Webinar | Resilience in Adversity: Delivering NTD Services in Conflict and Insecurity
Watch the recording in English, French, or Portuguese:
On October 23rd, USAID’s Act to End NTDs | East (Act | East) program hosted Resilience in Adversity: Delivering NTD Services in Conflict and Insecurity. The webinar highlighted tailored strategies to deliver NTD services in communities impacted by conflict and insecurity.
From Mozambique, we learned how ongoing conflict in Cabo Delgado has impacted health service availability and accessibility in the region. However, through close coordination with local partners and humanitarian agencies, the government and partners are identifying windows of opportunity to deliver NTD services. In Ethiopia, a Gender Equity and Social Inclusion (GESI) assessment supported health officials in the post-conflict region of Tigray to understand the needs of communities and tailor strategies for the resumption of NTD efforts. NTD leaders from Haiti shared their efforts to continue delivering NTD services wherever and whenever possible, despite insecurity and political instability. Finally, we learned from Uganda's experience delivering NTD services in the Karamoja region, an area that has faced many challenges due to migratory and mobile populations, cross-border movements, and insecurity due to cattle raiding.
Presenters:
- Henis Sitoe, Ministry of Health, Mozambique
- Mawo Fall, RTI International, Mozambique
- Marc Aurèle Telfort, Ministry of Public Health and Population, Haiti
- Genet Kassaye, WI-HER, Ethiopia
- Rapheal Opon, Ministry of Health, Uganda
Responses to questions asked during the webinar:
Q: Can you please share some of the redefined strategies for implementing field activities?
A: In Mozambique, the approach varies depending on the activity. For the surveys, we made a concerted effort to keep team sizes small in the field to avoid drawing attention. During interviews, teams worked diligently to minimize the time spent at each household. As mentioned in the presentation, we instructed teams to be discreet when taking GPS readings. Regarding MDA-related activities, we consistently employed a mixed strategy, favoring door-to-door distribution to prevent crowding at distribution points. In both cases, teams dedicated additional time to discussions with local administrative authorities about the security situation in the area. It was also crucial for these authorities to be informed about the teams' exact locations. - Answered by Act | East program staff.
Q: How do you find communication during field activities for activity implementation? What strategies are you using to effectively communicate while in communities in these conflict prone settings?
A: Communication during field activities is extremely important and there are always risks associated with moving around districts, especially when there is insecurity. Health teams can be mistaken for political parties and can be targets. In Uganda’s case, daily contact from teams to the Chief of Party (COP) is a must and when teams are in Karamoja, the COP communicates regularly with the regional office security contact. Satellite phones are also an option. Before teams enter any district, they liaise with the security personnel in the districts to find out where the latest hotspots are in order to avoid them. All measures of security are important when working in unsettled areas. - Answered by Act | East program staff.
Q: For Mozambique - Which age category mainly missed medicines during MDA carried out during the conflict since you reached a small proportion of the population?
A: Answered during webinar - We do not have the % of the population that did not receive the medicine. Medications were administered to all individuals present in the communities. However, we faced a challenge: those who relocated to another province due to instability in the area were not treated. This often included women with children and men.
Q: Can you please tell us more on the virtually observed therapy? How did you ensure the intake? How did you find the willingness and accesses of internet compared to DOT?
A: Answered during webinar - We targeted a population of individuals who wanted to take the drug at night because they were scared of side-effects, and we establish some criteria of enrollment like acceptance to send a short video while swallowing the drug, quality of the video to be accepted and counted as valid, and support from field agents to the participant. It was a pilot, and the results are very good. Internet services are accessible throughout the country in Haiti, but this pilot was conducted in an urban area where we were sure of availability of internet services.
Q: For Haiti - I recently saw an abstract on VOT (Video Observed Therapy) for Trachoma MDA in Haiti. Is this also an option you are considering for LF MDAs in these conflict communities? How do communities in these conflict areas perceive VOT?
A: Answered during webinar - Currently the MOH has no official data on the evidence of endemicity of Trachoma in Haiti. The virtual DOT was implemented as a pilot in 2023 and 2024 during LF MDA. Post-Webinar addition - The MOH does intend to use virtual DOT during the FY25 MDA in another large urban area.
Q: In the context of NTDs in fragile, conflict, and vulnerable settings, i) how can we approach or prioritize components of health systems strengthening, and ii) ensure disability inclusion?
A: NTD program implementers can help rebuild public confidence in the healthcare system by working through public facilities and health staff for NTD service implementation and can select distribution sites in or close to health facilities to embed service provision within the larger health system. Implementers can also help strengthen health information systems such as tally sheets, MDA registers, and HMIS/DHIS2 from community health centers to the district level, and can play a key role in capacity building for a weakened health workforce to accurately document population and uptake information in registers and tally sheets that generate usable data for a variety of health actors and sectors to use. Training and capacity building of local community groups and social structures such as the Women’s Health Development Army, community leaders, and the Health Extension Program, is needed to rebuild and mobilize these groups to support resumption of NTD services. Implementers can also consider integration or alignment of other priority health and development services with NTD service provision to bolster overall community support and awareness of resumed health care services post-conflict.
