End of Mission Report

Sierra Leone – Emergency Cholera Response 2012

Nick Brooks, WASH Advisor CARE Australia

Deployment Summary

4 week deployment to support emergency cholera response program in Sierra Leone. Deployed 13th September – 13th October 2012. Distinctive features of the response included:

·  Short project timeframe – limited to 6-weeks due to timeframe of DFID Rapid Response Facility (RRF) funding.

·  Wide geographical spread of cholera across Sierra Leone, and relatively small number of WASH actors, led to a CARE response over large area (4 Districts, 13 Chiefdoms) and bringing logistics challenges with movements of materials and staff for distributions, and staff communication. Transport challenges were compounded by the rainy season.

·  Project focus on distribution of cholera kits (Aquatabs, soap, ORS) and hygiene promotion through CARE staff (BCC and Outreach Officers) and trained community volunteers, in collaboration with local health authorities (DHMT, PHU).

·  National CARE response team with minimal WASH or emergency experience, although with good community mobilisation awareness and DHMT / PHU contacts in areas of operation.

·  Commitment of Country Office (CO) to learning from the response and building future WASH capacity and WASH programs in Sierra Leone. Rapid Accountability Review and After Action Review both carried out during the cholera response, and plans developed for future WASH programing / integration with existing CO health programs.

Outputs

·  Project oversight, technical support, and supervision of work planning ensured timely completion of emergency cholera response activities, including distribution of over 15,000 cholera kits at household level.

·  Support to CO operations support staff to ensure effective logistics process for the response, and tracking of materials distribution.

·  Support to M&E staff to ensure accurate reporting of project activities; timely collation / analysis of field monitoring from Outreach Officers and volunteers; and specific research into gender during the cholera epidemic and the impact of CARE radio messaging.

·  Preparation of WASH Capacity Development Plan for improved WASH responses in medium-long term. Including advice on selection of a WASH Focal Point in Sierra Leone CO. Also provision of practical tools for WASH assessment to be used in longer-term planning / proposal development in Sierra Leone.

·  Facilitation of Team Meeting (Makeni, 25th Sept) and After Action Review (Makeni, 2nd Oct). Output from team meeting was development of workplans at Chiefdom level by staff to ensure timely completion of program, and clarification of technical issues for distribution / hygiene promotion. Output from After Action Review fed into WASH Capacity Development Plan (also separate report prepared by Alain Lapierre).

·  Preparation of MOU for water treatment unit donation in Koinadugu, and facilitation of the handover process with the DHMT and MDM.

·  Led field monitoring of Aquatab use at household level and revision of dosing advice / messaging by CARE and through coordination the revision of the national drinking water standard for the cholera response.

·  Supported representation of CARE in co-ordination forums, in particular the national WASH/Social Mobilisation Working Group and District/Chiefdom-level coordination with local government and other NGO actors. Also activity reporting to Unicef / national level.

·  Prepared donor Concept Note and budget for transition from cholera.

·  Prepared initial 2 drafts of Final RRF Narrative Report for DFID, incorporating comments from country staff and program management.

Observations (Lessons Learnt)/ Conclusions

  1. Speed and Timeliness of CARE Response.

1.  The use of CO funds and timely accessing of CI ERF funds and the deployment of CI WASH Senior Sector Specialist and CARE UK Head of Emergencies were significant factors allowing the response to be kick-started effectively by the end of August.

2.  Comparative to other agencies implementing the RRF, it appears that CARE’s progress in the 6-week timeframe was one of the strongest performances.

3.  The national peak of cholera was in early August, so the overall humanitarian response (inc. donor, govt. and NGO response) could have had a bigger impact if warning signals had been responded to earlier in the year (for example cholera cases outside normal seasonal pattern).

4.  Highlighting the cholera risk in the updated CO EPP, and agreeing trigger factors with national WASH / Health peer agencies should help to address this.

