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Indonesia 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 U.S. 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 U.S. Agency for International Development

or the U.S. Government.

ENVISION FY18 PY7 Indonesia Work Plan

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ENVISION Project Overview

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

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

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

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

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

• NTD monitoring and evaluation (M&E).

At the country level, ENVISION supports 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; and

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

In Indonesia, ENVISION project activities are implemented by RTI International.


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

LIST OF TABLES ............................................................................................................................................. iii

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

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

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

b) Other NTD Partners ............................................................................................................ 8

2) National NTD Program Overview ...................................................................................................... 9

a) Lymphatic Filariasis ............................................................................................................. 9

b) Schistosomiasis ................................................................................................................. 11

c) Soil-Transmitted Helminths .............................................................................................. 11

3) Snapshot of NTD Status in Indonesia .............................................................................................. 13

PLANNED ACTIVITIES ................................................................................................................................... 14

1) NTD Program Capacity Strengthening ............................................................................................ 14

a) Strategic Capacity Strengthening Approach ..................................................................... 14

b) Capacity Strengthening Objectives and Interventions ..................................................... 14

c) Monitoring Capacity Strengthening .................................................................................. 15

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

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

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

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

d) Mapping ............................................................................................................................ 19

e) MDA Coverage .................................................................................................................. 19

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

g) Training ............................................................................................................................. 22

h) Drug and Commodity Supply Management and Procurement ........................................ 23

i) Supervision for MDA ......................................................................................................... 23

j) M&E .................................................................................................................................. 24

k) Supervision for M&E and DSAs ......................................................................................... 28

l) Dossier Development ........................................................................................................ 28

APPENDIX 1: Work Plan Timeline................................................................................................................ 29

LIST OF TABLES


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Table 1. Administrative and health structure in Indonesia .............................................................. 7

Table 2. Non-ENVISION NTD partners working in country, donor support, and summarized

activities .............................................................................................................................. 8

Table 3. Snapshot of the expected status of the NTD program in Indonesia as of September 30,

2017 .................................................................................................................................. 13

Table 4. Project assistance for capacity strengthening .................................................................. 16

Table 5. USAID-supported districts and estimated target populations for MDA in FY18 .............. 19

Table 6. Social mobilization/communication activities and materials checklist for NTD work

planning ............................................................................................................................ 21

Table 7. Planned DSAs for FY18 by disease .................................................................................... 27


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ACRONYMS LIST

ALB Albendazole

BBTKL National Environmental Health Laboratory, Ministry of Health (Balai Besar Teknik

Kesehatan Lingkungan)

BINPHARM Directorate General of Pharmaceuticals and Health Supplies, Ministry of Health

BR Brugia Rapid

CDC U.S. Centers for Disease Control and Prevention

CY Calendar Year

DEC Diethylcarbamazine Citrate

DEKON Special GOI funding to support national programs at the lower levels (dekonsentrasi)

DHO District Health Office

DOLF Death to Onchocerciasis and Lymphatic Filariasis project

DOT Directly Observed Treatment

DQA Data Quality Assessment

DSA Disease-Specific Assessment

EU Evaluation Unit

FOG Fixed Obligation Grant

FTS Filariasis Test Strip

FY Fiscal Year

GOI Government of Indonesia

GSK GlaxoSmithKline

HC Health Center

HQ Headquarters

IEC Information, Education, and Communication

LF Lymphatic Filariasis

M&E Monitoring and Evaluation

MDA Mass Drug Administration

Mf Microfilaremia

MOH Ministry of Heath

NGO Non-Governmental Organization

NTD Neglected Tropical Disease

NTF National Task Force

OKU Ogan Komering Ulu

OKUT Ogan Komering Ulu Timor

PHO Provincial Health Office

PSA Public Service Announcement

Q Quarter

RPRG Regional Program Review Group

SAC School-Age Children

SAE Serious Adverse Event

SAR Semi-Annual Report

SCH Schistosomiasis

STH Soil-Transmitted Helminths

STTA Short-Term Technical Assistance

Subdit Subdirectorate for Control of Lymphatic Filariasis, Soil-Transmitted Helminths, and

Schistosomiasis, Ministry of Health


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TA Technical Assistance

TAS Transmission Assessment Survey

USAID U.S. Agency for International Development

WHO World Health Organization


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COUNTRY OVERVIEW

1) General Country Background

a) Administrative Structure

Indonesia is the fourth largest country in the world, with a population of over 262 million people spread

throughout 13,000 islands. Following years of restructuring, Indonesia is currently divided into 34

provinces and 514 districts. Administrative and health structures related to the management of the

national neglected tropical disease (NTD) program are summarized in Table 1 below.

Table 1. Administrative and health structure in Indonesia

Level Bahasa Indonesia

term

Head official Related health structure

National Negara Presiden Ministry of Health, Subdirectorate for Control

of Lymphatic Filariasis, Soil-Transmitted

Helminths, and Schistosomiasis (Subdit)

Provincial Provinsi Gubernur Provincial Health Office

District Kabupaten–rural

Kota–urban

Bupati

Walikota

District Health Office

Subdistrict Kecamatan Camat Health center (puskesmas)

Village Desa–rural

Kelurahan–urban

Kepala Desa

Lurah

Health post (posyandu)

Hamlet Rukun Warga --

^ In Papua and Papua Barat, this level is called a distrik.

The Subdit, a unit within the Directorate General of Disease Control and Environmental Health of the

Ministry of Health (MOH), is the lead for lymphatic filariasis (LF), soil-transmitted helminths (STH), and

schistosomiasis (SCH) activities. A National Task Force (NTF) exists to oversee NTD policy, plans, and

activities. It consists of MOH staff, ex-MOH staff, and academics, with multilateral agency

representatives from the World Health Organization (WHO) and United Nations Children’s Fund invited

as observers. The NTF meets at least once a year to discuss specific issues and provide technical

recommendations for improving the LF, STH, and SCH programs.

At the national level, the Subdit is responsible for determining policies and procedures for program

implementation, supervising and mentoring lower-level staff, monitoring and evaluation (M&E), and the

procurement of drugs and operational supplies, such as rapid diagnostic tests. The provincial level is

responsible for supervision and M&E, and each province has a small budget to fund these activities.

District governments are required to provide operational budgets for LF and STH mass drug

administration (MDA), including training, drug distribution, and monitoring, and are directly responsible

for program implementation in their respective areas. Each community health center (HC) is responsible

for organizing activities in its catchment area in coordination with the village government and, following

recent official clarification by the MOH, has its own operations budget that may be used to support NTD

activities. In addition, each village has a small development budget provided by the national

government, which can also be used to support the promotion of the MDA. Beginning in 2015, the MOH

has been able to provide limited funding for LF/STH MDA through a special mechanism from the central

level that is called dekonsentrasi (DEKON), which can be used to augment local budgets as needed.

These funds are provided to provincial health offices (PHOs) and have been used to support the

supervision of MDA activities by provincial staff, advocacy and review meetings at the district level, and


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MDA implementation. The use of these funds is based on gaps in local budgets and local priorities.

These DEKON funds will be available to support the 2017 LF/STH MDA but at a much lower level than in

previous years. Coordination among these separate and disparate government units is critical to ensure

that sufficient resources are available to support all required NTD work because each unit makes its own

decisions on how to allocate their own budgets.

b) Other NTD Partners

Indonesia has two primary partner organizations providing funding support for NTD work: the U.S.