To reach people living with disabilities in complex settings, data from a recent Act | East assessment in Tigray, Ethiopia indicated that conducting targeted house-to-house visits for both health education and MDA distribution facilitates awareness and access to medicine among those experiencing mobility restrictions and social isolation. It was also recommended from the assessment findings to prioritize training for health workers, MDA distributors and NTD officials to counter stigma or misconceptions that may exist in the health workforce and ensure MDA is given to all eligible people, including women and the elderly living with disabilities. Census updates that include disability information can also help identify and reach people with disability at the household level. GESI-sensitive tools such as Ethiopia’s adapted Supervisor’s Coverage Tool (SCT) have also helped MDA implementers in complex settings ensure all members of a household are being reached with MDA through strategic mop-up by specifically incorporating disability identification variables and disability data disaggregation in the analysis of the SCT, as well as Coverage Evaluation Survey results. - Answered by Act | East program staff.
Q: For Mozambique - How are NTD interventions integrated into broader humanitarian efforts, and how do you overcome competition for resources and attention?
A: Before the NTD program resumed its activities in the stable areas of Cabo Delgado province, some MOH and RTI program managers met with nearly all the NGOs operating in the region. There is excellent coordination among the NGOs, which hold weekly meetings to discuss the province's security situation and share the latest information. During these meetings, the NGOs demonstrate a genuine willingness to collaborate, free from competition or the desire for specific attention. The primary objective is to ensure that care reaches those in need. - Answered by Act | East program staff.
Q: For Mozambique - What specific strategies have been implemented to maintain consistent supply chains for NTD medications and materials in areas where infrastructure has been destroyed?
A: As a reminder, the NTD program resumed operations in the districts only after they were deemed stable and secure. The districts where we operated were not destroyed; however, in two districts, some health posts had been damaged. In these cases, medicines were stockpiled at the district level. Each morning, supervisory teams collected these medicines and materials and distributed them to volunteer teams in the field. - Answered by Act | East program staff.
Q: For Uganda - How are NTD programs designed to be conflict-sensitive in Uganda, particularly in areas like Karamoja, where communities experience intermittent conflict? What measures are taken to avoid exacerbating local tensions while delivering health interventions?
A: During delivery of these health interventions, we encourage teams not to move to the field with army escorts in order to remain neutral. Teams conduct daily security briefs with district security officers before they travel to the field to make sure it is safe to conduct activities. Entry meetings are conducted with district officials to inform them about the activities that will be implemented and to seek their support in the implementation of these activities. It is also very important to work with local leaders (chiefs) to mobilize communities and also to influence uptake of MDA medicines. The program sensitizes the chiefs so that they are aware of what causes the disease, how it spreads, and how it can be prevented. Additionally, selecting medicine distributors from within their kraals/communities is important to support trust of the medicines being swallowed and to avoid non-compliance. Teams also work within health system structures to implement activities, by leveraging schoolteachers, health assistants, and others who are already part of and well known by the community. Village health teams (VHTs) are given branded t-shirts and other materials like posters and flip charts so that they are easily identified as VHT members. In Karamoja, cross-border collaboration with Kenyan health teams is particularly vital, because it helps mobilize Turkana pastoralists since they trust their own health teams. - Answered by Act | East program staff.
Q: Conflict situations often create funding gaps. What innovative financing mechanisms or partnerships have been developed in Uganda to ensure that NTD programs continue to receive necessary funding in times of conflict or political instability?
A: Through cross border collaboration we continue to work with Turkana teams in Kenya to ensure that NTD services reach the migratory pastoralists that usually cross from Kenya to Moroto in Uganda. Additionally, through collaboration with the Government of Uganda and Sightsavers, we have integrated trachoma surgeries with trachoma MDA to ensure that no one is left behind. Working with districts, health teams usually carry out integrated health outreaches (maternal and child health, malaria, TB screening) which trachoma screening is included in, and trachoma graders are part of these teams. Using MOH approved domestic resource mobilization guidelines, districts have also started allocating domestic revenue towards NTD prevention and elimination. Finally, regular district partner coordination meetings bring together all the partners in the region to share their lessons and learnings and potential areas for collaboration. - Answered by Act | East program staff.
Q: For Haiti - You noted that you analyzed reasons for non-participation in campaigns and adapted accordingly. Did the program conduct a special study to determine reasons for non-participation in campaigns, or what data did you analyze to adapt your strategy?
A: Data from multiple coverage evaluation surveys and after actions reviews indicated that people are reluctant to get involved in MDA due to fears of side effects, desire for food to take alongside medicines, and preference for options to take medicines before bed to reduce side effects. For these reasons, the Haiti Ministry of Health, with support from USAID’s Act to End NTDs | East program, began providing crackers and has utilized Virtual Direct Observed Therapy (VDOT) to allow participants to take medicines at home with food and before bed, while still conveying videos to confirm successful treatment. - Answered by Act | East program staff.