  1. Project Resourcing – Technical and Operations Staff

1.  Use of 4* existing CARE staff and 14* recent employees to quickly fill technical positions (Field Operations Manager, BCC Officers, Outreach Officers, M&E Officer) allowed field teams to ‘hit the ground running’, with strong contacts in the areas of operation (local govt., community leadership etc.) and professional knowledge of the context.

2.  It is recommended that the CO undertake a simple ‘performance evaluation’ process of the staff involved in the response, and this can inform team selection in future emergencies.

3.  It is also recommended to establish an Emergency Roster of competent staff at national level (as part of the EPP), and strong staff from the cholera response should be included within this. ‘Membership’ of the roster could also be advertised to identify high potential staff outside the organisation.

4.  There was insufficient operations support staff for the project, with logistics and administration staff doubling up on their existing work in Freetown or Makeni, and in other bases no dedicated support staff at all (Kambia, Kabala). In Makeni particularly the administrative / logistics workload was too high for the resources available. Adequate operations support is vital for a predominantly-logistical operation such as a cholera kit distribution. The impact on the project included delays to logistics operations and financial payments, and errors in dispatching/recording of materials. Project technical staff also spent an unacceptable amount of time on basic logistics tasks such as fuel purchase and monitoring of stock levels. (See also previous communications on Aquatab stocks).

5.  In such a time-limited project it is recommended to over resource staffing needs by 10-20% to ensure all key positions are covered in the event of staff illness, accidents or family issues. It was noted that field staff were frequently off work for short periods because of these issues and this had an impact on continuity of the activities.

  1. Logistics Issues

1.  A significant bottleneck to CARE’s response was the transport / dispatch of cholera kit materials from Freetown to the Hubs and onwards for pre-positioning in communities. Constraints included the decision to hand-count materials such as Aquatabs at multiple locations, and the use of individual 4*4 vehicles for bulk transport from Freetown to the field. In some cases programme vehicles were actually taken off field activities to transport materials from Freetown, causing further delays in the field. The use of 1*large hired truck eventually helped to remove this bottleneck, and in future responses should be utilised much earlier. CARE logistics staff should accompany any large shipment of this type to ensure no materials go missing.

2.  Procurement of the bulk cholera kit materials was achieved fairly quickly in Freetown, with support from CARE USA Logistics. However additional key items were only identified by the team as the project progressed – for example visibility banners, t-shirts, accountability materials, communications modems, rain jackets etc. It is recommended that a standard list of essential items for emergency response is included in the EPP and either contingency stocked or procured on Day 1 of a response.

3.  Communications between Freetown and the field, and between field staff were difficult due to inaccessible locations and poor internet connections. The airtel modems provided had limited utility. It is understood that a potential new V-Sat supplier has been identified for Makeni office and this should be followed up as soon as possible to facilitate technical reporting and logistics/finance-related communications.

4.  The petrol shortage in Sierra Leone during the project caused delays and increases in cost when preferred fuel suppliers became unavailable. Future responses should consider the cost-benefit of hiring diesel vehicles from the start as diesel had no availability problems.

  1. Technical Issues

1.  Cholera Kit distribution strategy:

o  The targeting strategy for beneficiary households within communities was unclear to staff and volunteers and in many cases insufficient kits were allocated per community (e.g. only 30 kits distributed within a community of 100 households). This presented a double inefficiency as (1) more communities had to be covered to reach initial targets; and (2) some communities received repeat distributions over multiple days. Both of these problems were exacerbated with the transport /logistical challenges of reaching the operational communities. In a cholera response it is strongly recommended to undertake blanket coverage of targeted (e.g. cholera prevalence) high risk communities.

o  At the start of the project there was discussion about the allocation of kits per household size. However the recommendation to provide extra kits to larger households was not taken up until much later (after Team Meeting in Week 5) when average household size was realised to be over 10 in some Chiefdoms. This would have had an impact on the amount of cholera ‘protection’ provided to beneficiaries in large households during the 1st few weeks of the project. Even when the distribution strategy was changed to provide 2 kits to households over 9 persons, this was not always implemented by Outreach Officers and volunteers.

o  Field teams were also unwilling to shift approach from house-to-house distributions to centralised distributions to improve efficiencies, although where this did occur – for example in Bombali Shebora institutions – it proved successful. It is recommended to always consider both approaches in future projects which have a distribution component.

