MALI Work Plan - ENVISION...MALI Work Plan FY 2018 Project Year 7 October 2017-September 2018 ENVISION is a global project led by RTI International in partnership with CBM International,

MALI Work Plan FY 2018 Project Year 7 October 2017-September 2018

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 US Agency for International Development or the United States Government.

ENVISION FY18 PY7 MALI Work Plan ii

ENVISION Project Overview

The US 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 global and country levels and support ministries of health (MOHs) to achieve their NTD control and elimination goals.

At the global level, ENVISION—in close coordination and collaboration with WHO, USAID, and other stakeholders—contributes to several technical areas in support of global NTD control and elimination goals, including the following:

• 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

• 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 the following:

• 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 (DSAs) and surveillance.

In MALI, ENVISION project activities are implemented by Helen Keller International.

ENVISION FY18 PY7 MALI Work Plan iii

TABLE OF CONTENTS ENVISION Project Overview .......................................................................................................................... ii

ABBREVIATIONS LIST ..................................................................................................................................... v

COUNTRY OVERVIEW .................................................................................................................................... 1

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

a) Administrative Structure ............................................................................................................... 1

b) Other NTD Partners ....................................................................................................................... 3

2) National NTD Program Overview………………………………………………………………………………………………….5

a) Lymphatic Filariasis ....................................................................................................................... 8

b) Trachoma ...................................................................................................................................... 9

c) Onchocerciasis ............................................................................................................................ 10

d) Schistosomiasis ........................................................................................................................... 11

e) Soil-Transmitted Helminths ........................................................................................................ 12

3) Snapshot of NTD Status in Country ................................................................................................. 14

PLANNED ACTIVITIES ................................................................................................................................... 15

1) NTD Program Capacity Strengthening ............................................................................................ 15

a) Strategic Capacity Strengthening Approach ............................................................................... 15

b) Capacity Strengthening Objectives and Interventions ............................................................... 15

c) Monitoring Capacity Strengthening ............................................................................................ 16

2) Project Assistance ........................................................................................................................... 18

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

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

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

d) Mapping ...................................................................................................................................... 20

e) MDA Coverage ............................................................................................................................ 20

f) Social Mobilization to Enable NTD Program Activities ............................................................... 26

g) Training ....................................................................................................................................... 31

h) Drug and Commodity Supply Management and Procurement .................................................. 31

i) Supervision for MDA ................................................................................................................... 32

j) M&E ............................................................................................................................................ 34

k) Supervision for M&E and DSAs ................................................................................................... 36

l) Dossier Development (no cost to ENVISION).............................................................................. 37

5) Maps................................................................................................................................................ 38

APPENDIX: Work Plan Timeline .................................................................................................................. 42

ENVISION FY18 PY7 MALI Work Plan iv

TABLE OF TABLES

Table 1. Administrative division of Mali in 2017 .................................................................................... 2

Table 2. Drug packages distributed in MDA ........................................................................................... 5

Table 3. Funding sources for MDA in Mali in 2018 ................................................................................. 6

Table 3a. MDA breakdown of partner support in 2018 by HD……………………………………………………………..6

Table 4. TASs planned for FY18. ............................................................................................................. 9

Table 4a. SCH treatment frequency in Mali until FY19 .......................................................................... 11

Table 5. Snapshot of the expected status of the NTD program in Mali as of September 30, 2017 ..... 14

Table 6. Project assistance for capacity strengthening ........................................................................ 17

Table 7. USAID-supported coverage results for FY17 ........................................................................... 20

Table 8. HDs with recurrent LF coverage problems as of FY16 ............................................................ 22

Table 9. FY17 MDA results for HDs with recurrent LF coverage problems .......................................... 23

Table 10. Low-coverage HDs for SCH treatment in FY16 (top) and FY17 (bottom)................................ 24

Table 11. Low STH coverage HDs ............................................................................................................ 25

Table 12. USAID-supported districts and estimated target populations for MDA in FY18 .................... 25

Table 13. Social mobilization/communication activities and materials checklist for NTD work planning...................................................................................................................................... 29

Table 14. Planned DSAs for FY18 by disease .......................................................................................... 36

ENVISION FY18 PY7 MALI Work Plan v

ABBREVIATIONS LIST

AE Adverse Event AFRO Africa Regional Office (WHO) ALB Albendazole CD Country Director CDD Community Drug Distributor CHW Community Health Worker CNHF Conrad N. Hilton Foundation CNIECS Centre National d’Information, d’Education et Communication pour la Santé (National

Center for Health Information, Education, and Communication) CSCOM Centre de Santé Communautaire (Community Health Center) CSREF Centre de Santé de Référence (Referral Health Center) CY Calendar Year DNS Direction Nationale de la Santé (National Health Directorate) DPLM Division de la Prévention et de la Lutte Contre la Maladie (Division of Disease Prevention

and Control) DQA Data Quality Assessment DRS Direction Régionale de la Santé (Regional Health Directorate) DSA Disease-Specific Assessment DTC Directeur Technique du Centre (Technical Director of the Health Center) ELISA Enzyme-Linked Immunosorbent Assay END Fund End Neglected Tropical Diseases Fund EPIRF Epidemiological Data Reporting Form ESPEN Expanded Special Project for the Elimination of NTDs EU Evaluation Unit FELASCOM Fédération Locale de l’Association de Santé Communautaire (Local Federation of

Community Health Associations) FOG Fixed Obligation Grant FTS Filariasis Test Strip FY Fiscal Year HD Health District HKI Helen Keller International HQ Headquarters ICT Immunochromatographic Test IEC Information, Education, and Communication INRSP Institut National de Recherche en Santé Publique (National Institute of Research and

Public Health) IVM Ivermectin JRF Joint Report Form JRSM Joint Request for Selected Medicines LF Lymphatic Filariasis

ENVISION FY18 PY7 MALI Work Plan vi

M&E Monitoring and Evaluation MCD Médecin-Chef de District (Health District Chief Medical Officer) MDA Mass Drug Administration MOH Ministry of Heath MRTC Malaria Research and Training Center MSHP Ministère de la Santé et de l’Hygiène Publique (Ministry of Health and Public Hygiene) NGO Nongovernmental Organization NTD Neglected Tropical Disease OEC Onchocerciasis Elimination Committee OMVS Organisation pour la Mise en Valeur du Fleuve Sénégal (Organization for the

Development of the Senegal River) ORTM l’Office de Radiodiffusion Télévision du Mali (Office of Radio and Television of Mali) OV Onchocerciasis PC Preventive Chemotherapy PCR Polymerase Chain Reaction PGIRE Le Programme de Gestion Intégrée des Ressources en Eau et de Développement des

Usages Multiples (Integrated Water Resource Management Project) PNEFL Le Programme National d’Élimination de la Filariose Lymphatique ou Éléphantiasis

(National Lymphatic Filariasis Elimination Program) PNLO Programme National de Lutte Contre l’Onchocercose (National Onchocerciasis Control

Program) PNSO Programme National de Soins Oculaire (National Program for Eye Health) PSI Population Services International PZQ Praziquantel Q Quarter RPRG Regional Program Review Group SAC School-Aged Children SAFE Surgery–Antibiotics–Facial cleanliness–Environmental improvements SCH Schistosomiasis SCI Schistosomiasis Control Initiative STH Soil-Transmitted Helminths STTA Short-Term Technical Assistance TA Technical Assistance TAF Technical Assistance Facility TAS Transmission Assessment Survey TCC The Carter Center TEO Tetracycline Eye Ointment TF Trachomatous Inflammation—Follicular (Active Trachoma) TFGH Task Force for Global Health TIPAC Tool for Integrated Planning and Costing TIS Trachoma Impact Survey TSS Trachoma Surveillance Survey

ENVISION FY18 PY7 MALI Work Plan vii

TOT Training of Trainers TT Trachomatous Trichiasis USAID U.S. Agency for International Development WB World Bank WHO World Health Organization

ENVISION FY18 PY7 MALI Work Plan 1

COUNTRY OVERVIEW

1) General Country Background

Mali’s neglected tropical disease (NTD) program began in 2007 as one of the original fast-track countries funded by the U.S. Agency for International Development (USAID). In 2009, the country reached full geographic scale (61 health districts [HDs]) for all of the preventive chemotherapy (PC) NTDs. Significant gains have been made in stopping HD-level mass drug administration (MDA) for trachoma in 66 out of 69 endemic HDs, 49 out of 75 districts for lymphatic filariasis (LF), and 2 out of 20 HDs endemic for onchocerciasis (OV). Revealing the data from schistosomiasis (SCH) evaluations in 38 HDs revealed that 10 HDs achieved the criteria for disease control (less than 5% heavy intensity infections in sentinel populations) and that 12 HDs achieved the criteria for disease elimination as a public health problem (less than 1% heavy infections in sentinel populations). For soil-transmitted helminths (STH), 34 out of 38 HDs evaluated from 2014 to 2016 had zero prevalence among the school-aged children (SAC) examined. Epidemiological and entomological surveys conducted in 2015 demonstrated progress towards OV elimination in five HDs. However, confirmation with additional studies—OV16 enzyme-linked immunosorbent assay (ELISA) and O-150 polymerase chain reaction (PCR) (in flies)—will be needed to determine whether OV transmission has stopped.

Growing political instability since 2012 interrupted the distribution of drugs in certain regions. Security and political problems contributed to the suspension of MDA in the three northern regions of Gao, Kidal, and Tombouctou and in three HDs in Mopti region (Douentza, Teninkou, and Youwarou). The ENVISION objective for fiscal year 2017 (FY17) was to treat 100% of the eligible HDs with MDA. In FY18, USAID funding will support MDA in all 75 HDs (10 new HDs have been created in FY17) and the following surveys: LF (transmission assessment surveys [TASs]), SCH (sentinel and spot check site surveys), STH (sentinel and spot check site surveys), OV (epidemiological survey), and data quality assessments (DQAs). Trachoma impact surveys (TISs) and trachoma surveillance surveys (TSSs) will be supported by the Conrad N. Hilton Foundation (CNHF).

a) Administrative Structure

Mali is a large West African country located in the Sudano-Sahelian zone, covering 1,246,040 square kilometers. It is bordered to the north by Algeria, to the east by Niger and Burkina Faso, to the west by Senegal and Mauritania, and to the south by Guinea, Côte d’Ivoire, and Burkina Faso. The climate in Mali is characterized by two seasons: a dry season (nine months) and a rainy season (three months [July–September). It is also crossed by two major rivers, the Niger and the Senegal. Dams were built on both rivers, and fishing and rice cultivation areas create ecological areas where certain NTDs thrive. Mali is endemic for the following PC NTDs: LF, OV, SCH, STH, and trachoma. The population in Mali is estimated to reach 19,747,160 people in 2018, with most of the population concentrated in the south and the center of the country.1

Mali’s administrative and political structure is divided into 10 regions (two new regions were implemented in 2017) and the District of Bamako, 59 prefectures, and 703 rural and urban communes (Appendix 4). The health system structure is delineated differently and has the following structure, as of 2016 (Table 1):

1 Direction Nationale de la Statistique et de l'Informatique du Mali (National Directorate of Statistics and Information of Mali).


Table 1. Administrative division of Mali in 2017

Administrative structure Number of administrative structures

Regions 101

Prefectures 59

Rural and urban communes 703

Health districts 752

Health regions 11

Community health centers 1,240 1 Mali implemented two new regions in 2017: Menaka from Gao and Taoudenit from Tombouctou. 2In 2017, 10 new HDs were created in the new regions of Menaka and Taoudenit. The 10 new districts were created from Gao and Tombouctou regions and are called Achourat, Al-Ourch, Araouane, Boujbeha, Foum-Elba, Taoudenit, Anderamboukane, Inekar, Menaka, and Tidermene.

