the different levels of government through policies, norms, and programs. It also

demands the consolidation of community participation processes, in the actions of monitoring, control and prevention. Processes that will allow the sustainability of interventions from the competent institutions and the population itself.

To this end, joint work mechanisms have been established, which allow the analysis of project progress in implementation and sharing of the results. In addition, the following common guidelines for project intervention have been defined:

1. Strengthen the articulated work with the corresponding Ministries of Health and their different instances at the territorial level. 2. Promote communication with the different levels of government: municipalities, regional governments (Peru), national level. 3. Encourage alliances with the project that is implemented in Central America, and other actors at the binational and regional levels, to consolidate Zika's prevention strategies: among them, ORAS-CONHU (Regional Andean Health Organization - Hipólito Unanue Agreement), academy. 4. Incorporation of the risk reduction and gender approaches, and articulation with other interventions that are carried out in the project areas that have a relation or impact on the prevention and control of vector-borne diseases. 5. Development of communication strategies with the communication for development methodology (C4D), which seeks social and behavioral change (CCS & C) and validation of field material and common guidelines for the two countries. 6. Strengthening community participation in the prevention and control of Zika. 7. Strengthening the capacities of the different institutional and community / social actors at the local level. 8. Advocate for policy development at the local, regional and national authority levels to strengthen Zika's prevention and control measures and programs, prioritizing interventions aimed at social and behavioral change at household and community levels. 9. Work with the project management indicators and impact indicators defined by USAID. 10. Develop innovative strategies to work with adolescent men and women and with women and men of reproductive age. 11. Articulation with the academy to generate or update knowledge and innovative proposals in Zika prevention.

In this context and within the framework of the project, we propose to carry out the following actions: Y1: Binational Workshop on Strategic Communication: evidence, results and proposals in Ecuador and Peru; to build a binational communication strategy within the framework of the Project.

Y2: Two international meetings or events will be held for: a) Exchange of experiences in Zika prevention in the Andean and Central American region; 2) Theoretical, conceptual and methodological advances in the Andean countries for prevention and control of Zika and its complications. Y3: At least 2 meetings will be held a) Binational to review proposals for public policies and regulations at the national, regional and local level, for municipalities, health systems and communities, b) Proposals for policies and innovations at the regional level (LAC).

In this framework, it is also planned to develop Binational and/or Regional meetings that will be carried out in the second phase of the Project (years 2 and 3). Recommendations of the exchange events will be socialized with strategic allies (UNICEF, PAHO, go mosquito, Assist, etc.), other projects from the same donor (Save the Children or others) and health sector authorities. No subcontracts are foreseen unless collaboration and / or co-financing of national or regional events.

1.5. Relevant context changes

1.5.1. Political Context

Ecuador and Peru during year 1, experienced political processes that influenced the development of the project.

In Ecuador, the change of government carried out in May 2017 led to a stagnation of interventions and decision-making by outgoing authorities. The change of some authorities led to delays in the formalization of agreements with the Ministry of Public Health. To this it is added that the intervention cantons, especially Manabí, were affected by the intense rains of the winter season, which demanded the concentration of the authorities in the mitigation of their effects. The current president Lenin Moreno, has raised more openness for coordination with the US government. Since there is no USAID office in Ecuador, support is required with a focal point in the Embassy that facilitates articulation and advocacy for project implementation.

In Peru, since the inauguration of the new president Pedro Pablo Kuczynski, two facts have passed the bill to the Peruvian economy: the effects of the corruption of the Odebrecht case and the floods generated by the Coastal Niño Event. However, a slight recovery is expected to materialize in the last two quarters of 2017, when the implemented reforms begin to bear fruit. The country requires private investment to ensure, in the medium and long term, sustained growth and quality. The trend of public investment will only begin to reverse when the Reconstruction process is under way. Private investment was affected by adverse global conditions and the uncertainty related to the corruption scandals of projects signed in previous years. Which resulted in the resignation of several ministers and questioning of other ministers such as in the health sector where the congress asked for explanations for the exponential increase of the emergent metaxenic diseases increased by effects of the Coastal Niño Event, where floods and the disruption of productive and social infrastructure in large areas of the country occurred, affecting over 1.2 million people. This scenario demanded the 11

involvement and concentration of authorities and health officials to humanitarian assistance to the affected population and recovery of their basic living conditions. Large territories were declared in health emergency given the dramatic increase of mosquitoes, as well as the concentration of the population, thus the dramatic increase of dengue and Zika cases. The affected areas in the Northern Coastal region coincide with the intervention area of the project causing the delay of some actions, but at the same time becoming an opportunity to work with communities; local, regional and national governments, enabling the dissemination of information on Zika prevention and control, favoring joint efforts.

1.5.2. Adverse hydroclimatic events

Since the end of January 2017, an event called The Coastal Niño occurred due to the abrupt increase in sea surface temperatures, which generated heavy rains and storms, resulting in floods, mass land movements and other associated phenomena in the Ecuador- Peru region.

According to information from the National Emergency Operations Center (COEN-INDECI) on April 19, 2017, at the national Peruvian level, the disasters had left 113 people dead and over 1'200,000 people affected; 41,028 homes destroyed or uninhabitable and 240,401 affected; 166 schools collapsed/uninhabitable and 2,064 affected; 710 affected health facilities of which 39 collapsed or uninhabitable. In addition to this, more than 26 thousand km of roads were destroyed or affected; 323 bridges destroyed and 536 affected; more than 60 thousand Ha of arable land was lost. 205 shelters and 3,342 tents were installed, housing for over 32,000 vulnerable people in precarious conditions.

As of April 1, there were 11 departments declared in health emergency for 90 days. The figures show the severe impact of the so-called Coastal Niño for the country, for the regional and local economy, and especially for rural livelihoods of the most vulnerable populations.

Although there is still no precise diagnosis, the collapse of numerous water and drainage systems has been evidenced in several sectors of the country, which has been a source and factor of increase in diseases and epidemics. By April 2017, 868 people were affected by dengue, Zika and another 4,442 people had a high probability of being affected. The numerous sectors affected by the recent floods are in a critical situation due to the accumulation of garbage and other solid waste that impede the mobility of people and the provision of basic services, this is rapidly deteriorating the quality of life of the families and putting their health situation at risk.

1.4.3 Epidemiological information

According to a recent WHO Update, 48 countries and territories in the Americas have confirmed autochthonous, vector-borne transmission of Zika virus disease, [1] while five countries have reported sexually transmitted Zika cases (Figure 1). Since epidemiological week (EW) 44 of 2016, no additional countries or territories of the Americas have confirmed autochthonous, vector-borne transmission of Zika virus disease.

Figure 1. Countries and territories in the Americas with confirmed autochthonous (vector- borne) Zika virus cases, 2015-2017.

The trend of reported cases continues in Mexico, Central America, continues to decline, with the exception of Belize, in South America where an increase in the number of suspected and confirmed Zika cases was observed between EW 49 of 2016 and EW, with an increasing trend of suspected and confirmed cases being observed, mainly due to increases in the number of reported cases in Argentina, Bolivia (Plurinational State of), Brazil, Ecuador, and Peru. Between EW 10 and EW 14 of 2017, an average of 1,246 suspected and confirmed cases were reported per week in this sub-region.

Congenital syndrome associated with Zika virus infection. - To date, 26 countries and territories in the Americas have reported confirmed cases of congenital syndrome associated with Zika virus infection. In EW 15 and EW 17 of 2017, Ecuador and Barbados reported for the first-time confirmed cases of congenital syndrome associated with Zika virus infection. In the last eight weeks (EW 10 to EW 17 of 2017), Brazil, Colombia, Costa Rica, Ecuador, Grenada, Guadeloupe, Guatemala, Martinique, Mexico, Puerto Rico, and the United States of America updated their number of cases of congenital syndrome associated with Zika virus infection.

Guillain-Barré syndrome (GBS) and other neurological disorders. - In EW 17 of 2017, Barbados reported its first five cases of Guillain-Barré syndrome (GBS) associated with Zika virus infection.

In Ecuador.

According to the epidemiological bulletin1 of the Ministry of Public Health of the country, up to the epidemiological week 52 of 2016, 2,946 cases were reported, while in 2017 until the epidemiological week 32 2,192 cases were reported, of which 1,403 were confirmed by laboratory and 789 by epidemiological link.

Figure 2. Geographical distribution of confirmed Zika cases per provinces, year-2017 (Epidemiological Week-N°32)

Among the provinces with the highest number of reported cases are Guayas with 1,082, Manabí with 759 and Santo Domingo with 133, the population group being mostly affected women between 20 and 49 years old. These cases include 670 pregnant women, 117 in Manabí, 36 in El Oro and 6 in Esmeraldas, provinces with notable effects due to the intense rainy season of 2017 and the aftermath of the April 2016 earthquake in Esmeraldas and Manabí. The birth registration of 293 infants of mothers positive for ZIKA V infection, of which there have been two deaths and 7 with Vertical transmission of Zika without congenital malformation syndrome.

Figure 3: 2016 (SE-52) and 2017 (SE-32) confirmed Zika cases on pregnant women in Ecuador by province

Although at the moment and in consequence of various factors such as environmental and responsive operations by different institutions, the frequency of cases has decreased notoriously. The current vector is widespread. It is present in more than 5.200 localities across 23 of the 24 provinces that make up the country. These localities are inhabited by an estimated 9 million people which ensures the possibility of new spreads and Zika epidemics around the country.

Figure 3. Comparative Analysis of Zika Cases in Ecuador, years 2016 (SE-52), 2017 (SE-32)

In Peru

According to the MINSA’s epidemiological bulletin, since 2016 until the SE-24 of 2017 a total of 7.647 Zika Cases (1.312 confirmed cases and 6.335 suspected) were notified. The areas of Loreto and Cajamarca constituted the geographical areas englobing a 99.1% of all cases.

For 2017 until the SE-24 a total of 5.978 cases were notified. 91.3% (5.455) suspected and 8.7% (523) Confirmed (Refer to Table 1). 90.7% of all national cases notified were reported in the departments of Ica and Loreto.

The tendency in 2017 shows an increase of cases on the SE-03. This is a continuation of the outbreaks in the cities of Iquitos, Yurimangas and Nauta (Department of Loreto) since the last weeks of 2016 to the first of 2017. After this outbreak and an initial incremental tendency, we observe a detrimental tendency. On the SE-10 a notorious increase in cases is presented due to the outbreak in the Chincha province (Department of Ica). This outbreak had a rapid increase. In only two weeks (SE-12 to SE- 14) it multiplied the weekly case frequency more than ten times. The majority of cases were observed on SE-14.

From 2016 to the SE-24, 2017, 217 pregnant women with confirmed Zika infection were notified (92 on 2016 and 125 over the course of 2017). 82% of infected pregnant women have been notified in the Department of Loreto (56 in 2016 and 47 in 2017) and in the Department of Ica (74 in 2017).

Since June 2016 until SE-24, 2017, pregnant women infected with Zika gave birth to 81 living newborn babies. Three abortions and one stillbirth were reported.

