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Original Proposal - PROPOSAL FOR

VIEWS: 76 PAGES: 60

									                                  PROPOSAL FORM

                 SIXTH CALL FOR PROPOSALS



                                                Somalia



           Essential support for the
         implementation of the National
               Malaria Strategy.




Nairobi, 03/08/2006



GFATM Proposal Form Somalia Final Version.doc             i
How to use this form

PROPOSAL SECTIONS FOR COMPLETION BY APPLICANTS


                                                                                                                  page

     1.     Proposal Overview ............................................................................1

     2.     Eligibility ..............................................................................................

     3.     Applicant & Proposal Endorsement
            3A: Applicant Type ...........................................................................
            3B: Proposal Endorsement..............................................................

     4.     Component Section.............................................................................

     5.     Component Budget .............................................................................


ATTACHMENTS TO THE PROPOSAL FORM FOR COMPLETION BY APPLICANTS

     A.     Targets and Indicators Table
     B.     Preliminary Procurement List of Drugs and Health Products


 A list of all annexes to be attached to the Proposal Form by the applicant can be found at the end of
 sections 3 and 5 the Proposal Form




Malaria proposal to GF Rd6 for Somalia: GFATM Proposal Form Somalia Final Version.doc                                    ii of 60
How to use this form

       Abbreviations
       BCC            Behavioral Change Communication
       CBO’s          Community Based Organizations
       CHW            Community Health workers
       CSZ            Central and Southern Zone
       DHB            District Health Boards
       DIO            District Information Officer
       EU             European Union
       FSAU           Food Security Assessment Unit for Somalia
       GIS            Geographic Information System
       HIS            Health Information System
       HP             Health Post
       HSC            Health Sector Committee (part of SACB)
       IEC            Information, Education and Communication
       INGO’s         International Non governmental Organizations
       IPT            Intermittent Preventative Treatment
       IRS            Indoor Residual Spraying
       LLIN           Insecticide-Treated Nets
       JNA            Joint Needs Assessment
       KAP(B)         Knowledge, Attitude and Practice (& Behavior)
       LLIN           Long Lasting Insecticide treated Net
       LNGOs          Local Non-governmental organization
       MCH            Maternal & Child Health
       M&E            Monitoring and Evaluation
       MDG            Millennium Development Goals
       MoH            Ministry of Health
       NEZ            North East Zone
       NDVI           Normalized Difference Vegetation Index
       NWZ            North West zone
       OPD            Outpatient Department
       PR             Principal Recipient
       PHC            Primary Health Care
       Q              Quarter (3 month)
       RBM            Roll Back Malaria
       Rd             Round (2, 5 or 6) from GF
       RDP            Reconstruction and Development Plan
       RDT            Rapid Diagnostic Test
       SACB           Somalia Aid Coordination Body
       SACB HSC       Somalia Aid Coordination Body Health Sector Committee
       SP             Sulfadoxine Pyrimethamine
       SRCS           Somali Red Crescent Society
       SR             Sub Recipient
       TBA            Traditional Birth Attendants
       TFG            Transitional Federal Government
       TOR            Term of Reference
       TOT            Training of Trainers
       UNDP           United Nations Development Programme
       UNICEF         United Nations Children Fund
       UIC            Union Of Islamic Courts
       VHC            Village Health Committees
       WHO            World Health Organization
       WMD            World Malaria Day
       Y              Year




Malaria proposal to GF Rd6 for Somalia: GFATM Proposal Form Somalia Final Version.doc   iii of 60
1 Proposal Overview
1.1 General information on proposal

    Applicant Name                       Somalia Aid Coordination Body Health Sector Committee

    Country/countries                    Somalia


                                                         Applicant Type

                  National Country Coordinating Mechanism

                  Sub-national Country Coordinating Mechanism

                  Regional Coordinating Mechanism (including small island developing states)

                  Regional Organization

                  Non-Country Coordinating Mechanism Applicant


                                            Proposal component(s) and title(s)

         Component                                                             Title

          HIV/AIDS1

          Tuberculosis1
                                 Essential support for the implementation of Somalia’s Malaria Strategic Plan
          Malaria
                                 2007-2012

                                      Currency in which the Proposal is submitted

                  US$

                  Euro




1
    In contexts where HIV/AIDS is driving the tuberculosis epidemic, HIV/AIDS and/or tuberculosis components should include
    collaborative tuberculosis/HIV activities. Different tuberculosis and HIV/AIDS activities are recommended for different epidemic
    states; for further information see the ‘WHO Interim policy on collaborative TB/HIV activities,’ available at
    http://www.who.int/tb/publications/tbhiv_interim_policy/en/.



Malaria proposal to GF Rd6 for Somalia: GFATM Proposal Form Somalia Final Version.doc                                 1 of 60
1 Proposal Overview
1.2 Proposal funding summary per component
Table 1.2 – Total funding summary
                                                   Total funds requested (US$)
Component
                           Year 1       Year 2        Year 3        Year 4         Year 5         Total

Malaria                   6,489,621    6,607,321     6,314,402    4,899,756       3,368,163    27,679,263

Total                     6,489,621    6,607,321     6,314,402    4,899,756       3,368,163    27,679,263



1.3 Previous Global Fund grants
                                                                     Table 1.3 – Previous Global Fund grants
                                                      Previous grants
Component
                                      Rounds                            Current Amount ( US$)

HIV/AIDS                                4                                        10,004,644

Tuberculosis                            3                                        13,825,351

Malaria                                 2                                        12,886,415




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2 Eligibility
Only those Proposals that meet the Global Fund’s eligibility criteria will be reviewed by the
Technical Review Panel.

2.1 Technical eligibility
2.1.1 Country income level

 Country/countries                       Somalia


              Low-income


2.2 Functioning of Coordinating Mechanism
Due to the protracted crisis in Somalia described on section 3A there is no CCM structure able to fulfill all the
requirements of the GFATM guidelines. In the absence of an official CCM, the Somali coordination Body
SACB, created in 1993 so as to provide a forum for coordination of the international aid to Somalia, has been
recognized by bilateral, multilateral and global funding donors and mechanisms (e.g. GAVI and GFATM) as
a functioning coordination mechanism (see annex 3: III).

Since 2001, the Health Sector Committee (HSC) of the SACB has successfully presented funding proposals
to GAVI, DFID and GFATM (rounds 2/3/4). Specific tools, procedures and structures have been developed
and the TOR of the HSC and Heath Sector Coordinator adapted so as to comply with the responsibilities
expected from a CCM, according to the GFATM guidelines.

At the meeting held on 13th May with the three existing health authorities and the GFATM team (Portfolio
Manager and LFA), the SACB HSC was requested by all partners to develop a joint proposal (non-CCM) for
the round 6 of the GFATM. (see annex 3: III: 8).

 2.2.1 Broad and inclusive membership

       a) People living with and/or affected by the disease(s)
           Provide evidence of membership of people living with and/or affected by the disease(s).

 The SACB constituency does not include all partners outlined for the make-up of a normal CCM.
 Nevertheless GFATM related processes (development of proposals, selection of PR and SRs, quarterly
 review meetings) are managed in a transparent manner seeking broad participation from stakeholders. In
 the last years efforts have been made to fight the stigma and empower PLWHA to be included in the
 decision making structures and processes. Inclusion of PLWHA is one of the criteria for selection of SRs
 developed by the SACB HSC for the HIV/AIDS project. Broadening the representation of civil society in
 the HSC is currently underway so as to enhance the participation of people affected by the diseases in the
 prevention and response efforts.

       b) Selection of non-governmental sector representatives
           Provide evidence of how those Coordinating Mechanism (CM) members representing each of
           the non-governmental sectors (i.e. academic/educational sector, NGOs and community-based
           organizations, private sector, religious and faith-based organizations, and multi-/bilateral
           development partners in country) have been selected by their own sector(s) based on a
           documented, transparent process developed within their own sector.

 In order to maintain its technical neutrality crucial for the operations in all the zones affected by this
 chronic conflict, the HSC of the SACB does not include government representatives at the committee
 level, though the existing and emerging local authorities are included in the process through transparent
 information sharing and participation of their senior representatives at the major strategic and managerial
 decisions through the quarterly review meetings.
 The SACB HSC membership includes individual International NGO members (50% of the members) in



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2 Eligibility
 order to represent the concerns/problems in their zonal areas of operation. The membership is rotational
 (every six months) and subject to compliance with basic criteria of participation in the health coordination
 process (see TOR Annex 3: III: 1). The HSC membership includes as well the main UN agencies active in
 the health sector (25% of members) and major donors funding the sector, so as to guarantee the technical
 guidance and avoid overlapping and duplication. Since 1996, the Somali Civil society is represented in the
 HSC by the IFRC/SRCS (Federation and Somali Red Crescent Societies) as a permanent member, due to
 their presence in all regions and recognized neutrality. Additional efforts are being made to enhance the
 civil society representation through the inclusion of local NGOs in representation of the LNGOs operating
 in each zone. Criteria for membership are the same as requested from INGOs. The NGO consortium for
 Somalia is invited by the HSC to select one LNGO from each zone that match the requirements.
 Decisions are made by majority of 70% provided a quorum of 50% + 1 members. Any major disagreement
 between partners must be reflected in the minutes for the record. Once approved all minutes are shared
 with the GFATM (portfolio manager and LFA) and posted on the web for open access for all partners.
 Since 2006, the LFA is invited is an observer of the GFATM so as to provide guidance and to witness the
 transparency of the process.
 The HSC meets regularly on a monthly basis so as to address the major issues related to the health
 sector and to provide strategic guidance, to address specific emergencies and to solve emerging conflicts
 between stakeholders.
 Since the approval of the GFATM proposals, additional meetings are called “ad hoc” so as to address
 specific requirements related to the GFATM projects and procedures. In order to ensure transparency all
 meetings are recorded and the minutes are made available on the SACB Web site. (www.sacb.info)
 Please see the constitution and rules of the SACB HSC in the annex 3:III: for further details.


 2.2.2 Documented procedures for the management of conflicts of interest
       Where the Chair and/or Vice-Chair of the Coordinating Mechanism are from the same entity as the
       nominated Principal Recipient(s) in this proposal, describe and provide evidence of the applicant’s
       documented conflict of interest policy to mitigate any actual or potential conflicts of interest arising in
       regard to the applicant’s operations or responsibilities.

 In line with the GFATM guidelines and in order to avoid any conflict of interest, the TOR of the HSC was
 reviewed and since the approval of the first proposal (round 2) the agencies acting as PR for the GFATM
 projects cannot apply for the role of Chair of vice-chair. In addition to this there are two positions of vice
 chair, so as to allow the chair to step down on issues where its condition as SR could create a potential
 conflict of interest.
 All three positions (chair and two vice –chairs) are voluntary and elected for a six months period by voting
 in case there would be more than one candidate. At least one of the three should not be a SR.
 For the on-going GFATM projects an MOU has been developed between the PR and the local authorities.
 According to this MOU the HSC has a role to play in the oversight of the project, in ensuring synergies
 with other health projects/programs and in the arbitration of any potential conflicts arising among partners.


 2.2.3 Documented and transparent processes of the Coordinating Mechanism
       Please describe and provide evidence of the CCM’s documented, transparent and
       established:

       a) Process to solicit submissions for possible integration into this proposal.

 As described under section d, the SACB HSC has circulated through its general mailing list made up of
 more than 250 organizations, institutions and individuals working and/or concerned by Somalia, the
 proposal forms and guidelines as well as a concept paper and proposal drafts for comments and
 additions. In addition to this information sharing a consultative process was carried out with local
 authorities and stakeholders to discuss proposal contents and budgets.
 The proposal is built on the National Strategy for Malaria which was developed in 2005 in a highly
 participatory process (funded by GFATM round 2) involving all health authorities and organizations. The



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2 Eligibility
 strategy development process was based on evidence emerging from operational research conducted in
 Somalia. On specific technical issues assistance is requested to regional technical bodies (e.g. EMRO,
 ESARO, UNAIDS).
 In addition to the emails, updates on the process are presented at general meetings and included in the
 minutes circulated to all partners and posted on the web. Meetings related to GFATM projects are tape-
 recorded by the Health Sector Coordinator of the SACB for further reference or consultation in case of
 conflict. Final document of the proposal is posted on the SACB website.

       b) Process to review submissions received by the CCM for possible integration into this proposal.

 The technical team appointed by the SACB HSC compiles and incorporates in the successive drafts,
 comments and additions that have been received from partners and discussed at the malaria technical
 meetings. The final drafts including the comments received from partners are shared within the SACB
 HSC and these are discussed at the special HSC meetings that are called for reviewing the proposals.
 This process is the same process used since 1996 for the development of strategies, guidelines and
 standards being used in the different health programs and is recorded on the monthly minutes of the
 general meetings, malaria working group and HSC meetings. Official endorsement is requested from the
 three health authorities and included in annexes 3: I.
 Due to the highly volatile political situation and its operational implications, selection of SRs is not
 conducted during the proposal development process, but is planned to be conducted between the period
 of approval of the proposal and the signing of the grant. This to ensure maximum flexibility and feasibility
 between the work plan and the rapidly evolving situation. The tools and process to be used for this
 proposal are the same used for the selection of SRs on the HIV/AIDS proposal (presented by GFATM as
 best global practice at the MENA conference in Morocco 2005).

       c) Process to nominate the Principal Recipient(s) and oversee program implementation.

 The Principal Recipient was nominated by the members of the SACB HSC through a vote of its members.
 Please see the attached list of signatures of SACB HSC members endorsing the selection of PR. In
 addition, the recommendation of the local health authorities was sought.
 The SACB HSC oversees program implementation with the PR providing regular updates at the monthly
 SACB HSC meeting. In addition, on behalf of the HSC, a Malaria Management Team provides sustained
 technical guidance and support to the PR for the transparent and coordinated management of
 interventions under GFATM.
 Since the approval of the GFATM proposals the fulltime health coordinator seconded by the EC to the
 HSC has included as a substantial part of his TOR (see annex 3:III:3) the direct oversight of the process
 through his participation in the management team and quarterly review meetings so as to ensure
 synergies with all the other health programs and interventions and to assist in conflict solving. The SACB
 health sector coordinator (SHSC)participates in all technical groups and reports to the HSC on a monthly
 basis on major developments on the health sector including the progress on GFATM projects. The SHSC
 maintains regular interaction with the LFA and the Portfolio manager on matters of general interest
 (operational context) and on issues specifically related to GFATM projects

       d) Process to ensure the input of a broad range of stakeholders, including CCM members and
          non-CCM members, in the proposal development process and grant oversight process.

 The proposal development process for Round 6 started with a presentation to all members of the HSC of
 the SACB. The reasons for applying and the timeframe of the process were explained. A concept paper,
 outlining the main objectives of the proposal and some selected activities was sent to all partners,
 including the health authorities on the 10th July 2006 (see Annex 3:I:2). The writing team met the health
 authorities of Somaliland and Puntland to discuss the content and to have their inputs. Due to the
 insecurity at the time of proposal-writing, the TNG authorities in the Central-South were not available for
 face-to-face discussions. Instead, consultations were made via email (see annex 3: IV:1).
 All feedback and inputs received were incorporated in a second draft circulated on the 24th July to all
 partners and stakeholders for further debate. A second meeting of the HSC was held to receive final
 comments and an endorsement of the final draft (see annex 3: I: 9-10). As part of the process of proposal




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2 Eligibility
 development, consultative meetings were held in Somalia with local authorities and stakeholders.
 All stakeholders have the chance to oversight the implementation process through quarterly review
 meetings, monthly minutes and other reports and have the possibility to contact directly the PR and the
 HSC on matters of concern. The health sector coordinator (SHSC) plays a role of facilitating and following
 up this process. The HSC responds to concerns from partners directly (at meetings, through email or
 official correspondence) and through launching joint assessments when necessary. The HSC informs
 directly the GFATM on any major problem encountered, either through the LFA (observer at the monthly
 meetings) or/and direct communication to the Portfolio manager.




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3 Applicant type
3A.1 Applicant
                                                                                                   Table 3A.1 – Applicant

            Non-CCM Applicants                                   complete section 3A.6



3A.6        Non-CCM Applicants

                                                                        Table 3A.6 – Non-CCM Applicant: basic information

    Name of Non-CCM
                                     Somalia Aid Co-ordination Body, Health Sector Committee (SACB-HSC)
    Applicant

    Street address                   5th Fl Kalson Towers, Parkland, Nairobi, Kenya


                                              Primary contact                          Secondary contact

    Name                             Giovanni Porta2                           Tanya Shewchuk

                                     Chair, SACB Health Sector                 Chair, SACB Malaria Working
    Title
                                     Committee                                 Group

    Organization                     C/- SACB Secretariat                      C/- SACB Secretariat
                                      th
                                     5 Fl Kalson Towers                        5th Fl Kalson Towers
                                     Parklands, Nairobi                        Parklands, Nairobi
    Mailing address
                                     Kenya                                     Kenya

    Telephone                        + 254 20 3754145/6/7/8                    + 254 724 450047

    Fax

    E-mail address                   gracen@unops.org                          tshewchuk@unicef.org


            Indicate the type of your sector (tick appropriate box):

                  Academic/educational sector
                  Government
                  NGOs/community-based organizations
                  People living with and/or affected by HIV/AIDS, tuberculosis and/or malaria
                  Private sector
                  Religious/faith-based organizations
                  Multilateral and bilateral development partners in country
                  Other
                  Somalia Aid Coordination Body- Health Sector Committee




2
 The primary contact is the SACB-HSC chair, rotating on a six monthly basis. Alternative contact is the
coordinator of the HSC, Dr Imanol Berakoetxea (imanol@kenyaweb.com).


Malaria proposal to GF Rd6 for Somalia: GFATM Proposal Form Somalia Final Version.doc                      7 of 60
3 Applicant type
 3A.6.2 Rationale for applying outside a Coordinating Mechanism

         a) Non-CCM proposals are only eligible if they satisfactorily explain that they originate from one
            of the following:
            i) Countries without legitimate governments;
            ii) Countries in conflict, facing natural disasters, or in complex emergency situations (which will
                be identified by the Global Fund through reference to international declarations such as
                those of the United Nations Office for the Coordination of Humanitarian Affairs [OCHA]); or
            iii) Countries that suppress, or have not established partnerships with civil society and NGOs.
            Describe which of the above conditions apply to this proposal.

 Somalia has not had a recognized central government for the last 16 years following the collapse of the
 government in December 1989. Basic conditions that apply to countries where the government plays a
 major role in establishing and leading a CCM are currently not present in Somalia. The country can also
 be considered to be a complex emergency as it is both prone to natural disasters such as drought and one
 with continuing conflicts within its borders.

 Political situation
 The TFG – As an outcome of two years of peace negotiations held in Kenya with support from the
 international community, a new transitional constitutional charter was agreed upon and a Transitional
 Federal Government (TFG) was established in Nairobi (Kenya) in November 2004. The TFG has since
 attempted to relocate from Nairobi to Somalia in order to take up its responsibilities establishing itself in
 the town of Jowhar and then transferring to Baidoa as temporary bases. Since 2005, serious
 fragmentation has occurred within the TFG preventing the establishment of functioning government
 institutions and the initiation of the longer term reconciliation process.

 During the first six months of 2006, the most intense fighting in over a decade has taken place around
 Mogadishu. Serious military confrontations have occurred between militia affiliated with the Union of
 Islamic Courts (UIC) and those allayed to the TFG. A recent tentative ceasefire between the two groups
 and peace talks in Sudan has broken down with the movement of Ethiopian troops across the border in
 defense of the TFG. As a result the situation is highly volatile and unpredictable both in terms of the
 transitional process and in terms of operational access for the near future. There is talk of sending peace-
 keepers but with no firm commitment to date.

 Somaliland (North West Zone, former British Somalia), which had voluntarily joined Somalia in 1960
 declared unilaterally their independence in May 1991 and though it has not received international
 recognition to date, has been able to establish and maintain peace and a basic administration conducting
 elections within international standards according to international observing bodies. The Somaliland
 administration did not participate in the peace conferences and has not subscribed the Transitional
 Federal Charter. To date Somaliland continues to seek for international recognition, having recently
 applied for membership to the AU. The North Eastern part of Somalia - established in 1998 their own
 administration as the Puntland State of Somalia. They participated in the formation of the TFG and
 subscribe to the Transitional Federal Charter. Currently, there is a dispute between Puntland and
 Somaliland regarding administrative control over two contested regions which affects access to
 humanitarian/development operations in the area.