• 11 health regions (including Bamako)

• 75 health districts

• 1,240 community health centers (Centres de Santé Communautaire [CSCOMs])

Within Mali’s health system, there are four levels of health facilities:

1. CSCOMs, which offer basic preventive and therapeutic services at the local level

2. HD level (referral health centers [Centres de Santé de Référence (CSREFs)])

3. Regional level

4. National level

CSCOMs fall under the CSREFs, which are the first level of referral and are typically located at the HD headquarters (HQ) level. The CSREFs fall under the regional hospitals, the second level of referral. The third level of referral hospitals are the six national hospitals located in Bamako (five) and Kati (one). Regional- and HD-level directors and staff members of the CSREFs and CSCOMs provide oversight to public health initiatives occurring within their catchment area. The National Health Directorate (Direction Nationale de la Santé [DNS]) develops the elements of the national policy on public health and safety and ensures the coordination and supervision of regional services. The DNS is organized centrally and has five divisions—Reproductive Health, Nutrition, Regulation of Health Institutions, Public Health and Food Safety, and Disease Prevention and Control (Division de la Prévention et de la Lutte Contre la Maladie [DPLM])—and one unit—the Unit of Training, Planning and Public Health Information.

The NTD program and disease-specific programs operate under the purview of the DPLM. Each region, including the District of Bamako, has a Regional Health Directorate (Direction Régionale de la Santé [DRS]) that is responsible for adapting DNS’s policies to meet local needs; therefore, each DRS provides technical and institutional support to HDs at an intermediary level. Within each DRS, there is a regional-level NTD Focal Point who is responsible for matters under the supervision of the Regional Director of Health. At the HD level, there is also an NTD Focal Point who oversees and coordinates NTD activities


under the supervision of the Chief District Medical Officer. The Regional NTD Focal Points are the direct line of communication with the national disease program coordinators under the leadership of the Chief of the DPLM, who reports to the National Director of Health. At the health area level, the Technical Directors of Health Centers (Directeur Technique du Centre [DTCs]) are in charge of the implementation of activities at the health center and village levels.

b) Other NTD Partners

History of USAID support

Mali began integrated NTD control in 2007 as a fast-track country of the USAID-funded, RTI-managed NTD Control Program, uniting already-existing vertical, disease-specific programs into integrated NTD treatment strategies. In 2008, Helen Keller International (HKI) became the sub-grantee providing technical assistance (TA) to the Ministry of Health and Public Hygiene (Ministère de la Santé et de l’Hygiène Publique [MSHP]) in Mali in support of the integrated national NTD program. From 2007 to 2011, Mali scaled up treatments across the country for the five target NTDs: LF, OV, SCH, STH, and trachoma. Significant progress was made, with 100% geographic coverage reached for all five NTDs, adequate program and epidemiological coverage sustained over time, and disease-specific assessments (DSAs) providing evidence to stop MDA and begin post-endemic surveillance for LF and trachoma in certain areas. A military coup d’état beginning on March 22, 2012 led to the temporary suspension of USAID funding.

In September 2012, HKI signed a memorandum of understanding with the End Neglected Tropical Diseases Fund (END Fund), which provided funding support from October 2012 through April 2013. With funding from END Fund through HKI and continued assistance from the other partners to the Mali NTD program, including The Carter Center (TCC) and Sightsavers, MDA took place in July–August 2012 (for trachoma) and in October–December 2012 (for LF, OV, SCH, and STH) in the regions of Bamako, Kayes, Koulikoro, Mopti, Segou, and Sikasso; MDA did not take place in the three northern regions of Gao, Kidal, and Tombouctou for logistical and security reasons.

During the suspension of USAID funding, END Fund awarded HKI a follow-on grant for the period April 2013–March 2014 to support the remaining calendar year 2013 (CY13) MDA in the six southern regions and selected impact assessments for LF and SCH/STH. END Fund’s support of MDA activities ended in 2013. Since then, trachoma MDA, TISs, and TSSs have been supported by HKI, TCC, and Sightsavers with a grant from the CNHF.

On September 6, 2013, the U.S. Department of State lifted restrictions on bilateral assistance to Mali, which allowed USAID to resume funding through ENVISION. This funding resumed in January 2014 and included support for LF, OV, SCH, and STH MDA (May–June 2014). In FY14, two of the three northern regions (Kidal and Tombouctou) conducted MDA for the first time since 2012. Gao was unable to conduct MDA in 2014 because of continued violence in the region in mid-May 2014. Currently, all endemic HDs are receiving MDA. Activities in all 11 health regions of Mali will take place with technical and financial support from the USAID-funded ENVISION project in FY18.

Donor Financial Support

The Government of Mali provides support to the national NTD program by paying staff salaries and providing office space and meeting rooms. In addition to funding from USAID through the ENVISION project, the following donors are currently supporting NTD activities in Mali. Table 2 provides more detail on partner activities implemented with these funds.


• CNHF funds trachoma elimination through HKI, TCC, and Sightsavers, supporting mainly the S, F and E components of the Surgery–Antibiotics–Facial cleanliness–Environmental improvements (SAFE) strategy and some targeted MDA (if needed), TISs, and pre-validation of trachoma elimination.

• Sightsavers provides MDA treatments for OV/SCH/STH in partnership with HKI in 14 HDs (in Koulikoro and Sikasso). Sightsavers will treat OV in partnership with World Bank (WB) in two HDs of Sikasso region (Sikasso and Kolondièba). Sightsavers will fund all the integrated activities at the regional level and will also support DNS participation in these activities (i.e., training of trainers [TOT], MDA launching ceremony, MDA supervision, MDA campaign data sharing meeting, and drug delivery from the region to HDs) for Koulikoro region. They will also support the regional-level TOT in Sikasso region.

• TCC provides technical and financial assistance to MSPH for morbidity management and disability prevention for trachoma (S, F, and E components of the SAFE strategy) and TISs. It also provides tetracycline eye ointment (TEO) during trachoma MDA. This is accomplished with funding from CNHF and from the Carter Center internal funding.

• END Fund supports the management of LF morbidity, notably hydrocele surgery in the regions of Sikasso, Segou, Koulikoro, Mopti, Bamako, Kayes, and Tombouctou, through HKI.

• Project SAHEL (WB) is supporting NTD activities from 2016 to 2019 in the 12 HDs that border Burkina Faso and Niger (Sikasso, Kadiolo, Koutiala, Yorosso, Tominian, Bankass, Koro, Douentza, Gourma-Rharous, Ansongo, Menaka, and Tin-Essako) with funding provided directly to the government. They plan to support MDA and LF morbidity management. Research projects and NTD activities are planned in four other non-border HDs (Bougouni, Yanfolila, Kita, and Kolondieba). The WB will support these activities by providing malaria treatment for children in all of these HDs. MDA activities will be co-financed with Sightsavers in two HDs (Kolondièba and Sikasso). The WB project will also provide support for stand-alone STH treatment in four HDs (Koro, Tin-Essako, Koutiala, and Yorosso) ENVISION will deliver the MDA drugs to these specific HDs but will not provide MDA campaign funding. WB will fund all the integrated activities at the regional level and support DNS participation in these activities (i.e., training, MDA launching ceremony, MDA supervision, MDA campaign data sharing meeting, and drug delivery from the region to HDs) for Gao, Kidal, Meneka, Mopti, and Sikasso regions. They will not fund the regional-level TOT in Sikasso region because this activity is already supported by Sightsavers.

• Organization for the Development of the Senegal River (Organisation pour la Mise en Valeur du Fleuve Sénégal [OMVS]) – Phase II of OMVS’s Integrated Water Resource Management Project (Le Programme de Gestion Intégrée des Ressources en Eau et de Développement des Usages Multiples [PGIRE]), which is funded by WB, was launched in July 2016 for a total of three years. PGIRE will support MDA for SCH and STH and the distribution of long-lasting insecticide-treated nets in the HDs situated in the Senegal River basin, including those in Mali and provide technical assistance to the MOH and staff at the district and community level. OMVS financed MDA activities in 10 HDs in Kayes region (including 2 new HDs created in FY16) and 7 HDs in Koulikoro region in FY18. The nongovernmental organization (NGO) Population Services International (PSI) is the implementing partner in Mali. OMVS (with, as of June 22, 2016, PSI) supported the national program by providing praziquantel (PZQ) for the treatment of SAC and adults at risk. In FY18, OMVS/PGIRE will support SCH MDA in 12 HDs. The treatment for OV and STH will be conducted by Sightsavers and HKI in Koulikoro region. OV will be treated by HKI in Kayes region (except for Kita HD, which will be supported by WB). OMVS/PGIREII will fund all the


integrated activities at the regional level and support DNS participation in these activities (i.e., training, MDA launching ceremony, MDA supervision, MDA campaign data sharing meeting, and drug delivery from the region to HDs) for Kayes region.

2) National NTD Program Overview

Mali has been implementing an integrated NTD control program since 2007, integrating the efforts of strong vertical, disease-specific programs with well-established elimination strategies for LF, OV, and trachoma and control strategies for SCH and STH. These vertical programs include the National Lymphatic Filariasis Elimination Program (Le Programme National d’Élimination de la Filariose Lymphatique ou Éléphantiasis [PNEFL]), National Onchocerciasis Control Program (Programme National de Lutte Contre l’Onchocercose [PNLO]), National Program for SCH/STH, and National Program for Eye Health (Programme National de Soins Oculaire [PNSO]).

Mali currently distributes two drug packages consecutively: ivermectin (IVM) and albendazole (ALB) for the treatment of LF, OV, and STH and PZQ for the treatment of SCH. It should be noted that STH treatment will be associated with SCH treatment in areas where LF treatment has stopped and where OV is not endemic (then, the drugs given are PZQ and ALB). In HDs where these two drugs are administered, the treatment strategy is shown below (Table 2).

Table 2. Drug packages distributed in MDA

Five days Three days Five days

IVM + ALB --- PZQ

MDA uses a community-based strategy: community drug distributors (CDDs) and community health workers (CHWs) distribute drugs to eligible individuals in the communities either house to house, at a fixed location, or via a mobile strategy for nomadic populations. In some areas, teachers help distribute the drugs to SAC aged 5–14 years, while CHWs distribute drugs to other community members. Combining SCH treatment with OV MDA was discussed with the Ministry of Health (MOH) during the annual review in July 2017. However, there are concerns about the simultaneous use of two different dose poles by the CDDs and the potential for mixing up the poles. The MOH is still considering this option for the future but no final decision has been made.

In FY18, the following NTD MDA objectives are planned:

LF: No HDs are planned for LF treatment in FY18 with ENVISION support (26 HDs will undergo TAS1 in FY18).

OV: 20 HDs will be treated

SCH: 51 HDS will be treated.

STH: 37 HDs will be treated in FY18.

Trachoma: Depending on the results of the evaluations scheduled in July 2017, three HDs may undergo MDA (Ansongo, Nianfunké, and Bourem).


Table 3. Funding sources for MDA in Mali in 2018

Number of Districts with MDA Funding Source

NTD ENV OMVS-PSI WB ENV/

Sightsavers Sightsavers

/WB CNHF TCC TOTAL HDs

LF 0 0 0 0

OV 6 0 1 11 2 20

SCH 29 9 11 2 51

STH* 21 1 13 2 37

Trachoma 3** TEO only 3

TOTAL 56 10 25 15 2 3 111 *Seven HDs will be treated only for STH; the remaining 30 HDs will be treated through the SCH or OV MDA campaign. **Dependent upon the survey results; CNHF will fund if necessary.

