JSI Gavi Technical Assistance Final Report - South Sudan

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JSI Gavi Technical Assistance Final Report - South Sudan October 2013 – March 2016 Exhibit A-6

JSI GAVI TECHNICAL ASSISTANCE FINAL REPORT - SOUTH SUDAN October 2013 – March 2016

JSI Research & Training Institute, Inc.

Exhibit A-6

Submitted to Gavi

May 31, 2016

3 Gavi New Vaccine Introduction · JSI Technical Assistance · South Sudan Final Report

TABLE OF CONTENTS Table of Contents .................................................................................................................................... 4

Acronyms ................................................................................................................................................ 5

INTRODUCTION .............................................................................................................................. 6

Overview/Country Context .................................................................................................... 6

ACTIVITIES AND ACHIEVEMENTS ........................................................................................... 7

Start up for JSI/Gavi-NVI ...................................................................................................... 7

Documentation/Monitoring Tools ......................................................................................... 8

Technical Working Group/Coordination ............................................................................... 8

Resource Mobilization ........................................................................................................... 9

Cold Chain and Logistics ..................................................................................................... 10

Social Mobilization and Communication ............................................................................ 11

CSO Capacity Building........................................................................................................ 11

Supervision/Training............................................................................................................ 13

ADDITIONAL SUPPORT - PROJECT EXTENSION PERIOD (APRIL 2015-FEBRUARY 2016) .................................................................................................................................................... 15

EPI Review/Pentavalent PIE Preparations........................................................................... 15

High-Level Advocacy Visit ................................................................................................. 15

Joint REC Training and IPV Introduction Training ............................................................ 15

Gavi Joint Appraisal ............................................................................................................ 15

HSS Planning ....................................................................................................................... 16

RI Roadmap Development ................................................................................................... 16

Additional Support for Polio ................................................................................................ 17

CHALLENGES IDENTIFIED AND PROPOSED SOLUTIONS ............................................ 18

INDICATORS .................................................................................................................................... 19

ANNEX I: PENTAVALENT INTRODUCTION CHECKLIST .............................................. 22

ANNEX II: STATUS OF PENTAVALENT TRAININGS AT STATE AND COUNTY LEVEL AS OF MARCH 2016 ......................................................................................................... 29


ACRONYMS AD Auto-Disable Syringes AEFI Adverse Events Following Immunization AFRO WHO Africa Regional Office CDC U.S. Centers for Disease Control and Prevention CHD County Health Department CHW Community Health Worker cMYP Comprehensive Multi Year Plan CSO Civil Society Organization DPT Diphtheria, Pertussis and Tetanus DPT-HepB-Hib Pentavalent Vaccine EPI Expanded Program on Immunization Gavi Gavi, the Vaccines Alliance HBV Hepatitis B Virus HCW Health Care Worker HepB Hepatitis B HF Health Facility Hib Haemophilus influenzae ICC Inter-Agency Coordinating Committee IEC Information, Education, Communication IRE Initiative for rural Empowerment ISS Immunization Services Support JSI JSI Research & Training Institute, Inc. MDG Millennium Development Goals MOH Ministry of Health MSF Médecins Sans Frontières NGO Non-Governmental Organization PIE Post Introduction Evaluation POC Protection of Civilians RI Routine Immunization REC Reaching Every County TWG Technical Working Group UNICEF United Nations Children’s Fund USAID United States Agency for International Development VVM Vaccine Vial Monitor WCBA Women of Child Bearing Age WHO World Health Organization


INTRODUCTION In September 2013, Gavi, the Vaccine Alliance (Gavi) engaged JSI Research and Training Institute, Inc. (JSI) to provide technical support to the introduction of the pentavalent vaccine in South Sudan and its integration into the country’s routine immunization program. From September 2013 through February 2015, JSI provided technical assistance to the Expanded Program on Immunization (EPI) of the Ministry of Health (MOH) of South Sudan to support the preparatory activities for the vaccine, its national launch, and monitoring and supervision of its implementation and integration into the routine immunization (RI) system. During this initial contract time period, a team of technical experts and consultants supported the implementation and management of project activities, consisting of a combination of in-country support by an Immunization Technical Advisor, Dr. Lavrick Tunda, and an expert EPI Consultant, Mr. Ramas Jambo, as well as JSI/HQ and regional technical staff (including Drs. Asnakew Tsega and Femi Oyewole, who provided short-term in-country technical assistance).

In April 2015, the project was extended, and its technical scope expanded to include: support to HSS planning and implementation, further development and advocacy for in-country buy-in to the Routine Immunization (RI) Roadmap for Strengthening the EPI in South Sudan, and continued support to building the capacity of local civil society organizations (CSOs) to engage in RI. Based on feedback and discussion with Gavi, the project re-organized its technical support during this period by recruiting a regional immunization expert, Dr. K.O. Antwi-Agyei, to provide high-level technical assistance to the MOH EPI Unit through periodic, extended visits to Juba and remote technical support (along with Dr. Tsega and the JSI/HQ team). Dr. Antwi-Agyei’s initial visit to Juba was in May 2015 to follow-up on pentavalent roll-out, implementation of recommendations from previous assessments, as well as on the progress of the RI Roadmap development from the outline developed by the JSI/Gavi NVI Technical Director, Lora Shimp, and JSI consultant, Dr. Femi Oyewole. Over the course of the project’s extension period, Dr. Antwi-Agyei and the other JSI advisors continued to provide technical assistance to the pentavalent vaccine roll-out and to assist the EPI to outline further capacity building and supervision activities. In addition, they liaised with UNICEF and partners to review vaccine distribution and status of the cold chain to improve the management of pentavalent and other vaccines within the routine immunization services at all levels of the health system.

The following is a summary of project activities, challenges identified, proposed solutions, and major achievements throughout the duration of the project.

Overview/Country Context Although there was MOH commitment to the introduction of pentavalent vaccine, numerous competing priorities and the security situation in South Sudan posed significant challenges. The civil unrest which began in South Sudan in December 2013 created a volatile security situation in the country that has not been resolved, slowing implementation of planned activities and progress on addressing recommendations. The unrest resulted in accessibility issues and service delivery gaps in areas throughout the country and increased internal population displacements and interruption to the cold chains in three states (Unity, Jonglei, and Upper Nile). As a result, most key partners delayed or put planned activities on hold.


