MMDP PROJECT SEMI-ANNUAL REPORT - USAID

MMDP PROJECT SEMI-ANNUAL REPORT October 1, 2017 – March 31, 2018

Prepared for: Emily Wainwright, AOR MMDP Project, USAID

Submitted by: Helen Keller International

Date: May 15, 2018

For more information: Stefania Slabyj, Project Director, [email protected]

mailto:[email protected]

MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 2

THE MMDP PROJECT

The Morbidity Management and Disability Prevention (MMDP) Project is a five-year project

funded by the United States Agency for International Development (USAID) with the goal of

strengthening national ownership and capacity within a select number of countries to scale up

the provision of quality services for the management of morbidity, disability and disfigurement

related to trachoma and lymphatic filariasis in a manner that will help to meet disease elimination

targets. To achieve this goal, the MMDP Project will focus on the following four intermediate

results:

1. Strengthened MMDP data availability and quality for decision-making at the country level.

2. Strengthened support for MMDP implementation scale-up and quality improvement at the

country level.

3. Strengthened capacity of MMDP systems within Ministries of Health.

4. Provision of global leadership through building-upon the knowledge and evidence-base for

MMDP preferred practices and policy.

The MMDP Project is a global project led by Helen Keller International in partnership with the

African Filariasis Morbidity Project and RTI International. The project is funded by the US Agency

for International Development under Cooperative Agreement No. AID-OAA-A-11-00054. The

period of performance for the MMDP Project is July 22, 2014 through July 21, 2019. The authors

views expressed in this publication do not necessarily reflect the views of the United States

Agency for International Development or the United States Government.

Cover photo: Mossi trichiasis patient in Burkina Faso being taken for surgery by son, 2017. (photo: HKI)


CONTENTS

ACRONYMS ................................................................................................................. 4

EXECUTIVE SUMMARY ................................................................................................. 6

KEY PROGRESS INDICATORS ....................................................................................... 7

BURKINA FASO ............................................................................................................ 9

TRACHOMA ........................................................................................................................................... 12

LYMPHATIC FILARIASIS ......................................................................................................................... 19

CAMEROON ............................................................................................................... 27

TRACHOMA ........................................................................................................................................... 30


ETHIOPIA ................................................................................................................... 40

TRACHOMA (Oromia) ............................................................................................................................. 43

TRACHOMA (Tigray) ............................................................................................................................... 55


GLOBAL PROJECT ...................................................................................................... 80

PROJECT ACTIVITIES ............................................................................................................................. 81

OPERATIONAL ACTIVITIES .................................................................................................................... 96

APPENDICES .............................................................................................................. 98


ACRONYMS AIM Accelerating Integrated Management

CBHW Community Based Health Workers

CDC US Centers for Disease Control and Prevention

CNTD Centre for Neglected Tropical Diseases

CSPS Center for Health and Social Promotion (Centre de Santé et de Promotion Sociale)

DFID Department for International Development

DGS Central Health Directorate (Direction Générale de la Santé)

DMDI Disease Management and Disability Inclusion

DMT Dedicated Mobile Team

DQT Dedicated Quality Team

DRS Regional Health Directorates (Direction Régionale de la Santé)

ECU Eye Care Unit

EMMP Environmental Monitoring and Mitigation Plan

EMMR Environmental Mitigation and Management Report

ESPEN Expanded Special Project for Elimination of Neglected Tropical Diseases

FASTT Filaricele Anatomical Surgical Task Trainer

FHF Fred Hollows Foundation

FMOH Federal Ministry of Health

FOG Fixed Obligation Grant

FY Fiscal Year

GAELF Global Alliance to Eliminate Lymphatic Filariasis

HCWM Health Care Waste Management

HDA Health Development Army

HEAD START Human Eyelid Analog Device for Surgical Training And Skills Reinforcement in Trachoma

HEW Health Extension Worker

HKI Helen Keller International

HMIS Health Management Information System

HRD Human Resources Directorate

IC/HCWM Infection Control and Health Care Waste Management

ICTC International Coalition for Trachoma Control

IEC Information, Education, and Communication

IECW Integrated Eye Care Worker

IESO Integrated Emergency Surgical Officer

LF Lymphatic Filariasis

LFTW Light for the World

LSTM Liverpool School of Tropical Medicine

MDA Mass Drug Administration

MMDP Morbidity Management and Disability Prevention

MMMM Monthly Morbidity Management Meeting

MOH Ministry of Health

MOST Ministry of Science and Technology

NaPAN National Podoconiosis Action Network

NGO Non-Governmental Organization

NTD Neglected Tropical Disease


NTTF National Trachoma Task Force

ORHB Oromia Regional Health Bureau

PFSA Pharmaceutical Fund and Supply Agency

PHCU Primary Health Care Unit

PNLCé National Blindness Prevention Program (Programme National de Lutte contre la Cécité)

PNMTN National Neglected Tropical Disease Control Program (Programme National de lutte

contre les Maladies Tropicales Négligées)

QA Quality Assurance

RHB Regional Health Bureau

SAFE Surgery, Antibiotics, Facial cleanliness, Environmental improvement

SECU Secondary Eye Care Unit

SNNPR Southern Nations, Nationalities, and People’s Region

SSE Surgical Society of Ethiopia

STTA Short-term Technical Assistance

TA Technical Advisor

TAB Technical Advisory Board

TAP Trachoma Action Plan

TEC Trachoma Expert Committee

TEO Tetracycline Eye Ointment

TIS Trachoma Impact Survey

TRHB Tigray Regional Health Bureau

TT Trachomatous Trichiasis

UIG Ultimate Intervention Goal

UNC University of North Carolina

USAID United States Agency for International Development

WHO World Health Organization

WoHO Woreda Health Office

ZHD Zonal Health Department


EXECUTIVE SUMMARY In the first half of FY18, the Morbidity Management and Disability Prevention (MMDP) Project continued to strengthen both national ownership and global capacity for the scale-up of trachoma and lymphatic filariasis (LF) care and treatment. During the reporting period, the project made significant achievements, leveraged on-the-ground experience, and strengthened capacity and lessons learned, to support Burkina Faso, Cameroon, and Ethiopia to move closer towards meeting the 2020 elimination goals for trachoma and LF.

The MMDP Project supported 10,897 trachomatous trichiasis (TT) surgeries during the reporting period, advancing ministry of health efforts to meet the trachoma elimination goals. This required screening 224,031 individuals living in endemic areas, using a variety of community mobilization and new case-finding strategies. In addition to supporting intensive trichiasis management, the project also supported activities that improved the evidence base for trachoma elimination planning in the three countries. In Burkina Faso, the project supported the national program’s development of a Trachoma Action Plan (TAP). In Cameroon, the project contributed to the national program’s assessment of trichiasis burden through implementation of a TT-only survey in Mada district, and supported coordination between the national program and WHO to make available Tropical Data’s analysis of prior trachoma survey results.

The project also increased the three countries’ capacity to provide high-quality hydrocele surgery and lymphedema management services. In collaboration with ministries of health, the project supported the training of 11 surgeons to provide high-quality hydrocelectomies using the MMDP Project-developed FASTT training package. In addition, the project trained 40 health staff on hydrocele surgery support and care. In the first half of the fiscal year, the project supported 536 hydrocele surgeries across the three countries and trained 717 lymphedema patients in self-care.

The project also supported a range of activities aimed at ensuring a longer-term sustainability of LF morbidity management in project countries and beyond through health systems strengthening and the integration of activities into the routine health system. One such example is a project-supported workshop in Ethiopia to discuss the inclusion of the FASTT training package in the pre-service training curriculum of surgeons and integrated emergency surgical officers. Another example is the interest of the Ministry of Science and Technology in Ethiopia in manufacturing the simulator locally. The project has been working to prepare for an upcoming LF MMDP training workshop for Francophone African countries. The workshop, sponsored by ESPEN, will strengthen participating countries in their LF technical capacities and in preparing a plan for LF elimination dossier submission to WHO.

In the first half of FY18, the MMDP Project continued to develop and refine tools and resources to address challenges in trachoma and LF morbidity management identified by the global community. The project carried out an evaluation of the FASTT training package in Burkina Faso, which found that the training package is a useful tool that provides a comprehensive system for teaching the basics of hydrocele surgery. Another tool, the “Training trichiasis surgeons for trachoma elimination programs” manual, developed by the project with ICTC partners, was formally accepted as a preferred practice by ICTC.

In the second half of FY18, the MMDP Project will continue its support to ministries of health to close the gap to meet elimination criteria for both trachoma and LF. The project will continue to distill lessons learned from its practical implementation experience, particularly around piloting the implementation of outcome assessment and surgical audit as two distinct activities; the use of TT-operative photos as potential predictors of surgical outcomes in a programmatic setting; and quality assurance and post-operative follow-up of hydrocele surgery. The project will also plan for the last year of the project and identify the remaining global and local priorities in the global fight to eliminate trachoma and LF that can be accomplished by the end of the project.


KEY PROGRESS INDICATORS The MMDP Project works at both the national and global levels to expand the capacity of

ministries of health to provide quality MMDP services for trachoma and LF as a part of global

disease elimination efforts. The project also works to support service delivery and implement

quality assurance measures which contribute to stronger health systems, and to improve data

availability and use, disseminate best practices, and contribute to advancing the global agenda by

sharing experiences and collaborating with local and international partners.

The two tables below highlight the key achievements from the reporting period. All activities are

described in more detail in subsequent sections of the report.

Table 1: Summary of FY18 support to MMDP Project countries: Q1-Q2

FY18 Support to MMDP Project Countries: Q1-Q2

Trachoma Achievements LF Achievements

10,897 TT surgeries total

• 4 TT surgical campaigns (Burkina Faso)

• 137 TT surgery teams operating, including 4 dedicated mobile teams (Ethiopia)

• 3 intensified surgical camps and 2 “minicamps” (Ethiopia)

224,031 people screened total

536 hydrocele surgeries

717 lymphedema cases trained in self-care

Refresher/debriefing session for three TT surgeons (Cameroon)

11 new hydrocele surgeons trained using FASTT

6 people trained in TT campaign/outreach management (Cameroon)

27 health staff trained in hydrocele surgery support

249 case finders & community mobilizers trained (Cameroon)

13 health staff retrained in post-hydrocele surgery survey implementation (Ethiopia)

1 district assessed for burden through a TT-only survey (Cameroon)

Technical/Meeting Support to project-supported countries

Technical/Meeting Support to project-supported countries


Table 2. Key project activities: Q1-Q2

Goal Key Activities

Build service capacity

Training in and use of WHO guidelines and standards for TT management, including diagnosis, counseling, surgery and post-surgical follow-up

Training in and use of global guidelines and standards for hydrocele management, including diagnosis, counseling, surgery, and post-surgical follow-up

Short-term technical assistance to Benin and Cote d’Ivoire to train surgeons and national trainers using the HEAD START training package

Training of a Francophone HEAD START master trainer for TT surgery

Service delivery

Provision of TT surgery through multiple operational platforms, including outreach campaigns, dedicated mobile teams, and static site services

TT and hydrocele case finding and confirmation, including house-to-house visits and extensive social mobilization activities

Provision of hydrocele surgery through intensive camps and routine health system

Provision of equipment and consumables for TT and hydrocele surgery

Quality assurance

Update of TT supportive supervision tools

Exploration of remote technical support as a potential quality assurance strategy for TT surgeon training and surgery

Continued implementation of an array of quality assurance measures for TT and hydrocele surgery

Improve data availability and use

Analysis of TT and hydrocele surgical quality, patient satisfaction, and data quality as part of post-operative monitoring

Review of and revision to TT data for decision-making during trachoma action planning

Assessment and update of FASTT training package

Liaising with WHO’s Tropical Data initiative to facilitate national programs obtaining age- and sex-standardized TT estimates from recent and historical trachoma surveys

Disseminate best practices

Convening of partners for a MMDP Technical Update featuring the “Training Trichiasis Surgeons for Trachoma Elimination Programs” manual

Publishing of the “Training Trichiasis Surgeons for Trachoma Elimination Programs” manual as an ICTC preferred practice

Planning for an LF MMDP workshop for Francophone countries

Facilitation of Monthly Morbidity Management Meetings of the LF MMDP community

Dissemination of TT and LF best practices and lessons learned in collaboration with global and local partners at international meetings, including COR-NTDs, ASTMH and others


TT surgery in the community in Burkina Faso in 2017. (Photo: HKI)

BURKINA FASO

• The MMDP Project conducted four trichiasis outreach campaigns, screening a total of 38,218 people and providing surgery to 288 individuals.

• The project supported the national program in a multi-day Trachoma Action Plan strategic planning meeting to assess progress achieved towards elimination targets, identify gaps and outline next steps.

• The project supported 392 hydrocele surgeries, and conducted 6-12 month follow-up of 61 patients after the surgery to assess clinical and quality-of-life outcomes.


IN BRIEF

In the first half of fiscal year 2018 (FY18), the MMDP Project continued to support intensive

trichiasis management services in the Center North and Hauts-Bassins regions. Four trichiasis

surgery campaigns took place in the first half of the fiscal year, collectively screening 38,218 people

to find 384 confirmed trachomatous trichiasis (TT) cases and provide 288 people with surgery,

with additional cases referred to higher-level facilities and counselled as appropriate. The project

also implemented outcome assessment and surgical audit activities to follow up 3-6 months after

surgery with TT cases operated during last year’s Hauts-Bassins campaigns in June and July 2017.

The national program’s multi-day Trachoma Action Plan (TAP) strategic planning meeting took

place during the reporting period, with the project providing a facilitator and contributing to the

discussion of progress achieved towards elimination targets and the planning of upcoming

activities.

Lymphatic filariasis (LF) activities moved forward as well. The project continued supporting

hydrocele surgeries in multiple districts (392 surgeries over the course of the reporting period)

and conducted a follow-up study of hydrocele surgery patients 6-12 months after surgery. Burkina

Faso also hosted the project’s Filaricele Anatomical Surgical Task Trainer (FASTT) evaluation,

which resulted in the training of five new hydrocele surgeons in the Center South region. Follow-

up of lymphedema patients trained by the project at the end of FY17 took place early in the fiscal

year.

PROGRAM BACKGROUND

TRACHOMA

Burkina Faso’s baseline mapping, completed in 2007, provided a crude estimate of over 33,000

individuals with trichiasis. At the start of the MMDP Project, roughly one third of the national

burden was estimated to exist in the two project-supported regions of Center North and Hauts-

Bassins. However, this epidemiological picture is evolving for two key reasons. First, age- and

sex-standardization of trachoma survey data is increasingly yielding lower estimates of burden.

This suggests that the data available at the start of the MMDP Project, which were never

standardized by age and sex, likely overestimate the backlog. Second, in 2017, 19 trachoma impact

surveys (TIS) were completed in health districts across the country (14 were funded by the END

in Africa Project and five by the World Bank). These survey results have yielded revised trichiasis

estimates for the assessed districts, some of which are targeted by the project. As of the February

2018 TAP meeting, the national program estimates the country’s backlog to be closer to 25,202

cases, although estimates for a number of districts rely on data that have not been standardized

by age and sex.

In the Center North region, the project has targeted four of the region’s six districts, as two

districts were determined to have 0% TT prevalence at the time of their baseline survey. At the

start of the MMDP Project, these four districts collectively had a non-standardized, theoretical


Ultimate Intervention Goal (UIG) of approximately 6,108 cases, of which roughly 12% were

operated or otherwise made known to the health system through the project’s FY16 and FY17

campaigns. However, following the release of preliminary 2017 TIS data for three of these

districts, the region’s theoretical UIG at the time of the most recent survey decreased to

approximately 1,250 total cases. To date, the project has addressed approximately 20% of this

revised burden estimate through its provision of trichiasis management services.

The Hauts-Bassins region, first targeted by the project in FY17, currently consists of eight

districts. At the onset, the project targeted the three districts with the highest theoretical UIGs

at the time. Collectively, these three priority districts had a non-standardized UIG of 2,184, of

which roughly 6% were operated or otherwise made known to the health system through the

project’s FY17 campaigns. Of the remaining five districts in the region, one district did not have

a TT UIG at either its 2017 or 2010 TIS, indicating that no project intervention was needed. The

other four districts had a combined UIG of 782 at the time the project began planning activities

in the region and were not prioritized. However, new data made available to the project during

the February 2018 TAP indicate several key shifts in the region’s epidemiological landscape. Five

of the region’s eight districts have dropped below the TT elimination threshold according to their

most recent TIS, leaving only three districts with a theoretical UIG at the start of FY18. Two of

these districts have not been surveyed since 2009 and were therefore targeted with project-

supported TT-only surveys (see Assessing Disease Burden section) in the FY18 workplan. However,

given competing national program priorities following the TAP (several post-mass drug

administration (MDA) surveillance surveys have to be completed by the end of June 2018), the

project is moving forward with a campaign in these two districts in the second half FY18 rather

than implementing TT-only surveys. The third and final district, which has a theoretical, non-

standardized UIG of 115 cases, was targeted in Q2 of FY18 (see Trichiasis Management, Including

Surgery section). For a summary table of project-supported progress towards the UIG in each

targeted district, by fiscal year and in relation to district-level UIGs, see Appendix A (Table A1).

LYMPHATIC FILARIASIS

LF was found to be endemic in all of Burkina Faso’s 63 health districts following the completion

of mapping in 2002. The MMDP Project initially used national program estimates to plan LF

activities in the two project regions of Center North and Hauts-Bassins. Prior to provision of

services, the project compiled burden data from health facilities in the targeted districts to actively

identify hydrocele and lymphedema management cases for support in the community.

In the Center North region, the project has conducted hydrocele surgery and/or lymphedema

management services in all six districts. During the reporting period, the project conducted 268

hydrocele surgeries. To date, the project has conducted a total of 560 hydrocele surgeries in the

region, which represents all of the cases that could be confirmed by a surgeon during project

activities and roughly 50% of the regional burden as last estimated by the national program. The

298 lymphedema cases managed to date with project support (in FY17) represent approximately

38% of the national program’s estimated number of cases in the region.


In Hauts-Bassins, the project has targeted cases from five1 of the regions’ eight districts with

hydrocele surgery and/or lymphedema management services. These four districts are estimated

to have the highest number of lymphedema and hydrocele cases in the region. The 160 hydrocele

surgeries conducted to date under the project represent all of the cases that could be confirmed

by a surgeon during project activities and more cases than had last been estimated by the national

program. The 83 lymphedema cases managed to date with project support (in FY17) represent

approximately 26% of the latest estimated number of cases in the region.

For a summary table of the project’s LF disease management achievements to date, in relation to

regional targets and burden estimates, see Appendix A (Table A5).

MAJOR ACCOMPLISHMENTS FOR THE REPORTING PERIOD

TRACHOMA

STRATEGIC PLANNING

In the first half of the fiscal year, the project participated in strategic planning meetings to support

the preparation for FY18 activities and the development of Burkina Faso’s TAP. Coordination

and planning meetings were held with the Regional Health Directorate (DRS) in both the Center

North and the Hauts-Bassins regions to review FY17 activities achieved, present the FY18

workplan to stakeholders, and integrate FY18 activities into the districts’ and health areas’ various

action plans. The meetings also presented an opportunity to review the Fixed Obligation Grant

(FOG) agreement for each DRS (Center North and Hauts-Bassins) and to develop a timeline for

the implementation of FY18 activities. The planning and coordination meeting for the Center

North was held in Kaya in January 2018, while the Hauts-Bassins meeting was held in Bobo Dilasso

in February 2018.

From February 5-9, a TAP development meeting led by the national program was held in

Ouagadougou. In addition to supporting the pre-TAP working sessions in January, the project

supported Mr. Chad MacArthur to facilitate the meeting while the END in Africa Project

supported the meeting costs. The meeting was attended by regional health bureau staff,

representatives from the Ministry of National Education and Literacy, the National Program for

Water and Sanitation in Burkina Faso, Sightsavers, l’Occitane Foundation, USAID, and HKI MMDP

and END in Africa Projects.

The meeting provided an opportunity for the major trachoma actors to come together to take

stock of progress made to date and to strategically plan for the coming years leading to

elimination. The national trachoma program in Burkina Faso is at a critical point for trachoma

elimination, having stopped MDA campaigns in all formerly endemic districts throughout the

1 Only four districts have a functioning operating room, but identified cases from the fifth district of N’dorola were

referred to the nearest facility providing project supported hydrocele surgeries.


country. Additionally, the national program has resources available from USAID and the World

Bank to address trichiasis on a large scale. Based on current data, the program has identified the

need to conduct 15 surveillance surveys and 16 TT-only surveys to demonstrate elimination

criteria have been met. These surveys will continue to not only enrich the evidence-base for

demonstrating progress made toward elimination, but also be the inputs from which the program

will need to continually revise plans, particularly in targeting districts for trichiasis intervention.

The TAP meeting was held following the availability of results from 19 trachoma surveys

conducted the previous fiscal year with support from the END in Africa Project and the World

Bank. The week’s discussion focused on each component of the trachoma Surgery, Antibiotics,

Facial cleanliness, and Environmental improvement (SAFE) strategy separately, identifying the

current status of progress made to date, and the remaining actions needed to arrive at

elimination. At the end of the discussion regarding country-specific progress for each SAFE

component, the relevant section of the dossier was reviewed. As a final step, the group identified

and recorded next steps for each SAFE component, which the national program agreed to finalize

and share with the meeting participants.

On March 15, a post-TAP meeting took place to begin finalizing the next steps document. Due

to the national program’s participation in MMDP Project campaigns and preparations for the

various post-MDA surveillance surveys, the process has been slow. At the time of report writing,

the finalization of the document was ongoing.

ADVOCACY

Advocacy activities during the reporting period included advocacy days, feedback meetings, and

correspondence with local leaders. In February 2018, the project organized a one-day advocacy

day in both Orodara and N’dorola health districts in Hauts-Bassins. Since these districts are new

to the MMDP Project, the purpose of the advocacy days was to present an overview of the

MMDP Project’s activities planned for each district in FY18, provide information on the TT

management services that would be provided, and seek the support of district leadership. The

meetings were attended by administrative, civil society, traditional, and religious authorities.

During the meetings, HKI staff sought the support of the various district leaders to mobilize

members of their communities for campaign activities.

The project also held meetings on project implementation outcomes in both regions in January

and February to assess the implementation of FY17 activities. The meetings, which were attended

by political, traditional and religious authorities, were used to review the successes of the

previous campaigns and look at areas for improvement, such as sensitization of community

members to increase TT surgery uptake, sources of financing, and the different contributions and

expectations of the stakeholders.

To ensure the participation and commitment of community members, letters were sent to

political and administrative leaders in Center North and Hauts-Bassins, notifying them of

upcoming campaign activities. The letters included information on the TT surgeries that would

be provided and encouraged the participation of the leaders and their communities.


SOCIAL MOBILIZATION AND BEHAVIOR CHANGE

Community-level social mobilization activities included the broadcast of radio messages, the use

of public criers before and during campaigns, and the distribution of information, education, and

communication (IEC) materials.

Using local radio stations, the project disseminated information about trachoma and the project’s

activities throughout the target districts. Messages were broadcast in French and in local

languages through educational programs and radio magazine shows. In addition, public criers

delivered information at the village level about trachoma and the availability of services for

trichiasis. The messages delivered included surgery dates, availability of screening services, the

source of funding for the surgeries, and who to contact for more information.

The project reproduced and distributed IEC materials developed in previous fiscal years. The

table below describes the type and quantity of materials reproduced for FY18 activities.

Table 3. IEC/social mobilization materials messages produced with USAID funding

Type of material Brief description of material Target audience Quantity

Poster (trichiasis

surgery)

The poster shows an overview of

trichiasis surgery, emphasizing that

it can preserve sight.

Communities in

endemic areas/people

with trichiasis

1000

Poster (trachoma and

TT management)

The poster provides an overview

of the symptoms of trachoma and

directs those with similar

symptoms to go to the health

center for diagnosis and treatment.

Communities in


with trachoma

1000

Leaflet (trachoma

disease stages)

The leaflet includes photos and a

brief description of the WHO-

defined stages of trachoma. It

includes directive actions based on

the stage of the disease.

Health center workers 250

Brochure (trachoma

and TT)

Description of trachoma and its

management

Health center workers

and communities in


with trichiasis

900


CAPACITY BUILDING

There were no capacity building activities for trachoma conducted during the reporting period.

ASSESSING DISEASE BURDEN

Following the completion of trachoma surveys in 19 districts in 2017, in early FY18 the project

worked to obtain updated TT prevalence data for these districts. The National Neglected

Tropical Disease Control Program (PNMTN) shared its most recent data during the February

2018 TAP meeting, after which the project updated its TT data tools to align with the data shared.

The project has also been providing support to the PNMTN to develop a protocol for the three

TT-only surveys planned for FY18. (Two surveys are planned in the Hauts-Bassins region in

N’dorola and Orodara districts, as described in the FY18 work plan, and one survey, in

Barsalogho district of the Center North region, was carried over from the FY17 work plan into

FY18). The project’s support of these surveys in the first half of FY18 has taken the form of

supporting liaising between the PNMTN and Tropical Data to ensure the Francophone protocol

that is developed will be in line with World Health Organization (WHO)-endorsed survey

standards. Finalization of the protocol and implementation of the surveys is planned for the

second half of the fiscal year. The PNMTN, however, also plans to conduct surveillance surveys

in 22 districts over the course of FY18. These upcoming surveillance surveys, which are a high

priority for the national program, may result in delays to the planned TT-only surveys, depending

on the PNMTN’s prioritization of time and human resources.

Finally, the project has continued to track, analyze, and discuss during campaign preparatory

meetings the geographic coverage of its TT management services. This geographic coverage data

at the sub-district level provides additional documentation of the project’s contribution to

reaching the UIG in its targeted regions – particularly in the Center North, where the most TT

surgery campaigns have been conducted.

TRICHIASIS MANAGEMENT, INCLUDING SURGERY

During the first half of the fiscal year, the project supported the implementation of four TT

campaigns (three in Center North region and one in Hauts-Bassins). The first campaign was held

in Kaya in January 2018, the second in Boussouma in February 2018, the third in Dafra in March

2018, and the fourth in Kongoussi in March 2018. Across four campaigns, a total of 38,218 people

were screened, of which 384 people were confirmed to have trichiasis. Among these confirmed

cases, 288 received surgery, 13 were referred to a higher level of care, and 22 refused all services

(both surgery and epilation). When surgery was not conducted (because the individual refused

or was referred, or was otherwise not recommended to have surgery), those who consented

were epilated; however, per current national program guidance, these individuals did not receive

epilation forceps.

For FY18, the project continued to use the strategy of performing TT case identification through

door-to-door case finding and TT surgeries on the same day. Each TT surgery campaign lasted

ten days and started with a preparatory meeting at the DRS. During this meeting, the HKI staff


and district leadership provided an overview of FY18 campaigns: the number of campaigns

planned in each region, the number of cases targeted, the data collection tools to use, and relevant

results from the FY17 campaigns. Particular attention was given to the review of the data

collection tools to ensure that forms were filled out correctly and completely throughout the

campaigns. HKI staff reviewed common mistakes found on the forms and provided tips to avoid

them. They also reiterated the importance of correct data to accurately estimate the disease

burden for the country and appropriately plan for the provision of services for the districts. At

the end of the meeting, each surgery team was assigned a schedule for the campaign.

During the campaigns, the screeners, accompanied by Community Based Health Workers

(CBHWs), examined people in their households. The CBHWs serve as guides and interpreters,

thus playing a crucial role in introducing the screeners to each household. Also, because they are

familiar with the communities, CBHWs were sometimes aware of suspected cases. Due to long

distances between households, the screeners and CBHWs often walked for hours to ensure that

as many people as possible were screened. Once a TT case was identified, the screeners explained

the disease as well as the surgery being offered. The suspected case was then referred to the

surgery site, which could either be at a Center for Health and Social Promotion (CSPS) or at

another appropriate site in the village, such as a classroom.

At the surgery site, the surgeon confirmed the TT diagnosis and operated on those who

consented. After surgery, individuals received post-operative counseling and tetracycline eye

ointment (TEO)/Zithromax. At select surgery sites, HKI staff also took photos of the operated

eye immediately after surgery as part of a photo-taking activity that is currently being piloted as

an additional quality assurance measure. Post-surgical monitoring was conducted at the surgery

site on Day 1 by the surgeons, who removed the bandage and assessed the operated eyelid. On

Day 8, the CSPS health workers who took part in the campaign conducted post-surgical

monitoring. Monitoring operated cases 3-6 months after surgery will take place in the second half

of FY18.

Complicated cases, such as those with lower-lid or post-operative trichiasis, were referred to a

health facility equipped to handle such cases. Individuals who refused surgery were encouraged

to accept epilation. Within the project’s campaign model, refusals are intended to be registered

in the health system and receive follow-up from the local head nurse; in practice, however, it is

difficult for the project to track the frequency and outcomes of refusal management. As described

in the Monitoring & Evaluation section below, in the second half of FY18, the project will explore

new management strategies of refusal cases.

On the last day of each campaign, the surgical teams, HKI supervisors, and the district leadership

held a debriefing meeting at the district level. In addition to reviewing preliminary campaign

results, they assessed remaining drugs and consumables to ensure the appropriate management

of stock and to better assess procurement needs for future campaigns.


COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT

Procurement during the reporting period involved primarily:

• Pharmaceuticals for TT surgery: Pharmaceuticals were purchased via the USAID-

approved wholesaler (IMRES) and delivered to the country in Q2. The only exception to

this was the lidocaine with adrenaline, which was not available from any USAID-approved

wholesaler or from the National Medical Pharmacy in Burkina Faso. HKI therefore used

private funds to procure the items separately. The project worked with members of its

Trachoma Technical Advisory Board (TAB) to adapt a mixing protocol for lidocaine with

adrenaline developed by Johns Hopkins University. The protocol was translated into

French and shared with the National Program, which is in the process of reviewing the

protocol and in the interim decided to proceed using lidocaine only. For the reporting

period, lidocaine (without adrenaline) was used during TT surgery campaigns. Drugs

purchased in Burkina Faso were purchased from the National Medical Pharmacy, which

complies with the national regulations on the management of drugs and is subject to

quality control analysis and certification.

• HEAD START surgical simulator parts: HEAD START consumables are procured

centrally by the MMDP Global team. In FY18, eight orbits and 150 eyelids were shipped

to Burkina Faso to be used for surgeon refresher trainings.

SUPPORTIVE SUPERVISION

Ministry of Health (MOH) and HKI staff in Burkina Faso provide supervision throughout the

campaigns. During case finding in villages, they observe screeners’ interaction with and

examination of the individuals visited, providing feedback as appropriate. They also support the

case finding team to accurately and comprehensively complete the data collection forms. At the

surgery site, they monitor the various non-technical components outlined in the project’s

supportive supervision checklists and support the surgery team to troubleshoot any issues that

arise.

Because surgeries are performed in the field, issues that arise can range from helping to repair

broken equipment to having to stand in for the assisting nurse. For example, during the Kaya

campaign, one of the surgical tables broke right before surgery. With assistance from HKI staff,

the surgeon and the nurse were eventually able to repair the table and proceed with the surgeries.

On the same day, while the surgeon was operating on a patient, the nurse was called back to his

post for an emergency. HKI staff therefore had to step in and assist the surgeon by holding an

additional source of light so he could finish operating.

When technical supervisors are available, they also work with surgery teams to track use of

equipment and consumables and plan accordingly for future campaigns. Technical supervision of

TT surgeons is provided by the assistant national trainers trained by the project in FY17 to serve

both roles. While the goal is for each surgeon to receive technical supervision at least once a

year, human resource constraints have made it challenging to have a technical supervisor present

at each site during each campaign. Depending on needs, during a campaign, technical supervisors


are sometimes assigned as the surgeons on the teams and are, therefore, too occupied with case

management to provide technical supervision. The project is currently exploring the availability

of Dr. Amir Bedri Kello, the project’s primary technical assistance provider for TT surgery, to

conduct a training of additional technical supervisors.

SHORT-TERM TECHINCAL ASSISTANCE

There were no short-term technical assistance activities for trachoma conducted during the

reporting period.

MONITORING AND EVALUATION

The project conducted routine M&E activities during the reporting period as part of each

campaign. These activities included tracking geographic coverage of TT management services,

managing TT surgery data to ensure flow of information from the on-the-ground surgery teams

up to the national level, and holding a surgical campaign assessment during the campaign debrief

meetings described in the Trichiasis Management section.

In the first quarter of FY18, the project conducted 3-6 month follow-up of the last two TT

campaigns of FY17. The campaigns took place in June and July 2017, covering three districts in

the Hauts-Bassins region (one campaign covered the district of Dafra, and the other covered the

districts of Dandé and Dô). Since the third month following these campaigns fell in FY18, the

project carried out 3-6 month follow-up in October 2018 as part of FY17 carryover activities.

For this 3-6 month follow-up, the project implemented a two-pronged approach to conducting

surgical audit as distinct from “centralized” follow-up (also referred to as “outcome assessment”).

As described in the FY18 work plans, this is a new approach for the MMDP Project. The project

began piloting this approach in Burkina Faso at the end of FY17 and continued implementing it in

FY18 in Dafra, Dandé, and Dô.

For the surgical audit component, the project actively sought out individuals in their home. A

portion of those who received surgery during the FY17 campaigns were randomly selected to

receive a follow-up visit from a team comprised of a surgeon, representatives from the PNMTN

(including a technical supervisor), representatives from the DRS, and HKI staff. There were two

teams; one covered Dafra, while the other covered Dandé and Dô. To increase the chances of

finding people at home, the teams either called the head nurse assigned to the villages of the

selected cases or directly called the person who received surgery. Each team started out by first

visiting the health center covering the individual’s village to confirm that the person received Day

8 follow-up, request the post-operative follow-up forms, and be accompanied to the person’s

home by a CBHW. Once in a person’s home, the team explained the purpose of the visit,

interviewed the person, and conducted a clinical examination of the operated eye(s). Fifty people,

representing approximately 34% of the individuals who received surgery during the campaigns,

were followed up with through these visits. The results of the clinical examination indicated

satisfactory surgeon performance in the most recent campaigns. Based on this analysis of the

data, the project determined there was not a need to hold a refresher training of surgeons prior

to implementing the first TT campaigns of FY18. The few complications identified were either


post-operative TT, in which case the individual was referred to a health facility, or granuloma,

which were corrected on site by the surgeon who was part of the follow-up team. If the follow-

up team determined that an individual’s post-operative TT was severe, the surgeon would epilate

the individual before referring the individual.

For the centralized follow-up (or outcome assessment) component, the project worked with

national and regional representatives to invite individuals to return to a central location for

examination 3-6 months following surgery. The specific location was determined in consultation

with local health staff, taking into consideration the distance people could reasonably be expected

to travel. From across the two campaigns in Dafra, Dandé, and Dô, 20 patients (in addition to

those examined through surgical audit) presented at their designated location, representing

approximately 14% of the individuals who received surgery.

Initial implementation of these two activities has already yielded valuable lessons for the Burkina

Faso national program. While conducting two distinct activities has resulted in additional people

receiving a 3-6 month follow-up examination, reaching 100% of operated cases remains a

resource-intensive, logistically complicated endeavor. Decentralized surgical output during

campaigns compounds this difficulty, as the project must coordinate with the national program

to organize and staff a large number of “centralized” sites to prevent individuals from needing to

travel too far. Furthermore, ensuring technical supervision on surgical audit teams remains a

challenge, particularly when the presence of the same technical supervisors is also requested for

multiple campaigns that are happening during a short period of time. Within a context where

MMDP Project-trained surgeons are in high demand, the challenge of limited technical availability

is amplified when the same individuals are needed for surgical audit and outcome assessment in

addition to campaigns. In the second half of FY18, the project will continue to refine its

implementation of both activities, piloting adjustments with the goal to continue to increase the

number of people receiving 3-6 month follow-up using the resources available.

In the second half of FY18, follow-up of individuals who have refused surgery will be integrated

into surgical audit, when possible. As refusals are not currently documented in a way that

facilitates partner, including HKI, access to lists of refusals, the project will need to first explore—

in close collaboration with the national program—approaches to systematically share this

information.


STRATEGIC PLANNING

The project’s FY18 work plan did not include strategic planning activities for LF. However, based

on a request, the MMDP Project shared information on its hydrocele surgery training and

implementation activities with the World Bank funded-project in Burkina Faso. The National LF

Coordinator confirmed that the hydrocele surgery training activities conducted under the World

Bank project used the FASTT national trainers and the FASTT training package. The FASTT


cartridges were not available at the time of the training but have since been provided to the MOH

by the MMDP Project, for future hydrocele surgery trainings under the World Bank project.

ADVOCACY

There were no advocacy activities for LF included in the FY18 work plan.


During the reporting period, the project disseminated information about LF through local radio

stations, community health workers, and public criers. Radio messages were broadcast in French

and in local languages in the form of radio magazines and educational programs. In addition, public

criers and health workers delivered information at the village level. The messages delivered

included information on the availability of services for LF including hydrocele surgery dates,

availability of screening services, the source of funding for the surgeries, and who to contact for

more information.

CAPACITY BUILDING

No capacity building activities for LF were included in the FY18 work plan. However, as described

under the project’s global activities, in February 2018 Burkina Faso hosted the MMDP Project’s

FASTT training and evaluation. A total of five Burkinabe surgeons and one assistant (an

anesthesiologist) were trained in hydrocele surgery as part of this activity.


In FY18, the project continued supporting hydrocele case finding in the Center North region (six

districts) and the Hauts-Bassins region (five2 districts), as part of FY17 carryover activities. In

addition, in the context of the FASTT training and evaluation conducted in Burkina Faso, a case

finding activity was organized in one district in the Center South region to identify hydrocele

patients for the training.

In Burkina Faso, LF burden data on suspected hydrocele and lymphedema cases are routinely

captured by the health system at the health center level. Health centers register suspected cases

who are identified in the community by a CBHW or by health staff when a suspected case self-

presents at the health center. The health center then keeps information about these cases on file

at the facility but does not systematically transmit the information to other levels of the health

system. In districts targeted by the MMDP Project, the project requested these lists from the

health centers through the regional health bureaus. The cases identified using this approach are

considered “registered” and are summarized in Table 4 below.

In addition, to supplement the hydrocele burden data routinely collected by health centers in

targeted districts and to confirm hydrocele cases before surgery, the MMDP Project, through

health center staff and the CBHWs, requested that people with symptoms go to their nearest

2 Only four districts have a functioning operating room, but identified cases from the 5th district of N’dorola were

referred to the nearest facility providing project supported hydrocele surgeries.


health center for diagnosis, where hydrocele cases were confirmed by surgeons. The cases

confirmed using this method are also summarized in Table 4 below. In some districts, more

people self-reported at the health center than had originally been registered as suspected cases

through the routine health system.

Table 4. Results of project-supported LF case finding to date: FY17-FY183

Region District

Number of

suspected

cases of

hydrocele

registered by

health centers

Number of

hydrocele cases

confirmed by

surgeons during

project-supported

active case finding

Number of

suspected

lymphedema

cases

registered by

health centers

Center North Barsalogho 90 81 22

Center North Boulsa 156 131 201

Center North Boussouma 160 614

53

Center North Kaya 175 200

Center North Kongoussi 267 84 100

Center North Tougouri 230 180 113

Hauts-Bassins Dafra 10 22 22

Hauts-Bassins Dande 2 20 6

Hauts-Bassins Houndé 16 42 44

Hauts-Bassins N’Dorola 38 N/A5 68

Hauts-Bassins Orodara 22 20 174

Center South Saponé6 50 20 N/A

Total 1,216 661 1,003

3 The lymphedema cases presented in the table were registered during FY17, with data finalized in FY18. The hydrocele

cases presented in the table were registered and/or confirmed during FY17 and FY18. 4 Boussouma does not have a functioning operating room, so cases from that district are referred to Kaya. 5 In N’Dorola, burden data were only collected through the lists the project requested from health centers. As the district

did not have a functioning operating room for the project to conduct surgeries, the project did not send surgeons to this

location to confirm cases. 6 The burden data presented for Saponé is not representative of the entire district. The data were only collected from 15

health centers in the district, as the goal of the data collection was to identify a sufficient number of hydrocele cases for

the training of hydrocele surgeons as part of the FASTT evaluation, rather than to assess the full burden in the district.


HYDROCELE SURGERY

To date, hydrocele surgeries in Burkina Faso have taken place primarily in two regions under the

MMDP Project: Center North and Hauts-Bassins. These hydrocele cases are managed through

the routine health care system, with the MMDP Project providing assistance in case identification,

supervision, provision of drugs and consumables, as well as fees related to the surgical procedure.

Patients remained at the health center for an average of three days to monitor surgical wounds

and any potential complications. Post-surgical monitoring is described in the Monitoring &

Evaluation section.

In the Center North region, the project supported 268 hydrocele surgeries in the first half of

FY18. Combined with the 292 surgeries conducted during previous reporting periods, to date

the project has supported a total of 560 hydrocele surgeries in the region through the routine

health system and as part of hydrocele surgeon training sessions. Through this achievement the

project was able to operate all hydrocele cases identified and confirmed through its screening

activities.

In the Hauts-Bassins region, as of the end of FY17, the project had supported 56 surgeries through

the routine health system and as part of hydrocele surgeon trainings.7 A total of 104 people

received hydrocele surgery within the routine healthcare system during the reporting period,

representing all cases confirmed by the project in the region to date. In preparation for these

FY18 surgeries, the project reviewed the implementation of FY17 LF activities with the Hauts-

Bassins DRS. This review led to meetings with teams regarding delays in the execution of

hydrocele surgeries in the Hauts-Bassins region. For example, discussions with the teams revealed

the high demand for the limited number of sufficiently equipped operating rooms as a key

challenge. Following these meetings, the project worked closely with the national programs and

the DRS to ensure availability of operating rooms for MMDP Project surgeries. In addition, the

project worked with health center staff in the targeted districts to encourage suspected cases to

come to the health center specifically when a surgeon was available to confirm and operate cases.

An additional 13 surgeries were conducted in February 2018 in the district of Saponé (in the

Center South region) as part of the FASTT training and evaluation. Following the training and

evaluation, an additional seven surgeries were conducted with the remaining supplies, resulting

in a total of 20 project-supported surgeries in Saponé.

LYMPHEDEMA MANAGEMENT

Lymphedema management activities were continued in the Hauts-Bassins and Center North

regions as part of the extension of the DRS Hauts-Bassins and Center North FY17 FOGs into

FY18. The project completed its distribution of washing kits to the patients trained in

lymphedema management in FY17: 298 patients in Center North and 83 patients in Hauts-Bassins.

An additional 26 kits were provided to health centers for their activities. During Q1 of FY18,

follow-up visits of trained individuals took place as part of the routine health system. Specifically,

7 Although the FY17 APR reported 48 surgeries, additional data were reported by the national program after APR

submission.


CBHWs followed up in the communities with lymphedema patients who had received training

and kits from the project, and health center staff conducted follow-up when patients came to the

health center. To ensure these activities took place as planned, the MOH and MMDP Project

arranged periodic supervision visits, as described in the Supportive Supervision section.


Pharmaceuticals and consumables used during the reporting period were procured in FY17,

except for the purchase of lidocaine with adrenaline. In FY17, the project also procured materials

for hydrocele surgeon training, which were then shipped in FY18. 60 cartridges were shipped to

Burkina Faso. A portion of the cartridges was used during the MMDP Project’s FASTT training

and evaluation, the rest will be used for future FASTT trainings. FASTT consumables are procured

centrally by the MMDP Global team.


During the first half of FY18, a team of PNMTN staff accompanied by a regional surgeon and

MMDP Project staff periodically visited operating theaters in the targeted districts in Hauts-

Bassins and Center North regions. Since hydrocele surgeries take place through the routine

health system, supervision visits were scheduled on an ad-hoc basis. The MMDP Project

supervision checklist was not used for every visit, but the general principles of the checklist were

always followed. These visits made it possible to summarize accomplishments by operating

theater, congratulate the health center staff on their commitments, and document challenges

encountered during the management of hydrocele surgeries in the two regions. Supervision visits

also provided an opportunity to update the database of operated patients.

In addition, the MMDP Project team, along with national program and regional heath bureau staff,

supervised follow up activities of lymphedema cases in both regions during the first half of FY18.

As follow-up is conducted within the routine health system, the project was not able to

systematically supervise every patient follow-up visit; however, MOH and project staff periodically

arranged supervision visits to observe and support health staff as they conducted follow up as

part of their routine activities.

SHORT-TERM TECHNICAL ASSISTANCE

There were no short term technical assistance activities for LF conducted during the reporting

period.


In November and December 2017, the MMDP Project conducted a follow-up study of individuals

who received hydrocele surgery 6-12 months prior. For these surgeries, the project had already

collected, compiled, and analyzed follow-up data collected within five days of surgery, which

revealed extremely low rates of complications (approximately 2%). This additional six-month

follow-up was part of the project’s quality assurance measures, in line with WHO-recommended


indicators, to assess surgical outcomes. The project also included a quality of life, as perceived by

the patient, assessment component.

The study followed up with patients who had received hydrocele surgery through the project

between December 2016 and June 2017 (6-12 months prior). A total of 63 patients (37 in the

Center North and 26 in Hauts-Bassins) received surgery within this time period and were eligible

for follow-up. The project compiled and shared this list of eligible individuals with the health

facilities where the surgeries were performed. As the facilities already had the patients’ contact

information on file from the time of the surgery, facility nurses and local CBHWs contacted the

patients, and gave them a specific appointment time to come to the facility. CBHWs played a

valuable role in finding patients, using their networks if the person could not be reached by phone

or did not present at the health facility as requested.

All eligible patients were reached, except for one 80-year-old man who had died (unrelated to

the surgery). For the 62 individuals who came to the health facility for examination (36 in Center

North and 26 in Hauts-Bassins), the medical record was pulled from the facility files, and the

person was interviewed and examined. All clinical examinations were conducted by surgeons

who, in many cases, had traveled from regional hospitals to the facility specifically for this purpose.

Among the 62 examined, one patient (1.6%), who initially had a bilateral hydrocele, had

recurrence on one side and was invited back to the hospital for surgery. During the interview,

98% of patients expressed that they were very satisfied and/or would recommend the surgery to

others suffering from hydroceles. In addition, 98% of patients reported that they noticed

improvements in their ability to conduct daily tasks, and 97% confirmed improvements in their

social interactions.

For the hydrocele surgeries that took place in FY18, data from follow-up within five days are still

being transmitted from health facilities on a rolling basis and will be summarized in the Annual

Progress Report. In addition, the project worked with the national program to review and validate

data from the previous year’s LF activities. These data validation sessions were held in Center

North on September 25-27, 2017 and in Hauts-Bassins on October 2-3, 2017.

CROSS-CUTTING ACTIVITIES

NTD SECRETARIAT

The MMDP Project supported the Neglected Tropical Disease (NTD) Secretariat during the

reporting period by supporting telephone and internet services.

ENVIRONMENTAL MITIGATION AND MONITORING PLAN

Preferred infection control and medical waste management practices were utilized during the

management of hydroceles and TT surgery campaigns in Hauts-Bassins and Center North. Sharps

boxes, trash bags, autoclaves, and equipment for decontamination were used at health facilities

and surgery sites. When available, biomedical waste incinerators were used at health facilities,


and hydrocele-related waste was incinerated in accordance with WHO protocols for processing

of biomedical waste. When incineration equipment was not available, surgeons were responsible

for transporting the waste to a site with an incinerator for proper disposal. In October 2017, the

project submitted a revised Environmental Mitigation and Monitoring Report (EMMR) to USAID.

INTEGRATION WITH OTHER DISEASES

Case identification and referral within the health system took place for any hernia cases identified

during the hydrocele case confirmation.

HEALTH SYSTEMS STRENGTHENING

During the reporting period, the MMDP Project contributed to strengthening the health system

in Burkina Faso as follows:

• Leadership and Governance: The project’s support for leadership and governance

took the form of providing financial resources to the MOH to support its program in

FY18, through signing two FOGs with the Central Health Directorate (DGS) and the DRS

for the Center North and Hauts-Bassins regions.

• Service Delivery: The project’s support for delivery of trichiasis management services

and hydrocele surgery, and its establishment of routine quality assurance practices

accompanying these surgeries, help to strengthen Burkina Faso’s ability to deliver effective,

safe, high-quality interventions to people suffering from trichiasis and hydrocele.

• Health information: The project’s support of the national program’s management,

analysis, and sharing of monitoring and evaluation data related to disease management

activities will help to strengthen the MOH’s ability to manage trachoma and LF morbidity.

CHALLENGES AND LESSONS LEARNED

• Human resource constraints place significant time demands on a small pool of technical

staff who are needed to provide TT surgery, conduct technical supervision of surgeries,

and/or participate in post-operative follow-up. The project has responded to this

challenge by training additional surgeon trainers and technical supervisors, and by having

technical supervisors play a ‘double role’ of both operating and supervising during

campaigns with more limited staffing.

• Non-surgical resources are also in high demand, with the national program forced to

balance both the MDA and MMDP components of Burkina Faso’s trachoma elimination

activities. With so many post-MDA surveillance surveys that must be completed by the

end of June 2018, the national program has needed to put certain MMDP Project-

supported activities (e.g., TT-only surveys) as second-tier priorities.

• A current global shortage of lidocaine with adrenaline has made it difficult for the project

to procure the originally planned quantities. In response to this unforeseen shortage, the


project collaborated with the Trachoma TAB to develop a protocol for mixing lidocaine

and adrenaline, which is currently being reviewed by the national program and national

pharmacy staff.

• The length of time required to finalize and disseminate official trachoma survey results has

posed a challenge for the project, affecting the project’s ability to plan and implement

activities based on the most recent data. As coordinating the analysis and sharing of survey

data between the national program and Tropical Data can take a significant amount of

time, the project has found that strategic meetings bringing together key stakeholders in

person, such as a TAP, are the most successful in facilitating data sharing.

• The MMDP Project’s model of conducting hydrocele surgeries through the routine health

system has several important programmatic implications. First, the routine health system

has a finite capacity that cannot always meet the full demand for provision of surgeries

and post-operative care, particularly if other pressing medical issues must be addressed

by the facility at the same time. In response to this challenge, the project has learned that

close coordination and more frequent communication with the national program and

health facility staff can help ensure facilities prioritize using operating rooms for hydrocele

surgery, when appropriate.


Patient screening tools activity in Sirdjam village in Far North Cameroon, 2017. (Photo: William Nsai/Studio 3)

CAMEROON

• In preparation for its first trichiasis campaign of FY18 the MMDP Project held a refresher training and debriefing session for three TT surgeons, trained six health area nurses and district staff in campaign management, and trained 249 community outreach workers in social mobilization strategies.

• Post-operative follow-up of individuals 3-6 months after trichiasis surgery was conducted in two districts, reaching 67 people.

• The MMDP Project supported hydrocele surgery and post-operative follow-up for 58 individuals.


IN BRIEF

In the first half of FY18, the MMDP Project engaged in strategic planning, advocacy, social

mobilization, capacity building, and disease assessment activities for trachoma and lymphatic

filariasis (LF) morbidity management and disability prevention (MMDP).

Related to trachoma, key activities during the reporting period included trainings for surgeons,

health area nurses, and community outreach workers. The project also held a series of advocacy

meetings with key district, regional, and national stakeholders. These activities were conducted

in preparation for the first campaign of the fiscal year, scheduled for April 2018 in Touboro

district in the North. In addition, post-operative 3-6 month follow-up visits took place for the

two trachomatous trichiasis (TT) campaigns conducted in FY17. The results from this follow-up

will be used to shape TT surgeon refresher trainings later in the year. The project also

contributed to Cameroon’s assessment of trichiasis burden through implementation of a TT-only

survey in Mada district, and by supporting coordination between the national program and World

Health Organization (WHO) to make available Tropical Data’s analysis of prior trachoma survey

results.

For LF morbidity management, the project continued to provide support for hydrocele surgeries,

with 58 surgeries conducted. The project completed all planned surgeries and associated five-day

post-operative follow-up by the end of Q1. The project also participated in the national program’s

annual national evaluation and planning meeting for integrated control of Neglected Tropical

Diseases (NTDs), held in February, which included initial discussions of an integrated strategic

plan for the morbidity management of all NTDs, including LF and trachoma.

PROGRAM BACKGROUND

TRACHOMA

Cameroon has three regions that have not met elimination criteria for trachoma: the North, Far

North, and Adamaoua. In 2016, the trichiasis data collected in the North and Far North during

2010-2012 baseline mapping was standardized by age and sex, resulting in a significant reduction

of the estimated country backlog as compared with baseline projections. Standardization of

Adamaoua region baseline trichiasis data is still pending (see Assessing Disease Burden section).

When the MMDP Project began providing TT surgeries in FY16, the national remainder against

the Ultimate Intervention Goal (UIG) was estimated to be 3,421 TT cases nationally: 2,471 in the

Far North,8 808 in the North, and 142 in Adamaoua. However, following the completion of 2017

Trachoma Impact Surveys (TIS) in 13 districts in 2017, and the implementation of two TT-only

surveys (one in 2016 and one in 2017), the country’s UIG estimates are currently under revision.

While the national program has not yet released new estimates, the preliminary data made

8 This figure reflected the estimated UIG after taking into consideration the TT surgeries that Sightsavers had supported

in the Far North prior to the start of the MMDP Project.


available to the project suggest potentially higher revised UIGs of closer to 3,351 in the Far North

and 1,752 in the North, with the Adamaoua data updates still pending.

In the North region, the project has consistently targeted Poli and Touboro districts since FY16.

These districts were two of the three districts with TT prevalence above the elimination

threshold at the start of the MMDP Project. Following the project’s provision of intensive

trichiasis management services, each district conducted a new epidemiological survey (a 2016 TT-

only survey in Touboro and a 2017 TIS in Poli). However, the preliminary survey results showed

both districts to be above the WHO threshold for elimination, thus warranting further project

intervention in FY18. The project is tracking geographic coverage of TT management services in

the two districts as interventions are ongoing.

In the Far North region, in FY16 the MMDP Project supported two TT outreach campaigns in

the district of Mokolo, one of the four districts that had a remaining UIG at the start of the

project. The campaigns resulted in 267 people operated or otherwise made known to the health

system. The project did not support any campaigns in FY17 given pending 2017 TIS surveys. Based

on the preliminary data recently made available to the project, currently seven districts are

estimated to have a remaining UIG. In the second half of FY18, the project is targeting one of

these districts, Meri, which has a UIG of approximately 935. The preliminary 2017 TIS data for

Meri estimated a UIG of 1,020, but Sightsavers has conducted an estimated 85 surgeries since the

survey. For a summary table of MMDP Project-supported progress towards the UIG, see

Appendix A (Tables A1 and A2).


Mapping in Cameroon for LF between 2010 and 2012 determined that 158 of the country’s 181

health districts were endemic. Since then, more than 80% of endemic districts have successfully

interrupted transmission of LF. However, data on LF morbidity in Cameroon are limited and

inconsistent, highlighting the need for a national plan to identify and manage LF morbidity cases

with high quality services. Given the MMDP Project’s focus on the North and Far North regions

for trichiasis activities, the project selected these regions to pilot hydrocele surgery and

lymphedema management training activities in FY17. The goal of the pilot was to determine key

strategies and lessons learned for providing LF MMDP services, to ultimately contribute to a

national strategic plan for LF elimination in Cameroon. This pilot included five districts: two in

the North (out of 15 LF-endemic districts in the region) and three in the Far North (out of 28

LF-endemic districts in the region).

The project initially selected its pilot districts based on the amount of suspected hydrocele and

lymphedema cases identified during FY16 pre-transmission assessment surveys, which the project

used as a platform for LF burden data collection in close collaboration with the ENVISION

Project. Before beginning disease management activities, the project designed and implemented

enhanced hydrocele and lymphedema case finding activities to refine burden estimates prior to

delivery of services. This case confirmation identified more hydrocele and lymphedema cases in


the pilot districts than could be addressed through the project’s provision of services. The project

has provided hydrocele surgery to 95 of the 300 cases identified through its enhanced case finding

(with 58 of these surgeries conducted during the reporting period); in FY17, the project trained

112 of the 148 identified lymphedema cases in self-care. As the scale of the pilot was not designed

to address the full disease burden across all five targeted districts, the remaining cases have been

shared with the appropriate health system staff for follow-up outside of the project. For a

summary table of the MMDP Project’s LF disease management achievements to date, in relation

to current burden estimates, see Appendix A (Tables A5-A6).


TRACHOMA

STRATEGIC PLANNING

During the reporting period, MMDP Project staff participated in strategic planning meetings

related to national evaluation and planning for the integrated control of NTDs. In January 2018,

the project attended a national-level coordination meeting organized and funded by the national

program. The meeting was held to prepare for a larger three-day national evaluation meeting in

February funded by ENVISION. That meeting brought together all the key actors involved in the

implementation of NTD control activities in Cameroon, including NTD control program

managers (onchocerciasis, LF, trachoma, schistosomiasis and intestinal worms),

WHO/Cameroon, representatives from partner non-governmental organizations (NGOs)—HKI,

Accelerating Integrated Management (AIM), Sightsavers, International Eye Foundation,

PersPectives, Good Neighbors, and FAIRMED—and regional health delegates. The main objective

of the meeting was to evaluate activities carried out in FY17 and discuss an action plan for FY18;

presentations included an overview of NTD activities implemented in each region. During the

meeting, the national program introduced AIM as the lead for the development of an integrated

strategic plan for the morbidity management of all NTDs, including LF and trachoma. It was noted

during the meeting that it would be important for AIM to involve other relevant stakeholders in

the development of the plan. Once a first draft is available, key partners, including HKI, will be

closely involved in the review. At the time of reporting AIM was still working on the draft.

Furthermore, during the second half of the project year, the project will contribute to the

integrated strategic plan by sharing lessons learned from its FY17 pilot of LF management

activities.

ADVOCACY

Advocacy activities during the reporting period included district- and regional-level advocacy

meetings. District-level meetings were held in February 2018 with administrative, religious, and

traditional authorities in the Touboro district prior to the TT surgery campaign scheduled for

April 2018. During the meetings, authorities were informed of campaign objectives, the schedule

of the surgical teams, and how they could support field activities. As a result of these meetings,


local authorities pledged to send public releases to all the heads of villages asking them to provide

any assistance needed for the implementation of TT campaigns, especially the mobilization of

community members. This assistance could take the form of helping to spread sensitization

messages through local channels, including churches, mosques, and markets, to encourage people

to attend the community meetings. Similar meetings were held at the regional level with the new

North regional delegate, regional governors, and regional-level religious and civil authorities (who

committed to sending letters supporting project activities to their district-level counterparts).

Approximately 52 people attended these district- and regional-level meetings.


During the reporting period, information, education, and communication (IEC) tools and

materials that were developed and used in the 2017 campaigns were reproduced for the two

FY18 campaigns that will take place in the North. The project delivers these materials to the

regional delegate’s office, which in turn distributes them to health centers at the district level to

disseminate them to the appropriate individuals in the community. The remaining social

mobilization activities, including radio spots and community meetings, will begin in Q3.