Table 3a. MDA breakdown of partner support in 2018 by HD

Region District Implementing partner per district and per disease

LF OV SCH STH Trachoma Bamako Commune 1 HKI Bamako Commune 2 HKI Bamako Commune 3 HKI Bamako Commune 4 HKI Bamako Commune 5 HKI Bamako Commune 6 HKI Gao Ansongo WB WB Gao Bourem HKI HKI Gao Gao HKI HKI

Gao Almousrat HKI HKI

Kayes Bafoulabe HKI OMVS-PSI Kayes Diema OMVS-PSI Kayes Kayes HKI OMVS-PSI Kayes Kenieba HKI OMVS-PSI Kayes Kita WB-PS WB-PS Kayes Sagabari HKI HKI Kayes Sefeto HKI HKI Kayes Nioro OMVS-PSI Kayes Oussoubidiagna HKI OMVS-PSI Kayes Yelimane Kidal Abeibara HKI Kidal Kidal HKI Kidal Tessalit HKI Kidal Tin-Essako WB-PS Koulikoro Banamba OMVS-PSI



LF OV SCH STH Trachoma Koulikoro Dioila SS/HKI SS/HKI Koulikoro Fana SS/HKI SS/HKI Koulikoro Kalabancoro SS/HKI Koulikoro Kangaba SS/HKI Koulikoro Kati SS/HKI OMVS-PSI OMVS-PSI Koulikoro Kolokani SS/HKI SS/HKI Koulikoro Koulikoro SS/HKI Koulikoro Nara OMVS-PSI Koulikoro Ouelessebougou SS/HKI Mopti Bandiagara HKI Mopti Bankass WB-PS WB-PS Mopti Djenne HKI Mopti Douentza WB-PS WB-PS Mopti Koro WB-PS WB-PS Mopti Mopti HKI Mopti Teninkou HKI HKI Mopti Youwarou HKI HKI Segou Barouéli Segou Bla HKI Segou Macina HKI Segou Markala HKI Segou Niono HKI Segou San HKI Segou Segou HKI Segou Tominian Sikasso Bougouni Sikasso Kadiolo WB-PS- Sikasso Kignan SS/HKI Sikasso Kolondieba SS/WB-PS Sikasso Koutiala WB-PS Sikasso Niena SS/HKI Sikasso Sélingué SS/HKI SS/HKI Sikasso Sikasso SS/WB-PS WB-PS Sikasso Yanfolila Sikasso Yorosso WB-PS Tombouctou Diré HKI HKI Tombouctou Goundam HKI HKI

Tombouctou Gourma-Rharous WB-PS WB-PS

Tombouctou Niafunké HKI HKI



LF OV SCH STH Trachoma Tombouctou Tombouctou HKI HKI Taoudenit Achourat HKI HKI Taoudenit Al-Ourch HKI HKI Taoudenit Araouane HKI HKI Taoudenit Boujbeha HKI HKI Taoudenit Foum-Elba HKI HKI Taoudenit Taoudenit HKI HKI

Menaka Anderam-boukane WB-PS WB-PS

Menaka Inekar WB-PS WB-PS Menaka Menaka WB-PS WB-PS Menaka Tidermene WB-PS WB-PS

WB-PS – World Bank - Project Sahel; HKI – Helen Keller International; SS – Sightsavers; OMVS/PSI - Organisation pour la Mise en Valeur du Fleuve Sénégal – Population Services International. Lymphatic Filariasis

Historical data and MDA

The national strategy is to eliminate LF, which is caused by Wuchereria bancrofti and transmitted by Anopheles mosquitoes in Africa, by the year 2020 through yearly treatment with IVM and ALB according to World Health Organization (WHO) guidelines. Mali aims to halt the transmission of LF by the end of FY18 (when the last HDs will undergo TAS1). LF was endemic throughout Mali according to the mapping done by PNEFL in 2004 using immunochromatographic tests (ICTs). MDA with IVM and ALB began in 2005 in Sikasso region to treat LF and OV. Over time, the scale up of treatment continued, first in the OV co-endemic HDs and then in other HDs. In 2009, 100% geographic coverage was reached. This coverage was maintained until 2012 when serious insecurity in the northern 13 HDs in Gao, Kidal, and Tombouctou regions prevented MDA from taking place. Additionally, during the 2012 MDA, three HDs in Mopti region were inaccessible because of security concerns, and therefore, MDA activities were not conducted; MDA activities resumed in these three HDs in 2013. MDA restarted in Kidal and Tombouctou regions in 2014 and in Gao in 2015. In Kidal, MDA was successfully integrated into the national immunization days in 2014 and 2015. In 2015, six HDs in Bamako and two HDs in Kayes (Nioro and Kita) were not treated because of the limited availability of ALB in Mali. In FY17, there was a delay in the MDA (originally scheduled for March 2017 but completed in June 2017) because of a country-wide strike by medical/healthcare staff. MDA was conducted in the 16 HDs that have undergone pre-TAS in FY17. Except for Kidal region (four HDs) and two HDs in Mopti region, all HDs reached at least 65% epidemiological coverage in 2017. In Kidal, the MDA campaign was integrated with the immunization campaign. No HDs are scheduled for LF treatment in FY18 with USAID funding unless the HDs fail TAS1 (see below).

Survey results

A total of 49 HDs have achieved the criteria to stop LF treatment according to the latest TAS1 (2015 and 2016) and TAS2 (2015; 2 HDs) results. Pre-TASs were conducted in FY17 in 16 HDs in four regions—4 in Gao, 5 in Tombouctou, 4 in Kidal, and 3 in Mopti—using filariasis test strips (FTSs). Preliminary results indicate that all HDs passed pre-TAS and will be submitted for TAS1 in early FY18 (Table 4). Therefore,


Mali is on track to stop MDA nationwide in FY18, a huge achievement and a vital step towards the declaration of LF elimination in Mali.

Table 4. TASs planned for FY18.

FY18 activities Total USAID-supported Comments # of districts with pre-TAS 0 0

# of districts with TAS1 26 HDs (10 EUs) 26 HDs (10 EUs)

The 16 HDs that conducted pre-TAS in

FY17 have been split into 26 HDs.

# of districts with TAS2 47 HDs 47 HDs # of districts with TAS3 2 HDs 2 HDs

Cognizant of the workload for FY18 regarding TAS, the MOH has started planning for these surveys to ensure that they will be completed as planned. In FY18, TAS1 surveys are planned in 10 evaluation units (EUs) (across 26 HDs, including the 10 HDs added because of redistricting in FY17).

• TAS1 surveys in 26 HDs (originally 16 HDs) in Kidal, Tombouctou, Gao, Taoudenit, and Mopti regions

• TAS2 in 47 HDs in Koulikoro and Sikasso regions, and

• TAS3 in two HDs in Sikasso region

With the support of END Fund, morbidity management activities were conducted in Mopti, Sikasso, Koulikoro, Segou, and Tombouctou until 2017. WB will support LF morbidity mapping (in the form of a national census) and morbidity management in the HDs that they support directly in Quarter (Q)4 of 2017.

In summary, all 75 HDs are expected to stop MDA in FY18. The LF program will turn its attention to the compilation of data in FY18 for eventual dossier submission, and the program is seeking financial support for a consultant (through the Expanded Special Project for the Elimination of NTDs [ESPEN]) as a first preference.

a) Trachoma


Mali was historically a country with a heavy disease burden of trachoma. The national strategy is to eliminate trachoma by 2018, and the country is on track to meet this ambitious target. Mali is currently implementing the SAFE strategy for the elimination of trachoma as a public health problem, according to WHO guidelines and recommendations. Nationwide baseline mapping in the late 1990s found active trachoma prevalence values ranging from 23.1% to 46.7% and an overall trachomatous trichiasis (TT) prevalence of 2.5%. Evidence of widespread endemicity led to the launch of a trachoma control program through the National Program for Blindness Prevention (now PNSO) in 1998, with the first round of Zithromax® distributed in 2002.

Surveys

After more than 10 years in the fight against trachoma, 66 of the 69 endemic HDs have reached the criteria to stop MDA. The most recent TIS was conducted in Oussoubidiagna in early 2017, and the trachomatous inflammation—follicular (TF) prevalence was 0%. PNSO has received training in the WHO-


approved Tropical Data system for surveys in 2016 and July 2017 and will use Tropical Data in September 2017. Three TISs are planned before the end of the calendar year, and 19 TSS are planned in FY18, all with CNHF support. There are plans to establish a national trachoma elimination committee to guide Mali towards elimination and eventual dossier submission (planned to be supported by CNHF beginning in March 2017).

TT surgery

Since 2009, the PNSO reduced its trichiasis surgical backlog to fewer than 11,150 cases. The current backlog is fewer than 7,000 cases as the result of an intense TT surgery outreach with implementation and technical support from TCC, HKI (non-ENVISION funding), and Sightsavers. With funding from the CNHF, the PNSO believes it has the necessary resources to reach its Ultimate Intervention Goal for trichiasis surgery in 2018. In FY17, the attention shifted to HDs with lower backlogs and those beginning surveillance as the search for the last remaining cases intensifies.

b) Onchocerciasis


The current national objective is the elimination of OV by 2025 through annual regular IVM treatment with a minimum requirement of 80% programmatic coverage. OV is endemic in 34 HDs in the regions of Kayes, Koulikoro, Sikasso, Segou, and Mopti; of these 34 HDs, 20 are receiving IVM treatment currently, and the other 14 are under epidemiological surveillance. In FY17, 20 HDs were treated. Except for two HDs in Koulikoro region, all the HDs reached therapeutic coverage of at least 65% in FY17. In FY18, 6 HDs will be treated with ENVISION support, 11 with joint funding by ENVISION and Sightsavers, 2 with support from Sightsavers/WB, and 1 with support from WB alone, for a total of 20 HDs.

Surveys

After more than 30 years of efforts against OV, the PNLO has achieved the WHO control objectives (the original control objectives) in 20 HDs, as confirmed by epidemiological and entomological surveys. In FY15, with ENVISION support, the prevalence of OV by skin snip was zero in the HDs of Kati and Kolokani (3,422 people sampled) and Bougouni (1,741 sampled). Entomological surveys revealed no infection in blackflies in the HDs of Bougouni, Yanfolila, Kalabancoro, and Sélingué.

With ENVISION support, epidemiological evaluations were conducted in two HDs (Yanfolila and Bougouni) in FY15, and no positive case was found in the 4,005 people tested. No OV surveys were performed in FY17. The program must operationalize the national Onchocerciasis Elimination Committee (OEC) meeting and develop an OV elimination strategy before conducting any OV surveys.

To consolidate the achievements described above, the PNLO will focus on carrying out epidemiological and entomological surveys to confirm whether transmission has been interrupted and whether post-treatment surveillance can be started. The most recent OV WHO guidelines will be followed in using the new diagnostic methodology. To accelerate achieving the national elimination of OV, the PNLO created a National Committee for the Certification of the Elimination of Onchocerciasis (OEC). ENVISION had planned to support these meetings during FY17, but because of delays in choosing committee members, the national OV program has not yet finalized the OEC. ENVISION is not able to support two meetings in FY18 and the program is aware of this constraint. ENVISION will support a workshop to review OV data (during the committee meeting) to develop a sound OV elimination strategy and identify appropriate plans and strategies to achieve the 2025 national elimination goal. Surveys are planned to be


implemented in 20 HDs currently under treatment and the two HDs that have reached the criteria to stop MDA.

c) Schistosomiasis


The current strategy for SCH in Mali, according to the National Schistosomiasis Strategic Plan, is control of morbidity by 2020, which is in line with existing WHO guidelines. The national program for SCH/STH was established in 1982, and two national surveys were subsequently conducted (1984–1989 and 2004–2006) that confirmed urogenital and intestinal SCH endemicity in Mali. Treatment targeting SAC and high-risk adults in all endemic regions was established in 2005 with support from the Schistosomiasis Control Initiative (SCI). This treatment strategy continued as part of the integrated effort since 2007 with funding from USAID, OMVS, and Sightsavers. In FY17, 37 HDs were targeted for MDA with support from ENVISION, OMVS, and Sightsavers. Except for HDs in Kidal, all HDs reached the therapeutic coverage for SAC (75%) in FY17.

