ETHIOPIA Work Plan

ETHIOPIA Work Plan

FY 2017

Project Year 6

October 2016-September 2017

ENVISION Project Overview

The U.S. Agency for International Development (USAID)’s ENVISION project (2011-2019) is designed to support the vision of the World Health Organization (WHO) and its member states by targeting the control and elimination of seven neglected tropical diseases (NTDs) including, lymphatic filariasis (LF), Onchocerciasis (OV), schistosomiasis (SCH), three soil-transmitted helminths (STH; roundworm, whipworm, hookworm) and trachoma. 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 global level, ENVISION –in close coordination and collaboration with WHO, USAID and other stakeholders- contributes to several technical areas in support of global NTD control and elimination goals, including:

• 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:

• Strategic annual and multi-year planning
• Advocacy
• Social mobilization and health education
• Capacity strengthening
• Baseline disease mapping
• Preventive chemotherapy (PC) or mass drug administration (MDA)
• Drug and commodity supply management and procurement
• Program supervision
• M&E, including disease-specific assessments (DSA) and surveillance

In Ethiopia, ENVISION project activities are implemented by RTI International (RTI), the Fred Hollows Foundation (FHF), and Light For The World (LFTW).

TABLE OF CONTENTS

Page

Acronyms List

COUNTRY OVERVIEW

1)General Country Background

a)Administrative Structure

b)NTD Program Partners

2)National NTD Program Overview

a)LF

b)OV

c)SCH/STH

d)Trachoma

3)Snapshot of NTD status in Ethiopia

PLANNED ACTIVITIES

1)NTD Program Capacity Strengthening

a)Strategic Capacity Strengthening Approach

b)Capacity Strengthening Interventions

c)Monitoring Capacity Strengthening

2)Project Assistance

a)Strategic Planning

b)NTD Secretariat

c)Advocacy for Building a Sustainable National NTD Program

d)Social Mobilization to Enable NTD Program Activities

e)Training

f)Mapping

g)MDA Coverage and Challenges

h)Drug and Commodity Supply Management and Procurement

i)Supervision

j)M&E

3)Maps

Appendix 1. Work plan Timeline

Appendix 2. Table of USAID-supported Provinces/States and Districts

TABLE OF TABLES

Table 1. NTD partners working in Ethiopia, donor support, and summarized activities

Table 2. LF endemic woredas by region after 1% remapping exercise

Table 3. OV endemic Woredas by region

Table 4. SCH and STH endemic woredas by region

Table 5. Number of woredas that fall into each treatment category and their progress toward elimination in 2020

Table 6. Snapshot of the expected status of NTD program in Ethiopia as of Sept 30, 2016

Table 7: Project assistance for capacity strengthening

Table 8: Social mobilization/communication activities and materials checklist for NTD work planning

Table 9: USAID-supported coverage results for FY15 and FY16** and targets for FY17

Table 10. List of PFSA branches allocated by training cluster and region

Table 11: Planned Disease-specific Assessments for FY17 by Disease

List of Figures

Figure 1: 2016 OV Disease Distribution and Biannual vs. Annual treatment

Acronyms List

ALBAlbendazole

APOCAfrican Programme for Onchocerciasis Control

AmrefAfrican Medication and Research Foundation

BCCBehavior Change Communication

CDDCommunity Drug Distributor

CIFF Children’s Investment Fund Foundation

CNTDCentre for Neglected Tropical Diseases, Liverpool School of Tropical Medicine

CYCalendar Year

DFATDepartment of Foreign Affairs and Trade (Australia)

DFIDDepartment for International Development (U.K.)

DQAData Quality Assessments

DSADisease-Specific Assessment

END FundEnd Neglected Tropical Disease Fund

EOEEACEthiopia Onchocerciasis Elimination Expert Advisory Committee

EPHIEthiopian Public Health Institute

ESHIEnhanced School Health Initiative

F and EFacial Cleanliness and Environmental Improvement (part of the SAFE strategy)

FHFFred Hollows Foundation

FMOHFederal Ministry of Health

FPSUFilariasis Programmes Support Unit, Liverpool School of Tropical Medicine (formerly known as CNTD)