In response to the humanitarian crisis in the country, the MOH and international NGOs met regularly in forums like Health Cluster meetings, NGO-coordinated meetings, and Technical Working Groups (TWGs), with a predominant focus on addressing immediate health needs. Despite these challenges, the MOH’s EPI Director, Dr. Anthony Laku, continued to advocate in the health forums for the new vaccine introduction and requested partners not to shift resources meant for pentavalent introduction to other activities. In the beginning of May 2014, a peace agreement between the feuding parties was officially signed. With these encouraging developments, the introduction plan was adjusted to take place in phases, with pentavalent to be introduced at the national level and in the seven stable states as Phase 1 and subsequently in the three conflict states (as stability allowed).

Despite the challenges and delays, the MOH/EPI, JSI, and partners continued to work together to launch the pentavalent vaccine on July 16, 2014. JSI worked with the EPI and TWG to provide technical inputs to the preparatory activities for the launch and has assisted with training and supervision activities at the sub-national level. This included providing technical and supervision support to county teams and health workers to ensure implementation of the new vaccine and the strengthening of routine immunization services, as possible, in the stable states.

Unfortunately, as of March 2016, the security situation in the three conflict-affected states continues to impede training and pentavalent roll out. In an effort to reach these three states and given the possibility of DPT stock-outs due to insufficient quantities of remaining DPT vaccine, the government coordinated with partners working in these areas to receive the pentavalent vaccine, provided there is a functional cold chain. However, full scale up of the introduction of the vaccine in these areas has been postponed indefinitely, and as per reporting from the data managers in these states, coverage remains low. Where possible, staff of NGOs who provide immunization services at Protection of Civilian (PoC) sites have been given some orientation to continue the administration of the pentavalent vaccine in place of DPT where routine immunization (RI) is functioning, and NGOs are expected to continue their support to pentavalent training in these conflict areas.

ACTIVITIES AND ACHIEVEMENTS Start up for JSI/Gavi-NVI Upon award of the exhibit in September 2013, Dr. Asnakew Tsega and the JSI/HQ team consulted with Dr. Laku to outline technical support needs to be addressed by JSI through this Gavi support. In October, JSI sent an international immunization expert consultant, Dr. Femi Oyewole, to South Sudan for three weeks to assist in laying the ground work for Gavi-NVI’s technical support. Ms. Heather Casciato, JSI Senior Program Officer, also traveled to Juba to coordinate with Dr. Oyewole and assist with office set-up and recruitment of the local JSI Technical Advisor, Dr. Lavrick Tunda. Dr. Oyewole worked closely with the MOH/EPI and met with partners to assess the preparedness for pentavalent introduction, identify key areas of support that JSI could provide, and orient Dr. Tunda on the overall technical approach.


Documentation/Monitoring Tools Updated immunization technical documents and management tools were required for the pentavalent vaccine introduction in South Sudan. Dr. Oyewole created drafts of several documents to aid in incorporation of the pentavalent vaccine into the country’s routine immunization system, including:

• Updating the EPI Policy for South Sudan to include the pentavalent vaccine;

• Revising monitoring tools for the EPI to include pentavalent vaccine (tally sheets, summary sheets, register, child health card);

• Developing pentavalent introduction training materials for South Sudan;

• Updating the pentavalent introduction plan and timeline for South Sudan;

• Updating Adverse Events Following Immunization (AEFI) guidelines for South Sudan.

Dr. Tunda collaborated with the EPI and key stakeholders to elicit input to finalize these documents and support their use. These tools were presented to the TWG for endorsement on February 20, 2014. Additionally, JSI coordinated to secure UNICEF funding for printing the documents. Training documents were printed for distribution for the planned launch in June 2014. Following their endorsement by the ICC, monitoring tools were sent for translation into Arabic for use in states bordering Sudan. Dr. Tunda and Mr. Ramas facilitated the distribution of materials as part of their travel to states to conduct trainings and supervision visits.

Technical Working Group/Coordination At the national level, partners and other stakeholders (MOH/EPI, JSI, Core Group, UNICEF, WHO, MSF-Swiss, IMC, Jhpiego, NPA Medair) met on a weekly basis as a Technical Working Group (TWG), chaired by Dr. Laku. The meetings served as a forum to share information and coordinate planning, including drafting/finalizing documents for the pentavalent introduction. During the meetings, progress on preparations for the pentavalent introduction was reviewed, including logistics and cold-chain readiness, availability of funding, communications materials, outlining and planning training needs, and continuously updating the activity schedule to monitor implementation.

Following the outbreak of civil unrest in the country in December 2013, the MOH and partners met in different forums to address public health risks, health needs, and gaps in response to the growing humanitarian crisis. These meetings focused on interventions to support rapid needs assessments to ensure health service delivery, vaccinations (routine and campaigns), outbreak response (e.g. for measles and cholera), surveillance and communicable disease control. They addressed program issues as well as identified resources to assist in tackling the overwhelming humanitarian crisis. During this time, the TWG also continued to meet weekly, as possible, to discuss preparations for the pentavalent introduction and link with these other interventions, when feasible.


In the months before the pentavalent vaccine launch, the JSI team facilitated the technical reviews of the introduction documents, coordinating with ICC members to incorporate their feedback for finalization. The ICC endorsed the materials on May 22, 2014.

Following the launch of pentavalent vaccine in July 2014, the JSI team provided updates to the TWG on the rollout activities, including distribution of materials, trainings in the counties, and supervision visits. In addition, the team provided updates to partners via Health Cluster Meetings, the Health Partners’ Forum Meeting, as well as at a meeting of Lead Agencies, led by Dr. Samson Baba of the MOH (conducted in early October 2014). In these meetings, members of the JSI team shared updates on the rollout of pentavalent vaccine and discussed concerns on the status of trainings and immunization performance.

