Cross Border Initiative for Polio Eradication in the Horn of Africa:

Operationalizing and Strengthening

APHA 2015Chicago, USA

Bal Ram Bhui, CGPP HOAFilimona Bisrat, CGPP Ethiopia

Anthony Kisanga, CGPP South SudanMercy Lutukai, CGPP HOA

CORE Group Polio Project (CGPP)

Presentation Objectives

• To provide an overview of process of Cross Border Initiative for Polio Eradication in Horn of Africa

• Share achievements of cross border initiative for polio eradication.

• Challenges and lesson learnt

WPV & cVDPV: HOA, 2013-14

2013:• Ethiopia: 9• Somalia: 194• Kenya: 14 (14th July)

• Total: 217

2014:• Ethiopia: 1 (5th Jan)

• Somalia: 5 (11 August)

• Kenya: 0• Total: 6cVDPV in South Sudan: 2(9th & 12th Sep 2014 Onset)

Polio outbreaks in HOA

Border Population at Risk• Border communities share

ecology, epidemiology, culture, and values

• Border communities are likely to be: Hard to reach, Left outs, Socio-economically disadvantaged

• Borders are porous, free movement

• People move for trade, pastures, health care, education, cultural reasons, recreation, migration, conflict and security

Cross border meetings for polio evolution

• 2012 Cross border meetings of Ethiopia, Somalia, South Sudan, Sudan and Kenya in 4 operational sites organized by MOH Ethiopia

• 2013 Cross border meeting in Kisumu between South Sudan, Uganda and Kenya organized by WHO

• African Region cross border meetings- Kampala, Uganda (2004), Abuja, Nigeria (2010), Lusaka, Zambia (2011) and Natitingou, Benin (2013) supported by WHO

• Cross border meetings by CORE Group South Sudan with Ethiopia, Kenya, DRC, Uganda

Recommendations from past Cross Border Meeting

• Agree on criteria to define at-risk border districts• Agree on need for early warning and response system and harmonization

of activities with IDRS implementation and surveillance training• Agree on sharing of technical expertise and disease information and

improve coordination of disease control activities• Identify need for community based surveillance system to supplement

data obtained from health facility• Engage community in solving public health issues• Strengthen partner commitment• Increase local resources in cross border initiatives• Integrate cross border activities in annual health planning process• Involve other sectors (Water, Infrastructure, Traders) and stakeholders

(immigration and border security)

Operationalizing and Strengthening Cross-Border Initiative

• WHO AFRO Guidance for Cross Border Initiative for public health issues

• EAC Institutional Framework for Cross border Integrated Disease Surveillance and Response in East Africa Region

• CORE Group CBI Model building on above two

CORE Group in HoA• HOA regional secretariat in

Nairobi• CGPP Project in Ethiopia since

2001• CGPP Project in South Sudan

since 2010• CGPP in Kenya and Somalia

since 2014• CGPP Management Model

– Secretariats – global, country– Implementing partners – CORE

Group NGOs, National NGOS

Coordinative partnership to joint working relationship

• Country is responsible for resource mobilization for implementation of cross border activities

• Monitoring of implementation of activities done separately by each border health authority

• But activities are well aligned and strategic and operational information is shared regularly with all partners

• Partner organizations – CORE Group, WHO extends technical and financial supports to each country health authority

Goal and Objectives of CGPP CBI• Goal: Contribute to global eradication by

improving the population immunity in cross border communities and population with an effective AFP surveillance

• Objectives: To promote cross border collaboration between health, administrative authority of border regions and the partners for polio eradication efforts

Scope of CGPP Cross Border Initiative• Advocacy to border county/district health authority

for cross border initiative• Interventions to improve mass polio vaccination• Institute cross border surveillance• Interventions to improve routine immunization• Country and joint planning• Institute governance system – Cross Border Health

Committee• Establish mechanism for communications• Involve stakeholders

Scope of CGPP CBI• Implementation– Each country implements its plan of action– Training – planning, surveillance, immunization– In county monthly review/shared with counterparts– Quarterly joint review meeting– Annual review and planning meeting inclusive of border

health facilities– Supporting partner supports implementation

• Monitoring and Evaluation– Monitoring of workplan implementation– Monitoring of performance indicators

• Inputs, process, outputs, outcome

Results• Cross border Initiative Operation Guide developed• Cross border initiative functional with cross border health committee in

