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 Report - IRD - Progress Report (IRD)

 Report date: 13.08.1999

Progress Report
For
Department of State-Funded
Emergency Distribution of Pharmaceuticals Project
In
Azerbaijan

February 15 - August 14, 1999

Submitted
To
The U.S. Department of State
By
International Relief and Development
1616 P Street, NW, Suite 350
Washington, DC 20036
Phone: 202-234-2740 FAX: 202-234-2782
E-Mail: akeys@clark.net

August 15, 1999

  1. Summary Sheet
Project Title: The IRD Emergency Medical Distribution Project in Azerbaijan
Project Objectives: - provision of essential pharmaceuticals,
- medical supplies, and equipment to vulnerable populations; and (b)
-mobilization of technical, management and training support required to ensure that correct medicines are provided to the right beneficiaries at the right time
Project Location: Western Azerbaijan, primarily in the district of Khanlar
Project Duration: February 15, 1999 to August 15, 1999
Project Participants Office of the Coordinator of U.S. Assistance to the New Independent States, Department of State
Save the Children
Mercy Corps International
USAID
Adventist Development & Relief Agency
SAVAB
ICTHUS
   Northwest Medical Teams
   Magnificat Global Health Foundation
   Lutheran World Relief
   Worldwide Humanitarian Aid
   Human Resources Center of N.A.
Project Beneficiaries: 250,000 internally displaced persons (IDPs) and refugees
Total Project Value: $2,839,215
Date of Report August 15, 1999

II. Overall project status

During the reporting period IRD became operational in Azerbaijan. A country office was established in Baku and a field office in Khanlar. Office space was leased, staff recruited, office furniture and equipment procured. Further, during the reporting period IRD established solid working relationships with the US Embassy, USAID, other PVOs and Government of Azerbaijan (GOAZ) officials.

IRD was temporarily co-located with SAVAB; a local PVO also involved in health care projects. Subsequently, IRD located other office location to provide more space for staff and to ensure that the public viewed IRD and SAVAB as separate organisations.

In February 1999, IRD was registered with the GOAZ and opened a local bank account. During the same period IRD acquired the services of a consultant (Dr. Jeyhoun Mamedov) to consult with all the major humanitarian aid players in Azerbaijan and to establish procedures for procurement, office management, project implementation, monitoring and evaluation, reporting and for personnel and financial management. The Country Director and Dr. Mamedov met with national and local medical authorities and obtained the support and co-operation of the Ministry of Health and the Vice-Minister of the Cabinet of Ministers in charge of IDP and humanitarian assistance. This consultant also interviewed candidates for the IRD medical director and finance manager positions. The consultant prepared a short-list of candidates and IRD/Washington selected the successful candidates from this list.

During March early April, 1999, IRD participated in a number of coordination meetings with PVOs, namely CARE, Global Care, ICHTUS, Save the Children/US, MSF-Holland, MSF-Belgium, IFRC, IRC, AzRC, Counterpart, ECHO, UNHCR, UNICEF, USAID, Mercy Corps International, IFRC, ICRC, Relief International, UMCOR, World Vision and the Adventist Development and Relief Agency. These meetings helped to avoid duplication of effort and led to a division of labor in implementing health care activities in Azerbaijan. Several meetings were also held with cabinet ministers and the Ministry of Health to reach agreement on the specific areas for distribution of pharmaceuticals and medical supplies. Finally, during the aforementioned period, IRD hired a senior monitor, warehouse manager, office manager, and support staff.

In meetings with MCI, the USAID, umbrella grant administrator, it was learned that a grant would be made to a US NGO for a cost-recovery pharmaceutical project in three villages near Goranboy. As a result, IRD indicated willingness to modify its plans for distribution in this area and agreed not to interfere with this project. This was communicated to MCI and USAID. IRD President met with the MCI US staff to inform them of the IRD program and indicate IRD policy to collaborate with other US NGOs in Azerbaijan and with USAID funded projects.

In March, the Country Director and Medical Director visited the IRD offices in Tbilisi and Zugdidi, Georgia to see a successful IRD DOS-funded pharmaceutical distribution project in action. Many technical assistance lessons were learned that enabled the IRD Azerbaijan project to develop rapidly.

During April 1999, IRD met with the head doctors of hospitals in targeted areas to refine the list of essential pharmaceuticals and supplies and agree on the specific areas for assistance under the project. The necessary data on each hospitals capacity and operational procedures was also collected. As a result, all major implementing partners -- the target hospitals, the Ministry of Health and PVOs were prepared for implementation of this project. The main PVOs involved are MSF-Holland, MSF-Holland, Mercy Corps International and Save the Children (SC).