From August through December 2014, Dr. Tunda and Mr. Ramas met with various implementing partners to help arrange the integration of pentavalent refresher trainings with the National Immunization Days (NIDS) held on November 4-7, 2014 as well as with separate accelerated campaigns for routine immunization that were also being conducted in some states. In February 2015, the JSI team also attended the National Immunization Review, along with consultants Dr. Oyewole and Ms. Grace Kagondu, to update national and state immunization focal points on the status of the pentavalent introduction, and to review coverage. This was also an opportunity to map out additional needs at sub-national level for ensuring pentavalent vaccine integration with routine as well as to discuss potential new activities, including a workshop for civil society organizations (CSOs) to further orient and solicit their involvement in and build their technical knowledge of the rollout of pentavalent vaccine and routine immunization (in collaboration with the MOH and the Initiative for Rural Empowerment (IRE)).

During the 2015 extension period, in addition to contributing to TWG discussions related to the pentavalent introduction, Dr. Antwi-Agyei supported the TWG in planning for the launch of the IPV vaccine as well as plans for coordinating the joint EPI Review/Pentavalent PIE and the High Level Advocacy (HLA) visit. By December 1, 2015, the IPV vaccine had been introduced in the seven stable states in South Sudan, and Dr. Antwi-Agyei continued to support the planning for the HLA visit (to include Gavi/HQ representatives and external partners) to help identify dates and prepare invitation letters for partners (see below for additional information on planning for the EPI Review/PIE and HLA visit).

Resource Mobilization During the initial months of the project (i.e. from September 2013 and into early 2014), JSI worked with the MOH and UNICEF to assist in clarifying communications with Gavi for the release of the pentavalent introduction grant funds and updates from the MOH on the audit report to Gavi. Gavi funding for the pentavalent vaccine introduction was being channeled through WHO and UNICEF and additional implementation support coordinated with various other partners. The vaccines were provided by Gavi, co-financed by the Government of South Sudan. Operational costs were detailed in the introduction plan, sent to Gavi on March 2, 2014, and totaled $1,016,778. A $200,000 budget shortfall was


identified, to which partners were solicited to contribute, and the gap was successfully narrowed. Following the submission and approval of the plan with Gavi, pre-introduction funds were released to facilitate the national training of trainers on pentavalent vaccine. The JSI team contributed to this process by assisting the MOH/EPI in creating the detailed costing for activities and sub-activities, based on the funding Gavi had approved for the pentavalent proposal.

Continued funding gaps required additional partner contributions for certain activities during the process. For example, the MOH mobilized funds from implementing agencies working in South Sudan - IMA World Health, Health Pooled Fund and the USAID-funded MCHIP/JHPEIGO - to support the MOH in the printing of the field guide training materials. Dr. Tunda also liaised with the Health Pooled Fund to help facilitate their contribution towards the balance of the funding. Dr. Tunda and Mr. Ramas assisted with distribution of training materials by bringing them from Juba to the states and counties while conducting training visits in the field. The JSI team also frequently advocated with partners including the lead partner agencies for each state both in Juba and in the state capitals to solicit their contributions to county-level trainings.

Cold Chain and Logistics In order to prepare for the introduction of pentavalent vaccine, a cold chain assessment was conducted with UNICEF and partners to ensure space for the vaccine. Given new facilities that had been equipped at central level, and the similar size of pentavalent to the DPT 10-dose vials being replaced, no additional cold room capacity was necessary. UNICEF provided generators to run the cold chain in each state and solar fridges for each county. One pressing challenge was the lack of human resources to manage the cold chain. A plan was made at national level, with WHO and UNICEF to assist with recruitment of eight national staff to assist in EPI management; however, these staffing needs are not yet sufficiently addressed.

As a result of the unrest in Juba and the northern states, reports from EPI managers and partners in Jonglei, Unity, and Upper Nile states indicated that the cold chain in these areas was no longer functional. The assessment found that the cold chain in the Central Vaccine Stores (CVS) in Juba remained functional following the civil unrest and that two additional cold rooms had been successfully installed by a UNICEF contractor to accommodate the new vaccines, redistribution of remaining DPT, and vaccines for campaigns - in addition to the traditional antigens for routine immunization. Dr. Tunda visited Torit and Wau, the capitals of Eastern Equatoria and Northern Bahr El Ghazal state, to assess the states’ cold chains, which were reported to be functional.

From July 2014 through February 2015, given that many of the pentavalent trainings had not been conducted prior to the launch, Dr. Tunda and Mr. Ramas continued with visits to states for state and county trainings and supervisions, including supervision of the cold chain at those levels. During the project’s extension period, certain states and counties were identified as in need of additional supervision and support, to which Mr. Ramas carried out a


series of targeted supervisions to Primary Health Care Centers (PHCCs). In Torit, Eastern Equatorial State (EES), for example, Mr. Ramas visited Lologo and Gurie PHCCs and found proper storage of vaccines as well as good immunization service delivery. Additionally, Mr. Ramas and Dr. Antwi-Agyei visited the central cold store to monitor the status of pentavalent vaccine storage, and they found sufficient viable vaccines available (433,850 doses expiring in August 2016 or December 2016).

Social Mobilization and Communication Social mobilization materials were developed by the MOH in collaboration with WHO, UNICEF and the TWG (including input from JSI). The materials and messages targeted health managers, local authorities, and community leaders to influence policymakers and encourage families to come for immunization services and gain public acceptance for the new vaccine as part of the routine immunization schedule.

Training materials were developed by the social mobilization sub-committee and included posters, T-shirts, and banners. The sub-committee for social mobilization and the TWG collectively developed English and Arabic jingles (including a pentavalent song) to be played on various radio channels, which required several revisions to ensure quality and reach to the target population as well as the general population. During the supervision in the states, Dr. Tunda and Mr. Ramas shared the jingles with the EPI managers and county EPI supervisors to be played in state/county FM radio stations.

One week before the national launching of pentavalent, a fact sheet was distributed to the top leadership officials who would participate in the launch, including the governor for Central Equatoria, the city mayor, NGO representatives, lead agencies, donor communities and the line ministries for education, youth and sports, gender and social welfare.

In supervision visits to five states (Western Equatoria, Eastern Equatoria, Central Equatoria, Western Bahr El Ghazal and Warrap) in the months immediately following the launch, Dr. Tunda and Mr. Ramas found that the communities accepted the pentavalent vaccine, that parents/guardians were seeking vaccination services for their children, and that health workers were comfortable administering the new vaccine. They also noted instances of mothers bringing children older than the recommended age to receive pentavalent vaccine. This indicates a need for careful messaging to parents, and additional training for health workers on the vaccine protocol and communication techniques to explain to mothers the proper age for receiving the vaccine.

