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MOZAMBIQUE Work PlanFY 2017Project Year 6

October 2016–September 2017

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

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

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 ([STHs] roundworm, whipworm, hookworm) and trachoma. ENVISION’s goal is to strengthen NTD programming at global and country levels and support ministries of health (MOHs) to achieve their NTD control and elimination goals.

At the global level, ENVISION—in close coordination and collaboration with WHO, USAID and other stakeholders—contributes to several technical areas in support of global NTD control and elimination goals, including:

drug and diagnostics procurement, where global donation programs are unavailable

capacity strengthening

management and implementation of ENVISION’s Technical Assistance Facility (TAF)

disease mapping

NTD policy and technical guideline development

NTD monitoring and evaluation (M&E).

At the country level, ENVISION provides support to national NTD programs by providing strategic technical and financial assistance for a comprehensive package of NTD interventions, including:

strategic annual and multi-year planning

advocacy

social mobilization and health education

capacity strengthening

baseline disease mapping

preventive chemotherapy (PC) or mass drug administration (MDA)

drug and commodity supply management and procurement

program supervision

M&E, including disease-specific assessments (DSAs) and surveillance.

In Mozambique, ENVISION project activities are implemented by RTI International in support of the Ministry of Health.

ENVISION FY17 PY6 Mozambique Work Plani

TABLE OF CONTENTSPage

ENVISION Project Overview.......................................................................................................................... i

List of Tables............................................................................................................................................... iii

Acronyms List.............................................................................................................................................. iv

Country Overview........................................................................................................................................6

1) General Country Background...........................................................................................................6

a) Administrative Structure..............................................................................................................6

b) NTD Program Partners.................................................................................................................7

c) USAID Support.............................................................................................................................8

2) National NTD Program Overview...................................................................................................10

a) Lymphatic Filariasis (combined with STH if appropriate)...........................................................10

b) Trachoma...................................................................................................................................10

c) Onchocerciasis...........................................................................................................................11

d) Schistosomiasis..........................................................................................................................12

e) Soil-transmitted helminths........................................................................................................12

3) Snapshot of NTD status in Mozambique........................................................................................13

Planned Activities......................................................................................................................................14

1) NTD Program Capacity Strengthening...........................................................................................14

a) Strategic Capacity Strengthening Approach..............................................................................14

b) Capacity Strengthening Interventions.......................................................................................15

c) Monitoring Capacity Strengthening...........................................................................................16

2) Project Assistance..........................................................................................................................17

a) Strategic Planning......................................................................................................................17

b) NTD Secretariat..........................................................................................................................18

c) Advocacy for Building a Sustainable National NTD Program......................................................19

d) Social Mobilization to Enable NTD Program Activities...............................................................19

e) Training......................................................................................................................................21

f) Mapping.....................................................................................................................................22

g) MDA coverage and Challenges..................................................................................................22

h) Drug and Commodity Supply Management and Procurement..................................................23

i) Supervision................................................................................................................................24

j) M&E...........................................................................................................................................25

3) Maps..............................................................................................................................................27

ENVISION FY17 PY6 Mozambique Work Planii

Appendix 1. Work plan Timeline...............................................................................................................31

Appendix 2. Table of USAID-supported Provinces/States and Districts.....................................................33

LIST OF TABLES

Table 1: NTD partners working in Mozambique, donor support, and summarized activities......................9

Table 2: Snapshot of the expected status of the NTD program in Mozambique as of September 30, 2016..................................................................................................................................................................13

Table 3: Project Assistance for Capacity Strengthening.............................................................................15

Table 4: Social mobilization/communication activities and materials checklist for NTD work planning....21

Table 5: USAID-supported coverage results for FY15** and targets for FY17...........................................23

Table 6: Planned disease-specific assessments for FY17 by disease..........................................................26

ENVISION FY17 PY6 Mozambique Work Planiii

ACRONYMS LIST

ALB AlbendazoleAFRO WHO Africa Regional OfficeCMAM Centre for Drugs and Medical Supplies CST Coverage Supervision ToolDFID UK Department for International DevelopmentDPS Provincial Health DirectorateDQA Data Quality AssessmentDSA Disease-Specific AssessmentFOG Fixed Obligation GrantFPSU Filarial Programme Support Unit (Formerly known as the Centre for Neglected

Tropical Disease CNTD)FY Fiscal YearGET 2020 WHO Alliance for the Global Elimination of Blinding Trachoma by the Year 2020GTMP Global Trachoma of Mapping Project HKI Helen Keller InternationalICOSA Integrated Control of Schistosomiasis in Sub-Saharan AfricaICT Immunochromatographic Test ICTC International Coalition for Trachoma ControlIEC Information, Education and Communication INGO International Nongovernmental OrganizationINS National Institute of StatisticsITI International Trachoma Initiative IU Implementation UnitIVM IvermectinKAP Knowledge, Attitudes, and PracticesLF Lymphatic FilariasisM&E Monitoring and EvaluationMDA Mass Drug AdministrationMECC Mozambique Eye Care CoalitionMISAU Ministry of Heath (Ministério de Saúde)NGO Nongovernmental OrganizationNSC National Steering Committee NTD Neglected Tropical DiseaseOV OnchocerciasisPC Preventive Chemotherapy PZQ PraziquantelRPA Resident Program AdvisorSAE Serious Adverse EventSAFE Surgery–Antibiotics–Facial cleanliness–Environmental improvementsSBCC Social Behavior Change CommunicationSCH SchistosomiasisSCI Schistosomiasis Control InitiativeSCORE Support of Competitive Research

ENVISION FY17 PY6 Mozambique Work Planiv

SMS Short Messaging Service STH Soil-Transmitted HelminthsTA Technical AssistanceTAP Trachoma Action PlanTAS Transmission Assessment SurveyTAF Technical Assistance FacilityTEMF Trachoma Elimination Monitoring FormTEO Tetracycline Eye OintmentTF Trachomatous Inflammation–FollicularTIPAC Tool for Integrated Planning and CostingTIS Trachoma Impact SurveyTrust Queen Elizabeth Diamond Jubilee TrustTSS Trachoma Surveillance SurveyTT Trachomatous TrichiasisUSAID United States Agency for International DevelopmentWASH Water, Sanitation and Hygiene WHO World Health OrganizationZTH Zithromax®

ENVISION FY17 PY6 Mozambique Work Planv

COUNTRY OVERVIEW

1) General Country Background

a) Administrative Structure

Until recently, Mozambique had 128 districts, divided into 142 implementation units (IUs). In 2015, redistricting resulted in the current demarcation of 159 districts. The subdivision of districts took place in the provinces of Maputo, Manica, Nampula, Tete, and Zambézia. The province of Gaza is also expected to undergo redistricting in the near future. Currently, there are 50 districts requiring mass drug administration (MDA) for trachoma, 113 for lymphatic filariasis (LF), 159 for schistosomiasis (SCH), and 151 for soil-transmitted helminths (STHs). Mapping has been completed for all five neglected tropical diseases (NTDs) treatable through preventive chemotherapy (PC), though there remains uncertainty about the hypo-endemic status of onchocerciasis (OV) in some districts.

Under the coordination of the National Directorate of Public Health, each province is responsible for planning and coordinating the implementation of NTD activities in each IU. The provincial representatives coordinate activities at the provincial level, act as an in intermediary body between the district and national level, and report to both provincial and national bodies.

At the central level, the Ministry of Health (MISAU) is organized into two arms: (1) the National Directorate of Public Health, under which the National NTD Program operates, and (2) the National Directorate of Medical Assistance, within which is the Ophthalmology Department. Under both of these arms, the provincial and district directorates of health operate throughout the country.

Although the Ophthalmology Department is under the National Directorate of Medical Assistance, it also operates under the National NTD Program (under the National Directorate of Public Health). The National NTD Program and the Ophthalmology Department work in close collaboration, and most decisions related to trachoma control activities and the SAFE strategy (Surgery–Antibiotics–Facial cleanliness–Environmental improvements) are made jointly.

