[Final version] Polio Eradication Initiative of CORE PVOs in Bangladesh Final Evaluation Report for CARE-Bangladesh, PLAN International, Save the Children (USA) and World Vision￾Bangladesh Report prepared by Dr. Iqbal Anwar, Evaluation Team Leader Submitted to: PEI Secretariat CORE Group, Bangladesh & David Newberry, Project Director, Sara Smith, Senior Technical Advisor, CORE Group Partners Project 220 I Street NE Suite 270 Washington, DC 20002 Tel: 202-608-1847 Fax: 202-543-0121 Contact Person CARE-Bangladesh (Lead PVO) Dr. Smarjit Jana Sector coordinator H&P Dr. Ziya Uddin Sector support Coordinator, H&P Dr. Mahbubur Rahman Director PEI Secretariat H # 60 ,R # 7/A, Dhanmondi– R/A, Dhaka -1209 Phone : 880- 2-8114195 –98, 8114207 –09 E-mail: carehnp@bangla.net E-Mail :carebang@bangla.net World Vision Bangladesh Dr. Ratu G Saha Team leader, TSG & NHC Dr. Saidur Rahman Health Specialist 34, Kamal Ataturk Avenue, Banani Phone : 880-2–8813555-57, 8112187 E-mail : ratu_saha@wvi.org E-Mail : saidur_rahman@wvi.org PLAN Int. Bangladesh Dr. Dr. Khairul Islam Director Program support Dr Dr. Rebeka Sultana Project Coordinator H # 55 ,R # 7/A. Dhanmondi R/A, Dhaka – 1209 Phone : 880 -2–9120289 ,9122630 E- mail : islamk@bangla.net E – mail : rebeka.sultana@planbd.org Save the Children (USA) Dr. Nizam Uddin Ahmed Head Health, Population & Nutrition Mr. Amdadul Haque, Project Officer H # 35A, R #9A, Dhanmondi R/A, Dhaka –1209 Phone : 880 –2-9115291,9114619 E-mail : ahmedn@bangla.net E-mail :amdad@bangla.net T A B L E OF CONTENTS EXECCUTIVE SUMMARY 1-2 Chapter 1 INTRODUCTION 1.1Background of Polio Eradication Initiative Project 1.2Partners 1.3Objectives, Strategies and Working Areas 1.4 PEI Secretariat in Bangladesh 3 3 3 3 5 Chapter 2 METHODOLOGY 2.1 Evaluation Team 2.2 Process 2.3 Dissemination 6 6 6 7 Chapter 3 FINDINGS 3.1 Facilitation for Quality NID 3.2 Social Mobilization 3.3 Strengthening AFP Surveillance 3.4 Improvement of Routine EPI Coverage 3.5 Establishment of Polio Secretariat and its Role 3.6 PVO – Wise highlights of some unique feature 8 8 10 11 13 15 18 Chapter 4 LESSONS LEARNED 4.1 PEI Project Strategies 4.2 PEI Secretariat 19 19 19 Chapter 5 RECOMMENDATIONS AND CONCLUSION 5.1 Recommendations 5.2 Conclusion 20 20 21 ACRONYMS AFP : Acute Flaccid Paralysis AHI : Assistant Health Inspector AusAID : Australian Agency for International Development CC : City Corporation CS : Civil Surgeon CHO : Chief Health Officer DC : Divisional Coordinator DCS : Deputy Civil Surgeon DFID : Department for International Development DPT : Diphtheria, Pertussis, Tetanus EPI : Expanded Program on Immunization FPI : Family Planning Inspector FSC : Field Support Coordinator FWA : Family Welfare Assistant GOB : Government of Bangladesh HA : Health Assistant HI : Health Inspector HQ : Headquarters IOCH : Immunization and Other Child Health KI : Key Informant MCH : Maternal and Child Health MO : Medical Officer MOHFW : Ministry of Health and Family Welfare NGO : Non Governmental Organization NID : National Immunization Day OPV : Oral Polio Vaccine OSO : Operations and Surveillance Officer PEI : Polio Eradication Initiative PIB : Plan International Bangladesh PM : Program Manager PVO : Private Voluntary Organization SMO : Surveillance Medical Officer TA : Technical Assistance TST : Time Steam and Temperature Indicator TT : Tetanus Toxoid UFPO : Upazila Family Planning Officer UH&FPO : Upazila Health and Family Planning Officer UNICEF : United Nations Children’s Fund USAID : United States Agency for International Development VVM : Vaccine Vial Monitor WHO : World Health Organization WVB : World Vision Bangladesh LIST OF APPENDICES Appendix I : Tools used to serve as interview guidelines during field visits Appendix II : List of key persons (by title) met with in the field Appendix III : List of national level important key people met in Dhaka Appendix IV : Map showing project areas and areas visited PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 1 EXECUTIVE SUMMARY Background In May 2000, four CORE PVOs in Bangladesh, in collaboration with the Ministry of Health and Family Welfare and funding from the Washington based USAID supported Child Survival Resource Group launched the Polio Eradication Initiative Project in 50 upazila of 16 districts. The main focuses of the project were capacity building of relevant MOHFW and local NGO people required for conducting quality NID, extensive social mobilization, improving AFP surveillance and ensuring high routine immunization coverage using its predetermined strategies. The project was developed for a period of two years and is on no-cost extension for five months starting from May 2002. Right from the beginning, the PEI Project has played a catalytic role to work through and with the MOHFW and other key polio partners. Slightly more than two years after the project life, the final evaluation was undertaken to document the achievements/successes and share the lessons learned. Methodology The Evaluation Team reviewed the project documents, visited the working areas in different districts to gather first-hand qualitative information on the work undertaken by the project. The team also met with national level key people belonging to the agencies/organizations engaged in polio eradication including CORE PVOs. The principal focus of the methodologies used was to look at the following program aspects: ß Facilitation for quality NID ß Social mobilization for creation of demand and local resource mobilization ß Strengthening of AFP surveillance ß Improvement of routine EPI coverage ß Establishment of Polio Secretariat and its role Findings and Recommendations The work undertaken by the PEI Project has been highly appreciated at all levels of the MOHFW starting from the national down to the field levels including the community. The voices were particularly strongly among those who worked closely at upazila, union and community levels. Apart from those, district and PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 2 divisional level staff of WHO, UNICEF and IOCH acknowledged the valuable contributions made by the project in its intervention areas. The managers/supervisors at upazila and supervisors/workers at the field levels were found to be more confident and skilled in doing their jobs centering round polio eradication. Innovative and aggressive social mobilization activities have been successful in raising awareness of polio and creation of demand for available and accessible services provided through NID and routine EPI sessions. This approach has also been useful in mobilizing community resources both in kinds and cash. At the community level, the knowledge about the nearest NID as well as the nearest routine EPI site along with its days was found to be extremely good. Very good turnout of target age group of children was observed while visiting the routine EPI session. Creation of a huge number of Key informants within the community has strengthened the existing AFP surveillance network. Only a little training and good follow up could make this happen. The recognition of their work by the appropriate authority can keep their motivation high. The establishment of a central Secretariat has been found to be unique when a group of PVOs/organizations works together with a common funding source to achieve a common goal implementing similar strategies. It has pushed forward the CORE PVO dynamics through the strategies of coordinated mix of careful opportunity targeting, combining voices and activities, and resources which has significantly impacted for mobilizing GOB and other support. When Bangladesh is at the verge of polio eradication, all the key players engaged in polio eradication should continue their uninterrupted efforts together. In order to make it happen, the PEI Project of CORE PVOs ought to be extended till the certification, probably in 2005 and expanded in areas where there is an urgent need of improvement in polio eradication activities. If the project is not extended to function after September 2002, the CORE PVOs should continue to play their role in polio eradication efforts through their existing individual other health care. PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 