Ethiopia Work Plan FY 2016 Project Year 5

Transcription

1 Ethiopia Work Plan FY 2016 Project Year 5 October 2015 September 2016 ENVISION is a global project led by RTI International in partnership with CBM International, The Carter Center, Fred Hollows Foundation, Helen Keller International, IMA World Health, Light for the World, Sightsavers, and World Vision. ENVISION is funded by the US Agency for International Development under cooperative agreement No. AID-OAA-A The period of performance for ENVISION is September 30, 2011 through September 29, The author s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

2 ENVISION Project Overview The U.S. Agency for International Development (USAID) s ENVISION project ( ) 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), trachoma, and three soil-transmitted helminths (STH; roundworm, whipworm, and hookworm). ENVISION s goal is to strengthen NTD programming at global and country levels and support Ministries of Health (MOH) to achieve their NTD control and elimination goals. At the global level, ENVISION in coordination and collaboration with WHO, USAID, and other stakeholders contributes to several technical areas in support of global NTD control and elimination goals, including: 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, and 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: 1. Strategic annual and multi-year planning 2. Advocacy 3. Social mobilization and health education 4. Capacity strengthening 5. Baseline disease mapping 6. Preventive chemotherapy (PCT) or mass drug administration (MDA) 7. Drug and commodity supply management and procurement 8. Program supervision 9. M&E, including disease-specific assessments (DSA) and surveillance In Ethiopia, ENVISION project activities are implemented by RTI International (RTI), Light for the World (LFW), and Fred Hollows Foundation (FHF). ii

3 TABLE OF CONTENTS Page LIST OF TABLES... v LIST OF FIGURES... v LIST OF CHARTS... Error! Bookmark not defined. ACRONYMS LIST... vi COUNTRY OVERVIEW ) General Country Background... 1 a) Administrative Structure... 1 b) NTD Program Partners... 3 i.) LF Partners... 3 ii.) Onchocerciasis Partners... 4 iii.) STH/SCH Partners... 4 iv. Trachoma Partners... 5 National NTD Program Overview ) Lymphatic Filariasis ) Onchocerciasis ) Soil-Transmitted Helminths and Schistosomiasis ) Trachoma ) Full SAFE Gap Analysis for FY16 Targeted Regions Full SAFE in Tigray Full SAFE Coverage in Beneshangul-Gumuz Region Full SAFE Coverage in Gambella Region ) Snapshot of NTD status in Ethiopia PLANNED ACTIVITIES ) Project Assistance a) Strategic Planning b) NTD Secretariat c) Advocacy d) Social Mobilization e) Capacity Building/Training f) Mapping g) MDA iii

4 h.) Drugs and Commodity Supply Management and Procurement i) Supervision j) Short-Term Technical Assistance k) M&E ) Maps Appendix 1. Work Plan Activities Appendix 2. Table of U.S. Agency for International Development-supported Ethiopian Provinces/States and Districts iv

5 LIST OF TABLES Table 1. Official MDA calendar from the FMOH... 2 Table 2. NTD partners working in country, donor support, and summarized activities... 7 Table 3. LF endemic woredas by region... 9 Table 4. Onchocerciasis endemic woredas by region Table 5. SCH and STH endemic woredas by region Table 6. Trachoma endemic woredas by region Table 7. Snapshot of the expected status of NTD program in Ethiopia as of Sept 30, Table 8. Oromia, Tigray, and Beneshangul-Gumuz development and dissemination of health messages Table 9. USAID-supported districts and estimated target populations for MDA in FY Table 10. Planned disease-specific assessments for FY16 by disease LIST OF FIGURES Figure 1: OV Disease distribution and treatment regimen v

6 ACRONYMS LIST ALB Albendazole APOC African Programme for Onchocerciasis Control AUSAID Australian Agency for International Development BCC Behavior Change Communication CDC United States Centers for Disease Control and Prevention CDD Community Drug Distributors CHSA Charity Health and Services Administration CIFF Children s Investment Fund Foundation CNTD Centre for Neglected Tropical Diseases, Liverpool School of Tropical Medicine CY Calendar Year DFID Department for International Development DQA Data Quality Assessments DSA Disease-Specific Assessments END Fund End Neglected Tropical Disease Fund ESHI Enhanced School Health Initiative F and E Facial Cleanliness and Environmental Improvement FHF Fred Hollows Foundation FMHACA Food, Medicine, Healthcare Administration and Control Authority FMOH Federal Ministry of Health FPSU Filariasis Programmes Support Unit FOG Fixed Obligation Grant FY Fiscal Year GAELF Global Alliance for the Elimination of Lymphatic Filariasis GTM Grarbet Tehadiso Mahber GTMP Global Trachoma Mapping Project HDA Health Development Army HEW Health Extension Worker HMIS Health Management Information System HW Health Worker ICTC International Coalition for Trachoma Control IEC Information, Education and Communication ITI International Trachoma Initiative IVM Ivermectin LF Lymphatic Filariasis LFW Light For the World MALTRA Malaria/Trachoma Intervention implemented in Amhara Region M&E Monitoring and Evaluation MDA Mass Drug Administration MEB Mebendazole MfM Menshen fur Menshen MMDP Morbidity Management and Disability Prevention Program MOH Ministry of Heath NGDO Nongovernmental Development Organization NGO Nongovernmental Organization vi

7 NTD ODF ORHB OCSSCO OV PCR PCT PFSA PZQ REMO RHB SAC SAE SAFE SCH SCI SNNPR STH TA TAP TEO TCC TF TIPAC TOT TT USAID WASH WHO ZTH Neglected Tropical Disease Open Defecation Free Oromia Regional Health Bureau Oromia Credit & Savings Share Onchocerciasis Polymerase Chain Reaction Preventive Chemotherapy Pharmaceutical Fund and Supplies Agency Praziquantel Rapid Epidemiological Mapping of Onchocerciasis Regional Health Bureau School-Aged Children Serious Adverse Events Surgery-Antibiotics-Facial cleanliness-environmental improvements Schistosomiasis Schistosomiasis Control Initiative Southern Nations, Nationalities, and People s Region Soil-Transmitted Helminths Technical Assistance Trachoma Action Plans Tetracycline Eye Ointment The Carter Center Trachomatous Inflammation Follicular Tool for Integrated Planning and Costing Training of Trainers Trachomatous Trichiasis U.S. Agency for International Development Water, Sanitation, and Hygiene World Health Organization Zithromax vii

8 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 9 regions are further subdivided into 68 zones which consist of 839 administrative woredas (districts). Each woreda has an average population of 100,000 people. The woredas are further divided into 16,523 kebeles. The smallest unit of local government, the kebele 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 ( ) in June 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 as an indicator to the National Health Management Information System (HMIS), 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 by The Ethiopian Public Health Institute (EPHI), formally the Ethiopia National Health Research Institution until 2014, is a separate government entity from the FMOH. EPHI conducts all NTD mapping and disease-specific assessments (DSAs). EPHI recently completed an LF, STH, and SCH mapping initiative for most of the country in 2014 and is currently engaged in targeted confirmatory mapping for those diseases (see disease specific sections for further explanation). EPHI also carried out hypoendemic delineation mapping for onchocerciasis in October 2014 with support from African Programme for Onchocerciasis Control (APOC). EPHI also conducts NTD operational research. The FMOH oversees coordination and implementation of Ethiopian health programs on a national level, and the Regional Health Bureaus (RHBs) do so on a regional level. RHBs follow country-wide, healthrelated 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 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 and in compliment to the National Master Plan as well as other key NTD documents such as Regional Trachoma Action Plans (TAPs). RHBs currently have split the level of effort of NTD focal persons with other disease initiatives (e.g., malaria and HIV/AIDS) though ENVISION and other NTD partners are strongly advocating for dedicated NTD teams as the other, larger disease initiatives like malaria tend to take precedence in terms of actual program time. 1

9 The FMOH and RHBs currently carry out many health initiatives at three levels: Primary Health Care Units (PHCUs), the Health Extension package, and the Health Development Army (HDA). PHCUs are woreda-level medical clinics. On average, there are five PHCUs per woreda. 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, including NTD intervention through MDA. 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 to form health development teams. Overall, there is an average of 30 development teams in each kebele. In terms of NTD interventions, use of the HEWs and members of the HDA has been found to be very effective. HEWs handle all of the MDA registrations and supervision while the HDA assists with mobilization and directly observed treatment. Although HDAs can administer albendazole (ALB) and ivermectin (IVM), they cannot administer Zithromax (ZTH) because it is an antibiotic. This task is left to the HEWs. Mebendazole (MEB) and praziquantel (PZQ) are distributed by teachers through school-based distribution except in woredas with high-risk groups or a prevalence over 50%, in which case the HEWs lead community-wide distributions. The FMOH adopted a campaign-style MDA in 2013 using the HEWs, HDAs, and teachers for all NTDs. The move away from rolling MDAs, which was supported by the Community Directed Treatment with Ivermectin strategy, has been very successful in reducing the average time for MDAs from 1 month to 5 days to cover the same area. The FMOH has established an official calendar for disease-specific MDA campaigns in an effort to coordinate programs throughout the country, give drug donation programs a uniform schedule with which to match delivery dates, and ensure that MDA distributions are completed before the rainy season (May through September). This calendar is essential in coordination efforts because of the number of districts carrying out biannual treatments for onchocerciasis in CY (See Onchocerciasis section for more detail) Table 1. Official MDA calendar from the FMOH Program Round 1 Round 2 Remarks/Justification Trachoma: Communitybased distribution carried out by HEWs with mobilization assistance from HDA SCH and STH: School-based deworming carried out by teachers with supervision from HEWs OV and LF: Community based distribution carried out by HDA with supervision from HEW Second week of November through February Second week of October (Round 1 for STH in twice per year woredas) Second week of October (for all OV and LF-endemic areas) First week of March (Round 2 for STH in twice per year areas) First week of April for OV Round 2 only This allows adequate time interval between Trachoma and other PCT MDA Scheduling at these times ensures covering all school aged children at the beginning of the school year to improve learning throughout the academic year. LF-endemic districts included in Round 1 MDA will be integrated with STH and will increase efficient and reduce quantity of ALB tablets required Round 2 OV MDA will be undertaken without ALB 2

10 b) NTD Program Partners As one of the most endemic countries in the world for NTDs, Ethiopia has witnessed an exponential increase in the number of donors and implementing partners since the launch of the NTD Master Plan in Largely as a result of FMOH leadership, donors and implementing partners now recognize that with coordinated efforts a large impact can be made in terms of the size of the population treated, progress towards 2020 elimination and control goals, and sustainable capacity building. Due to the number of partners involved, they have been categorized below according to disease. This section provides a brief overview of current ENVISION support to present a comprehensive picture of the remaining gaps; the disease-specific sections will provide more detail on the support that is provided. Table 2 presents an overview of each partner s roles and responsibilities. i.) LF Partners There are currently 113 woredas that are endemic for LF in Ethiopia and, with approval of this work plan, 100% geographic coverage will be achieved in FY16 for LF MDA. The partners involved to achieve this coverage are as follows: With ENVISION s support in FY15, Light for the World (LFW) targeted 7 woredas with MDA in Western Oromia and RTI targeted 14 woredas in Beneshangul-Gumuz, addressing 19% of the endemic geographic burden in the country. The Carter Center (TCC) targeted 12 woredas in Amhara, 1 woreda in Oromia, 9 woredas in SNNPR, 7 woredas in Gambella, and 2 woredas in Beneshangul-Gumuz with MDA, addressing 28% of the endemic woredas in the country. Through funding from the UK Department for International Development (DFID), the Filariasis Programmes Support Unit (FPSU), formerly Center for Neglected Tropical Diseases (CNTD), targeted 12 woredas in Oromia and 8 woredas in SNNPR, addressing 18% of the endemic woredas in the country in FPSU is implementing directly through the FMOH. The USAID-support Morbidity Management and Disability Prevention (MMDP) project is globally primed by Helen Keller International and led by RTI in Ethiopia. In July 2015, the MMDP project will conduct numerous activities focused on LF, including conducting burden assessments for hydrocele and lymphedema in Beneshangul-Gumuz and Oromia; conducting situational analysis in Beneshangul- Gumuz, Oromia, and Tigray; adapting the WHO LF toolkit to the Ethiopian context; training clinical health workers on lymphedema and adeno-lymphangitis (ADL) management; and training surgeons to conduct hydrocele surgeries. DFID is also supporting an LF MDA and morbidity initiative through FPSU, with whom RTI is currently working to coordinate MMDP activities and avoid duplication of efforts. This coordination is being led by the FMOH, which, after consultation with both partners, is allocating specific zones and regions to specific projects for surgical interventions. In addition, RTI staff meet with FPSU staff whenever they are in country to share information on upcoming activities. Both projects are working with the FMOH to standardize protocols for initiatives that will be carried out in multiple regions such as the LF situation analysis and burden assessments. For cross-cutting initiatives such as the training of hydrocele surgeons, the projects will share costs and technical experience wherever possible and focus funding into the specifically assigned regions. FPSU will also engage the National Podoconiosis Action Network (NAPAN) as a sub-partner to carry out lymphedema and hydrocele burden assessments in Amhara and SNNPR in woredas that are co-endemic for both LF and podoconiosis. 3

11 ii.) Onchocerciasis Partners There are currently 179 woredas that are endemic for OV. With approval of this work plan, 95% geographic coverage will be achieved in FY16. The remaining 5% is located within the Amhara region. TCC is currently considering supporting these. The partners involved to achieve this coverage are as follows: ENVISION provides support for MDA for 14 woredas in Beneshangul-Gumuz and in 23 woredas in Oromia through LFW, totaling 19% of geographic coverage. With joint support through APOC (and likely its successor), LFW supports MDA in an additional 21 woredas, addressing 11% of the geographic burden TCC continues to provide majority of the OV support in the country with some joint support from APOC. TCC currently provides treatment support for 54% of the geographic burden in Ethiopia, including 7 woredas in Gambella, 1 woreda in Beneshangul-Gumuz, 34 woredas in SNNPR, 42 woredas in Oromia, and 13 woredas in Amhara. TCC has also pledged technical support to the National Onchocerciasis Laboratory for analysis of OV-16 dried blood spots, skin snip microscopy, and polymerase chain reaction (PCR) analysis of black flies. The Ethiopian Government s decision to move OV from a control to an elimination program greatly expanded the need for financial support at a time when traditional donors are facing an uncertain future. APOC has provided support for more than a decade to OV-endemic areas in Ethiopia. However, its support has been steadily decreasing every year, and the FMOH has not received confirmed funding amounts until well into the Ethiopian fiscal year (July 1 to June 30). However, even with the closure of APOC and the focus of its replacement organization still in question, the FMOH is not concerned about the gaps that this may represent in endemic woredas. Most of the APOC support in Ethiopia took the form of vehicle purchase and initial trainings, but the yearly cost of MDA implementation is currently supported solely by the partners in country. The only exception to this are 22 woredas in Oromia that are supported jointly by Light for the World and APOC. LFW is currently looking for additional support to address this gap in CY2016. iii.) STH/SCH Partners While some mapping results are still pending, there are 299 woredas endemic for SCH and 312 endemic for STH above the treatment threshold. With approval of this work plan, 100% geographic coverage for STH/SCH MDA will be achieved in FY16. The ENVISION project has not specifically targeted SCH or STH in Ethiopia except in the ancillary benefits of STH addressed through LF MDA and in technical support to the FMOH and the RHBs. The partner landscape for STH and SCH primarily involves a pooled fund among the Schistosomiasis Control Initiative (SCI), Evidence Action, Children s Investment Fund Foundation (CIFF), and the End Neglected Tropical Disease (END) Fund. This pooled fund breaks down as follows: DFID is funding SCI to implement SCH MDA in endemic woredas over 4 years starting in In SCH and STH co-endemic woredas, STH will also be targeted. In , SCI treated 95 woredas with the highest SCH prevalence with this funding. In Calendar Year (CY) , SCI will be scaling up SCH treatments to all endemic woredas in the country. Also in CY 2014, the END Fund supported the FMOH directly to target 10 million children for one year of bi-annual STH treatment. Amhara, Oromia, and SNNPPR were the targeted regions for 4

