Ethiopia Work Plan FY 2018 Project Year 7
October 2017–September 2018
ENVISION is a global project led by RTI International in partnership with CBM International, The Carter Center, Fred Hollows Foundation, Helen Keller International, IMA World Health, Light for the World, Sightsavers, and World Vision. ENVISION is funded by the U.S. Agency for International Development under cooperative agreement No. AID-OAA-A-11-00048. The period of performance for ENVISION is September 30, 2011, through September 30, 2019.
The author’s views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. Government.
ENVISION Project Overview
The US Agency for International Development (USAID)’s ENVISION project (2011–2019) is designed to support the vision of the World Health Organization (WHO) and its member states by targeting the control and elimination of seven neglected tropical diseases (NTDs), including lymphatic filariasis (LF), onchocerciasis (OV), schistosomiasis (SCH), three soil-transmitted helminths (STH; roundworm, whipworm, and hookworm), and trachoma. ENVISION’s goal is to strengthen NTD programming at global and country levels and support ministries of health (MOHs) to achieve their NTD control and elimination goals. At the global level, ENVISION—in close coordination and collaboration with WHO, USAID, and other stakeholders—contributes to several technical areas in support of global NTD control and elimination goals, including the following: • Drug and diagnostics procurement, where global donation programs are unavailable • Capacity strengthening • Management and implementation of ENVISION’s Technical Assistance Facility (TAF) • Disease mapping • NTD policy and technical guideline development • NTD monitoring and evaluation (M&E)
At the country level, ENVISION provides support to national NTD programs by providing strategic technical and financial assistance for a comprehensive package of NTD interventions, including the following: • Strategic annual and multi-year planning • Advocacy • Social mobilization and health education • Capacity strengthening • Baseline disease mapping • Preventive chemotherapy (PC) or mass drug administration (MDA) • Drug and commodity supply management and procurement • Program supervision • M&E, including disease-specific assessments (DSAs) and surveillance
In Ethiopia, ENVISION project activities are implemented by RTI International, Fred Hollows Foundation, and Light for the World.
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TABLE OF CONTENTS ENVISION Project Overview ...... ii LIST OF TABLES ...... iv LIST OF FIGURES ...... iv ACRONYMS LIST ...... v COUNTRY OVERVIEW ...... 1 1) General Country Background ...... 1 a) Administrative Structure ...... 1 b) NTD Program Partners ...... 3 2) National NTD Program Overview ...... 6 a) Trachoma ...... 6 b) LF ...... 8 c) OV ...... 11 d) SCH/STH ...... 12 3) Snapshot of NTD Status in Ethiopia ...... 15 PLANNED ACTIVITIES ...... 16 1) NTD Program Capacity Strengthening ...... 16 a) Strategic Capacity Strengthening Approach ...... 16 b) Capacity Strengthening Objectives and Interventions ...... 17 c) Monitoring Capacity Strengthening ...... 17 2) Project Assistance ...... 21 a) Strategic Planning ...... 22 b) NTD Secretariat ...... 24 c) Building a Sustainable National NTD Program ...... 24 d) Mapping ...... 25 e) MDA Coverage ...... 25 a) Social Mobilization to Enable NTD Program Activities ...... 29 b) Training* ...... 31 c) Drug and Commodity Supply Management and Procurement ...... 35 d) Supervision for MDA ...... 36 e) M&E ...... 38 f) Supervision for M&E and DSAs ...... 41 g) Dossier Development ...... 42 3) Maps ...... 43
ENVISION FY18 PY7 Ethiopia Work Plan iii APPENDIX 1: Work Plan Timeline...... 47 APPENIDX 2: Table of USAID-supported Regions and Districts in FY18 ...... 50
LIST OF TABLES
Table 1. Official MDA calendar from the FMOH ...... 3 Table 2. NTD partners working in Ethiopia, donor support, and summarized activities ...... 4 Table 3. Number of woredas that fall into each treatment category and their progress toward elimination in 2020 (Note: All but six USAID-supported woredas are on track to complete all required rounds of MDA by 2020*) ...... 7 Table 4. LF endemic woredas by region after 1% remapping exercise ...... 10 Table 5. OV endemic woredas by region ...... 12 Table 6. SCH and STH endemic woredas by region ...... 14 Table 7. Snapshot of the expected status of NTD program in Ethiopia as of September 30, 201715 Table 8. Project assistance for capacity strengthening ...... 19 Table 9. ENVISION partners and implementation mechanisms under the integrated model (as of September 30, 2017) ...... 22 Table 10. USAID supported coverage results for FY15–FY17 Q1–Q2 ...... 25 Table 11. USAID-supported districts and estimated target populations for MDA in FY18 ...... 26 Table 12. Social mobilization/communication activities and materials checklist for NTD work planning ...... 30 Table 13. Training targets (FHF, RTI, and LFTW) ...... 33 Table 14. Reporting of DSA supported with USAID funds that did not meet critical cutoff thresholds as of September 30, 2017 ...... 41 Table 15. Planned DSAs for FY18 by disease ...... 41
LIST OF FIGURES
Figure 1. Ethiopia health care levels and units ...... 2 Figure 2. Training cascade of national integrated NTD training curriculum ...... 32 Figure 3. 16 PFSA main and sub-branches ...... 35 Figure 4. Ethiopia LF, OV, STH, SCH, and Trachoma Endemicity Maps...... 43 Figure 5. Ethiopia LF, OV, STH, SCH, and Trachoma Geographic Coverage Maps, ...... 44 Figure 6. Ethiopia Progress Toward LF Elimination Map ...... 45 Figure 7. Ethiopia Progress Toward Trachoma Elimination Map ...... 46
ENVISION FY18 PY7 Ethiopia Work Plan iv ACRONYMS LIST
ALB Albendazole APOC African Programme for Onchocerciasis Control Amref African Medication and Research Foundation AZT Azithromycin BCC Behavior Change Communication CIFF Children’s Investment Fund Foundation CNTD Centre for Neglected Tropical Diseases, Liverpool School of Tropical Medicine CY Calendar Year DAG Data Action Guide DFAT Department of Foreign Affairs and Trade (Australia) DFID Department for International Development (U.K.) DHIS District Health Information System DQA Data Quality Assessments DSA Disease-Specific Assessment END Fund End Neglected Tropical Disease Fund EOEEAC Ethiopia Onchocerciasis Elimination Expert Advisory Committee EPHI Ethiopian Public Health Institute ESPEN Expanded Special Project for the Elimination of NTDs (ESPEN) F and E Facial Cleanliness and Environmental Improvement (part of the SAFE strategy) FHF Fred Hollows Foundation FMHACA Food, Medicine, and Healthcare Administration and Control Authority FMOH Federal Ministry of Health FPSU Filariasis Programmes Support Unit, Liverpool School of Tropical Medicine (formerly known as CNTD) FOG Fixed Obligation Grant FY Fiscal Year GTM Grarbet Tehadiso Mahber GTMP Global Trachoma Mapping Project HDA Health Development Army HEW Health Extension Worker HMIS Health Management Information System ICT Immunochromatographic Test IEC Information, Education and Communication IPLS Integrated Pharmaceutical Logistics System ITI International Trachoma Initiative IVM Ivermectin JRSM WHO Joint Request for Selected Medicines LF Lymphatic Filariasis LFTW Light For The World M&E Monitoring and Evaluation MDA Mass Drug Administration MEB Mebendazole MfM Menschen für Menschen MMDP Morbidity Management and Disability Prevention Program MOH Ministry of Health
ENVISION FY18 PY7 Ethiopia Work Plan v MOU Memorandum of Understanding NGO Nongovernmental Organization NAPAN National Podoconiosis Action Network NTD Neglected Tropical Disease OEPA Onchocerciasis Elimination Program for the Americas OV Onchocerciasis PCR Polymerase Chain Reaction PC Preventive Chemotherapy PFSA Pharmaceutical Fund and Supplies Agency PHCU Primary Health Care Unit PZQ Praziquantel REMO Rapid Epidemiological Mapping of Onchocerciasis RHB Regional Health Bureau RTI RTI International SAC School-Aged Children SAE Serious Adverse Events SAFE Surgery-Antibiotics-Facial cleanliness-Environmental improvements SCH Schistosomiasis SCI Schistosomiasis Control Initiative SNNPR Southern Nations, Nationalities, and People’s Region SOP Standard Operating Procedure STH Soil-Transmitted Helminths SCT Supervisors Coverage Tool TAF Technical Assistance Facility TAS Transmission Assessment Survey TF Trachomatous Inflammation–Follicular TIPAC Tool for Integrated Planning and Costing TOT Training of Trainers TT Trachomatous Trichiasis TWG Technical Working Group USAID US Agency for International Development WASH Water, Sanitation, and Hygiene WHO World Health Organization ZTH Zithromax®
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COUNTRY OVERVIEW
1) General Country Background
a) Administrative Structure
Ethiopia is a federated nation comprising nine autonomous regions (Afar; Amhara; Beneshangul-Gumuz; Gambella; Harari; Oromia; Somali; the Southern Nations, Nationalities, and People’s Region [SNNPR]; and Tigray) and the two city administration councils of Addis Ababa and Dire Dawa. Each region is constitutionally allowed self-determination; the federal government is responsible for the military and foreign affairs, international treaties, and other overarching issues of interest to the entire nation. The nine regions are further subdivided into 95 zones, which consist of 861 (and 11 refugee camps) administrative woredas (districts). The woredas are further divided into 16,523 kebeles. The kebele, which is the smallest unit of local government, consists of 5,000 people on average. The Ethiopia Federal Ministry of Health (FMOH) focuses on eight priority neglected tropical diseases (NTDs): lymphatic filariasis (LF), onchocerciasis (OV), trachoma, soil-transmitted helminths (STH), schistosomiasis (SCH), podoconiosis, dracunculiasis, and leishmaniasis. Ethiopia has witnessed a tremendous scale-up in NTD activities since the official launch of the National Master Plan for NTDs (2013–2015) in June 2013. In November 2013, the Minister of Health established an NTD team and appointed an NTD team leader to accommodate this scale-up. NTD mass drug administration (MDA) treatment results were also added to the National Health Management Information System (HMIS) as an indicator, and the FMOH has integrated NTD program planning into the existing platform of annual, woreda-level micro-planning for health initiatives. In May 2015, the FMOH updated the National Master Plan to incorporate the strategies and implementation plans for all eight NTDs from 2016 until their elimination and control goals are reached (by 2020). The FMOH oversees the coordination and implementation of Ethiopian health programs on a national level, and the Regional Health Bureaus (RHBs) do so on a regional level. The FMOH NTD case team has grown since the launch of the National Master Plan thanks to greater investment from the government in crucial staffing positions. RHBs follow country-wide, health-related initiatives issued by the FMOH but also maintain a large degree of autonomy in determining their priority health intervention areas and implementation timelines. RHBs also must approve mapping and disease-specific assessment (DSA) results before the FMOH can declare them official. In terms of NTDs, RHBs have developed their own Regional NTD Master Plans within the framework to complement the National Master Plan and other key NTD documents, such as Regional Trachoma Action Plans. Currently, RHBs usually split the efforts of NTD focal persons among multiple disease initiatives (e.g., malaria and HIV/AIDS), though ENVISION and other NTD partners are advocating strongly for dedicated NTD teams because the other, larger disease initiatives, such as those for malaria, tend to take precedence in terms of actual program time. The FMOH and RHBs currently conduct various health initiatives through tertiary, secondary and primary health care provision levels (see Figure 2). For the purposes of NTDs, the primary level is where most engagement takes place. The primary level is divided into three Primary Health Care Units (PHCUs), the Health Extension package, and the Health Development Army (HDA). PHCUs are woreda-level medical clinics, and on average, each woreda contains five PHCUs. The Health Extension Program, which was created to address medical intervention needs at the community level, consists of an integrated set of 16 health packages. NTD intervention through MDA is not addressed within these 16 health packages,
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though the FMOH NTD team is trying to integrate NTDs more into the health package framework (as detailed throughout this work plan). The FMOH has trained and deployed approximately 38,000 health extension workers (HEWs) across the country to implement these health packages. They are government-salaried, trained, community-based health workers. Finally, the HDA is a community-level cadre composed of six women health volunteers per community. Each member of an HDA is assigned five households. The HEWs lead groups of HDA members in forming health development teams. Overall, an average of 30 development teams exist in each kebele.
Figure 1. Ethiopia health care levels and units
In terms of NTD interventions, the FMOH relies heavily on HEWs and members of the HDA. HEWs handle all the MDA registrations and supervision, and the HDA assists with mobilization and directly observed treatment. Although HDAs can administer albendazole (ALB) and ivermectin (IVM), they cannot administer azithromycin (AZT) because it is an antibiotic. Instead, this task is left to the HEWs. Mebendazole (MEB) and praziquantel (PZQ) are distributed by teachers via school-based distributions, except in woredas with high-risk groups or a prevalence over 50%; in these woredas, the HEWs lead community-wide distributions. The FMOH adopted a campaign-style MDA in 2013 for all NTDs that involves the HEWs, HDAs, and teachers. The shift away from “rolling” MDA, which was supported by the community-directed treatment with IVM strategy, has been very successful in reducing the average time for MDA, covering the same area, from one month to five days. The FMOH has established an official calendar for disease-specific MDA campaigns to coordinate programs throughout the country, provide drug donation programs on a uniform schedule with which to match delivery dates, and ensure that MDA distributions are completed before the rainy season (May‒September) (Table 1). This calendar is essential for coordination efforts because of the number of woredas conducting bi-annual treatments for OV (see the OV section for more detail).
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Table 1. Official MDA calendar from the FMOH Program Round 1 Round 2 Remarks/Justification Trachoma: Community- October/November and n/a This allows adequate time based distribution March/April interval between trachoma performed by HEWs with and other preventive mobilization assistance chemotherapy MDA. from the HAD SCH and STH: School- October (Round 1 for First week of April This schedule ensures that all based deworming STH in twice-per-year (Round 2 for STH in school-aged children are conducted by teachers woredas) twice-per-year areas) covered at the beginning of with supervision from the school year, thereby HEWs improving learning throughout the academic year. OV and LF: Community- October (for all OV- and First week of April for LF-endemic woredas based distribution LF-endemic areas) OV Round 2 only included in Round 1 MDA performed by the HDA will have the ancillary benefit with supervision from of addressing STH. HEWs Round 2 OV MDA will be undertaken without ALB.
b) NTD Program Partners
One of the most NTD-endemic countries in the world, Ethiopia has witnessed an exponential increase in the number of donors and implementing partners looking to effect NTD programming since the launch of the NTD Master Plan in 2013. Largely because of FMOH leadership, donors and implementing partners now recognize that with coordinated efforts, a substantial impact can be achieved in terms of the size of the population treated, progress toward 2020 elimination and control goals, and sustainable capacity building. Table 2 presents an overview of each partner’s roles and responsibilities.
