UNDP Tajikistan, The Grants Implementation Unit Bokhtar 37/1 Str. Dushanbe, Tajikistan ПРООН в Таджикистане, Подразделение по реализации грантов Таджикистан, Душанбе ул. Бохтар,37/1 Tel: (992 47) 441 06 68, 441 06 70; Fax: (992 37) 227 37 12 www.aids.undp.tj ANNUAL PROGRESS REPORT (1 April 2007 – 31 March 2008) General information Donor: The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) Principal Recipient: United Nations Development Programme (UNDP), Tajikistan Number and Title of the Grant: TAJ-506-G04-M– Grant of the Global Fund to Fight AIDS, Tuberculosis and Malaria to support Program to fight tropical diseases (malaria) in the Republic of Tajikistan for 2006-2010 Project Number: TAJ-506-G04-M (00050923 in UNDP classification) Place of Operation: Republic of Tajikistan Total Proposal Sum for 5 years: 5,383,510 US Dollars Phase 1 sum approved: 2,772,000 US Dollars Amount disbursed by GFATM to date: 3,143,631.33 US Dollars Amount expended from the beginning of the program implementation: 2,729,734.11 US Dollars Start-up date: 1 April 2006 Duration of the programme: 2 years 1 Background Information The UNDP Project Implementation Unit (PIU) continues the realization of Round 5 GFATM Malaria grant. The grant aims at prevention of deaths caused by malaria, interruption of tropical malaria transmission, reduction of malaria morbidity and containing and prevention of malaria outbreaks in Tajikistan. The project is implemented in line with the country’s strategic “Program to fight tropical diseases (malaria) in the Republic of Tajikistan for 20062010”, which aims at strengthening existing activities and health care system on malaria control in the country. The implementation of the project started in April 2006. To date, out of the totally allocated funds (USD 2,772,000), approved for the first two years of the project, the amount of USD 2,729,734.11 was utilised. The most vulnerable groups of people from 36 project districts of the country were reached in the course of eight quarters (from April 2006 to March 2008) through vector control activities. The main beneficiaries of the project are pregnant women, children and general population. An agreement with the Republican Centre to fight Tropical Diseases (RTDC) and the Agency for Technical Cooperation and Development (ACTED) for the implementation of the second year of the First Phase has been signed. The main sub-recipients of the grant remain the World Health Organization (WHO), RTDC and ACTED. Malaria incidence in the country has decreased dramatically, from 2,309 cases in 2005 to 636 cases in 2007. In November 2007, the NCC technical working group met to evaluate the implementation results of the 1st Phase and to prepare a Request for Continued Funding of the Round 5 GFATM Malaria grant for Second Phase. Considering limited funds (USD 2,611,510), allocated for the next three years of the project, and considerable reduction of malaria cases (especially P.falciparum cases), NCC decided to reduce the number of years in Second Phase from three to two (April 2008-April 2010). This will strengthen the achieved results and accelerate the process of P.falciparum malaria elimination in Tajikistan. A total of USD 2,611,508 is requested for the period of two years. The Request was submitted to and approved by GF Secretariat. For P.vivax malaria control purposes, a process of project proposal development for Round 8 for 2009-2015 is initiated to ensure back up of the achieved epidemiological malaria situation and preparation for P.vivax malaria elimination in the Republic by 2015. Implementation of the program Objective 1. To strengthen institutional capacities of national malaria control programme/general health services and to enhance capacities for decision-making related to malaria Service Delivery Area 1. Supportive environment: health system strengthening Visits of international consultants During the year, five World Health Organization (WHO) consultants conducted six visits to Tajikistan to provide technical support to UNDP/PIU in implementation of the project. Table 1. Number of visits conducted by the WHO consultants Name of WHO consultant Date of visit 1 Andrey Zvantsov 29 April-28 May 2007 2 Michael Gordeev 17-31 August 2007 Alla Baranova 7-20 October 2007 4 Rossitsa Kurdova 22 November-13 2007 5 Andrey Zvantsov 16 February-30 March 2008 6 Elkhan Gasimov 19 November-8 December 2007 3 December Aim of the mission Conduct a training on entomology and development of educational materials Operational research on PCR studies on genetic investigation of malaria parasites and vectors and assessing their outcomes Conduct a training on programme management and development of training modules for malaria control and prevention Conduct a training course on malaria data collection, processing and analysis as well as to assist in improving the quality of laboratory diagnosis of malaria Planning of vector control activities and operational research related to malaria vectors and development of proposal for Round 8 Mid-term evaluation of the malaria control project. The main recommendations from the consultants were – further strengthening of RTDC institutional capacity in terms of disease management, vector control, improvement of laboratory services, epidemic control, and surveillance, continuation of operational research and community awareness activities. The reports on activities implemented by the consultants are available upon request. 