Agency for International Development (USAID) and WHO (Table 2). WHO provides limited support for LF

transmission assessment surveys (TASs), strategic meetings, pilot web-based reporting system

development, supervision, and SCH elimination. Since the beginning of the LF/STH MDA program, the

MOH has accepted donations of albendazole (ALB) from GlaxoSmithKline (GSK) through WHO. In mid-

2016, following budget cuts, the Indonesia MOH accepted a large donation of diethylcarbamazine

citrate (DEC) tablets from Eisai Company, Ltd. of Japan through WHO to provide the MOH with the

necessary drugs to expand programmatic support to more endemic districts. Beginning in 2017, the

MOH has continued to utilize the WHO drug donation program to offset gaps in their own ability to

procure sufficient ALB and DEC from local manufacturers through the government procurement system.

The MOH will also continue to procure the required diagnostic tests, Brugia Rapid (BR) tests and filariasis

test strips (FTSs), for 2018 with government funds. Through the Task Force for Global Health, USAID is

supporting operational research around failed TAS3 in Alor district.

Other partners are also implementing limited activities in Indonesia. U.S. Pharmacopeia implemented a

scoping study in fiscal year 2017 (FY17) to determine the in-country capacity to manufacture NTD drugs.

Additionally, in FY17, the Bill and Melinda Gates Foundation, through Washington University’s Death to

Onchocerciasis and Lymphatic Filariasis Project (DOLF), funded OR on the safety of ivermectin, ALB, and

DEC (‘triple drug’) therapy in one district.

For STH-only MDA, the MOH procures its own ALB for distribution in those areas implementing STH-only

MDA.

Table 2. Non-ENVISION NTD partners working in country, donor support, and

summarized activities

Partner Location

(Regions/States) Activities

List other donors

supporting these

partners/activities

MOH Central, province,

and district

LF/STH MDA support in ~122 districts in 2017

including advocacy, M&E, and limited capacity

building activities.

Drug procurement of ALB and DEC, as well as FTS

and BT tests

WHO

WHO Jakarta with field

visits to

implementing

provinces/districts

Provides technical and limited financial support

for strategic planning, M&E, and

donation/importation of ALB (2016, 2017, and

2018), DEC (2016, 2017, and 2018), and FTSs/BR

tests for special activities (2017)

GSK and Eisai

Provides financial and technical support for SCH

elimination activities in two endemic districts

MOH


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Partner Location

(Regions/States) Activities

List other donors

supporting these

partners/activities

U.S.

Pharmacopeia

Jakarta Implementation of an Assessment of

Pharmaceutical Management of NTDs

USAID

University of

Indonesia:

DOLF

Jakarta with field

work

Triple drug MDA Bill and Melinda

Gates Foundation

University of

Indonesia:

Coalition for

Operational

Research on

NTDs

Alor OR to follow up on failed TAS3 USAID

2) National NTD Program Overview

a) Lymphatic Filariasis

In 2005, the Government of Indonesia (GOI) decreed filariasis elimination to be one of the national

priorities to combat communicable diseases, and fully endorsed the WHO goal of eliminating LF as a

public health problem globally by 2020. All three types of lymphatic parasites—Wuchereria bancrofti,

Brugia malayi, and Brugia timori—are prevalent in Indonesia, with B. malayi being the most widespread.

Currently, LF is considered endemic in 236 districts, with 61 million people still requiring LF MDA in 176

districts and 14,932 chronic cases of either lymphedema or hydrocele reported. Mapping of the entire

country using night blood to analyze the prevalence of microfilaremia (Mf) was completed in 2016.

Program Goal

The goal stated in the integrated NTD Plan of Action 2016–2020 was to reach 100% geographic coverage

of LF MDA in 2016 and, thereby, be able to stop mass treatment by 2020. However, the MOH fell short

of this goal because of serious financial constraints beyond its control. Four endemic districts were

unable to begin implementing their planned MDA in 2016, and several of the districts that started MDA

in 2016 did not reach sufficient coverage to meet WHO requirements. The MOH is now determined to

reach 100% geographic coverage in 2017 and has ensured that sufficient funding to support MDA is now

available from a variety of sources at every level of government, from the provincial to the village level.

Current projections indicate that the national program will be able to stop MDA in all districts after the

2021 LF/STH MDA.

Current national strategies follow the latest WHO guidance for LF (primarily that outlined in the 2011

TAS manual) and are consistent with the major recommendations from international experts provided

during WHO regional NTD expert meetings over the last two years. October has been designated as

Bulan Eliminasi Kaki Gajah (LF Elimination Month), and MDA is typically organized across most endemic

districts during this month.

The key challenges for the program in FY18 include the following:

• Meeting the 100% geographic coverage goal;


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• Ensuring that quality drugs are available in a timely fashion;

• Significantly increasing compliance; and

• Ensuring sustainable district-level budgets for MDA.

MDA

A total of 51.2 million people live in 150 districts requiring LF MDA in October 2017, and 14.7 million live

in 43 full districts and one partial district pending pre-TAS/TAS results, and 32.7 million people live in 43

full districts and two partial districts currently in post-MDA surveillance.1 In October 2016, LF/STH MDA

reached 43.8 million people in 181 LF-endemic districts (98.3% geographic coverage). The MOH is

determined to reach 100% geographic coverage in 2017 and has increased access to district and HC

funding support for LF/STH MDA. The MOH has also conducted several advocacy meetings at the

provincial and district levels across the country to ensure proper organization and management of MDA.

Although districts in Indonesia often report effective epidemiological coverage for LF/STH MDA, recent

surveys continue to show that marked differences can exist between reported coverage and the actual

proportion of people ingesting drugs. This compliance problem is common in Asia, where directly

observed treatment (DOT) is not always enforced, and presents a huge challenge for the Subdit and the

health services at the lower levels in terms of changing the attitudes of health personnel and

communities toward the importance of DOT during MDA.

TASs

TASs are implemented in Indonesia as school-based, cluster surveys using BR tests in Brugia spp. areas

and immunochromatographic tests (ICTs) (and FTSs as of January 2017) in W. bancrofti areas. Since

2009, 61 districts have implemented TAS1 to determine whether MDA can be stopped (including eight

districts that implemented a re-TAS1). Of the 61 districts that have implemented TAS1 and re-TAS1, 55

have passed (90%). Of the 32 districts that have implemented TAS2, 23 have passed (72%). Ten districts

have implemented TAS3 (90% passed).

Given the challenges associated with interpreting TAS results in Brugia spp. areas in Indonesia, a TAS

Expert Meeting was held in March 2016 to provide Indonesia with specific guidance. The experts

recommended that the critical cut-off in Brugia spp. areas, which use antibody tests to determine

prevalence, should remain the same as that recommended in the TAS manual and that the MOH should

use TAS checklists to better prepare and supervise TASs and investigate TAS failures. The experts also

recommended that all positive BR results be tested for a second time and that any discordant results be

removed from the sample. All of these measures have been incorporated into the standard practices of

the Subdit. Since that meeting, no districts have failed TAS.

During FY17, 32 districts will implement TAS (TAS1=25, TAS2=2, and TAS3=5). In FY18, 56 districts are

planning to implement a total of 59 TAS. Thirty-six (36) districts will implement 37 TAS1 surveys, 11

districts will implement a total of 13 TAS2 surveys; and 9 districts will implement a total of 9 TAS3

surveys.

USAID support

USAID support began in FY11, with financing for LF/STH MDA in 13 districts scattered throughout the

country. After a review of LF endemicity and MDA data, ENVISION, the MOH, and USAID agreed on a

1 As October 2017 MDA is reported in FY17 workbooks, the districts requiring MDA data matches with the FY17

SAR1 workbook, while the pending and post-MDA surveillance data come from FY18 work planning workbook.