 Security
 In addition to the political instability, common banditry affects access and operations in many regions (see
 list of major security incidents affecting humanitarian staff in annex 3: IV: 3) while organized large-scale
 piracy has escalated to unprecedented levels (according to the International Maritime Bureau the coast of
 Somalia qualifies as the most dangerous in the world) affecting the transport and safe delivery of
 humanitarian goods and with an enormous impact in the cost of the operations. Further details can be
 found in attachments (ICG and UN arms embargo reports and FSAU piracy report).

 Coordination and Structures
 The international community has pledged to support a transitional process towards the reconstruction of
 the country under a federal transitional charter. A Joint Needs Assessment process (JNA) has been



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3 Applicant type
 launched and is about to be completed and should culminate in an international donors conference in
 support to the Reconstruction and Development Plan (RDP). A coordination and monitoring committee
 has been created to support the process and a Joint Planning Committee should establish Joint Thematic
 Committees to be the future coordination structures where international partners and local authorities
 would collaborate at a technical level.

 The Somali Aid Coordination Body and its Health Sector Committee is committed to provide technical
 support for the future development of the proposed joint coordination structures that would include the
 authorities and civil society from the three zones as part of the architecture of the transition. Until this
 takes place, the coordination and structures as described below will be relied upon.

 As described in detail in the annex 3:I:1, the Somalia Aid Coordination Body (SACB) forum was
 established in 1993 as a body attempting to provide basic coordination structures as well as a vehicle
 through which international actors and local organizations could interact to better serve the interests of the
 Somali people. Since May 1995, the Health Sector Committee of the SACB (see TOR in annex 3:III:1) has
 been offering to all partners (international, local professionals and emerging local authorities) a forum that
 ensures proper coordination and provides technical guidance on priority areas within the health sector
 addressing both acute emergencies and transitional activities along the continuum of rehabilitation and
 development.

 The Health Sector Committee (HSC) has been meeting in Nairobi on a monthly basis since its inception,
 and, despite the difficult operational environment, plays an important coordination role recognized by
 international actors as well as by local health authorities. An average of 25 international organizations has
 participated in the monthly meetings since 1995. In 2002, the HSC was asked to endorse a joint country
 proposal to the GAVI Fund. Funds from GAVI are managed by UN agencies (UNICEF/WHO) while the
 SACB Health Sector Committee provides the required oversight in coordination of the implementation and
 monitoring of the EPI strategy. The SACB HSC was also successful in the Round 2 Application to the
 GFATM for Malaria, Round 3 for TB and Round 4 for HIV/AIDS.

 Despite being a non-CCM, the HSC is committed to assuming the role expected by the GFATM from a
 CCM according to the standard guidelines and has implemented the following measures:
         Reviewed and adapted its TOR and the TOR of its fulltime Health Sector Coordinator to reflect
         this responsibility.
         Developed through an open and democratic process, rules, tools and procedures ensuring the
         required participation, transparency and accountability in developing joint proposals and selection
         of the PRs and SRs for the various grants. This process was highlighted as an example of best
         practices at the Mena conference Morocco in 2005.
         Established through a participatory and transparent manner additional coordination and
         management structures responding to the GFATM requirements.
         Conducted joint monitoring assessments to facilities to ensure proper utilisation of project
         resources.
         Maintains an active information sharing system open to all SACB partners (through open
         meetings, minutes and email communication) and accessible to the general public (SACB
         website).
         Includes the LFA as an observer to the HSC meetings and processes.

 Due to the fact that the SACB is a coordination forum and not an organization or institution, it does not
 have either the legal entity or the financial/managerial capacity to receive the funds requested from the
 Global Fund. For this reason the HSC called for relevant and qualified agencies to be put forward for the
 role of PR. The HSC’s role is to ensure transparent and accountable fund allocations in order to better
 serve the developed strategies and to avoid duplication and maximize synergies with other sources of
 funding to the health sector. This is ensured by the monthly co-ordinating activities of the Malaria Working
 Group and through the on-going technical support provided by the malaria management team (described
 in 3A63).

 Funds from the GFATM have allowed for the regular participation of representatives (focal points) from the
 existing and emerging local health authorities of Somaliland, Puntland and Central/South in the
 implementation and monitoring process as conducted through the quarterly review meetings. This offers
 an opportunity to build the technical and managerial capacities of the local focal points which contributes
 to the intervention’s sustainability and to the overall recovery of the health sector in Somalia. The



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3 Applicant type
    participation of the three health authorities in this technical forum is also an opportunity to increase
    dialogue among professionals and technical leaders within this difficult transitional period towards the
    recovery of the country in general and the health sector in particular.

    N.B.: In order to ensure transparency and accountability among all partners, minutes from the general
    health meetings and from the relevant working groups are shared on a monthly basis with all partners
    including the GFATM portfolio manager and LFA and are available on the website for verification of the
    level of coordination and technical discussions held.

    To enhance participation of the Somali civil society in the coordination process, Somali NGOs have been
    invited to join the HSC and represent the Local NGOs and CBOs from the three zones.



            b) Describe your organizations attempts to include this proposal in the relevant CCM’s final
               approved country proposal and the responses, if any, from the CCM.

                  N/A


    3A.6.3 Consistency with national policies
            Describe how this proposal is consistent with, and complements, national policies and strategies
            (or, if appropriate, why this proposal is not consistent with national policy).
    Due to the 16 years of protracted crisis and in the absence of a central functioning authority, the SACB
    supports the development of joint plans and strategies among the international partners as well as local
    strategies (e.g. Somaliland and Puntland). Through the support of the GFATM Round 2, the SACB HSC,
    together with existing and emerging local health authorities, articulated a national malaria strategic plan3.
    The plan, developed in line with the global Roll Back Malaria Initiative, aims at reducing by a half the
    malaria burden by the year 2010. It also reflects the commitment expressed in the Millennium Declaration
    and specifically in the Millennium Development Goal 4: “Have halted by 2015 and begun to reverse the
    incidence of malaria”.

    The component strategy presented in this proposal is based on this Malaria Strategic Plan and the
    quarterly technical discussions that have followed. A few components of the strategic plan have been left
    out for different reasons, though mainly due to new insight gained on the epidemiology of the disease.
    (See 4.4.2) The proposal also reflects other important documents such as the Malaria Treatment
    Guidelines and Communication Strategy.

    The local health authorities of the three zones have participated in the development of this proposal
    through a consultation process where the component strategy was constructed. Other partners have also
    fed into the content of the proposal. Letters of support from the health authorities are attached in the
    annex Chp3:I to the proposal.




3
    “Malaria Strategy” 2005-2010


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List of Annexes to be Attached to PROPOSAL Malaria, Chapter 3


                                                                                     Name/Number given
 Relevant item on
                        Description of the information required in the Annex         to annex in
 the Proposal Form
                                                                                     application

 Section 2: Eligibility: Not Applicable

 Section 3A: Applicant Type; Non CCM

 3A.6                   Documentation describing the organization such as            3:III:1 TOR Health
                        statutes and by-laws (official registration papers) or       Sector Committee,
                        other governance documents, documents evidencing             Health & Nutrition,
                        the key governance arrangements of the organization, a       SACB
                        summary of the organization, including background and
                                                                                     3:III:2 Update on the
                        history, scope of work, past and current activities, and a
                                                                                     Health sector, SACB
                        summary of the main sources and amounts of funding.
                                                                                     3:III:5 SACB
                                                                                     procedures for
                                                                                     GFATM, Oct 04
                                                                                     3:III:4 Malaria
                                                                                     Management Team
                                                                                     Responsibilities
                                                                                     4:4 Final vol I, SACB
                                                                                     Health Strategy,
                                                                                     3:III:6 SACB Donor
                                                                                     report 2004
                                                                                     3:III:7 SACB Donor
                                                                                     report 2003
                                                                                     5:6 Summary of
                                                                                     health funding from
                                                                                     2004 Donor report

                        Documentary evidence of any attempts to include the
 3A.6.2 b               proposal in the relevant CCM’s final approved country        N/A
                        proposal and any response from the CCM.

                                                                                     3: I Letters of
                        Provide evidence from relevant national authorities that
 3A.6.3                                                                              Endorsement of
                        the proposal is consistent with national policies and
                                                                                     Proposal with note on
                        strategies.
                                                                                     conformity

 Section 3B: Proposal Endorsement: N/A

 Other documents relevant to sections 1-3 attached by applicant:

 3A.6.2                 TOR HSC-Coordinator                                          3:III:3

 3A.6.2                 Letter of endorsement of PR                                  3:I

 3A.6.2                 Letter on non selection of SR                                3:II:1, 3:II:2

 3A.6.2                 SACB health strategy,                                        4:4

 3A.6.2                 JNA health sub-cluster                                       4:7




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List of Annexes to be Attached to PROPOSAL Malaria, Chapter 3

                                                                                       Name/Number given
 Relevant item on
                       Description of the information required in the Annex            to annex in
 the Proposal Form
                                                                                       application

 3A.6.3                Donors report 2004 or scanned table page 151                    5:6

 3A.6.3                Malaria strategy 2005- 2010                                     4:5

 3A.6.2                Testimony J Prendergast ICG on Somalia July 06                  3:IV:1

 3A.6.2                UN arms embargo report May 06                                   3:IV:2

 3A.6.2                Security report, list of security incidents, July 04- July 06   3:IV:3

 3A.6.2                ICG report July 2005                                            3:IV:4

 3A.6.2                FEWS net, sea piracy report                                     3:IV:5

 3A.6.3                Assembling the evidence and modeling risks, Snow
                                                                                       4:16
                       March 2006




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4 Component strategy, Malaria

4.1 Indicate the estimated start time and duration of the component
Since the HSC unanimously endorsed the continuation of the same PR due to the positive evaluation of
performance during Phase 1 (Round 2 grant) it is expected that this will reduce delays observed in the past
related to protracted negotiations of the grant between GFATM4 and the PR. Should the proposal be
accepted, the HSC commits to launching a transparent selection process of SRs using similar tools proven
successful in the recent past and taking into consideration the operational scenario prevalent at that moment
and evolution of the transitional process. This selection of the SRs will be finalized prior to the signing of the
grant (i.e. within six months from approval of the proposal).
                                                                 Table 4.1.1 – Proposal start time and duration
                                                  From                                       To

    Month and year:                             April 2007                               April 2012


4.2 Contact persons for questions regarding this component
                                                                                Table 4.2 – Component contact persons

                                            Primary contact                        Secondary contact

    Name                          Imanol Berakoetxea                       Tanya Shewchuk

                                  Coordinator, SACB Health Sector          Chair, SACB Malaria Working
    Title
                                  Committee                                Group

    Organization                  C/- SACB Secretariat                     C/- SACB Secretariat
                                    th
                                  5 Fl Kalson Towers                       5th Fl Kalson Towers
                                  Parkland, Nairobi                        Parkland, Nairobi
    Mailing address
                                  Kenya                                    Kenya

    Telephone                     +254 20 375 4145                         +254 724 450047

    Fax                           +254-20-3754149

                                  sacb.so@undp.org;
    E-mail address                imanol@kenyaweb.com;                     tshewchuk@unicef.org
                                  imanol.berakoetxea@undp.org




4
 HIV Round 4 SR selection process commenced once grant was approved by the GFATM and completed
by grant signing. The process has been mentioned as best practice by the GFATM and was presented
during the GFATM MENA in Morocco, July 2005.


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4 Component strategy, Malaria
4.3 Component executive summary


 4.3.1 Executive summary
       Describe the overall strategy of the proposal component, by referring to the goals, objectives and
       main activities, including expected results and associated timeframes. Specify the beneficiaries and
       expected benefits (including target populations and their estimated number).

 The current GFATM round 2 funding for malaria in Somalia will come to an end in June 2007. Major
 achievements have been made since the start of this grant in July 2004, despite the prevailing complex
 and challenging operating environment. For the first time, an overall malaria control strategy has been
 articulated. The Somalia Malaria Strategy (2005-2010) outlines a comprehensive approach for malaria
 control activities and provides a common framework for continued resource mobilisation. The objectives
 and activities proposed for round 6 are based on this strategy, which was developed jointly with all
 stakeholders. Secondly, GFATM funding enabled the introduction of Artemesinin Combination Therapy
 (ACT) and malaria Rapid Diagnostic Tests (RDT) in selected public health facilities. In addition, Long
 Lasting Insecticide Nets (LLIN) were distributed on a large scale and, in high risk areas, Intermittent
 Preventive Treatment (IPT) for pregnant women was provided through antenatal care services. Major
 efforts have been made to improve the knowledge base on malaria in Somalia, and expert technical
 advice has guided the development of current plans.
 Somalia has some of the worst health indicators in the world. Despite the round 2 achievements, malaria
 remains an important public health problem. Official figures of 36,732 cases reported in 2003 (World
 Malaria Report 2005) are considered to underestimate the true burden of malaria in Somalia, reflecting
 incomplete reporting and limited use of public health facilities. A malariometric survey conducted under
 round 2, gave an overall prevalence of parasitaemia of 8.3%, with marked differences between the
 different zones (12.3% South, 5% Central, 6.8% NW and below 1% NE). However, due to logistic
 problems, the survey was carried out in the dry season, and may therefore also underestimate true
 prevalence. Moreover, experts argued that a prevalence survey might not be the best way to estimate the
 malaria burden in this particular setting and researchers from the KEMRI/Wellcome Trust were therefore
 asked to model malaria risk in Somalia. They estimated that overall transmission intensity is low to
 medium in the South and unstable in the North of the country with short periods of localized high
 transmission, posing an important clinical burden on all age groups because of poorly developed
 functional immunity in the population.
 In order to tackle the persistent malaria burden, and to build on the major achievements under round 2,
 the Health Sector Committee of the Somalia Aid Coordination Body (HSC SACB), in agreement with the
 local health authorities and key stakeholders, decided to respond to the sixth call for proposals from the
 GFATM, currently the most important funding source for malaria control in Somalia. The overall goal of
 this proposal is “to reduce the malaria burden in Somalia by 50 percent” (as per the “Malaria Strategic
 Plan 2005-2010”). The proposal has three main objectives reflecting the major areas of intervention: 1) To
 increase provision of malaria diagnosis and treatment to 90% of public health facilities; 2) To increase
 coverage of prevention methods in targeted malarious areas for pregnant women and children under five
 to 80%; 3) To strengthen the capacity of the ministries of health in close collaboration with national and
 international partners.

 Increased provision of malaria diagnosis and treatment will be achieved through the following main
 activities: procurement and distribution of ACTs, procurement and distribution of diagnostic supplies
 (RDTs and/or laboratory supplies where relevant), and training of health workers on case management.
 Under round 2, only hospitals, MCHs and a limited number of health posts used ACTs and RDTs (25% of
 public health facilities). One of the most important targets for this proposal is not only to guarantee the
 continuation of supplies introduced under round 2, but also to increase the number of facilities covered to
 90% of public health structures, thus significantly increasing access for the population to prompt and
 effective treatment.

 Prevention remains an important component of this proposal. Reaching 80% coverage in under fives and
 pregnant women in malarious areas will be achieved through the following activities: procurement and
 distribution of 1,200,000 LLINs by year 5, provision of IPT to pregnant women in high transmission areas,
 and a strong IEC/BCC component supporting all of the above mentioned activities (including treatment


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4 Component strategy, Malaria
 and diagnosis). These activities will be targeted to areas where they are most relevant, with nets mainly
 distributed in the south of the country, and IPT only provided in 80 MCHs situated in high transmission
 areas.

 In order to strengthen the capacity of the ministries of health, an important part of the requested resources
 will be dedicated to the following activities: 1) Establishing 4 referral laboratories, which will enable the
 local health authorities to undertake quality assurance of microscopy services in peripheral health facilities
 and (refresher) training of their own laboratory staff; 2) Technical assistance and operational support to the
 ministries to facilitate regular supervision and monitoring of malaria activities; 3) An important Health
 Systems Strengthening (HSS) component, including operational research; and 4) Activities for prediction
 and containment of Epidemics, especially important in the parts of the country experiencing unstable
 malaria transmission.

 Through the health systems strengthening component a national monitoring and evaluation (M&E)
 framework will be developed by the end of year 2 addressing the information needs at each level of the
 health system (focussing on the peripheral level). The main objectives are: a) building capacity of local
 health staff/managers in collecting analysing, interpreting and using information for planning and M&E
 purposes, and b) ensuring coordination between various stakeholders and GFATM programs, thus
 reducing duplication and increasing data availability and utilization. The main activities include: revising
 the existing health information systems (HISs), establishing HIS management structures at different levels,
 and conducting operational research. The HISs require revision as they are currently inadequate for
 documenting disease patterns and access to service provision/coverage. There is a lack of integration of
 the different information sources which leads to an incomplete picture of the health situation both at local
 and national levels. The development and implementation of the M&E framework, particularly at peripheral
 level, will take time during which the present information flow needs to be supported and strengthened.
 The proposed methodology aims at developing a comprehensive M&E framework while avoiding a
 breakdown of the present system in the interim. The preparation of the present proposal took into
 consideration the complexities of the Somali context and the transitional process, the existing initiatives
 related to HIS, and the TRP’s evaluation of the HSS proposal presented to GFATM in the previous round.

 This proposal not only builds on the achievements under round 2 but also takes into account important
 lessons learnt under the previous funding cycle. The lessons learnt are mainly linked with the challenging
 operational environment in Somalia which is characterized by fluidity in international actors and their
 operational priorities. Firstly, under GFATM round 2, sub-recipients (SRs) were selected at the time of
 proposal-writing and, by the time of grant implementation, not all remained available or appropriate. It was
 thus decided that for Round 4 (HIV/AIDS) and subsequent rounds, the process of SR selection will be
 launched once the grant is approved. The result has been a SR selection process that has been
 commended by the GFATM as best practice, with appropriate SRs on board and timely implementation.
 Secondly, an M&E component to support supervision by the local health authorities was not initially
 included in round 2. However, support has been made available to the Health Authorities under the
 current round and for round 6, a strong M&E component, including institutional and human resource
 capacity building has been foreseen. Thirdly, the distribution of LLINs to the end users experienced
 important delays, especially in the early stages of round 2. In the later stages the problem was solved by
 “booking” nets ahead of grant signing to ensure that LLINs arrived in country in a timely manner. For this
 new submission, planning of resources takes into consideration the lead times with, for example,
 procurement commenced in Year 1 for distribution in Year 2.

 Particular attention has been made to addressing the following weaknesses highlighted by the TRP
 Review Forms of the unsuccessful Round 5 submissions: 1) “It is not clear in which areas the activities are
 to develop and how the resources would be shared by different governments”. Resources for capacity
 building and system support will be shared equally by the three ministries, while those for service delivery
 and program implementation will be allocated in proportion to the number of delivery points in each area
 and the malaria transmission pattern. 2) “No attention to local authorities and how to mainstream the
 project into the public sector if the transitional government succeeds. There is no exit plan for UNICEF as
 the proxy Ministry of Health”. Capacity-building that focuses on local authorities is included in this proposal
 in order to strengthen the public sector. This will provide the foundation for when a transitional government
 succeeds. Both UNICEF and the SACB HSC are committed to working with the authorities and to the
 transitional process, in line with the health sector recovery outlined in the on-going Joint Needs
 Assessment (JNA). Although the current political situation is not conducive to formulate an exit strategy,
 both the National Malaria Strategy and this proposal have been developed with the active participation of



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4 Component strategy, Malaria
 the different health authorities. However, at the end of phase 1, the political situation will be re-assessed
 and, if feasible, modalities and timing of an exit strategy will be developed in collaboration with the health
 authorities. 3) “Very top-down approach to HIS. HIS appears to be organized around meeting donor and
 program needs rather than local decision-makers and communities; It is unclear how managers at health
 centers and communities would be able to use the data for their own planning and accountability”. The
 HIS component considers the needs of all users of health information with a comprehensive M&E
 framework that takes into account the existing data collection systems and the information needs at each
 level, crucial in informing the health sector during the transition/reconstruction of the country. The bottom-
 up approach, piloting HIS in a limited number of districts, focuses on local needs rather than establishing a
 software-oriented central system. 4) “Heavy administration and technical assistance costs with very little
 local capacity building.” and “Exit plan with benchmarks for UNICEF and manager of database would be
 helpful”. The HSS component has a strong focus on building the capacity of local health authorities.
 External technical assistance is provided mainly over the first part of the program, and is phased out once
 systems and capacities of local counterparts have been built.