In May 2016, there was a change in staffing within the National NTD Program and the trachoma focal point was appointed as NTD Coordinator. The National NTD Program will maintain responsibility for managing mass drug administration (MDA) campaigns for trachoma, LF, SCH, and STHs as well as the sentinel sites for LF. Any operational research is typically handled by the National Institute of Statistics (INS), which also sits in MISAU at national level.

The National NTD Steering Committee (NSC) formed in 2014 continues to hold quarterly meetings to discuss key issues on NTD control and elimination and to make recommendations to the National NTD Program. The Committee represents various government stakeholders such as the Department of School Health, INS, and Centre for Drugs and Medical Supplies (CMAM), among others, and is a platform where new results can be shared and new health policies discussed. In the past, it also served to de-centralize the program by bringing partners from other sectors.

ENVISION FY17 PY6 Mozambique Work Plan6

b) NTD Program Partners

The National NTD Program in Mozambique is fortunate to have highly committed partners working in collaboration with each other and with MISAU to provide the best possible support to the national program. The collaboration of partners draws on organizations funded by USAID and the United Kingdom Department for International Development (DFID) including government, national nongovernmental organizations (NGOs), international NGOs (INGOs), and private donors.

The main partners include the Integrated Control of Schistosomiasis in Sub/Saharan Africa (ICOSA), funded by DFID and implemented by the Filarial Programmes Support Unit (FPSU) (formerly known as Centre for Neglected Tropical Disease). FPSU provides support for the implementation of LF/STH and SCH/STH MDA in districts targeted by the national NTD control program.

In addition to their support of the ICOSA project, FPSU is supported through DFID funding as part of a group of multidisciplinary initiatives based at the Liverpool School of Tropical Medicine in the United Kingdom. The main focus of their work is to reduce the transmission of LF and support the efforts to achieve elimination targets by 2020. In past years FPSU supported activities such as trainings, sentinel sites and spot check surveys for LF, and procurement of diagnostics and office equipment, such as laptops, for the NTD department. Their focus in 2017 will be on reviving some of the activities that did not take place in FY16, including sentinel sites and Transmission Assessment Surveys (TAS). Depending on the results of the pre-TAS sentinel site surveys conducted in 2016, TAS will be carried out in up to 43 districts in Niassa, Cabo Delgado, Nampula, and Zambézia between 2016 and 2017. FPSU also provides support for LF morbidity management and works closely with several leprosy organizations. The Unit will continue to support MDA and morbidity case management and hydrocele surgeries until at least August 2017, when its current funding expires.

As part of the ICOSA partnership, the Schistosomiasis Control Initiative (SCI) provides direct support for sentinel sites and spot check surveys for SCH and STH. Although the SCI Support of Competitive Research (SCORE) project in Cabo Delgado came to an end in 2015, SCI through its subgrant to FPSU continues to support the SCH MDA at national level.

WHO’s Mozambique country office appointed a new NTD focal point in early 2016 who has been successful in bridging the gap that existed between WHO and the National NTD Program. With the support of the WHO Africa Regional Office (AFRO) the country WHO NTD focal point was able to encourage the use of the WHO Integrated NTD Database. RTI ENVISION and FPSU will be involved in providing follow-up support after the database training. Both organizations have open and frequent communication about programmatic and technical issues related to the NTD program. WHO, RTI ENVISION, FPSU, and MISAU’s NTD department, including higher level staff, had their first technical meeting in June 2016 to support the transition period of the new NTD Coordinator and to help align upcoming activities and offer technical support where needed. The elimination dossiers for LF and trachoma and the Integrated NTD Database were among the main priority subjects discussed.

The Malaria Consortium entered the NTD arena in Mozambique in 2014 with support from the Bill and Melinda Gates Foundation. In 2015, the Consortium supported a cross-sectional survey in four districts of Nampula that focused on social and behavior change communication (SBCC), including a knowledge, attitudes, and practices (KAP) survey on SCH, related to the importance of community dialogue in communities. The findings of the KAP survey indicated that awareness of the disease was high; however, knowledge of causes and prevention techniques was poor. The Malaria Consortium became an active member in the NTD Steering Committee meetings and annual NTD Partners meeting, where it led a


subcommittee for strengthening social mobilization prior to MDA. ENVISION hopes to collaborate with the Malaria Consortium and MISAU to improve the National NTD Program’s social mobilization strategy.

In 2014, RTI International was selected by the Queen Elizabeth Diamond Jubilee Trust (The Trust project) to assist MISAU in coordinating the scale-up of trichiasis surgeries. The five-year Trust-funded project is managed by Sightsavers UK through the International Coalition on Trachoma Control (ICTC). The implementing partners who work closely with MISAU at provincial and district level and closely with RTI at country level are Sightsavers and Light for the World. The project is focused on building capacity for conducting trichiasis surgical outreach and building the capacity of ophthalmology technicians throughout the country. The Trust project has a strong emphasis on the ‘S’ (surgery) component of the SAFE strategy, which complements the ‘A’ (antibiotic) component, led by ENVISION. Partnerships with both organizations and RTI have strengthened since 2014 and are expected to remain strong as RTI rolls out the program into the third year.

The relationships with the water, sanitation and hygiene (WASH) sector partners also strengthened in FY16 and are expected to continue to grow as partners including WaterAid, World Vision, UNICEF, and Save the Children become increasingly interested in maximizing the impact of WASH activities on NTD control and prevention. Through these partnerships, ENVISION is exploring ways in which some key messages such as the importance of hand and face-washing to prevent eye diseases (among others) can be disseminated via the various partners’ activities. Globally, WaterAid is branching its focus to water and health and in Mozambique, it is interested and engaged in many of ENVISION’s activities and eager to participate in ENVISION meetings and trainings. In FY16, WaterAid facilitated one of the WHO modules on WASH from the Program Managers Trainers Course. WaterAid became a regular member of the Mozambique Eye Care Coalition (MECC) as did Helen Keller International (HKI), among other organizations. ENVISION and WaterAid collaborated in a local primary school in Maputo Province on Global Hand Washing Day to introduce key messages on trachoma prevention through face and hand washing. The collaboration was successful and interactive with primary school aged children being taught the importance of keeping both hands and face clean. It is expected that ENVISION will continue working on community strategies for addressing NTD and WASH and advocating for the importance of water and sanitation to help reduce the prevalence of NTDs in Mozambique. It is also hoped and encouraged that the partnership can be replicated in other ENVISION/WaterAid countries.

c) USAID Support

USAID support for NTDs began in 2011 with provincial-level trachoma mapping in three northern provinces. In 2012, USAID expanded its support with the formal startup of the ENVISION project in Mozambique. Since then, ENVISION has been a main partner of the National NTD Control Program, working closely with the National Trachoma Control Program, international and national partners, donors, and Provincial Health Directorates (DPSs) to ensure that NTD strategies are harmonized and, when appropriate, integrated. Through USAID funding and in partnership with the DFID supported Global Trachoma Mapping Project (GTMP), the National Program completed trachoma mapping in 2014.

ENVISION continues to support trachoma MDA in endemic districts, impact surveys in qualifying districts, and national-level support and capacity strengthening. Since the inception of ENVISION some of the supported activities have included support for the first Data Quality Assessment (DQA); development of information, education, and communication (IEC) materials; national-level planning meetings; and trainings on the use of the Tool for Integrated Planning and Costing (TIPAC) and fixed obligation grants (FOGs). The need for a comprehensive FOG training, bringing all the provincial finance focal points together, has been recognized and will be planned for FY17. (See Planned Activities section).


The USAID Mozambique Country Mission has been very supportive of the ENVISION project and participates in various meetings, trainings, and MDA throughout the year. For the last two years, high-level USAID staff have travelled with RTI staff to the field to be involved in the MDAs. The NTD focal point in the Mission meets with the Resident Program Advisor (RPA) frequently to discuss the program status and challenges. The relationship is valuable to the success of the project.

Table 1: NTD partners working in Mozambique, donor support, and summarized activities

Partner Location (Regions/States)

Activities Is USAID providing direct financial support to this partner?