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goal of LF elimination in Sumatra and Kalimantan by 2020. ENVISION scaled up LF/STH MDA in FY12 and

FY13, mostly in Sumatra, to help the MOH reach full geographic coverage in that region. ENVISION will

support LF/STH MDA activities in October 2017 working with local non-governmental organizations

(NGOs) in 28 districts, all of which received ENVISION support in the past. For the October 2018 LF/STH

MDA, ENVISION will continue its support for 16 districts.

Past ENVISION support was instrumental in assisting the MOH to complete LF mapping for the country.

ENVISION has also provided assistance and capacity building for (1) MDA implementation at the

national, district, and village levels in 51 districts; (2) pre-TAS and TAS implementation; (3) coverage

surveys, data quality assessments (DQAs), and an integrated NTD database at the national level; and (4)

overall LF/STH policy and strategies at the national, provincial, and district levels.

b) Schistosomiasis

Indonesia’s goal is to eliminate SCH, caused by Schistosoma japonicum, as a public health problem by

2020, following a strategic plan created with WHO assistance. The strategy includes surveys and

treatment of humans, vectors (snails), and animal reservoirs (rats, cattle, and dogs).

SCH is endemic in Poso and Sigi districts in Central Sulawasi province, with an at-risk population of

approximately 22,600 people. Control activities ended in 2005; however, in 2010, Kato-Katz surveys

showed a resurgence of transmission with an average prevalence of infection of 3.81% (range: 0–12.33)

at 21 sites in the two districts. These areas have restricted access to potable water and sanitation, and

few families have latrines. Although targeted MDA took place from 2010 to 2014, surveys in 2014

showed an increase in the average prevalence from 0.80% to 1.61% in Sigi and from 0.64% to 0.82% in

Poso. Selective treatment (test-and-treat positives and family members) was provided to 5,319 people

in 2016 in at-risk communities. The MOH provides the funding for the distribution and procurement of

praziquantel. Currently, the program has gaps in funding for surveys and the treatment of animal

reservoirs.

ENVISION has not supported SCH activities in the past.

c) Soil-Transmitted Helminths

Indonesia has one of the highest numbers of children requiring preventive chemotherapy for STH in the

world. In the last 15 years, 173 districts in Indonesia have been surveyed to assess STH prevalence using

Kato-Katz, and over 40,000 individuals (mostly children) have been sampled. The results show that STH

infection is widespread in the country, with an average prevalence of 28.12% (range: 0%–85%). In 2012,

the MOH released an STH policy stating that all districts should implement one annual round of STH

MDA in preschool and school-age children (SAC), unless districts have evidence showing the need for no

treatments or two annual treatments.

According to this policy, 10.1 million preschool children (1–4 years) and 16.4 million SAC (5–12 years)

need at least one round of MDA per year. The MOH’s goal is MDA coverage of at least 75% of preschool

children and SAC in all endemic districts by 2020. This goal is based, in part, on strategies in the WHO

STH Strategic Plan and the Deworming for School-Aged Children manual, although district-level

population-based cluster surveys are also recommended to measure prevalence and intensity. In

districts without LF/STH MDA, STH-only MDA for preschool children is being scaled up to be delivered

through the vitamin A or National Weighing programs, whereas STH-only MDA for SAC is implemented

through the Directorate of Child Health Support’s school health program in primary schools.


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The national STH program continues to face serious challenges in meeting its goal. In 2016, only 60% of

districts implemented STH MDA, with 35% providing STH treatment through combined LF/STH MDA and

25% through other national health programs, such as the vitamin A program.

Although considerable effort has been focused during the last year on improving coordination among

the various health programs involved in reaching preschool children through the nation-wide, village-

level integrated health posts, challenges remain, including coordination at each level of government,

logistics, training, and reporting and recording. Insufficient resources, both human and financial, also

represent challenges in strengthening school-based STH MDA in non-LF endemic areas. In the past,

ENVISION provided technical assistance (TA) and a small amount of funding for advocacy and

information, education, and communication (IEC) to kick-start STH-only MDA. Currently, all STH-only

activities are self-funded by the government.


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3) Snapshot of NTD Status in Indonesia

Table 3. Snapshot of the expected status of the NTD program in Indonesia 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

ACHIEVEMENT

DISEASE-

SPECIFIC

ASSESSMENT

(DSA) NEEDS

A B C D E F G H I

Disease

Total No.

of districts

in country

No. of

districts

classified

as endemic

No. of

districts

classified

as non-

endemic

No. of

districts

in need

of initial

mapping

No. of districts

receiving MDA

as of 09/30/17

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

514

236# 278 0 28 122 0* 60^

Pre-TAS: 27

TAS1: 36

TAS2: 11

TAS3: 9

SCH 2 512 0 0 2 0 0 0

STH 514 0 0 28 122 390## 0 0

# The FY17 work plan had 239 districts endemic, but the MOH has remapped in three districts and changed their

status to ‘non-endemic’.

* 26 districts are implementing pre-TAS or TAS and are not scheduled to implement MDA in 2017; they are not

included in column F, G, or H.

^Column H includes 43 districts have passed TAS1 as of 27 July. It also includes 17 districts which will implement

TAS1 (as well as Alor and Tanjung Jabung Barat, which will implement TAS as part of OR) between July and Sept

2017 and are assumed to pass. ## As of July 2017, this includes only districts receiving LF/STH MDA in this calculation. While the MOH is planning

STH-only MDA in other districts, that specific number is not currently available or included in the FY18 workbooks.


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PLANNED ACTIVITIES

1) NTD Program Capacity Strengthening

a) Strategic Capacity Strengthening Approach

Capacity goals

The Subdit’s goal is to have in place before the end of the ENVISION project in 2019 a fully functioning

national NTD program, including the following:

• The majority of activities—if not all—funded from national and district budgets;

• Implementation of quality MDA following established best practice, including participatory

cadre training, sweeping as necessary, enforced DOT, targeted social mobilization, effective

local supervision, and a responsive SAE management system at all levels;

• Timely procurement and efficient management of drugs and other program supplies, such as

rapid diagnostic tests;

• Effective collaboration on the organization of all pre-TAS and TAS with the BBTKL and provincial

laboratories and health authorities; and

• An up-to-date, responsive, and efficient data management system that provides accurate

evidence for all reporting.

Capacity strengthening strategy

To strengthen program management, the Subdit has requested support from ENVISION to continue to

engage in three major strategic approaches this year: strengthening the quality of MDA nationally,

institutionalizing M&E capacity, and strengthening data use.

b) Capacity Strengthening Objectives and Interventions

Objective 1: Strengthen Program Capacity to Implement Quality MDA in All Districts

Special efforts will continue to assist the Subdit to consolidate the lessons learned and best practices

from the “ENVISION experience” and expand their use into non-ENVISION districts.

Intervention 1: Improving MDA Management in ENVISION-supported Districts. ENVISION will continue

to collaborate with the Subdit to improve the quality of MDA management in the 28 ENVISION-

supported districts in October 2017, with an emphasis on increased frequency and quality of supervision

by the Subdit, partner NGOs, and DHOs during MDA implementation. Visits to low-performing HCs will

be prioritized, and special activities identified to address the specific issues in the 12 low-performing

districts will be implemented. During preparations for the October 2018 MDA, ENVISION will continue

efforts to improve the quality of MDA management by focusing on strengthening DHO and HC

coordination meetings and cadre training through refined terms of reference, improved tools, and more

participatory presentations. ENVISION will also work with those districts that have relatively low

performance to adjust and adapt the standard MDA activities to better respond to the local situations.

Intervention 2: Improving MDA in non-ENVISION-supported Districts. In FY17, the updated cadre

training presentation and Cadre Handbook were presented and then electronically shared with all

districts planning MDA during the national LF program review meeting. In FY18, to reinforce the


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availability of these materials in non-ENVISION districts, they will again be shared electronically with all

districts planning LF/STH MDA. Furthermore, ENVISION will provide additional copies of both the Cadre

Handbook and the MDA Registration Book for distribution to non-ENVISION districts through the Subdit.

