Nepal Work Plan - ENVISION

Nepal Work Plan FY 2017 Project Year 6 October 2016-September 2017

ENVISION is a global project led by RTI International in partnership with CBM International, The Carter Center, Fred Hollows Foundation, Helen Keller International, IMA World Health, Light for the World, Sightsavers, and World Vision. ENVISION is funded by the US Agency for International Development under cooperative agreement No. AID-OAA-A-11-00048. The period of performance for ENVISION is September 30, 2011 through September 30, 2019. The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

ENVISION FY17 PY6 Nepal Work Plan

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ENVISION Project Overview

The U.S. Agency for International Development (USAID)’s ENVISION project (2011–2019) is designed to

support the vision of the World Health Organization (WHO) and its member states by targeting the

control and elimination of seven neglected tropical diseases (NTDs), including lymphatic filariasis (LF),

onchocerciasis (OV), schistosomiasis (SCH), three soil-transmitted helminths (STH; roundworm,

whipworm, and hookworm) and trachoma. ENVISION’s goal is to strengthen NTD programming at the

global and country levels and support Ministries of Health (MoH) to achieve their NTD control and

elimination goals.

At global level, ENVISION—in coordination and collaboration with WHO, USAID, and other

stakeholders—contributes to several technical areas in support of global NTD control and elimination

goals, including

drug and diagnostics procurement, where global donation programs are unavailable

capacity strengthening

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

disease mapping

NTD policy and technical guideline development, and

NTD monitoring and evaluation (M&E).

At the country level, ENVISION provides support to national NTD programs by providing strategic

technical and financial assistance for a comprehensive package of NTD interventions, including:

strategic annual and multi-year planning

advocacy

social mobilization and health education

capacity strengthening

baseline disease mapping

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

drug and commodity supply management and procurement

program supervision

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

In Nepal, the ENVISION project activities are implemented by RTI International.


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TABLE OF CONTENT

Page ENVISION Project Overview .......................................................................................................................... ii

TABLE OF CONTENT ..................................................................................................................................... iii

List of Tables ................................................................................................................................................ iv

ACRONYMS LIST ............................................................................................................................................ v

COUNTRY OVERVIEW .................................................................................................................................... 7

1) General Country Background ............................................................................................................ 7

a) Administrative Structure ............................................................................................................... 7

b) NTD Program Partners .................................................................................................................. 8

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

a) Lymphatic Filariasis ..................................................................................................................... 10

b) Trachoma .................................................................................................................................... 13

c) Soil-Transmitted Helminths ........................................................................................................ 14

PLANNED ACTIVITIES ................................................................................................................................... 16

1) NTD Program Capacity Strengthening ............................................................................................ 16

Strategic Capacity Strengthening Approach ....................................................................................... 16

Capacity Strengthening Interventions ................................................................................................ 16

Monitoring Capacity Strengthening .................................................................................................... 17

2) Project assistance ............................................................................................................................ 18

a) Strategic Planning ....................................................................................................................... 18

b) NTD Secretariat ........................................................................................................................... 19

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

d) Social Mobilization to Enable NTD Program Activities ............................................................... 21

e) Training ....................................................................................................................................... 24

f) Mapping ...................................................................................................................................... 25

g) MDA ............................................................................................................................................ 25

h) Drug and Commodity Supply Management and Procurement .................................................. 26

i) Supervision .................................................................................................................................. 27

j) M&E ............................................................................................................................................ 28

Appendix 1. Table of USAID-supported Regions and Districts IN FY17 ...................................................... 31

Appendix 2. Table of FY17 Plan of Activities ............................................................................................... 32


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List of Tables

Table 1: NTD partners working in country, donor support and summarized activities ................................ 8

Table 2: Snapshot of the expected status of the NTD program in Nepal as of September 30, 2016 ......... 15

Table 3: Project assistance for capacity strengthening .............................................................................. 17

Table 4: Measuring Progress of Capacity Strengthening ............................................................................ 18

Table 5: Social Mobilization/Communication Activities and Materials Checklist for NTD work planning . 23

Table 6: USAID supported coverage results for FY16 and targets for FY17 ................................................ 26


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ACRONYMS LIST

ALB Albendazole CDD Community Drug Distributors CHD Child Health Division D(P)HO District (Public) Health Office DEC Diethylcarbamazine Citrate DQA Data Quality Assessment DSA Disease-Specific Assessments DWSS Department of Water and Sanitation Services EDCD Epidemiology and Disease Control Division FCHV Female Community Health Volunteers FPSU Filariasis Programme Support Unit FTS Filariasis Test Strips GoN Government of Nepal HQ Headquarters ICT Immunochromatographic test IEC Information, Education, and Communication ITI International Trachoma Institute JRSM Joint request for selected medicines KCCO Kilimanjaro Centre for Community Ophthalmology LF Lymphatic Filariasis M&E Monitoring and Evaluation MDA Mass Drug Administration MoE Ministry of Education MOH Ministry of Health and Population NHSP3 National Health Sector Programme III NGO Nongovernmental Organization NNJS Nepal Netra Jyoti Sangh NPR Nepalese Rupee NTD Neglected Tropical Disease NTP National Trachoma Program PC Preventive Chemotherapy PPICD Policy, Planning, and International Cooperation Division PSAC Pre-School-Aged Children SAC School-Aged Children SAE Serious Adverse Events STH Soil-Transmitted Helminths STTA Short-Term Technical Assistance TAS Transmission Assessment Survey TF Trachomatous Follicles ToT Training of Trainers TSS Trachoma Surveillance Survey


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TT Trachomatous Trichiasis TWG Technical Working Group USAID United States Agency for International Development VDC Village Development Committee WHO World Health Organization


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COUNTRY OVERVIEW

1) General Country Background

a) Administrative Structure

Nepal, bordering India on three sides and China on the fourth, is made up of 75 districts, divided into five development regions. Districts are further divided into municipalities or village development committees (VDCs), depending on the population size and infrastructure of a geographic area. Both municipalities and VDCs are further divided into wards, which are the lowest level of administration in the country. Each district has a local health, education, and other offices, which are responsible for implementing government programs. In smaller districts where district hospitals and public health offices are integrated, there are district health offices; larger districts have separate public health offices, and the NTD control program is housed within public health. (For convenience, throughout the work plan, these will both be abbreviated D(P)HO.) Below the D(P)HOs are 9 to 11 reporting units (sub-district-level health facilities), and under each reporting unit health facility, there are five to seven village-level health facilities. Female community health volunteers (FCHVs), who report to village level health facilities, are the main cadre that conduct public health campaigns at the community and household levels. Every district has District Education Office (DEO) and 20-25 resource centers in their catchment area. Resource persons who manage the resource centers mobilize and coordinate government activities. Each school has a school health teacher who is responsible for health activities, including school health program. Under the school health program, school health teacher’s coordinates with local health facilities for deworming in school-aged children (SAC).

Nepal is endemic for three of the targeted neglected tropical diseases (NTDs) for which chemotherapy are available: lymphatic filariasis (LF), trachoma, and soil-transmitted helminths (STH). The Government of Nepal (GoN) initiated LF elimination activities in 2003 and the STH control program for SAC in grades 1–5 in 2008. Later, the program expanded to cover school children in grades 1–10 in fiscal year (FY) 2009. The trachoma elimination program was started in 2002 by a Nepali non-governmental organization (NGO), Nepal Netra Jyoti Sangh (NNJS), through the National Trachoma Program (NTP). In 2010, the GoN approved the “Plan of Action for Neglected Diseases in Nepal: An Integrated National Control Program (2010-2014).” This document focuses on the joint efforts between the Ministry of Health (MoH) and the Ministry of Education (MoE) to eliminate and control NTDs that can be treated with preventive chemotherapy (PC). The GoN has developed National Guidelines and Tentative Plan of action for the Elimination of Lymphatic Filariasis in Nepal (2016-2020) and is preparing a new plan of action for 2016—2020 for an integrated work plan for NTDs.