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Table 2. NTD partners working in Ethiopia, donor support, and summarized activities Is USAID Other donors providing supporting these Partner Location Activities financial partners/activities? support to this partner? FMOH Federal level - Coordinate all NTD activities at the national Yes WHO, SCI level and provide technical assistance to the regions, zones, and woredas during supervision - Facilitate drug supply management in the country - Provide support for TT-related training through the Hon. Minister’s TT initiative EPHI Federal level - OV delineation mapping No SCI, The Carter Center - OV/LF/trachoma impact assessments - Collaborating with SCI and Evidence Action to conduct the M&E components of the STH/SCH pooled funding initiative RTI Federal level, - Provide capacity building and technical support Yes No Beneshangul- at the federal level, including implementation of Gumuz, the integrated NTD database, the Tool for Gambella, Integrated Planning and Costing (TIPAC), and Tigray, and technical secondments at the federal and Oromia regional levels - Provide direct implementation support to the Beneshangul-Gumuz RHB for OV, LF, and trachoma and to the Gambella RHB for trachoma - Through MMDP Program, provide TT surgery quality assurance activities and LF morbidity activities (hydrocele and lymphedema training, LF morbidity burden assessments, and situational analysis) FHF Oromia - Support the full SAFE strategy in 44 woredas (5 Yes (ENVISION DFAT, DFID, private zones) with funding from ENVISION and the and MMDP) donors Australian Department of Foreign Affairs and Trade (DFAT) - Support 112 woredas (10 additional zones) for MDA and TT surgeries by ENVISION and MMDP - Support the full SAFE strategy for 18 woredas (1 zone) in Oromia through DFID SAFE support LFTW Tigray and - Implement MDA in 10 LF-OV co-endemic Yes (ENVISION DFID, Austrian Oromia woredas, 39 OV-endemic woredas, and 42 and MMDP) Government, private trachoma-endemic woredas in Oromia with donors ENVISION funding - Obtain support from ENVISION and MMDP for MDA and TT surgeries in 22 woredas (3 zones) and 1 LF woreda in Tigray - Support a SAFE strategy in 9 woredas (1 zone) in Tigray with funding from DFID SAFE ORBIS SNNPR - Support a SAFE strategy in 63 woredas in SNNPR No DFID, private donors with the DFID SAFE grant and additional funding from Orbis
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Is USAID Other donors providing supporting these Partner Location Activities financial partners/activities? support to this partner? The Carter Amhara, - Implement a SAFE strategy in 152 woredas in No DFID, Lions Club, Center Oromia, Amhara with a DFID SAFE grant and funding private donors SNNPR, from the Lions Club and additional sources. Beneshangul- - Implement MDA for LF and OV in 100 woredas Gumuz, and in Amhara, SNNPR, Oromia, Gambella, and Gambella Beneshangul-Gumuz with funding from the Lions Club and other funders GTM Oromia and - Implement the full SAFE strategy in 5 woredas in No Private donors SNNPR Oromia and 7 in SNNPR MfM Oromia and - Implement the full SAFE strategy in 3 woredas in No Private donors Amhara Oromia and Amhara CNTD Federal level - Implement MDA in 22 LF-endemic woredas in No DFID, Liverpool and Oromia Oromia and SNNP regions University, numerous and SNNPR - Provide support to LF MMDP activities in smaller donors RHBs Amhara and SNNP END Fund FMOH - Address all STH/SCH in Ethiopia as part of a joint No Numerous private fund. The END Fund may look to support other business donors diseases as the need arises. Evidence Action FMOH - Receive funding jointly with SCI from CIFF over 5 No No years - Work with SCI to coordinate the M&E component of the SCH/STH pooled fund CIFF FMOH - Apply the 5 years of funding acquired to address No No STH - Allocate 85% to the government - Provide the remaining funds to the END Fund to leverage matched funds and to SCI and Evidence Action over 5 years (as noted immediately above) SCI FMOH - SCI provides funding as a part of joint fund to address all STH/schistosomiasis in Ethiopia CARE Amhara and - Utilize funds donated by Johnson & Johnson to No Johnson & Johnson Afar conduct a pilot cost-benefit analysis of adding NTDs to existing WASH programs - Focus the pilot activities 12 kebeles in fourworedas (three kebeles per woreda) in South Gondar, Amhara Amref Afar - Conduct trachoma MDA in the three woredas No END Fund with prevalence exceeding 10% in Afar with support from the END Fund Peace Corps Amhara, - Place Peace Corps volunteers in woredas with a No (though RTI Peace Corps Tigray, high trachoma prevalence to improve facial does facilitate SNNPR, cleanliness and environmental improvement (F in-service Oromia and E) in the communities trainings for - Use volunteers to assist with MDA for all Peace Corp targeted NTDs trainees on NTDs)
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2) National NTD Program Overview
a) Trachoma
The FMOH is following the 2020 elimination goals set forth by the WHO, which state that clinical signs of active trachoma (TF) should be found in less than 5% of children aged 1–9 years, and TT cases, unknown to the health system, occur in less than 1 per 1,000 people living in a woreda.1 With more than 82.8 million people currently requiring intervention through MDA and an estimated TT backlog of 880,317 (original GTMP result), achieving these goals by 2020 represents a great challenge for Ethiopia. The impressive feat of mapping the entire country for trachoma began with the National Survey on Blindness, Low Vision, and Trachoma (2005–2006). The results from this mapping exercise indicated that Ethiopia is the most endemic country in sub-Saharan Africa, with an average, countrywide prevalence of active trachoma of 40.1%. After this national survey, through support from The Carter Center, the Amhara RHB completed baseline trachoma surveys for all 10 zones (152 woredas) in the region in 2007. The next major step forward in the collection of epidemiological data by the trachoma program in Ethiopia was the GTMP, which began in 2013 and was funded by DFID. With the GTMP, trachoma surveys throughout the country are now complete, except in 22 woredas affected by insecurity in Somali region. The results of these mapping efforts revealed that 541 woredas (68% of the woredas in the country) have TF prevalence at or above 10%. However, with the availability of Pfizer-donated Zithromax in CY2015 for one round of MDA for woredas with baseline TF prevalence of 5%‒9.9%, 96 additional woredas will require support for a single round of MDA and the subsequent impact survey; this will bring the total number of woredas requiring MDA for trachoma in Ethiopia to 687 woredas. As mentioned in the partner section, 83% of the endemic woredas with TF over 5% have support for MDA; 42 woredas with TF of 10%‒29.9% in the regions of SNNPR and Somali have no support. As such, they constitute the greatest obstacle toward achieving global elimination goals (Table 3).
1 http://apps.who.int/iris/bitstream/10665/208901/1/WHO-HTM-NTD-2016.8-eng.pdf?ua=1
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Table 3. Number of woredas that fall into each treatment category and their progress toward elimination in 2020 (Note: All but six USAID-supported woredas are on track to complete all required rounds of MDA by 2020*) Regions Number of Number of woredas Number of woredas Number of woredas woredas with with 10%‒29.9% TF with 30%‒49.9% TF with ≥50% TF 5%‒9.9% TF (3 years of MDA) (5 years of MDA) (7 years of MDA) (1 year of MDA) MDA start date required to achieve 2020 2018 2016 2014 elimination by 2020* Oromia 23 115 125 2 Beneshangul-Gumuz 7 4 0 0 Gambella 0 13 0 0 Tigray 3 23 20 0 SNNPR 6 78 54 2 Afar 19 3 0 0 Somali 21 18 4 0 Amhara 17 67 52 8 TOTAL 96 321 255 12 Support available to Support for 7 NO YES Yes, all started in complete the final woredas in Must start by CY18 to Supported by FMOH 2011 or 2012 round of MDA by Beneshangul- achieve three rounds funding in 2020? Gumuz, 7 of MDA by 2020: CY2016/2017: 24 in woredas in 24 endemic districts in SNNPR, Oromia started SNNPR 4 in Somali. Note through RTI in and 18 endemic that the continued FY17. Support for districts in Somali funding for the next 17 woredas in need to start MDA 4 rounds of MDA western Oromia for these 28 and Tigray woredas is not targeted for FY18 guaranteed. * These six woredas are districts which split off of Mekele town in Tigray region and weren’t mapped via the GTMP project until CY2016. MDA within these six districts will be completed by CY2021.
As discussed in the Partners section, ENVISION currently supports trachoma MDA in 222 woredas in Oromia through its partners FHF and LFTW and 28 woredas in Tigray through its partner LFTW. Because ENVISION can only support the “A” component of the SAFE strategy, RTI has drawn together a consortium of support to achieve the full SAFE package in almost all woredas (WASH support still needs additional funding in some of these woredas). The USAID-supported MMDP Program plays a particularly important role in this consortium in that it addresses the TT surgery support in all the woredas where ENVISION supports MDA in the regions of Oromia and Tigray. Note that ENVISION also supports trachoma MDA in 13 woredas in Gambella and 11 woredas in Beneshangul-Gumuz, but the other elements of the SAFE strategy are not as strong due to fewer WASH partners and no TT surgery support. ENVISION is currently advocating with the government to use domestic finance funding for NTDs to address this gap. In Ethiopia, the addition of 96 additional woredas that need one round of AZT treatment represented a dramatic increase in the denominator when trying to achieve 100% geographic coverage for the
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country. ENVISION proposed the following strategy in FY17 to address the 31 5-9.9% woredas in ENVISION supported areas: • In FY17, ENVISION supported one round of MDA in 14 woredas with 5%–9.9% TF in Oromia and Beneshangul-Gumuz. Pending successful impact surveys, this will reduce the number of 5%– 9.9% prevalence woredas from 96 to 82. • In FY18, ENVISION will support impact surveys in all 14 woredas treated in FY17 as well as one round of MDA in the remaining 17 woredas, which are found in western Oromia (15) and Tigray (2). This will reduce the number of 5%–9.9% TF prevalence woredas from 82 to 65 within the country. It will also address all 31 of the 5-9.9% woredas at baseline within the ENVSION supported regions. • In FY19, ENVISION will propose to support impact surveys in the 17 woredas treated in FY18 and advocate for funding to address any remaining 5%–9.9% prevalence woredas in other regions that other partners have not yet addressed on a case by case basis.
b) LF
As stated in the revised National Master Plan (2016‒2020) and in accordance with the WHO Global LF- Elimination Strategy, the FMOH is targeting LF for elimination by 2020. In compliance with Lymphatic Filariasis: A Manual for National Elimination Programs,2 the national program uses an MDA strategy combining IVM and ALB in entire at-risk populations. MDA coverage must be at least 65% of the total population in an endemic area for at least five years before conducting TAS to determine whether MDA can be stopped. In the 45 LF-endemic woredas that are co-endemic with OV, ALB can be added to the existing IVM MDA. Currently, the triple drug administration of ALB, IVM, and PZQ is not used in practice, although this strategy may be considered by the FMOH in some co-endemic areas after one to two years of separate treatments, per WHO guidelines. In areas targeted for LF MDA, school-aged children (SAC) are not specifically targeted with a separate MDA for STH unless the woreda has a prevalence >50%, and bi-annual treatment is required. It is important to note that Loa loa is not endemic in Ethiopia and, thus, does not present a barrier to using IVM. By the end of CY16, 67 out of the 71 endemic woredas in the country received their first round of treatment; thus, conducting the fifth round of LF MDA by the end of 2020 in these 67 woredas (96%) is possible (Table 4). The four remaining woredas are not ENVISION supported and were not treated until 2017 and therefore will not complete the fifth round of treatment until 2021. These projections assume that all endemic woredas will achieve the minimum epidemiologic coverage each year for all five years of the MDA, which may not be the case. ENVISON is working with the FMOH to complete its own Transmission Assessment Tracker to better understand progress towards dossier preparation. The FMOH has also stated in the National Master Plan that, by 2020, the estimated hydrocele and lymphedema burden within the 71 endemic woredas must be established through burden assessments. Furthermore, per the National Master Plan, all those living within these woredas should have access to hydrocele surgery within their zonal hospitals, and those in need of lymphedema care should have access to that care within a 10-kilometer radius of their home. The initial LF mapping in Ethiopia occurred in CY08—113 woredas were surveyed in the regions of Gambella, SNNPR, Beneshangul-Gumuz, Amhara, and Oromia by The Carter Center using immunochromatographic tests (ICTs). Of the 113 woredas, 34 were found to be endemic for LF. MDA
2 http://apps.who.int/iris/bitstream/10665/44580/1/9789241501484_eng.pdf
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was immediately initiated in all 34 of these woredas, again with the support of The Carter Center; these woredas have received treatment since 2008. Starting in June 2013, Ethiopia targeted 659 additional woredas for mapping through a nationwide initiative led by EPHI and the FMOH NTD team with funding support from DFID through FPSU (known as CNTD at the time). The 2013 mapping was conducted using current WHO guidelines for initial LF assessments: in each implementation unit, two sites were selected based on the high likelihood of ongoing transmission, and in each site, a convenience sample of 100 adults aged 15 years or older was tested for antigenemia with an immunochromatographic test (ICT.) During this 2013 mapping initiative, podoconiosis mapping was also conducted by identifying woredas as endemic for podoconiosis if lymphedema cases were found that exhibited negative ICT results. As a result of the 2008 and 2013 mapping activities, a total of 113 woredas were found to be endemic for LF. In 45 of the 113 woredas, a single ICT-positive case was found in one of the selected villages (1% prevalence). The FMOH was hesitant to designate these woredas as endemic and, thus, commit to beginning a costly five-year treatment plan. At the request of the FMOH, the Task Force for Global Health supported EPHI in implementing a more robust LF mapping methodology based on targeting older SAC, also called the “mini-TAS.” Per this methodology, if three or more antigen-positive children were found, then the woreda was confirmed as endemic. EPHI completed this remapping initiative in February 2015. The results revealed that only three woredas (two in Amhara and one in SNNPR) out of the 45 woredas remapped were endemic for LF, corresponding to a 53.6% reduction in the number of people at risk for LF (Table 4). The official number of endemic woredas stated in the National NTD Master Plan is now 70. However, a district split in Oromia in FY17 now puts that number at 71. Note that two woredas in Oromia and one woreda in SNNPR had already implemented one round of MDA with funding from FPSU before being assigned a new non-endemic status. The FMOH ceased all future rounds of MDA within these three woredas. USAID support for LF began in FY15. Through ENVISION support, LFTW currently targets 10 woredas with MDA in western Oromia and one woreda in Tigray; FHF targets one woreda in West Arsi zone in eastern Oromia; and RTI targets 12 woredas in Beneshangul-Gumuz. Through the USAID-supported MMDP, RTI has conducted LF burden assessments in 26 woredas (# of lymphedema patients= 14,822, # of hydrocele patients= 1,170). In addition to the burden assessments supported by CNTD and the WHO, the country now has patient estimates for 42 (60%) of the 70 LF-endemic districts in the country. The burden assessments have detected a total of 33,048 possible lymphedema patients and 1,883 possible hydrocele patients.
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Table 4. LF endemic woredas by region after 1% remapping exercise Year of Number of Number of Year in the fifth endemic endemic Initial which MDA round woredas Population at risk Region woredas population began: of MDA: with after remapping before 1% at risk number of number remapping remapping woredas of results woredas Afar 1 0 73,006 0 2012: 3 2016: 3 Amhara 19 8 2,830,444 986,369 2015: 21 2019: 2 Beneshangul- 2013: 11 2017: 11 14 13 618,795 603,913 Gumuz 2012: 2 2016: 25 2009: 5 2020: 5 Gambella 7 7 218,919 227894 2015: 2 2019: 22 Harari 1 0 18,549 0 2015: 143 2019: 12 Oromia 36 18 3,836,933 1,838,892 2016: 3 2020: 3 2017:2 2021:2 2012: 8 2016: 86 SNNPR 30 24 3,174,335 2,289,927 2015: 114 2019: 10 2016: Tigray 5 1 590,952 135,511 2021: 1 2017:1 6,082,506 TOTAL 113 71 11,361,933 (53.6% reduction) 1 Three woredas in Amhara began treatment in the remainder of CY16 2 In CY15, sentinel and spot check pre-TAS failed in the five woredas that began treatment in 2009. Five more years of treatment are currently planned unless sentinel and spot check assessments conducted every two years reveal that a TAS is appropriate. 3Two out of 14 woredas treated in 2015 were categorized as non-endemic after the remapping. The FMOH decided to stop MDA. One additional woreda, Kofle, started MDA in FY17 4 One out of 11 woredas treated in 2015 categorized as non-endemic after the remapping. The FMOH made the decision to stop the MDA. Six woredas will begin MDA in the latter half of CY16 with support from FPSU and The Carter Center. 5 CY16, sentinel and spot check pre-TAS failed in the five woredas that began treatment in 2012. 6 in CY17, sentinel and spot check pre-TAS conducted in the six woredas that began treatment in 2012, and three of them failed.
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c) OV
In 2013, Ethiopia declared that the country’s National Master Plan was shifting from OV control to OV elimination. OV elimination is defined by WHO and the FMOH as follows:3 • Interventions have reduced O. volvulus infection and transmission below the point where the parasite population is believed to be irreversibly moving to its extinction. • Interventions have been stopped. • Post-intervention surveillance for an appropriate period has demonstrated no recrudescence of transmission to a level suggesting recovery of the O. volvulus population. • Additional surveillance is still necessary for the timely detection of recurrent infection. In 2014, national and international experts, including experts from ENVISION, formed the EOEEAC to help guide the FMOH in implementing this strategic shift. In October 2014, the committee held its inaugural meeting, with support provided by The Carter Center, which focused on creating the national OV elimination guidelines. The creation of the document was based on the WHO Geneva 2001-approved guidelines and the 2013 WHO/NTD Strategic and Technical Advisory Group draft guidelines, with consideration of the experiences of the Onchocerciasis Elimination Program for the Americas (OEPA), APOC, and in Sudan and Uganda. The guidelines propose several strategies, including bi-annual MDA, transmission zone mapping, and targeted vector control. The overarching theme for interventions described by the guidelines is that each OV-endemic area requires a tailored approach rather than the one-size-fits-all interventions practiced by the APOC model. Based on the successes of OEPA and in Uganda and Sudan, the guidelines recommend bi-annual MDA with IVM as the main strategy for interrupting transmission. The FMOH currently endorses bi-annual treatment for newly endemic areas that are IVM naïve or any annual treatment area that is not on track to end MDA in 2020. The Ethiopian elimination guidelines stipulate that moving woredas from an annual to a bi-annual treatment schedule should be dictated by the following indicators: • The positive skin snip rate among adults in any community is >2%. • Skin snip-positive children <10 years of age are found in any community. • The OV-16 rates in children <10 years exceed >0.1% (95% confidence interval). • The PCR infectivity in flies exceeds >1/2,000 (95% confidence interval). • The seasonal transmission potential (as calculated by Pool Screen®) exceeds 20 Larval stage 3 (L3/person/year (95% confidence interval). As of April 2017, all 194 woredas endemic for OV are on a bi-annual treatment schedule. The guidelines stipulate that impact assessments will be conducted in these woredas after five years of bi-annual treatment. RTI plays an active role during the development of the OV guidelines as a member of the OV TWG member and as an EOEEAC member. Several phases of OV mapping have occurred in Ethiopia since 1997. In 1997 and 2001, APOC conducted rapid epidemiological mapping of OV (REMO) in the western part of the country, and 78 woredas were found to be endemic in SNNPR, Amhara, and Oromia regions. Subsequent REMO mapping in 2004, 2011,
3 http://apps.who.int/iris/bitstream/10665/204180/1/9789241510011_eng.pdf?ua=1
ENVISION FY18 PY7 Ethiopia Work Plan 11
and 2012 revealed additional endemic woredas in western Oromia, SNNPR, Beneshangul-Gumuz, and Amhara. In 2014, as the Ethiopian program shifted from a control strategy to an elimination strategy, EPHI conducted hypo-endemic delineation throughout the western part of the country. The cumulative mapping results identified 188 endemic woredas, including more than 17 million people at risk and 5.8 million living in hyper- and meso-endemic areas. As mentioned in the OV partners section, this number increased in FY18 to 194 due to the creation of five new woredas through redistricting and the addition of one urban center that is surrounded by OV-endemic woredas. Whether or not mapping is “complete” is technically difficult to determine. For many years, the FMOH and APOC have assumed that only the western part of the country would have OV because the vast majority of fast-flowing rivers are found in this area. However, recent mapping in arid countries found OV in areas previously thought to be environmentally unsuitable. Accordingly, in CY17, the FMOH decided to conduct OV mapping in the remaining unmapped 222 woredas in the country, largely due to the understanding that they cannot achieve elimination without understanding the OV prevalence. The first phase of mapping will start in September 2017 in 124 woredas in eastern Oromia and Amhara regions. The second phase of mapping will include the remaining 98 woredas in the regions of Afar and Somali and will occur in November 2017.