Table 5. IEC/social mobilization materials messages produced with USAID funding

Type of

material

Brief description of material Target

audience

Quantity

Posters A2 format (59.4 x 42 cm): they include images of TT cases

and awareness messages inviting community members to

be screened for free treatment. The posters were hung in

each village at locations where people gather, including

markets, public wells and places of worship.

Community

members

1,500

Flyers A5 format (14.8 x 21 cm): they include images of TT cases

and awareness messages inviting community members to

be screened for free treatment. The flyers were

distributed at the household level.

Community

members

18,000

Fact

sheets

A5 format (14.8 x 21 cm): fact sheets with awareness

messages for community outreach workers to distribute.

Outreach

workers

500

CAPACITY BUILDING

During the reporting period, a two-day refresher/debriefing session for three TT surgeons and a

TT surgeon assistant in the North was held in March 2018. This session did not include HEAD

START as the surgeons had already participated in a successful HEAD START refresher session

in FY17. Results from supportive supervision (in FY17) and 3-6 month post-operative follow-up

(in FY18) further confirmed that HEAD START was not necessary, and that the training should

focus on TT case management, including the importance of standardizing pre-operative

counselling messages; assessing the level of correction “on the table”; health care waste

management; and providing supportive supervision specifically of nurses and health care workers

during TT campaigns.


In addition to the refresher/debriefing session for surgeons, the project organized trainings of

health area nurses and community outreach workers. The two-day health area nurses training

was held in March. Four health area nurses and two staff from the Touboro health district

participated. Health area nurses are responsible for organizing all campaign activities at a health

center. This includes holding community meetings, training community outreach workers,

monitoring social mobilization activities, and helping with the actual surgery process. The training

was based on key training manuals recommended by the International Coalition for Trachoma

Control and included aide memoires developed by the MMDP Project in FY17 as support

materials. The training covered surgery site organization, pre- and post-operative training, and

post-operative monitoring. In addition, the project reviewed and analyzed the data collected

through supportive supervision activities to date and tailored the refresher training to focus on

topics identified as areas for improvement. As a result, the training emphasized preferred

practices related to patient counseling, patient flow management, infection control, and

management of biomedical waste.

The community outreach workers training consisted of four sessions held March 8-10 in the

health areas of Mbang Ray, Dompta, Djom, and Mafare, which are targeted for surgery campaigns.

A total of 249 community outreach workers were trained in Touboro district. The main objective

of the training was to provide community outreach workers with the skills required to implement

social mobilization and sensitization activities. More specifically, the trainees learned how to

disseminate the following information in very simple terms in local languages: symptoms of

trachoma, risks associated with TT, and the advantages and availability of TT surgeries. They were

also trained in the mobilization, counselling, and referral of people for post-operative

appointments. The trainings were led by the health area nurses previously trained by the project.

The methodology used consisted of plenary discussions, group discussions, and role-playing.

Supervision of the activity was provided by joint teams of staff from HKI and the Regional

Delegation from the North.


In the first half of FY18, the project supported the National Blindness Prevention Program

(PNLCé) to update Cameroon’s trichiasis disease burden data in several key ways. While data

discussions with the national program have been ongoing throughout the life of the project, the

release of updated data in recent months, as described below, highlights the significant progress

that was achieved during the reporting period. Collectively, these updated data sets will inform

the PNLCé’s ongoing planning for elimination and contribute significantly to the preparation of

Cameroon’s upcoming Trachoma Action Plan (TAP), to be held in the second half of FY18.

In Q1 of FY18, the MMDP Project supported a TT-only survey in Mada district in the Far North,

collaborating closely with the PNLCé and WHO’s Tropical Data. Mada was selected for a TT-

only survey because the district’s TT data had not been updated since its 2010 baseline survey,

as its initial TF prevalence was not high enough to trigger MDA activities. Updating the initial

baseline TT prevalence (of 0.40% among the total population) enables the PNLCé and MMDP

Project to determine whether intensive TT management activities are still needed in the district


to achieve elimination. Although the TT-only survey was targeted in the project’s FY17 work

plan, a Tropical Data-certified trainer was not confirmed until the very end of FY17. Therefore,

the survey took place in the first quarter of FY18. In October 2017, the project supported the

PNLCé in its collaboration with Tropical Data to develop a protocol for the survey, and in

November 2017, supported a TT-only survey training of eight graders and eight recorders. The

survey team engaged in data collection throughout the month of November, under MOH and

MMDP Project supervision. The project also liaised extensively with the PNLCé and WHO to

facilitate access to, and dissemination of, Tropical Data’s analysis of the survey data. These results

showed an age-and sex-standardized TT prevalence of 1.26%, indicating the need for intensive

TT management services. The project, therefore, chose to move forward with the two Mada TT

campaigns tentatively planned in Cameroon’s FY18 work plan.

Also during the reporting period, the project facilitated collaboration between the Cameroon

PNLCé and WHO to share Tropical Data’s final analysis of TT-only survey results from Touboro

district. Although the MMDP Project completed this TT-only survey in October 2016, the project

was only able to access preliminary results during FY17. The final results were made available to

the project in January 2018 and indicated a TT prevalence of 0.77%. During this same time period,

the project supported the PNLCé to access an additional data set: Tropical Data’s analysis of the

TT prevalence data generated by the 2017 TIS.

Finally, the project has been supporting the PNLCé in requesting Tropical Data’s retrospective

analysis of three additional data sets—Adamaoua region’s baseline survey results, the 2014 TIS

results, and the 2015 TIS results—to have data standardized by age and sex. The project provided

assistance developing a data dictionary for the Adamaoua baseline data, which was finalized and

shared with the PNLCé in January 2018. Once the Adamaoua baseline data are age and sex

standardized, the project will assess whether two TT-only surveys will take place in the region

as tentatively planned in the FY18 work plan.


There were no TT surgery campaigns during the reporting period. The first TT campaign is

planned for April 2018 in Touboro district in the North region.


Procurement during the reporting period involved primarily:

• Pharmaceuticals for TT surgery: Pharmaceuticals were purchased via the USAID-

approved wholesaler (IMRES). The only exception to this was lidocaine with adrenaline,

which was not available by any USAID-approved wholesaler; therefore, HKI procured the

item with private funds. To ensure the quality of lidocaine with adrenaline procured locally

in-country, the team purchased them from the national pharmacy, which follows the

national drug guidelines and management in Cameroon.

• HEAD START surgical simulator parts: HEAD START consumables were procured

centrally by the MMDP Project global team. During the reporting period, eight orbits and


100 eyelids were shipped to Cameroon for use during the upcoming surgeon refresher

training in the Far North.


Joint teams from HKI and the North Regional Delegation supervised both the health area nurse

training and the community outreach worker training that took place in Touboro. The goal of

this supervision was to verify the effectiveness and quality of the training sessions. Specifically,

supervisors ensured that the appropriate cadre of health worker attended each training, topics

and content covered aligned with the training objectives, and trainers used the appropriate

methodology (including hands-on and role-playing exercises). Supportive supervision of TT

management activities will be conducted as part of routine campaign activities in the second half

of the fiscal year.


During the reporting period, Dr. Amir Bedri Kello provided support to the national trainers to

develop a tailored refresher training plan for the refresher/debriefing session for TT surgeons in

the North (see Capacity Building section). Due to the security situation, which prevented external

consultants from traveling in the region, Dr. Bedri provided this technical support remotely. He

participated in skype sessions with the project team, and reviewed and analyzed surgeon

performance data to help develop the refresher training plan. Dr. Bedri also began working

remotely with the national trainers to develop a training plan for a Q3 training of TT surgeons in

the Far North.


The project began the fiscal year by supporting 3-6 month follow-up for the two TT campaigns

conducted in FY17. As described in the FY18 work plan, the project is shifting its approach to 3-

6 month follow-up by working to incorporate both outcome assessment and surgical audit as

two distinct activities. In the low-burden context of Cameroon, however, recent campaigns have

not yielded a sufficient number of surgeries to enable auditing at least 20 patients per surgeon, as

is the current preferred practice for surgical audit. To address this challenge, the project is

employing an integrated approach incorporating both surgical audit and outcome assessment

principles. In line with the surgical audit principle of objectivity, a technical supervisor provided

oversight to ensure surgeons accurately assessed and reported complications, and to use the

activity as an opportunity for surgeon learning. In keeping with the objective of outcome

assessment, which aims to provide a 3-6 month exam to 100% of people receiving surgery, all

operated cases were invited to return to a centralized location—in this case, a health center—

to receive a follow-up exam. The follow-up team then sought out those who did not come to

the health center.

In October 2017, the project conducted 3-6 month monitoring in Poli district. A total of 34

people received surgery in FY17 as part of the project’s May 2017 campaign. The follow-up team

attempted to reach all of these individuals and was ultimately able to find and examine 26 people


(76% of those receiving surgery). During March 15-21, 2018, the project supported another

follow-up activity in Touboro district, where the project had held its second and final FY17

campaign in September 2017. Forty (74%) of the 54 people who received surgery during that

campaign were examined by the follow-up team. Out of the 40 individuals examined during this

activity, 25 people (63%) arrived at the health center, while the remaining 15 people (38%) were

found and examined in their homes. This experience indicates that inviting individuals to return

to a health facility is a feasible approach to reaching cases 3-6 months after surgery, but further

outreach—and possibly home visits—remain necessary to ensure 100% of cases receive this

critical follow-up examination. During FY18 campaigns, the project will build off this experience

to refine its strategies for following up with those receiving surgeries, with the dual goal of

reaching as many people as possible and systematically auditing the performance of all surgeons

operating under the project. As additional follow-up activities are conducted, the project will be

able to better compare the data collected at health centers with the data collected in cases’

homes, in order to identify any trends in outcomes and to gauge the effectiveness of various

strategies for encouraging cases to self-present at a health facility.

Based on indications of relatively low complication rates from these two follow-up activities, the

project determined in collaboration with the PNLCé that additional training on HEAD START

was not needed in the North prior to the start of FY18 campaigns. However, the project will

continue to closely monitor the performance of surgeons throughout the rest of the fiscal year,

recommending additional practice on HEAD START if needed.

In addition to these quality assurance activities, following the FY18 release of updated TT

prevalence data in select districts (see the Assessing the Disease Burden section), the MMDP Project

began supporting the PNLCé to organize TT data in advance of the upcoming workshop to

develop a national TAP. To inform the discussions planned during this workshop and to support

the PNLCé in preparing its trachoma elimination dossier, the project has begun compiling the TT

data that will be needed as part of dossier submission, using the WHO template. The project

aims to discuss these data with the PNLCé and Sightsavers early in Q3, in advance of the TAP.

Finally, prior to the first TT surgery campaign of FY18, the project made minor updates to its

data collection tools. Several registry updates were made to address issues raised in FY17, such

as the need to clarify which eye is referenced when post-operative signs and symptoms are

recorded. The project also adapted its data collection processes to ensure the appropriate data

continue to be captured as the project’s strategies, particularly those for case finding, continue

to evolve. Recent changes also included updating the geographic coverage tool so that it reflects

the administrative re-organization of health areas within project districts that took place at the

end of FY17. The project will continue to monitor coverage of TT management services during

all FY18 campaigns.



STRATEGIC PLANNING

During the reporting period, the project participated in the annual national evaluation and

planning meeting for integrated control of NTDs, as described above in Trachoma Strategic

Planning. Based on the content of the yet-to-be-drafted AIM’s integrated strategic plan for the

morbidity management of NTDs, the MMDP Project will adapt its FY18 work plan activities to

support the national program in developing priority actions and drafting a strategic plan for LF

morbidity management accordingly.

ADVOCACY

There were no advocacy activities for LF included in the FY18 work plan.


There were no social mobilization and behavior change activities for LF included in the FY18

work plan.

CAPACITY BUILDING/TRAINING

There were no capacity building activities for LF included in the FY18 work plan.


There were no disease burden assessment activities for LF included in the FY18 work plan.

HYDROCELE SURGERY

A total of 58 people received surgery in Q1 of FY18 across five districts in the North and Far

North. Surgeries were performed in Ngong and Bibemi health centers in the North, and Kar-

Hay, Kaele and Guidiguis health centers in the Far North. During the reporting period, the health

district hospital, where surgeries took place, coordinated with the district’s health centers to plan

surgeries for confirmed cases. Confirmed cases had been identified during community meetings

held in FY17. Their diagnosis was first confirmed by a health area nurse, then officially confirmed

by a surgeon. Once a schedule with surgery dates and times had been established for Q1 of FY18,

the health centers worked closely with community outreach workers to communicate the

appointments to the confirmed cases, who arrived at the hospital the evening before their surgery

to check in and start the pre-operative case management process.


There were no lymphedema management activities included in the FY18 work plan.


There were no commodity supply management and procurement activities for LF included in the

FY18 work plan.



The hydrocele surgeons trained in June 2017 received close technical supervision during the

hydrocele surgeries conducted in September 2017. In this first phase of surgeries, a FASTT master

trainer observed each surgeon, providing technical supervision and targeted technical feedback.

Once the surgeons demonstrated sufficient improvement in the areas identified, they

independently conducted surgeries from October to December 2017, with non-technical

supervision carried out jointly by HKI and Regional Delegation teams. This non-technical

supervision included ensuring the required consumables and drugs were available, that data was

collected properly, and that patients were not required to pay for the project-supported surgery.

SHORT TERM TECHNICAL ASSISTANCE

There were no short term technical assistance activities for LF included in the FY18 work plan.


Beginning in FY17, the project supported hydrocele surgeries in the five district hospitals of

Ngong, Bibemi, Kaele, Guidiguis, and Kar-hay. As described in the Hydrocele Surgery section, a

portion of these surgeries initially planned for FY17 were carried out in the first quarter of FY18.

As part of this hydrocele case management, the project continued to support health staff to

conduct post-operative follow-up within five days of surgery. To ensure high quality of data

reported by district hospitals, the MMDP Project organized on-site review of the raw data

collection forms, cross-checking various forms against each other and working with hospital staff

to address any inconsistencies. Of the 95 patients receiving project-supported surgery in FY17

and FY18, 100% received follow-up within five days following surgery. In total, nine of the 95

patients were diagnosed with complications within five days post-surgery. Additional care was

provided to all patients with complications, and they were kept under observation at the hospital

until the complications were resolved.

Prior to the start of the surgeries, the project conducted an “Obstacles to Surgery” study in

September 2017. The survey was integrated into the case identification activity described in the

Hydrocele Surgery section, in the districts of Bibemi (North region) and Kar-Hay (Far North

region). The survey sought to identify potential obstacles that may prevent individuals from

seeking or receiving hydrocele surgery. During the reporting period, the project synthesized and

analyzed the data. In summary, a total of 86 individuals were interviewed about their knowledge

of health facilities that provide hydrocele surgery, means of transportation to these facilities, and

initial thoughts on the costs and other factors that could influence the decision to have surgery.

Less than one third of the respondents (31%) said they would be capable of covering all costs

associated with the surgery. Of the remaining 59 respondents, 44 (51%) reported that they would

be able to cover only those costs related to transportation and food associated with the

surgery—leaving 15 people (17%) who reported being unable to support any of the costs. In

addition, some respondents identified fear as a potential obstacle—specifically, fear of erectile

dysfunction or of becoming sterile following surgery, fear of dying or the operation hurting, or

fear of how others might perceive them after the surgery. Key findings from the report will be

shared with LF stakeholders, including the MOH, to inform the country’s strategic planning.



NTD SECRETARIAT

As discussed in the Trachoma Strategic Planning section above, the project participated in two

central-level meetings during the reporting period. During the meetings, participants reviewed

FY17 NTD activities, including those of the MMDP Project, and developed detailed

implementation plans for FY18 activities.


Preferred infection control and medical waste management practices were utilized during the

hydrocele surgeries conducted in five districts in the North and Far North. All the health facilities

used biomedical waste incinerators, and hydrocele surgery-related waste was incinerated in

accordance with WHO protocols for processing of biomedical waste. In October 2017, the

project submitted a revised Environmental Mitigation and Monitoring Report to USAID.

Data collected through supervision visits conducted during a previous TT campaign and related

to infection control and health care waste management were analyzed. Specific issues and

challenges observed (such as nonsystematic segregation of contaminated and non-contaminated

waste in the operating room, or related to sterilization process) were discussed and reviewed

during the refresher training for TT surgeons and the training for nurses organized prior to the

first campaign planned for April FY18.


Case identification and referral within the health system took place for any hernia cases identified

during the hydrocele case confirmation.


In FY18, the project contributed to strengthening the heath system in Cameroon as follows:

• Leadership and Governance: MMDP Project support for leadership and governance

took the form of providing financial resources to the MOH to support its program in

FY18, through the signing of two FOGs with the PNLCé and the Regional Health

Directorate (DRS) for the North region.

• Health workforce: The project’s training of surgeons and health area nurses contributes

to further human resource development of the health system staff in Cameroon. The

supportive supervision activities provided under the TT and LF programs also contribute

to strengthening health workforce capacity.

• Health information: The project’s continuous collaboration with the national program

to share monitoring and evaluation data related to disease management activities, and to

access updated survey data assessing the trichiasis disease burden, will help strengthen

Cameroon’s health information system and inform future MOH planning.



• The security situation in Cameroon continues to present a challenge to project activities,

limiting the ability of consultants to provide support in the areas targeted during TT

campaigns. To ensure continued support and oversight of training and capacity

strengthening activities, the project supported Dr. Amir’s provision of remote technical

assistance for the Q2 Touboro trainings and is continuing to explore how this remote

support can be effectively used to support additional project activities.

• The project has found that coordinating with multiple points of contact across the national

program and Tropical Data to share the latest trachoma survey data can take a significant

amount of time. The project has learned that strategic meetings that bring all the key

stakeholders together in person, such as a TAP, are the most successful in facilitating

sharing of data.

• The MMDP Project’s model of conducting hydrocele surgeries through the routine health

system means working with a limited human resource pool. For example, MMDP Project-

trained nurses were sometimes not available during all phases of project activities. In

response to this challenge, the project has learned that close coordination and more

frequent communication with the national program and health facility staff can help ensure

that project-trained staff are available for the pre- and post-operative care that

accompanies hydrocele surgery. In addition, the project will continually assess the

availability of trained human resources and determine any additional training needs.

• Hospital staff should be closely involved in hydrocele surgery planning activities, including

scheduling of surgeries, to ensure that patient beds are available for all operated patients

until discharge, with a provision for extra time for potential complications.

• The results of the “Obstacles to Surgery” study in Cameroon reveal that the most

important barrier to patients seeking surgical care is cost. This information will be taken

into consideration in the background information used to prepare the country’s strategic

plan of action.


Physician confirming hydrocele condition as part of a hydrocele surgical camp in Ginir hospital, Bale Zone, Oromia,

Ethiopia, 2017. (Photo: Abrham Tilahun/Lael Photo and Video Art)

ETHIOPIA

• Despite insecurity during the reporting period, a total of 185,813 people were screened and 10,609 people received trichiasis surgery through static sites, outreach campaigns, and dedicated mobile teams.

• The MMDP Project supported 86 hydrocele surgeries and trained 717 people with lymphedema in self-care.

• The MMDP Project adapted implementation strategies to respond to insecurity in project areas through the innovative use of trichiasis surgery minicamps.


IN BRIEF

In the first half of fiscal year 2018 (FY18), the MMDP Project supported the Federal Ministry of

Health (FMOH) to advance its commitment for morbidity management activities through the

adoption of national guidelines and policies. In December 2017, the FMOH adopted national

guidelines for supportive supervision, surgical audit, and outcome assessments to monitor the

quality of trichiasis (TT) surgery. These guidelines ensure a minimum standard in conducting these

activities, to ensure quality services are provided to the people of Ethiopia. Additionally, the Head

of the Oromia Regional Health Bureau (ORHB) wrote a letter to the region’s hospitals, health

centers and health posts stating that free treatment for hydrocele and lymphedema should be

provided to all patients needing these services. This letter was a result of an MMDP Project-

supported meeting in February 2018 to review progress made towards providing services to

hydrocele patients and to plan services in Oromia for the upcoming months.

In addition to these positive leadership steps by the FMOH and ORHB, a few challenges also

arose. In Oromia, the primary challenge was insecurity, which disrupted all health programming

and made planning TT surgery camps difficult or impossible in some areas, particularly in Borena,

Bali and West Harerghe zones. Months of protests and unrest culminated in the declaration of a

state of emergency on February 17, 2017 following the resignation of the Prime Minister.

However, despite the insecurity, Fred Hollows Foundation (FHF) closely monitored the situation,

and when local situations were calm, implemented surgical activities. By doing this, FHF reached

96% of their trichiasis surgery target for the reporting period.

In Tigray, the main challenge to the MMDP Project was an ophthalmic clinical officer’s training

course that recently began at Mekelle University. Of the 17 active TT surgeons in MMDP Project

areas, five enrolled in this training course to further their careers. To counter this, Light for the

World (LFTW) proposed a new activity to train more TT case finders to sweep house-to-house,

ensuring a more efficient use of the remaining TT surgeons’ time during outreach. In addition,

LFTW held discussions and made an agreement with Mekelle University to utilize the TT surgeons

enrolled in the training on weekends, following the case searches during the rest of the week.

This approach appears to be working well, as numbers of surgeries have increased each month

since this strategy was implemented. Overall, despite this difficulty, LFTW reached 76% of its

target for the reporting period.

For lymphatic filariasis (LF) activities, RTI focused on two areas: 1) planning and mainstreaming

activities and 2) supporting the Gambella region to begin implementation of hydrocele surgery

services. RTI supported the planning meeting in Oromia discussed above and organized a meeting

with several universities to discuss mainstreaming the Filaricele Anatomical Surgical Task Trainer

(FASTT) surgical simulator into the medical colleges’ skills laboratories. This proposal was met

positively by the participants, and the project will further efforts to this end in the remaining half

of the fiscal year. For hydrocele service provision, RTI, in partnership with the Surgical Society of

Ethiopia (SSE), provided refresher training to six surgeons and integrated emergency surgical

officers (IESOs) in three hospitals in Gambella. During the reporting period a total of 86 hydrocele

surgeries were conducted.


PROGRAM BACKGROUND

TRACHOMA

Ethiopia’s national backlog of TT cases was estimated by the World Health Organization (WHO)

at 693,037 individuals in March 20169. The FMOH committed to addressing the entire backlog

through the “Ethiopian Initiative to Clear the TT Backlog: Fast Track to the Elimination of Fast

Track Initiative.” With support from numerous partners, the FMOH and respective regional

health bureaus (RHBs) of Amhara, Oromia, Tigray, and Southern Nations, Nationalities and

Peoples’ (SNNP) regions have begun implementing this initiative. The USAID-funded MMDP

Project supports the regions of Oromia and Tigray. Based on the ultimate intervention goal (UIG)

data in the 2015 National Trachoma Action Plan (TAP), the MMDP Project plans to address 11%

of the overall UIG in the country. During the reporting period, the project10 reached cases from

142 woredas (113 in Oromia and 29 in Tigray). (see also Appendix A, Tables A1 and A2):

• In Oromia, baseline mapping estimated more than 200,000 TT cases in the whole region;

the MMDP Project-supported area spans ten of twenty zones with an estimated UIG of

54,782 at the beginning of the project11. In the first half of FY18, the project reached 8,342

persons with TT surgery; combined with the FY16-17 output, a total of 35,046 individuals

have been operated (64% of the estimated UIG)12.

• In Tigray, the MMDP Project is targeting 31 woredas across five zones in FY1813. At the

start of the project, the estimated UIG was 22,272. In FY18, 2,267 individuals have been

operated to date; cumulatively, over the course of the project, 17,194 individuals have

received surgery, or 77.2% of the estimated UIG14.


Initial country-wide mapping to measure LF endemicity was conducted in 2013, then updated in

2015 with confirmatory remapping of select woredas that identified 70 woredas as LF-endemic.

In 2017, redistricting resulted in one additional LF-endemic woreda, bringing the total number to

71. Since mapping did not establish the LF morbidity burden for each of these woredas, the

9 http://www.trachomacoalition.org/GET2020/ 10 The MMDP Project currently supports 131 woredas in Oromia (increased from 115 in the FY18 work plan due to

redistricting) and 31 in Tigray. It should also be noted that cases operated during the reporting period came from four

woredas not designated as MMDP Project-supported areas in Oromia. These four woredas are accounted for in the 142

woredas. 11 Due to redistricting that occurred during FY17, the number of zones increased from eight to ten. 12 A total of 38,488 individuals have been operated or otherwise made known to the health system in Oromia (managed

through epilation, referred, or refused), which is approximately 70.3% of the UIG; however, Ethiopia only utilizes persons

operated when calculating progress against the UIG. 13 As described in the FY18 work plan, LFTW has expanded to the non-urban areas of the six woredas of Mekelle, which

increased the number of woredas receiving project support from 25 woredas spanning four zones to 31 woredas spanning

five zones. 14 A total of 17,900 individuals have been operated or otherwise made known to the health system in Tigray, which would

equal approximately 80.4% of the UIG reached, should Ethiopia begin to utilize these figures in its calculations.


FMOH established a goal of conducting burden assessments in all LF-endemic woredas by 2020.

The MMDP Project has supported burden assessments in 36 (51%) of these woredas.

Prior to MMDP Project activities, LF morbidity management activities had only been conducted

in a small percentage of the country’s LF-endemic woredas. Since FY17, the MMDP Project has

targeted nearly half of the country’s total endemic woredas for hydrocele surgery and

lymphedema management activities (see Appendix A, Tables A5 and A6). The woredas targeted

in FY18 span three regions: Beneshangul-Gumuz, Oromia, and Gambella. In the project’s fourth

region, Tigray, all known hydrocele cases received project-supported surgery in FY17. The 86

hydrocele surgeries conducted to date in FY18, combined with the 417 conducted in FY17,

represent approximately 34% (503/1,492) of the total hydrocele surgery needs in these four

regions as estimated by the burden assessments. However, to date, only 14% of the FY18 target

has been reached. The 650 individuals with lymphedema trained in self-care in FY18, combined

with the 599 trained in FY17, represent roughly 127% of the cases targeted by the project as part

of the feasibility study and 7% (1,249/17,586) of the total estimated number of cases (see

Lymphedema Management section below).


TRACHOMA (Oromia)

STRATEGIC PLANNING

Zonal IECW TT surgery performance review and planning meeting

The objectives of the Integrated Eye Care Workers (IECW) performance review and planning

meetings were to review the progress of TT surgery performance, identify major

accomplishments and challenges, learn from the previous period’s work, and develop plans for

the remaining period. These meetings were supported by FHF through institutional funding.

The review and planning meetings provided an opportunity to assess the progress of TT surgery,

identify associated problems and develop an action plan for the subsequent performance periods.

TT surgery performance in the selected woredas were presented and discussed at each meeting.

These meetings were planned to be implemented in the 10 MMDP Project-supported zones for

530 participants with an average number of 53 participants in each zone. The participants included

RHBs Neglected Tropical Disease (NTD) team, Zonal Health Department (ZHD) heads and

NTD focal persons, ICEWs, Primary Health Care Unit (PHCU) Directors where IECWs are

stationed, Woreda Health Office (WoHO) head/deputy head, woreda NTD focal persons and

FHF staff. To date, these meetings have been held in eight zones with the meetings held in each

zonal capital.

High-performing IECWs and woredas reporting the strongest TT surgery performance shared

lessons learned from implementation of outreach activities and factors that contributed to their

achievements. Aseko and Shirka woredas of Arsi, Guba Koricha woreda of West Harerghe, and


Dugda Dawa woreda of Borena zones were among the woredas which shared lessons that

enabled them to achieve high TT surgery performances. The success factors attributed to high

TT surgery performance in these woredas were the commitment of IECWs and woreda health

offices (health office heads, NTD focal persons) and strong coordination between IECWs,

woreda health offices, health extension workers (HEWs), kebele structures and community

leaders.

Major challenges identified that contributed to low TT surgery performance were also discussed

during the meeting. These included the long-standing social unrest in the region, frequent

turnover of health sector leaders, and inaccessibility of some kebeles due to poor road

infrastructure.

Another key topic discussed was the increasing inaccessibility of patients living in remote areas.

IECWs also expressed concern that there is low TT case turnout in some areas even where

there has been an increased focus on social mobilization and case finding. FHF and the ZHD

continued to stress the need for active case finding and coordinating activities closely with kebele

leaders.

Due to the social unrest in Oromia, travel across the woredas and zones was banned for several

weeks at various times during the reporting period, therefore, the IECWs were not able to carry

out planned outreach activities. Moreover, political leaders, health sector leaders, and the

community at-large were focused on issues related to the insecurity, including support to the

internally displaced. These challenges have led to a decrease in performance in quarter two (Q2),

however, once the areas are secure, the IECWs will start to conduct outreach again.

At the end of the performance review and planning meetings, each woreda developed a woreda-

specific action plan that incorporated lessons learned from other woredas. Specifically, the plans

detailed the roles and responsibilities of woreda health office heads, NTD focal persons, PHCU

directors and IECWs. Most of the action plans incorporated the reactivation of the woreda-level

workers to closely monitor TT surgery activities, strengthening social mobilization using kebele

and community structures and town criers, and TT case finding by HEWs.

FHF plans to complete the remaining zonal IECW performance review and planning meetings in

April 2018.

ADVOCACY

Zonal-level advocacy meetings

The objective of advocacy meetings is to create an opportunity for administrative and political

leaders to understand the burden and socioeconomic impact of trachoma, highlight the ongoing

TT interventions, and subsequently foster greater ownership and leadership by the zones. These

meetings were funded by FHF through institutional funding. FHF planned to conduct 10 zonal

level advocacy meetings in FY18 with an average of 54 participants per zone, for a total of 540

participants.