The GoN plays a strong and important role in the nation’s NTD program. In addition to the technical leadership of the MoH, the GoN provides financial support for the implementation of mass drug administration (MDA) for control of LF and STH. This includes the purchase of diethylcarbamazine citrate (DEC) used during LF MDA and funding for community-based LF MDA in more than half of all districts. The MoH and MoE provide joint funding for school-based STH MDA in all 75 districts. The MoH provides technical oversight of the trachoma program, although it is implemented by NNJS (an NGO), and it funds trachomatous trichiasis (TT) surgeries. The Department of Water, Sanitation and Sewerage (DWSS) provides funds to improve the water and sanitation systems and contributes to the environmental improvement activities of the trachoma and STH programs.


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b) NTD Program Partners

The Nepal NTD control program is supported by two collaborating partners in addition to the ENVISION project (Table 1). The World Health Organization (WHO) provides technical advice, coordinates drug donations through the Joint Request for Selected Medicines (JRSM) form, and provides funds for LF morbidity management. The Filariasis Programmes Support Unit (FPSU), at the Liverpool School of Tropical Medicine (formerly the Center for Neglected Tropical Diseases), provides funding to the MoH for social mobilization during the LF MDA and for morbidity management, particularly for morbidity mapping and hydrocele surgeries. In FY16, morbidity mapping was conducted in two districts (Kanchanpur and Dhading). Preliminary results show 3800 cases (3000 hydrocele, 800 lymphedema) in Kanchanpur and 2200 cases (1400 hydrocele, 800 lymphedema) in Dhading. By end of Q1, 2500 hydrocele surgeries have been done. EDCD provides persons living with lymphedema counseling, information, and orientation for self-care in areas where the morbidity management and disability prevention (MMDP) project is being implemented. The donated self-care kit includes a bucket, a towel, soap, mug and antiseptic cream. Funding for these activities is provided by GoN in their health budget and by FPSU.

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

Partner Location (Regions/States)

Activities

Is USAID providing direct financial support to this partner?

List other donors supporting these partners/ activities

MoH Central level/all endemic areas

- Overall program leadership and national-level coordination among partners

- Developing national strategy and plan of action for NTDs

- Conducting pre-school and school-based STH deworming activities

- Procuring DEC for LF MDA

- Supporting meeting/training costs - Program implementation,

monitoring and supervision of district-level activities

- Management/coordination for surveillance and survey

No WHO

WHO Country Office

Central level/all endemic districts

- Technical assistance

- Coordination for drug and diagnostic donation and shipment

- Funding for morbidity management

- Monitoring and supervision of LF MDA activities

No

RTI/ENVISION

Central level support to EDCD/MOH and NTP with field support visits to implementing districts

- Provide technical assistance to EDCD/MOH in monitoring and evaluation (M&E), advocacy, and capacity building

- Supports mass drug administration (MDA) implementation in districts

- Support surveys through local NGOs

Yes


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Partner Location (Regions/States)

Activities

Is USAID providing direct financial support to this partner?

List other donors supporting these partners/ activities

RTI/Health for Life (H4L)

Central and district level

- Strengthen the MOH's capacity to plan, manage, and deliver high-quality family planning and maternal, newborn and child health (FP/MNCH) services

- Address local health systems governance

- Data for decision making and evidence-based policy development

- Human resources management, quality improvement systems, and knowledge and behavior change

- Technical assistance

Yes, Mission funding

FPSU Central/district level

-LF morbidity mapping -Morbidity management -Social mobilization and advocacy

No UK Department for International Development

Integrated Nutrition Program (“Good Nutrition SUAHARA-II)

Central level/40 districts

Sanitation and hygiene related-activities in 40 USAID-funded SUAHARA districts with a goal of declaring these districts open defecation free

Yes*

Social Empowerment and Building Accessibility Centre (SEBAC) Nepal

District level/6 districts

Funding for water system construction, toilet construction, and hygiene and sanitation in Kailali, Kanchanpur, Darchula, Achham, Dolakha and Sindhupalchowk districts

Yes*

*Funding is provided by the USAID/Nepal Mission and includes water, sanitation, and hygiene components


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2) National NTD Program Overview

Nepal’s NTD program is coordinated at the national level through the Policy, Planning, and International Cooperation Division (PPICD). The chief of PPICD acts as the NTD Coordinator, in addition to his other duties. The NTD Secretariat is also housed in the PPICD and provides assistance to the NTD Coordinator in assuring coordination and reporting among the divisions managing the disease programs.

The GoN also has established the NTD Steering Committee and a Technical Working Group (TWG) for management of NTDs in Nepal. The Steering Committee supervises and oversees the TWG, coordinates NTD interventions with other line ministries (e.g., MoE and DWSS), and advocates for the NTD program at national and international levels. The TWG coordinates implementation and monitoring of the MDAs, surveys, and other activities. The TWG develops strategies for technical challenges, such as improving coverage in urban areas. While coordination takes place at these higher levels, each disease program is housed in a different MoH division (or NGO, in the case of trachoma), and thus each disease program is implemented separately.

It is important to note that implementation of MDA is coordinated but not integrated in Nepal. In districts co-endemic for LF and STH, one round of MDA is conducted by the Epidemiology and Disease Control Division (EDCD) and a second round is carried out by the Child Health Division (CHD). In districts where only STH is endemic or where LF treatment has stopped, CHD coordinates school-based MDA.

a) Lymphatic Filariasis

The national LF program is housed in the MoH’s EDCD. Nepal’s Plan of Action clearly outline strategies and plans to eliminate LF as a public health problem by 2020 through MDA with albendazole (ALB) and DEC on an annual basis for six years. Nepal is more than halfway to the achievement of its elimination goal. By the end of FY16, 31 districts are expected to have passed transmission assessment surveys (TAS) and stopped treatment and an additional 10 districts will have completed at least six rounds of MDA.

Nepal is endemic for LF in 61 districts. Mapping was done with a combination of immunoChromatographic test (ICT) cards, night blood surveys of microfilaremia, and clinical cases. Initially, 14 districts were not mapped, based on their high altitude and low levels of the vector. In 2012, two mountainous districts that border LF-endemic districts, Gulmi, and Khotang, were mapped using the original WHO mapping protocol and ICT cards as the diagnostic. Results confirmed that these two districts were not endemic with LF. Similarly, in 2012 Darchula was remapped and result showed 1.3% prevalence. The remaining 12 districts, Taplejung, Sankhuwasabha, Solukhumbu, Dolakha, Rasuwa, Manang, Mustang, Dolpa, Mugu, Jumla, Humla and Kalikot, have not been mapped on assumption that given their mountainous geography, they are unlikely to be endemic with LF. Recently reported cases of malaria and dengue in some of these districts have led to concerns about the potential for LF transmission, and RTI will be following up with EDCD to gather additional data in FY17.

In FY17, EDCD is planning to treat 36 districts, conduct pre-TAS in 10 districts, TAS-I in 15 districts, and TAS-III in 5 districts. ENVISION funding and technical assistance will be requested for some of the MDA districts and all of the surveys.

i) MDA


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In FY17, EDCD plans to conduct LF MDA in 36 districts. Six of these districts, Saptari, Siraha, Okheldunga, Rolpa, Rukum and Salyan, completed their sixth round of MDA in 2016 and will complete TAS-I in August–September 2016. If they pass these planned TAS surveys, then they will not require MDA and only 30 districts will be targeted for treatment. EDCD has requested that ENVISION fund MDA in 16 of the 36 districts1.

As noted in previous work plans and semi-annual reports, low coverage during MDA in urban areas is a particular challenge in Nepal. To address the issue, the MOH adopted a separate strategy for urban MDA in FY15. This strategy included a special advocacy campaign to increase the coverage targeting private health facility staff, professional bodies, schools, local clubs of ethnic minorities, municipality staff, and media persons, and included independent in-process monitoring. To increase coverage rates, the MoH also established additional booths for drug administration in public places, such as in public and private hospitals, schools, and local community clubs, and used health workers, rather than FCHVs, to carry out house-to-house visits for drug administration. It also made drinking water available for swallowing the medicine. This approach continued in FY16 and expectations are that coverage will be increased slightly. However, preliminary findings from monitoring and supervisory visits conducted during the 2016 MDA continue to identify rumors and the fear of side effects as the main reasons why the people are refusing to participate in MDA in the urban areas. The GoN plans to strengthen advocacy and social mobilization activities during FY17 MDA. In addition, during the LF expert meeting, EDCD is planning to address several pre-TAS failures (see below), existing LF elimination program approaches for urban coverage will be discussed.

