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CMAM Surge Approach East Africa Consultation Workshop

Nairobi, Kenya

April 27th - 29th

2016

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1. Introductions & Objectives

The CMAM Surge Approach – Operational Guide provides an introduction and overview to the

Surge Approach and outlines in a series of steps the initial introduction, implementation,

monitoring and adaptation processes. It provides a toolkit with guidance or templates for each

step found in the annex section. The purpose of the consultation workshop is to provide

feedback to Concern Worldwide and its team of technical consultants on the guide and its

applicability in different contexts.

The specific objectives of the consultative workshop were:

o Objective 1: Familiarize Country Teams about Surge Approach.

o Objective 2: Review draft Global CMAM Surge Approach – Operational Guidance.

o Objective 3: Plan next steps for Country and Global use of the Surge Approach.

The overall facilitation of the workshop was done by consultants Peter Hailey of the Centre for

Humanitarian Change (CHC) as part of a larger contract to support development of the Surge

Approach Operational Guide with support from and Erin McCloskey (also of the CHC).

2. Workshop Organization & Methodology

The workshop was structured in the following way:

Wednesday Morning:

Familiarize Country Teams about Surge Approach.

i. Overview

ii. Learnings from Kenya

iii. Learnings from Uganda

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Wednesday Afternoon and Thursday Morning:

Review draft Global CMAM Surge Approach – Operational Guidance.

i. Step 1 to 4

ii. Step 5 to 7

Thursday Afternoon:

Plan next steps for Country and Global use of the Surge Approach.

i. Country

ii. Global

Specific facilitation methodologies (role play, debate, analyzing own data, etc.) were used to

promote an adult learning approach. They were chosen in the spirit of David Kolb’s Experiential

Learning Model. Kolb defines learning as “the process whereby knowledge is created through

the transformation of experience”. This model emphasizes the importance of reflection on

one’s own or the teams own experiences and using these reflections to strategically

conceptualize a plan of action. Kolb’s model represents this process in a cyclic nature which

entails four key stages:

i. Concrete experience,

ii. Reflective Observation,

iii. Abstract conceptualization, and

iv. Active experimentation.

Much of the workshop was spent in group work. The groups were organized by country teams

so that they could reflect on how the approach and the guidance provided might work in their

own context. Facilitators were assigned per country team so that they might support the

discussion, facilitate use of the tools and also record how it was for the teams to work through

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the guidance. Facilitator Workbooks were provided to aid the capturing of comments and

reflections. Country Workbooks were also provided so that country teams may capture any

relevant points for moving Surge forward in their country.

Feedback/Outcome

During the course of the workshop, Facilitators captured key points on the use of the tools and

guidance in their workbooks. At the end of each day the country Facilitators met with the

workshop Facilitators to discuss comments and observations as well as whether or not the

facilitation process was being effective. On the third day, April 29th, a smaller group of key

people met to review the overall feedback that the workshop produced for the Operational

Guide. Andi Kendle (the consultant drafting the Global Guide) participated by skype so that she

could capture key points for quick adaption of the guide.

The key points coming out of the discussion were as follows [with how they have been

addressed in red italics]:

- Countries requested an advocacy/briefing pack on the surge approach to support

dissemination of the concept to MoH/Donors/Key stakeholders [This will hopefully be

covered with the Synthesis Paper and the workshop powerpoints to be shared with

participants]

- Format of the guideline should be “pull-out” tools [Tools are shown in the guide itself and

will be provided as a folder of actual, adaptable tools that can be used immediately.]

- Create a FAQ section for easy reference to key questions that the surge approach

encounters [This has not been done but a what Surge is and isn’t is now in a table and text

boxes throughout suggest important issues to consider]

- As the process rolls out then key indicators to monitor the performance of a surge in a HF

should be developed [A list of potential M&E indicators is provided in the annex, but this

needs more collective work as the approach gets trialed in new contexts]

- Formatting of the guide should consider how it will appear when photocopies and/or printed

in black and white [We have tried to take this into consideration as much as possible, but

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there may still be some shades of grey that are difficult to distinguish and will require

checking back with the original – the guide will also be makde available in word so it can be

adapted]

- Step 1: the section could include information on how to prepare HFs before the process

begins and provide a format for them to collect/collate the necessary data. [Now included in

the Facilitator’s Guide] Guidance is required on how to reflect women’s workload which

affects HF attendance.[now listed as an e.g.]

- Step 2: Participants found the guidance confusing. More reflection is required on how to

make this section easier to utilize. There is still confusion on how to assess surge capacity

versus general CMAM capacity. [Considerable works has been done on this section and the

suggested exercise for this step in the Faciliator’s Guide]

- Step 3: Participants felt the suggested calculation would not work for centres with high

average monthly admissions. Suggestion is to include a calculation into later versions of the

guide – once there is more practical experience in implementing Surge in a variety of

contexts. [A high and low caseload scenario/ calculation is now provided in the guide under

this Step]

- Step 5 – should reinforce that MoH-MoH commitments should be part of the annual

workplan (and not a standalone activity) [This is now mentioned]

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3. Evaluation

Once the workshop was completed an online Survey Monkey was sent to participants in order to collect feedback on the workshop objectives and methods.

Questions also attempted to assess the participants’ willingness and ability to apply learning and concepts from the workshop in their own contexts. A total

of seventeen (17) participants completed the online survey, a summary of the findings are as follows:

Topic 1. Workshop Content

Strongly Agree or

Agree No opinion Disagree

I felt the workshop was relevant for me 100% 0% 0%

I felt the workshop was interesting for me 100% 0% 0%

I felt the workshop content was just right - not too heavy, not too light 76% 12% 12%

I feel like I will be able to remember the things I learnt in a month from now 88% 12% 0%

I want to tell others about what we did during the workshop 88% 12% 0%

I feel like I will be able to use the learning gained from the workshop 88% 12% 0%

Topic 2. Workshop Design

Strongly Agree or Agree

No opinion Disagree

I was well informed about the objectives of the workshop 83% 12% 5%

I felt well prepared for the workshop 64% 29% 5%

I received enough information on CMAM Surge Approach before the event 76% 17% 5%

I felt the difficulty of the workshop was just right for me 94% 5% 0%

I felt that the workshop was just the right length for me 47% 29% 24%

I felt the speed of the workshop was just right for me 70% 24% 5%

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Topic 3. Facilitators

Strongly Agree or Agree

No opinion Disagree

I found the facilitators were well prepared 94% 0% 5%

For me the facilitators communicated the information clearly 100% 0% 0%

The facilitators made the workshop interesting for me 100% 0% 0%

The facilitators were helpful for me 100% 0% 0%

Topic 4. Workshop Results

Strongly Agree or Agree

No opinion Disagree

I accomplished my objectives for the workshop 88% 12% 0%

I think the workshop achieved its objectives 83% 12% 5%

I think the final work plans were realistic and achievable 41% 47% 12%

Topic 5. Moving the CMAM Surge approach forward

Strongly Agree or Agree

No opinion Disagree

I feel that I want to support the Surge Approach in my country? 94% 5% 0%

I feel I have enough information to start moving the Surge Approach forward in my country 64% 17% 17%

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Topic 6: What else would you need to start effectively supporting Surge in your country?