12 this support due to their high endemicity. This support was meant to address the gap of STHendemic woredas that are not co-endemic with SCH or LF. END Fund also committed funds over 3 years for SCH control starting in CY 2015 last year. In CY 2015, END Fund is currently proposing increasing that amount. CIFF has secured 5 years of funding to address STH: 86% will go to the government, with the remaining funds going to END Fund to leverage matched funds, and to SCI and Evidence Action over 5 years. Evidence Action will act in a technical and supervisory capacity as well as act as bridge for knowledge sharing between the Ethiopian and Kenyan deworming programs. To facilitate operational research, Johnson and Johnson will donate funds to Care Ethiopia to carry out a pilot analyzing the cost-benefit of adding NTDs into existing water, sanitation and hygiene (WASH) programs. The pilot will be conducted in South Gondar in Amhara in 12 kebeles in 4 woredas (3 kebeles per woreda). In CY 2015, The Partnership for Childhood Development started the Enhanced School Health Initiative (ESHI) project, a three-year project involving 30 schools combining STH/SCH MDA with a complete package of WASH interventions (e.g., latrines, running water, etc.) along with WASH behavior change communication (BCC) integrated into the curriculum. iv. Trachoma Partners There are 571 woredas in Ethiopia that are endemic above the treatment threshold for trachoma. With approval of this work plan, 86% geographic coverage will be achieved in FY16. The partners involved to achieve this coverage are as follows: ENVISION currently supports 107 woredas in Oromia for trachoma MDA through partners LFW and FHF. This support addresses 19% of the geographic burden in the country. With DFID funding (further detailed below), LFW is also conducting trachoma MDA in 9 woredas in S. Tigray zone in Tigray region, FHF is addressing 19 woredas in East Harerge in Oromia region, and Orbis is addressing 61 woredas in the SNNPR region thereby addressing 16% of the geographic burden. TCC continues to support all 152 woredas in the Amhara region, addressing 27% of the burden. Local nongovernmental organizations (NGOs) are also actively participating in the trachoma effort in Ethiopia. Menshen fur Menshen (MfM) is currently supporting the FMOH conduct full surgery-antibiotics-face cleanliness-environmental improvements (SAFE) activities in 5 woredas in Oromia and 6 woredas in Amhara. Grarbet Tehadiso Mahber (GTM) is supporting full SAFE support in 3 woredas in Oromia. Beyond MDA, the other components of the SAFE strategy are being addressed in the aforementioned woredas either through complete funding of the full SAFE strategy by one donor or through creative partnerships with multiple donors, the FMOH, and RHBs to achieve each aspect of the SAFE strategy. After the completion of the Global Trachoma Mapping Project (GTMP) in Ethiopia in CY 2013 (with exception of the some select woredas in the Afar and Somali region), DFID signed an agreement with Sightsavers to implement a multi-country, trachoma SAFE project for 39.4 million, of which 10 million is obligated for Ethiopia. The zones of Tigray South in Tigray region through LFW, East Harerge in Oromia through FHF, East Gojjam in Amhara through TCC, and Wolaitta in SNNPR through Orbis were chosen as the targets for this funding and activities began in April For the Amhara region, TCC is continuing to pledge full SAFE support for the entire region with funding from several sources, including the aforementioned the Lions Club and the DFID SAFE project. While 5

13 funding has been secured for 2016, TCC has made it clear that their funding is secured from year to year and there is no guarantee of long term support. After having conducted impact assessments in the Amhara region after 5 consecutive years of treatment that show need for continued implementation of the A, F, and E components, TCC is currently exploring barriers to F and E implementation. In FY16, the MMDP project is targeting support to the FMOH to address the remaining eight target zones that still represent a surgical gap for the trachomatous trichiasis (TT) backlog in Oromia and Tigray. In Oromia, MMDP will provide support for TT surgeries in these 8 zones to the Oromia Regional Health Bureau through FHF. There is an estimated TT backlog of 91,112 (80,900 ultimate intervention goal (UIG)). Subtracting the cases to be addressed by the NGO GTM in their three intervention woredas (28,284 UIG), the UIG in these eight zones for which the MMDP Project is responsible for is 52,616. To provide the Facial Cleanliness and Environmental Improvement (F and E) in these zones, the Oromia Regional Health Bureau has pledged to use its One WASH project funds to target 141 trachoma endemic woredas. In Tigray, MMDP will provide support for TT surgeries to the Tigray Regional Health Bureau through LFW. Central, Eastern and N. Western Zone will be targeted with a total UIG of 21,189. Together with the One WASH project (see SCH/STH section), LFW will be providing support to the TRHB for the F and E components with its own funding. In April 2014, the Federal Minister of Health pledged 10 million birr ($500,000) to launch an initiative aimed to clear the TT backlog in Ethiopia and has prioritized achieving LF, OV, and trachoma elimination. The Minister officially launched the initiative on February 13, 2015, and it will roll out in one zone in each of the four major regions (Tigray, SNNPR, Oromia and Amhara). In the new Ethiopian government fiscal year, which begins in July 2015, and additional 30 million birr ($1,500,000) towards TT and LF morbidity trainings has been proposed. The status of this funding is still under review by the FMOH as of October Finally, the International Trachoma Initiative (ITI) regional office is based in Addis Ababa. In addition to carrying out the ZTH quantification for the country, the ITI regional office also provides extensive technical assistance to the FMOH and RHBs in completing mapping, finalizing TAPs, as well as various social mobilization and operational research opportunities. 6

14 Table 2. NTD partners working in country, donor support, and summarized activities Partner Location Activities FMOH Federal level - Coordinate all NTD activities at national level and provide TA to the regions, zones, and woredas during supervision - Facilitate the drug supply management in the country - Provide support for TT training through Hon. Minister s TT Initiative EPHI Federal Level EPHI is a separate entity from the FMOH. It conducts mapping, M&E, and operational research activities for the government of Ethiopia. Currently, EPHI is involved in the following NTD-related activities: - Remapping of 45 woredas at 1% LF prevalence with funding from the Global Health Task Force - OV Delineation Mapping - OV/LF/trachoma impact assessments - Collaborating with SCI and Evidence Action to carry out the M&E components of the STH/SCH pooled funding initiative. RTI Federal, - Provide capacity building and technical support at Beneshangul- the federal level, including implementation of the Gumuz, and integrated NTD database, the TIPAC, and technical Oromia secondments at the federal and regional level. - Provide direct implementation support to Beneshangul-Gumuz RHB for OV and LF - Through MMDP in FY15 FY16, provide LF morbidity activities (hydrocele and lymphedema training, LF morbidity burden assessments, and situational analysis) FHF Oromia - Support full SAFE strategy in 44 woredas (5 zones) with funding from ENVISION and DFAT. - 8 additional zones are targeted for TT surgeries by MMDP in FY15 FY16 - Support full SAFE strategy for 18 woredas (1 zone) in Oromia through DFID SAFE support LFW Tigray and Oromia - Support MDA in 7 LF-endemic woredas and 23 OVendemic woredas in Oromia with ENVISION funding. Support 41 woredas in Oromia for full SAFE ( A component supported by ENVISION while FHF supports S, F, and E) - Support additional 21 woredas for OV via APOC/LFW collaboration - MMDP to support TT surgeries in 21 woredas (3 zones) in Tigray in FY15 FY16 - Support SAFE strategy in 9 woredas (one zone) in Tigray with funding from DFID SAFE ORBIS SNNPR Support SAFE strategy in 67 woredas in SNNPR with DFID SAFE grant and additional funding from Orbis 7 Is USAID providing financial support to this partner? Yes No Yes Yes Yes No Other donors supporting these partners/ activities? WHO, SCI SCI, TCC No DFAT,DFID private donors DFID, Austrian Government, Private donors DFID, Private

15 Partner Location Activities International Is USAID providing financial support to this partner? Other donors supporting these partners/ activities? donors TCC Amhara, Oromia, SNNPR, Beneshangul- Gumuz and Gambella GTM Oromia and SNNPR MfM Oromia and Amhara FPSU Federal level and Oromia and SNNPR RHBs Implement SAFE strategy in 152 woredas in Amhara with DFID SAFE grant, Lions Club and additional funding No DFID, Lions Club, Private donors Implement MDA for LF and OV in 97 woredas in Amhara, SNNPR, Oromia, Gambella and Beneshangul- Gumuz with funding from Lions Club, APOC, and other funders Implement full SAFE strategy in 10 woredas in Oromia No Private donors Implement full SAFE strategy in 11 woredas in Oromia and Amhara Implement MDA in 31 LF endemic woredas of Oromia & SNNP regions with targeted expansion in 2016 Provide support to LF MMDP activities in Amhara and SNNPR END Fund FMOH END Fund currently a part of joint fund to address all STH/SCH in Ethiopia. There is a possibility that END Fund may look to support other diseases as the need arises. Evidence Action FMOH CIFF will provide funding to SCI and Evidence Action over 5 years. Evidence Action and SCI will coordinate the M&E component of the SCH/STH pooled fund. CIFF FMOH CIFF has secured 5 years of funding to address STH; 85% of this will go to the government, and the remaining funds will go to END Fund to leverage matched funds, and to SCI and Evidence Action over 5 years (as noted above under Evidence Action) CARE Amhara, Afar Johnson and Johnson will donate funds to Care Ethiopia to carry out a pilot analyzing the cost-benefit of adding NTDs into existing WASH programs. The pilot will concentrate in South Gondar in Amhara in 12 kebeles in 4 woredas (3 kebeles per woreda) Partnership for Childhood Development SNNPR ESHI project in SNNPR: 30 schools combining STH/SCH MDA with complete package of WASH interventions (e.g., latrines, running water) along with WASH BCC integrated into the curriculum. No No No No No Private donors DFID, Liverpool University, Numerous smaller donors Numerous private business donors No No No Johnson & Johnson No Imperial College National NTD Program Overview 8

16 1) Lymphatic Filariasis The FMOH is working to achieve the 2020 elimination goals set forth by WHO for LF. Country-wide mapping was completed in June 2014 by EPHI with support from FPSU. As can be seen in Chart 1: Nationwide LF Program and Epidemiologic Coverage (see Appendix 1), major increases in the population targeted for treatment took place in 2012 and 2013 as the country-wide mapping moved towards completion. By 2013, 113 woredas were found to 1% prevalence (Table 3). In 2014, all of the Gambella region was removed from the targeted population as they carried out impact assessments and became the first woredas in the country to successfully stop MDA. EPHI is currently remapping all 46 woredas with exactly 1% endemicity with technical and financial support from the Task Force for Global Health. This remapping initiative is a pilot of a methodology meant to better assess areas in which insufficient data is available (i.e., woredas exactly at 1% with only 1 case per implementation unit) to make programmatic decisions. These 1% woredas are currently counted as endemic by the FMOH for MDA; however, if the confirmatory mapping reveals that these woredas are less than 1%, they will be removed as targets. Confirmatory mapping is expected to be completed in November ENVISION is not currently targeting any of the 1% woredas. Table 3. LF endemic woredas by region Region No. of Endemic Woredas Population at risk Afar 1 73,006 Amhara 19 2,830,444 Beneshangul-Gumuz ,795 Gambella 0 0 Harari 1 18,549 Oromia 36 4,033,348 SNNPR 30 3,174,335 Tigray 5 590,952 TOTAL ,558,349 Many of the newly mapped LF endemic areas are co-endemic with OV and can be treated with the addition of ALB to existing IVM MDA. Currently, triple drug administration of ALB, IVM, and PZQ is not in practice though may be considered by the FMOH in some co-endemic areas after 1 to 2 years of separate treatments, according to WHO guidelines. In areas where LF MDA is targeted, school age children (SAC) are not specifically targeted with a separate MDA for STH unless the woreda has a prevalence of >50% and biannual 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. 9

17 The most recent update of the NTD Master Plan in May 2015 highlighted the necessity to connect the impact of indoor residual spraying (IRS) program and the bed net distribution programs for malaria on LF. These programs are currently being carried out on a massive scale in Ethiopia, but their joint efficacy against LF is not being tracked. In FY16, through its technical advisory role at the FMOH, the ENVISION project will establish the intersection between IRS and bed net distribution woredas with LF prevalence by linking the different partners together and fostering more open exchange and communication between the malaria and NTD projects. Currently, this is not a focus of the FMOH or any other partners in the country. The results of this work will be written up and disseminated to partners and the FMOH. With technical support from MMDP and the DFID-supported morbidity project, guidelines for lymphedema and hydrocele management were completed in June Ethiopia is the first country in Africa to complete such guidelines at a national level. The guidelines were adapted to the Ethiopian context from current WHO guidelines on LF morbidity management and harmonized with podoconiosis morbidity management techniques. Representatives from both the MMDP project and the DFIDsupported LF morbidity project, as well as the Ethiopia Surgical Society, the National Podoconiosis Action Network, EPHI, and other LF/Podo implementing partners participated in adapting the guidelines. In July 2015, the LF hydrocele surgical training manual was completed in a workshop with FPSU and the MMDP project sharing the cost to support per diem of participants and venue rental. 15 surgeons are targeted for certification as Hydrocele Surgery Master Trainers at Addis Ababa University in September 2015 with FPSU supporting the per diem of participants and MMDP funding the cost of Dr. Sunny Mante to facilitate. These Master Trainers were drawn from all of the regions that are LF endemic and will return to their regions to train other hydrocele surgeons to address the hydrocele backlog. As aforementioned, several partners collaborate to support LF MDA. DFID funding through FPSU reached 20 woredas in 2015 and further expansion to 12 woredas is planned in ENVISION s support of LF activities began in FY15 through RTI and LFW. RTI directly supported 14 woredas in Assosa and Kemashi zones in Beneshangul-Gumuz. LFW addressed 7 woredas in the zones of East Wollega, West Shoa and Horuguduru in Oromia Region. RTI has collaborated with LFW, TCC, FPSU, and the FMOH to address the remaining gap of 11 woredas in Tigray and Oromia proposed in this work plan. RTI s expansion strategy for LF is to target zones that complement other ENVISION-supported MDAs taking place. If approved, Ethiopia will achieve 100% geographic coverage (not including the 46 1% woredas currently being remapped) for LF MDA and will be on track to achieve the WHO s 2020 LF elimination goals. 10