Zone of ongoing transmission along the Indian border

In FY16, three districts Figure 1 (Kapilvastu, Banke and Dang) along the border with India all failed pre-TAS surveys after at least five and up to eight years of MDA. Banke had antigenemia (Ag) prevalence of 15.84 %, Dang of 12.46%, and Kapilvastu, a district that failed TAS in 2013, had 14.85%. There appears to be a zone of persistent transmission along the border with India. Dang and Banke, which border one another and India’s Uttar Pradesh state, have had prevalence at mapping (>20%). The two districts have had variable coverage since treatment started in 2011, and sentinel and spot check site surveys showed prevalence of 11.5-18.5% in these districts. Dang also borders Kapilvastu. Following TAS failure in 2013, Kapilvastu was treated in 2014 and 2015 and special emphasis was placed on ensuring good coverage in areas that had the highest rates of Ag during the TAS. Reported coverage for the two years was 81.0% and 79.1%. RTI, at EDCD’s request, conducted coverage surveys in FY14 and FY15 and found that Kapilvastu’s surveyed coverage was 47.2% in FY14 but had improved to 72.8% in FY15. While all three districts will receive another round of MDA in 2017, EDCD and ENVISION are concerned about ongoing transmission. The MOH, EDCD, WHO and ENVISION are planning an expert meeting in FY17 Q2 to review the situation in Kapilvastu and the other districts to determine how to proceed in addressing the ongoing transmission.

Figure 1: Zone of Ongoing LF Transmission

1 Three of the districts EDCD has requested ENVISION fund (Rolpa, Rukum and Salyan) will undergo TAS-I in

FY16 Q4 and may not require MDA.


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ii) Pre-TAS

In FY17, EDCD plans to conduct pre-TAS in 10 districts which will complete their fifth round of MDA in March 2017 (Dailekh, Darchula, Baitadai, Dadeldhura, Doti, Achham, Bajhang, Bajura, Kailali, Kanchanpur).

iii) TAS

Six districts (Siraha, Saptari, Okhaldhunga, Rolpa, Rukum and Salyan) had antigenemia of <2% at both sentinel and spot check sites in early FY16. These districts completed their sixth round of MDA in March 2016, and TAS-I for these districts is scheduled for August-September 2016. In FY17, EDCD plans to conduct TAS-I in 15 districts (Ilam, Jhapa, Morang, Panchthar, Sunsari, Terhathum, Bardiya, Jajarkot, Surkhet, Dhankuta, Myagdi, Parbat, Baglung, Lamjung, and Lalitpur-rural) where Pre-TAS is planned in Aug-Sept 2016.

TAS-I conducted in May-June 2016 in five districts found that all districts (Kaski 0.13%, Bhaktapur 0.13%, Kathmandu-rural 0.25%, Kathmandu-Metropolitan city 0.5%, Lalitpur urban 0.37%, Arghakhanchi 0% and Pyuthan 0%) have antigenemia of <2%. As a result, MDA will be stopped in these districts.

In FY17 Q4, TAS-III surveys will be conducted in two evaluation units (EUs) comprised of five districts (Parsa, Makwanpur, Chitwan, Nawalparasi and Rupandehi). ENVISION funded TAS-II in these districts in FY14 and all passed.

In an effort to address morbidity management and disability prevention, GoN has been implementing lymphedema management activities and hydrocele surgeries since FY15. Morbidity management


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activities have been initiated in the most affected villages based on reporting from the D(P)HOs during the MDA campaign. In FY15, 38 of the 41 districts where LF MDA was conducted reported 10,354 cases of either lymphedema or hydrocele. In FY16, the MoH also allocated funding, including some funding received from FPSU, to perform 11,000 surgeries for hydrocele. Central, zonal and district hospitals, and regional health directorates (RHDs), in coordination with the D(P)HOs in the region, are performing hydrocele surgeries. The funding covers all costs related to surgeries. Doctors performing surgeries are trained by GoN and there is a referral system from communities to designated hospitals to treat suspected cases. This commitment and budget allocation for surgery shows that GoN has taken a leadership role in addressing LF morbidity management using the existing health system. In FY16, FPSU also conducted morbidity mapping in two districts (Dhading and Kanchanpur). Preliminary results shows 3,000 hydrocele and 800 lymphedema cases in Kanchanpur whereas Dhading has 1400 hydrocele and 800 lymphedema cases. FPSU is planning with EDCD to extend support to two additional districts (Okhaldhunga and Saptari) in FY17. GoN is also planning to allocate a similar budget to manage these cases in FY17.

USAID support for Nepal’s NTD programs began in 2009, under the USAID-funded NTD Control Program and continues under the ENVISION project. Support for the LF program includes funding for the annual MDA in selected districts identified by EDCD, printing and delivery of information, education, and communication (IEC) materials, training manuals, and reporting forms to all LF MDA districts; in LF sentinel and spot check site surveys, post-MDA coverage surveys, TAS and organizing meetings for planning and review of the program activities at central and district levels; technical assistance to develop the NTD plan of action, M&E plan and national LF guidelines. Since 2011, USAID has provided support for LF/STH MDA in 56 districts, pre-TAS in 51 districts, TAS in 33 districts, re-mapping in 3 districts and baseline survey in 10 districts. USAID funding through ENVISION/RTI also has supported planning and review meetings, training for FCHVs before MDA and training orientation to GoN officials and NGO personnel on TAS before TAS are carried out for their capacity building.

b) Trachoma

The Nepal MoH continues to outsource all eye-care services to networks of local NGOs that operate eye hospitals and clinics. The NTP is housed in NNJS, a local NGO with a network of eye hospitals in all five regions of Nepal. The NTP receives oversight from the MoH, but it operates semi-independently and has been implementing trachoma control activities in Nepal since 2002. Nepal’s goal is to achieve the elimination of blinding trachoma as a public health problem by 2017 using the SAFE strategy.

It was believed that the NTP had completed trachoma mapping in FY14, after a series of remapping surveys designed to determine the subdistrict-level prevalence of 27 districts that were conducted with ENVISION support. These surveys and previous mapping in the late 1990s and early 2000s determined that 19 districts were endemic above the treatment threshold of 10%, and one additional district, Baitadi, had a prevalence of 5.0%-9.9% and was treated with one round of MDA. In 2015, the NTP determined that a reassessment of mapping was required in four districts due to concerns about an unqualified grader. The re-mapping of the four mountainous districts (Jumla, Humla, Mugu, and Kalikot) is completed. Results show that trachomatous inflammation – follicular (TF) prevalence in Humla is 1% Mugu is 0.4%, Jumla is 0.2% and Kalikot is 0.7%. Similarly, TT prevalence in Humla is 1 per 1000 and in Mugu is 0.5 per 1000 and no prevalence were found in remaining two districts (Jumla and Kalikot). Thus, NTP has completed mapping in all 75 districts and no more MDA is needed in the country.


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In FY14, NTP completed all planned MDA activities and all impact surveys were completed in 2015. All 20 districts had TF prevalence of <5% at impact. In FY15, NTP completed pre-validation surveillance activities in 10 out of 20 endemic districts showing TF prevalence <5%. In 8 out of 10 districts (Dailekh, Rasuwa, Doti, Bara, Parsa, Banke, Rolpa, and Bardiya), TT prevalence was <1 per 1000. NTP referred all cases of TT found during the surveys to the closest eye hospital (these are a network of 17 eye hospitals within the country and all perform TT surgery) for trichiasis surgery. In FY16, NTP will complete pre-validation trachoma surveillance surveys (TSS) in 8 out of the remaining 10 districts. The final two districts, Achham and Baitadi, will be eligible for pre-validation surveillance in FY17 since they passed their final impact surveys in April 2015.