Table 5. OV endemic woredas by region Region Number of Population at risk endemic woredas Amhara 19 2,327,692 Beneshangul-Gumuz 21 1,098,993
Gambella 8 272,260 Oromia 111 11,005,670 SNNPR 35 3,129,771 TOTAL 194 17,834,386
In Ethiopia, controlling OV through IVM MDA began in the Kaffa-Sheka zone of SNNPR in 2001. In 2001‒ 2013, APOC, The Carter Center, the Lions Club, and LFTW were the major supporters of the FMOH in this OV-control effort. Scale-up to other parts of the country continued in 2004, and another wave of expansion was implemented in 2014. Until 2013, Ethiopia’s OV-control program only supported MDA in meso- and hyper-endemic areas with REMO results exceeding 20%. Hypo-endemic woredas were not targeted as part of the control strategy. In FY15, FY16, and FY17 through ENVISION, USAID supported bi-annual MDA in 14 woredas in Beneshangul-Gumuz via direct implementation through RTI. In Oromia, ENVISION funding was provided to LFTW to support the Oromia RHB in conducting bi-annual MDA in 50 woredas..
d) SCH/STH
Though not stated in the WHO NTD roadmap, Ethiopia has taken the initiative to eliminate SCH and STH so that they will no longer present public health problems by 2025. This goal will require the repeated treatment of at least 75% of SAC (enrolled and non-enrolled) in Ethiopia. According to the National STH/SCH Action Plan, the long-term goals associated with this control program are as follows: • Eliminate STH-related morbidity in children by 2020
ENVISION FY18 PY7 Ethiopia Work Plan 12
• Eliminate SCH-related morbidity by 2020 • Reduce the mean intensity of infection with Schistosoma mansoni by 65%‒80% in sentinel sites following four rounds of treatment • Reduce the mean intensity of infection with S. haematobium by 75%‒90% in sentinel sites following one round of treatment • Reduce the proportion of individuals harboring heavy infection with S. mansoni by 60% • Reduce the proportion of individuals harboring heavy infection with S. haematobium by 70% • Reduce the proportion of individuals harboring heavy infection with STH by 60% • Ensure that treatment coverage is expanded to pre-school children in the future
The nationwide mapping of STH and SCH took place in three different phases. The first phase took place between 2013 and April 2014. The EPHI, with technical and financial support from WHO, the SCI, Evidence Action, and the Partnership for Child Development, completed baseline mapping in 535 woredas. The second phase of mapping took place a year later, between February and April 2015, targeting 229 woredas in the regions of Afar and Somali. This phase was again implemented by EPHI with financial support from the Bill and Melinda Gates Foundation and WHO African Regional Office through the “Mapping the Gaps” projects. Based on the results of the first two phases, a total of 412 woredas are endemic for SCH (69 hyper-endemic, 153 meso-endemic, and 190 hypo-endemic), and 741 woredas are endemic for STH (279 hyper-endemic, 215 meso-endemic, and 247 hypo-endemic). The WHO is currently supporting a final phase of mapping to mop up the last 55 remaining woredas (34 in Afar, 15 in Somali, and six in Amhara) with funding obtained from WHO. The mapping of the 34 woredas in Afar was complete as of the writing of this work plan, with final data sets pending analysis. The EPHI will map the remaining 21 woredas in Somali and Amhara by December 2017. STH infections are distributed very widely throughout the country, and more than 57 million people are estimated to be living in the 741 STH-endemic woredas. According to the current national situation, intestinal SCH, S. mansoni, is far more prevalent throughout the country than uro-genital SCH, S. haematobium, which is generally isolated in the Rift Valley region (predominantly in Oromia). At least 45 million people are estimated to be living in the 412 SCH-endemic woredas. The government of Ethiopia’s Growth and Transformation Plan II (CY15–20) plans for massive expansion of irrigation schemes and an exponential increase in sugar cane fields, both of which provide ideal conditions for the endemic vectors: Biomphalaria pfeifferi and Biomphalaria sudanica for S. mansoni and Bulinus abssynicus and Bulinus africanus for S. haematobium. The FMOH is open to performing vector control via the application of molluscides, but no funding for this work is currently available.
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Table 6. SCH and STH endemic woredas by region Region/Administrati SCH endemic Population at risk for STH endemic Population at ve Council woredas SCH woredas risk for STH Addis Ababa 0 0 9 (all low 0 endemic) Afar 3 (mapping 208,962 10 (mapping 177,209 pending in 15 completed but woredas) pending data analysis for 34 woredas) Amhara 90 (mapping 11,986,366 152 (mapping 13,858,112 pending in 15 pending for 6 woredas) woredas) Beneshangul-Gumuz 19 871,727 21 367,193 Dire Dawa 1 412,245 1 0 Gambella 12 389,538 14 429,355 Harari 6 158,641 4 42,010 Oromia 147 17,467,557 300 22,992,701 SNNPR 70 7,553,541 158 17,253,598 Somali 30 (mapping 2,520,779 31 (mapping 1,049,511 pending in 15 pending in 15 woredas) woredas) Tigray 34 4,072,693 41 1,174, 057 Total 412 45,642,049 741 56,169,689
In past years, SCH and STH MDA were performed intermittently by various NGOs and government initiatives on small, targeted scales. In CY07, Ethiopia treated approximately one million SAC for SCH and STH with support from Save the Children. These treatments were part of a one-time campaign, and no funding was provided for future years. CY13 represented the first implementation of a sustained national STH/SCH MDA strategy. Ethiopia secured 3.5 million tablets of PZQ (sufficient to treat approximately 1.4 million children) and 6.8 million tablets of MEB through WHO, Merck Serono, and Johnson & Johnson drug donation programs, and SCI provided financial and technical support for the distribution of these treatments. In CY14, the FMOH distributed approximately 7.8 million STH treatments across 236 woredas to SAC in Amhara, Oromia, and SNNPR, leveraged by a donation from the END Fund. These treatments focused on woredas that were not captured in the CY13 distributions because they were above the treatment threshold for STH but were not SCH endemic. In CY17–18, the FMOH will attempt to scale up to the national level by targeting all 412 SCH and 741 STH woredas. USAID support for STH/SCH is provided primarily as an ancillary benefit, treating STH through the LF MDA regimen. In FY17, the ENVISION project treated 82,211 people living in the eight ENVISION- supported woredas that are LF endemic and have an STH prevalence exceeding 20%. Members of the ENVISION team also are members of the STH/SCH working groups and ensure that the ENVISION work plan is closely aligned with that of the STH/SCH implementing partners.
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3) Snapshot of NTD Status in Ethiopia
Table 7. Snapshot of the expected status of NTD program in Ethiopia as of September 30, 2017
Columns C+D+E=B for each Columns F+G+H=C for each disease* disease* MDA MAPPING GAP DETERMINATION MDA GAP DETERMINATION DSA NEEDS ACHIEVEMENT A B C D E F G H I No. of No. of woredas Expected no. expected to be in of woredas No. of Total No. No. of No. of No. of woredas need of MDA at where criteria woredas of woredas woredas woredas receiving MDA any level: MDA for stopping requiring Disease woredas classified classified in need as of 09/30/17 not yet started, or district-level DSA in as as non- of initial has prematurely MDA have as of Ethiopia endemic endemic mapping USAID- Others stopped as of been met as of 09/30/17 funded 09/30/17 09/30/17
LF 71 791 0 271 47 0 0 Pre TAS - 92
OV3 194 446 222 63 131 0 0 0
SCH 862 412 374 55 0 346 0 0 0
STH 741 45 55 8 468 0 0 0 Trachoma4 686 176 22 274 298 97 17 355 1 This number includes 22 LF endemic woredas, 2 LF woredas pending FMOH decision after redistricting, 3 refugee camps 2All are at Beneshangul-Gumuz region and 1 woreda ; Assosa Town is not endemic for LF but included in LF Pre TAS 3 Note that the number of woredas in need of initial mapping has greatly increased in FY18 in comparison to FY17 because the FMOH has decided to map the entire country for OV, including in arid regions, through the support of ESPEN. 4 The 22 woredas requiring mapping are in the Somali region 5 The following regions require impact assessments in 2017: Amhara (21), Oromia (10), and SNNPR (14)
ENVISION FY18 PY7 Ethiopia Work Plan 15
PLANNED ACTIVITIES
1) NTD Program Capacity Strengthening
a) Strategic Capacity Strengthening Approach
Standardization of NTD Tools and Protocols Since the launch of the NTD Master Plan in 2013, the FMOH has endeavored to create a national NTD program in which all regions and implementing partners adhere to the same standardized protocols, tools, and best practices. In FY17, ENVISION supported M&E; information, education, and communication (IEC); and supervision standardization workshops, which resulted in the national adoption of mandatory protocols for supervisory visits, coverage assessments, social mobilization, and DSAs. In FY18, ENVISION will further this standardization process by ensuring that all of its DSAs and coverage surveys are led by the FMOH under the protocols established within the national M&E framework. ENVISION also proposed the organization and storage of all treatment data through the integrated NTD database in FY17. However, with the pending rollout of District Health Information System (DHIS) 2 as the national HMIS tool, the FMOH has requested that a compatible DHIS 2 platform be created for NTDs in FY18. This will be funded by the Bill and Melinda Gates Foundation and implemented by RTI.
Integration of NTD Drugs into the National Supply Chain The FMOH believes that incorporating NTD drugs into the country’s current supply chain system will create less dependence on implementing partners and a more sustainable program in the future. In the past, implementing partners were responsible for collecting NTD drugs from the central storage hub in Addis Ababa and ensuring that they were transported all the way to the community distribution points. This system operates completely outside of the national supply chain system, which relies on the Pharmaceutical Fund and Supplies Agency (PFSA) to deliver all medical consumables to the health post level throughout the country. In CY16, the government expanded the number of PFSA hubs in the country from 11 to 16 to better facilitate the delivery of medical supplies to every corner of Ethiopia. In FY17, together with other partners, ENVISION supported a supply chain training with the primary goal of familiarizing PFSA officers in the 16 hubs with NTD drug management while at the same time familiarizing government NTD supply chain staff at all levels with how the PFSA operates. The PFSA delivered all of the targeted drugs needed in FY17 partly thanks to the coordination and support provided by ENVISION. To continue this success and improve upon the supply chain system, the FMOH intends to complete the National NTD Supply Chain Standard Operating Procedure (SOP) and bolster the reverse supply chain mechanism in FY18 with technical support from ENVISION.
Strengthening of NTD Program Management and the HEW Workforce The FMOH recognizes the need to bolster the regional, zonal, and woreda offices’ ability to conduct successful NTD programming, given that each zone represents several woredas and an average of more than a million people. With more than 80 million people at risk for at least one NTD, the investment of time and human resources to conduct all of the necessary MDAs at the sub-woreda level is also massive. Every region currently follows its own MDA schedules determined by drug availability and the schedules of other community health initiatives. With MDA often required twice a year for OV, once a year for LF, possibly
ENVISION FY18 PY7 Ethiopia Work Plan 16
twice a year for STH/SCH, and once a year for trachoma, NTD interventions have become one of the greatest demands on the community health infrastructure. HEWs, the backbones of the MDA mechanism, may be called out of their health posts to attend woreda-level NTD trainings and post-MDA reviews four or five times a year within a single district, leaving their communities without health care providers.
In FY17, the FMOH intended to address these issues by creating a standardized integrated training and M&E platform for NTDs. However, after several meetings with RHBs and implementing partners in September 2016 the FMOH realized that rolling out the integrated training plan nationwide would not be possible by the target date of October 2016. All of the partners, including ENVISION, were asked to defer the integrated plan until later in CY17 while a series of pilots were conducted to test the feasibility of the integrated model. As a result of these ongoing pilots, revised funding and implementation mechanisms are proposed in this work plan to enable the rollout of the integrated NTD platform in FY18. This will include an integrated training and an integrated M&E protocol implemented at the woreda level.
b) Capacity Strengthening Objectives and Interventions
ENVISION Strategy to Support FMOH Capacity Building Plan Objective 1: Standardization of NTD Tools and Protocols • Intervention 1: Ensuring the DSAs planned in the ENVISION work plan are conducted per the national standardized M&E framework (see M&E section) • Intervention 2: Adaptation of the integrated NTD database into a DHIS 2 platform (see M&E section) Objective 2: Integration of NTD Drugs into the National Supply Chain • Intervention 1: Support FMOH to further the integration of NTD drugs into the HCMIS and Integrated Pharmaceutical Logistics System (IPLS) with focus on finalizing national NTD supply chain SOP (see Supply Chain section) • Intervention 2: Support FMOH to implement a more robust reverse supply chain (see Supply Chain section) Objective 3: Strengthening of NTD Program Management and the HEW Workforce • Intervention 1: Supervise the Integrated NTD training rollout (see Training section) • Intervention 2: Provide the oversight of the integrated M&E framework implemented at a woreda level (see M&E section)
c) Monitoring Capacity Strengthening
Monitoring the Standardization of NTD Tools and Protocols • Ensuring the DSAs planned in the ENVISION work plan are conducted per the national standardized M&E framework: In the FY18 work plan, ENVISION will propose conducting 60 trachoma impact surveys and 12 pre-TAS surveys for LF. It will also conduct a number of
ENVISION FY18 PY7 Ethiopia Work Plan 17
coverage surveys. ENVISION will ensure these activities are FMOH-led with significant contribution from local universities. − Indicator to measure the outcome of this activity: . Number of people trained per the protocols developed in the National Integrated NTD M&E Framework: ENVISION will track the number of individuals trained (graders, recorders, etc.) according to the mandatory, standardized protocol put forth by the FMOH. This will ensure a reservoir of technical skill within the country capable of conducting future assessments and training replacements. • Adaptation of the integrated NTD database into a DHIS 2 platform: Given that the rollout of the DHIS 2 NTD platform will take most of FY18 (detailed in the M&E section), the ultimate success of that rollout will depend on the progress made to establish the system at a regional level. − Indicator to measure the outcome of this activity: . Number of accurate and timely reports received directly by the FMOH via the DHIS2 interoperating system by the end of FY18: The NTD DHIS 2 platform is targeted for rollout in four different regions in FY18 by the FMOH. RTI will report on the number of treatment reports, DSAs, coverage survey exercises, etc., received through the DHIS 2 system in comparison to reports received via email, submitted written reports, etc. to measure uptake of the tool.
Monitoring “Strengthening NTD Program Managers and the HEW Workforce” • Integrated HEW NTD training: In the past, HEW refresher trainings have been conducted immediately before MDA to ensure that all the information required to conduct a safe, high- quality MDA was re-emphasized and fresh in the minds of the HEWs. With the new integrated HEW NTD training, the government has mandated that only one MDA training will be allowed— in October. This means that for the MDA conducted in April and May, HEWs will need substantial reference materials as well as reminders of the most pertinent MDA-related information. ENVISION will implement the plan detailed in the Training section to address these concerns. − Indicator to measure the outcome of this activity: . Knowledge retention rate among HEWs: RTI, together with ENVISION partners, will implement knowledge tests (both written and practical exercises) at a series of critical junctures to assess whether the HEWs fully comprehend and retain the knowledge from the original training. These junctures will include the conclusion of the integrated NTD training for HEWs, at the post-MDA review, and in two woredas within each of the regions, a randomized sample of HEWs will complete a knowledge test just before the second round of MDA in April and May. The information gleaned from these tests will be compiled by ENVISION partners and used to inform the FMOH about any revisions needed to the training strategy in FY19.
Monitoring Integration of NTDs into the National Supply Chain • The PFSA seconded staff, together with the FMOH NTD logistics officer, will act as the liaison between the PFSA, the FMOH, and implementing partners. They will keep partners updated as to drug shipment schedules and directly address any issues with delays or logistics challenges as
ENVISION FY18 PY7 Ethiopia Work Plan 18
early as possible to allow partners to adjust their MDA plans accordingly. As an additional activity in FY18, the PFSA seconded staff will focus on improving the reverse supply chain of NTD drugs. − Indicator to measure the outcome of this activity: . Number of supervisory visits conducted that included evaluation of supply chain integration with a focus on reverse supply chain: During routine supervisory visits in ENVISION-supported regions, ENVISION partners will evaluate each regional, zonal, woreda, and sub-woreda health office to ascertain if drugs were delivered in a timely fashion and in accordance with the quality standards established by the FMOH and international drug donors. The PFSA secondment will submit a monthly report to the RTI office to discuss the challenges encountered with integration of the supply chain. RTI will then conduct monthly meetings with the FMOH, the PFSA and RTI Ethiopia leadership to address these challenges.