18 2) Onchocerciasis Chart 2: Nationwide OV Program and Epidemiologic Coverage (See Appendix 1) demonstrates the increase in targeted population and treatment coverage due to several rounds of mapping for OV carried out in Ethiopia since In 1997 and 2001, rapid epidemiological mapping of onchocerciasis (REMO) was carried out 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, and 2012 found additional endemic woredas in West Oromia, SNNPR, Beneshangul-Gumuz, and Amhara. In 2014, as the Ethiopian program shifted from a control to an elimination strategy, hypo-endemic delineation was carried out throughout the western part of the country. The cumulative results of mapping revealed 179 woredas that are endemic with more than 16 million people at risk, of which 5.8 million live in hyper and meso-endemic areas (Table 5). The question of whether or not mapping is complete is a technically difficult one to answer. The entire western part of the country that is arid but does have fast flowing rivers has not been mapped. However, the FMOH is not currently suggesting that a full mapping initiative is required for these areas. In FY16, FMOH plans to carry out targeted entomological evaluation to confirm if OV transmission is occurring before identifying that Western Ethiopia represents a gap in mapping. To achieve elimination, FMOH will also need to carry out transmission zone mapping within endemic woredas to better target interventions. This would involve taking a biopsies (skin snips) and conducting OV-16 serology along rivers to establish sentinel sites, and then continuing OV-16 serology throughout the rest of the zones across all age groups. Finally, while entering data into the WHO Integrated NTD Database, it was discovered that 57 woredas targeted since 2004 by FMOH and APOC do not have corresponding baseline information. Although RTI is working with FMOH, APOC, and the targeted woredas to find the missing data, our ability to precisely measure impact in these woredas is hampered. Table 4. Onchocerciasis endemic woredas by region Region No. of Endemic Woredas Population at risk Amhara 16 2,103,991 Beneshangul-Gumuz 21 1,054,055 Gambella 7 218,919 Oromia ,304,597 SNNPR 35 3,202,217 TOTAL ,883,779 In Ethiopia, the control of OV through IVM MDA began in Kaffa-Sheka zone of SNNPR in From 2001 to 2013, APOC, TCC, the Lions Club, and LFW were the major supporters of FMOH in this OV control effort. Scale up to other parts of the country continued in 2004 and another wave of expansion was carried out in Up until 2013, Ethiopia s OV control program only supported MDA in meso- and hyper-endemic areas with REMO results that were greater than 20%. Hypo-endemic districts were not targeted as part of the control strategy. 11

19 In 2013, Ethiopia declared that the country was shifting from OV control to OV elimination in its National Master Plan. OV elimination is defined by WHO and FMOH as follows: 1 1. Interventions have reduced O. volvulus infection and transmission below the point where the parasite population is believed to be irreversibly moving to its extinction 2. Interventions have been stopped 3. Post-intervention surveillance for an appropriate period has demonstrated no recrudescence of transmission to a level suggesting recovery of the O. volvulus population 4. Additional surveillance is still necessary for timely detection of recurrent infection. In 2014, the Ethiopia Onchocerciasis Elimination Expert Advisory Committee (EOEEAC) was formed with national and international experts, including experts from the ENVISION project, to help guide FMOH implement this strategic shift. In October 2014, the committee held its inaugural meeting, with support provided by TCC, which focused on creating the national onchocerciasis elimination guidelines. The creation of the document was based on the WHO Geneva 2001 approved guidelines, the 2013 WHO/NTD Strategic and Technical Advisory Group STAG draft guidelines, and with consideration of the experiences of the Americas (OEPA), APOC, Sudan (Abu Hamad focus), and Uganda. The guidelines propose several strategies, including biannual MDA, the previously discussed transmission zones mapping, and targeted vector control. The overarching theme towards interventions in the guidelines is that each OV-endemic area would need a tailored approach rather than the one-size-fits-all interventions practiced by the APOC model. Based on successes in Uganda, Sudan, and OEPA, the guidelines recommend biannual MDA with IVM as the main strategy for interrupting transmission. The FMOH currently endorses biannual treatment for newly endemic areas that are IVM-naïve or any annual treatment area that is not on track to end MDA in The elimination guidelines stipulate that moving woredas from an annual to a biannual treatment schedule should be dictated by the following indicators: skin snip positive rate among adults in any community is >2%; any skin snip positive children <10 years of age in any community Ov16 rates in children <10 years exceed >0.1% (95% CI) PCR infectivity in flies exceeds >1/2000 (95% CI) Seasonal Transmission Potential (as calculated by PoolScreen R ) exceeds 20 L3/person/year (95% CI). As of July 2015, 122 of the 179 of the woredas endemic for OV are on a biannual treatment schedule. The guidelines stipulate that impact assessments will be carried out in these woredas after 5 years of biannual treatments (10 rounds). 1 APOC/WHO Conceptual and Operational Framework of Onchocerciasis Elimination with Ivermectin Treatment. Available at 12

20 Figure 1: OV Disease distribution and treatment regimen 37.70% 2015 OV Disease Distribution (% of woredas) 27.87% 34.43% Hyper endemic Woreda Meso- Endemic Woreda Hypo- Endemic Woreda Biannual vs. Annual Treatments by Woreda (# of woredas) x/year 2x/year In FY15, ENVISION supported 14 woredas in two zones for biannual MDA in Beneshangul-Gumuz via direct implementation through RTI. A small amount of APOC funding was also earmarked for Beneshangul-Gumuz. While ENVISION supported the majority of the financial and technical support to the Round 1 of distribution, the APOC funds were used to purchase one vehicle for each of the two zones as well as some of the per diems for supervisory activities. ENVISION supported the entire costs of Round 2. In Oromia, ENVISION funding through LFW supported the RHB to carry out biannual MDA in 42 woredas. In terms of funding gaps, as noted in the Onchocerciasis Partners section, the FMOH is confident that funding for the previous APOC-supported areas will continue and is not requesting any additional support for these woredas. In FY16, there are 22 woredas which still need support, 10 of which are included in the expansion proposed in this work plan. If the current support continues and plans for expansion for both TCC and ENVISION are approved, Ethiopia will have 95% geographic coverage for OV. 13

21 3) Soil-Transmitted Helminths and Schistosomiasis Though not stated in the WHO NTD roadmap, Ethiopia has taken the initiative to eliminate schistosomiasis and STH to a level where they are no longer a public health problem by This will require the repeated treatment of at least 75% of school-aged children (enrolled and non-enrolled school-aged children) in Ethiopia. According to the National STH/SCH Action Plan, the long-term goals associated with the control program are to Eliminate STH-related morbidity in children by 2020 Eliminate SCH-related morbidity by 2020 Reduce mean intensity of infection with S. mansoni by 65-80% in sentinel sites following four rounds of treatment Reduce mean intensity of infection with S. haematobium by 75-90% in sentinel sites following one round of treatment Reduction in proportion of individuals harbouring heavy infection with S. mansoni by 60% Reduction in proportion of individuals harbouring heavy infection with S. haematobium by 70% Reduction in proportion of individuals harbouring heavy infection with STH by 60% Ensure treatment coverage is expanded to pre-school children in future years Mapping for STH/SCH has been ongoing since December TCC led a mapping effort in conjunction with ENVISION-supported trachoma impact assessments in the Amhara region in However, this mapping only included mapping of Schistosoma mansoni and STH due to the lack of urine dipsticks. In a separate initiative from December 2013 to April 2014, EPHI led mapping for STH/SCH (including both S. hematobium and S. mansoni) in all 9 regions with funding and technical guidance from the SCI. These mapping efforts did not target on a wide-scale the regions of Somali, Afar, and Fin-Fine Special region due to the belief that these areas possessed below treatment threshold prevalence for both diseases. However, targeted sampling in these areas has revealed higher than expected infection levels. To complete the national picture of distribution, EPHI has secured funding from WHO-AFRO and the Bill & Melinda Gates Foundation to carry out mapping in these 220 remaining woredas. Amhara is also being included for remapping to capture the S. hematobium prevalence of the region. This mapping is targeted for completion by September As the national picture stands now, intestinal SCH, S. mansoni, is far more prevalent throughout the country than uro-genital SCH, S. hematobium, which is relegated to the Rift Valley region (predominantly in Oromia). According to the STH/SCH action plan, there are estimated to be at least 32 million people living in the 299 woredas endemic for SCH. The Growth and Transformation Plan II (CY ) of the government of Ethiopia plans for massive expansion of irrigation schemes and an exponential increase in sugar cane fields, both of which provide ideal conditions for the endemic vector, Biomphalaria pfeifferi and Biomphalaria sudanica for S. mansoni and Bulinus abssynicus and Bulinus africanus for S. hemotobium. FMOH is open to vector control through the application of molluscides but funding for this is not currently available. STH infections are distributed very widely in the country and over 40 million are estimated to be living in the 312 STH-endemic areas (Table 7). It is important to note that final mapping results have not yet been made available for parts of Afar, Somalia, and Amhara. There is some discrepancy between the targets from the known mapping results, which are used in this work plan, and the targets listed in the STH/SCH Action Plan that assumes that all woredas where mapping is still ongoing would be endemic. 14

22 This was done for planning purposes by the FMOH and to secure sufficient funding moving into It is also worthwhile to note that the FMOH plans to treat hypo-endemic woredas for SCH every two years rather than every three years because of the logistical constraints involved in successfully carrying out a program with such a long interval between treatments. The FMOH will also most likely distribute MEB with any SCH MDA regardless of whether or not that woreda is above the 20% threshold for STH to maximize logistics and cost value for SCH treatments. Table 5. SCH and STH endemic woredas by region Region/Administrative Council SCH Endemic Woredas Population risk for SCH Afar 3 136,095 at STH Endemic Woredas Mapping pending Population risk for STH Amhara 49 8,382, ,625,654 Beneshangul-Gumuz , ,924 Dire Dawa 9 423,032 Mapping pending Gambella , ,591 Harari 6 162,791 Mapping pending Oromia 95 11,220, ,019,981 SNNPR 60 6,705, ,105,766 Somali 3 299, ,449 Tigray 41 4,179, ,738 Total ,774, ,285,104 at In past years, SCH and STH MDA had been carried out intermittently by various NGOs and government initiatives on a small, targeted scale. In 2007, Ethiopia treated approximately 1 million school children for SCH and STH with support from Save the Children. These treatments were a one-time campaign without funding for future years. However, 2013 represented the first time a sustained national STH/SCH MDA strategy was implemented. Ethiopia secured 3.5 million tablets of PZQ (sufficient to treat approximately 1.4 million children) and 6.8 million tablets of MEB through the WHO, Merck Serono and Johnson and Johnson drug donation programs. SCI provided financial and technical support for the distribution of these treatments. In 2014, the Ethiopian FMOH distributed approximately 7.8 million treatments for STH to SAC in the regions of Amhara, Oromia, and SNNPR, leveraged by a donation from The END Fund. These treatments focused on woredas that were not captured in the 2013 distributions because they were above the treatment threshold for STH but were not SCH-endemic. Note: A nationwide STH/SCH treatment coverage map is not included here because the treatment data have not yet been finalized and approved by the FMOH. In terms of environmental improvement to combat STH and SCH (as well as trachoma), several initiatives are underway by the Ethiopian government. An initiative by the FMOH, Ministry of Education, Ministry of Water Resources and the Water, Sanitation and Hygiene (WASH) sector has pledged the following goals: An open defecation free (ODF) certification process for woredas with the goal of full latrine access by % of communities in the country will achieve ODF status by Access to basic sanitation for all of Ethiopia by 2015, 15

23 70% of the Ethiopian population practicing hand washing at critical times and safe water handling of treatment at home In addition to the ODF campaign, the largest coordinated WASH effort taking place in the country is known as the One WASH National Programme (OWNP). The OWNP was officially launched in April 2013 and will be implemented across all the 9 regions and 2 administrative councils of the country until All WASH programs and partners must pool their money in this program, which has the following four components: (1) rural WASH (2) urban WASH, (3) institutional WASH, and (4) program management and capacity building. The components most pertinent to NTD prevention are the rural WASH component, which has an allotment of 1.03 billion dollars to address agrarian and pastoralist communities; and the Institutional WASH, which has an allotment of million dollars to address water and sanitation in schools and health institutions. In its technical advisory and advocacy role, ENVISION is currently conducting high level advocacy meetings comprising multiple NTD partners to ensure that woredas endemic for STH, SCH, and trachoma are prioritized for these WASH interventions. As was detailed in the partner section, a five-year strategy to address all of the MDA requirements for SCH and STH in Ethiopia will begin through a concerted support effort to the FMOH through END Fund, CIFF, Evidence Action, and DFID-funded SCI. In an exciting example of cross-country collaboration, the Ethiopia FMOH is also working with the Kenyan National Deworming Program to promote technical advice and experience sharing that has been largely facilitated through Evidence Action. All of the aforementioned STH/SCH funding from the END Fund, SCI, Evidence Action, and CIFF will be pooled together into one fund with the goal of complete STH and SCH geographic coverage starting in CY The FMOH will be the recipient of all implementation funds. It is important to note that as CIFF and the END Fund try to finalize their funding amounts, there is a chance that support will be needed in the out years to continue complete geographic coverage. However, in CY2016 and CY2017, 100% geographic support is currently anticipated. 16

24 4) Trachoma Ethiopia is recognized as having the highest burden of trachoma in the world; the FMOH is following the 2020 elimination goals set forth by the WHO. According to the Ethiopia National NTD Master Plan: over 40% of children 1 9 years of age suffer from active trachoma in many hyper-endemic districts and trichiasis has been observed even in children less than 15 years of age; a reflection of the gravity of the problem. Impact assessments carried out in Amhara region with support from TCC have shown that even after five years of treatment in highly endemic areas, TF prevalence declined only from 62.6% (at baseline) to 26.3%, while TT decreased from 5.2% (at baseline) to 4%. Although this is a marked reduction, TF prevalence still remained well above intervention thresholds. Perhaps more distressing, it has been shown that stopping MDA after the prescribed MDA implementation interval in areas without adequate F and E components will result in a resurgence of prevalence. Therefore, the official policy of the FMOH and the Pfizer donation of ZTH through the ITI require the full SAFE strategy anywhere ZTH MDA is carried out. As such, elimination of blinding trachoma requires a multi-sectorial approach. As can be seen in Chart 3: Nationwide Trachoma Program and Epidemiologic Coverage (see Appendix 1), the targeted population and treatment coverage has experienced a major surge since trachoma treatments first began in The impressive feat of mapping the entire country for trachoma began with the National Survey on Blindness, Low Vision, and Trachoma ( ). Results from this mapping indicated that Ethiopia is the most endemic country in the world, with an average prevalence of active trachoma throughout the country of 40.1%. Through TCC support, the Amhara RHB completed baseline trachoma surveys to all 10 Zones (167 woredas) in The next major step forward in the collection of epidemiological data for the trachoma program in Ethiopia was the GTMP (from 2012 to 2014), funded by DFID. As a result of GTMP, trachoma surveys are now complete throughout the country with the exception of some zones remaining in the Somali region due to security reasons. The results of all of these mapping efforts revealed that 568 woredas, or 68% of the woredas in the country, have TF% above 10% (Table 8). The combined population at risk for these woredas is more than 70 million people requiring intervention through MDA with 880,317 people with TT in Ethiopia, who need urgent eyelid surgery to prevent blindness from trachoma. Table 6. Trachoma endemic woredas by region List of Endemic Region No. of Endemic Woredas Population at risk Afar 3 143,716 Amhara ,537,998 Beneshangul-Gumuz 4 258,965 Gambella ,608 Oromia ,419,056 SNNPR ,922,449 Somali 16 1,848,154 Tigray 37 4,449,545 Total ,964,490 17