For 2017 even though there is a decreasing tendency on the number of cases the sickness is spreading to a larger number of departments (09) and districts (39) than the previous year. 7 districts in the Department of Loreto notifying Zika cases, 12 districts in the Department of Ica, 6 districts in the Department of Tumbes, 3 districts in the Department of La Libertad, 2 districts in the Department of San Martin, 2 districts in Metropolitan Lima, 2 districts in the Department of Cajamarca and 3 districts in the Department of Piura.

The vector Aedes albopictus, carrier of Dengue, Chikungunya and Zika is spread throughout 448 districts of the country. 14 million people live in those districts which represents a high risk of sickness spreading. This might happen as the cases increase in places where preventive measurements are not enough nor efficient.

1.6. Key partnerships and alliances

The project will continue to be implemented in 3 provinces and 10 cantons of Ecuador, and in Peru 4 departments and 20 districts. To this end, the project team has identified important stakeholders to coordinate actions, complement efforts and build synergies, who will also contribute to build

sustainable strategies, promote scientific research to build evidence and enhance learning. Further analysis can be found in (Annex 2 (mapping of partners & allies).

Key strategic partners are the Ministries of Health (MoH) of Peru and Ecuador as well as the regional and national UNICEF offices. CARE has a long history working with the MoH on issues relevant to public health among vulnerable populations, while CARE´s work with UNICEF has mostly been on advocacy-related efforts.

The second category established for the actors is that of the ministries that are important in the holistic strategy envisioned. They include the Ministries of Education, Culture, Labor Economy and Finance and Social Inclusion.

Another category is that of the subnational governments where we grouped provincial governments and local municipalities, which are close to the territories. These actors are critical contributors to the project’s sustainability.

In the fourth category, we included a number of International Cooperation’s that bring together bilateral and multilateral cooperation. These stakeholders are relevant given the opportunity of complementarity, co-financing and knowledge sharing.

We also included the “other relevant stakeholders" category that includes Networks and Clusters, mostly related to health, education, humanitarian aid and governance.

1.7. Project Outcomes, Strategies, Activities and Work Plan for Phase II, years 2 and 3

As aforementioned during the years 2 and 3 actions will be taken to implement a regional strategy in South and Latin America. These strategies are pointed towards the exchange of experiences by sharing the best discoveries. This will serve the purpose of public policy making.

1.7.1. Best practices in community participation and mobilization on prevention, promotion and practices regarding Zika identified.

Phase II - Years 2 & 3:

1. In the areas of vector control, community surveillance, use and monitoring of ovitraps, based on the results of the EBA study (Ecuador) and the results of the competition to identify best practices (Peru). The best practices will be validated, implemented and used to develop new or update protocols or guides. The systematization will be carried out through consultancies (Ecuador) and the competition in Peru.

2. Behavioral change - with a gender and cultural diversity approach, a mid-term evaluation of the change in individual and collective knowledge, attitudes and practices with respect to dengue and chikungunya prevention campaigns, risk perception of zika and the recognition of signs and symptoms of Zika, implemented from the findings. Including information on measures taken in 19

homes, control of pregnancy in adult women and adolescents, and self-care of health in women.

3. Community surveillance: Ecuador with EBA results will have a proposal for community surveillance through a monitoring and early warning system. The implementation piloting will begin at the end of the first year and continue in the second to evaluate results.

4. Use and monitoring of ovitraps: In Peru, the competition developed with CAD allowed to identify the good practice of using ovitraps in the Municipality of Ventanilla where the regulations established by the MINSA were correctly applied. This experience is being disseminated by the implementers themselves in the scope of the project.

1.7.2. Immediate testing of best practices and lessons learned from EBA and KAP on Zika prevention in priority risk areas.

Based on EBA and KAP findings, immediate testing and validation on effective vector control strategies, communication messages and community surveillance activities will take place in priority risk areas. Immediate testing and implementation will be adapted and tailored to target audiences (household level and local authorities/leaders).

Year 2 & 3: a. Vector control - We will work with the health services in selected risk areas, in training of health workers on current and / or new or modified protocols or guides, based on the results of the EBA and KAP studies, providing continuous feedback on efficiency, as a priority in households with pregnant women and / or reproductive age. a. Behavioral Change - The communication and community participation strategy developed from the EBA and CAP is implemented in the two countries to impact on behavioral change to ensure understanding and acceptance of key messages and minimize Zika spread. This strategy is deepened in the second year. In the case of Ecuador it will begin at the end of the first year and deepen in the second year of the project. b. Community surveillance - strengthening local health services and local government capacities in relation to Zika (Early Warning Systems), based on the efficient and correct use of ovitraps (Peru). The competition developed with CAD allowed to identify the good practice of using ovitraps in the Municipality of Ventanilla where the regulations established by the MINSA were correctly applied. This experience is being disseminated by the implementers themselves in the scope of the project. c. In Ecuador, we work with school centers and community spaces with children and adolescents of school age to act as facilitators of prevention and promotion.

1.7.3. MoH monitoring system includes a friendly feedback system for local governments and community use to enable a continuous gathering and analysis of best practices at community level.

Development community surveillance system includes feedback mechanisms between health facilities, local governments and communities.

Year 2 & 3:

a. Adapt feedback and alerting mechanisms based on reports from community leaders, health facilities, conducting prevention and monitoring activities to ensure that information is collected correctly.

b. Inform the population in priority areas about the implementation of surveillance activities and about the role of community health agents to reduce stigma and misconceptions, and increase active participation in data collection.

c. In coordination with the Ministry of Health, training and capacity building will be carried out to strengthen local governments in the collection of information, analysis and communication of results to influence decision-making and formulation of municipal plans.

d. Improve community surveillance through economical and user-friendly technology, formats and information systems.

e. Assist in the development and establishment of local municipal surveillance systems as well as early warning capacities to effectively identify and respond to alerts and alarms, especially with respect to community roles in risk prevention and monitoring at the neighborhood level and of home.

1.7.4. Communication strategy with unified key messages (segmented by audience and through gender and diversity lens) implemented by all parties and stakeholders

Year 2 & 3:

a. The implementation of the communication strategy initiated in Peru in August and which will start in Ecuador at the end of September and intensify in Y2 and Y3. Based on the results of the CAP, including formal and informal alternative means of communication (such as ICT) to increase and accelerate the impact on behavioral change and seek understanding and acceptance of key messages, especially of the risks of microcephaly in newborns of infected mothers and risky sexual behavior, especially among adolescents.

b. The communication strategy for development adapted to schools of primary and secondary education on prevention practices, personal and health care, vector control and surveillance

will be implemented, based on the experiences developed by CARE, UNICEF and MINSA / MSP.

c. Provide technical assistance to MINSA / MSP and GAD communication units to incorporate best practices and learned lessons into their communication / campaign strategies and to lead the coordination and unification of key messages among institutions, with emphasis on the behavioral change approach and the incorporation of non-traditional / informal communication channels to better reach different social and cultural contexts and reduce campaign costs.

1.7.5. Scaling up of sustainable policies, strategies, and protocols from the local level to national and bi-national levels for policy making.

Advocacy will be carried out with local governments, through sharing the results, successful experiences and evidence developed. From these findings, recommendations will be made to authorities to strengthen Zika's prevention programs and vector control with community participation.

In addition, there will be exchange meetings of experiences at the national and bi-national levels for drafting recommendations for public policy.

In this case there were no resources allocated in Ecuador for the 5.1 and 5.2 activities for years 2 and 3 for which reassignment is required, thus deviating from the first-year budget.

Year 2 and 3:

a. Y2: Two international meetings or events will be held for: a) Exchange of experiences in the Zika project in the Andean and Central American region; 2) Theoretical, conceptual and methodological advances in the Andean countries for prevention and control of Zika and its complications.

b. Y3: At least 2 meetings will be held a) Binational to review proposals for public policies and regulations at the national, subnational and local level, for municipalities, health systems and communities.

1.8. Zika Work plan - Oct 2017-Sep 2019

COST COST ACTIVITIES COST Y2 Y3

R1: Best practices in community participation and mobilization on prevention, promotion and practices regardin

A.1.1. . Evidence-Based Analysis of community based systems on roles and performance of vector control at household and $ 26.940,80 $ 25.753,90 $ 52.694,70 community levels.

Ecuador $ 10.310,80 $ 9.000,00 $ 19.310,80 Peru $ 16.630,00 $ 16.753,90 $ 33.383,90

A.1.2. KAP studies in selected areas on individual and collective behavior change regarding prevention, care giving to childbearing $ 74.495,46 $ 72.410,00 $ 146.905,46 age women and pregnant women.

Ecuador $ 27.495,46 $ 24.000,00 $ 51.495,46 Peru $ 47.000,00 $ 48.410,00 $ 95.410,00 A.1.3. Evidence-Based Analysis on inter-sector and community participation, roles and performance of community-based $ 15.560,80 $ 19.407,50 $ 34.968,30 surveillance systems.

Ecuador $ 10.310,80 $ 9.000,00 $ 19.310,80 Peru $ 5.250,00 $ 10.407,50 $ 15.657,50

R2: Testing of best practices and lessons learned against zika found through the EBA and KAP implemented imm

A.2.1. Training of local health and municipalities personnel, and community health agents on new protocols based on EBA and KAP $ 64.393,16 $ 51.990,00 $ 116.383,16 findings on vector control best practices and lessons learned.

Ecuador $ 48.993,16 $ 36.188,00 $ 85.181,16 Peru $ 15.400,00 $ 15.802,00 $ 31.202

A.2.2. Based on EBA and KAP findings, develop and validate communication messages to improve knowledge and understanding on key risks of zika, especially on microcephaly in $ 73.765,70 $ 46.788,20 $ 120.553,90 babies of infected women, and key prevention and care giving practices.

Ecuador $ 58.225,70 $ 30.890,00 $ 89.115,70 Peru $ 15.540,00 $ 15.898,20 $ 31.438,20

A.2.3. Support local health facilities to develop and validate a friendly feed-back and monitoring system on implementation of $ 70.533,98 $ 51.292,40 $ 121.826,38 adapted protocols at household levels, with priority of those with pregnant women or women in child-bearing age

Ecuador $ 51.553,98 $ 31.743,00 $ 83.296,98 Peru $ 18.980,00 $ 19.549,40 $ 38.529,40 23

COST COST ACTIVITIES COST Y2 Y3

R3: MoH monitoring system includes a friendly feedback system for local governments and community use to enable a continuous gathering and analysis of best practices at community level

A.3.1. Adapt and design a friendly, cost-effective and efficient reporting and early warning system for animadores and community health workers to include community based activities and results in $ 56.503,61 $ 41.575,00 $ 98.078,61 formal MoH monitoring systems.

Ecuador $ 51.283,61 $ 39.000,00 $ 90.283,61 Peru $ 5.220,00 $ 2.575,00 $ 7.795,00 A.3.2. Develop a culturally adapted social information system on surveillance activities and community health workers roles to reduce rejection and enhance community participation in providing $ 330.075,06 $ 216.832,00 $ 546.907,06 sound information.