In the reporting period, FHF conducted five zonal advocacy meetings in Illubabora, Arsi, West

Harerghe, East Shewa and Buno Bedele zones; meetings were held in the respective zonal capitals.

Meeting participants included: ORHB NTD coordinators, ZHD heads, NTD focal persons, zonal

administrators and political affairs chiefs, woreda administrators and political affairs chiefs, woreda

women’s and children’s affairs heads, and WoHO heads/deputy heads.

Although FHF aimed to conduct all the advocacy meetings during the reporting period, ongoing

social unrest in much of the region led administrative and political leaders to prioritize the

restoration of security over health programming. Additionally, various government initiatives,

such as the launching of a six-week environmental conservation campaign in all woredas, were

also prioritized over TT surgery advocacy meetings.

In the five zones that completed the advocacy meetings, zonal health offices requested the

participation of IECWs in the meetings. IECW participation strengthened the discussions since

they could share lessons and challenges faced while implementing TT surgery outreaches and

camps. Additionally, the participants brainstormed how the various administrative and political

leaders could support activities. The advocacy meetings were jointly led by political and health

sector leaders to create a sense of leadership and accountability for the health sector staff. The

advocacy meetings in Arsi and Illubabora were immediately followed by TT surgery minicamps.

FHF began implementing smaller surgery camps in response to the Ethiopian government’s ban

on large-scale campaigns due to insecurity in the region. The recent declaration of a State of

Emergency across Ethiopia makes it difficult to schedule future advocacy meetings, but FHF plans

to finish advocacy meetings before May 2018.

Woreda level Advocacy meetings

The woreda-level TT surgery advocacy meetings have the same general objectives as the zonal-

level advocacy meetings and were planned for ten woredas, and were supported by FHF

institutional funding. Woredas are prioritized based on high estimated number of cases and need

for an intensified camp. The advocacy meetings are held immediately before intensified TT camp

activities start.

During the reporting period, FHF implemented six out of the ten planned woreda-level advocacy

meetings. Meeting participants include HEWs, kebele leaders, IECWs, PHCU directors, woreda

health office leaders and NTD focal persons. Approximately 700 participants were estimated to

participate; thus far 702 participants have participated in the six woreda-level advocacy meetings.

The meetings highlighted TT surgery progress, shared lessons learned and enabled the

development of detailed action plans to implement intensified TT surgery camps in the woredas.

Lessons learned from areas where there is successful coordination between HEWs, kebele

leaders, PHCUs, and IECWs, such as Munesa and Gololcha woredas where the kebele leaders

actively support the HEWs in case finding, were documented and will be used to promote similar

coordination in other woredas.

In all meetings, the community leaders have agreed that more TT cases could have been screened

if the kebele leaders worked more closely with HEWs. The HEWs also admitted that they were


poorly engaged in TT case findings for various reasons: lack of commitment on their part, lack of

support from PHCUs and kebele leaders and expectation of per diem payment, which is given

under vaccination programs. The large program area with limited telecommunications and

transportation makes it difficult for the IECWs to be in continual contact with kebele leaders and

HEWs across the district. Activities, such as the intensified surgical camps and minicamps, which

are supported in areas with high numbers of cases, provide an opportunity for advocacy and

engagement with kebele leaders. At the end of each advocacy meeting, a micro-plan was

developed by participants for each kebele with clear roles and responsibilities for the planned TT

surgery intensified camps and routine TT surgery outreach services. HEWs and kebele leaders

also agreed on their roles in social mobilization and case finding and committed their support for

the intensified camps and routine surgical outreach. The remaining five woreda-level advocacy

meetings will be held where intensified camps can be planned in Q3-Q4; this will be highly

dependent on the security situation.


In FY18, FHF planned to disseminate TT messages to inform community members about TT

surgery services by radio in collaboration with the Oromia broadcasting network to reach 17

million people residing in the zones supported by the MMDP Project. The radio spots in Afan

Oromo encourage individuals with TT to seek out surgical services and communities to refer

cases to HEWs and IECWs for surgical services. These messages are the same as developed last

year. FHF has not developed an overall social mobilization and behavioral change strategy

separate from what is detailed in the annual work plan.

Given that more than 70% of TT cases in Ethiopia are women, the messages are prepared by

female actresses and focus mainly on encouraging women to seek the services. The messages

also ask that those women who have had TT surgery encourage women with unoperated TT to

present for surgery. The radio broadcasts aired twice a week starting from July 2017 through the

end of March 2018 and were supported by FHF institutional funding.

CAPACITY BUILDING

FHF plans to conduct three categories of trainings in FY18: a training for 40 new IECWs, a

refresher training for 22 IECWs and TT case screening and counseling training for 260 HEWs.

Training of TT Surgeons, Evaluation and Certification

The training for new IECWs will focus on replacing those IECWs who have left their posts due

to promotions, education, and other commitments. FHF conducted an assessment to determine

whether IECWs were still posted to MMDP Project sites and whether the posted IECW was still

conducting TT surgery activities. The assessment determined that 21/125 IECWs left their posts

or stopped working on TT surgeries. FHF planned to organize an IECW training early in quarter

two (Q2), but the training was postponed due to insecurity. Although FHF started the IECW

training in late March 2018 at Yabelo Hospital in Borena zone, only the theoretical session was


finished by the end of the reporting period. The training will be fully reported on in the next

reporting period. The activity will be supported by both MMDP Project and FHF funds.

IECW refresher training

The IECW refresher trainings address surgical skill gaps identified during supportive supervision

and TT surgical quality audits. By the end of February 2018, FHF identified only one of eight

IECWs audited with poor surgical outcomes with a need for a skill refresher. The IECW will be

refreshed in late April, at the same time as another IECW identified in FY17 who has not yet

received retraining15. Insecurity and transportation challenges have delayed the surgical audits,

and the majority are planned for Q3 (see Monitoring & Evaluation section). With the recent

deployment of a dedicated quality team (DQT) and planned supportive supervision in the

upcoming months, FHF will continue with audits and supervision to identify any IECWs with skill

gaps and will organize any needed refresher trainings.

HEWs case screening and counselling training

FHF planned to train 260 HEWs on TT case screening and counseling in woredas that did not

receive this training in FY17. The aim of the training is to build the skill of HEWs to identify TT

cases, provide counseling and refer patients to the surgical sites.

The HEWs’ training was not conducted during the reporting period because the health staff have

been unable to travel to the woredas and organize the training due to insecurity. Additionally,

experience has shown that the productivity of HEWs increases if the training is immediately

followed by an intensified TT surgery camp or minicamp. FHF plans to train HEWs in alignment

with upcoming TT surgery camp activities during Q3.


A trachoma impact survey was conducted in the woreda of Metu, in Illubabora Zone, with

support from the ENVISION Project. The age adjusted TF prevalence in children 1-9 years is

0.16% and the TT prevalence in adults 15 years and above is 0.03%. Since the district is now

under the threshold for elimination for both TF and TT, project-supported TT surgical services

will stop and FHF will work with the zonal and woreda government to hand over any remaining

TT surgeries.


FHF planned and implemented a combination of three TT surgery delivery approaches to achieve

the MMDP Project FY18 target of operating 18,560 patients. The service delivery strategies

include: static and outreach services by the IECWs, dedicated mobile teams (DMTs), and

intensified surgical camps. TT surgeons use the Trabut surgical method throughout the MMDP

Project-supported areas. During the reporting period, a total of 8,342 patients received TT

15 In the FY17 SAR2 report, FHF stated that 12 IECWs were yet to be provided supervision/refresher. This was a

misstatement since 1 has left the program, 10 had a minimum of 2 directly observed surgeries during supervision

activities/skill assessment in Q3 and Q4 2017 and were not recommended for skill refresher. One IECW still needs

refresher training.


surgery. This is 45% (8,342/18,560) of the annual target and 96% (8,342/8,724) of the reporting

period target. To put this into context, since the start of the MMDP Project, FHF has supported

35,046 TT surgeries, 64% of the estimated UIG.

In terms of quarterly progress, FHF achieved TT surgery performance of 123% (4,783/3,898) of

the planned target for Q1; however, insecurity decreased performance to 74% (3,559/4,826) in

Q2. MMDP Project zones with better security conditions during the reporting period, such as

East Shewa, Guji and Bunobedelle, performed 38% of TT surgeries (3,275/8,724). West Harerghe

and Bale zones, on the other hand, which have the highest estimated number of cases to operate

but experienced much more insecurity, only accounted for 19% (1,675/8,724) of the surgeries

conducted. FHF will continue to monitor the security conditions and take advantage of breaks in

the insecurity to conduct program activities.

While working to enhance TT surgical output utilizing all TT surgery provision strategies, FHF

has tried to reach most villages to make TT surgery services available. Accordingly, FHF has

reached 1,697 kebeles out of 2,752 (62%) of the total kebeles found in all MMDP Project-

supported woredas.

IECW Static Sites and Outreach

IECWs are stationed at woreda-level PHCUs and conduct TT surgeries in their respective health

facilities (static services), as well as during outreach activities. FHF plans for each IECW to

perform two, three-day outreach sessions per month, including travel, surgery and post-operative

follow-up activities. However, FHF has been flexible in the implementation of the schedule and

duration of the outreach based on the fact that most outreaches are organized in distant and

remote areas where cases are found, and, therefore, three days is not always enough. In some

woredas, IECWs have stayed for weeks to conduct TT surgeries before returning home. Most

outreach activities are organized at health posts, schools or farmer training centers.

In FY18, FHF planned for the IECWs to conduct 7,520 TT surgeries by static and outreach service.

During the reporting period, 3,181 TT surgeries were performed by IECWs during outreach

activities, and 96 TT surgeries were performed through static services, for a total of 3,277 TT

surgeries. In total, 44% (3,277/7,520) of the annual surgery target has been met. During the

reporting period, approximately 61% (76/125) of the IECWs were found to be surgically active

in any given month. As mentioned above, FHF plans to train 21 IECWs to replace those no longer

active (see Capacity Building section).

Despite the continued unrest and public protest in most MMDP Project-supported areas in

Oromia, FHF cluster offices and zonal technical advisors have been carefully monitoring the

situation and continue to support IECWs to provide TT surgical services. FHF-supported IECW

performance reviews are a platform to review performance and have leveraged the support of

health sector leaders to achieve the targets despite the challenging operating environment.


Dedicated Mobile Teams (DMTs)

DMTs consist of two TT surgeons and one coordinator to provide TT surgical services in

woredas with high estimated numbers of cases. DMT TT surgeons conduct a high volume of TT

surgeries, support case management and provide mentoring to IECWs during intensified camp

activities. During this reporting period, a fourth DMT was added. During the reporting period,

20% (1,000/5,040)16 of the planned DMT surgeries for the year were conducted; however, this

does not count their contribution during the intensified camps, as the intensified camp data are

aggregated by camp and not segregated by surgeon type.

The newly established DMT is stationed at Bale Robe hospital in Bale zone and is expected to

provide TT surgery in the remote and nomadic pastoralist parts of this zone. To recruit this team,

a vacancy announcement was made by Bale Hospital and a practical examination was used during

the recruitment process, supervised by FHF staff. The individuals selected were previously trained

and certified TT surgeons. One was an IECW in Bale Zone and the other was an ophthalmic

nurse from East Shoa. This DMT commenced TT surgery in February 2018 after receiving a two-

day orientation training by FHF staff and RTI’s Quality Assurance (QA) Officer.

To counter the lower than planned productively of DMTs caused by insecurity, FHF relocated

DMTs to woredas in the MMDP Project area with better security. For example, the Shashemene

DMT was mobilized to Gechi woreda of Bunobedelle zone which currently has no active IECW.

Additionally, the DMT in West Harerghe was relocated to Arsi zone to support TT surgical

activities.

To improve the performance of DMTs, FHF paid for and organized a day-long DMT performance

review meeting in January in Addis Ababa for all DMTs, cluster coordinators, zonal NTD technical

advisors, and program managers to come together and undertake an in-depth review of the DMT

performance and prepare an action plan for the remaining period. The biggest challenges are the

limited participation of the kebele leaders during social mobilization and the expectation of

payment by these leaders (both per diem and salary). The identified challenges were taken up by

FHF cluster coordinators to discuss with zonal and woreda health officers.

Intensified TT Surgical Camps

FHF planned to perform 6,000 TT surgeries through the intensified TT surgical camp strategy in

the five zones with the largest estimated number of TT cases (Bale, Borena, Arsi, West Arsi, and

West Harerghe zones). However, insecurity in the region forced FHF to become innovative when

intensified camps could not be conducted. This led to implementing smaller “minicamps” since

security measures from the government did not allow the convening of large-scale campaigns

except in Bunobedelle, Illubabora and Guji. The intensified camps and minicamps bring together

DMTs and IECWs not only to operate on high volume of TT surgeries but also provide an

opportunity for experienced DMT surgeons to provide mentoring and coaching to IECWs on

16 This does not include surgeries conducted by DMT members during intensified camps.


surgical skills. This is accomplished by assigning a DMT to travel to a specific woreda and work

directly with the IECWs.

Of the ten planned intensified camps for the reporting period, FHF was able to accomplish the

following: full-scale intensified camps in Bunobedelle zone (one camp in three woredas),

Illubabora zone (one camp in four woredas), and Guji zone (one camp in two woredas); as well

as minicamps in East Shewa zone (one minicamp in seven woredas) and Arsi zone (one minicamp

in 19 woredas) during the reporting period.

During the reporting period, a total of 4,065 TT cases were operated through the intensified

camp and minicamp strategies (68% of target).

Patient Counseling

Counseling for TT cases is primarily provided by the HEWs and the TT surgeon (IECW or DMT)

to ensure that the patient is given the necessary information before deciding to undergo TT

surgery. The HEWs screen and counsel the patient at home, health post, or at community

gathering areas to encourage them to visit IECWs or DMTs to receive surgical services. The

surgeon is responsible for counseling the patient on the importance of surgery, the procedure,

the risk if not treated, and other information before surgery. Post-surgery, the TT surgeon

counsels the patient to return for the next day and then seven to 10 days and three to six months

following the surgery. Patients are given appointment reminder cards for these follow-up visits.

The surgeon also counsels the patient on how to take care of the surgical wound.

If an individual refuses surgery, he or she is counseled by the TT surgeon on the importance of

TT surgery and the individual’s contact information is shared with HEWs trained in counselling.

HEWs will then visit these cases one to two times to provide further counseling on the surgery.

Patient Referrals and Refusal Management

During the reporting period, 4% (391/9,219) of individuals with confirmed TT were found to need

referral services to secondary or tertiary eye care units. Referrals include patients with high blood

pressure and other medical complications, post-operative TT, lower eyelid TT, and pediatric TT.

Approximately 4% (403/9,212) of the TT patients with confirmed TT refused surgical services.

Individuals were first counseled by the IECW. If the individual refuses, the HEWs trained in

counseling by the MMDP Project and kebele leaders continue to counsel the individuals. Following

refusal of the surgery, the IECW links the refusal cases to the HEWs. The HEWs, in collaboration

with kebele leaders, are trained to continually advise the cases on the importance of having

surgical management using influential persons in the community and relatives. Anecdotal evidence

from discussions with program staff show reasons for refusal include 1) fear of surgery, 2) not

wanting surgery during farming season, 3) not wanting surgery before social commitments, such

as weddings or funerals, or 4) having no one to accompany them to surgery.


Epilation

In this reporting period, FHF commenced epilation services only through the DMTs in cases

where individuals with few lateral lashes were refusing surgery. Only DMTs offered these services

as they are highly-skilled and able to provide epilation if the individuals continue to refuse surgery

after counseling. Nine TT patients were provided epilation in lieu of surgery. FHF limits the

support for epilation to individuals with TT who have less than five inverted lateral eyelashes and

have refused surgery after counseling. Individuals with more lashes are not offered epilation and

are counseled to receive surgery. It is important to note that these individuals were not counseled

on epilation outside of the surgical setting due to mandate from the FMOH not to encourage the

practice of epilation, and the FMOH does not support the distribution of forceps to individuals

who refuse surgery.

TT case registers and reporting forms capture reasons for referral, refusals and epilation. The

register also provides details regarding referral cases so the IECW can provide referral papers

and record feedback received from the hospitals that managed the cases. Refusals who were

provided epilation are linked to trained HEWs for further counseling to accept TT surgery. No

data are available as to whether any of these patients later opted for surgery.


In FY18, FHF planned to procure 24 types of commodities for the MMDP Project-supported

zones, and a combination of FHF and MMDP Project funds were used to procure TT supplies

during the reporting period. FHF supports the purchase of items that are considered restricted

commodities per U.S. government regulations, and, therefore, all drugs purchased in FY18 were

purchased with non-MMDP Project funds.

FHF typically conducts bulk procurement once or twice a year. Occasionally, shortages of items

at the Pharmaceuticals Fund and Supplies Agency (PFSA) at the time of bulk procurement or

unanticipated needs will require another procurement. A commodity stock balance report is

tabulated monthly and communicated to FHF program staff by the store keeper.

In terms of challenges, until 2018, Zithromax had not been given post-surgery; however, the

FMOH has agreed that Zithromax will be used post-surgery and requested it through its 2018

Zithromax application, which was approved by the trachoma expert committee (TEC). In addition,

the lack of some supplies, such as tetracaine, lidocaine with adrenaline and blades, in the local

market is a chronic challenge. For example, although RTI provided FHF with tetracaine for the

first half of FY18, FHF had a difficult time finding mre and only located enough to last until the

end of June. FHF will plan procurement in Q3 to cover the remaining need; in the future, FHF

will mitigate this challenge by starting the procurement process early and by communicating

frequently with RTI if challenges are faced.


FHF organizes supportive supervision for TT surgeons to ensure IECWs are observed while

conducting surgery and assessed on their ability to manage the TT surgery program in their


respective areas. In FY17, FHF trained the following: 24 individuals on supportive supervision; 12

ophthalmologists, ophthalmic nurses, and cataract surgeons from six hospitals on direct surgical

supervision; and 12 zonal NTD focal persons and zonal NTD technical experts on the operational

side of TT case management. Supervisory teams consist of the FHF TT surgery supervisor and

TT surgery quality coordinator, as well as trained supervisors from secondary eye care hospitals

and zonal health offices.

During the reporting period, FHF planned to provide supportive supervision to 40 IECWs (in

Arsi, East Shewa, West Arsi, Bale and Borena zones), but due to insecurity, was only able to

provide supportive supervision to 21 IECW (12 in Arsi and 9 in East Shewa zones). Over the

course of the project year, FHF plans to visit each IECW at least once through supportive

supervision and surgical audits.

The MMDP Project supportive supervision checklist was used to collect information pertaining

to TT surgery: patient counseling, data management, operative procedures (pre, intra and post),

infection prevention and instrument processing. Supervisory visits included: 1) discussions with

IECWs, PHCU directors, NTD focal persons and patients; 2) observation of surgical procedures,

infection prevention precautions, and 3) review of case registration books.

The main finding of the supervisory visits in Arsi zone is that all IECWs visited have maintained

the required standard levels in patient counseling, recording and reporting, surgical technique,

operative procedures and infection prevention. The team also observed that adequate TT surgery

commodities are available at health facilities. Furthermore, most districts visited have prioritized

TT surgery interventions in the woreda.

The supervision teams also identified low TT surgery performances in some woredas due to

difficulty in organizing outreach activities in very remote villages and the availability of vehicles. In

certain woredas, such as Digelu Tijo of Arsi zone, political and health sector leaders provided

little support for community mobilization and integration of TT surgery with other health

activities. Another persistent challenge is competing priorities that take up some of the IECWs’

time.

The findings of the supportive supervision visits are communicated directly to the IECWs during

the visit and any issues are immediately addressed by the supervision team. Each supervisory visit

is also recorded in a report detailing the findings and recommendations for subsequent actions.

The supervisory team also provides feedback to PHCU directors and WoHOs, and actions,

where required, are agreed to at all levels. One recommendation was to continue the

organization of zonal level advocacy meetings to garner the support of the administrative and

political leaders. Integration of TT surgical services with other health services at the community

level (community health days, immunization outreach) was found to be a missed opportunity. The

supervision team recommended presenting the supervision findings during the advocacy meetings

and IECWs’ performance review and planning advocacy meetings.

In MMDP Project-supported areas, FHF will continue to utilize the MMDP Project supportive

supervision checklist until the newly introduced FMOH supportive supervision guidelines have


been rolled out (see below in FMOH/NTTF Surgical Audit Guidance). Feedback that FHF continues

to receive regarding the supportive supervision checklist by government staff is that the MMDP

Project supervision checklist was found to be too detailed, not user friendly, and time-consuming

for routine use. The supervisors felt that too much time was spent filling out the form and not

enough time working on the specific challenges of the individual being supervised. FHF plans to

continue to conduct supportive supervision in the second half of FY18.


No external short-term technical assistance is planned in Oromia in FY18.


Surgical audits

FHF uses surgical audits as another tool to evaluate TT surgeon performance and quality. If the

outcomes of the patients operated by the surgeon are poor, FHF will evaluate the surgeon while

operating during a supportive supervision visit, and when recommended by the supervisor, a skills

refresher training tailored to the individual surgeon to improve their surgical skills will be held.

During the reporting period, eight IECWs were audited by FHF and TT surgery supervisors

(three in Arsi, one in West Arsi, and four in East Shewa zones) and one IECW was audited by

the new DQT in West Arsi (see below); 63 patients received followed-up as part of these audits.

Surgeons who have never been audited were prioritized, including IECWs who had performed

high numbers of TT surgeries, had high number of refusals, or were recommended from

supervisory visits. In the FY18 workplan, FHF had based its plans around the number of patients

to follow-up, per previous MMDP Project guidance, and planned to include 1,248 patients during

the audits; to date, 5% have been reached (63/1,248). The main reasons for the low output against

planned targets are the delayed establishment of the DQT and the insecurity, limiting the ability

to move around the woredas and zones.

Dedicated Quality Team

In Q2, FHF hired a full-time DQT which includes a qualified TT surgery supervisor and a

coordinator. The TT surgery supervisor is an optometrist, certified TT surgeon and trainer of

IECWs and has been employed by FHF as a DMT surgeon since 2014. The DQT coordinator is

responsible for organizing the surgical audit activities and communicating with zonal health

departments, woreda health offices, IECWs, HEWs and community leaders before and during

the activity. This individual was formerly an IECW in West Arsi zone and is a public health officer

by training. Shashemene hospital hosts the team as it is a referral hospital with a secondary eye

care unit located relatively in the center of the MMDP Project zones. FHF, in collaboration with

the RTI QA Officer, trained the DQT. The training included an overview of the MMDP Project

and discussion on trachoma, TT and the surgical audit protocol. The training took place both in

the classroom and the field, where an audit was conducted with FHF’s TT surgery quality

coordinator. Following theoretical orientation and practical support, the DQT started field work

the last week of February 2018, accompanied by the FHF surgical quality coordinator.


Now that the DQT is in place, the pace to conduct the audits will increase, and FHF will also

intensify the use of government staff from hospitals to support additional audits.

Current Surgical Audit Framework

The current methodology used for surgical audits is:

1. IECWs are prioritized and selected for audit using the following criteria: operated on low

or high number of surgeries, identified as needing extra supervision during the training

or during supervisory visits, and reported many refusals;

2. A sample of 15% of patients within the 3-6 month post-operative window are randomly

selected using data from the surgeon’s logbook;

3. The surgical audit team travels house-to-house with the IECW who performed the

surgeries, a local guide, and, if possible, the woreda NTD coordinator, to conduct the

audit;

4. Patients are examined by the TT supervisor for post-operative TT, eyelid margin

abnormality, granuloma, and patient satisfaction. If a patient is not available, this is noted

on the data collection form and another patient is visited.

5. If the audited IECW is found to have greater than 10% post-operative TT, granuloma or

eyelid margin abnormality, the IECW is scheduled for a skills evaluation by a supervisor.

The skills evaluation includes direct observation of a minimum of two TT surgeries and

feedback from the supervisor, who may then recommend the surgeon for a full skills

refresher training.

6. The skills refresher training is a five-day practical training delivered by a TT surgery

supervisor. As part of the refresher training each IECW is expected to operate a

minimum of five eyelids under strict supervision.

FMOH/NTTF Surgical Audit Guidance

The FMOH/NTTF held a two-day meeting in December 2017 to introduce, discuss, and adopt

new guidelines on surgical quality. FHF plans to follow the new guidelines for surgical quality

audits following the national training and roll-out of the activity. The FMOH guidelines will require

a change in patient sampling: instead of randomly sampling 15% of patients, the FMOH guidelines

calls for a lot quality assurance methodology, wherein up to 40 patients per surgeon may be

included in the audit.

3-6 Month Outcome Assessments

As part of the MMDP Project, FHF plans for IECWs to conduct 3-6 month post-surgery outcome

assessments for all operated cases. During counseling after surgery and during the one-day and

7-14 day follow-ups, surgeons advise the patients to return 3-6 months after surgery. Patients

are given appointment cards to remind them of the follow-up visit. Supportive supervision and

outcome assessment reports show that 146 patients were followed up passively (individuals

report to the health facility where the IECW is stationed 3-6 months after surgery) by eight

surgeons, and no complications were reported. However, it should also be noted that the

outcome assessments are conducted by the surgeon who conducted the surgery; therefore, the


data may be biased. Therefore, FHF relies heavily on supervision and surgical audit findings to

determine surgeon skill level.

Some reasons why patients do not attend these 3-6 month follow-up visits have been anecdotally

captured by IECWs: the patients did not recall the appointment period and had to travel far to

the health facility or appointment sites. During IECW review and planning meetings, these follow-

up visits were discussed, and FHF determined that IECWs who have good counseling skills and

are well-known by their patients were more likely to have patients attend the 3-6 month follow-

up visit. This topic will continue to be discussed during review and planning meetings and

supportive supervision visits.

TRACHOMA (Tigray)

STRATEGIC PLANNING

Regional-level Strategic Planning Meeting

On December 5, 2017, in collaboration with the Tigray Regional Health Bureau (TRHB), LFTW

facilitated a strategic planning meeting in Mekelle and, of the 75 participants anticipated, 72

participants from the TRHB, zonal and woreda administrations (including zonal social affairs),

woreda health offices and eye care units attended the meeting. The main absentee was a

representative from the women and children’s affairs who was unable to participate due to

conflicting priorities. The objective of this meeting was to discuss the challenges and lessons

learned from FY17, plan for the remainder of the year, and better understand how to reach cases

with TT services to achieve the estimated remaining UIG in FY18.

During the meeting, discussions focused on the FY16 and FY17 TT surgery performance and

challenges, TT surgery targets for FY18, number and distribution of available certified TT

surgeons working in the MMDP Project-supported woredas, approaches for case identification,

and findings from the pilot house-to-house case identification strategy in Department for

International Development (DFID)-supported project areas. Participants agreed on action points

to meet the FY18 targets. To meet the targets, it was determined that changes to two main areas

were necessary: strengthening political commitment and revision of the current case-finding

strategy.

The case-finding strategy in MMDP Project areas to date has focused on mass mobilization, which

does not reach everyone and does not convince all those it does reach to present during outreach.

To revise the strategy, participants proposed scaling up the systematic house-to-house case

finding strategy in MMDP Project areas where there are hard-to-reach cases and a high estimated

number of cases. LFTW held a one-day training to train case finders to carry out this work, and

thus far, 12 kebeles from two woredas were selected to try out the systematic house-to-house

case finding strategy. A total of 238 TT cases were confirmed. Of these, 217 agreed to undergo

surgery, 20 minor cases were epilated, and one case refused all services. Further analysis will be

conducted in Q3 to determine whether this strategy identified more cases than would have been

found using the previous outreach strategy.


Strategic Planning Meetings at Zonal Level

In FY18, LFTW planned to conduct three one-day meetings in the Central, North Western, and

Eastern zones of Tigray. In December 2017, TRHB and LFTW conducted these meetings as

planned. A total of 240 participants out of 246 planned attended, including representatives from

TRHB, TT surgeons, zonal administrations, eye care units (ECUs), WoHOs and health centers.

Although representatives from cultural associations and disabled people organizations, woreda

women and children affairs offices were invited, they did not attend due to conflicting priorities.

The main objective of these meetings was to develop detailed zonal- and woreda-level

implementation plans to reach the remaining cases and to work towards trachoma elimination.

Presentations focused on the trachoma elimination strategy, with a specific focus on zonal and

woreda-level progress over the last year. In addition, an orientation was given on a planning tool,

adapted from the International Coalition for Trachoma Control (ICTC) TAP template, to be used

for district-level microplanning by each district team. Using the planning tool, the breakout groups

calculated the TT backlog and UIGs of a specific district. Additional information in each plan

included the number of TT surgeons available, the number of surgeries a surgeon can perform

per day, the number of outreach days that a surgeon can conduct per month and planned steps

to carry out the systematic case-finding strategy described above.

Additionally, there was also a discussion on how to fill the human resources gap given that five

of the 17 active certified surgeons in the MMDP Project zones were enrolled in the ophthalmic

officer training at Mekelle University. The solution was to agree with the University to continue

to utilize the surgeons during times that did not conflict with their coursework. Looking forward

to FY19, 19 new diploma-level ophthalmic nurses are expected to graduate from Mekelle

University and could possibly trained to serve as TT surgeons.

Zonal-level Quarterly Monitoring Review Meetings

In FY18, LFTW planned to conduct quarterly one-day performance review meetings in the three

zones. These meetings were postponed due to other government meetings and are rescheduled

for the first week of April 2018.

