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Quarterly Report 3 April 01 – June 30, 2007

Integrated Health Services Project (Project AXxes) USAID Cooperative Agreement No: 623-A-00-06-00058-00

Democratic Republic of Congo

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Deke se

Moba

Sakania

Pweto

Sandoa

KilwaKin da

Kiyam bi

Songa

Nyunzu

Kabal o

Punia

Dilol o

Lome la

Kail o

Kalemie

Tun da

Kapanga

Minga

Kaniama

Kin du

Lubudi

Lubao

Kibombo

Lubutu

An koro

Tsh udi Loto

Kongolo

Mitwaba

Kalamba

Nyem ba

Kalol e

Kansimba

Pangi

Kitenge

Fizi

Kamana

Kasaji-Kisenge

Mikope

Kabam bare

Samba

Kasenga

Djalo Djeka

Kabinda

Kamina

Kitangwa

Bena Dibele

Kafakum ba

Kabon go

Kunda

Al ungul i

Katako Kombe

Kole

Lue bo

Mushe ngeBul ape

Mutshatsha

Kin kondja

Mul ungu

Kiku la

Mufu nga-Sampwe

Lukaf u

Lul ingu

Kayamba

Mul ongo

Yangala

Manika

Bun keya

Tsh ofa

Bukam a

Nyanga

Kalima

Luam bo

Kanzenze

Lusam bo

Lual aba

Obokote

Dilala

Manono

Lusan gi

Kipush i

Mwetshi

Mutena

Demba

Kil ala Bal anda

Kambove

Luiza

Lodja

Fungurum e

Kitutu

Kalen da

Butum ba

Van gak ete

Kamonia

Kankenge

Shabunda

Kasongo

Pania Mu tombo Mbulul a

Lwamba

Kate nde

Luputa

Itom bwe

Kamwesh a

Be nale ka

Ndekesha

Fere keni

Sarambila

Lubunga

Banga L ubaka

Kampene

Tsh ibal a

Mweka

Kamiji

Kim bi Lul enge

Kabon do-Dianda

Nundu

Mukanga

Mutoto

Ndjoko Pun da

Kalonda Oue st

Mikalayi

Maswika

We mbo-Nyama

Mwenga

Bun yaKiri

Male mba-

Nkulu

Kapol owe

Lubondayi

Omondjadi

Kalomba

Kanda-Kanda

Miabi

Ludim bi L ukula

Bibanga

Bil omba

Kam

ituga

Tsh ikula

Tsh its himbi

Il ebo

Minem bwe

Kaniola

Uvira

Kalambayi Kabanga

Dibaya

Kamina Base

Tsh ilen ge

Panda

Bun konde

Bijo

mbo

Likasi

Ru zizi

Gan dajika

Kabe ya-

Kamwanga

Kalonge

Kasansa

Kanzala

Dikungu Ts humbe

Lemera

Minova

Mwana

Tsh ilundu

Kaleh e

Id jwi

Kabare

Mukum bi

Tsh ikapa

Walungu

Mubumbano

Wikong

Tsh ikaji

Makota

Katana

Ndesh a

Nyangezi

Mpokolo

Mwene -Ditu

Lukonga

Tsh ite nge

Mul umba

Katoka

Kaziba

Miti-Murhes a

Nyantende

Bukavu

Kasai-Occ

Kasai-Or

Katanga

Sud-Kivu

Maniema

Ka lon da Ou est

Moba

Fizi

Kole

Ilebo

Mweka

Miabi

Lubao

Pweto

Demba

Punia

Luiza

Idjwi

Pangi

Bukama

Nyunzu

Lubudi

Kalehe

Sandoa

Lomela

Lubutu

Dibaya

Dekese

Lubef u

ManikaDilala

Mwenga

Kamiji

Kipus hi

Kambove

Kongolo

Kasongo

Kaniama

Katanda

Kasenga

Kibombo

Kabongo

Walungu

Sakania

Mitwaba

Kazumba

Kapanga

Tshikapa

Shabunda

Gandagika

Kabambare

Mwene-Dit u

Dimbe lenge

Lupatapat a

Mutshatas ha

Katako-Kombe

Malemba-Nkulu

Kabeya-K.

Uvira

Lodja

Luebo

Likasi

Kamina

Manono

Kabalo

Dilolo

Kabare

Kolwezi

Kalemie

Lusambo

Tshilenge

Tshimbulu

Kindu

Bukavu

Kananga

Lubumbashi

Mbuji-Mayi

Project AXxes

Partner Implementation MAPRevised October 2006

CRSECCWVINot Selected

Partner Region District

Nord S. Kivu

Kolwezi

Haut-Lomami

Kasais

Bukavu, Centre , Ouest

Nbre ZS

CRS

ECC

ECC

WVI

WVI

S. Kivu

K. Occ

Katanga

Katanga

S. Kivu 905,835

647,688

1,506,377

1,334,918

2,891,324

7,286,14257

PopulationPopula tion

Implementing Partners by HZ Cluster

S o m e H Z a r e a p p r o x i m a t i o n s p e n d i n g o f f ic i a l r e -d e li m i t a t i o n in f o r m a t io n

21

12

9

8

7

Lake

Inland shorelines

Route Nati onal e asphaltéeRoute Nati onal eRoute secondaire en terre bat tueRoute locale

Chemin de fer

#Y Chef-lieu de district%[ Chef-lieu de province

#S Chef-lieu de territoi re

0 100 Kilometers

Map makin g by AXxes IMA GIS Unit , November 2006

USAIDFROM THE AMERICAN PEOPLE

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I. TABLE OF CONTENTS

I. Table of Contents 2

II. Abbreviations 3

III. Executive Summary 5

IV. Table of Planned Activities and Actual Accomplishments 6

V. Commentary on Work Plan Activities Component A 13

V. Commentary on Work Plan Activities Component B 21

V. Commentary on Work Plan Activities Component C 24

Consortium and Project Management 26

F. Medical Waste Management 26

G. Security Report 27

H. Program Performance Indicators 28

Annex 1: Program Performance Indicators Table 30

Annex 2: DPT3 Vaccination Coverage Map 34

Annex 3: Tuberculosis Detections Rate Map 35

Annex 4: Health Facilities Scheduled for Rehabilitation 36

Annex 5: Supervision at Health Zones 39

Annex 6: Distribution of Project Materials (Cumulative) 40

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II. ABBREVIATIONS

AIDS Acquired Immune Deficiency Syndrome AMSTL Active Management of the third Stage of Labor ANC Antenatal care BASICS Basic support for institutionalizing Child survival BCC Behavior Change Communication BCZS Bureau Central de la Zone de Santé (Health Zone Central Office) CCIA Coordination Committee inter agency CCIH Christian Connection international Health CDT Centre de depistage et traitement C-IMCI Community-Based Integrated Management of Childhood Illness CODESA Comité de Développement et Santé COSA Comité de Santé COP Chief of party CRS Catholic Relief Services CYP Couple Years of Protection DOCS Doctors on Call for Service (a.k.a. DOCS HEAL Africa) DPT Diphteria Polio Tetanus DMO District medical office DOTS Directly Observer Treatment Strategy DRC Democratic Republic of Congo (also DR Congo) ECC The Protestant Church of Congo EPI Expanded Program on Immunization FBO Faith-Based Organizations FP Family Planning GBV Gender Based Violence GAVI Global Alliance for Vaccines and Immunizations GESIS Gestion du Système d’Information Sanitaire GHC Global Health Conference HGR General Reference Hospital Hopital Général de Référence HIS Health Information System HIV Human Immunodeficiency Virus HKI Helen Keller International HPSK Health Public School of Kinshasa HZ & HZMT Health Zone and Health Zone Management Team ICC Interagency Coordination Committee IMAWH Interchurch Medical Assistance World Health IMCI Integrated Management of Childhood Illness (PCIME in French) IPT Intermittent Preventive Treatment IPS Inspection Provinciale de la santé ( Provincial Health Office) IRM Innovative Resources Management ITNs Insecticide Treated Mosquito Nets IUD Intra Uterine Disposal JHU Johns Hopkins University KPC Knowledge Practice Comportment LLIN Long-Lasting Insecticide-treated Nets (also known as ITNs)

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MCZ Heath Zone Medical (Medecin chef de Zone) MID Médecin inspecteur de district M&E Monitoring and Evaluation MOH Ministry of Health MSH Management Sciences for Health NGO Non-Governmental Organizations ORT Oral Rehydration Therapy OFDA Office of Foreign disaster assistance PCIME IMCI in English – Integrated Management of Childhood Illness PEV Programme Elargie de Vaccination (EPI in English) PHSK Public health school of Kinshasa PMA Paquet Minimum d’Activité (Minimum Package of Assistance) PMP Performance Monitoring Plan PMTCT Prevention of Mother-to-Child Transmission of HIV PNLMD Programme National de Lutte contre les maladies diarrhéiques PNLS Programme National de Lutte contre le SIDA (National AIDS Program) PNLT Programme National de Lutte contre la Tuberculose (TB National Program) PNTS Programme National de Transfusion sanguine (National Blood Safety Program) PNLP Programme National de la lutte contre le Paludisme PNSR Programme National de la Santé de la Reproduction POPPHI Prevention of Postpartum Hemorrhage Initiative PRONANUT National Program for Nutrition RHS Reproductive Health Services SOW Scope of work STI Sexually Transmitted Infections SANRU Health Development Program of ECC based on the SANRU I, III & III projects SNIS Système National d’Information Sanitaire (National Health Information System) TA Technical Assistance TB Tuberculosis TOT Training of trainers UNC University of North Caroline UNICEF United Nations Children's Fund UNFPA United Nations Fund for Population Activities VCT Voluntary Counseling and Testing VFR Vesicle fistula repair WHO World Health Organization WRC World Relief Corporation WVI World Vision International

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III. EXECUTIVE SUMMARY

AXxes is a three-year $42 million dollar USAID-financed primary health care project designed to revitalize the national system of primary health care in 57 health zones across the DRC. It is implemented by a consortium of international NGOs with IMA World Health (IMAWH) as the prime recipient, and ECC, CRS and World Vision as sub-partners. AXxes provides health zone development assistance based on the “Appui Global” strategy of the Ministry of Health through three major components.