Ecuador $ 158.975,06 $ 114.188,00 $ 273.163,06 Peru $ 171.100,00 $ 102.644,00 $ 273.744,00

A.3.3. Training of local health services personnel, local governments and community health workers on community-based $ 47.755,04 $ 37.222,00 $ 84.977,04 follow-up and monitoring systems

Ecuador $ 33.055,04 $ 21.056,00 $ 54.111,04 Peru $ 14.700,00 $ 16.166,00 $ 30.866,00

R4: Communication strategy with unified key messages implemented by all parties and allies, using formal and in

A.4.1 Based on EBA and KAP findings, develop and implement formal and informal communication strategies (including ICT) to improve knowledge and understanding on key risks of zika, $ 104.040,67 $ 86.977,50 $ 191.018,17 especially on microcephaly in babies of infected women, and key prevention and care giving practices.

Ecuador $ 79.790,67 $ 62.000,00 $ 141.790,67 Peru $ 24.250,00 $ 24.977,50 $ 49.227,50

A.4.2. Identify the communication role and community acceptance of animadores and other community health workers in influencing knowledge building and behavior change in communication $ 39.298,83 $ 32.231,00 $ 71.529,83 campaigns key messages.

Ecuador $ 21.598,83 $ 14.000,00 $ 35.598,83 Peru $ 17.700,00 $ 18.231,00 $ 35.931,00

A.4.3. Develop a culturally adapted social communication for development system based on MoH and UNICEF experience. $ 33.497,98 $ 28.546,77 $ 62.044,75

Ecuador24 $ 19.374,90 $ 14.000,00 $ 33.374,90 Peru $ 14.123,08 $ 14.546,77 $ 28.669,85 A.4.4. Implement a communication for development strategy adapted for primary and secondary schools on prevention, health and personal care, vector control practices and surveillance $ 55.008,78 $ 53.968,77 $ 108.977,55 practices, building up from focused experiences implemented by CARE, UNICEF and MoH.

Ecuador $ 23.485,70 $ 21.500,00 $ 44.985,70 Peru $ 31.523,08 $ 32.468,77 $ 63.991,85

COST COST ACTIVITIES COST Y2 Y3

R5: Scaling up of sustainable policies, strategies, and protocols from the local level to national and bi-national levels for policy making.

A.5.1. In selected areas in Peru and Ecuador, train local government staff in managing the metaxenic budgetary program to $ 27.347,73 $ 33.210,00 $ 60.557,73 include in regular planning processes a stipend for animadores.

Ecuador $ 13.747,73 $ 19.000,00 $ 32.747,73 Peru $ 13.600,00 $ 14.210,00 $ 27.810,00

A.5.2. Technical support to local governments to promote and enhance local inter-sector and community coordination platforms $ 49.219,02 $ 40.716,00 $ 89.935,02 for joint planning of community health plans.

Ecuador $ 28.019,02 $ 19.000,00 $ 47.019,02 Peru $ 21.200,00 $ 21.716,00 $ 42.916,00 A.5.3. Support bi-national mutual learning and exchange of experiences, results and recommendations of the EBA and KAP studies through joint field visits, discussion events and $ 22.010,80 $ 20.051,00 $ 42.061,80 documentation to adjust national and local plans of action to the proven best practices and protocols.

Ecuador $ 10.310,80 $ 8.000,00 $ 18.310,80 Peru $ 11.700,00 $ 12.051,00 $ 23.751,00 A.5.4. Organize at least one international event, with other countries to share the results of the Evidence Based Analysis and KAP study, as well as successful experiences of adjusted $ 31.456,44 $ 70.100,00 $ 101.556,44 implementation strategies and their results impact on the virus outbreak in community health care systems.

Ecuador $ 11.456,44 $ 10.000,00 $ 21.456,44 Peru $ 20.000,00 $ 60.100,00 $ 80.100,00

TOTAL DIRECT COSTS $ 1.121.904 $ 929.072 $ 2.050.976 Ecuador $ 657.988 $ 482.565 $ 1.140.552,68 Peru $ 463.916 $ 446.507 $ 910.423,19

COST COST DESCRIPTION COST Y2 Y3

1. SALARIES $ 589.917 $ 613.513 $ 1.203.430 Ecuador $ 294.936 $ 303.784 $ 598.720 Peru $ 294.981 $ 309.729 $ 604.710 2. ALLOWANCES / STAFF BENEFITS $ 281.615 $ 292.567 $ 574.182 Ecuador $ 156.395 $ 161.087 $ 317.482 Peru $ 125.219 $ 131.480 $ 256.699 4. TRAVEL & TRANSPORTATION $ 78.761 $ 80.283 $ 159.044 Ecuador $ 33.837 $ 37.498 $ 71.336 Peru $ 44.923 $ 42.785 $ 87.708 5. EQUIPMENT & SUPPLIES $ 12.227 $ 12.488 $ 24.715 Ecuador $ 3.538 $ 3.538 $ 7.076 Peru $ 8.689 $ 8.950 $ 17.640 Project Management Activities: $ 42.140 $ 90.736 $ 132.876 Ecuador $ 4.341 $ 26.341 $ 30.682 Peru $ 37.799 $ 64.395 $ 102.194 7. SUB-AWARDS $ 1.035.950 $ 1.126.367 $ 2.162.317 Ecuador$ 1.035.950 $ 1.126.367 $ 2.162.317 Peru $ - $ - $ - 8. OTHER DIRECT COSTS $ 117.340 $ 119.244 $ 236.584 Ecuador $ 65.263 $ 65.605 $ 130.868 Peru $ 52.077 $ 53.639 $ 105.717 9. INDIRECT COSTS $ 342.632 $ 362.340 $ 704.972 Ecuador $ 239.871 $ 256.592 $ 496.463 Peru $ 102.761 $ 105.749 $ 208.509

TOTAL DIRECT & INDIRECT COSTS $ 2.500.582 $ 2.697.538 $ 5.198.120 Ecuador $ 1.834.132 $ 1.980.812 $ 3.814.944 Peru $ 666.450 $ 716.727 $ 1.383.177

* LEVEL OF EXECUTION

Local households, communities and municipalities

Subnational provincial and regional governments

National Ministers and strategic partners

Program Management

No significant change from the approved proposal:

Position/Team Description Steering Guarantee oversight of the project´s advance and intermediate results through annual Committee meetings, influencing the adoption of proven successful protocols and strategies and policy making at all levels of intervention. For operational purposes, national working groups will meet twice a year. Binational Senior Includes Project Director, Deputy, M &E and learning teams, Program Managers (Peru Management Team and Ecuador). Responsible for approving the project´s operational plans, oversee compliance in terms of timeliness and quality of outcomes, and follow-up of the project’s implementation. Project Provide credible technical leadership, coordination and collaboration with all Director (and implementing partners, and strategic management and oversight of partnerships and Deputy) activities to achieve project objectives. The Project Director and the Deputy Project Director will act as the Project Managers in Ecuador and Peru. M&E Staff Responsible for the general program monitoring and evaluation, data management, assure the adequate tracking of indicators for monitoring the projects performance, support the implementation of the monitoring and evaluation plans. Communication for Responsible for developing and implementing the communication strategy, which Development includes validating messages related to specific health-related issues and relaying Specialists those messages to the public. Field coordination Follow-up on the implementation closely in the field with the local actors, team monitoring and gathering information, and developing relationships with local authorities, health services and community leaders.

1.9. Cost Share

Details of CARE Ecuador cost share

a) The cost share provided by the Municipal Government will be in kind concerning materials, technical management and others. b) First year, the cost share will be focused on local and community actors, including Municipal Government and community organizations, in Manabí (province with highest incidence of Zika in the country). c) The total cost share amount for the first year will be around US $ 287,250, of which 84% corresponds to Municipal Government and community organizations of Manabí. d) The cost share provided by Municipal Government and community organizations of Manabí is around 9% in the first year and the cost share provided by the El Oro province will be included for the second year. e) We expect the first part of cost share from the Academy around US $ 22.000 (8%)

In relation to the Ecuador cost share, a request will be made for diversification of sources of funding for cost share.

To date, the following value of Cost Share of municipalities of Manabí and potable water joints has been raised:

Cost Share Management Ecuador

Budget Y1: $ 287.250 Registration at July 30: $ 98.371 Balance $ 188.879

Details of CARE Peru cost share:

a) Stipend for health “animadores” for US $ 90.000. b) Acquisition of pesticides and personal protective equipment for vector control activities for US $135.000. It is a counterpart of the Project (investment of Municipalities and MINSA), USAID funds will not be used for the purchase of pesticides, protective equipment or spraying. For these purposes, the MINSA staff complies with the regulations and protocols established by the Ministry.

c) Communication material to raise awareness and prevention of Zika for US $60.000. d) The total MoH cost share for de Fiscal Year 1, is US $185.000.

Cost Share Management Peru Budget Phase I: $ 307,006 Registration at Jun-17 111,200 (-) Balance $. 195,806

2. MEASUREMENT, MONITORING, EVALUATION AND LEARNING PLAN

This plan is developed in accordance with USAID's request: data collection approach, a revised logical model, monitoring and evaluation plans, and indicators table.

2.1.Data collection

CARE Ecuador and CARE Peru implement a system of data collection and reporting as an efficient tool that facilitates the reporting of results. This system optimizes time, reduces errors, improves the quality of information and allows the timely collection of data according to the dynamics of the project. This system has contributed to the decision-making process based on the changes produced and facilitates the lessons learned on the methodologies used in the execution of the project activities. To implement the system, the project team will use interrelated procedures and instruments that will make it possible to measure and evaluate the quantitative and qualitative fulfillment of each project result.

The system is structured in six components, from which CARE Ecuador, CARE Peru and its implementing partners monitor the progress of the Project's performance indicators: 1) mechanisms 29

to ensure the quality of information; 2) training, accompaniment and capacity building with partners in project implementation; 3) verification; 4) supervision; 5) feedback and 6) reporting.

2.2. Monitoring and Evaluation Plans

The data collection and reporting system has been implemented in a planned and orderly manner, through the Monitoring and Evaluation Plan that has been implemented with the technical and financial team of the Project in Ecuador and Peru, which has allowed the visualization of technical and financial institutions. For this, CARE has used the Integral Monitoring Schedule tool, organized based on the activities included in each of the Results. Monitoring activities have been carried out on the most significant budget execution and the most substantial commitments in terms of project implementation, indicators and results.

The Monitoring and Evaluation Plan includes a focus on providing technical and financial support, including the following actions:

. Conducting “on-site” assessments of the progress being reported in the various operational reports, in order to verify the data reported, both regarding budgetary and programmatic execution. . Revising the existing evidence of the advances being reported, also from both the budgetary and operational perspectives. In the case of budget execution, by reviewing samples of purchase receipts, invoices, payroll, etc. . Identifying situations that could put the implementation of the project at risk, in order to enhance timely decision-making. . Providing technical assistance in those areas where limitations are observed.

In addition, as part of the Project Monitoring and Evaluation Plan, the criteria and definitions used for the measurement of performance indicators were standardized through forms, homologation of means of verification, qualitative and quantitative reports and consolidation of information in a centralized database.