Table 8. Project assistance for capacity strengthening Project Capacity strengthening How these activities will help to correct needs assistance area interventions/activities identified in situation above Regional Integrated NTD Preparation Meeting FMOH capacity building focus addressed: Strengthening NTD program management and the a. Strategic HEW workforce Planning • Will provide a platform for the introduction of the integrated NTD training package to the zonal and woreda levels Engaging Peace Corps FMOH capacity building focus addressed: Strengthening NTD program management and the HEW workforce • Providing a community-level perspective of the success of the integrated NTD training including the knowledge retention of important MDA protocols by the HEWs FMOH Technical Advisor Secondment FMOH capacity building focus addressed: Standardization of NTD tools and protocols • Preparing/adapting national guidelines according to WHO recommendations b. NTD • Technically advising on the NTD research secretariat working group terms of reference and NTD research symposium
FMOH M&E Officer (and data manager) FMOH capacity building focus addressed: Secondment Standardization of NTD tools and protocols • Maintaining NTD database and TIPAC and training FMOH staff on these tools • Leading, together with RTI M&E staff, the rollout of the DHIS 2 NTD database • Conducting RHB-level database trainings • Leading M&E standardization workshop
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Project Capacity strengthening How these activities will help to correct needs assistance area interventions/activities identified in situation above Pharmaceutical Fund and Supplies Agency FMOH capacity building focus addressed: (PFSA) Secondment Integration of NTDs into the national supply chain • Building NTDs into current PFSA supply chain mechanisms • Complete PFSA NTD supply chain SOP • Liaison between FMOH, PFSA, and implementing partners • Co-facilitate the NTD PFSA and implementing partner coordination training Regional Health Bureau Technical Advisor FMOH capacity building focus addressed: Secondments --Standardization of NTD tools and protocols • Assist with adapting the DHIS 2 NTD database to the regional level
--Strengthening NTD program management and the HEW workforce • Assist with rollout of integrated NTD training of HEWs Regional-level NTDs Stakeholders Meeting FMOH capacity building focus addressed: c. Building advocacy for a --Strengthening NTD program management and the sustainable HEW workforce national NTD • Broadening the ability of the NTD program program management at the regional levels to work cross-sectorally with other departments d. Mapping N/A e. MDA coverage N/A f. Social N/A mobilization to enable NTD program activities g. Training (See trainings in Table 14) Reverse supply chain analysis and FMOH capacity building focus addressed h. Drug supply improvement Integration of NTDs into the national supply chain and commodity • Address an issue specifically noted by management partners and RHBs to the PFSA during supply and procurement chain forum Supervising the MDA with a particular focus FMOH capacity building focus addressed: on ensuring that the woreda health offices are i. Supervision for empowered to conduct the supervisory --Strengthening NTD program management and the MDA protocols stipulated in the integrated NTD HEW workforce M&E framework • Assess quality of MDAs after rollout of integrated NTD training of HEWs Trachoma Impact Surveys, Pre-TAS, and FMOH capacity building focus addressed: Coverage Surveys --Standardization of NTD tools and protocols j. M&E • Train survey teams according to standardized protocols stipulated in the national integrated NTD M&E framework
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Project Capacity strengthening How these activities will help to correct needs assistance area interventions/activities identified in situation above Supervision of Trachoma Impact Surveys and FMOH capacity building focus addressed: Pre-TAS --Standardization of NTD tools and protocols • Assist with adapting the DHIS 2 NTD database k. Supervision for to the regional level M&E and DSAs
Begin preparation for trachoma and LF --Standardization of NTD tools and protocols l. Dossier dossiers • Working one-on-one with the FMOH NTD development case team staff to better understand what is required within the dossiers m. Short-term technical N/A assistance
2) Project Assistance
FY18 Background Information
Oromia FHF/LFTW Oromia is the largest region in Ethiopia and requires several partners to achieve MDA coverage of the targeted NTDs. For this reason, ENVISION will support the Oromia RHB through two different ENVISION partners (FHF and LFTW). FHF will supervise the implementation of the integrated model in 14 zones of Oromia, while LFTW will supervise the implementation of the integrated model in the five remaining zones in western Oromia.
Tigray LFTW LFTW is the ENVISION partner in the Tigray Region and will implement MDA in three zones. As mentioned above, LFTW will support the Tigray RHB and the three targeted zonal offices for implementation of the integrated model. They will also provide technical and logistical oversight.
Beneshangul-Gumuz RTI In Beneshangul-Gumuz, RTI will provide direct support to the RHB and will target the Assosa, Kamashi, and Metekel zones. This support will focus on implementation of the integrated model.
Gambella RTI RTI will provide direct support to the RHB for one round of trachoma MDA in all 13 trachoma-endemic woredas. Table 9 provides details of the ENVISION partners’ implementation activities. Please note that, to maintain clarity throughout the work plan, the implementing partner is located after each activity heading in parenthesis.
ENVISION FY18 PY7 Ethiopia Work Plan 21
Table 9. ENVISION partners and implementation mechanisms under the integrated model (as of September 30, 2017) Organization Region Number/name of zones Targeted diseases/ number of woredas
FMOH capacity N/A N/A building
OV/LF: 14 woredas (12 are LF co-endemic and 2 are Beneshangul- OV endemic only) Trachoma: 11 RTI 3 zones: Assosa, Kamashi, and Metekel Gumuz woredas STH: 0 SCH: 8 woredas Trachoma: 13 woredas Gambella 4 zones: Agnua II, Itang, and Mejang, Nuer II STH: 0 SCH: 0
14 zones: North Shoa, Finfine, Jimma, Trachoma: 135 woredas Southwest Shoa, Arsi, West Arsi, West LF: 1 FHF Oromia Harege, Borena, Bale, Guji, West Guji, East STH: 48 woredas Shoa, and Illubabor, Buno Bedele SCH: 12 woredas OV: 49 woredas (9 are LF co-endemic) 5 zones: Horuguduru, East Wollega, West LF only: 1 woreda Oromia Wollega, Kellem Wollega, and West Shoa Trachoma: 46 woredas STH:26 woredas LFTW SCH: 2 woredas Trachoma: 28 woredas 3 zones: Central Tigray, East Tigray, and LF: 1 woreda Tigray Northwest Tigray STH: 0 SCH: 18
a) Strategic Planning
The ENVISION project continues to support the FMOH with its strategic objectives surrounding the elimination and control of NTDs and is considered a key partner to the national program. RTI, FHF and LFTW staff provide technical guidance and programmatic advice both in the formal setting of FMOH-led technical working groups and through ad-hoc meetings held with the NTD case team leader and disease focal persons. In this role, in CY2016, ENVISION assisted the FMOH to update the Ethiopia NTD Master Plan (2016-2020). While there are no plans to formally revise this document until 2020, it is treated as a “living” document. NTD partners, including the ENVISION project, help the FMOH to update goals and targets as appropriate during the Mid-Term and Annual review meetings. In FY17, strategic planning support will largely focus on the FMOH’s NTD Integration plans. Important Note: In the past, ENVISION has co-supported the NTD Annual Review Meeting, the Mid-Term Review Meeting, and the NTD scientific symposium. Given the large funding needs to conduct the DSAs this year, as well as budget reductions, ENVISION will not provide this support in FY18 beyond technical guidance provided during the meeting by ENVISION staff. Activity 1: Regional Integrated NTD Preparation Meeting (RTI, FHF, and LFTW). This meeting will be an opportunity for the RHBs and zonal health offices to prepare for integration. It will involve aligning an MDA calendar (taking into account zones and woredas that are currently on a treatment schedule that is
ENVISION FY18 PY7 Ethiopia Work Plan 22
not in line with the federal calendar referenced above) and mapping out the co-endemic districts with an appropriate training schedule. The meetings will take one day and will take place in all ENVISION- supported regions in October of FY18. Activity 2: Regional Annual Review Meetings (RTI, FHF, and LFTW). Regional annual review meetings are an opportunity for the entire region to meet with representatives from the zonal health offices and for stakeholders to review the year’s successes and challenges. Because there are numerous NTD implementing partners, this meeting provides an opportunity to coordinate activities and share best practices. ENVISION and the FMOH will also use this meeting to evaluate the progress of the three priority capacity building foci with specific focus on the four regions ENVISION supports. Given the size and unprecedented scale-up of NTD interventions and the implementation of the integrated NTD platform—this meeting is crucial to ensure that goals are being met and zonal offices are successfully coordinating multiple disease interventions. This review meeting will also be an opportunity to continue ongoing efforts to coordinate NTD WASH activities in the region. Participants from the region and zonal health departments will attend the two-day review meeting. Activity 3: Zonal-level Post-MDA Review Meetings (RTI, FHF, LFTW). A one-day zonal post-MDA review meeting in each zone supported by ENVISION will build upon the woreda-level post-MDA review meetings and allow an opportunity for compiling woreda MDA reports for each of the zones. Again, this will be an optimal opportunity for woreda health officers to share experiences surrounding the integrated NTD training rollout and adjust the microplanning strategy for the next campaign. Activity 4: Woreda-level Post-MDA Review Meetings (FHF). One-day post-MDA review meetings are held in each woreda to share, compile, and analyze treatment reports as well as reflect upon success and challenges regarding the recent MDA distribution. This process strengthens the capacity of the sub- national NTD staff to use their data and allows for the woreda offices to better prepare for future MDA. These meetings will be particularly important in FY18 because they will allow the HEWs to reflect upon the integrated NTD training rollout (see Training section). The participants are MDA distribution team leaders, field supervisors, kebele leaders, and the woreda health office NTD team. The woreda health office leaders and woreda administrators lead the discussion and provide direction for future MDAs. Activity 5: TIPAC Maintenance (RTI). Note that the TIPAC is regularly updated by the FMOH NTD program manager (seconded by RTI) and the FMOH NTD team. It is a fully functioning tool used by the FMOH for fiscal year planning and to complete the WHO Joint Request for Selected Medicines (JRSM). Activity 6: FY19 National-level ENVISION Planning Workshop (RTI). In the latter half of FY18, RTI will hold a planning workshop with the FMOH, USAID representatives, ENVISION partners, and the RHBs to plan for FY19. The workshop will include a brief technical review of successes and challenges in FY18 that will be used to inform the FY19 plan. The facilitators of the workshop will use the Data Action Guide (DAG) to ensure that activities are data driven. Budget sessions will also be included in order to build strong budgets based on uniform unit costs across all of ENVISION’s partners in Ethiopia. The workshop will last for two days. Activity 7: FY19 Regional-level ENVISION Planning Workshop (LFTW). The purpose of the workshop is to promote joint planning, ensure that costs are equitably distributed, and to build a sense of ownership by implementers from the onset. Facilitators of the workshop will also use the DAG to ensure that activities are data driven. Representatives from LFTW partners, namely Tigray Region and the Oromia zones of East Wollega, West Wollega, Kellem Wollega, Horo Guduru Wollega, West Shoa and will attend the three-day ENVISION work planning workshop in Addis Ababa. In all, 38 participants from zonal and regional offices will gather and plan the FY19 ENVISION work plan based on the learnings from FY18.
ENVISION FY18 PY7 Ethiopia Work Plan 23
b) NTD Secretariat
Activity 1: Engaging Peace Corps (RTI). Ethiopia currently hosts the largest Peace Corps program in the world with over 200 volunteers working in communities across the country in the Education and Health sectors. The Health sector volunteers primarily focus on HIV, WASH, and malaria initiatives, working to support and build the capacity of HEWs. It is important to note that the entire methodology of Peace Corps, emphasized during the volunteers’ training and placement, is to enable, not undermine, the role of the HEWs. The volunteer is a resource for the HEWs and provides a mean to access resources (health education materials, behavior change strategies, etc.) that otherwise might not be available to a community-level health worker. The FMOH fully endorses and approves this activity. After several advocacy meetings led by RTI and The Carter Center, the FMOH, Peace Corps, RTI, and The Carter Center have signed a joint MOU to place Peace Corps health volunteers in highly endemic trachoma woredas (co-endemicity with other NTDs is a secondary consideration) at the start of their two years of service. The volunteers will specifically focus on helping HEWs organize MDAs, identify TT cases, and teach the community about F and E. In FY17, the widespread insecurity and protests led to the evacuation of most volunteers from the country. A meeting held in April of 2017 sought to get the Peace Corps/NTD collaboration back on track now that the country was deemed secure enough to reintroduce volunteers. RTI and The Carter Center will continue to lead NTD modules during Peace Corps pre-service and in-service training in FY18.
c) Building a Sustainable National NTD Program
Given that Ethiopia has demonstrated unrivaled domestic financing towards NTDs, ENVISION’s support efforts have generally centered on endorsing the FMOH’s initiatives via social media and through technical support. ENVISION also plays a major role in encouraging cross-sectoral partnerships with implementing partners outside of the NTD sphere and with departments that do not generally play a role in NTD intervention. Regional-level stakeholder meetings, such as the ones described below, have already resulted in greater awareness and participation from myriad governmental and non- governmental partners within the regions of Gambella and Beneshangul-Gumuz. In FY18, ENVISION will continue this strategy in Oromia and Tigray through the implementing partner, LFTW. Activity 1: Regional-level NTDs Stakeholders Meeting (LFTW). The fight against NTDs should not be the responsibility of the health sector only, as it requires strong inter-sectoral collaboration among different sectors. Participants will be top level management officials of regional bureaus including RHBs, project zonal health departments, Water and Mineral Office, Education Bureau, Communication Affairs Office, Women and Children Affairs, Social and Labor Affairs, Finance and Economic Development Bureau, and FMOH and NTD program implementing partners working in the region. LFTW will facilitate the meeting with the Tigray RHB in Tigray and the Oromia RHB in Oromia. RTI supported similar meetings in Beneshangul-Gumuz (FY15) and Gambella (FY16). Activity 2: SAFE sensitization meeting in “new” trachoma woredas (LFTW). There are 19 new districts (five districts in Kellem Wollega, 11 districts in West Wollega, and three districts in Tigray Region) that will implement Trachoma MDA for the first time in FY18. These districts, with active trachoma prevalence of 5%–9.9%, require only one round of trachoma MDA. Participants at the meeting will be zonal-level health officers; district-level sector officers; 2 participants from each district health office, education office, women and children affairs office, communication affairs office, water and mineral
ENVISION FY18 PY7 Ethiopia Work Plan 24
office, social and labor office, and kebele leaders. The aim of district-level sensitization and stakeholder dialogue is to promote the ownership and active participation of every stakeholder.
d) Mapping
As of the writing of this report, there are currently 22 woredas remaining in the country that are unmapped for trachoma that do not current have total financial support. These woredas are all located in the Somali region and were not addressed during GTMP due to an unstable security situation. The FMOH now feels that all of the Somali Region is safe and secure and is ready to move forward with a robust trachoma program. In order to close the mapping gap, the FMOH has put forward a sizeable portion of domestic funding, and the WHO also has agreed to contribute. ENVISION is currently advocating with International Coalition for Trachoma Control to find the remainder of the mapping costs by September FY17. No ENVISION funding is required for this mapping (Table 10).