List other donors supporting these partners/ activities

Schistosomiasis Control Initiative (SCI)

Central level and in endemic areas for schistosomiasis

SCH/soil transmitted helminth (STH) sentinel site and spot check surveys beginning in 2011

No UK Department for International Development (DFID) funded via sub grant from SCI to FPSU

Filarial Programme Support Unit (FPSU)

Central level, as well as all areas endemic for SCH and LF

Lymphatic filariasis (LF)/STH and SCH/STH mass drug administration (MDA) in districts targeted by the national neglected tropical disease (NTD) control program; includes trainings, diagnostics, and supervision

No DFID Funded

Malaria Consortium

Nampula Province Social and behavior change communication (SBCC) in one province with extended funding to do more research; sharing of SBCC lessons at national level meetings

No Bill and Melinda Gates Foundation

Sightsavers Nampula Province (currently) and extending to Zambézia province in FY17

Implementation of trichiasis surgical outreach campaigns. Work with Provincial Health Directorate (DPS) in the provinces.

No Queen Elizabeth Diamond Jubilee Trust; DFID; RTI

Light for the World

Cabo Delgado and Sofala provinces

Implementation of trichiasis surgical outreach campaigns. Work with DPS in the provinces.


RTI ENVISION Central level Capacity Strengthening, including training and implementation of the Tool for Integrated Planning and Costing, data quality assessments, the World Health Organization-Integrated NTD Program Managers Training. Support is also provided to the Ministry of Health to coordinate major NTD meetings and technical workshops such as the Annual review meeting, drug coordination meetings and the steering committee

Yes USAID


Partner Location (Regions/States)

Activities Is USAID providing direct financial support to this partner?

List other donors supporting these partners/ activities

meetings. Support for all aspects of trachoma MDA in endemic districts through fixed obligation grants to provinces.

RTI Central level Coordination of trichiasis surgical scale-up


2) National NTD Program Overview

a) Lymphatic Filariasis (combined with STH if appropriate)

The goal of the WHO Global Programme to Eliminate Lymphatic Filariasis is to eliminate the disease as a public health problem by 2020. A study of the geographical distribution of LF in Mozambique was carried out in 2005–2006 and additional surveys followed in 2012 and 2013. LF immuno-chromatographic tests (ICTs) were used to assess the W. bancrofti circulating antigen and found a prevalence ranging from 0% to 80%. The disease is widely distributed throughout the country with 113 districts endemic and nearly 20 million people at risk of contracting the disease. Nampula Province is most affected followed by Cabo Delgado, Zambézia, and Niassa.

FPSU is the main partner working with MISAU to eliminate LF and has been supporting MDA in Mozambique since 2010, providing annual treatment with ivermectin (IVM) plus albendazole (ALB) to the entire eligible population in endemic areas, per WHO guidelines. According to FPSU, the population treated for LF has increased from 1.6 million in 2009 to 14 million in 2014, preventing 4 million new infections of LF since 2010.

Although baseline prevalence mapping has been completed for LF, the national program has maintained that there are certain areas that were not appropriately mapped and therefore should be remapped. In collaboration with MISAU, FPSU is planning to do a small sample study of leprosy and LF in eight districts in Cabo Delgado, which is expected to take place in July 2017. This will be used as a pilot and the results from the eight districts will determine whether more districts will be required to be re-mapped.

LF morbidity management, including hydrocele surgery, is specifically treated at health facilities on a limited basis through a government-supported system of referral units for corrective surgery. The leprosy program in Mozambique is strong, with self-care groups for the management of lymphedema, adenolymphangitis, and small skin lesions. A coordinator for the leprosy program recently began working within the NTD department at MISAU and has close engagement with the leprosy organizations at both national and international levels, as well as with WHO AFRO.

The LF MDA is not USAID-funded.

b) Trachoma

All of the 140 suspected trachoma-endemic districts have been mapped. Results showed prevalence of Trachomatous Inflammation–Follicular (TF) among 1–9 year olds of <5% in 75 districts, 5–9.9% in 28


districts, 10–29.9% in 22 districts, and ≥30% in 15 districts. The 15 districts with ≥30% TF, all in Niassa Province, were initially mapped at provincial level, prior to GTMP. Concerns around the methodology originally used and lack of clinical cases in the area led to the recommendation to conduct district-level impact surveys in 2015 after only 1–2 rounds of MDA. These subsequent surveys showed that all districts had <5% TF and did not require MDA. Therefore, these 15 districts (23% of the 65 districts initially shown to have TF prevalence of ≥5%) are now under surveillance. In the 28 districts with 5–9.9% TF at baseline, MISAU aims to conduct a single round of MDA followed by an impact survey. In FY16, MISAU will conduct MDA in 4 of these districts (i.e. 5-9.9% TF) that are closest to 10% TF, in Tete Province, with support from ENVISION. A single round of MDA in the remaining 24 districts is being planned for calendar year 2017. Among the 22 districts with 10–29.9% TF, 5 districts of Cabo Delgado Province will conduct their third round of MDA and 17 districts of Manica, Nampula, and Zambézia provinces will conduct their second round, all with support from ENVISION in FY16. Mozambique is on track to stop MDA for trachoma in all districts by 2018.

In addition, a detailed re-analysis in March 2016 of the pre- GTMP mapping results from five districts of Nampula Province (USAID funded) showed that baseline prevalence in two districts (Erati and Nacala-A-Velha) was 5–9.9% TF rather than ≥10% TF as originally indicated. As both of these districts have already conducted one round of MDA, further MDA is not required, thus they are scheduled for an impact survey in FY17.

Trachoma MDA has taken place consistently every year since 2013, reaching full geographical coverage by 2015 in all districts with baseline TF prevalence of > 10%. In FY15, of the 22 districts (redistricted from the original 19 districts) targeted and treated with ENVISION support, all but one of these (95%) achieved sufficient (80%) program coverage.

The ‘A’ component of the SAFE strategy is covered through USAID funding, with the ‘S’ component addressed through the Trust project. However, the ‘F’ and ‘E’ components of the strategy require additional support to reinforce the control and prevention of trachoma. (See earlier section on collaboration with WaterAid).

In April 2016, ENVISION and MISAU organized a provincial-level Trachoma Action Plan (TAP) workshop in Nampula Province, which followed on from the first TAP workshop in Cabo Delgado. The workshop was a success and opened doors for the NTD and WASH communities to broaden their dialogue about ways in which trachoma can be prevented at the provincial level. A session on F&E taken from the ICTC Toolkit was given by the RPA. Participants were receptive to incorporating F&E messages with MDAs.

Trachoma has made its way up the government agenda over recent years, and the progress made in Mozambique has gained international attention and recognition. The ENVISION project will provide technical support to MISAU to fully understand and complete the WHO trachoma elimination dossier. WHO Mozambique is also engaged and anxious to see this process move forward. They may be willing to provide extra technical support should it be necessary.

Trachoma MDA in Mozambique is USAID-funded, and there is no other type of funding for trachoma MDA.

c) Onchocerciasis

OV is endemic in the republics of Malawi and Tanzania, which border Mozambique in the northern and central regions; however, there is still little epidemiological evidence of transmission patterns in Mozambique. In 1997, the Faculty of Medicine at the Eduardo Mondlane University published a study carried out in Zambézia Province in the district of Milange, confirming the presence of the disease in


that area. In 2001, a rapid epidemiological mapping for OV was carried out in Niassa, Cabo Delgado, Zambézia, and Tete with 114 villages selected, though only 97 villages were successfully screened. The results confirmed the existence of the disease at a hypo-endemic level, with over 85% of patients being male. In 2007, the second rapid epidemiological mapping for OV was carried out, and the results showed that the prevalence of nodules detected had more than doubled.

According to MOH and the African Program for OV Control, delineation mapping is important to identify pockets of transmission that are potentially not being covered through LF MDA and that may require one or two rounds of IVM treatment each year in order to achieve OV elimination. MISAU and the National Institute of Health (INS) are each aiming to conduct OV surveys using up-to-date diagnostic tools; however, it is not yet clear if this will complete the necessary delineation mapping or if additional support will be needed. In addition, the lack of a rigid border entry system between Mozambique and neighboring countries may facilitate the spread of disease as the movement of people continues.