2.3. Revised logic model

During implementation of the first year and in the WP drafting phase for years 2 and 3, difficulties were identified in the reporting of some indicators, because the wording was not clear. After the in- depth review, it was concluded that it was necessary to specify the indicators of the project's logical framework, in order to guarantee the correspondence between results, activity and indicator, in such a way that they constitute an adequate input for project management, monitoring and evaluation. For this, a working team was formed to prepare an initial proposal and subsequently the review and validation was carried out in a binational working meeting, in which the Director and Deputy Director 30

of the project and specialists in Epidemiology of Ecuador and of Monitoring and Evaluation of Peru and Ecuador participated. This is attached to this document with a solution to make modifications and improvements in writing to have greater precision and concordance of results, activity and indicators.

2.4. Indicator Tables

The table below describes, for each indicator, the unit of measure, source and frequency of data collection, and the use of the information collected. This was initially defined. In the document of support that is sent it is proposed to modify it. An additional indicator was incorporated into result 2, which is called Indicator 21; "Number of community control and monitoring events involving families, communities, municipalities, health systems and community water management organizations". In indicators 6, 10 12 and 15, the term "control groups" was changed to "focus groups". In the performance indicators matrix Zika M & E Framework indicators were incorporated in congruence with each result.

IR Performance Indicators: WP & Definition and Data Frequency of Use of Information Zika Framework Unit of measure Source Collection/Reporting

R1: Best I. 1. Number of EBA reports on best count, studies reports Base line, midterm and for communication and decision- practices in practices on vector control. final. making community I.2. Number of KAP studies count, studies reports Base line, midterm and for communication and decision- participation implemented and shared at local and final. making and national levels mobilization I.3. Number of EBA reports on count, studies reports Base line, midterm and for communication and decision- on prevention, community surveillance practices final. making promotion and Knowledge: % of individuals of Percentage, Households Annual for communication and decision- practices reproductive age in project areas people survey at making regarding Zika who can name one vector intervention identified. transmission and one sexual areas transmission prevention method. Behavior: % of individuals of Percentage, Households Annual for communication and decision- reproductive age in project areas people survey at making who have taken at least one action intervention within the last month to prevent Zika areas infection or its consequences. R2: Immediate I.5. Number of health personnel of count, personnel Workshop Quarterly for communication and decision- testing of best selected areas implementing best attendance making practices and practices. record lessons Pre and post learned from test EBA and KAP Photographi on Zika c record

prevention in I.6. % of people from focus groups Percentage, KAP reports Base line, midterm and for communication and decision- priority risk (KAP implementation), who have people final making areas. increased knowledge and apply better practices in prevention and care-giving against Zika I.7.Number of follow-up and count, reports reports Quarterly for communication and decision- monitoring reports on application of making adapted protocols at household levels in selected areas. I.4. Improve the efficiency of Percentage reports Base line, midterm, for communication and decision- ovitraps in at least 10% for vector final making control and community surveillance. (Y2) I. 21. Number of events of control Count, Lists of Quarterly/annually for communication and decision- and community surveillance events participants making involving families, communities, municipalities, health systems, community water management organizations. % of communities where physical activities Percentage Local Quarterly for communication and decision- for vector control are implemented reports of making the health facilities R3. MoH I.9. Number of community health count, personnel Reports Quarterly for communication and decision- monitoring workers dully providing periodic making system surveillance reports to local health includes a services. (Y3) friendly I.10. % of people in focus groups Percentage, Reports Quarterly for communication and decision- feedback who have provided information for making system for community surveillance system 33

local I.11.Number of health personnel and count, reports Reports Monthly/quarterly for communication and decision- governments community health workers trained making and in community based surveillance community system. use to enable a I.8. Number of healthcare facilities count, health reports Quarterly for communication and decision- continuous with Zika clinical guidelines facilities making gathering and counseling services (WHO). analysis of I.12.% of adolescents in focus percentage, Workshop Quarterly for communication and decision- best practices groups who know and understand people attendance making at community prevention practices record Pre level. and post- test Photographi c record % decrease in egg density, from percentage, reports Monthly/quarterly for communication and decision- baseline, in targeted geographic making areas. % decrease in mosquito frequency, percentage, reports Monthly/quarterly for communication and decision- from baseline, in targeted making geographic areas. # affected individuals referred to count, people Health Quarterly for communication and decision- care and support services. facility making reports: Community reference form for health promotion # communities with members count, personnel reports Quarterly for communication and decision- actively participating in Zika making 34

monitoring, prevention, and/or support activities. % of communities where physical percentage, Local Quarterly for communication and decision- vector monitoring activities are reports of making being implemented. community activities of health facilities # of people trained in vector control. count, personnel Workshop Monthly/quarterly for communication and decision- attendance making record Pre and post test Photographi c record I.13. Number of health services count, personnel reports Monthly/quarterly for communication and decision- R4: workers sharing information with making Communicatio local governments and community n strategy with for decision making on Zika unified key prevention, surveillance and control. messages I.14. % of selected priority areas Percentage Reports Quarterly for communication and decision- (segmented by with set coordination and making audience and information Zika control platforms through among community leaders, local gender and governments and health services. diversity lens) implemented I.15. % of people in focus groups Percentage Reports Quarterly for communication and decision- by all parties who increased awareness on making prevention and control against Zika infection.

and I.16. % of the vulnerable population Percentage Reports Quarterly for communication and decision- stakeholders informed on prevention and control making of Zika % of women of reproductive age in percentage, Household Annual for communication and decision- project areas who can identify the people survey making potential risks of ZIKA infection during pregnancy and one sexual transmission prevention method. Reach: # of individuals of Count, people Household Monthly/annual for communication and decision- reproductive age in project areas survey, making who have received Zika messages. reports # Zika events that involve families, count, events Agenda of Quarterly for communication and decision- schools, local governments, or the meeting. making community organizations. Attendance list of Zika. Photographi c record R5: Scaling up I.17. % of local governments in Percentage, local Documents Semester for communication and decision- of sustainable selected areas that include planning governments making policies, for Zika prevention and control strategies, and as part of annual budget. In Peru, protocols from includes stipends for local health the local level workers as part of annual budget. to national and I.18.% of selected areas with joint Percentage, documents Semester for communication and decision- bi-national inter-sector planning of Zika areas making levels for prevention and control coordination policy making. including other stakeholders and communities

I.19. # of public information count, events Reports , Semester for communication and decision- meetings or other means on progress Lists of making of Zika control plans at the local participant level. I.20. Number of exchange and count, events Reports , Semester for communication and decision- learning meetings held at local, Lists of making national, binational and participant international levels. # communities with community Count documents Quarterly for communication and decision- plans for the prevention and control making of Zika.

3. ENVIRONMENTAL MANAGEMENT & MITIGATION PLAN (EMMP)

The necessary actions have been taken to comply with the provisions of the "INITIAL ENVIRONMENTAL REVIEW", especially in Section 2.6. DETERMINATIONS AND CONDITIONS RECOMMENDED.

Project: Zika Response in Ecuador and Peru Life of Project: October 1st, 2017 to September 30th, 2019 Implementing Agencies: CARE Ecuador and CARE Peru

Persons responsible for overseeing implementation of the EMMP: Cecilia Tamayo Project Director, [email protected]; Maria Espinoza Project Manager for Peru, [email protected]

Currently in both countries progress is made in the fulfillment of the established commitments.

3.1. Environmental Mitigation and Monitoring Y1 Report:

Following the first year the report is presented.

Environmental Mitigation and Monitoring Y1 Report (EMMR) List each List any outstanding issues relating to required Mitigation Country Status of Mitigation Measures Remarks conditions Measure At the start of each training event it is verified that the areas are clean and orderly, and that there are bins for solid waste disposal during the event. Food service providers will have restricted use of plastics, technopor and other disposable materials during training Incorporate issues of solid and liquid waste management into events. Instead, they will use paper bags and crockery or the methodological guidelines for training courses. glassware. Prepare and confirm approval of a checklist for during and -The project team has some educational materials made with after the event. sturdy materials that allows for their continuous use. We will recommend CARE´s Promote among participants the use of USB flash drives at all Two banners are used for all events in order to avoid administrative team to include a clause events to save files electronically instead of printed materials. excessive use of synthetic materials and to rationalize on restricting the use of disposable Implement an electronic monitoring card to report compliance expenses. materials on all food service orders. with the guidelines. Sheets of paper are reused for the printing of technical CARE employees need to be made Incorporate in the satisfaction sheet the fulfillment of the documents (such as training guidelines), administrative aware of the importance of rationalizing Peru established rules of coexistence such as the care of the documents (such as training event expenses) and others the use of paper. environment and space where the events take place. (such as copies of invitation documents). The officials responsible for Prepare educational materials, directed towards Also, when event participants do not require a paper environmental management and/or environmental managers, on the importance of solid waste 1. Education, invitation, they are invited electronically (by email, WhatsApp solid waste collection services should management in the prevention of metaxenic diseases. Technical messages or text message) or phone calls. be included at trainings or project Request further information from the health authority Assistance, -During the training events promoted and/or funded by the awareness events. regarding the harmful effects on the environment that may be Training project, there is always a CARE employee verifying caused by pyriproxyfen, a hormonal inhibitor that is currently compliance with environmental care guidelines. being used in some districts of the Piura Region, replacing -The educational materials used contain messages consistent temephos with environmental regulations and the presentations and communication material strengthen messages of physical removal of the vector. -The project does not include the purchase of pesticides or repellents. During the training workshops, the issue of proper use of water, recycling and solid waste management has been Within the framework of agreements addressed. with GAD's, institutional officials have Sheets of paper are reused for the printing of technical Provision of services of differentiated waste collection for final been trained in the use of protocols with documents (such as training guidelines), administrative disposal by the municipalities. Ecuador adequate practices for the management documents (such as training event expenses) and others Promote among participants the use of USB flash drives at all and final disposal of containers and (such as copies of invitation documents). events to save files electronically instead of printed materials. wastes likely to become potential In event participants do not require a paper invitation, they are breeding sites. invited electronically (by email, WhatsApp messages or text message) or phone calls.

39 In each district, facilities have been identified that meet basic requirements such as having good lighting, ventilation, and sanitation services, for the convenience of participants. The project promotes the use of repellent and light-colored, long-sleeved clothing, to avoid mosquito bites. Fieldwork activities have been carried out during daytime hours. Develop a checklist for during and after each focus group. Due to the outbreak of dengue, Before conducting the KAP surveys, the appropriate location Develop a checklist. chikungunya, and Zika in the Piura and inputs are verified, as well as all the necessary Prepare safety briefing for field teams. Region and the large proliferation of permissions from participants. Peru In times of rains this measure can become difficult, which will mosquitoes, it was necessary to use During the trainings the project recommends the use of light affect personal protection measures. laminated repellent pads (which work clothing, long sleeves, and insect repellent. Develop a safety booklet that includes preventive measures with plugs connected to electrical Security is provided for the field teams using convenient and specific field work procedures. installations). 2. Research transportation with drivers that know the route. and We look for places that are clean, with adequate hygienic Development services, and with no exposure to the vector. We promote the use of repellent on the work team in the areas with greatest vector presence and cases. Prior to field visits, facilitators and researchers are reminded of measures to prevent mosquito bites.