NNJS provides TT surgery through its network of eye hospitals throughout the country. During the remapping surveys carried out in FY13 and FY14 and a surveillance survey in FY15, NTP identified and referred TT cases to NNJS hospitals and primary eye-care centers. Evidence indicates that the numbers of TT cases have decreased significantly, and the TT backlog was recalculated based on recent impact and remapping surveys. NTP has found it difficult to identify TT patients unknown to the healthcare system, and at Nepali hospitals, 75% of the TT surgeries are performed on Indian patients crossing the border. After the methodology for TT-only surveys has been finalized by WHO, the NTP would like to conduct surveys in formerly endemic districts, so as to determine the true burden of TT. The NTP recognizes that identifying TT cases is an extremely important activity toward reaching its ultimate intervention goal (UIG) for elimination. NTP plans to train health staff and community volunteers to identify the remaining cases and refer them for treatment. Funding for TT surgery is provided through the MoH, WHO, and NNJS.

Since 2009, USAID funding has assisted NTP to conduct trachoma MDA in 4 districts, mapping in 8 districts, remapping in 23 districts, impact surveys in 13 districts, and surveillance surveys in 18 districts. This support included sending three Ophthalmic Assistants to attend GTMP training, and training of survey graders and enumerators involved in the trachoma surveys. RTI also collaborated with John Hopkins University in FY15 to train graders to ensure quality of training and skills of graders, and to conduct research on new diagnostic methods for surveillance.

c) Soil-Transmitted Helminths

The NTD control program aims to control STH in SAC through two rounds of annual treatment with ALB to reduce the intensity of infection and prevent infected individuals from morbidity due to STH. The CHD implements STH control activities for pre-school-aged children (PSAC), SAC, and pregnant women. In collaboration with the MoE, CHD conducts school de-worming as a major sub-activity under the School Health and Nutrition Program, targeting 6.1 million school-aged children annually. In 2012, the program achieved national coverage for public school children in grades 1–10. In 2013, the program was rolled out to include children in private schools in the same grades. In FY17, STH MDA will continue targeting schoolchildren through grade 10, as in the previous years. PSAC is treated through the Vitamin A program implemented by CHD and pregnant women are treated during their antenatal visit to health facilities in second trimester under safe motherhood program.

All 75 districts in Nepal are considered to be endemic for STH, based on district-level studies carried out in the 1990s and 2000s. In FY14–FY15, at the request of CHD, RTI funded a local NGO to conduct a national STH prevalence survey to determine the prevalence and intensity of STH among SAC. The national prevalence survey was powered to both the region and the homogeneous ecological zone. The results indicated that national STH prevalence is 20.7%, with a disease-specific prevalence 14.6% for


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roundworms, 4.7% for hookworms, and 5% for trichuris. The highest prevalence of STH was found in the Mid-Western Development Region (27.7%), followed by the Western Development Region (26.5%). In 2015, a complementary survey to determine the prevalence of STH among PSAC and women of child-bearing age was conducted with funding from the MoH, United Nations Children’s Fund, and the U.S. Centers for Disease Control. The results of this survey will be available in 2016 and the MoH will use the results of both surveys to revise its existing deworming policy in line with WHO recommendations by 2017.

The STH MDA is coordinated with the LF MDA so that where LF is still endemic, one round of MDA is done with DEC+ALB. PSAC and pregnant women are treated with support from other funders. As the LF program has begun scaling down, the government-funded STH MDA has taken over providing deworming through a school-based platform. EDCD shares the information about districts where LF MDA has stopped with the CHD and based on this information the government-funded STH MDA resumes its SAC de-worming program as usual e.g. twice a year under school health program.

USAID support for Nepal’s NTD programs began in 2009. ENVISION support for the STH program includes funding for the STH sentinel site surveys to find out prevalence of STH, National STH survey, STH MDA through LF treatment, training to health workers, resource personnel of district education offices, school teachers in selected districts for STH MDA printing or training manual and reporting forms for school deworming programs under STH. Under this support STH sentinel site surveys were completed in 5 districts, a national STH prevalence survey was conducted in 25 EUs, and training on deworming was provided to health workers, district education resource persons, and school teachers in 13 districts.

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

Columns C+D+E=B for each

disease* Columns F+G+H=C for each disease*

MAPPING GAP

DETERMINATION MDA GAP DETERMINATION

MDA ACHIEVEMENT

DSA NEEDS

A B C D E F G H I

Disease

Total No. of

Districts in

COUNTRY

No. of districts

classified as

endemic**

No. of districts

classified as non-

endemic**

No. of districts in need of initial mapping

No. of districts receiving MDA as of 09/30/16

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

any level: MDA not yet started, or has

prematurely stopped as of

09/30/16

Expected No. of districts where

criteria for stopping

district-level MDA have been

met as of 09/30/16

No. of districts requiring DSA as of 09/30/16

USAID- funded

Others

Lymphatic filariasis

75

61 14 0 18 18 0 25 Pre-TAS: 10 TAS-I: 15 TAS-III:5

Onchocerciasis 0 75 0 N/A N/A N/A N/A N/A

Schistosomiasis 0 75 0 N/A N/A N/A N/A N/A

Soil-transmitted helminths

75 0 0 18 57 0 0 0

Trachoma 20 55 0 0 0 0 20 TSS: 2


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*If Columns C+D+E do not equal B for mapping of each disease, or if Columns F+G+H do not equal C for treatment of each disease, please reconfirm figures and then add detailed footnotes explaining the discrepancies. **If mapping results aren’t available at the time of work planning, add a footnote explaining how many districts were mapped and for which endemicity data aren’t yet available. Do not count them as districts in need of initial mapping (Column E). ***For trachoma, include districts with 5-9.9% TF at baseline in column C since they are considered endemic, but footnote the number of districts that fall into this category. ****Kapilvastu did not conduct MDA in FY16.

PLANNED ACTIVITIES

1) NTD Program Capacity Strengthening

Strategic Capacity Strengthening Approach

ENVISION is committed to strengthening Nepal’s capacity to complete its elimination goals before the end of the project. This year, ENVISION will focus on three specific strategic areas: the first (and most important) is conducting a national capacity strengthening assessment to understand where the MoH is now and the national NTD control and elimination goals for the next 5-10 years. This will include the current situation and capacity needs for various departments of the MoH (including EDCD, CHD, the Public Health Laboratory, etc.). The second strategic area is resource mobilization. ENVISION will work with MoH and the national TWG to develop a vision, goal, and objectives based on the NTD Road Map and Plan of Action for mobilizing additional resources and partners (international and domestic) in sustaining the gains of the NTD program. The final strategic area is to strengthen the national M&E capacity and documentation of success. ENVISION will support NTP and EDCD to begin documentation for the elimination dossiers. We will also concentrate on improving capacity to document successes and challenges within the scientific literature.

Capacity Strengthening Interventions

National capacity strengthening assessment: ENVISION’s RPA will coordinate closely with EDCD, CHD, NTP, and others within the MoH to convene a meeting which will be facilitated by a local consultant. During the meeting, ENVISION, the MoH, and partners will conduct an in-depth country-led capacity


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building assessment to identify the state of the human resource, organizational, and systems capacity and determine the capacity strengthening needs for the NTD program over the next 5-10 years. This assessment will generate a report, which will then inform the Plan of Action and ENVISION’s work plan activities for FY18 and FY19. Resource mobilization planning: During the Plan of Action meetings and the TWG meetings, ENVISION’s RPA will introduce and continue to advocate for development of a resource mobilization plan for the future. While no specific funding is allocated, it will be a key discussion point during national meetings in FY17, with a goal of having the resource mobilization objectives included in the final Plan of Action. Strengthen M&E capacity and documentation of success: TAS Training: A national TAS training will be facilitated by CDC and a focus will be aimed at engaging the national public health laboratory and district NTD staff. This will help to improve sustainability of the LF elimination program’s capacity for surveys and surveillance.

Table 3: Project assistance for capacity strengthening

Project assistance area

Capacity strengthening interventions/activities How these activities will help to correct needs identified in

situation above

Strategic Planning

TWG Meeting Plan of Action Dossier preparation meeting Advocacy for resource mobilization strategy

To address the absence of sustainability and resource mobilization of national program

Dossier preparation

NTD secretariat Support for NTD coordination

Improve capacity and coordination of NTD activities at the MOH

Training (please see the Training section for specific Training activities.)