Component A: Increase access to, quality of, and demand for multi-sectoral, integrated PHC

Component B: Increased Capacity to the health zone and the referral system

Component C: Increased capacity of national health programs and provincial/district offices The AXxes Project has now completed nine out of thirty-six months. Over the course of the third quarter, AXxes conducted the following major activities:

1. Conducted assessment of medicine depots capacity for drug credit system

2. Started rehabilitation of health facilities

3. Trained 149 laboratory technicians in proper diagnostic testing for TB, malaria and HIV

4. Started working towards opening PMTCT site in 20 health zones

5. Initiated two pilot projects with World Relief and Innovative Resources Management

6. Started distribution of Long Lasting Insecticide Treated Nets

7. Supported the provincial vitamin A and mebendazole campaigns

8. Training workshop with HKI for HZ teams to improve routine delivery of Vit. A

9. Advanced the organization of the health zone census with all major stakeholders

10. Responded to two epidemics (measles and cholera)

11. Trained over 1293 health zone staff in reproductive health

12. Started support to the MOH at the Provence and District levels

13. Conducted training “Transforming Managers into Leaders” led by MSH

14. Organized the Conseil d’Administration meetings in AXxes assisted health zones.

15. Facilitated the implementation of the baseline KPC survey in all health zones

16. Implemented partners’ meetings in Lubumbashi and Kinshasa

17. Improved tracking of medical waste management The third quarter was marked by the withdrawal of MERLIN from the AXxes project and the subsequent transfer of their South Kivu health zones to CRS. CRS immediately commenced activities in the five health zones and will be fully operational in these zones in quarter four. Challenges during the third quarter continued to be centralized around two themes;

1. Generalized insecurity throughout South Kivu and 2. Coordination with various NGOs in AXxes-assisted zones who work with a divergent

approach to health care delivery and support.

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IV. TABLE OF PLANNED ACTIVITIES AND ACTUAL ACCOMPLISHMENT

Quarter

Activities 1 2 3 4

%

Complete Comments

Component A: Increase access to, quality of, and demand for multi-sectoral, integrated PHC A1. Increase access to HC x..

Provide each HC and HGR with care protocols

x..

20%

Care protocols and treatment for Reproductive Health have been distributed to all HC in targeted HZ while ordinogram will be only given after PMA training and after its revision by 5th direction

Train each HGR and HC staff in correct use of curative care protocols ( ordinogramme)

x 0% Postponed until August

Provide each HGR and HC with essential drugs x.. 0% Ordered drugs expected 4th quarter

Equip at least 60% HC/HZ with mini Kits x.. 0% Mini kits expected 4th quarter

Equip each HGR with HGR kits and surgical boxes x.. 0% Surgical boxes expected 4th quarter

A2. Reinforce referral system x..

Promote use of protocols x..

20% HGRs and HCs have started using reproductive health protocol in June

Establish preferential tarification for referred patients ( at least 20% less than other patient)

x.. 20%

Not yet accomplished but the process is going on in collaboration with IPS and other partners for each HZ

Equip geographical strategically HC of reference x.. 0% To be done as soon as available

Establish episodic Payment system

x..

30%

Not yet accomplished but the process is going on in collaboration with IPS and other partners for each HZ. Implementation to start as soon as AXxes drugs are available

Rehabilitate HGR and at least 2 HC/ HZ x..

20% HCs have been selected and the MOUs signed with constructors, construction has started at some sites

Provide instructions for referral

30%

CRS provided all HGR and HC with documents of referral system and follow-up should be done through field supervision

A3. Establish blood testing & grouping at HGRs

& CSR x..

Train HGRs & CSR Lab Staff in screening for transfusion-transmissible infections, blood grouping, compatibility testing, the storage and transportation of blood products

x

86% 149 lab technicians trained out of 174 planned

Encourage the HZ team to educate, motivate, recruit and retain low-risk blood donors, especially the volunteer non-remunerated blood donors from low-risk population

x..

0% Part of PMA training 4th quarter

Provide HGR with adequate HIV, HBs, HCV et RPR and blood group tests, and transfusion supplies

x.. 50%

HIV tests and RPR tests are available in all HZs. Complete kits will be available soon

Ensuring that assisted HZs follow current PNTS guidelines on the clinical use of blood transfusions

x..

50%

Implemented in some Kolwezi, South Kivu and Kasai zones where trained in blood transfusion through the National program happened last year. Guidelines are have been distributed to all HZ supported by AXxes

Providing training in the clinical use of blood including alternatives to transfusion and in how to prevent transfusions by early treatment of all conditions that could result in need for transfusions (obstetrical complications, anemia, trauma)

x..

75% Covered in laboratory training and will be reinforced in PMA training.

A4. Establish PMTCT x..

Recruit a consultant for developing PMTCT implementation program

x 100% Brown consultants and UNC were chosen

8

Quarter

Activities 1 2 3 4

%

Complete Comments

Begin PMTCT implementation in HGR and selected HC

x.. 20%

Selection of zones has been made and planning for training has started

5. Integrate Zinc treatment in treatment of

diarrhea x..

Facilitate workshop for zinc x.. 0% Delayed to 4th quarter

Conduct a pilot program to test for acceptance of the provision of Zinc and low-osmolarity ORS for children with diarrhea will also be implemented by HKI in several HZs during the year one

x..

Delayed to 4th quarter

TOT for Zinc , Vit A and ORT integration ( HKI) x.. 50% Vit A and ORT training completed

Int'l Trip: South-South visit to ZN program (HKI) x 0% Delayed to early 4th quarter

Workshop to review / elaborate BCC messages on Zinc

x.. 0% Delayed to 4th quarter

6. Clinic IMCI x

Train HZTMs as TOT, HGR and HC staff in IMCI including management of Diarrhea, ARI, fever, Measles, malnutrition and other child diseases

x.. 0%

IMCI training will be combined in PMA training 4th quarter

Provide HC with IMCI drug package including ORS, Zinc , ACT and antibiotics.

x.. 0% As soon as drugs are available

Provide HGR and HC with protocols and IMCI forms

x.. 0% As soon as available

7. Integrate C-IMCI in collaboration with World

Relief x..

Train C IMCI team ( 4 pers from HZMT and 1 pers from the community) as trainers

x.. 0%

IMCI training will be part of PMA training 4th quarter

Support Selected relays training x..

0% IMCI training will be part of PMA training 4th quarter

Facilitate the Reproduction of available and proven educational materials (flipcharts, tip cards, posters, pamphlets, etc)

x.. 50%

Many of the education materials have been reproduced

8. Development of Water Sources and

Promotion of Hygiene and Sanitation x..

Training of water and sanitation coordinators x.. Scheduled for 4th quarter

Rehabilitation of existing/build community water wells

x.. 20%

Water sources have been selected, water committees formation is ongoing

Promote Construction of latrines in health centers and incinerators in hospitals

x.. 10%

The MOUs with constructors signed, purchase of materials ongoing at most sites

9. Improve malaria treatment at HC and HGR x..

Provide each HGR and each HC with national protocols

x 25%

Protocols already printed by the COP team and waiting for distribution to the partners

Improve laboratory capacity in diagnosing malaria including provision of labo supplies and training for each HGR and selected HC laboratory staffs in collaboration with MSH

x..

50% Most technicians have been trained. Complete laboratory supplies will come next quarter.

Training HZTMs, each HC and HGR staff in management of malaria including preventive aspects

x.. 0% Part of PMA training

Provide each HZ with ACT x..

0% Drugs have been ordered centrally through IMAWH, expecting arrival early August

Provide HGR and HC with other malaria drugs (quinine, Fansidar)

x.. 0% The drugs ordered by IMAWH will arrive in August

10. Improve and promote malaria prevention x..

9

Quarter

Activities 1 2 3 4

%

Complete Comments

Training HZTMs, each HC and HGR staff in management of malaria including preventive aspects

x.. 0% To be done as a part of PMA

Integrate IPT as part of FANC in each health center x.. 0% as soon as available

Develop social marketing activities for LLINs x.. 0% to be done as a part of MPA

Provide an average of 2800 LLINs/year/HZ that will be sold at subsidized price (05 $) to the targeted population ( pregnant women and child under five)

x..