In FY17, the development of a SCH/STH transition plan was initiated because the success of the LF program meant that 49 HDs stopped LF MDA and sustainable SCH/STH programs should be developed by the Malian MOH. As a result, STH treatment was integrated with SCH in 29 HDs and will be integrated again in FY18 in HDs where SCH treatment is planned according to WHO recommendations. The Mali SCH treatment schedule is provided from FY17 to FY19 in Table 4a. The SCH/STH program has yet to develop a solid transition plan, and ENVISION will provide technical assistance to help the program draw concrete conclusions with clear next steps in FY18.

In FY18, 51 HDs will be targeted for MDA: 29 HDs with ENVISION support, 9 with OMVS/PSI support, 11 with WB support, and 2 with joint HKI and Sightsavers support.

Table 4a. SCH treatment frequency in Mali until FY19

SCH endemicity (using WHO criteria) PZQ and STH treatment schedule (number of HDs per

year)

FY17* FY18 FY19

SCH STH SCH STH SCH STH***

High prevalence ≥ 50% 19 0 19 0 19 0

Moderate prevalence (≥10% to < 50% for SCH and 20%-50% for STH) 9 10 29 3 9

Low (< 10% for SCH and 0.1% to 20% for STH) 9 39 3 20 7

0% (for STH)** 0 15 0 14 0

TOTAL 37 64 51 37 35

*FY17 PZQ MDA was not implemented, as per the new categorization. The data were updated recently (in July–August) according to FY17 survey results. STH prevalence results are those collected at baseline. **The Mali LF programs intends to treat for LF for those HDs which passed pre-TAS in FY17 and so these HDs will receive STH treatment through LF in FY18 . *** All HDs in Mali will undergo TAS-STH surveys in FY18 and so FY19 treatment will depend on these results.


Surveys

Almost 10 years of integrated NTD control have impacted SCH morbidity. A review of the survey results obtained with the Kato Katz method from 2014 to 2016 from sentinel sites in 38 HDs was performed to measure the impacts of the interventions. These data showed that 12 HDs have achieved the criteria for elimination (less than 1% of heavy-intensity infections in sentinel populations) and that another 10 have achieved the criteria for disease control (less than 5% of heavy-intensity infections in sentinel populations). Eight out of the 12 HDs evaluations planned for FY17 were conducted. For the remaining four HDs, the surveys were canceled because of security issues and a strike of health staff and teachers. Data from these evaluations show that the SCH prevalence decreased in six HDs and increased in two HDs. Among the six HDs where the prevalence decreased, three achieved the criteria for elimination and the other three have achieved the criteria for disease control. In FY18, the SCH/STH program plans to conduct SCH surveys in three HDs: Kita, Koulokani (planned for FY17 but not completed), and Bla.

d) Soil-Transmitted Helminths


The current strategy for STH in Mali is control of morbidity by 2020 by reaching 75% coverage of SAC and pre-SAC according to WHO guidance. During the 2004–2006 surveys for SCH (noted above), data on STH prevalence (using Kato Katz) were also collected and showed that STH was endemic across Mali. From 2004 to 2007, the national NTD program began treatment with ALB, coupled with the SCH MDA. Since the start of the integrated program in 2012, STH treatment has been integrated with the MDA for LF, and all 75 HDs have received at least five rounds of MDA. In FY16, 53/65 STH-endemic HDs were treated with ENVISION support. Twelve other HDs were not treated because of the lack of drug availability as some drugs were lost from the store.

In FY17, the MDA for SCH/STH treatment was completed as follows in 64 HDs (out of 65 planned):

• STH/LF in 16 HDs

• STH/OV in 6 HDs

• STH/SCH in 29 HDs

• STH alone in 13 HDs

According to survey data, in FY18, the program plans to treat HDs only where there is a need (and/or a lack of data for decision-making). In this transition phase, the program will review the MDA needs according the survey data and decide to stop MDA in HDs where the prevalence of STH is zero. ENVISION will provide TA to the program to complete the STH transition plan with clear steps in FY18.

In FY18, 37 HDs will be treated. STH treatment with ALB will be conducted alone in seven HDs and integrated with OV MDA in five HDs and SCH MDA in 25 HDs. The national program has decided to treat for STH in HDs that lack recent survey data (38 HDs have prevalence data [see below], and 37 do not, although we are awaiting data from 10 HDs surveyed in FY17). The ALB needed for this treatment plan will be provided through the WHO donation program.

Surveys

The most recent results available to date are from the SCH-STH surveys conducted in 2014 and 2016, which showed that 34 out of 38 HDs evaluated had a zero prevalence among SAC. Additional surveys have been implemented in eight HDs. In FY17, 8 out of 12 HD evaluations planned were conducted. In


the remaining four HDs, the surveys were not conducted because of security issues and a strike of MOH health workers and teachers. Data from these evaluations have shown that the STH prevalence is 0% in the eight HDs surveyed. A data review suggested that additional surveys should be performed to confirm these results because only sentinel sites were used in these older studies and to integrate future evaluations with TAS1 surveys.

Future STH surveys will be integrated with TAS1 in northern regions in FY18. This integration will represent an opportunity to reevaluate STH data in these 26 HDs (the 16 HDs undergoing TAS1 and the 10 new HDs created from these 16 HDs).


3) Snapshot of NTD Status in Country

Table 5. Snapshot of the expected status of the NTD program in Mali as of September 30, 2017

Columns C+D+E=B for each disease* Columns F+G+H=C for each disease*

MAPPING GAP DETERMINATION MDA GAP DETERMINATION

MDA ACHIEVEMEN

T 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 mappin

g

No. of districts receiving MDA as of 09/30/17

No. of districts expected to be in need of MDA

at any level: MDA not yet

started, or has prematurely stopped as of

09/30/17

Expected No. of districts

where criteria for stopping district-level MDA have

been met as of 09/30/17

No. of districts

requiring DSA as of

09/30/17 USAID- funded Others

LF

75

75 0 0 266 0 0 49 26

OV 34 40 0 171 3 0 14 0

SCH 75 0 0 312 20 0 247 05

STH 75 0 0 233 14 0 388 04

Trachoma 69 6 0 0 09 0 66 3

1OV MDA, 6 HDs will be supported by ENVISION and 11 by ENVISION and Sightsavers 2SCH MDA, 29 HDs will be supported by ENVISION and 2 by ENVISION and Sightsavers. 3STH MDA, 21 HDs will be supported by ENVISION and 2 by ENVISION and Sightsavers 4STH surveys in FY18 will be integrated with TASs. 5SCH surveys will be supported by WB. 6TAS1 will be conducted in 26 HDs in FY18. 7SCH treatment is not planned for 24 HDs in FY18 according the MDA schedule, this is an off- year treatment cycle, which is based on prevalence. 8Although there are no stop-MDA criteria for STH, the prevalence data indicate that MDA can be suspended because of low prevalence and that treatment should be targeted to the individual level. 9No HDs were treated in FY17 and these 3 HDs will undergo TIS before the end of calendar year 2017 with Hilton Foundation funding. At the time of writing, the Mali program is updating its workbooks to reflect recent redistricting. In late FY16, Mali added two new regions and ten additional HDs, for a total of 75 districts.


PLANNED ACTIVITIES

1) NTD Program Capacity Strengthening

a) Strategic Capacity Strengthening Approach

Capacity goals and capacity strengthening strategy

Based on the situation analysis described above, ENVISION and the Mali MOH have identified the following priorities as foci for capacity strengthening to continue the successful efforts to eliminate and control NTDs in Mali:

• advocate for increased MOH staff numbers

• identify and apply for new funding sources and develop a mechanism for sustained STH/SCH control

• increase laboratory technicians’ capacity/training

• strengthen data management and use (integrated database maintenance and use)

While ENVISION recognizes that the priorities mentioned above are critical for the MOH, both parties (ENVISION and the MOH) have selected three objectives that fit ENVISION’s current scope and strengths:

1. increase lab technicians’ skills to perform OV16 ELISA 2. strengthen data management and use, including the maintenance and use of the integrated

database 3. improve annual plan implementation and budgeting to increase the sustainability of the NTD

program

b) Capacity Strengthening Objectives and Interventions

Objective 1: Increase laboratory technicians’ capacity to perform OV16 ELISA: ENVISION plans to train the laboratory technician team on how to perform OV16 ELISA using video materials provided by WHO. This will include instructions on how to conduct the test according to the protocol and advice on using a pilot area in Bamako to ensure that the assay is working well. This activity will further strengthen the capacity of the MOH to conduct critical DSAs. The video training platform is planned because the NIAID lab is not able to provide ELISA training. The video training will be discussed at the OV meeting in FY18.

Objective 2: Strengthen data management and use: As noted above, there has been strong interest in the national integrated database. Most historical data have been entered and confirmed by the disease-specific coordinators. The integrated data base will be transferred to DNS M&E office the final months of FY17. ENVISION will continue to provide coaching and on-the-job training to the MOH to take ownership of the database and use it to generate key program documents, such as the WHO Joint Reporting Form, until a database manager is appointed. In addition, ENVISION will continue to play a convening role between divisions, working with the MOH to encourage the use of the integrated NTD database as a tool to support program planning. ENVISION will also support ongoing data entry from CY16 and CY17. A complete data set will be needed to support the compilation of information for the trachoma and LF dossiers.


Objective 3: Improve annual plan implementation and budgeting: Through the TIPAC, ENVISION will assist the MOH in planning NTD activities over the next five years. A detailed five-year plan will allow the MOH to capture all the NTD activities to be conducted and more easily identify areas that need additional support. These outcomes will be used to advocate with certain officials for NTD programs and additional support. ENVISION will assist the program in using the TIPAC in FY18.

Monitoring Capacity Strengthening

Informal meetings, e-mails, phone calls, and regularly scheduled quarterly review meetings with the MOH will be used to review progress made toward achieving the planned capacity strengthening outcomes using the following strategy to measure success (Table 6).

Objective 1: Increase laboratory technicians’ skills to perform OV16 ELISA: ENVISION is scheduling the training of laboratory technicians on OV16 ELISA to accurately and efficiently meet assessment needs in Q1 of FY18. The progress toward the ability to perform OV16 ELISA in Mali will be monitored quarterly throughout FY18 and through other informal, ad hoc meetings. Indicators will include the development of a working protocol and the implementation of ELISA that meets the quality control criteria set by the manufacturer.

Objective 2: Strengthen data management and use: ENVISION will support the MOH to convene various stakeholders, including the different MOH divisions and disease-specific coordinators, Sightsavers, TCC, WB, OMVS, and other partners, to review progress on database completion, identify obstacles to its usage, and propose solutions to overcome them. Feedback gathered during these meetings on how the database and other monitoring and evaluation (M&E) tools could be made more user friendly will be passed on to WHO and the ENVISION HQ M&E team. A strong data set will be very important in the compilation of data for the LF and trachoma dossiers. Indicators will include the completion of a functional database and feedback provided on the utility of these tools.