With personnel who have participated In meetings with health personnel, municipalities and Establish a formal agreement with health personnel, GADs, in surveys and other field activities, it community, emphasis is placed on the use of appropriate Ecuador and community to implement this prevention and control has been urged that they implement the clothing as protection, as well as the use of repellents to strategy. advice on personal protection and reduce man-vector contact. prevention

Peru Not applicable to CARE Peru Not applicable to CARE Peru Not applicable to CARE Peru

3. Small- Scale Water and Within the framework of the agreements Community training in appropriate water use practices, Sanitation The municipalities have limited resources to provide an signed with GAD's, the need to manage Ecuador including covered storage when necessary, as well as adequate system of water supply and proper disposal. resources has been suggested to the appropriate wastewater disposal (proper drainage). corresponding instances.

40 Some municipalities in the project intervention areas have carried out garbage collection campaigns. Work plans agreed between health establishments and local governments emphasize the physical elimination of needless materials from the municipality's environmental management office. *Elimination of mosquito breeding sites within homes and educational institutions has been promoted.In addition, with funds from other projects, CARE donated 20 motor pumps to drain the water accumulated resulting from the intense rains of the El Niño Costero Phenomenon.Local governments are encouraged to carry out the removal of ditches and Revise work plans and Monitor compliance plans. Awareness elimination of stagnant water caused by the rains.As part of and training of municipal personnel responsible for the the promotion of preventive measures, local populations are collection of solid waste.Ensure the health sector incorporates advised to clear these near their homes, to avoid mosquito the same messages in their intended action plans. Awareness breeding.*The municipalities, regional government, and and training of municipal personnel responsible for the Ministry of the Environment have identified sensitive collection of solid waste.Ensure the health sector incorporates It is necessary to share information and ecosystems and are responsible for their management.CARE the same messages in their intended action plans. Require experiences on environmental has an environmental care policy that staff must make the inventory of wetlands, water sources, and management from other CARE effective in their interventions.*Project personnel are familiar mangroves.Include in the project information material that projects. There are wetlands in the with the Malathion insecticide regulations used in thermo safety measures against the pesticide will be developed. districts of Veintiséis de Octubre and Peru nebulization activities for the removal of adult mosquitos. Organize meetings with MINSA, Regional Health Directorate, Sechura.Abatization is an activity widely These specifications are found in the Technical Health professional colleges, and researchers on products used in known by the population, and the Standard for the Implementation of Monitoring and Control of vector control activities.There is already a Ministry of Health reluctance to use it mostly has to do 4. Vector Aedes aegypti, Dengue Vector in the National Territory, protocol for household inspections and Temephos with erroneous beliefs or mistrust within Control approved by R.M. 797-2010 / MINSA.*In training activities, application.We need to strengthen this topic in the population. families are recommended to leave the Abate (temephos) communications with the population. Request reports post- inside the water containers, since it is a substance that is safe them nebulization activities, to learn the effectiveness of for human health.There is currently no evidence of informed malathion.Project staff need more information about rules and consent from families and communities during the regulations to propose changes, include Zika PERSUAP and “abatización” In meetings with DIRESA it is promoted that sensitive ecosystems in the project areas prior to fumigations, local populations are informed of the fumigation schedule and the upcoming measures.*Project staff participated in one training session for volunteer health inspectors on the use of pyriproxyfen. They also participated in a meeting for communicators where ideas were exchanged on how to properly inform the population about this new product.*The Ministry of Health has a protocol for household inspections and Temephos application.A training course on vector control protocols was held for 20 facilitators, and information has been provided through electronic means. The Project is developing activities to create awareness in the community for In events with community and other stakeholders, the need to the identification of risk, collection and The community does not consider certain containers as improve the home environment to reduce potential vector adequate disposal of recipients and Ecuador potential hatcheries and does not carry out a periodic removal breeding sites was highlighted. Removing unusable artificial potential nurseries through community of these containers. containers and others. participation days, ludic-educational activities in schools and schools and agreements with local governments.

41 CARE Piura staff have participated in technical groups on health, health communications, water and sanitation, education and shelter, spaces formed in the wake of the Niño Costero phenomenon. Activities are carried out in accordance with the emergency protocols established by COER Lambayeque. A meeting was held with the COER representative to follow up on the implementation of Risk Management Plans and Municipal Contingency Plans that include measures against Systematization of experiences (in process). Zika. Follow up to COEL pending. The COEL of the Municipal District of Aguas Verdes Incidence in COER and COEL on the elaboration of Peru incorporated the Contingency Plan against the phenomenon contingency plans against Zika and other metaxenic of el Niño Costero, and with the technical support of the diseases. 5. project, vector control against Aedes aegypti was Follow up on the COEL of the districts prioritized by the Emergency incorporated (the plan is being approved). project is pending. Response *CARE Peru, through a different funding source, has delivered 4,185 humanitarian aid kits in Piura, which included: safe water, personal hygiene, and protection (mosquito nets and repellents) and also carried out health education regarding the use of these kits and physical prevention measures. The project coordinated with the COER for the storage and distribution of humanitarian aid.

The project staff has joined the emergency response The coordination of activities is developed with different Ecuador mechanisms and acts according to established protocols and stakeholders so that each one assumes the role that standards. corresponds to him depending on his availability.

3.2. Years 2 & 3 Environmental Mitigation and Monitoring Plan

Activity 1: Education, Technical Assistance, Training (including Policy Guidance) Typically, there are no direct adverse environmental impacts resulting from this category. Indirect impacts are possible if care is not taken to ensure appropriate environmental considerations are incorporated into education programs, technical assistance, trainings, and policies. IEE Condition Mitigation Monitoring Timing and Responsible Parties During the educational, training and • Review and improve methodological guides and  Use of checklists for quality  CARE staff; during technical assistance activities, solid education and training tools to make explicit control during and after training Education, Technical wastes are generated that must be mention of the correct management of solid and activities. Assistance, Training. managed appropriately. liquid wastes generated at these events. Q2, Q3, Q4. • Promote the reuse of educational and outreach materials, along with limited use of disposable materials. • Conduct monitoring and feedback to ensure the correct application of these guidelines. The contents of vector control • Review training plans and educational materials CARE staff; during training for communities and to ensure they contain messages that are • Report on educational and Education, Technical technical staff must be in line with consistent with environmental regulations. communication materials Assistance, Training. Q2, environmental regulations. regarding compliance with Q3, Q4. environmental regulations

Activity 2: Research and Development Typically, there are no direct adverse environmental impacts resulting from this category. Indirect impacts are possible depending on methodology and approach for data collection and surveillance. Illustrative examples include: • Introduction of new modes of vector-borne transmission if health and safety protocols are not followed. • Risk of social unrest or physical harm to data collectors in locations where public sensitization has not previously taken place or public misinformation results in fear of outsiders (as witnessed during the Ebola crisis). IEE Condition Mitigation Monitoring Timing and Responsible Parties During data gathering and community • Methodological guides and research tools, such  Use of checklists for  CARE staff; during investigation activities, there is a risk of as focus groups, explicitly define appropriate quality control during and and after “focus increased exposure to vectors. places and times to prevent vector exposure, after “focus group” group” activities. especially when working with women's and youth activities. Q1, Q2. groups. • The Project implements simple prevention measures, such as wearing light colored clothing, long sleeves and insect repellent. • Conduct monitoring and feedback to facilitators to ensure that guidelines are implemented properly. During home visits or direct observation • Methodological guides, observation tools and KAP Use of checklists for quality CARE staff; during tours of the environment to identify KAPs surveys are designed with explicit reference to the control during and after the and after “focus in the prevention and control of vector- scheduling of appropriate spaces and hours for working direct observation and KAP group” activities. Q1, borne diseases, there is a risk of increased days, especially when working with women's and survey activities. Q2, Q3, Q4. vector exposure. youth groups. • The Project will take basic prevention measures, such as wearing light colored clothing, long sleeves and insect repellent. • Monitor and feedback facilitators to ensure that guidelines are being implemented properly.

Activity 3: Small-Scale Water and Sanitation In these interventions, the positive environmental impacts significantly outweigh any negative externalities. The negative impacts are minimal, and can be controlled in a variety of ways. IEE Condition Mitigation Monitoring Timing and Responsible Parties Improvements in Community and • Review plans to improve water and  Reporting on the compliance of CARE staff; during Municipal Water and Sanitation sanitation systems to ensure they are water and sanitation systems with interventions in water Systems must abide by existing rules consistent with environmental regulations. environmental regulations. and sanitation systems. and regulations. • Promote appropriate water use practices, Q3, Q4. including covered storage when absolutely necessary, and appropriate wastewater disposal (proper drainage). • Disseminate appropriate domestic and community sanitation practices (disposal of containers, tires, garbage dumps, etc.) The Project will work with Municipal • Revised solid waste management plans Reporting on compliance with CARE staff; during Governments to encourage to ensure their correspondence with environmental regulations in the area interventions in solid improvements in solid waste environmental regulations. of solid waste management at the waste management. management in the framework of • Appropriate solid waste management household and Municipal Government Q3, Q4. existing laws and regulations. practices disseminated to the public to levels. prevent the creation of potential mosquito breeding sites at the household and community levels. • Workshops with the community in coordination with local governments to collect containers, tires and other items, and ensure adequate final disposal.

45 Activity 4: Vector Control The primary tenant in vector control is environmental modification, that is altering the environment so specific vectors cannot exist, or reducing to such an extent that their presence is so minor they no longer pose a threat. There are several approaches to vector control (environmental modification, surveillance, fumigation, IRS, LLINs), each with varying degrees of potential impacts and requisite mitigation measures. Physical environment alterations: remove or reduce the locations where vectors breed, for mosquitoes this may range from eliminating areas of standing water around town to drainage of stagnant ponds or alternation of waterways to increase water flow. Such approaches must be carefully planned to limit the impact to sensitive biological areas. IEE Condition Mitigation Monitoring Timing and Responsible Parties Physical vector control actions include the identification • Strengthen municipal vector  Reporting on the CARE staff; during and removal of mosquito reproduction sites, the draining control plans, when they exist, to compliance of physical interventions in of stagnant water when possible, while taking care not to ensure that they are implemented in vector control efforts with vector control affect sensitive ecosystems and complying with existing accordance with environmental regulatory frameworks and systems. Q3, Q4. laws and regulations. regulations. standards. • Appropriate practices have been promoted in the area of identification and removal of mosquito breeding sites and management of standing water and drainage systems. • Identify areas with sensitive ecosystems to promote protective actions. • Strengthen processes with municipal technical teams regarding training and application of existing environmental norms and regulations. The Project does not include the application of chemical Reporting on vector control CARE staff; during pesticides nor biological larvicides, which are handled by • To give continuity by informed activities involving the interventions in the Ministries of Health; however it will work with the consent of families and communities in application of chemical and vector control population and the community to ensure informed consent relation to the abatement (temephos biological substances and systems. Q3, Q4. and with the ministries to determine the types of products 1%) made by MPH. regulatory frameworks. that are being used, and the corresponding regulations. • Socialize learning with government and academic agencies on evidence- based analysis and best practices in the application of these products. 46

Activity 5: Emergency Response

IEE Condition Mitigation Monitoring Timing and Responsible Parties  Emergency response efforts includes  Project staff will participate in inter-institutional  Reporting on  CARE staff; in the action that could have impacts on the coordination mechanisms at the national and local level, compliance with event of emergency household and community and will proceed in accordance with established emergency response response situations. environment. emergency response protocols. protocols.