50% 38900 LLNs were distributed to 15 HZs in Kolwezi and Kasai

Diffuse keys messages on malaria through community relay

x.. 20% Reactivation of relays is ongoing

Develop communication program focused on home care, care seeking and recognition of signs of danger that include BCC materials et relay training

x.. 10% Reactivation of relays ongoing

Supervise activities x..

80% Almost all supervision at the project level is being done. HZs are supervising about 70% of planned

11. Promote good nutritional practices x..

Promote early and exclusive breastfeeding, appropriate weaning practices, ( Initiative Hopitaux Amis des bebe)

x.. 100%

Implementation is going on in all hospitals and HCs. To reinforce supervision and monitoring

Support the diffusion of nutrition key messages through HZ team, HGR, HC and Community-IMCI relays

x.. 0% Included in PMA training

Reinforce growth monitoring by distributing card, equipping facilities with scales, height boards and registers for growth monitoring;

x..

70%

GMP materials have been distributed in all HZs except Scales and height boards not yet available. Also trained heatlth personnel on GMP during RH training. Monthly supervision is being done.

12. Increase VIT A and Iron coverage among

targeted population x..

Micro planning at all levels, beginning with health centers;

x 100%

Integrated microplanification has been done in all HZs

Support distribution of vitamin A plus mebendazole through both special campaigns and routine services;

x.. 100% Vit A campaign was a success in all HZs.

Integrate Iron distribution to all pregnant and lactating women;

x.. 20%

Some HZs received Iron from other partner and distribute systematically during FANC

Conduct a pilot program to increase Vit A demand by the community

x.. 50%

10 HZs selected, training done. Waiting for relays training and educational supports to be reproduced

13. Integrate the RED, REHA, REC approaches

including training of HZTMs and HC staff x..

Support Micro plan process for each health area and the for each HZ

x.. 100% Integrated microplanification done in all HZs

Encourage and Support census of population in each health area

x..

40%

For South Kivu, a task force to spearhead this excercise has been done with strong leadership from AXxes. All INGOs and other stakeholders have been asked to contribute and AXxes has already done so but there is still a gap of 100 000$ to be covered by other partners. In Kolwezi, the principle has been agreed; AXxes will lead the census team. Census appears in the agenda of the next Provincial meeting planned end of July

Provide HZ with refrigerator fuel x.. 100%

Support HC to develop outreach activities ( bike x.. 70% Distributed bikes and management tools

10

Quarter

Activities 1 2 3 4

%

Complete Comments

and cold chain boxes, management tools)

Participate in CCIA meetings x..

70%

Participated in SK and Katanga in May and June meetings. Main point of discussion was on how to improve vaccination

Provide Cold chain equipment (solar refrigerator) and supplies for each HZ according to the results of need assessment In collaboration with Unicef

x.. 50%

73 refrigerators were bought and distributed to partners. Waiting for solar refrigerators, cold boxs and others supplies

Recruit for each cluster a technician for repairing existing refrigerators

x.. 100% Recruited 4 (2 SK, 2 Kolwezi) technicians.

Train HZMTs and HC staff in PEV Activities x.. 0% Part of PMA training

Organize accelerated immunization in the health zones with low coverage

x..

10%

Identified the HZs with low coverage (Kolwezi are Lubudi, Bunkeya and Fungurume; Bunyakiri and Minova in South Kivu. Plans for acceleration campaign will likely start in Seeptember to November

Provide each HC with BCC materials in collaboration with UNICEF

x.. 15% Discussions with UNICEF ongoing.

Diffuse immunization messages through community relay

x.. 0%

Relay training will take place in 4th quarter. So far messages are diffused through HC

Reinforce immunization diseases Surveillance system by training staff and relays and providing HC with technical forms The new M&E will be a big opportunity

x..

40% Technical forms are available in HCs and HGRs. Training included in PMA

Support epidemic response x.. 100% CRS responded to two epidemics

Promote injection safety in each HC by communication providing selected HC with incinerator

x.. 20% MOUs signature with constructors

Integrate DQS practices in the routine of HZ functioning

x.. To be done in collaboration with PEV in quarter 4

14. Integrate Family Planning and services in

each HC and HGR supported by the project x..

96% In Kalonge HZ, the RH training was postponed because of insecurity

Train HZMTs ( 4/HZ) as TOT and the they will train HC staffs (2/HC) and HGR staffs (4/HGR) in RH/FP

x.. 88%

1293 health wporkes have been trained out of the 1464 planned

Provide and secure PF commodities to the selected structures

x.. 100%

Integrate PMTCT and Voluntary Counseling and Testing (VCT) as part of Family Planning services in HGR (1/HZ) : 20 sites 1st year

x.. 10%

Identified 5 HZs (2 in Kolwezi and 3 in SK) and 15 sites, 3 in each HZs to implement PMTCT

Introduce RH/PF monitoring activities in each HZ x.. 50% On going

IImmpprroovvee ccoollllaabboorraattiioonn wwiitthh UUNNFFPPAA x.. On going

15a. Improve Antenatal Care x..

Train HZTMs, HC and HGR staffs x..

Facilitate the provision of the minimum package of activities for antenatal in each Health Center This package include: detection of High risk pregnancy, IPT, LLINs, Iron-folic acid, Tetanus toxoid, Screening and treatment for ISTs, FP information and commodities, Health information

x..

65%

IPT, iron are available in Manika, Lualaba, Dilala from WHO, UNICEF and DCP (mining company) in Kolwezi and Katana and Kalehe from BDOM and IRC In South Kivu resp. AXxes LLNs not yet supplied in South Kivu

Support Heath center in organizing outreach visits for the population up to 5 km ( bikes, cold chain and other commodities)

x.. 70%

Bikes are available in all HZs and was appreciated that it was a pressing need for outreach activities. There are few cold box for carrying vaccines

Provide HC with STIs drug according to the PNLS therapeutic regiments

x.. 0% as soon as available

11

Quarter

Activities 1 2 3 4

%

Complete Comments

Integrate Behavior Change Communications (BCC) on reproductive health in HC and through Community-Based Integrated Management of Childhood Illness (C-IMCI)

x..

0% Reactivation of relays ongoing and IMCI training planned 4th quarter

15b. Improve Intrapartum Care x..

Train HZTMs, HC and HGR staffs and midwifes on birth management including management of third stage of Labor

x.. 100%

Promote appropriate prevention of PPH in each maternity

x.. 100%

Provide each maternity with birth kits and birth management tools

x.. 50%

Birth management tools are available in all maternities but still waiting for birth kits

Provide and promote appropriate use of oxytocine in each maternity

x.. 100% To reinforce as soon as AXxes drugs are available

Provide HGR and selected HC with blood safety commodities

x.. 100%

Received and distributed 9700 HIV determine tests and RPR provided

Rehabilitate maternities x.. 20% In progress

Improve emergency surgical services in HGR and other strategically placed health facilities

x.. 0%

15c. Improve Postpartum Care x..

Train HZTMs, HC and HGR staffs and midwifes in maternal and newborn health and nutrition

x.. 100%

Promote appropriate management of PPH in each maternity

x.. 100%

Provide HC and HGR with Post partum management tools

100% CPoN tools provided

Provide maternity with Vitamin A in collaboration with UNICEF,HKI and PRONANUT

x.. 0%

16. Increase availability and improve quality of

essential newborn care services x..

Train HZTMs, HC and HGR staffs and midwifes in Newborn care

x.. 100%

Provide each maternity with Newborn essential care protocols

x 100%

Develop a program of communication on essential newborn care based on interpersonal communication through facility and community health workers and the mass media In collaboration with UNICEF and BASICS

x..

10% On going with the technical support of Basics (component C)

Promote in each maternity Newborn essential care including clean cord care, drying, keeping mother and infant warm (kangourou), early/exclusive breastfeeding, basic newborn resuscitation techniques where indicated

x..

100%

Provide maternities with antibiotics for neonatal infections & supplies

x.. 0% Waiting for drugs

17. GBV interventions and fistula reparation x

Identify NGOs ( local and international) which are involved in GBV activities in field

x 100%

Elaborate and diffuse key educational messages regarding the prevention of gender discrimination

x..

On going. All of existing messages were collected. Reproduction and Distribution will be done after relay training in quarter 4

Promote gender objectives for staff composition x.. On going. Taken in consideration for each training

12

Quarter

Activities 1 2 3 4

%

Complete Comments

and participation in trainings and activities activity and in the contract with HZMT. To be reinforced during CODESA training in Quarter 4

Set Strict criteria for the minimum proportion of women among the village health activists and CODESA/COGE members

x.. 25%

Sensitization to encourage women participation is going on

Select strategic HGR where obstetric fistula services will be developed

x.. 100% 10 HGR are selected

18. Improve TB detection x..

Collaborate closely with the national program x.. 100%

Improve labo staff capacity and provide labo supplies

x.. 100% To reinforce as soon as labo supplies are available

Reinforce the capacity of HZ teams to implement the TB program by training them in supervision within the normal activities of the HZ and DOTS

x.. 0% To work with PNT/MIP as sectorial plans

Put in place or reinforce 3 geographically well distributed “Centre de Depistage et de Treatment (CDTs)” in each HZ; providing them with microscopes and needed lab consumables

x..