FOGFixed Obligation Grant

FYFiscal Year

GTMGrarbet Tehadiso Mahber

GTMPGlobal Trachoma Mapping Project

HDAHealth Development Army

HEWHealth Extension Worker

ICTImmunochromatographic Test

IECInformation, Education and Communication

ITIInternational Trachoma Initiative

IVMIvermectin

LFLymphatic Filariasis

LFTWLight For The World

M&EMonitoring and Evaluation

MDAMass Drug Administration

MEBMebendazole

MfMMenschen für Menschen

MMDPMorbidity Management and Disability Prevention Program

MOHMinistry of Health

MOUMemorandum of Understanding

NGONongovernmental Organization

NTDNeglected Tropical Disease

OEPAOnchocerciasis Elimination Program for the Americas

OCSSCOOromia Credit & Savings Share Company

OVOnchocerciasis

PCRPolymerase Chain Reaction

PCPreventive Chemotherapy

PFSAPharmaceutical Fund and Supplies Agency

PHCUPrimary Health Care Unit

PZQPraziquantel

REMORapid Epidemiological Mapping of Onchocerciasis

RHBRegional Health Bureau

RTIRTI International

SACSchool-Aged Children

SAESerious Adverse Events

SAFESurgery-Antibiotics-Facial cleanliness-Environmental improvements

SCHSchistosomiasis

SCISchistosomiasis Control Initiative

SNNPRSouthern Nations, Nationalities, and People’s Region

STHSoil-Transmitted Helminths

TAFTechnical Assistance Facility

TASTransmission Assessment Survey

TFTrachomatous Inflammation–Follicular

TIPACTool for Integrated Planning and Costing

TOTTraining of Trainers

TTTrachomatous Trichiasis

UIGUltimate Intervention Goal

USAIDU.S. Agency for International Development

WASHWater, Sanitation, and Hygiene

WHOWorld Health Organization

ZTHZithromax®

ENVISION FY17 PY6 ETHIOPIA Work Plan

1

COUNTRY OVERVIEW

1) General Country Background

a) Administrative Structure

Ethiopia is a federated nation comprising nine autonomous regions (Afar; Amhara; Beneshangul-Gumuz; Gambella; Harari; Oromia; Somali; the Southern Nations, Nationalities, and People’s Region [SNNPR]; and Tigray) and the two city administration councils of Addis Ababa and Dire Dawa. Each region is constitutionally allowed self-determination; the federal government is responsible for the military and foreign affairs, international treaties, and other overarching issues of interest to the entire nation. The nine regions are further subdivided into 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 kebele, which is the smallest unit of local government, consists of 5,000 people on average.

The Ethiopia Federal Ministry of Health (FMOH) focuses on eight priority neglected tropical diseases (NTDs): lymphatic filariasis (LF), onchocerciasis (OV), trachoma, soil-transmitted helminths (STH), schistosomiasis (SCH), podoconiosis, dracunculiasis, and leishmaniasis. Ethiopia has witnessed a tremendous scale-up in NTD activities since the official launch of the National Master Plan for NTDs (2013–2015) in June 2013. In November 2013, the Minister of Health established an NTD team and appointed an NTD team leader to accommodate this scale-up. NTD mass drug administration (MDA) treatment results were also added to the National Health Management Information System as an indicator, and the FMOH has integrated NTD program planning into the existing platform of annual, woreda-level micro-planning for health initiatives. In May 2015, the FMOH updated the National Master Plan to incorporate the strategies and implementation plans for all eight NTDs from 2016 until their elimination and control goals are reached (by 2020).

The FMOH oversees the coordination and implementation of Ethiopian health programs on a national level, and the Regional Health Bureaus (RHBs) do so on a regional level. RHBs follow countrywide, health-related initiatives issued by the FMOH but also maintain a large degree of autonomy in determining their priority health intervention areas and implementation timelines. RHBs also must approve mapping and disease-specific assessment (DSA) results before the FMOH can declare them official. In terms of NTDs, RHBs have developed their own Regional NTD Master Plans within the framework to complement the National Master Plan and other key NTD documents, such as Regional Trachoma Action Plans. Currently, RHBs split the efforts 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 because the other, larger disease initiatives, such as malaria, tend to take precedence in terms of actual program time.