 There are three ministries of health with mandates in different parts of the country due to the protracted
 political crisis since the collapse of the central government in December 1990. Although challenging at
 times, program implementation and the current proposal writing process have been carried-out in close
 collaboration with the ministries. In the present context, this proposal is submitted by the SACB HSC in
 agreement with the health authorities and key stakeholders. The volatile operational environment, with
 often limited access to certain parts of the country due to insecurity, requires a strong partnership for the
 implementation of the proposed activities. UNICEF will be responsible as the Principle Recipient (PR) and
 will work together with the local health authorities and other sub-recipients for the implementation of the
 proposed malaria control and health systems strengthening program. .

 Implementing a national malaria program in Somalia is challenging, not only because of the complex
 environment but also because of the unusual malaria transmission pattern. As new evidence emerges
 from ongoing operational research, the current “interim” strategy will require review. With the support of
 GFATM, Somalia will thus be able to develop increasingly evidence-based strategies; in order to meet the
 malaria related international targets set under the Millennium Development Goals. For Somalia, funding
 from the GFATM will not only be an essential contribution to the reduction of the malaria burden but will
 also help the local health authorities to lay the foundations for a strengthened health system.


 4.3.2 Synergies
       If the proposal covers more than one component, describe any synergies expected from the
       combination of different components—for example, TB/HIV collaborative activities.

 Synergies and multiplying effects between the malaria and the HSS component are described in section
 4.6.6



4.4 National program context for this component
4.4.1 Indicate whether you have any of the following documents (tick appropriate box), and if so,
      please attach them as an annex to the Proposal Form:

              National Disease Specific Strategic Plan (Annex 4:5)
              National Disease Specific Budget or Costing
              National Monitoring and Evaluation Plan (health sector, disease specific or other)
              Other document relevant to the national disease program context (e.g. the latest disease
              surveillance report)
          •    Malaria diagnosis and treatment guideline for Somalia, MERLIN/UNICEF/SACB, 2006
               (Annex 4:6).
          •    Simplified guidelines for MCH/OPD health workers in low/high transmission areas,
               MERLIN/UNICEF/SACB, 2006 (Annex 4:18 & 4:19).



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4 Component strategy, Malaria
          •    Malaria in Somalia: Assembling the evidence and modeling risk; Snow RW, Noor AA, Hay SI
               (2006) (Annex 4:16)
          •    Final Draft Malaria Communication Strategy 2005-2010 (Annex 4:11)


 4.4.2 Epidemiological and disease-specific background
       Describe, and provide the latest data on, the stage and type of epidemic and its dynamics (including
       breakdown by age, gender, population group and geographical location, wherever possible), the
       most affected population groups, and data on drug resistance, where relevant. With respect to
       malaria components, also include a map detailing the geographical distribution of the malaria
       problem and corresponding control measures already approved and in use. Information on drug
       resistance is of specific relevance if the proposal includes anti-malarial drugs or insecticides. In the
       case of TB components, indicate, in addition, the treatment regimes in use or to be used and the
       reasons for their use.

 Malaria epidemiology
 The World Malaria Report (2005) gives the following statistics on malaria in Somalia:
           23,349 cases reported in 2003 of which 7,571 were laboratory confirmed.
           Malaria incidence at 2.36/1,000/year.
           17% of children reported fever in the previous 2 weeks (no significant differences between males
           and females or urban and rural populations; MICS 1999).
           18% of all fever cases in children under five received anti-malarial treatment 24% in rural and 11%
           in urban areas (no significant difference between males and females; MICS 1999).
 The numbers reported are unlikely to be accurate, underestimating the true malaria burden, because of
 under utilization of health facilities and incomplete reporting. In addition, most cases are diagnosed
 clinically, making it difficult to provide an accurate estimate of the real burden of malaria in Somalia.

 A consequence of the long lasting civil war is that the epidemiology of malaria has not been well
 described. Between the 1940’s and 1990’s only a few studies on malaria infection and vector composition
 were done in the north (Glasgow & MacInnes, 1943; Wilson, 1949; Maffi, 1958). For the South and Central
 areas of Somalia there have been even fewer studies. The World Malaria Report (2005) describes malaria
 transmission in Somalia as “unstable” in Puntland and Somaliland, “moderate” in the central and “high” in
 the south. P Falciparum is reported to be the predominant parasite species (95% of all infections) and An.
 Arabiensis the main vector.

 However, in 2006, the “Lysenko” map (Lysenko &
 Beljaev, 1969) represents our only published source of
 information on the spatial limits of various categorical
 descriptions of P. falciparum transmission intensity. The
 distribution of historical risk compiled by Lysenko and
 colleagues for Somalia is shown on the right. Its coarse
 definition of risk is a result of almost no empirically
 driven descriptions of endemicity up to 1968 but
 nevertheless represents a reasonable “expert” opinion
 on the distribution of malaria risks ranging from hyper-
 endemic around the two major river courses to pockets
 of meso-endemicity and large areas of hypo-endemic
 transmission. According to the Lysenko map nowhere
 was classified as holo-endemic and no area regarded
 at no risk. More recently, studies were done by
 Kassatsky (1998), Burns (2002) and WHO/Merlin
 (2005). The Kassatsky and Burns studies, used for the
 development of the malaria strategic plan (2005),
 defined 3 distinct endemic zones: Hypo-endemic in the
 northern and central parts of Somalia, meso-endemic in
 between the rivers in the south, and hyper-endemic in
 the riverine areas.

 The GFATM funded cross-sectional prevalence survey was conducted between January and February



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4 Component strategy, Malaria
 2005 covering three zones of Somalia (WHO-Merlin, 2005). The final sample included 11 473 subjects of
 all age groups in 351 villages located in 57/88 selected districts. The survey in the North–East zone
 (Puntland) was postponed to May-June 2005. This survey was successfully completed on 2675 individuals
 from 29 villages in eight districts (WHO, 2005). However, there were notable difficulties with the
 implementation of the survey in the Southern, North Western and Central Zones. Quality assurance of
 survey methods and blood slide reading was absent and the final report questions the utility of the smear
 readings. However, the results of the RDT assessments
 were felt to be more reliable and showed total positivity
 rates of 12.3%.

 The MEPHG of the KEMRI/Wellcome Trust mapped
 malaria risk in Somalia, using the RDT prevalence data
 from the 2005 survey, in order to guide the next
 malariometric survey. In his report a map based on NDVI
 (Normalized Difference Vegetation Index) and distance to
 permanent water bodies is presented (see map). They
 conclude: “The dependent parasite prevalence data
 exhibited a marked heterogeneity and such localized
 features of risk would be hard to model and map at a
 country or regional level. Whilst we can assume that on
 average transmission intensity is low and unstable across
 large areas of the central and northern parts of the
 country, localized high transmission, probably temporally
 related, do occur. The extent and magnitude of these
 localized high transmission conditions might be hard to
 map and model. Their impact on disease risks remains
 unknown but one could probably assume that they pose an
 important clinical burden on all age groups traditionally        Orange = unstable transmission risk; green =
 used to low parasite exposure and thus have a poorly             hypo-endemic risk; and red = meso-endemic
                                                                  risk.
 developed functional immune response.”

 The report, which can be found in annex 4:16, recommended against further national prevalence surveys
 arguing that: “where malaria infection prevalence is over-dispersed, difficult to collect data and assure
 quality, the national sample survey approach may not be the optimal design to understand localized
 patterns of malaria transmission and epidemiology.” A sentinel district approach was recommended to
 better understand malaria (clinical) epidemiology (see section on operational research).
 Drug resistance studies
 WHO carried out therapeutic efficacy studies of chloroquine (CQ) at three sites in 2002-2003. It was found
 that total treatment failures varied between 76.0% and 88.5% for CQ and between 7.9% and 12.2% for
 Sulphadoxine-Pyrimethamine (SP). In studies conducted in 2004 the sensitivity to amodiaquine (AQ)
 ranged from 2.8% to 28%, with no explanation so far for such a disparity in the results (especially since
 AQ has not been used previously in Somalia and the existent resistance is expected to be due to cross-
 resistance with CQ and possibly cross border population movements (AQ was widely used in Kenya for
 example). The interim malaria strategy, endorsed by the SACB health sector committee and zonal health
 authorities, states that CQ will no longer be used in Somalia as first line treatment and will be replaced by
 the Artemesinin-based combination therapy. In 2006, Artesunate (AS) and SP were introduced as first line
 treatment at hospital and MCH/OPD level. Currently studies are being conducted on drug efficacy of AS +
 SP (the current 1st line) and AS + AQ (a potential alternative). Looking at resistance patterns in Somalia’s
 neighboring countries, SP is compromised in both Kenya and Ethiopia. Most likely, first line treatment will
 need to be changed during the course of the proposed GFATM funding and it is therefore foreseen to test
 AS + LUM (Coartem ®) in 2007 and 2008.




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4 Component strategy, Malaria
 4.4.3 Disease-control initiatives and broader development frameworks

       a) Describe comprehensively the current disease-control strategies and programs aimed at the
          target disease, including all relevant goals and objectives with regard to addressing the disease.
          (Include all donor-financed programs currently implemented or planned by all stakeholders and
          existing and planned commitments to major international initiatives and partnerships.)

 Given the economic, political and security difficulties faced by Somalia, donor funding is essential for the
 functioning of disease-control programs. For Malaria, by far the most important is the “Malaria Control in
 the Chronic and Complex Emergency of Somalia: Scaling up Prevention, Detection and Case
 Management through Coordination and Partnership.” funded through Round 2 of the GFATM and ending
 in 2007. UNICEF, the Principal Recipient of the programme, along with seven other sub recipients (WHO,
 World Vision, COSV, Merlin, AAH, CISP, and, up to 2006, IFRC) are the main implementing agencies of
 this national malaria control programme. However, irrespective of whether or not an agency is a sub-
 recipient of the GFATM, all health partners supporting public health facilities receive support from the
 GFATM project in terms of supplies, training, supervision and technical guidance. Agency-specific projects
 (ex: Gedo Health Consortium, IMC, SRCS) have received support and are using the new malaria
 treatment guidelines and consumption follow-up tools developed under round 2. Increasing efforts are
 being made to integrate malaria prevention and treatment with other maternal and child health
 interventions, including LLINs and IPT delivery through ANC, EPI activities and nutritional programs.
 The goal of the program is to reduce under-five, maternal and adult morbidity and mortality due to malaria
 and to contribute to building a national health system.

 One of the major achievements of the program is the establishment of the Malaria Strategy 2005-2010,
 finalized and endorsed in a 2005 workshop (see annex 4:5), bringing together the three health authorities
 for a consultative meeting with UN agencies and INGO partners. The strategy describes the overall goal of
 the malaria control program (beyond the timeframe of the strategy): “To eliminate malaria as a public
 health problem and obstacle to socio-economic development in Somalia, through sustained efforts by local
 authorities in collaboration with national and international partners.” It is based on the priorities outlined by
 the Roll Back Malaria Initiative. Its main objectives for the malaria control program by the year 2010 are:
      o To reduce under five, maternal and adult morbidity due to malaria by 50%
      o To reduce under five, maternal and adult mortality due to malaria by 50%
      o To strengthen ministries of health capacity in close collaboration with national and international
          partners.
 The GFATM funded KAP survey (Lynch, 2005 Annex 4:12), the LLIN situation analysis (Graham, 2005)
 and drug resistance studies (WHO, 2005) were used to define the main strategies: disease management;
 vector control; prevention and control of malaria in pregnancy; and epidemics prevention and control.
 Supporting strategies identified in the strategy document are: human resource development; IEC;
 monitoring and evaluation; and operational research. All of these areas are reflected in the objectives and
 service delivery areas of this proposal.

 In addition, a communication strategy for malaria (Malaria Communication Strategy 2006-2010, Damian
 2005) and treatment guidelines (see annex 4:11), that aim to support the implementation of the malaria
 strategy, have also been developed. The above mentioned achievements under round 2 GFATM funding
 are proof that despite the challenging context, substantial progress has been made. These achievements
 will be the basis for a further scaling up of malaria control activities proposed for round 6.

       b) Describe the role of HIV/AIDS-, tuberculosis- and/or malaria-control efforts in broader
          developmental frameworks such as Poverty Reduction Strategies, the Highly-Indebted Poor
          Country (HIPC) Initiative, the Millennium Development Goals or Sector-Wide Approaches.
          Outline any links to international initiatives such as the WHO/UNAIDS ‘Universal Access
          Initiative’ or the Global Plan to Stop TB or the Roll Back Malaria Initiative.

 At present, Somalia is not part of broader development frameworks such as HIPC or SWAPs.
 As mentioned above, the Malaria Strategy (2005-2010) has been developed in line with the global Roll
 Back Malaria Initiative, which aims at reducing by half the malaria burden by the year 2010. It also reflects
 the commitment expressed in the Millennium Declaration, specifically in Millennium Development Goals 4


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4 Component strategy, Malaria
 (reduction of child mortality), 5 (improve maternal health) and 6 (combat HIV/AIDS, malaria and other
 diseases). The strategy is also in line with the World Health Assembly declaration (2005) “to establish
 national policies and operational plans to ensure that at least 80% of those at risk of, or suffering from,
 malaria benefit from major preventive and curative interventions by 2010 in accordance with the WHO
 technical recommendations so as to ensure a reduction in the burden of malaria of at least 50% by 2010
 and 75% by 2015.


 4.4.4 National health system
       a) Briefly describe the (national) health system, including both the public and private sectors, as
          relevant to reducing the impact and spread of the disease in question.

 Somalia health indicators are among the worst in the world and are a reflection of the chronic conflict that
 has affected the country for the last 15 years.
                       •    Children < 5 years underweight: 25,8%
                       •    Under 5 mortality rate: 219 per 1000 live births
                       •    Infant mortality rate: 130 per 1000 live births
                       •    1 year old fully immunized: 36% in the year 2000
                       •    Maternal mortality rate: 1,100 per 100,000 (2000), 1,600
                            (2004)
                       •    Life time risk for maternal death: 1 in 10 women


                      Health indicators for Somalia, the WHO World Health Report, 2005

 The national health system is divided in the zonal areas described under 3A.6.2 with a Ministry of Health
 and Labour in Somaliland, a Ministry of Health in Puntland and a Ministry of Health of the Transitional
 Federal Government located in Central-South. In both Puntland and Somaliland efforts have been made
 to put in place the basic elements of a health care system which are delivered by the Health Authorities
 and NGOs. In the Central-South, public health services are provided mostly by NGOs. Overall, the public
 health network is largely fragmented given the divisions and the variety of agencies and programs. The
 package of services provided by health facilities is conditioned by the external support received. Few
 national strategies and policies have been developed in more than a decade with notable exceptions like
 the Malaria Strategy (2005-2010).
 Most health infrastructures were seriously damaged and looted during the civil war. Recent inventories
 report 86 hospitals (with 24 functional public hospitals) and just under 200 health/MCH centres and 470
 health posts, though the functioning status of many health facilities is unknown. Overall, the public health
 care network is small and concentrated where security conditions allow. Facilities are generally poorly
 equipped although recent donor funding is assisting to improve this situation including the establishment of
 60 laboratories through the GFATM Round 2. Private health care outlets have proliferated, and their
 features are poorly documented. Overall, the quality of the provided care is a source of concern and needs
 improvement.
 The health workforce is small and relatively under-skilled. Skilled cadres in Puntland are fewer than 200
 while in Somaliland this figure is around 400. No reliable counts are available for Central - Southern
 Somalia and the number of workers operating private outlets is unknown. The ranks of laboratory
 technicians, pharmacists and midwives are also diminutive. The performance of health workers is
 considered poor as they are often not properly supported. Many were trained before the war and they are
 irregularly or not supervised (with the exception of the GFATM TB program and GFATM Malaria existent
 but under resourced).
 There is a lack of sustained resources to finance supplies and appropriate quality drugs such as LLINs
 and ACTs. UNICEF / WHO / GFATM support the supply of drugs needed by disease-control programs
 including Malaria. Many NGOs acquire drugs through their own channels however Malaria drugs supplied
 by the GFATM are available to all organizations. Wholly unregulated drug selling outlets are counted in the
 thousands and over-prescription of drugs through this channel is considered to be commonplace.
 There is no consolidated estimate of the resources allocated to health care provision in Somalia from
 public and private sources. Most public financing to health care is provided by the international community
 with the GFATM presently as one of the largest donors. External contributions were below US$ 5 per head



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4 Component strategy, Malaria
    in 1993. It is impossible to quantify private spending and guess-estimates vary between 80% and 55% of
    all health financing. Many of the public facilities run a cost-recovery system however Malaria tests and
    treatment are provided for free.
    At present there are several information systems developed by different programs aiming at collecting
    health related data5. The general morbidity/ mortality data are recorded and compiled at Health Posts and
    MCH facilities. Some facilities also produce summaries on neonatal and safe motherhood data. The
    monthly summaries are sent to FSAU-Nairobi for nutrition, to UNICEF for EPI and less consistently to
    UNICEF for morbidity data. At hospital level, standard register are not consistently used and data are not
    disseminated. In addition to facility based reporting, other sources of information derive from occasional
    national and sub-national studies and surveys: eg: Socio-Economic Survey 2002, MICS 2006. Others
    include KAP and Behaviour surveys (e.g. Malaria 2005) and surveillance studies (tuberculin survey and
    malariometric study conducted respectively in 2005 with GFATM funds).
    Access to health services is low and uneven, particularly once the needs of the significant nomadic
    population and the extremely low population density are taken into account. Economic, cultural and
    gender barriers also play an important role in limiting the access to health services, in particular for the
    most vulnerable groups. Regular supervision and surveillance activities are limited given the lack of
    systems and infrastructure.
    In the absence of local health institutions, the SACB (Somali Aid Coordinating Body) was set up in 1993 to
    coordinate international aid to Somalia. Based in Nairobi, the SACB is an open forum of all relevant
    stakeholders and is supported by UNDP and major international donors including the EC, World Bank,
    DFID and the Italian Embassy. It is composed of various sectoral committees, one of which is the HSC
    (Health Sector Committee), which has a specific mandate of addressing health sector issues. UNICEF,
    WHO and other partners are responsible for health programs and projects, whilst implementation of health
    interventions and services is through international and local NGOs as well as community based
    organizations (CBOs). Health strategies, programs and interventions in Somalia are made through
    consultative processes including HSC/SACB, NGOs, UN bodies and the local Somali authorities.
    Technical working groups have been established via the SACB HSC and are open to all organizations
    working in Somalia. A Malaria Working Group, established in 1999, discusses malaria control issues and
    a Health Information Systems Working Group(1997) facilitates coordination to support the development of
    HIS. Meetings are held regularly and minutes shared with the HSC and with the Somali Health Authorities.

          b) Given the above analysis, explain whether the current health system will be able to achieve and
             sustain scale up of malaria interventions. What constraints exist?

    As expected, the impact of 15 years of conflict on the health system has been profound affecting all its
    components from human resources to infrastructure, management to support systems. The challenge it to
    re-establish systems and develop the needed capacities to manage them. For malaria control, key
    constraints in the system include:
            Lack of infrastructure for referral laboratories and of systems for supervision and quality control of
            the laboratory network
            Lack of sustained resources to finance supplies such as LLINs and appropriate quality drugs
            Private sector that is unregulated or controlled
            Little capacity within the health ministries and few resources
            Poor health information system and lack of reliable health statistics
    This proposal addresses the systemic issues by providing additional resources to build capacities and for
    service provision. A referral laboratory network and the related quality assurance mechanism will be
    established and needed malaria supplies will be secured. Efforts will be channeled for strengthening local
    health authority capacities and HIS.
    The proposal expands on the successful approach taken in GF round 2 where treatment with ACTs has
    been introduced at MCH and Hospitals. The number of facilities accessing ACTs will be increased by
    expanding to the community health posts through community health worker training and supportive
    supervision. The coverage of interventions such as LLIN distributions and IPT that were launched through
    Round 2 will also be increased. The national referral laboratory system that will be established through
    this proposal will improve the performance of the peripheral labs established under Round 2.