e) MDA Coverage
Table 10. USAID supported coverage results for FY15–FY17 Q1–Q2 Fiscal # Districts # Districts Percentage year not not # Rounds Treatment Treatment of meeting meeting # persons NTD of annual target targets treatment epi program treated distribution # DISTRICTS # PERSONS target met coverage coverage PERSONS target target LF FY 15 1 19 1 1 852,807 724,499 85.0% FY16 1 24 0 0 1,442,778 1,156,602 80.2% FY17 1 24 1 1 1,626,197 521,527 32.1% Round 1 38 1 1 2,019,288 1,917,359 95.0% FY 15 2 Round 2 37 0 0 1,983,360 1,942,886 98.0% Round 1 56 0 0 3,368,356 3,300,099 98.0% OV FY16 2 Round 2 51 0 0 2,946,542 494,832 16.8% FY17 Round 1 60 1 6 3,744,208 3,228,664 86.2% 2 Round 2 60 3,727,592 0 0% Round 1 6 3 1 335,617 298,022 88.8% FY 15 2 Round 2 0 0 0 0 0 0 Round 1 3 1 0 180,675 161,084 89.2% FY16 2 STH Round 2 6 0 0 485,702 478,433 98.5% FY17 Round 1 8 0 0 650,937 82,211 12.6% 2 Round 2 3 330,303 0 0% TRA FY15 1 85 1 1 8,592,474 4,896,791 57.0% FY16 1 200 7 7 23,464,839 16,859,717 71.9% FY17 1 209 4 4 29,333,995 13,534,051 21.2% *Epi and program coverage as defined in the workbooks
ENVISION FY18 PY7 Ethiopia Work Plan 25
Table 11. USAID-supported districts and estimated target populations for MDA in FY18 Total # of Remark Age groups Number of Number of eligible targeted rounds of Distribution districts to NTD people to (per disease distribution platform(s) be treated workbook be targeted annually in FY18 instructions) in FY18 In addition, 3 refugee camps of Beneshangul- Gumuz (BG) with Lymphatic Entire population Community 28,431 eligible 1 24 1,673,433 filariasis above 5 years MDA population are to be treated, and total population eligible will be 1,701,864* Community In addition, 4 Round 1 63 3,848,197 MDA refugee camps of Community BG with 41,170 Entire population MDA eligible population Onchocerciasis above 5 years are to be treated, Round 2 63 3,848,197 and total population eligible will be 3,889,367 In addition, 2 refugee camps of BG with 6,627 eligible population and 6 refugee Entire population Community camps of Gambella Schistosomiasis 1 129 3,923,686 above 5 years MDA with 97,338 eligible population are to be treated, and total population eligible will be 4,027,651 In addition, 2 refugee camps of BG with 14,656 eligible population and 6 refugee Soil-transmitted Entire population Community camps of Gambella 1 178 6,579,814 helminths above 5 years MDA with 97,338 eligible population are to be treated, and total population eligible will be 6,691,808 Including, 2 refugee Community camps of BG with Trachoma Entire population 1 237 MDA 25,013,223 21,870 eligible population and 7
ENVISION FY18 PY7 Ethiopia Work Plan 26
Total # of Remark Age groups Number of Number of eligible targeted rounds of Distribution districts to NTD people to (per disease distribution platform(s) be treated workbook be targeted annually in FY18 instructions) in FY18 refugee camps of Gambella with 383,706 eligible population are to be treated, and total population eligible will be 25,418,799
Planned FY18 MDA Activities
Oromia NOTE: Recently administrative redistricting occurred in Illu Aba Bora Arsi, Borena, East Shoa, Guji, West Harege, and West Wollega zones of Oromia Region. As result of this, the total number of woredas increased from 160 to 174 woredas in ENVISION supported areas. Additionally, two zones (Buno Bedele and West Guji) were created in ENVISION supported areas which has increased the total number of zones supported by ENVISION in Oromia from 12 to 14. This, in turn, has increased the number of trachoma-endemic woredas, with TF prevalence above 5%, in ENVISION-supported areas from 254 to 267 Activity 1: MDA coverage meeting in Southwest Shoa zone (FHF). Even though the overall MDA treatment coverage of Southwest Shoa zone is above the minimum therapeutic coverage, it is relatively low in comparison with other zones To address this, FHF plans to undertake meetings with key government and community leaders at Southwest Shoa zone in FY18 prior to the MDA period. The advocacy meeting will be followed by similar meetings in two consistently low performing woredas in Southwest Shoa (Sodo Dachi and Kersa Malima woreda) and intensified social mobilization (see Social Mobilization) at the kebele and community level. Activity 2: MDA coverage meetings in Sodo Dachi and Kersa Malima Woredas (FHF): FHF will once again conduct community meetings in Sodo Dachi and Kersa Malima woredas in Southwest Shoa zone. To change the current situation related to the MDA misconception in the two woredas, FHF has planned to undertake community sensitization meetings with key government and community leaders in both woredas following the zonal level advocacy meeting. Activity 3: Trachoma MDA (FHF). In FY18, FHF will support the Oromia RHB in addressing 122 trachoma- endemic woredas in 10 of the 14 zones ENVISION supports. Four zones with a population of 6,647,202(West Arsi, Bale, West Guji, Guji) are conducting MDA in July/August 2017 and will wait until October FY19 to conduct the next round of treatment. The targeted population at risk for these 10 zones will be greater than 14.3 million in FY18. Trachoma MDA in each zone will be completed within seven days. MDA teams are comprised of four members with a HEW assigned to lead the team. Other team members include kebele administrators and volunteers. One team is assigned to every 1,000–2,000 people to ensure that directly observed treatment is possible at every distribution point.
ENVISION FY18 PY7 Ethiopia Work Plan 27
Activity 4: LF MDA (FHF). ENVISION will support the Oromia RBH through FHF to conduct MDA for a second year in the one LF-endemic woreda in FY18. Because ENVISION is already supporting FHF to conduct trachoma MDA in the woreda, it is a strategically nominal cost to support an additional LF MDA round two weeks later in FY18. ENVISION will support the MDA logistics, dose poles, and production of MDA reporting forms and writing materials for HEW supervisors where gaps are identified. Activity 5: Trachoma MDA (LFTW). In FY18, ENVISION will support the Oromia RHB through LFTW in conducting MDA in 62 woredas in western Oromia addressing 6,036,573 million people at risk. Of these districts, 19 have a prevalence of 5%–9.9% and will be treated for the first time in FY18. Four of these districts are newly created after redistricting in West Shoa. OV, LF, and trachoma MDA activities are all supported through ENVSION in western Oromia, which will create a favorable environment for the integrated NTD training of HEWs activity. ENVISION will support the MDA logistics, dose poles, and production of MDA reporting forms and writing materials for HEW supervisors where gaps are identified. Activity 6: OV/LF MDA (LFTW). In FY18, ENVISION will support the same 46 woredas that it supported in FY17 as well as an additional 3 newly formed districts from existing districts of West Wollega (2) and West Shewa (1) zone that the FMOH has declared as endemic since they are emerged from OV-endemic woredas. These 49 woredas (9 of which are co-endemic for LF) will be targeted for Round 1 of IVM treatment in October/November and Round 2 of IVM treatment six months later using the community- based drug distribution mechanism. ENVISION will support the MDA logistics, dose poles, and production of MDA reporting forms and writing materials for HEW supervisors where gaps are identified. Activity 7: STH/SCH MDA (FHF and LFTW). FHF and LFTW will support STH/SCH treatment in the 124 STH co-endemic woredas and 82 SCH co-endemic woredas
Tigray Activity 8: Trachoma MDA (LFTW). In FY18, ENVISION will support the Tigray RHB through LFTW to conduct MDA in 30 endemic woredas. LFTW will begin the campaign at the same time in all four zones and carry out the MDA concurrently with the goal of completing all trachoma MDA in the region within one week. ENVISION will support the HEWs and supervisors traveling outside of their duty stations and MDA logistics such as dose poles, registers, and reporting forms for the new woredas and areas where gaps are identified. Note that after this round of MDA, ENVISION will conduct impact surveys in 19 of the 27 woredas in Tigray. Activity 9: LF MDA (LFTW). ENVISION will continue to support the treatment of 10 endemic districts of Oromia of which 9 are co-endemic for OV and the one LF endemic woreda in Tigray through the same mechanism mentioned in the Tigray Trachoma MDA section. Activty 10: STH/SCH MDA (LFTW). LFTW will give support STH/SCH treatment in the two co-endemic woredas. They will implement the enhanced supervision strategy to ensure they mentor woreda offices on the integrated M&E framework implementation.
Beneshangul-Gumuz Activity 11: OV and LF MDA (RTI). In Beneshangul-Gumuz, ENVISION will continue to support MDA in 14 OV-endemic woredas, 11 of which are also endemic for LF. In November of FY18, RTI will support Round one of IVM treatment in all 14 of the OV woredas, together with administering ALB in the 12 woredas co-endemic with LF. Six months later, in May of FY18, ENVISION will support Round two of IVM
ENVISION FY18 PY7 Ethiopia Work Plan 28
treatment to all 14 woredas. ENVISION will support the MDA logistics, dose poles, and production of MDA reporting forms and writing materials for HEW supervisors where gaps are identified. Activity 12: Trachoma MDA (RTI). In FY18, RTI will target four woredas between 10-29.9% TF prevalence with the third round of MDA and 7 woredas with TF prevalence between 5 – 10% which were treated in FY17. Additionally, RTI will also target two refugee camps for trachoma MDA. Activity 13: STH/SCH MDA (RTI). RTI will give support STH/SCH treatment in the two co-endemic woredas. They will implement the enhanced supervision strategy to ensure they mentor woreda offices on the integrated M&E framework implementation.
Gambella Activty 14: Trachoma MDA (RTI). In FY18, ENVISION will support the same 13 woredas for trachoma MDA that were targeted in FY16 and FY17. HEWs will be used as team leaders and community volunteers as social mobilizers. After the refugee camps in the region are mapped, RTI will target these additional populations if they are found to be endemic. ENVISION will support the MDA logistics, dose poles, and production of MDA reporting forms and writing materials for HEW supervisors where gaps are identified. Impact surveys for these 13 woredas will be conducted in FY19. RTI will also support trachoma MDA in seven refugee camps. Activty 15: STH/SCH MDA (RTI). None of ENVISION’s currently supported woredas in Gambella have a prevalence above the treatment threshold.
a) Social Mobilization to Enable NTD Program Activities
FMOH Activity 1: MDA radio messaging (FHF, LFTW, and RTI). FHF, LFTW, and RTI have created trachoma, OV, and LF awareness messages to be broadcast via radio both before and during the actual MDA. Contained within the short broadcasts are trachoma messages that include basic information about timing and locations of MDA and raising of SAFE awareness (for trachoma MDA). The messaging will run for eight days in each of the zones targeted by ENVISION, a few days prior to and during their respective MDA campaign schedules. Activity 2: Banners (LFTW). In FY18 LFTW will produce 4,000 banners for trachoma MDA; the goal is to have at least two banners per kebele or one per distribution site. The banners will be displayed at health facilities, other central points within the kebele, and drug distribution sites one week before MDA to ensure that community members are aware of the date and locations of MDA. Note that FHF and RTI have already produced a sufficient number of banners in FY17. Activity 3: Dissemination of health messages through MDA distribution teams (FHF, LFTW, and RTI). ENVISION will also disseminate health messages through MDA distribution teams. Each MDA distribution team is composed of four team members, the team leader, who is a HEW or health professional, plus three community volunteers selected from each community or “Gare.” The volunteers announce the MDA service to the community and provide information regarding the drug distribution by walking through the village with a megaphone. To standardize messaging across the teams, each distribution team will be provided with a printed version of key trachoma messages explaining what trachoma is, how it can be prevented, the antibiotic given, and why it is given. Activity 4: School-based NTD education programs (LFTW). LFTW’s experience in Tigray and western Oromia has shown that most resistance and refusal to MDA were by young people, particularly high
ENVISION FY18 PY7 Ethiopia Work Plan 29
school students and teachers near urban areas. In FY18, LFTW will start NTDs awareness creation programs at 20 selected high schools located in communities surrounding town areas. This strategy will include after-school clubs and some lessons on NTDs integrated into the current curriculum. Local health workers will deliver one-day training to school teachers and student leaders on NTDs, including information on how to integrate the program in school’s extracurricular portfolio.
Table 12. Social mobilization/communication activities and materials checklist for NTD work planning Is there an IEC strategy indicator/ Where/when Key Target (materials, mechanism to Other Category will they be Frequency messages population medium, track this comments distributed activity etc.) material/ activity? If yes, what? FHF MDA -MDA will Community Radio 6 days before Once % of audience who N/A Participation take place at members the MDA annually recall hearing x location on campaign messaging during x day post-coverage assessments -The drugs provided are free and safe
-Includes additional messaging on the SAFE strategy LFTW MDA -MDA will Community Radio and TV 8 days before Twice % of audience who Participation take place at members the MDA annually for recall hearing x location on campaign OV MDA messaging during x day and once for post-coverage trachoma assessments -The drugs Community Braille Will be handed Twice Targeted follow-up provided are members brochures out to disabled annually for conducted by free and persons OV MDA experts at LFTW safe organizations and once for trachoma -Includes additional messaging on the SAFE strategy RTI MDA -MDA will Community Radio 6 days before the Twice % of audience who Participation take place at members MDA campaign annually for recall hearing x location on OV MDA and messaging during x day once for post-coverage trachoma assessments -The drugs provided are
ENVISION FY18 PY7 Ethiopia Work Plan 30
Is there an IEC strategy indicator/ Where/when Key Target (materials, mechanism to Other Category will they be Frequency messages population medium, track this comments distributed activity etc.) material/ activity? If yes, what? free and safe
-Includes additional messaging on the SAFE strategy
b) Training*
*Training for Trachoma Impact Surveys, Pre-TAS and Coverage Surveys: See M&E section As described in the Capacity Building section, the FMOH has prioritized the rollout of an integrated NTD training for HEWs throughout the country as a major programmatic necessity. The curriculum consists of a four-day training in which all the NTDs in the National Master Plan will be addressed. Topics will include basic facts about each disease, information on the disease-specific MDA treatment regimens, and roles and responsibilities of each health system tier; community mobilization and disseminating health messages; organization of distribution teams; and serious adverse event (SAE) reporting, data quality management, and how to develop supervisory plans. At least a half day of the training at each tier will be devoted to MDA microplanning. The FMOH is currently adapting the integrated NTD training manual per the results of an expanded pilot project conducted in five zones in SNNPR from January 2017 to June 2017. Note that ENVISION has specifically requested the inclusion of representatives from the Women’s Affairs Office and representatives from associations of people with disabilities at each of the trainings below to help ensure that these two groups of people, the two groups most affected by NTDs, are fully engaged in the MDA campaigns. The FMOH plans to use a cascade system for this training in which each health system tier is targeted for a training of trainers (TOT) in how to conduct an integrated NTD training for HEWs. The cascade will begin at the FMOH in the form of a partner review of the integrated NTD training package in September FY17, and then the training will cascade down to the zones and woredas and finally the HEWs. The training cascade and related training activities are described in Figure 6 and Table 13. Note that RTI will measure retention and application of the training topics via knowledge tests administered at a series of critical junctures during FY18.
ENVISION FY18 PY7 Ethiopia Work Plan 31
Figure 2. Training cascade of national integrated NTD training curriculum
FMOH Integrated NTD Training: Partners' Forum September 2017: The FMOH will invite partners and RHB representatives to a review of the integrated NTD training package. Partners will create a national coordination plan. After this meeting, ENVISION will meet with the implementing partners for each region and plan how to divide training support.
Zonal Health Officer TOT on Integrated NTD Training of HEWs
October 2017: Zonal health officers will meet at the regional capital for a four-day training on the integrated NTD manual.
Woreda Health Officer TOT on Integrated NTD Training of HEWs
October 2017: Woreda officers will meet at zonal capitals for a four-day training on the integrated NTD manual.
Integrated NTD Training of HEWs
October 2017: HEWs will meet at woreda offices for a four-day training on the integrated NTD manual.
Disease-Specific NTD Training for HDAs (for OV/LF)
HEWs will return to their communities and train the HDA before any MDA campaigns throughout the year.
ENVISION FY18 PY7 Ethiopia Work Plan 32
Table 13. Training targets (FHF, RTI, and LFTW)
Number Name of other Number to be trained of Location of funding partner (if Training groups Training topics training training(s) applicable, e.g., New Refresher *Total days MOH, SCI) Oromia (FHF) Zonal MDA TOT: Integrated NTD 1002 1002 2 Zonal capital None woreda health office Training Modules in each head/deputy head, MDA designed by the respective coordinators, MDA FMOH: All PC NTDs zone supervisors, and addressed in one microplanning for the session training Woreda-level Cascading MDA Integrated NTD 25,420 25, 420 4 Woreda None Training: health professionals Training Modules capital or involved in the MDA, MDA designed by the nearby supervisors, and drug FMOH: All PC NTDs towns distribution team (HEWs, addressed in one Kebele administrator) training MDA rapid intra campaign WHO Supervisory 801 801 1 Woreda None assessment for selected Coverage Tool capital or district & zonal health protocol (adapted nearby professionals by FMOH) towns Post-MDA survey training Post-MDA survey 25 25 1 Woreda None (trachoma) tool manual capital or nearby towns Oromia (LFTW) Zonal MDA TOT woreda Integrated NTD 332 332 2 Zonal capital None health office head/deputy Training Modules in each head, MDA coordinators, designed by the respective MDA supervisors, and FMOH: All PC NTDs zone microplanning for the session addressed in one training Woreda-level Cascading MDA Integrated NTD 996 996 2 Woreda None Training health profession Training Modules capital or involved in the MDA, MDA designed by the nearby supervisors, and drug FMOH: All PC NTDs towns distribution team (HEWs, addressed in one Kebele administrator) training MDA rapid intra campaign WHO SCT protocol 332 332 1 Woreda None assessment for selected manual capital or district & zonal health nearby professionals towns Oromia (RTI) Trachoma Impact Survey WHO Trachoma 33 60 93 7 Woreda None Impact Survey capital or Guidelines nearby (GTMP/Tropical towns data) Tigray (LFTW) Zonal MDA TOT woreda Integrated NTD 104 104 2 Zonal capital None health office head/deputy Training Modules in each head, MDA coordinators, designed by the respective MDA supervisors, and FMOH: All PC NTDs zone microplanning for the session
ENVISION FY18 PY7 Ethiopia Work Plan 33
Number Name of other Number to be trained of Location of funding partner (if Training groups Training topics training training(s) applicable, e.g., New Refresher *Total days MOH, SCI) addressed in one training Woreda-level Cascading MDA Integrated NTD 3120 3120 2 Woreda None Training health profession Training Modules capital or involved in the MDA, MDA designed by the nearby supervisors, and drug FMOH: All PC NTDs towns distribution team (HEWs, addressed in one Kebele administrator) training MDA rapid intra campaign WHO Intra- 104 104 1 Woreda None assessment for selected campaign capital or district & zonal health assessment nearby professionals protocol manual towns Tigray (RTI) Trachoma Impact Survey WHO Trachoma 30 14 54 7 Woreda None Impact Survey capital or Guidelines nearby (GTMP/Tropical towns data) Beneshangul-Gumuz (RTI) Woreda health officers TOT Integrated NTD 63 63 4 Assosa None on Integrated NTD Training of Training Modules HEWs (RTI) designed by the FMOH: All PC NTDs addressed in one training Integrated NTD Training of Integrated NTD 200 200 4 Woreda None HEWs and Teachers (RTI) Training Modules towns designed by the FMOH: All PC NTDs addressed in one training Training of Supervisors (RTI) Supportive 105 105 4 Woreda None supervision towns techniques. Pre-Transmission Assessment WHO Pre-TAS/TAS 16 16 3 Beneshangul None Survey (Pre-TAS) guidelines -Gumuz Implementation Teams Trachoma Impact Survey WHO Trachoma 20 7 27 7 Woreda None Impact Survey capital or Guidelines nearby (GTMP/Tropical towns data) Gambella (RTI) Woreda Health Officer TOT Integrated NTD 52 52 4 RHB/Gambel None on Integrated NTD Training of Training Modules la HEWs (RTI) designed by the FMOH: All PC NTDs addressed in one training Integrated NTD Training for Integrated NTD 500 500 4 Woreda None HEWs and Teachers (RTI) Training Modules Towns designed by the
ENVISION FY18 PY7 Ethiopia Work Plan 34
Number Name of other Number to be trained of Location of funding partner (if Training groups Training topics training training(s) applicable, e.g., New Refresher *Total days MOH, SCI) FMOH: All PC NTDs addressed in one training Training of supervisors Supportive 128 128 4 Woreda supervision towns techniques *Note that all HEWs will be asked to participate in the integrated NTD training package, as it is the first time it has ever been rolled out.
c) Drug and Commodity Supply Management and Procurement
From the central drug store, the PFSA delivers all the necessary NTD-related drugs to the 16 PFSA hubs throughout the country (see Figure 7). Once the drugs arrive at the PFSA hub, the PFSA then delivers them to the woreda health offices. The primary goal of the PFSA and its hub schematic is to reach all public health facilities within a 160–300 km radius.