Similarly, in FY17, Subdit staff, funded by ENVISION, made supervision visit to 13 non-ENVISION districts

at critical times during the preparation for and implementation of MDA. This support for the supervision

and mentoring of non-ENVISION districts will continue in FY18.

Objective 2: Strengthen Interdepartmental Collaboration to Institutionalize M&E Capacity

ENVISION will continue to support the Subdit in establishing official relationships with appropriate units

within the MOH, such as the BBTKL and provincial health laboratories, to implement the various DSAs

required to document elimination and track the control of the NTDs endemic in the country.

Intervention 1: Interdepartmental Collaboration. ENVISION will work with the Subdit to organize a

national coordination meeting with the BBTKL and provincial laboratories to facilitate more realistic

scheduling, better preparation, improved implementation, and more discussion, analysis, and

dissemination of results. If possible in FY18, the collaboration will expand to include local universities—

particularly those in the more isolated parts of Indonesia—to ensure coverage in these areas.

Intervention 2: On-the-job M&E Practice. To further strengthen the effectiveness of this partnership,

ENVISION will also continue to provide on-the-job practice opportunities for selected staff from each of

these units by including them in ENVISION-funded M&E activities in the coming years. The emphasis will

be on ensuring the sustainability of these important M&E activities by helping the Subdit to collaborate

with critical partners that are already beginning to share the responsibility for funding many of the

required surveys this year.

Objective 3: Strengthen Data Management and Use

Intervention 1: Applying DQA and Coverage Survey Recommendations. ENVISION will support the

implementation of recommendations from previous DQAs and coverage surveys to strengthen the

comprehensive reporting system through regular meetings with the Subdit and DHOs, and during

supervision visits to all ENVISION-funded activities. ENVISION will also continue to model data use for

decision-making in all ENVISION-led meetings, provide coaching to selected staff on analyzing data and

applying the results to improve program implementation, continue delivering mentorship on integrated

database management while advocating on behalf of the Subdit for improved reporting functions, and

help strengthen the capacity for timely and quality reporting to WHO by the Subdit. (These activities are

all described in more detail in the M&E section below.)

Intervention 2: Subdistrict Data Analysis. Building on the success of past support, ENVISION will continue

to build capacity at all MOH levels to analyze multi-year data at subdistrict levels and thereby identify

areas with low coverage that require improved planning, training, and supervision.

c) Monitoring Capacity Strengthening

Both routine informal meetings and regularly scheduled review meetings with the Subdit will be used to

track progress made toward achieving the desired capacity strengthening outcomes using the following

indicators to measure success.

Objective 1: Strengthen Program Capacity to Implement Quality MDA in All Districts

Indicators:

• Percentage of districts with epidemiological coverage above recommended levels;


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• Number of joint supervision visits made by ENVISION and Subdit staff and issues addressed;

• Updated WHO guidelines and recommendations translated into national policy;

• National NTD plan and annual work plan available;

• Appropriate management of all reported SAEs; and

• Number and quality of provincial/district coordination meetings held in both ENVISION and non-

ENVISION areas.

Objective 2: Strengthen Interdepartmental Collaboration to Institutionalize M&E Capacity

Indicators:

• All partners fully fluent in the guidelines and protocols for pre-TAS and TAS, including a clear

division of work involving the Subdit, BBTKLs, and provincial health laboratories, to be measured

through post-tests, supervision checklists, and monitoring visits during implementation;

• Ability to use diagnostic tools, measured using TAS training and in TAS supervisory checklists;

• Number of TASs co-supervised by ENVISION and TAS supervisors; and

• Number of TASs implemented according to WHO guidance.

Objective 3: Strengthen Data Management and Use

Indicators:

• Use of integrated database: all historical data are complete and used to prepare WHO reporting

forms and coverage reports and to inform annual planning;

• DQA and coverage survey results from previous years: survey reports available,

recommendations and related activities included in annual work plans, and outcomes of

implementing recommendations tracked; and

• Number of subdistricts implementing enhanced strategies for improving coverage.

Table 4. Project assistance for capacity strengthening

Project

assistance area Capacity strengthening interventions/activities

How these activities will help

to correct the needs identified

in the situation above

a. Strategic

planning

• Coaching, mentoring, experience sharing, and

providing opportunities for hands-on practice

in comprehensive program management,

including strategic planning to the entire

Subdit team by ENVISION

• ENVISION LF/STH project review and planning

meeting

These activities will help

strengthen national-level program

management and share the

ENVISION experience with non-

ENVISION districts.

d. Social

mobilization

• Ensuring the use of best practices in districts

by providing the LF MDA Cadre Handbook to

priority non-ENVISION districts

This activity will help share the


ENVISION districts.

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


17

i. Supervision

• Supervisory visits by MOH for 2017 LF/STH

MDA implementation and 2018 LF/STH MDA

support activities

This activity will help improve

management capacity at the

Subdit and help them share the


ENVISION districts.

k. M&E (please see the M&E section for specific M&E capacity strengthening activities)


18

2) Project Assistance

a) Strategic Planning

Meetings to Develop Enhanced MDA Strategies with ENVISION-supported Districts: As discussed in the

MDA section below, ENVISION will use the results of the October 2017 MDA and previous coverage

surveys to help districts better plan and implement the next round of MDA. In preparation for the

October 2017 MDA, ENVISION worked with the DHO and partner NGO from each of 12 districts

designated as needing special attention, because of either previous low performance or inexperience in

program management, to develop innovative interventions and creatively adjust standard activities to

better respond to local opportunities for success. ENVISION will expand this approach to include all 16

districts to be supported during the October 2018 MDA, including the 12 previously low-performing

districts. ENVISION will, therefore, organize special planning meetings with each of the 16 ENVISION-

supported districts prior to the development of their FOGs and associated budgets. Provincial-level

meetings will be organized in Aceh (seven districts), South Sumatra (four districts), North Sumatra (two

districts), and the districts of Tanjung Jabung Timur, Melawi and Kota Batam, for a total of six meetings.

Each one-day meeting will include 10–30 participants from the relevant PHO, DHO and partner NGO and

ENVISION. Special efforts will be made to include other ministries, such as education and religious

affairs, in these meetings to encourage more active support and involvement in MDA. During these

meetings, the comprehensive analysis of all available data will be discussed (using the TAS failure

checklist if appropriate), possible reasons for low performance will be determined, and appropriate

strategies to respond to the local situation in each area will be developed. These strategies may include

activating the local network of religious leaders, more effectively utilizing local media, developing more

compelling IEC materials using the local language, providing additional training for cadres, training

additional cadres, increasing the involvement of local village heads and village midwives, and/or

implementing more active supervision at all levels. Once participants arrive at a consensus on

recommended strategies, the DHO and NGO will complete detailed planning at the district level. The

individual strategies will be included in the proposals to be finalized during the ENVISION Project Review

and Planning Meeting and funded within the FOG for each respective district. These meetings will be

critically important to assist the DHOs to design and implement more effective activities to support their

local MDA in collaboration with the relevant partner NGO.