70.6%

23.5%

70.6% 70.6% 70.6% 82.4%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

In-country training Regional training Advocacy briefs tosupport

dissemination ofSurge concept

Professionaltechnical supportand/or Mentoring

Exchange visit toexisting

programmes

Finalized guidelineand tools

6. What else would you need to start effectively supporting Surge in your country? (Check all that apply)

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Topic 7: How would you improve this Surge workshop?

Topic 8. What session did you enjoy the most?

Participants stated that they most enjoyed the Theory of Surge and Country Experiences (Kenya & Uganda) session with 41% of participants rating

this session in their top 5 favorite session of the workshop. While they least enjoyed the Step 5 - Formalizing Commitments session with 0% of

participants ranking this session in their top 5 favorite sessions conducted during the workshop.

Topic 9. What did you find most valuable about the workshop?

Learning from others (6)

Practically learning about the CMAM Surge approach (4)

50.0%

37.5%

12.5%

37.5%

6.3%

25.0%

12.5%

12.5%

37.5%

6.3%

81.3%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%

Give better information before workshop.

Clarify objectives.

Reduce the content

Increase the content

Make workshop more interesting.

Improve organisation.

Make more difficult.

Make less difficult.

Slow down workshop.

Speed upworkshop.

Give more time for workshop

7. How would you improve this workshop? (Check all that apply)

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Countries started at a similar level of understanding (1)

The Facilitation methodology (1)

Topic 10. What did you find was the least valuable about the workshop?

The role plays (1)

Applying the draft toolkit as a group (1)

Would have liked more time on the basics (1)

4. Annexes Annex A: Participants list

type Name of participant Designation work country

1 Concern Sameh Gamal Ahmed Al - Awlaqi Nutrition Programme Manager, Darfur Republic of Sudan

2 Concern Isaack Hussein Nutrition Programme Manager, S. Kordofan Republic of Sudan

3 Concern Haroun Salih Mohammed Burma National Nutrition Advisor, Darfur Republic of Sudan

4 Concern Njoroge Kamau Senior Manager Health and Nutrition Somalia

5 Concern Du’ale Adam Nutrition Programme Coordinator Somalia

6 Concern Thembisani Maphosa Nutrition PM, Aweil (N. Bahr el-Ghazal) South Sudan

7 Concern Alice Awuor Health and Nutrition Coordinator, Aweil South Sudan

8 Concern Terefe Getachew Emergency Nutritionist Ethiopia

9 Concern Hussein Sied Emergency Manager Nutrition, Wolllo Ethiopia

10 Concern Joseph Odyek Surge PM Uganda

11 Concern Gudrun Stallkamp Senior Nutrition Advisor Uganda

12 Concern Rebecca Oketcho Emergency Nutritionist Uganda

14 Concern Sajia Mehjabeen Nutrition Advisor Global (based in Bangladesh)

15 Concern Margaret Bee Health Advisor Global (based in London)

16 Concern Suzanne Fuhrman Health and Nutrition Advisor Global (based in NY)

17 Concern Ciara Passmore CMAM Surge Programme Officer (based in Dublin)

18 Consultant Peter Hailey Consultant (worskhop facilitator) Global

19 MoH Salwa Abdelrahim Sorkatti Nat Nut Prog Dir - Fed MoH Sudan Republic of Sudan

13 MoH Nagwa Abdallah Idriss Nut Dir W Darfur State - MoH Sudan Republic of Sudan

20 MoH Hanaa Garelnaby Ahmed Garelnaby Nat CMAM focal point Fed MoH Sudan Republic of Sudan

21 MoH Albert Lule MoH Uganda

22 MoH John Anguzu MoH Uganda

23 MoH Dr Hufane MoH Somalia

24 MoH Onesmus Kilungu MoH Somalia

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25 MoH Gabriel Garang Lual Aweil North County Health Dept. South Sudan

26 MoH Andrew Wieu Kuac Dut Aweil West County Health Dept. South Sudan

27 MoH Shibiru Yadeta Nutrition Expert - Federal MoH Ethiopia

28 UNICEF Kidist Negash UNICEF-Ethiopia Ethiopia

29 IMC Suzanne Brinkman Nutrition Adviser Global

30 GOAL Sinead O'Mahony Nutrition Adviser Global (based in Dublin)

31 ACF Fabienne Rousseau Nutrition Adviser ACF

32 Save the Children Yusuf Gunu Save the Children Nigeria

34 ECHO David Rizzi ECHO Global

35 Save the Children Assumpta Ndumi Save the Children Kenya

Annex B: COUNTRY PLANS – WHAT IS NEXT FOR SURGE MODEL?

Country Ethiopia Note majority of the plan focuses on consultation as it is expected that this process will take at least 4 months. As Ethiopia are in the process of revising their CMAM guideline this is a prime opportunity to incorporate a note on surge into this revision. However in order to do this the consultation process will need to be expedited. With this in mind during the workshop the below consultation plan and request for external advisor support was discussed. This would be needed in order for the below plan to be achieved given the current emergency situation and workload of NGO, UNICEF and MoH staff who are based in country.

If the consultation process is successful and the approach ratified by the FMoH it is proposed to incorporate the surge approach into the planned pilot by UNICEF under the current CMAM guideline revision to introduce MUAC cut off of < 11.5cms for SAM case admission (replacing the former cut off of 11.5cm). The surge approach will assist in the expected 200% increase in referred cases during this pilot. Those present at the workshop believe that this would be possible even if surge is not incorporated into the current revision of the CMAM guideline and could act as the evidence base that FMoH may need to include surge in future guidelines. UNICEF have had a proposal to do this pilot in Sekota and if this is the case ACF – F who are working there would be happy to support the testing of the increased MUAC cut off and surge pilot.

Set-up stages ACTIONS INDIVIDUAL OR GROUP RESPONSIBLE FOR ACTIONS

Consultation Post workshop:

CWW to schedule a meeting with their PD, Kate Golden and Sajia Murjadee on the

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planned discussed for surge pilot / adoption in Ethiopia and request additional support for analysis of what surge can bring to Ethiopia and consultation workshop planning.

UNICEF to include recommendation in their briefing report to contribute to the surge consultation workshop in Ethiopia and in the pilot of MUAC 11.5cm for admission criteria for SAM management under new guideline.

MoH to include recommendation in their report to have a consultation meeting on surge.

GOAL and ACF to discuss and brief colleagues @ HQ and people in country and provide support on analysis and consultation workshop.