25 In FY15, ENVISION provided strategic support to the FMOH to update the National TAP and complete the Gambella and Beneshangul-Gumuz regional TAPs. Every region now has a TAP, with the exception of Afar region (included in this work plan). Because ENVISION can only support the A component of the SAFE strategy, RTI has worked to develop some creative partnerships. In 2014, ENVISION awarded a grant to LFW to address trachoma MDA in three zones in Oromia; however, LFW did not have the funding to address the other S, F, and E components. Also in Oromia, FHF, with funding from Australia s Department of Foreign Affairs and Trade (DFAT), was implementing the full SAFE strategy in the four adjacent zones of North Shoa, South West Shoa, FinFine, and Jimma. In the spirit of SAFE coordination, RTI, LFW, and FHF agreed to a strategy in which ENVISION funded the A component in the 43 endemic woredas of North Shoa, South West Shoa, FinFine, and Jimma. As a result, FHF had enough funding to carry out S, F, and E implementation in Horuguduru, West Shoa and East Wollega. This strategy provided a means to ensure full SAFE implementation for over 9 million people in all ENVISION-supported zones in FY15, without which the program would have been prohibited from carrying out trachoma MDA (Map 1). Map 1: FY15 ENVISION SAFE Strategy 18

26 5) Full SAFE Gap Analysis for FY16 Targeted Regions If Oromia, Tigray, Beneshangul-Gumuz and Gambella regions are addressed by USAID through the work plan outlined below, geographic coverage for trachoma MDA will reach 86% 2. The only remaining gaps will be 62 woredas in SNNPR region, 13 woredas in Somali region, and 4 woredas in Afar region. DFID and Sightsavers are currently exploring reallocating additional global funds to Ethiopia to provide full SAFE to the remaining 62 woredas in SNNPR. This would bring the total geographic coverage for full SAFE to 97% with all woredas above 30% prevalence addressed. If this support occurs, Ethiopia, the most endemic country in the world for trachoma, would be on track to achieve the 2020 elimination goals. Full SAFE in Oromia region: In FY16, SAFE could be implemented through the rest of Oromia through the following mechanisms (Map 2): S- There are 160 total zones in need of TT surgical intervention in Oromia. DFAT will continue to address surgeries in its current seven zones by funding FHF. The DFID SAFE project will address surgeries in one zone, East Harege, also through FHF. The Minister s Initiative will provide $125,000 to Oromia to target training for TT surgeries in one pilot zone in FY15. The USAID MMDP project will fund preparations for scale up in FY15 including training of TT surgery teams, etc. and then scale up surgeries to the remaining 8 zones (116 woredas) of Oromia in FY16. A- ENVISION currently funds and implements MDA in 8 zones (85 woredas) through FHF and LFW. As of February 2015, DFID SAFE addresses MDA in 1 zone (10 woredas), East Harerge, through FHF. This leaves 9 zones (116 woredas) with no MDA coverage. These 9 zones are proposed for USAID support within the work plan below in order to achieve full SAFE in all of Oromia. F and E- The Oromia RHB has pledged dedicated WASH activities focused in 144 woredas in Oromia. Trachoma endemic woredas not currently under SAFE intervention will be prioritized. DFAT-, DFID- and USAID-supported areas will collaborate with the National Trachoma Task Force to create comprehensive F and E interventions. Note: DFID has not yet awarded the F and E component of their SAFE package so that may provide another opportunity for collaboration. If all of Oromia is covered with full SAFE it would address 41% of the remaining gap woredas in Ethiopia and will provide 29 million people with full SAFE coverage. 2 All geographic coverage percentages for trachoma are based on the known quantity of trachoma endemic woredas (571). However, there are 52 woredas in Afar and Somali that were not mapped during the GTMP initiative due to insecurity. The mapping of Somali is currently ongoing and Afar is targeted later in the year with GTMP funding. 19

27 Map 2: Oromia SAFE expansion scenario 20

28 Full SAFE in Tigray While ENVISION is not currently supporting operations in Tigray, ENVISION partner LFW has been supporting trachoma activities in the region with other funding and is ready for geographic scale-up. The DFID SAFE project will support LFW to implement full SAFE in South Tigray zone, leaving 3 other zones (26 woredas) in Tigray requiring SAFE scale-up. In FY16, full SAFE could be scaled up throughout the region with through the following mechanisms: S- LFW will address surgeries in the zone of South Tigray (7 woredas) with DfID SAFE funding. The USAID MMDP project will support LFW to carry out TT surgeries in the remaining three zones of Central, Northwest and East Zones (21,189 UIG). This support will join with the Hon. Minister s contribution of $125,000 USD for TT surgery training in Central Zone. A- LFW will address MDA in South Tigray (7 woredas) with DfID SAFE funding. This will leave Central, Northwest, and East zones as the last remaining MDA gaps. These 3 zones are proposed for MDA intervention with USAID support in the workplan below. F and E- LFW will use its own funding to address F and E. The Tigray One WASH campaign will also contribute. ENVISION and Tigray partners will advocate that woredas targeted by One WASH are prioritized based on their trachoma endemnicity status. This plan for Tigray region will address 7% of the remaining woredas needing MDA for trachoma in Ethiopia and will provide approximately 4.4 million people with full SAFE coverage. 21

29 Map 3: Tigray SAFE expansion Scenario 22

30 Full SAFE Coverage in Beneshangul-Gumuz Region Beneshangul-Gumuz offers a unique opportunity for taking a major step towards eliminating blinding trachoma by All four of the trachoma endemic woredas in the region have TF prevalence between 10 30%, indicating that three years of MDA with good coverage are required before impact assessments can be implemented. Furthermore, while the TT backlog is large in comparison to the population size of the region, eliminating the backlog via dedicated mobile teams can be accomplished within three years, especially with assistance from Amref. According to the FMOH, Beneshangul-Gumuz also has unusually high access to safe water, meaning that the F and E component can largely focus on behavior change communication rather than hardware. Addressing these areas in FY16 can be incorporated into ENVISION s current OV and LF work in the region. S- Detailed planning of support for surgery, antibiotic distribution, and F&E is underway and could potentially include funders such as the MMDP, END Fund, and the Minister s TT Initiative, as well as mobile teams supported by Amref. A- In this work plan, it is proposed that RTI, with ENVISION funding, implement MDA in the remaining 1 zone (4 woredas), in coordination with current LF and OV MDA. F and E- Beneshangul-Gumuz has an unusually high percentage of safe water access and all four trachoma endemic woredas are targeted for open defecation free status. The Finnish NGO, FINwash, is currently conducting full WASH scale up programs including hardware and latrines in all 4 of the trachoma endemic woredas. ENVISION would work with FINwash to insert SAFE messaging into their BCC/ICE materials. This plan for trachoma in Beneshangul-Gumuz Region would address 1% of the remaining woredas needing MDA in Ethiopia and will provide about 211,905 people with full SAFE coverage. Map 4: Beneshangul-Gumuz SAFE expansion Scenario 23

31 Full SAFE Coverage in Gambella Region Like Beneshangul-Gumuz, Gambella offers an opportunity for the FMOH and ENVISION to achieve a major win in eliminating trachoma by All thirteen woredas in the region have TF prevalence between 10 30%, indicating that three years of MDA with good coverage are required before impact assessments can be implemented. According to the Gambella TAP, Gambella also has unusually high access to safe water as well as numerous WASH partners on the ground. The One WASH campaign described earlier is being carried out in 8 of the 13 endemic woredas with additional program underway through Catholic Relief Services and FINwash in the remaining 5 woredas. S- Detailed planning of support for surgery, antibiotic distribution, and F&E is underway and could potentially include funders such as the MMDP, END Fund, DFID, and the Minister s TT Initiative. A- In this work plan, it is proposed that RTI, with ENVISION funding, implement MDA in all 13 zones in coordination with OV MDA. One challenge will be ensuring that the Zithromax is available. ITI has promised to add Gambella s Zithromax requirements to the quantification to be reviewed during the November 2015 TEC. It is also important to note that an additional challenge in Gambella will be the continuing influx of refugees from South Sudan. The refugees are predominantly originating from Jonglei State which is known to be highly endemic for trachoma. ENVISION is currently working with the Gambella RHB and refugee agencies to determine the approximate number of refugees that would need treatment to determine if they can be captured in the FY16 MDA. F and E- All 13 woredas in Gambella have a WASH projects underway so incorporating pertinent F and E messages into those projects would be the main focus of these components. This plan for trachoma in Gambella Region would address 2.3% of the remaining woredas needing MDA in Ethiopia and will provide about 211,905 people with full SAFE coverage. 24

32 Map 5: Gambella SAFE expansion Scenario 25

33 6.) Snapshot of NTD status in Ethiopia Table 7. Snapshot of the expected status of NTD program in Ethiopia as of Sept 30, 2015 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 districts Expected No. No. of No. of No. of districts expected to be in of districts No. of No. of Total No. districts districts receiving MDA need of MDA at where criteria districts districts of classified classified as of 09/30/15 any level: MDA for stopping requiring Disease in need Districts in as as nonendemic* has prematurely not yet started, or district-level DSA of initial Ethiopia endemic* mapping USAID- MDA have as of * * Others funded stopped as of been met as of 09/30/15 09/30/15 09/30/15 LF OV SCH STH Trachoma of the 113 woredas that had a result of exactly 1% prevalence during the original mapping are currently being remapped. 2 Of the 39: 7 in Amhara, 5 in Tigray, 1 Afar, 8 SNNPR and 18 Oromia 3 5 woredas in the Gambella region were planning TAS within CY2015 at the writing of this report 4 In SCH and STH 199 woredas for each diseases mapping is under process by EPHI. This mapping is fully funded. 5 The 52 woredas in need of mapping are in the Somali and Afar regions. GTMP has the funding but is waiting until the region is considered more secure 6 Impact assessment needed in 2015 and 16, all of them are in Amhara) 26

34 PLANNED ACTIVITIES 1) Project Assistance a) Strategic Planning The original NTD master plan that launched in 2013 only set strategic planning goals until 2015, at which time, the master plan would be updated with the completed mapping information and partner involvement. A workshop to update the Master plan was conducted with funding from WHO in June 2015 and strategic planning goals were carried all the way to the 2020 elimination date. ENVISION staff participated in this workshop and provided technical guidance. The FMOH support proposed below is based on some of the requests that came forward from that workshop. FMOH NTD Annual Review Meeting (RTI). The NTD Annual Review, supported by RTI, is for the FMOH, RHB, and pertinent woredas (such as those that are highly endemic for a particular NTD and/or have had particular success/challenges worth sharing) to meet and review activities from the past year and plan for the coming year. The FMOH has requested this meeting be held once annually for four days as it allows the FMOH to interact with the regions and zonal representatives on national NTD matters. ENVISION will fund the per diem and travel costs for government representatives from all regions, while the WHO has agreed to support all venue, refreshment, and stationary costs. ENVISION will also provide logistic and technical support to the FMOH in preparation for the meeting, including assistance to make graphs and tables to better illustrate important discussion points. National NTD Task Force Meeting (RTI). National NTD Task Force members come from the FMOH, universities, select RHBs, nongovernmental development organizations (NGDOs), and select international experts, as necessary. The Task Force Meeting provides an opportunity for the FMOH, RHBs and nongovernmental partners to evaluate NTD activities throughout the country and evaluate goals set during the Annual NTD Review Meeting. It is a platform to distribute materials, announce any changes in protocol, and give voice to the decisions of the disease subcommittees. The FMOH has requested that ENVISION support the National NTD Task Force Meeting, which is to be held once a year for one day, directly following the Annual Review Meeting. In FY16, ENVISION will fund the per diem of the government participants. Travel will not be included here as those costs will be covered under the NTD annual review activity. The WHO will support venue, refreshment, and stationary costs. ENVISION will also provide technical support by assisting the FMOH to prepare any documents and reports to be shared, as well as attending the meeting to provide any updates from the global NTD community and technical guidance, as is required. Afar Trachoma Action Plan Workshop and Finalization (RTI). The Afar region is the last remaining region without a completed regional TAP. In FY15, ENVSION supported the update of the national TAP and the completion of the Beneshangul-Gumuz and Gambella regional TAPs. These exercises proved enormously helpful in galvanizing the RHBs to seek support for trachoma intervention, as well as to better understand their own trachoma burden. In FY16, the FMOH has requested RTI to support the completion of the Afar TAP. ENVISION staff will lead the TAP workshop together with representatives from ITI. It will last for three days and a fourth day will be reserved for the core writing group to finalize the TAP document. ENVISION will support the venue, per diem, and travel for this activity. 27

35 Oromia Oromia Regional Annual Review Meeting (RTI). The Oromia Annual Review meeting, supported by RTI, is an opportunity for the entire region to meet with representatives from the zonal health offices and stakeholders to review the year s successes and challenges. Given the size and unprecedented scale-up of NTD interventions in Oromia, including MDA for trachoma, OV, LF, and STH/SCH, for more than 25 million people, the region-wide TT surgical initiative, and hydrocele/lymphedema interventions, 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. ENVISION will support the per diem, venue, and participants travel, as well as act in a technical advisory role to the meeting. Zonal-level Pre-OV/LF MDA Planning Meeting (LFW). A one-day planning meeting in each zone will be held by LFW before MDA is implemented. Representatives from woreda-level health offices, health workers, and other stakeholders will attend. The objective of the meeting is to communicate the annual work plan previously agreed upon with the Regional Health Bureau and Zonal Office, decide the HEW and HDA training schedules, and choose the MDA start date in each woreda. The woreda-level health officers will then communicate this to the kebeles in the woreda-level pre-mda planning meeting (described below). It is important to note that this activity will only be carried out before Round 1 of OV/LF MDA as it is meant to be a planning meeting for the entire year. ENVISION will fund the per diem, travel, and venue costs for this activity. Woreda-level Pre-MDA Planning Meeting (LFW). In each of the 43 district capitals, LFW will hold a planning meeting for two days to prepare the kebeles and health posts for MDA. An additional day is necessary at the woreda-level planning meeting to allow for micro-planning and drug delivery coordination down to the front-line health post. Representatives from kebele health posts, prominent community leaders, and other stakeholders attended. The objectives of the meeting were to communicate the annual work plan to the kebeles and discuss the training and MDA schedules for the next year. ENVISION will fund the per diem and travel of the participants. Woreda-level Post-MDA Review Meeting (FHF). Post-review meetings will be held for one day by FHF and LFW at the Woreda-level in all 18 zones to share, compile, and analyze reports, results, experiences, and challenges regarding the recent MDA distribution. Two representatives from all respective districts health offices, zones, the Oromia Regional Health Bureau (ORHB), and LFTW/FHF program officers will attend and use the information to improve upon MDA in the following year. In each of the 160 Woredas, the two highest and two lowest performing kebeles will be selected based on MDA therapeutic coverage to compare and discuss challenges at the distribution-level and to highlight and share best practices. This meeting will also be used as an opportunity to compile reports and pay per diems to MDA supervisors. If a woreda has multiple MDAs for different diseases, the review meeting will take place at the end of the MDA cycle (one meeting annually). RTI will attend a randomized selection of these meetings to stay informed about the MDA challenges faced in the region by community implementers. ENVISION will fund the per diem and travel costs of the participants. Zonal-level Post-MDA Review Meeting (FHF and LFW). A Zonal-level Post-MDA Review Meeting will be held for one day at each of the 18 zonal offices by both FHF and LFW to build upon the woreda-level post review meetings. All activities and outputs from before, during, and after the MDA campaign will be discussed and the opportunity will be used to compile and analyze treatment reports. As with the woreda-level meetings, all post-mda review meetings will take place after any scheduled MDA coverage assessments. As part of the meeting, one woreda per zone receives a certificate of recognition for their achievements as the highest performing woreda. That woreda will give a presentation on best practices 28