20% Selection of CDTs done. Waiting for kits

Promote TB program and CB-DOTS will be done through relays with BCC materials and via radio

x.. 0% to reinforce. Waiting for relay training

Support the implementation of community-based DOTS (CB-DOTS) strategy with the active participation of local communities in providing the treatment supervision through community relays

x..

0% to reinforce where the structure already exist and to implement where unavailable

Provide HZ with PATI 4 x..

50%

8 HZs in Kolwezi have received after training supported by Global funds to PNT. PNT will provide for the rest of the HZ

Component B: Increased Capacity to the health zone and the referral system B1. Develop Human Resources of HZMT,

including training and supervision x..

TA visit (MSH: Ntumba) for AXxes partners Leadership training

x 100%

1st part done, second part in August, MIP and MID were present

Train HC staff in PMA x 0% Begin Q4

Begin financing HZ operations x.. 100%

Support Monthly HC supervision by HZMT x..

100% The supervision rate has improved through AXxes support

Train HCs to increase referral rate during the PMA session

x.. 0% To begin in Q4

Train hosp staff to increase back referrals x..

Train doctors in VFR for key referral hospitals x x

0% 6 Doctors have been selected for training planned for 4th quarter

Improve drug Supply Mgmt to reduce stock outs x..

Reinforce Surveillance system x..

B2. Reinforce HZ co management et community

participation x..

Establish/Activate HZ Admin Councils x.. 100%

Establish contracts & co-mgmt principle with HZs x 100%

Reinforce CODESA to become functional

x..

53%

8 out of 15 HZs have functional CODESAs in WVI. Reactivation continues for other partners. . This activity will be reinforced during CODESA training Q4

Activate CODESAs with balanced gender x.. 25% 4 CODESAs out of 15 have women representatives

13

Quarter

Activities 1 2 3 4

%

Complete Comments

participation WVI. Sensitization is going on for other partners and data will be completed. This activity will be reinforced during CODESA training Q4

Train NGOs in proposal development & mgmt and Fund multisectoral IGAs to support HC

x.. 0% to be done in Q4

B3. Establish and reinforce M&E in Health

Zone x..

Facilitate KPC surveys in selected HZs x x 100%

Encourage HZMT monthly reviews w/ providers & COGE

x.. 100%

Implement HC complete HIS monthly reporting x.. x.. 100%

Integrate GESIS in HZ (training and provision of computers)

x..

0%

In process. M&E worked with SNIS department on improving the format and integrating AXxes indicators. Trainings for Katanga and Kasai Or are planned for Q4

Consortium and Project Management Functions Hold quarterly meeting with implementing partners x 100% Two held this quarter

Distribute locally procured project commodities x..

100% Distributed to partners. Some items still waiting to be sent to HZs

Distribute of externally procured commodities x.. 10% Most items have not arrived yet

Component C: Increased capacity of national health programs and provincial/district offices

Facilitate provincial/district meetings

x..

20%

Most of meetings will be supported during the 4th quarter. So far Comite de pilotage for Kasai east was facilitated

Participate in HZ CA meetings x..

100% Almost all of the CA meeting were held and district or provincial levels participates

Supervise HZs at least once per year x.. In

progress AXxes will start funding this activity during the second semester

Improve SNIS reports completude et promptitude

x..

In

progress

All of the HZ received forms and report to the Province level. Gesis will be integrated in august in Katanga and kasai Oriental

Trips to support provincial/district level x.. Develop priority MOH support plan x.. 100% Conduct MOH needs assessment x.. 100 % Facilitate policy & topical mtgs & workshops x.. 20%

Implement MOH technical support plan x..

In

progress Waiting for the Provincial and district “Fiche techniques”

Identify ST TA for selected topics

x..

100 %

Basics for PEV and New Born, JHU for SNIS and Surveillance, Browns for PMTCT, MSH for leadership, HKI for nutrition and Zinc, HPSK for management and surveillance

Facilitate task forces for selected topics x.. 0%

Proposed candidates for UNIKIN SPH x 100%

Train MOH in strategic planning, finances, mgmt. x.. 80% First step of training on leadership was organized and

Hire MOH Technical Advisors x.. 60% In progress for basics, HPSK

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V. COMMENTARY ON WORK PLAN ACTIVITIES COMPONENT A

Increase access to, quality of, and demand for multi-sectoral, integrated PHC

A1. Increase access to HC

Essential Medicines: In preparation for the arrival of essential medicines, an evaluation of the regional pharmaceutical depots and pharmaceutical management partners in Kamina, Kolwezi and Bukavu was conducted. The objective of these assessments was to better understand the local capacity and infrastructure for pharmaceutical and financial (particularly related to credit programs) management and to identify areas for improvement. After adapting an evaluation checklist, MSH consultant Gabriel Bukasa conducted the three rapid assessments along with the AXxes procurement and distribution advisor, Ben Munongo. The assessments were carried out during the second half of May 2007. During the assessments the depots in Kamina and Bukavu were found to be functional with differing levels of pharmaceutical management capacity. In Kolwezi there was no existing regional pharmaceutical depot structure. A meeting was held with local AXxes project and health sector partners to develop a plan. The local Catholic diocese agreed to allow use of their old depot building and to supply a member of their congregation to assist the district pharmacist to manage the depot. MSH is developing the tools for tracking the drug credit system and will work with the identified local staff to train them on pharmaceutical management to ensure that the depots and credit system function well. IMA World Health will also send a consultant to the field in September to follow-up on deficiencies noted in the MSH report and ensure correct start up and implementation of a drug credit system. Care Protocols: The care protocols have still not been officially accepted by the MOH. A compromise was reached at the end of quarter three allowing AXxes to modify parts of the old protocol and bring them up to date ahead of the new protocols which will go into effect later this year. This will allow the project to move on with PMA training in August.

A2. Reinforce referral system

Payment by episode: Discussions have started on implementing a payment by episode system with a reduction for referrals, but in most areas they are waiting for the drugs and equipment to arrive before implementing the new system. Three HZs, Bunkeya in Kolwezi and Kalonge and Katana in South Kivu already apply the system through other NGOs namely Catholic Monastery, IMC and BDOM respectively. In Katana for instance, the referred patients pay 50% of the set price. Figure 1: Repairs of Mutoto maternity

15

Rehabilitation of health facilities: This activity was planned for fourth quarter but all implementing partners have started this activity. The assessments of the facilities needing repairs have been done and the work has been bid out to contractors. In the Kasai region much of the work has already been completed (see Annex 4 for details).

A3. Establish blood testing and grouping at HGR and HCs

The MSH’s consultant, Grace Kahenya, made two visits to the DRC this quarter. The first trip was to conduct a rapid baseline assessment of laboratories capacity and capability to perform HIV testing, malaria testing, TB smear microscopy and blood transfusion services. She also worked with AXxes staff to develop an appropriate curriculum for the training course and reference material. The second visit was to provide technical support for the training of trainers in laboratory organization, management, HIV testing, malaria testing, TB smear microscopy and blood transfusion services. The strengths and weakness of the course were reviewed with the key facilitators. The above activities were undertaken in collaboration with AXxes staffs, Ministry of Health, Catholic Mission Hospitals and the School of Public Health. The TOT Training was done at the Public Health College in Kinshasa from 23rd April to 5th May in collaboration with MSH. The trainers then trained 149 laboratory technicians in Bukavu, Kolwezi and Kananga. There is one more pool of 25 laboratory technicians to be trained in Kamina. In close collaboration with PNTS, AXxes identified centers and provided them with blood security supplies. The supplies consisted of HIV Determine tests, EDTA Capillary, Chasse buffer, boxes of 100 lancet blood and RPR tests. In addition, AXxes provided PNTS with technical tools for the centers. The complete blood safety kits arrive early fourth quarter. Microscopes and a more complete kit of laboratory supplies will arrive the end of fourth quarter.

A4. Establish PMTCT Work has started with Brown Consultants, UNC and the PNLS on improving PMTCT protocols and opening 60 sites in 20 zones. At the end of the quarter Judith Brown came to Congo and met with all the stakeholders involved with PMTCT. She identified some of the weak points in what is currently being done and is modifying the protocols, training and monitoring forms to make the AXxes program more effective than what has been done up until now in Congo. Training for this program will be done in the fourth quarter.

A5. Integrate Zinc in the treatment of diarrhea This activity got off to a slow start because of a lack of consensus between key actors involved in the integration of zinc into Congo’s diarrhea treatment protocol. These problems have been resolved and the forth quarter will have an accelerated amount of activity in this area.

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A6. Clinic IMCI This activity is delayed because of postponed training and the lack of commodities. Most of this will be resolved in the fourth quarter.