Short-term technical assistance

Local consultant: National capacity assessment International consultant: Trachoma dossier

Assessment of the SWOT of the capacity of the NTD program to help recommend and prioritize capacity building activities

Monitoring Capacity Strengthening

ENVISION staff will continue to meet on a monthly basis with EDCD and NNJS to discuss progress of planned capacity strengthening activities and needs in key technical, managerial, financial, and operational areas. These meetings will serve as a platform to regularly monitor and assess capacity strengthening and to update the assessment mentioned above. TWGs and other meetings described under Strategic Planning will also serve as an opportunity for ENVISION and the EDCD to more broadly discuss capacity strengthening needs, opportunities and progress. ENVISION will ensure that there is an effective dialogue mechanism between MOH and among the all stakeholders on issues relating to identifying NTD capacity gaps, opportunities and priorities. In addition, there will be clarity and awareness of establishing the resource mobilization vision, mission goals and priorities among all the stakeholders.


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Table 4: Measuring Progress of Capacity Strengthening

Activities Indicator

National Capacity Strengthening Assessment

Number of capacity strengthening activities identified and prioritized for implementation in FY18 and FY19 by ENVISION and other stakeholders

National TAS training

Number of trainees whose knowledge has been improved in TAS methodology and implementation after pre and post-test.

Resource mobilization

The MOH has defined resource mobilization strategic goals and related objectives. The NTD team and stakeholders are aware of how they can contribute to achieving these goals.

2) Project assistance

USAID’s support for Nepal’s NTD programs began in 2009 under the USAID-funded NTD Control Program and continues under the ENVISION Project. Through RTI, USAID provides funding and technical support to the LF, STH, and trachoma programs. In FY17, program activities will include funding for the annual LF MDA in 16 districts with DEC+ALB , including advocacy and social mobilization, delivery of IEC materials, training manuals, and reporting forms to all LF MDA districts; Pre-TAS and TAS surveys; TSSs; organizing workshops and meetings for planning and reviewing program activities at central and district levels; and deworming of SAC during LF MDA in 16 districts; capacity strengthening activities; and providing ongoing technical assistance to develop the NTD M&E plan and support the continuous use of the WHO Integrated NTD database. The activities proposed are aimed at achieving the following priorities as set by USAID for FY17:

maintaining high quality MDA with appropriate coverage

strengthening M&E capacity

documenting success

reinforcing capacity building

a) Strategic Planning

In FY17, RTI will provide financial and technical support to EDCD to implement the following LF planning

related activities:

NTD Steering Committee/Technical Working Group meetings ENVISION through RTI will fund three NTD Steering/TWG meetings, and the ENVISION Resident Program

Advisor will attend and participate. These meetings provide oversight for the national NTD program, and

RTI will report on the progress of planned activities funded by ENVISION and to provide technical

expertise and advice.

National Stakeholders Meeting to Review and recommend new NTD Plan of Action Nepal’s first national NTD Plan of Action (2010–2014), ended in 2014, and in FY15, the MoH requested assistance from ENVISION to develop the next plan. RTI will provide funding and technical support for


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two meetings in FY17 in addition to WHO’s contribution to ensure that the Plan of Action is finalized and endorsed by the TWG and the MOH. Nepal NTD M&E Plan EDCD has expressed an interest and requested support to draft an NTD M&E plan based on on the NTD Plan of Action which details actions required for the next five years. The M&E Plan will highlight the indicators to ensure that the NTD Control Program is on track to eliminate LF and trachoma, and control STH. The M&E plan will build on success achieved in stopping MDA for trachoma in all endemic districts and stopping MDA for LF in nearly half of the endemic districts by the end of 2016. It will lay out the M&E activities that should be carried out through 2020. ENVISION will support a local consultant to work with the team in drafting the M&E plan. Annual Review Meeting The meetings focus on the review of previous MDA activities and lessons learned to develop and inform plans in line with EDCD and ENVISION priorities. During the meetings, previous MDA coverage results, challenges and resource management issues are discussed. Coverage data received through ENVISION and EDCD are presented in these meetings for information and discussion. ENVISION will fund district level managers’ attendance in these meetings. RTI has begun conversations with EDCD to begin to advocate for additional resources from the GoN to fund the implementation of future meetings. NTP dossier pre-preparation meeting Nepal has successfully implemented MDA in 20 endemic districts under management guidance of NTP and NNJS. TSS conducted in 18 districts has shown prevalence below the cutoff point. The remaining TSS for the two districts is planned in FY17. ENVISION will support a consultant to facilitate dossier meeting for stakeholders in FY17 to review and discuss the existing data, gaps and a plan to fill the gaps for submission of the dossier.

b) NTD Secretariat

The NTD Secretariat, established within the PPICD in 2013, plays an important role in fostering coordination among the MoH divisions implementing LF-, STH-, and trachoma-related activities, Department of Education (DoE) and DWSS. This coordination includes high-level support for planning and budgeting processes to all divisions and stakeholders implementing NTD activities. For example, the Secretariat works with all divisions to review and present their NTD-specific budget activities to the PPICD chief. The Secretariat also facilitates strategic and policy dialogue among NTD stakeholders by coordinating regular technical and oversight meetings for all NTD program offices. ENVISION will fund costs related to running the NTD Secretariat including communications and supplies. In FY17, RTI also will continue to fund a consultant seconded to the MoH as an assistant NTD coordinator. The NTD coordinator provides high-level support for NTD planning and budgeting processes to all divisions and stakeholders implementing NTD activities. He is responsible for facilitating all strategic and policy dialogue among all the key NTD stakeholders by coordinating regular technical and oversight meetings.

c) Advocacy for Building a Sustainable National NTD Program

LF Regional Planning Meetings


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RTI will provide funding to conduct three regional planning meetings. This is an important pre-MDA planning activity for the national NTD program. EDCD, in partnership with RTI staff, will facilitate the regional meetings. They are designed to engage and mobilize key regional stakeholders to support LF MDA. ENVISION will be funding district level managers to participate in these meetings.

Central level Sensitization Meeting ENVISION will fund one interaction meeting each for media journalists, health professionals and education professionals organized by EDCD at the central level. The purpose of this meeting is to discuss the LF campaign, provide briefing materials, and answer questions about the disease. In this meeting GoN will seek support from these professional groups to ensure successful implementation of LF MDA.

District-level advocacy meetings in Banke District In Nepal, urban districts have been struggling to achieve adequate programmatic and epidemiological coverage over the past few years. This is because in such areas, the population is diverse and has varied economic and social status. RTI in collaboration with EDCD plans to intensify advocacy activities in Banke, one of the districts in the zone of ongoing transmission located along the Indian border. In 2015, pre-TAS demonstrated an LF prevalence of 15.84%. EDCD and RTI plan to tap into the networks of imams to champion MDA participation in Banke. ENVISION will fund advocacy meetings including interaction meetings with local medical and nursing associations, health professional organizations, teachers’ associations, private medical and nursing colleges, schools and social/religious leaders. These advocacy meetings are designed to solicit support for MDA.

District Planning and Review Meetings RTI will fund districts planning/review meetings in 16 districts prior to the LF MDA. At these meetings, D(P)HO staff are expected to make presentations showing results from the previous year’s MDA and outline the plan for the upcoming MDA. Based on the information shared, the DHO team discusses and develops a district MDA implementation plan for the upcoming MDA. This plan includes mobilization of available resources, actions to address gaps, monitoring and supervision strategy, advocacy, SAEs and drug supply management plans. In FY17, more attention will be focused on ways to reach communities which experience low participation during previous rounds of MDA. RTI staff will attend some of these meetings in coordination with EDCD and WHO technical staff.

District-Level Journalist’ Interaction Meetings Nepal has a history of SAEs in previous LF MDA campaigns, and media attention during the LF MDA has been identified as crucial to providing correct information and clear message to the population. The Nepal program has found that engaging with the news media as partners at the central and local levels helps to ensure the provision of factual news reports and prevent negative campaigns and false rumors about LF MDA. There have not been any reported SAE cases in FY16. RTI will also fund 16 district level journalists’ interaction meetings to build on the success of the previous media interactions. The D(P)HO will invite local print and audio-visual journalists to a one-day meeting to educate them on the purpose of the LF campaign, project achievements and challenges; provide briefing materials; and answer questions about the disease. In addition to the 16 district-level journalists’ interaction meetings. ENVISION and EDCD staff will attend some of the district events to answer questions and help with the sensitization.