2 Development of educational materials Guidelines for the prevention and control of malaria in Tajikistan and for monitoring and evaluation of the impact of malaria prevention activities were developed, approved by the Ministry of Health of the Republic of Tajikistan and translated into local languages (Russian and Tajik). The guidelines are being duplicated and will be distributed among the country's health facilities. In addition, in accordance with the work plan, UNDP/PIU re-printed 10 types of WHO publications – Malariology, Guidelines for vector control, Malaria vectors in CIS, Malaria microscopy, Malaria surveillance manual, Malaria guidelines for health staff, IRS guidelines, Biocontrol guidelines and laminated posters for parasites and vectors. The educational materials are distributed to entomologists, parasitologists, laboratory technicians and doctors of infection department, who participate in the trainings conducted by RTDC. Service Delivery Area 1. Supportive environment: human resources Indicator: Number of health authorities, laboratory staff, entomologists and health staff trained/re-trained in malaria case management, treatment and epidemic control and data collection, processing and analysis During the reporting period, 587 health authorities, laboratory technicians and health staff were trained through trainings on malaria diagnostics, entomology, project management, epidemiology, malaria data collection and analysis, progress and financial reporting. Table 2. Number of seminars conducted within the first year of GFATM malaria grant # of # of Topics of seminars Location Category of participants seminars participants Laboratory diagnostics of 4 RTDC 40 Laboratory doctors and technicians malaria Malaria data collection and 1 RTDC 20 Health workers analysis Planning, implementation Entomologists and entomology and evaluation of efficacy of 1 RTDC 18 assistants at regional and district activities on malaria control level and prevention RTDC, Sughd Specialists working for infections Programme management 1 and Khalton 20 control at state structures, SES and TDC TDCs Epidemiology, clinics, GBAO, Sughd Health personnel at primary level treatment and prevention of 16 and Khalton 378 (FAP, SUB and SVA). malaria TDCs RTDC, Sughd Re-fresher courses on malaria 7 and Khalton 105 Laboratory technicians diagnostics TDCs International training on Specialists at republican and 1 Moscow 6 malariology regional level Total 31 587 The following changes were made to this component in the course of the project year: At the MoH request, additional trainings on epidemiology and malaria treatment were conducted for health staff at primary level (FAP, SUB and SVA). Monitoring and evaluation of laboratory technicians’ knowledge showed poor results; therefore refresher courses for them were organised and conducted. The RTDC specialist conducts training on epidemiology for staff at primary level 3 Objective 2. Improvement of capacities for and access to early diagnosis and adequate treatment of malaria Service Delivery Area 1. Treatment: Prompt, effective diagnosis and anti-malarial treatment Indicator: Number of health and laboratory facilities sufficiently supplied with items for disease diagnosis, treatment and prevention, and implementing quality control procedures During the year(you use this expression often- try to use synonyms) , expendable materials (scarificator, preparation glass, immersion oil , solution of Giemsa and etc.), anti-malarial drugs were distributed to health and laboratory facilities in 64 districts of the country, and 400 automaxes, 400 protection clothes and 400 pairs of shoes, were distributed to 33 districts, where the anti-malarial activities were implemented. Parasitological laboratories The Republican TDC national consultants conducted a quality control of parasitological laboratories in 11 districts of Sughd and Khatlon regions (Shaartuz, Kabadian, N.Khisrav, Kumsangir, Jami, Kurgan-tube, Isfara, Asht, Spitamen, Khojent and Kairakkum). The monitoring result showed that all target laboratories are adequately equipped and all revealed cases of malaria are appropriately treated. However, knowledge of some laboratory technicians, who took course on malaria diagnostics in 2003 through Merlin, was not adequate. Therefore refresher courses were organised and conducted for them. The courses were conducted with savings made from trainings. Indicator: Number and percentage of patients receiving treatment of P.vivax malaria from all P.vivax malaria cases detected Number and percentage of patients receiving treatment of P.falciparum malaria from all detected P.falciparum malaria cases Number and percentage of patients receiving treatment of severe and complicated P.falciparum malaria from all P.falciparum malaria cases detected In total, during the project year (April 2007-March 2008), 622 cases of malaria were detected and registered in the country. Out of them, 615 cases were of P. vivax malaria and 7 cases of P. falciparum malaria. All patients were treated as in- or out-patients through local health care facilities. No any case of severe and/or complicated P.falciparum malaria was registered in the country. It is worth mentioning that the malaria case morbidity in the country decreased by 53% compared to the same period last year when 1314 cases were registered. For details please refer to the Chart below. 