·  Aquatab strength. The initially agreed Sierra Leone standard dosing of Aquatabs for all peer agencies actually gave a higher than acceptable Free Residual Chlorine. Following testing CARE (and other agencies) adjusted the dosing from 1*67mg tablet for 10 litres to 1*67mg to 20 litres. Although field teams were quick to amend the messaging through volunteers, the negative impact of the initial higher strength / taste chlorine dosing in terms of Aquatab acceptance is unknown. During spot-checks in some villages all households tested were recording 0mg/L FRC (note: overall between 50-60% of households recorded acceptable FRC). As this is perhaps the most challenging part of behaviour change during a cholera response, it highlights the need for stronger hygiene promotion around use of Aquatabs; this was missed out from the CARE-reproduced posters, and could have been a stronger element of the drama and radio sessions. A bigger push for follow-up household visits by volunteers could also have focussed on Aquatab use.

2.  Water Treatment Unit donated to Kabala Hospital had problems with the hose connections for the bladders and was missing the right type of chlorine for the machine. This led to delays in the machine being operational. More recently MDM could also have implemented installation of the machine in a timelier manner. It is recommended for the CO to continue to monitor the situation with the Water Treatment Unit, checking any other problems encountered and monitoring quantities of water distributed. Issues with the supply / stocking of CARE WASH materials in Dubai will be followed up directly with CARE USA.

3.  Capacity building of DHTMs / Co-ordination activities. It was challenging to monitor the support given to DHMTs for co-ordination activities, and initially CARE staff were simply recording number of meetings they attended. There is a greater need (1) to understand what were the capacity needs of DHMT which CARE could practically address (this could be part of the planned WASH assessment in operational Districts), and (2) for CARE field staff to share key outputs from co-ordination meetings / qualitative feedback which could have been used for reporting or follow-up in Freetown.

4.  WASH Advocacy. The discussion at co-ordination forums in Freetown (WASH / Social Mobilisation group, C4 etc.) appeared remote to field realities, and some issues discussed nationally were insignificant to the immediate cholera prevention task. In future responses it is recommended to strengthen the links between CARE-input / advocacy to national co-ordination fora and field-based realities. For example the practice of shock chlorination at District level by local govt. and other NGOs presented an acceptance challenge to Aquatab distribution, despite earlier agreement at national level that shock chlorination was not a recommended practice.

  1. Gender.

1.  Field teams were not able to fully mainstream gender into the project. The house-to-house distribution approach would have been positive in directly reaching women, and the M&E Officer undertook a number of dedicated ‘gender and cholera’ focus group discussions (however this was too late in the project for results to be incorporated into the activities).

2.  To an extent this is understandable given the general impact of cholera across the community, and the short timeframe of the project which precluded a number of program quality initiatives.

3.  However the issue of gender and WASH remains extremely relevant for transitional WASH programing and future long-term WASH. It is recommended that more comprehensive gender analysis is undertaken as part of forthcoming WASH assessment in the project Districts.

  1. Accountability

1.  A rigorous system was created for project accountability, including a feedback-line; provision of project information on radio and posters; post-distribution monitoring and feedback boxes. However the system was implemented too late to have made an impact and that insufficient priority was given by field staff in communicating the accountability process (feedback numbers etc.) to beneficiaries. For example late ordering of the feedback boxes (week 4) and procurement lead-time meant that these were actually cancelled; post distribution monitoring forms were only submitted to M&E teams in the last few days of the project, and so weren’t used on a regular basis by field staff to address issues from beneficiaries (For more on this see Final Report of Rapid Accountability Review).