In 2016 a research publication came out titled ‘Onchocerciasis, an undiagnosed disease in Mozambique: identifying research opportunities’ in the open access Parasites and Vectors journal with a collaboration of researchers from UEM, San Diego University and University of Granada in Spain. One of the recommendations is to research further into the transmission of blackflies in Mozambique and neighboring countries to identify if blackfly breeding poses a risk to public health in Mozambique.

d) Schistosomiasis

SCH is prevalent throughout all IUs in Mozambique. A study on the prevalence of SCH carried out in 2007 by the INS revealed district prevalence varied from 3.6% to 100%, with the national average being 43%. The most endemic provinces are Niassa, Cabo Delgado, Nampula and Zambézia. Almost 27 million people are at risk. Out of the 159 IUs, 45% are hyper-endemic (≥50%), 51% are meso-endemic and 4% are hypo-endemic. Treatment schedules include once per year, once every two years, and once every three years, depending on the baseline prevalence. Therefore the actual number of districts being targeted for praziquantel (PZQ) in any given year fluctuates, depending on disease prevalence. In FY16 a drug requisition problem with PZQ resulted in delays of MDAs. USAID does not support SCH MDA in Mozambique. Districts that are targeted for sentinel site and spot check site surveys are encouraged to use Kato-Katz kits to diagnose both the presence and intensity of infection for SCH and STH.

To-date, SCI has procured the Kato-Katz kits for MISAU.

e) Soil-transmitted helminths

STH Intestinal parasites affect the poorest populations, often those living in remote, rural areas, and are prevalent throughout all IUs in Mozambique, with 151 of the 159 districts endemic above the treatment threshold of 20%. A study carried out in Mozambique in 2007 on the prevalence of STH demonstrated a wide distribution of high prevalence ranging from 12% to 81%. Out of the 160 IUs, 73 are hyper-endemic, 78 have a prevalence between 20% and 50%, and 8 have a prevalence of <20%. The most affected provinces are those in the north, namely, Niassa, Cabo Delgado, Nampula, and Zambézia. USAID does not support STH MDA in Mozambique.


3) Snapshot of NTD status in Mozambique

Table 2: Snapshot of the expected status of the NTD program in Mozambique as of September 30, 2016

MAPPING GAP DETERMINATION MDA GAP DETERMINATION MDA

ACHIEVEMENT DSA NEEDS

A B C D E F G H I

Disease

Total No. of

Districts in

COUNTRY

No. of districts

classified as

endemic

No. of districts

classified as non-

endemic

No. of districts in need of initial mapping

No. of districts receiving MDAas of 09/30/16

No. of districts expected to be in need of MDA at

any level: MDA not yet started, or has

prematurely stopped as of

09/30/16

Expected No. of districts where

criteria for stopping

district-level MDA have been

met as of 09/30/16

No. of districts requiring DSAas of 09/30/16

USAID-funded Others

Lymphaticfilariasis

159

113 0 0 113 0 0

Pre-TAS: TAS1: TAS2: TAS3:

Onchocerciasis * - - - - - - - -

Schistosomiasis 159 0 0 0 159 0 - -

Soil-transmitted helminths

151 0 0 0 151 0 - -

Trachoma**65 94 0 26 0 24 15 TIS: 11

TSS: 15*OV is believed to be hypo-endemic in Mozambique, and MISAU is conducting surveys in FY16 to determine the extent of transmission.

**Number endemic includes 30 districts with baseline TF prevalence between 5–9.9%. Of these, 4 districts that were close to 10% (9.8%) plan to conduct the one required round in FY16. Two other districts in this group were originally thought to be above 10%, but based on re-analysis of the mapping data are now found to have prevalence between 5–9.9%. They conducted MDA in 2015. Therefore, in FY17 a single round of MDA is needed in 24 districts with prevalence between 5–9.9%.


PLANNED ACTIVITIES

1) NTD Program Capacity Strengthening

a) Strategic Capacity Strengthening Approach

ENVISION’s approach to capacity strengthening in FY17 will rely heavily on coaching and mentorship through close collaboration between ENVISION Mozambique staff and their counterparts at MISAU. While the focus of ENVISION’s capacity strengthening efforts will continue to be on trachoma, these initiatives will benefit the NTD department as a whole, especially due to its small size and lack of disease specific focal points. As the primary partner in Maputo, ENVISION is well-positioned to provide day-to-day mentoring on general aspects related to program and supply chain management and M&E. Other partners also support capacity strengthening and the ENVISION RPA coordinates activities to avoid duplication of effort and minimize the burden on MISAU. For example, FPSU led a course for provincial finance managers, Malaria Consortium led social mobilization workshops and both partners contributed greatly to the Program Manager’s Training Course.

Staff from the ENVISION Mozambique team will be responsible for working directly with MISAU to strengthen capacity for planning, budgeting, supply chain management, and M&E. They will be responsible for providing training and follow-up support on any tools, as well as keeping MISAU informed of global developments in NTD guidelines. Capacity strengthening through exposure trips, experience sharing and supportive supervision will also be emphasized.

ENVISION’s strategic capacity strengthening approach in FY17 will focus on three key areas:

1. NTD program and financial management: Strengthen capacity of MISAU at national and provincial levels to effectively plan and budget integrated NTD programs. ENVISION Finance Manager to strengthen capacity of central and provincial level finance staff.

2. M&E, data management, and data analysis: Increase national team’s M&E knowledge, institute a system for high quality data, and develop a culture of data use. See the M&E section for more details. Recruitment of an M&E officer secondment to provide support and training to MISAU.

3. Supply chain management: Drug logistics consultant to work closely with MOH to pass knowledge on to an identified person within the NTD department.


b) Capacity Strengthening Interventions

Table 3: Project Assistance for Capacity Strengthening

Project assistance area

Capacity strengthening interventions/activities

How these activities will help to correct needs identified in situation above

a. Strategic planning

ENVISION RPA to serve as coach/mentor to neglected tropical disease (NTD) coordinator.

Guide NTD and Ophthalmology departments in planning of the NTD Annual Review and to encourage data use in the meeting through the Data for Action Plan guide.

Build capacity of the national coordinator to effectively manage the National NTD Program by ongoing coaching of project management best practices.

Build capacity in evidence-based decision making, by encouraging the National NTD Program to take the lead in using data to inform the Annual NTD Partner Review Meeting.

b. Program and financial management

ENVISION Finance Manager to serve as mentor for provincial staff in fixed obligation grant development and budgeting.

Build capacity in financial management through on-the-job training and mentoring.

d. Social mobilization

Provide coaching and on-the-job training to use the Social Mobilization Strategy Guide

Build capacity of the MOH team to design and implement effective social mobilization strategies through introducing the process of collecting and reviewing data and using them to inform the social mobilization strategy.

e. Training (please see the Training section for specific Training activities.)g. Mass drug administration (MDA)/MDA challenges

Introduce the Coverage Supervisory Tool (CST)

Build capacity of sub-district supervisors to monitor MDA progress and take action to improve it by introducing the CST.

h. Drug supply management & procurement

Recruit Drug Logistics consultant to assist in collaboration between MISAU and Centre for Drugs and Medical Supplies, oversee packaging of drug kits and reverse supply chain management, as well as provide support with the importation of NTD drugs.

Build capacity of MOH to manage drug supply and procurement through providing on-the-job training and coaching.

i. Supervision Joint RTI-MOH supportive supervision

trips to provide on-the-job training and coaching.

Build capacity of all those involved in MDA implementation, through enhanced supportive supervision.

j. Short-term technical assistance

Trachoma expert to help MISAU fill in the WHO trachoma elimination dossier.

Build capacity of heads of Ophthalmology and NTD departments to complete the trachoma dossier through a workshop and ongoing coaching.


Project assistance area

Capacity strengthening interventions/activities

How these activities will help to correct needs identified in situation above

k. M&E (please see the M&E section for specific M&E Capacity Strengthening activities.

Additional areas

Translate and develop technical materials in Portuguese.

Consolidate in an online location so that MISAU has easy access to information.