Further, Nicole Jordania, a health care consultant, carried out an assessment of IRD/Azerbaijan program and personnel as well as procurement, financial management and accountability systems. She met with GOAZ, USAID, and NGOS. She analysed the ability of the program to meet its stated objectives and made recommendations to IRD/Washington regarding improvements and changes that were needed. Finally, in April a Memorandum of Understanding (MOU) was prepared between IRD and SC (the recipient of the USAID umbrella grant -- to ensure that there was no overlap with SC projects in Azerbaijan. This MOU was signed in May and provides for joint training of medical personnel, provision of medical supplies from IRD to SCF. IRD agreed not to provide pharmaceuticals as humanitarian assistance in the Goranboy area where the SCF cost-recovery project will be located.

During May, IRD acquired a warehouse in Khanlar in cooperation with the Adventist Development and Relief Agency (ADRA) and the Local Executive Committee. The warehouse was repaired; shelves and electric lines were installed; and a warehouse security system was established. A computerised inventory control system was designed in anticipation of the arrival of the medicines and supplies.

In June 1999, a trip to Baku and Khanlar was organised for the IRD/Georgia country director and finance manager. The purpose of the meeting was to become familiar with the Azerbaijan project, review implementation of administrative systems and to provide technical assistance. Just after that the IRD President visited Baku and Khanlar to assess progress being made under the project. The President also had meetings with UNHCR, USAID, SC, MCI, GOAZ ministers and officials and others and visited the IRD-Azerbaijan field office, target hospitals, warehouse, and had meetings with local Executive Committee. The IRD President met with all IRD staff and reviewed office procedures.

In July 1999, the President travelled again to Azerbaijan to review progress made under the project and to confirm the recommendations set forth in the Jordania report. During this visit, the President decided it was prudent to make program and leadership changes. The Medical Director, who had performed exceptionally, was named the Acting Country Representative. A decision was also made at that time to move the field office from Khanlar to Ganja for several reasons; because it is a larger regional population center and convenient to IRD warehouse facilities, better communication links, including email, are available, and the Ganja location affords better contact with other NGOs.

The IRD/Azerbaijan Medical Director travelled to Georgia to observe local program activities, including procurement, financial management and project accountability systems that had been in place in Georgia for a year. The IRD/Georgia staff was quite helpful in providing information and recommendations on ways to strengthen the program, management, and accountability systems in Azerbaijan.

III. Implementation

A. Project Objectives: This project is designed to: (a) provide essential pharmaceuticals, medical supplies and other material assistance to the targeted populations; and (b) mobilize the technical, management and training support required to ensure that the right medicines and services are provided to the right beneficiaries at the right time.

B. Reporting Period IRD Activities Undertaken in Effort to Achieve Project Objectives: These activities included the following: (1) Identification of the highest priority vulnerable groups for receipt of medicines and supplies; (2) Coordination of the shipment of pharmaceuticals, supplies and equipment from the US to Azerbaijan via DOSs transportation program; (3) Monitoring of the distribution of donated pharmaceuticals, equipment and supplies and carried out follow-up assessments to ensure that the correct commodities were delivered to the agreed upon target groups; and (4) Organization of medical training carried out through a training of trainers program for health personnel in the areas of diagnosis, prescription protocols and treatment.

C. Criteria for Selection of Beneficiaries: War and conflict have taken a severe toll on Azerbaijan. The fighting with Armenia displaced up to one million people from the conflict areas.

Most of the liberated areas in Azerbaijan have received no humanitarian aid. Therefore, the health status in these areas is extremely poor. In these, IDPs and refugees by-pass the defunct primary health care facilities and go directly to hospitals. This limits disease prevention efforts at the district and sub-district level and contributes to a further decline in the already inefficient and expensive health care system. On a related issue, the GOAZ is providing grants and other benefits to the beneficiaries, such as utility payment exemptions, but these grants are frequently delayed in the governments bureaucracy. (The term liberated areas refers to areas in fifteen administrative districts of Azerbaijan near Nagorno-Karabakh. These are: Gazakh, Agstafa, Tovuz, Gedabay, Khanlar, Geranboy, Terter, Agdam, Agjebedi, Beylegan, Fizuli and Sadarak (in the Nakhichvan Autonomous Region, NAR), Shanur (NAR), Babek (NAR) and Djulfa (NAR).)

The leading causes of death in Azerbaijan are non-communicable diseases, particularly cardiovascular diseases (World Bank, Azerbaijan Health Sector Survey, Baku 1997). Infectious diseases are of serious concern, particularly among IDP and refugee populations. The infant mortality rate in Azerbaijan is over 23, which is one of the highest in the world. Infant mortality rates are higher in the newly liberated areas because mothers in the liberated areas often do not seek pre-natal and post-natal health care. That aside, over 50 percent of the recorded infant deaths are caused by respiratory illnesses. Other diseases cause an additional 15 percent of infant deaths.