CSO Capacity Building Throughout the project, the JSI team worked with the EPI, Health Education Unit and multi-agency partners to discuss and outline strategies for strengthening the engagement of CSOs in supporting the routine immunization system and incorporation of pentavalent vaccine into the routine schedule. This included discussions with IRE and Catholic Relief Services (CRS), who were leading the organization of the CSO Platform that was under development to enable approved CSOs to receive Gavi support. In collaboration with the MOH and IRE,


JSI also led the planning of a workshop (held from July 1-2, 2015) for CSOs working in immunization to provide them with a technical orientation and solicit/outline their contributions to the rollout of pentavalent vaccine and support for routine immunization. The JSI team helped to facilitate drafting the workshop agenda and concept note, identifying participants, organizing the workshop logistics, and obtaining the necessary approvals from MOH leadership. The objectives of the workshop were to:

• Provide a forum for local CSOs/NGOs to have a common understanding of their expectations in the delivery of routine immunization services;

• Provide updates to CSOs/NGOs on the status of pentavalent introduction, routine immunization coverage, and on practical aspects of RI and REC;

• Discuss the CSO platform and the current engagement of CSOs with routine immunization and Health Systems Strengthening (HSS);

• Outline the potential role for CSOs with immunization ICC (for both national and state levels); and

• Discuss support for RI and Reaching Every Community/Child (REC), including drafting of guidelines for how CSOs can support routine services more broadly.

JSI collaborated with the South Sudan Health and Immunization Platform (SSHIP), which is coordinated by IRE, to facilitate the workshop for representatives from twenty CSOs from around South Sudan who are implementing programs on immunization and related activities. Grace Kagondu, a JSI consultant contracted to support the CSO workshop, and Mr. Oniba Opio, JSI’s Immunization Advisor for the USAID-funded MCHIP Project, provided technical support to the coordination and facilitation of the workshop. Dr. Samson Baba, MOH/DG-PHC, provided opening remarks and Dr. Laku, Dr. Bimpa of WHO, and C4D Officers of UNICEF also provided facilitation at the workshop.

After the successful completion of the workshop, Dr. Antwi-Agyei continued to collaborate with Mr. Farid Adinan, IRE Executive Director, to oversee completion of the CSO workshop report and its internal review before dissemination. Dr. Antwi-Agyei has also continued to facilitate dialogue on follow-up actions and next steps that had been identified from the workshop, including:

• Registration of the platform (application for letter of no objection to the MoH)

• Introduction of the platform to the State authorities.

• Development and submission of action plans by CSOs

• Discussion of the plan with the EPI team

Although establishment of the CSO platform was identified as a critical next step for CSOs to fully engage in support to RI services and advocacy efforts, the process has been met with several challenges and has not yet been completed as of March 2016. Despite


advocacy efforts from both the JSI team and the CRS/IRE team to secure support from the MOH leadership for the Platform to complete its registration, the MOH has required additional information on the CSOs’ ability to manage their community funding and raised questions around their use of external funding sources (other than Gavi funds through CRS). There are also concerns that most of the CSOs are located mainly around the capital city, Juba, and not spread across the country, limiting their ability to reach target populations.

An additional challenge to finalization of the CSO Platform registration and engagement has been a change in leadership that took place in late 2015. During that period, CRS terminated its contract with IRE, and as of March 2016, discussions continue on the future of the Platform and its leadership. CRS is currently recruiting for another organization to work with and serve as its coordinator. Following this recruitment, the coordinator will continue to advocate with the MOH for a letter of support for the CSO platform to complete its registration.

Supervision/Training The JSI team provided substantial input to the EPI in development and finalization of the training materials for the pentavalent launch, including facilitating incorporation of partner inputs. As part of the preparations for the introduction of the vaccine, health workers were trained at the national level Training of Trainers (TOT) to then train others at the state level and to advocate for and manage the new vaccine properly in the states (including transportation of the vaccines, injection materials and other dry supplies). Dr. Asnakew Tsega co-facilitated the national TOT. In total, 18 participants – including each state’s EPI manager and cold chain officer - attended the training from nine of the ten states (Unity state did not participate due to logistics. WHO, UNICEF, ISDP/MCHIP and JSI officers also attended the TOT.)

After the launch of pentavalent vaccine on July 18, 2014, JSI focused its efforts on the continuing roll-out of state and county-level training and supervision. This support to the states was conducted through field visits to the seven stable states and also required coordination from Juba. A comprehensive immunization supervision checklist was used during supervision (refer to the pentavalent introduction lessons learned document for more details), with discussions on strengths/weaknesses/gaps as well as on-site corrections made, as possible. In the months following the launch, JSI staff succeeded in visiting all seven stable states at least once and conducted supervision visits in several counties and health facilities (HFs). Some of the issues found during the supervision include:

• Poor waste management (safety boxes were filled beyond ¾ of the box);

• Vials of various vaccines with VVMs at Stage 4 were found mixed with vaccine vials in Stage 1 and 2;

• Recapping of needles;


• Pentavalent vaccine was pre-prepared in syringes to inject children when the facility is busy;

• Some health facilities do not have government immunization registers;

• Health facilities do not monitor their monthly vaccine coverage;

• Some HFs kept pentavalent with frozen (unconditioned) ice packs in their vaccine carriers.