A7. Integrate C-IMCI in collaboration with World Relief

One of the greatest inconsistencies across health zones in the DRC is the degree of community involvement in activities contributing to good health and sustainable development. To examine and improve upon the factors that contribute to active communities, the AXxes project has designed two pilot programs. The first, with World Relief, will build upon the successful implementation of Care Groups in countries such as Rwanda and Mozambique. The second, with IRM, will focus on improving the capacity of communities to strategically select income-generating activities that are best-suited to their particular context. World Relief (WR) is providing technical assistance to Project AXxes to build capacity for community mobilization, participatory training, and supportive supervision for community relays. World Relief assistance will focus on C-IMCI interventions that contribute to meeting AXxes program objectives for Component A - Integrated Primary Health Care. WR is providing technical assistance directly to CRS, the AXxes implementing partner in the pilot area, Mubumbano health zone. Technical assistance will be provided in six steps: (1) situation analysis; (2) staff development; (3) planning, (4) implementation; (5) assessment; and (6) dissemination for scale-up to other AXxes assisted zones. The situational analysis was conducted from May 28th to June 3rd by World Relief’s Maternal and Child Health Specialist. IRM will work with CRS to implement the “Community Participation” element of Component B. IRM will use the COAIT methodology (Community Options Analysis and Investment Toolkit) to reinforce the capacity of CODESA’s to (1) select sustainable income-generating activities that support health-promoting activities and (2) develop new projects and manage activities. During the third quarter, IRM conducted initial site visits to the health zones of Nyangezi, Mubumbano, Walungu, Ruzizi, Uvira, Bagira, Ibanda and Kadutu.

A8. Development of Water Sources and Promotion of Hygiene and Sanitation

This activity is scheduled for the fourth quarter but some work has already begun. Most health zones have selected sites for capping springs and the work for constructing latrines at health centers has been incorporated into the health center rehabilitation work. Nine health zones in Katanga and seven in South Kivu will be supported by a UNICEF financed “Village Assainis” project. This is an $850,000 project that will cap 320 springs, build 38,000 latrines, train and support water and hygiene specialist and train 3,500 community relais in promoting hygiene.

A9. Improve malaria treatment at HC and HGR Except for the laboratory training, this activity is delayed because of postponed PMA training and the lack of commodities.

17

A10. Improve and promote malaria prevention

Because of cost recovery from the sale of nets during the SANRU project, there was a small stock of nets available for project AXxes. 38,900 nets were distributed in 15 zones in the Kasai and Katanga regions. Training for the proper targeting and pricing of nets is planned for early fourth quarter in Katanga.

A11. Promote good nutritional practices

Exclusive breastfeeding and appropriate weaning practice messages are being disseminated through the health facilities. These messages will be reinforced in the PMA training in August. Growth monitoring cards and registers for growth monitoring have been distributed to all health zones.

12. Increase VIT A and Iron coverage among targeted population Vitamin A campaign: The Vitamin A and Mebendazole Campaign from 10th to 12th May was organized by PRONANUT with funding support from UNICEF and HKI. AXxes implementing partners attended and participated in collaborative meetings with the MIPs UNICEF, HKI, and other NGOs involved in the campaign. The campaign has been successful compared to the last campaign conducted in November 2006. Coverage for the Vitamin A campaign in May 2007 was 104% in the Kolwezi area and 103% in the South Kivu. Obviously there is a problem with the denominator but comparing the May results to November 2006, there is more than a 10% improvement. Vitamin A routine: In collaboration with HKI, CRS/AXxes organized training for the HZMTs of five health zones to improve the delivery of and demand for routine vitamin A treatment. The training covered the following topics:

� Basic knowledge on vitamin A � Guidelines for integration of the routine supplementation in vitamin A � Useful tools for integrating routine vitamin A activities � Communication strategies

CRS/AXxes, in collaboration with the IPS, selected the following health zones for participation in the pilot project: Bagira, Nyangezi, Mwana, Ruzizi and Walungu. Iron supplement: Iron distribution to pregnant women has increased but is not fully implemented because of lack of iron. An air shipment of all medicines and supplements needed for the CPN has arrived and will be distributed to the zones as soon as the goods clear customs.

A13. Integrate the RED, REHA, REC approaches

Census: In South Kivu and Katanga there are a large number of UN agencies and INGOs. These partners are using various denominators based on outdated information. As mentioned above in

18

the commentary on the Vit. A campaign, the current population figures are clearly inaccurate. The likely result of the AXxes census is that the indicators will be revised downward. As this is a contentious issue, CRS and WV have been proactive in engaging all stakeholders in the AXxes census. The results thus far have been positive; for example, CRS has received commitments to contribute financial and logistical support to the census from Louvain Developpement, Malteser, BDOM/Bukavu, International Medical Corps, UNICEF and WHO. CRS is continuing to seek out additional funds to complete the necessary budget. If, however, CRS is unable to gather the needed funding during the fourth quarter, it will conduct the census with the resources already available. In the Kasai region the idea of a census was not as threatening and many zones have already completed their census but need to have them validated. CCIA meetings: In South Kivu, the major challenge that the CCIA attempted was to develop a strategy, and mobilize partners, to conduct a population Census. In Katanga, the CCIA meeting in May focused on putting up a chronogram of activities for measles campaign planned between September and December 2007. In June the CCIA concentrated on reviewing PEV activities from January to April 2007 Cold chain: All HZs have received kerosene for their refrigerators. In South Kivu and Katanga technicians to repair broken refrigerators have been identified and will start the work in July. Seventy kerosene refrigerators have arrived and are being distributed to the health zones based on the needs assessment done last fall. Injection safety: Sites to build incinerators have been identified around HGRs. One incinerator has been constructed in the health zone of Uvira and three others are currently underway in South Kivu. In the mining area the cost of constructing an incinerator is higher than what was budgeted. WV AXxes is working with the community to contribute in making burnt bricks and provide labor to reduce the cost.

A13B Support of Epidemic Response

Measles Epidemic in Uvira: The Uvira health zone experienced an epidemic of measles during the third quarter. As outlined in the table below, a marked increase in cases occurred between week 1 and week 16 of the epidemiologic calendar, resulting in mortality rate of 0.6% (6 deaths / 1080 cases).

Based on this information, CRS/AXxes organized a joint evaluation of the epidemic with the BCZS, WHO and the office of EPI/South Kivu. The joint team visited two of the most severely effected aires de sante, Mulongwe and Makobola. The following observations were made:

� More than 90% of the cases were in non-vaccinated children or in children with an unknown immunization status.

� The most severely affected age category was 12-59 months, and more than 75% percent of cases occurred in male children.

Figure 2: A one year old boy

from the Kabimba health center

19

� The aires de santé reporting the highest number of cases were Mulongwe, Makobola, Kabimba, Kabindula, Kalundu Cepac and Kasenga.

� The treatment of cases has been relatively good but a rupture of certain drugs was noted � Some errors in reporting and coding were also noted and corrected. � � The joint evaluation team made concrete recommendations and shared the final report

with all of the necessary parties to ensure that the response to the epidemic addressed the most critical immediate needs. The specific contributions of CRS/AXxes are listed below:

� Launched and led the initial evaluation into the epidemic � Reinforced the EPI routine activities via briefings with health center nurses, the provision

of fuel for supervisions, and distribution of bicycles to health zone staff � Supported immediate awareness-raising activities through the distribution of BCC

materials including the national directives on measles surveillance

Epidemic alert and initial investigation Response : Medical care, reinforcement of routine EPI routine, formative supervisions Cholera Outbreak in the Ruzizi Health Zone: On May 4, 2007, after learning of reports describing several deaths from cholera in the centre de brassage de Luberizi, and heeding a request from the political and health officials of South Kivu, CRS/AXxes organized a joint evaluation of the outbreak with WHO, Aide Medicale Internationale, and the BCZS. With the authorization of the military authorities, the joint team led a field investigation into the situation of the camp. The team determined that an epidemic did not exist but did confirm several cases

Evolution of the Measles Epidemic from Week 1 to Week 24 in Uvira Cases and Deaths

0

50

100

150

200

250

300

Weeks of epidemic

c d

c 18 16 32 34 37 50 52 58 58 80 96 107 92 89 103 127 128 119 116 243 140 85 82 62 d 0 0 0 0 0 0 2 1 0 0 3 0 0 0 1 1 2 1 1 2 6 1 1 0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

1

2

1

2

20

of cholera. From weeks 1-18, a total of 38 cases were reported, of which 2 resulted in deaths (mortality rate of 5%). The joint team described the following two factors as the most likely causes of the outbreak:

� A momentary rupture in the water supply due to a breakdown in the adduction supplying the camp.

