COVID 19 EMERGENCY - Support to a Preparedness and Response Plan in Northern Uganda

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Project location: UGANDA, West Nile District
Project start date: August 2020 - Project end date: November 2020
Project number: 2020-031
Beneficiary: AMREF Health Africa Onlus

Amref's priority areas in Uganda include health and nutrition, food security and WASH activities. In particular, the focus of the health sector is maternal-child and reproductive health, prevention of communicable diseases, by strengthening the health system through training of health personnel at district, regional, national and community level. The organization is currently engaged in 20 projects in more than 30 districts of the country. 

The threat posed to people in Africa is considerable taking into account the continent’s 1.2 billion people and its weak health systems that are already overburdened with ongoing disease outbreaks and other health issues. As Michael Yao, WHO’s head of emergency operations in Africa noted, because the continent’s health systems “are already overwhelmed by many ongoing disease outbreaks” prevention and early detection – trace, mobilize, detect, test, treat, isolate – are vital.

Amref is currently at the forefront of COVID19 preparedness and response, working with all levels of stakeholders at the regional, national and local levels. Amref is member of the national taskforce response to COVID-19 in various countries where it operates in including Ethiopia, Kenya, Malawi, Senegal, South Sudan, Uganda, Tanzania and Zambia, and it is also member of the Africa COVID-19 Response Committee of the African Union (AU) and of Africa Centres for Disease Control and Prevention (CDC) and it is working closely with African Health Ministers to avert this spread in Africa. 

One of Amref’s focus is strengthening frontline health workers. In fact, Amref has trained numerous healthcare providers in infection prevention and control. This includes providing guidelines on specimen collection, storage and transport for safe delivery of samples to reference laboratories for confirmation amongst other activities.
With our in deep knowledge of health services, our close involvement with communities, and our wide network throughout sub-Saharan Africa, Amref Health Africa is already:

• supporting national governments and institutes to organize preventive measures and mount responses, as needed;
• providing training on infection, prevention and control measures to health workers;
• disseminating educational materials to keep communities informed;
• providing regular updates to healthcare workers;
• advising and facilitating the transport of specimens to national testing laboratories;
• Advising on workplace preparedness.

Amref is currently leveraging its entire infrastructure: the Amref Flying Doctors Emergency Evacuation Services, Amref Enterprises Limited for training Community Health Volunteers through mobile phones and the Institute for Capacity Development for the training of frontline health workers and youth-led advocacy work. 

Amref is using all its digital solutions and innovations: Leap - http://www.leaphealthmobile.com/,  Jibu, and M-Jali, all of which tie in to Amref Health Africa’s long-standing presence in our eight COVID-19 priority countries. 

The approach entails joint development and customization of digital training content that will be deployed to health workers through their mobile devices (basic and/or smartphones). The digital content has been customized to fit the needs of target audiences which includes consideration of skilled level of the audience, language preference and preferred channels (text or audio messages).

Amref Health Africa has consistently supported Ministries of Health and WHO during outbreak interventions including facilitating the provision of critical healthcare to remote communities across Africa as evidenced by participation during roll out of control measures during the Ebola outbreaks in Uganda 2000 and 2012, and in Senegal and Guinea in 2014, the cholera outbreak in Kenya (2017) and the Lassa fever outbreak in Nigeria (2018).

For these reasons, Amref is a reliable and well positioned partner in the health sector which brings in a competitive advantage in mainstreaming readiness to the COVID19 pandemic risk in Uganda.

COVID-19 in Africa
According to the Africa Centre for Disease Control and Prevention (Africa CDC), by 15th May 2020 the death toll from the COVID-19 pandemic on the African continent had reached 2.563 and confirmed positive cases had surpassed 75.500.
COVID-19 will imminently overwhelm already fragile public health systems. Without quick and decisive actions, more people in Africa will get infected, including critical health personnel – the backbone of an already over-stretched health system. The mortality rate of patients in sub-Saharan Africa is expected to be higher, not just for COVID-19 patients but populations suffering from other infectious and tropical diseases such malaria, TB and HIV. The implications on health systems in Africa and their economies will be long-lasting, setting back economic growth (currently projected by the Brookings Institute to drop by 3%)1. However, MOHs, in partnership with the WHO and the Africa Centers for Disease Control (CDC), are jointly mobilizing resources and building capacity for a national response to flatten the curve.