5
 Among which: Routine nutritional surveillance (FSAU), EPI and MCH (UNICEF), AFP and Surveillance system (WHO), UNFPA
supported RH projects (CARE) .



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          c) Please describe national health systems strengthening plans as they relate to these constraints.
             If this proposal includes a request for resources to help overcome these constraints, describe
             how the proposal will contribute to strengthening health systems.

    Constraints faced in the malaria control program will be mitigated by the strengthening of the health
    system. In addition to the disease management and prevention activities described above, the proposal
    also focuses on the capacity building of the local authorities in terms of supervision and management as
    well as addressing the weaknesses of the health information system.
    Three malaria zonal teams will be established as the main structures for malaria control. The capacities of
    these teams will be built so that that the systematic supervision of health facilities and training of health
    staff on malaria case management and prevention are carried-out. The malaria zonal teams will work
    closely with zonal HIS units and within a national HIS system that will be developed.
    A national M&E framework will be developed so that reliable information for assessing progress towards
    global goals, planning at national level, directing and harmonizing foreign aid, is available. An M&E
    framework, commonly shared, will facilitate coordination between various stakeholders thus reducing
    duplications and the burden of data collection and analysis. At sub-national level, data will assist in
    program (including malaria) performance monitoring. Data will be used at point of collection, allowing the
    health workers to know the health profile in their catchment area and to identify major constraints in
    services delivery. The overall aim is for the capacities of the emerging local health authorities to be built in
    collecting analysing, interpreting and using information for planning and M&E purposes.

4.5 Financial and programmatic gap analysis

    4.5.1 Overall needs assessment
          a) Based on an analysis of the national goals and careful analysis of disease surveillance data and
             target group population estimates for fighting the disease component, describe the overall
             programmatic needs in terms of people in need of these key services. Please indicate the
             quantitative needs for the 3-5 major services that are intended to be delivered (e.g. anti-retroviral
             drugs, insecticide-treated bed nets, Directly Observed Treatment Short-Course for TB
             treatment). Also specify how much of this need is currently covered in the full period of the
             proposal by domestic sources or other donors.

    In working towards the national goals of reducing malaria disease burden by 50% a range of service
    delivery areas have been identified as requiring support including the strengthening of health authorities’
    capacities. The major services include effective anti-malaria treatment, quality laboratory diagnosis, long-
    lasting insecticidal nets, IEC and health system strengthening.
    The majority of the population is at risk of malaria – either living in areas of low, unstable transmission or
    in higher transmission areas comprised of seasonal or year-round transmission as described in section
    4.4.2. In this context of post-conflict transition in some areas and chronic conflict in other parts of the
    country, uncertainty surrounds population figures. Working figures are thus established for planning
    purposes. Most public funding to health care is provided through external financing (estimated at less than
    $5/head) with domestic sources considered relatively small.6 The GFATM is one of the largest
    contributors to health in Somalia.
    Effective diagnosis and anti-malaria treatment:
    Since 2005, malaria first line treatment has been changed from chloroquine to the ACT (AS + SP) upon
    confirmed diagnosis in the Treatment Guidelines and at health facilities across the country. Children under
    five years of age living in highly endemic areas are treated based on a clinical diagnosis in accordance
    with WHO recommendations. This important change was supported through GFATM Round 2 funding and
    is based on the national strategy and in line with WHO recommendations. These services need to be
    continued and also coverage increased so to reach the community-level through community health
    workers working in health posts. The number of uncomplicated cases that will be treated increases every
    year as more health posts will be covered. In year 1 an expected 80,000 uncomplicated cases will be
    treated going up to 140,000 in year 5. We estimate that for every case treated, 5 cases need to be tested.
    However, although the number of RDTs increases every year, there is a simultaneous decrease by 25,000

6
    JNA Social Services and Protection of Vulnerable Groups Health Sub-cluster Report April 2006


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 tests per year as RDTs will be fazed-out in those facilities providing quality microscopy diagnosis. We
 estimated 2% of all cases to be severe malaria cases. These cases are outside of any epidemics or
 outbreaks. The GFATM is the sole source of funding for this service with UNICEF providing oral quinine in
 its MCH/Health Post kits.
 Quality laboratory diagnostics: Through Round 2, 60 laboratories were established across the country.
 These laboratories require regular support to function as well as a quality assurance mechanism in order
 for them to be able to service an estimated 100,000 patients at MCHs and hospitals. In addition to
 GFATM resources, WHO provides support for services through some training activities as well as the
 technical assistance of a senior laboratory technician ($60.000).
 LLINs: More than 900,000 have been distributed through the Round 2 proposal with a further 1,200,000
 required for Round 6 to have 80% of the target groups (under 5s and pregnant women in high
 transmission areas) sleeping under an LLIN. These risk groups are reached through distributions
 integrated with other activities such as ANC, EPI outreach and nutrition programs. Through its emergency
 interventions, UNICEF distributes approximately 5000 family kits a year each containing an LLIN
 (approximately $50,000). Swim for Malaria has pledged 10,000 LLINs for Somalia in 2006 and it is hoped
 that this can be repeated for future years.
 IEC: Communication will target all health workers in the country and 80% of identified vulnerable groups.
 To maximize effectiveness, multiple communication techniques, including interpersonal and participatory
 communication will be utilized, supported by mass media approaches such as posters and leaflets.
 Multiple entry points into communities will be used, building on activities and initiatives already in place,
 such as water and sanitation programming, communication around food emergency programs and
 community development programs. A number of malaria communication materials have already been
 prepared using resources from GFATM round 2. A communication strategy has been drafted, and
 communication activities will be carried out in accordance with this strategy

         b) Based on an analysis of the national goals and objectives for fighting the disease component,
            describe the overall financial needs. Such an analysis should recognize any required
            investment in health systems linked to the disease. Provide an estimate of the costs of meeting
            this overall need and include information about how this costing has been developed (e.g.,
            costed national strategies, medium term expenditure framework).

 In the current Somali context, no attempts have been made by the various authorities to estimate the costs
 of meeting national goals.



 4.5.2     Current and planned sources of funding

         a) Describe current and planned financial contributions, from all relevant domestic sources
            (including loans and debt relief) relating to this component.

 As stated in 4.4.4, the financial input of local authorities to overall public health services is less than 2% of
 the overall funding of the Public Health Sector which is estimated to be below $5 per head. Apart from the
 funding provided through the GFATM round 2, support for Malaria programming from the national budgets
 is therefore considered to be minimal.

 Due to the state of governing structures, the international outstanding debts are not being paid and no
 debt burden relief (Highly Indebted Poor Countries initiative) can be given.

         b) Describe current and planned financial contributions, anticipated from all relevant external
            sources (including existing grants from the Global Fund and any other external donor funding)
            relating to this component.

 Few potential donors for malaria programming exist for Somalia in the current context outside of the
 Global Fund. If peace is established, substantial amounts of funds may be available via donor pledges
 geared towards the reconstruction and development of the country. Presently, donors tend to focus on the
 establishment of federal transitional institutions rather than funding the health sector. In the meantime, in
 addition to the GFATM, it is anticipated that UNICEF and WHO will continue to support malaria disease



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4 Component strategy, Malaria
 control as shown in the financial gap analysis table.

 Other donors support public health facilities upon which the
 malaria control program rely. These donors support primary
 health care, tertiary care and nutritional interventions but have
 not committed specifically for malaria interventions (such as
 antimalarials, LLINs, etc). In the table to the right, please find a
 breakdown of committed support for health care in Somalia that
 includes both single and multiple year grants such as the
 GFATM (source: SACB Donor Report 2004).

 Without GFATM support, the implementation of the Malaria
 Strategy would not be possible. Furthermore, there is no
 apparent alternative source of resources to finance the overall
 supplies needs such as LLINs and appropriate quality drugs.

 There is currently no support provided by any donor for referral
 laboratories (quality assurance) and limited support via
 UNICEF for supportive supervision of MCHs in Puntland and
 Somaliland ($30,000 per annum) but not focusing on malaria.
 For HIS, as described in 4.4.4, organizations are collecting data
 specifically related to their disease or program but have neither
 invested in strengthening an overall system nor the capacities
 of health authorities. The cost related to data collection in the
 different vertical programs or by implementing organizations is not available.


 4.5.3 Financial gap calculation
       Provide a calculation of the gap between the estimated overall need and current and planned
       available resources for this component in table 4.5.1-3 and provide any additional comments below.

 Calculating financial gaps is challenging given the lack of central authorities with whom to engage in order
 to produce an estimated overall need. Although a National Malaria Strategy exists, a costing to achieve its
 targets has never been done due to the fragmentation of the national health system, the volatile political
 situation and the limited understanding of the true malaria burden in Somalia. Taking into consideration
 the current implementation and absorption capacity and the funds provided through malaria specific
 UNICEF/WHO programs (see table 4.5 1-3), the present budget is the only cost estimate available for
 resources needed in the next 5 years.




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4 Component Section Malaria
                                                                                                                Table 4.5.1-3 - Financial contributions to national response on Malaria

                                                                                          Financial gap analysis (US$)

 Malaria                                                    Actual                         Planned                                               Estimated

                                                  2004                 2005        2006               2007                    2008                   2009                   2010

 Overall needs costing (A): A malaria
 needs assessment has not been carried out        N/A                  N/A         N/A                 N/A                     N/A                    N/A                   N/A
 for Somalia given current context.

 Current and planned sources of funding:

 Domestic source: Loans and debt relief
 Not applicable considering the current           N/A                  N/A         N/A                 N/A                     N/A                    N/A                   N/A
 context.

 Domestic source: National funding
 resources (health budget very low with no         0                    0           0                   0                        0                     0                      0
 specific funds allocated to malaria)


 Total domestic
                                                   0                    0           0                   0                        0                     0                      0
 sources of funding(B)

                         External source 1      1,823,998            4,917,191   5,045,048         1,100,424                     0                     0                      0
                    Global Fund Grant round 2

                         External source 2
                                                368,500              367,000     368,500             411,000                367,000                367,000                367,000
                          (see annex 4.20)

 Total external, sources of funding
                                                2,192,498            5,284,191   5,413,548         1,511,424                367,000                367,000                367,000
 (C)

 Total resources available (B+C)                2,192,494            4,010,468   3,264,239         1,511,424                367,000                367,000                367,000

 Unmet need (A) - (B + C)                         N/A                  N/A         N/A                 N/A                     N/A                    N/A                   N/A




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 4.5.4 Additionality
       Confirm that Global Fund resources received will be additional to existing and planned resources,
       and will not substitute for such sources, and explain plans to ensure that this will continue to be true
       for the entire proposal period.

 GFATM resources, while extremely important for the implementation of the Malaria Strategy for 2007 to
 2012, are not the only source of support for this initiative and are additional to other funding (details see
 annex 4: 20). The coordination mechanisms currently in place, such as the SACB/HSC Malaria Working
 Group and zonal health coordination meetings, demonstrate an ongoing commitment to malaria from both
 national partners and international organisations. Currently, it is estimated that external contributions are
 approximately USD 5/person for public health funding. While this is deemed very low for health services in
 a protracted crisis it does demonstrate a continued commitment from international donors and agencies.

 It is expected that progress in the establishment of a functional transitional government structure will be
 followed by a substantial increase in the funding availed by the international community committed to the
 reconstruction of Somalia. The process (Joint Needs Assessments, Development Plans, donor
 conferences) have been laid out in preparation for this phase. Once finalised and if successful, the
 recovery of the health sector is expected to receive a substantial amount of funding for the next 10 years.
 Given the recent escalation of violence, the possibility exists that support for the recovery period will be
 postponed. In this scenario, the present level of funding in the health sector is anticipated to continue
 focusing on life saving interventions and on creating the necessary conditions for future recovery.

 This application will help to strengthen coordination and the scaling up of interventions that have proven
 effective. In time, and with a conducive environment, it is expected that a fully fledged, evidence-based
 malaria control program will be possible. The Malaria Strategy, which outlines a systematic and holistic
 approach to scaling up, provides a common framework for continued resource mobilisation. This will assist
 in streamlining the additional funding into unfunded elements, rather than duplicating activities or
 substituting resources. Focal points from Somalia have also helped to identify a range of strategies to
 ensure greater financial and in-kind commitment from local authorities, local communities and the private
 sector. Cost-sharing schemes have been established across the health sector, some with demonstrated
 resilience and local acceptability.


4.6 Component strategy

 4.6.1 Goals, objectives and service delivery areas
       Provide a clear description of the program’s goal(s), objectives and service delivery areas (provide
       quantitative information, where possible).

 The overall goal of this project is to reduce the malaria burden in Somalia by 50 percent. (As per the
 “Malaria Strategic Plan 2005-2010”).

 The proposal has three main objectives that contribute to the overall goal:
 1. To increase provision of malaria diagnosis and treatment to 90% of (public) health facilities
 SDA1: Treatment (prompt, effective anti malaria treatment). ACTs and RDTs will be supplied in order to
 achieve the target of 90% of public health facilities, including health posts, providing a correct case
 management, as per the national protocol. Health workers will be trained and facilities with a lab will
 receive the necessary supplies.

 2. To increase coverage of prevention methods in targeted malarious areas for pregnant women
 and children under five to 80%
 SDA1: LLIN: By year 5, 80% of all under fives and pregnant women in targeted malarious areas will be
 sleeping under an LLIN. In total 1,200.000 LLINs will be procured to achieve this target.
 SDA2: Prevention for pregnant mothers: IPT will be further up scaled to in order to have 80% of pregnant
 women who are attending 80 MCHs in areas classified as high transmission, covered.
 SDA3: IEC/BCC: The IEC/BBC component will focus both on the health workers using job-aids and key



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4 Component Section Malaria
 messages at the health centre, as on the community, passing messages on prevention and treatment
 through community mobilisers, radio messages, and specific activities such as World Malaria Day.

 3: To strengthen ministries of health’s capacity in close collaboration with national and
 international partners.
 SDA 1: Quality assurance: Four referral labs will be established for quality control of malaria microscopy,
 supervision of peripheral labs and (refresher) training of lab technologists.
 SDA 2: Institutional & HR capacity building: Technical assistance and operational support will be given to
 the ministries of health in order to achieve regular supervision.
 SDA 3: Information systems and Operational Research: Operational research will be done in three
 sentinel districts and aims to answer a number of specified research questions linked with RBM indicators
 for programme evaluation. The HIS component aims at establishing/strengthening the overall HIS and
 developing a common M&E framework for the whole health system.
 SDA 4: Prediction and containment of epidemics: An emergency preparedness plan will be established
 and implemented in the different zones. This will include training of a pool of people on epidemic detection
 and response (including vector control with IRS), pre-positioning of a contingency stock and monitoring of
 insecticide resistance.



 4.6.2 Link with overall national context
       Describe how these goals and objectives are linked to the key problems and gaps arising from the
       description of the national context in section 4.4.4 Demonstrate clearly how the proposed goals fit
       within the overall (national) strategy and how the proposed objectives and service delivery areas
       relate to the goals and to each other.

 The proposal aims at improving the health status of the Somalia population by addressing the key
 problems and gaps identified in the health sector: Low access to quality diagnostic, curative and
 preventive services, under-skilled health workers, insufficient financial resources allocated to health,
 unregulated and under-resourced quality drug supply system and an inadequate HIS.
 The overall goal of the project is to reduce morbidity and mortality in Somalia due to malaria. This will be
 achieved through the following objectives: prevision of prompt and effective malaria treatment, increase
 coverage of preventive measures and strengthening of institutional capacity. Objective 1 addresses the
 problem of low access and inadequate supplies by increasing coverage of quality case management from
 25% (currently only hospitals and MCHs) to 90% of all public health facilities. Objective 2 focuses on
 prevention, while objective 3 is building capacity of the local health authorities thus enabling them to
 address some of the above mentioned key problems. These objectives are closely linked and together
 contribute to reduced malaria morbidity and mortality through improved disease management like
 increased access to preventive measures and treatment, a focus on vulnerable groups and better
 epidemic preparedness and the monitoring of quality control and emphasis on supervision activities. All
 are framed within a widely endorsed strategy for malaria control at the national level.
 The Malaria Strategy 2005- 2010 was developed in close collaboration with all relevant stakeholders
 through a consultative process (see annex 4:5) with funding from Global Fund Round 2. Four principal
 strategies were identified: disease management; vector control; prevention and control of malaria in
 pregnancy; and epidemics prevention and control. These four areas are reflected in Objectives 1 and 2
 this proposal. Supporting strategies identified are: human resource development; IEC; monitoring and
 evaluation; and operational research. Again, all of these areas are reflected in the service delivery areas of
 this proposal. This proposal can therefore be considered as part of the National Malaria strategy and will
 contribute to achieving coordinated results.
 Behavioural change communication (BCC), insecticide-treated nets (LLIN), malaria in pregnancy and
 prediction and containment of epidemics all address prevention of malaria and advocate for the proper use
 of effective drugs and tools addressing issues as self-prescription and misconceptions. Prompt and
 effective anti-malarial treatment ensures that patients are given effective and appropriate care and
 treatment hence reducing the avoidable mortality whilst procurement and supply and health infrastructure
 development ensures that the appropriate drugs and diagnostic capacity are in place to be used by
 properly trained staff. Good case detection ensures that malaria cases are identified and that other
 diseases often mistaken for malaria are identified and properly addressed. Reinforcing human and
 institutional capacity (referral labs, training of health staff) strengthens the health authorities in their role.



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 Information system strengthening and operational research development are crucial for understanding the
 real dimensions and patterns of malaria, and tailoring the strategy accordingly.. Finally through the support
 given in the prediction and containment of epidemics, local authorities will be able to respond to local
 malaria epidemics.


 4.6.3 Activities
       Provide a clear and detailed description of the activities that will be implemented within each service
       delivery area for each objective. Please include all the activities proposed, how these will be
       implemented, and by whom.

 Multiple sub-recipients will carry-out key activities and will be selected through a transparent process
 under the oversight of the HSC similar to the one established and successfully implemented for the
 HIV/AIDS grant in 2004 (see annex 3:II:HIV).
 Objective 1.
 SDA 1: Prompt, effective malaria treatment
 Treatment
 Currently 194 facilities (170 MCHs and 24 hospitals) are using ACT (AS + SP), introduced under round 2.
 The provision of ACTs through hospitals and MCHs will be maintained beyond the final year of the Round
 2 grant, through this proposal. In addition to ACT treatment being available at the Hospital and MCH level,
 access to ACTs will be expanded to the community-level through community health workers at 470 health
 posts. This increase in coverage will be done through a gradual scaling up over four years building on the
 experiences of pilot introduction through an NGO partner in 2007 using Round 2 resources. Expansion will
 be gradual in order to ensure correct implementation, including CHW training in malaria case management
 and supportive supervision. For severe malaria cases, rectal Artesunate is being procured for pre-referral
 at the MCH-level. IV quinine is used at the hospital. Artesunate IM is pre-positioned at the zonal level for
 treatment of severe cases during epidemics.

 Training
 Numerous organisations with differing capacities are currently supporting health posts. Some partners
 such as health authorities and INGOs have the in-house capacity to carry-out training of health post
 workers whereas other organisations will require external facilitators. A standard training package will be
 developed. Training will commence in Year 1 with the aim of training approximately 125 health post staff
 (CHWs) a year over four years. All MCH (170) and hospital facilities (24) will receive refresher training in
 malaria case management in conjunction with any necessary change in treatment protocols as a result of
 increasing levels of parasite resistance to the current combination. A standard training package will be
 used and TOT training organised. Key partners including the health authorities and NGOs will ensure the
 refresher training for health staff (totalling 580). It is planned for this to take place as from Year 2.

 Supervision
 Regular monitoring and evaluation will be carried out to ensure proper case management. Monitoring will
 be done at the zonal level by the malaria zonal teams based on the framework established by the TB
 control program funded by the GFATM. The monitoring focuses on the MCH/Hospital level and with
 limited supervision of the HPs. This activity is included under objective 3, SDA 2 which provides more
 details. For CSZ, where malaria is more prevalent and access more difficult, NGO partners will
 complement this supportive supervision by focusing on the HPs that are supported by their organizations.
 The aims for the NGOs to supervise half of their HP a year.