� An insufficient number of latrines CRS/AXxes wrote a report of the situation and distributed it via WHO to the health community. The various actors in the health zone responded by providing cholera treatment kits and CRS/AXxes provided 16,000 packets of the water purification product PUR. CRS/AXxes also began work on the construction of additional latrines in the camp. For their prompt and effective response to the outbreak, CRS/AXxes received the written appreciation of the MIP on behalf of the political and health authorities of the province. A14. Integrate Family Planning and services in each HC and HGR supported by the

project

The DRC is among the countries with the worst infant and maternal health indicators. In response, the AXxes project has made mother and infant health a major focus of its activities. During the second quarter, a “training of trainers” (TOT) session was held in which 70 health zone staff were trained in the key tenets of reproductive health. During the third quarter, those trained in the TOT session

conducted trainings in all AXxes health zones. These trainings targeted 1293 staff

Figure 4: Training session for HGR and HC staff on Reproductive

Health: Role playing to improve service delivery of cycle beads.

Figure 3: Figure 3: Handover by CRS/ Project AXxes and the BCZS

Ruzizi of 16,000 PUR sachets to Colonel Shulungu, Commmandant

du CBR Luberizi

21

members of health zone hospitals and health centers and were conducted in collaboration with IPS/South Kivu and the National Program of Reproductive Health.

22

A15. Improve Antenatal, Intrapartum and Postpartum Care Training for maternal care was incorporated into the reproductive health training. Messages for PPH and maternal and newborn nutrition were covered. The drugs for STIs, oxytocine and birth kits will come fourth quarter.

A16. Increase availability and improve quality of essential newborn care services Training for essential newborn care was also incorporated into the reproductive health training. Messages for clean cord care, drying baby, keeping mother and infant warm (kangaroo), early/exclusive breastfeeding, and basic newborn resuscitation techniques where included.

A17. GBV interventions and fistula reparation Fistula repair: Ten hospitals where programs for fistula repair will take place have been identified. Panzi, Tshikaji and Heal Africa hospitals will be the training sites for 8 doctors and 8 nurses who will be trained in fistula repairs. Contact has been made with the structures and Panzi is ready to receive 4 doctors and 4 nurses in September. Discussion are on going with Tshikaji and Heal Africa as to when their training will start.Until this program is fully functional, a mobile program with doctors from Panzi and Tshikaji hospitals has been set up to go around to the ten hospitals; Panzi, Tshikaji, HGR Kitutu, HGR Shabunda, HGR Malemba Nkulu, HGR Kabongo, HGR Dibindi, HGR Manika, HGR Fungurume, HGR Lodja. Community GBV activity: Meetings have been held with other organizations doing GBV work to define the role AXxes needs to play in this area. It is now well established that for a GBV program to have impact, intervention must be holistic covering all aspects of GBV response:

� Judicial aspect � Medical case Management � Psychological and social accompaniment which include community sensitization � Economical

It would be almost impossible for one intervening partner to cover all of these aspects so all actors in the field are required to combine their efforts to give a efficient response. An “NGO synergy against GBV” and “Joint Initiative” have been organized in each Province to coordinate all NGOs and UN agencies involved in GBV activities. This Structure is piloted by the UNFPA. Project AXxes has chosen to intervene on the medical and psycho-social aspects by focusing in community sensitization and mobilization against GBV. The integration of family planning and RH activities in all of the heath areas is part of the medical response to GBV. AXxes will also emphasis Fistula Repair

A18. Improve TB detection Training for laboratory technicians has been completed in most zones. Discussion with the PNT on opening new CDTs according to the population needs has been conducted. The PNT thinks that it is more practical to reinforce existing CDTs than opening new ones. The staff receives quarterly primes of $210 from Foundation Damien so opening new CDTs would mean more staff

23

that would also need primes for motivation. AXxes will continue to collaborate with the PNT and Foundation Damien on how best we can serve the people

VI. COMMENTARY ON WORK PLAN ACTIVITIES COMPONENT B

Increased capacity to the health zones and referral system

B1. Develop Human Resources of HZMT, including training and supervision Leadership Training: This quarter MSH began the leadership development program (LDP). The MSH consultant, Jana Ntumba, worked with the AXxes team to build the facilitation team, set up the training center, and determined facilitator team assignments. She led the implementation of first LDP Workshop for MIPs, MIDs and Project AXxes staff. The workshop gave an overview of leadership, leadership practices - scanning and focusing - and management practices - planning. A debriefing meeting was held with the AXxes team and included initial planning for the second LDP workshop. The next training will take place October. Supervision: Formative supervision is among the most important managerial aspects of health system reinforcement and the AXxes project. It is a process that aims to guide, instruct, correct and reinforce the activities of health zone staff so as to improve performance. The main objectives of supervision are the following:

� Improve the capacity/performance of health zone management staff at all levels � Improve the quality of service delivery � Identify problems and solutions � Increase the ulitilization of services � Reinforce the internal relationships of the health system

In the AXxes project, supervisions are conducted across three levels which mirror the structure of the health zone system in the DRC; supervisions at the MOH level, provincial level, and health zone level. The responsible parties for conducting AXxes supervisions are listed in the table below:

General Project AXxes Supervision plan Table 1

SUPERVISOR SUPERVISED FREQUENCE OBJECTIVES

IMAWH

Partners: CRS, WV, ECC National Level Provincial Level Health Zone Level

Monthly Quarterly Annually

Finance/Technical Finance/Technical Finance/Technical

ZS (BCZ et HGR) Monthly Finance/Technical/Logistical CRS, WV, ECC

CS Monthly (at least 2 health centers)

Finance/Technical/Logistical

BCZS CS Monthly

(all health centers) Finance/Technical/Logistical

For the third quarter, the number of supervisions conducted by the AXxes team is reported in the table below. A table of supervision by the BCZS of every health center within its zone is in Annex 5.

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Supervisions of health zones conducted by AXxes staff (Quarter Three) Table 2

April May June

Total HZs HZs Visited

% of HZs visited

HZs visited

% of HZs visited

HZs visited

% of HZs visited

50 40 80% 49 98% 48 96%

As the table in Annex 5 demonstrates around 70% of the health centers were supervised each month by the HZMTs. The supervision results in written feedback to the health centers in the majority of the health zones. In general old SANRU assisted zones seem to have comprehended the need for supervision more than health zones with emergency assistance backgrounds. Supervision of activities in HZs, HGRs and HCs: Supervision in the field was reinforced this quarter. All HZ and HGRs were supervised in May and June as planned. In April the coverage was low especially by WV AXxes staff. Key observations include:

� WV AXxes is reinforcing its collaborative actions with HZMTs so that HZMTs begin to own project activities and put more of their commitment to following up plans and bring about results.

� There is high turn over of staff in the health zones, hospitals and health centers in Kolwezi area because of attractive benefit packages offered by other Mining companies in the area. Some key positions have been vacant for many years and this weakens the pace of work in the area. For instance in South Kivu, Katana District does not have the MID. A number of HZs do not have MSZs. WV has discussed this with the MID and the MIP and will put this on the August agenda at the Provincial level to brainstorm what can be done to ensure filling of the vacant positions and that HZ structures continue to retain its personnel. This is especially because many of them have been trained by AXxes and are need to move the project forward.

� There are also key personnel from health zones such as MCZ and MSZ who have two jobs; they work in the HZs but also are employed in private hospitals. The MIP in Kolwezi has promised to address this matter urgently.

� There was insecurity in Bunyakiri and Kalonge HZs especially in May 2007. Insecurity was due to the hostile activities of Rasta group which is a break away group of FDLC. Project activities had to put on hold and movements to and from the areas was limited. Our plan is to put communication devices in our Land Cruiser and at the base in Bunyakiri. We will also continue to participate in OCHA meeting to get updates of security issues in the project area.

Figure 6: Joint Supervision BCZS-CRS/AXxes of the HC in

Makobola /UVIRA

25

B2. Reinforce HZ co-management and community participation Conseil d’adminstration: The CA is the most important management meeting within the HZ. These meetings include all stakeholders in the health zone and are held in order to discuss and then approve an action plan for the health zone. A member of the AXxes team participated in most of the CAs and ensured that the priorities of the AXxes project were included in the health zone action plan. In previous years, typically only 30% of health zones organized a CA meeting. This year, due in large part to the organization provided by the AXxes team, 95% of the health zones conducted their CA. Some for the first time in 8-10 years. The only health zone that has not yet conducted its CA is Kaniola, which had to reschedule due to insecurity linked to the massacre of May 26, 27th. (For more information on the security situation in South Kivu, see section VIII). Small Grants: Ten Local NGOs have been identified as possible recipients of small grants. They are currently preparing projects to be reviewed by the selection committee.

B3. Establish and reinforce M&E in Health Zone

KPC survey: The KPC survey was conducted from 17th April to 11th May 2007 facilitated by survey consultants from Kinshasa who trained and supervised the entire exercise. In each HZ, a local survey team of 6 members was formed and trained in survey methodology. Ninety six (96) households per HZ were sampled. Data entry personnel were recruited locally and data were analyzed centrally by IMAWH. JHU M&E Support: JHU has continued to deconstruct GESIS, the government’s electronic database, created in Microsoft Access. The objective of this exercise is to understand and preserve the integrity of the SNIS database as it gets rebuilt in MySQL to extract AXxes’ indicators. MySQL is the intended platform for the AXxes project. Some indicators have been modified and intervention areas have shifted in this quarter. JHU’s approach to M & E expects changes. In order to accommodate changes efficiently, it has been necessary to invest efforts into creating a sound and flexible intellectual basis for the project. In that regard, JHU reached two milestones: 1) the design of logical framework (log frame) as the knowledge representation of the ensemble of M & E corpus. This framework named “AXxes” will be proposed to the scientific community when it is fully evolved. The logframe will be imbedded in the AXxes Dashboard; 2) a related initiative is the development of ontology that describes the links among various M & E concepts. In tandem with the intellectual development, JHU has mapped the project’s M &E requirements gathered in February and March in the Congo, to four technology tools: Visual Mining, Xcelsius, PPT Tools and Voxiva. JHU is in process of selecting the most appropriate among these. The selected tool will be used to build the dashboard in the next quarter.