Objective 3: Improve annual plan implementation and budgeting: The development of the five-year strategic plan and TIPAC training were completed in FY17. ENVISION will support the MOH to convene staff and partners to discuss the progress toward completing data entry into the TIPAC and to review the utility of TIPAC in providing useful information for advocacy of new funding sources. As with the review of progress in the use of the integrated database, obstacles to TIPAC usage will be identified and a plan put in place to resolve them. Feedback gathered during these meetings on how the TIPAC could be made more user friendly will be fed back to WHO and ENVISION HQ. Providing training and support for the MOH staff to start using TIPAC will help build capacity that will be needed after the end of ENVISION in FY19. Indicators will include the completion of the TIPAC and the collation of feedback on its utility to the program.


Table 6. Project assistance for capacity strengthening

Project assistance area Capacity strengthening interventions/activities

How these activities will help to correct needs identified in

situation above

a. Strategic Planning

Coaching and on-the-job training: Integrated database and TIPAC assigned to designated MSHP staff

This will help the MSHP to identify additional funding to fill the gaps and ensure program sustainability.

b. Drug Supply and Commodity Management and Procurement

Coaching: Ensure that the approved drug management plan is well executed

This activity will avoid substantial quantities of expired drugs

c. Supervision for M&E and DSAs

On-the-job training on OV16 ELISA The national laboratory currently lacks the capacity to implement OV16 ELISA. This training will allow this assay to be run in Mali and facilitate making stop-MDA decisions.

d. Dossier Development

Consultant: ENVISION will assist the program to hire a consultant to start LF dossier development (potentially via WHO/ESPEN).

The consultant will initiate the dossier process with MSHP staff and partners. The country will be able to continue the process when the consultant is gone. This activity will help to start the process of gathering the necessary information for LF dossier development.

e. Short-term TA

Coaching: Strengthen data management and use and update the NTD integrated database with 2016 and 2017 data

This activity will help the NTDs program achieve an accurate database and be ready for dossier development. Decisions on program activities need to be based on evidence, and all data must be housed in a single location that is accessible to the MOH.


2) Project Assistance

a) Strategic Planning

In FY18, Mali’s NTD program plans to help consolidate the country’s achievements in terms of NTD control and elimination. Efforts and strategies will be implemented to maintain 100% geographic coverage, even in areas of insecurity. In addition, mop-up activities will be strengthened in HDs with low epidemiological coverage rates, in addition to assessments for all NTDs. In FY18, the NTD activities will be implemented in a multi-partner context. Coordination meetings with the partners were held throughout FY17, and the partners will continue to meet on ad hoc and quarterly bases (at a minimum), in addition to the planning and monitoring meetings with the MOH. These meetings are important to avoid duplication and potential complications in the multi-partner areas of intervention.

The ENVISION team will also provide support to the NTD program in using TIPAC for FY18 activities and will continue advocacy to encourage MSHP staff to take ownership of this process.

Activity 1: NTD annual review and national stakeholders’ meeting (operational planning workshop) (HKI Strategic Planning)

The purposes of these two meetings are to review the previous year’s activities and plan for the next year’s activities in the presence of the MOH and all partners. These two meetings will be combined in Q4 of FY18 because many of the same stakeholder will be involved in both activities in June 2018. The five-day meeting will include two days for the review and three days for the work planning workshop. At the review meeting, the national NTD program will define its annual NTD control and elimination objectives and discuss the results from the MDA campaign and surveys. This meeting provides an opportunity to implement changes where needed, such as to improve MDA coverage and share lessons-learned and best practices. The operational planning workshop will review the schedule of program activities for each disease, particularly the implementation dates for the MDA activities, impact evaluations, and research studies at the national and regional levels.

These meetings bring together the NTD coordinator, NTD disease-specific coordinators, members of the NTD Technical Coordination Committee, regional representatives, ENVISION staff, all relevant partner organizations, USAID, and RTI and HKI HQ staff. After the annual review, the Steering Committee (see below) will meet to exchange lessons learned and discuss the action plan proposed by the Technical Coordination Committee.

Activity 2: NTD Technical Coordination Committee meetings and NTD Steering Committee meetings (HKI Strategic Planning)

The NTD Technical Coordination Committee is a technical body responsible for implementing NTD-related activities. This committee plans activities, conducts active implementation monitoring, and validates the results of NTD MDA or DSAs. It meets quarterly and also holds special meetings (no more than twice a year). The DNS chairs the Committee meeting. Members include the DPLM; NTD program coordinators; representatives of the National Health Information, Education, and Communications Center (Centre National d’Information, d’Education et Communication pour la Santé [CNIECS]); the National Institute for Public Health Research (Institut National de Recherche en Santé Publique [INRSP]); the Faculty of Medicine and Dentistry (Faculté de Médecine et d’OdontoStomatologie)/Malaria Research and Training Center (MRTC); HKI; and other partners. All NTD partners will be invited.

The NTD Steering Committee meets every six months to review and validate the results of the NTD MDA campaigns. One of the Steering Committee meetings is held at the end of the annual review meeting.


The Secretary-General of the MSHP chairs the Steering Committee. It is composed of a member of the cabinet of the MSHP, the National Director of Health, the head of the DPLM, the head of the section responsible for combatting the disease, the NTD program coordinators, the Health Planning unit, the Training and Information Planning Unit, the Public Health and Hygiene Division, INRSP, the Faculty of Medicine and Dentistry/MRTC, HKI, and other NTD partner representatives.

Activity 3: Regional review meetings (NTD MDA campaign)

Annual one-day regional feedback meetings (in all 11 regions) on the NTD campaign outcomes are held after the conclusion of the MDA campaign, most often at the end of the fiscal year. These will take place at the regional and at the district level (in eight districts, ENVISION will support seven of the HD level review meetings). Participants at the regional review meetings include regional representatives, national NTD coordinators, and national-level partners and district level staff who will travel from their respective HDs. Participants at the district level meetings include the directors of health centers, the chief medical officers and NTD focal points. A technical and financial assessment of the MDA campaign is conducted at this meeting. Problems encountered during the campaign are identified, solutions proposed, and recommendations developed to improve future campaigns. Recommendations for corrective activities are made to the HDs for areas with low treatment coverage rates. During supervision, ENVISION verifies that these recommendations are implemented. These meetings offer an important opportunity to provide information, including the operational plans for the coming year, to all actors participating in NTD control activities. The results of these meetings help to guide the topics for discussion at the annual review meetings held at the central level.

Activity 4: OEC meetings (HKI Strategic Planning)

The OEC will meet (at a frequency to be determined at the strategy meeting) to prepare for the elimination of OV in Mali and the submission of an elimination dossier to WHO. The members of the OEC are not yet finalized or officially sanctioned by the MOH. This will be a three-day meeting. The committee will include members from the MOH, national experts and researchers in OV, and international experts in OV, and WHO will be invited to attend. This meeting will ensure that progress toward elimination is being made, that an OV elimination strategy is developed, and that data from surveys are reviewed, that the collected data and complete and will help to prepare for the eventual submission of an elimination dossier to WHO. If a national elimination strategy does not emerge from this meeting, ENVISION will not support any further meetings of the OEC. This meeting will aid in decision-making and strategy development as Mali reaches its elimination targets.

b) NTD Secretariat

Activity 1: Supporting the NTD secretariat (HKI NTD Secretariat)

The members of the NTD Secretariat include the coordinators of the four NTD programs, a pharmacist, and the head of the disease control section, who reports to the head of the DPLM

c) Building Advocacy for a Sustainable National NTD Program

The CNIECS supports the NTD program in implementing its 2017–2021 strategic plan by conducting advocacy and social mobilization activities in support of efforts to combat NTDs.

In FY18, advocacy activities will focus on the following activity: Organize advocacy sessions at the central and regional levels


One-day sessions will be organized in Bamako and five other regions. This advocacy activity targets community leaders and is focused on engaging the community in NTD activities.

d) Mapping

No mapping activities are planned in FY18.

e) MDA Coverage

Table 7. USAID-supported coverage results for FY17

NTD # Rounds of

annual distribution

Treatment targets (FY17)

# DISTRICTS

# Districts not

meeting epi

coverage target in

FY17*

# Districts not

meeting program coverage target in

FY17*

Treatment targets (FY17)

# PERSONS

# Persons treated (FY17)

Percentage of treatment

target met (FY17)

PERSONS

LF 1 11 5 NA 1,339,233 1,177,860 87.9% OV 1 17 NA 2 3,595,956 3,269,295 90.9% SCH 1 20 NA 3 1,741,158 1,631,520 93.7% STH 1 42 NA 3 3,589,142 3,269,652 91.10% TRA 0 NA 0

Districts with insufficient coverage

LF treatment coverage

Overall, the percentage coverage of LF treatment has been very strong, with 87.9% of people targeted receiving treatment (Table 8). However, some districts have had low coverage in FY15, FY16, and FY17. Four HDs have been identified as having recurrent problems with respect to LF treatment (epidemiological coverage <65% for two consecutive years), all of which are located in Kidal region: Abeibara, Kidal, Tessalit, and Tin-Essako (Tables 9 and 10). This is a region of Mali with persistent security issues, which have led to reduced epidemiological coverage. In addition to Kidal, the HDs of Teneinkou and Youwarou also did not reach sufficient epidemiological coverage. Again, security is a major issue in these HDs, which suffer recurrent terrorist attacks. As of July 9, 2017, security in the northern regions of Mali continues to be a concern.

In FY16, 10 HDs had poor coverage with respect to LF treatment. In some of these HDs, MDA was performed during Ramadan or the rainy season. This schedule resulted from the late delivery of drugs caused by a miscommunication among the shipping agent, WHO, and the MOH. Following this delay, new procedures have been implemented to ensure that HKI and other partners are involved in tracing the drug orders and assisting the program with enhanced follow-up. Improving drug ordering and management is essential for the timely delivery of drugs to the districts and, thus, avoiding delaying the campaign into either Ramadan or the rainy season. The rains made some villages and areas inaccessible at the time of the MDA, which decreased the coverage rate. This year, the JRSM was submitted in April 2017, leaving sufficient time for drug delivery and earlier MDA. This early submission has been a critical first step toward avoiding delays. However, security issues have again led some HDs to have less than optimal coverage, particularly in Kidal. For seven of these HDs, this was their last LF MDA.


In FY17, treatment in Kidal did not achieve acceptable coverage rates for the third consecutive year. Programmatic coverage has been reported at 33% in FY17. However, despite this poor coverage, the data from pre-TAS indicated that no HD in Kidal reported any FTS-positive cases and for this reason, Kidal was schedule for TAS1 survey in FY18, with RPRG approval. Security remains a concern in this region (as described above), and the MOH is actively trying to find solutions to operate as smoothly as possible in Kidal while keeping staff as safe they can. The population of Kidal is estimated at just over 91,000 for FY18. However, the MOH suspects that the constant threat of insecurity has led to a substantial decrease in the number of people living in this region. This suspicion seems to be supported by the geographic coverage data for FY17. Out of a possible 101 villages, 90 were visited, corresponding to a geographic coverage of 90%. As refusal to participate in the MDA has not been reported in Kidal, these data support the observation that low coverage in Kidal is partly, if not wholly, attributable to the fact that the target population is much smaller than indicated by the most recent census.

Ideally, a new census should be performed in Kidal. This activity has been suggested, but because of the political instability and security situation, it is unlikely to occur. Indeed, the population of Kidal has been sensitive about enquiries as to the numbers of people living in villages and in households. Another solution proposed by the MOH is to conduct MDA in two stages: initial MDA followed by a mop-up MDA.