Figure 3. 16 PFSA main and sub-branches
Note that the PFSA does not have the capacity to deliver to sub-woreda locations, so this is the point in the supply chain when additional partner support is necessary. The woreda health office, with partner support, distributes the drugs per the census to the health posts in each kebele. For OV/LF MDA, the drug distributors will collect the drugs from the health posts and distribute them to the community. For trachoma MDA, HEWs will distribute the drugs. As mentioned in the Capacity Building section, the FMOH intends to pilot sub-woreda drug delivery in FY18 through the PFSA mechanism.
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Unused drugs are returned to woreda health office drug stores to be used for the next round of MDA. Expired drugs are collected in each woreda and presented to the woreda-level expired drug disposal committee. The committee decides on disposal based on the nature of the drug and as per the national expired drug disposal guidelines. Activity 1: Finalization of NTD supply chain management standard operating procedures (RTI). RTI’s PFSA secondment and the FMOH NTD supply chain focal person will finalize NTD supply chain SOP that will guide all FMOH and PFSA staff in handling NTD drugs. This will include all the required handling and distribution instructions, as well as SAE reporting, as required by the FMOH, Food, Medicine, and Healthcare Administration and Control Authority (FMHACA), the pharmaceutical company, and the donor (such as ENVISION). Once completed and signed by the Infectious Disease Director, the PFSA will circulate this document to all PFSA hubs. ENVISION partners will also help circulate the document to supply chain focal persons throughout the region. This activity will have no extra cost for the ENVISION project. Note that this document may also provide a useful reference for NTD supply chain SOP that other countries could also use. Activity 2: Reverse logistics improvement strategy (RTI). As described in the Capacity Building section, the PFSA secondment will conduct an assessment specifically focusing on reverse supply chain issues for NTDs. He will conduct this analysis during his regular supervisory visits and compose some strategies to address any shortcomings he finds. The ability to return drugs to the woreda health offices after MDA has been cited as a major supply chain challenge by the PFSA. ENVISION will support the seconded PFSA staff member to track the drugs down to the health center level to assess the reverse supply chain system at the lowest tier. This cost will also include the secondment’s participation in the Zithromax physical inventory activity described below. Activity 3: Transporting drugs from the woreda health center to the distribution points (RTI, FHF, LFTW). In all four supported regions, the ENVISION project will support either the procurement of fuel for woreda-level health post vehicles or, if vehicles are not available, ENVISION will support the rental of a vehicle. Whenever possible, ENVISION will ensure the drug deliveries are carried out in conjunction with other activities such as MDA training supervision. Activity 4: Zithromax physical inventory (FHF). Immediately after completion of MDA camp, FHF will take a physical inventory of remaining Zithromax and tetracycline eye ointment and make sure that left- over drugs are returned to woreda health office drug stores to be used for the next round of MDA. Implementing partners include drug inventory spot checks within their supervisory checklists. However, this will be a more exhaustive activity that also provides an excellent frame of reference for the current NTD supply chain capacity building efforts. The national NTD supply chain team will use this opportunity as part of the reverse logistics analysis.
d) Supervision for MDA
Supervision of Integrated MDA (FHF, LFTW, and RTI) It is important to note that as of the writing of this work plan, the results of MDA coverage assessments currently underway are not yet available. Once these activities are complete, ENVISION partners will use this information to hone supervision foci accordingly. For any drug distribution program, strong supportive supervision is mandatory during three phases of drug distribution, which are the following: 1. Pre- drug distribution supervision: Woreda health offices and zonal health departments will conduct supervision to ensure all logistics are in place and ready for the actual distribution.
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2. Supervision during drug distribution: This stage requires intensive supervision from the regional, zonal, woreda, kebele, and HEW work force. The aim of this supervisory stage is to make sure the MDA will take place as per the standards and to provide appropriate support required at field level. Particular attention will be given to assuring the collection of accurate data according to the FMOH protocols. 3. Post drug distribution supervision: District supervision teams and district MDA coordinators are highly engaged during this stage. The aim of this supervisory stage is to evaluate if the intended coverage is achieved or not, assess the quality of the data, and to collect all supplies and reports for compilation. Feedback is provided during post-MDA meetings at the woreda and zonal levels (see Strategic Planning section). Kebele/sub-kebele levels. The community-based MDA approach foresees a high involvement of the respective communities and local stakeholders, especially the HDA. For OV/LF MDA, HDAs have the task to complete household forms, update census data, and distribute the drugs. The HEWs, health center staff, and district NTD focal persons supervise the HDA. The HEWs keep records at the health posts and report to the health centers. Health staff at the health centers report to the woreda health offices. As mentioned previously, the HDA is not allowed to directly distribute AZT as it is an antibiotic. Instead, the HEWs distribute the drugs directly to the community from the health post. Health staff from health centers and woreda NTD focal persons will supervise the HEWs. In addition, FHF, LFTW, and RTI seconded staff will perform spot checks of HDA/HEW performance. Woreda level. At the district level, the zonal and regional NTD focal persons supervise program activities. FHF, LFTW, and RTI staff will regularly visit woreda-level health offices to ensure that the woreda NTD focal persons are supervising distribution and collating and submitting reports. There will also be annual performance review meetings at woreda levels (see Strategic Planning) to reflect on achievements, constraints, and lessons learned that will be used as input for the next work schedule. Zonal level. ENVISION partners will support the respective regional health officer to ensure monitoring of programmatic activities at the zonal health offices. There will also be an annual performance review meeting to reflect on achievements, constraints, and lessons learned that will be used as an input for the next work schedule. Continuous supervision of daily MDA activities (pre, during, and post) at all levels is carried out by many zone supervisors and field supervisors. Technical and management teams composed of ENVISION partners, FMOH, and Oromia RHB staff, as well as staff from all the aforementioned levels, will be engaged in all stages of the MDA campaign and in conducting standardized supervisory visits in the field. As an example, details, such as zone supervisor feedback, reporting, HEW knowledge assessment, MDA distribution team organization, and dosage administration, will be measured and assessed by ENVISION. On average, a field supervisor will support three to four teams and is expected to visit each team at least every other day during the campaign week. The field supervisor is expected to collect daily reports, review daily performances of the team, and take appropriate measures to correct any deviations from the plan. The supervisor will also check the way the distribution team is organized, check if the social mobilization is adequate, and provide written feedback to the distribution team. The field supervisor checks how key messages are being delivered, including information on drug side effects, and whether the right dosages of drugs are being given with correct measurements. The woreda coordinators are composed of NTD team leaders, deputy/heads of woreda health offices, and drug store managers. Along with zonal supervisors, they mainly focus on supporting villages when unanticipated problems arise, compiling woreda-level reports, and reporting to zonal health
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departments, supervising and evaluating the performance of field supervisors as measured against their supervision plan, and providing overall direction regarding challenges that can arise during the campaign. The coordinators will provide daily updates to the woreda administrator and zonal health department. The zonal supervisor will also ensure that woreda authorities give due attention to the campaign. From past experiences, it was evident that woredas tend to perform better when people from the zonal health department are closely following their activities. The presence of the zonal supervisors usually ensures that woredas will fully focus on the campaign throughout the week. The drug store manager, who is the third coordinator, will focus on drug supply chain management for the campaign. Field supervisors and coordinators usually will meet daily, in early morning or late evening, to discuss progress and jointly find solutions to address problems.
e) M&E
Activity 1: Rapid intra-campaign MDA assessment (FHF). Sustained high drug coverage is crucial to achieving the elimination goal regarding trachoma. Reported treatment coverage is the most cost- effective and efficient way for monitoring MDA but of little value if the reported coverage is not accurate. Some reported coverage may be regarded as accurate due to different reasons, including denominator issues, intentional falsification, and lack of quality reporting. To bridge such gaps during the MDA, intra-campaign assessment or coverage monitoring is planned in all MDA implementing woredas during MDA campaign weeks using the Supervisor’s Coverage Tool (SCT). This tool was developed by WHO in collaboration with the Neglected Tropical Disease Support Center at the Task Force for Global Health; it is designed to implement this assessment. Activity 2: LF pre-TAS (RTI). RTI will conduct pre-TAS in nine woredas (including Assosa Town) in Beneshangul-Gumuz in FY18. These nine woredas have consistently demonstrated strong coverage at or above 65% for the five years of MDA. There are three additional woredas that have completed five rounds of treatment, but had one round out of the five where coverage was between 50 and 60%. ENVISION is still in discussion with the FMOH about whether or not an additional round of MDA should occur within these three woredas before pre-TAS. The ENVISION Ethiopia team will consult its Regional Program Review Group focal person to discuss the issue of these three woredas further. The national LF TWG will meet in September 2017 for a final decision. In the meantime, the project will budget for nine pre-TAS. LF pre-TAS training: ENVISION plans on training 4 pre-TAS survey teams, each with the following team members: • One person responsible for registering children and managing supplies (the local health officer • Two phlebotomists and test preparer (from the regional hospital lab) • One test reader (from the regional hospital lab) In terms of facilitation, three members of the FMOH and EPHI recently attended a TAS training in Kampala, Uganda. The Carter Center and EPHI also have experience conducting pre-TAS and baseline sentinel and spot-check sites in other regions. As this is the first time ENVISION has supported the pre- TAS in Ethiopia, RTI has included a request for an expert from the US Centers for Disease Control and Prevention to co-facilitate these trainings (see Cross Portfolio request) to ensure good quality and consistency with WHO guidelines. The training will last for three days and will be fully supported by the ENVISION project.
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Pre-TAS protocol: During the initial mapping for LF, EPHI did establish some sentinel sites. RTI is currently working with EPHI and the FMOH to compare the full list of sites with the 12 woredas currently targeted for pre-TAS. If a targeted woreda does not have previously established sentinel sites, the survey teams will establish sentinel sites in kebeles that have a history of high prevalence and LF-related morbidity (lymphedema or hydrocele) gleaned from the LF burden assessments. The national LF TWG will adapt the TAS Preparation checklist, Supervision checklist, and the Failure checklist to the national context. The national program will also seek to make some modifications to the TAS checklists so that they can be used during the pre-TAS. RTI will provide technical inputs for this exercise as it may prove useful for other countries going through the pre-TAS process. The following criteria will be observed, drawn from the WHO TAS training manual: • Approximately 300 samples will be gathered from people aged 5–50 years, using filariasis test strips collected from at least two sites per woreda. • Each woreda will have one sentinel site and one spot-check site. • Sentinel sites will be areas of known high transmission; spot-check sites will be areas at high risk of continued transmission, e.g., due to low MDA coverage. • Pre-TAS sentinel and spot-check site data will be collected after the 5th effective MDA round to determine whether the district can move to implementing a TAS. Pre-TAS sentinel sites are the same villages as the baseline sentinel sites (when possible). • All other issues with finger blood preparation and collection will follow the standard job aid. Only woredas that have a result of microfilaraemia < 1% or antigen < 2% will pass the pre-TAS and be considered for implementation of a TAS. Districts that do not achieve this cut-off will be required to continue MDA for two additional rounds before implementing another pre-TAS. Note that no subsequent MDA rounds will occur following the pre-TAS until the results are finalized. If any woredas fail the pre-TAS, after a detailed analysis of the TAS checklists, the ENVISION Ethiopia team will create a plan of action with the national LF TWG to analyze the failure and create a road map for the subsequent two rounds of MDA to be as strong as possible. This road map would include an enhanced MDA strategy tailored to the specific woreda with an intensified supervision strategy. Activity 3: Trachoma impact survey (RTI). With support from ENVISION, RTI will conduct 66 trachoma impact surveys in FY18 (7 woredas from Beneshangul-Gumuz, 40 woredas in Oromia and 19 woredas in Tigray). Note that there are an additional 20 woredas that could feasibly be addressed with an impact survey in September of FY18. However, given the budget and time implications, the project has decided to schedule these 20 impact surveys for October of FY19. These first 66 impact surveys will target trachoma-endemic woredas with a prevalence of 10%–29.9% that started treatment in 2015 and completed the third round of MDA in CY217. In addition, impact surveys will also be conducted in woredas with a prevalence of 5%–9.9%, which were treated in FY17. These woredas have carried out successive MDA rounds with strong coverage as per WHO recommendation and are ready for DSA, though there are challenges in the implementation of other SAFE components. Trachoma impact survey training: In order to complete the 66 woredas targeted in FY18, ENVISION will need to train 48 trainers and 48 recorders. As the GTMP certified 129 graders and 139 recorders within Ethiopia in CY2013/2014, the project should be able to build experienced survey teams in each of the three targeted regions.
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However, a refresher training will be required for those previously certified, and replacement certification of new candidates may also be necessary. RTI will secure one of Ethiopia’s seven graders certified as a trainer of trainers to facilitate the training. Trachoma impact survey protocol: The FMOH requires the use of Tropical Data and the GTMP-based mapping methodology, which uses a two-stage cluster random sampling. The enumeration unit will be the woreda (assuming an average population size of 100,000–250,000 people), and the cluster will be the kebele (sub-district). The surveys will set the number of households required per cluster at 30. The surveys will require a total of 1,222 children aged 1–9, but the graders will screen everyone in the household, with results in adults aged 15+ years and over used to establish TT prevalence. During the impact surveys conducted in FY17, the project assumed 20% of a household aged of one and nine. The average household size based on census data is 10 people, so RTI made a very conservative estimate of two children per household. This resulted in the need for 21 (20.36) clusters per evaluation unit (1,222 children/30 households/2 children per household). However, while conducting these impact surveys, an insufficient number of children were found to adequately power the study, so additional clusters were added. In FY18, RTI will use a ratio of 1.6 children per household to ensure adequate sample size, which will result in 26 clusters required per evaluation unit (1,222 children/30 households/1.6 children). These numbers may fluctuate slightly based on demography of each region, but this calculation will serve as the base for budgeting and planning purposes. Activity 4: Post-MDA coverage survey (RTI, FHF). In FY18, post-MDA coverage surveys will be executed by RTI and FHF in their respective implementation areas. The post-MDA coverage surveys are conducted with the objective of assessing the validity of reported MDA coverage against beneficiary statements, assessing the quality of the service, identifying limitations/gaps of the trachoma campaign, and developing strategies for addressing them. RTI will conduct the coverage survey in three woredas of Gambella. Following discussion with ENVSION, FHF will conduct post-MDA coverage surveys in the seven woredas of southwest Shoa, which continue to challenge the program (see MDA coverage section). These seven woredas will be selected jointly by FHF and Oromia RHB, with criteria to include previous coverage surveys, areas where unfounded rumors arose, and any suspicious reports obtained from zones. Probability sampling using modified segment design with households, which is endorsed by the FMOH, will be utilized (using the WHO Coverage Survey Builder). The information from the coverage surveys will be used to improve overall performance and detect problem areas where the reported coverage data are not aligned with the actual coverage. It will also help assess whether reported coverage accurately represents events and results on the ground. ENVISION partners and the relevant RHB will visit any woredas in which reported coverage differs from surveyed coverage to troubleshoot causes with the local health offices.
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Table 14. Reporting of DSA supported with USAID funds that did not meet critical cutoff thresholds as of September 30, 2017 Number of Number of Number of remaining Type of evaluation Why did the DSAs Post-DSA endemic DSA units that did evaluation unit NTD conducted failure districts carried not meet not “pass” the with USAID activities (same as out critical cutoff DSA? support Table 2) thresholds Both woredas fell to just below 10%. Additional Coverage was round of MDA Impact Trachoma 686 10 2 strong in these (already Survey woredas. Reason conducted) and for not passing is impact survey unknown.
Table 15. Planned DSAs for FY18 by disease Number of Number of evaluation Diagnostic method Number of districts units Type of (Indicator: Disease endemic planned for planned for assessment microfilaremia, filariasis districts DSA DSA (if test strips, etc.) known)
Lymphatic filariasis 70 8 8 Pre-TAS Filariasis test strips
WHO, Trachoma Impact Trachoma 686 66 66 simplified Survey grading system
f) Supervision for M&E and DSAs
Activity 1: Supervision of pre-TAS and trachoma impact surveys (RTI). In terms of M&E and DSA activities, ENVISION partners have been supplied with the templates and tools (coverage survey builder, Tropical Data guidelines, etc.) required by the project. The goal of ENVISION in Ethiopia is that all the partners, including any local universities engaged, act in partnership and with technical consultation to ensure the most accurate results. RTI requires all partners to submit DSA and coverage survey protocols to the RTI country office for review by the M&E team in country and at headquarters before any implementation takes place. RTI country M&E staff, already trained and versed in the WHO protocols, will participate in these activities and ensure that the protocol is adhered to, together with representatives from the FMOH and the RHBs. RTI staff will review and edit the final report writing before a second revision takes places at RTI headquarters. ENVISION partners understand that prompt submission of the final report and data set to the FMOH and RTI, with a clear set of actionable follow-up activities, is a requirement of the deliverable. ENVISION supports the travel and staff time to support the supervision of these activities.