ADVOCACY

Advocacy Meetings for Political Leaders at the Zonal Level

In FY18, LFTW planned to conduct three one-day zonal level advocacy meetings with participants

from all five MMDP Project zones. Despite consensus by TRHB officials and political leaders on

the importance of the meeting, this meeting has been repeatedly postponed due to other

meetings and conferences. At the time of report writing, it has been scheduled for the first week

of April 2018.



HEW and HDA Network

In addition to the radio spots, LFTW uses the existing TRHB health service system to create

awareness of TT surgery availability. This network is structured in the following manner: one

Health Extension Worker (HEW) is responsible for 30 Health Development Army (HDA)

leaders; each HDA leader is responsible for six HDA members; and one HDA member is

responsible for communicating with five households. In FY16 the MMDP Project trained more

than 3,000 HEWs and HDAs on trachoma elimination strategies and case identification counseling

and referral. LFTW has encouraged HEWs and HDAs to integrate trachoma prevention and TT

surgery messages during their regular health-related meetings with community members,

community gatherings and household visits. These TT messages include that TT surgeries are

free and available.

MDA and Regional-level Comprehensive Eye Health Project Linkage

Previous years have shown that integrating MMDP Project activities with other diseases, such as

cataract campaigns, has led to effective and efficient service delivery. LFTW and TRHB have

agreed to integrate MMDP Project activities with the existing regional-level comprehensive eye

health services directly financed by LFTW. During MMDP Project TT surgery outreach, other

eye diseases such as cataract and, glaucoma are also identified and referred to the nearest

secondary eye care units (SECUs) by the outreach teams. Other minor cases, such as eye

infections, that require medical treatment on site are also treated.

Mass drug administration (MDA) will be conducted in all trachoma-endemic districts in April 2018,

and LFTW plans deploy all TT surgeons to the drug distribution sites for screening and TT

surgeries.

Radio Spots

To mobilize the community for TT surgery services and to create awareness around trachoma,

radio activities were planned for FY18 utilizing the local radio station Dimtsi Woyanie. This radio

station has the potential to reach to every kebele in Tigray. The contract was signed in March

2018 with MMDP Project funding and will support the broadcast of radio spots three days a week

for 13 consecutive weeks, beginning in March. The MMDP Project-supported radio spot was

produced by the International Trachoma Initiative country office in collaboration with Dimtsi

Woyanie and the TRHB communication office. It was pre-tested and broadcast in FY17; in FY18,

a short message that encourages already operated cases to return for follow-up was added

through funding from the MMDP Project. The key messages of these radio spots are that TT

surgery provision is free and that people should attend outreach camps when these are held near

their community.


CAPACITY BUILDING

Refresher Training for TT Surgeons

During the first week of March 2018, LFTW planned to conduct a five-day refresher training for

all 17 TT surgeons trained and certified in FY16 and still active17. This training did not take place

due to the TRHB banning any trainings or meetings during the reporting period due to other

priorities. The refresher training has been rescheduled for the first week of April. Although

several surgeons are now enrolled in a training course at Mekelle University, they will still take

part in this training to maintain their surgical skills.

New TT Surgeon Training

When developing the FY18 workplan, LFTW took into consideration the overall 13% attrition

rate of TT surgeons over the past two years in both MMDP Project and DFID-supported areas.

In addition, Mekelle University planned to introduce an ophthalmic officer training course, which

was presumed would attract TT surgeons for career advancement, although LFTW had assumed

that the FMOH would deploy newly graduated optometrists to Tigray to fill current staffing gaps.

With this in mind, LFTW planned to train five new TT surgeons in FY18 with MMDP Project

support. However, so far the FMOH has deployed only one new optometrist to MMDP Project

zones, and, therefore, the training is postponed for the foreseeable future.


With support from the ENVISION Project, twenty-two MMDP Project-supported woredas were

scheduled for trachoma impact surveys in FY18, although none have taken place to date. As MDA

is planned for late April 2018, the impact surveys will likely take place in early FY19.


In FY18, LFTW is supporting the TRHB and FMOH to reach 5,981 cases in the MMDP Project-

supported areas of Tigray region (Central, North Western, Eastern, Western zones, and the

non-urban areas of six woredas of Mekelle zone), which was the estimated number of all

remaining cases at the time of FY18 work planning. Surgery is conducted by ophthalmic

professionals (not IECWs) based in secondary and primary eye care units. In the MMDP Project-

targeted zones, there are 24 trained and certified TT surgeons, although only 17 have been

actively operating. LFTW provides TT surgery services using both static and outreach services.

Static services are provided at two secondary and eight primary ECUs in the five targeted MMDP

Project zones, each of which has at least one trained and certified ophthalmic nurse. The FY18

surgery target for static services is 221, based on the small number of patients who present at

ECUs given the distance from their homes. For outreach, TT surgeons travel from the ECUs to

health centers and health posts in the communities per a pre-determined schedule. Through

outreach, 5,760 patients are targeted for services.

17 A total of 18 TT surgeons were trained and certified in FY16; however, one since resigned.


During the reporting period, static sites accounted for 4% (92/2,267) of all surgeries; the other

2,175 patients were reached through outreach services. A total of 241 outreach campaigns were

organized, reaching 314 kebeles at least once (196 kebeles in Central zone, 74 in North-Western,

29 in Western, 10 in Mekelle, and 5 in Eastern zone). Though the number and length of outreach

visits vary, on average, each surgeon conducted outreach for five days per month. For the

reporting period the goal was to conduct 2,991 surgeries, and the project reached 76% of that

goal despite having fewer TT surgeons available. However, the house-to-house systematic case

finding approach appears to be proving its effectiveness, as the number of cases has increased

each month since implementing the strategy. One concern for continuing this house-to-house

strategy is the cost and the project’s ability to reach all targeted areas with this strategy in the

available budget.

Pre-Surgery Screening and Counseling

TT surgeons conduct health education to patients before conducting screening. The messages

include a general overview about trachoma and its complications, different management options

(surgery or epilation) and encourages the patient to accept the recommended management

strategy for any eye condition found.

After the group health education session, TT surgeons screen the suspected cases to confirm TT.

During the reporting period, a total of 2,418 cases were confirmed from screening 30,128

individuals. Those with minor conditions that can be treated on site are treated; others are

referred to care at the ECUs. Patients with confirmed TT but with only one or two lateral

trichiatic eyelashes are counseled for epilation. For patients with confirmed TT needing surgery,

patient counseling is then provided using the standard MMDP Project patient counseling format

which is adopted from the ICTC outreach manual.

After surgery, patients are asked to return the next day for patch removal by the surgeon. During

this follow-up, patients are encouraged to come back to the outreach site seven days post-surgery

for removal of the silk sutures, which will be removed by either the TT surgeon or by a trained

outreach coordinator. All patients who underwent TT surgery received post-operative

counseling, had their patch removed, and were assessed for complication by the surgeon on the

day after the surgery; all patients had their sutures removed and were again examined for

complications seven days after the surgery by the TT surgeon or trained clinical nurse at the

outreach site.

Refusals and Epilation

Patient are only offered epilation in two cases: if there are one or two lateral trichiatic eyelashes

not touching the cornea or a patient refuses to undergo surgery. During the reporting period, a

total of 151 patients were counseled for epilation. Of those, 120 were offered epilation because

they refused surgery, and 73 accepted epilation. The most commonly cited reason for refusing

surgery and epilation was because they preferred surgery, but at a more convenient time (for

example, after the harvest). For those who agree to epilation, the TT surgeons conduct the

epilation, as it is against FMOH policy to provide epilation forceps to a TT patient. When epilation

is performed, the surgeon tells the patients that it is a temporary solution and surgery will


eventually be needed. Those undergoing epilation are encouraged to contact the ECU for the

next outreach campaign.

The main reasons for refusing surgery were fear, unwillingness to be operated during

farming/harvesting seasons, social commitments (such as weddings), and lack of relatives to bring

the patient back home after surgery. The refusal rate during the reporting period was 4.9%, similar

to last year. While the rate has not increased, LFTW believes that the last cases to reach will be

harder to reach in terms of geography and willingness to accept services, and will continue to

monitor the data.

Tracking Refusal and Epilation Cases

Lists of TT patients who were epilated and those who refused both surgery and epilation were

given to the outreach coordinators for continuous follow up and counseling18. The outreach

coordinators then provided their lists to the respective case finders based on the patient address

for continuous follow up and counseling.


The TRHB submits requests for consumables and other items to LFTW. The list of consumables

to be procured is then checked by the procurement team at LFTW and the Director Eye

Health/NTDs to ensure alignment with WHO guidelines and quality. Quantities are also checked

in line with the projected targets for the period. Once this is confirmed and approved by the

Director, LFTW provides approval to TRHB. The request is sent to the Mekelle branch of the

PFSA to provide the available specifications and unit costs. Items procured are then stored at the

TRHB drug store, which is managed by a pharmacist. When items are not available at PFSA, they

are procured using a competitive bidding process led by LFTW.

The ECUs where the TT surgeons are based submit validated stock requisitions to the TRHB

store pharmacist. These are based on the expected number of TT surgeries to be conducted in

their catchment areas. The TRHB store pharmacist then delivers the requested items to the

ECUs. Once the ECUs receive the drugs, the items are kept at the ECUs’ drug stores, which are

managed by pharmacists or pharmacy technicians. The TT surgeons then withdraw the supplies

from the ECU drug store upon formal request. The TT surgeons report back the utilization of

supplies to the ECU store pharmacist after outreach campaigns are completed. The ECU

pharmacist reports the drug balance to TRHB.

For FY18, the necessary consumables were procured in advance by RTI and LFTW, with the

exception of restricted commodities. These restricted commodities were purchased during the

reporting period with LFTW institutional funding.

During the FY17 Zithromax quantification workshop, the TRHB applied for post-operative

Zithromax aligned with the planned FY18 TT surgery target. Accordingly, post-operative

Zithromax was approved by the TEC and transported from the national PFSA located in Addis

18 LFTW does not yet have data on the number of these individuals followed up and is determining how best to track

this.


Ababa to the regional PFSA hub located in Mekelle. Unfortunately, the regional PFSA hub

delivered the post-operative Zithromax to the woredas instead of the ECUs where the TT

surgeons are located. In some cases, the woredas provided the post-operative Zithromax to

patients; however, the registry does not capture this information, so the quantity provided is not

available. After discussing with FMOH, the drug is being collected by the TRHB drug store to be

re-distributed to the ECUs.


There are currently nine supportive supervisors who are trained cataract surgeons, ophthalmic

officers, or senior ophthalmic nurses. Seven of the nine are senior government employees from

the three SECUs with many years of experience. Two of the supervisors are LFTW seconded

staff.

The supportive supervisors were trained by the MMDP Project in FY16 and received refresher

training in FY17. Supportive supervisors are assigned to specific geographic areas within the

MMDP Project-supported area. This creates a sense of responsibility, as the supportive

supervisors are then accountable for that specific area.

The supervisors use the MMDP Project supportive supervision checklist to assess the quality of

services and adherence to WHO and FMOH guidelines, as well as the effectiveness of the static

and outreach strategies. The FMOH checklist is based on the MMDP Project checklist; therefore,

no specific adaptation is anticipated. In addition to the checklists, supportive supervisors also fill

in the database for easy access, analysis and use of findings from supportive supervision visits.

During the reporting period, 40 technical visits to outreach and static sites were conducted by

the supportive supervisors for a total of 81 days spent in the field at outreach sites (health posts

and health centers). In general, surgical practice is strong since all TT surgeons in Tigray are

certified ophthalmic nurses or optometrists. The main issues found during these visits include

incomplete registration forms, poor patient counseling, and poor community mobilization in

some outreach sites.


No external short-term technical assistance is planned in Tigray in FY18.


Surgical Audits

In FY18, LFTW plans to audit 14 surgeons. Initially LFTW planned to begin surgical audits at the

beginning of the fiscal year to use the findings to provide input for the refresher training of TT

surgeons. However, the final version of the national quality assurance guidelines was not released

until December 2017, and, LFTW waited until these guidelines were available. In January 2018,

supervisors, trained by LFTW NTD/Eye Health Director in FY16 (and refreshed by the Director

in FY17) began carrying out the surgical audits using the methodology from the FMOH guidelines.

The method is a change from previous years with sampling based on patients operated by a


specific surgeon, rather than by geographical area, which should provide more reliable

information about specific TT surgeon performance.

During the reporting period, LFTW conducted audits for five surgeons. For the five TT surgeons

audited, a total of 133 people with 200 operated eyelids were examined. The result of the audit

shows that post-operative TT is ≤5% in all surgeons and therefore have “acceptable” results per

the FMOH guidelines.

The main challenge with the FMOH guidelines is the number of eyelids that need to be examined

per surgeon: the auditor/supervisor needs to examine up to 40 eyelids operated within the

previous 3 to 6 months, which may require sampling patients from many districts. This has shown

to require a significant investment in time and human resources, as it has taken approximately 10

days to audit each surgeon.

3-6 Month Outcome Assessments

In FY18, in addition to counseling operated patients to return after 3-6 months for follow-up,

LFTW began to provide patients with an appointment card to be used as a reminder to the

patient. District health office trachoma focal persons, outreach coordinators and case identifiers

were also asked to mobilize patients for 3-6 month outcome assessment by information

registered in the TT surgery registration book. Patients are asked to return to the outreach sites

so that the surgeon or the supervisor can assess the outcome of the surgery. When organizing

an outreach, LFTW uses surgeons from the closest ECU; however, occasionally, surgeons from

other MMDP Project-supported zones are utilized. Thus, the outcome assessment may or may

not be conducted by the surgeon who performed the surgery. So far, during the reporting period

only 126 patients returned to the outreach sites. Positive outcomes (no post-operative TT, eyelid

margin abnormality, or granuloma) have been reported. However, there is some concern of bias

in the reporting, particularly when it is the surgeon who performed the surgeries reporting the

outcomes. The project is continuing to advocate for a technical supervisor to be present.

Zonal and Regional Program Coordinators’ Monitoring Visit

LFTW program and zonal coordinators have regular monthly visits to the ECUs and WoHOs to

discuss and provide feedback to officials on the identified gaps and strengths of TT surgery

outreach and progress against targets. In addition to woreda health offices and ECUs, the

coordinators visit the woreda and zonal political administrations to discuss with political leaders

any outstanding issues.

LFTW Director Eye Health/NTDs Technical Assistance and Monitoring Visits

LFTW’s Director Eye health/NTDs planned two technical assistance and monitoring visits for

FY18. The first was originally scheduled for November 2017, but due to scheduling conflicts took

place in January 2018 in the Central and North-Western zones of Tigray. The director attended

three outreach campaigns and provided technical support for six TT surgeons and two supportive

supervisors during his three-day visit. In addition to providing technical support while TT

surgeons conducted surgery and supportive supervisors provided supervision, he also attended

the one-day post-operative follow-up at the outreach sites. During TT surgeon’s refresher


training planned for April 2018, the findings from the follow-up visits will be used to tailor the

five-day training. After the training, the director will also conduct a second follow-up visit as per

the workplan to ensure the learnings from the training are properly implemented.


STRATEGIC PLANNING

Hydrocele Surgery Planning and Performance Review Meeting

For FY18, RTI had originally planned to support the FMOH conduct a national hydrocele surgery

planning and performance review meeting to set goals for 2018. However, after the workplan

was approved, the FMOH determined that it would not hold this meeting. Instead, RTI worked

with the ORHB to organize a regional hydrocele planning workshop with MMDP Project funding,

given the low output over the previous year.

This workshop was held in Adama on February 6, 2018. The meeting was presided over by the

Deputy Head of the ORHB, and the regional NTD focal point. In attendance were a total of 44

individuals, including medical directors, general surgeons and IESO) from six hospitals; 14 zonal-

and woreda-level focal persons; Zeina Sifri, Senior Technical Advisor for the MMDP Project at

Helen Keller International (HKI); one representative from the SSE; and five staff from RTI Ethiopia,

including RTI’s Chief of Party, Technical Advisor, MMDP Program Manager, MMDP Project

Manager and Data Manager.

During the meeting, the following presentations were made and discussed:

• High-level summary of the national and regional-level NTD programs;

• Global MMDP Project highlights by HKI;

• The estimated LF morbidity burden and how to address this burden;

• Experiences in hydrocele surgery, and challenges in ensuring hydrocele surgery availability,

including the continued political instability;

• Development of hydrocele surgery plans by the hospitals, zonal- and woreda-level NTD

focal persons to reach the patients identified during the burden assessments;

• Efforts by the RHB to ensure free treatment for all hydrocele and lymphedema patients.

In follow-up to the last point, the RHB has issued a letter stating that all services for LF-related

morbidity would be available free of charge to patients. These services include transportation of

patients, hydrocele surgery, lymphedema management and other related costs19.

Additional action points from the meeting include:

• Ensuring burden assessment findings are provided to the respective hospitals and zonal-

and district-level NTD focal points;

• Auditing and sharing the status of surgeons trained on hydrocele surgery;

19 Per the hydrocele surgery protocol, all patients undergoing surgery are admitted to the hospital for three days;

however, the letter from the hospital only specifies admission on an “as needed” basis.


• Finalizing the memorandum of understanding between RTI and the hospitals targeted for

hydrocele surgery support in FY18;

• Planning surgery weeks by hospital and setting dates by which each hospital/zone aims to

operate the known cases;

• Identification of sites with high burden and planning for minicamps and conducting

readiness assessments in those hospitals;

• Holding a follow-up meeting in June to discuss progress.

Consultative Workshop on Inclusion of FASTT Hydrocele Surgery Training in

Medical School Pre-Service Training

In FY18, RTI planned to hold a one-day consultative workshop to introduce the FASTT training

package to representatives of several universities in Ethiopia and discuss mechanisms for

integrating the training package and simulator into skills laboratories and the curriculum of these

universities’ medical colleges. The long-term objective is to provide students with a standardized

approach, based on the latest WHO hydrocele surgery guidelines, to learn hydrocele surgery

during their pre-service training, in an effort to ensure all patients in Ethiopia with hydrocele

receive quality surgery.

On February 5, 2018, with MMDP Project funds, this workshop was held in Addis Ababa and

attended by a total of 16 participants, including representatives from the Universities of Addis

Ababa, Gondar, Jimma, Debretabor, Mekelle, and Hawassa, and St. Paul Millennium Medical

College. In addition to the university representatives, Zeina Sifri from HKI; Sarah Martindale and

Jan Douglass from the Centre for Neglected Tropical Diseases (CNTD) at Liverpool School of

Tropical Medicine (LSTM); Dr. Asrat Mengiste from the National Podoconiosis Action Network

(NaPAN); Drs. Andualem Deneke and Dereje Gulilat from the SSE and Addis Ababa University;

and Dr. Fikreab Kebede, Sharone Backers, Teshale Yadeta and Haile Kassahun from RTI attended.

The discussion during the workshop focused on the hydrocele burden in Ethiopia, experience in

hydrocele surgery, the FASTT training package, and approaches to integration. The universities

indicated their interest to include the FASTT training package into the surgeon/IESO curricula

and agreed that the SSE would lead the integration process. The MMDP Project will support any

future meetings or workshops to move the process forward.

The first step is to provide the Ministry of Science and Technology (MOST) the physical and

chemical properties of the FASTT cartridges, which will help to forecast the scope of integration

and time the process will take. In conjunction with the workshop with the universities, RTI and

HKI met with MOST on February 7, 2018 in Addis Ababa to discuss the potential to produce

FASTT bases and cartridges locally. The delegation met with the MOST State Minister, Professor

Afework Kassu, who gave his support to this collaboration and assigned an expert to support

this effort. At the time of the writing of this report, the MMDP Project is working with Ho’s Art,

the FASTT manufacturer, to discuss the details of the possibility of this technology transfer and

legal counsel to ensure there are no intellectual property issues. The MMDP Project will fully

document the process of the integration of the FASTT training package and curriculum, and it

could possibly serve as a resource to other countries.


Consultative Workshops on Inclusion of Lymphedema Management in the

Comprehensive Pre-Service Training of Nursing Curriculum

In the FY18 workplan, RTI included support to the Human Resource Development (HRD)

Directorate at the FMOH to conduct two workshops to integrate lymphedema management into

the pre-service nursing curriculum. Although these workshops have not taken place, on October

10, 2017, Dr. Fikreab Kebede, RTI Senior Technical Advisor, visited the FMOH and met with the

Nursing Initiative Coordinator at the HRD and the NTD team regarding possibilities of

integration. A consensus was reached that a discussion would be held during a national nursing

curriculum revision meeting that the Directorate was planning to hold in November 2017;

however, this meeting has not taken place.

A wider consultative meeting was held on January 25, 2018 with the NTD and HRD teams at the

FMOH during which inclusion of lymphedema management and other case management of NTDs

was discussed. In addition to integrating lymphedema management, the NTD team extended the

initiative to include the clinical management aspects of other NTDs. RTI was further asked to

draft the curriculum on lymphedema management. RTI provided a concept draft to the FMOH

team to consider; a further draft will be provided for HKI’s input once discussions continue. RTI

is also discussion with Jhpiego the mainstreaming process as Jhpiego leads the Human Resources

for Health Project.

Participation in National Trachoma Taskforce and LF/Podoconiosis Technical

Working Group

RTI attended the NTTF meeting on October 20, 2017 to review progress and outstanding issues

on the draft national guidelines for TT surgery service supervision, outcome assessments and

surgical audits. The meeting identified further editorial work and requested members of the

drafting team. RTI has reviewed and provided feedback on these documents, and provided

technical support in developing and finalizing the supportive supervision guidelines, ensuring the

inclusion the infection control and healthcare waste management (IC/HCWM).

To this end, a national consultative workshop was conducted in Adama from December 7-9,

2017. RTI was represented by Teshale Yadeta (MMDP Manager), Asrat Gebretsadik (TT Quality

Assurance Officer) and Dr. Fikreab Kebede. The team further facilitated and supported regional

teams in action planning exercises for implementing the guidelines. The consultative workshop

was attended by approximately 90 participants from the RHBs, implementing partners, tertiary

and secondary eyecare units, universities, and the Ethiopia Ophthalmic Society.

In addition, Dr. Fikreab Kebede of RTI, participated in the NTTF meeting held on January 4, 2018

at the FMOH. Participants discussed the need to develop training manuals to guide

implementation of TT surgical audits and manage post-operative TT. The NTTF assigned the

Training and Quality Assurance committee to develop these manuals.


ADVOCACY

RTI did not plan any advocacy-related activities in the MMDP Project FY18 workplan.


Messaging on LF MMDP

LF Tool Printing

New Hope manual

In FY16, the “New Hope” manual, a CDC manual on lymphedema management, was adapted to

the Ethiopian context, including translation into Amharic, and was pre-tested. In FY17, this manual

was translated into Tigrigna and Oromiffa. Additionally, RTI planned to print the New Hope

Toolkit to give to all lymphedema patients in MMDP Project-supported areas. During the

reporting period, RTI printed 14,731 copies in three languages. Of those printed, a total of 8,985

have been distributed to the woreda health offices and health centers (960 of the Amharic

version; 7,920 Oromiffa and 105 Tigrigna), and these tools are provided to the patients once they

are enrolled for lymphedema management services.

Post-hydrocele surgery flash cards

In FY17, RTI collaborated with the SSE and the FMOH to develop post-hydrocele surgery patient

care flash cards in Amharic, Oromiffa and Tigrigna. The flash card is designed as reference

information for the patient and as a teaching tool for the clinical healthcare workers and HEWs

following hydrocele surgery. During the reporting period, the MMDP Project produced 269

Amharic versions and 712 Oromiffa versions of the flash card.

Lymphedema management flash cards

The lymphedema management flash card was drafted in FY17, although not finalized. The flash

card will be finalized in FY18, after the planned feasibility study (see Lymphedema Management

section) is completed.

Mobilization of Patients for Hydrocele Surgery

In FY18, the MMDP Project planned to use both community-based mobilization through the HEW

and HDA network and radio spots, for a total of 48 days of broadcasting, to mobilize patients for

hydrocele surgery.

For seven days prior to the FASTT training that took place from December 25-29, 2017 at

Gambella hospital, the Gambella RHB and the Gog and Abobo woreda health offices conducted

social mobilization through radio spots. The radio spots were the same as those used in FY17 in

Beneshangul-Gumuz with translation by the RHB into the local language, Agnuwa. Experts from

the Regional Education Bureau translated the messages and reviewed them for acceptability in

terms of religious, cultural, and social values; formal pre-testing was not conducted. The messages


emphasized that the surgery is provided free of charge. The radio spots were broadcast once per

day to five woredas.

In addition, HEWs, HDAs, and woreda- and kebele-level administrative leaders mobilized patients

for the hydrocele surgery campaign. The rest of the radio spots will be utilized in Oromia and

Beneshangul-Gumuz in campaigns planned in the next reporting period.

Assessing the Effectiveness of Radio Spots

In FY18, RTI planned to ask patients presenting for hydrocele surgery how they learned about

the availability of hydrocele surgery services by administering a short questionnaire to patients as

part of intake. However, with the novelty of surgery in Gambella, RTI determined that this activity

will take place in the next reporting period.

CAPACITY BUILDING

Training of Hydrocele Surgeons

In FY18, the MMDP Project planned to support national efforts to expand surgical services for

hydrocele to the Gambella region with trainings for six surgeons and/or IESOs from three

hospitals (Gambella, Tepi, and Mizan Aman). Two separate trainings were planned: one at

Gambella Hospital (with two surgeons/IESOs targeted) and one at Mizan Aman University

hospital in Southern Nations, Nationalities, and People’s Region (SNNPR), with two

surgeons/IESOs each targeted from Tepi and Mizan Aman Hospitals, which serve populations in

the LF-endemic districts in Gambella region.

During the reporting period, the training at Gambella Hospital took place from December 25-29,

2017 and one surgeon and one IESO were trained. The training at Mizan Aman University hospital

took place from February 12-17, 2018 and two surgeons and two IESOs (one of each cadre from

both Mizan Aman and Tepi hospitals) were trained.

The four-day trainings each consisted of one day of classroom lecture and training on the FASTT

surgical simulator and three days of practical training on patients. The materials that were used

included the MMDP Project-developed training curriculum and the FMOH’s Hydrocele Surgery

Handbook.

Refresher Training of Clinical Workers on Post-Hydrocele Surgery Survey

In FY18, RTI planned to conduct a 9-12-month follow-up survey of patients operated on during

the first hydrocele surgery campaign in Assosa, Beneshangul-Gumuz in FY17 and who also

previously participated in a survey within five days following their surgeries. The objective of

these surveys is to assess surgical outcomes and to better understand the long-term impact of

the surgery on the patient’s quality of life. As it has been a year since that survey, RTI determined

that a refresher training should be held to ensure the clinical workers conducting the survey

remember the protocol. The refresher training for the clinical workers was held on February 18,

2018 in Assosa town. A total of 13 (five female) clinical workers participated in the training.


The main challenge of this training was that there was not adequate time for the practical sessions.

The training in Tigray did not take place during the reporting period and is planned for April 2018,

to be immediately followed by the survey. The survey was meant to include patients from Oromia

as well; however, due to insecurity in Oromia during the Day 5 data collection period, that follow-

up was not possible. RTI will consider including Oromia in the 9-12 month survey if the security

situation allows.

Training of Clinical Workers in Lymphedema and Post-Hydrocele Surgery

Management

During the reporting period, RTI planned to train 42 clinical workers in Beneshangul-Gumuz,

Oromia, and Gambella to provide both lymphedema management and post-hydrocele surgery

management. These plans slightly shifted for two reasons: 1) per USAID guidance that

lymphedema activities begin after the conclusion of the feasibility study; and 2) the training of

hydrocele surgeons in Gambella necessitated training for clinical healthcare workers to care for

hydrocele patients at the proper intervals post-surgery (five, seven, 14 and 30 days; six and 12

months). Therefore, in conjunction with the FASTT training in Gambella, a one-day training was

held on December 25, 2017 for a total of 13 (one female) clinical workers from the Gog, Abobo,

and Itang woredas. The training was conducted by the SSE and focused exclusively on post-

hydrocele surgery care for the reasons listed above.

On February 12, 2018, an analogous training took place in Mizan Aman in conjunction with the

FASTT training at that hospital. A total of 13 clinical healthcare workers (five female) participated

from the Dimma, Godere and Mengesh woredas of Mejang zone and two hospitals in SNNPR

(Mizan Aman and Tepi). The inclusion of the hospitals in SNNPR is due to the proximity to the

LF-endemic districts of Gambella.

The principal lessons learned during this training and from previous experience is that certain

factors enable the clinical workers to conduct this follow-up, including:

• Commitment and ownership from the Head of the RHB to provide patients food and

accommodation for post-surgery visits. Patients generally stay near the hospital until day

7 post-surgery and return for day 14 and one-month follow-up visits. The woreda health

offices or NTD focal persons take responsibility to arrange these logistical details;

• PHCU and trained clinical workers’ commitment to provide the post-operative care on

the proposed dates and forgo participation in competing activities;

• Monitoring of follow-up from RHB NTD focal persons and RTI regional technical advisor;

• Clear information provided to the clinical workers on the number of patients to whom

they will provide follow-up care and the specific follow-up activities, as well as the contact

information for each patient.

Once the lymphedema management feasibility study has been completed, RTI will determine

further training needs for clinical healthcare workers for lymphedema management.



No LF disease burden assessments were planned in FY18.

HYDROCELE SURGERY

In FY18, RTI plans to support 600 hydrocele surgeries. To date, 86 patients have been operated,

mostly in Gambella region.