3 Chapter 1 INTRODUCTION 1.1 Background of Polio Eradication Initiative The government of Bangladesh along with its different development partners is committed to eradicate olio from this country. In order to perform this challenging and gigantic task, USAID has been playing an important role since the beginning of the endeavors. As part of USAID’s commitment to eradicate polio globally the CORE Group (USAID funded Child Survival Resource Group based in Washington) has launched its Polio Eradication Initiative (PEI) for the countries which are yet to be freed from the burden of this childhood disease concentrated in the Indian sub-continent and some parts of sub-Saharan Africa. CORE Group’s PEI project in Bangladesh – the Polio Eradication Initiative of CORE PVOs in Bangladesh – commenced on 1 May 2000. The project was developed for a period of two years and is on no-cost extension for five months starting from May 2002. The Innovations The two innovations contained in the CORE Group’s polio eradication initiative in Bangladesh compared with other concurrent and previous programs are: Ú Formation of an organized collaboration among the CORE Group PVOs essential for maximum impact of the interventions; Ú Development of a unified bundle proposal for the CORE PVOs working in Bangladesh with strong working partnership with all other relevant key partners. 1.2 Partners PEI’s CORE PVOs are CARE-Bangladesh, PLAN International, Save the Children – USA and World Vision Bangladesh. The other relevant partners are MOH, USAID, WHO, UNICEF, IOCH (USAID funded) and ROTARY. 1.3 Objectives, Strategies and Working Areas of PEI Project Objectives p To strengthen the on-going polio eradication initiatives of the MOH including the supplementation of routine immunization by National Immunization Days (NIDs) p To strengthen AFP surveillance system through “Lay Reporting” of AFP case from community level PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 4 p To facilitate Mop-up campaigns for high-risk areas and to support field level activities to maintain high routine immunization coverage p To facilitate capacity building process of all concerned at different levels and establishment of a Polio Secretariat in CARE-Bangladesh for organized collaboration. Major Strategies p Capacity building of MOH managers, supervisors and field staff and local NGO staff from the district down to the community levels p Coordination and collaboration with partner NGOs and other local level partners p Extensive community mobilization p Inter-sectoral linkage for more involvement Target Population and Working Areas Total number of upazila: 50 under 16 districts including 1 CC Total population: 11,008,980 Number of children under 5 years: 1,683,618 Number of population under 15 years: 4,954,040 With a view to achieving its objectives, the PEI Project has focused on · Quality NID - Capacity building of relevant GOB and local NGO people for micro￾planning, effective field management, facilitative supervision and performance data analysis for decision-making and also of different segments of community to add their resources to the efforts being made by the GOB - Raising awareness and demand creation through extensive social mobilization · Reaching the unreached, high-risk and missed or “zero” dose children · Improving lay reporting for AFP case identification PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 5 · Ensuring high routine immunization coverage 1.4 PEI Secretariat in Bangladesh A Secretariat has been established in CARE-Bangladesh as lead PVO of this partnership to coordinate the total activities and it has started its operation since May 2002. The key responsibility of the Secretariat is to act as a bridge or communication channel between the PEI Project and the GOB and other relevant agencies/organizations engaged in polio eradication, between the partnering CORE PVOs and the CORE HQ and to ensure required coordination. 1.5 Purpose and Objectives of the Final Evaluation In an effort to evaluate that over the past two years, the PEI Project has successfully implemented its strategies to achieve the pre-set objectives of the project. The Scope of Work developed for the Final Evaluation include the following specific objectives: ê To assess the achievements of PEI Project within the operational areas of each partnering PVO ê To assess the project achievements in terms of project outputs and outcomes and also explore reasons for not meeting the objectives (if any) ê To assess the achievements in the capacities of MOH at different levels, local NGOs and different community segments so that they are capable of making effective plans and implementing the polio eradication activities ê To examine the project’s approaches to bring the changes in terms of raising community awareness, developing effective social mobilizati on network and community participation required for social mobilization activities through utilization of local resources, skill development and better management practices of MOHFW field staff, supervisors and upazila/district level managers ê To assess the functional effectiveness of the Polio Secretariat in coordinating and facilitating initiatives of the partnering PVOs and to assess its role in liaison and communication between the Secretariat and CORE-HQ, partnering PVOs, MOH and other key polio partners ê To make recommendations on future directions/involvement of Polio Secretariat as well as of the CORE PVOs in Bangladesh to continue with the currently ongoing campaign for polio eradication from Bangladesh ê To review issues identified by Evaluation Team a nd/or project/other partners ê To identify and share lessons learned with all concerned PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 6 ê To highlight major achievements and constraints that affected the project activities Chapter 2 METHODOLOGY 2.1 Team The Evaluation Team was composed of the following members: Dr. Iqbal Anwar National Consultant, Team Leader Dr. Subhra Chakma Medical Officer, EPI, MOHFW Dr. Momena Medical Officer, EPI, MOHFW Dr. Md. Shamsuzzaman Medical Officer, EPI, MOHFW Ms. Kohinoor Begum Training Officer, EPI, MOHFW 2.2 Process In order to achieve the objectives of Final Evaluation, the team members conducted a review of the existing documents of the project and attended briefing sessions presented by PEI Secretariat and the CORE PVOs. They then developed checklists to serve as interview guidelines for the field visits covering all levels of attention of polio eradication activities including NID, routine EPI, social mobilization and AFP surveillance (Appendix I). These field visits were conducted in 8 upazila and 1 City Corporation of 7 districts. During the field visits, the team members met with the people at different levels from the district down to the union of MOH, SMOs/DCs of WHO, OSOs/FHC of IOCH, CORE PVO staff at upazila levels, local level NGO representatives and different segments of the community. The team members also observed GOB organized EPI sessions and interviewed mothers both at EPI sites and at the community level. The team members and itineraries complete with key persons (by title) met with in the field are attached in Appendix II. The team leader also met with national level important key people of different partner agencies/organizations engaged in polio eradication activities, Polio Secretariat Director and the representatives of the CORE PVOs based in Dhaka (list of people met is attached in Appendix III). Following the field visits, the team held plenary review sessions of their findings. They also divided into subgroups based on program aspects and prepared overviews of those findings identifying achievements, issues of concerns, lessons learned and recommendations. These findings were also discussed in plenary review for presentations to key stakeholders in polio eradication in Bangladesh. The program aspects were as follows: ¸ Facilitation for quality NID including pre-NID planning, field management during NID, post-NID review i.e. use of performance data for decision-making ¸ Social mobilization for creation of demand and local resource mobilization PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 7 ¸ Strengthening of AFP surveillance ¸ Improvement of routine EPI coverage ¸ Establishment of Polio Secretariat and its role 2.3 Dissemination Sharing of the lessons learned and recommendations with all concerned that include donors, MOHFW officials, WHO, UNICEF, IOCH and other NGOs/PVOs. PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 8 Chapter 3 FINDINGS 3.1 Facilitation for quality NID The effective provision of ensuring quality NID an important and integral part of polio eradication efforts requires a commitment to 100 percent coverage by everyone engaged in the campaign from different levels of GOB officials to those who create demand and administer oral polio vaccine. These people need to have a clear chain of command between them with clearly spelled out roles, tasks and targets so that they are all capable and accountable and every child, who should be, is administered OPV. The commitment needs to be channeled into a coordinated management structure, which can plan, implement/organize, supervise and monitor the program. Moreover, facilitation is crucial when the systems are in place but are not functional the way they should be. The evaluation team found that in order to make these happen, the PEI project as a part of its capacity building efforts as catalyst, facilitated a sequential materialization of a number of activities to be undertaken before, during and after an NID. They were as follows: q Formation of Task Force with UNO as the chairperson, UHFPO as the member secretary and all other upazila level officers as members. It sits before an NID with only one agenda i.e. NID in order to ensure inter-sectoral collaboration and cooperation, and to develop upazila Action Plan on NID. Besides, the performance of immediate past NID is reviewed, problems (if any) are discussed to strategize solutions. This has been done because of the fact that monthly Upazila Development Coordination Committee meeting has to include quite good number agendas where adequate time/attention on NID can not be ascertained. q Holding of pre-NID upazila level advocacy and planning meetings with UHFPO in the chair and is participated by all upazila level mangers and supervisors of MOHFW, representatives from relevant non-government agencies/ organization including local NGOs before each NID. The agendas of the meeting include micro-planning, logistics support and organization of orientation/training etc. A post-NID review meeting is organized as well with the participation of similar group of people. In order to make the meetings effective all relevant facts and figures are presented and are discussed thoroughly with active participation of all concerned. PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 9 q Development of union level NID Action Plan encompassing the identification and recruitment of volunteers based on need, their orientation on session organization, VVM, and basics of record keeping. q Effective field management ensuring accessibility of the mothers/caretakers of children of target age groups, availability of all necessary logistics including vaccines, and quality of service including proper screening, administration of appropriate doses, maintenance of cold chain, need based counseling and proper record keeping. This important aspect of NID is well reflected in the Action Plan developed prior to NID which encompasses - Support at field level activities ensuring social mobilization and distribution of responsibilities to the partners - Support to logistic management that includes estimation and calculation of logistics for NID, ensuring availability of vaccines timely at field levels - Support to develop effective NID supervisory and quality monitoring activities q Institutionalization of checklist-based facilitative supervision during NID and Child-to Child Search by the 1st and 2nd line supervisors. In doing so, it was started with join supervision where the role of the local PEI staff was catalytic. q Preparation of quality NID report to be shared with all concerned as and when needed. q Provision of selection and rewarding the best performer of NID from MOHFW field staff and volunteers. PEI’s strategy to strengthen the capacity of local level NGOs has been found to be positively impacted on various levels of planning, implementing and monitoring the polio eradication activities. This public-private collaboration has been a synergy, which in tern has optimized the available resources avoiding duplication of work and double dipping of resources. Issue of Concern–Approved vs. Actual No of Personnel and Resources The Evaluation Team observed that there were positions that were not filled by appropriate personnel at different levels. In addition, some of the personnel did not have the necessary resources to carry out their tasks adequately. For examples, some 1st and 2nd line supervisors were unable to carry out supervision especially for hard to reach areas because they had neither transport nor adequate transport allowance to do so. In other instances, there was an observed inadequacy/lack of clear understanding about task assignment and specific responsibilities that lead to a reduced motivation and commitment to NID. PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 10 3.2 Social mobilization for demand creation and local resource mobilization Provision of service whether or not this is a quality one, will not necessarily make sure that will be availed by them for whom they have been made available. Along with the provision of availability of services there must be a demand for that. These demand creation efforts can be much more effective whenever they are a good mix of the efforts made by both service providers and the beneficiaries i.e. the community. Moreover, community’s involvement in public sector system ensures the mobilization of extra resources and accountability. Probing of different community groups, by the Evaluation Team, demonstrated that the PEI project has successfully implemented some innovative and sustainable approaches to create demands required for achieving the targets of NID. Additionally, there was more of a commitment on the part of the community to support the NID. The awareness raising and demand creation activities in PEI Project areas have been found to be unique to complement the national level mass media campaign. The activities include ß Involvement of public representatives like Union Council Chairmen/Members, religious leaders like Imams, school headmasters/assistant teachers, opinion leaders and professionals having equipped with simple messages on polio and its eradication ß Organization of rallies of different natures e.g. cycle/motor cycle rally, bull cart rally, fat men rally, van rally etc ß Organization of football tournament and some other popular events of sports in rural Bangladesh ß Performing drama by “Children Theatre Group” formed with local children at different visible places like school ground, market, street and community premises etc. the script of which is totally on polio ß Arrangement of other cultural events like area specific popular folk songs at suitable places of the community for better turnouts ß Hanging banners, wall writing, drum beating, use of public address system on rental basis and of the mosques ß Special announcement by Imams on NID before/after prayers including Jumma prayer Another beauty of the project is – the mobilization of local community resources. Some Union Council Chairmen, community leaders, philanthropists donate PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 11 money or announce prizes for rewarding best performing workers/volunteers during NID. Some of them sponsor for rallies/football tournament or some other relevant events/items like banners, badges, NID caps and T-shirts. In some unions, Community Clinic Management Committees have been formed and oriented in order to ensure the smooth functioning of the community clinics established within their vicinities. Amazingly, one union council chairman whose sister became a victim of polio about twenty years back mentioned in a choking and emotional voice “With my limited capacity, I