During the project’s extension period, Dr. Antwi-Agyei and Mr. Ramas discussed with Dr. Laku the priority states and counties in need of additional, targeted supportive supervision to identify reasons for low immunization coverage and discuss measures to improve their performance. In order to avoid duplicating supervisions to the same areas, the JSI/Gavi-NVI team also coordinated with MCHIP Immunization Technical Advisor, Mr. Oniba Opio and, based on these discussions, Mr. Ramas carried out a series of additional supportive supervision visits to select Primary Health Care Unit (PHCUs) & PHCCs in three states: Western Equatoria (WES – Ibba and Maridi counties), Eastern Equatoria (EES – Magwi County), and Central Equatoria (CES – Lainya County). In discussions with the State EPI Manager for WES, Ibba and Maridi counties were identified as the weakest performing, with lack of regular performance feedback from the state level, weak data management and use for decision making, and no clear strategy for community mobilization for RI. To help build the county’s capacity for mobilization, the CORE Group has been working with community groups, leaders, and vaccinators, which is being reinforced and shared with partners, including in the discussions and follow-up recommendations during the CSO workshop held in July 2015. Some key recommendations that Mr. Ramas provided to the counties, state, and the national EPI included:

• Prioritizing the monitoring of routine immunization data and use for action

• Improving linkage of social mobilization and community involvement with service delivery to increase demand and utilization

• Using every opportunity to conduct supportive supervision, coaching, and feedback – through visits, on-the-job, via telephone, etc.

• Conducting REC microplanning

Several of the areas identified can be improved as the REC trainings cascade down to the lower levels of the health system, with follow-up on REC implementation (see below for additional information on the REC TOT).


ADDITIONAL SUPPORT - PROJECT EXTENSION PERIOD (APRIL 2015-FEBRUARY 2016) EPI Review/Pentavalent PIE Preparations In order to conduct the PIE within 12 months of the pentavalent vaccine introduction (launched in July of 2014), the dates were originally scheduled for August 17-28, 2015. Unfortunately, the EPI and WHO pushed back the dates. As an alternative, to maximize the in-country presence of partners and stakeholders to participate in the PIE, it was agreed that the comprehensive EPI review would be scheduled to coincide with the evaluation, with JSI and others advocating for the joint activity to take place by mid-October 2015 to avoid further delay. However, due to other competing campaign activities and scheduling conflicts, the activity continues to be postponed, and as of March 2016 is tentatively scheduled for June of 2016. In the meantime, Dr. Antwi-Agyei and the JSI team have assisted with the adaptation of tools for the EPI Review, logistics planning for the working groups, and integrating and harmonizing the PIE questions with the standard EPI review format so that they are ready as soon as the schedule is confirmed.

High-Level Advocacy Visit During the EPI Managers Meeting in Zimbabwe in March 2015, a joint High-Level Advocacy (HLA) visit to South Sudan by global and regional partners was proposed for early September 2015. During his technical assistance visit in May 2015, Dr. Tsega assisted the EPI Manager and WHO Medical Officer to develop a Terms of Reference (TOR) and identify the next planning steps for the visit. However, as of March 2016, the visit has been postponed indefinitely due to security concerns, as well as a change in the WHO Country Representative. The HLA visit is one of the priority activities for 2016 identified in the RI Road Map; however, the date is not yet fixed.

Joint REC Training and IPV Introduction Training From July 27-31, 2015, Dr. Antwi-Agyei participated in and supported a joint REC / IPV introduction TOT, hosted by WHO. The training aimed to build the routine immunization capacity of State EPI Coordinators and partners in each of the 10 states. The training also oriented participants on the planning for introduction of IPV into South Sudan’s RI system and cascade training and supervision to lower levels (with IPV introduced in December 2015).

Gavi Joint Appraisal The Gavi Joint Appraisal (JA) was initially planned to coincide with the 2015 EPI Review/PIE. Although the EPI Review/PIE was postponed at the last minute, the presence of several international/regional partners who had traveled to South Sudan enabled the JA to be conducted in August 2015. The week of 17th August was used to write the draft JA report. An initial planning meeting of the Appraisal Team was organized for August 24th, and the draft report of the JA was reviewed by the team over the subsequent three days. The


findings and recommendations of the JA were presented and ratified at an ICC meeting on August 28th, 2015. Dr. Antwi-Agyei actively participated in the JA, helping to prepare the draft report, participating in the review of the report and development of slides for the debriefing to the ICC, and providing reports from JSI’s experience on the introduction of pentavalent vaccine in the country. After the completion of the appraisal, Dr. Antwi-Agyei and Dr. Tsega provided inputs and feedback on the JA report, including incorporating information on the post-introduction supervision which was conducted by JSI to support the MOH in the pentavalent rollout.

HSS Planning Dr. Antwi-Agyei assisted the MoH/EPI and partners to review the HSS plan and time frame, to plan for the new tranche of Gavi HSS funds that will be distributed to South Sudan in 2017. To address human resource challenges throughout the EPI system, WHO plans to use some of the Gavi HSS funds to recruit five additional staff to support routine immunization (with each to be assigned to 2 states). The funds will be released through WHO and UNICEF, as agreed to by the MoH, and staff will be hired as soon as funding is released.

With JSI’s advocacy, the EPI had tentatively planned to host an HSS workshop with national and state-level EPI and Public Health staff in late 2015. Given limited resources for State participation, JSI discussed with Dr. Laku about the possibility of adding a two-day HSS workshop to the end of a MenA workshop planned for the third week of December 2015, as the target participants would already be in Juba and some of the JSI funds could be applied. The 2-day HSS workshop would have provided state-level health staff the opportunity to discuss and plan in detail their preparations for the new HSS-funded activities in the first two years (2016-2017). Additionally, the workshop would have also been an opportunity to orient state-level staff on the RI Road Map and solicit their feedback. Unfortunately, many of the pertinent participants were unavailable to attend the MenA workshop, and the HSS activity has been postponed for later in 2016.

RI Roadmap Development A draft immunization workplan was developed by the MOH and partners in 2015; however, it does not provide a longer-term vision and detailed plan for strengthening routine immunization in South Sudan. One of the recommendations resulting from the Joint Appraisal was that the partners in South Sudan should develop a medium term “road map” for routine immunization strengthening. In collaboration with the EPI Director, JSI has taken the lead in developing an initial draft of the Road Map and has worked with MOH staff and in-country partners to advocate for its ratification.

Ms. Shimp and Dr. Tsega assisted in developing the outline of the RI Roadmap and suggested that an overview of the main RI activities and a timeline be included in the Road Map. Dr. Antwi-Agyei continued the discussions, worked with Dr. Laku in-country to expand the first draft, and assisted in clarifying the purpose and facilitating dialogue on the RI Road Map and its relationship with the cMYP. He advocated to the EPI and partners on the benefit of an RI Road Map to help prioritize and specify RI strategies and activities in future planning for


Gavi/HSS. JSI’s technical team then provided further inputs and revisions to the document, and Dr. Laku shared the draft with other partners on the EPI TWG.