ENVISION LF/STH MDA Project Review and Planning Meeting: A two-day ENVISION LF/STH MDA

Project Review and Planning Meeting is planned for March 2018, and participants will include Subdit

staff, two DHO staff from each of the 16 ENVISION-supported districts, the LF Focal Points from the

PHOs in the five associated provinces, staff from the six expected partner NGOs, and representatives

from WHO and USAID/Indonesia. The purpose of this meeting will be to evaluate the October 2017

LF/STH MDA activities, including an extensive review of all relevant data and sharing of best practices

and lessons learned, such as the results of the special interventions designed by the several low-

performing districts. This information will form the basis for determining more effective, practical

mechanisms to achieve the targeted coverage rates in 2018 and to promote DOT and improve the

management of SAEs. This meeting will also be used to review and finalize both district and NGO

budgets for activities to be funded by ENVISION within the 2018 FOGs and to determine district-level

cost share. A total of 71 participants will be included in this two-day meeting.

LF/STH MDA District Coordination Meetings: During July and August 2018, district coordination

meetings will be organized by the DHO in each of the 16 ENVISION-supported districts. These meetings

will involve relevant local stakeholders to secure annual district-level commitments to social

mobilization and cadre training activities and for the successful implementation of the LF/STH MDA.


19

ENVISION will also support the travel expenses for NGOs to attend these meetings. These meetings will

also be used to plan district-level support activities for the LF/STH MDA and to coordinate schedules and

responsibilities.

LF/STH MDA HC Coordination Meetings: After the district coordination meeting, an HC coordination

meeting will be organized in each HC within the ENVISION-supported districts during August and

September 2018. Participants will include heads of villages and representatives from health posts and

other sectors. The objectives of these meetings will include reviewing the timelines for all supporting

activities; discussing how best to promote increased social mobilization, DOT implementation, and

improved SAE management; and organizing the upcoming MDA. These meetings will be fully funded by

the respective DHO as part of their cost share with ENVISION.

b) NTD Secretariat

NTD Secretariat Office Supplies and Operational Cost Support: ENVISION will continue to provide

limited funds to support MOH operational costs, including monthly internet and national mobile phone

service within Indonesia for the Subdit. This will allow the Subdit to continue to engage the current high-

bandwidth internet service provider necessary to access and share the large amounts of data needed to

maintain the M&E database and program files. ENVISION will also provide small amounts for stationery

and office supplies.

c) Building Advocacy for a Sustainable National NTD Program

There are no ENVISION activities for building advocacy in FY18.

d) Mapping

All LF mapping and remapping for Indonesia has been completed by the Subdit, with support from

ENVISION prior to the end of 2016. No additional mapping is required this year.

e) MDA Coverage

Planned FY18 MDA Activities

Table 5. 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

between 2 and 70

years

1 Community

MDA 16 5,362,111

STH

Entire population

between 2 and 70

years

1 Community

MDA 16 5,362,111

ENVISION support to October 2017 and October 2018 LF/STH MDA

For the October 2017 LF/STH MDA, ENVISION will provide support to a total of 28 districts.


20

For the October 2018 LF/STH MDA, ENVISION will support 16 districts (Table 5). The following are the

major changes from the previous ENVISION MDA support:

• Nine districts will be implementing Pre-TAS instead of 2018 MDA.

• One district, Tanjung Jabung Timur, failed their Pre-TAS in early 2017 and will now be required

to continue LF/STH MDA for two more rounds.

It is assumed that all districts implementing final rounds of MDA in October 2017 will achieve sufficient

coverage to be eligible for Pre-TAS in FY18. If other previously ENVISION-supported districts do fail a

Pre-TAS or TAS, ENVISION will consider supporting the required continuation of their LF/STH MDA in

October 2018 if sufficient time is available to develop a FOG and obtain approval from USAID.

Support for MDA in October 2017: ENVISION has contracted with 10 partner NGOs to provide TA and fill

in funding gaps for comprehensive LF/STH MDA implementation in 28 districts. These 28 districts are

mainly on the island of Sumatra but also include a scattering of other districts across the Indonesian

archipelago. Major activities funded, either directly by ENVISION or through a DHO cost share, include

coordination meetings at the district and HC levels, M&E training, cadre training, community

registration, social mobilization, MDA implementation, sweeping, and reporting and recording.

Beginning in FY16, additional funding has also been provided to ensure stronger and more effective

supervision by both the DHO and partner NGO to all low-performing HCs and a sample of other HCs in

their area based on the standard ENVISION supervision checklists, particularly for key activities, such as

cadre training and the actual MDA implementation. Furthermore, additional support was provided to

the 12 districts classified as low performing (see above) to enable them to respond to their local issues

in creative, innovative ways and achieve significant improvements in the coverage and quality of their

MDA.

Support for MDA Preparations before October 2018: In FY18, ENVISION will engage partner NGOs to

provide continuing assistance to 16 districts using the same approach and methodology but with

additional attention given to supervising and mentoring all low-performing HCs in their respective areas.

The NGOs will also be engaged to promote the implementation of DOT during all preparation activities

and supervision visits. In addition, if previously ENVISION-supported districts fail a pre-TAS or TAS,

ENVISION will consider supporting the required continuation of their LF/STH MDA in October 2018 if

sufficient time is available.

Of the 51 districts supported by ENVISION during the October 2016 LF/STH MDA, all achieved epi

coverage rates exceeding 65%. However, while reported coverage is good, coverage survey results have

revealed problems in compliance, with a difference of up to 30 percentage points between reported

coverage and the number of people actually ingesting the drugs. To address issues of compliance in all

ENVISION-supported districts, ENVISION will focus on three activities:

1. Supervision visits will be implemented during both the 2017 MDA and the preparation activities

for the 2018 MDA by ENVISION staff, partner NGOs, PHOs, and DHOs to all HCs with low

coverage. Visits will be conducted during both the cadre training and the actual MDA

implementation and will use revised supervisory checklists.

2. The cadre training materials were updated and simplified last year to focus on the key issues of

why LF MDA is important, DOT, eligibility criteria, and communicating about adverse events

(AEs) with the community—with more time given in the agenda for answering questions from

the cadres and those that they frequently receive from their communities. Because the cadres

comprise the main point of contact with the community, it is essential that they understand and

can communicate the reasons for implementing MDA and can respond to community members’


21

most frequent reasons for refusing to participate. The revised training materials resulted in

much more effective training and will be further utilized during cadre training in FY18. In

addition, several districts will be piloting a new approach to improve the effectiveness of the

cadre training by significantly reducing the class size, which should result in more active

participation by the cadres and provide an opportunity for more focused dialogues around the

real problems they are facing in the field.

3. Attention to improving the quality of the district coordination meetings will be increased, with

ENVISION staff mentoring NGOs to develop district presentations that include analyses of past-

year MDA coverage data by HC, the importance of higher coverage targets, and the promotion

of DOT.

f) Social Mobilization to Enable NTD Program Activities

Airing of the LF/STH Public Service Announcement (PSA): During FY18, ENVISION will process the final

payment for the airing of the PSA during the LF/STH MDA in October 2017 (Table 6).

Printing and Shipping of the LF MDA Cadre Handbook and MDA Registration Books: Based on

extensive feedback from the field during supervision visits, one of the most appreciated and useful

materials has been the Cadre Handbook, which was revised in 2016 to include the promotion of DOT as

a critical priority and a clearer explanation of AEs and how to manage them. This handbook is also the

major material distributed during the cadre training and helps to reinforce all of the important issues

discussed. The MDA Registration Books are also an important tool to assist the cadres to compile lists of

all members of their communities and track the quantities of drugs needed and the uptake of the MDA.

Although these critical materials have been printed and distributed in the past, there is a need to

provide additional copies for ENVISION-supported districts to respond to cadre turnover and

compensate for the loss and very short shelf life of these materials in Indonesia’s hot and humid climate.

Table 6. Social mobilization/communication activities and materials checklist for NTD

work planning

Category Key messages Target

population

IEC activity

(e.g.,

materials,

medium,

training

groups)

Where/wh

en will they

be

distributed

Frequency

Has this

material/message

or approach been

evaluated?