COVID 19 in Uganda
On May 15th had 160 confirmed cases, 63 recoveries, 0 deaths. The Ministry of Health (MoH) with the support of stakeholders has acted quickly to avert infections. All border points including the Entebbe International airport have been closed and travel ban imposed on all travellers from all COVID-19 high risk countries.
The government has mobilised stakeholders to coordinate activities under the National COVID-19 Response Plan. The move came after Uganda reported its first confirmed case of the COVID-19 on March 22. One week later, the number surpassed 30 and the government announced a 14-day imposed lock-down with restrictions on movement of people. 

Uganda is one of the countries that hosts the highest number of refugees, mostly from South Sudan and DRC.   Over 1,411,098 refugees live in Uganda (0-4 years 226,449, 5-11 years 358,458, 12-17 years 247,943, 18-59 years 539,439 and above 60 years 38,779).  Although there is relative stability in the influx of refugees, more refugees continue to trickle in with a monthly registration of new refugee staggering around 1980 people as of April 2020. The Rhino refugee settlement where Amref Health Africa implements interventions host over 118,182 (51% women and 26% youths) refugees with a total of 30,158 households (OPM data, updated to April 2020). The majority of these 61% children (under 18 year), and women form 52.5% of the population.

The push factors for the refugees to flee from South Sudan have been clashes between armed groups, tribal clashes, violence and sexual abuse, lack of basic services, food insecurity. The most affected ethnic groups are of; Madi and Lotuko from the Eastern Equatoria and Juba, the ethnic groups of Kakwa and Pojulu, coming from Central Equatoria region, and small ethnic groups such as Dinka, Nuer and Lotuku coming especially from the states of Mugo, Yei and Lanya. Already the massive number of refugees has put enormous pressure on the scarce resources of the West Nile Region and on the basic service delivery system; health, education, land, food supply. This continued to raise tensions between the refugee and the host communities. The refugees among others thrive with serious difficulty to meet basic needs, they have limited access to services because of distance between the camps and the service points. 

The refugee crisis in Uganda and West Nile in particular is not new. It has already gone through a wave of more than 4 humanitarian interventions. Because of this Government of Uganda, UNHCR and other development partners have preferred to pursue the path of sustainable interventions that integrate the refugees into the national system and ensure sharing of resources. The challenge has been even with more influx of refugees the local government resource example number of health workers in health facilities does not necessarily increase with the additional burden posed by refuges influxes, and as earlier noted the distances/remoteness of the refugees camps do not favour effective access to services. That is why the refugees and communities hosting refuges in West Nile have a common problem of; inadequate food supplies for the household. 
High rate of acute malnutrition (14.2%). Data on morbidity related to refugees indicate that the most common diseases are malaria (69%), diarrhea (42%) and typhoid fever (36%). In Rhino camp, 64.6% of admissions to health facilities were due to malarial episodes, 7.6% to respiratory tract infections and 29,1% to other illnesses (UNHCR, February 2020). 

In the West Nile region 5% of the total population (144,905 out of 2,898,100) face severe food insecurity (phase 3,IPC ) caused by long periods of drought, agricultural production limited to subsistence, poor purchasing power, the influx of refugees that restricts access to food supplies and services. 

These conditions pose a very high potential risk to both nationals and refugees. Already from the recent outbreak, it is clear that the refugees are more vulnerable and are likely to be marginalized in such outbreak as reported by one health work. The challenges noted in the refugees’ settlement especially Rhino camp following the COVID-19 outbreak is that; most of the IEC materials produced by MOH did not favor communication in refugees’ settings, MoH did not translate the materials in the local languages spoken by the refugees. Making the refugees lack knowledge on how to manage the crisis and protect themselves.

Currently the priority needs related to the COVID 19 risks are:
(i) strengthening the health system (both formal and informal) to proactively detect COVID-19 early; 
(ii) strengthening the health system to manage cases and stop infections; 
(iii) empowering the community to lodge a strong defence against infections at community level;
(iv) Government capacity to enforce public health and social order precautionary measures.