 Resistance monitoring
 The efficacy of the current first line treatment combination, Artesunate plus Sulfadoxine-Pyrimethamine,
 will be monitored to ensure that it remains an effective treatment. As described in 4.4.2., sensitivity testing
 is taking place in 2006 and 2007 through Round 2 support in sentinel sites with WHO oversight. Drug
 resistance monitoring will be continued under Round 6 with a study design based on the recent WHO
 recommendations to take place in the rainy seasons of Year 1 (2008) and Year 3 (2009). A consultant will
 manage three study sites located in the Central-South with a team of 6 for enrolment, analysis and active
 follow-up.

 Diagnosis
 The diagnosis policy has been developed taking into account the largely unstable nature of malaria,



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 mostly P.faciparum. In areas of low, unstable transmission, clinical diagnosis is confirmed either by
 microscopy or an RDT. In high transmission areas, clinical diagnosis for children under the age of five is
 used, in accordance with WHO recommendations for IMCI.

 Microscopy refresher training
 Microscopists trained under Round 2 will receive refresher training in order to maintain and improve
 quality. Training will be carried out at the zonal level and each microscopist will receive a two-week
 refresher training every two years as from Year 2 (In year 1, this is supported by Round 2). This is
 additional to the on-the-job training that will take place during supervision visits. Monitoring visits will be
 carried out by staff from the reference laboratory as part of Quality Assurance. Slides will regularly be
 submitted for quality control and where necessary, microscopy staff will receive on-the-job training at the
 referral centre (see Objective 3 SDA 1).

 Laboratory support
 Reagents and other consumables (see annex 5.3) used for the diagnosis of malaria will be procured and
 provided to the 60 laboratories.

 Procurement & distribution of drugs and RDTs
 Expert opinion suggests that treatment failure in Somalia with SP may soon be over the WHO
 recommended threshold and thus a change to a combination with Lumefantrin should be anticipated. In
 this proposal, ART+LUM are budgeted for the treatment of uncomplicated malaria as from Year 2 in a co-
 blister formulation with Year 1 drugs covered by the Round 2 proposal. Effective treatment is therefore
 secured for the hospital and MCH level with gradual expansion to community health workers at health post
 level. For severe malaria, rectal Artesunate is procured for pre-referral at the MCH level. IV quinine is
 used at the hospital as a second line drug for severe malaria and treatment failure. Artesunate IM will be
 procured to be pre-positioned at the zonal level for the treatment of severe malaria during epidemics.

 RDTs for detecting P. falciparum (estimated at more than 95% of cases in Somalia) will be procured and
 distributed for MCHs and Health Posts. In those MCHs with microscopy services, RDTs will no longer be
 used once good quality of microscopy has been confirmed through quality assurance. It is thus anticipated
 that the number of RDTs required will drop each year from Year 3 with 20 fewer MCHs a year requiring
 RDTs. However, the gradual increase in the number of health posts supported with RDTs and ACT, will
 mean that each year the number of RDTs needed still increases (see Drugs and RDT planning in the
 detailed budget spreadsheet).

 In the Somali environment where there is unstable malaria, there is a challenge in understanding the true
 burden of the disease. With the introduction of RDTs (and consumption follow-up tools) in the second
 quarter of 2006, it is anticipated that a clearer picture will emerge. This will assist with supply-planning and
 needs forecasting which proves to be challenging at present. The PR will consult the Malaria Working
 Group on issues related to procurement and on the development of procurement plans. The PR’s
 Procurement Centre in Copenhagen will procure drugs and RDTs based on standard tendering
 procedures and quality control. Only drugs and RDTs that are WHO-approved will be procured.
 Distribution channels for this material will be the same as those utilized for GFTAM Round 2 and will build
 synergies with the GFATM HIV/AIDS Program. Commodities are transported to regional hubs in Somalia,
 including warehousing where appropriate in Somalia, and from there to health facilities. Health facilities
 receiving these supplies will report on consumption and their needs

 Objective 2.
 SDA 1: LLINs
 Through Round 2, more than 900,000 LLINs are being procured for Somalia. To date, over 300,000 have
 been distributed through 120 distribution points that are integrated with ANC activities in health facilities,
 MCH facilities and nutritional interventions. A further 230,000 nets are expected to arrive in Somalia
 before the end of 2006. The balance for the programme is to arrive and be distributed in 2007 (as part of
 Phase II that was signed July 25 2006). Currently, the results of coverage indicators regarding LLIN
 distribution via Round 2 are not available. A MICS survey that was to provide these indicators was halted
 in June due to heavy fighting in the country and will recommence as soon as it is safe to do so.

 The LLIN strategy has been to first consolidate health facility delivery. Secondly, it uses outreach
 strategies through other fixed-site activities such as nutrition and emergency distributions. As a third step
 partner organisations are currently piloting distribution through EPI outreach and localised mass



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 community distribution in order to increasing coverage particularly in those areas most malarious and
 difficult to reach. Through Round 6, these strategies will be continued with a strong focus on integration
 particularly as reaching some parts of the country are a challenge.

 Nets are distributed mostly free of charge to the end user or, in some health facilities where a cost-
 recovery system is in place, at a highly subsidised rate ($0.50). Health facilities that charge for the LLINs
 must have a waiver system in place for those that do not have the ability to pay. Proceeds from the sale of
 nets are channelled back into the health facility. In community outreach programmes, nets are always
 provided for free.

 Procurement of LLINs
 Based on findings in the 2005 KAPB survey (annex 4: 12), conical LLINs are considered the most suitable
 for Somali households. WHOPES recommended LLINs will be procured by the PR in consultation with the
 Malaria Working Group regarding procurement plans. The PR’s Procurement Centre in Copenhagen will
 be responsible for procurement including tendering and quality control. Supply chain mechanisms will be
 consistent with current processes, and include warehousing where appropriate in Somalia.
 Over the course of the programme, 1,120,000 nets will be procured in order to reach a coverage of 80% of
 pregnant women and children under five in malarious areas. This takes into account the need to replace
 the LLINs distributed under Round 2.

 Distribution and monitoring
 Security is an issue regarding LLIN distribution particularly as the malarious areas are largely located in
 areas that experience insecurity and conflict. Distributions in these areas rely mainly on partners including
 INGOs, NGOs and CBOs. The PR ensures that LLINs are distributed to the partners’ locations within
 Somalia, mainly via road. The partners receive support to distribute the nets to the beneficiaries (transport,
 per diems etc.) and carry-out household monitoring visits. The PR monitors the activity via its zonal
 coordinators. Coverage will be monitored via a coverage survey in Year 3 (please see Objective 3 SDA 2)
 and through the next MICS survey organized and funded by UNICEF to be held in Year 5.

 SDA 2: Malaria in pregnancy
 Approximately 96,000 women attend ANC at MCHs where IPT guidelines apply and the objective by the
 end of the programme is for 80% to receive preventive treatment. IPT guidelines apply to areas classified
 as high transmission and currently, 80 MCHs fall within this classification. The classification is expected to
 be modified as the knowledge of disease pattern increases culminating in a strategy review in Year 2.

 Hemoglobin rapid testing machines (Hemocues) have been supported with funds from Round 2 and
 support in terms of consumables is required. Training on malaria in pregnancy is included as part of case
 management training for all levels of health care workers with particular focus on IPT for MCH workers.

 Procurement of drugs and material
 SP will be procured for use as IPT as well as consumables for Hemocues. The PR will consult the Malaria
 Working Group on issues related to procurement and on the development of procurement plans. The PR’s
 Procurement Centre in Copenhagen will procure drugs based on standard tendering procedures and
 quality control. Only drugs and material that are WHO-approved will be procured.

 Distribution channels for this material will be the same as those utilized for GFTAM Round 2 and will build
 synergies with the GFATM HIV/AIDS Programme. Commodities are transported to regional hubs in
 Somalia, including warehousing where appropriate in Somalia, and from there to health facilities. Health
 facilities receiving these supplies will report on consumption and their needs.

 SDA 3: IEC & Behavioural Change Communication
 Under GFATM Rd 2 a Malaria Communication Strategy (2006 – 2010) was developed. It highlights the
 strategies to be used in supporting communication on the interventions described in the Somali Malaria
 Strategy. Round 6 will continue to support the production of materials for health facility level, whilst
 increasingly focussing on the introduction of community based malaria communication and delivery of key
 malaria messages at household level. This proposal aims to utilise existing community structures to
 increase ownership of malaria control activities within the Primary Health Care (PHC) programs as
 implemented by partners in the highly malarious area of South Central zone.

 Increase community awareness on malaria prevention:


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 The managers of primary health care (NGO PHC Coordinators) programs will be trained on IEC and BCC.
 This will enable the different agencies to supervise and guide the community mobilisers and community
 health workers at the health post level on malaria communication.

 At community level multiple communication techniques, including interpersonal and participatory
 communication supported by mass communication will be used. Community mobilisers will be trained by
 NGOs in malaria communication techniques and will be provided with communication materials to
 stimulate community dialogue around malaria. Participatory materials and techniques for malaria used
 successfully in other countries are currently being adapted for the Somalia context. Community dialogues
 will be organized in highly endemic areas (by the PHC and the CM) on malaria for 1 day in 50 locations
 per year, in close collaboration with religious leaders and traditional healers. Upon training they will be
 issued with fact sheets on malaria so that they can disseminate the same at focus group discussions,
 mosques, women’s group meetings, schools and community meetings. IEC and BCC strategies will focus
 on improving treatment seeking behaviour, recognition of signs and symptoms, new malaria treatment,
 where to access it and follow up at household level. Fifteen community mobilisers will be recruited in
 highly malarious endemic areas each responsible for 20 communities (300 communities in total). They will
 be trained for 2 days on community mobilization and advocacy in Q4 of Y1. Each community mobiliser will
 work with 20 community health workers. In year 2 and 3, 150 CHWs will be trained for 2 days (300 in
 total).
 For CHWs, trainings on IEC and BCC will be on the improvement of disease management both at health
 facility and community level. Under Rd 6, ACT will gradually be rolled out to 470 health posts. BCC will
 work towards improving the skills of health workers in counselling patients.

 Media placement, IEC development & production
 Malaria communication through mass media using Regional FM stations, which are a key source of
 information among the Somali community (as per the KAP study), will continue to disseminate key malaria
 messages in the form of spots or programs. The programs will be aired on 10 radio stations with
 approximately two spots leading-up to and during the rainy season. The messages will be technically
 developed through the malaria working group. Radio stations will be sub-contracted for airing the
 messages.

 Development of health workers job aids on malaria treatment for 300 health facilities
 Simple quick reference health worker bench aids will be developed in Y1. This includes drug dosage
 charts, treatment algorithms, RDT instruction sheets and a flip chart for conducting communication
 sessions at health facility level.

 High level regional advocacy on the World Malaria Day
 The celebration of World Malaria Day (WMD) in 2006 proved to be very successful with high level
 involvement from both political and religious leaders, and the communities where the celebrations took
 place. We therefore planned to celebrate WMD in 10 different locations every year on the 25th of April.
 Multiple methods will be used including IEC material (posters, booklets), radio messages, community
 resource persons and leaders.

 Malaria Field days
 Community mobilisers will organize malaria days at community level, establishing linkages between
 communities and health workers and NGOs responsible for service delivery. Each year, creative
 performers will assist the community mobilisers in 5 locations using drama, poetry and role plays to pass
 messages to the audience.

 Objective 3.

 Capacity building of the local health authorities and health workers is a key component of this proposal.
 Efforts will be made to set up sustainable structures and mechanisms for quality assurance of laboratory
 services, supervision of health facilities, HIS and epidemic preparedness and response.

 SDA 1: Quality assurance
 To establish 4 referral laboratories:
 In selected hospitals, four referral laboratories (one in each area: Somaliland, Puntland, Central and
 South) will be set-up. The selected facilities will be renovated and the labs equipped in year 1. The labs
 will have 3 main tasks: Quality control of malaria microscopy, on-the-spot supervisions of the peripheral



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 labs, training of new lab technologists and refresher trainings of previously trained staff. The necessary
 human resources will be recruited and trained. Other GFATM funded programs in Somalia will be able to
 use these labs for quality control in the future. No materials and equipment for TB and/or HIV/AIDS quality
 control has been foreseen in this proposal since resources are available and will be used by the other
 GFATM funded programs.
 Laboratory diagnostic capacity has been expanded to 60 facilities with trained microscopists located in
 MCHs through Round 2. Microscopy is currently supported by RDTs, to allow for the cross checking of
 results. Once good standards are achieved, RDTs will be removed and microscopy only will be relied upon
 for confirmation. This investment will ensure the continuity of laboratories as a cost-effective diagnostic
 service for the future. For facilities that do not have a laboratory, including some MCHs and Health Posts,
 RDTs will continue to be relied upon for the confirmation of malaria (P. falciparum) as described above. In
 addition, the confirmation of malaria cases will provide important data on disease burden. This will be used
 in conjunction with other evidence-based information in revising the Malaria Strategy (2005-2010) in order
 to strengthen disease control.

 Training and human resource development:
 Each of the four referral labs will have 3 lab technicians. One will be the laboratory focal point who is also
 part of the zonal malaria team (see below). The lab technologist will receive incentives and training. In
 2007, WHO will send (and pay for) 4 lab technologists (1 from each zone) to an “Advanced Malaria
 Microscopy Training” in Oman. It is foreseen to send another 4 technologists in year 1 through the current
 proposal.

 Supervision and quality control of peripheral laboratories:
 On-the-spot supportive supervision of peripheral lab activities will be conducted in collaboration with the
 malaria focal points of the health authorities on a quarterly basis. Each laboratory technician will spend 15
 days every quarter on on-the-spot supervision. Standardized tools for lab supervision established under
 round 2 will be used. These tools evaluate the presence of equipment and supplies, and the functioning of
 the lab. A random sample of slides is taken to the referral labs for quality control and feedback will be
 provided. A support budget will enable the lab focal points to visit peripheral labs for supervision.

 Technical assistance:
 For a period of 2 years, technical assistance will be provided by three senior (international) lab
 technologists. They will train (mainly on malaria but also on TB and HIV/AIDS related quality control),
 supervise and assist their local counterparts. After this period this post will be slowly phased-out by
 keeping one senior lab technologist for the whole country (roaming) for one more year. It is expected that
 after three years of intensive training and on-the-job supervision, the international position will no longer
 be needed. The four national lab technicians will then be able to run these labs independently, with overall
 supervision of the malaria technical coordinator and/or the WHO RBM malaria coordinator for Somalia.
 Annual external evaluations will be carried out by a consultant. Each year an annual workshop will be
 organized to evaluate the overall quality assurance program.

 SDA 2: Institutional & HR capacity building
 Human resource development:
 Emerging evidence of the high level of over-diagnosis of malaria in Somalia and the introduction of new
 diagnostic and treatment protocols call for a solid supportive supervision not only to ensure the quality of
 the interventions but also to provide continuous on the job training to field staff. Current supervision of
 health facilities and quality control of laboratories is weak and irregular. Strong teams will be established in
 each of the 3 ministries to supervise the activities at health facility level. The MOH malaria focal point will
 receive incentives and will be trained on “Planning and Management of Malaria”. Under round 2, WHO will
 fund all focal points to participate in this training. Three additional people of the MOH will attend the same
 training in year 3. The establishment of supervision teams also aims to build the capacity of the local
 authorities so as to increase their ownership and to address the future sustainability of the program by
 strengthening the health system

 Infrastructural development:
 The malaria zonal teams will be provided with office equipment and the necessary funds to cover running
 costs.

 Supervision of health facilities:
 A support budget will enable the malaria zonal teams to visit peripheral health facilities for supervision.



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 The team will spend 30 days of every quarter on supervision at the health facilities. Every quarter
 minimum 15 health facilities will be supervised in each zone, prioritizing the hospitals and MCHs but
 gradually increasing supervision visits to health posts over time. In Somaliland and Puntland, the MOH
 focal points will have an assistant who will focus on HP supervision. However, most of the HPs are
 situated in the South/Central, where NGOs will be responsible to do regular visits, as currently the MOH
 does not have the capacity to take this on alone. Standard supervision tools will be established to facilitate
 supervision visits and streamline the reporting.

 Technical assistance:
 It is planned to have three international staff recruited by a SR to act as counterparts to the MOH focal
 points. Their role is to monitor and evaluate programme activities and to build the capacity of the local
 counterparts. They will play a leading role in RBM also at the quarterly health coordination meetings being
 held at the zonal level organised by local health authorities, and to achieve practical synergies with other
 programmes and sectors and guide and facilitate collaboration between relevant partners involved in
 malaria control.

 In addition, the fragmentation of the current health system (with 3 ministries of health) justifies a strong
 country coordination component. The WHO RBM coordinator will be responsible to provide oversight of
 the malaria activities in Somalia. He will be assisted by the malaria technical coordinator who is
 responsible for the supervision of the zonal malaria focal points (international), operational research and
 malaria technical issues. The post of malaria technical coordinator is further justified as being essential by
 the complexity of the operational environment, the need to supervise pilot projects in different
 epidemiological strata, and the need for additional supervision and monitoring of INGO partners
 (impossible for the RBM coordinator alone). Further issues justifying this post are: easier access to field
 projects (not always possible for UN staff), enhanced interaction with NGO partners at Nairobi level
 (seconded to SACB/HSC) and additional technical expertise. Moreover, the strong malaria M&E
 component with international staff on the field assisting the local authorities (similar to the TB M&E set-up)
 who will need overall supervision and support at the central level.

 As results of drug sensitivity testing, coverage surveys and the above mentioned operational research
 become available, a review of the current strategy will need to be done by year 3 of the proposal. A
 workshop will therefore be held to present all results on malaria studies and M & E findings, to discuss the
 strategy changes needed and to build consensus on decisions to be taken.

 Every quarter, a workshop will be organized at the zonal level to evaluate the implementation of the
 malaria activities according to the work plan. These meetings will bring all key stake holders together to
 assure effective coordination (RBM coordinator, malaria zonal focal points of the MOH, malaria zonal focal
 points, vector control focal points, lab focal points, focal points of the PR and the malaria technical
 coordinator).

 SDA 3: Information Systems and Operational Research
 Revising the existing HIS and developing a national M&E Framework:
 The development of the national M&E framework will be a participatory, consensus building process
 involving different stakeholders at all levels of the health system. The process will take into account the
 existing data collection systems and the information needs at the different levels, aiming at harmonizing
 and integrating them in one comprehensive M&E framework used by all stakeholders. In order to build
 consensus and ensure the required consistency, the existing HISWG will guide the process seeking the
 amplest participation. The working group will be open to all interested parties and it will coordinate all the
 internal and external contributions. Workshops for presenting, discussing and endorsing the framework will
 be conducted at different levels.

 The definition of standard HIS tools and procedures will be a crucial step for developing a common M&E
 framework. The following issues will be addressed: a) identification of minimum data sets for each level of
 the health system; b) selection of appropriate indicators, definition of standards, identification of data
 sources and definition of (bi-directional) flow of information; c) design of tools and definition of procedures
 for data processing; d) implementation of strategies for improving data utilization.

 It is foreseen that the system development and testing will take two years. In year three, design and
 development of training programs, guidelines and implementation manuals; formulation of information
 policy and regulations; identification and costing of the necessary resources for HIS implementation will



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 take place. The funds requested to the GF will be used to cover the process of HIS development. The
 funds required to implement the system on national scale will be sought from other sources.

 Establish pilot districts for developing and testing the revised HIS
 In light of the limited resources available and the Somali context (difficult access and the limited security in
 some areas of the country), it is not feasible to implement a HIS on national scale at once. It is therefore
 suggested to identify a limited number of districts where developing and testing the revised HIS. Once the
 HIS content and procedures are finalized, the system can be gradually expanded to the rest of the
 country. This approach will also allow addressing the following issues:
     The possibility of integrating at local level the data collected by the different existing HISs, and linking
     data collected at community level with those generated at health facilities, thus providing a
     comprehensive picture of the local health situation and the provision of comprehensive indicators for
     M&E (second generation surveillance).
     The need of verifying/ validating the findings derived by eventual wide-scale, national studies. One
     example is the recent tuberculin survey, which yielded very different estimates for TB ARI (between
     0.8 and 3.9 % p.a.) in different areas of the country and raised doubts on whether the selected sample
     was representative.
 One pilot district in each of the three zones will be identified according to the following criteria: reasonable
 security and access; partners on ground; estimated population; functioning health facilities providing HTM
 services. Provisionally, three areas have been selected: Gebiley/Hargeisa (Somaliland); Garoowe
 (Puntland); and Merka/Qoryooley (South), which represent approximately 12% of the total population and
 14% of the health facilities in the country. In each district one Information Officer (see below) will be
 deployed.