If no, please detail

in narrative how

that will be

addressed.

MDA

Participation

-MDA will take

place at the local

drug post in

October.

-The drugs

provided are free

and safe.

-Some side effects

are normal, and

they will pass

-Drugs should be

swallowed in the

presence of a

health

worker/cadre.

Community

members

TV Spots National TV 300 spots

on four

national TV

stations

(September

to October

2017)

-% of audience

who recall seeing

the spot during

MDA supervision

or the coverage

survey.

-# of times

messages aired on

TV during the

reference period

(source: TV

broadcast reports)


22

MDA

Implementation

-MDA will take

place at the local

drug post in

October.

-The drugs

provided are free

and safe.

-Some side effects

are normal, and

they will pass. If

not, go to the

nearest HC.

-Ensure that drugs

are ingested in

front of you.

Cadre Cadre

Handbook

During

cadre

training

40,000 Yes, during

previous cadre

training and use in

the field

MDA

Implementation

List of community

population and

uptake of MDA

Cadre MDA

Registration

Book

During

cadre

training

40,000 Yes, during several

previous rounds of

MDA

g) Training

Training for LF/STH MDA is a cascade process that starts with NGO and district LF Focal Points, who then

train the HC staff, who then train the cadres.

NGO Training: In FY18, NGO training is planned as a two-day training that will be conducted back to

back with the ENVISION 2018 LF/STH MDA Review and Planning Meeting. Over the past several years,

ENVISION has been building local NGO capacity through training, site assessments, and on-the-job

supervision, starting with training on USAID rules and regulations and basic knowledge of LF and

continuing with training on data collection and analysis. In FY17, ENVISION focused on improving the

quality of supervision by these partner NGOs and emphasized the supervision of cadre training and MDA

implementation at low-performing HCs. Discussions also included NGO responsibilities in reporting SAEs

and how to help reduce the impact of concerns about SAEs in the community. In 2018, ENVISION will

consult with all NGO partners to identify areas of focus for the training, potentially including

organizational capacity building, better communications, the development of more strategic local

responses, continued improvements in supervision and reporting, and methods of facilitating the

implementation of DOT in all project areas. The aim is to ensure that local NGOs have the capacity to

influence local health programs and assist with meeting coverage and compliance requirements.

ENVISION will continue to apply the approach used in FY17 to actively involve NGO partners in all

presentations and discussions and encourage sharing among equals and creative problem solving.

Approximately 14 participants will be involved.

LF/STH MDA HC Staff Training: Beginning in Year 3, based on the results of the DQA, the project added

one additional day to the district coordination meeting to facilitate training HC staff on the use of

updated reporting forms. Because of the success of this training in bridging this communication gap in

the field, ENVISION will continue this activity in FY18 with a strengthened focus on implementing DOT

and improving SAE management and reporting at the HC level using the key messages from the cadre

handbook. ENVISION will work with our partner NGOs to provide appropriate materials and methods for

the DHOs to train HC staff during the ENVISION Project Review and Planning Meeting. The importance of

this training and the cadre training (described below) will be emphasized during the ENVISION Project

Review and Planning Meeting. Several sessions of the Project Review and Planning Meeting will be

devoted to sharing experiences and best practices among the NGOs and DHOs on how to adapt these


23

trainings to better respond to both the local situation in each area and the capacity/experience of the

trainees and how to better use the evidence available to stimulate greater motivation. These ideas will

be reinforced during visits by ENVISION staff to the low-performing districts for the district coordination

meetings and during regular discussions with NGO partners by telephone and email.

LF/STH MDA Cadre Training: Through local NGOs in the 16 districts where LF/STH MDA is being

supported with USAID funding in FY18, ENVISION will ensure that all cadres receive timely and adequate

training on all aspects of the LF elimination program. This training, which uses a standardized

PowerPoint and pre-/post-tests, will emphasize the need to participate in the program and how to

register the population, record treatments, supervise drug ingestion, identify and treat AEs, and refer

SAEs. The PowerPoint presentation was revised and updated for use during preparations for the

October 2016 MDA and now includes more colorful and attractive graphics and additional messages on

DOT. The presentation has also been designed to encourage more interactive discussions and enhance

the active participation of the cadres. Each HC will be encouraged to adapt the presentation to local

conditions using the local language, if appropriate, and/or local examples and to emphasize coverage

data from each health post to further stress the need for both sweeping and DOT. Three HC staff

overseeing the MDA campaign will conduct the training in each HC. The aim will be to train four cadres

per health post. Over 95% of cadres are women, and this training aims to give them the skills they need

to become respected advocates for preventive health care in their communities. Several of the districts

will also pilot a new approach for this training with significantly smaller class sizes to encourage more

active participation by the cadres and provide more opportunities for practical and realistic problem

solving for situations that cadres face in the field.

Although this will be refresher training for many of the cadres who were trained in previous years, the

fact that LF/STH MDA only occurs once a year necessitates refresher training annually to ensure that

cadres can adequately respond to the communities’ questions and report population registration and

treatment coverage data correctly.

Each DHO and partner NGO will attend the cadre trainings in each low-performing HC in their district

and in approximately 20% of the other HCs to monitor appropriate implementation using a training

supervision checklist. ENVISION has already assisted the NGOs in prioritizing HCs for supervision based

on a comprehensive review of HC-level coverage data from past MDA years.

h) Drug and Commodity Supply Management and Procurement

Shipping Drugs for LF/STH MDA to ENVISION-supported Districts: In FY18, ENVISION will continue to be

responsible for arranging the shipment of the required DEC and ALB to each of the 16 ENVISION-

supported districts, well in advance of MDA. ENVISION will also ensure that only pre-qualified drugs

from both Eisai and GSK donations are used in ENVISION-supported districts.

Procurement of FTS to Support Pre-TAS in Tasikmalaya: As an exception to the process outlined above,

ENVISION will procure the required FTSs for the pre-TAS in Tasikmalaya District because the Subdit was

not able to include the procurement of FTSs for pre-TAS within their budget this year.

i) Supervision for MDA

Supervisory Visits by NGO and DHO Staff for 2017 LF/STH MDA Support Activities: To provide

supervision assistance, the ENVISION partner NGOs will supervise and mentor the actual MDA

supervision and sweeping activities in all of the 28 ENVISION-supported districts during the 2017 LF/STH

MDA in October and November 2017. They will focus their attention on those HCs that have been


24

identified as low performing based on their historical epidemiological and program coverage numbers.

The NGOs will also be responsible for supervising an additional 20% of the HCs in each district to ensure

the maintenance of good program implementation. The NGO, together with DHO staff, will fill out

monitoring forms and checklists to assess the implementation of the various components of the MDA;

these will be submitted and reviewed by ENVISION staff. The results from these checklists will be

presented at the next ENVISION Program Review and Planning Meeting to highlight common issues,

such as the inconsistent use of DOT, appropriate management of SAEs, and reasons for non-compliance.

ENVISION staff will also review these supervisory checklists upon submission and discuss any critical

issues with central MOH staff to provide feedback to the NGO and DHO on how to resolve the issues

during future rounds of MDA.

Supervisory Visits by PHO, DHO, and NGO Staff for 2017 LF/STH MDA and 2018 MDA Support

Activities: As in previous years, ENVISION will provide funding in the FOGs for the PHO, DHO, and local

partner NGO to supervise the implementation of the 2017 MDA and preparation activities for the 2018

MDA in each of their respective areas. The results from the 2017 MDA will be used to determine priority

HCs. Priority HCs will become the focus of intensive supervision by both DHO and NGO staff during all

critical preparation activities, such as M&E training, cadre training, HC coordination meetings, and

registration. The DHO and NGO staff will also be supported to supervise a limited number of other HCs

in their respective catchment areas to encourage best practices across each district.