47 4. ANNEXES:

4.1.ANNEX 1. Project Partner & Allies Mapping.

48 Institution Interest Resources Type of Relationship Relationship Strategy Contact person Description Potentials Actor status 1. STRATEGIC PARTNERS USAID-Peru Accompaniment and Articulation and relationship Active to Partnership Member of the Steering Jaime Chang. monitoring of the with government actors and other Donor Agreement Committee (Binational) development of the Project. technical resources (specialists) Strengthen the role of the Technical inputs for C4D, Active to Initiated Member of the Steering Ma.Luisa Fornara UNICEF community in local health learning and political incidence. Donor Coordination Committee (Binational) (Peru representative) Representation Peru systems to reduce the Zika Cooperation and coordination (Peru). Specific agreement And Ecuador direct and mitigate its impacts on with actors such as USAID, Cooperation Permanent participation in Hugo Razuri (Peru Health partner in this families. MSP, Others. Agreement the Zika cluster. Officer ) Initiative (Ecuador) Coordination with provincial Grant Leaity representatives of UNICEF Ecuador Representative (Ecuador) Katherine Silva (Ecuador Health officer). Ministry of Health of Reduce the impact of the Regulation, Active in Good Member of the Steering Minister of Health Ecuador Zika virus in Ecuador, with Planning and coordination, favor relationships but Committee (coordination in process ) measures of promotion, responsible for the National Plan. low profile Direct relationship and Consuelo Santamaría prevention, detection, Decentralized Structures with through strategic partners National Undersecretary of monitoring, control and EAIS and TAPS such as UNICEF, PAHO and Health Promotion and Equality. recovery and risk Program and budget. UNFPA Inti Quevedo Bastidas communication. Undersecretary of Public Health Surveillance. Ministry of Health of Regulator of public health in Political decisions and technical Active in We have a Higher political will and Minister of Health. Peru the country resources favor favorable opinion predisposition for Patricia Jannet García Funegra document to the collaborative work (General Deputy Minister of Public project Directions). Health Silvia Pessah Pending: Complementarity of efforts General director of Invitation to join for synergistic interventions María del Carmen Calle Strategic the Steering (technical units). Dávila Interventions in Committee Strategic Director of Public Health Member of the Steering Interventions in Public Health Center for Committee Dra. Gladys Ramírez Epidemiological Director General of Surveillance and Epidemiology Disease Control

49 General Direction of National Authority on It proposes standards and directs Active in Initial Collaborative work Mirtha Trujillo Environmental Health Environmental Health and monitoring and super-vigilance favor Coordination General direction (DIGESA) Food Safety actions General Direction for The Department of They have the legal mandate in Active in Initial Approach to the managers, Eduardo Alvarado Vásquez. Health Promotion and Community Participation health promotion activities, favor Coordination presentation of the project General direction. Territorial develops strategic alliances specialized personnel and and proposal of articulated Management with institutions and social financial resources work. organizations for citizen participation.

General direction for Assist and guide MINSA in They have the legal mandate in Active in Initial Approach to the managers, Lily Sánchez Vera. Communications the formulation of communication activities in favor Coordination presentation of the project General direction communication strategies health, specialized personnel and and proposal of articulated and manage strategic financial resources work. communication plans and health advertising campaigns. 2. GOVERNMENT ORGANISM Ministry of Education Rector of Education in Collaboration in sensitization to Potentiall In process National and sub-national Maria Ines Gutierrez Prado of Peru Peru the educational community, y active in coordination in the C4D Chief of the Office of National -National Defense favor strategy Defense and Disaster Risk Office Management. -DREs MINEDU. -UGELes Angelica Maria Montané Lores, General director of the General Directorate of Regular Basic Education

DREs Tumbes: Walter Raúl Ponce Serna Piura: Mg. Pedro Periche Querevalú – Lambayeque Education Regional direction: Ulises Guevara - Regional Manager of Education and UGELes Jaén: Luciano Troyes Rivera - UGEL Direction

50 Ministry of Education School health, be part of Regulation, Planning and Active in Non-formal with Meeting with authorities and Sucre Canton Education of Ecuador the national response plan coordination, responsible for NNA favor local district presentation of the project in District. Ing. Richar Cevallos to Zika. education. authorities. the provinces of Manabí Education district. Huaquillas, Include content, De-concentrated level to Excellent with Esmeraldas and El Oro. Las Lajas y Arenillas Education educational materials. communities. schools Establish joint agreements. District Lcdo. Darwin Azansa Interest in relation to Muisne Education district. UNICEF Diosa Cuero It continues to be managed at the national level Manta To reduce the impact of Regulation, Planning and Active in Good relations Establish relationship Alberto Velíz Mera Portoviejo the Zika virus in the coordination, responsible for the favor Mariella Macías Sucre – San Vicente territory, with measures of National Plan in territory. Ángela González Jama – Pedernales promotion, prevention, Decentralized Structures with Jorge Cedeño Muisne detection, monitoring, EAIS and TAPS Sazquia Lastra Huaquillas, Las Lajas, control and recovery and Program and budget. Grace Mendoza Arenillas Health communication of risk. district Ministry of Culture of Report and Communicate National media (Radio and TV) Potentiall To start Approach to the managers, Executive director: Hugo Coya Peru: National Institute the y active in presentation of the project Honores of Peruvian Radio and Informar y Comunicar las favor and proposal of articulated Television - IRTP work Ministry of Labor of Generate knowledge about Members of the Latin American Potentiall To start Approach to the direction of Patricia Rosario Pimentel Peru: ESSALUD potentials in Zika effects to Network for Health Technology y active in the IETSI, presentation of the Álvarez ( IETSI Director) (Institute of sanitary insured population. Assessment. Access to specialized favor project and proposal of evaluation and scientific information systems. articulated work investigation) Highly specialized HR Ministry of Defense of Potentiall To start Approach to managers at Luis Alfonso Zuazo Mantilla, Peru: y active in national and regional level. Head of INDECI (in charge) National Institute of favor Civil Defense - INDECI 3. SUBNATIONAL GOVERNMENTS Peru Regional According to the Political decision, financial resources Potentiall To start Approach to the Governors, Governments Organic Law of (PpR, and PP) and technical y active in presentation of the project (GORE’s) Regional (DIRESAS). favor and proposal of articulated GORE Tumbes Governments, its work Governor of Tumbes: Ricardo essential purpose is to Flores Dioses GORE Piura promote regional Governor of Piura: Reynaldo development, integral, Hilbck

51 GoRe Lambayeque sustainable. In terms Governor of Lambayeque: of health, GORE's Humberto Acuña Peralta. GORE Cajamarca promote and carry out Governor of Cajamarca activities to promote Hilario Porfirio Medina and prevent health, Vásquez people and the environment Municipalities of Promotion of health Exclusive competence in the provision Active in Cooperation Meeting with authorities and Manabí: Manabí, Esmeraldas related to water, of water, sanitation and solid waste favor Agreements presentation of the project in Rossana Cevallos Torres, and El Oro of Ecuador: sanitation and solid services. signed with 10 the provinces of Manabí Alcaldesa de San Vicente waste, as well as Installed capacity in social GADs Esmeraldas and El Oro municipal mayor Manabí: Healthy development and OOPP. Establish joint agreements Angel Rojas, Jama municipal Municipalities of San Municipalities. Environmental Management Units mayor Vicente Budget items and share cost in kind Gabriel García Robles, Jama, Pedernales municipal mayor Pedernales, Manuel Gilces Mero, Sucre Sucre, municipal mayor Manta and Jorge Zambrano Cedeño, Manta Portoviejo municipal mayor Agustín Casanova Cedeño, Esmeraldas: Portoviejo municipal mayor Municipality of Muisne Esmeraldas: Eduardo Proaño Gracia El Oro: municipal mayor Municipalities of El Oro: Arenillas, Jhon César Chérrez Anguizaca, Huaquillas and Arenillas municipal mayor Las Lajas Ronal Wilfrido Farfán Becerra, Huaquillas municipal mayor Willian Valencia Valdéz, Las Lajas municipal mayor Municipal According to the Political decision, financial resources Potentiall To start Approach to Provincial and Tumbes municipal mayor Governments of Peru Organic Law of (PpR, and PP) and technical. y active in District Mayors, presentation Municipalities, they favor of the project and proposal of Manuel Diego Enrique De Lama are governing bodies, articulated work Hirsh Contralmirante Villar, promoter of local Contralmirante Villar municipal Tumbes development, their mayor Municipality Provincial competencies are Mercedes Jacinto Fiestas linked to the provision Zarumilla, Tumbes Félix Garrido Rivera, Zarumilla Provincial municipal mayor

52 Municipality of local public services: Aguas Verdes district Environmental Ely Pintado Córdova, Aguas Municipality sanitation, health and Verdes District Mayor (Zarumilla, Tumbes) health, and the Piura district protection and Oscar Miranda Martino, Piura Municipality (Piura, conservation of the District Mayor Piura) environment Castilla district Municipality (Piura, Piura) Catacaos district Juan Francisco Cieza Sánchez, Municipality (Piura, Catacaos District Mayor Piura) Cura Mori district Macario Silva Vilches, Cura Municipality (Piura, Mori District Mayor Piura) Veintiseis de Octubre Práxedes llacsahuanga, 26 de district Municipality Octubre District Mayor (Piura, Piura) Morropón district José Montenegro Castillo, Municipality Morropón District Mayor (Morropon, Piura) Chulucanas district Chulucanas District Mayor Municipality Jose Montenegro Castillo (Morropon, Piura) Sullana district District Mayor Sullana Carlos Municipality (Sullana, Tavara Polo Piura) Bellavista district Bellavista (Piura) District Municipality (Sullana, Mayor Segundo Aguilar Piura) Seminario Talara Province Talara District Mayor Municipality Jose Bolo Bancayan Los Órganos district Los Organos District Mayor Municipality (Talara, Jhonny Tinedo Marchan Piura)

53 Máncora district Mancora District Mayor Municipality (Talara, Victor Hidalgo lopez Piura) Sechura district Sechura District Mayor Municipality (Sechura, Piura) Jaén district Jaén, District Mayor Municipality (JAén, Walter Prieto Maitre Cajamarca) Bellavista de la Union Bellavista District Mayor district Municipality Juan Fernandez Perez (Sechura, Piura) Local Media in Peru Piura radio Media with audience. Active in In process Communicate Velia Concha - Radio Cutivalu favor Direction (Piura) Manuel Antonio Bazán Chero . Industry Diaries Newspaper Director Lambayeque diary. Local Press. INDECI Implements response Active in Good relations Tumbes: actions in sub-national favor SESSAREGO CRUCHETT, governments and civil MANUEL EDUARDO society to emergencies DIRECTOR OF THE DESCONCENTRATED DIRECTION OF TUMBES