Build capacity of NTD department through making available Portuguese-language resources.

c) Monitoring Capacity Strengthening

The ENVISION RPA is in regular contact with the NTD Coordinator to discuss program accomplishments and needs. In FY17, the RPA will be sure that these discussions have a clear capacity strengthening focus at least quarterly. In addition, other routine meetings and deliverables will provide an opportunity to assess the efficacy of ENVISION’s capacity strengthening activities. Through these meetings, supportive supervision checklists, and routine data reporting sources (ENVISION workbooks, impact survey reports, etc.) ENVISION will measure the following indicators:

Timely and high quality submission of Trachoma Elimination Monitoring Form (TEMF) and the WHO Joint Application Package (JAP) to WHO

National NTD Plan finalized and annual work plan available

Clearly defined organizational chart identifying individual roles and responsibilities and including to be hired positions

Number of drug stock outs and % drug wastage

Central and provincial staff able to define Program and Epidemiological coverage and provide thresholds for each disease.


2) Project Assistance

a) Strategic Planning

NTD National Annual Partners’ Review Meeting: The first NTD National Annual Partners´ Review Meeting took place in 2013, with support from ENVISION. The meeting continues to occur annually and is the principal opportunity for national and international partners and stakeholders to convene and discuss the progress of the National NTD Program. The meeting takes place over 3 days and is led by MISAU. Donors, local and international NGOs, WHO, and MOH staff from national and provincial levels are invited to attend. The primary objective of the meeting is to bring the various stakeholders together to discuss challenges and achievements and plan for the upcoming year. It also provides an opportunity for partners to identify any major funding gaps.

ENVISION Annual Work Plan Meeting: ENVISION will provide support to the NTD Department and the Ophthalmology Department at MISAU for a one-day NTD annual work plan meeting where all potential ENVISION activities will be discussed and later shared with the larger MOH team and other NTD partners. The main costs are for lunch and printing of materials. ENVISION’s role is to organize and facilitate the meeting, take meeting minutes, incorporate data into the discussions so that plans and decisions are informed by evidence, and collaborate with MISAU in addressing action points. This meeting allows both ENVISION and MISAU to reflect on challenges and successes of the past year and discuss expectations for the upcoming year.

NTD National Steering Committee (NSC), Central Level: The NSC is organized by ENVISION in close collaboration with MISAU. Meetings will be held three times a year to discuss technical issues related to the NTD program. The central level NSC is made up of key partners from the various government stakeholders including CMAM, INS, Ministry of Women and Social Affairs, Ministry of Water and Sanitation and the National NTD Program. Representatives from pharmaceutical companies, and INGOs such as Malaria Consortium and FPSU, and those working with leprosy also participate. When possible, higher level MOH staff participate and open the meeting. The meeting provides an important platform to discuss technical topics such as supply chain issues, as well as new MOH policies, strategies to improve progress towards program goals, and input from other sectors such as water, sanitation, and education. MISAU shares results from recent activities and discusses coverage issues and challenges with human resources. Feedback and guidelines generated from regional and international meetings are also presented and discussed with the committee for further comments and recommendations on implementation. Costs associated with these meetings include refreshments and printing of materials.

CMAM/MOH/RTI Coordination Meeting: In FY17, ENVISION will continue to support coordination meetings between the CMAM, MOH, and RTI. These meetings were successful in the past as mechanisms to bring the CMAM and MOH together to ensure the consistency and timeliness of the Zithromax® supply. In FY17 the WHO country office drug procurement representative will also be invited to participate in the meeting. ENVISION will be responsible for coordinating two meetings in FY17 to discuss drug logistics and monitor supply, distribution channels, key contacts, and drug usage. These meetings will help in the monitoring of excess drug supply and keeping a check on validity. ENVISION’s role will be to facilitate the meeting, including providing space, recording and circulating minutes, and incorporating data into decision-making discussions. Costs are minimal and include only refreshments and stationery.

Annual Ophthalmology and Statistics Meeting: Every year, the head of the Ophthalmology Department holds a meeting in one of the provinces where ophthalmologists and ophthalmic technicians join


together to discuss and reflect on activities of the previous year and plan for the upcoming year. ENVISION will provide support for the meeting, as trachoma control and trachoma data will continue to be high on the agenda. The meeting will also serve to provide updates on MDA, progress of trachomatous trichiasis (TT) surgeries, information about trainings, and any issues involving publications or data. The outcomes from the meeting will feed back to the NTD Department to evaluate any action items that are to be conducted jointly; however, NTD Department participation in the meeting will be expected. Costs for this three-day meeting are shared between partners, and ENVISION will provide funding for the meeting space and the travel for approximately 10 people. ENVISION will help facilitate the logistics of the meeting and record and circulate notes.

Provincial Trachoma Action Plan Workshops: ENVISION will provide technical guidance and financial support for two three-day TAP workshops; one in Manica Province and the other in Zambézia Province, in coordination with the National NTD Program. These are the last two provinces still requiring a TAP and the workshops will be a replica of those that took place in Cabo Delgado (2015) and Nampula (2016). They will bring together key players from the provincial level, including actors from the WASH and education sectors, to develop the TAP, which will provide a clearer understanding of the activities needed in the provinces in order to eliminate blinding trachoma. In addition to financial support, ENVISION’s role will be to provide technical guidance before the meeting and to facilitate the meeting. By the end of the workshops, the provinces will have a draft of a TAP at the provincial level.

National Trachoma Dossier Elimination Workshop: Mozambique has progressed rapidly towards its trachoma elimination goal. In order to prepare for official certification of elimination of trachoma, ENVISION will provide funding and technical support for a four-day workshop to introduce the trachoma dossier, review data, and determine a plan for dossier finalization. ENVISION will provide continuous support after the workshop to ensure the dossier is completed with high quality and in a timely manner.

b) NTD Secretariat

Office costs : ENVISION will continue to cover basic operational costs for the NTD Secretariat, including office supplies, paper and toner for printing, and communications in the form of air time. Other partners such as FPSU support the secretariat through provision of internet access for the NTD Department and electrical equipment like laptops. ENVISION and FPSU communicate with each other, so there is no duplication of efforts in operational costs.

Translations: Translations between English and Portuguese are often needed as MISAU requires all documents and official communication in Portuguese. Several documents must be translated each year (including the work plan) for either MISAU, USAID, or RTI Headquarters. When possible, the ENVISION team uses a local translator who is familiar with the type of work we do.

Travel costs: Travel for the NTD Coordinator to attend two trachoma MDA launches is included under the ENVISION NTD Secretariat budget. These trips are considered supervision travel and are aimed at improving coordination and integration across all NTDs.


c) Advocacy for Building a Sustainable National NTD Program

Advocacy: ENVISION continues to emphasize the importance of advocacy through platforms such as the MECC, of which the RPA was chair from 2012–2016. The MECC meetings will continue to take place under the new chair, Sightsavers, and will still bring together all the main eye-care health partners and staff from MISAU as well as other inter-sectorial partners from water, sanitation, and education. This group will continue to act as an advocacy platform for important issues of eye health in Mozambique.

The RPA has been getting more involved with the social communication department at MISAU to see where the possibilities lie in raising awareness of NTDs through advocacy channels, not only to those concerned with eye health in Mozambique but also directed to the general population of the country. The RPA is now a member of the Social Communication and Advocacy Working Group, which was formed as a subgroup of the NTD NSC.

ENVISION will also continue to advocate with other Program partners and donors to maintain strong partnerships and international support for MISAU’s NTD efforts.

Social Communication and Advocacy Working Group (no costs involved):Through participation in the Social Communication and Advocacy Working Group of the NTD NSC, ENVISION will be able to better understand where the weaknesses are in advocacy and will have an opportunity to work with MISAU to strengthen the NTD program through raising awareness of the diseases, specifically trachoma. There will be no costs associated with taking part in this working group as the support will be through the RPA’s participation in meetings.

Mozambican Eye Care Coalition (no costs involved): ENVISION will continue to participate in the MECC group, which acts as the main eye care health group in the country with collaboration from INGOs, local NGOs and MISAU. Recently, other sectors such as Ministry of Education have participated in the meetings and shared their experiences regarding the challenges of eye care health in schools. This group has been recognized as a lead in eye care in neighboring sub-Saharan African countries.