 Establish a HIS management structure:
 An appropriate HIS management structure will be created/strengthened at the different levels of the health
 system. The set-up of such a structure aims at improving the existing system(s) while gradually developing
 a more rational one and avoiding a break down of the present information flow. No formal training courses
 are foreseen in this phase. HIS staff recruited/ seconded will acquire the necessary skills through on-going
 assistance and supervision of the expatriate staff. The HIS management structure will be established at
 central, zonal and district levels.

 Central level: An expatriate HIS Country Coordinator will be recruited for the entire duration of the project,
 S/he will have the overall responsibility for implementing the activities foreseen under this component:
 coordinate the revision of the HIS and develop the M&E Framework; provide assistance and supervise
 HIS Teams at Zonal and District levels; organize and conduct workshops; ensure the operationality of the
 central dissemination unit; coordinate and integrate the various M&E and data collection systems (HTM
 and other vertical programs); coordinate the planned research activities. Funds are requested to cover the
 salary and transport costs.

 A Central Dissemination Unit, based in Nairobi, functioning as a national clearinghouse for dissemination
 of data, will be established. The Unit will be responsible for compiling the health data received from the
 Zonal HIS Units, control programs and eventual study results, and disseminating them as widely and
 transparently as possible to all stakeholders. The Unit will make use of the existing data management
 resources and structures of partner organizations (FSAU and UNICEF). Funds are requested for
 publishing the information received from different sources on a web site (hosted on an existing web site or
 developing a new one) and producing regular dissemination HIS reports.

 Zonal level: In each of the three zones a Zonal HIS unit will be established (or strengthened) within the
 respective MOHs. While in Central/South Somalia the unit should be created from scratch, in Puntland
 and Somaliland the existing units require strengthening in terms of human and financial resources. In both
 cases, the main objective is building capacity of the local health authorities in collecting analysing,
 interpreting and using information for planning and M&E purposes. The Units will receive the data from the
 health facilities, districts (where established) and vertical programs and will be responsible for their
 compilation, analysis and dissemination (workshops and annual reports). Compiled data and indicators will
 be forwarded to the Central Unit for wider dissemination. Two MOH staff in each zone will be assigned to
 the Unit. One expatriate expert in each Unit will provide technical assistance for the first three years. It is
 expected that by year four the local staff will have acquired sufficient skills to proceed autonomously. The
 local health authorities will make available adequate space within their premises. Funds are requested for


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 covering the salaries of local and expatriate staff, rehabilitating and furnishing of the Units, providing
 adequate equipment and covering the related running costs.

 District level: One person seconded by the respective MOH, will be appointed as District Information
 Officer (DIO) for each pilot district. They will assist the health care workers in collecting and reporting data,
 be responsible for integrating the different reports originated in the area, coordinating the various program-
 specific data collection activities (HTM and other vertical programs), organizing regular dissemination
 meetings with local authorities and communities, provide feedback to HWs, forwarding the compiled
 reports and agreed indicators to Zonal HIS Units. They will receive regular supportive supervision from the
 HIS Coordinator and the respective Zonal HIS Units. Resources will be provided for salaries,
 transportation, organization of meetings and running costs. Achievements and performances of the DIOs
 will be evaluated at the end of the second year and, if positive, gradually expanded to other districts.

 Operational research:
 Considering the constraints and limitations of nation-wide surveys, it is proposed to conduct a series of
 linked operational research to tackle the major information gaps. The operational research agenda will be
 developed around selected sites (which will coincide with the above mentioned HIS pilot districts in order
 to create synergies) representing the diverse malaria epidemiology, geo-political framework and
 population settlement patterns that characterize Somalia. Two preliminary activities will be conducted in
 2006-2007 (year 3 of GFATM round 2): 1) Developing a high resolution geographic information system
 (GIS) platform of population, health services and access routes; 2) Assemble retrospective clinic data on
 patient burdens and malaria specific indicators.

 The proposed operational research component will build on the above activities and will aim at answering
 two further research questions that will complement the overall evaluation of the national malaria program
 and will provide useful information for the other GFATM funded programs: a) “What are the population
 characteristics in terms of physical, social and economic accessibility to clinical services determining the
 provision of adequate diagnosis and therapy?” and b) “How are patients of all ages who reach formal
 clinical service providers assessed, diagnosed, treated and counseled?”. The research methodology (and
 detailed budget breakdown) is described in annexes 4:17 & 5:6. In year 1 (baseline), a first evaluation will
 be conducted in the pilot districts, to be repeated in 2011. This will allow monitoring trends over time and
 assessing the impact of the activities proposed for prevention and treatment for malaria, TB and
 HIV/AIDS. The HIS country coordinator, in collaboration with the malaria technical coordinator, will be
 responsible to keep an overall overview on operational research related issues.

 A MICS is organized for 2006 (but put on hold at time of writing due to insecurity) and will be repeated in
 2010. The results will provide key indicators on malaria for M&E. However, there is still a need to do a
 national malaria program coverage survey in order to be able to evaluate (half-way through the project)
 the different targets set-out under this proposal. A budget is foreseen to conduct such a survey in Year 2.

 The impact indicator used is incidence of clinical malaria cases as suggested in the GF M&E toolkit. For
 Somalia, routine data will be insufficient to calculate this indicator and it will be necessary to use
 epidemiological models. A consultant will be hired every year to do this exercise.

 SDA 4: Prediction and containment of epidemics:
 Develop an epidemic preparedness and response plan:
 In order to establish a comprehensive malaria preparedness and response program using the current
 health services it is essential to have a better understanding of the spatial-temporal characteristics of
 malaria case-presentation to health services to be used to signal localized outbreaks (early detection).

 The retrospective analysis conducted in round 2 will be used to map transmission events around health
 facilities. The results will form the basis for establishing an evidence-based malaria early detection system
 using the formal health system. This is related to the operational research that will be conducted on
 access to health care and it will provide evidence on the efficiency of the formal health system in detecting
 outbreaks.

 The “prediction” component will be addressed by evaluating whether there are local climatic and
 ecological features of malaria transmission that can predict “hot spots” to be used as part of a malaria
 early warning or prediction system. Preliminary investigations in Somalia between synoptic NDVI and
 parasite rate surveys have been non conclusive and there is a need to investigate the theoretical and



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 logistical potential for early detection of the above mentioned transmission clusters.

 This question should be answered (methodology see annex 4:17) before a complex national early warning
 system is set-up. If proven useful, it will be important to seek linkages with existing climatological
 surveillance done by FSAU/FEWS in Somalia on food security and nutrition. In addition, the health
 authorities focal points will need to be trained on how to obtain and interpret data produced by the malaria
 early warning system to be used for policy decisions.

 Building on and using the recommendations of the results of the above mentioned consultancies, and the
 consultancy done under round 2 GFATM funding, an emergency preparedness and response plan will be
 developed. A workshop will be done to finalize the preparedness plan and build consensus.

 Procurement and distribution of contingency stock
 Drugs and equipment for vector control will be purchased and pre-positioned in each zone. Surveillance
 and IRS material and equipment will be procured through globally accepted tender and procurement
 protocols.

 Training on epidemic detection and response:
 Once the epidemic preparedness and response plan is established and approved, a training of trainers will
 be done in each zone. These trainers will then train health workers on epidemic preparedness and
 response.

 Operational cost of epidemic response:
 A budget is foreseen in order to enable a response team to quickly react in case of an epidemic alert.
 Apart from transport and per diems this also includes a contingency budget to start an epidemic response
 while other sources of funding are explored.

 Insecticide resistance monitoring:
 IRS is an important component of epidemic response and as such, resistance to the insecticides used
 needs to be closely monitored. Therefore, insecticide resistance will be tested on a yearly basis. The
 vector control focal points will take mosquito samples and, using the WHO provided test kits, test for
 resistance to the insecticides used in LLINs and for IRS.


 4.6.4 Performance of and linkages to current Global Fund grant(s)

        a) Provide an update of the current status of previous Global Fund grants for this disease
           component, in the table below.
                                                                                             Table 4.6.4. Current Global Fund grants

                                          Grant number                   Grant amount USD                Amount spent (USD)

            GF Grant 1

                                                                                                               8,712,689 (98%of
            GF Grant 2                 SOM-202-G01-M-00                            12,886,415*
                                                                                                                disbursed funds)

            GF Grant 3

            GF Grant 4
 * Phase II grant agreement was signed July 25, 2006 and funds not yet disbursed at time of this submission.

        b) Please identify for each current grant the key implementation challenges and how they have
           been resolved.

 One of the most important implementation challenges for the Malaria Grant relates to the changing Somali
 context which sees fluidity in international actors or changes to their operational priorities. Under GFATM
 R2, sub-recipients were selected at the time of proposal-writing, and by the time of grant implementation,
 not all were available or appropriate as sub-recipients. This delayed program implementation and caused
 other difficulties for proper management. It was thus decided that for Round 4 (HIV/Aids) and subsequent



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    rounds, the process of sub-recipient selection would be launched once the GFATM approves the grant.
    The result has been a SR selection process that has been commended by the GFATM as best practice.
    By initiating the SR selection immediately on notification by the TRP on the success of the proposal, timely
    implementation has been guaranteed, as appropriate SR were on board prior to the grant signing.
    Another challenge has been to work in a context that consists of three zonal authorities where politics
    have hampered or blocked implementation (such as the malariometric survey). The solution has been to
    try to concentrate on the technical issues at hand and to bring together the health authorities in order to
    discuss and agree on over reaching strategies. It represents the first and only platform for discussion
    amongst the three authorities. Regular review meetings are organized where potential problems can be
    identified and thus more easily managed. It is foreseen that this kind of communication will be continued
    via Round 6.
    A particular challenge in the program has been a change in the context from the time of proposal-writing.
    At the time, two of the three health authorities were not in existence and thus support and capacity-
    building was therefore not foreseen. A partial solution was found for Phase II where some resources were
    mobilized as support. Further support is sought through the Round 6 application in order to strengthen
    health authorities’ capacities, systems and infrastructures.
    Developing a malaria control strategy in a context where HIS is weak and where study results have been
    inconclusive has also represented an important challenge. It was agreed by all partners that an interim
    strategy was necessary until further evidence was available. In order to strengthen the knowledge of
    malaria in Somalia, a leading expert has been consulted (Dr. Robert Snow of the KEMRI/Wellcome Trust)
    in order to guide the selection of operational research and data to be collected that will be used to review
    the strategy during Round 6.
    One of the main challenges of the Round 2 grant was the long lead times for LLINs which are particularly
    lengthy for conical nets. The transition from Phase I to Phase II was also problematic as in the PR’s
    system, goods can only be ordered for a signed grant. In order to overcome these problems, LLINs will be
    ordered upon grant signing with the plan to distribute as from Year 2. Nets to be distributed in the first half
    of Year 3 will be budgeted under Year 2 to avoid delays due to the Phase I & II transition.

                                                                                                 Yes
          c) Are there any linkages between the current proposal and any existing            complete d)
             Global Fund grants for the same component? (e.g. same activities,
             same targeted populations and/or the same geographical areas.)                      No
                                                                                             go to 4.6.5.

          d) If yes, clearly list such linkages and describe how this proposal builds on, but is not duplicative of
             the funding provided under current Global Fund grants.

    It is anticipated that there will be an overlap between the Round 2 and Round 6 proposal of three months.
    This is planned to help ensure a smooth transition from one grant to the next and in order to launch the
    implementation of key gap areas.
    When it comes to duplication of funding, activities and posts in the 3-month overlap period will be funded
    by one or the other grant but not both. For example, posts and operational costs covered under Round 2
    will only be taken up by Round 6 in Quarter 2. Also, duplication such as for studies and surveys
    conducted under Round 2 will not be repeated.
    This submission builds on the achievements and key learnings of the initial grant. The targets proposed in
    this submission expand on the targets set under Round 2 such as net coverage and treatment targets.
    Activities carried out such as the introduction of ACTs; the establishment of laboratories; training in case
    management, vector control and diagnosis; and studies and surveys are, rather than being repeated,
    strengthened where needed and expanded where possible through this proposal.
    The gap areas of the current program have been identified and a review of the TRP’s comments provided
    through the TRP Review Forms of the unsuccessful Round 5 submissions for Malaria and HSS7 made.
    The key gaps addressed in this proposal include the lack of a M&E structure, a quality assurance

7
 TRP Review Form – Round 5 for proposals: “Essential Support for the implementation of Somalia’s Malaria
Strategic Plan 2005 – 2010” and “Strengthening a Comprehensive and Integrated Health Information System
(Somalia)”


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4 Component Section Malaria
 mechanism, capacity building of health authorities and reliable health information. Particular attention
 has been made to address weaknesses highlighted by the TRP (in addition to comments related to
 proposal format and information):
     “It is not clear in which areas the activities are to develop and how the resources would be shared by
     different governments” (Malaria Proposal)
     Resources for capacity building and system support will be shared equally by the three ministries,
     while those for service delivery and program implementation will be allocated in proportion to the
     number of delivery points in each area and the malaria transmission pattern.
     “No attention to local authorities and how to mainstream the project into the public sector if the
     transitional government succeeds. There is no exit plan for UNICEF as the proxy Ministry of Health”
     (Malaria Proposal)
     Capacity-building that focuses on local authorities is included in this proposal in order to strengthen
     the public sector. This will provide the foundation for when a transitional government succeeds. Both
     UNICEF and the SACB HSC are committed to working with the authorities and are committed to the
     transitional process. Although the current political situation is not conducive to formulate an exit
     strategy, both the National Malaria Strategy and this proposal have been developed with the active
     participation of the different health authorities. However, at the end of phase 1, the political situation
     will be re-assessed and, if feasible, modalities and timing of an exit strategy will be developed in
     collaboration with the health authorities.
     “Very top-down approach to HIS. HIS appears to be organized around meeting donor and program
     needs rather than local decision-makers and communities; It is unclear how managers at health
     centres and communities would be able to use the data for their own planning and accountability”
     (HSS proposal)
     The HSS component considers the needs of all users of health information with a comprehensive
     M&E framework that takes into account the existing data collection systems and the information
     needs at each level. The bottom-up approach, piloting HIS in a limited number of districts, focuses on
     local needs rather than establishing a software-oriented central system.
     “Heavy administration and technical assistance costs with very little local capacity building.” (HSS
     Proposal) “Exit plan with benchmarks for UNICEF and manager of database would be helpful.” (HSS
     Proposal)
     In this proposal, capacity-building activities including HIS, quality assurance, supportive supervision
     focus on the local authorities. External technical assistance is provided over the first part of the
     program and is phased out once systems and capacities of the local authorities have been built.


 4.6.5 Linkages to other donor funded programs

                                                                                              Yes
                                                                                          complete b)
       a) Are there any linkages between the current proposal and any other
          donor funded programs for the same disease
                                                                                              No
                                                                                          go to 4.6.6.

       b) If yes, clearly list such linkages and describe how this proposal builds on, but is not duplicative of
          the funding provided by other donors, including in respect of health system strengthening
          activities.

 As described under section 4.5.2, few potential donors for malaria programming exist for Somalia in the
 current context outside of the Global Fund.

 In the meantime, in addition to the Global Fund, it is anticipated that UNICEF and WHO will continue to
 support malaria disease control within the framework of the Malaria Strategy (2005-2010) and HIS as
 shown in the financial gap analysis table.

 Other donors support public health facilities upon which the malaria control program rely. These donors
 support primary health care, tertiary care and nutritional interventions but have not committed specifically


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4 Component Section Malaria
 for malaria interventions. Furthermore, a recent EC call for proposal includes a component for
 strengthening the health systems and developing managerial tools for hospitals. The activities, under the
 coordination of the SACB, will create synergies with the health strengthening component of this proposal.

 As mentioned above, the referral labs will also be used by the TB and HIV programs and the
 strengthening of the HIS component will include TB and HIV related health information.


 4.6.6 Activities to strengthen health systems

       a) Describe which health systems strengthening activities are included in the proposal, and how
          they are linked to the disease component.

 The HSS activities included in the proposal aim at establishing/ strengthening the overall HIS and
 gradually developing a comprehensive national M&E Framework (Objective 3, SDA 3 - Information
 System and Operational Research). The purpose is to obtain reliable information for assessing progress
 towards global goals, support planning at national level, directing and harmonizing foreign aid and
 monitoring programs performances at the different levels of the health system. A common M&E framework
 will facilitate coordination between various programs reducing duplications and allowing a more effective
 use of resources. The HSS component will be addressing four major areas: revision of the existing HIS(s)
 and development of an integrated M&E framework; establishment of a HIS management structure;
 establishment of pilot districts; operational research.
 The overall goal is “to reduce the burden of malaria of 50% by 2012”, which will be evaluated through the
 “estimated incidence of clinical malaria cases”. Reliable data on malaria epidemiology, health service
 performances, determinants influencing health care seeking behaviour and use of preventive measures,
 are necessary to monitor and evaluate the project performance towards the set goal. The fragmentation of
 the existing HIS is not able to provide such information and the revision/ strengthening of the system is
 therefore considered necessary.

       b) Explain why the proposed health systems strengthening activities are necessary to improve
          coverage to reduce the impact and spread of the disease and sustain interventions.

 The revision of the existing HISs and the development of an integrated M&E framework for the different
 levels of the health system (national, intermediate and peripheral) coupled with the conduction of focused
 operational research, will allow the linking/ triangulation of data deriving from different sources (surveys,
 routine, surveillance, OR, etc.), with a consequent better understanding of disease patterns, quality of
 service delivery and identification of key determinants influencing preventive and curative interventions.
 Such information will be used to identify constrains and solutions for improving the quality and coverage of
 malaria control activities.

       c) Describe how activities to strengthen health systems, integrated within this component, will have
          positive system-wide effects and how it is designed in compliance with the surrounding context
          and aligned with government policies.

 The above considerations apply also for the health system in general. The proposal aims at creating the
 basis for an operational HIS system by building the capacity of the local health authorities to collect,
 analyze and use health data for planning and managerial decisions. Gradually, further components (HR,
 infrastructures, equipment, drugs, etc.) will be added to the system thus creating the basic tool for M&E
 purposes. The establishment of pilot districts will allow the development and testing of standard tools and
 procedures for information system at peripheral level. While, initially it is more geared towards collecting
 malaria-related data, the system will gradually expand its scope by including TB and HIV/AIDS programs
 and general services data. The strengthening of HIS zonal unit and of the central dissemination unit will be
 functional to the information needs of other specific disease control programs and of the health system as
 a whole. The proposed HSS component has been developed taking into consideration the Somali context.
 At present there are no information policies or strategies developed by the local authorities. This proposal
 aims at creating the basis for their development.




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4 Component Section Malaria
                                                                                                   Yes
       d) Are there cross-cutting health systems strengthening activities                     complete e) and f)
          integrated within this component that will benefit any other component
          included in this proposal?                                                               No
                                                                                              go to g)

       e) If you answered yes for d), describe these activities and the associated budgets and identify and
          explain how the other components will benefit.

 N/A

       f) If you answered yes for d), confirm that funding for these activities has not also been requested
          within the other component. Please refer to the Round 6 HSS Information Sheet on
          http://www.theglobalfund.org/en/apply/call6/documents/ before completing this section.

 N/A

                                                                                                   Yes
       g) Is this component reliant on any cross-cutting health systems                       complete h)
          strengthening activities that have been included within other
          components of this proposal?                                                             No
                                                                                              go to 4.6.7.

       h) If you answered yes for g), describe these activities and the associated budgets and identify and
          explain how this component will benefit.

 N/A


 4.6.7 Common funding mechanisms

                                                                                                  Yes
                                                                                              answer questions below.
       a) Is part or all of the funding requested for the disease component intended to be
          contributed through a common funding mechanism?
                                                                                                  No
                                                                                              go to 4.8

       b) Indicate in respect of each year for which funds are requested the amount to be funded through a common
          funding mechanism.