The four HDs in Kidal will undergo TAS1 in FY18, assuming RPRG approval and ENVISION can find local staff to work in the region. It is possible that training for TAS1 will be performed in another, more secure region before TAS1 implementation. A consultant will be hired to supervise the MDA in the northern regions, as has been done in previous years.


Table 8. HDs with recurrent LF coverage problems as of FY16

Region District FY16 Coverage Cause of low coverage Proposed next step

Gao Bourem 56.5%

Treatment administered during Ramadan.

Displacement of the nomadic population.

A mop- up was performed in Bourem.

Kayes Kayes 64.0% MDA performed during the rainy season.

This HD will not be treated for LF in FY17 for TAS1.

Kayes Kita 29.9% Incomplete results because of missing reports.

This HD will not be treated for LF in FY17.

Kayes Nioro 63.8% Incomplete results because of missing reports.


Kayes Oussoubidiagna 63.7% Campaign conducted during the rainy season.


Mopti Teninkou 30.8%

Skipped rounds of MDA because of insecurity.

Some villages inaccessible during the rainy season.

The rainy season will be avoided; treatment is

planned for April.

Mopti Youwarou 52.2%

Skipped rounds of MDA because of insecurity.

Some villages inaccessible during the rainy season.

The rainy season will be avoided; treatment is

planned for April.

Segou Barouéli 57.9% MDA conducted during restrictive

periods (i.e., Ramadan and the rainy season).

No LF treatment is planned for FY17.

Segou Markala 53.6% Campaign conducted during the rainy season.


Sikasso Koutiala 64.3% Campaign conducted during the rainy season.



Table 9. FY17 MDA results for HDs with recurrent LF coverage problems

Region District

FY15 coverag

e

FY16 coverag

e

FY17 coverag

e

Changes made to

FY17 MDA

Cause of continued

low coverage

Proposed next step (where coverage continues to be

low)

Kidal Abei-bara 40% 11% 16%

MDA was integrated with the

immuniza-tion

campaign

Security issues

There is an ongoing discussion among the NTD partners, the immunization program, and other public health intervention programs to determine the right denominator the program should consider because most of the population is displaced.

Kidal Kidal 32% 36% 26%


immunization

campaign

Security issues Same comment as above.

Kidal Tessa-lit 44% 54% 36%


immunization

campaign


Kidal Tin-Essako 65% 23% 17%


immunization

campaign


Mopti Tenen-kou 57% N/A Security

issues Same comment as above.

Mopti You-warou 65% N/A Security

issues Same comment as above.

ENVISION does not support trachoma activities in Mali.

OV Coverage

Overall, the Mali OV program treated 89.5% of the of target population. However, there were two HDs in FY16 that had insufficient coverage, both in Kayes region: Kita and Oussoubidiagna. Kita did not report all of its MDA results as this is a relatively newly created HD, and the mechanisms for good MDA reporting were not in place. In addition, MDA was implemented later during the rainy season, which led to poorer than expected coverage because of late delivery of the drugs. In Oussoubidiagna, the coverage rate was 79.6%. This slightly poorer than expected coverage was also attributable to the campaign being conducted during the rainy season, due to late drug delivery. The ALB shipment was very late because of a miscommunication between the shipping company and WHO Africa Regional Office (AFRO).


SCH Coverage

The FY16 SCH campaign treated 91% of the target population, but four HDs achieved less than optimal coverage: one in Kayes (Yelimane), two in Sikasso (Kignan and Koutiala), and one in Tombouctou (Diré) (Tables 10 and 11). In Yelimane, Kignan, and Diré, the SCH campaign was conducted during Ramadan, leading to poorer than expected coverage. The campaign was late because all the drugs are delivered together in each region, and as the other drugs were late, the PZQ was shipped with the late-arriving drugs. A mop up, to improve coverage, was implemented in Tombouctou (the data are still not available). Timely ordering and delivery of PZQ for the SCH campaign will help to avoid delays, and for FY18, the PZQ drug order was submitted to WHO AFRO in April 2017. Assuming that the PZQ arrives on time, there is no reason to expect delays in FY18. In Koutiala, the CDDs distributed the drug to adults and SAC, and thus, the drug supply was insufficient for the target population. Improved training for this HD has been proposed to ensure that the CDDs know the target population for the SCH campaign.

In FY17, the MDA coverage was relatively low in all HDs in Kidal, although all the HDs reached therapeutic coverage rates of at least 75% among SAC.

Table 10. Low-coverage HDs for SCH treatment in FY16 (top) and FY17 (bottom)


Kayes Yeli-mane 71.1% Treatment during

Ramadan Treatment must not be implemented during

Ramadan.

Sikasso Kignan 66.8% Treatment during Ramadan

Treatment must not be implemented during Ramadan.

Sikasso Kou-tiala 67.8%

CDDs gave PZQ to adults. This situation was

corrected in the HD. Training at the HD level will be increased.

Tombouctou Diré 71.5%

Treatment during Ramadan and security

issues

A mop up was performed in Tombouctou, and results are expected.


Kidal Abei-bara 22% Security issues

There is an ongoing discussion among the NTD partners, the immunization program and other public health intervention programs to determine the right denominator the program should consider because most of the population is displaced.

Kidal Kidal 32% Security issues Same comment as above.

Kidal Tessalit 42% Security issues Same comment as above.

Kidal Tin-Essako 23% Security issues

Same comment as above.


STH Coverage

The STH program treated 94.7% of the target population in FY16. Four HDs did not achieve sufficient epidemiological coverage. All four HDs are in Kidal region, as described in the LF low coverage section. In Kidal, serious security issues have led to poor STH coverage in FY15, FY16, and FY17. The Mali STH program will investigate methods of implementing MDA in these insecure areas, such as the Hit and Run strategy developed by WHO and adapted for MDA in Cameroon and the other possible solutions described above.

Table 11. Low STH coverage HDs

Region District FY15

cover-age

FY16 cover-

age

FY17 cover-

age

Changes made to

FY16 MDA

Cause of continued

low coverage

Proposed next step (where coverage continues to be

low)

Kidal Abei-bara 40% 11% 16% N/A Security

issues Use hit and run strategy.

Kidal Kidal 32% 36% 26% N/A Security issues Use hit and run strategy.

Kidal Tessalit 44% 54% 36% N/A Security issues Use hit and run strategy.

Kidal Tin-Essako 65% 23% 17% N/A Security

issues Use hit and run strategy.

Planned FY18 MDA Activities

Table 12. USAID-supported districts and estimated target populations for MDA in FY18

NTD

Age groups targeted

(per disease workbook

instructions)

Number of rounds of distribution

annually

Distribution platform(s)

Number of districts to be treated

in FY18

Total # of eligible

people to be targeted in FY18

LF Entire population above five years 1 Community

MDA 0 0

OV Entire population above five years 1 Community

MDA 17* 3,595,956

SCH SAC only 1 Community and

School-based MDA

31** 2,251,820

STH SAC only 1 School-based MDA 23*** 853,147

Trachoma *OV MDA: 6 with ENVISION support only and 11 with ENVISION and Sightsavers support **SCH MDA: 29 with ENVISION support only and 2 with ENVISION and Sightsavers support ***STH MDA: 21 with ENVISION support only and 2 with ENVISION and Sightsavers support


In FY18, the following NTD MDA objectives are planned:

LF: No HDs are planned for LF treatment in FY18 with ENVISION support (26 HDs will undergo TAS1 in FY18).

OV: 20 HDs will be treated

SCH: 51 HDS will be treated.

STH: 37 HDs will be treated in FY18 (21 with ENVISION support). Thirteen will be treated with WB support, two with ENVISION/Sightsavers support, and one by OMVS/PSI.

Seven HDs will be treated with ALB only: three with WB support and four with ENVISION support (Kidal region). The remaining districts will be treated for SCH (24 HDs) and OV (6 HDs).

Trachoma: Depending on the results of the evaluations scheduled for July 2017, three HDs may undergo MDA (Ansongo, Nianfunké, and Bourem).

A mop-up strategy will be implemented where needed to improve coverage rates. ENVISION will assist and provide technical support to the program for implementation, follow up, and subsequent data sharing. As Mali is close to stopping LF transmission, STH treatment will be integrated with SCH or OV treatment where possible as no HDs will be treated for LF in FY18 with ENVISION support. The priority was given to SCH/STH combined treatment because the target populations are same: the treatment strategy is a school-based methodology combined with a community-based strategy. The number of HDs scheduled for treatment in FY18 include the 10 newly created HDs.

f) Social Mobilization to Enable NTD Program Activities

In FY17 and prior years, communities were informed via grassroots media (radio), national television, and campaign launch activities, such as banners and posters, town criers, and in mosques and other places of worship. In addition, advice cards were used during the MDA campaign. The information, education, and communication (IEC) tools are reviewed each year by CNIECS, the MOH, and partners. Feedback from the field and the MDA coverage data are used to review the IEC materials, with particular focus on HDs with low coverage. In June 2017, CNIECS completed field surveys of partners to ensure that the IEC materials are effective. New materials, such as leaflets/pamphlets and flashcards, were created for each disease in FY17 and are, therefore, not required for FY18. From FY17 Schisto MDA coverage survey, preliminary data indicate that >10% of the SAC hear about the MDA via radio. This is a significant number of SAC reached by the media when we consider they are spending much of their time at school and the fact that they will report to their parents, their community and friends the NTD message heard on radio and TV. The NTD message aired on TV is done by the USAID Mission Director in Mali participating in MDA and sensitizing the Malian population to be treated for NTDs. This is very appreciated, the Mission showing their support to the local government in the fight to eliminate and control the NTDs. The Schisto MDA coverage survey report, when finalized, will be shared with USAID. The preliminary result of this survey shows that the radio and TV broacasts contribute to the success of the NTD program in Mali and showcase USAID support to the government for NTDs elimination.

In FY18, as in FY17, in addition to the use of media at the national level (the Office of Radio and Television of Mali [l’Office de Radiodiffusion Télévision du Mali (ORTM)] and private television stations), local radio will be used at the regional and HD levels to flood the communities with information on efforts to combat NTDs. These local radio spots will be combined with the use of public criers and community and religious leaders to inform the community and raise awareness. With private television stations’ audiences growing, these outlets will be an additional asset. The messages delivered through


social mobilization address the benefits and safety of the drugs used in MDA. They also provide clear information on the distribution times and locations and other places where treatment may be obtained if someone misses the main distribution in the village. Results from the coverage surveys will be available at the end of July 2017 and will be used to assess the effectiveness of the IEC materials and adjust them if required.

Activity 1: Design workshop and distribution of the messages

First, a one-day workshop will be held to develop and validate the messages for the NTD control efforts, taking into account the results from the coverage surveys. During this workshop, the messages are developed with updated information for each disease, drug and the dates of the treatment. Participants will include CNIECS (Mali media specialists), DNS staff, technical and financial partners, researchers involved in NTDs, and any other individuals who can help design innovative messages/materials. After the messages/materials are developed and tested in a population sample, they will be translated into and recorded in local languages. Next, they will be sent to the audio-visual media for local and national distribution. ENVISION will support the costs for the workshop, radio broadcasts, and the production of CDs of the radio broadcasts to provide to the regions.

