monitoring and evaluation

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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
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