Hydrocele surgery in MMDP Project-supported areas is conducted through two approaches: 1) a

campaign approach, utilizing the HEW/HDA network and radio spots to mobilize many patients

for surgery during a specific period, and 2) routine services, in which hospitals themselves reach

out to patients or patients self-report. The method of hydrocele surgery recommended by the

MMDP Project is resection, and the majority of patients received surgery through this method

(81/86). The remaining patients were operated through the eversion technique, which is

recognized by WHO, as these were minor cases and the surgeons judged that this technique was

appropriate for those cases.

During the reporting period, two hydrocele surgery camps were held, one each at Gambella and

Mizan Aman hospitals, following the trainings of hydrocele surgeons held at each hospital (see

Capacity Building section). During the reporting period, the importance of the woreda health offices

was underlined in mobilizing patients for surgery, as they were the primary drivers for these

efforts in Gambella. They were also instrumental in ensuring that patients had a place to stay and

food to eat after their release from the hospital until Day 7 post-surgery, ensuring patients

received the proper follow-up care.

While RTI has only reached 14 % of its annual target to date, this was primarily due to supporting

Gambella to institute services. The second half of FY18 will be focused on supporting Oromia and

Beneshangul-Gumuz to conduct hydrocele surgery campaigns, particularly now that the former

has commitment from the RHB and plans for campaigns by hospitals. With the plans from the

hospitals, an additional 321 patients are targeted for surgery by early July 2018 in Oromia alone.

In Beneshangul-Gumuz, two campaigns are planned in May 2018 targeting approximately 100

patients total. Additional campaigns will be planned and conducted as needed in Q4.

One lesson learned is to not rely entirely on the burden assessment findings to recruit patients

to seek surgical services. Although the overall number of cases in Gambella region discovered

through the burden assessments was low (69), only 56% of those operated during the camps were

identified during the burden assessments. RTI will look further into the origin of these patients to

determine where those missed are coming from. Additionally, RTI will further examine the radio

messages’ effectiveness in the second half of FY18.

Hospital Readiness Assessments

In November 2017, a team from RTI and the SSE conducted hospital readiness assessments in

three hospitals: Gambella hospital, which serves the LF-endemic districts in the northern part of

Gambella region, and two hospitals in the SNNPR region that serve populations in the LF-endemic

districts in the southern part of Gambella region (Mizan Aman University Teaching Hospital and


Tepi Hospital). The objective of these assessments is to evaluate whether a given hospital has the

proper staffing, facilities, equipment/instruments, laboratory services, medication, spaces for

consultation and waiting areas (for patients prior to surgery), and meal services.

To conduct the readiness assessments, the team adapted the draft World Health Organization

MMDP situation analysis tool for LF. In addition, the team conducted a facility observation and

interviewed key staff (hospital management, operating room, pharmacy and laboratory). The team

also evaluated the operating rooms, waiting rooms, training halls, and IC/HCWM practices and

sites. Based on the findings, the team concluded that the hospitals were of sufficient quality to

hold the planned FASTT trainings and subsequent campaigns. Key observations include:

Pre-Camp Screening

No pre-camp screening exercises took place as in FY17; instead, the burden assessment data,

along with social mobilization via HEWs/HDAs and the radio, were utilized to inform patients of

the campaigns.

Patient Counseling and Pre-Surgical Care

The day before surgery, surgeons screened patients using the MMDP Project pre-operative

assessment form in consultation with the FMOH and SSE. Patients were then offered voluntary

HIV testing alongside other basic laboratory tests (urinalysis, haemoglobin, and blood group). All

patients were then observed swallowing pre-operative antibiotics. Prior to surgery, patients

signed a written consent form to undergo surgery following counseling on the surgical procedure

and possible complications and risks.

Patient Follow-up

Per FMOH guidelines, patients should be hospitalized until Day 3 following the surgery to ensure

a surgeon follows up with each patient prior to discharge, and to ensure one aseptic change of

dressing prior to patient discharge. Following discharge, patients return home under the care of

clinical healthcare workers trained to recognize post-operative complications, treat minor post-

operative complications and refer patients back to the hospital when required, perform sterile

changes of dressing, and report their findings. The clinical healthcare workers follow-up the

patients at days 5, 7, 14, 30 and 60, as well as at 6 and 12 months.


The FY17 workplan included a study to examine the feasibility of providing community-based

lymphedema management services, and NaPAN was selected to assist with this work. The general

objective of this study is to compare two community-based lymphedema management

interventions (a basic package of care, or “non-intensified,” and an “intensified” model) to provide

evidence for decision-making to scale up LF MMDP services in all endemic districts in Ethiopia. At

the time of the writing of this report, the FMOH expressed to RTI and HKI that the delays in

carrying out the study are holding up its ability to scale-up lymphedema services in Ethiopia.

As originally planned the feasibility study would compare the two approaches for lymphedema

managements. In the six MMDP Project intensified woredas, lymphedema patients are provided


with a kit of basic supplies (soap, ointment, towels) to enable them to perform the required

washing. The clinical workers training patients receive supportive supervision for three

consecutive months and two quarterly visits from NaPAN staff. In the six woredas of the non-

intensified arm, no kits are provided to the patients and supervision to the clinical workers is left

to the health system. The feasibility study could not be completed in FY17 and this activity was

carried over into FY18.

To conduct the evaluation of the two models, a number of activities first needed to be completed,

some of which have taken place but not all. The status of the various activities required in order

to conduct the feasibility study are listed below:

1. Training of clinical healthcare workers (FY17). While only twelve districts were selected

as part of the feasibility study of the two different models, in FY17 a total of 207 persons

were trained in 32 woredas20 (41 persons trained from intensified woredas), including

clinical health care workers stationed at woreda-level health centers. Additional trainees

included staff from district hospitals, woreda health offices and NTD focal persons. During

the training, the clinical workers were taught about LF; care for patients with lymphedema,

as well as counseling, provision of patient follow-up, referrals, and reporting. Support

materials utilized during the training include the FMOH’s MMDP guidelines for LF and

podoconiosis and NaPAN’s manual on psychosocial and economic rehabilitation for LF

and podoconiosis patients.

2. Communication activities to inform people with a swollen leg that care is available at the

local health center (FY17-18). This included health education sessions on lymphedema

sessions and care at the health centers, production of a poster on LF and podoconiosis

(due to co-endemicity of the diseases and the FMOH’s approach to integrate care for

lymphedema due to both conditions), and broadcast of radio/television programs. These

communication activities were conducted and paid for by the health system.

3. Train patients to care for their lymphedema (FY17-18). To date, 1,316 patients in the

intensified arm have been trained to conduct self-washing (599 in FY17 and 717 in FY18).

In the non-intensified areas, the data have not yet been collected.

4. Provide patients in the intensified arms with basic supplies (bandages, Vaseline, soaps,

basins, and towels) free of charge (FY17). A total of 26 health centers received these

supplies to provide to patients and buckets for each health center to use for

demonstration during patient visits. At the time of the writing of the report, NaPAN is

working to collect information regarding the distribution to the patients, and this will be

reported on in the next reporting period.

20 Clinical healthcare workers were trained in 32 woredas in FY17; however, RTI and NaPAN recognized that this would

be too many woredas for an evaluation. Therefore, six woredas were selected for “intensified” intervention, described

above. All other woredas (26) implemented “non-intensified” intervention, but only six of these were selected for

inclusion in the evaluation.


5. Cascade training to health extension workers to be supervised by the RHBs and zonal

health departments at the PHCU and the PHCU to observe cascade to the health center

level (FY17-18). This was accomplished in the intensified arm. Cascade training was not

supported by the MMDP Project in the non-intensified arm.

6. Supportive supervision by NaPAN monthly (for three months) has been conducted in all

26 health centers in the six woredas in the intensified arm (FY17-18). One of two

quarterly supportive supervision visits were conducted in the woredas in Oromia and

Tigray. The second quarterly visits are planned for April 2018 in those regions. In

Beneshangul-Gumuz, the first quarterly visit is planned for April 2018. As a note, NaPAN

is not providing any supportive supervision to the non-intensified woredas; RHB and zonal

health departments are to conduct supportive supervision.

7. The protocol for the evaluation has been drafted and comments from the project’s LF

Technical Advisory Board (TAB), including USAID, have been received and are under

review (FY18).

Once the protocol has been revised, NaPAN will proceed to collect data to evaluate the two

models. Dependent on comments from the TAB, this may include:

• A review of medical charts to determine the number of visits each lymphedema patient

made to the health center, the drugs/supplies received, and the clinical outcomes recorded

(number of acute attacks experienced during the previous month);

• Focus group discussions with patients to assess whether patients understand the

treatment procedures, their perceptions of the feasibility of continuing adherence to the

washing and their perceived impacts of the intervention;

• Key informant interviews with clinical healthcare workers and decision-makers in the

woredas, zones and regions regarding the feasibility of providing community-level

lymphedema services;

• Costing data from the study will be compiled to better understand the investments

required to offer these services at scale.

One of the lessons learned in conducting the activities is that RTI had not recognized from the

outset the level of mentoring to partner staff required to ensure the overall success of the study.

For example, in the future, RTI would want to oversee the development of a data collection

framework for all information that will be relevant to the study. As an example, all patients in the

“intensified intervention” woredas were to receive a kit with basic supplies. The supplies were

delivered to the health centers and assumptions were made that each patient would receive them.

However, there was no tracking system to ensure that each patient received a full kit. Although

NaPAN is working to collect patient-level distribution on its supervisory visits, RTI will work to

ensure that in future activities, these systems will be agreed upon prior to implementation.



During the reporting period RTI worked with partners FHF and LFTW to determine FY18 needs

and procured the necessary consumables for surgeries. RTI also procured 21,450 tubes of

tetracycline eye ointment (TEO) through the USAID-approved wholesaler, IDA, for FY19

activities. As the procurement was conducted in tandem with the procurement for the

ENVISION Project, the TEO has not yet shipped to Ethiopia. Given past experience, the

procurement was done early so that the TEO is available at the beginning of the FY19 fiscal year

and surgeries are not delayed. For hydrocele surgeries in Gambella, CNTD-LSTM provided

payment directly to Gambella hospitals (and is currently making payment to Mizan Aman hospital)

to cover the cost of restricted items utilized during the surgery.

Additionally, RTI received HEAD START supplies from HKI and has since distributed some of

these items to LFTW and FHF. The main difficulty noted during the reporting period was the

unavailability of certain items, such as surgical blades; however, by repeatedly checking with the

PFSA, enough were located for activities during the reporting period.


Supportive Supervision of Hydrocele Surgeons by SSE Consultants

The SSE conducted two visits to hospitals during the reporting period: one to Assosa hospital in

preparation for and during the October 2017 USAID-HKI field visit to Assosa hospital. As this

visit was not organized as a supportive supervision visit but rather to prepare for the visit,

recommendations were not generated. The second visit took place in March 2018 to Pawe

hospital in Beneshangul-Gumuz.

Although the full report is not yet available, a key strength noted was that surgeries were done

in Pawe General Hospital by the FASTT-trained hydrocele surgeon and IESO per the resection

technique steps detailed in the FMOH’s hydrocele surgery handbook. Additionally, all patients

were provided with preoperative antibiotics and full-body baths prior to surgery. Surgeons

operated in keeping with the project infection prevention protocol as per WHO

recommendations. Finally, all patients were registered in operating room registry books provided

by the MMDP Project.

The visits also noted that patients were operated and discharged on the day of surgery, rather

than being hospitalized for three days as per FMOH and MMDP Project guidelines. RTI has

discussed this with the hospital, and the hospital agreed to the three-day hospitalization. A

memorandum of understanding is being signed to this effect.

Supportive Supervision to Clinical Workers Providing Lymphedema Management

Services by NaPAN Consultants

The training of clinical workers on lymphedema management and supervisions activity is on hold

until the feasibility study is conducted (see Lymphedema Management section).


Supportive Supervision to LFTW and FHF

RTI’s QA Officer regularly conducted supportive supervision visits to both Tigray (LFTW) and

Oromia (FHF) for TT surgery campaigns and quality assurance activities (e.g. surgical audits).

Below are summarized findings from the supervision conducted during the reporting period.

During his supportive supervision visits, the QA Officer provides immediate feedback to TT

surgeons, PHCU directors and other relevant personnel to ensure they are aware of any issues.

The QA Officer also discusses his findings with either FHF or LFTW staff present during the

supervision and regularly shares findings with both FHF and LFTW offices in Addis Ababa.

Strengths identified by the QA officer during the supportive supervision visits include:

• HEWs properly referred cases to the campaigns;

• House-to-house screening by nurses and HEWs during outreach contributed to a strong

mobilization of cases;

• Magnifying loupes were used for screening;

• Surgeons provided good counseling, filled out forms and registers correctly and provided

informed consent to the patients;

• In some of the woredas there was strong commitment from the kebele and zonal leaders,

as they worked together to organize outreach activities;

• All equipment, supplies, and medications were present, including tetracaine and

Zithromax;

• Eyelids were correctly labeled pre-operatively;

• Proper aseptic technique and sterility practices were maintained pre-, intra- and post-

operatively;

Areas for improvement identified by the QA officer during the visits include:

• In some cases, surgeons were overloaded by work and had no assigned assistants;

• IEC materials were not always available for social mobilization;

• Although the surgeons had magnifying loupes, they were often old and had a narrow

working area and short distance;

• Hand sanitizer was not always present during patient screening;

• In some instances, surgical hand washing was not properly done by the surgeons due to

lack of a water system in the health center; an immediate recommendation was to collect

water via jerrycans to use for handwashing before surgery;

• Problems with final waste disposal. For example, incinerators were not fenced properly,

and some waste materials were seen outside the incinerator.


No short-term technical assistance was requested in FY18.



Tracking LF MMDP Interventions: Hydrocele Surgery

The MMDP Project utilizes a standard set of reporting tools for hydrocele surgery, including:

• Medical history form, which is filled out by the examining surgeon;

• Hydrocele surgery register, which is filled out by the surgeon in the operating room;

• Post-operative patient follow-up form, which is filled out by the surgeon on Day three

post-surgery and afterwards by clinical workers at a health center level, and,

• Hydrocele surgery performance reporting form to be compiled by each hospital and sent

to the RHB and then from the RHB to the FMOH.

For hydrocele surgery, assessments and follow-up are completed at hospital and health centers,

and the RHB submits hydrocele surgery performance reports to the FMOH. At present, RTI

collects information from the hospitals that conducted hydrocele surgeries and uses this

information to harmonize with the national integrated NTD database. These data are not yet

reported through the health management information system (HMIS) as planned.

Post-hydrocele Surgery Follow-up Survey

In FY17, the MMDP Project conducted a survey five days post-surgery among patients operated

during the first hydrocele camps conducted in Beneshangul-Gumuz region to determine the

clinical outcomes of the surgery and establish information regarding patients’ quality of life and

economic situation. The project sought to follow-up at least 30% of patients operated (53/175

patients); a total of 68 patients were followed-up. RTI aimed to follow-up the same 68 patients

at the 9-12-month post-surgery benchmark to determine clinical status and whether the patients

perceived any quality of life or economic changes. The survey took place in February 2018. Each

data collector required between two to seven days to complete the survey to reach the targeted

number of participants, and 63/68 patients were located and surveyed. At the time of report

writing, the data analysis is ongoing and will be shared in the next reporting period.

During the reporting period, an analogous survey was planned in Tigray but did not take place. It

will take place in May 2018, immediately after the refresher training for clinical workers on the

data collection tool (see Capacity Building section). As noted above, should security improve, the

survey will also be conducted in Oromia.


NTD SECRETARIAT

No financial support is provided directly to the FMOH or RHBs by any partner. Technical support

was supplied during the above-described activities and during meetings.

FY19 MMDP Project Work Planning Meeting (Planned)

The FY19 MMDP Project workplan meeting is planned for June 7-8, 2018.



In all health centers, there is an infection control and patient safety team. This team is responsible

for all infection control activities, injection safety and disposal of healthcare waste. Additionally,

infection control and waste management is monitored during routine supervision activities for

the MMDP Project. During the reporting period, two of FHF’s supportive supervision visits and

99 of LFTW’s assessed all areas of the EMMR monitoring. Additionally, all supportive supervision

led by RTI’s QA Officer for TT surgery utilizes the MMDP Project supportive supervision

checklist, which includes IC/HCWM, and IC/HCWM sessions are included as part of trainings.

For example, during this reporting period, the hydrocele surgery trainings and the refresher

training for the data collectors for the 9-12 month post-hydrocele surgery follow-up training

included IC/HCWM sections, and there is a section on this in the ongoing TT surgeon training in

Oromia. The LFTW Director Eye Health/NTDs pays close attention to IC/HCWM during his

technical assistance visits and IC/HCWM is consistently prioritized by supportive supervisors in

Tigray, utilizing the MMDP Project supportive supervision checklist. In addition, the FMOH

recognized the importance of IC/HCWM and included it in the supportive supervision checklist

for TT surgery. Additionally, one aspect of the hospital readiness assessments for hydrocele

surgery is to determine the availability of infection control and waste management facilities: the

assessment requires the teams to determine whether autoclaves and incinerators are present

and how non-hazardous waste is disposed.


FHF

FHF has previous experience integrating TT surgery with other activities, such as cataract surgery

and MDA campaigns. Specifically, in East Harerghe (a DFID project zone) TT surgery was

integrated with cataract surgery campaign supported by the Himalayan Cataract Project in 2017.

This approach was attempted in Bale zone in October 2018 but could not be carried out

successfully because of the instability in the zone during the time of the activity. Currently, FHF

is working with Arsi ZHD to integrate TT surgery with MDA campaigns.

LFTW

LFTW and the TRHB have agreed to integrate MMDP Project activities with the existing regional

level comprehensive eye health services directly financed by LFTW. During cataract campaigns

organized at hospitals, the team plans not only for cataract surgeries but also for TT surgery. As

an example, during the cataract campaigns in Axum and Adigrat hospitals, in December 2017 and

February 2018, respectively, approximately 130 TT patients were operated.

LFTW and TRHB have also tried to integrate refractive error services with MMDP Project

activities. Although in DFID-supported areas LFTW tried unsuccessfully to couple refractive

error screening in school with screening for TT in those communities, LFTW has plans to

integrate refractive error screening with TT screening at the community level to ensure that the

comprehensive eye care package is available to patients.


RTI

Per FMOH guidelines, lymphedema management is conducted holistically: there is no distinction

between lymphedema due to podoconiosis and lymphatic filariasis in terms of care. Therefore,

the ongoing lymphedema management as part of activities for the feasibility study will likely reach

both types of lymphedema patients.


SERVICE DELIVERY

• Trichiasis management: Direct medical service provision for TT patients is provided in

static and outreach settings by trained and certified TT surgeons. Government-employed

TT surgeons provide TT surgery from static sites, with the training and systems

established enabling ongoing provision of care beyond the life of the project. Outreach

activities provide service delivery closer to the patient, making services more accessible.

• 3-6 month surgical quality audits: Examination of TT surgery patients 3-6 months following

the surgery to assess the quality of services provided is conducted by experienced eye

care professionals. Follow-up trainings are provided when findings from these assessments

reveal a need for skills refreshers. Feedback provided by supervisors allows TT surgeons

to continue to develop their skills.

• Community mobilization and awareness raising: Activities that raise the awareness of

community members, such as radio spots and social mobilization by HEWs, help to ensure

those in need of the services are aware of their availability, now and into the future.

• The MMDP Project’s support for hydrocele surgery ensures that hydrocele cases have

access to services. The trainings for surgeons and clinical healthcare workers (for post-

hydrocele surgery follow-up and management) as well as the hospital readiness

assessments ensures that these services are of high quality. Since the MMDP Project also

fully supports the cost of the surgery (including patient travel, laboratory work,

consumables, in-patient hospitalization for three days, and follow-up care), the services

are affordable to patients.

• Purchase of the consumables and medications required for TT and hydrocele surgery

ensures their availability for the services provided through the MMDP Project.

• The TRHB has developed a plan to establish an NTD unit within the regional health

structure to push for improved mainstreaming of NTD activities. Although this unit is still

being formed, the MMDP Project has helped to build the capacity of various cadres of

TRHB personnel in TT surgery, monitoring and evaluation, project planning, financial

management, and behavior change. These cadres are all working in different levels of the

health system so that these skills can then be transferred to other areas of work not

necessarily linked to MMDP activities.


• With referral linkages in Tigray, the trachoma outreach campaigns have been used to

identify and refer major eye disease to the nearby SECUs, strengthening the links between

the PHCUs and higher-level care and increasing the number of major eye disease managed

at the SECUs and hospitals. For instance, between January and December 2017, over

6,000 cataract surgeries were conducted, and a substantial number of patients had been

referred during TT outreach campaigns.

HEALTH WORKFORCE

• Experienced eye care professionals provide supportive supervision to TT surgeons on all

aspects of TT surgery, providing TT surgeons the opportunity to improve skills.

• The consultative workshop on inclusion of FASTT hydrocele surgery training in medical

schools’ pre-service training is a step towards ensuring that the medical schools have a

surgical simulator for their skills labs, which will help ensure medical students understand

how to perform the resection technique.

• The training of the six hydrocele surgeons to serve the Gambella region ensures the

availability of a cadre of surgeons with standardized training to provide high-level care to

patients in that region.

HEALTH INFORMATION

• The reporting structures are aligned with the HMIS pathway and the system allows

decision makers to have access to reliable, usable, understandable and comparative data.

TT surgery provision is currently captured in the HMIS.

LEADERSHIP/GOVERNANCE

• Advocacy meetings facilitated by the ZHD and WoHO provide an opportunity for all

stakeholders, such as administrative bodies and local leaders, to understand service

delivery and allow a platform for inclusion in the development of activities at a local level.

• The hydrocele surgery planning and performance meeting provided an opportunity to

engage the leaders of the ORHB to better understand the burden of hydrocele in the

region and to plan services. It also provided the Head of the ORHB with information and

a platform to announce that the ORHB and the hospitals would take leadership within

the region to ensure both hydrocele and lymphedema patients would receive free care.

• LFTW strives to promote increased ownership and leadership of the MMDP Project

interventions by the TRHB leadership by enabling the TRHB to lead on key decisions

related to project implementation and in terms of human and other resources

management. One way in which this is accomplished is through fixed obligation grants,

which encourages implementation of rigorous governance measures to ensure

transparency of the use of resources and enables them flexibility to make decisions

regarding financing of activities in accordance with the milestones.



• In Oromia, recurrent social unrest in almost all parts of the region was the greatest

challenge during this reporting period and hindered movement within the region. This has

affected FHF’s performance of surgery, supportive supervision, and surgical audits in most

zones. As political leaders’ and sectors’ attention was primarily focused on issues related

to the instability, the TT surgery program was not a priority. In addition, the recent

replacement of numerous political leaders and health sector managers at the woreda level

has been a challenge, as FHF needs to orient these new stakeholders to the project.

• In Tigray, the main challenges revolved around quality assurance activities. For outcome

assessments, although HDAs and HEWs actively encourage operated patients to come to

a central point for follow-up, only 126 patients presented. To address this, LFTW modified

the radio messages to include information about follow-up and has added additional days

to TT surgeon outreach plans to ensure they have time to examine operated patients.

Additionally, the FMOH guidelines for surgical audits have proven to be very time-

consuming; it has taken an average of 10 days to conduct a surgical audit for one surgeon,

and this makes it difficult for the supervisors to conduct supportive supervision.

• A lesson learned in Tigray is that the house-to-house case-finding strategy, immediately

followed by a camp, appears to be quite effective, though expensive. LFTW is planning to

implement this strategy in hard-to-reach areas teams may only be able to access once and

areas with high numbers of estimated cases to operate.

• Some follow-up visits to hydrocele surgery patients were not conducted as planned. To

remedy this issue, RTI plans to map clinical workers to hydrocele surgery patients to

ensure each understands which patients he or she is responsible for following up with.

• During this reporting period, 18 patients operated for hydroceles in Beneshangul-Gumuz

were released on the same day. RTI will continue discussions with the hospitals on the

importance of hospitalizing patients until Day 3 and determine the support required by

the hospitals, if any, to adhere to this protocol.

• The FMOH’s push to move MDA towards an integrated approach has taken up a great

deal of the FMOH, RHB, and partners’ time, leaving less time for the MMDP Project. It

has been decided that Beneshangul-Gumuz and Gambella will move forward with

integration, while Oromia will not. While RTI envisions that this issue will still preoccupy

much of FY18, we believe the impact will lessen in FY19.

• The delay in the feasibility study has delayed expansion of lymphedema management to

other woredas as per the approved workplan. Funds earmarked within the FMOH for

expansion have been reprogrammed as a result.

UPDATE ON FY18 IMPLEMENTATION TIMELINE

See the attached timelines.


LF community case identification and referral in Far North, Cameroon, 2017. (photo: William Nsai/Studio 3)

GLOBAL PROJECT

• The MMDP Project worked with the International Coalition for Trachoma Control (ICTC) partners to develop a manual titled “Training trichiasis surgeons for trachoma elimination programs”. This guide is a companion to the WHO yellow manual, “Trichiasis Surgery for Trachoma”, and a new ICTC preferred practice.

• In partnership with the National NTD Control Program in Burkina Faso, the MMDP Project conducted an evaluation of the FASTT training package. The evaluator provided recommendations to update it and supported its widespread use.

• The project’s Technical Advisory Boards for trachoma and LF held meetings to provide guidance on key project activities.


IN BRIEF

During this reporting period, the MMDP Project continued to provide technical and

programmatic support to national governments and the international community. The project

provided support for health systems strengthening in project countries by focusing on capacity

building for quality assurance of service provision for both trachoma and LF interventions. Surgical

activities and capacity building, combined with supportive supervision, patient follow-up and in

the case of trichiasis, surgical audits, all contributed to strengthen the programmatic, public health

and clinical aspects of trachoma and LF control programs in Burkina Faso, Cameroon and

Ethiopia. At the global level, the project shared its experiences and lessons learned with NTD

partners through open discussions as well as joint sessions and presentations at the annual COR-

NTD and American Society of Tropical Medicine and Hygiene (ASTMH) meetings. The project

partnered with experts from ICTC, University of North Carolina (UNC) at Chapel Hill, Johns

Hopkins University, Sightsavers, WHO and others to develop a training guide for TT surgeon

trainers (to be used in conjunction with the WHO Trichiasis Surgery for Trachoma manual), which

has been endorsed as an ICTC preferred practice. The project hosted and jointly organized a

technical webinar on the “Training Trichiasis Surgeons for Trachoma Elimination Programs”

manual, along with a presentation by Sightsavers on its TT Patient Tracker. The project also

evaluated the FASTT training package, which will be updated based on the evaluation findings and

recommendations from a recent WHO consultation on hydrocele.

PROJECT ACTIVITIES

SURGICAL CAPACITY AND HEALTH SYSTEMS STRENGTHENING In the first half of FY18, the MMDP Project continued its work supporting surgical initiatives for

trichiasis and hydrocele surgery in the three project countries, as well as in Benin and Côte

d’Ivoire. The project’s focus on quality assurance of surgical activities includes capacity building

and supportive supervision initiatives which are complemented by a rigorous patient follow-up

system that records patient outcomes and assesses whether any retraining of surgeons is needed.

During the reporting period, the project discussed with each of the country national programs

the challenges encountered conducting quality assurance measures and how to adapt quality

assurance systems to better suit each country. One such example is the project’s efforts to

follow-up with a higher proportion of operated TT cases through outcome assessments. The

project is also working closely with the countries to adapt and help them adopt country-specific

trichiasis surgical audit protocols.

In partnership with ministries of health, the project has put in place quality assurance measures

that are being used systematically in all three project countries. In Ethiopia, the Federal Ministry

of Health (FMOH) is working with the project to set up quality assurance systems that are in

some instances exceeding the project’s quality assurance standards, which are based on

international recommendations. One such example is hydrocele patient follow-up. WHO

recommends countries collect patient information within five days of surgery and the number of


patients with recurrence (which is typically attributable to the surgery if it appears 6-12 months

after surgery). In its FASTT training, the MMDP Project encourages countries to conduct patient

follow-up at additional timepoints, including at seven and 14 days and between one and three

months. The FMOH has adopted all of these follow-up points. The project’s advocacy to routinely

include quality assurance measures, and its demonstration of their feasibility, contribute to

strengthening the countries’ delivery of these interventions within the existing health structure.

Capacity Strengthening in Trachomatous Trichiasis

• Training of a Francophone HEAD START master trainer for TT surgery: In

addition to the activities conducted at the country level, the project continued its efforts

from FY17 to increase the cadre of Francophone HEAD START master trainers beyond

Dr. Amir Bedri Kello. Following a training of national trainers in Cote d’Ivoire in early

FY18, the project supported Dr. Bedri to mentor Dr. Kengmogne while he was

supervising the training of four surgeons in Cote d’Ivoire. On that occasion, Dr. Bedri also

assessed the progress Dr. Kengmogne has made since the FY17 training and discussed

with him the areas that required further practice. The project is planning additional

mentoring opportunities for Dr. Kengmogne that align with Dr. Bedri’s visits to

Cameroon in the second half of FY18. In collaboration with its Senior Scientific Advisor

Dr. Emily Gower, the project is utilizing remote supervision to provide opportunities for

Dr. Bedri to remotely supervise Dr. Kengmogne in his work as a national trainer in

Cameroon. Finally, the project is working with Dr. Emily Gower to develop a standardized

assessment tool for potential HEAD START master trainers that could be used by others

in the global community.

• Short-term technical assistance for TT surgery: In Q1 of FY18, the project

provided short-term technical assistance (STTA) to Benin and Cote d’Ivoire by training

national trainers and surgeons using the HEAD START training package. The training was

also an opportunity for the project to discuss recommended supportive supervision

approaches to support surgical quality. Prior to the trainings, the project confirmed with

the national programs that they were on-track to screen and identify the required number

of TT patients for each of the trainings, but in both instances, this proved to be a challenge

as they fell short of the goal. Further details regarding these trainings are presented under

the STTA section.