Partnership with WaterAid at country level (no costs involved): ENVISION Mozambique’s partnership with WaterAid has continued to grow. One of the primary objectives of the partnership is to advocate for a continued and strengthened link between WASH and NTDs through better informing the Water and Sanitation Department of the Mozambican government’s commitment to eliminate trachoma as a public health problem by 2020. Due to the strength of the partnership, the RPA was invited to a high-level meeting at the Ministry of Public Works and Housing with the Director of the Water and Sanitation Department to discuss the links between water and trachoma. The RPA was also invited to take part in a WASH Central Working Group to address trachoma concerns and issues from an NGO perspective. WaterAid and RTI agree on the importance of continued collaboration, including the sharing of plans and outcomes of activities where there is an overlap between WASH and NTDs and participating in and advocating for each other’s activities. This partnership has been commended at higher levels and was recognized at the recent GET 2020 Meeting in Sydney as a partnership to replicate in other ENVISION/WaterAid countries.

d) Social Mobilization to Enable NTD Program Activities

Understanding effectiveness of different strategies of Social Mobilization Workshop: A two-day workshop will be held in Maputo in Q1 with the National NTD Program, partners, and the social communication department at MISAU (DEPROS) to discuss social mobilization messages and platforms. The IEC and Social Mobilization for NTDs Guide will be used to walk the group through the process of


reviewing current evidence, defining messages targeted at specific audiences, and developing a refined overall strategy, including evidence-based methods of communication. Results of KAP surveys and other assessments conducted by partners will be used to inform the strategy, including the KAP survey ENVISION will support after the September 2016 trachoma MDA. The workshop will be interactive to allow partners to engage with each other and MISAU to determine how they can complement each other’s work in this area. ENVISION will provide financial support for the workshop, including lunch, space, per diems, and travel costs for selected provincial level staff who will bring an “on-the-ground” perspective to the meeting. The expected outcome will be a draft NTD Communication Strategy that will cover all diseases.

Where possible, ENVISION and the Trust program will incorporate each other’s messages so that all trachoma-related activities emphasize a holistic approach to trachoma control though the SAFE strategy. The Trust messages are predominately based on the F&E components of the SAFE strategy and are shared with patients and their caregivers post-surgery. They highlight the importance of face washing and environmental cleanliness in the prevention of trachoma, especially at community level. This collaborative approach does not require any additional costs for either program.

Production of IEC materials: ENVISION will continue to support the production of IEC materials for MDA, but with a focus on trachoma only in FY17. The exact materials to be produced as well as quantities will be determined based on the outcomes of the Social Mobilization Workshop. MISAU has requested the purchase of vests which are used to identify the community drug distributors during the MDA. It is expected that messages will continue to be simple yet effective with local dialects being used where necessary. In FY17, MISAU has requested that in addition to producing materials for MDA, ENVISION also support the production of new materials to be placed in health centers throughout the year. Health centers across the country currently lack information on trachoma and other NTDs. Health staff do not always have the knowledge necessary to handle suspected cases of TF and TT and as a result, patients seeking help may not be provided adequate medical advice. The aim of the health center materials is to better inform both health staff and patients on signs, symptoms, prevention and referrals for trachoma-related issues.

Radio messaging: Radio is the most common means of communication in Mozambique, especially community radio at the district level. Messages will be played on local radio stations throughout the districts targeted for MDA with Zithromax (ZTH) and tetracycline eye ointment (TEO). Exact messages and frequencies will be determined after the Social Mobilization Workshop.

Use of megaphones to disseminate information to communities: Megaphones are another common form of sharing information at the community level and are used for various campaigns. They are used to inform people of the timing of MDA and who is eligible to receive treatment. They also allow supervisors to provide basic information on trachoma prevention to the population. There are sufficient quantities of megaphones in the country, so ENVISION will only need to provide batteries for megaphones in all provinces.

MDA messaging via short messaging system (SMS), and trachoma-related information throughout the year (SMS): SMS has become widely used in Mozambique as one of the most common forms of communication and dissemination of information, though it is still new for NTDs. ENVISION will be the first partner to engage in this activity for MDA. In FY17, ENVISION will support MISAU in developing and disseminating SMS messages to mobile phones informing the population of the upcoming MDA, including dates and locations. SMS messages will be sent a week before, in the middle, and on the second to last day of the MDA to remind people to participate. Messages will be clear and concise. ENVISION will support this in all provinces undergoing the trachoma MDA in FY17 and will work closely


with MISAU as it is common for Ministries to have agreements in place with the service providers to minimize costs.

Table 4: Social mobilization/communication activities and materials checklist for NTD work planning

Category Key messages

Target population

IEC strategy (materials, medium,

activity etc.)

Where/when will they be

distributed

Frequency

Is there an indicator/

mechanism to track this

material/activity? If yes, what?

Other comment

s

MDA Participation

The drugs provided are free and safe for the entire family. Everyone in the family should participate. Timing and location of MDA.

Community members

Radio

SMS

Local station 2 weeks in advance of MDA and during MDA

Radio messages play 4 times per day for 1 week before and during the MDA; SMS will be sent one week before MDA, in the middle of MDA, and on the penultimate day

# of times messages aired on radio during reference period—Radio broadcast reports

# of messages disseminated pre and during MDA

Disease Prevention

Basic information about trachoma prevention

Community members

SMS Service provider

During the year

# of messages throughout the year

e) Training

Needs for the upcoming year are focused on strengthening supervision and financial management. The annual trachoma pre-MDA training will continue in order to train new provincial and district focal points and provide refresher training and updates to those trained in the past. ENVISION will provide technical and financial support for the trainings.

Fixed obligation grant training for provincial staff: The objective of the FOG training is for provincial teams to understand FOG requirements and be better equipped at preparing budgets and deliverables. The provincial teams will come to Maputo for the training, which will cover background information about the FOG, drafting of program descriptions, implementation plans, and completion of deliverables and reporting. Costs for this activity will include transport, per diems, and training materials. The NTD central team will also be invited to participate.


Supportive supervision workshop for national and provincial NTD focal points: The NTD Coordinator has requested supervision training to strengthen the quality of supervision from the national and provincial supervisors. A three-day supportive supervision workshop will be held in Maputo and led by the central-level MOH. It will cover various aspects of supervisory roles and highlight ways to make supportive supervision more effective to have a better impact on staff and the quality of the MDA. Supervisors will share their best practices and challenges of being supervisors during MDA. As a team, the supervisors, MOH, and ENVISION will identify the gaps in terms of capacity needs and strengthening. ENVISION will introduce the electronic Supportive Supervision Checklist and encourage its use by both central and provincial staff during the MDA. This training is seen by the Ministry as strongly needed, and all aspects of MDA for NTDs will be discussed. NTD focal points from all provinces will participate. Input from the provincial-level supervisors will be valuable in guiding ENVISION on how we can improve supervision in the field.

Trachoma pre-MDA training, provincial training: Trachoma MDA trainings will be planned for all provinces conducting MDA. The trainings will be led by MISAU and will cover relevant information on trachoma MDA, including components of the SAFE strategy, social mobilization, reporting and management of serious adverse events (SAEs), distribution and administration of ZTH and TEO. Results of the DQA conducted in 2015 will be incorporated into training materials so that an increased emphasis is placed on accurate reporting and data management and review techniques. The provincial training will occur over two days in each province and will support approximately two district health technicians from each district.