In collaboration with the MOH, JSI organized and co-facilitated a two-day workshop on February 29 – March 1, involving MOH/EPI, different units of the government, and partners. The objectives of the workshop were:

• To review the draft road map and to reach consensus on its implementation

• To develop a national plan of action to improve routine immunization in the country

• To align different partners’ plans with MOH plans and to support states in coordinated implementation.

The Road Map workshop was conducted over two days and also linked with cMYP planning. Participants included MoH staff from different units as well as WHO, UNICEF, BMGF, MSF, Core Group, CRS, ISDP/MCHIP, the Health Pooled Fund, the CDC Immunization Project and JSI. At the workshop, it was agreed that a comprehensive EPI review should be held before developing the next cMYP, and this has been scheduled for June 2016.

The workshop began with JSI presenting the draft RI Road Map document to the participants, followed by a plenary discussion. The participants were then divided into three groups, each reviewing the draft and developing a plan for the national level, the seven stable states, and the three conflict affected states. Given fruitful discussions and participation from all partners, the exercise could not be completed by the end of the second day of the workshop; thus, a small group from the MOH, JSI, WHO, UNICEF and MSF met for a final half-day and finalized the plan for 2016 to 2018. As of March 2016, the Road Map is serving as an annual plan for 2016 and is being reviewed by different levels of the government and partners to foster ownership.

Additional Support for Polio While in Juba, Dr. Antwi-Agyei also participated in and assisted with the planning for a WHO-convened workshop to develop a workplan for implementing recommendations from the Outbreak Assessment Mission for vaccine derived polio. Representatives from the EPI, WHO, and UNICEF all participated. The plan has been submitted to the WHO AFRO office.


CHALLENGES IDENTIFIED AND PROPOSED SOLUTIONS Primary Challenges of Vaccine Introduction

Solutions Implemented

Delayed submission of MOH’s clarifications on repartition of funds hampered the release of Gavi funds and caused a delay in implementation of activities (e.g. printing, training and social mobilization), resulting in a delay in the planned launch.

JSI assisted in facilitating communication between the MOH/EPI, UNICEF, WHO and Gavi to expedite the release of funds for implementation of the pre-introductory activities (e.g. printing of IEC materials, advocacy, printing of training material, training of TOT at the national level etc.)

Insecurity and renewed political hostilities between the government and the opposing party resulted in disruption of services from MOH and partners.

JSI worked within the constraints to collaborate with partners to plan for the national introduction in the seven stable states, while collaborating with partners to prepare for completion in the other three conflict-affected states, when feasible/safe.

Shifting timelines due to concurrent/ overlapping immunization activities (i.e. with campaigns, meetings and other reviews, etc.)

JSI participated in the TWG to regularly update Action Plans to harmonize planned EPI activities and keep pentavalent introduction and the RI Roadmap as part of the focus.

Delays in ICC endorsement of the draft documents for pentavalent introduction and subsequent delays in having the documents printed and distributed in time

JSI regularly followed up with the MOH for endorsement of the pentavalent documents, and advocated for the ICC meetings to be held to ensure their official endorsement. In order to have the materials available and distributed for the introduction trainings, JSI staff also liaised with in-country partners to encourage their contributions to reproduce the documents for the states that they support. JSI facilitated the printing process and assisted with distribution of materials to states and counties during training and supervision visits.

Inaccessibility of some of the counties during the rainy periods

JSI conducted training and supervision activities with state/county teams during the dry period (when these counties were accessible).

Continued insecurity in some states and travel restrictions (for international travelers)

Despite continued travel restrictions and the need to ensure safety for international travelers to South Sudan, Dr. Tsega, Dr. Femi Oyewole, and Dr. Antwi-Agyei were able to travel within the Juba area). Dr. Tunda and Mr. Ramas provided national and state-level support, traveling to states and counties as time and security allowed.

Primary Challenges of Vaccine Introduction

Solutions Implemented

Partners needed additional advocacy/guidance to prioritize conducting the county trainings and monitoring on pentavalent roll out

The national and state MOH (with communication assistance from JSI, as appropriate) advocated and followed-up with partners on the cascade training for the pentavalent vaccine introduction to the frontline health workers. This is also included in the RI Roadmap, with continuing advocacy for its finalization and implementation.

Limited supervision to the states JSI conducted supervision visits to the states and counties and shared findings with the MOH/EPI and partners. Additional support for supervision and monitoring on the pentavalent introduction and roll-out are needed from the national level, (e.g. MOH, WHO, UNICEF and other implementing and CSO partners). This is being discussed with the TWG and CSO partners.

INDICATORS The project used a set of illustrative indicators to track and monitor progress throughout the course of implementation. Following are a summary of the indicators as well as the latest status for each as of March 2016: Illustrative Indicator

Definition/ clarification

Data source / collection method

Frequency of data collection

Results to-date

Workstream 1: New vaccine introduction

Vaccine pre-introduction plans finalized and implemented

# and % of plans prepared and implemented; ICC subcommittees established with TOR and meeting regularly

Record review Monthly report

Quarterly Vaccine pre-introduction plan developed and shared with partners Pre-introduction plan finalized by sub-committee


Illustrative Indicator




Results to-date

Recording, reporting, and monitoring tools are updated, printed and distributed

# and % of EPI management tools revised to reflect new vaccine information and available at health facility level Technical guidelines revised to reflect new vaccine; reporting tools revised


Once, before vaccine introduction

Monitoring tools and technical guidelines have been endorsed by ICC. Updated immunization register developed with WHO and partners and distributed by the MOH Department of Planning and M&E. MOH translated the documents into Arabic

Health workers capable of using pentavalent vaccine properly

Minimum of one trained health worker per health facility providing immunizations (public and private); Regular supervision


At least once before vaccine introduction

7 stable states conducted TOT and training cascaded to the county levels (see Annex II). Most counties have completed trainings, with roll-out continuing in the conflict-affected states.