Trachoma Surveillance Dissemination ENVISION will fund the NTP to conduct regional and central-level dissemination meetings for districts where trachoma surveillance surveys have taken place to share findings and discuss next steps toward


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trachoma elimination. The proposed dissemination meeting is expected to share the results and status of trachoma with GoN officials and other stakeholders working in the health sector including those responsible for WASH activities. Under the SAFE strategy, face washing and environmental sanitation is expected to continue after trachoma elimination has been achieved. This meeting is expected to advocate with GoN and stakeholders to continue their sanitation activities to ensure sustainability of trachoma elimination status. This activity includes support for per diems, accommodation, transportation and refreshments.

d) Social Mobilization to Enable NTD Program Activities

In FY17, the goal of the social mobilization strategy is to ensure that IEC activities proposed will address the fear of adverse events as noted in all coverage surveys, create demand for MDA participation and possibly stimulate community dialogue in endemic LF districts. The ENVISION Social Mobilization/IEC guide will be used to ensure that the activities proposed are able to reach their intended target population and impact. Apart from encouraging individuals among the target population to increase MDA participation, these activities aim to help reduce the fear associated with taking NTD drugs and address compliance issues. ENVISION support is expected to ensure that key MDA IEC messages are correctly conveyed to the right target population using the best approaches and channels and that the messages are adequately coordinated with planned MDA and other communication activities. Television Broadcasts As confirmed in the coverage survey findings, mass media is one of the main sources of MDA awareness in Nepal. National and local TV channels are considered very reliable in providing information. The media plays an important role in success of LF MDA. RTI will fund the development of public service announcements about LF MDA for national television broadcast. Messages will include up-to-date information to the public about the date and locations of MDA and the safety of DEC+ALB. Newspaper Publishing At the request of EDCD, RTI will fund LF MDA related advertisements in national newspapers that provide messages informing the general population and raising awareness about LF MDA campaigns and their importance. The publications will also reinforce the date and locations of MDA and safety of DEC+ALB. Bags for Community Drug Distributors (CDDs) As the key frontline workers for the NTD program, FCHVs are the most trusted source of information for MDA, and this has been confirmed by analysis of coverage surveys conducted in FY14 and FY15. In FY17, RTI will procure MDA-branded bags for each FCHV in 16 ENVISION supported districts to use while distributing medicines. These bags clearly identify the FCHVs as working for the MDA program and as an official distributor of medicines. The purpose is to increase visibility/program branding and provide motivation for FCHVs. Production of Banners for LF MDA Social mobilization activities including the support RTI provides to EDCD is an integral part of MDA pre-implementation activities. In FY17, RTI will support social mobilization for the LF MDA through several activities including the production of banners for 16 districts scheduled for LF MDA. The banners will be distributed to all the health posts in 16 districts where MDA is taking place. The banners will be displayed at health facilities and other central points within the VDC, to ensure that community members are aware of the date and locations of MDA.


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District Interaction Meetings- VDC, Ward and municipal level In FY17, RTI will provide funding to organize 16 district sensitization and awareness meetings. Districts managers will mobilize communities in advance of the LF MDA. All district stakeholders, including members of civil society organizations, will be invited to the district headquarters to participate in the events. These district-level interaction meetings will provide opportunities to orient stakeholders on the status of LF in the district, need for MDA, and on how they can support the LF MDA campaigns; ultimately, the goal is to increase the communities’ participation in MDA by raising awareness and addressing their concerns. Community-level Mobilization In each of the 16 districts funded by ENVISION, local health workers and FCHVs will help display MDA banners, and hold meetings with local community leaders and school teachers to inform them of the MDA a few weeks before it is scheduled to occur. School Health Education-Teacher interaction, VDC, municipal level In each of the 16 districts funded by ENVISION, local health workers will train selected teachers to provide information to students and teachers about LF MDA. ENVISION has found this to be a key activity that successfully sensitized students, teachers and their family members to participate in the MDA. Community FM Radio and Newspaper MDA Awareness Generation RTI will fund 16 D(P)HOs to conduct MDA awareness-raising campaigns using local FM radio stations. The local radio campaigns are expected to persuade key beneficiary audiences to participate in MDA, or to remind them of the importance of MDA. The local FM radio stations are an important channel to reach beneficiary population and provide information about MDA and NTDs. Also, it is a vital way to keep the public updated about the date and locations of MDA. RTI’s support will include broadcast and publishing of MDA messages on community FM radio and local newspapers Miking One of the best communication strategies for providing information to people in rural communities is based on the idea of integration with the culture of the target community. “Miking” (the use of trucks with microphones) is used as additional channel to inform communities about LF MDA dates and venues using megaphones to attract community attention. The proposed activity has successfully increased participation in LF MDA in previous years.


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Table 5: Social Mobilization/Communication Activities and Materials Checklist for NTD work planning

Category Key

Messages Target

Population

IEC Strategy (materials, medium,

activity etc.)

Where/when will they be distributed

Frequency

Is there an indicator/

mechanism to track this

material/activity? If yes, what?

Other Comments

MDA Participation

MDA will take place at all wards of 16 districts for 3 days

Community members

Posters/Banners Hung in all health facilities and at center points/schools 1 week before MDA

Once Percentage of audience who recall seeing the poster and message – in coverage survey

The drugs provided are free and safe, who should and should not take the drugs

Community members

Radio, TV, News Paper Radio, TV, News Paper

Local station. 2 weeks in advance of LF MDA campaign

Messages play 7 times per week during the hours of 7am – 10 pm Message printed 1 time in News papers

No. of times messages aired on radio during reference period- Radio broadcast reports Percentage of audience who recall message- coverage survey

Some side effects are normal and they will pass

Information about MDA date and location

Community members

Megaphone (Miking)

2 weeks in advance of LF MDA campaign

Daily Percentage of audience who recall hearing MDA message – in coverage survey

Disease Prevention

Taking NTD drugs for 6 yrs will prevent diseases

Drug Distributors and Community members

Radio, TV, News Paper

Local station. 2 weeks in advance of LF MDA campaign

Messages play 7 times per week from 7am – 10 pm

Radio, TV, News Paper

Other Promoting visibility of

Community members

Posters/Banners Hung in all health facilities and

Once Percentage of audience who recall seeing the


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Category Key

Messages Target

Population

IEC Strategy (materials, medium,

activity etc.)

Where/when will they be distributed

Frequency

Is there an indicator/

mechanism to track this

material/activity? If yes, what?

Other Comments

NTD Program

at center points/schools 1 week before MDA

poster and message – in coverage survey

Social mobilization activities in the zone of ongoing transmission and low coverage districts: In addition to all the advocacy activities proposed, ENVISION will work closely with EDCD and fund activities at national and district level to intensify social mobilization activities in the zone of on-going transmission and other in low-coverage districts. ENVISION will fund activities in one district in the zone of ongoing transmission (Banke).

e) Training

ENVISION will provide support to train and retrain national and district staff as part of the capacity strengthening support to the national NTD program to ensure effective implementation of MDA and M&E activities. LF MDA Training of Trainers One-day training of trainers (ToT) at the district level for D(P)HO staff will be carried out by MoH, WHO and RTI staff. This program ensures that district trainers have a strong working knowledge of LF, the MDA’s purpose and process, MDA data reporting chain, SAEs, and supervisory responsibilities. This activity will be conducted at the district-level as a part of LF MDA for district supervisors during district level orientation and interaction. In return these district level supervisors will train health workers and CDDs. LFA MDA Refresher Training for Health Workers and CDDs A one-day training will be held for health workers and FCHWs participating in the LF MDA to ensure they understand the MDA’s purpose, their role, how to manage SAEs, and how to record information about the MDA. Refresher Training for Trachoma Graders In FY17, ENVISION is funding NTP to organize refresher training for trachoma graders. (More details available in the M&E section). Refresher Training for TSS enumerators In FY17, ENVISION is funding NTP to train TSS enumerators. (More details available in the M&E section). Training for TAS and pre-TAS RTI will conduct a training for the NGO and national laboratory staff who will conduct the planned TAS and pre-TAS surveys. (More details available in the M&E section).