Prepare and analysis to present on what is being done in now in emergency preparedness and response in Ethiopia and what surge can add.

Coordinate consultation meeting with ENCU to brief FMoH on Surge.

If consultation process is a success and FMoH endorse model do the following:

1. Contextualise surge guideline to Ethiopia process

2. Pilot surge in UNICEF planned pilot of increasing MUAC cut off for admission of SAM to 11.5cm which is expected to be done once the updated guideline is finalised and the current emergency is over. Sekota is being suggested for this and ACF are working here and agree to host the pilot.

CWW

UNICEF

MoH

GOAL and ACF

CWW &ext Nut Advisor

CWW & ext Nut Advisor

CWW to lead and MoH and UNICEF to contribute and review.

CWW, ACF, MoH and UNICEF.

Dissemination to a wider level

Financing

Training

Planning (where, when, stakeholders)

Uganda Country Plan

Set-up stages ACTIONS Timelines INDIVIDUAL OR GROUP RESPONSIBLE FOR ACTIONS

Consultation Feedback, information sharing with the nutrition technical working group for feedback. 2nd May Albert

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and dissemination

Feedback to UN orgs and donors etc.

National level stakeholders meeting to brief the team on surge approach and share information.

Regional (Karamoja) level stakeholders meeting to brief the team on surge approach and share information.

Regular follow-up consultations

Specific district meetings, karamoja (DHO, DNCC)

May

3rd Wk of May

May/June

Ongoing.

May 3rd wk

MoH (Dr. Anguzu, Albert/Concern.

MoH/DHOs/Concern/

MoH/IDHOs/Concern

Financing Source finance for the training

Toolkit development/guide

Exchange visit (HF staff, MoH, Concern).

Sourcing funds for the surge support package (sources: donors, MoH).

May ongoing. MOH/Concern

Training Refresher training for the health workers.

Revision of thresholds

June/July MOH/Concern

Planning (where, when, stakeholders)

Development/refining of surge support/activities and costing

Costing of the surge support

Define/agree on process to adopt the surge tool to the Ugandan context.

Advanced development of Ugandan toolkit

Support from Concern Kenya

Q2/3/4

June/Jul/Aug onwards ongoing.

Q3/Q4

MOH/Concern

Concern.

South Sudan Country Plan

Set-up stages ACTIONS INDIVIDUAL OR GROUP RESPONSIBLE FOR ACTIONS

Feedback meeting/advocacy

Follow up discussion for planning for next steps in country with CWW and CHD CHD and CWW

Hold meeting at state level with DG and Minister CHD and CWW

Hold meeting at county level with CHD, County commissioner, and facility in-charge, and other in-charge – mostly just to tell them about what is surge, and could be as an add on to a coordination meeting rather than a separate meeting.

CHD and CWW

National level meetings

Find out the stage that the national level guideline review is at CWW

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Meet with Director of PHC CWW

Meet with HPF CWW

Meet with UNICEF (and WHO?) CWW

Piloting 5 in Aweil West

4 in Aweil North

Go through the steps of the Surge approach (beginning steps only?)

CHD and CWW

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Sudan Country Plan

Set-up stages ACTIONS INDIVIDUAL OR GROUP RESPONSIBLE FOR ACTIONS

Consultation 1. Introducing SURGE model to the health staffs, draft action plan based on the discussion

2. Consultation with CD and PD highlighting the ideas that came up from the health staff consultation meeting

H&N Program coordinator

H&N Program coordinator

and Program Manager

Dissemination to a wider level

MoH

TWG of SNS

Cluster

H&N Program coordinator

Program Manager

Program Manager

Financing The team will decide after internal consultation and formulating a country action plan. There is already some flexibility within the existing funding mechanism.

Will look for internal financing

Program Manager

Training Organize training for the CHWs for the SURGE that is expected to happen in May-June H&N Program coordinator

Planning (where, when, stakeholders)

Present the findings to wider community and seek for funding to scale up.

Set-up stages ACTIONS INDIVIDUAL OR GROUP RESPONSIBLE FOR ACTIONS

Consultation Concern to share resources and lessons learned from Kenya and Uganda

National level presentation on surge model for Technical Working Group (FMOH) outlining successes from Kenya and Uganda. Meeting to be led by FMOH, with Concern present.

Develop Concept note on Surge in Sudan

Consultation workshop – National level Attendees (UN, NGOs, donors, representatives from SMOH for the pilot states, FMOH officials). Facilitated by FMOH and Concern.

FMOH and Concern

Dissemination to a wider level

Orientation workshop at State level (1 day) Attendees – SMOH officials, Health Management Team (locality level – from selected health centres where pilot will take place) Facilitated by SMOH and Concern, with representative from FMOH

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Create small committee at State Level to oversee implementation of surge

Financing Approach donors (e.g. UNICEF, OFDA, WFP, WHO) to discuss surge model and ask for funding.

Discuss with Ministry of Finance

Training Training/planning session (including threshold setting) – at health facility - involving participants who will actually be implementing surge - locality health management team and HF in-charge from the selected health facilities (in afternoons at health facility). Facilitated in local language.

Planning (where, when, stakeholders)

Adaptation of materials to Sudan context

Translation of guide

Prepare facilities for implementation of surge

Pilot in 4 health facilities in 2 areas (total 8) – one where Concern works and one where Concern does not work (West Darfur and South Darfur) – for 1 year.

Review lessons from pilot – validation assessment

Adapt approach according to findings of pilot.

TOT to scale up surge at a wider level using facilitators who have personally been involved in surge approach

Support from global partners

Technical support – workshops, materials, implementation and monitoring, evaluation of pilot, review of findings from pilot

Financial support

Annex C: Facilitator’s Workbook

This workbook is for facilitators to capture parts of the discussion which are relevant to adapting the guidelines for global use. Add spaces below each question to create workspace for entering reflections of group work faciltator during each relevant session.

SESSION 2 – Generating ownership for Surge Model. Participants will role play standard responses to increases in acute malnutrition based on a provided scenario.

Be sure to capture what the actors and observer’s reaction to the standard support response.

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SESSION 4 – Introducing country experiences.

Record any relevant points raised during the Q&A session. SESSION 6 – Step 1 Trend and Risk Analysis. Participants will create the charts and conduct the analysis on seasonal trends and other factors affecting health seeking behaviours. Facilitators should recognize that participants may not be aware of the specifics of the location for which they have brought their data – support by probing questions. But do not allow them to get caught up in that individual HF, ex. If they know festivals affect health seeking behaviour they could hypothesize where and how it would have an effect.

Capture the reactions from the group as they work through the tools. What is working? What is not working? What reflections do they have?

SESSION 7 – Step 2 Capacity Development. Participants will work through the capacity review and gap analysis using the provided guide.

Keep the discussion focused on capacity to manage a surge and not just general capacity to manage CMAM services.