The FMOH and RHBs currently conduct various 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, and on average, each woreda contains five PHCUs. The Health Extension Program, which was created to address medical intervention needs at the community level, consists of an integrated set of 16 health packages, 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 in forming health development teams. Overall, an average of 30 development teams exist in each kebele.

b) NTD Program Partners

As one of the most NTD-endemic countries in the world, Ethiopia has witnessed an exponential increase in the number of donors and implementing partners since the launch of the NTD Master Plan in 2013. Largely as a result of FMOH leadership, donors and implementing partners now recognize that with coordinated efforts, a substantial impact can be achieved in terms of the size of the population treated, progress toward 2020 elimination and control goals, and sustainable capacity building. Table 1 presents an overview of each partner’s roles and responsibilities.

Table 1. NTD partners working in Ethiopia, donor support, and summarized activities

2) National NTD Program Overview

a) LF

As stated in the revised National Master Plan (2016‒2020) and in accordance with the WHO Global LF-Elimination Strategy, the FMOH is targeting LF for elimination by 2020. In compliance with Lymphatic Filariasis: A Manual for National Elimination Programs,[1] the national program uses an MDA strategy combining IVM and ALB in entire at-risk populations. MDA coverage must be at least 65% of the total population in an endemic area for at least five years before conducting transmission assessment surveys (TAS) to determine whether MDA can be stopped. In the 46 LF-endemic woredas that are co-endemic with OV, ALB can be added to the existing IVM MDA. Currently, the triple drug administration of ALB, IVM, and PZQ is not used in practice, although this strategy may be considered by the FMOH in some co-endemic areas after one to two years of separate treatments, according to WHO guidelines. In areas targed for LF MDA, SAC are not specifically targeted with a separate MDA for STH unless the woreda has a prevalence >50%, and bi-annual treatment is required. It is important to note that Loa loa is not endemic in Ethiopia and, thus, does not present a barrier to using IVM.

The FMOH has also stated in the National Master Plan that by 2020, the estimated hydrocele and lymphedema burden within the 70 endemic woredas must be established through burden assessments. Furthermore, according to the National Master Plan, all those living within these woredas should have access to hydrocele surgery within their zonal hospitals, and those in need of lymphedema care should have access to that care within a 10-kilometer radius of their home.

The initial LF mapping in Ethiopia occurred in CY08—113 woredas were surveyed in the regions of Gambella, SNNPR, Beneshangul-Gumuz, Amhara, and Oromia by The Carter Center using immunochromatographic tests (ICTs). Of the 113 woredas, 34 were found to be endemic for LF. MDA was immediately initiated in all 34 of these woredas, again with the support of The Carter Center. Starting in June 2013, Ethiopia targeted 571 additional woredas for mapping through a nationwide initiative led by EPHI and the FMOH NTD team with funding support from DFID through FPSU (known as CNTD at the time). The 2013 mapping was conducted using current WHO guidelines for initial LF assessments: In each implementation unit, two sites were selected based on the high likelihood of ongoing transmission, and in each site, a convenience sample of 100 adults aged 15 years or older was tested for antigenemia by ICT. During this 2013 mapping initiative, podoconiois mapping was also conducted by identifying woredas as endemic for podoconiosis if lymphedema cases were found but exhibited negative ICT results.

In 45 of the 113 woredas found to be endemic for LF, a single ICT-positive case was found in one of the selected villages (1% prevalence). The FMOH was hesitant to designate these woredas as endemic and, as a result, commit to beginning a costly five-year treatment plan. At the request of the FMOH, the Task Force for Global Health supported EPHI in implementing a more robust LF mapping methodology based on targeting older SAC, also called the ‘mini-TAS’. According to this methodology, if three or more antigen-positive children were found, then the woreda was confirmed as endemic. EPHI completed this remapping initiative in February 2015. The results revealed that only 3 woredas (2 in Amhara and 1 in SNNPR) out of the 45 woredas remapped were endemic for LF, corresponding to a 53.6% reduction in the number of people at risk for LF (Table 2). The official number of endemic woredas stated in the National NTD Master Plan is now 70. Note that two woredas in Oromia and one woreda in SNNPR had already implemented one round of MDA with funding from FPSU before being assigned a new non-endemic status. The FMOH ceased all future rounds of MDA within these three woredas.