36 and challenges to adjust micro-planning and strategies for the following years campaign. RTI will attend a randomized selection of these meetings to stay informed about challenges the zones are facing and explore ways to improve future MDAs with the partners. ENVISION will fund the per diem and travel costs of the participants. Woreda-level Post-MDA Review Meeting (LFW). Similar to the meeting in Oromia, this meeting will be carried out by LFW in all woredas at the woreda level to assess the success of the MDA and discuss ways to improve in the future. It will also be used as an opportunity to collate and clean reports and pay per diems. ENVISION will fund the per diem and travel costs of attendees. Beneshangul-Gumuz 3 Beneshangul-Gumuz Regional Annual Review Meeting (RTI). In FY15, Beneshangul-Gumuz RHB led an enormous expansion of NTD activities in the region. All 14 of the ENVISION-supported OV/LF woredas were treated for the first time in FY15. In addition, STH/SCH MDA, with support from the pooled fund discussed in the Country Overview section, was carried out throughout the region for the first time in FY15. As is proposed in this work plan, Beneshangul-Gumuz (with support from RTI) will also target trachoma in FY16 for the first time. ENVISION will support a two-day NTD Annual Review meeting after all MDAs are complete (targeted for August 2015) to help the RHB assess the success of these expansions. ENVISION will support the per diem, venue, and the travel of participants and will attend the meeting to provide technical input. Woreda-level Post-MDA Review Meeting (RTI). Woreda-level Post-MDA Reviews were not carried out in Beneshangul-Gumuz in FY15. During FY16, work planning and support for these meetings was the top request of the RHB as it felt that the HEWs and HDA in every woreda will feel more a part of the regionwide effort if they have an opportunity to discuss challenges and best practices in their woreda. These post-mda review meetings will also be used to collate and clean reports and pay per diems for HEWs. ENVISION will support the per diems and travel expenses for participants in all 18 woredas for this oneday meeting. The woreda-level health office will provide the venue. Gambella 4 Gambella Regional Annual Review Meeting (RTI). This one-day meeting by RTI will allow Gambella to assess the trachoma program support proposed in this work plan. All of Gambella s population will be targeted with Zithromax for the first time in FY16. The Annual Review Meeting will be an opportunity for the Regional Health Bureau to discuss areas of improvement with the woreda-level health office, align SAFE activities, and assess the challenges with integrating trachoma MDA into a long-standing OV treatment program. It will also be an opportunity to discuss how the influx of refugees from South Sudan has affected MDA and allow for better planning in the next fiscal year. ENVISION will support the venue, per diem, and travel of participants. 3 The Beneshangul-Gumuz RHB has decided to hold its MDA planning meetings for all tiers in concurrence with the MDA trainings. Therefore, there are no costed planning meetings for this region in FY16. As there are only three zones in Beneshangul-Gumuz, the RHB has also decided to forgo zonal Post-MDA review meetings and discuss the MDAs in plenary at the annual review meeting. 4 In Gambella, ENVISION has not included woreda-level Pre-MDA planning meetings and zonal-level Post-MDA meetings in this work plan due to the fact that TCC has provided long-standing strategic planning support in the region. RTI will collaborate with TCC to add the trachoma MDA planning into this pre-existing strategic planning platform to save funds and better integrate NTD intervention planning. In return, ENVISION will support the regional annual review meeting and woreda-level Post- MDA review meetings for both trachoma and OV together. 29

37 Woreda-level Post-MDA Review Meeting (RTI). Supported by RTI and similar to the regional annual review meeting, the Woreda-Level Post-MDA Review Meeting will be an ideal opportunity to assess successes and areas for improvement. It will also be an opportunity for woreda-level health offices to see how the influx of South Sudanese refugees into their communities has affected the MDAs. ENVISION will support the per diem and travel of participants. The woreda-level health offices will provide the venue. b) NTD Secretariat Due to the magnitude of the NTDs in Ethiopia and the high-performing, yet small size, of the NTD FMOH and RHB teams, ENVISION has agreed to provide key technical staff that are embedded within the respective ministries (federal or regional). It is important to note that the day-to-day activities of these secondments are ultimately determined by the FMOH and RHBs though supervision is provided by both the aforementioned government offices and RTI. LFW and FHF also have staffing placed at the zonal and regional offices in their respective areas of support. However, these staff are not secondments. Rather, FHF and LFW maintain full control of the activities of these staff members while the regional and zonal offices have agreed to provide office space. For this reason, these staff are not detailed in this work plan. FMOH FMOH Technical Advisor Secondment (RTI). In FY15, ENVISION provided a technical secondment to the FMOH with a concentration on strategic planning to bring Ethiopian policy and planning on track with 2020 elimination goals. Since that time, the secondment has been a crucial member of the FMOH NTD team and has lead the drafting of the Minister s TT Initiative work plan, the LF Morbidity Guideline, the STH/SCH Action Plan, and the Updated NTD Master plan. He has also been an asset as the focal person for the coordination of numerous new implementing partners across the country to avoid redundancies in funding. In FY16, ENVISION/RTI will continue to support this secondment. While a major focus of his will continue to center around strategic planning and NTD partner collaboration, he will also expand his focus to help address issues with NTD morbidity management and NTD WASH. FMOH Data Manager Secondment. (RTI) In FY15, the FMOH NTD team had no data managers or M&E specialists. All data was stored and analyzed by the disease managers who were also burdened with numerous other program management duties. To address this challenge, ENVISION provided support for an NTD data manager secondment. His primary goal was to collect all of the historical treatment data across the country to populate the WHO Integrated NTD Database, as well as to populate and implement the TIPAC. Now that these goals have been accomplished, ENVISION/RTI will continue to support the seconded data manager to help cascade the database to the regional level, update the Integrated NTD Database with all the new data coming in from the regions, and continue to work with the FMOH to use the TIPAC in evidence-based work planning. Pharmaceutical Fund and Supplies Agency (PFSA) Secondment (RTI). The PFSA is responsible for delivering all medical consumables down to the health post level throughout the country. Currently, the PFSA deliveries do not include transportation of NTD drugs. In FY16, the FMOH will be greatly expanding the number of PFSA hubs in the country from 11 to 16. The Minister of Health has stated that one of the primary capacity building goals of NTD partners should be to support the PFSA to manage all NTD drug distributions. While NTD supply management is new to the PFSA, the organization already has experience with the requirements of campaign-style supply chain through the vaccine programs they support. It is important to note that this will be a gradual process that will take place throughout 30

38 CY2015 and CY2016 and will heavily involve collaboration with the partners in country. Drug donation programs will be fully notified of this change and will be included in the planning phases from the beginning. The donation programs will still deliver the drugs to the national level and the FMOH will then, in turn, coordinate with the PFSA to distribute the drugs to the 16 hubs throughout the country. Regional Health Bureaus and partners will still be depended on to help coordinate the delivery of drugs from the hubs to the zones/woredas/communities. This system will not differ greatly from the current system in which the Regional Health Bureaus have to arrange transport and pick up the drugs from the central PFSA store. There will be PFSA hubs in all of the regional capitals and the RHB will still be in charge of coordinating the correct shipments with the PFSA. Accordingly, ENVISION is proposing a new secondment to the PFSA National office whose sole charge will be to coordinate delivery of NTD drugs to the various PFSA hubs in coordination with the FMOH, RHBs, and partners. The RTI-supported secondment will implement a situation analysis on the current medical supply delivery mechanism to better understand the challenges and opportunities of the integration of NTD drug delivery. They will also work the FMOH NTD team to ensure that TIPAC is adequately addressing all drug orders in the jointdrug request form and that all of those drugs, upon arrival into the country, flow smoothly from the PFSA national warehouse, to the new PFSA hubs, and on to the health posts in time for planned MDAs. It is important to note that secondments to the PFSA are very common. USAID-supported EPI, HIV ART programs, and TB programs have all seconded specific focal persons to the PFSA. The secondment selected will be expected to have extensive knowledge of the Ethiopian supply chain system. Any specific training required concerning NTDs will be provided by RTI at the start of the secondment s employment If necessary, RTI can also arrange for the secondment to work with ENVISION s NTD drug logistics officer in Tanzania or Uganda for additional training. Engaging Peace Corps: 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, indoctrinated during the volunteers training and placement, is to enable, not undermine, the role of the Health Extension worker. 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 TCC, the FMOH, Peace Corps, RTI, and TCC are now collaborating on a joint MOU to place Peace Corps health volunteers in highly endemic trachoma woredas (co-endemicity with other NTDs is a second consideration) at the start of their 2 years of service. The volunteers will specifically focus on helping HEWs organize MDAs, identify TT cases, and teach the community about F and E. RTI is working with Peace Corps and regional partners to identify ideal sites and strategies for volunteer placement (i.e.- multiple volunteers in one heavily endemic woreda, possible scope of work for the volunteer, etc.) The availability of the health volunteers by region is as follows: Amhara: 10 volunteers Oromia: 10 volunteers SNNPR: 8 volunteers Tigray: 7 volunteers Volunteers will arrive in country in January 2016 and will be placed in their communities in April RTI and TCC will work with Peace Corps and FMOH to create a training module for the volunteers 31

39 during their in-service training in January and will provide technical support as is needed. The volunteers will not report to RTI in any way nor will RTI supervise their activities. This will be the role of the woreda-level health office and Peace Corps. No funding will be required for this activity except for the travel and per diem of RTI technical advisors to attend the Peace Corps pre-service training and level of effort for adapting the training modules from existing materials. Oromia and Tigray Technical Advisor Secondment (LFW). LFW is planning to place 5 secondments in Tigray and 6 secondments in Oromia. As an organization, LFW follow an implementation philosophy of devolved responsibility to the regional health bureau and each of the LFW-supported zonal health departments. To address the deficit of human resources necessary for the exponential increase in NTD-related activities, LFW bolsters these offices with technical and financial secondments rather than increasing their own office staff. As most zonal departments do not have a dedicated NTD officer, technical secondments are a very important to train and support the existing health staff in all NTD-related matters (MDA, supervision, etc.). Financial secondments train the existing finance staff to manage fixed obligated grants and track MDA-related costs. LFW and the zonal offices work together to create a monthly work schedule for the secondments. In fact, the terms secondments may be somewhat of a misnomer as this is essentially LFW staff that are physically placed within the zonal offices but still maintain a strict system of reporting and supervisory check-ins to the LFW head office. LFW supervises the secondments together with the ORHB and TRHB by organizing weekly call-ins and visits to the field offices on at least a monthly basis. Beneshangul-Gumuz Technical Advisor Secondment (RTI). RTI will continue to support the NTD technical advisor secondment to the RHB that began in January 2015 to build the RHB s capacity in the implementation of OV/LF, and now trachoma, MDA throughout the region. The RHB NTD staff continues on with two full-time employees who are managing MDA distribution for more than 600,000 people. The secondment will help the RHB NTD team to plan and carry out MDA trainings and help implement coverage surveys and DSAs. He will also work with the FMOH Data Manager to install the integrated database at the RHB. The secondment will be under the direct supervision of the RHB and the ENVISION NTD program manager. Gambella Technical Advisor Secondments. (RTI) Gambella currently has one NTD staff person who manages the treatment of OV, trachoma, STH, and SCH in 13 woredas. ENVISION proposes to place two RTIsupported secondments within the Gambella Regional Health Bureau to build the RHB s capacity in the implementation of OV, and now trachoma, MDA throughout the region. The RHB will assign half of the woredas in the region to each secondment. While the primary focus of the secondments will be trachoma, they will also assist with OV, STH and SCH MDAs and DSAs throughout the year. They will also have the additional task of coordinating MDA in the refugee camps. Both secondments will be under the direct supervision of the RHB and the ENVISION NTD program manager. 32

40 c) Advocacy FMOH Celebration of the 500 millionth Zithromax treatment. (RTI) Multiple partners are currently participating in the planning stages of a celebration for the distribution of the 500 millionth dose of Zithromax in early October. The celebration will highlight the work of elimination partners as well as plans for MDA expansion thanks to support from major donors like USAID and DFID. The celebration will be led by the National Trachoma Task Force in Ethiopia and ITI. ENVISION has successfully advocated to have the 500 th millionth dose administered in a woreda near Ambo, Oromia where MDA is supported by LFW through ENVISION support. Through DFAT funding, FHF is supporting the S, F and E in this woreda thus providing a good opportunity to showcase this unique partnership. Together with funding from ITI and DFID, ENVISION will support a portion of the cost for the transport of participants from Addis as well as speaker systems, banners, etc. NTD Scientific Symposium. (RTI) At the NTD Annual Review and Taskforce meeting held in July 2015, one of the top recommendations that came forward to move NTDs more into the center focus of the Ethiopia scientific community was to hold an NTD scientific symposium. This two-day event would invite national and international scientists to present NTD-related research findings to high ranking scientists in the Ministry of Health, various Ethiopian universities and the Ethiopian Public Health Institute. This meeting would be held at the recently launched NTD research center at Arba Minch University in SNNPR. Numerous partners, including the WHO, SCI, and TCC have pledged funding to this initiative. ENVISION will fund the per diem and travel of 10 participants from the aforementioned institutes for this meeting. Oromia Community Sensitization meetings. (FHF) In FY15, four woredas reported that rumors of side-effects in the communities resulted in poor therapeutic coverage. In FY16, FHF will undertake a community sensitization meeting that involves key community figures, kebele leaders, and woreda administration authorities in the selected woredas where such rumors have arisen. During the sensitization meeting, key messages will be delivered to increase the awareness of the participants on trachoma and the antibiotics distributed. These messages will be derived from the SAE materials that ENVISION developed. The participants will transmit the key messages to the wider community and will encourage the general community to take Zithromax and thereby limit the impact of the rumors during the MDA. ENVISION will fund this activity for all four woredas. Tigray The DFID Trachoma project is already planning to support a regional advocacy event in CY2015. ENVISION staff will attend the event to highlight both the ENVISION and MMDP-supported activities. However, ENVISION will not be contributing funding support to this activity in FY16 Beneshangul-Gumuz There is no planned advocacy support in FY16 as a Region-wide NTD advocacy meeting is targeted in September of FY15. 33

41 Gambella Gambella Advocacy Meeting. (RTI) The Gambella RHB is experiencing a doubling of their NTD activities as they move to target trachoma MDA with ENVISION support in FY16. The RHB would like to hold an advocacy meeting with all major stakeholders in the region to attract technical and funding support to this SAFE expansion. ENVISION will fund the venue and per diem for this meeting. It will take place over 1 day and participants from all of the health, education and water sectors will be invited. d) Social Mobilization The majority of the population of the targeted zones will need to be informed about the importance of MDA, as well as risks and prevention measures related to NTDs. The activities described below (also see Table 12) will help ensure that community leaders and decision makers are aware of the importance of MDA and support the implementation. The social mobilization activities described below are especially crucial given that the majority of the woredas targeted for MDA in FY16 will be receiving treatments for the first time. The efficacy of these tools will be tested through focal groups before mass production and measured via specific questions during the MDA coverage surveys. Some communities will be randomized during the coverage surveys to undertake full KAP surveys. FMOH LF Public Service Announcement. (RTI) The Minister of Health has requested that a video be made to highlight LF. RTI will work with a professional film company in Addis Ababa to create the video and feature prominent Ethiopian short-distance runner, Mohammed Aman as an LF advocate. Key issues addressed in the video will be the importance of MDA, necessity to sleep under a bed net, and ways to support community members suffering from LF morbidity through lymphedema management techniques. The audio from the PSA will be edited to match the radio broadcast format to reach rural communities. The FMOH will play the video on the nationwide broadcasting channel, EBC 1, as well as on the National Radio station, ERC 1, which allows free airtime for government messaging. This intervention uses an innovative approach that conveys simple but direct messages about LF by involving patients and celebrities that can attract attention and response across the various population groups, both literate and illiterate, throughout the country. Furthermore, FMOH-driven videos such as this one have been created for HIV and polio as an effective means of starting a national dialogue about the diseases. ENVISION will support the cost of the creation of the PSA and provide technical advice on its content. The FMOH would also like to target additional NTDs, specifically STH and trachoma, in separate PSAs. The creation of these additional videos may be targeted in later fiscal years due to the cost. Oromia MDA Launching Event (FHF). A coordinated launching event will be organized by FHF in each of the eight new zones in Oromia to kick off the trachoma MDA campaign. The ceremony s agenda will include speeches from influence-makers concerning the importance of SAFE, music/circus clubs, and basic health education messages regarding trachoma. Local government authorities and/or key figures in the community will publically take Zithromax to encourage the general population and endorse the drug s safety. ENVISION will support the per diem of participants, venue rental, and entertainment MDA Mobilization: Dissemination of Health Messages (FHF and LFW). Before MDA implementation it is important to sensitize and raise the community s awareness about the program, its objectives, and activities. Populations from the targeted zones will be informed by FHF and LFW about the importance 34