Pentavalent vaccine fully integrated into routine immunization system

New vaccines available and used regularly; Quarterly monitoring of coverage (for Penta) post-introduction; Supervision

Record review and supervision visits

Once for record review; ongoing monitoring through supervision

Pentavalent vaccine has been integrated into the routine immunization system in the 7 states. JSI conducted supervision with state/county teams in many of the counties, but additional supervision and partner engagement in monitoring penta roll-out are needed.


Illustrative Indicator




Results to-date

Country co-financing process and communication with Gavi improved

Key advocacy meetings conducted; teleconference/meeting discussions held between country and Gavi; co-financing discussed on ICC agenda

Annual Progress Report to Gavi

Annual The TWG meets regularly, with leadership by the MOH/EPI, to mobilize and coordinate government and partner support, including Gavi funding. Gavi provided the pentavalent pre-introduction grant, with funds disbursed through WHO and UNICEF. MOH mobilized partners (e.g. IMA-WH; USAID/MCHIP (Jhpiego) and Health Pooled Fund) to support printing of the training field guide and other materials. TWG and Gavi need to continue discussions on co-financing and support for penta roll-out and monitoring, including linkages with RI and HSS. The advocacy for government co-financing will continue in the coming months.


ANNEX I: PENTAVALENT INTRODUCTION CHECKLIST In order to track the key activities involved with the new vaccine introduction in South Sudan, the Gavi-NVI team developed the following tool, which was updated by the field team at regular intervals. This example is from December 2015:

N Issue Status Action(s) to be taken

Lead Agency/ Focal point

1 Need for cold chain equipment

A Assessment for cold chain equipment

The cold chains in Juba, Yambio, Torit, Wau, Kuajok Aweil and Rumbek are functional. JSI visited Juba Central cold chain, Wau, Yambio, Torit and Kuajok state cold chains.

Completed. UNICEF

B Advocacy to targeted new partners for additional cold chain equipment

Although replacement equipment has been sent, additional cold chain needs in unstable areas will need to be assessed, when possible. UNICEF emailed assessment tool to partners to update MOH and UNICEF on gaps to be addressed

Completed. UNICEF

C Additional cold chain equipment needs (and if so, by when)

All states (10) had received additional cold chain equipment, e.g. solar ice liners and deep freezers for the storage of vaccines and ice packs

Monitor the situation on the ground in conflict areas and in stable states.

UNICEF

D Distribution plan for new equipment

UNICEF distributed solar fridges and generators to the 3 conflict-affected states. Pending installation.

UNICEF planning to send technician to install solar fridges

UNICEF

E Distribution and installation of new cold chain equipment at county and health facility levels

The two cold rooms in Wau are completed, shelves remain to be fixed.

UNICEF to send carpenter to fix shelves.

UNICEF




2 Revision of recording, reporting and of the monitoring EPI tools

A Revision of technical guideline and other EPI policy documents

Technical documents for pentavalent introduction were reviewed by partners and endorsed by ICC. The MOH M&E Director for Planning wanted the documents including the monitoring tools translated into Arabic for states that board the Sudan.

Completed. JSI/ WHO/ MOH

B Revision of all EPI management tools (tally sheet, immunization register, child health card, reporting forms, etc.)

As above Completed. JSI/WHO/ MOH

C Distribution of revised EPI tools

Partners printed the revised EPI tools endorsed by ICC. Dr. Tunda provided soft copies of monitoring tools to partners to print for data collection, and JSI assisted and facilitated distribution with partners.

Completed. JSI

D Availability of the revised EPI tools at health facility level

Dr. Tunda requested partners to print tools and use in the facilities to facilitate data collection.

Revised EPI tools distributed; however, monitoring of their availability in counties/sub-counties is needed on an on-going basis.

JSI

3 Training of health workers and logisticians




A Availability of the adapted training materials (Trainers’ guide, modules for health workers at peripheral level)

2000 copies of field training guide were printed (A5 1200 & A4 800).

The MOH/EPI, UNICEF and partners facilitated the distribution of the field training materials to the 7 stable states; monitoring of their availability in counties is needed.

MOH and partners

B Training of trainers

TOT conducted at the national level and 7 states

Training conducted in most counties in the 7 states, with training continuing in the remaining counties and the 3 conflict-affected states

MOH/ UNICEF/ WHO/ JSI/ Partners

C Training of logisticians (installment and maintenance of cold chain equipment)

Ongoing On-the-job training of national/states/county cold chain officers and assistants

UNICEF

D Training of health professionals at the operational level

Conducted the National TOT and state TOTs

Training has been conducted in most counties in the 7 states and is being cascaded to the sub-counties.

MOH/ Partners/ JSI/ UNICEF/ WHO

E Training of community health educators and/or CSOs

To be conducted next quarter

Partners have plans to train Home Health Promoters (HHP). CSO orientation workshop to be conducted.

Partners

4 Advocacy, Communication & Social Mobilization




A Stakeholder sensitization and advocacy

Ongoing at national, states and county levels.

Advocacy and community sensitization to be intensified through radios, TV programs and visits to the states to increase vaccine demand

MOH-EPI/ WHO/ UNICEF/ JSI/ Partners

B Key messages developed (to address KAP and any possible concerns of parents for this vaccine)

Social mobilization group developing relevant messages to increase demand for mothers/caregivers to bring children for immunization

Sub-committee for social mobilization reviewing and updating key messages (in four languages).

Social Mobilization Group

C Pretest of the messages and communication materials

UNICEF pretested the pentavalent introduction materials amongst women

Pretest conducted before final printing of the IEC materials.

Social Mobilization Group/ MOH

D Media identification and sensitization

Media groups were oriented during one day in MSH conference hall

MOH/JSI/WHO/UNICEF oriented and guided media in communicating messages to the general public. MOH provided fact sheets and handouts of presentations

UNICEF/ MOH/ WHO/ JSI/ Partners

E Communication in the community

Started in small scale In the coming quarter and over the next year, this needs to be intensified, using penta jingles and penta song

ALL

5 Vaccine and injection material supply




A Readiness to receive the vaccine and injection material

CVS has enough space for the new vaccine and injection materials

Two more cold rooms are being installed to have more capacity to receive additional penta and continue to store campaign vaccines, remaining DPT, and RI vaccines

UNICEF/ MOH

B Reception of penta vaccine and injection material

The vaccine and materials have been received and distributed to states and counties

Ongoing monitoring of vaccine and injection material distribution and stock levels

UNICEF/ MOH

C Registration of vaccine doses and of the syringes, etc.