Capture the reactions from the group as they work through the tools. What is working? What is not working? What reflections do they have? SESSION 8 – Step 3 Threshold Setting. Participants will work through the calculations as well as debate some issues in threshold setting.

Note difficulties or comments as participants work through the calculations. Capture relevant arguments in the debate that affect threshold setting in the guide. Capture the “winner” of each debate.

SESSION 9 – Step 4 Defining and Costing Surge Activities. Participants will work through defining activities undertaken in a surge response. They should indicate those that can be done at a HF level and those that have no associated cost.

Capture the reactions from the group as they work through the tools. What is working? What is not working? What reflections do they have? SESSION 10 – Wrap up.

Note down any relevant reflections from the day that are relevant for the guidelines.

SESSION 11 – Step 5 Agreements and Documentation of Support. Participants detail types of agreements they would require and they adapt the Kenyan agreements for their contexts.

Capture relevant points on what types of agreements are required and how the MoU should be adapted.

SESSION 12 – Steps 6 & 7 Monitor, Trigger, Provide, & Scale Down. Participants role play the Surge Model response to increases in acute malnutrition.

Capture actor and observer reactions to implementing the steps as detailed in the guide. What works? What does not work? What needs to be

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adjusted so that it is more effective?

SESSION 13 – Reviewing and monitoring surge activities. Country teams review the indicator matrix to assess if it is practical and will be relevant for their context. Participants also discuss an ideal learning cycle for the surge model.

Capture reactions to the indicator matrix. Is it practical, relevant, necessary? Capture discussion about the frequency and style of an ideal learning cycle.

SESSION 14 – Moving Surge up to HMT Level. Country teams will define their reporting and communication lines and any changes that occur during a time of shock.

Note how reporting and communication lines are affected in times of shock. Capture relevant points of the discussion for how different levels of the MoH structure can/should be involved in the Surge Model. SESSION 15 – Drafting Country Plans.

Capture any bottlenecks, concerns, comments that country teams have as they are defining their next steps for the Surge Model. SESSION 16 – Next steps for Global/Regional level. PH moderates a discussion on the next steps required to support roll-out of Surge Model.

Capture relevant points from the discussion.

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Annex D: Facilitator’s Guide

Global Surge Toolkit Workshop Facilitation Guide

Items Required - Name tags - Attendance sheets for participants to sign - Copy of Guidelines (one per person) - Flipchart paper (2 or 3 packs) - Markers – 2 packs of assorted colours - Sticky tack/blu tack (for hanging etc. If not available get 2 rolls of masking tape) - Large size post-it notes (if not available get VIPP cards) - Health facility data per country from one small HF - Print out of guiding questions for Step 1 (15 copies) - Print out of capacity review and gap analysis guiding questions for Step 2 (15 copies) - Print out of summary actions table for Step 4 (10 copies) - Print out of Kenyan agreements (15 copies) - Print out of indicator matrix (15 copies) - Print out of format for the drafting of country plans (or on laptops) - Print out of workshop evaluation form (30 copies)

DAY ONE – WEDNESDAY APRIL 27

TH, 2016

Time Duration Presenter Facilitator Activity Objective Resources Required

9:00-9:20

Total 20 mins

Peter/Ciara

Concern

Kenya - Security

PH SESSION 1 - WELCOME

Welcome (10 mins)

1) Welcome participants and introduce Workshop topic 2) Key facilitator (PH) to introduce himself

Security brief (10 mins)

1) Security advice for Nairobi

- To acknowledge subject of workshop

- To introduce PH - To ensure participants

have the information they need to safely stay in Nairobi

9:20-10:20

Total 60 mins

PH PH SESSION 2 – OVERVIEW OF WORKSHOP - To get to know each other

Flipchart and

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Participant introductions (15 mins)

1) Participants share their name, position, organization, and any prior experience with Surge Approach with the plenary

Generating ownership for Surge Approach – role play (30 mins) 1) Volunteers are requested from the plenary to

participate in a role play 2) Roles required: beneficiaries, Health facility staff,

Community representatives, NGO staff, district and national MoH staff, UNICEF, donors, etc (more individuals can be added as appropriate)

3) Other participants are asked to be active observers (they will be asked to comment as the role play unfolds)

4) PH briefly describes a scenario where there has been a sudden and significant increase in cases of severe acute malnutrition (SAM) at a health facility (from 20 to 120 new admissions in one month)

5) Starting with the health facility level, the actors role play what would happen in such a situation during a standard (non-surge model) approach

6) After 5-7 minutes the role play is stopped and the observers are asked for the comments

7) PH then provides more information on the scenario – a new NGO with a lot of money suddenly arrives in the area

8) After another 5-7 minutes the role play is stopped for further comments from the observers

Recap (15 mins)

1) PH reviews set objectives for workshop, personalizing to highlight what came out in role play

2) Agenda is reviewed in plenary, highlight how it links with the objectives

- To generate ownership for the surge approach within each country team

- To begin to highlight how the CMAM Surge approach does things differently

markers

Scenario

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10:20-10:50

Total 30 mins

Tewoldeberha Daniel (UNICEF Kenya)

PH SESSION 3 - THEORY

Theory of CMAM Surge (30 mins)

1) What it is 2) What it isn’t 3) What it could be

- Introduce the Surge Approach concept

Powerpoint

10:50-11:05

Total 15 mins

BREAK

11:05 -12:05

Total 60 mins

Yacob Yishak (KE) Joseph Odyek&MoH? (UG)

TBD SESSION 4 – INTRODUCE COUNTRY EXPERIENCES

Kenya (30 mins) 1) Present country experience (20) 2) Q&A (10)

Uganda (30 mins) 1) Present country experience (20) 2) Q&A (10)

- Explore the experience of 2 countries in implementing the Surge Approach

Powerpoint

12:05-12:30

Total 25 mins

PH TBD SESSION 5 – INTRODUCTION TO THE GUIDE

Intro to CMAM Surge Guide (25 mins) 1) Introduce key steps 2) Introduce tools

- To increase understanding of the content and purpose of the Surge Guide

12:30-13:30

Total 60 mins

LUNCH

13:30-14:30

Total 60 mins

Group facilitators list

PH SESSION 6 – STEP 1 TREND AND RISK ANALYSIS

Session 6A - Group Work (45 mins): 1) Group discusses factors that affect Health Facility (HF)

workload 2) List them out, be sure to include factors affecting

malnutrition as well as those that affect HF access and health-seeking behaviour

3) Create a chart (2-year time span) of these factors ensuring that they are presented in the appropriate month, put this chart aside

4) Review data from the health facility registers, on recorded cases of diarrhea, pneumonia, malaria, SAM

- To ensure the Trend and Risk Analysis process in the guide is applicable across the countries present

Data from a HF (mock dataset will be provided if needed)

Print out of guiding questions for analysis

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5) Create a chart of the recorded admissions, using a 2-year time span

6) Using both charts together, analyse the information, use the print-out of the guiding questions. Ensure someone is recording key points of the discussion

7) Once the charts are analysed, shift the discussion to the current reality, ex, any current abnormal occurrences? If participants are not aware of the locality, have them imagine a scenario that would be suitable to their context.