42 of MDA, as well as risks and prevention measures related to specific NTDs (e.g., trachoma, LF, and OV). Health education and sensitization will be implemented through different ways of communication, such as transmission of the information through local radio (more information below), community meetings, banners posted on public places, and distribution of various types of IEC materials, such as leaflets and posters. Since Oromia enjoys its own radio and TV stations, which broadcast in Afan Oromo, in order to assist with MDA mobilization, FHF and LFW have created OV, LF, and trachoma awareness messages that will be broadcast both before and during MDA. Contained within the short broadcasts are FMOH messages, basic information about timing and locations of MDA, and messages raising awareness of the SAFE strategy and bed net usage. ENVISION is currently in discussion with the Oromia RHB about the possibility of procuring free air time for these broadcasts. However, funding for broadcast costs is still included in the FY16 budget in case such an agreement is not reached. A potential collaboration with all NTD partners for increased messaging beyond what is funded by ENVISION will be discussed to take maximum opportunity of this air time. Tigray MDA Mobilization: Dissemination of Health Messages (RTI). In Tigray, ENVISION, with help from LFW, will support the Tigray RHB to create and produce health messages via radio broadcasts, posters, and brochures for LF and trachoma. These messages will be similar to those created for Oromia, but they will be translated into Tigrinya and adjusted for any cultural specificity required for the Tigray region. This messaging is of particular importance as it will be the first time that MDA has been done in the Tigray regions targeted by the project. Beneshangul-Gumuz MDA Mobilization: Dissemination of Health Messages (RTI). In Beneshangul-Gumuz, teaching materials, posters, and brochures will be produced by RTI to mobilize the community and provide health education during MDA activities. ENVISION will support the printing of the materials and the distribution of pamphlets while mobilizing targeting communities via town criers and public address systems. ENVISION will also adapt BCC and IEC materials from FHF, TCC and LFW that target trachoma in the four woredas that are above the treatment threshold and which will be targeted for the first time in FY16. The Beneshangul-Gumuz RHB has successfully established an agreement with the local radio station both before and during scheduled MDAs at no cost to the project. Gambella MDA Mobilization: Dissemination of Health Messages (RTI). RTI will use the same strategy in Gambella as will be used in Beneshangul-Gumuz, but with a greater focus on the behavioral change aspect of the SAFE strategy in all 13 trachoma endemic woredas. The current situation with radio broadcasts and the languages of the broadcasts is still being explored during the writing of this work plan. 35

43 Table 8. Oromia, Tigray, and Beneshangul-Gumuz development and dissemination of health messages No. of Woredas Brochures Posters Banners Flip Charts Town Criers Montarbos (Vehicle with Speaker Systems) Radio Messages Oromia OV (LFW) 36 30, N/A N/A N/A N/A One message broadcast twice a day, twice a week, for 12 days across all zones at once LF (LFW) 4 4, N/A N/A N/A N/A One message broadcast twice a day, twice a week, for 12 days across all zones at once Trachoma (FHF) ,259 N/A 160 N/A 12, One message broadcast twice a day for 6 days in 12 zones (each zone will have a tailored message) Tigray Trachoma 22 Produced in FY15 Produced in FY15 N/A N/A N/A N/A One message broadcast twice a day, twice a week, for 12 days across all zones at once Beneshangul-Gumuz OV 14 28, N/A (one for each zone ) LF 12 28,436 Two messages broadcast per day for one month Trachoma 4 13, Two messages broadcast per day for one month Gambella Trachoma (one for each zone) 36

44 e) Capacity Building/Training FMOH The FMOH has taken a very strong role in leading NTD activities within the country especially given the federated nature of the country. Partners are successfully coordinated by the FMOH to avoid redundancies and achieve near 100% geographic coverage for all PC NTDs (see Country Background). A revised National NTD Masterplan (June 2015), Oncho elimination guidelines (October 2014), National and Regional Trachoma Action Plans ( ), an STH/SCH Action plan (December 2014), and a detailed TT Surgery Backlog Elimination plan (January 2015) are all examples of national policies that have been created to ensure that the country is moving successfully towards 2020 elimination goals in a manner consistent with best practices. WHO Integrated NTD Database Regional Rollout (RTI). In FY15, RTI supported the FMOH to complete the integrated NTD database, including the capture of all NTD treatments and disease specific assessments in the country s history. The database has become a crucial component of the FMOH s work planning process. The regional health bureaus of Beneshangul-Gumuz, Tigray, and Oromia are currently requesting the cascade of the integrated database to the regional level. RTI s Data Manager secondment will travel to each of the three regional offices to conduct trainings with the NTD team on the use of the database (Note: The Gambella Regional Health Bureau has not yet decided about implementing this tool in their office). As the data for all regions has already been collected and entered in FY15, the training will mostly be centered on manipulating and analyzing the data and establishing a regiment for future data entry. ENVISION will support the travel of the data manager to the regional office both for the five-day initial training and a two-day follow up three months later. No venue or per diem cost will be necessary as the training will be held within the regional office. The Oromia, Tigray, and Beneshangul-Gumuz RHBs have agreed to contribute a dedicated desktop computer to house the database. Other regions that request this service will be considered if additional support from regional partners can be provided. Oromia Zonal TOT for Trachoma MDA (FHF). In each zone, a TOT will be held by FHF with the goal to train a trainer for each woreda. This trainer will be the key facilitator for the woreda-level training of supervisors and distribution team leaders. Health professionals and FHF technical advisors will facilitate the TOT. Due to the proposed expansion into eight new zones and attrition of previous trained personnel, ENVISION feels that it is necessary that all TOT trainees, including new participants and participants from the previous year, undergo this activity. ENVISION will fund the travel, per diem, and venue costs of this activity. Woreda-level Training of Supervisors and Distribution Team Leaders for Trachoma MDA (FHF). The selected zone supervisors, woreda administrators, kebele administrators, coordinators, field supervisors, and team leaders will be trained by FHF over a three-day period. Training will cover topics, such as roles and responsibilities, community mobilization and passing of health messages, volunteer selection, organization of distribution teams, SAE management, data quality management, and how to develop supervisory plans. In addition, HEWs will be trained on SAFE strategy, with a particular focus on behavior change elements. Both during and after the MDA, HEWs will be expected to hold community conversations to pass on their knowledge to community members in a way that is appropriate and easily understood by the community. The community conversations will strongly focus on the effectiveness of antibiotics for trachoma prevention, i.e., MDA, face washing, and use of latrines and personal and 37

45 environmental hygiene to prevent trachoma transmission. ENVISION will fund the travel and per diem for this activity while the woreda-level health offices will support the venue. Refresher Training of Healthcare Providers and HEWs for OV and LF MDA (LFW). 5 Health extension workers from each kebele and health care providers from the health posts will be trained by LFW at the woreda level so that they can then train the HDA on drug distribution and supervise the MDAs in their respective kebeles. The training will be a one-day refresher training carried out before OV/LF Round 1 and OV Round 2. These trainings are necessary due to high turnover and to properly prepare and motivate the distribution force before the MDA. ENVISION will fund the per diems and transport costs for this activity. Refresher Training of OV Community Drug Distributers and Community Supervisors (LFW). Supported by LFW, volunteers from the HDA in each community will be trained by health extension workers at their village centers. The community will select these volunteer community drug distributers. Community supervisors from each kebele will also be trained to oversee community mobilization and assist the HEWs with general supervision. The community supervisors will also elected by the community. Training will be a one-day refresher training carried out before OV/LF Round 1 and OV Round 2. These trainings are necessary because of high turnover and to properly prepare and motivate the distribution force before the MDA. ENVISION will fund the per diems and transport costs for this activity. Tigray Central-level TOT for Trachoma MDA (LFW). Three people from each district and six people from the region will be trained by LFW to function as trainers for HEW drug distributers and supervisors. The district health office management from the district health offices will select the trainers; they will be NTD focal persons who will later supervise MDA activities. ENVISION will fund the per diem, travel, and refreshments for this activity. Woreda-level Training of Trainers for Trachoma MDA (LFW). Similar to the cascade strategy described in the Oromia section above, the woreda-level TOT trainers (supported by LFW) will train the woredalevel health officers from the 21 targeted woredas on trachoma MDA and the SAFE strategy. All of the trainers targeted at the woreda level will also act as supervisors during the actual MDA. ENVISION will fund the per diem, travel, and venue costs of this activity. Health Care Providers and HEWs Training for Trachoma MDA (LFW). Supported by LFW, the woredalevel health officers in the training described above will train all of the healthcare providers and HEWs in their respective woredas to administer MDA. Participants will also be trained in all aspects of the SAFE strategy. ENVISION will fund the per diem, travel, and venue costs for this activity. Supply Chain Management Training (LFW). As this is the first time a large-scale MDA has been carried out in Tigray, the ITI regional office has requested that a brief training on storage, tracking, and transport of Zithromax be provided to the Tigray RHB. LFW will support the training, which will target two pharmacists and drug logistics officers from the RHB and three representatives from the targeted zones. ENVISION will fund the per diem, travel, and refreshments for this activity. 5 It is important to note that the word refresher is meant to capture both previously trained distributors and supervisors as well as replacement distributors and supervisors that are filling a position lost to turn over. 38

46 Beneshangul-Gumuz Refresher Regional and Zonal TOT Trainings for OV/LF (RTI). Supported by RTI, this one-day training will bring together MDA trainers who were first trained at the beginning of FY15. These trainers were originally selected by the RHB as leaders in their respective communities suited both to train and supervise their fellow HEWs. This refresher training will not only provide a technical overview of OV and LF MDA, but will also allow the RHB to address pertinent issues that arose during FY15 MDA. ENVISION will fund the per diem, venue, and travel for this activity. Refresher Health Care Provider and HEW Training for OV/LF MDA (RTI). This one-day refresher training (supported by RTI) will target health workers and HEWs who will then cascade the training to the HDA. The refresher training is targeted to occur before both the OV/LF Round 1 and OV Round 2. The training is necessary because of high turnover and will help prepare and motivate the HEWs for the upcoming MDA. ENVISION will fund the per diem, venue, and travel for this activity. Training of Woreda-level Health Officers, Community Supervisors, and HEWs for Trachoma MDA (RTI). As there are only four woredas that are above the treatment threshold, RTI will target all woreda-level health officers, community supervisors, and HEWs in one training in each woreda. Similar to the Oromia activity listed above, this training will ensure that HEWs are trained in the behavior change aspects of the SAFE strategy. ENVISION will fund the per diem and travel for this event. The woreda health office will support the venue. Gambella Zonal-level TOT for Trachoma MDA (RTI). As this will be the first year in which the region will implement trachoma MDA, ENVISION will support a three-day TOT training (led by RTI). This training will address all of the aforementioned trachoma training topics, including the behavior change aspects of the SAFE strategy. The trainers trained will return to their woredas to cascade the training to healthcare providers and HEWs. ENVISION will support the per diem, travel, and venue for this activity. Health Care Provider and HEW Training for Trachoma (RTI). Supported by RTI, trainers from the zonallevel TOT will carry out training in all 13 endemic woredas targeting all health care providers and HEWs. The HEWs will return to their health posts to train the HDA in community mobilization before the MDA. ENVISION will support the per diem and travel for this activity. 39

47 f) Mapping While there are some woredas that have not been mapped or are being re-mapped for STH, SCH, LF, and Trachoma (OV is fully mapped), mapping is planned within the next year and full funding is available. Therefore, no mapping support is planned for FY16. g) MDA FMOH No support to the FMOH is planned for this activity in FY16. Oromia Trachoma MDA Campaign Week (FHF). In FY16, FHF will undertake trachoma MDA in 160 endemic woredas in 12 zones. This is an increase of 117 woredas, representing an additional 10 million people, from the FY15 targets. Trachoma MDA in each zone will be completed within seven days. MDA teams comprise 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 will support the per diem for the HEWs and supervisors traveling outside of their duty stations for this activity. The Federal Ministry of Health is currently working with the National Trachoma Task Force, as well as the other NTD partners, to create an Integrated NTD reporting format that will start at the kebele level and flow up through the woreda, zonal, and, finally, the federal level. However, at this time, the integrated reporting forms have not been finalized. Therefore, ENVISION will continue to use the woreda and kebele reporting forms devised during the 2015 trachoma MDA under the leadership of the Oromia RHB, including the kebele and woreda-level summary reports, drug consumption and follow up, supervisor work plan and feedback forms, and Serious Adverse Effects Reporting forms. FHF has also devised trachoma training modules that will be implemented during the previously described trainings. ENVISION will support the printing of these materials. Service Fees for MDA Distribution Per Diem Payments (FHF). In order to ensure that per diem payments arrive to the MDA teams on time and to save on additional finance staffing costs, FHF will use the microfinance institution of Oromia Credit and Savings Share Company (OCSSCO). OCSSCO charges a small service fee plus 1% of the total per diem paid for this service. In 2014 and 2015, the service performed very smoothly and proved to be an efficient tool for making payments to a large number of training/mda participants. The service fees included in this budget are for woreda-level participants covering MDA distribution per diem, woreda-level training, and the Woreda Review Meeting per diem. This method is not being used in LFW and RTI areas because per diem payments are made through the Regional/Zonal Health Bureaus. This is possible because RTI and LFW operational areas are relatively small and manageable in comparison to FHF s operational area which includes the enormous geographic scope of Eastern Oromia with a population of greater than 20 million people. OV/LF MDA (LFW). The ORHB has been implementing projects on OV control for nine years with support from LFW. In FY14/15, there were 24 new endemic districts discovered, which were then targeted for biannual treatment with the support from the ENVISION project. In FY16, LFW will target these same 24 woredas, as well as an additional 12 woredas that were not identified by the FMOH as endemic in time to include them in FY15 treatment rounds. These woredas will be targeted for Round 1 of IVM treatment in October FY16 and Round 2 of IVM treatment six months later (March FY16). During 40