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VII. COMMENTARY ON WORK PLAN ACTIVITIES COMPONENT C Support to MOH

One part of the AXxes component C covering priority activities was approved on May 2007. This part relates to the provincial and district MOH level support activities. These activities are directly linked to the AXxes health zone activities. Most of them are related to provincial and district level fundamental functions like HZ supervisions, review meetings, HZ data management, policies and strategy dissemination, and holding HZ administrative councils in order to approve HZ action plans. The MOH provincial and districts teams are still elaborating the technical plans to start realizing these activities. The following component C activities have been organized during the third quarter:

� Provincial/ District MOH Needs assessment and Provision of equipment and materials � Leadership development program training � Support to the organization of the “Comite de Pilotage” of Kasai oriental � Support for PEV review meeting in Lubumbashi � Zinc program activities with HKI

1) Provincial/ District MOH Needs assessment et provision of equipment and materials A rapid needs assessment was done to identify Provincial/ District MOH needs in terms of equipment and materials for M&E system and supervision activities. From this assessment, AXxes project has already provided all 14 selected districts and 4 provinces with motorcycle (helmet included) and generators (except Katanga MOH office which do not need generator as electricity is almost permanent). IT equipment including desktop, printer, and photocopier are already ordered for all of the district and province MOH offices.

2) Leadership development program training From May 25 to 27, MIPs and MIDs from all of supported provinces and districts attended the first phase of the Leadership training session organized by AXxes COP with the technical assistance of MSH. Program managers and Provincial coordinators of the AXxes implementing partners also attended the meeting. The main purpose of the meeting was to improve their leadership capacities and help them to work as a team in each province. We took this opportunity to clarify some points of the project and harmonize views with Provincial and districts MOH staff. The next session is planed for the last week of august in Bukavu for 2 days.

3) Support to the organization of the Comite de Pilotage of Kasai oriental AXxes contributed material support and the technical organization for the second meeting of the “comite de pilotage” of Kasai oriental. AXxes participated actively in the meeting and worked with the MOH Provincial teams and other partners (UNICEF, FED9, and Coopi) on the elaboration of the provincial action plan.

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4) Support for PEV review meeting in Lubumbashi The AXxes team participated actively in CCIA meetings to prepare for the PEV review meeting in Lubumbashi. The main goal of the meeting was to evaluate activities realized during the first semester and to adjust strategies and approaches in order to achieve the expected national DPT3 coverage (80%). The AXxes PM participated in the meeting. While in Lubumbashi, discussions were held with the PEV director and Dr Michel Othepa from Basics (JSI) on reinforcing PEV capacity through technical assistance from BASICS Imunization. From this discussion a SOW for JSI TA was elaborated and approved by both PEV and AXxes. In collaboration with UNICEF and WHO, AXxes contributed for transportation and accommodation fees for AXxes supported Provincial MOH staff to attend this meeting. Some important points that came out of the meeting were:

� Why is Wild Polio virus still circulating, especially in Equator province, despite polio immunization campaigns?

� The organization of campaigns in Equator must be improved by reinforcing supervision, providing materials in time and sanctioning MCZ and PEV staff who are stealing funds from the campaign

� Most of the provincial and district CCIAs are not functional � The management of PEV at the central and provincial level must change and some people

that are not performing must be let go. Considering the points above, it is apparent that AXxes has a role to play through the component C (TA for PEV, Supervision subsidies and support for Provincial staff, support for CCIA and provincial meetings) and the support of EPI in the HZs (support for cold chain and supervision)

5) Zinc program activities with HKI Project AXxes has initiated through HKI discussions with the National Program of Diarrhea Disease Management, different partners working on Zinc like MSH, Basics and UNICEF, on the best way of implementing the program and how to obtain zinc tablets. In collaboration with HKI, AXxes implementing partners have already identified the pilot HZs for zinc implementation. A KPC protocol is elaborated and supervisors are already trained. A study trip to look at the zinc implementation program in Madagascar is planed for the next month with the national program. Implementation of a zinc program in 12 zones will start at the end of August.

6) SNIS and GESIS improvement The AXxes M&E team worked with the SNIS department of the 5th direction on improving and integrating GESIS in the provincial MOH offices. District and provincial staff in Katanga and Kasai Oriental will be trained in August. The GESIS software was revised with some AXxes key indicators. The adaptation will be done in the field during the training and the installation of the program.

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VIII. CONSORTIUM AND PROJECT MANAGEMENT

Change of Health Zones: Because of increased assistance from DFID and World Bank into the Maniema region, USAID decided to move assistance from Maniema to other health zones that have greater need. On May 15th assistance was stopped in the ten zones Project AXxes assisted in Maniema. Since this was two thirds of the zones where Merlin was the implementing partner, it was decided that it would be best for the project if Merlin handed over the five remaining zones it was assisting in South Kivu to CRS. The handover was done on June 28, 2007. When there is approval from the USAID contracting officer, Project AXxes will start assistance in seven new zones in East Kasai and Bukavu.

Quarterly Partners’ Meeting: The project organized two partner’s meetings during the third quarter; the first to review the progress in second quarter and to plan for third quarter activities, and the second to review sector plans and plan for the fourth quarter. The second meeting in late June also brought together the MIP and MIDs of all of the AXxes-supported provinces and districts to participate in a training designed by Management Sciences for Health on “Transforming Managers into Leaders”. Over twenty individuals from all of the implementing partners as well as several technical partners participated in the meetings. Distribution of Commodities: One of the major challenges of the AXxes project is the distribution of project materials across a geographic area larger than most countries in Africa and characterized by poor roads, dysfunctional railways and unreliable air transportation. Despite the challenges, AXxes has successfully distributed almost all project materials that were available to send to the partners (see Annex 6) Development vs. Emergency Approach: Emergency-oriented NGOs in South Kivu have a vastly different approach to assisting health zones than the AXxes project. Given the long history of emergency interventions in South Kivu, there are occasional misunderstandings of the AXxes approach. CRS and WV have developed coordination plans with all partners in the health zones. These plans outline the respective responsibilities of each partner. To address the misunderstandings related with the AXxes approach, CRS has organized a PR campaign to remind the other INGOs and community groups of the AXxes “development” philosophy.

IX. MEDICAL WASTE MANAGEMENT

This quarter the project started moving the health zones towards compliance with USAID IEE standards. The project has started construction of incinerators to improve the waste management in all hospitals and health centers have been advised to put security fences around safe pits to keep out intruders. Current practices in most health institutions assisted by AXxes are as follows.

� Safe handling: Handling of medical wastes is performed using universal precautions. Hospitals and health center workers wear gloves when examining and treating patients. There are rubbish bins/containers in examination and treatment rooms for immediate disposal of used bandages, sharps, cotton and the like. In addition, health personnel have been trained in universal precaution during laboratory and reproductive training. Gloves have been distributed in all hospitals and health centers.

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� Disposal of pathological wastes (e.g blood, removed body organs): This is done by burying in safe burial pits dug around the hospital or a health center. Disinfection is done prior to burial. To prevent odor the layer is covered by a layer of soil then the pit is covered by a metallic sheets.

� Sharps (e.g syringes, blades, broken glasses): These are also buried but in a separate pit. � Other (e.g gloves, bandages, and clothing): These are incinerated in the incinerators.

However, many incinerators are not working and so these wastes are thrown in a pit and burnt.

� Pharmaceutical wastes: These are burnt after authorization from Minister of Health of the Province. The MID and other Government officials must be present during disposal to ensure compliance.