– 3 sites in Kenya with Somalia, Ethiopia, South Sudan and Uganda and – 3 sites in South Sudan with Kenya, Uganda, DR Congo

• Mapped and profiled cross border villages, border crossing points, border health facilities using standard tools– 3 border sub county, Turkana county, Kenya poses 30 border crossing points,

about 700 cross everyday, 35 border villages with about 10 thousand under 5 population

• High level of commitment and support from MOH, County Health Office, Immigration and Security offices

• High level of commitment from polio Partners – WHO and UNICEF and NGOs

Results

• Vaccination of children in crossing points with polio during campaign– Kenya vaccinated 3816 (1%) of in 5 border counties in Aug

2015– South Sudan vaccinated 8,864 in Nov and Dec 2014 and

12,225 in Feb and Mar 2015 in 5 counties• South Sudan vaccinated 6,514 children in 7 permanent

cross border vaccination points from August 2014• Moyale Somali region of Ethiopia established

permanent vaccination sites on 14 crossing points that is vaccinating children's for polio

Results

• AFP Surveillance– Increased rate of AFP case detections– Community based surveillance instituted– Sharing of surveillance data with border

counterparts– Joint case investigation

• Cross border committee meetings – monthly in country, quarterly and annual between countries

Challenges and Recommendations– Country capacity varies – technical, health infrastructure,

resource leveraging– Need for priority commitment from National and Local

government and MOH institutions– Need for continued operationalization and strengthening of

process and activities– Need for improved accountability, documentation, reporting and

monitoring– Potential for integrating other diseases and cross border health

issues– Need for adequate resource mobilization for border health

facilities and communities– Border security

Extras

Inputs and activities

Cross Border Initiative Framework – WHO AFRO

WHO AFRO Guidance for Cross Border Initiative for public health issues

• Three type of joint working relationships– Cooperation, Coordination, Collaboration

• Attributes of Successful Joint Working Relationship– Purpose, Process and structure, Resources, Strategic and

operational communications• Operationalization of joint working relationship– Strategic planning, Defining the scope, identifying

stakeholders, Governance, Operational Plan, Monitoring and Evaluation, Advocacy, Communication

EAC Institutional Framework for Cross border Integrated Disease Surveillance and Response in East

Africa Region• Operational procedures

– Identification of priority animal and human diseases– Establishment of Cross Border Disease Surveillance and Response Team

• Regional Rapid Response Team (RRT), District RRT

– Cross border DSR Committee– Mechanism for sharing epidemiological information– Community based disease surveillance in the cross-border zones– Joint planning for Epidemic Preparedness, Investigation and Synchronized

Response– Training– Joint designation of ground crossing points for implementation of IHR

(2005)– Workplan template and suggested activities– Monitoring for Implementation

Scope of CGPP CBI• Advocacy to border county/district health authority

for cross border initiative– Discuss on goals, objectives, cross border health

committee and ToR• Initiation meeting – Border county/district health

office come together to initiate the initiative– Formation of cross border health committee– Agree on plan for Cross border health situation

assessment• Country ownership and resource mobilization

Scope of CGPP CBI• SIA

– Improve quality of mass polio campaigns in border communities and population

– Improve synchronization of polio campaigns in cross border points– Establish permanent vaccination points at major crossing points– Improve PEI efforts in transit hubs and routes

• AFP surveillance– Establish cross border surveillance for AFP and selected disease and conditions

in cross border facilities– Joint case investigation and response– Establish mechanism for sharing of AFP surveillance data– Establish a community based surveillance

• Routine Immunization– Improve routine immunization services to border villages with

outreach/mobile clinics

Scope of CGPP CBI• Planning

– Identification and profiling of border crossing points, border communities and transit hubs and routes

– Joint mapping of border crossing points and border communities– Improve micro planning– Country specific cross border initiative plan– Joint country cross border plan

• Governance– Develop a cross border health committee with designated co-sharing positions– Representation of county and sub county health offices and relevant technical programs– Representation of stakeholder – immigration, security, non-health sectors, business

community– Manual for planning, governance, implementation, reporting ad monitoring– Periodic in-country and joint review and planning meetings– Designated focal persons for communication

Scope of CGPP CBI• Communication between partners

– Vertical and horizontal communication between health authorities and facilities

– Immediate, weekly, and monthly frequency– Sharing of surveillance, polio campaign data, routine immunization

data– Sharing of meeting minutes

• Stakeholders– National, County, Sub county and health facility authorities– Surveillance staff, Immunization Staff– County governments– County border security agency– County immigration agency