48 Round 2, three OV/LF co-endemic woredas will be addressed, as well as seven woredas only endemic for LF, six of which are targeted by ENVISION for the first time in FY16. The combined population treated in these woredas will approach four million people. ENVISION will support the MDA logistics, dose poles, and production of MDA reporting forms and writing materials for HEW supervisors. Tigray Trachoma MDA (LFW). In the Tigray Region, almost 2.9 million individuals residing in 22 woredas are targeted to receive Zithromax in FY16 through ENVISION support. This will be the first time any of these woredas will have received Zithromax. LFW will begin the campaign at the same time in all three zones and carry out the MDAs concurrently with the goal of completing all trachoma MDAs in the region within one week. ENVISION will support the per diems of HEWs and supervisors traveling outside of their duty station. LF MDA (LFW). In the Tigray region, only 1 woreda is currently confirmed as LF endemic while 4 other woredas are exactly at 1% and scheduled for remapping via the aforementioned. ENVISION will support the treatment of this one woreda through the same mechanism mentioned in the Tigray Trachoma MDA section. Beneshangul-Gumuz OV and LF MDA (RTI). In Beneshangul-Gumuz, 14 woredas are on a biannual treatment schedule and all but two are also endemic for LF. In November of FY16, RTI will support Round 1 of IVM treatment in all 14 of the OV woredas, together with administering Albendazole in the 12 woredas co-endemic with LF. Six months later, in May of FY16 ENVISION will support the Round 2 of IVM treatment to all 14 woredas as these zones represent catch-up areas and require biannual treatment according to the OV elimination policy established by the FMOH. Trachoma MDA (RTI). Only four woredas in the Metekel Zone are currently endemic for trachoma and above the treatment threshold. RTI will target these four woredas for Zithromax distribution in February 2016 as no drugs were ordered for these woredas in the CY2015 quantification. Gambella Gambella Trachoma MDA (RTI). Gambella will target 13 woredas for Zithromax distribution with ENVISION/RTI support in February 2016 as no drugs were ordered for these woredas in the 2015 quantification. ENVISION will build upon the distribution structure established by the OV program to complete the distributions. After the East Africa Cross-Border Trachoma Meeting held in July of 2015, the Ethiopian FMOH NTD team requested ENVISION provide funding for a member of the S. Sudan MOH NTD team to travel to Gambella during the MDA planning stages with the specific focus of helping to arrange MDA in the refugee camps. ENVISION will also support the travel and per diem of this member of the S. Sudan NTD team. This cost is located in the international travel section. 41

49 Table 9. USAID-supported districts and estimated target populations for MDA in FY16 NTD Targeted Age Groups No. of Annual Distribution Rounds Distribution Platform(s) Number of Districts to be Treated in FY16 Total No. of Eligible People Targeted in FY16 Lymphatic Filariasis Onchocerciasis Entire population 5 years and older Entire population with a height of 90cm and above 1 2 Community MDA Community MDA Oromia: 10 Tigray: 1 Beneshangul-Gumuz: 12 TOTAL: 23 woredas Oromia: 36 Beneshangul-Gumuz: 14 TOTAL: 50 woredas Oromia: 856,610 Tigray: 111,052 Beneshangul-Gumuz: 448,167 TOTAL: 1,415,829 Oromia: 2,724,005 Beneshangul-Gumuz: 521,995 TOTAL: 3,246,001 Schistosomiasis Soil-transmitted helminths Oromia: 19,667,933 Community Oromia: 160 Tigray: 2,888,672 MDA Tigray: 22 Beneshangul-Gumuz: 266,734 Entire (distributed Beneshangul-Gumuz: 4 Trachoma 1 Gambella: 400,377 population by HEW Gambella: 13 from health posts) TOTAL: 199 TOTAL: 23,223,716 42

50 h.) Drugs and Commodity Supply Management and Procurement Thanks to ENVISION funding and technical support to implement the TIPAC in FY15, the WHO joint request form will be populated through this tool. Currently, Zithromax is not ordered as part of the WHO Joint Request Form, but through a separate process coordinated by the International Trachoma Initiative and in collaboration with the WHO. Twice a year, representatives from the ITI office in Addis Ababa and ITI Atlanta meet with the FMOH, members of the RHBs, and implementation partners in Ethiopia. No Zithromax is ordered without both the FMOH s confirmation of the targeted areas and the guarantee of funds either by the FMOH, RHB, or implementing partner. Drug requests for trachoma and OV/LF MDAs are made jointly with RHBs on an annual basis. They are imported into the country via the FMOH and stored at a central drug store in Addis Ababa. For FY16, RTI will import tetracycline eye ointment (TEO) for trachoma MDA into the country through the FMOH and will store it at PFSA central hub. From the central drug store, a pharmacist and logistics officer will deliver the allocated drugs to each zonal health office drug store. Each district health office will get its share of drugs for the MDAs from the zonal health office drug store. The district health office will then distribute the drugs according to 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, the health extension worker will distribute the drugs. In the case of adverse events, people are referred by the HEW to the nearby health facility. In case of Serious Adverse Effects (SAEs), a form will be filled out and submitted directly to the Ethiopian Food, Medicine, Healthcare Administration, and Control Authority. All SAEs must also be reported to WHO, RTI, ORHB, and FMOH. For trachoma, a separate form is also required for submission to the ITI. All SAEs will be investigated and confirmed by the aforementioned organizations. During the MDA trainings, an extensive module on adverse and serious adverse events is included in the curriculum. ENVISION has also worked with the Task Force for Global Health to rollout an SAE manual. This has been shared with all ENVISION partners, the FMOH, and the Regional Health Bureaus targeted for support. It will also be shared at the TOT trainings for HEWs. Transporting of Drugs and Supplies from FMOH Warehouses to RHBs, Woredas, and Kebeles (RTI, FHF and LFW). The transportation costs are to ensure that all of the required IVM, Albendazole, Zithromax, and TEO arrive at their destination shortly preceding the targeted MDA in Oromia, Tigray, Beneshangul- Gumuz, and Gambella. As per FMOH regulations, a trained pharmacist and logistics officer must also accompany each drug shipment to ensure that the drugs are handled and stored in accordance with international guidelines and the PFSA. It is important to note that the Minister of Health has requested building the capacity of the PFSA in relation to delivery of NTD drugs be one of the primary goals of NTD implementing partners. With support from RTI, LFW, and FHF, and in light of this request, ENVISION is supporting a secondment to sit at the PFSA (see NTD secretariat) to assist with this transition. ENVISION will also support the rental of lorries and four wheel drive vehicles to deliver the drugs from the RHB to the MDA distribution sites as well as loading and unloading costs and storage fees where necessary. ENVISION will also pay the per diem of the trained pharmacist and logistics officer. As the PFSA assumes its new role, it is hoped that more of these costs will be greatly reduced in future fiscal years. i) Supervision MDA Supervision of OV, LF, and Trachoma (RTI, FHF, and LFW). 43

51 Kebele/sub-kebele levels: The community-based MDA approach foresees a high involvement of the respective communities and local stakeholders, especially the health development army. 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 Zithromax as it is an antibiotic. Instead, the health extension workers 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, LFW, 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, LFW, 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 an input for the next work schedule. All levels of training include details on WHO and MOH regulations for the respective diseases. The protocols used are also included in the HEW NTD pocket guide created by ENVISION for the FMOH in FY15. 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 a large number of zone supervisors and field supervisors. Technical and management teams comprised of ENVISION partners, FMOH, and ORHB staff, as well as staff from all of 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. ENVISION will support the per diem and travel of supervisors during MDA as well as in the review meeting detailed in the Strategic Planning section of this work plan. j) Short-Term Technical Assistance No short-term technical assistance is required in FY16. k) M&E Post MDA Coverage Survey (RTI, LFW, FHF). Post-MDA coverage surveys will be conducted in Oromia for trachoma/ov/lf and in Beneshangul-Gumuz for OV/LF to achieve the following: Assess validity of reported MDA coverage against statement of the beneficiaries; Evaluate the quality of the service; and Identify limitations/gaps of the MDA campaign and develop strategies for addressing them. ENVISION has developed questionnaires to interview household members regarding their experience with the MDA campaign conducted in their area. Multistage random sampling will be used to select the 44

52 surveyed households in the targeted kebeles. In the first stage, four woredas will be selected from the zone (one woreda with a reported high coverage and the other with low coverage). The third and fourth woredas will be randomly selected from the remaining two woredas to increase the validity of the findings of the MDA held in the zone. The number of households surveyed will be determined by taking the number of the required sample size divided by the average household number (4.8 people). This information will be used to improve overall performance and detect problem areas where the reported coverage data is not aligned with the actual coverage. It will also help assess whether reported coverage is what is actually happening on the ground. There are reports in Ethiopia and elsewhere that drug distributors sometimes manipulate reports and put aside drugs to match the reports. In Ethiopia, such report manipulations have been reported not only in mass drug administration campaigns but also during national immunization days. Because of this experience, the regional health bureaus strongly urge organizations to conduct post MDA coverage surveys to determine the real coverage after campaigns. Where false reports are found, the Regional Health Bureau takes corrective measures to educate and motivate the HEWs who made the mistakes. RTI will target 14 woredas endemic for OV and LF and 4 woredas for trachoma. The Beneshangul- Gumuz RHB has never carried out a coverage survey for any of its disease initiatives. As an emerging region, the RHB is very concerned about the strength of their HEW/HDA distribution system, given that the entire system was established just two years ago. By conducting this coverage survey, the RHB feels it will demonstrate to the lower administration tiers that accountability is expected and supervision and follow up could be undertaken at any time. It will use the results of the coverage survey to make FY17 s refresher training more targeted on evidence-based improvements. LFW will target 18 woredas in Western Oromia particularly concentrating on woredas co-endemic for OV, LF, and trachoma. LFW has never implemented a coverage survey before in these woredas and will attempt to analyze the coverage for all three diseases. Of particular concern to LFW and the RHB is the fact that these woredas are the first OV-endemic woredas to implement biannual distribution within the region. The RHB wants to assess how carrying out three diffierent MDA rounds (OV/LF 1, trachoma, OV2) affects the treatment coverage within the region. It is important to note that the coverage surveys carried out in the LF endemic woredas will also be the basis for carrying out LF morbidity burden assessments in Western Oromia for the MMDP program. FHF will conduct a coverage survey for trachoma MDA in 48 woredas selected from within the 12 zones (4 woredas from each zone). FHF has never carried out a coverage survey before in these woredas and 4 of the 12 zones have conducted one round of trachoma MDA while the other 8 zones are new to MDA. Where one round of MDA has taken place, the 4 zonal offices have expressed a need to carry out spot check reports on the woreda-level health offices and the HEWs. In the 8 remaining zones, the RHB feels strongly that a coverage survey in the first year for the 8 zones is necessary to validate MDA results. The RHB and FHF feel it is important to establish a culture of accountability and supervision early on in the MDA cycle especially given that all 5 years of MDA must have strong coverage in order to achieve 2020 goals. Data Quality Assessment (DQA [RTI]). A current challenge with NTD data quality is that data received at the national level is often incomplete, not timely, and of questionable accuracy. Formal DQAs have been used for other public health interventions, such as immunizations, HIV/AIDS, tuberculosis, and malaria, but DQAs have rarely been used for NTDs. The FMOH will be able to use the WHO NTD DQA tool to assess accuracy, reliability, precision, completeness, timeliness, and integrity of data. Supported by RTI, as part of the DQA exercise, the data in available reports will be recounted at each level of the NTD reporting system (e.g., community, woreda, district, region, and federal) and compared with the values that were reported for that level to verify the reported data. Additionally, individuals who are involved 45

53 in data collection and reporting will be interviewed in order to qualitatively assess the NTD data management system. Finally, an action plan will be developed with recommended actions to address any areas that need strengthening. A DQA was carried out in FY15 focusing on OV MDA in Oromia which yielded several valuable action points for the FMOH to improve the OV reporting system, particularly given the change from the CDTI system to reliance on the HDA. The FMOH has requested a DQA in Beneshangul-Gumuz in FY16 focusing on LF and Trachoma in order to assess the newly introduced reporting system to an emerging region. ENVISION will support the FMOH to carry out one DQA in FY16 in an ENVISION-supported area in three to four woredas. Onchocerciasis Impact assessments (RTI). In FY15, ENVISION planned to support onchocerciasis impact assessments in 22 woredas in three zones of Oromia. However, the FMOH decided wait a full eight months since the MDA round in February 2015 before implementing the impact assessments. This was to allow adequate time for the resurgence of OV MF to definitively determine if transmission was still occurring. For this reason, ENVISION has pushed the impact assessments into October of Note: The use of skin snips is being evaluated as a tool by the Ethiopia Elimination of Onchocerciasis Committee. The committee will me in October 2015 to discuss whether this tool is still the best possible tool or if the country should move to using only Ov-16 serology. Thus, the protocol listed below may change. Onchocerciasis EPI evaluation is a two-phase process to ascertain OV elimination progress and when it is safe to stop treatment. Phase 1a assesses progress towards elimination thresholds. In addition to the skin snips, Ov-16 serology through dried blood sampling will also be carried out. Sites are chosen based on at least 10 years of ivermectin treatment at 70% therapeutic coverage and high-level pre-treatment endemicity of greater than 40% nodule prevalence. Ten villages per site are chosen for evaluation by skin snip. ENVISION is only including Phase 1A support in this work plan. If skin snip results are still above the treatment thresholds, then these 22 woredas will move into the good coverage but poor impact category and the Oncho Elimination committee will advise on whether or not biannual treatment should begin. If these woredas are below the treatment threshold, then Phase 1B will also need to be carried out. Phase 1b confirms the breaking point for elimination has been reached and treatment can be discontinued. This is done via skin snip and entomological evaluation of the black fly population along nearby rivers. If Phase 1b verifies that OV transmission has been broken, treatment will be discontinued and post-mda surveillance will begin. ENVISION will work with the FMOH and other NTD partners to advocate for Phase 1b should the results of Phase 1a necessitate it. ENVISION will also advocate for funding should these woredas fail Phase 1a and need to be moved into a biannual treatment regimen. Table 10. Planned disease-specific assessments for FY16 by disease Disease No. of endemic districts No. of districts planned for DSA Type of assessment OV 179 Woredas 22 woredas OV epidemiological assessment (Phase 1A) Diagnostic method (Indicator: Mf, ICT, hematuria, etc.) OV-16 Serology (DBS) combined with skin snip microscopy 46

54 7) Maps 47

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63 Appendix 1. Work Plan Activities Fiscal Year 2016 Activities National program implementation Ongoing project operational functions Office management Strategic planning Federal Ministry of Health (FMOH) Neglected Tropical Disease (NTD) Annual Review Meeting (RTI International) National NTD Task Force Meeting (RTI) Afar Trachoma Action Plan Workshop and Finalization (RTI) OROMIA Oromia Annual Review Meeting (RTI) Zonal-level Pre- Onchocerciasis (OV)/Lymphatic Filariasis (LF) Mass Drug Administration MDA) Planning Meeting (LFW) Woreda-level Pre-MDA Planning Meeting (Light for the World [LFW]) Woreda-level Post-MDA Review Meeting (Fred Hollows Foundation [FHF] and LFW) Zonal-level Post-review Meeting (FHF and LFW) TIGRAY Woreda-level MDA Post-review Meeting (LFW) BENESHANGUL-GUMUZ NTD Annual Review Meeting (RTI) Woreda-level Post-MDA Review Meeting (RTI) GAMBELLA NTD Annual Review Meetings (RTI) Woreda-level Post-MDA Review Meeting (RTI) Advocacy OROMIA Celebration of the 500 Millionth Zithromax treatment NTD symposium Community sensitization meetings (FHF) Social mobilization FMOH LF public service announcement (RTI) OROMIA 56