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g) Dossier Development
Dossier development will be a focus of ENVISION office and seconded staff in FY18. The historical treatment data has already been collected, and new data are updated in the integrated NTD database regularly. RTI will work with the FMOH to create dossier trackers which will capture all of the necessary data surrounding treatment, morbidity, etc. by woreda within a single file. Activity 1: Improving hard copy storage (FHF). In FY18, FHF is supporting the woreda health offices in storing all of the hard copies of trachoma-related interventions. This includes information on MDA treatments spanning several years, TT surgeries, F and E documentation, etc. ENVISION will support the purchase of one box file per woreda health office for this initiative. If it works well, ENVISION will expand this support to all its woredas.
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3) Maps
Figure 4. Ethiopia LF, OV, STH, SCH, and Trachoma Endemicity Maps
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Figure 5. Ethiopia LF, OV, STH, SCH, and Trachoma Geographic Coverage Maps4,5
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Figure 6. Ethiopia Progress Toward LF Elimination Map
4 It is important to note that there are currently no gaps for trachoma support in the Oromia region. The current areas marked as “Endemic but not targeted for MDA” represent the four zones which the ENVISION project postponed from September FY18 to October FY19 both to align with the FMOH’s MDA schedule and to accommodate budget reductions. 5 Please note that ENVISION currently estimates that it will support (at no additional cost to the project) 3, 923, 686 treatments for SCH and 6,579,814 treatments for STH in FY18 through the FMOH’s integrated plan. These estimates are based on the co- endemicity of STH/SCH in woredas ENVISION is currently supporting for trachoma, OV and LF. However, the STH/SCH final targets are still in discussion with the FMOH as it coordinates with all of the implementing partners involved. ENVISION anticipates having these final targets by the end of August at which time it will provide an updated map.
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Figure 7. Ethiopia Progress Toward Trachoma Elimination Map
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APPENDIX 1: Work Plan Timeline
Partner FY18 Activities
Management Support RTI Technical/Programmatic support to country teams and national program FHF Technical/Programmatic support to country teams and national program LFTW Technical/Programmatic support to country teams and national program Project Assistance Strategic Planning RTI Regional Integrated NTD Preparation Meeting (Beneshangul-Gumuz) RTI Regional Integrated NTD Preparation Meeting (Gambella) FHF Regional Integrated NTD Preparation Meeting (Oromia) LFTW Regional Integrated NTD Preparation Meeting (Tigray) RTI Regional Annual Review Meeting (Beneshangul-Gumuz) RTI Regional Annual Review Meeting (Gambella) FHF Regional Annual Review Meeting (Oromia) LFTW Regional Annual Review Meeting (Tigray) RTI Zonal Level Post MDA Review Meetings (Beneshangul-Gumuz) RTI Zonal Level Post MDA Review Meetings (Gambella) FHF, LFTW Zonal Level Post MDA Review Meetings (Oromia) LFTW Zonal Level Post MDA Review Meetings (Tigray) FHF, LFTW Woreda Level Post MDA Review Meetings (Oromia) LFTW Woreda Level Post MDA Review Meetings (Tigray) RTI TIPAC Maintenance RTI FY19 National-Level ENVISION Planning Workshop LFTW FY19 Regional-Level ENVISION Planning Workshop NTD Secretariat RTI Engaging Peace Corps RTI Secondments Building Advocacy for Sustainable National NTD Program LFTW Regional Level NTDs Stakeholder Meeting LFTW SAFE Sensitization Meeting in New Trachoma Woredas
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Partner FY18 Activities
MDA Coverage FHF MDA Coverage Meeting in Southwest Shoa Zone FHF MDA Coverage Meeting in Sodo Dachi and Kersa Malima Woredas FHF Trachoma MDA (Oromia) FHF LF MDA (Oromia) LFTW Trachoma MDA (Oromia) LFTW OV/LF MDA (Oromia) FHF, LFTW STH/SCH MDA (Oromia) LFTW Trachoma MDA (Tigray) LFTW LF MDA (Tigray) LFTW STH/SCH MDA (Tigray) RTI OV and LF MDA (Beneshangul-Gumuz) RTI Trachoma MDA (Beneshangul-Gumuz) RTI STH/SCH MDA (Beneshangul-Gumuz) RTI Trachoma MDA (Gambella) RTI STH/SCH MDA (Gambella) Social Mobilization to Enable NTD Program Activities RTI MDA radio messaging (Beneshangul-Gumuz) RTI MDA radio messaging (Gambella) FHF MDA radio messaging (Oromia) LFTW MDA radio messaging (Tigray) RTI, FHF, Disseminate Health Messages through MDA Distribution Teams LFTW LFTW Banners LFTW School-based NTD Education Programs LFTW Delivery of IEC Materials Training n/a- Not ENVISION supported Drug Supply Management and Procurement RTI Finalization of NTD Supply Chain Management Standard Operating Procedures RTI Reverse Logistics Improvement Strategy RTI, FHF Transporting drugs from woreda health center to the distribution points FHF Zithromax physical Inventory Supervision for MDA
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Partner FY18 Activities
RTI Supervision of integrated MDA (Beneshangul-Gumuz) RTI Supervision of integrated MDA (Gambella) FHF, LFTW Supervision of integrated MDA (OV/LF/STH/SCH/Trachoma) (Oromia) LFTW Supervision of integrated MDA (OV/LF/STH/SCH/Trachoma) (Tigray)
Monitoring and Evaluations RTI DHIS 2 NTD Database Roll-Out Plan FHF Rapid Intra Campaign Assessment RTI LF Pre-TAS RTI Trachoma Impact Survey (Beneshangul-Gumuz) RTI Trachoma Impact Survey (Tigray) RTI Trachoma Impact Survey (Oromia) FHF Post MDA Coverage Survey (Oromia) RTI Post MDA Coverage Survey (Gambella) Supervision for Monitoring and Evaluation RTI Supervision of Pre-TAS RTI Supervision of TIS Dossier Development FHF Improving hard copy storage
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APPENIDX 2: Table of USAID-supported Regions and Districts in FY18
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A LF,OV,SCH,STH, Pre 1 Beneshangul Gumuz Asosa Asossa TRA X X X TAS LF,OV,SCH,STH, Pre 2 Beneshangul Gumuz Asosa Assosa Town TRA X X X TAS LF,OV,SCH,STH, 3 Beneshangul Gumuz Asosa Bambasi TRA X X LF,OV,SCH,STH, 4 Beneshangul Gumuz Asosa Homosha TRA X X X X TIS LF,OV,SCH,STH, 5 Beneshangul Gumuz Asosa Kurmuke TRA X X X TIS LF,OV,SCH,STH, Pre 6 Beneshangul Gumuz Asosa Menge TRA X X X X TAS TIS LF,OV,SCH,STH, 7 Beneshangul Gumuz Asosa Oda bildigilu TRA SCH,STH X X X LF,OV,SCH,STH, Pre 8 Beneshangul Gumuz Asosa Sherkole TRA LF X X X X TAS TIS LF,OV,SCH,STH, Pre 9 Beneshangul Gumuz Kamashi Agalometi TRA SCH,STH X X X TAS LF,OV,SCH,STH, 10 Beneshangul Gumuz Kamashi Belo Jegonfoy TRA X X X LF,OV,SCH,STH, Pre 11 Beneshangul Gumuz Kamashi Kamashi TRA SCH,STH X X X X TAS
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Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A LF,OV,SCH,STH, Pre 12 Beneshangul Gumuz Kamashi Sedal (Sirba Abay) TRA LF X X X TAS LF,OV,SCH,STH, Pre 13 Beneshangul Gumuz Kamashi Yasso TRA SCH,STH X X X TAS LF,OV,SCH,STH, 14 Beneshangul Gumuz Metekel Bullen TRA SCH,STH X X X LF,OV,SCH,STH, 15 Beneshangul Gumuz Metekel Dangure TRA X X TIS LF,OV,SCH,STH, 16 Beneshangul Gumuz Metekel Dibate TRA X X X LF,OV,SCH,STH, 17 Beneshangul Gumuz Metekel Guba TRA LF X X TIS LF,OV,SCH,STH, 18 Beneshangul Gumuz Metekel Mandura TRA SCH,STH X X LF,OV,SCH,STH, 19 Beneshangul Gumuz Metekel Pawe TRA X X LF,OV,SCH,STH, 20 Beneshangul Gumuz Metekel Wombera TRA X X X TIS Beneshangul Gumuz Tongo Sp. LF,OV,SCH,STH, LF,SCH,S Pre 21 Wereda MaoKomo TRA TH X X X TAS LF,OV,SCH,STH, 22 Gambella Agnua II Abobo TRA LF X X X LF,OV,SCH,STH, 23 Gambella Agnua II Dimma TRA X X X LF,OV,SCH,STH, 24 Gambella Agnua II Gambella TRA LF X X X LF,OV,SCH,STH, 25 Gambella Agnua II Gog TRA X X X LF,OV,SCH,STH, 26 Gambella Agnua II Jor TRA SCH,STH X X X
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Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A LF,OV,SCH,STH, 27 Gambella Itang Itang TRA X X X LF,OV,SCH,STH, 28 Gambella Mejang Godere TRA X X X LF,OV,SCH,STH, 29 Gambella Mejang Mengeshi TRA X X X LF,OV,SCH,STH, 30 Gambella Nuer II Akobo TRA X X X LF,OV,SCH,STH, 31 Gambella Nuer II Jikawo TRA SCH,STH X X X LF,OV,SCH,STH, 32 Gambella Nuer II Lare TRA X X X LF,OV,SCH,STH, 33 Gambella Nuer II Makoy TRA X X X LF,OV,SCH,STH, 34 Gambella Nuer II Wanthuwa TRA X X X LF,OV,SCH,STH, 35 Oromia Arsi Amigna TRA X X LF,OV,SCH,STH, 36 Oromia Arsi Aseko TRA X LF,OV,SCH,STH, 37 Oromia Arsi Bale TRA X LF,OV,SCH,STH, 38 Oromia Arsi Chole TRA X X X LF,OV,SCH,STH, 39 Oromia Arsi Digelu & Tijo TRA X LF,OV,SCH,STH, 40 Oromia Arsi Diksis TRA X X LF,OV,SCH,STH, 41 Oromia Arsi Dodota TRA X
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Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A LF,OV,SCH,STH, 42 Oromia Arsi Enkelo Wabe TRA X X LF,OV,SCH,STH, 43 Oromia Arsi Gololcha TRA X X X LF,OV,SCH,STH, 44 Oromia Arsi Shanan Kolu TRA X X X LF,OV,SCH,STH, 45 Oromia Arsi Guna TRA X X X LF,OV,SCH,STH, 46 Oromia Arsi Hetosa TRA X LF,OV,SCH,STH, 47 Oromia Arsi Jeju TRA X LF,OV,SCH,STH, 48 Oromia Arsi Limuna bilbilo TRA X LF,OV,SCH,STH, 49 Oromia Arsi Lode hetosa TRA X LF,OV,SCH,STH, 50 Oromia Arsi Merti TRA X X LF,OV,SCH,STH, 51 Oromia Arsi Munesa TRA X LF,OV,SCH,STH, 52 Oromia Arsi Robe TRA X LF,OV,SCH,STH, 53 Oromia Arsi Seru TRA X X X LF,OV,SCH,STH, 54 Oromia Arsi Shirka TRA X LF,OV,SCH,STH, 55 Oromia Arsi Sire TRA X LF,OV,SCH,STH, 56 Oromia Arsi Sude TRA X X X
ENVISION FY18 PY7 Ethiopia Work Plan 53
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A LF,OV,SCH,STH, 57 Oromia Arsi Tena TRA X LF,OV,SCH,STH, 58 Oromia Arsi Tiyo TRA X LF,OV,SCH,STH, 59 Oromia Arsi Zuway dugda TRA X X LF,OV,SCH,STH, 60 Oromia Borena Arero TRA X LF,OV,SCH,STH, 61 Oromia Borena Dhas TRA X LF,OV,SCH,STH, 62 Oromia Borena Wachile TRA X X LF,OV,SCH,STH, 63 Oromia Borena Dillo TRA X LF,OV,SCH,STH, 64 Oromia Borena Dire TRA X LF,OV,SCH,STH, 65 Oromia Borena Dubluk TRA X LF,OV,SCH,STH, 66 Oromia Borena Miyo TRA X LF,OV,SCH,STH, 67 Oromia Borena Moyale TRA X LF,OV,SCH,STH, 68 Oromia Borena Guchi TRA X LF,OV,SCH,STH, 69 Oromia Borena Teltele TRA X LF,OV,SCH,STH, 70 Oromia Borena Eliwaye TRA X LF,OV,SCH,STH, 71 Oromia Borena Yabelo TRA X X
ENVISION FY18 PY7 Ethiopia Work Plan 54
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A LF,OV,SCH,STH, 72 Oromia Borena Gomole TRA X X LF,OV,SCH,STH, 73 Oromia E. Shewa Adama TRA X X 74 Oromia E. Shewa Adea LF,OV,TRA X LF,OV,SCH,STH, 75 Oromia E. Shewa Boset TRA X X LF,OV,SCH,STH, 76 Oromia E. Shewa Fentale TRA X X X 77 Oromia E. Shewa Gimbichu LF,OV,TRA X 78 Oromia E. Shewa Liben LF,OV,TRA X 79 Oromia E. Shewa Gumi Eldalo LF,OV,TRA X LF,OV,SCH,STH, 80 Oromia E. Shewa Lome TRA X LF,OV,SCH,STH, 81 Oromia E. Wellega Boneya Bushe TRA X X X X TIS LF,OV,SCH,STH, 82 Oromia E. Wellega Diga TRA X X X TIS LF,OV,SCH,STH, 83 Oromia E. Wellega Ebantu TRA X X X LF,OV,SCH,STH, 84 Oromia E. Wellega Gida Ayyana TRA X X X X LF,OV,SCH,STH, 85 Oromia E. Wellega Gubu Sayo TRA X X TIS LF,OV,SCH,STH, 86 Oromia E. Wellega Gudaya Bila TRA X X X TIS LF,OV,SCH,STH, 87 Oromia E. Wellega Guto Gida TRA X X TIS
ENVISION FY18 PY7 Ethiopia Work Plan 55
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A LF,OV,SCH,STH, 88 Oromia E. Wellega Haro Limu TRA X X X LF,OV,SCH,STH, 89 Oromia E. Wellega Jima Arjo TRA X X TIS LF,OV,SCH,STH, 90 Oromia E. Wellega Kiremu TRA X X LF,OV,SCH,STH, 91 Oromia E. Wellega Leka Dulecha TRA X X TIS LF,OV,SCH,STH, 92 Oromia E. Wellega Limu TRA X X X 93 Oromia E. Wellega Nekemte Town LF,OV X LF,OV,SCH,STH, 94 Oromia E. Wellega Nunu Kumba TRA X X X TIS LF,OV,SCH,STH, 95 Oromia E. Wellega Sasiga TRA X X X TIS LF,OV,SCH,STH, 96 Oromia E. Wellega Sibu Sire TRA X TIS LF,OV,SCH,STH, 97 Oromia E. Wellega Wama Hagalo TRA X X X X TIS LF,OV,SCH,STH, 98 Oromia E. Wellega Wayu Tuka TRA X TIS LF,OV,SCH,STH, 99 Oromia Finfine Zuriya Akaki TRA X X 10 LF,OV,SCH,STH, 0 Oromia Horo Guduru Abay Comen TRA X X X X 10 LF,OV,SCH,STH, 1 Oromia Horo Guduru Abe Dongoro TRA X X X X 10 LF,OV,SCH,STH, 2 Oromia Horo Guduru Amuru TRA X X X X X