8) Using the past analysis and any relevant current information, discuss what can be expected at this HF for the next 3 months

9) Facilitator to capture, in their workbook, any relevant points or difficulties the country team faces while going through the exercise

Session 6B – Gallery viewing (15 mins) 1) Hang the charts in the Gallery 2) Have one group member stay with the charts to

explain, while the other groups members rotate to view work of other groups

Flip chart paper, makers, sticky tack for hanging charts

14:30-15:15

Total 45 mins

PH SESSION 7 – STEP 2 CAPACITY DEVELOPMENT

Group Work (45) 1) Consider the same geographical area as in Step 1 2) Groups review the capacity of the health structure

using the guide and scoring system provided 3) Summarize the key strengths and weaknesses that

have been discussed 4) Finally, the group works through the key questions to

establish the health facilities capacity to manage CMAM services

5) Facilitator to capture, in their workbook, any relevant points or difficulties the country team faces while going through the exercise

- To ensure the Capacity Development step in the guide is applicable across the countries present

Capacity review/gap analysis guide

Mock data set to be provided as needed

15:15-15:30

BREAK

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15:30-16:15

Total 45 mins

Identify debate moderator

PH SESSION 8 – STEP 3 THRESHOLD SETTING

Calculations & Debate (45) 1) PH quickly describes the point of Step 3 – setting

thresholds. And describes the debate – we will be holding two separate brief debates which touch on two issues affecting the setting of thresholds

2) Participants break into 5 teams and before the debate they work through trying the calculation for validating thresholds. (15 mins)

3) Participants can use Tool 8 to guide them. Information for Parts A&B can come from their HF data used in Step 1.

4) Next each team is given a “side” they will support 5) Teams have 5 mins to prepare their arguments and

need to choose 1 debater 6) The first two teams will debate whether to use new

admissions or numbers “in charge” when setting thresholds

7) Each debater has 3 mins to present their arguments 8) Each debater will then have 1 minute for rebuttal 9) Plenary decides “winner” 10) The last 3 teams will debate whether to use objective,

subject, or a mixed method for validating initial set thresholds

11) Debate proceeds as in steps 5-7 above 12) Facilitators note key arguments and “winners” in their

workbooks

- To generate ownership among participants by debating some issues identified in threshold setting

16:15-17:15

Total 60 mins

Group facilitators PH SESSION 9 – STEP 4 DEFINING AND COSTING THE SURGE ACTIVITIES

Session 9A Group work (40) 1) Review the work in Step 1 & 2 from this morning 2) Using the post-it notes, participants write actions that

should be done to adapt and manage an increasing malnutrition caseload and a deteriorating health and nut situation. (ONE action per post-it only)

3) Consider different actions that would take place within different health system functions (HSS pillars)

- To ensure the Defining and Costing Surge Activity step in the guide is applicable across the countries present

Large size post-it notes

Flip chart paper

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4) Be sure to also consider specific community level actions

5) Go through the cards and indicate actions which a health facility could do themselves (highlight or circle these ones)

6) On a flipchart draw a curve as seen in Tool 9 of the Surge Guide (demonstrating a spike in admissions)

7) Place the post-its with the actions onto the curve, placing them in the respective phase they would be carried out in (ie. Normal alert, serious and emergency)

8) Facilitator suggests additional surge actions from master list in order to prompt discussion. Facilitators must also be clear that the activities are specific to surge and not just basic health system strengthening ones

9) Once complete, summarize the actions using the provided format

10) Put an asterisk beside actions that have a cost implication

11) Facilitator to capture, in their workbook, any relevant points or difficulties the country team faces while going through the exercise

Session 9B – Gallery viewing (15 mins) 1) Hang the charts in the Gallery

Have one group member stay with the charts to explain, while the other groups members rotate to view work of other groups

Markers

Sticky tack or tape

Formats for them to fill?

17:15-17:30

Total 15 mins

PH SESSION 10 – WRAP UP (15) 1) Review key points for the day 2) Set the stage for tomorrow’s work

- To summarize key issues brought up during the day

DAY TWO – THURSDAY APRIL 28TH

, 2016

Time Duration Presenter Facilitator Activity Objective Tools Required

8:45-9:00

Total 15 mins

PH Start-up Day 2 1) PH welcomes back participants 2) Collects any reflections from the first day 3) Sets tone for Day 2

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9:00-9:30

Total 30 mins

Group Facilitators PH SESSION 11 – STEP 5 Formalizing Commitments

Group work (30) 1) Country groups briefly sketch out what types of

agreements would be required to formalize the surge approach in their country, and briefly start to fill out Tool 13

2) Consider links between MoH-Partners, MoH-MoH (ex. district and national), and MoH-early warning systems, or other

3) The various agreements being used in Kenya are then distributed and country teams indicate changes that would be required in order to make it relevant in their context

4) Facilitators move through agreements step by step and probe for adaptations – highlighting if the key elements are there, are they specific enough etc.

5) Facilitators to note any relevant points in their workbook

- To define what types of agreements would be necessary to make the Surge Approach effective in different contexts

- To review and adapt the Kenyan agreements

Copy of Kenya Agreements

9:30-10:30

Total 60 mins

Group facilitators PH SESSION 12 – STEP 6&7 MONITOR, THRESHOLDS, SCALING UP & SCALE DOWN SURGE ACTIONS

Group Work – Role play 1) PH quickly describes Steps 6&7 in the Surge Guide 2) Volunteers are requested from the plenary to

participate in a role play 3) Roles required: beneficiaries, Health facility staff,

Community representatives, NGO staff, district and national MoH staff, UNICEF, donors, etc (more individuals can be added as appropriate)

4) Other participants are asked to be active observers (they will be asked to comment as the role play unfolds)

5) PH briefly describes a scenario where there has been a sudden and significant increase in malnutrition beneficiaries at a health facility

6) Starting with the health facility level, the actors role play what would happen in such a situation with the Surge Model in place and according to the steps in the

To ensure the sequence of events as detailed in the guide would work in the different country contexts

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Guide 7) PH stops the role play at the scale down – for Step 7.

Observers to comment. Participants asked to refer back to STEP 4 for the types of actions they had detailed in their plans

8) Facilitators to note down any aspect of the guidance that would need to be changed or adapted to work within the various countries

10:30-10:45

BREAK

10:45-11:45

Total 60 mins

Group facilitators PH SESSION 13 – REVIEWING AND MONITORING SURGE ACTIVITIES

Indicator matrix review (30) 1) Country groups review the Kenya indicator matrix and

contextualize for their setting 2) When reviewing the indicators, groups are to consider

the practicality of the indicators in terms of the type of information collected as well as the tools, frequency, etc.