• TT capacity strengthening activities for nurses and health care workers: One

of the lessons the project learned through its interventions is that nurses and health care

workers are crucial to the successful implementation of MMDP interventions, as they

contribute to the overall quality of the service delivered to the patients. However, these

health care workers are usually not the main target of capacity building interventions. In

FY18, the MMDP Project added other components to the supportive supervision tools to

be able to fully assess and identify potential gaps in knowledge, attitude or practices of the

nurses and health care workers: counseling, infection control, health care waste

management (HCWM), social mobilization and screening, data collection. The information


collected through supportive supervision is fed back into the training to ensure that it is

adapted to meet the specific needs of the nurse trainees. In addition, the aide memoire

for TT nurses developed in FY17, based on preferred practices and WHO guidelines, is

being used during training activities. During the reporting period, the project used the

aide memoire in a training of four nurses in campaign organization and management in

Cameroon.

Health Systems Strengthening in Trachomatous Trichiasis

• Benin Trachoma Action Plan follow-up workshop: As part of the STTA support in

Benin, the project supported the national program to organize a two-day workshop in

December 2017 to identify practical next steps based on the 2015 TAP. The workshop

was attended by five participants from the national program, three from RTI/ENVISION,

and one of the national trainers trained by the MMDP Project. During the workshop, the

group developed a draft detailed action plan based on the TAP and global

recommendations. Also, as part of the workshop the group defined key activities related

to essential components of a TT intervention. Additional details regarding the workshop

are provided under the STTA section of this report.

• Patient Follow-up activities: As part of the STTA provided to the national programs

in Benin and Cote d’Ivoire, the project worked closely with the national trainers and the

national coordinators to ensure that patient follow-up would be integrated into any future

surgical management of TT. In both cases, the national programs committed to carrying

out patient following up related to any TT surgery activity. Both countries also committed

to following-up with patients who had been operated on under the MMDP Project-

supported training. The project is working closely with both countries to ensure this

follow-up takes place.

Capacity Strengthening in Hydrocele

• Training module for nurses and health care workers: The FASTT training package

includes patient post-operative care and follow-up guidelines in line with global

recommendations. One of the crucial elements of high-quality patient care that helps

decrease the risk of infection is proper hygiene and the post-operative sterile change of

the dressing. During the reporting period, the project used feedback from the trainings

conducted in the project countries to update the training module for nurses and health

care workers. In the second half of FY18, the project will further update the module by

incorporating recommendations from the FASTT evaluation report and the WHO

consultation on hydrocele surgery.

Health Systems Strengthening in Hydrocele

• FASTT evaluation report recommendations: In the first half of FY18 the MMDP

Project conducted an independent evaluation of the FASTT training package. Details are

included under the Surgical Quality Assurance section below. The main conclusion of the


evaluation is that the FASTT training package is a useful teaching tool for teaching the

basics of hydrocele surgery for health staff in charge of operating on hydrocele patients.

Specific recommendations related to health systems strengthening include inviting the

entire surgical team (anesthetists and support staff) to a FASTT training. In previous FASTT

trainings, support staff have participated in the theoretical part of the training but not the

training on the FASTT simulator or surgery on patients. Based on the evaluation

recommendation, the project will revise the FASTT training package to include this as a

standard practice. As the training package includes potential changes to systemic hospital

practices, the evaluator recommended that hospital leadership (administrators and nurse

leadership) participate in the training to be able to support at a hospital level the planning

and provision of hydrocele surgery services.

SURGICAL QUALITY ASSURANCE

In the first half of FY18, the MMDP Project worked with the national programs in the three

project countries to further refine the surgical quality assurance strategies used by the project.

The use of the HEAD START surgical simulator led to the development and use of the FASTT

simulator for hydrocele surgery training in FY17. In FY18 the project conducted an evaluation of

the FASTT training package to assess its impact on surgeon skills. Additional TT surgical quality

assurance components include the use of supportive supervision, patient follow-up and surgical

audits, and the project is in the process of revising these tools based on its TT surgical

management experience. In addition, the remote supervision tool developed on a pilot basis in

FY17 was further refined in FY18 for use in upcoming TT activities.

• TT surgical outcome assessment: In the first half of FY18, the project strengthened

post-operative outcome assessments of TT patients at 3-6 months post-surgery.

Outcome assessments target the patient and aim to have 100% of operated trichiasis cases

seen by a qualified surgeon as part of routine follow-up. Building from past experience

using surgical audits, the project sought to have each program develop a strategy for

independent outcome assessments to test and refine over the course of the year.

Country-specific examples of how this effort was rolled out is described in more detail in

the Improving Data Availability and Use section.

• TT surgical audit: Continuing the project’s focus on quality, surgical audits of trichiasis

surgeons continued in all project countries in the first half of the year. The surgical audit

focuses on individual surgeon performance, focusing the cases selected for follow-up more

narrowly on a single surgeon. As with outcome assessments, the approaches used for

surgical audits vary across project-supported countries, as surgical output, total number

of active surgeons, and geographic distribution of populations influence the country-

specific approaches to surgical audits. Country-specific approaches to and outcomes of

audits are detailed in the M&E subsection of the trachoma portion of each country’s

report.


• Update of supportive supervision tool: The MMDP Project collected feedback from

the three project countries on the use of the supportive supervision tool, which is under

revision with input from Dr. Gower. The updated tool is in the process of being finalized

and will be shared with the three project countries. In Ethiopia, the FMOH is finalizing its

own national quality assurance guidelines for trichiasis, and the project’s supportive

supervision tool is in-line with these guidelines. In Cameroon, the supportive supervision

data was collected and triangulated with the 3-6 month follow-up results to define and

develop a tailored capacity building plan for TT surgeons, as well nurses and health care

workers.

• Remote technical support: In FY17, the project explored the possibility of providing

remote technical support in response to a recommendation made by the HEAD START

master trainer, Dr. Bedri, following an in-country visit. Initial work using remote support

in FY17 led to the recommendation to continue to try to utilize this method to provide

technical feedback. In FY18, the project facilitated Dr. Bedri’s provision of remote support

to national trainers in Cameroon to assist with a refresher training of TT surgeons and of

nurses and health care workers. Through email and Skype calls, Dr. Bedri assisted in the

analysis of results from supportive supervision and 3-6 month follow-up of operated TT

cases. Following this co-review, Dr. Bedri worked with the national trainer through Skype

and email to develop the curriculum for the training. In the second half of the year, the

project will work with Dr. Bedri to provide remote supportive supervision during a

training of TT surgeons in the Far North in Cameroon, as he will be unable to participate

in-person as the area is inaccessible to foreigners due to insecurity.

• FASTT hydrocele surgery training package evaluation: In partnership with the

National NTD Control Program in Burkina Faso, the MMDP Project organized a FASTT

hydrocele surgery training as part of an evaluation of the FASTT training package, led by

an external evaluator, Dr. Catherine deVries. The purpose of the evaluation was to assess

the impact of the training package on surgeon skills. However, in order to address

potential ethical concerns about measuring baseline skills of surgeons (without

intervention or correction by the evaluator), a revised protocol that excluded the pre-

training evaluation component was developed and shared with the project’s LF Technical

Advisory Board (TAB). Based on the comments from the TAB, the project worked with

Drs. deVries and Gower to revise the protocol and questionnaires. The finalized

evaluation materials were shared with the LF TAB and the evaluation was conducted in

February 2018. The evaluation report was submitted by Dr. deVries and shared with the

project’s LF TAB in March 2018 for discussion during the April TAB meeting.

The report concluded that the FASTT training package is a useful teaching tool that

provides a comprehensive system for teaching the basics of hydrocele surgery: pre-op

evaluation, intra-operative considerations, instruments, instrument care, and post-

operative wound care, for health staff in charge of operating on hydrocele patients.

Specific recommendations related to health systems strengthening include inviting the

entire surgical team (anesthetists and support staff) to a FASTT training. In previous


FASTT trainings, support staff have participated in the theoretical part of the training but

not the training on the FASTT simulator nor surgery on patients. Based on the evaluation

recommendation, the project will revise the FASTT training package to include this as a

standard practice. As the training package includes potential changes to systemic hospital

practices, the evaluator recommended that hospital leadership (administrators and nurse

leadership) participate in the training to be able to support at a hospital level the planning

and provision of hydrocele surgery services. Based upon the evaluation results, the

evaluator recommended, “As the FASTT training package is the most up-to-date and

comprehensive curriculum available for training and continuing medical education for

surgeons performing hydrocele surgery, encourage its immediate use and develop a means

to alert users of available updated materials (e.g., via a WhatsApp message or website

with a link to the project materials).”

• Hydrocele surgery follow-up: In addition to patient follow-up within five days of

surgery, in FY18 the project conducted hydrocele surgery follow-up of patients within the

6-12 month period following surgery to assess for recurrence and confirm surgical

outcome. The project continued to collect this data during the reporting period. In the

second half of FY18, the project will analyze this data, and the results will be shared with

local and global partners.


As part of its scope, the MMDP Project responds to technical assistance requests from ministries

of health and global partners for TT- and LF-related activities. In the first half of FY18, in

consultation with USAID, the project conducted a follow-on training to a FY17 regional training

of four national TT surgeon trainers from Benin (two) and Cote d’Ivoire (two). There were

several challenges in carrying out both STTA requests, and the project shared with USAID a

lessons-learned document highlighting the specific challenges encountered, lessons learned and

proposed solutions.

• National training of TT surgeons, Cote d’Ivoire: The project worked with the HKI

country office and the national program in Cote d’Ivoire to carry out a national training

of TT surgeons in Buna District, Cote d’Ivoire in October 2017. The preliminary planning

activities were coordinated with the national program and key requirements for the

training were shared with the national program, including the selection criteria for the TT

surgeons and the need for 50 patients for the surgery component of the training. The two

national trainers previously trained under the MMDP Project in FY17 led the training of

four TT surgeons, with support from the MDDP Project team of Drs. Bedri and

Kengmogne. A total of 14 patients were identified for the training, which was insufficient

for all participants. Therefore, the training was refocused on the two national trainers to

provide them with additional surgical opportunities.

• National training of TT surgeons, Benin: Based on the training experience in Cote

d’Ivoire and the skill level of the two national trainers, the project discussed with USAID


and proposed to focus the Benin training on strengthening the surgical capacity of the two

national trainers. With USAID concurrence, the TT surgery training was conducted in

Tchaourou district in December 2017. Nine patients were operated on during the

training. The project shared with USAID that one of the lessons learned from the Cote

d’Ivoire and Benin trainings is that low-endemic countries present a challenging situation,

where it may be difficult to identify potential trainers that meet the required selection

criteria of having robust TT surgical experience. Following the Benin and Cote d’Ivoire

STTA activities, the project recommends in-depth discussions with a national program to

understand the skills and experience available at the country-level for TT surgery and the

capacity for patient mobilization and screening, prior to any commitment for technical

support. In addition, depending on the country situation and based on the above

experience, the project recommends considering foregoing the two-tiered approach of

national TT surgeon trainers and TT surgeons in favor of one level that may prove to be

sufficient in some contexts, particularly where the national trichiasis burden is low.

• Benin Trachoma Action Plan follow-up workshop: As discussed under the Health

Systems Strengthening section, project discussions with the NTD Coordinator revealed

that although Benin had a TAP, no additional action steps had been conducted since its

development in 2015. In December 2017, the project worked with the national program

to organize a workshop that was attended by five members of the national program, three

staff from RTI/ENVISION and one of the national trainers trained by the MMDP Project.

By the end of the workshop the participants had developed a draft detailed action plan,

based on the TAP and in accordance with preferred practices and global

recommendations. The feedback from this activity was very positive and the national

program was grateful for the work that led to a roadmap to help them reach the

elimination goal.

• LF MMDP Workshop for Francophone Africa: In partnership with WHO-Expanded

Special Project for Elimination of Neglected Tropical Disease (ESPEN), Global Alliance to

Eliminate Lymphatic Filariasis (GAELF), and US Centers for Disease Control and

Prevention (CDC), in FY17, the MMDP Project led an LF MMDP workshop focused on

six Anglophone countries. In FY18, the project was invited by ESPEN to help organize and

facilitate a similar workshop for Francophone countries in Africa to take place in April

2018. As part of planning activities during the reporting period, the project participated

in calls for workshop facilitators and shared the modules that were used in the

Anglophone workshop the previous year.


Table 6. Overview of TT and LF Tool/Resource Development in FY18

Tool FY18 Goal Status Language

Trachoma

TT Surgeon Training Package Dissemination The manual was adopted as ICTC preferred practice

PowerPoint slides and leaflets finalized and available for dissemination

Presented during HKI technical webinar - Feb. 18

French version under translation

English and French

Standardized Supportive Supervision Checklists for TT Management

Dissemination Disseminated

Additional internal revision of the tools

New revised version will be utilized in FY18

English and French

Laminated support documents for TT surgeons, including surgical checklist (included in TT training package)

Dissemination Finalized

English and French

Aide memoire for nurses trained in TT management support and to train health care workers involved in TT activities (only available in French)

Dissemination Disseminated English and French

Guidelines and support materials for infection control and health care waste management

Dissemination Disseminated

English and French

Upgraded TT Surgery Video

In consultation with the international trachoma community it was determined that this is not a current priority.

National and Master Trainer Assessment Tools

Finalization In consultation with Drs. Bedri and Gower, the project is developing and testing the tools to be shared with the ICTC

English and French

LF

WHO LF MMDP Toolkit Dissemination Revising/finalizing

Pending WHO clearance

English and French

FASTT Training Package Dissemination Evaluating/finalizing English and French

FASTT training resources for nurses/ health care workers

Dissemination Finalizing English and French


SUPPORTING GLOBAL ELIMINATION PLANNING

Accurate TT estimates at the district level remain integral to the ability of countries to plan the

interventions needed to reach WHO’s elimination criteria, particularly in low endemicity

countries. As described in the country-specific sections of this report, the MMDP Project is

playing a key role assisting the national program in Cameroon by liaising with WHO’s Tropical

Data initiative to calculate age- and sex-standardized TT estimates from historical surveys. The

project is also closely tracking the relationship between survey data and on-the-ground

observations (e.g., data on screening, surgical output, and geographic coverage). Through this

data collection and analysis, the project aims to support national programs to document the

efforts that have taken place in districts where TT estimates, despite being age and sex

standardized, may contradict other information on TT prevalence. As the project works in

districts that are reaching the ‘last mile,’ the project is well positioned to raise key questions in

the global trachoma community that will help refine elimination planning at the global level.

In Burkina Faso, as part of the discussion and planning around the last mile, the national program

supported a TAP workshop in February 2018. The meeting was supported by the MMDP and the

END in Africa Projects. The MMDP Project engaged Mr. Chad MacArthur to facilitate the

meeting, which was attended by the l’Occitane Foundation, Sightsavers, and included participation

from members of the water and school-health sectors of the ministry. The meeting provided a

forum to discuss progress made to date on achieving the elimination criteria for both interruption

of transmission and trichiasis. The meeting included a review of the epidemiological data for

trichiasis, including provisional categories to help prioritize districts: those in need of immediate

service provision, those in need of a TT-only survey and those which will receive revised

estimates to better inform decision-making within the coming year. As part of the meeting, the

participants prepared a list of action items pertinent to each component of the Surgery,

Antibiotics, Facial cleanliness, and Environmental improvement strategy. Following the meeting,

the project has continued to support the national program to move the action items forward,

specifically, data entry into the WHO elimination dossier template and trichiasis service provision

in priority areas. A similar trachoma action planning meeting is planned in Cameroon for the

second half of FY18 with costs shared across the MMDP and ENVISION Projects.

On the LF front, the MMDP Project continued to support WHO to finalize the LF MMDP Toolkit.

The MMDP Project worked with the WHO LF Focal Point in Geneva to incorporate the new

illustrations developed under the MMDP Project and develop short descriptions of each of the

toolkit documents for posting on the WHO website. At the request of WHO, the project

developed a facilitator’s guide to conduct a LF MMDP workshop similar to the ones carried out

in SEARO and Tanzania. The draft guide is currently under review by WHO.

Following the planned April 2018 WHO-ESPEN LF MMDP workshop for Francophone countries,

the project will discuss with the Burkina Faso national program next steps to begin preparing the

LF MMDP elimination dossier. In Cameroon, the project will support in the last half of FY18 a LF

strategic planning workshop with local and global partners.


IMPROVING DATA AVAILABILITY AND USE

The MMDP Project continued to collect, review, compile, and analyze data corresponding with

its TT and LF indicators, which are summarized in Appendix A. In addition to summarizing project

activities and results, these indicators have enabled the project to strengthen its internal

programmatic feedback loops and engage in evidence-based decision-making. For example, as

described in the country-specific sections of this report, the project has relied on its 3-6 month

post-TT surgery outcome data to determine the nature and timing of FY18 surgeon training

activities.

Trachomatous Trichiasis

Piloting new approaches to TT surgery quality assurance, through the implementation of outcome

assessments (previously called centralized follow-up) and surgical audits as two distinct activities,

has been another key M&E priority in FY18. The project began working with staff in Burkina Faso,

Cameroon, and Ethiopia to develop country-specific approaches and corresponding protocols

that reflect the nuances of the different country contexts.

• In Burkina Faso, the project has been piloting outcome assessment as a new, separate

activity since the end of FY17. Initial implementation has resulted in 20 additional people

receiving an examination 3-6 months after surgery during the reporting period, yet the

majority of those who receive this important follow-up exam are successfully reached

only when the project actively seeks them out in their homes. Early lessons learned by

the project highlighted the time- and resource-intensive nature of outcome assessment in

the Burkina Faso context, as surgical outreach sites are often widely geographically

dispersed. As a result, the team must organize, staff, and supervise many “centralized”

follow-up sites within a single district. For surgical audits, a new protocol is under

development that 1) adjusts the project’s previously implemented sampling strategy so

that it is surgeon-based, 2) assures the audit team composition reflects current global

preferred practices, and 3) narrows the scope of the follow-up interview so that it focuses

most heavily on verifying and assessing surgeon performance. The new protocol will be

piloted in Q3, although the limited availability of surgeons and technical supervisors (who

are the same individuals participating in TT surgery campaigns and outcome assessments)

poses a challenge to staffing surgical audit teams.

• In the low-burden setting of Cameroon, the number of individuals receiving TT surgery

during a campaign is often small enough that it is feasible for the project to actively seek

out all operated cases in their homes 3-6 months after surgery. Within this context, the

project is revamping its 3-6 month questionnaire components to align with current

preferred practices for both outcome assessments and surgical audits, so that the activity

may fulfill the objectives of both activities to the greatest extent possible when surgical

output is very low. A surgical audit protocol outlining a process for surgeon-based

sampling is also under development for use when surgical output is high enough to warrant

sampling. The revised approach will be piloted during the 3-6 month post-operative

window for the campaigns conducted during FY18.


• In Ethiopia, the project’s roll out of its FY18 approach coincided with the FMOH’s

unveiling of a comprehensive and integrated approach to TT surgical quality assurance.

To ensure alignment with the FMOH’s national guidelines, the project paused its piloting

of new processes during Q1 and instead provided feedback on the draft guidelines the

FMOH shared with partners for review. In December 2017, the FMOH convened a

meeting to discuss the guidelines that was attended by project staff in Ethiopia. Following

this meeting, the global project team began working with in-country partners to develop

practical implementation strategies for surgical audits and outcome assessments based on

FMOH guidelines and current best practices shared by the international trachoma

community.

• Analysis of data gathered through TT supportive supervision tools will take place primarily

in the second half of FY18, as Q1 and Q2 were focused on revising the project’s existing

tools and checklists to facilitate user completion of the materials and increase the

frequency of data sharing. The project will rely primarily on the data generated from the

revised checklists to analyze the data as described in the FY18 work plan, with special

emphasis on linking supportive supervision results with post-operative outcome data, to

the extent possible.

• The project has also begun planning the details of its exploration of TT surgery refusals.

As described in the FY18 work plan, this activity was initially envisioned as compiling

qualitative data on refusals at the time that refusals are documented, with the goal of

identifying, understanding, and, to the extent possible, addressing the underlying reasons

in each country-specific context. However, as part of the discussions that took place

during the Q2 TAP in Burkina Faso, the project identified the opportunity to support the

national program in strengthening its approach to systematically documenting refusals. In

FY18, the project will prioritize supporting a clear system to identify and document TT

case refusals within the existing health system. Proper case refusal management should

enable the health system to know where TT case refusals are for continued counseling

and provision of opportunities for TT surgical management.

Hydrocele

• MMDP Project guidance is that all patients undergoing hydrocele surgery receive a follow-

up within five days post-surgery, as recommended by WHO. The project has used lessons

learned from TT surgery quality assurance to conduct patient follow-up 6-12 months

post-hydrocele surgery, including questions on quality of life changes. The project is

conducting this activity in all three countries. Once the data is compiled and analyzed the

project plans to prepare a comprehensive document looking at surgical services, patient

outcomes within five days of surgery and recurrence in the 6-12 months following surgery.

The document will be finalized later in the project year.


OPERATIONAL RESEARCH

The project worked closely with the project’s Senior Scientific Advisor, Dr. Emily Gower, WHO

and Sightsavers to conduct operational research activities in an effort to develop and share

technical guidance related to MMDP in support of USAID’s portfolio.

• Surgical management of post-operative TT: Based on discussions with the WHO

Trachoma Medical Officer Dr. Anthony Solomon and Dr. Gower, the project included in

its FY18 workplan support of programmatic research activities to develop a training

curriculum on surgical management of postoperative trichiasis. The proposed project

support relies in part on preliminary activities conducted by Dr. Gower, in collaboration

with Dr. Merbs from Johns Hopkins University. These preliminary activities encountered

delays and the project is in regular contact with Dr. Gower with regards to the revised

timeline. At this stage no set dates have been shared for the proposed activities that could

be supported by the project, including surgeon trainings on a pilot basis. In the meantime,

Dr. Gower has also approached several donors with a proposal to help support the

surgical management of post-operative TT activities and there has been no conclusive

feedback yet. Dr. Gower is working to obtain IRB approval from UNC to facilitate the

surgical work once activities start. The MMDP Project’s involvement is currently on-hold

pending further discussions with USAID regarding the project’s future involvement.

• Predictors of TT surgical outcomes: In Q2 of FY18, eight project staff in Burkina

Faso and Cameroon received training in taking photographs of operated eyes immediately

before and after trichiasis surgery. The photos will be used to generate additional

information regarding potential predictors of surgical outcomes in a programmatic setting,

and to help facilitate unbiased assessment of surgical outcomes during outcome

assessment and surgical audits. MMDP Project global team members provided the

trainings (which took place in January in Burkina Faso and in March in Cameroon), which

included detailed planning for the roll-out of the pilot for the first TT campaigns of the

year. Those trained in photo-taking were individuals who already participate in supervision

of TT surgical and post-operative follow-up activities. During the reporting period,

Burkina Faso piloted the photo-taking with a sample of 55 operated cases during its first

four campaigns, the results of which the project is currently assessing. In Cameroon,

MMDP Project staff trained five surgeons and supervisors in the North in photo-taking,

using the post-operative follow-up in Touboro district in March 2018 as an opportunity

for informal practice. The photo-taking pilot will take place during the first FY18 TT

campaign, planned for Q3. The quality and quantity of photos collected, and the logistics

of taking photos within each country’s campaign model, will inform the project’s potential

integration of photo-taking into future campaigns.


• Evaluation of the FASTT training package: As discussed above, the MMDP Project

worked with Dr. deVries to lead the evaluation of the FASTT training package during a

training in Burkina Faso. The evaluation report provided the following recommendations

that will be discussed with the project’s TAB during its quarterly meeting in April 2018.

o Integrate technical updates into the FASTT videos and training materials to be

consistent with the 2017 WHO consultation on surgical management of hydrocele

surgery.

o Consider including entire surgical teams, including anesthetists and support staff,

as participants in the FASTT training. Also, as systemic hospital practices may need to change to incorporate the recommendations in the FASTT training package, it

may be important to engage hospital leadership (administrations and nurse

leadership) in the training.

o As the FASTT training package is the most up-to-date and comprehensive

curriculum available for training and continuing medical education for surgeons

performing hydrocele surgery, encourage its immediate use and develop a means

to alert users of available updated materials (e.g., via a WhatsApp message or

website with a link to the project materials).

o Encourage the use of the evaluation tools included in the FASTT training package

to evaluate participant skills on the FASTT simulator and on patients.

DISSEMINATING BEST PRACTICES

Scientific Leadership

The MMDP Project worked closely with its local and global partners, to prepare and submit

abstracts and presentations for conferences. The project is also working on white papers and

manuscripts for publication in peer-reviewed journals. They include the following:

• Annual Meeting of the Coalition for Operational Research on Neglected

Tropical Diseases, November 2017, Baltimore, Maryland: (accepted)

o Breakout session: Post-trichiasis surgery follow-up at 3-6 months: Experiences and

lessons learned (joint with Kilimanjaro Centre for Community Ophthalmology,

Sightsavers, UNC)

o Innovation Lab sessions:

▪ FASTT: A Surgical Simulator for Hydrocele Surgery;

▪ MMDP Toolkit to Address Lymphatic Filariasis Disease (joint with CDC)

• ASMTH Annual Meeting, November 2017, Baltimore, Maryland: (accepted)

o Symposium: Follow-up tools for surgical quality assurance

o Abstracts for oral presentations

▪ TT screening and active case finding, an opportunity for eye health

programs: Case study of the MMDP Project in Burkina Faso

▪ Outcomes of a Pilot Hydrocele Surgery Camp in Ethiopia (RTI submission

under the MMDP Project in Ethiopia)


o Abstracts for posters:

▪ Management of the quality of trichiasis surgery services in a community

setting in Cameroon: Implementing a quality assurance approach

▪ Confirming Trachomatous Trichiasis prevalence: Pilot TT-only survey in

Touboro health district in North Cameroon

• Submissions to the 2018 ASTMH Annual Meeting: (submitted, awaiting

feedback)

o Symposium: Health Systems Strengthening through Capacity Building and Service

Delivery for Hydrocele Surgery: Case studies from Africa and Asia. Submitted in

collaboration with Center for Neglected Tropical Diseases (CNTD)-Liverpool

School of Tropical Medicine (LSTM)

o Abstracts for oral and poster presentations (to be determined):

▪ Quality of Life Changes and Post-Operative Follow-Up of Hydrocele

Surgery Patients

▪ Community-based approach to identify hydrocele cases: Results of a pilot

in five health districts in Cameroon

▪ The “last mile” of trichiasis management in Cameroon: Aligning

implementation and epidemiological data at the threshold of trachoma

elimination

▪ Identification of barriers to hydrocele surgery: Case study of the Bibemi

and Kar-Hay health districts in Cameroon

▪ Strengthening the quality of trachomatous trichiasis surgical services: Using

an integrated supportive supervision approach

• The MMDP Project is preparing case studies, peer reviewed articles, white

papers, and grey literature on the following topics:

o Experience in TT case finding across countries;

o Experience offering epilation counseling for TT cases that refuse surgery;

o LF situation analysis, burden assessment and health facility assessment experiences

across the project countries;

o Hydrocele surgery and post-operative follow-up; and

o FASTT evaluation results.

• Manual for trainers titled “Training Trichiasis Surgeons for Trachoma

Elimination Programs”: As described above, in FY18 the MMDP Project finalized this

training manual as an ICTC preferred practice in partnership with global partners. The

MMDP Project also finalized a French translation of the manual and submitted it to ICTC

for review. We anticipate the French version will be available by the end of FY18.

• MMDP Technical Updates: In February 2018, the MMDP Project organized a NTD

technical update featuring the “Training Trichiasis Surgeons for Trachoma Elimination

Programs” manual. An introduction and background was provided by Dr. Emily Gower


(UNC at Chapel Hill). An overview of the manual was presented by Dr. Amir Bedri Kello

(Light for the World) and Sabrina La Torre (Helen Keller International). Sarah Bartlett

and Kim Jensen from Sightsavers presented on the Trichiasis Surgery Patient Tracker: A

common application. More than 50 people registered for the webinar, and 30 logged into

the platform at the time of the webinar. Following the live presentation, the project shared

the presentations, a link to the recording of the webinar, and a complete list of questions

with responses (as all questions were not able to be addressed during the webinar itself)

with registrants. An exit survey, in which half of webinar participants responded, showed

an overall positive response to the webinar, and that participants felt the speakers were

knowledgeable. Participants also responded that the topics presented were relevant as

priority issues to trachoma elimination and that the content was relevant to their jobs.

• NTD NGDO Network – Disease Management Disability and Inclusion

Working Group (DMDI): The MMDP Project presented remotely on the trachoma

and LF-related indicators collected under the project to the DMDI meeting in the UK in

March 2018. The presentation was well received and followed by an active discussion and

questions from the audience members.

FACILITATING GLOBAL COLLABORATION

During the reporting period, based on internal discussions and discussions with USAID, the

MMDP Project intensified its collaboration efforts to raise the visibility of the project with local

and global partners and to create opportunities for additional partnerships. This effort has not

only increased the project’s visibility and transparency within the global community, but also has

led to potential new partner initiatives in both trachoma and LF. A few examples of these new

initiatives include the project’s discussions with Sightsavers on its TT patient tracker app, and the

webinar that the project organized with global technical TT experts. On the LF front, the project

submitted a joint symposium application with CNTD-LSTM for hydrocele surgery and health

systems strengthening, and the project is currently discussing with Sightsavers its work in

hydrocele surgery. The project will continue to contribute to global conversations on MMDP

through presentations and discussions on lessons learned as highlighted under the Improving Data

Availability and Use and Disseminating Best Practices sections.