Supervisory Visits by the MOH for 2017 LF/STH MDA and 2018 MDA Support Activities: During the

implementation of the 2017 LF/STH MDA campaign and preparation activities to support the 2018 MDA,

Subdit staff will be provided with funding from ENVISION to supervise selected activities in selected

districts (including both ENVISION-supported districts and non-ENVISION-supported districts), with an

emphasis on those critical activities, such as district coordination meetings and cadre training in

problematic areas, where the national-level staff can be most effective. Although the Subdit does have

its own funding available for supervision, this limited amount is usually insufficient to cover all of the

travel required to adequately supervise the national program and is often not available during periods

critical to the successful implementation of MDA. Therefore, ENVISION will provide support for

approximately 30 four-day trips for Subdit staff during FY18.

Supervisory Visits by RTI ENVISION: RTI ENVISION will provide an additional level of supervision

covering many areas that need special attention and routine supervision of all ENVISION-sponsored

activities as part of our best practices to ensure proper program management at all levels. These visits

will be conducted in collaboration with the appropriate staff from the DHO, PHO, and/or MOH. All RTI

ENVISION staff use standardized supervision checklists or NGO assessment forms to collate information

and include these in their trip reports. For planning purposes, we have budgeted supervision visits to

approximately 14 districts during the implementation of the FY17 LF/STH MDA and supervision visits to

approximately 10 districts during preparations activities for the FY18 LF/STH MDA, including DHO

coordination meetings and cadre trainings. In addition, to ensure the proper management of grant

funds, ENVISION will implement grant and financial management assessments in each of the partner

NGOs selected to receive FOGs to support the FY18 LF/STH MDA.

j) M&E

Ongoing M&E TA: The ENVISION Indonesia Senior M&E Specialist and M&E Officer will continue to work

together with Subdit staff to support all M&E activities in the ENVISION work plan and assist with all

related reporting. Additionally, they will work closely with Subdit staff upon request to assist with

national-level non-ENVISION M&E activities and reporting to WHO. They will encourage the tracking of

activities against the national M&E plan included as part of the NTD Plan of Action 2016–2020.


25

Furthermore, they will ensure oversight of data entry and the analysis of results from LF sentinel and

spot-check sites and will supervise these sites and TASs whenever possible.

Integrated NTD Database: For the past several years, ENVISION has supported the rollout of the

integrated NTD database, including training Subdit staff and hiring consultants to enter historical LF

data. The Subdit continues to enter data into the database, though often inconsistently, and has used

the database on occasion to generate WHO forms, such as the Joint Reporting Form. However, the

Subdit continues to prefer to use its own methods to compile reports. To encourage the Subdit’s use

and adoption of the database, in late FY17, ENVISION plans to demonstrate new and updated features

of the integrated NTD database, including the generation of updated Joint Reporting Forms and

Epidemiological Reporting Forms. The additional reports are expected to better address the Subdit’s

reporting needs. During FY18, the ENVISION M&E Specialist and M&E Assistant will continue to be

available to work closely with the M&E Focal Person at the Subdit to build her capacity to sustain the

database, as requested.

DQA: DQAs were conducted in Indonesia in FY14 and again in FY17. As a result of recommendations

from the FY14 DQA, MDA registers were revised, and training in reporting and recording was organized

for ENVISION-supported districts. Archiving was also standardized. Clear reporting instructions based on

written guidelines have also been developed and issued by the national level, although according to

findings from the FY17 DQA, lower levels are often unaware of these instructions. During FY18,

ENVISION will continue to encourage the Subdit to expand the number of staff with a working

knowledge of the integrated database, as recommended in the FY17 DQA report, and will provide

additional training in reporting and recording to all non-ENVISION districts. ENVISION will also continue

to encourage the Subdit and PHOs and DHOs to implement other recommendations from the FY17 DQA

that have not yet been addressed, including determining deadlines for each step in the reporting cycle

and requiring all reports to be signed and dated.

LF/STH MDA Coverage Survey: ENVISION will support a coverage survey in six ENVISION-supported

districts that implemented LF/STH MDA in October 2017 and were also included in the 2015 MDA

Coverage Survey organized by the University of Indonesia with support from ENVISION. This new survey

will be used to both confirm the reported coverage numbers from the October 2017 MDA and indicate

the levels of compliance in each district. The results from this survey will be compared with those from

the 2015 Coverage Survey to track the impact of ENVISION interventions and measure compliance

following multiple rounds of MDA for the first time in Indonesia. The standard ENVISION coverage

survey protocol and methodology will be used to facilitate comparing the results of the two surveys. The

final report will include analyses of the October 2017 MDA results and comparison with the results from

the 2016 Coverage Survey. The results will be presented to the Subdit and to each of the districts

involved. All of this information will then be used to inform improvements in local strategies,

communication efforts, and program management to ensure that future MDA is of the highest quality

possible.

LF Pre-TAS Sentinel and Spot-Check Sites: Based on the latest data review with the Subdit, in FY18, out

of the 27 districts that will implement pre-TAS, ENVISION will support pre-TASs in 13 districts that have

received ENVISION support during MDA and should be able to meet the criteria of achieving at least five

rounds of MDA with epidemiological coverage above 65% following the 2017 MDA. For each pre-TAS,

data will be collected from one sentinel site and one spot-check site per district.


26

Assessments will be done following the approach below:

1. Approximately 300 samples from people aged 5–50 years should be collected from at least two

sites (villages) using blood films to detect Mf. In very difficult-to-reach W. bancrofti areas, such

as Tasikmalaya, FTSs will be used.

2. Blood collection should be performed between the hours of 10 pm and 2 am (except for the

district using FTSs, where blood collection will be conducted during the day).

3. Districts with populations <1 million will have one sentinel site and one spot-check site. Districts

with populations >1 million will have two sentinel sites and two spot-check sites.

4. Sentinel sites will be areas of known high transmission; spot-check sites will be areas at high risk

of continued transmission (e.g., because of low MDA coverage).

5. Pre-TAS sentinel and spot-check site data will be collected after the fifth effective MDA round to

determine whether the district can move to implementing a TAS. Pre-TAS sentinel sites will be

the same villages as the baseline sentinel sites.

6. All other issues relating to preparation and analysis of samples, including blood collection, slide

coloration, and microscopic examination, are addressed in the standard protocol developed

based on WHO M&E guidelines.

The sentinel and spot-check site assessments will be managed by the central-level team, and laboratory

technicians will be engaged at the provincial and district levels. The results will be entered into the

integrated NTD database and shared with the districts through a formal letter from the Subdit. Only

districts that have a result of Mf <1% or antigen <2% will pass the pre-TAS and be considered for TAS

implementation. Districts that do not meet these cut-offs will be required to continue MDA for two

additional rounds before implementing another pre-TAS. All slides will be read by lab technicians from

either the local BBTKL or the provincial laboratory. ENVISION will also arrange for cross-checking of all

positive slides and 10% of the balance at the University of Indonesia Faculty of Medicine.

LF TASs: In FY18, of the 37 TAS1 planned for FY18 by the Subdit, ENVISION will support a total of 23

TAS1 in 23 districts. (The districts planning TAS1 in FY18 are undertaking pre-TAS in Quarter [Q]3–Q4

FY17 and will only implement TAS if the pre-TAS results indicate Mf <1% or antigen <2%.) The TAS will

apply antigen testing with FTSs in W. bancrofti areas or antibody testing with BR tests in Brugia spp.

areas among SAC who are sampled according to WHO guidelines. All rapid diagnostics will be provided

by the Subdit.