3) Participants can indicate info collect as part of routine programming and that which would be surge specific

4) Facilitators capture relevant parts of the discussion in their workbook

Learning cycles (20) 1) In order for the surge approach to stay relevant, a

learning cycle should be established in order to ensure learning is incorporated into model design. This is the proof of concept phase for Surge and therefore there should be frequent review to assess effectiveness of the surge response

2) Country groups discuss the frequency and style of a learning cycle that would be appropriate for their context

3) Facilitators to capture relevant parts of the discussion in their workbook

- To review the suggested indicators and ensure they are context specific and practical

- To suggest a learning cycle that will ensure the Surge Approach is continually relevant and efficient

Indicator matrix

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11:45-12:45

Total 60 mins

SESSION 14 – MOVING SURGE UP TO Health Management Team (HMT) LEVEL

Diagram (20) 1) Country teams reflect on reporting and communication

lines in the MoH/partners from community up to national level

2) Create a diagram to reflect the relationships 3) Facilitator to probe with questions as to how these

relationships might change during shocks 4) Add to the diagram any changes that might occur 5) Facilitator guides participants to reflect on how this

affects the application of a Surge Approach 6) Facilitators notes any relevant part of the discussion in

workbook

Plenary Discussion (40) 1) PH moderates a plenary discussion on how to involve

different levels of MoH management in the Surge Approach

2) The discussion should cover how the DHMT will monitor their own capacity to assess when it is exceeded and how they will trigger upstream support (ie . if several HFs in the district are “surging”)

3) Can bring in experience from Kenya and Uganda?

Diagram adjustments (15) 1) Country teams take another look at their diagrams and

make any adjustments required based on the plenary discussion.

- To generate understanding of how reporting and communication lines are affected by shocks and what it means for Surge Approach success

Flip chart paper

Markers

13:00-14:00

Total 60 mins

Lunch -

14:00-14:45

Total 45 mins

PH SESSION 15 – DRAFTING COUNTRY PLANS

Work Groups (45) 1) Using the provided format, groups draft next steps for

the Surge Approach in their contexts 2) Facilitators capture relevant points in their workbooks

- To provide space and time for country teams to define next steps for the Surge Model in their individual contexts

Format for country teams to fill

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14:45-15:45

Total 60 mins

PH SESSION 16 – NEXT STEPS AT GLOBAL OR REGIONAL LEVEL

Plenary Discussion (40) 1) PH moderates a plenary discussion on the next steps

required at Global or Regional (?) Level in order to support Surge Approach roll-out

2) Discussion should touch on investments required, possible funding opportunities, coordination or tech support mechanisms (steering group?), how to capture and share learning on experiences, timelines, etc.

3) Facilitators to capture relevant discussion points in their workbooks

Individual Commitments (20) 1) All participants are asked to reflect on what they can

personally do to move the Surge Approach forward in their country or their organization

2) They write down 2 or 3 commitments 3) Participants are asked if anyone wants to share their

commitments with the plenary

- To support identification of next steps required at Global or Regional level to support Surge Approach roll-out

- To make individual commitments to support roll-out of the Surge Approach

15:45-16:15

Total 30 mins

PH SESSION 17 – WORKSHOP EVALUATION To assess if workshop has met its objectives

Workshop evaluation form

16:15-16:30

Total 15 mins

?? PH SESSION 18 – CLOSING

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Annex E: Summary of reflections from working groups (from Faciliator’s Workbooks)

Ethiopia Sudan Somalia South Sudan Uganda Session 2: Generating Ownership

Good participation and making people think of the different actors perspectives (eg. DHMT). Consider layout of the room, to make sure the observers can hear

Role plays was an important way of creating a feeling of what happens during emergencies where planning and coordination can be difficult delaying the response.

Participants appreciated the role play as a methodology in the workshop.

Session 4: Introducing country experiences

Caution should be used when comparing surge for declaring an emergency in comparison to the WHO thresholds. Given concerns around coverage of programmes and capacity of HF and staff surge cannot replace GAM rates. Both have their place and a different function.

Useful to hear from the Kenya and Uganda team from their learning

Session 6: Step 1 Trend and Risk Analysis

1. Difficult to do at health facility in Ethiopia as over 15000 s. Not much difference between health posts and overall woredas so not sure if it is worthwhile doing it per H or health post.

2. difficult to see the relationship between SAM and season if they are on 2 different charts.

3. Less is more –is this too much data on one chart and

They started by focusing on the data rather than the events calendar. It would be better to give them the data set later at the point they need it.

Participants preferred discussing in their own language – recommend translating the tools when using with HF staff.

Tool 1 – I suggest reordering the bullet points so that they list the factors before drawing chart. The examples are helpful to get people thinking (e.g. festivals, rainfall etc)

Flicking between the main

There are many external factors that affect the caseload in a particular area and so it’s really difficult to factor in events that will affect the caseload.

The health system depends on the support from other actors, sometimes multiple, so it also depends on the presence of other actors in the areas.

Population movement also depends on the conflict which in turn affects the caseload.

Made it on a smaller paper first to sketch it out

Workload of hf? Or is it workload of mothers?

From larger group: hard to know if the scale was bigger or smaller than expected

Mogadisu – calendar is very seasonal based, so chart is difficult if things are unpredictable.

But this should be practical about the past 2 years, or more generally about what happens year on year? Should make the events specific to what

It is important to reference link the steps with the tools at the annexes can be in brackets at the steps section .e.g. step 1 trends and situation analysis (use tool 11 page 40).

Where possible, there should be provision for the risk/situation analysis to be done on computer based excel sheet in computer.

There should be a template in the tools to

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difficult to understand.

4. Template to collect data needed to plot graph to be shared with HF to prepare this data.

operational guide and annexes confused participants. It was best just referring to the tool (annex)

Needed more time.

For the purpose of the workshop, it might be more straight forward to just use one year’s data not 2. They spent a lot of time trying to pull out the data from their programme dataset. It would have been useful to provide a template for them to fill in the data in advance. They may need 2 weeks notice to prepare the data.

It’s also very difficult to access morbidity data from the new health facilities and might not be possible to compare it with the SAM caseload

However, the caseload spikes always coincided with the rainy season and diarrhea outbreak

happened in past 2 years, and even include the things that happened that are unpredictable.

Workload of women not included in the chart

A template for data to give to HFs to help with organizing the data?

In Kenya it was ok because they used the DHIS data, but could do so that they get organized 2-3 weeks time

enable teams prepare the data in advance, which data and for what period of time.

It is good to put a suggestion in a box, for the health workers to challenge their assumptions which can be based on their routine knowledge especially when doing risk analysis e.g. assumption that diarrhea will come in a particular period or will automatically cause increased cases of malnutrition.

Possibility of doing a standard risk analysis for a region e.g. a district.