The intervention aims at contributing to the control of the COVID19 incidence among refugee and host communities of Rhino Camp in Northern Uganda.  
As a member of the national COVID19 task force, Amref will work in close collaboration with the Ministry of Health and the other actors who are plying an active role in the of and preparedness to the emergency. Amref will contribute in strengthening Risk Communication, Infection Prevention and Control, Community Engagement and reinforcing the coordination of district actors.
The action will target key community frontline actors like the Village Health Teams (composed by community members) trained to deliver awareness sessions to the population on how to prevent COVID 19 contagion and how to behave in case of symptoms. The VHTs are the link between the remote communities and the health facilities and play a key role in the community to enhance the demand for health. Other community leaders (such as religious leaders, camp commandants, women representatives) will receive orientation on how to better advice and address the villagers on COVID 19 prevention. 
Another key target group are the governmental Health Workers deployed at Health facility level who will be trained on COVID-19 Prevention/Control and Community Based Disease Surveillance (CBDS). Moreover, the VHTs and the HWs (100 in total coming from the 5 districts of Rhino Camp) will be enrolled to the digital solutions and innovations: Leap - http://www.leaphealthmobile.com/,  Jibu, and M-Jali, which foresee customization of digital training content that will be deployed to health workers through their mobile devices (basic and/or smartphones). Both VHTs and HWs will be provided with Personal Protection Equipment (masks, gloves, sanitizers, etc..) and trained to proper use.
 Moreover, the project will enhance the level of coordination among the existing different levels (community, camps, district, local authorities). All these entities play a role in the preparedness to and control of the contagion but needs support to better coordinate.  The intervention will benefit about 50.000 persons.

The general goal of this project, which received a grant from the Nando and Elsa Peretti Foundation, is to contribute to the control of the COVID19 incidence among refugee and host communities of Rhino Camp Arua District in West Nile Region of Northern Uganda by strengthening Risk Communication, Infection Prevention and Control (IPC/PPE), Community Engagement and reinforcing the coordination of district actors.

Specific objectives of the proposed project

1. Strengthening the capacity for case management, infection prevention and control in the health facilities providing service to the refugees and host communities of Rhino camp;
2. Increase community awareness on the prevention of COVID-19 among the refugees and host communities of Rhino settlement.

Expected results of the project

Result 1
Improved awareness of COVID19 and its consequences through accessible and trusted information as a base for surveillance, case detection and management;

Result 2
 Improved capacity of 5 health facilities (each facility is attended by over 200 people/day) to respond and manage COVID-19 cases including referrals;

Result 3
Improved coordination at all levels (community, district and national level) to respond to COVID 19 – or other – outbreaks.

Foreseen activities for result 1
1.1 Conduct a 2 days orientation of 50 Village Health Teams (VHTs) from Rhino camp on COVID-19 Prevention/Control and Community Based Disease Surveillance (CBDS) 

The Village Health Team is composed of community members active at community level. Each VHT is assigned to a certain number of family members of refugee households, with the duty of providing them with basic health care and to promoting good sanitation practices. They are the frontline in the community health surveillance and their role in rural area is crucial. 
The 50 VHTs will be selected among the already active in the project area (Amref has trained more than 60 in the last year) to orient them to Community-based Surveillance (CBDS). The scope of CBDS is limited to systematic on-going collection of data on events and diseases using simplified case definitions and forms and reporting to health facilities for verification, investigation, collation, analysis and response as necessary. It is intended for improving public health surveillance and response by linking communities with their local health facilities. 

1.2 Conduct a 2 days orientation of 50 community leaders (25 camp commandants from Rhino camp and 25 local council leaders form the host communities) on COVID-19 Prevention/Control and Community Based Disease Surveillance (CBDS)

Community leaders (camp commandants, local council leaders) are another group of persons who have a special role in the communities. They are generally respected and trusted by the community and can influence people behavior. In an emergency context such as COVID 19 related risks, they can play a relevant role in spreading appropriate containment measures and early cases detection. The 2 days orientation will serve this scope.

1.3 Facilitate 50 VHTs to carry out community awareness campaigns within the selected zones of Rhino Refugee settlement. 

The VHTs, supported by the community leaders will carry out 2 days per week awareness sessions to the local population for 4 months. The community will be informed on how to prevent contagion and major symptoms; social distances measurement as well as hygiene awareness as a mean to prevent contagion.

1.4 Procure PPEs and other supplies for 50 VHTs from the project districts of Nebbi, Zombo, Yumbe, Moyo and Koboko on COVID-19 preparedness and response (10 VHTs per district).