 N/A

       c) Describe the common funding mechanism, whether it is already operational and the way it functions.
          Identify development partners who are part of the common funding mechanism. Please also provide
          documents that describe the functioning of the mechanism as an annex.

 N/A

       d) Describe the process of oversight for the common funding mechanism and how the CCM will participate in
          this process.

 N/A

       e) Provide an assessment of the incremental impact on projected targets as a consequence of the funds being
          requested for this component, which are to be contributed through the common funding mechanism.

 N/A




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4 Component Section Malaria
         f) Explain the process by which the applicant will ensure that funds requested in this application, that are
            contributed to a common finding mechanism, will be used specifically as proposed in this application.

 N/A


 4.6.8 Target groups
         Provide a description of the target groups, and their inclusion during planning, implementation and
         evaluation of the proposal. Describe the impact that the program will have on these group(s).

 Target groups include the following:
          Pregnant women and children under five years of age in high endemic areas this is the first time
          this reference has been used—would keep to the same way of describing the places with high or
          seasonal transmission
          Other vulnerable groups including people living with HIV/AIDS (PLWHA), IDPs/refugees and
          nomadic populations moving from low to high endemicity areas
          Populations of all ages residing in epidemic prone areas
          Local health authorities and health personnel in all areas irrespective of endemicity of malaria
 Local authorities and health personnel have been involved in preparing this proposal to a greater extent
 than in GFATM Round 2, by providing inputs to its development in terms of activities and methodologies.
 Their involvement in the implementation is guaranteed by their inclusion in the malaria management
 teams and their participation in supervision, monitoring and evaluation activities. They will benefit from the
 improved infrastructures, capacity building activities and strengthened health information system.
 The groups targeted for health education activities will become agents for further dissemination of
 information on malaria transmission, prevention and adequate care seeking behaviors within their
 communities. The planned qualitative and quantitative studies to be conducted at health facility and
 community level (HF surveys, KAP, MIS, MICS) will allow the direct involvement and participation of the
 target groups to monitoring and evaluating the provision of services, identifying eventual gaps and
 constraints. Within the HSS component, the development of pilot district/community HIS will require their
 direct involvement. The expected impact on vulnerable groups is reduced morbidity and mortality
 associated with malaria.
 Civil society organizations and NGOs through needs assessments, operation research and their
 participation in the SACB forums, will provide a voice for the various target groups.



 4.6.9    Social stratification
                                                                                           Table 4.6.9 Social stratification

                                        Estimated number and percentage of people reached who are:

                                                                             Living in rural                Other
                                    Women               Youth (<18)
                                                                                 areas                  (Nomadic)
                                      50%                   55%                   37%                        18%
 Obj 1: SDA 1: Treatment
                                     226,500               247,500               165,150                    81,000
                                      20%                   80%                   37%                       10%
 Obj 2: SDA 1: LLINs
                                     236,000               957,600               468,051                   119,360
                                      100%           No data on pregnancy          37%                       10%
 Obj 2: SDA 2: IPT
                                     244,800            under 18 years.           89,842                    24,480
                                       50%                   55%                  37%                       10%
 Obj 2: SDA 3: IEC
                                    1,357,584             1,481,491              588,554                   264,362

 Obj 3 (SDA 1-4)                       N/A                   N/A                   N/A                       N/A




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4 Component Section Malaria
 4.6.10 Gender issues
       Describe gender and other social inequities regarding program implementation and access to the
       services to be delivered and how this proposal will contribute to minimizing these gender inequities.

 Recognizing the higher vulnerabilities of women to the adverse consequences of malaria, the proposal
 includes activities to strengthen prevention and control of malaria during pregnancy in order to reduce
 malaria-associated maternal illness and low birth weight.
 Gender roles and relations within the household are of crucial importance to the management of malaria.
 Women’s access to resources and their bargaining power within the household have a major influence on
 treatment seeking behavior both for themselves and their children. IEC and health education activities will
 include a focus on women’s decision making roles in malaria treatment in order to reduce barriers of
 access. Health workers will be sensitized on gender issues and how it impacts upon health care utilization.
 Gender balance during selection of trainees and recruitment of staff will be sought. Women’s groups,
 schools, churches and other important forums will be used to emphasize the importance gender equality.

 M&E indicators will be disaggregated by gender in order to monitor the effective targeting of the program.


 4.6.11 Stigma and discrimination
       Describe how this component will contribute to reducing stigma and discrimination against people
       living with HIV/AIDS, tuberculosis and/or malaria, as applicable, and other types of stigma and
       discrimination that facilitate the spread of these diseases.

 Within Somalia, there is no stigma associated with malaria.


 4.6.12 Equity
       Describe how principles of equity will be ensured in the selection of patients to access services,
       particularly if the proposal includes services that will only reach a proportion of the population in
       need (e.g., some antiretroviral therapy programs).

 Despite the complexities of the political and ethnic context found in Somalia, equal access by all segments
 of the population irrespective of their origin, clan, religion or political affiliation is one of the basic non
 negotiable principles of the Code of Conduct for all partners of the SACB network. This principle will be
 strongly defended and promoted through the provision of free services to all patients and through
 adequate advocacy campaigns.
 A major factor constraining the proper diagnosis and treatment of malaria is the low access to health care
 for many Somalis. Only 50% of the population is within two hours walk of a public health facility. The
 situation is of particular concern for nomadic populations and, to a lesser degree, for rural (sedentary)
 populations as the table indicates
             Table: Physical access to public health care among different groups in Somalia [Lynch 2005]
                             URBAN              IDPs          NOMADIC               RURAL            TOTAL
                             N=604             N=608            N=628                N=696            2536
      < 1 hour                47.4               49.8              6.2                17.5            29.6
      1-2 hours               29.3               18.1             11.9                21.4            20.1
      2-4 hours               16.4               10.7             39.5                34.5            25.7
      > 4 hours                4.3               20.1             40.4                24.6            22.6
      No response              2.6                1.3              1.9                 2.0             2.0
      TOTAL                   100.0             100.0            100.0               100.0            100.0

 By providing free diagnostic and curative services to all patients, subsidized LLINs (free of charge in case
 of vulnerable groups) and piloting community based interventions to rural and nomadic populations
 ensuring the development of strong advocacy and communication strategy through mass media, the
 program addresses social equality issues and defends the right of “health for all” allowing equal access
 for the poorest sectors of the population, which will not be limited by economic factors.



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4 Component Section Malaria
 4.6.13 Sustainability
       Describe how the activities initiated and/or expanded by this proposal will be sustained at the end of
       the program term.

 The sustainability of the intervention at the end of the program term will mainly depend on the
 improvement of the political situation in the country. As in other post-conflict transitional contexts, in
 Somalia peace and stability are the key prerequisites for the recovery and rehabilitation of the health
 system. Even with the scenario of a durable peace settlement and the start of recovery activities, a full
 recovery of the health sector will require decades and will rely heavily on external assistance.
 The vision and the overall strategic approach for reconstructing the health sector have been outlined in the
 “Reconstruction and Development Program for Somalia”, based on the findings of the recent Joint Need
 Assessment (JNA). The Vision on the sector is that by the end of 2011, national and regional health
 authorities will have acquired a stronger technical, managerial and financial capacity; they will rely on
 improved management systems and they will be able to lead and sustain: a) the increased coverage and
 improvement of quality of basic health care, b) the development of efficient health system, and c) the
 progressive reduction of inequality in access to basic services. The proposed strategy contemplates a)
 consolidating and rationalizing the existing health care delivery system, b) filling some of the most serious
 gaps in service provision, and c) putting in place the building blocks for sustained recovery, i.e. the
 institutions and management instruments necessary to ensure efficient, effective and equitable health
 care.
 The interventions foreseen in this proposal are consistent with and functional to the achievement of the
 above described RDP objectives.



4.7 Principal Recipient information
4.7.1 Principal Recipient information

                                                                          Table 4.7.1: Nominated Principal Recipient(s

                                                                                               Single
       Indicate whether implementation will be managed through a single
       Principal Recipient or multiple Principal Recipients.
                                                                                               Multiple


                                    Responsibility for implementation

                                                                                  Address, telephone, fax
 Nominated Principal
                           Area of responsibility       Contact person             numbers and e-mail
    Recipient(s)
                                                                                         address

                                                                                UNICEF Somalia Support
                                                                                Center
                                                                                P.O. Box 44145-00100
                                                     Mr. Christian Balslev-
 UNICEF-Somalia            All                                                  Nairobi, Kenya
                                                     Olesen
                                                                                Tel: +254 20 762 3950
                                                                                Fax: +254 20 762 3965
                                                                                email: cbalslev@unicef.org




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4 Component Section Malaria
4.8 Program and financial management

 4.8.1 Management approach
       Describe the proposed approach of management with respect to planning, implementation and
       monitoring the program. Explain the rationale behind the proposed arrangements.

 As the preferred Principal Recipient, UNICEF will be responsible for the overall programmatic and financial
 management of the project. All financial arrangement will meet its principles and guidelines. Contractual
 arrangements will be entered into with successful tender and sub recipient grant organizations. The
 Principal Recipient will provide regular reports to the HSC as agreed upon by the PR and the HSC in April
 2004 (see annex 3:I:14).

 Program planning and implementation will be carried out within the framework established under Round 2.
 The PR participates to a Malaria Working Group that tackles technical issues such as changes in drug
 regimens. A Malaria Management Team, on behalf of the HSC, provides sustained technical guidance
 and support to the PR for the transparent and coordinated management of interventions under GFATM
 Round 2. This structure will continue for Round 6.
 Funding will be distributed through grants and tender arrangements as outlined below in section 4.10.1.
 Under the oversight of the SACB HSC, a detailed implementation plan will be formulated in the first
 quarter of the project and a time plan developed relating to the tender arrangements required.
 Regular review meeting will be organized both on the zonal level, by the MOH, as at central level, by the
 Malaria Management Team. All progress reports will be shared with the health authorities and other
 relevant partners. Through the SACB system, mechanisms are in place for information sharing and
 feedback.



 4.8.2 Principal Recipient capacities

       a) Describe the relevant technical, managerial and financial capacities for each nominated Principal
          Recipient. Please also discuss any anticipated shortcomings that these arrangements might
          have and how they will be addressed, please refer to any assessments of the PR(s) undertaken
          either for the Global Fund or other donors (e.g., capacity-building, staffing and training
          requirements, etc.).

 See 4.8.2 d)

                                                                                           Yes
       b) Has the nominated Principal Recipient previously administered a
          Global Fund grant?
                                                                                           No

                                                                                           Yes
       c) Is the nominated PR currently implementing a large program funded by
          the Global Fund, or another donor?
                                                                                           No

       d) If you answered yes for b) or c), provide the total cost of the project and describe the
          performance of the nominated Principal Recipient in administering previous grants (Global Fund
          or other donor).

 UNICEF has been nominated, accepted and approved as the PR for two previous Global Fund grants:
 Malaria (Round 2) and HIV/AIDS (Round 4). The Malaria grant, July 2004 – June 2007, is in the amount
 of $12,886,686. For HIV/AIDS the total project cost is $24,922,007 with an initial grant of $ 10,004,644.
 The PR’s capacity and performance of managing GFATM grants has been demonstrated through the
 progress on the Malaria R2 grant as has been reported in the progress reports and as part the Phase II
 funding request. This program has progressed as planned and is producing results.
 The organization has been working in Somalia for over two decades, and maintains a large operational



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4 Component Section Malaria
 presence throughout the country. UNICEF works in collaboration with partners to implement programs
 with an approach that is adapted to levels of the security, stability and the capacity of counterparts. As with
 previous program cycles, the UNICEF 2004 - 2008 country program is based on a) understanding of the
 evolving situation in Somalia, b) recognition of the activities of local authorities, and humanitarian and
 development partners; and c) lessons learned. The vision and challenge that guides the proposed country
 program is twofold: first, to invest in long term development and institutional capacities; and second, to
 support programs for the immediate survival and holistic development of all children and women and their
 active participation in the development of their communities.

       e) If you answered yes for b) or c), describe how the PR would be able to absorb the additional
          work and funds generated by this proposal.

 Through round 2, UNICEF demonstrated its capacity to absorb the additional work and the funds
 generated by the proposal.


 4.8.3 Sub-Recipient information

                                                                                              Yes
                                                                                          complete the rest of
                                                                                       4.8.3
       a) Are sub-recipients expected to play a role in the program?
                                                                                              No
                                                                                          go to 4.9

                                                                                              1–5

                                                                                              6 – 20
       b) How many sub-recipients will or are expected to be involved in the
          implementation?
                                                                                              21 – 50

                                                                                              more then 50

                                                                                              Yes
                                                                                         complete 4.8.3. d) -e)
                                                                                       and then go to 4.9
       c) Have the sub-recipients already been identified?
                                                                                              No
                                                                                          go to 4.8.3. f) – g)

       d) Describe the process by which sub-recipients were selected and the criteria that were applied in
          the selection process (e.g., open bid, restricted tender, etc.).

           N/A

       e) Where sub-recipients applied to the Coordinating Mechanism, but were not selected, provide the
          name and type of all organizations not selected, the proposed budget amount and reasons for
          non-selection in an annex to the proposal.

           N/A

       f) Describe why sub-recipients were not selected prior to submission of the proposal.

 The SACB HSC is committed to the GFATM’s requirement that SR selection be carried out in an open and
 transparent process. Somalia has developed a selection process to fit the criteria that have been
 highlighted by the GFATM as an example of best practice at the GF MENA conference in Morocco in
 2005. This is a time-consuming process that cannot be carried-out in the proposal writing timeframe and
 like for the HIV/AIDS grant, is set to start upon approval of the proposal by the TRP.
 Furthermore, due to the volatile situation in Somalia, the experience of the SACB HSC regarding previous


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4 Component Section Malaria
 grants is that selection of SRs closer to the start-date is more reflective of the situation at hand avoiding
 delays in implementation. The GFATM TB program for example, saw two of the pre-selected sun-
 recipients withdraw, even before the grant agreement was signed.
 A letter has been written to the GFATM Board and TRP on this subject and a copy can be found in annex
 3:II:1

          g) Describe the process that will be used to select sub-recipients if the proposal is approved,
             including the criteria that will be applied in the selection process.

 The SR selection will be finalized prior to the signing of the grant (i.e. within six months from approval of
 the proposal). The HSC commits to launching a transparent SR selection process once news on grant
 approval is received and using similar tools proven successful in the recent past. It will be organized in a
 similar fashion to SR selection of the HIV/AIDS (see annex 3: II: HIV). HIV Round 4 SR selection process
 commenced once grant was approved by the GFATM and completed by grant signing.
 In annex 3:II:HIV:10, please find the process used for the HIV grant that will be adapted for this disease
 component. This open transparent selection process can be outlined as follows:
      -     A call for interested organizations will be launched by the SACB HSC once TRP approval on the
            proposal is received and an applicant package provided
      -     After the closing date for applications, standard tools for assessing the submissions and the
            organisations will be used to evaluate and rank potential sub-recipients by a committee made up
            of members of the SACB HSC and the PR.
      -     The criteria used to score the applicants are amongst others, the quality of the application, the
            applicant’s M&E capacity, how target groups are addressed and the budget with extra points for
            matching contributions, workplans, creative planning and a consortium approach (see annex 3: II;
            HIV-6).
 Upon selection of successful applicants, contractual agreements between the PR and SRs will be
 prepared by the PR (by the date of grant signing)



4.9 Monitoring and evaluation

 4.9.1 Plans for monitoring and evaluation
          Describe how the targets and activities indicated in the Targets and Indicator Table (attached as
          Attachment A to this proposal, see section 4.6) will be monitored and evaluated. Please identify any
          surveys to which this proposal is contributing.

 The monitoring and evaluation of the project will be conducted using a mix of different data sources:
 structured supervision of health facilities and laboratories, routine reporting, surveillance system, health
 facility and community surveys, operational research. The information will be used to review project results
 and constraints in order to strengthening weak components, modifying implementation modalities,
 identifying alternative approaches and monitor disease trends. The following table lists the indicators
 identified for M&E the malaria control program with the respective data sources and frequency.
 Supervision – The proposed supervisory structure and activities reflect those adopted by the current TB
 Control Program funded under the GF Rd2. Such system has shown to be appropriate in the Somali
 context and to allow proper M&E of the program. The members of the malaria zonal teams will conduct
 supervisory visits to the health facility providing malaria services in order to monitor key program activities.
 A standard checklist for supervisory visits will be adopted. The supervisors will check the appropriateness
 of: diagnosis, classification and treatment of malaria cases, management of supplies and health
 information system. At the end of the visit, the problems identified and the actions to be taken will be
 discussed with the health facility staff. Similarly, the laboratory supervisors will monitor the laboratory
 activities and perform quality control of the microscopy. Supervisory visits will be used for conducting on
 the job training and the local staffs will be extensively involved as appropriate to strengthen local capacity.
 Findings and recommendations of each visit will be recorded to facilitate follow-up on actions taken and
 progresses achieved.



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4 Component Section Malaria
 Routine HIS – The existing HIS is fragmented and inadequate to provide reliable information. Data on
 malaria collected by various organizations are not standardized and often they are not shared with other
 partners. The HSS component of the proposal aims at improving the present set-up by strengthening data
 collection, analysis and dissemination while gradually developing a comprehensive M&E Framework for
 the country. The establishment of pilot districts will allow developing and testing an integrated HIS by
 coordinating the different vertical data collection activities and integrating the information at local level.
 Following evaluation, such set up will be expanded to the remaining districts in the country. Pilot districts
 will also allow linking community with health facilities data and validating the findings derived by wide-
 scale, national studies. Data originated by the present and foreseen surveillance/ early warning systems
 will be integrated in the general HIS. All data will be disaggregated and analyzed by gender, age and
 where relevant by specific vulnerable groups.
 Surveys and studies - Different surveys at community level are planned in the next few years. One
 MICS, including a malaria module, will be conducted in year 2006 and repeated in year five. The surveys
 will be funded by UNICEF. In year three a MIS at national level is planned in order to evaluate the
 achievements half-way through the project. The selected pilot districts will be included in the national
 surveys and the results will be compared with national figures in order to validate the results. Moreover,
 sensitivity testing of the current first line treatment is planned in years 2008 and 2010 (two studies are
 going to be conducted in sentinel sites in 2006 and 2007 through Round 2 support) and insecticide
 resistance will be tested on a yearly basis.
 Operational research – Considering the constrains and limitations of nation-wide surveys, a series of
 linked operational research to tackle major information gaps will be conducted, namely: how out-patients
 are clinically assessed, diagnosed, treated and counseled and what are the barriers to accessing prompt
 and appropriate care. The research will be conducted in selected sites (coinciding with the HIS pilot
 districts) representing the diverse malaria epidemiology, geo-political framework and population settlement
 patterns. Such operational research will build on those conducted in 2006-2007 (year 3 of GFATM round
 2): 1) Developing a high resolution geographic information system (GIS) platform of population, health
 services and access routes; 2) Assemble retrospective clinic data on patient burdens and malaria specific
 indicators. In year 1 (baseline), a first evaluation will be conducted in the pilot districts, to be repeated in
 2011. This will allow monitoring trends over time and assessing the impact of the program.


 4.9.2 Integration with national M&E Plan
       Describe how performance measurement for this program is proposed to contribute to and/or
       strengthen the national Monitoring and Evaluation Plan for this component. If a national Monitoring
       and Evaluation strategy exists, please attach it as an annex to the proposal, and provide a summary
       of key linkages with the national Monitoring and Evaluation Plan and data collection methods.

 At present no malaria-specific or general national M&E Framework exists. A major result expected by the
 HSS component of the present proposal is the development of a comprehensive M&E framework for the
 country with identification and definition of information need, procedures and tools for the different levels of
 the health system.


4.10 Procurement and supply management of health products

 4.10.1 Organizational structure for procurement and supply management
       Briefly describe the organizational structure of the unit currently responsible for procurement and
       supply management of drugs and health products. Further indicate how it coordinates its activities
       with other entities such as National Drug Regulatory Authority (or quality assurance department),
       Ministry of Finance, Ministry of Health, distributors, etc.