TASs will be conducted among first- and second-year primary school pupils (if >75% of children in the

area attend school) or among children aged six–seven years within the community (if <75% of children

in the area attend school). The survey will use a cluster methodology.

Each TAS will be implemented by a team consisting of one PHO staff, DHO staff, two HC staff, and two

cadres per cluster and a national-level supervisor from the Subdit, BBTKL, regional health laboratory,

and/or local university, with assistance from ENVISION. In each district, four teams will implement TAS

simultaneously. The surveys will be performed between November 2017 and September 2018. All

surveys will utilize the newly developed TAS preparation and supervisory checklists for each of the

various components. In all areas, duplo testing (double testing) of all positive samples will be conducted,

and any discordant results will be considered as “undetermined” and not included in the survey sample

size. The results and next steps will be shared with the districts through a formal letter from the Subdit.

If any districts fail either the TAS2 or TAS3, ENVISION will work with the Subdit to submit a request to


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the WHO RPRG for advice on next steps, per the guidance in the 2011 WHO LF TAS manual and the 2016

LF TAS Expert Meeting in Jakarta.

For all ENVISION-supported districts that fail either a pre-TAS or TAS, ENVISION and our partner NGOs

will work with the respective DHO and their HCs prior to the next round of MDA to (1) utilize the TAS

checklists and in-depth data review to investigate the failure; (2) where possible, organize focus groups

to collect information from cadres and/or community members; (3) enhance their local social

mobilization strategy to include more local-specific activities, such as engaging religious leaders or other

influential people, providing media in the local language, or increasing the funding for cadres to travel to

all low-performing villages; (4) increase the promotion, implementation, and monitoring of DOT; and (5)

increase the amount of active supervision of the HC, DHO, and NGO staff in low-performing areas to

assist with local problem solving and increase local motivation.

Table 7 lists the DSAs planned for FY18.

Table 7. 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., Mf or

FTS)

LF 236 27 (13 with

USAID funds)

27 (13 with

USAID funds) Pre-TAS 26 Mf; 1 FTS

LF 236 36 (23 with

USAID funds)

37 (23 with

USAID funds) TAS1 3 FTS; 32 BR; 2 Mixed

LF 236 11 (0 with USAID

funds)

13 (0 with

USAID funds) TAS2 6 FTS; 7 BR

LF 236 9 (0 with USAID

funds)

9 (0 with

USAID funds) TAS3 1 FTS; 6 BR; 2 Mixed

Note: One district, Buton Tengah, has not been included as USAID-supported TAS1 in the program workbook as this change was

made after the database closed on August 3, 2017.

TAS Training for PHOs and DHOs: In August 2018, staff from the 56 districts planning TAS1 and TAS2 in

2019 together with their provincial-level counterparts will need to be trained in TAS implementation,

including eligibility, sampling, preparation, testing methodology, and the interpretation of results. To

help PHOs and DHOs understand the purpose of the surveys and the process, a three-day training on

TAS methodology and how to use the appropriate rapid tests will be conducted based on the WHO TAS

training modules. Pre- and post-tests will be used to evaluate the participants’ changes in knowledge

after training, and their abilities to use and read the rapid diagnostic tests will be assessed. ENVISION

will fund, organize, and co-facilitate the training with the Subdit. Approximately 81 participants will

attend the training.

Pre-TAS Preparation Workshop: A two-day workshop will be organized in Jakarta with participants from

the 13 districts that will be implementing pre-TAS in FY18, together with two individuals from each of

the associated provincial health services and senior managers from the relevant BBTKLs or provincial

laboratories to coordinate plans, budgets, and schedules for pre-TAS implementation. This workshop

will include an explanation of the standard protocol and budgeting and scheduling of the individual pre-


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TAS for each district. The workshop will be organized by ENVISION in collaboration with the Subdit and

held in May 2018.

National LF M&E Coordination Meeting: ENVISION will assist the Subdit in organizing a two-day

coordination and planning meeting in Jakarta for representatives from the 10 regional BBTKLs and

approximately 10 provincial health laboratories to establish clearer guidance on the roles and

responsibilities to be shared among these organizations in pre-TAS and TAS implementation in support

of the national LF program. This meeting will focus on the practical issues related to the coordination

and implementation of these surveys, including scheduling and budgeting issues. Previous experience

from implementing the surveys in the field will also be discussed, problems identified, and best practices

shared. Approximately 40 participants will be involved, with priority given to staff who have been

previously trained as TAS supervisors and participated in supervising TAS in the field. Following this

meeting, the Subdit will request funding support from WHO to organize a similar coordination meeting

for the senior management of these various units to endorse the results of this first meeting officially.

k) Supervision for M&E and DSAs

As ENVISION staff and staff from the Subdit are directly involved in the organization and field

implementation of each of the ENVISION-supported DSAs outlined within this work plan, there is no

need to organize special, additional supervision visits. The supervision of these activities is an integral

part of the responsibilities of the ENVISION M&E team, and during this supervision, they fully ensure

that all WHO guidance is followed and that the required WHO TAS or ENVISION-created pre-TAS

supervisory checklists are completed.

l) Dossier Development

The national LF program in Indonesia will be unable to complete the implementation of LF/STH MDA

until 2021 at the earliest, and subsequently, at least five years of surveillance will be needed before a

dossier for elimination can be developed. Therefore, it is probably too soon to prioritize this process.

The Subdit is aware of the type of data that will be required for the dossier and has established

appropriate systems to collect and archive these data. ENVISION will offer to help draft the mapping

section of the dossier to capture this important information as soon as possible before institutional

memory fails. The Subdit is also aware that morbidity management must be addressed in the

elimination dossier and is beginning to establish the appropriate mechanisms to respond to the needs of

people living with chronic LF adequately. The MOH has district-level estimates of the numbers of

patients with lymphedema and hydrocele that are reported to WHO annually.


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APPENDIX 1: Work Plan Timeline

FY18 Activities

Project Assistance

Strategic Planning

Meetings to Develop Enhanced MDA Strategies with ENVISION-supported Districts

ENVISION LF/STH MDA Project Review and Planning Meeting

LF/STH MDA District Coordination Meetings (funded in the FOGs)

LF/STH MDA HC Coordination Meetings (funded in the FOGs)

NTD Secretariat

NTD Secretariat Office Supplies and Operational Cost Support

MDA Coverage

Support for MDA in October 2017 (through FOGs)

Support for MDA Preparations before October 2018 (through FOGs)

Social Mobilization to Enable NTD Program Activities

Printing and Shipping of LF MDA Cadre Handbook and MDA Registration Books

Training

NGO Training

LF/STH MDA HC Staff Training (funded in the FOGs)

LF/STH MDA Cadre Training (funded in the FOGs)

Drug Supply Management and Procurement

Shipping of Drugs for LF/STH MDA to ENVISION-Supported Districts

Procurement of FTS for Pre-TAS in Tasikmalaya

Supervision for MDA

Supervisory Visits by NGO and DHO Staff for 2017 LF/STH MDA Support Activities (funded in FOGs):

Supervisory Visits by MOH for 2017 LF/STH MDA and 2018 MDA Support Activities

Supervisory Visits by PHO, DHO and NGO Staff for 2017 LF/STH MDA and 2018 MDA Support Activities (funded in

FOGs)

Supervisory Visits by RTI ENVISION

M&E

Ongoing M&E TA (no costs involved)

Integrated NTD Database (no costs involved)

DQA (no costs involved)


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FY18 Activities

LF/STH MDA Coverage Survey

LF Pre-TAS Sentinel and Spot-Check Sites

LF TASs

TAS Training for PHOs and DHOs

Pre-TAS Preparation Workshop

National LF M&E Coordination Meeting

STTA

External STTA for TAS Implementation

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