Piura: PEREZ LEAL, ORISON

Lambayeque: BASAURI ARAMBULO, AGUSTIN SIMON ELADIO

Cajamarca: NUÑEZ CARRION, JORGE DAVID Regional Direction of Joint work, includes working Tumbes: Wilmer Jhon Davis Health (DIRESAS Y with Municipalities for PPR. Carrillo GERESAS) Rector of public health in the country. It establishes the technical guidelines in

54 relation to the health Piura: Hernán Efilio García of the population Cabrera

Lambayeque: Pedro Cruzado Puente - Regional manager Cajamarca: Juan Valencia Hipólito Head of the Regional Health Directorate 4. INTERNATIONAL COOPERATION: a) Bilateral Binational Sustainable development Access to financing and advocacy Potentiall In process Presentation of the Project Development Plan for of the border region y active in the Border Region favor b) Multilateral PAHO Technical advisory body of Experience in global health, access Potentiall Coordination of Defined the articulation of Raúl Gonzales the Ministries of Health of to up-to-date scientific y active in actions and actions in communication ( Peru representative) Peru and Ecuador with a information, convening capacity. favor advocacy with strategy and Zika prevention Celso Bambaren (Peru RRD ). spokesperson for public Execution of related projects MoH and control. GinaTambini policies In Ecuador Ecuador representative. Martha Rodríguez – Communication Consultant César Díaz - Epidemiologist

UNFPA Technical advice on sexual Agreement with the Peruvian State Potentiall To start in Peru Articulation of actions and Elena Zuñiga (Peru and reproductive health to provide methods of family y active in technical support representative and specialized planning, Implementation of favor In Ecuador is Zilda Carcamo (RRD Peru) spokesperson related projects defined the Ecuador advises the National cooperation and Mario Vergara –Ecuador Government in SSR articulation of representative activities in SSR Soledad Guayasamín- SSR and prevention of specialist. Zika SAVE THE Experience in working Potentiall Agreement signed in Santiago Dávila (Ecuador CHILDREN with children and y active in Ecuador, includes articulation Director) community work. favor with the Zika Project in Aníbal Velásquez (Director of Central America Zika Project in CA)

55 ORAS CONHU Regional support body to Support for the construction of Potentiall First approaches Presentation of the Project the Ministers of Health of shared agendas between the y active in Involved in learning for Luis Beingolea the Andean Region Ministries of Health. favor inclusion of Zika in regional (Executive Secretary) health strategies Cruz Roja Ecuatoriana Part of its institutional Volunteers Active in Good relations Identify the management San Vicente Red Cross agenda Link with WHO for the specific favor levels. Presentation of the Rosa Cevallos Health and community topic of Zika project in the provinces of It continues to be managed at development Manabí Esmeraldas and El the national level Oro Joint agreements 5. ACADEMY National University of Generation of Strengthening national research and Potentiall To start Recovery of experiences of Jorge Alarcón Villaverde. San Marcos scientific- development capacities in key areas for y active in working together with the Direction (UNMSM). Center for technological alliances competitiveness favor UNMSM Biomedical and between the Peruvian Environmental State, companies, Technological universities and Research. national and foreign research centers. Peruvian University Eduardo Gotuzzo, Cayetano Heredia Direction (UPCH) Institute of Tropical Diseases Alexander Von Humboldt Pontificia Universidad Lucho Peirano Catolica del Peru Rómulo Franco PUCP- Faculty of Marcial Rubio Communication for Marcela Chueca Development and Carlos Eduardo Aramburu Faculty of Social Sciences Central University of Student practices in Active in Alliance work together. Marcelo Aguilar. Ecuador: Faculty of vectortrol activities, favor Community Link Project Director of the Institute of Medicine Zika prevention, Public Health detection of suspected cases through visits to homes Generation of scientific evidence

56 Technical University of Training of human Installed capacity in Manabí. Active in Approach Vicente Veliz Briones. Manabi talent. Community Link Programs favor Alliance work together. Rector of the University Studies and research. Community Link Project Yira Vázquez. Internships for Dean of the Faculty of Health undergraduate Sciences students 052632677 Technical University of Student practices in Active in In process alliance for work. Dr. Efrain Beltran. Machala vectorrol activities, favor Community Link Project Medicine Zika prevention, visits to homes Generation of scientific evidence Andina Simón Bolívar Meta-analysis of Theoretical and methodological Active in To start Jaime Breilh. University studies on Zika proposal of community epidemiology favor Rector Training of human Postgraduate studies and research. 0992949390 talent. Community Link Programs. Eloy Alfaro Laica Proposals for Programs of connection with society Active in Approach and Meeting with authorities and Miguel Camino Solórzano University articulated work with favor joint activities presentation of the project. 0980488433 local institutions Establish joint agreements Technical University of Proposals for Programs of connection with society Active in Approach Meeting with authorities and Omelio Gorroto Southern Manabi articulated work with favor presentation of the project. 0998446988 local institutions Establish joint agreements 6. OTHER RELEVANT ACTORS Network of Friendly The Plan of Action of A space of concentration and mutual Active in To start Through the Municipality of Municipal mayor :Marco Municipalities and the Network includes support that allows municipalities to favor San Borja, active partner of Alvarez Vargas Communities among its priorities develop healthy projects, programs and the network. the protection of public policies aimed at improving the environmental health quality of life of the population, and climate change facilitated by the Ministry of Health of Peru with the support of PAHO / WHO Professional Schools Medical College, Advocacy for policy decisions and Active in In process Political will and Tumbes: Obstetrics College technical resources favor predisposition for Rina Marlene Bejarano Tafur, collaborative work Regional Council XXIII Tues Piura: Arnaldo Lachira, Medical College -VII Piura Lambayeque: Juan José Cruz Venegas, Regional Council VIII Chiclayo Cajamarca:

57 Edmundo Zambrano Linares, Regional Council XVII Cajamarca MIDIS It is a body of the . Active in To start Tumbes: Executive Branch favor Rosa Marleny Torres Beltrán whose main objective 994423498 is to improve the [email protected] quality of life of the population in situations of vulnerability and poverty, to promote the exercise of their rights, access to opportunities and the development of their own capacities. National Humanitarian Contribute to risk Public and private organizations with Potentiall To start Presentation of the project Ana María Rebaza (co-leader- Network prevention and the capacity to articulate efforts y active in and articulation of work plans OCHA) and y Luis Alfonso Cluster: Protection and mitigation towards common goals before the Zika favor in the sectorial tables Zuazo Mantilla (co-leader Cluster Health (clusters) INDECI)

Young Community Development of life Education and prevention programs Active in Approach Meeting with authorities and Hirma Peñafiel Reporters skills and abilities favor presentation of the project. 0989615839 Ecuador Establish joint agreements ZAP (vectorontrol), CARE should If these actions are ASSIST and UNICEF collaborate with them implemented in Peru and Project as well. Ecuador in FY18, will facilitate coordinated activities aimed at improving the implementation.

58 ANNEX # 4.2

Identification of the Best Practices through a Competition

Background

The main objectives of the Bi-national Project “Zika Response in Ecuador and Peru” are to increase community, local and national capacities to deliver efficient and timely response to the Zika Virus outbreak, and enhance regional and national efforts to help decrease the rates of Zika transmission. Therefore, knowledge management and policy advocacy are cornerstones for achieving the proposed results.

One of the results to be achieved by the project is the identification of the best practices validated and lessons learned in prevention and control of the Zika Virus in order to disseminate and replicate them in different regions of the country, and achieve their institutionalization through renewed intervention strategies and policies, helping to strengthen the Government’s capacity for prevention and response to the Zika Virus at all levels. For this reason, a first milestone towards achieving these results is the identification of best practices for them to be disseminated and promoted. Considering that the Ministry of Health (MoH), Local Governments, and various civil and non-governmental organizations are promoting and developing actions and initiatives for the prevention and control of diseases transmitted by Aedes Aegypti, it was determined that a more efficient strategy for the identification and collection of innovative and effective practices at national level is the promotion of a competition that recognizes and rewards them.

In this way, the data collection process was reversed because the project, through the competition, created interest among managers who sent applications.

Best Practices Prize

CARE Peru together with the Civil Association “Ciudadanos al Día” (CAD)1, created the Prize for Best Practices in Prevention and Control of Zika as a platform for recognition to identify, document, reward, share and promote the replication of successful experiences of communities and private and public institutions in the prevention and control of the Zika Virus. In order to align the documentation of the applications with the project objectives regarding evidence-based analyses (EBA) of community surveillance and vector control systems, the following categories were established in the rules of the prize:

1. Citizen and Community Participation in Vector Control.

This category includes cases where community members in the intervention area participated actively and responsibly in prevention, surveillance and/or control activities and strategies. Applicants must particularly show that, as part of efforts to prevent and control the Zika virus disease, the community played a key and pivotal role by being an active part of the management of the project at different stages.

2. Cooperation between Public Agencies in Surveillance and Control.

This category includes experiences of prevention, surveillance and/or control of the Zika virus disease that have been managed by an array of partner governmental agencies that share responsibilities, strategies, resources, among others. The approach in these experiences is the work articulated as a strategy to achieve beneficial results for the citizens.

It was also established that candidates should be public and private institutions (social, non-profit organizations, non-profit or for-profit organizations, and private companies).

Process

The process of identifying the best practices in prevention and control of the Zika virus is as follows:

1. Creation of an Specialized Team:

1 Since 2005, the renowned Award on Good Practices in Public Management is organized on an annual basis by the Civil Association “Ciudadanos al Día”. (See: http://www.premiobpg.pe )

59 The specialized team included professionals representing the Ministry of Health, USAID, UNICEF, and PAHO, who developed the prize rules2 and the evaluation criteria.

2. Dissemination of the Prize: To ensure an adequate invitation and participation of communities and public and private institutions, the prize delivery was disseminated through media interviews and press conferences in the three regions targeted by the project. This made it possible not only to position the Project “Zika Response in Ecuador and Peru”, but also incorporate the Zika virus as a public health issue in the media agenda.

3. Reception of Applications: Ciudadanos al Día reviewed all the applications to verify whether the information complied with the requirements listed in the competition rules. To make registration easier, an online3 registration form was developed.

4. The Team Deliberation Process: Two working groups were formed, and each one focused on reviewing the applications for practices by category, verifying the criteria for inclusion of best practice. Also, the team prepared a shortlist of three finalist practices so that the jury were able to determine the winner. The evaluation criteria established in the rules are as follows:

a) Citizen welfare: the application report should give account of an experience oriented to citizens, this means that its implementation has made it possible for people to be better off in quality of life, especially in the preservation of health. b) Result indicators: the application report should describe and support the results achieved after the implementation of the experience. These results should demonstrate positive changes for people and their environment c) Potential for replication: The practice should demonstrate that has potential for replication and/or has been replicated by others in the same agency or by third parties.