At the local level, in addition to local radio, other mobilization channels (e.g., public criers, traditional and religious leaders, managers of women’s and youth organizations, and other groups) will be used to ensure that the messages are distributed widely amongst the population. These individuals will be asked to distribute the awareness messages at places of worship, in neighborhoods/villages, during meetings, and to households. This is done in the community with no cost to ENVISION. Appropriate materials will be used to provide the information distributed through these channels (i.e., advice cards, images, comic books, posters, brochures, and banners; these are available from FY16, and there is no need to re-print them if the messages are deemed to be appropriate following the review during the workshop – these costs will not be borne by ENVISION). A supply of these materials is available in certain regions and may be redeployed in HDs and health areas where the need exists. These materials will facilitate the communities’ understanding of the topics related to the targeted NTDs, the importance of participating in the MDA, and the availability of free treatment for adverse events (AEs). At the national level, the messages will be distributed via ORTM TV. To ensure that these messages are effective, supervision teams will conduct missions in problem HDs to ensure that the communication/mobilization activities are implemented and to talk with the populations about the impacts of these messages on changing their behavior. Comic books targeting SAC will be created with stories of NTD prevention activities (WB supported). Aides memoires (memory aids) focusing on NTD prevention will be produced for the CDDs (one per CDD).

Activity 2: National MDA campaign launch

The launch will be organized and chaired by a high-ranking official of the MOH. Administrative and local government authorities will also be present. This will provide an opportunity to involve community leaders, including village/neighborhood and religious leaders and managers of women’s and youth groups. The ORTM national television station will cover the event, and reporting will target the entire population of Mali. To enhance visibility, printed fabrics, T-shirts, and caps will also be produced and distributed to administrative authorities, local governments, and community leaders.

Activity 3: Regional MDA launch ceremony Regional launches will be held in 11 regional administrative centers where MDA will be implemented and will be chaired by the Governor or President of the Regional Council.


Activity 4: Monitoring/supervision of communications activities

The national mixed teams, which are composed of the CNIECS, DNS, and programs, will travel to problem HDs during the campaigns to help them prepare and implement successful communications activities. They will also visit the participating radio stations; community, religious, and association leaders; and other actors involved in mobilizing the population to assess the situation by using a checklist of strengths and areas for improvement. They will verify the general impacts of the messages on the population using a standardized questionnaire developed by ENVISION. Then, they will develop relevant recommendations to resolve problems experienced at the various levels of the health pyramid.


Table 13. Social mobilization/communication activities and materials checklist for NTD work planning

Category Key messages Target population

IEC strategy (e.g., materials, medium,

and activity)

Where/when will they be distributed? Frequency

Is there an indicator/mechanism

to track this material/activity? If

yes, what?

Other comments

MDA participation

Mobilize community leaders and reinforce their involvement in NTD activities.

Village chiefs, religious leaders, women’s group leaders, community health association, traditional communication networks, teachers, radio disc jockeys

Organize a one-day meeting targeting community leaders in low-coverage HDs.

Three days before the of the campaign at the HD level.

Meeting report with participants’ engagement

MDA participation

Produce messages and radio and television spots.

General population

Produce aides memoirs for each CDD and comic books for children on NTDs and their prevention. The comic books will be produced in seven local languages. Radio spots will be produced in French and local languages. Produce 150 CDs per HD for local radio stations.

CNIECS Local and HD level radio stations DRS

Twice daily in each language for seven days just before and during the campaign.

Percentage of the population who report hearing about the campaign on local radio and being persuaded to participate in MDA by the messages on radio Percentage of people who had knowledge of MDA because of the messages


Category Key messages Target population

IEC strategy (e.g., materials, medium,

and activity)

Where/when will they be distributed? Frequency

Is there an indicator/mechanism

to track this material/activity? If

yes, what?

Other comments

Broadcast messages on television and local radio

General population

Broadcast messages in French and seven local languages. Broadcast messages and announcements on local and HD-level radio.

One week before the start of the campaign activities Twice daily for 30 days on local radio

One broadcast per language per day

Percentage of people who knew about the availability of drugs and that they are free of charge and of high quality

Will be done during the post-MDA coverage survey

NTD activity participation

Different media Population Organize two press conferences at the national level (campaign launch and annual review).

National level

Coordination Follow-up, supervision

Members of the national supervisory mobilization committee in certain HDs before and during the campaign.

Follow the supervision of social mobilization activities in the regions (non-WB HDs) at the national level.


Results from the coverage survey will be used to tailor the type and quantity of IEC materials and social mobilization activities according to the most effective strategies. These changes will be implemented in consultation with RTI and USAID.

g) Training

In FY18, the staff training will be conducted on a cascade basis, as indicated below.

Activity 1: TOT – Participation at the Regional Level

The national NTD program coordinators organize the regional trainings in all 11 regions. Each training session is held at the regional administrative center for the HD’s chief medical officer (Médecin-Chef de District [MCD]) and/or his/her representative, the NTD Focal Point, the regional pharmacist, a representative of the teaching resource center, a representative of the Regional Federation of Community Health Associations of Mali, and a representative of the Local Federation of the Community Health Associations of Mali (Fédération Locale de l’Association de Santé Communautaire [FELASCOM]).

Activity 2: TOT – Participation at the HD Level

At this level, the MCD and NTD district Focal Points will conduct the training for the DTC, FELASCOM representatives, and primary school teachers. This one-day training will be held at the CSREFs.

Activity 3: Training of CHWs – CSCOM level

The training sessions at this level, which will be provided by the CSCOM DTCs, will bring together two CHWs from each village (three or four workers from large villages or neighborhoods will receive training) and Community Health Association representatives. This one-day training will be held at the CSCOM.

Activity 4: Training of Lab technicians on OV16 Elisa (HKI Training)

Upon request of the OV Coordinator, lab technicians at central level will be trained on OV16 Elisa. This is an opportunity for the OV Program to build local capacity on performing the new OV test as the skin snip is more and less well-tolerated by the population.

h) Drug and Commodity Supply Management and Procurement

Drug ordering for FY18: Joint Application Process

In FY18, as in FY17, HKI, through ENVISION, supported the programs to develop and monitor the joint request to WHO, the donation program, and all other stakeholders. The FY18 drug order was placed in April 2017, unlike in prior years, when it was placed in July. By submitting the request earlier, the country should avoid any delay in receiving the drugs. The order was placed before the final 2017 MDA campaign outcomes were available because the campaign is still underway.

The drug supplies (IVM, ALB, and PZQ) were requested by the program by submitting the JRSM to WHO in April 2017. Simultaneously, a request for ALB+IVM (for FY18 activities) was also submitted to the Mectizan Donation Program for OV MDA in 20 HDs using WHO’s Joint Request Form.

In FY18, the joint application process for FY19 will be started and completed by the end of March 2018. ENVISION will provide technical support to the Drug Supply Manager to fill the application.


Activity 1: Drug transport from the national warehouse to regions

The HKI team will meet regularly with the DNS to review and handle the MDA logistics needs and will work with the DNS to ensure adequate monitoring and drug supplies. The drug supply plan will be prepared during a meeting of the Technical Coordination Committee and validated by the DNS. The validated drug supply plan is one of the deliverables needed to complete this drug supply phase in the DNS’s FOG. The MOH and WHO will inform the HKI team when orders are placed so that they can support the NTD national program during its interactions with WHO regarding drug supplies.

When the drugs arrive in the country, they are stored in the NTD national program’s main warehouses. With technical support from HKI via ENVISION, the national NTD program is responsible for supplying the regions, which, in turn, supply the HDs with the necessary drugs. Subsequently, the HDs supply the CSCOMs, to which CDDs come to pick up the drugs for distribution in the villages. All drugs intended for a specific health center are delivered during the training of the center’s DTC.

ENVISION provides technical support to the MSHP coordinators to complete the drug request forms. ENVISION will also provide the TA necessary to conduct physical inventories at the regional level during supervision and feedback.

Activity 2: Reverse logistics from regions to the national warehouse (HKI Drug Supply Management)

When the MDA campaigns end, the CHWs must return the remaining drug supplies to the health centers, which then send the supplies on to the HD and, subsequently, to the regional level for physical inventory. The new NTD drug logistics management plan will strengthen this process in FY18.

All reports provided by the CHWs containing information on drug inventories will be sent to the CSCOMs. The coverage data are sent to the HD, regional, and central levels after being validated at each level during regional review meetings. The DRS will be asked to notify the central-level pharmacist of the physical inventory of remaining stocks.

Mali has policy documents governing biomedical waste management. Wastes produced during the campaign are managed pursuant to the standards and procedures in effect in the country. Empty azithromycin bottles are returned to the health center to be destroyed and incinerated.

The FTS cards for the PNEFL are stored in DNS cold rooms. The pharmacist monitors the temperature daily. Currently, the other programs do not have products that require cold storage.

AEs in Mali are reported during the campaign. None were serious, and the most common were headache, nausea, or vomiting. An AE reporting template is in place, and AEs are reported to the health zone, HD, and regional levels. Materials have been developed to collect this information (i.e., the type of reaction and treatment) by drug administered. The cascade trainings emphasize the appropriate behavior in the case of undesirable events (minor or serious).

i) Supervision for MDA

This supervision is organized jointly and independently by the MSHP (NTD program, DNS, and CNIECS staff) and HKI NTD teams.

In FY18, supervision activities will be conducted at each level of the health pyramid, as described below. Solutions will be recommended onsite for all levels of supervision. In addition, all of the issues noted in the supervision checklist will be discussed during feedback and annual review meetings. During these supervision activities, the problems identified will be corrected to improve the quality of the NTD


activities. ENVISION will feed information back to the HD and regional levels to ensure that these recommendations are put in place.

The supervision tools are reviewed and revised annually with support from ENVISION, taking into account WHO directives and the operational plan of the national NTD program. These tools are presented and shared with participants during the TOT. Scorecards and treatment reporting forms are provided to the CDDs to collect MDA information. These tools are easy to use and do not require a high level of education. The supervision teams particularly monitor the targets’ compliance with treatment, the proper use of dose poles, the proper maintenance of the scorecards, drug packaging, and drug availability or stock-outs.

Activity 1: Supervision of national-level MDA

The NTD national program coordinators will conduct supervision activities in the regions to ensure that distribution campaigns comply with treatment directives. In collaboration with the Regional Directorates, CSREFs, and CSCOMs, the central level will review the documents concerning the management of drugs received, outcomes obtained by the health centers, and problems identified. In addition to supervision at the regional level, the NTD national program coordinators will go to health areas and villages to observe the MDA and offer solutions to specific problems.

Activity 2: Supervision of regional-level MDA

The DRSs will supervise the HDs during the MDA campaign. In collaboration with the MCDs and NTD Focal Points, they will review documents on the management of drugs received, results obtained by the health center, and all problems encountered. Recommendations will be made on site, and the problems identified will be discussed during the annual review meetings. They will ensure that data gathering has been conducted and that the report forms are maintained properly. The supervision will last for five days per MDA series and be implemented by two two-person teams. This strengthened supervision plan (i.e., with more teams) will enable the regional supervisors to supervise both the training of the DTCs and CDDs and the MDA activities in certain health areas.

Activity 3: Supervision of HD-level MDA

The MCDs and NTD Focal Points will provide supervision in the health areas where distribution is taking place. The HD’s NTD Focal Points will choose the health areas to be supervised. In collaboration with the MCDs, they will review documents on the management of drugs received, results obtained by the health centers, and problems identified. They will also examine documents relating to the distribution scorecards, distribution supplies, and supervision programs in the villages and direct a physical drug inventory. The supervision activities will last for five days per MDA round and be implemented by two two-person teams.