Frontline health workers are at risk of transmission of COVID-19 and should be provided with Personal Protective Equipment (PPE). The intervention will provide personal protective equipment (gloves, surgical masks, hand sanitisers; N95 masks if involved in contact tracing) in adequate quantity. Training on how properly use PPE will be provided as well. 

Performance Indicators for result 1
- 50 VHTs trained on CBDS
- 90% of them have adequately understand and are able to perform CBDS
- 80% of Community leaders have adequately understood the CBDS and are keen to spread to support 

- Source of verification
- Entry and exit tests 
- Training reports
- Questionnaires/interviews
Foreseen activities for result 2

2.1 Train 50 health workers including laboratory staff on COVID-19 Prevention/Control and Community Based Disease Surveillance (CBDS).

The training will be conducted by expert professionals coming from the Arua District Health Office (DHO) and will last 3 days. Main topics:  (1) Orientation on identification of IDSR diseases, conditions and public health events at the community level; (2) - Case definitions for use at the community level; (£) Establishing a community-based surveillance structure (4)  Reporting a suspected case or public health event; (5) Investigating and confirming a suspected public health event in a local community (6) Exercises and case studies.The health workers will be trained in cohorts of 10 participants. 

2.2 Procure PPEs (personal protective equipment) for the 5 health facilities from the project districts of Nebbi, Zombo, Yumbe, Moyo and Koboko on COVID-19 preparedness and response

The intervention will provide Personal Protective Equipment (PPE) (gloves, surgical masks, hand sanitizers; N95 masks if involved in contact tracing) in adequate quantity. Training on how properly use PPE will be provided as well.

2.3 Roll out of Jibu platform & Call Centre Jibu is a smart mobile learning solution that enables access to health information and training (100 among VHTs and HWs)
Amref is using all its digital solutions and innovations: Leap - http://www.leaphealthmobile.com/,  Jibu, and M-Jali, all of which tie in to Amref Health Africa’s long-standing presence in our eight COVID-19 priority countries. 
The approach entails joint development and customization of digital training content that will be deployed to health workers through their mobile devices (basic and/or smartphones). The digital content has been customized to fit the needs of target audiences which includes consideration of skilled level of the audience, language preference and preferred channels (text or audio messages).

Performance Indicators for result 2
- 50 HWs trained on CBDS
- 90% of them have adequately understand and are able to perform CBDS
- 90% of the VHTs and WHs (100 in total) are able to use the digital health technology 
- 80% of Community leaders have adequately understood the CBDS and are keen to spread to support 

- Source of verification
- Entry and exit tests 
- Training reports
- Questionnaires/interviews

Foreseen activities for result 3

3.1 Facilitate monthly monitoring and reviews of the COVID interventions by leaders of the settlement and host communities

The intervention will facilitate monthly monitoring meeting with the leaders of the settlements and the host communities to share information on the SBDC status. These meetings will be supported by Amref staff with the aim of fostering linkages and collaboration and keeping a certain level of alert and community monitoring.

3.2 Facilitate monthly monitoring and reviews of the COVID interventions by the district leaders (DHO, CAO, RDC and OPM)

At the level health authorities, the monthly meeting will guarantee a constant sharing of data and info on COVID 19 cases in order to be able to promptly react in case of an outbreak and to refer to the higher level.

Performance Indicators for result 3
- At least 50 among local authorities and community leaders are involved in the coordination meetings
- 80% of them acknowledge a valuable result from the coordination meetings 

- Source of verification
- Project reports
- Questionnaires/interviews

The expected outcomes of this project are:

Result 1
Improved awareness of COVID19 and its consequences through accessible and trusted information as a base for surveillance, case detection and management;

Result 2
 Improved capacity of 5 health facilities (each facility is attended by over 200 people/day) to respond and manage COVID-19 cases including referrals;

Result 3
Improved coordination at all levels (community, district and national level) to respond to COVID 19 – or other – outbreaks.

Direct Beneficiaries

- Around 50000 persons reached at different level with the awareness sessions at community level conducted by the VHTs and at health facility level by the HWs.
- 5 health facilities manned by 50 health workers provided with IPC and Personal Protection Equipment (PPE); 
- 50 health workers and 50 VHTs trained in surveillance, reporting and prevention of COVID19; 
- coordination of > 20 CSOs, 50 refugee welfare committees with District Health Authorities, CAO, OPM and UNHCR.

Indirect beneficiaries
Around 150.000 people (Rhino total population)

AMREF Health Africa Onlus
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