will do everything possible for the eradication of polio from Bangladesh”. His high level of commitment was well demonstrated when the Evaluation Team came to know that during NID no routine work of that union council is undertaken and everyone gets involved in NID activities. Finally, probing of perception of mothers with children under five years of age of the areas visited, by the Evaluation Team demonstrated that there was a good level of understanding about NID, their nearest sites and the turnouts during NID was reported to be quite high. Issue of Concern – Bridging Between the MOHFW People and the Potential Community Group Formation of different community groups and the momentum already generated through their active participation and enthusiasm. There is a fear of fall of this momentum, if there is no frequent interaction between them and the field level GOB people, and/or there is a gap between the demand created and the services provided. Devising a mechanism can be instrumental to bridge up the gaps. 3.3 Strengthening AFP Surveillance Bangladesh has achieved remarkable success in its drive to eradicate polio. No virologically confirmed cases have been detected for almost two years since an infant developed polio due to type 1 wild poliovirus on 22 August 2000. The lack of wild poliovirus isolates in the subsequent period has occurred in spite of much improved surveillance for acute flaccid paralysis (AFP). The key factor resulting in this success is the conduction of increasingly effective NID, which, based on careful pre-planning and mobilization of public-private resources (man, money, material and monitoring) have succeeded in reaching a very high level of coverage of the targeted children under five years of age. Dependable routine immunization, confirmed by coverage survey to be sustained over the past decade, has also helped achieve this success. PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 12 There has been a notable progress in AFP surveillance since its induction in Bangladesh in March 1998. But AFP surveillance has been markedly strengthened by the creation of a cadre of Surveillance Medical Officers (SMOs) by WHO. They have been trained by WHO to strengthen the surveillance system that has been put in place through health facility based active surveillance, case investigation and 60-day follow up of AFP cases. They work in close collaboration with their government counterparts. One of the key roles of the SMOs is to provide frequent training and orientation for government mid-level mangers, supervisors and field workers and as well as NGO health staff, hospital staff, general practitioners, Rural Medical Practitioners and other primary level health care providers on facility and community based AFP reporting, case investigation and follow up. Divisional Coordinators have also been recruited by WHO to supervise, support and manage the SMOs network. Operations and Surveillance Officers (OSOs) employed by Immunization and Other Child Health (IOCH) project to provide support for surveillance in the city corporations and bigger municipalities. They are supported by three Field Support Coordinators (FSCs) who are also recruited by IOCH. According to the findings of Review of AFP Surveillance in Bangladesh – July/ August 2001, the coordination between SMOs, OSOs and their government counterparts was excellent, flow of information between them was free and quick and the response to AFP cases was fast. But the private sector was not fully integrated into the active AFP system and that some cases of AFP were being missed. The Evaluation Team members during their visits to the PEI intervention areas tried to look at those areas of improvement. They observed some visible changes because of the following efforts made by the project: ß Effective coordination between SMOs, PEI staff and their government counterparts ß Identification of Rural Medical Practitioners, Traditional Healers, Imams, School Teachers, community leaders, local NGO staff and RMP crew members to act as Key Informants (KIs) for AFP/Lay reporting ß Organization of orientation for the KIs working jointly with SMOs and the government counterparts ß Establishing a linkage between the KIs and field level government staff such as HA, FWA, HI, AHI and FPI ß Periodic meeting with the KIs in order to keep their motivation high, review their performance are fresh their knowledge at the union level With regard to knowledge of surveillance, visits of the Evaluation Team to the operational level revealed a clear understanding of the case definition for AFP PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 13 surveillance on the part of all levels (district and upazila level managers, field level staff and community level people like KIs). The team also noted that the data obtained from surveillance activities were being used to plan further actions for eradication efforts. Data management including updated display boards on NID performance and AFP cases were maintained in all the area visited. UH&FPO of an UHC reported that till date of the current year about one third of the identified AFP cases was reported by KIs. All SMOs, DC, OSOs and FSC met at the field level spoke in one voice to mention that community’s involvement in the AFP surveillance has significantly strengthened the AFP surveillance network of the PEI Project intervention areas. They also opined that community mobilization activities of the project have been found to be unique in raising awareness and creating demands during NID. Issue of Concern – Regular Follow up of KI’s Activity by MOHFW Field Staff Recognition of performance has always been seen to boost up the motivation of the performer. Failure to do so can have a reverse effect. Hence, there is an extreme need of devising a simple mechanism through which there should be regular interactions between the field level MOHFW workers like HI/AHI, FPI, HA or FWA and the KIs. This can also provide opportunity to refresh/update their knowledge. Ensuring the presence of notifying KI(s) in the monthly review meeting held at UHC for the recognition of their performance can also be a useful way. 3.4 Improvement of Routine EPI Coverage Along with the achievement of NID targets, sustained high coverage of routine EPI coverage is essential for eradication of polio from Bangladesh. In urban areas of Bangladesh immunization services are provided by both municipal and city corporation authorities and by NGOs as well as private practitioners. In rural areas EPI services are provided very largely by the MOHFW through outreach sessions at sites (using block approach of each ward of a union) supplied with vaccines from UHC and with syringes and needles mostly now centrally sterilized, plus more frequent sessions at some fixed centers such as UHC and recently established and functional Community Clinics. During the field visits, the Evaluation Team met with the people at different levels from the district down to the union of MOH, CORE PVO staff at upazila levels, local level NGO representatives and different segments of the community using the interview guidelines on routine EPI. The discussion meeting and interview revealed PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 14 ß Good coordination between all stakeholders and providers of EPI at operational levels ß A functioning management structure at all levels from district to union of health care with clearly defined responsibilities for EPI, effective management skills and identified individual’s task ß Problem solving skills that was particularly evident in how upazila level monthly meeting are now effectively dealing with how to improve the system of EPI services ß Effective supervisory structures and monitoring systems with plans and targets based on local findings and checklist based facilitative supervision which all have enabled to analyze EPI program performances and make plan accordingly at all levels ß Preparation of EPI workplan at upazila and union levels ß Coordinated technical assistance (TA) initiatives for capacity building which has lead to a situation where the effects of initiatives are optimal and there are clear plans for phasing