Activity 4: Supervision of the CSCOM level

The DTCs will conduct supervision activities in villages where MDA is being held. They will observe the MCDs during distribution and will make recommendations and propose solutions to problems encountered. This supervision will confirm the MCDs’ knowledge of NTDs; the protocols for drug distribution, supply, and drug management; and their data collection and transmission skills. The supervisors will also hold interviews with village and community leaders to assess the coverage of the target population in a given area. They will prepare a supervision report and send it to the MCD. This report will note all areas where proper implementation practices were not followed. The supervision will last for five days per MDA round in the DTC and be implemented by one team per CSCOM.


Activity 5: Supervision of insecure areas (HKI Supervision MDA)

The security situation in some areas of Mali continues to be a concern. ENVISION staff cannot travel to districts in Gao, Tombouctou, Menaka, and Taoudenit regions. For this reason, ENVISION will hire local supervisors to monitor the campaign in these areas. This strategy had been used since FY15, and typically, two supervisors are hired per region. ENVISION will support three regions (Gao, Tombouctou, and Taoudenit), and Menaka will be covered by WB. These supervisors are trained by the ENVISION team before the campaign and remain in contact with the ENVISION team throughout the supervision period, as confirmed by a final report. This supervision facilitates achieving high coverage rates in regions that implement MDA, improving the MDA campaign in general, and better understanding the problems that occur during MDA.

j) M&E

The successful efforts to combat LF, trachoma, and OV have led to changes in the epidemiological profiles of these diseases, resulting in necessary epidemiological assessments in line with WHO recommendations. The OV program currently projects that it will use only OV16 ELISA and PCR tests for the epidemiological surveys in FY18. This change will require additional training for the survey team members on using the new techniques. The LF TAS evaluations are scheduled in 75 HDs in FY18: 26 TAS1, 47 TAS2, and 2 TAS3. In FY18, the STH surveys will be combined with the LF TAS surveys in at least 26 HDs where the program does not have recent survey data and where security allows. The remaining STH surveys will be combined with SCH surveys, as in the past. All HDs in Mali that were surveyed for the pre-TAS in FY17 passed the assessment, and the results will be submitted to the Regional Program Review Group (RPRG) for TAS1 approval in FY18.

Activity 1: Improving use of TAS outcomes checklists for program managers

Mali’s LF program has not used the TAS checklist prior to planning and implementing the previous TAS activities or after conducting the TAS because the WHO TAS checklist was not previously available. However, HKI monitors to ensure compliance with WHO standards, and the protocol used for the TAS evaluations was reviewed and approved by the HKI’s NTD senior technical advisor for compliance. The checklist developed recently by WHO was shared with the LF program, and the ENVISION team will encourage the program to use it in future evaluations.

Activity 2: Integrated NTD Database

The historical data for all the NTD programs have been input into the integrated database and validated by the program coordinators. Data up to CY15 have been input, and the program needs to update the database with data from 2016 and 2017 (MDA and surveys). The database will be also used to generate the Joint Report Form (JRF) and the Epidemiological Data Reporting Form (EPIRF). Currently, the challenge is for the DNS to take ownership of this database and be responsible for updating the data regularly by advocating for the appointment of an NTD Data Manager. A refresher training on the database for stakeholders will be conducted in FY17, possibly by the consultant who worked on inputting the historical data. In FY18, the ENVISION team will support the MOH in taking over the management through regular monthly check-ins with the MOH Data Manager and updating of the national integrated database. Only HKI ENVISION staff time is expected to be required in this activity, for now.


DSAs

One of the key roles of the ENVISION project is to provide support for M&E activities, which make achieving the NTD elimination objectives possible. All the DSA protocols will be reviewed to ensure compliance with WHO directives before implementation. The project will support the MSHP in the design, implementation, and analysis phases.

The following activities are scheduled for FY18:

Activity 1: TAS

In Mali, 49/75 HDs have reached the criteria to stop MDA. The LF TAS will be implemented in all 75 HDs in the 11 health regions, including the newly created districts. The program will conduct TAS1 in 26 HDs, TAS2 in 47 HDs, and TAS3 in two HDs. WHO recommends TAS1 after a successful pre-TAS survey and five rounds of LF treatment. The program plans to conduct TAS1 surveys in 26 HDs (16 HDs plus 10 HDs created by the redistricting) in Gao, Tombouctou, Kidal, and Mopti regions. MDA began in 2008 in Tombouctou and in 2009 in Kidal, Gao, and Mopti. These HDs were affected by the security crisis. As a result, three HDs in Mopti (Youwarou, Teninkou, and Douentza) did not have MDA for one year, five HDs in Tombouctou (Diré, Tombouctou, Goundam, Nianfunké, and Gourma-Rharous) and four HDs in Kidal (Kidal, Abeibara, Tin-Essako, and Tessalit) did not have MDA for two years, and four HDs in Gao (Gao, Ménaka, Ansongo, and Bourem) did not have MDA for three years. However, all of these HDs have had at least five rounds of MDA. The decision was made to conduct TAS in these HDs despite the fact that the five rounds of MDA were not consecutive and did not reach effective coverage because they had low levels of antigen at baseline during mapping and successfully passed pre-TAS with only one positive case in all 16 HDs. All TASs will be combined with STH surveys (Kato Katz). This is the current plan, and actual implementation will be pending RPRG approval. If RPRG does not approve, then ENVISION should instead support another round of MDA in FY18.

TAS1 will be performed in four EUs, one in each region implementing TAS1 (see Table 16 for additional details).

TAS2 will be implemented in 17 EUs covering a total of 47 HDs.

TAS3 will implemented in the first two HDs that achieved the stop-MDA criteria in Sikasso region (Bougouni and Yanfolila) in 2012. These HDs then passed TAS2 in 2015 and are now scheduled for TAS3 in 2018.

The TAS1, 2, and 3 surveys will be integrated with STH surveys in FY18. WHO guidelines for TAS and SCH integrated surveys will be used. This activity will be an opportunity to obtain data for the 26 HDs where SCH/STH programs do not have recent data, and combining the surveys is practical given the security situation.

Activity 2: Sentinel/control evaluations for SCH/STH and re-evaluation surveys

In FY17, sentinel site surveys were planned in 12 HDs (Kita, Sagabari, Sefeto, Kolokani, Kati, Dioïla, Bankass, Douentza, Koro, Youwarou, Koutiala, and Yorosso) but were conducted only in 8 HDs. The prevalence of SCH in SAC decreased in six HDs but increased in two others. All planned surveys were not completed because of the indefinite MOH staff strike and the teachers’ strike. The prevalence of STH in the SAC examined was zero in all eight HDs surveyed (Sagabari, Sefeto, Kati, Dioïla, Bankass, Koro, Koutiala, and Yorosso).

Surveys for STH will be conducted in all 75 HDs in Mali through integration with TAS1, TAS2, and TAS3. SCH surveys will be conducted in three HDs: Kita, Koulokani, and Bla.


Table 14. Planned DSAs for FY18 by disease

Disease No. of

endemic districts

No. of districts planned for

DSA

No. of EUs planned for

DSA (if known)

Type of assessment

Diagnostic method (Indicator: e.g.,

microfilaremia or FTS)

LF 75

26 6 TAS1 FTS

47 17 TAS2 FTS

2 1 TAS3 FTS

OV* 35 22 18 Epidemio-logical OV16 ELISA

OV* 35 17 17

Entomological (with

Sightsavers support)

O-150 PCR

Trachoma 69 19 19 TSS TF and TT

SCH 3 Kato Katz

STH 75 Kato Katz

*OV stop surveys must have prior validation by the OEC after a full data review.

k) Supervision for M&E and DSAs

The supervision is conducted jointly (HKI, DNS, DRS, and one staff from the district).

Activity 1: DSA protocol review

In-country ENVISION staff provide TA to the national program for protocol development (e.g., sampling and methodology). ENVISION ensures that WHO guidelines are shared with the national program staff and followed. ENVISION assists the program in sharing data with the RPRG to receive approval, as appropriate. Besides staff time, there are no costs related to this activity.

Activity 2: Supervision of field activities (HKI Supervision M&E DSA)

The ENVISION M&E team supervise all surveys except those implemented in HDs with security issues, in which local supervisors are located. During this supervision, the team ensure that the activities are implemented as written in the approved protocols. This allows for prompt correction in the field and ensuring that the correct methodology is used. For northern regions, HKI staff maintain communication with the surveyor during the survey itself to ensure that the survey is implemented correctly.


Activity 3: Report review

The NTD program submits a final report to ENVISION staff after DSAs have been implemented. This gives the ENVISION staff time to review and make corrections where necessary.

l) Dossier Development

The Mali LF program has made substantial progress toward eliminating LF as a public health problem. Thus, 49/75 HDs have reached the stop-MDA criteria, and the 16 remaining districts passed the pre-TAS in FY17 (these 16 HDs were split into 26 HDs in FY17). In addition to this progress, the program’s historical data up to 2015 have been recorded in the NTD integrated database. This tool will be very important to develop the LF elimination dossier. Therefore, the country can conduct TAS2 in 47 HDs, TAS3 in 2 HDs, and TAS1 in 26 HDs in FY18.

Activity 1: Complete LF historical data entry into the integrated NTDs database up to 2017

The DNS, with partners’ support, will input the LF data (from both MDA and surveys) into the integrated NTDs database so that all relevant data will be kept in one location and accessible. This activity will be completed in Q1–2 of FY18.

Activity 2: LF elimination dossier template presentation

The LF program will present the LF elimination dossier template to the partners and DNS M&E section to inform the MOH about the various dossier components and the requirements for successful submission. This activity will take place during a Technical Committee meeting in first six months of FY18.

Activity 3: Complete the LF elimination dossier MDA section

As Mali progresses toward LF elimination, the MDA data will be recorded in the dossier template in preparation for the submission of the final document. This activity will take place Q1–2 in FY18.

Note that there are plans to establish a national trachoma elimination committee to guide Mali towards elimination and eventual dossier submission.


3) Maps

Note: Endemic status means requiring MDA





APPENDIX: Work Plan Timeline

FY18 Activities Q1 Q2 Q3 Q4

O N D J F M A M J J A S

Management Support Steering committee Joint application matrix filled out and submitted to WHO Training of laboratory technicians on OV16 ELISA Project Assistance Strategic Planning National stakeholders’ meeting and NTD annual review Technical Coordination Committee meetings and NTD Steering Committee meetings Regional review meetings (NTD MDA Campaign) Meeting to review OV strategy and OEC meeting NTD Secretariat Building Advocacy for Sustainable National NTD Program Advocacy session at the central and regional levels Mapping MDA Coverage Social Mobilization to Enable NTD Program Activities BCC materials review meetings National MDA campaign launch Regional MDA launch ceremony MDA sensitization messages broadcast Training TOT (regional level) TOT (HD level) Training of CHWs (CSCOM level) Drug Supply Management and Procurement Drug transport from national warehouse to regions Reverse logistics from regions to the national warehouse Supervision for MDA MDA drug package 1 (IVM+ALB or IVM alone or ALB alone) MDA (PZQ or PZQ+ALB) M&E LF TAS1 – STH (4 EUs, 26 HDs)


FY18 Activities Q1 Q2 Q3 Q4

O N D J F M A M J J A S LF TAS2 – STH (17 EUs, 47 HDs) LF TAS3 – STH (2 EUs, 2 HDs) OV epidemiological assessments (18 HDs) OV entomological assessments (18 HDs) TIS or TSS SCH sentinel site surveys MDA Coverage surveys Dossier Development Update of historical data STTA MMDP Hydrocele and elephantiasis cases census and cure Trichiasis case surgery


Documents

MALI Work Plan - ENVISION...MALI Work Plan FY 2018 Project Year 7 October 2017-September 2018 ENVISION is a global project led by RTI International in partnership with CBM International,