5. Jury Decision: From the shortlist submitted by the team, the jury chose the winning practices based on the criteria evaluation. It should be noted that the jury consisted of leading figures in the scientific and academic fields. (Pictures)

See below a few pictures of the milestones that marked the development of the process for organizing the Prize for the Best Practices in prevention and control of the Zika virus.

Creation of Specialized Team Dissemination of the Prize Team Deliberation Process Jury Decision Award Ceremony

Results

As a result of this process, 23 best practices were identified, a winner in each category was selected, and an honorable mention was given. These were recognized at an award ceremony attended by each of the managers that submitted applications, and various key actors of the project. The applications represent 7 regions in the country.

2 See below the rules of the Prize to Best Practices in Prevention and Control of the Zika Virus: http://www.care.org.pe/wp-content/uploads/2017/02/Bases-del-Premio-a-las-Buenas-Pr--cticas-de-Prevencion-y- Control-del-Zika-final.pdf 3 Online registration form: https://form.jotformz.com/70583985856677

60 Region Category: Citizen and Community Category: Cooperation between Participation in Vector Control Public Agencies in Surveillance and Control Cajamarca (Jaén) 2 1 Callao 1 0 Iquitos 0 1 Lambayeque 2 4 Lima 1 5 Piura 1 1 Tumbes 5 1 Total 12 11

The winning practices were4:

Name of practice Category Region Articulated and Multi-Sectorial Response to Cooperation between Public Metaxenic Diseases: Dengue, Chikungunya Agencies in Surveillance and Lambayeque and Zika in the District of Pátapo 2016 – 2017 Control Community Response for Elimination of Aedes Citizen and Community aegypti Mosquito Breeding Grounds in the Lambayeque Participation in Vector Control town of Batangrande

It should be noted that the jury decided to give an honorable mention to the Best Practice in Prevention of Zika with Multi-Sectorial Public Actors in Epidemiological Stage II that the Public Health Committee in Miraflores submitted for the management that was implemented to develop effective prevention measures in the District of Miraflores, Lima.

After the success of the invitation and response of communities and public agencies, the organization of two more editions of the prize has been established in the project actions Also, Ciudadanos al Día is developing the systematization of 15 best practices among the finalists and winners.5

4 Watch summary videos of the winning practices by clicking the following link: https://www.flickr.com/photos/155502826@N05/albums/72157682822919321/with/35327460375/ 5

61 Virtual version: Info graphic of the Prize to Best Practices in Prevention and Control of Zika Virus

62 Annex #: 4.3

New Protocols based on Good Practices in Vector Prevention and Control

Background

In the award for Good Practices in prevention and control of Zika Virus, 23 good practices were successfully identified and documented. Managers and implementers of these practices were invited to attend the award ceremony, and taking advantage of their presence a workshop and a Fair were organized to share experiences in order to deliver recommendations and learnings that may provide feedback into the work they are doing. Participants hearing the good practices in prevention and Representatives of Chulucanas,Piura, show Simultaneously, a consultant was hired who control of Zika virustheir best community practice participated in the fair and carried out a literature review on current regulations and laws, and successful experiences in vector control (Aedes Aegypti) at national and international level. The consultant also made field visits to learn from the experiences in vector control in the Districts of Morropón y Sechura (Region of Piura). It should be noted that Sechura is a very special case as no cases of Dengue fever occurred or were reported.

Identification of New Protocols

As a result of the analysis made of the experiences shared in good practices for prevention and control of Zika, the field work in Morropón and Sechura, and the review of literature, 6 protocols on vector control were selected.

The protocols that were identified6 are:

 Protocol 1: Community Participation for Vector Control This protocol refers to the involvement of population informed, organized and led by a community leader to implement an Education, Communication and Social Participation Plan for the prevention of arboviruses.

 Protocol 2: Focal Treatment This protocol makes reference to an operation consisting of a succession of activities that are related to placing a certain amount of “larvicide” (or a similar chemical substance) into tanks containing water or that can contain water, located inside or around the house, and a decision to destroy or bury them during inspections was not made.

 Protocol 3: Collection and Elimination of Unusable (solid waste)  This protocol refers to the elimination of any objects considered as not usable that may stay in open areas of the house, or outside it, with the capacity to store water (or that could potentially store water) and could potentially become a breeding ground for Aedes aegypti mosquito.

 Protocol 4: Ten minutes to Tackle Aedes aegypti Mosquito The campaign “10 minutes to Tackle Dengue” was originally an initiative of researchers and communication professionals of Instituto Oswaldo Cruz/Fiocruz in Brazil. This campaign seeks to motivate people to invest only ten minutes of their time once a week to search and eliminate the breeding grounds of Aedes aegypti in their homes.

6 For information about the draft document on the new protocols, check the following link: https://goo.gl/rCr8iJ

63  Protocol 5: Perifocal Treatment This protocol refers to residual spraying of “adulticide” insecticides that are applied around breeding grounds located inside or near the house.

 Protocol 6: Space Spraying This protocol refers to the use of chemical adulticides that allow eliminating adult mosquitos that come into contact with the insecticide when flying in order to reduce mosquito population that is potentially infectious.

Implementation

After identification and preparation of protocols, a training was held to train trainers in the use of protocols by region, and to replicate it in the Project areas. For this, a Network of Facilitators was established in order to maintain communication among participants, and to share experiences of training and implementation of protocols. It should be noted that the creation of a virtual platform has been planned.

Also, the trained facilitators that transfer knowledge to their peers through workshops are being tracked. The Project has considered the monitoring and evaluation of every Protocol in its implementation.

65 Annex #: 4.4 Community-Based Surveillance System (CBSS)

Introduction:

The involvement of the affected populations (Baly, 2007; Park, 2004) in the process of understanding the problem, and their participation in interventions for promotion, prevention (Healy, 2014; Castro, 2012) and mosquito (vector) control (Shriram, 2009; Khin, 2012). As recognized by the countries involved and their instances of integration (Mesoamerica Projecta, 2012: 23, 30), because the A. aegypti is an anthropophagic vector which lives and reproduces in or near homes, the role of the community is critical to implement and sustain health promotion, prevention, and breeding site identification measures, as well as the active application of strategies to reduce mosquito populations, protect from bites, and seek early diagnosis, among other aspects.

Evidence also suggests that successful community participation requires a communal learning process (Pérez, 2007; Rangel, 2008), capacity building, and overcoming the barriers that persist in the community itself (Toledo-Romaní, 2006), in the different levels of government, and in the institutional management which limits community participation (UNICEF, 2016: 4).

Community participation strategies should not exclude nor relax the participation of the local health sector7, but instead these should interact and empower each other, as well as define the most appropriate technologies in interventions (Wai, 2012; Kittayapong, 2006). Preferably the development of strategies should involve participation at all levels, from individual, family, and community, and even in the formulation and implementation of public policy (in the health, education, environmental, and municipal sectors, among others) (UNICEF, 2016: 4).

With this context and in line with the evidence demonstrating that community participation is an essential and cost-effective component for vector control, the project “Together against Zika” has as one of its expected Project results (Activity 3) the development of a monitoring system for vector control, including an accessible feedback mechanism, for use by local governments and the community.

I. Objective: Pilot a community-based surveillance system in two local governments in Tumbes to gradually scale-up their implementation

II. Process/activities

1. The development of an early-alert information system which connects the community with national institutions responsible for surveillance and response (developed in close collaboration with the community), and training for its proper functioning, both based on the principle of community participation and their involvement in early identification of health threats and promotion of (or demand for) the appropriate response by the authorities and specialists responsible.

7 Comprehensive health care: Comprehensive health care model based on family and community: Technical document/Ministry of Health. General Health Directorate. Technical Secretariat Renewal Commission of the MAIS-BFC – Lima: Ministry of Health; 2011. 124 p.; ilus., tab https://goo.gl/Hkk6sv MSP ECUADOR: National Undersecretariat of Public Health Governance. National Articulation of the SNS and Network. Comprehensive care model for family, community, and intercultural health. Ecuador 2012 https://goo.gl/234t16 First advances of the operationalization of the Comprehensive Health Model based on Family and Community (MAIS-BFC), Churcampa. https://goo.gl/rXK8Bf

1.1 Gather useful information in a timely manner to measure trends and engage in the analysis and timely responses that avoid, control or mitigate the effects of a potential Zika outbreak or epidemic. The system will be sufficiently accessible and of interest to the different stakeholders and will facilitate the cooperation between community and State, which will subsequently lead to success stories and eventual long-term alliances. It will include the following attributes: simplicity, flexibility, acceptability, sensitivity, positive predictive value, representativeness, and opportunity.

Implementation of surveillance and vector control by community health agents will be considered. However, we propose to ‘go a step further’ in community participation and the role of local governments. In addition to the organizational aspects, and given vulnerability, risks, and health care needs, the participation of CHWs may include promoting demand for family planning services, identifying pregnant women and orienting them to demand ANC services, and monitoring ANC for quality, recalling that Zika is the first arbovirosis with capacity for sexual transmission.

Generate a proposed information system for the documentation of entomological monitoring and control, by modules.

(a) Surveillance protocol for Aedes aegypti using ovitraps by health workers with the participation of community agents Evidence shows that the use of ovitraps by health care workers with the participation of community volunteers is a simple, effective and low-cost method to determine vector density and produce timely and specific information to direct community-based environmental management control measures, and for public health services to intervene in more delimited areas. The Ministry of Health also has technical guidelines for the surveillance of vector breeding sites carried out by health workers. Protocols must also be developed for the participation of community agents and the wider community in the monitoring of vector density and breeding sites. Community health agents can develop the monitoring of ovitraps with community support. The primary role of community health agents is weekly inspection and collection of egg samples deposited by the vector in geo-referenced ovitraps located every 100 to 200 meters. The community agent records the number of eggs in a geo-referenced system, for the community to then organize measures to eliminate breeding sites around the positive ovitraps and communicate to the network of health services in each region to implement the corresponding control measures around positive ovitraps.

(b) Control protocol for Aedes aegypti by community health agents and the community Evidence shows that monitoring vector density provides information that must be analyzed to act in a preventative and timely manner. Every surveillance system must be accompanied by control measures for when vector density rises and becomes a risk for the transmission of arbovirosis. Community agents will support the control measures that the network of health services implements.

(c) Proposal of adjustments and/or development of an Information System for the registration of entomological monitoring and control information, by modules The various existing systems and software will be identified and examined, and the management, future development and sustainability aspects of the System will be evaluated. Among other options, it is proposed to examine the subscription of services by local governments. If it is necessary to use licenses, license costs for the two municipalities of Tumbes will be included in the pilot's costs for six months8.

8 Approximate cost and maximum of S/.50 per district, per month

67 C.1. Data management module, including registration of CHW, volunteers, administration of ovitraps, etc. C.2. Data recording of CHW activity module, including vector infestation baseline, surveillance record of ovitraps, vector control actions C.3. Report module, for summary and report.

1.2. Community feedback: Through community meetings or other accessible tools (e.g. use of flags) to share information and activities to be carried out by the CHW, municipal government, families