out individual TA initiative with a view to sustainability Issues of Concern–Approved vs. Actual No of Personnel and Resources The Evaluation Team observed that there were positions that were not filled by appropriate personnel at different levels. While sanctioned posts are insufficient in relation to the current population, many of those sanctioned lie vacant. In addition, some of the personnel did not have the necessary resources to carry out their tasks adequately. For examples, some 1st and 2nd line supervisors were unable to carry out their planned supervision especially for hard to reach areas because they had neither transport nor adequate transport allowance to do so. There is still a gap between the planned and actual number of monthly outreach EPI session. As reported, mostly are due to inclement weather. In the course of the team’s field visits to PVO’s intervention areas, government EPI outreach sites were visited and some EPI activities were observed. The key findings include ß Mostly were well organized and equipped, staffed and with reliable supplies including vaccines ß Acceptable standards of sterilization (found with TST sticker), and of injection technique and dosage but some gap of knowledge and practice of vaccine handling. Discussions with staff (HA/FWA) at session sites revealed a high level of knowledge of proper EPI program activities, norms and recommendations. When questioned, they gave appropriate answers but when observed there were still deficiencies in practices suggesting that the PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 15 missing link was regular facilitative supervision specially for hard to reach areas and continuing education ß Advance registration of newborn eligible is used for immunization planning which is obviously a valuable tool. ß Good turnouts of pre-registered eligible infants ß Current dropout rate between DPT1 and Measles is about 15% - 20% which is lower than that of national average. Dropout of individuals and overall dropout are monitored and acted upon through follow up of children at the household levels. ß Organization of immunization sessions at fixed sites, especially UHC is relatively poor. As a result, these are not that attractive and comfortable to encourage more clients to visit. ß Probing of perception of mothers with children under five years of age of the areas visited, by the Evaluation Team demonstrated that there was a good level of understanding about routine EPI, their nearest sites and frequency of sessions. Issues of Concern – Counseling, Screening and Bridging Between the MOHFW People and the Potential Community Group Many missed opportunities for immunization are occurring because mothers/female caretakers are rarely being screened and counseled for TT (although was not within scope of the Evaluation Team) when they bring a child for immunization, and at hospital sick children are not being screened and referred for immunization. Furthermore, counseling is being neglected or rushed when sessions are busy or sites are crowded. Dropout is still not used as a standard program indicator. 3.5 Establishment of Polio Secretariat and its Role The Polio Secretariat was established at the CARE-Bangladesh headquarter. General management of the Secretariat and the Director happened to be a shared responsibility of all four PVOs. The Secretariat has been staffed with one Director and a couple of support hands. As proposed, CARE has lead in operationalizing the Secretariat. Main purposes of establishing the Secretariat were to ê Serve as the main linkage and collaboration agent and information channel among all partners and donors for achieving improved NID coverage, networking, data analysis and problem solving PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 16 ê Establish network among different NGOs, professional bodies, sectors and stakeholders for information sharing on polio eradication activities ê Prepare regular and special progress reports and make presentations to all concerns in order to keep them updated ê Partner CORE PVOs to obtain necessary technical assistance from different well recognized sources like WHO, UNICEF, CDC, USAID, IOCH and GOB and organize need based training/orientation/discussion at different levels of program operations ê Establish sustainable country level PVO collaboration partnerships, under the direction of MOH and with donors or other partners and as directed by the collaboration group ê Maintain liaison with PEI Director/Technical Adviser at CORE-HQ and at the region ê Partner with MOH, WHO, UNICEF, USAID and others engaged in polio eradication The approach of looking at the whole gamut of Polio Secretariat by the Evaluation Team was to review available documents, meeting with national level key people of different key players engaged in polio eradication efforts such as MOHFW, WHO, UNICEF, IOCH relevant donors and the CORE PVOs including the Secretariat people. The Evaluation Team during its meeting with the CORE PVOs emphasized on Secretariat’s modus operandi and its accomplishments as opposed to the preset roles, future potentials, and the problems encountered in performing the assigned roles. But the meeting with different key players focussed on their perceptions about the Secretariat, its visibility as a bridge or two-way communication channel between them and the CORE PVOs which have actually been implementing the project. The discussion meetings coupled with review of documents revealed the following findings: ß The establishment of a central Secretariat has been found to be unique when a group of PVOs/organizations has worked together with a common funding source to achieve a common goal implementing similar strategies. ß It has pushed forward the CORE PVO dynamics through the strategies of coordinated mix of careful opportunity targeting, combining voices and activities, and resources which has significantly impacted for mobilizing GOB and other support. ß In order to voice an advocacy process required to facilitate the public sector, it has passed through a number of sequential phases with the active participation of the CORE PVOs and other relevant partners which include PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 17 - Learning and documentation that include fact-finding and the creation of the initial, basic information base - Understanding the elements and inter-play of CORE PVO choices, priorities, and opportunities via analysis of the basic information base - Strategizing and planning i.e. choosing of the strategic options that are most likely to produce the most impact and creation of a costed plan. - Implementation and assessment to ensure that the facilitation process and strategy emerge from the needs of the service providers and recipients, that they are having the desired end result. ß Holding of periodic meeting with the participation of CORE PVOs at the Secretariat office the agendas of which used to vary but review of project’s progress used be more or less common. ß The Secretariat has functioned reasonably well in compiling information gathered from the CORE PVOs to be shared with the relevant departments of MOHFW and other polio partners on a regular basis through its participation in national level meetings on polio eradication efforts. It also carried back the information from the counterparts to be channeled to the PVOs. Same is the case as long as the channeling of information is concerned between the Secretariat and the CORE-HQ. But a number of the uniqueness of the project could have been highlighted in different forum that would in tern give the project more mileage and better visibility to all concerned. ß Nevertheless, the conduction of an “Experience Sharing Workshop” in April 2002 in Dhaka with the participation of all concerned both from home and abroad was useful in ventilating the project's experience. ß The efforts given behind the establishment of strong networking and linkage with key players engaged in polio eradication by the Secretariat have been found to be worthy. ß Arrangement of cross-country visits such as visits to India by Bangladesh PVOs and to Bangladesh by Nepal PVOs was extremely useful to learn each