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Project management and M & E training The ENVISION program manager and the M&E coordinator are newly hired and will be trained in management, planning, monitoring and evaluation. They are also responsible for coordinating with GoN counterparts and leading meetings and workshops. Therefore, considering their roles and responsibilities it is important to build their leadership capacity through training. The proposed training will enhance their leadership skills and improve their performance. Tax update training to admin/finance staff Every year the GoN announces its yearly tax structure which is applicable for next fiscal year. To account

for any changes to tax regulations, ENVISION proposes for the admin and finance staff to participate in

the tax update training. This training is annually provided by a local audit firm and/or related

institutions.

f) Mapping

LF: 63 districts have been mapped, 61 districts are endemic, 2 are not endemic, and 12 districts have never been mapped because of their high altitude and the lack of evidence of vector transmission. In previous WHO Regional Office for Southeast Asia meetings, WHO has advised that the 12 districts do not need to be mapped. However, RTI will be following up with the MOH and WHO/Regional Programme Review Group to document recent evidence of malaria and dengue transmission in some districts to confirm that no additional mapping is necessary. Trachoma: All districts have been mapped and the remapping of the 4 remaining districts in FY16 districts (Jumla, Kalikot, Mugu and Humla) has been completed. Results shows that no MDA is required in these districts as prevalence rates are below 5%. No further mapping is needed. STH: ENVISION supported a national prevalence survey in FY13-FY14, and no further mapping is needed.

g) MDA

In FY16, 72% of 18 districts achieved the minimum required coverage (program coverage >80%) for LF (100% of 18 districts achieved >65% epidemiological coverage). 100% of 18 districts achieved the minimum required coverage (Program coverage >75% of SAC) for STH in FY16. The focus in FY17 is on maintaining good coverage and improving LF performance in the other 28%.


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Table 6: USAID supported coverage results for FY16 and targets for FY17

NTD # Rounds of annual

distribution

Treatment target (FY16)

# DISTRICTS

# Districts

not meeting

epi coverage target in

FY16*

# Districts

not meeting program coverage target in

FY16*

Treatment targets (FY16)

# PERSONS

# persons treated (FY16)

Percentage of

treatment target met

(FY16) PERSONS

FY17 treatment

targets #

DISTRICTS

FY17 treatment targets # PERSONS

LF 1 18 0 5 5,898,798 4,750,127 80.53% 16 4,727,179.

STH 1 18 0 5 5,898,798 4,750,127 80.53% 16 4,727,179.

STH (SAC)

1 18 0 5 1,629,248 1,311,985 80.53% 16 1,305,647

LF/STH MDA In FY17, RTI will provide funding for the LF/STH MDA in 16 districts (Table 6). Drug administration will be carried out by trained health workers and volunteers including FCHVs, who are empowered through the MDA training to help eligible people to take medicines under observation during the campaign and answer questions from participants. MDA Census Prior to LF MDA each FCHW visits every household in their designated area and update their register. Names of household are updated with their names and age to ensure eligibility for taking drugs during LF MDA. The census register is also used for planning drug requirement. MDA & SAE Management Nepal has had cases of SAEs in the past and as a result has developed a strong system to address any reported SAEs. If an SAE occurs during LF MDA, the D(P)HO responds through rapid response teams of physicians and health workers to manage SAEs during the time of MDA in coordination with local hospitals. The D(P)HO will also report any suspected or confirmed SAE cases to EDCD, which then reports it to the WHO country office and RTI.

h) Drug and Commodity Supply Management and Procurement

Joint Request for Selected Medicines EDCD develops the JRSM with technical support from WHO and ENVISION. The MoH uses the WHO JSRM form to request ALB for LF and STH MDA. ENVISION has been building the capacity of EDCD by closely working with EDCD to produce the required data for the preparation of the JRSM. In FY17, RTI will continue to provide this critical technical support to EDCD and WHO. NTD Drug Quantification Quantification and procurement of DEC is handled by the MoH Logistics Management Division, in consultation with EDCD, and procurements are done on a multi-year basis. The quantification and forecasting is conducted using population targets in coordination with program districts. RTI provides technical support in preparing the forecast and drug needs for MDA. Warehousing, Transportation, and NTD Drug Distribution


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All drugs are stored in the central warehouse in Kathmandu upon arrival in Nepal. All drugs procured for MDA are transported to regional stores for re-distribution to district health stores. In FY17, ENVISION will support 16 districts to transport and deliver ALB and DEC drugs to health facilities where they will be provided to the FCHVs and CDDs to give to the eligible population in the community for directly observed uptake during the campaign. Handling, Storage and Transportation of FCHVs Bags RTI will support storage and transportation cost of bags for FCHVs from the national warehouse to 16 districts before LF MDA.

i) Supervision

MDA and Survey Supervision As in previous years, RTI will fund central-level staff from MoH/EDCD to carry out supervision of the LF MDA in FY17. During house to house visit for LF MDA both CDDs support each other to ensure quality of MDA and ensure proper recording. Their work is supervised by health facility supervisors. RTI also conducts joint supervision with MoH and WHO during and after the MDA campaign. Together with the central-level supervision team, the MoH will involve municipality authorities, district education officials, and D(P)HO staff in supportive supervision during MDA in urban areas. ENVISION also funds district- and village-level supervision in 16 LF MDA districts. MoH officials follow a supervision checklist during their monitoring visits and report back to the program about their findings. The checklist includes cross checking of the data collected from the census, number of people who took medicines, adverse events that occurred during the MDA, preparedness to manage SAEs, use and availability of IEC materials, required drug stock with CDDs etc. In order to ensure that there is a record of supervisory findings each year, supervisors complete a visit report after each visit, which is kept at EDCD and the D(P)HO offices, and RTI staff and MoH program officials discuss whether corrective action is warranted. In trainings and meetings ENVISION staff ensure that GoN regulations and WHO policies for LF MDA are clearly shared with participants and they understand these. During monitoring and supervision visits ENVISION staff conduct meetings with DPHOs and check with CDDs to find out adherence to regulations and policies. If needed ENVISION staff provides onsite suggestions and coaching. MoH, EDCD, WHO and RTI will supervise and monitor LF Pre-TAS and TAS being carried out in the districts. During this supervision RTI will ensure the samples has been chosen as per WHO guideline and survey protocols including ethical clearance from NHRC and consent from respondents are taken and properly followed. MoH, EDCD, NNJS/NTP, WHO, and RTI will also supervise and monitor the trachoma TSSs. MoH has developed a supervision checklist as outlined in the WHO guidelines for this activity. Supervision of subawards RTI supervises all subawards issued to NGOs for technical work. In FY17, this will include awards to the NTP for TSSs, as well as local NGOs for pre-TAS, TAS-I and TAS-III surveys. During the period of performance of these grants, RTI staff will meet with NGO staff, provide technical trainings as necessary, and observe field work. They will discuss any findings and issues with the NGO management, help determine corrective action where necessary, and ensure the smooth running of these activities. In addition, EDCD, NTP, and WHO staff will assist in providing supervision as necessary.