64 Fiscal Year 2016 Activities MDA launching event (FHF) MDA mobilization- dissemination of health messages (FHF and LFW) TIGRAY MDA mobilization- dissemination of health messages (LFW) BENESHANGUL-GUMUZ MDA mobilization- dissemination of health messages (RTI) GAMBELLA MDA mobilization- dissemination of health messages (RTI) Capacity Building and Training FMOH World Health Organization (WHO) Integrated NTD Database regional rollout (RTI) OROMIA Zonal TOT for trachoma MDA (FHF) Woreda-level training of supervisors and distribution team leaders for trachoma MDA (FHF) Refresher training of healthcare providers and Health Extension Workers (HEW) for OV and LF MDA (LFW) Refresher training of OV community drug distributers and community supervisors (LFW) TIGRAY Central-level TOT for trachoma MDA (LFW) Woreda-level training of trainers for trachoma MDA (LFW) Health care providers and HEWs training for trachoma MDA (LFW) Supply chain management training (LFW) BENESHANGUL-GUMUZ Refresher regional and zonal TOT trainings for OV/LF (RTI) Refresher training of health care providers and HEWs training for OV/LF MDA (RTI) Training of woreda-level health officers, community supervisors, and HEWs for trachoma MDA (RTI) GAMBELLA Zonal-level TOT for trachoma MDA (RTI) Health care provider and HEW training for trachoma (RTI) MDA OROMIA Trachoma MDA campaign week (FHF) Service fees for MDA distribution per diem payments (FHF) OV/LF MDA (LFW) TIGRAY Trachoma MDA (LFW) LF MDA (LFW)_ BENESHANGUL-GUMUZ 57

65 Fiscal Year 2016 Activities OV and LF MDA (RTI) Trachoma MDA (RTI) GAMBELLA Gambella trachoma MDA (RTI) Drug Commodity Supply Management and Procurement Transporting of Drugs and supplies from FMOH warehouses to Regional Health Bureaus, woredas, and kebeles (RTI, LFW, and FHF) Supervision MDA supervision of OV, LF, and trachoma Monitoring and Evaluation Post-MDA coverage survey (FHF and RTI) Data quality assessment (RTI) OV Impact Assessment 58

66 Appendix 2. Table of U.S. Agency for International Developmentsupported Ethiopian Provinces/States and Districts Administration Level 1 (Region and Zone) Administration Level 2 (District) Total Population Beneshangul-Gumuz Assosa Assosa 107,493 Beneshangul-Gumuz Assosa Assosa Town 32,472 Beneshangul-Gumuz Assosa Bambasi 65,402 Beneshangul-Gumuz Assosa Homosha 29,221 Beneshangul-Gumuz Assosa Kurmuke 22,489 Beneshangul-Gumuz Assosa Menge 54,079 Beneshangul-Gumuz Assosa Oda bildigilu 73,356 Beneshangul-Gumuz Assosa Sherkole 33,166 Beneshangul-Gumuz Kamashi Agalometi 30,607 Beneshangul-Gumuz Kamashi Belo Jegonfoy 40,509 Beneshangul-Gumuz Kamashi Kamashi 24,034 Beneshangul-Gumuz Kamashi Sedal (Sirba Abay) 24,185 Beneshangul-Gumuz Kamashi Yasso 17,131 Beneshangul-Gumuz Metekel Bullen 61,179 Beneshangul-Gumuz Metekel Dibate 89,577 Beneshangul-Gumuz Metekel Mandura 54,759 Beneshangul-Gumuz Metekel Pawe 61,218 Beneshangul-Gumuz Tongo Sp. Wereda MaoKomo 67,278 Oromia Arsi Amigna 96,795 Oromia Arsi Aseko 110,584 Oromia Arsi Bale 97,633 Oromia Arsi Chole 117,816 Oromia Arsi Digelu and Tijo 185,925 Oromia Arsi Diksis 109,752 Oromia Arsi Dodota 87,261 Oromia Arsi Enkelo Wabe 77,670 Oromia Arsi Gololcha 225,572 Oromia Arsi Guna 100,725 Oromia Arsi Hetosa 165,436 Oromia Arsi Jeju 144,074 Oromia Arsi Limuna bilbilo 213,881 Oromia Arsi Lode hetosa 142,573 Oromia Arsi Merti 120,609 Oromia Arsi Munesa 220,179 Oromia Arsi Robe 219,371 Oromia Arsi Seru 63,163 59

67 Administration Level 1 (Region and Zone) Administration Level 2 (District) Total Population Oromia Arsi Shirka 216,178 Oromia Arsi Sire 103,327 Oromia Arsi Sude 193,565 Oromia Arsi Tena 87,563 Oromia Arsi Tiyo 114,473 Oromia Arsi Zuway Dugda 138,405 Oromia Bale Agarfa 135,433 Oromia Bale Barbare 116,232 Oromia Bale Dawe Kachen 39,609 Oromia Bale Dawe Sarar 55,195 Oromia Bale Delo Mena 121,568 Oromia Bale Dinsho 50,466 Oromia Bale Gasara 101,318 Oromia Bale Ginir 184,424 Oromia Bale Goba 52,180 Oromia Bale Gololcha 130,369 Oromia Bale Goro 109,857 Oromia Bale Gura Dhamole 38,480 Oromia Bale Harana Buluk 104,971 Oromia Bale Lege Hida 80,315 Oromia Bale Mada Walabu 125,655 Oromia Bale Rayitu 42,873 Oromia Bale Sawena 84,789 Oromia Bale Sinana 152,694 Oromia Borena Abaya 134,254 Oromia Borena Arero 42,739 Oromia Borena Bule Hora 345,469 Oromia Borena Dhas 31,809 Oromia Borena Dillo 29,575 Oromia Borena Dire 65,396 Oromia Borena Dugda Dawa 111,755 Oromia Borena Gelana 90,339 Oromia Borena Melka Soda 76,968 Oromia Borena Miyo 65,789 Oromia Borena Moyale 39,910 Oromia Borena Teltele 81,108 Oromia Borena Yabelo 108,411 Oromia E. Shewa Adama 202,186 Oromia E. Shewa Adea 168,147 60

68 Administration Level 1 (Region and Zone) Administration Level 2 (District) Total Population Oromia E. Shewa Boset 184,117 Oromia E. Shewa Fentale 79,041 Oromia E. Shewa Gimbichu 111,240 Oromia E. Shewa Liben 98,689 Oromia E. Shewa Lome 113,698 Oromia E. Wellega Boneya Bushe 61,652 Oromia E. Wellega Diga 88,603 Oromia E. Wellega Ebantu 46,172 Oromia E. Wellega Gida Ayyana 146,940 Oromia E. Wellega Gubu Sayo 54,930 Oromia E. Wellega Gudaya Bila 70,813 Oromia E. Wellega Guto Gida 118,543 Oromia E. Wellega Haro Limu 66,803 Oromia E. Wellega Jima Arjo 114,350 Oromia E. Wellega Kiremu 61,259 Oromia E. Wellega Leka Dulecha 94,475 Oromia E. Wellega Limu 94,250 Oromia E. Wellega Nunu Kumba 84,870 Oromia E. Wellega Sasiga 105,105 Oromia E. Wellega Sibu Sire 132,185 Oromia E. Wellega Wama Hagalo 62,883 Oromia E. Wellega Wayu Tuka 85,159 Oromia Finfine Zuriya Akaki 80,987 Oromia Finfine Zuriya Bereh 86,412 Oromia Finfine Zuriya Mulo 46,303 Oromia Finfine Zuriya Sebata Awas 129,205 Oromia Finfine Zuriya Sululta 153,143 Oromia Finfine Zuriya Welmera 110,099 Oromia Guji Adola Wayyu 33,842 Oromia Guji Anna Soraa 123,395 Oromia Guji Bore 152,981 Oromia Guji Dama 84,442 Oromia Guji Girja 65,735 Oromia Guji Goro Dola 90,142 Oromia Guji Hambala Wamana 145,710 Oromia Guji Liben 104,081 Oromia Guji Odo Shakiso 124,654 Oromia Guji Qerca 298,767 Oromia Guji Saba Boru 126,178 61

69 Administration Level 1 (Region and Zone) Administration Level 2 (District) Total Population Oromia Guji Uraga 227,939 Oromia Guji Wadera 66,857 Oromia Horo Guduru Abay Comen 64,727 Oromia Horo Guduru Abe Dongoro 87,998 Oromia Horo Guduru Amuru 71,106 Oromia Horo Guduru Guduru 129,265 Oromia Horo Guduru Hababo Guduru 59,625 Oromia Horo Guduru Horo 98,609 Oromia Horo Guduru Jardega Jarte 64,758 Oromia Horo Guduru Jimma Ganati 85,011 Oromia Horo Guduru Jimma Rare 74,084 Oromia Illu Aba bora Becho 48,664 Oromia Illu Aba bora Bedele 101,515 Oromia Illu Aba bora Borecha 96,776 Oromia Illu Aba bora Chewaka 73,492 Oromia Illu Aba bora Chora 132,635 Oromia Illu Aba bora Dabo Hana 54,651 Oromia Illu Aba bora Dega 52,081 Oromia Illu Aba bora Diediesa 111,931 Oromia Illu Aba bora Doreni 47,963 Oromia Illu Aba bora Hurumu 56,516 Oromia Illu Aba bora Meko 28,750 Oromia Illu Aba bora Metu 80,957 Oromia Illu Aba bora Yayo 70,336 Oromia Jimma Chora 118,001 Oromia Jimma Deddo 372,822 Oromia Jimma Gera 148,280 Oromia Jimma Gomma 279,275 Oromia Jimma Gumma 79,262 Oromia Jimma Kersa 210,801 Oromia Jimma Limmu Kossa 210,535 Oromia Jimma Limmu Seka 146,701 Oromia Jimma Manna 192,240 Oromia Jimma Nonno Benja 93,678 Oromia Jimma Ommo Nadda 316,674 Oromia Jimma Saka Chekorsa 265,274 Oromia Jimma Satema 133,472 Oromia Jimma Shabe Sombo 144,450 Oromia Jimma Sigimo 119,447 62

70 Administration Level 1 (Region and Zone) Administration Level 2 (District) Total Population Oromia Jimma Sokoru 176,146 Oromia Jimma Tiro Afeta 171,025 Oromia North Shoa Zone Abichugna 98,042 Oromia North Shoa Zone Aleltu 70,447 Oromia North Shoa Zone Debre Libanos 60,547 Oromia North Shoa Zone Degem 130,575 Oromia North Shoa Zone Derra 238,144 Oromia North Shoa Zone Girar Jarso 87,958 Oromia North Shoa Zone Hidhabu Abote 109,529 Oromia North Shoa Zone Jidda 70,116 Oromia North Shoa Zone Kimbibit 99,048 Oromia North Shoa Zone Kuyu 161,532 Oromia North Shoa Zone Were Jarso 186,581 Oromia North Shoa Zone Wuchale 128,527 Oromia North Shoa Zone Yaya Gulale 72,299 Oromia S.W. Shewa Ameya 160,549 Oromia S.W. Shewa Becho 99,159 Oromia S.W. Shewa Dawo 95,656 Oromia S.W. Shewa Elu 82,259 Oromia S.W. Shewa Goro 60,064 Oromia S.W. Shewa Kersa Malima 106,966 Oromia S.W. Shewa Seden Sodo Rural 90,942 Oromia S.W. Shewa Sodo Dachi 57,443 Oromia S.W. Shewa Tole 82,674 Oromia S.W. Shewa Woliso 194,183 Oromia S.W. Shewa Wonchi 122,662 Oromia W. Harerge Ancar 108,960 Oromia W. Harerge Boke 105,400 Oromia W. Harerge Burka Dhintu 95,000 Oromia W. Harerge Chiro 47,230 Oromia W. Harerge Daro Lebu 192,465 Oromia W. Harerge Doba 171,941 Oromia W. Harerge Gemechis 236,201 Oromia W. Harerge Guba Koricha 158,213 Oromia W. Harerge Habro 248,597 Oromia W. Harerge Hawi Gudina 64,401 Oromia W. Harerge Mesela 191,852 Oromia W. Harerge Mi'eso 170,222 Oromia W. Harerge Tullo 189,318 63

71 Administration Level 1 (Region and Zone) Administration Level 2 (District) Total Population Oromia W. Shewa Ade'a Berga 160,350 Oromia W. Shewa Ambo Zuria 141,803 Oromia W. Shewa Bako Tibe 164,621 Oromia W. Shewa Chelia 128,136 Oromia W. Shewa Dano 128,093 Oromia W. Shewa Dendi 229,740 Oromia W. Shewa Dire Inchini (Tikur Inchini) 94,057 Oromia W. Shewa Ejere 115,297 Oromia W. Shewa Elfeta 75,312 Oromia W. Shewa Ilu Gelan 80,807 Oromia W. Shewa Jeldu 267,319 Oromia W. Shewa Jibat 94,971 Oromia W. Shewa Meta Robi 184,441 Oromia W. Shewa Mida Kegn 104,339 Oromia W. Shewa Nono 110,688 Oromia W. Shewa Toke Kutaye 159,495 Oromia West Arsi Adaba 183,305 Oromia West Arsi Dodola 228,286 Oromia West Arsi Gadeb Asasa 247,721 Oromia West Arsi Kofele 225,661 Oromia West Arsi Kokosa 189,430 Oromia West Arsi Kore 136,461 Oromia West Arsi Nensebo 150,721 Oromia West Arsi Shala 200,225 Oromia West Arsi Shashemene 258,953 Oromia West Arsi Siraro 214,592 Oromia West Arsi Wondo 112,524 Oromia West Wellega Ayira 63,543 Oromia West Wellega Babo Gambel 79,585 Oromia West Wellega Begi 158,224 Oromia West Wellega Bodji Chokorsa 64,585 Oromia West Wellega Bodji Dirmeji 57,475 Oromia West Wellega Genji 80,368 Oromia West Wellega Guliso 93,204 Oromia West Wellega Haru 85,150 Oromia West Wellega Jarso 63,968 Oromia West Wellega Kiltu Kara 68,353 Oromia West Wellega Kondala 128,495 Oromia West Wellega Lalo Asabi 101,117 64

72 Administration Level 1 (Region and Zone) Administration Level 2 (District) Total Population Oromia West Wellega Mene Sibu 164,513 Oromia West Wellega Nedjo Rural 155,597 Oromia West Wellega Nole Kaba 80,853 Oromia West Wellega Seyo Nole 100,453 Oromia West Wellega Yubdo 51,170 Tigray Central Tigray Ahferom 222,288 Tigray Central Tigray Geter Adwa 121,222 Tigray Central Tigray Kolla Temben 173,081 Tigray Central Tigray Laelay Maichew 93,560 Tigray Central Tigray Mereb Leke 137,244 Tigray Central Tigray Naeder Adet 133,822 Tigray Central Tigray Tahtay Maichew 126,964 Tigray Central Tigray Tanqua Abergele 116,094 Tigray Central Tigray Werehilehi 187,459 Tigray Eastern Tigray Atsibi Wonberta 143,669 Tigray Eastern Tigray Erob 33,107 Tigray Eastern Tigray Ganta Afeshum 110,144 Tigray Eastern Tigray Glomekeda 108,502 Tigray Eastern Tigray Hawzien 137,844 Tigray Eastern Tigray Kilte Awlaelo 132,205 Tigray Eastern Tigray Saesi Tsaeda Amba 172,397 Tigray North West Tigray Asgede Tsimbla 173,530 Tigray North West Tigray Laelay Adyabo 143,619 Tigray North West Tigray Medebay Zana 161,293 Tigray North West Tigray Tahtay Adiabo 116,973 Tigray North West Tigray Tahtay Koraro 87,748 Tigray North West Tigray Tselemti 177,713 65