The project emphasizes primary health care and preventive medicine. The type of medical assistance provided under this project is based on criteria from a public health perspective. Medicines were selected for treatment of the following eight most prevalent illnesses:

i) Hypertension and cardiac related conditions
ii) Cancer
iii) Anxiety, neurosis and other psycho-neurological disorders
iv) Acute respiratory diseases (including bronchitis, asthma, pneumonia, tuberculosis)
v) Gastro-intestinal tract disorders
vi) Different types of Dermatitis and Scabies
vii) Goiter
viii) Cystitis, colitis

D. Progress Made Under Project to Date: Aside from urgent humanitarian needs, activities under the project aim to rationalize the delivery of health care by providing essential pharmaceuticals and other medical commodities to primary health care facilities and providing information, technical and training assistance to rebuild the referral system. Volunteer medical teams accompanied the delivery of the medicines, equipment and supplies to ensure delivery to targeted facilities; to confirm that proper prescription practices are being used; and to carry out priority health training activities.

During the period covered in this progress report, IRD coordinated closely with USAID, SC and MCI. Further, in an effort to avoid any duplication of effort IRD and SC signed a Memorandum of Understanding (MOU) that spells out a division of labor between IRD and SC. That aside, IRD is a member of the PVO Coordination Council and in this forum reports on IRD activities and acquires information regarding the activities carried out by other PVOs.

Pharmaceuticals and other Medical Assistance Provided: Three shipments of pharmaceuticals and medical supplies was cleared through customs in Baku on July 12, 13, and 14, 1999 and delivered to the IRD warehouse in Khanlar. A complete inventory was begun. The non-medical commodities arrived through the port of Poti and were delivered to the IRD warehouse in Khanlar on July 5.

The following hospitals are targeted for receipt of the commodities:

1. Goranboy Central District Hospital

a. Number of beds 312
b. Number of staff 477
c. Inpatient visits per year 1,512
d. Outpatients per year 150,000

2. Naftalan Center District Hospital

a. Number of beds 50
b. Number of staff 81
c. Inpatients per year 621
d. Outpatients per year 40,016

3. Ter-Ter Center District Hospital

a. Number of beds 280
b. Number of staff 365
c. Inpatients per year 1,394
d. Outpatients per year 152,665

4. Ter-Ter Children Hospital

a. Number of beds 70
b. Number of staff 120
c. Inpatients per year 349
d. Outpatient per year 13,400

5. Khanlar Center District Hospital

a. Number of beds 295
b. Number of staff 230
c. Inpatients per year 2,143
d. Outpatients per year 124,537

6. Hadjikend IDP Medical Point

a. Number of beds
b. The number of staff 3
c. Inpatients per year 1,105

7. Ganja Hospital for Vulnerable people (name after Abbas Sahat)

a. Number of beds 345
b. Number of staff 402
c. Inpatients per year 2,056
d. Outpatients per year 54,000

8. Ganja Emergency Aid Hospital

a. Number of beds 475
b. Number of staff 440
c. The number of patient visits per year 2,030

9. Ganja Children Hospital

a. Number of beds 100
b. Number of staff 75
c. Inpatients per year 560
d. Outpatients per year 20,751

The above target hospitals will be responsible for transportation of the pharmaceuticals in coordination with monitoring by IRD staff.

Medical commodities were received from Magnificat Global Health Foundation, Northwest Medical Teams, and Human Resources Center of North America. The total value of the medical commodities received to date is $2,698,435. The general categories of pharmaceuticals, medical supplies, and non-medical supplies received are as follows:

Pharmaceuticals:

Antacids
Antibiotics.
Cardiovascular drugs
Diuretics
Antianemiec
Vitamins
Musculoskeltar and joint diseases drugs
Medicines for eye disorders

Medical Supplies:

* Dressing material
* Catheters
* Gloves
* Specula's
* Diagnostic sets (for diabetes mellitus)
* Needles and syringes
* Administration Sets and many types of kits

Non-medical commodities:

IRD provided winter clothing and blankets. Lutheran World Relief (LWR) provided these relief materials to IRD for use under the project.