Scope of CGPP CBI• Implementation– Each country implements its plan of action– Training – planning, surveillance, immunization– In county monthly review and shared with counterpart– Quarterly joint review meeting– Annual review and planning meeting inclusive of border

health facilities– Supporting partner supports implementation

• Monitoring and Evaluation– Monitoring of workplan implementation– Monitoring of performance indicators

• Inputs, process, outputs, outcome

Progress – Kenya – Cross border initiative sites

Cross border initiative place

Border region of Kenya

Between – county health office and countries

Achievements

Lokichhogio, Turkana, Kenya

Turkana West, Kibish, Loima – Turkana, Kenya

Kapoeta East-South SudanGaabong-Uganda

3 meetings done

Moyale, Marsabit, Kenya

Moyale, North Horr – Marsabit Wajir North – Wajir - Kenya

Moyale - Ethiopia 3 meetings done

Garissa, Garissa, Kenya

Dadaab, Fafi, Hulugo – Garissa East, Garissa South- Kenya

Gedo, Lower Juba region - Somalia

One meeting done

Mapping border crossing points, border villages and population sizes

Kenya counties Sub counties# crossing points

Average in a day

# border villages

Estimated U 5 pop

Border country

Kibish 7 386 5 479 EthiopiaKibish 7 38 15 1,119 South SudanLoima 4 87 4 1,143 UgandaTurkana West 11 200 10 7,085 South SudanTurkana West 1 10 1 120 Uganda

Total - Turkana 3 border sub counties 30 721 35 9,946

Ethiopia, South Sudan and Uganda

Wajir North 24 77 25 4,695 EthiopiaWajir South 3 117 4 6,735 Somalia

Total - Wajir2 border sub counties 27 194 29 11,430

Ethiopia, Somalia

Garissa Dabaab 8 47 8 1,089 Somalia

Wajir

Turkana

August 2015 Kenya SIA Results in four cross border counties- Turkana, Marsabit, Wajir, Garissa

Data Number PercentTotal vaccinated in the campaign 560207Number vaccinated in area outside household play ground, street etc. 64567 11.5%Number vaccinated in Bus Station 1634 0.3%Number vaccinated in Border Crossing point 3916 0.7%Number vaccinated in Water Points 6041 1.1%Number vaccinated in Nomadic Settlement 7777 1.4%

South Sudan cross border initiative sites

Cross border initiative place in South Sudan

With neighbour border region and country

Year of establishment

Morobo-South Sudan Koboko-Uganda 2012

Adi-DR Congo 2012

Kajo-Keji-South Sudan Moyo-Uganda 2013

Yumbe-Uganda 2013

Magwi-South Sudan Amuru-Uganda 2013

Lamwo-Uganda 2013

Adjumani-Uganda 2013

Kapoeta East-South Sudan Turkana West- Kenya 2013

South Sudan Cross border collaboration meetings

• Quarterly Review Meetings: • The project supported a cross border committee meeting between

Uganda and South Sudan on the 6th Feb. 2015, with 24 people in attendance.

• Another meeting supported by the project at the county level and brought together DR Congo, Uganda and South Sudan, this was held in Aru DRC Congo from 30-31 /4/2015 with total attendance of 43 participant

• The quarterly review meetings were to discuss activities and plans on cross border special vaccination posts, upcoming NIDs and information on surveillance

• Annual Review meeting:• Core Group South Sudan organized together an annual review meeting in

Arua-Uganda to discuss progress so far made, share information on immunization, surveillance, challenges and way forward in 30-31 July 2015. This meeting brought along 44 participants from Uganda, DRC and South Sudan.

South Sudan – Children vaccinated at border crossing points with Kenya, Uganda and DR

CongoCross border counties Number of children immunized during

campaignCounties 2014 (Nov, Dec) 2015 (Feb, Mar)Magwi 1,475 2,091Kapoeta East 471 110Kajo-Keji 1,349 1,345Nzara 1,481 1,438Morobo 4,088 7,241Total 8,864 12,225

South Sudan – Children vaccinated at border permanent vaccination post with Kenya, Uganda and DR Congo

County # of vaccination post Bordering country Total # of children vaccinated

# of zero dose

Kajo-Keji 4 Uganda 1,216 6Magwi 1 Uganda 1,052 1Kapoeta East

1 Kenya 3,120 38

Morobo 1 Uganda/DRC 1,126 0Total 7 3 6,514 45

Special vaccination posts set up throughout the week along busy routes connecting countries . Children 0-15 years passing the border vaccinated with OPV. Core Group started this initiative in August 2014.