Trachoma pre-MDA training, district training: The two health district technicians trained at the provincial level will train the selected drug distributors (also health technicians) in the districts. They are responsible for administrating drugs and filling in registers and will be trained on the same topics that will be covered in the provincial-level training, including trachoma MDA, components of the SAFE strategy, social mobilization, reporting and management of SAEs, distribution and administration of ZTH and TEO. Results of the DQA conducted in 2015 will be incorporated into training materials so that an increased emphasis is placed on accurate reporting and data management and review techniques. Teams of two drug distributors are expected to distribute drugs to 5,000 people during the week of MDA. Also in the districts, the MDA distribution teams will provide a one-day training to community volunteers. The focus is on social mobilization and communicating with local leaders, who are highly influential in health activities including MDA. Volunteers are then better equipped to mobilize their communities, which is their primary responsibility during MDA. In Mozambique, volunteers do not distribute any medications or complete any reporting forms. Those responsibilities are given to the district health technicians who receive a more rigorous training, as mentioned above.

f) Mapping

Baseline mapping for LF, OV, SCH, STH, and trachoma has been completed; however, delineation mapping for OV may be required and cross-border conversations are expected to take place in the near future between Mozambique and Malawi.


g) MDA coverage and Challenges

In FY15, 95% of 22 districts with USAID-supported MDA for trachoma achieved the minimum required coverage. The focus is on maintaining good coverage in these districts and improving performance in the other 5%.

Mozambique is currently at geographic scale for the treatment of LF, SCH, STH, and trachoma, and although gaps in geographic coverage do occur due to delays in implementation, these have not impacted trachoma. While the ENVISION project supports the National NTD Program in coordinating NTD activities in an integrated way, the project has primarily supported the scale-up of ZTH and TEO distributions for trachoma.

FY17 Trachoma MDA: In FY17, ENVISION will target nearly 5.2 million people in 39 districts for trachoma MDA. This includes 24 districts that had baseline prevalence of TF between 5–9.9% and require one round of MDA, and 15 districts with baseline TF prevalence between 10–29.9% that will be conducting their third and final round of MDA. Therefore, FY17 is anticipated to be the final year of trachoma MDA in Mozambique. MDA is planned for all six provinces in July 2017, requiring a high level of coordination and collaboration with MISAU throughout the entire planning and implementation process.

In support of the FY17 MDA, ENVISION will supply materials needed for the MDA including daily registers, reporting forms, vests, SAE forms, dose poles, t-shirts, banners, and cups. Banners, t-shirts, and vests are used to identify official distribution points, volunteers, and supervisors, respectively. The use of t-shirts and vests in the campaigns relays a positive image during the MDA and is a way to further promote the work of the national health workers. All materials are clearly marked with MOH, USAID, RTI, and ENVISION logos. It is important for the communities to be able to make the link between campaigns, and since there is a high level of illiteracy in the country, images and colors need to be easily identifiable.

ENVISION will also support the rollout of the Coverage Supervisory Tool to give sub-district supervisors a means by which they can self-monitor the program in their supervisory areas and verify the data they receive during daily reporting. The Coverage Supervisory Tool is covered in the M&E section below.

The ENVISION project is always looking at ways in which coverage challenges can be identified and improved to increase the level of participation. Table 5 provides FY15 coverage results and FY17 targets.

Table 5: USAID-supported coverage results for FY15** and targets for FY17

NTD# Rounds of

annual distribution

Treatment target FY15

# DISTRICTS

# Districts not meeting epi coverage

target in FY15*

# Districts not meeting program coverage target in

FY15*

FY15#

Treatment targets

PERSONS

FY15# treated PERSONS

FY15 %

of treatment target metPERSONS

FY17 treatment

targets#

DISTRICTS

FY17 treatment

targets #

PERSONS

TRA 1 22 1 3,008,466 2,736,402 90.1% 39 5,196,742*Epi and Program coverage as defined in the workbooks** FY16 MDA is planned for September 2016

h) Drug and Commodity Supply Management and Procurement

Drug repackaging, drug transportation, and delivery to provinces and communities: CMAM manages all pharmaceuticals and medical supplies. It is responsible for importation, distribution, and


management of drugs and medical items within Mozambique. ENVISION will continue to serve as a vital link between the International Trachoma Initiative (ITI) and MISAU to ensure that the importation of ZTH and TEO is carried out in a timely manner and with open communication. ENVISION, in coordination with CMAM and MOH, will support the transportation costs of shipping the ZTH and TEO from Maputo to the province warehouses, to ensure that drugs are pre-positioned before the MDA. ENVISION will also fund the transport of drugs from the provincial warehouse to the communities, using DPS vehicles.

A drug logistics consultant: A drug logistics consultant supported by ENVISION will continue to work with CMAM and ENVISION to facilitate the importation process, repackage trachoma drugs, and send them in kits to the provinces for pre-MDA district distribution. The re-packaged kits consist of the necessary quantities of ZTH, TEO, and IEC materials for each district. This position is crucial as the contacts with CMAM and understanding the sequence of the importation process are essential for smooth drug transportation.

Reverse supply chain management: Approximately two weeks after the MDA, ENVISION, in close collaboration with MOH, will provide support for reverse supply management in the six provinces targeted for ZTH. The process takes approximately four days per province, and though led by ENVISION, relies heavily on participation of provincial and district staff. At the end of the MDA, a staff member from ENVISION plus a staff member from MISAU will work with the NTD provincial and district focal points to transport the remaining Zithromax® from the district level to the provincial drug warehouse to be stored. This process provides the opportunity to account for the drug stock remaining after MDA, which then helps with the verification of MDA coverage. The security and accessibility of warehouses at the provincial level is also stronger, which ensures they are stored safely and facilitates tracking of drugs throughout the year. Through the reverse supply management process, ENVISION has the opportunity to train MOH staff on drug management best practices and inventory monitoring. All expired ZTH and empty bottles are incinerated as one of the last steps in this activity.

Drug supply calls: In FY17, MOH and ENVISION staff will make follow-up calls to district-level NTD focal points to verify arrival and quantity of drugs delivered to district distribution teams one week after leaving CMAM. Callers will use a guide to record results and expedite any information to the national coordinator that may indicate issues with pre-MDA drug supply. By formalizing these calls, the project aims to identify conditions for stock-out and take corrective action before the distribution of drugs takes place so that either additional drugs can be sent to the district, or if an oversupply of drugs is reported, measures can be taken to secure extra stock and redistribute those drugs accordingly

The Handbook on Serious Adverse Events was translated and distributed to the provinces and central level in 2015. Supervisors are reminded during MDA training that SAEs occurring during or shortly after MDA must be reported within 24 hours to MISAU, WHO, drug donation programs, and pharmaceutical companies, and in the case of ZTH distributions, to RTI. MISAU provides SAE reporting forms as part of each MDA so that they can quickly investigate reports and prevent false accusations. SAE reporting requirements are reviewed during Steering Committee Meetings as well as pre-MDA trainings. In FY17, ENVISION will work with MISAU to reinforce the adverse event and SAE requirements during the NSC meetings, in MDA and supervision trainings, and during supportive supervision trips to the field. Use of electronic checklists to highlight problems or challenges during the MDA will help provide effective and quick corrective action as well.

i) Supervision

Supervision support before and during the MDA by supervisors to ensure high level quality of activity: Supervision at every phase of the MDA is a critical part of the overall activity. Pre-MDA, supervision


occurs to ensure that logistically, drugs, IEC materials, and people are where they should be in due time. Distances can be extensive between one distribution point and another, so supervisors need to confirm that there are no hold-ups that could delay the campaign. The ENVISION RPA and NTD Coordinator conduct joint supervision trips with higher level MOH representation, and in recent years, the head of the Health office and NTD focal point at USAID travelled together to the provincial launch. This trip involves supervision of various districts within the province, ensuring that the campaign is running smoothly. Simultaneously in another province, the RTI Finance Manager and members of the NTD Department participate at another launch and carry out similar supervision activities.

Supervisors are responsible for monitoring and collecting data and for reporting the overall progress of the MDA in their province, including social mobilization. They are responsible for ensuring that all procedures and protocol are adhered to and that communication is frequent with the central level.

j) M&E

M&E secondment: As mentioned in the Capacity Strengthening section, one of ENVISION’s goals in FY17 is to improve MISAU’s capacity to effectively monitor and evaluate its program. The current ENVISION-Mozambique team lacks sufficient M&E capacity to take on ENVISION’s planned activities as well as to dedicate time to strengthening the MISAU team. At the request of MISAU, ENVISION will second an M&E specialist who will be responsible for training an identified member of the MISAU NTD team to take on M&E capacities as ENVISION support ends. This position will start in late FY16 to support the post-MDA coverage survey planned for Q1 of FY17, and will continue through FY17. This individual will be responsible for planning, implementing, and reporting on all M&E activities, as well as mentoring and coaching MISAU.