other’s strengths and replicate them as and when needed. ß Finally, commissioning of PEI Project Final Evaluation by the Secretariat, which started with the preparation of Scope of Work and continued through the organization of a debriefing session. In between it coordinated field visits and made necessary arrangement of meeting with different national level key people belonging to polio partners. Issue of Concern – Leadership of the PEI Secretariat There has been a frequent turnover of the leadership at the Secretariat which in tern has negatively impacted in keeping the consistency of the activities of the Secretariat. This has also faded the importance of the Secretariat not only to its CORE PVOs but also to other polio partners. PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 18 Apart from that there was a missed opportunity of getting exposed to each other’s uniqueness of approaches with a view to exploring the possibility of replication within the partnering PVOs and beyond. PVO-wise Highlights of Some Unique Features CARE-Bangladesh · Use of other project staff and logistics in PE activities in time of needs · Use of RMP crew members to act key informants and volunteer during NID · Use of chowkidars/dofadars for community mobilization through IPC during NID · Distribution of reminder cards using community resources during 1st round of NID Plan International Bangladesh · Formation of Children’s Theater Group to disseminate health messages including polio through cultural events like drama at the community levels · Organization of innovative rally like fat men rally, bull-cart rally etc · Supporting local level NGOs for building their capacities required to supplement the GOB efforts in polio eradication · Formation of Community Clinic Management Team Save The Children (USA) · Formation of Task Force at upazila level with UNO in the chair for NID · Use of chowkidars/dofadars for community mobilization through IPC during NID as well as routine EPI · Identification and use of young members of the community @ 2 per site to act as volunteers for routine EPI · Formation of a pool of trainers on NID and routine EPI drawing people from local NGO and GOB people World Vision Bangladesh · Use of community volunteers already identified for other development projects in the same areas during NID · Organization of NID sites at the brothels/jail for the children of CSW and female prisoners respectively · Organization of locally popular “pot song” before NID for demand creation · Organization of boat mobile team for hard-to-reach areas during NID PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 19 Chapter 4 LESSONS LEARNED 4.1 PEI Project Strategy q Project’s strategy to facilitate capacity building efforts through catalytic roles for upazila level mangers and supervisors, field level supervisors/workers and local level NGOs has been found to be effective as it can make the systems in place much more functional. q When total victory is the result of fighting against a public health problem like polio, as its eradication is possible within a predetermined period, effective coordination among the key players engaged in fighting is extremely useful in order to optimize the resources. q A combination of an audience-specific simple training and a good follow up mechanism can create a huge number of first line health cadres which can galvanize the current AFP surveillance network. q Regular sharing of experience is useful in ventilating each other’s uniqueness and their replication if possible or needed. q Improved client-provider interactions and counseling is crucial for improved client satisfaction and with increased demand and utilization. q Raising awareness of polio and creation of demands are not the only results of extensive social/community mobilization activities. If rightly approached, different segments of the community demonstrate the feeling of ownership and mobilize their resources (man-time, money and material), which is a unique example of public-private joint effort. 4.2 PEI Secretariat q Establishment of a Secretariat with skeleton staff was a unique concept because of the fact that it worked as a two-way communication between the project and other polio partners. As a result, there was no need for all the CORE PVOs to participate in any nationa l level meetings/events where it voiced on behalf of them and relayed back the message to them which in tern saved their staff time and money. It could be considered for other health components. PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 20 q Data should not only be used for reporting to the HQ/donor but also be used for internal (PVOs) consumption for decision-making. Chapter 5 RECOMMENDATIONS AND CONCLUSION 5.1 Recommendations q When Bangladesh is at the verge of polio eradication, all the key players engaged in polio eradication should continue their uninterrupted efforts together. In order to make it happen, the PEI Project of CORE PVOs ought to be extended till the certification, probably in 2005 and expanded in areas where there is an urgent need of improvement of polio eradication activities. q In addition to filling vacant positions, maximize government/NGO/community cooperation in joint staffing at sites where needed and possible. q In leveraging community support and collaboration with the government and other polio players, cement the ties between the MOHFW field level staff and the different community groups like trained KIs and other community groups that include public representatives, religious leaders, school teachers etc. q Continue onsite facilitative supervision and quality monitoring of EPI services with special focus on good infection prevention practices, proper screening and quality counseling to avoid missed opportunities and minimize dropouts. Also improve site management and staffing by incorporating on the spot volunteers and community support. q A system of reporting an AFP case on routine EPI Tally Sheet has been introduced. Therefore, whenever any AFP case is identified and investigated, ensure checking of corresponding Tally Sheet of the same area which should reflect the same. q As quality assurance is a continuous process, plan and conduct need based local refresher training for the EPI service providers and promoters including one-to-one and problem solving sessions. q Improve further the “use of available data for decision-making or action” especially at the field levels to identify and track/follow up ‘zero’ dose children and children due or late for routine immunization. PEI PROJECT FINAL EVALUATION REPORT JULY/AUGUST 2002 21 q Consider/plan to add convenient session for routine EPI, for example weekly holidays to ‘catch up’ sessions after missed sessions. This can be useful to minimize the gaps between the planned and actual sessions held. q Ensure sustained leadership of the Secretariat with a capable, credible and experienced person and widen the role of the Secretariat with a view to getting involved in national level decision-making process and/or for advocacy. 