ENVISION FY18 PY7 Ethiopia Work Plan 56
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A 10 LF,OV,SCH,STH, 3 Oromia Horo Guduru Guduru TRA X X X 10 LF,OV,SCH,STH, 4 Oromia Horo Guduru Hababo Guduru TRA X X X 10 LF,OV,SCH,STH, 5 Oromia Horo Guduru Horo TRA X X 10 LF,OV,SCH,STH, 6 Oromia Horo Guduru Jardega jarte TRA X X X 10 LF,OV,SCH,STH, 7 Oromia Horo Guduru Jimma Ganati TRA X X 10 LF,OV,SCH,STH, 8 Oromia Horo Guduru Jimma Rare TRA SCH,STH X X 10 LF,OV,SCH,STH, 9 Oromia Illu Aba bora Alge Sachi TRA X X 11 LF,OV,SCH,STH, 0 Oromia Illu Aba bora Becho TRA X X X 11 LF,OV,SCH,STH, 1 Oromia Buno Bedele Bedele TRA SCH,STH X X 11 LF,OV,SCH,STH, 2 Oromia Illu Aba bora Bilo Nopa TRA X X 11 LF,OV,SCH,STH, 3 Oromia Buno Bedele Borecha TRA X X X 11 LF,OV,SCH,STH, 4 Oromia Illu Aba bora Bure TRA X X X 11 LF,OV,SCH,STH, 5 Oromia Buno Bedele Chewaka TRA SCH,STH X X X 11 LF,OV,SCH,STH, 6 Oromia Buno Bedele Chora TRA X X 11 LF,OV,SCH,STH, 7 Oromia Buno Bedele Dabo Hana TRA X X
ENVISION FY18 PY7 Ethiopia Work Plan 57
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A 11 LF,OV,SCH,STH, 8 Oromia Illu Aba bora Darimu TRA X X 11 LF,OV,SCH,STH, 9 Oromia Buno Bedele Dega TRA X X 12 LF,OV,SCH,STH, 0 Oromia Illu Aba bora Didu TRA X X 12 LF,OV,SCH,STH, 1 Oromia Buno Bedele Diediesa TRA SCH,STH X X 12 LF,OV,SCH,STH, 2 Oromia Illu Aba bora Doreni TRA X X 12 LF,OV,SCH,STH, 3 Oromia Illu Aba bora Hurumu TRA X X 12 LF,OV,SCH,STH, 4 Oromia Buno Bedele Meko TRA X X 12 LF,OV,SCH,STH, 5 Oromia Illu Aba bora Metu TRA SCH,STH X X TIS 12 LF,OV,SCH,STH, 6 Oromia Illu Aba bora Nono Sale TRA X X 12 LF,OV,SCH,STH, 7 Oromia Illu Aba bora Yayo TRA X X X 12 LF,OV,SCH,STH, 8 Oromia Jimma Botor Tollay TRA X X 12 LF,OV,SCH,STH, 9 Oromia Jimma Chora TRA X X 13 LF,OV,SCH,STH, 0 Oromia Jimma Deddo TRA X X 13 LF,OV,SCH,STH, 1 Oromia Jimma Mancho TRA X X 13 LF,OV,SCH,STH, 2 Oromia Jimma Gera TRA X X
ENVISION FY18 PY7 Ethiopia Work Plan 58
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A 13 LF,OV,SCH,STH, 3 Oromia Jimma Gomma TRA SCH,STH X X X 13 LF,OV,SCH,STH, 4 Oromia Jimma Gumma TRA X X X 13 5 Oromia Jimma Kersa LF,OV,TRA X 13 LF,OV,SCH,STH, 6 Oromia Jimma Limmu Kossa TRA SCH,STH X X X 13 LF,OV,SCH,STH, 7 Oromia Jimma Limmu Seka TRA X X 13 LF,OV,SCH,STH, 8 Oromia Jimma Manna TRA X X X 13 LF,OV,SCH,STH, 9 Oromia Jimma Nonno Benja TRA X X 14 LF,OV,SCH,STH, 0 Oromia Jimma Ommo Nadda TRA SCH,STH X X X 14 LF,OV,SCH,STH, 1 Oromia Jimma Omo Beyam TRA X X X TIS 14 LF,OV,SCH,STH, 2 Oromia Jimma Saka Chekorsa TRA X X X 14 LF,OV,SCH,STH, 3 Oromia Jimma Satema TRA X X 14 LF,OV,SCH,STH, 4 Oromia Jimma Shabe Sombo TRA X X 14 LF,OV,SCH,STH, 5 Oromia Jimma Sigimo TRA X X X 14 LF,OV,SCH,STH, 6 Oromia Jimma Sokoru TRA SCH,STH X X 14 7 Oromia Jimma Tiro Afeta LF,OV,TRA X
ENVISION FY18 PY7 Ethiopia Work Plan 59
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A 14 LF,OV,SCH,STH, 8 Oromia Kelem Wellega Anfilo TRA SCH,STH X X X 14 LF,OV,SCH,STH, 9 Oromia Kelem Wellega Dale sedi TRA X X TIS 15 LF,OV,SCH,STH, 0 Oromia Kelem Wellega Dale Wabera TRA X X X X X TIS 15 1 Oromia Kelem Wellega Dambi Dolo LF,OV,SCH,STH X X 15 LF,OV,SCH,STH, 2 Oromia Kelem Wellega Gawo Kebe TRA X X TIS 15 LF,OV,SCH,STH, 3 Oromia Kelem Wellega Hawa Gelan TRA X X X TIS 15 LF,OV,SCH,STH, 4 Oromia Kelem Wellega Lalo Kile TRA SCH,STH X X TIS 15 LF,OV,SCH,STH, 5 Oromia Kelem Wellega Seyo TRA X X X 15 LF,OV,SCH,STH, 6 Oromia North Shoa Zone Abichugna TRA X X TIS 15 LF,OV,SCH,STH, 7 Oromia North Shoa Zone Debre Libanos TRA X X 15 8 Oromia North Shoa Zone Degem LF,OV,TRA X 15 LF,OV,SCH,STH, 9 Oromia North Shoa Zone Derra TRA X X X 16 LF,OV,SCH,STH, 0 Oromia North Shoa Zone Girar Jarso TRA X 16 1 Oromia North Shoa Zone Hidhabu Abote LF,OV,TRA X 16 LF,OV,SCH,STH, 2 Oromia North Shoa Zone Jidda TRA X X X
ENVISION FY18 PY7 Ethiopia Work Plan 60
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A 16 3 Oromia North Shoa Zone Kuyu LF,OV,TRA X 16 4 Oromia North Shoa Zone Were Jarso LF,OV,TRA X 16 LF,OV,SCH,STH, 5 Oromia North Shoa Zone Wuchale TRA X X 16 LF,OV,SCH,STH, 6 Oromia North Shoa Zone Yaya Gulale TRA X 16 LF,OV,SCH,STH, 7 Oromia S.W. Shewa Ameya TRA X 16 LF,OV,SCH,STH, 8 Oromia S.W. Shewa Becho TRA X 16 LF,OV,SCH,STH, 9 Oromia S.W. Shewa Dawo TRA X 17 LF,OV,SCH,STH, 0 Oromia S.W. Shewa Elu TRA X 17 LF,OV,SCH,STH, 1 Oromia S.W. Shewa Goro TRA X 17 LF,OV,SCH,STH, 2 Oromia S.W. Shewa Kersa Malima TRA X 17 LF,OV,SCH,STH, 3 Oromia S.W. Shewa Seden Sodo Rural TRA X 17 LF,OV,SCH,STH, 4 Oromia S.W. Shewa Sodo Dachi TRA X 17 LF,OV,SCH,STH, 5 Oromia S.W. Shewa Tole TRA X 17 LF,OV,SCH,STH, 6 Oromia S.W. Shewa Woliso TRA X 17 LF,OV,SCH,STH, 7 Oromia S.W. Shewa Wonchi TRA X
ENVISION FY18 PY7 Ethiopia Work Plan 61
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A 17 8 Oromia W. Harerge Ancar LF,OV,TRA X 17 9 Oromia W. Harerge Boke LF,OV,TRA X 18 0 Oromia W. Harerge Burka dhintu LF,OV,TRA X 18 1 Oromia W. Harerge Chiro LF,OV,TRA X 18 2 Oromia W. Harerge Daro Lebu LF,OV,TRA X 18 3 Oromia W. Harerge Doba LF,OV,TRA X 18 4 Oromia W. Harerge Gemechis LF,OV,TRA X 18 5 Oromia W. Harerge Guba Koricha LF,OV,TRA X 18 6 Oromia W. Harerge Habro LF,OV,TRA X 18 7 Oromia W. Harerge Hawi Gudina LF,OV,TRA X 18 8 Oromia W. Harerge Mesela LF,OV,TRA X 18 9 Oromia W. Harerge Mi'eso LF,OV,TRA X 19 0 Oromia W. Harerge Gumbi Bordede LF,OV,TRA X 19 1 Oromia W. Harerge Tullo LF,OV,TRA X 19 LF,OV,SCH,STH, 2 Oromia W. Shewa Ade'a Berga TRA X X
ENVISION FY18 PY7 Ethiopia Work Plan 62
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A 19 LF,OV,SCH,STH, 3 Oromia W. Shewa Ambo Zuria TRA X X X TIS 19 LF,OV,SCH,STH, 4 Oromia W. Shewa Bako Tibe TRA X X 19 LF,OV,SCH,STH, 5 Oromia W. Shewa Chelia TRA X X X 19 LF,OV,SCH,STH, 6 Oromia W. Shewa Dano TRA X X 19 LF,OV,SCH,STH, 7 Oromia W. Shewa Dendi TRA X X TIS 19 LF,OV,SCH,STH, 8 Oromia W. Shewa Ejersa Lafo TRA X X 19 Dire Inchini (Tikur LF,OV,SCH,STH, 9 Oromia W. Shewa Inchini) TRA X X TIS 20 LF,OV,SCH,STH, 0 Oromia W. Shewa Ejere TRA X 20 LF,OV,SCH,STH, 1 Oromia W. Shewa Elfeta TRA X X TIS 20 LF,OV,SCH,STH, 2 Oromia W. Shewa Ilu Gelan TRA X X X 20 LF,OV,SCH,STH, 3 Oromia W. Shewa Jeldu TRA X X X TIS 20 LF,OV,SCH,STH, 4 Oromia W. Shewa Chobi TRA X X X 20 LF,OV,SCH,STH, 5 Oromia W. Shewa Jibat TRA X X X TIS 20 LF,OV,SCH,STH, 6 Oromia W. Shewa Meta Robi TRA X X 20 LF,OV,SCH,STH, 7 Oromia W. Shewa Meta Wolkite TRA X X
ENVISION FY18 PY7 Ethiopia Work Plan 63
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A 20 LF,OV,SCH,STH, 8 Oromia W. Shewa Mida Kegn TRA X X 20 LF,OV,SCH,STH, 9 Oromia W. Shewa Nono TRA X X X TIS 21 LF,OV,SCH,STH, 0 Oromia W. Shewa Toke Kutaye TRA X X TIS 21 LF,OV,SCH,STH, 1 Oromia W. Shewa Liben Jawi TRA X X X 21 LF,OV,SCH,STH, 2 Oromia West Arsi Kofele TRA SCH,STH X X 21 LF,OV,SCH,STH, 3 Oromia West Wellega Ayira TRA X X 21 LF,OV,SCH,STH, 4 Oromia West Wellega Babo Gambel TRA X X X X TIS 21 LF,OV,SCH,STH, 5 Oromia West Wellega Begi TRA X X X TIS 21 LF,OV,SCH,STH, 6 Oromia West Wellega Bodji Chokorsa TRA X 21 LF,OV,SCH,STH, 7 Oromia West Wellega Bodji Dirmeji TRA X X 21 LF,OV,SCH,STH, 8 Oromia West Wellega Genji TRA X X X TIS 21 LF,OV,SCH,STH, 9 Oromia West Wellega Gimbi Rural TRA X X X X TIS 22 LF,OV,SCH,STH, 0 Oromia West Wellega Gimbi Town TRA X X 22 LF,OV,SCH,STH, 1 Oromia West Wellega Guliso TRA X X 22 LF,OV,SCH,STH, 2 Oromia West Wellega Haru TRA SCH,STH X X X X TIS
ENVISION FY18 PY7 Ethiopia Work Plan 64
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A 22 LF,OV,SCH,STH, 3 Oromia West Wellega Homa TRA X X TIS 22 LF,OV,SCH,STH, 4 Oromia West Wellega Jarso TRA X 22 LF,OV,SCH,STH, 5 Oromia West Wellega Kiltu Kara TRA X X X TIS 22 LF,OV,SCH,STH, 6 Oromia West Wellega Kondala TRA X X X X TIS 22 LF,OV,SCH,STH, 7 Oromia West Wellega Lalo Asabi TRA X X 22 LF,OV,SCH,STH, 8 Oromia West Wellega Leta Sebu TRA X X X 22 LF,OV,SCH,STH, 9 Oromia West Wellega Mane Sibu TRA X X X TIS 23 LF,OV,SCH,STH, 0 Oromia West Wellega Mendi Town TRA X X 23 LF,OV,SCH,STH, 1 Oromia West Wellega Nedjo Rural TRA X X X 23 LF,OV,SCH,STH, 2 Oromia West Wellega Nedjo Town TRA X X X 23 LF,OV,SCH,STH, 3 Oromia West Wellega Nole Kaba TRA X X TIS 23 LF,OV,SCH,STH, 4 Oromia West Wellega Seyo Nole TRA X X X TIS 23 LF,OV,SCH,STH, 5 Oromia West Wellega Yubdo TRA X X X TIS 23 LF,OV,SCH,STH, 6 Tigray Central Tigray Ahferom TRA X X TIS 23 LF,OV,SCH,STH, 7 Tigray Central Tigray Geter Adwa TRA X X TIS
ENVISION FY18 PY7 Ethiopia Work Plan 65
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A 23 LF,OV,SCH,STH, 8 Tigray Central Tigray Kolla Temben TRA X X X TIS 23 LF,OV,SCH,STH, 9 Tigray Central Tigray Laelay Maichew TRA SCH,STH X X 24 LF,OV,SCH,STH, 0 Tigray Central Tigray Mereb Leke TRA X X TIS 24 LF,OV,SCH,STH, 1 Tigray Central Tigray Naeder Adet TRA X X X 24 LF,OV,SCH,STH, 2 Tigray Central Tigray Tahtay Maichew TRA X X X 24 LF,OV,SCH,STH, 3 Tigray Central Tigray Tanqua Abergele TRA X X TIS 24 LF,OV,SCH,STH, 4 Tigray Central Tigray Werehilehi TRA SCH,STH X X TIS 24 LF,OV,SCH,STH, 5 Tigray Eastern Tigray Atsibi Wonberta TRA X TIS 24 LF,OV,SCH,STH, 6 Tigray Eastern Tigray Erob TRA X X TIS 24 LF,OV,SCH,STH, 7 Tigray Eastern Tigray Ganta Afeshum TRA X TIS 24 LF,OV,SCH,STH, 8 Tigray Eastern Tigray Glomekeda TRA X X TIS 24 LF,OV,SCH,STH, 9 Tigray Eastern Tigray Hawzien TRA X X TIS 25 LF,OV,SCH,STH, 0 Tigray Eastern Tigray Kilte Awlaelo TRA X X X TIS 25 LF,OV,SCH,STH, 1 Tigray Eastern Tigray Saesi Tsaeda Amba TRA X X TIS
ENVISION FY18 PY7 Ethiopia Work Plan 66
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A LF, 25 OV,SCH,STH,TR 2 Tigray Mekele Adihaki A X X LF, 25 OV,SCH,STH,TR 3 Tigray Mekele Ayder A X X LF, 25 OV,SCH,STH,TR 4 Tigray Mekele Hadnet A X X LF, 25 OV,SCH,STH,TR 5 Tigray Mekele Hawelti A X X LF, 25 OV,SCH,STH,TR 6 Tigray Mekele Kuha A X X 25 LF,OV, 7 Tigray North West Tigray Asgede Tsimbla SCH,STH,TRA X X X TIS 25 LF,OV, 8 Tigray North West Tigray Laelay Adyabo SCH,STH,TRA SCH,STH X X X TIS 25 LF,OV, 9 Tigray North West Tigray Medebay Zana SCH,STH,TRA X X X TIS 26 LF,OV, 0 Tigray North West Tigray Tahtay adiabo SCH,STH,TRA X X TIS 26 LF,OV, 1 Tigray North West Tigray Tahtay Koraro SCH,STH,TRA X X X TIS 26 LF,OV, 2 Tigray North West Tigray Tselemti SCH,STH,TRA X X X TIS 26 LF,OV,SCH,STH, 3 Tigray West Tigray Kafta Humera TRA X X
ENVISION FY18 PY7 Ethiopia Work Plan 67
Baseline sentinel DSA (list type: TAS 2, TSS, sites (list MDA etc) No Mapping (list disease(s L O SC ST TR O SC ST TR . Region/Zone Health Districts disease (s) ) F V H H A LF V H H A 26 LF,OV,SCH,STH, 4 Tigray West Tigray Tsegede TRA X X 26 LF,OV,SCH,STH, 5 Tigray West Tigray Welkayit TRA SCH,STH X X 26 Beneshangul Gumuz Refugee LF,OV,SCH,STH, 6 Camp Sherkole Camp TRA X X X 26 Beneshangul Gumuz Refugee LF,OV,SCH,STH, 7 Camp Bambasi Camp TRA X 26 Beneshangul Gumuz Refugee LF,OV,SCH,STH, 8 Camp Tongo Camp TRA X X 26 Beneshangul Gumuz Refugee LF,OV,SCH,STH, 9 Camp Tsore Camp TRA X X X 27 LF,OV,SCH,STH, 0 Gambella Refugee Camp Pugnido Camp TRA X 27 LF,OV,SCH,STH, 1 Gambella Refugee Camp Pugnido II Camp TRA X 27 LF,OV,SCH,STH, 2 Gambella Refugee Camp Okugo Camp TRA X 27 LF,OV,SCH,STH, 3 Gambella Refugee Camp Jewi Camp TRA X 27 LF,OV,SCH,STH, 4 Gambella Refugee Camp Tierkidi Camp TRA X 27 LF,OV,SCH,STH, 5 Gambella Refugee Camp Kule Camp TRA X 27 6 Gambella Refugee Camp Nguenyiel X
ENVISION FY18 PY7 Ethiopia Work Plan 68
ENVISION FY18 PY7 Ethiopia Work Plan 69