300 Comparative chart on malaria cases registered during the first and second project years, by month. 250 250 247 228 200 167 150 130 121 113 100 59 50 98 96 81 71 77 58 40 31 0 7 1 0 March 2 February January December November 2006-2007 October September August July June May April 0 10 27 15 2007-2008 Objective 3. To promote cost-effective and sustainable vector control Service Delivery Area 1&2. Prevention: Indoor Residual sprayings/vector control and ITNs Indicator: Number of health districts in epidemic regions implementing vector control measures 4 Number and percentage of houses in malaria affected areas receiving indoor residual spraying (proxy for people reached) Number of bed nets distributed (proxy for people reached) RTDC continued the implementation of vector control activities. Initially it was planned to conduct the activities in 29 districts, however at the request of the Ministry of Health the activities were expanded to 4 additional districts. In total, during the reporting period, 33 districts most vulnerable to malaria were covered. Prior to implementation of the activities the RTDC and ACTED representatives held discussions with local governmental authorities, leaders of Jamoats and villagers to inform them of the purpose and importance of vector control measures. In accordance with the Work Plan the implementation of anti-malarial activities was planned for 6th and 7th quarters, but was conducted during the 5th and 6th quarters considering the fact that the malaria-transmission season in Tajikistan starts in April. It is worth mentioning that, during the implementation of vector-control activities (IRS and ITNs distribution), the target population was informed of how to avoid malaria, recognize its symptoms and respond to potential outbreaks. During the period from April to September 2007, ACTED and RCTD conducted vector control activities in 33 districts of the country. For details please refer to the table below. Table 3. Brief information on vector control activities implemented during the year Activities Regions covered Result Distribution of 9,884,000 4 districts in Khatlon region 134.2 hectares of stagnant ponds and 360 gambusia fishes (Shurabad, Bokhtar, Vakhsh and hectares of rice fields were covered Jami) and Vakhdat district in RRS Indoor residual spraying 33 districts of the country. Out of 31,856 households (99.6%), and the area of (IRS) them 13 districts were covered in 7964000 square metres were sprayed. two rounds and 20 districts in one round of IRS. Distribution of 29,985* ITNs 7 districts of Khatlon region (Vose, 11,495 households were covered and 86,932 Dangara, Jilikul, Kabadian, people benefited from the activity. Among Temurmalik, Khuroson and them 12,939 were children under 5 and 1,699 Farkhor) pregnant women. *29,985 bed-nets, out of 30,000, were distributed. The remaining 15 ITNs were lost during their transportation. A follow-up monitoring of anti-malarial activities was conducted by the Republican TDC and UNDP/PIU staff. During the monitoring the following omissions/errors were revealed: 1. 2. Gambusia fish distribution: The order of district Hukumats restricting rise growing lead to low coverage of rise fields with gambusia fish distribution; Weak collaboration with local Jamoats and low level of population awareness of malaria prevention measures IRS: Some livestock sheds and households were not sprayed Monitoring in Khuroson district revealed irrational use of insecticide, that is, 5 kg of Alphacypermethrine instead of 14 allocated was used. A Regional Monitoring Team was established in Khatlon region for better control and monitoring of the allocated IRS conducted by the disinfection team in Kulyab district In order to ensure proper and continued use of the distributed ITNs, ACTED staff undertook night monitoring activities. The night monitoring results demonstrated that mosquito nets were widely used by beneficiaries and that 83% were used correctly. In cases where the nets were not used properly, beneficiaries were reminded of correct use of nets and of the benefits of using them correctly. Objective 4. To improve capacities for timely response to and prevention of malaria outbreaks and epidemics 5 Service Delivery Area 1. Prevention: ITNs and malaria prevention during pregnancy Indicator: Indicator: Number of children under 5 who slept under an ITN the previous night Number of pregnant women who slept under an ITN the previous night Among the total beneficiaries of ITNs, ACTED has specifically targeted two particularly vulnerable categories of beneficiaries, pregnant women and young children. Through September 2007, ACTED distributed ITNs to: 1,699 