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j) M&E

M&E is a key area for the ENVISION project in Nepal, and RTI is committed to improving routine reporting while also carrying out DSAs. RTI employs an M&E coordinator in Nepal, who spends about 50% of his time at the MoH to provide technical assistance to EDCD and the NTD Secretariat staff. The M&E coordinator helps to address ongoing challenges and takes an active role in providing supervision and data collection of LF MDA, where he travels to some of the 16 LF MDA districts to help compile data reports. As part of the national NTD M&E strategic plan, RTI staff continued to engage in advocacy efforts within the MoH to add key NTD indicators to the National Health Sector Program III (NHSP3) implementation plan. In part due to RTI’s advocacy work, NHSP3 has agreed to incorporate key NTD-related indicators in its results framework and the activities in the basic health-care package. The NHSP3 is a critical document for the health sector in Nepal and guides all activities that will be implemented over the next five years. The addition of NTD indicators to the plan will ensure a high-level commitment to achieving the NTD program’s control and elimination goals. Following on the success with the NHSP3, in FY17, RTI staff will work with the NTD Secretariat and disease programs to advocate for the addition of NTD indicators into the national health management information system. As proposed in the FY16 program budget ENVISION provided technical assistance and funding for Nepal to carry out a DQA to understand the quality of routine data and the strengths and weaknesses of the national reporting system. Preparatory work is currently ongoing for the implementation of the DQA in the second week of September 2016. Data received at the national level is often incomplete and/or not reported in a timely manner. RTI plans to use the results of the DQA to strengthen the national reporting, feedback, and data management system in FY 2017. RTI HQ and in-country M&E staff will support this activity so there will be no additional cost. In FY16, RTI HQ staff conducted a three-day training to rollout the new WHO integrated NTD database for disease-specific Program Managers and NTD Secretariat staff. RTI engaged a local consultant to provide data entry assistance to the MoH. The historical data entry is in process and expected to be completed by the end of FY16. In FY17, RTI will monitor and provide management support to the NTD program managers and M&E personnel to build their capacity and to maintain the database. This will be accomplished through meetings to provide on-the-job training on the Integrated NTD Database, including ensuring a review of data received from the field and timely entry into the database. Pre-TAS and TAS orientation To strengthen the monitoring and evaluation capacity of the EDCD/MOH, RTI/ENVISION will be collaborating with EDCD and the WHO to orient/train district managers, focal persons and lab technicians on LF Transmission Assessment Survey (TAS). The objective of this training is to build the national monitoring and evaluation capacity to achieve the LF elimination goals. ENVISION will provide training for 30 district managers, 30 LF focal persons and 30 lab technicians on the use of LF diagnostics, the TAS methodology, and the use of TAS checklist. Management of WHO Integrated NTD Database In FY16, ENVISION trained and supported the establishment of the WHO integrated NTD database in Nepal. The historical data entry is complete for LF and trachoma. Since the inception of the USAID NTD Control Program in Nepal, ENVISION has played a critical role in supporting the management of NTD


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data at the national level. Data is now readily available for LF and the trachoma program. The STH program is in the process to enhance their collection process and to better manage the STH data. The MoH has requested ENVISION to continue to provide a secondary and an oversight support in maintaining the WHO Integrated Database, in order to maintain momentum gained in the past few years. In FY17, ENVISION will work with EDCD to also develop and prioritize a local management plan of the database. In FY17, ENVISION will support a local consultant to ensure that the integrated NTD database is updated in close coordination with the LF, Trachoma and the STH programs Nepal NTD M&E Plan GoN is in process of developing Nepal NTD M&E plan (2016-2030) and there has been a request from EDCD for support of a professional in drafting. RTI ENVISION will support a local consultant to work with the team in drafting this M&E plan. Refresher Training for Trachoma Graders In FY17, ENVISION will fund NTP to conduct refresher training on trachoma clinical grading for ophthalmic assistants. The aim of this training is to ensure high-quality clinical grading for all of the planned surveillance surveys (more details are available in the M&E section). Refresher Training for TSS enumerators NTP has completed TSS in 18 districts out of 20 endemic districts where trachoma MDA is completed. Only two districts (Achham and Baitadi) are remaining for TSS. As part of the planned final two TSS, RTI will fund training for the enumerators who will participate in the surveys.

Training for TAS and pre-TAS RTI will conduct a training for the NGO and National Laboratory staff who will conduct the planned TAS and pre-TAS surveys. As indicated in the NTD Capacity Strengthening section, the proposed activity will contribute to building the TAS implementation capacity of national lab staff and DPHO and all the NGOs implementing these surveys. Pre-TAS In FY17, RTI is planning to fund pre-TAS sentinel and spot-check site surveys in ten districts and the results will be used to determine which districts can advance to TAS. The ten surveys will be conducted in Dailekh, Darchula, Baitadi, Dadeldhura, Doti, Achham, Bajura, Bajhang, Kailai and Kanchanpur. RTI, MoH, and WHO staff will supervise these activities, travelling out to each district to visit multiple sites and ensure the quality of the surveys. In November, after the national budget has been finalized and approved, there should be less difficulty in engaging with EDCD staff. Decisions will be made based on the results of the surveys whether to move on to TAS or to repeat two rounds of MDA. TAS-1 TAS-I will take place in FY17 in the 15 districts of Myagdi, Parbat, Lamjung, Baglung and Lalitpur-rural, Ilam, Jhapa, Morang, Panchthar, Sunsari, Terhathum, Bardiya, Jajarkot, Surkhet and Dhankuta (estimated 10 EUs), following pre-TAS in five districts in August- November 2016 and a eighth/sixth round of MDA in February 2017. TAS-III As noted in the National NTD Program Overview, in FY17 ENVISION will fund TAS-III in the five districts of Parsa, Makwanpur, Chitwan, Nawalparasi, Rupandehi (2 EUs) which have passed TAS-II in FY14 in March-April 2017 to reconfirm that transmission is not reoccurring.


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Trachoma Surveillance Survey Impact surveys have been completed for all the 20 trachoma endemic districts. By the end of FY16, 18 districts have also completed pre-validation surveillance surveys. The preliminary findings of the surveillance surveys are indicating the absence of trachoma and no need to re-start MDA. In FY17, with ENVISION funding, NTP will carry out surveillance surveys in the two remaining districts, using WHO guidelines to survey 20 clusters in each district.

Workshop to finalize NTD M&E plan Based on the NTD plan of action (2016-2030), GoN is in process of developing NTD M&E plan with support from stakeholders. ENVISION will support a workshop to finalize the NTD M&E plan. Post MDA Coverage Surveys In FY17, ENVISION will conduct ten post MDA coverage surveys after MDA is completed. The coverage surveys will also be used to determine the effectiveness of the proposed social mobilization activities. The selection criteria will be the districts with the highest and lowest reported coverage. The proposed surveys will not only help verify the reported coverage but also help the national NTD program and RTI understand the reasons why people are participating in MDA campaigns and then assess the effectiveness of IEC materials. ENVISION will work closely with EDCD to revise approaches and activities needed to improve coverage and data reporting.


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Appendix 1. Table of USAID-supported Regions and Districts IN FY17

Region Health

Districts Trachoma

(TSS)

LF Post MDA

Coverage Survey

LF Pre TAS

LF TAS-I LF TAS-III LF MDA STH MDA

1

Eastern

Ilam X

2 Jhapa X

3 Morang X

4 Panchthar X

5 Sunsari X

Terhathum X

Dhankuta X

6

Central

Lalitpur-rural X X X

7 Parsa X X

8 Makwanpur X

9 Chitwan X

10 Bara X

Western

Myagdi X

11 Parbat X

12 Baglung X

13 Lamjung X

14 Nawalparasi X

Rupandehi X

15

Mid-Western

Banke X X X

16 Dang X

17 Bardiya X X X X

18 Dailekh X X X

19 Jajarkot X

Surkhet X

Salyan X X

Rolpa X X

Rukum X X

20

Far Western

Darchula X X X

21 Baitadi X X X X

22 Achham X X X X

23 Bajhang X X X

Bajura X X X

Doti X X X

Dadeldhura X X X

Kailali X X X X

Kanchanpur X X X

*STH MDA not funded by ENVISION but integrated with LF MDA


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Appendix 2. Table of FY17 Plan of Activities

FY17 Activities

National Program Implementation

Ongoing Project Operational Functions

Strategic planning

NTD Technical Working Group meetings - 3 events

National stakeholders meeting on New plan of action – 2 events

Annual Regional Review meetings -3 events

Trachoma Dossier meeting

NTD Secretariat

Advocacy

LF MDA regional level planning and - 3 events

Central level sensitization meeting -3 events

District level advocacy meeting in Banke

Social mobilization

TV broadcasting and newspaper publishing

LF MDA Supplies (Bags) - 16 districts

LF MDA 16 districts

STTA

Drafting Nepal NTD M & E Plan

Integrated NTD database

National capacity strengthening assessment for NTD

Trachoma dossier preparation

M & E

TAS III Orientation and survey 5 districts

LF MDA coverage survey 10 districts

Pre-TAS Orientation and survey 10 districts

TAS I in 15 districts

Workshop to finalize M & E plan

TSS in 2 districts

Documents

Nepal Work Plan - ENVISION