5.2 Conclusion If the project is not extended to function after September 2002, the CORE PVOs should continue to play their role in polio eradication efforts through their existing individual health care and other development programs. The Secretariat should also continue to exist, maybe in a wider form incorporating other relevant key players engaged in the field of health with a wider role as well. The intent is to ensue a well coordinated effort to achieve the goal of common concern not with much of a cost which could be borne by the participating partners. Appendix I Final Evaluation of PEI Project Guidelines for Discussion with CS/UHFPO/UFPO/MO-MCH/Chief Health Officer/MO-EPI/EPI Supervisor/ EPI Technician /NGO Executive Name: Designation: Dept./Organization: Address: Discussion points Response/Opinion Remarks Routine EPI · Key players for service delivery · Key players for demand creation through social mobilization · Coordination and collaboration · Vaccines and other EPI logistics · Cold chain maintenance/monitoring · Training status of service provider and promoter · Supervision · Quality and coverage monitoring · Record keeping and reporting · Use of data for decision making · Trend of EPI services in last 3 years NID · Key players for service delivery · Key players for demand creation · Coordination and collaboration · Vaccines and other EPI logistics · Cold chain maintenance/monitoring · Training status of service provider and promoter · Supervision · Quality and coverage monitoring · Record keeping and reporting · Use of data for decision making · Listing of “zero” dose children during NID · Trend of NID coverage in last 3 years · Local resource mobilization ß AFP Surveillance Systems - Identification - Specimen collection - ORI - Follow up - Reporting · Pictures of last 3 years (collect figures) ß Constraints for NID and/or routine EPI ß Any suggestion on CORE PVO’s PEI activities ß PEI of CORE PVOs will windup on 30th September, 02- what is your recommendation? Note: Chief health officer/MO-EPI for City Corporation or municipal areas Name of Team Member(s): Date: Final Evaluation of PEI Questionnaires for Community/Opinion Leaders (UP chairman/member, Municipal/CC ward commissioner, schoolteachers, imams, elite etc) Name of respondent: Occupation: Address Ward/Union: Upazila: District/CC: Name of interviewer: Date: Sl. # Questions Response Remarks 01. Have you heard of EPI program? Yes No 02. From where/whom have you heard? 03. Can you name six childhood EPI vaccines? Yes No Check 04. Can you name the nearest EPI site? Yes No * 05. Have you ever been there? Yes No 06. Do you have any role to play for EPI session? Yes No 07. If yes, what? 08. Have you heard of NID? Yes No 09. From where/whom have you heard? 10. Can you tell what is done on NID? Yes No 11. Can you name your nearest last NID site? Yes No * 12. Have you been there during NID? Yes No 13. How was the turnout? Good or bad, what could be the reasons behind? 14. Do you have any role to play during NID? Yes No * 15. If yes, what? 16. Have you received training on NID/AFP? Yes No * 17. If yes, who organized training? 18. Was there anything special/new in the observance of NID in last two years? Yes No 19. If yes, what was that? * * Verify with the relevant GOB/PVO person Final Evaluation of PEI Project Questionnaires for Community (Women with children under 5 years of age) Name of respondent: Occupation: Address: Ward/Union: Upazila: District/CC: Name of interviewer: Date: Sl. # Questions Response Remarks 01. Have you heard of EPI program? Yes No 02. From where/whom have you heard? 03. Can you name six childhood EPI vaccines? Yes No 04. Can you name your nearest EPI site? Yes No * 05. Do you know about date/day(s) of EPI session(s) of that site? Yes No * 06. Have you ever been there? Yes No 07. Why have you been there? 08. Have you heard of NID? Yes No 09. From where/whom have you heard? 10. Can you tell what is done on NID? Yes No 11. Can you name your nearest last NID site? Yes No * 12. Have you been there during NID? Yes No 13. Why have you been there? 14. How was the turnout? * Verify with the relevant GOB/PVO person Note: Interview at household level or outreach site. Final Evaluation of PEI Project Questionnaires for Key Informants (Rural medical practitioners1 , school teachers, community volunteers2 ) Name of respondent: Occupation: Address: Ward/Union: Upazila: District/CC: Name of interviewer(s): Date: Sl. # Questions Response Remarks 01. Have you heard of EPI program? Yes No 02. From where/whom have you heard? 03. Can you name six childhood EPI vaccines? Yes No 04. Can you name your nearest EPI site? Yes No * 05. Do you know about date/day(s) of EPI session(s) of that site? Yes No * 06. Have you ever been there? Yes No 07. Why have you been there? 08. Have you heard of NID? Yes No 09. From where/whom have you heard? 10. Can you tell what is done on NID? Yes No 11. Can you name your nearest last NID site? Yes No * 12. Have you been there during NID? Yes No 13. Why have you been there? 14. How was the turnout? 15. Have you heard of AFP/Lay Reporting? Yes No 16. From where/whom have you heard of AFP/Lay Reporting? * 17. Have you received any training on Lay Reporting? Yes No 18. If yes to # 15 and 17, do you have any role to play? Yes No 19. Tell about · Age group · What to do when you come across a lay case? 20. Who supervises you? Comments: * Verify with the relevant GOB/PVO person 1 RMP crew member –CARE working areas 2 Could be community mother, student, religious leader Final Evaluation of PEI Project Guidelines for Discussion with Polio Secretariat Personnel/Representatives from partners (USAID, DFID, AusAID, WHO, IOCH, UNICEF, ROTARY, BRAC, Line Director and PM MOH/ Chief H & P CORE PVOs, HSC –CARE, SSC –CARE, ACD – Program CARE, CD –CARE & Director Polio Secretariat) Name: Designation: Dept./Organization: Address: Discussion points Response/Opinion Remarks 1. Composition of the secretariat 2. Strategy/approach of the project 3. Modus operandi · Management support · Technical assistance · Performance review against the present objectives/indicators · Feedback to the implementing PVOs 4. Central mechanisms for · Coordination with different partnering organizations like GOB, WHO, UNICEF, IOCH · Coordination with CORE PVOs · Monitoring and evaluation activities 5. Documentation of project achievements and lessons learned and their dissemination · Whom to disseminate and how? 6. Learning from Secretariat Model/ Approach Any other comments: Name of Team Member(s): Date: Final Evaluation of PEI Project Checklist for EPI Session Organization and Service Delivery Name of EPI site *: Organized by: Staffing pattern: Frequency of session: …… session(s) per month Address: Name of observer(s): Date of observation: Things to be observed/discussed Observation/Findings Remarks 1. Organization of EPI session as per EPI guidelines · Location · Adequate EPI vaccines and other logistics · Adequate staff · Prescheduled with adequate preparation Yes/No Yes/No Yes/No Yes/No 2. Cold Chain is maintained according to EPI guidelines · Vaccine carrier in good condition · Thermometer in vaccine carrier · Standard number of icepacks · Ices of the icepack not melted · All vaccines are kept/used as per EPI guidelines Yes/No Yes/No Yes/No Yes/No Yes/No 3. Sterilization · Steam sterilizer is used for syringes/needles Yes/No 4. Screening for EPI is appropriate Yes/No 5. Counseling for EPI is done properly Yes/No 6. Missed opportunity is addressed Yes/No 7. Vaccines are administered as per EPI guidelines · Reconstitution of vaccines is done properly · Non-touch technique is followed · Correct amounts of vaccines are drawn/given · Routes of vaccination are appropriate · Post vaccination information is provided Yes/No Yes/No Yes/No Yes/No Yes/No 8. Record keeping and reporting are as per EPI guidelines · EPI vaccination card is filled up properly · Tally sheet and other relevant documents are filled up properly Yes/No Yes/No 9. Unused vaccines are returned/destroyed/discarded as per EPI guideline Yes/No Any other comments e.g. training status of staff, supervision of EPI services and client turnout: * Selected randomly Final Evaluation of PEI Project Guidelines for Discussion with PEI Field Level Manager/Staff Name: Designation: Dept./Organization: Address: Name of Team Member(s): Date: Discussion points Response/Opinion Remarks 1. Project goal/objectives 2. .Major areas of focus 3. Project strategies 4. Key roles of the project on · NID/Polio eradication activities · Routine EPI · Local resource mobilization. · Social mobilization · Monitoring of routine EPI/NID · Mechanism of feedback of field findings to the counterpart (GOB) · Assistance on AFP Surveillance (lay reporting, ORI, stool collection etc) · Training for imam/teacher/ traditional healer/UP bodies/GOB/ NID volunteer/key informant/other · Covering on border areas & hard-to￾reach areas during NID 5. Coordination with different partner organization. WHO/IOCH/ UNICEF/ MOHFW/ Others 6. Record keeping/reporting/monitoring system of PEI project. 