• Global Trichiasis Scientific Meeting: Although a date has yet to be set, the MMDP

Project has reconfirmed to Dr. Anthony Solomon of WHO its continued readiness to

help support a global trichiasis or trachoma scientific meeting, as per WHO needs.

• Monthly Morbidity Management Meetings of the LF MMDP Community and

ad hoc meetings of the TT MMDP Community: In FY18, the project facilitated and

served as the secretariat for the Monthly Morbidity Management Meetings of the LF

Community (MMMM). No meeting of the ad hoc Global TT Coordination Meeting took

place during the reporting period, and the project is using other international meetings

and its quarterly TAB meetings to engage with the TT community.


The MMMMs led by WHO include representatives from HKI, CDC, African Filariasis Morbidity

Project, GAELF, Government T.D. Medical College Hospital-India, the Malaria Consortium, RTI,

and USAID, with new members in FY18 including CBM, CNTD-LSTM, and Sightsavers. MMMMs

were held in October and December 2017 and January, March and April 2018.

During the reporting period, the project reinitiated its TABs. As presented in the workplan, the

project created two technical advisory boards, one focused on each disease. The LF TAB also

welcomed a new TAB member, Emily Toubali (USAID LF Consultant). All of the TAB members

who also serve as consultants on the project confirmed that they will volunteer their time on the

TAB.

The first of the quarterly meetings of the Trachoma TAB was held in December 2017. During

the meeting, the TAB elected Dr. Gower as the chair, and proposed and agreed on its terms of

reference for the TAB. The meeting focused on discussion of the main FY18 trachoma activities

planned for the project. The member participation was strong and discussions focused on several

points raised, namely the lidocaine with adrenaline shortage and proposed research activities.

Following the TAB meeting, the project reached out to TAB members to obtain their technical

feedback on a standard operating procedure to mix lidocaine with adrenaline. In the interim, the

Burkina Faso national program that does not have access to pre-mixed lidocaine with adrenaline

has decided to conduct surgery using lidocaine only.

The first quarterly meeting of the LF TAB was held in December 2017. It followed the same

format as the trachoma TAB meeting and the nominated chair was Dr. Charles Mackenzie. TAB

members actively participated in discussions on the upcoming project activities. Following the

meeting, the project reached out to the TAB members to obtain feedback on a number of planned

activities, including the 6-12 month protocol for hydrocele surgery patient follow-up, a

lymphedema management feasibility study protocol, and the FASTT evaluation protocol.

OPERATIONAL ACTIVITIES

HUMAN RESOURCES

During the reporting team, the project hired Geri Kemper as a Program Associate. This position

was created as a result of the project team restructuring that occurred in late FY17.

TRAINING AND PROFESSIONAL DEVELOPMENT

No global team training or professional development opportunities were funded by the MMDP

Project during the reporting period.

PROJECT MEETINGS

During the reporting period, monthly project team meetings were transitioned to weekly team

meetings, focusing on FY18 country and global work plans and project updates.


CENTRAL-LEVEL PROCUREMENT

Central-level procurement of supplies for FY18 trichiasis management and LF MMDP activities

took place throughout the reporting period. Details are provided in Table 7 below. The project

was not able to identify a USAID-approved wholesaler to provide lidocaine 2% with 1:100,000

adrenaline. As a result, the project procured the specific drug with organizational funds. As

Burkina Faso did not have a supplier with lidocaine with adrenaline (pre-mixed), during the

reporting period surgeries were conduct only with lidocaine (without adrenaline), as

recommended by the Burkina Faso national program. HKI purchased the lidocaine in Burkina

Faso with organizational funds.

Furthermore, due to the unavailability of TT surgery drugs from IMRES and the timing of the

campaigns, HKI purchased with organization funds the drugs needed for the first few campaigns

in Burkina Faso, so as not to delay TT campaigns.

Table 7. MMDP Project Headquarters Procurement (USAID-supported)

HEAD START FASTT

Pharmaceuticals

Burkina Faso 150 eyelids; 8 orbits 60 cartridges Various (via IMRES)

Cameroon 100 eyelids; 8 orbits - Various (via IMRES)

Ethiopia 576 eyelids; 36 orbits - -

DC Office 120 eyelids; 10 orbits 15 cartridges -

REPORTS TO USAID

The MMDP Project submitted the FY17 Environmental Mitigation and Monitoring Reports for

Burkina Faso, Cameroon, and Ethiopia in October 2017. The FY17 Annual Progress Report,

covering October 1, 2016 – September 30, 2017, was submitted in November 2017. Additionally,

informal monthly updates on project activities were shared with USAID throughout the fiscal

year.

FY18 WORK PLANS

A draft FY18 work plan and budget for the three MMDP Project countries and the global activities

was submitted to USAID on August 1, 2017. The revised work plan and budget based on USAID

feedback and comments was approved by USAID on December 5, 2017.


APPENDICES

APPENDIX A – MMDP PROJECT SUMMARY DATA TABLES

Trachoma (tables A1-A4)

• LF (tables A5-A8)

• Other Project Activities (table A9)

APPENDIX B – FY18 SEMI-ANNUAL REPORT IMPLEMENTATION TIMELINES


Trachoma

Table A1. TT Management Services: Targets vs. Actuals by Project Area

For each geographic area the MMDP Project has targeted with trichiasis management services, the following table

summarizes how project achievements relate to the area’s UIG.

• The project’s trichiasis management activities support progress towards the elimination threshold of a prevalence

of TT unknown to the health system of less than 1 case per 1000 total population. The project therefore tracks

the number of people receiving trichiasis surgery and the number of cases otherwise made known to the health

system. The number of cases otherwise made known to the health system is defined as all known cases of individuals

who refuse surgery or are referred by the project for surgery due to either lower eyelid trichiasis or an age of

less than 15 years. (Referrals due to post-operative TT are not included, to avoid counting the same individual

more than once.)

• As the epidemiological data used to calculate the UIG change with each new trachoma survey, the UIG will be

updated as needed in future reports to reflect the most recent estimates. The calculation of the Remainder against

the UIG considers all TT surgeries since the most recent survey, including those conducted by other implementers.

• UIG data for Ethiopia include data only from woredas covered by the MMDP Project.


Table A2. TT Management Services: Geographic Context

For additional details, please refer to the following country-specific notes:

Burkina Faso

• Although all four districts in the Center North with a UIG were originally planned for project intervention in FY16,

the coup d’état in September 2015 resulted in delays and the project’s inability to conduct activities as planned.

Ethiopia

• In Oromia, the MMDP Project’s area of coverage encompassed 115 woredas with a UIG at the time of FY18 work

planning. However, due to redistricting that took place at the beginning of FY18, this number of project-supported

woredas increased to a total of 142. The Oromia woredas not within the MMDP Project’s area of coverage are

towns or are supported by another partner.

• In Tigray, the project currently targets 31 woredas spanning five zones (increased from 25 woredas targeted in FY17,

and 22 woredas targeted in FY16).


Table A3. MMDP Project Achievements: Trichiasis Management (USAID-supported)

The following table provides a breakdown of the intensive trichiasis management services provided by the MMDP Project. Please note the following:

• The number of people confirmed with TT does not always equal the number of people who received surgery, were referred for surgery, or refused

surgery. Some individuals are lost to follow-up and not formally tracked by the project.

• Referrals: The project refers to a higher-level facility post-operative or lower-lid trichiasis cases as well as those <15 years old with TT.

• Epilation: Individuals are reported as receiving epilation counseling only if they were provided with a pair of high-quality forceps, as recommended in

the WHO Second Global Scientific Meeting on Trachomatous Trichiasis report. The project supports each Ministry of Health’s official stance on epilation.

The project will continue to advocate for the adoption of the recent WHO guidance regarding epilation as an alternative trichiasis management strategy.

• Number of people receiving surgery or otherwise made known to the health system: As the project’s trichiasis management activities

support progress towards the elimination threshold of a prevalence of trichiasis unknown to the health system of less than 1 case per 1000 total population,

the project tracks the number of people receiving trichiasis surgery and the number of cases otherwise made known to the health system. The number

of cases otherwise made known to the health system is defined as all known cases of individuals who refuse surgery or are referred by the project for surgery

(due to either lower eyelid trichiasis or an age of less than 15 years). Referrals due to post-operative TT are not included, to avoid counting the same

individual more than once.


Table A4. MMDP Project Achievements: Trichiasis Training (USAID-supported)

The following table provides a breakdown of the MMDP Project’s trichiasis training activities to date21.

• The table does not include FY15, as the year was a period of start-up and therefore did not have external trainings provided by the MMDP Project. Two

national trainers in Cameroon began training at the very end of FY15, which is captured in FY16 data due to the timing of reporting cycles.

• Recipients of surgeon refresher trainings are defined below as those who receive both an initial training and a second training from the project.

• Certification of TT surgeons by the MMDP Project follows the guidelines included in the WHO Trichiasis Surgery for Trachoma (2nd Edition) surgeon training

manual. National trainers are included in the number of TT surgeons certified if they are certified as part of the national trainer training process. In some cases,

individuals are already certified at the time of their national trainer training and therefore are not included in the number certified. In addition, TT surgeons

receiving refresher training are already certified and therefore not included in the number certified.

• Supervision training includes training of technical and non-technical supervisors. When supervision training is incorporated into national trainer training,

individuals trained in both capacities are counted in both table rows.

21 In Ethiopia, the cost of the FY17 training of 2,050 TT case finders (HEWs/HDAs trained by LFTW) was shared between the MMDP Project and ENVISION funds. In addition, the FY17

training of the 268 outreach coordinators in campaign management was financed by the Tigray Regional Health Bureau, with the MMDP Project providing technical support.


Lymphatic Filariasis

Table A5. LF Disease Management Services: Targets vs. Actuals by Project Area

The table below summarizes the project’s LF disease management achievements to date in relation to regional targets and current burden estimates.

Burden estimates represent data from only those districts targeted by the MMDP Project.


Table A6. LF Disease Management Services: Geographic Context

The table below provides an overview of the districts the MMDP Project has targeted with direct provision of LF disease

management services (i.e., hydrocele surgeries and/or lymphedema management training for individuals with

lymphedema). FY15 and FY16 are excluded from the table because the MMDP Project did not begin directly providing

LF disease management services until FY17.


Table A7. MMDP Project Achievements: LF Training (USAID-supported)

The following table provides a breakdown of the MMDP Project’s LF training activities to date.

• The table does not include FY15, as the year was a period of start-up and therefore did not have external trainings provided by the MMDP Project.

• Supervision training includes training of technical and non-technical supervisors. When supervision training is incorporated into national trainer training,

individuals trained in both capacities are counted in both table rows.

• Health staff trained in hydrocele surgery support include other operating room team members (e.g., anesthesiologists) and/or nurses trained in

hydrocele surgery follow up.


Table A8. MMDP Project Achievements: Additional LF MMDP Activities (USAID-supported)

The table below summarizes additional LF MMDP activities conducted to date.

• LF Burden Data Collection: The districts reported are those in which the project has supported the collection of LF burden data, which includes support

in the form of supervision and/or additional technical support. FY15 is not included in the table for Burkina Faso and Ethiopia because the project did not

begin supporting LF burden data collection in those countries until FY16.


Table A9. MMDP Project Achievements: Other Project Activities (USAID-supported)


Appendix B – FY18 Semi-annual Report Implementation Timelines

Global

FY18 Global Work Plan Implementation Timeline

Q1 Q2 Q3 Q4

O N D J F M A M J J A S

KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed

Capacity Strengthening

HEAD START Remote Technical Support C C C C C C I I I I I I

FASTT Hydrocele Surgery Training C

Health Systems Strengthening

Training of a Francophone HEAD START

Master Trainer C S

Resource/Tool Development C C C C C C I I I I I I

Updating FASTT hydrocele surgery video

based on latest WHO recommendations

from hydrocele consultation

I I I I I I

WHO Hydrocele Surgery Consultation C

Surgery costing exercise I I I I

Short Term Technical Assistance

HEAD START National Training of TT

Surgeons (Benin and Cote D'Ivoire) C C

Assessment of HEAD START TT Surgeons

training in Benin

Regional HEAD START Training

FASTT Training and Assessment C

FASTT ToT Workshop and the training of 8

hydrocele surgeons

Contribute towards the WHO impact of

HEAD START on TT recurrence study

Supporting Global Elimination Planning

Technical support to WHO in developing

standardized LF MMDP Workshop package &

Facilitator's Guide

C

Technical support to WHO for Francophone

LF MMDP Workshop C C

Technical support for review of French

version of the LF MMDP Toolkit S S S


Global, cont.

FY18 Global Work Plan Implementation Timeline

Q1 Q2 Q3 Q4



Improving Data Availability and Use

Maintain the project’s robust M&E system C C C C C C I I I I I I

Document results of 3-6 month follow-up

and surgical audits S S S

Analysis of data gathered through supportive

supervision activities S S S

Document reasons for refusal of TT surgery S S S

Operational Research

Surgical Management of Post-Operative TT:

Oculoplastic surgeon training S S S

Predictors of TT surgical outcomes C C C I I I I I I

Disseminating Best Practices

MMDP Technical Updates C S S

Scientific Leadership

NNN S

COR-NTDs C

ASTMH C

Facilitating Global Collaboration

Global Trichiasis Scientific Meeting 3 S

TAB Meeting TT / TAB Meeting LF C C S S

Monthly Morbidity Management Meetings of

the LF MMDP Community and ad hoc

meeting of the TT MMDP Community

C P C C P C S S S S S S

Operational Activities

Project Meetings C C C C C C S S S S S S

Reports to USAID C C C C C C S S S S S S

FY19 Work Plans S

Central-Level Procurement

Consumables (HEAD START, FASTT) and

Pharmaceuticals C C S S S S


Burkina Faso

FY18 Trichiasis Work Plan Implementation Timeline

Q1 Q2 Q3 Q4



Strategic Planning

PNMTN 2019 annual action plan S

Workshop for the development of the

FY19 MMDP Project work plan S

Workshop to finalize the FY 19 MMDP

Project work plan S

Quarterly coordination meetings C C

PNMTN technical and steering

committee workshops C

Meeting with the PNMTN to develop the

trachoma elimination dossier C C

Meeting on managing residual TT cases

(scale-down) P

Advocacy

Meeting on project implementation

outcomes in the Centre-Nord and Hauts-

Bassins regions

C C

Advocacy days in the Orodara and

N’dorola health districts C

Informing the administrative and political

authorities in the areas of intervention C C C S S

Social Mobilization and Behavior

Change Initiatives

IEC materials C C C

Local media C C C S S

Public criers C C C S S

Capacity Building/Training

Training for two national assistant

trainers / supervisors S

Training for TT surgeons using the HEAD

START surgical simulator S

Training for DRS and HD teams on

preferred practices for organizing a

grassroots campaign

S


Burkina Faso, cont.


Q1 Q2 Q3 Q4




Training for CSPS health workers on

diagnosis and postoperative follow-up S

CBHW training on case-finding and

referral S

Information sessions for traditional health

practitioners (THPs) S

Assessing the Trachoma Disease

Burden

Evaluation of the achievement of the UIG

in the Centre-Nord C C C S S

TT-only survey P P

Trichasis Management, Including

Surgery

Pre-surgery TT case-finding C C C S S

Equipment and supplies for the surgical

team C C C S S

Campaign preparatory meeting with the

ECD members and ICPs C C C S S

Preparatory meeting with the TT

screening and surgery teams C C C S S

Surgery camps C C C S S

Managing refusal cases C C C S S

Postoperative follow-up C S S S S

Treatment of referred TT cases C C C S S

Supportive supervision during the surgery

campaigns C C C S S

Data collection and transmission during

TT surgery campaigns C C C S S

Commodity Supply Management and

Procurement

Procure drugs and consumables C C C C


Burkina Faso, cont.


Q1 Q2 Q3 Q4



Supervision

Training sessions for two assistant

master-trainers S

Training sessions for TT surgeons S

Training sessions for DRS and DS teams

on preferred practices for organizing a

grassroots campaign

S

Training for CSPS health workers on TT

diagnosis and postoperative follow-up S

CBHW training on case-finding and

referral S

To supervise the meetings of information

to the profit of tradipraticians (TPS) S

Information sessions for traditional health practitioners (THPs)

S

TT surgical campaign C C C C C

Equipment and consumables management C C C C C

Short-Term Technical Assistance in

Trachoma

Develop TT-only survey protocol P

Postoperative TT management training P

Support for trainers to train assistant

national-trainers S S

M&E

Managing cases of reluctance or refusal C C C

Passive patient monitoring at the health

center 3-6 months post-surgery C S S S S

Evaluation of surgery and epilation quality C S S S S

Surgical camp assessment meeting C C C S S

Validation sessions P S

Geographic coverage of TT treatment

services C C C S S

TT surgery data management C C C S S


Burkina Faso, cont.

FY18 LF MMDP Work Plan Implementation Timeline

Q1 Q2 Q3 Q4



Strategic Planning

Advocacy

Social Mobilization and Behavior Change Initiatives

Disseminate awareness messages via local media C C C C C C


Assessing the LF Disease Burden

Active data collection C C C C C C

Hydrocele Surgery

Hydrocele cases identification C C C C C C

Provide hydrocele surgeries at district operating

blocs C C C C C C

Post-operative monitoring C C C C C C

Data collection and transmission C C C C C C

Lymphedema Management

Patient monitoring C C C

Data collection C C C

LF Commodity Supply Management and

Procurement

Procurement of the pharmaceutical products

and consumables for hydrocele surgical teams C C C

Develop kits for pharmaceuticals and

consumables C C C

Ensure provision of pharmaceuticals and consumables at all levels

C C C

Supervision

ICP quarterly supervision of CBHWs C

Annual supervision of the DRS teams C

Management of pharmaceuticals and

consumables C C C C C C

Supervise the CHR operating room team

members C C C C

Supervise the CMA operating room teams C

Home-based lymphedema treatment C C C C C

Waste Management C C C C C C


Burkina Faso, cont.

FY18 LF MMDP Work Plan Implementation Timeline

Q1 Q2 Q3 Q4



Short-Term Technical Assistance in LF

M&E

Biannual supervision of the ECDs C

Management of data on lymphedema

management and hydrocele surgery C C C C C

Data validation sessions P

FY18 Cross Cutting Activities Work Plan Implementation Timeline

Q1 Q2 Q3 Q4



NTD Secretariat

Office supplies C C C

IT equipment C C C

Communications C C C C C C S S S S S S

Environmental Mitigation and

Monitoring Plan

Mitigate harmful environmental impacts

and ensure that infection prevention

measures are followed

C C C C C C S S S S S S

Integration with other diseases

Disseminate the practices and the

outcomes/experiences during project

implementation

S S S S S S

Health System Strengthening

Communications and Media Relations

Planned Subawards to Local

Organizations and/or Governments


Cameroon


Q1 Q2 Q3 Q4



Strategic Planning

North Region - Mid Term Evaluation Meeting S

Far-North Region - Mid Term Evaluation

Meeting S

North Region - Regional Planning and

Evaluation Meeting S

Far-North Region - Regional Planning and

Evaluation Meeting S

National Evaluation and Planning Meeting C

FY19 Work Plan Development Meeting S

Coodination Meeting at regional and national

level C S S

Trachoma elimination working group

meetings S

Advocacy

North region - Advocacy meeting at regional

Level - with Regional Governor C

North region - Advocacy meeting at district

Level -Touboro Health District C

Far-North region - Advocacy meeting at

regional Level - with Regional Governor S

Far-North region - Advocacy meeting at

district Level - Meri Health District S


Change Initiatives

Revision and Production of IEC Material C C C

Community meetings for the first TT

campaign (North & Far-North) S

Community meetings for the second TT

campaign (North & Far-North) S

Production and diffusion of Radio - TV

magazine prior to the first TT campaign S

Production and diffusion of Radio - TV

magazine prior to the second TT campaign S


Cameroon, cont.


Q1 Q2 Q3 Q4




Refresher of TT surgeon in the North region C

Refresher of TT surgeon in the Far-North

region S

Professional development and remote

technical support for technical supervisors S S

Training of TT supervisors in the - Regional &

District level Far-North region P

Training of Health Area nurses first campaign

North (Touboro) C

Training of Health Area nurses second

campaign North (Touboro) S S

Training of Health Area nurses first campaign

Far-North (Meri) S

Training of Health Area nurses second

campaign Far-North (Meri) S S

Training of community members first

campaign North (Touboro) C

Training of community members second

campaign North (Touboro) S S

Training of community members first

campaign Far-North (Meri) C

Training of community members second

campaign Far-North (Meri) S S


Burden

TT only survey in Mada district in the Far

North C


Surgery

TT Campaign 1 - 2nd Quarter in the Far-

North & North S S

TT Campaign 2 - 3rd Quarter in the Far-

North & North S S


Procurement

Procurement C C C C C C


Cameroon, cont.


Q1 Q2 Q3 Q4



Supervision

Supervision of Community meetings prior to the first

TT campaign (North & Far North) S

Supervision of Community meetings prior to the

second TT campaign (North & Far North) S S

Supervision of Social Mobilization activities prior to

the first campaign (North & Far-North) C S

Supervision of Social Mobilization activities prior to

the second campaign (North & Far-North) S S

Supervision of refreshment of TT surgeon in the

North & Far North C S

Supervision of health area nurse training prior to the

first TT campaign (North & Far-North) C S

Supervision of health area nurse training prior to the

second TT campaign (North & Far-North) S S

Supervision of community outreach workers prior to

the first TT campaign (North & Far-North) C S

Supervision of community outreach workers prior to

the second TT campaign (North & Far-North) S S

Supervision of the first TT campaign (North & Far-

North) S S

Supervision of the second TT campaign (North & Far-

North) S

Short-Term Technical Assistance in Trachoma

Technical Assistance for the development of the

FY19 MMDP Workplan S S S

Technical Assistance for the Drafting of the

elimination Dossier C C C S S S S S S

M&E

Production of datas collect tools C C C

TT Camapign 1 - 3-6 month post TT follow up in

Touboro S

TT Camapign 1 - 3-6 month post TT follow up in

Meri S

3-6 month post-TT follow up in Poli C

Surgical Audit North & Far-North S S


Cameroon, cont.

FY18 LF Work Plan Implementation Timeline

Q1 Q2 Q3 Q4



Strategic Planning

Workshop for the documentation of lessons

learned from FY17 LF activities P

Workshop for the development of National

Strategic Plan for LF Morbidity Management P

Prepatory workshop #1 prior to the

development of National Strategic Workplan

for LF Morbidity Management

P

Prepatory workshop #2 prior to the

development of National Strategic Workplan

for LF Morbidity Management

P

Workshop for the validation of National

Strategic Plan for LF morbidity management P

Advocacy


Change Initiatives



Hydrocele Surgery

Hydrocele Surgeries in North and Far North

Districts C C C


LF Commodity Supply Management

and Procurement

Supervision

Supervision of hydrocele surgeries C C C


M&E


Cameroon, cont.


Q1 Q2 Q3 Q4



NTD Secretariat

Participation of HKI Staff in coordination

meeting at all levels C C C C C C S S S S S S

Workshop for the development of trachoma

elimination dossier


Monitoring Plan

waste management activities C C C S S


Community mass NTD drug administration

campaigns

Cataract data collection

Health System Strengthening

Human resources C C C C C C S S S S S S

Health information C C C C C C S S S S S S

Funding C C C C C C S S S S S S

Governance C C C C C C S S S S S S

Service offering C C C C C C S S S S S S


Organizations and/or Governments


Ethiopia


FHF

Q1 Q2 Q3 Q4



Strategic Planning

Zonal IECW Perfomance Review and

Planning Meetings1 C C C C C S

Advocacy

Zonal level advocacy meetings C C C C S S

Woreda level advocacy meetings C C C C S S


Change Initiatives

Community mobilization and awareness

raising to prepare for TT surgery C C C C C I S S S S S S


Training of TT Surgeons, Evaluation and

Certification P S S S

IECW skills refresher training

HEWs case screening and counselling

training: P S S


Burden

N/A


Surgery

Dedicated mobile teams C C C C C S S S

IECW static sites and outreach C C C C C I S S S S S S

Intensified TT surgical camps C C C S S S S

Patient counseling C C C C C I S S S S S S

Refusal management C C C C C I S S S S S S

Referral management C C C C C I S S S S S S


Procurement

Commodity supply management and

procurement C C S S

Supervision

Monthly supportive supervision P P P C C S S S S S S S


Ethiopia, cont.


FHF

Q1 Q2 Q3 Q4



Short-Term Technical Assistance

N/A

M&E

Reporting C C C C C I S S S S S S

Post-Operative Follow-up C C C C C I S S S S S S

Surgical audits P P C C C S S S S S S S

Data validation P P P P P I S S S S S S


Q1 Q2 Q3 Q4




Monitoring Plan

Implementation of environmental

Mitigation and Monitoring Plan C C C C C I S S S S S S


Ethiopia, cont.


LFTW

Q1 Q2 Q3 Q4



Strategic Planning

Strategic planning meetings at regional level C

Strategic planning meetings at zonal level C

Quarterly monitoring review meetings at zonal level

P S S S

Advocacy

Advocacy meetings for the political leaders at

zonal level S


Change Initiatives

MDA and regional level comprehensive eye

health project linkage with TT surgery C C C C C C S S S S S S

Radio spots P C S S S S S S


Refresher training for TT surgeons P S

New TT surgeon training P S S S S S S


Burden

N/A

Trichiasis Management, Including

Surgery

Static site TT surgery services C C C C C C S S S S S S

Outreach services C C C C C C S S S S S S

Patient counseling C C C C C C S S S S S S

Refusals management C C C C C C S S S S S S

Case referral C C C C C C S S S S S S


Ethiopia, cont.


LFTW

Q1 Q2 Q3 Q4




Procurement

Commodity supply management and

procurement C C S S

Supervision

Monthly supportive supervision C C C C C C S S S S S S

Short-Term Technical Assistance

N/A

M&E

Reporting C C C C C C S S S S S S

3-6 month post-surgery passive follow-up C C C C C C S S S S S S

Surgical Audits P P P I C C S S S S S S

Surgical quality assurance and post op follow

up C C C C C C S S S S S S

LFTW Director Eye Health/NTDs technical

assistance and monitoring visits P C S


Ethiopia, cont.


LFTW

Q1 Q2 Q3 Q4




Monitoring Plan

Implementation of Environmental Mitigation and Monitoring Plan



Integrating TT Surgery into regional comprehensive eye health project and F&E project


Health system strengthening

Supportive Supervision and Training for TT

Surgery C C C C C C S S S S S S

Surgical Audits P P P S C C S S S S S S

Supporting the FMOH and TRHB to

strenghten its referral system C C C C C C S S S S S S


Organizations and/or Governments P P P C


Ethiopia, cont.


RTI

Q1 Q2 Q3 Q4



Strategic Planning

Participation in National Trachoma

Taskforce (NTTF) C C

Advocacy

N/A


Change Initiatives

N/A


N/A


Burden

N/A

Trichiasis Management, Including

Surgery

N/A


Procurement

Purchase tetracycline eye ointment (FY19) C S S

Supervision

Supportive Supervision for TT Surgery C C C C C S S S S S S

Surgical Audits for TT Surgery C C C S S S S S S

M&E

N/A


Ethiopia, cont.


RTI

Q1 Q2 Q3 Q4



Strategic Planning

Hydrocele Surgery Planning and Performance

Review Meeting C S

Consultative Workshop on Inclusion of FASTT

Hydrocele Surgery Training in Medical School

Pre-Service Training

C

Consultative Workshops on Inclusion of

Lymphedema Management in the

Comprehensive Pre-Service Training of

Nursing Curriculum

P P

Participation in LF/Podo Technical Working

Group (TWG) meetings C C

Advocacy

N/A

Social Mobilization and Behavior Change

Initiatives

LF Messaging--Printing of Materials C

Assessing the Effectiveness of Radio Spots S S S

Airing of Radio Spots C S S S S S

Patient Mobilization by HEWs C C C C C S S S S S S

Patient Counseling C C C C C S S S S S S

Reporting Follow-up C C C C C C S S S S S S


Ethiopia, cont.


RTI

Q1 Q2 Q3 Q4




Training of Hydrocele Surgeons C C

Refresher Training of Clinical Workers on

Post-Hydrocele Surgery Survey C S

Training of Clinical Workers in Lymphedema

and Post-Hydrocele Surgery Management C C S


N/A

Hydrocele Surgery

Hydrocele Surgery C C C C C I S S S S S S


Lymphedema Management S

N/A

LF Commodity Supply Management and

Procurement

Hydrocele Surgery

Supervision

Supportive supervision for hydrocele surgeries C C C S S S S S S

Supportive supervision to clinical workers

providing LF management services C P C C C C S

Joint FMOH supervision with NaPAN P S


N/A

M&E

Tracking LF MMDP Interventions: hydrocele

surgery C C C C C I S S S S S S

Post-hydrocele surgery follow-up survey C S

Feasibility Study (NaPAN) S S S


Ethiopia, cont.


RTI

Q1 Q2 Q3 Q4



Environmental Mitigation and Monitoring

Plan

FY19 MMDP workplanning meeting S

Implementation of Environmental Mitigation and

Monitoring Plan C C C C C I S S S S S S


N/A

Health System Strengthening (HSS)

N/A

Communications and Media Relations

Publications I S

Case study development on TT surgery outcomes S S

Planned Subawards to Local Organizations

and/or Governments

NaPAN C C C C C C S S S

MMDP PROJECT SEMI-ANNUAL REPORT - USAID

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Transcript of MMDP PROJECT SEMI-ANNUAL REPORT - USAID