X. SECURITY REPORT A challenge to implementing the project in East has been the continued fighting in the area. Armed clashes in the North and South Kivu provinces continue to produce newly displaced populations. A machete massacre of 17 villagers (including 12 children) in Kaniola HZ by the Rastas/FDLR in South Kivu, and the potential for more attacks is causing panic among civilians. Ethnic tensions have also been exacerbated by incidents between the FARDC and the Banyamulenge. The Banyamulenge feel increasingly vulnerable and targeted, particularly after certain provincial officials (the governor and the archbishop) publicly implied that foreign elements are infiltrating South Kivu from all sides with the aim of destabilizing the province. Current security measures in the province are insufficient to ensure the protection of civilians and the province is currently experiencing food insecurity in certain areas. To the dismay of the international community, the UNHCR and FAO were also accused of partiality and involvement. In North Kivu, ex-dissident FARDC General Laurent Nkunda continues to consolidate his influence in the province while making demands on the GoDRC and threatening to withdraw from the “mixage” process of integration with the Congolese national army. Nkunda’s military elements are also currently carrying out military operations against Hutu-dominated FDLR in North Kivu. While fighting was previously concentrated around the area of Rutshuru, it has now spread. Clashes between Nkunda-loyal elements and the FDLR have caused terror and new waves of displacements. A first assessment mission estimates that over 5,000 families have been displaced in connection with the latest armed clashes. Sporadic clashes were also reported south of Lubero where certain Mayi-Mayi factions may have allied themselves with the FDLR. Although in many cases it has been very difficult to verify the numbers, since the beginning of the year approximately 164,000 people have been displaced in North Kivu. Initiatives were taken to set-up round table discussions with all concerned groups in North and South Kivu to explore durable political solutions to the current crisis. However, differences between provincial authorities and the central government have stalled the process. The opinion of most in Eastern DRC is that the increase in fighting, possibly leading to a new war, is a strong probability. The most probable scenario is that fighting will begin in North Kivu in the areas outside of Goma. This is likely to then spread into South Kivu. Sylvie van den Wildenberg, the spokeswoman for the United Nations mission to DRC (MONUC) in North-Kivu, said "all the indicators are flashing red at a security and a humanitarian level and we are seeing a rise in inter-community tensions. Since the beginning of the (integration) we have

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tallied more than 100,000 new displaced people in the province, extortion of civilians is reported virtually every day and troubling events are multiplying," she added. The impact of the insecurity described above on the AXxes project has been mainly to reduce access to certain health zones. As noted in the section on supervisions, the main reason why 100% of supervisions were not conducted was due to acute insecurity during the third quarter, notably in the health zones of Kaniola and Haut Plateau. There have also been reports of armed groups targeting INGOs, such as the hijacking of two Solidarite Internationale vehicles outside of Goma, the ransacking of Save the Children’s office in Shabunda and the pillaging of an ACF warehouse in Uvira on two separate occasions. Insecurity also results in population movements that place undue strain on health zone resources, such as in the hospital of Kaniola which was overwhelmed with victims of the massacre on May 27th.

XI. PROGRAM PERFORMANCE INDICATORS Because of the withdrawal of assistance from Maniema, the late transfer of the Merlin zones in South Kivu and problems with two zones in the Kolwezi area, there are less zones reporting this quarter than last. The total number of zones reporting was 43. This made analysis of trends difficult but a few indicators have shown enough change that they can probably be attributed to the project. As a result of extensive training and distribution of materials in areas of family planning, improved delivery services and vaccinations, there has been an improvement in indicators. Family Planning: The number of health centers that have family planning services has more than doubled from 238 in second quarter to 565. In conjunction with this the couple years of protection has increased from 2,602 to 3,933. A total of 1293 people were trained in reproductive health. This is 88% of the target for the year. Improved Delivery Services: This area of activity saw the most improvement. Several indicators improved; attended births, AMSTL, iron supplement and STI management. The AMSTL indicator showed a large improvement, but only 12 zones reported on this indicator. In actual numbers, the project is reporting only 3% of its target. Training for these services was combined with reproductive health and started at the end of second quarter.

0%

10%

20%

30%

40%

50%

60%

70%

80%

Atended

Births

AMSTL Iron Supp STI Mang

Improved Delivery Services

2nd Qtr 3rd Qtr

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Table 3

Yr 1 Target Quarter 2 Quarter 3 Performance Indicator

% Nber % Nber # HZs % Nber # HZs

Proportion births attended by skilled personnel 60% 177,408 59% 36,812 59 66% 40,514 43

(AMSTL) Number of women receiving Active Management of the Third Stage of Labor

40% 118,272 21% 2,300 10 51% 3,200 12

Percent of pregnant women visiting health centers receive iron supplements. 70% 206,976 61% 24,657 30 77% 45,307 41

Percent of Health center with syndromique approach of STIs management 50% 510 0% 0 2 48% 203 24

Vaccination Coverage: Increased supervision, “micro planification” and reinforcement of the cold chain have caused the vaccination coverage to improve for Measles and DPT3 but many zones are still under the year one target (see map in Annex 2). The increase of dropout is explained by the project reaching more children with DPT1.

Table 4

Tuberculosis: The tuberculosis program needs a lot of attention. Many zones are not reporting on the subject and more than half that are reporting have a detection rate that is less than 70%. Four of the zones in the Malemba Nkulu seem to have epidemic levels of TB with a detection rate of more than 140% of what is expected (see map in Annex 3).

Year 1 Target Quarter 2 Quarter 3 Performance Indicator

% Nber % Nber # HZs % Nber # HZs

Measles vaccination coverage 70% 180,587 70% 45,002 60 84% 43,950 43

DPT3 vaccination coverage 60% 154,788 61% 38,697 60 78% 40,749 43

Percent of drop-out DPT1/DPT3 10% 25,799 7% 4,440 24 18% 2,104 43

ANNEX 1: PROGRAM PERFORMANCE INDICATORS

1st year goal This period Objectives/

Activities

Performance Indicator

% Number % Number

Zones

Reporting

Component A: Increased access to, quality of, and demand for multi-sectoral, integrated PHC

Percent (%) of population served 60% 72% 43

Nbr health clinics built or rehabilitated (non-cumulative) 50 43

Rate of use of health services 35% 30.8% 43

Nbr of women 9 43

Nbr of men 281 43 Nbr people trained/in Management of PHC

Total 360 317 43

Nbr of women 0 43

Nbr of men 0 43

Increased access to integrated Primary Health Care

Nbr of persons trained in the use of "Ordinogramme "PMA (cumulative)

Total 1,224 0 43

Couple years of protection (CYP) for FP 30,000 3,933 21

Percent of Health center with Integrate Reproductive Health Services (RHS) and child spacing in their routine activities 80% 816 46% 566

43

Nbr of women 394 43

Nbr of men 899 43 Nbr people trained in (RH) Reproductive Health and Child Spacing / FP

Total 1,464 1,293 43

Number of individuals counseled on FP/RH 5% 77,396 6,774

Number of people that have seen or heard a specific FP/RH message ** 40% 1,212,288

Improve Reproductive Health, treatment of STIs and the practice of Child Spacing

Number of service delivery points reporting stock-outs of any contraceptive commodity offered by the SDP at any time during the reporting period 5%

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1st year goal This period Objectives/

Activities

Performance Indicator

% Number % Number

Zones

Reporting

Percent of pregnant women visiting health centers receive iron supplements 70% 206,976 77.1% 45,307 43

Percent of Health center with syndromique approach of STIs management 50% 510 47.5% 203 24

Percent of neonatal deaths * 4% 1.2% 23

Number of vaginal fistula repairs 13

Percent of newborns receiving antibiotic treatment for infection 80% 18.8% 293 43

Proportion of children receiving measles vaccination 70% 180,587 84.4% 43,950 43

DPT3 coverage 60% 154,788 78.3% 40,749 43

Percent of drop-out DPT1/DPT3 10% 17.9% 2,104 43

Increase the coverage of Immunizations Percent of diseases related to vaccinations are detected and reported within 14

days. 60% 0

Proportion children 6-59 months receiving Vitamin A Campaign 90% 1,197,504 96.0 750,100 26

Proportion children 6-59 months receiving Vitamin A Routine 10% 133,056 4.7% 7950 28

Percent of children 12-59 months have received mebendazole during each campaign. 80% 946,176 89.0% 671,369

43

Percent of children with diarrhea that have received zinc in the pilot areas 20% 43

Percent of lactating women using exclusive breastfeeding for first 6 months 40% 118,272 0

Percent of lactating women use appropriate weaning practices from 6 months 30% 88,704 0

Nbr of women 0 43

Nbr of men 0 43

Improve family Nutrition and coverage or utilization of Micronutrients

Number of people trained in maternal and newborn health & nutrition

Total 1,464 0 43 Percent /Number of children under the age of five with ARI/pneumonia are cared for correctly by health structures following national policy 60% 93.9% 26,156

43

Percent /Number of children under the age of five with diarrheal illnesses are cared for correctly by health structures following national policy guidelines 60% 90.9% 9,060

43

Number of water supply improved ( Non- cumulative) USAID financed 120 0.0% 0 43

Promote and improve the use of Integrated Management of Childhood Illnesses both in Clinics and the Community

Number of water supply improved ( Non- cumulative) non-USAID financed

43

Nbr of women 0 43 Reduce the incidence of

Number of people trained in malaria treatment

Nbr of men 0 43

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1st year goal This period Objectives/

Activities

Performance Indicator

% Number % Number

Zones

Reporting

Total 1,224 0 43

Nbr of households with at least one ITN (Cumulative) ** 20% 246,400 ND 0

Nbr of ITN distributed 20% 246,400 3,601 13

Nbr of USAID funded ITN distributed 20% 246,400 0 13

Percent of pregnant women in targeted health zones receive IPT 70% 206,976 57.1% 34353 43

Percent of pregnant women, received LLINs in targeted health zones 20% 59,136 2.5 456 13

Malaria, especially among pregnant women and children under five

Percent of children