Session 7: Step 2 Capacity Review

HF Capacity

Some questions don’t lend themselves to being scored such as question 6 and question 10 which does not have a standard to score against.

Q7 if it answers no should skip to 10.

For Ethiopia applying to Health Post level which are a lower cadre to clinical nurses and so some of the questions did not apply.

Also as the tool is a little long would it be possible to do this across all healthposts our

A participant was frustrated that we kept jumping about in the manual and should be more systematic in order.

The participants struggled with working through the exercises and giving feedback on draft. It would have been better for this workshop to be a training in the surge model and how to implement rather than working through a draft toolkit. A workshop with a smaller number of senior staff (eg Concern Nutrition advisors) could have first commented on and refined the guide then the workshop could be for training country staff and dissemination of the tools as I don’t feel that after this workshop they will have the capacity to roll out the surge

Absence of health structure-unique situation.

Counter referrals and follow up of SC cases is an issue.

Country already doing some aspects of SURGE. The community clinic has a system to cope with increase caseload but it’s not beneficiary friendly. E.g., they are limiting total admission per day and have advised community volunteers to send only certain amount of cases per day when there is a spike. The system might overlook the beneficiaries and focus on the workload of the health

Self-assessment, and not knowing how compare to other HF

Feedback from larger group

Calculation difficult because some staff work only part of the day, some staff work at night. A way to look at how much they work per person, rather than a calculation of all staff working the same hours and seeing the same patients

What about recording times for consultation actually through watching with a stopwatch

Some formulas like this already exist and have been worked out in the area. So when this, you could use the existing

1-4 scoring as 1 as best and 4

The tools looks complicated to use, especially the scoring what is the baseline for you to say its weak, strong etc.

The first three questions, we may want to focus on key services rather all?

The tool needs to be very specific.

The tool looks long and if it can be done on its own on a separate day.

There needs to be clarification where there are many clinical staffs e.g. 7 of them as all may not be working at the same time and using the formula it gives a very high unrealistic numbers.

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would it be possible to use a sampling methodology such as LQAS per woredas to get a representative idea of functionality across the woredas.

Staff Capacity

No differentiation between new and reviews, these will take a different amount of time.

No appreciation for small breaks, other commitments.

approach.

Tool 4 – there are too many questions and some are not very clear. It would be better to refine these and just focus on the really key questions (e.g. Is SAM treatment included in BPHS? – rather than asking about all services provided). Sometimes tables would be better than questions (e.g a table of current staffing levels and vacancies)

Tool 4: Scoring worked well but it is more intuitive if higher score reflected better service (i.e. 1= weak, 4 = excellent)

Tool 5 calculation: It would be clearer if the number of consultation hours is calculated in minutes so that can easily divide by length of consultation

Tool 4&5 – instead of assessing staff capacity generally, participants prefer to focus on nutrition staff.

workers.

The questionnaire was too long and the intended user is not clear enough.

as worst but could be that 4 is best 1 is worst

Some questions difficult to score as don’t know what is the benchmark for scoring

New admissions taking longer, and considering that when calculating consultations

Did it help identify chronic weaknesses and acute weaknesses? For me, I didn’t see this questions as conducive to this type of thinking. And does it need to? Isnt the point to assess the current capacity, and then later prioritizing the ability to respond to surges.

As part of the tool 5 it should be clear from the beginning that this is for consultations for all patients regardless of the reason for visit, and not only for SAM (As this is not mentioned until the part on # of patients that can be seen in a day).

Also, how does this apply to when we want to set district level thresholds (like trying to do in Kenya).

For the tool, it is not clear if the score is given as a whole for all questions inside of 1 box, it seems like this is the case, but then it seems that there might be different scores based on the different questions in 1 box.

Also, if we focus on SAM only, then maybe questions in tool 4 should focus on this (but in

Good to look at the tool used by Uganda for staff capacity assessment and see if there is anything to borrow from it.

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first question it asks about all services that are there).

Is the timing (2 half day afternoons really realistic for these first 3-4 steps) realistic? Talking to Joseph from Uganda it seems like it takes more time than this…..we want to keep it simple, but we also need to be realistic about what it takes.

Session 8: Step 3 Threshold setting

Tool 8 uses ‘new admissions’ in titles but uses caseload in text under title so not clear what the threshold is based on.

In Ethiopia do not use the term ‘caseload’ but use the term ‘total in programme’ so if caseload is chosen for thresholds should be explained well in guideline.

Discussion on caseload vs

new admissions going for caseload as new admission does not represent the full burden on the health facility.

Discussion on calculating

thresholds feeling at the table was that a mixed methods approach is best as it takes the context into account and allows the health facility / district health workers have a say.

Rather than calculate average (which is shewed by the surge) it is better to look at median or make an estimation of average in the non-surge months.

Debate: a good interactive method to discuss the difficult questions/considerations.

For Caseload: - Workload at the facility is

the main thing we want to address.

- Timely monitoring is possible

- It’s perfect for OTC, it will relate to the preparatory activities.

- They also take up as much time as new admission.

- If the focus is only on new admission, there is a risk of not enough focus on existing cases.

For Subjective (discussion and experience): - SURGE is about HSS and

not introducing new things. The formula was complex and needed explanation.

- HW knows the context and they know best.

- More flexible and takes into account what is happening and that’s what SURGE is about

For Objective (calculation): - Based on evidence and

will get solid and consistent result and can

The calculations for ‘normal’ of multiplying by 3 only makes sense in places with low average number of new admission (like 5 or less). But it doesn’t make sense in places with higher average number of new admissions. In these cases, a 1.5x calculation make more sense (for example when there are 16 average new admissions per month). Maybe the calculation has to be based on the context. Could this multiplying factor be standardized somehow, like in places of ‘low’, ‘average’, ‘high’ new cases.

Idea of new admissions for in-patient, and caseload for out-patient.

Clear directions need to be given to avoid confusion between the calculation for the capacity assessment and the one for threshold setting.

Good to put an explanation on why we are using 75%, 20% 4% etc, how did we end up with these figures.

The subjective threshold setting gives a greater flexibility and sense of control by the health workers.

The team feels using new admissions is more objective for the following reasons; not affected if there are technical issues with the nutrition program and children overstaying in the program, its clearly demonstrate deteriorating nutrition situation and is useful as an indication of a looming emergency. On the other hand, caseload is useful

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also avoid bias - Need base support - Easy to justify support to

donors and stakeholders. Mixed Method: - Consider staffing capacity

and supplies anf objective method provides overall validation

Need to simplify the threshold calculation for the health staffs.

as it depicts the workload.

The team felt that guided mixed method of threshold setting is preferred as it allows for flexibility as well as seal loopholes for misuse.

Debate in support of caseloads;

Caseload reflects the workload at the facility.

For OTP cases, workload is almost similar even during re-visits they got to do the checks, appetite test etc.