Pregnant Women 12,939 Children under the age of 5 Out of them 1,305 children and 221 pregnant women received the ITNs in March 2008. Night monitoring of their ITNs utilization is planned to be conducted in June 2008. Objective 5. To reinforce malaria surveillance including in-built mechanisms for monitoring and evaluation Service Delivery Area 1. Supportive environment: health system strengthening Indicator: Number of districts, where epidemiological and operational malaria database existed and where their capacities are adequate (existence of computer-based malaria information and reporting systems) Establishment of an epidemiological and operational malaria database An epidemiological and operational malaria database exists in 13 districts of the country. Office equipment and furniture, communication means have been provided to all 13 districts and specialists were hired and trained on data collection and analysis. Currently, those specialists use database in Excel programme. In addition, organizational works on establishment of computerized malaria information and reporting system in Access programme is ongoing. UNDP/GIU jointly with RTDC, ACTED and WHO developed a questionnaire for needs assessment of health structures in Tajikistan. All necessary information was collected all over the country. An analysis of data for 20062007 was finalized. The data-base was installed in all Regional TDCs and trainings on its usage are planned to be conducted for IT specialists, at regional level. Mobile teams During the project year, two TDC mobile teams (in Sughd and GBAO), in addition to two previously established, were formed. The mobile teams examined malaria foci in Khatlon region and RRS. Epidemiological surveillance conducted in Vakhdat district of RRS showed dramatic increase of adult mosquitoes Anopheles. Particularly, the number of An.Superpictus on one cubic metre of untreated surface in cattle sheds comprised from 10 to 80 species and in untreated premises from 2 to 12 species. Breeding of An.Superpictus mosquitoes larvae – the main malaria vector – was detected in Kafernigan chislley river-bed, which is 400 metres far from the foci and in the rice fields, which are 50-60 metres far from the foci, where the larvae of all ages were detected. The larvae of An. hyrcanus mosquitoes – secondary malaria vector – were detected in the pond located in the foci. Necessary anti-malarial activities were implemented in the malaria foci. Objective 6. To strengthen research capabilities Indicators: Number of operational studies planned and implemented within project areas The operational research on PCR-diagnostics of malaria vectors and parasites in Tajikistan was finalised by the end of December 2007. In total, 450 blood samples - in Vakhdat (100 samples), Temurmalik (150), Vakhsh (150) and Rudaki (50 samples) districts from population with high auxiliary temperature. All these samples were investigated on molecular genetic in Moscow, at Vavilov’s Insitute of General Genetics. As a result of the study of desoxyribonucleic acid (DNA) of malaria parasite has been isolated. DNA bank of malaria parasites (P.vivax and P.falciparum) is established for further genetic investigations. The list of malaria vector of Tajikistan has been changed. In Sughd oblast Anopheles artemievi was registered. The final report of the operational study will be submitted to the MoH and UNDP in February 2008. During the period from 27 August to 27 November 2007, an operational research on malaria vector resistance and irritability to synthetic pirethroids, applied in Tajikistan, and definition of residual action of insecticides on different surfaces was conducted and finalized. The research was conducted in Vakhsh and Bokhtar districts of Khatlon region and in Vakhdat city of RRS. The result of the research showed zero resistance and irritability of Anopheles superpictus mosquitoes to Alphacypermethrin. The insecticides containing Alphacypermethrin are very effective 6 and even after 2,5 months ensure 82% destruction of mosquitoes. Therefore, the IRS during malaria transmissions season should be conducted in two rounds and the interval between the rounds should not exceed 2 months. In addition, an operational research on rearing and distribution of the larvivorous fish (Poecilia reticulata) as alternative method on vector control was initiated in accordance with the request of the Ministry of Health #9-29/53278 dated from 11th of February, 2008. This unplanned research was conducted with savings remained from last year activities on researches. Two districts were selected as project districts in Khatlon region – Pharkhor and Shaartuz. The fish will be distributed to rice fields in project districts and effectiveness of the activity will be assessed during the malaria transmission season in 2008. Objective 7. To increase community awareness and participation in malaria prevention. Service Delivery Area 1. Prevention: BCC - community outreach Indicators: Number of people in affected areas reached by the community preventive programs Training of Community Health Workers (CHWs) and Community Health Volunteers (CHVs): Within the framework of this