7. Constraints on implementing field activities 8. Sharing and dissemination mechanisms of relevant information with all concerned Final Evaluation of PEI Project Guidelines for Discussion with Partner organization ( WHO Divisional Coordinator/SMO, FSC/OSO and PEF of IOCH, UNICEF - UPC/ Divisional Chief) Name: Designation: Dept./Organization: Address: Name of Team member(s): Date: Discussion points Response/Opinion Remarks 1. Coordination and collaboration 2. Their efforts/contribution to polio eradication activities 3. Quality of EPI service delivery 4. Role on AFP surveillance (Training, lay reporting, ORI etc) 5. Role of CORE PVOs on KI orientation 6. Suggestion on CORE PVO’s activities 7. CORE PVOs is going to wind up on 30th September ‘02 - what is your recommendation? 8. Any idea about polio secretariat? `* 9. Learning from secretariat approach * If yes, proceed for next question Appendix II LIST OF KEY PERSONS MET WITH DURING FIELD VISITS Persons Met/Title Place Team Member(s) Dr. Joyanta Datta, MO-CS Sylhet Ms. Kohinoor Begum Dr. Iqbal Anwar Dr. Abdul Hamid UH&FPO Gowainghat, Sylhet Ms. Kohinoor Begum Dr. Iqbal Anwar Mr. Md. Mahbubur Rahman UFPO Gowainghat, Sylhet Ms. Kohinoor Begum Dr. Iqbal Anwar Mr. Md. Hamid Ali EPI Technician Gowainghat, Sylhet Ms. Kohinoor Begum Dr. Iqbal Anwar Dr. Sirajul Islam UH&FPO Balaganj, Sylhet Ms. Kohinoor Begum Mr. P Kumar Das EPI Technician Balaganj, Sylhet Ms. Kohinoor Begum Dr. Md. Shafiqul Hossain DC, WHO Sylhet Ms. Kohinoor Begum Dr. Iqbal Anwar Dr. Sanawarul Bari FSC, IOCH Sylhet Ms. Kohinoor Begum Dr. Iqbal Anwar Mr. Alamgir Hossain UNICEF Divisional Chief Sylhet Ms. Kohinoor Begum Dr. Iqbal Anwar Dr. Tahsin Anam SMO, WHO Sylhet Ms. Kohinoor Begum Dr. Iqbal Anwar Dr. Md. Nurul Islam OSO, IOCH Sylhet Ms. Kohinoor Begum Dr. Iqbal Anwar Mr. Nurul Haque Asstt. Project Officer, PEI, CARE Gowainghat, Sylhet Ms. Kohinoor Begum Dr. Iqbal Anwar Ms. Rukshana Begum Asstt. Project Officer, PEI, CARE Balaganj, Sylhet Ms. Kohinoor Begum Dr. Daud Ali Miah DCS Khulna Dr. Subhra Chakma Dr. A B M Mahbubul Haque CHO, Khulna CC Khulna Dr. Subhra Chakma Ms. Nurun Nahar EPI Supervisor, Khulna CC Khulna Dr. Subhra Chakma Mr. Md. Hafizur Rahman EPI Supervisor, CS Office Khulna Dr. Subhra Chakma Dr. Amal Arefin DC, WHO Khulna Dr. Subhra Chakma Dr. Morshed Ahmed SMO, WHO Khulna Dr. Subhra Chakma Mr. Shahadat PEF, IOCH Khulna Dr. Subhra Chakma Persons Met/Title Place Team Member(s) Mr. Utpalendu Roy PM, PEI, WVB Khulna Dr. Subhra Chakma Mr. Chandan Z Gomez Area Dev. Coordinator, WVB Khulna Dr. Subhra Chakma Mr. Ashok Kumar Mandal SSP, Banophul (local NGO) Khulna Dr. Subhra Chakma Dr. S Mostafa Anwar CS Satkhira Dr. Subhra Chakma Dr. Mobarak Ali MO-CS Satkhira Dr. Subhra Chakma Dr. Rezaul Haque UH&FPO Kalaroa, Satkhira Dr. Subhra Chakma Dr. Prabir Kumar Mukherjee MO-MCH Kalaroa, Satkhira Dr. Subhra Chakma Mr. Abdul Jhaleque Khan FPI, Diara union Kalaroa, Satkhira Dr. Subhra Chakma Mr. Dina Mohan Das AHI, Joynagar, Sultanabad Satkhira Dr. Subhra Chakma Mr. Manik Chandra Paul APO, CARE Satkhira Dr. Subhra Chakma Dr. Paritosh Kumar Kundu UH&FPO Monirampur, Jessore Dr. Subhra Chakma Dr. Sanjoy Kumar Pathak MO Disease Control Monirampur, Jessore Dr. Subhra Chakma Mr. Mobashar Hossain EPI Technician Monirampur, Jessore Dr. Subhra Chakma Mr. A K M Baharul Islam HI Monirampur, Jessore Dr. Subhra Chakma Mr. Nrmal Kanti AHI, Khanpur union Monirampur, Jessore Dr. Subhra Chakma Dr. Mahfuzul Islam SMO, WHO Jessore Dr. Subhra Chakma Mr. Mihir Biswas Unit Manager, Ad-Din (local NGO) Monirampur, Jessore Dr. Subhra Chakma Dr. Nazrul Islam CS Nilphamari Dr. Shamsuzzaman Dr. Iqbal Anwar Dr. Mostakur Rahman MO-CS Nilphamari Dr. Shamsuzzaman Dr. Iqbal Anwar Dr. Abdul Jalil UH&FPO Chirirbandar, Dinajpur Dr. Shamsuzzaman Dr. Iqbal Anwar Dr. Abul Azad Mondol MO-MCH Chirirbandar, Dinajpur Dr. Shamsuzzaman Dr. Iqbal Anwar Persons Met/Title Place Team Member(s) Mr. Md. Isamuddin EPI Technician Chirirbandar, Dinajpur Dr. Shamsuzzaman Dr. Iqbal Anwar Mr. Shah M Jahurul Haque SACMO, Shaintara UHFWC Chirirbandar, Dinajpur Dr. Shamsuzzaman Dr. Iqbal Anwar Mr. Idris Ali HI Chirirbandar, Dinajpur Dr. Shamsuzzaman Dr. Iqbal Anwar Mr. Mohabbat Ali Program Unit Manager, PIB Chirirbandar, Dinajpur Dr. Shamsuzzaman Dr. Iqbal Anwar Mr. Rezaul Karim PEI Coordinator, PIB Chirirbandar, Dinajpur Dr. Shamsuzzaman Dr. Iqbal Anwar Mr. Sarwar Jamil Khondaker Theater Trainer, PIB Chirirbandar, Dinajpur Dr. Shamsuzzaman Dr. Iqbal Anwar Mr. Sunil Kumar Shaha Chairman, Tetulia union Chirirbandar, Dinajpur Dr. Shamsuzzaman Dr. Iqbal Anwar Mr. Shahidul Islam Director, SSS (local NGO) Chirirbandar, Dinajpur Dr. Shamsuzzaman Dr. Iqbal Anwar Dr. A K F Mazibur Rahman UH&FPO Jaldhaka, Nilphamari Dr. Shamsuzzaman Dr. Iqbal Anwar Dr. Md. Nabiul Islam MO-MCH Jaldhaka, Nilphamari Dr. Shamsuzzaman Dr. Iqbal Anwar Mr. Nur Alam Siddique EPI Technician Jaldhaka, Nilphamari Dr. Shamsuzzaman Dr. Iqbal Anwar Mr. Shamsul Islam FPI, Golna Jaldhaka, Nilphamari Dr. Shamsuzzaman Dr. Iqbal Anwar Mr. Narayan Chandra Sarker PEI Coordinator, PIB Jaldhaka, Nilphamari Dr. Shamsuzzaman Dr. Iqbal Anwar Dr. Razzakul Islam Health Program Coordinator, PIB Jaldhaka, Nilphamari Dr. Shamsuzzaman Dr. Iqbal Anwar Mr. Mir Hamidul Islam Khan Chairman, Mirganj union Jaldhaka, Nilphamari Dr. Shamsuzzaman Dr. Iqbal Anwar Dr. Jahangir SMO, WHO Nilphamari Dr. Shamsuzzaman Dr. Iqbal Anwar Dr. Md. Ishaq Khan CS Brahmanbaria Dr. Momena Dr. Iqbal Anwar Dr. A K M Nazrul Islam UH&FPO Nasirnagar, Brahmanbaria Dr. Momena Dr. Iqbal Anwar EPI Technician Nasirnagar, Brahmanbaria Dr. Momena Dr. Iqbal Anwar Mr. Md. Habib Mahmood Coordinator, HPN, Impact Area Save the Children USA Nasirnagar, Brahmanbaria Dr. Momena Dr. Iqbal Anwar Mr. Syed Nashidul Haque Nashid Field Officer, Impact Area Save the Children USA Nasirnagar, Brahmanbaria Dr. Momena Dr. Iqbal Anwar Persons Met/Title Place Team Member(s) Mr. Mohsin Wazed Upazila Coordinator, PEI Save the Children USA Nasirnagar, Brahmanbaria Dr. Momena Dr. Iqbal Anwar Dr. K M Hasan Ameen SMO, WHO Nasirnagar, Brahmanbaria Dr. Momena Dr. Iqbal Anwar Field Coordinator JUSSS ((NSDP funded local NGO) Nasirnagar, Brahmanbaria Dr. Momena Dr. Iqbal Anwar Mr. Hafez Shamsuzzaman Imam Nasirnagar, Brahmanbaria Dr. Momena Dr. Iqbal Anwar Mr. Joinal Abedin School Teacher Nasirnagar, Brahmanbaria Dr. Momena Dr. Iqbal Anwar Dr. Zakaria Moula Chowdhury Acting UH&FPO, MO-MCH Bancharampur, Brahmanbaria Dr. Momena Mr. Md. Shahidulla EPI Technician Bancharampur, Brahmanbaria Dr. Momena Mr. Abdul Kader School Teacher Bancharampur, Brahmanbaria Dr. Momena Mr. Abu Taher School Teacher Bancharampur, Brahmanbaria Dr. Momena Md. Mohsin Imam Bancharampur, Brahmanbaria Dr. Momena Appendix III LIST OF NATIONAL LEVEL KEY PERSONS MET WITH IN DHAKA Persons Met/Title Organizations/ Agencies Team Member(s) Dr. M Mahbubur Rahman Program Manager, CH and LCC MOHFW Dr. Iqbal Anwar Dr. David Snidack Medical Officer- EPI WHO Dr. Iqbal Anwar Dr. Zobaidul Haque Khan National Surveillance Officer WHO Dr. Iqbal Anwar Mr. Charles Llewellyn Deputy Team Leader, HPN Team USAID Dr. Iqbal Anwar Ms. Jenny Friedmann Program Coordinator, HPN Team USAID Dr. Iqbal Anwar Dr. Sukumar Sarker Project Management Specialist, HPN Team USAID Dr. Iqbal Anwar Ms. Vilaisan Campbell First Secretary, Development Assistance AusAID Dr. Iqbal Anwar Dr. E G P Haran Child Health Adviser IOCH/PATH Dr. Iqbal Anwar Dr. Smarajit Jana PC, HIV and Acting Sector Coordinator Health and Population CARE-Bangladesh Dr. Iqbal Anwar Dr. Ziya Uddin Sector Support Coordinator Health and Population CARE-Bangladesh Dr. Iqbal Anwar Dr. Muhammod Abdus Sabur Sector Manager, Health and Population DFID Dr. Iqbal Anwar Dr. Md. Manjur Hossain Project Officer, Health & Nutrition Section UNICEF Dr. Iqbal Anwar Dr. Khairul Islam Director, Program Support PLAN Dr. Iqbal Anwar Dr. Ratu G Saha National Health Coordinator and Team Leader, Technical Service Group WVB Dr. Iqbal Anwar Dr. Sayedur Rahman Health Program Specialist WVB Dr. Iqbal Anwar Dr. Nizam Uddin Ahmed Head, HPN Programs Save the Children USA Dr. Iqbal Anwar Dr. Shehlina Ahmed Health Adviser PLAN Dr. Iqbal Anwar Dr. Rebeka Sultana Health Program Coordinator PLAN Dr. Iqbal Anwar Mr. Kazi Amdadul Hoque Program Officer Save the Children USA Dr. Iqbal Anwar Dr. Md. Mahbubur Rahman Project Manager (Acting) and Director, PEI Secretariat CARE-Banglades h Dr. Iqbal Anwar Dr. Shamim Imam Ex Director, PEI Secretariat CARE-Bangladesh Dr. Iqbal Anwar