Development of M&E Plan (no costs involved): In FY17, ENVISION will work jointly with MISAU and other partners to develop an M&E strategy to accompany the recently developed 2016-2020 Master Plan. The M&E plan will guide the project toward its elimination goals and into the post-treatment surveillance period. ENVISION will support the M&E secondment to help develop the strategy and provide ongoing mentorship to MISAU on M&E related topics.

Integrated Database (no cost involved): The WHO AFRO is planning to provide in-country support for training on the Integrated NTD Database in early September 2016. WHO Mozambique will contract a local database manager who will be encouraged to provide follow-up support to MISAU upon completion of the Integrated Database. Database skills will be included as a preferred skill for the M&E secondment, who will also provide mentorship in data use on a long-term basis, so that multiple people within MISAU are comfortable with using the data to guide programmatic decisions.

Trachoma MDA coverage survey: ENVISION hoped to conduct its first post-MDA coverage survey in Mozambique in FY16, but due to slight delays in the MDA schedule, the coverage survey will roll-over into FY17. Through the coverage survey, ENVISION hopes to verify the reported coverage and increase confidence in the routinely high reported coverage values across diseases and years. The coverage survey will also include a KAP component to bring a better understanding of the factors that influence participation in the MDA, as well as effective forms of social mobilization. This information will be used in FY17 to guide the social mobilization strategy and determine what steps are needed if the reported coverage is not validated.

The Coverage Supervisory Tool (CST) will be rolled-out in FY17 to assist district- and sub-district supervisors in monitoring the trachoma MDA. The CST can be used at the end of each MDA round as a


form of in-process monitoring to determine whether or not MDA has achieved good coverage in a locality.

ENVISION Mozambique will provide technical assistance to eight districts in using the designed tool at the sub-district level. This is meant to be a rapid tool that provides instant feedback to the supervisors and program manager so that program performance can be improved. All supervisory areas in the selected districts will be included, and 20 individuals from each supervisory area will be questioned about participation in the MDA. Districts will be selected based on need and in collaboration with MISAU. It is expected that sub-district supervisors will continue to implement the CST in subsequent MDA rounds for all diseases and support future training in other districts. ENVISION will budget for 1 day of mop-up activities in approximately 20% of supervisory areas.

Trachoma Impact Survey: In FY17, ENVISION will support TIS in 5 districts in Cabo Delgado Province that had baseline TF prevalence between 10%–30% and have conducted three rounds of MDA, 4 districts in Tete Province that had baseline TF prevalence between 5%–9.9% and plan to conduct a single round of MDA in September 2016, and 2 districts in Nampula Province: Erati and Nacalha Velha. Of the districts requiring 3 rounds of MDA, all but one have reported coverage over 80% for the first 2 years of MDA. The third year of MDA is planned for September 2016. The trachoma coverage in Mueda district, in FY14 was just above 71%, but because baseline prevalence was only 12% and coverage increased in FY15, ENVISION and MISAU would like to proceed with planning the TIS survey. As part of the survey, 40 people will be trained on the Tropical Data protocol, using electronic data capture. In June 2016, three MOH staff and one ENVISION staff attended the Tropical Data training in Tanzania. There is now 1 certified master grader, 1 certified grader trainer, and 1 certified recorder trainer to lead the trainings in the provinces. Training will occur over 2 days prior to the surveys to train the teams in a field setting.

Trachoma Surveillance Survey: ENVISION will also support TSSs for all districts that are qualified. In FY17, this includes the 15 districts in Niassa Province that passed the impact survey in 2015. It should be noted that these districts were originally mapped at a provincial level and conducted 1–2 rounds of MDA before a reanalysis of the data showed that the high results from provincial-level mapping were unlikely. For that reason, they conducted the TISs in 2015 after 1 or 2 rounds of MDA. At the Trachoma Expert Committee meeting in June 2016, WHO confirmed that the 2015 surveys should be considered impact surveys, and surveillance surveys are recommended in FY17. As with the impact surveys, training will occur in the province prior to the survey. It will last 2 days and will target 20 individuals.

For both the Impact and Surveillance surveys, children between 1 and 9 years will be surveyed for prevalence of follicular trachoma TF and intense trachomatous inflammation (TI) and people ≥ 15 years will be surveyed for prevalence of trachomatous trichiasis (TT), scarring trachoma (TS), corneal opacity, and visual impairment. The WHO’s simplified trachoma grading system will be used to identify and register trachoma cases and the approach of Tropical Data protocol will be followed.

Table 6: Planned disease-specific assessments for FY17 by disease

DiseaseNo. of

endemic districts

No. of districts

planned for DSA

Type of assessment

Diagnostic method (Indicator: Mf, FTS,

hematuria, etc.)

Trachoma 65 1115

TISTSS Eye grading


Data Quality Assessment: In FY15, ENVISION supported the first DQA in Mozambique in N’gauma District in Niassa and Mueda District in Cabo Delgado, assessing indicators related to the 2015 PZQ MDA. Results indicated general weaknesses in data management at all levels. In FY17, ENVISION will support another DQA to assess whether improvements have been made and to identify remaining areas of improvement.

3) Maps

Updated shapefiles using the new geography of 159 districts are not yet available. The maps below are based on the previous geography with 142 districts.


APPENDIX 1. WORK PLAN TIMELINE

FY17 Activities

NTD Program Capacity Strengthening Build capacity of MISAU to fill in trachoma elimination dossierEnhance knowledge of drug supply chain to selected person in MOHInternal M&E capacity strengthening in MOHProject AssistanceStrategic PlanningNTD National Annual Partners’ Review MeetingENVISION Annual Work Plan MeetingNTD National Steering Committee, Central LevelCMAM/MOH/RTI Coordination MeetingAnnual Ophthalmology and Statistics Meeting Provincial Trachoma Action Plan WorkshopsTrachoma Dossier Elimination Workshop NTD SecretariatOffice costs TranslationsTravel costsAdvocacy for Building a Sustainable National NTD ProgramAdvocacySocial Mobilization to Enable NTD Program ActivitiesUnderstanding effectiveness of different strategies of Social Mobilization Workshop

Production of trachoma related IEC materials Development of Health Messages for radio pre-MDA Use of megaphones to disseminate information to communitiesSMS messaging throughout the year (information based) and pre/during MDA (MDA information)


FY17 Activities

TrainingFixed obligation grant training for provincial staff Supportive supervision workshop for national and provincial NTD focal pointsTrachoma pre-MDA training, provincial trainingTrachoma pre-MDA training, district trainingTrachoma survey training MappingMDA coverage and challengesFY17 Trachoma MDADrug and Community Supply Management and Procurement Drug repackaging, drug transportation, and delivery to provinces and communitiesReverse supply chain managementDrug Supply CallsSupervisionSupervision during drug transportation phaseSupervision during MDA

Short-Term Technical AssistanceDrug logistics consultant M&ETrachoma MDA coverage survey Coverage Supervisory ToolTrachoma Impact Survey in 5 districts in Cabo Delgado, 4 districts in Tete, 2 districts in Nampula, includes trainingTrachoma Surveillance Surveys in 15 districts in Niassa, includes trainingData quality Assessment


APPENDIX 2. TABLE OF USAID-SUPPORTED PROVINCES/STATES AND DISTRICTS

Region Health Districts LF Pre-TAS TAS1 TAS2 TAS3 TIS TSS OV Mapping

OV Epi Surveys

XCuamba XLago XChimbonila X

Niassa

Majune X Mandimba X Marupa X Maúa X Mavago X Mecanhelas X Mecula X Metarica X Muembe X N'gauma X Nipepe X Sanga X

Cabo Delgado

Ancuabe XChiure XMueda XNangade XPalma X

Tete Changara XDoa XMarara XMutarara X

Nampula Erati XNacala Velha X


envision project overview · web viewenvision will provide support to the ntd department and the...

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