Based on the actual capacity of each PVO, the commodities will be distributed in the following manner:

Local PVO area IDP Committees Families Beneficiaries Value USD
Kalbajar
Khanlar
X
X
1200
900
6000
4500
29,910
22,433
Khojali
Ganja/Icthus
X 1100 5500
250
27,418
1,246
Ter-Ter
Goranboy
X
X
1350
1000
6750
5000
33,648
24,925
Total 5 5,600 28,000 $139,580

In addition, three computers contributed by Worldwide Humanitarian Aid were received that will be installed in the three largest hospitals served by this program to improve internal control, data collection, and reporting.

Training activities: A medical team of Dr. Ilham Mamedov assisted by Adil Kuliyev conducted a six-week special training for local physicians, nurses and health care managers. Prior to launching the training programs, IRD consulted with MSF-Holland, MSF-Belgium, Offshore Medical Services, and UNICEF regarding their earlier training programs and applied lessons learned in designing and implementing IRD organized training activities. The trainers have extensive training backgrounds.

IRD medical team conducted multiple training seminars. The mission of this team was to train local health care professionals in the rational use of pharmaceuticals, proper treatment and prescription protocols and preventive medicine, treatment of diarrhea diseases. This training was coordinated with SCF in accordance with the MOU between IRD and SCF.

Approximately 450 local doctors and nurses, as well as the managers of the targeted facilities were trained in the use of IRDs monitoring and distribution system. Courses were held in 9 major hospitals and repeated twice daily to allow the greatest number of participants. The IRD medical staff received training at the beginning of the program in IRD monitoring policies and procedures. Training was also provided to the medical monitors who track prescription practices of the local doctors to record error and makes suggestions to the medical director for training to improve prescription practices.

The primary reference material used for the training was the WHO Guidelines for Training and pre-training and post-training knowledge tests were carried out. The primary training focus was "rational drug use. " Feedback from hospital directors was very positive.

Section 907: IRD staff studied section 907 of the US Foreign Assistance legislation carefully to make sure that the IRD program design was in compliance with the intent of the restrictions placed on US foreign aid to Azerbaijan. The IRD program was discussed with USDOS officials and with USAID and it was determined that the IRD program was appropriate for the guidelines developed by DOS for humanitarian assistance.

Logistics: IRD coordinated all the logistics for the project with the US Department of State for shipment of commodities and worked closely with the Azerbaijan health and customs authorities in expediting clearance the commodities through customs upon arrival. Shipments were based on need and consumption patterns and were delivered in the appropriate type and quantities. IRD staff tracked the medical commodities and supplies from arrival to delivery to the warehouse. Finally, IRD staff will ensure that no medicines, supplies or services were provided to Azerbaijan military or paramilitary personnel or organizations.

Monitoring: Three types of monitoring will be carried out: (a) monitoring of the quantities of distributed medicines; (b) monitoring of the prescription quality; and (c) monitoring of the distribution.

Monitoring of the distribution will be carried out as follows: (a) consumption forms completed by each IRD supported medical facility; (b) the monthly consumption form matched with the warehouse database and the stock available at participating health facilities; (c) the total amount commodities used checked against the consumption form quantities; and (d) random check made of each facilitys inventory on a rotational basis every two to three weeks. Each monitor will visit 1-2 hospitals each day.

The following checks on prescription quality will be carried out: (a) entered data from the prescription forms; (b) identified prescription errors, such as over-prescription, overdose, wrong prescription and contraindications; and (c) identified mistakes and findings passed to the officials concerned. The final distribution of the commodities will be monitored by: (a) carrying out random site visits to five percent of the beneficiaries; and (b) completing distribution monitoring forms and reporting the results to the IRD medical director.

It should be mentioned that quality and quantity monitoring would also be used. The quantity monitoring involves a calculation of medicines in each department and hospital. Quality monitoring involves checking proper treatment protocol and

prescription of delivered medicines. Monitoring forms and protocols have already been distributed to all hospitals and pharmacy staff has been trained.

Lessons learned: It is important to begin a pharmaceutical distribution project with a proper survey to determine the real field situation before the project is implemented. IRD learned again that it is important to coordinate with other NGOs working in the same target area to avoid duplication of effort and misunderstanding. IRD responded well when it learned of USAID's plan for a cost-recovery project and moved the location of the IRD project to Khanlar-Ganja area away from Goranboy. And IRD improved the training component of the project by signing a cooperative MOU with SCF.

It is necessary to hire strong professional local staff and to develop staff training to improve skills. The fact that IRD is an American NGO is attractive to Azeri professionals because they are eager to learn US management and program delivery standards. The Azerbaijan staff gained a lot from the experience of the IRD Georgia and headquarters staff in program implementation and in internal management systems.

IRD did a good job of organizing its warehouse staff and operation, developed a comprehensive monitoring system. This will serve the project well as it moves into large-scale distribution of medical commodities.



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