Progress – South Sudan – AFP surveillance

• Community based surveillance in place• Kajo-Keji- 6 AFP cases-Oct 2014- Sept 2015• Magwi- 5/10 AFP cases- Oct 2014- Sept 2015• Morobo- 2 AFP cases Oct 2014- Sept 2015• Kapoeta East- 2 AFP cases- Oct 2014-Sept 2015• Reporting of other diseases beside polio• 2 Measles cases identified in Morobo county which was

traced back to a village in DR Congo• Joint case investigation initiated within the border districts as

a results of the collaboration & coordination.• Cholera notification outbreaks in South Sudan and Uganda by

the cross border committees

Social mobilization and communication – South Sudan

• 5 – Joint radio talk shows were conducted, 1 in Kitgum – Uganda at Mighty Fire FM and 2 in Adjumani – Amani FM, Trans Nile broadcasting in Moyo- Uganda and Koboko FM.

• Translation of IEC materials in local language used along the border this was between Koboko-Uganda, Adi-DR Congo and Morobo-South Sudan

Ethiopia – Cross border initiative place

Cross border initiative place

Between – county health office and countries

Established when?

Moyale Somali and Oromia

Mersabit county of Kenya October 2014

Dollo Ado Somali Mandera county of kenya

On progress

Aysha Somali Adjacent districts of Djibouti

On progress

Progress - Ethiopia• CGPP started cross border initiatives in 2012. Involved in country

level CBM held in four different places with bordering countries (Kenya, Somalia, S. Sudan, Sudan and Djibouti )

• Following the Horn of Africa polio outbreak in 2013, CBM collaborative meetings were conducted in Djibouti and Jigjiga Ethiopia to discuss immunization, surveillance, and coordination for outbreak control.

• The Horn of Africa TAG understood country level cross border coordination has limitations in monitoring the implementation of planned activities. Recommended local level cross border coordination among bordering districts of countries.

• CORE Group Horn of Africa Regional Coordination Office and CGPP Ethiopia Secretariat started cross border coordination at local level in Moyale and Marsabit counties in October 2014.

Progress – Ethiopia (Contd.)• Since then, cross border communities, health facilities and crossing points

along the border have been mapped with mapping tool• Cross border health committee was established • Follow up cross border health committee meeting conducted at Moyale

etc. • Cross border implementation manual was developed by HOA CORE Group

and is being adapted to other countries• Other partners and stakeholders committed to sustaining the initiative• Permanent vaccination sites at 14 crossing points in Moyale now

vaccinating children against polio• During polio immunization campaigns vaccination posts will be established

at crossing points• Information sharing on immunization and surveillance is ongoing

Progress – Ethiopia – AFP surveillance

• Community based surveillance in place• 3 AFP cases reported by CVs in Moyale

Woreda out of reported 4 cases 2014/2015 according to week 31 WHO report

• CVs are providing health education and case searching in all districts

Summary of AFP Surveillance indicators by Region , Ethiopia Jan 01 – July 24, 2015

RegionExpected Cases (2015)

Reported (this period 2015)

Reported (same period 2014)

Reported this

Week

NP-AFP Rate

(annualized)

Stool Adequacy

(%)

Stool Cond.

(%)NPENT (%)

Compatibles

VDPV Cases

WPV Cases

A ABABA 14 11 14 0 2.8 82 100 0.0 0 0 0

AFAR 12 17 15 1 5.1 100 83 3.1 0 0 0

AMHARA 170 174 115 11 3.7 93 79 4.3 0 0 0

B/GUMUZ 9 8 11 1 3.2 88 75 0.0 0 0 0

D/DAWA 2 1 2 0 1.8 100 100 0.0 0 0 0

GAMBELLA 3 7 8 1 2.0 100 43 0.0 0 0 0

HARERI 2 2 3 0 3.6 100 100 0.0 0 0 0

OROMIA 315 263 231 15 3.0 92 80 1.8 0 0 0

SNNPR 165 128 136 9 2.8 97 87 6.0 0 0 0

SOMALI 46 67 81 3 5.1 94 88 4.1 0 1 0

TIGRAY 39 20 25 2 1.8 85 89 0.0 0 0 0

NATIONAL 777 698 641 43 3.2 93 82 3.3 0 1 0