project, ACTED selected and trained 414 CHWs and CHVs. Training topics included (1) the “Principles of Interpersonal Communication and Teaching Adults;” and (2) the “Methods of Health Education among Populations for Changing Their Attitudes towards Their Health.” In addition, CHPs were provided with specific information about malaria prevention. The trainings were led by ACTED Health Educators and the below table shows the training sessions that have taken place to date. Table 4: Number of CHWs and CHVs trained during the project year CHVs # trained District # villages jamoats trained trained religious CHWs activists teachers leaders Dangara 3 9 44 21 18 13 Khuroson 4 6 9 20 15 1 Farkhor 3 8 14 28 7 2 Kabadian 3 4 21 25 15 2 Vose 5 6 39 40 6 5 Jilikul 3 11 38 12 16 3 TOTAL 21 44 165 146 77 26 Total 96 45 51 63 90 69 414 Following these trainings, CHWs and CHVs (religious leaders, teachers and activists) organized a series of awareness raising activities within each village of intervention. Information disseminated through theatre shows and school competitions included explanations regarding how malaria is transmitted, its symptoms and why it is important for the community’s health status to adopt measures in order to prevent malaria. The malaria prevention knowledge and bookmarks among the schoolchildren were disseminated by CHWs and CHVs trained by ACTED and by RTDC CHWs. In total, 131,824 schoolchildren were covered. In addition, 3,039 villagers were trained on malaria prevention issues through seminars. Distribution of Awards at School Competitions and Role Plays at School Events in April 2008 7 In order to reach a larger target audience and ensure the message of malaria prevention is disseminated among most of the targeted beneficiaries, ACTED utilized mass media. Through the reporting period, 16 radio programmes and 9 TV information clips focusing on malaria prevention were produced and broadcast. These programmes included information on the ITN distribution, prevention and interviews with health authorities. MONITORING AND EVALUATION This year M&E team conducted regular quarterly monitoring visits to Rasht valley, RRS, Sughd and Khatlon regions to ensure effective implementation of malaria programme. Eight district Tropical disease centers, nine district SESs and two regional TDC have been visited by monitoring team. NGO ACTED, as a sub-recipient of the grant for ITN’s distribution and education campaigns for targeted districts of Khatlon region, has been monitored as well. It is worth mentioning that most of those monitoring visits were conducted jointly with specialists of Republican and Regional TDCs. They made valuable recommendations and contributed to immediate solving of problems. Recommendations were made to TDCs in regard to the quality of IRS, reporting, education provided and staff capacity building. UNDP/PIU M&E unit and TDC’s staff are being involved in development of data-base software in the base of RTDC. PIU M&E team jointly with TDC staff has conducted KAP survey in five districts of Khatlon region in order to define baseline specific indicators. Based on findings of the survey and monitoring visits of PIU/TDC relevant staff, a strategy for improvement of those areas where problems were revealed is being elaborated. COORDINATION The activities of UNDP Tajikistan were conducted in cooperation and coordination with the members of the National Coordination Committee to Fight AIDS, Tuberculosis and Malaria. NCC organised a technical working group conference to review and prepare the request for continued funding of Round 5 GFATM grant for Phase II. Strong cooperation and coordination was established between the implementers of the Round 5 of the GFATM malaria grant. All implementing partners actively participated in the meetings related to improvement of planned activities. A WHO consultant was invited to conduct a mid-term monitoring and evaluation of the project implementation. In addition, experts from MoH and the Centre for Healthy Life Style Promotion facilitated the production of health education materials. CONCLUSION The initial Work Plan for second year project implementation was revised in accordance with local conditions. All activities of the project were undertaken according to the revised work plan and all the indicators set for the current period were successfully achieved; some were even over-fulfilled. Implementation of operational researches was finalised as planned. Knowledge and skills of 587 health workers, at all levels, was enhanced through trainings. 622 malaria patients accessed health services and were treated. Health and laboratory facilities in 64 districts of the country were sufficiently supplied with drugs and medical equipment. People leaving in 33 malaria-prone districts benefited from complex vector control activities (indoor residual spraying, bed-nets and gambusia fish distribution). The overall health status and health related quality of life among the beneficiaries increased through awareness raising and health promotion activities. As a result, the general target population and 131,824 schoolchildren became less vulnerable to malaria outbreaks. 8