 The PR will consult the Malaria Working Group and zonal health authorities on the development of
 procurement plans. The PR will procure drugs, RDTs, LLINs and IEC materials using its standard
 procedures in regards to tendering and quality control. Its Procurement Centre in Copenhagen will
 undertake these activities for drugs and RDTs while its Pretoria Procurement Centre will be responsible for
 LLINs. Procurement of IEC material will occur both through the East Africa Regional Office and the
 Somalia Support Centre.



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4 Component Section Malaria
 Only drugs, RDTs and LLINs that are WHO-approved will be procured. In the current context, the health
 authorities are not procuring drugs or health products themselves but do endorse treatment guidelines and
 essential drug lists including those for malaria. The bulk of drugs supplied to public health facilities are
 provided through UNICEF which organizes planning sessions with the HEALTH AUTHORITIESs. Drug
 regulatory authorities have not been established to date in Somalia although through this grant, efforts will
 be made to strengthen their ability to do so. Distribution channels for drugs and health products will be the
 same as those utilized for the R2 Malaria Grant and will build synergies with the GFATM HIV/AIDS
 Program. Commodities are transported to regional hubs in Somalia, including warehousing where
 appropriate in Somalia, and from there to health facilities.
 Since the existing KIT system is not suitable for the provision and management of malaria supplies due to
 the need to respond to various epidemiological strata and due to the need to exert proper control over the
 quality of diagnosis (due to evidence of high over diagnosis), the management of malaria supplies will be
 given special attention by the UNICEF malaria team.
 WHO/sub-recipients, as selected, may procure other materials (including laboratory equipment and
 material) to support improved disease management. This procurement will be processed through globally
 accepted tender and procurement protocols.


 4.10.2 Procurement capacity

       a) Will procurement and supply management of drugs and                 Principal Recipient only
          health products be carried out (or managed under a sub-
          contract) exclusively by the Principal Recipient or will            Sub-recipients only
          sub-recipients also conduct procurement and supply
          management of these products?                                       Both

       b) For each organization involved in procurement, please provide the latest available annual data
          (in US$) of procurement of drugs and related medical supplies by that agency.

 In 2005, UNICEF procured more than $7,800,000 worth of drugs and related medical supplies for Somalia.


 4.10.3 Coordination

       a) For the organizations involved in section 4.10.2.b, indicate in percentage terms, relative to total
          value, the various sources of funding for procurement, such as national programs, multilateral
          and bilateral donors, etc

 In 2005, the sources of funding for procurement were 16% UNICEF funds and 84% donor funds (including
 governments, trust funds). Of the value of supplies procured, 35% of procurement was made for the GF
 Malaria Program.

       b) Specify participation in any donation programs through which drugs or health products are
          currently being supplied (or have been applied for), including the Global Drug Facility for TB
          drugs and drug-donation programs of pharmaceutical companies, multilateral agencies and
          NGOs, relevant to this proposal.

 Drugs and health products relevant to this proposal are not supplied through any donation program.


 4.10.4 Supply management (storage and distribution)

                                                                                           Yes, ??
                                                                                      BM/IMM
       a) Has an organization already been nominated to provide the supply
                                                                                         continue
          management function for this grant?
                                                                                            No



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4 Component Section Malaria
                                                               National medical stores or equivalent

                                                               Sub-contracted national organization(s)
       b) Indicate, which types of organizations will
          be involved in the supply management of
          drugs and health products. If more than              Sub-contracted international organization(s)
          one of the boxes below is ticked, describe
          the relationships between these entities.            Other:
                                                               Un agency: Unicef as PR shall cover the vast
                                                               majority of supplies and the management
                                                               thereof.

       c) Describe the organizations’ current storage capacity for drugs and health products and indicate
          how the increased requirements will be managed.

 UNICEF has warehousing facilities located in all the zones of Somalia (Bossaso, Hargeisa, Mogadishu
 and Jowhar). The drugs and health products for this proposal will be channelled through the current
 structure. There were no problems related to storage capacity for the supplies purchased under round 2,
 with increased requirements (mainly nets) well managed.

       d) Describe the organizations’ current distribution capacity for drugs and health products and
          indicate how the increased coverage will be managed. In addition, provide an indicative estimate
          of the percentage of the country and/or population covered in this proposal.

 UNICEF is responsible for supplying all public health facilities in Somalia with essential medicines using
 the kit system. Unicef has adapted for GF Round 2 it’s distribution and management system to
 incorporate the specificities of distribution of malaria related to drug, prevention and diagnosis material.
 There for the drugs and health products for this proposal can be absorbed into the current structure.


 4.10.5 Multi-drug-resistant TB

                                                                                             Yes
       Does the proposal request funding for the treatment of multi-drug-resistant
       TB?
                                                                                             No



4.11 Technical and Management Assistance and Capacity-Building

 4.11.1 Capacity building

       Describe capacity constraints that will be faced in implementing this proposal and the strategies that
       are planned to address these constraints. This description should outline the current gaps as well as
       the strategies that will be used to overcome these to further develop national capacity, capacity of
       principal recipients and sub-recipients, as well as any target group. Please ensure that these
       activities are included in the detailed budget.

 In the absence of formal training during the last 16 years compounded by a very severe “brain drain” from
 Somalia, at present the capacity for malaria control within local authorities continues to be limited.
 Moreover, the division of the country in three different zones with their respective local governments does
 not allow for the identification of a single entity which can represent and provide technical leadership for
 the whole country. The weak capacity of the current health system has proven challenging during GFATM
 round 2 grant implementation and needs to be strengthened to improve the disease control program. In
 order to overcome these constraints, and lay the basis for future autonomous management of malaria
 control activities, the programme intends to build the capacity of the local authorities at the various levels
 through formal cascade training of health staff, introduction of training modules in the existing and
 emerging schools and universities, on the job training provided during the supervision and direct technical
 assistance in the form of international counterparts (see 4.11.2) to the MOH focal points in the first two



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4 Component Section Malaria
 years.

 The malaria zonal teams, consisting of the malaria zonal focal point, the laboratory focal point, the vector
 control focal point (supported by WHO) and the malaria focal points of the PR, is expected to be supported
 by the program and to play a leading role in the process. They should participate in the joint supervision,
 operational research and participate at the quarterly review meetings and to all meetings in which major
 strategic or programmatic decisions have to be made. The way in which this capacity building component
 is addressed in the proposal can be found under section 4.6.3 (Objective 3 SDA 2). The capacity of the
 International partners (PR, SR and other implementing partners) to provide relevant technical support
 must also be strengthened so as to cope with the major staff turn over that affects the operational capacity
 and institutional memory of every organisation operating in Somalia. The SACB HSC plays a major role in
 trying to maintain technical consistency and institutional memory in the over-changing operational
 scenarios in Somalia.
 In the current transitional period the SACB HSC is expected to provide sustained support to existing and
 emerging health authorities in Somalia and to contribute to guiding the international community and the
 Somali authorities in the future health sector recovery process. The current situation requires the
 combination of emergency response tools with development tools with a focus on “learning by doing” and
 a substantial amount of commitment since many of the basic socio-economic and political variables
 relevant to achieve progress in RBM are beyond the control of the malaria programme.


 4.11.2 Technical and management assistance

          Describe any needs for technical assistance, including assistance to enhance management
          capabilities.

 Technical assistance will be required for different levels and activities:
 The fragmentation of the current health system (with 3 ministries of health) justifies a strong country
 coordination component. The WHO RBM coordinator will be responsible to keep on overall view on the
 malaria activities in Somalia. He will be assisted by the malaria technical coordinator who is responsible
 for the supervision of the zonal malaria focal points (international), operational research and malaria
 technical issues. The WHO laboratory coordinator (paid by WHO) will assist in the supervision and training
 of the laboratory focal point working in the referral labs. The country IEC coordinator will be responsible to
 oversee and guide all IEC and BCC activities in Somalia.
 On the zonal level, the malaria zonal teams will receive technical assistance from 3 international malaria
 zonal focal points in the first two years of the proposed grants. For the referral labs, 3 international staff
 will be recruited to be the counterpart of the MOH laboratory focal point. They will assist in the set-up of
 the referral labs, training of staff (both in the referral lab as in the peripheral labs), and supervision. For the
 HIS component a similar structure has been foreseen. All these international position will be fazed-out
 after two years, when local authorities should have the capacity manage the malaria program
 independently on a zonal level. Technical assistance will then only be provided in the form of external
 evaluation for quality assurance. A special training organized by WHO will provide the MOH focal point
 with the necessary managerial skills (see section 4.6.3 Objective 3 SDA 2: Human resource
 development).
 Technical assistance will also be provided for the planned resistance study, the malaria coverage survey
 in year 3 and for operational research.




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5 Component Budget Malaria
5.1 Component budget summary
                                                                                                                      Table 5.1 – Funds requested from the Global Fund

                                                                         Funds requested from the Global Fund (in Euro/US$)

                                                   Year 1            Year 2              Year 3          Year 4                Year 5                  Total

 Human resources
                                                   1,212,370         1,312,710           1,213,110        865,110                864,510            5,467,810
 Infrastructure and equipment
                                                     131,800                    -                   -             -                      -           131,800
 Training
                                                     207,949           363,659            257,269         174,359                166,929            1,170,165
 Commodities and products
                                                   3,227,855         2,764,609           2,596,209      1,865,409                323,809            10,777,890
 Drugs
                                                      93,907           564,094            553,891         654,785                626,582            2,493,259
 Planning and administration
                                                   1,052,989         1,178,750           1,192,424        916,593                822,833            5,163,589
 Other (Surveys and studies)
                                                     230,500            12,500              90,500         12,500                152,500             498,500
 Subtotal
                                                   6,157,371         6,196,321           5,903,402      4,488,756             2,957,163             25,703,013
 Other (Principal recipient)
                                                     332,250           411,000            411,000         411,000                411,000            1,976,250
 Total funds requested from the Global
                                                  6,489,621         6,607,321           6,314,402       4,899,756             3,368,163             27,679,263
 Fund




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5 Component Budget Malaria
5.2 Detailed Component Budget
      A detailed budget can be found in annex 5.2 (also provided in soft copy).

5.3 Key budget assumptions

 5.3.1 Drugs, commodities and products
       a) Provide a list of anti-retroviral (ARVs), anti-tuberculosis and anti-malarial drugs to be used in the
          proposed program, together with average cost per person per year or average cost per
          treatment course.
         See annex 5:3, table B.1
       b) Provide the total cost of drugs by therapeutic category for all other drugs to be used in the
          program. It is not necessary to itemize each product in the category.
         See annex 5:3, table B.2
       c) Provide a list of commodities and products by main categories e.g., bed nets, condoms,
          diagnostics, hospital and medical supplies, medical equipment. Include total costs, where
          appropriate unit costs.
         See annex 5:3, table B.3



 ACTs and RDTs have been distributed to hospitals and MCHs in 2006, together with consumption follow-
 up tools. However, detailed figures on the current consumption are not yet available. Without reliable
 health statistics, estimating the drugs needs for this proposal is therefore based on some key
 assumptions:
         7,571 confirmed cases reported by 42 health facilities in 2003.
         Completeness of reporting at 50% (WHO, pers. com.)
         Average number of cases per health facility reporting: 361 cases
         Health posts estimated to treat around 100 malaria cases per year.
 Taking into account a yearly increase of the number of health posts to be covered (with a target of 90% by
 year 5) the number of treatments needed were estimated at 80,000 in year 2 (year 1 covered by round 2)
 going up to 110,000 in year 5. The detailed calculations can be found in the “Detailed Budget” excel
 spreadsheet under “Drugs and RDT planning”.
 The list of anti-malarials used can be found in annex 5:3, table B.1
 Using the above mentioned assumptions and taking into account the different age classes, the average
 price of one treatment is at $2.05.
 The total cost of drugs in year 1 is only $3,456 as most drugs are covered by round 2 and at $204,262 for
 year 2 (see annex 5:3 Table B.2)
 Total cost for commodities and products can be found in annex 5:3 Table B.3


 5.3.2 Human resources costs
       In cases where human resources represent an important share of the budget, explain how these
       amounts have been budgeted in respect of the first two years, to what extent human resources
       spending will strengthen health systems’ capacity at the patient/target population level, and how
       these salaries will be sustained after the proposal period is over.

 Human resources accounts for 20% of the total funds requested. An important part of this amount is to
 cover the staff responsible for coordinating, training, supervising and monitoring the program, essential to
 ensure an adequate standard.


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5 Component Budget Malaria
 A range of the international positions have the objective to develop capacity and set up systems, there
 after (mainly in Y2 and Y3) the positions are handed over to the capacitated national staff.
      o for HIS three positions to be handed over in Y2 and the HIS coordinator position other donor funds
          to be sought after Y3,
      o for Lab quality assurance, the three Zone Lab positions to be handed over and only one roaming
          international Lab in Y2 to be made redundant in Y3)
 Included in this are eight Health Authorities staff who will work in close collaboration with temporary
 internationals working mainly on Quality Assurance and HIS in the first to three two years. In order to build
 their capacities, as part of the Malaria Zone team.
 For a country in a complex emergency situation like Somalia, the proposed funding will allow for the
 smooth running of activities for the duration of the program. The HR cost is high due to the total lack of
 publicly supported structures. Any program or activity devised in Somalia needs an injection into human
 capital and structures as well. It is hoped that in the meantime Somalia will be able to find a political
 solution to its internal problems. If this is achieved, the future government of Somalia, with the help of
 external donors, will be able to take over many of these roles
 A list of the different HR posts budgeted in this proposal can be found in annex 5.4 Table 5.3.2).


 5.3.3 Other key expenditure items
       Explain how other expenditure categories (e.g., infrastructure, equipment), which form an important
       share of the budget, have been budgeted for the first two years.

   Infrastructure and equipment represent less than 1% of the total budget. It includes material for the
   quality assurance mechanism being the rehabilitation and support of four referral laboratories, including
   microscopes; sprayers, insecticide and protective equipment for the IRS component; and, equipment
   sets for the environmental management component at the community level. Non-medical related
   infrastructure and equipment costs are only the rehabilitation of the 4 referral laboratories in year 1 at
   $42,800. (no annex included as these are the only costs representing an important share of the budget)




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5 Component Budget Malaria
5.4 Breakdown by service delivery area
                                                                                                    Table 5.4: Estimated budget allocation by service delivery area and objective.

                                                                                          Budget allocation per SDA (in Euro/US$)

          Objectives                    Service delivery area            Year 1          Year 2                  Year 3                  Year 4                  Year 5

 1/ To increase provision of
 malaria diagnosis and           SDA1 Treatment: prompt, effective
                                                                        426,998         1,020,119               978,498                  995,586                 958,446
 treatment package to 90%        antimalarial treatment
 of (public) health facilities

                                 SDA1 Prevention: LLINs                 3,071,280       2,625,605              2,534,525                1,803,725                259,325
 2/ To increase coverage of
 prevention methods in           SDA2 Prevention: Malaria prevention
                                                                         32,707          33,053                  33,398                  33,744                   34,090
 targeted malarious areas        during pregnancy
 for pregnant women and
 children under five to 80%      SDA3 Supportive Environment:
                                                                        172,108         272,112                 186,084                  176,550                 176,550
                                 Communication (IEC/BCC)

                                 SDA1 Suportive environment: Quality
                                                                        374,168         278,654                 202,042                  166,090                 166,090
                                 Assurance

 3/ To strengthen ministries     SDA2 Supportive environment:
                                                                        653,813         770,657                 750,113                  724,433                 724,433
 of health’s capacity in         Institutional & HR capacity building
 close collaboration with
 national and international      SDA3 Information system and
 partners                                                               814,029         651,839                 774,889                  237,321                 387,121
                                 Operational research

                                 SDA4 Prediction and containment of
                                                                        187,713         112,029                  30,763                  30,763                   30,763
                                 epidemics

                                                                        756,805         843,255                 824,092                  731,545                 631,347
 PR Support costs
 Total:                                                                 6,489,621       6,607,321              6,314,402                4,899,756               3,368,163




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5 Component Budget Malaria
5.5 Breakdown by implementing entities
                                                                 Table 5.5 – Allocations by implementing entities

                                       Fund allocation to implementing partners (in percentages)

                                       Year 1       Year 2       Year 3           Year 4            Year 5

 Academic/educational sector
                                        4.2%         0.2%         3.0%             0.2%              4.8%
 Government / Local Authorities
                                        6.7%         6.6%         6.1%             7.8%             11.4%
 Nongovernmental / community-
 based org.
                                       15.3%        20.5%        18.4%             18.4%            25.5%
 Organizations representing
 people living with malaria
                                        0.0%         0.0%         0.0%             0.0%              0.0%
 Private sector
                                        0.0%         0.0%         0.2%             0.2%              0.3%
 Religious/faith-based
 organizations
                                        0.0%         0.0%         0.0%             0.0%              0.0%
 Multi-/bilateral development
 partners (UNICEF/WHO)
                                       27.5%        31.9%        29.3%             31.3%            40.3%
 Others: UNICEF Copenhagen
 (LLIN, ACT, RDT)
                                       46.2%        40.6%        42.7%             41.6%            17.1%
 Total in %                             100%        100%         100%              100%              100%



5.6 Budgeted funding for specific functional areas
                                                                 Table 5.6 – Budgets for specific functional areas

                                  Funds requested from the Global Fund (in Euro/US$)

                     Year 1         Year 2       Year 3        Year 4            Year 5             Total

 Monitoring and
                     362,440       149,440      327,440       159,440           299,440          1,298,200
 Evaluation

 Procurement
 and Supply          637,527       904,753      805,595       700,043           371,685          3,419,602
 Management

 Technical and
 Management          808,000       876,000      804,000       456,000           456,000          3,400,000
 Assistance




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List of Annexes to be Attached to PROPOSAL Malaria, Chapter 4&5


 Section 4 (Component specific): Component Strategy

 4.4.1                   Documentation relevant to the national disease              4:5, 4:6, 4:16, 4:17,
                         program context, as indicated in section 4.4.1.             4:18

 4.6                     A completed Targets and Indicators Table                    4:1 Attachment A to
                                                                                     the Proposal Form

 4.6                     A detailed component Work Plan (quarterly
                         information for the first year and indicative information   4:2
                         for the second year).

 4.6.7 c)                Documentation describing the functioning of the
                                                                                     N/A
                         common funding mechanism.

 4.8.3 e)                Name and type of all Sub-Recipients not selected, the
                         proposed budget amount and the reasons for non-             N/A
                         selection.

 4.9.2                   National Monitoring and Evaluation strategy                 N/A

 Section 5 (Component specific): Component Budget

 5.2                     Detailed component Budget                                   5:2

 5.3.1                   Preliminary Procurement List of Drugs and Health            5:3 Attachment B to
                         Products (tables B1 – B3)                                   the Proposal Form

 5.3.2                   Human resources costs.                                      5:4

 5.3.3                   Other key expenditure items.                                5:5

 5.1 - 5.6               Available annual operational plans/projections for the
                         common funding mechanism, and an explanation of             N/A
                         any link to the proposal.

 Other documents relevant to sections 4-5 attached by applicant:
                         Summary of health & nutrition funding 2003 Donor
 4.5.2 b                                                                             4:8
                         Report
 4.5.2 b                 Summary of health & nutrition funding 2004 Donor
                                                                                     4:9
                         Report
                         Somalia 2006 NIDs Population Final
 4.6.3                                                                               4:10
                         Malaria communication Strategy 2005-2010
 4.4.1                                                                               4.11
                         KAP Final Report, Jan 05
 4.4.3                                                                               4:12

 4.6.3                   Working Paper LLINs Final report Feb 05                     4:14

 4.4.1 & 4.4.2           Assembling the evidence and modeling risk, Snow et
                                                                                     4:16
                         al, march 2006

 4.6.3                   Operational Research Sentinel site Proposal Somalia
                                                                                     4.17
                         June 2006




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List of Annexes to be Attached to PROPOSAL Malaria, Chapter 4&5

 4.4.1                   Simplified guidelines MCH/ OPD Low prevalence zone
                                                                              4:18
                         2006

 4.4.1                   Simplified guidelines MCH/ OPD Medium to high
                                                                              4:19
                         prevalence zone 2006

 4.5.3                   Table 4.5.1 to 3 external funds malaria              4.20

 4.6.3                   Operational research budget, July 06                 5:6




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