The national central cold chain and state cold chain register batch number and doses of vaccines

Similar practices need to be performed in HFs as well. MOH to provide vaccine control books

UNICEF/ MOH

D Availability of vaccine and injection material at all levels

Vaccine and injection material available at all levels

HFs to conduct regular vaccine inventory; technical support needed in logistics management at county/sub-county levels

ALL

6 Injection safety, waste management and disposal

A Availability of vaccines and syringes, needles, safety boxes, etc. at national level

The first vials of pentavalent and injection materials arrived in Juba on 21/05/2014.

Vaccines and injection material are being stored in the Central Vaccine store and preparations ongoing for distribution next quarter.

UNICEF

B Distribution of vaccines and syringes, needles, safety boxes, etc. to counties and HFs

State EPI and cold chains have distributed needles and safety boxes to counties and HFs

Partners to facilitate and support CHD with vaccines, needles and safety boxes

MOH




B Availability of functional incinerators at HFs

Some HFs have functional incinerator while others don’t, some don’t use them properly, some have damaged incinerators

Construction, rehabilitation, training and supervision needed

MOH/ WHO/ UNICEF /JSI

C Training for the correct use of incinerators

Conducted during the TOT at national, state and county levels

Discuss in new vaccine trainings; Conduct field visits in the 7 stable states

MOH/ UNICEF/ WHO/ JSI and partners

D Other tasks (to be defined)

7 Surveillance system updated for VPDs and AEFIs related to new vaccines

A Surveillance system for VPDs

Not strong yet Roll-out of pentavalent to be used as an opportunity to strengthen surveillance planning

MOH/ WHO

B Surveillance for AEFI

Forms for AEFI available. MOH and partners to conduct AEFI training at the national level and state levels and form AEFI committees at all levels

MOH/ UNICEF/ partners

C Training of staff for surveillance

Conducted during the TOT trainings

Cascade surveillance training for VPDs needs additional funding

WHO

D Surveillance reporting system activated for new vaccine

Forms already available, systems need to be re-enforced

Refresher training for health workers on correct use of the new surveillance forms

MOH/ JSI/ WHO/ UNICEF/ partners

E Other tasks for surveillance?

8 Launching ceremony preparation

A Introduction date set

Pentavalent was introduced on the 1st of July

Completed MOH/EPI




B Site for launching ceremony determined

Launching was conducted in Al Sabah Children Hospital

Completed MOH

C Preparation of the site with IEC materials and media

Committee for launching and Social mobilization was formed

Completed MOH/JSI/ UNICEF

D Ceremony arrangements

The launching committee completed, under the leadership of UNICEF

Completed UNICEF/ launching committee

9 Documentation

A Monitoring system in place for tracking introduction and roll-out

Monitoring and reporting tools distributed and in use (observed in areas where JSI conducted supervision)

Ongoing support (financial, HR, technical) is needed for states and counties to ensure quality of monitoring and reporting

MOH/ WHO/ UNICEF/ JSI

B Plan for follow-up in under-performing areas or counties where additional training/capacity building is needed

Discussed with TWG Plan needs to be further developed and partners engaged, including involvement of implementing partners and CSOs in counties/sub-counties


B Supportive supervision

Conducted in Western Bahar, El Ghazal, Warrap, Central, Eastern and Western Equatoria states and in the counties

To be conducted regularly using penta checklist


C Plans for PIE Discussed with TWG MOH and TWG to determine date and communicate plans with Gavi and partners

MOH/ WHO/ UNICEF/JSI/ Gavi/ partners


ANNEX II: STATUS OF PENTAVALENT TRAININGS AT STATE AND COUNTY LEVEL AS OF MARCH 2016

S/N STATES STATE TOT TRAINING

COUNTIES COUNTY TRAINING STATUS

PARTNERS

1 WESTERN BAHR EL GHAZAL (LEAD AGENCY- HEALTH POOLED FUND)

Jur River HealthNet TPO Wau County IMC Raja IMC

2 NORTHERN BAHR EL GHAZAL (LEAD AGENCY- HEALTH POOLED FUND)

North Aweil HealthNet TPO South Aweil IRC East Aweil IRC West Aweil Concern Central Aweiil IRC

3 LAKES (LEAD AGENCY- HEALTH POOLED FUND)

Awerial CCM Cueibet Diakonie/Health link Rumbek Center Save the Children/BRAC Rumbek East Save the Children/BRAC Rumbek North CuaMM (Doctors of Africa) Wulu SCiSS Yirol East CMM Yirol West CuaMM

4 EASTERN EQUATORIA (LEAD AGENCY- HEALTH POOLED FUND)

Magwi County ARC Kapoeta North SCiSS Lopal/Lafon Save the Children Budi NPA Kapoeta East ARC Torit County Save the Children Kapoeta South ARC Ikkotos AVSI


S/N STATES STATE TOT TRAINING

COUNTIES COUNTY TRAINING STATUS

PARTNERS

5 WESTERN EQUATORIA (LEAD AGENCY- MCHIP)

Mundri East MRDA Mundri West AAH Meridi County Malteser Yambio County WVI Ibba AMREF/AAH Ezo WVI Nagero Johaniter Nzara IMC/WVI Mvolo CMMB Tambura IMC

6 WARRAP (LEAD AGENCY- HEALTH POOLED FUND)

TWIC GOAL Tonj North World Vision Tonj South (CCM) DON BOSCO Tonj East Comitato Collaborazione Medica Gogrial West

World Vision, Norwegian Church Aid (NCA), MSF-B

Gogrial East THESO Abyei GOAL, MSF-Swiz

7 CENTRAL EQUATORIA (LEAD AGENCY- MCHIP)

Yei County AAH Lanya AAH Terekeka ADRA Morobu AMREF Kajokeji County ARC Juba County NPA

TOTAL 7 STATES 47 COUNTIES 44/47 COUNTIES 26 PARTNERS


Documents

JSI Gavi Technical Assistance Final Report - South Sudan