Caseloads are inclusive of new admissions.

Session 9: Step 4 Defining & Costing Surge Actions

Difficult to move conversation away from current policy, important to keep in mind for country specific trainings.

As CMAM is decentralized in Ethiopia a sense that a number of these tools are being used at the moment.

On costing it wasn’t clear if it was new additional costs or current costs i.e. RUTF supply or the additional costs i.e. additional RUTF supply.

Menu of surge acitivities

might be good to color code them for normal spike, alert, serious and emergency as per the box color coding this in the at the beginning of tool 11.

Don’t think transport

This has been the best session so far. Participants really engaged in the process and thought of lots of ideas. It was helpful to start with a brainstorm and get them thinking about different activities for the 6 building blocks of HSS, then refer to tool 11 afterwards for extra ideas. This session felt like less of a rush than earlier sessions.

Useful exercise to emphasize the importance of planning before a surge.

Participants found this exercise good (“this one is the best exercise”), but commented that yesterday’s sessions were confusing and recommend simplifying the guide.

This exercise was focused on the Health Facility but participants though that it would be useful to

Hard to talk about what we are already doing and what would be a part of sure (as there are gaps in what is supposed to be there, so that was talked about a lot)

Didn’t really think of new activities, but more about things that we are normally doing or know that should be done. But somehow I wanted them to think of new things and be creative about what can be done during a spike.

From group feedback: moving staff from outside the state – needing decided at state or national level

From table: currently in South Sudan they are reviewing the IMAM guidelines, so national level is busy with that. Maybe we can talk to them about

The tool generates good discussion among the team. Going through the building blocks one by one limits the team thinking rather the teams can randomly think about what they can do and later on try to classify them in the different building blocks and check areas they left out.

Step three should mention draw the chart on a plain flip chart.

The building blocks should be displayed close to the tool 9 to give a snapshot to the users.

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provision is feasible at any stage of an emergency in this context. Allow current ambulance to be used for SAM transport.

Changes will take a long time to cascade down to the community level after integration into the CMAM policy.

include higher levels too (eg. coordination meetings at HF and district and state level)

MOH staff said that for Surge it is better to differentiate between activities that can be handled at facility level, state level and federal level and define roles and responsibilities

including this (just a paragraph)

From CHD – there are these gaps that are already there, even the attitudes of the community. But things about the attitudes of the community, and some have food and finding the root causes of these things. So needing to work in community and strengthen.

Community part is missing. This is on treatment but not on working before that.

Surge should be viewed as a part of CMAM/IMAM and part of the on-going efforts. Even part of the oniong efforts, like community health strategy.

How to do this when there are different NGOS working in nutrition in the district? Reply that this can be govt led at coordination level.

From the guide about what is done in this stage – I don’t like how it is only to make a ‘surge package’ at dhmt level. What about an agreed surge package at facility level (mostly for ‘alert’ phase.

Session 11: Step 5 Agreements and Documentation

Structures in Ethiopia are very clear, once a model is evidence base and FMoH ratify approach and endorse it, system for cascading down from regional, zonal, woreda and kebele level is clear.

When document is signed by the head of the

Federal MoH will take the lead. Need agreement at national level between the different partners about introduction of surge.

MOU at State level – Concern and MOH

Also need to involve partners, donors,

No agreement needed. However, might need an addendum to the existing MoU to modify the admission criteria during emergency.

Meeting first for advocacy on this approach

MOU – CHD, DG at state, partner – 1 year currently, and this would make sense for surge too. Maybe as addendum to the MOU.

HFs that are for nutrition currently, but discussion of wanting to do nutrition in other

The MoUs may not be necessary for between the facility and the district management level but it is necessary to have some form of formal commitment to ensure that they are taking responsibility of some sort as well as for

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bureau so ppl in that department do not know about the agreement and what it entails. Before signing agreement all stakeholders should be briefed on their role and responsibility within the surge. This could be part of the agreement. Can hold a workshop to explain roles and responsibilities.

Who signs the agreement is dependent on budget amount i.e. <3 million @woreda level.

Health sector plan, coming up from kebele, woredas, zone and region. Review last years situation and sign agreement between Fmoh and Rmoh. Emergency is in a separate plan. Seasonal spikes are included in the one year plan.

Discussed surge team within ENCU. Gave overview of Ebola preparedness team in NDRMC.

After role play discussion points:

o Model empowers HF instead of coming to them afterwards with GAM rates and telling them like it is an emergency. Allows buy in from HF in CMAM scale up.

DHMT and HF.

The group got bogged down in the details of federal involvement and we didn’t get the time to discuss the finer details of other stakeholder involvement.

facilities

Coordination, supervision

We did not discuss national (We have no one from national level here), talk was mostly about how to agree at county level

Tewolde – about making sure national level is already aware before the spikes

Wording for levels (normal, alert, serious, emergency) – something else instead of calling it an emergency? 3 levels instead of 4?

them to be aware about what to expect.

Some of those suggestions in the pg 49 are detailed e.g. timings and processes making which may make the document long, it can be kept simple borrow from the current practice for the country.

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o NGO delivered RUTF rather than MoH or UNICEF.

o National level actors and some donors left out.

Session 12: Steps 6 & 7 Monitor, trigger, provide support

It was useful to repeat the same role play.

In Sudan, authority starts from district level. Health facility level has limited decision making, they see themselves as employees and refer to the district. For surge it is important to work at district level. So part C will be useful.

More able to handle on their own

HF staff know what is happening and what should happen

Role of Dhmt as central to the approach

Issue of who will pay for extra transport for additional supplies, and also for the trips to go an see if the situation is ‘validated’ at the HF, and coordination meetings

Waiting has to be reduced, for all the different level for action to finally take place

Session 15: Drafting Country Plans

Main bottleneck is buy in from the FMOH in Sudan. But some FMOH officials have visited Surge in Kenya and Salwa has attended this workshop and is on board with the approach and will advocate within FMOH for a pilot of the surge approach.

Also it was noted that often for workshops the people who are present are not the people who will actually be implementing so it is important to hold workshops at health facility level.

Importance of translation of tools and facilitation of HF workshops in the local language.

The teams involved seemed to be from the regional level and though they knew the system well, they felt that their authority reaches certain level where they will need to be seeking approval for the higher authorities; as such they could not set timelines with certainty.

The team seemed to agree on the next steps easily except the MoH teams were not very clear on the entry level of the national level team, when and how to involve them.

Having had prior

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experience it was easy for the team to schedule activities.

Team planning to tailor the guidelines to Uganda

Plans to focus on few districts them gradual scale up

Need for technical support from Kenya as well as exchange visit.

Session 16: Next steps for Global/ Regional level

Concern/consultants to make briefing pack available for participants to use back in their countries

Surge approach on ENN? – idea from Gudrun

Funding to agency to give tech support on Surge approach – idea from Gudrun

Countries say they want to keep connected