CFR Joint Needs Analysis and Response Strategy - PowerPoint Presentation

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CFRJoint Needs Analysis and Response Strategy

26 November 2019

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GeographyA northern African country with surface area of 1,759,540 sq.

kmShares border with Egypt, Sudan, Chad, Niger, Algeria and Tunisia and has 1,770 km long coast with Mediterranean Sea. 90% of the country is desert or semi-desert, 8.8% of it is agricultural land and mere 0.1% is forest. This geography influences the population distribution: Mediterranean coast harbours 90% of population, while Saharan part is scarcely populated

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DemographyTotal estimated population is 6,754,507 with annual growth rate of 1.45% (July 2018 UN estimate

).Total fertility rate of 2.03 children born/woman. 12% of the population is immigrants, while male/female ratio is 1.07.Overall life expectancy at birth 76.9 years.80.1% of total population is urban with annual rate of urbanization of 1.68%. Tripoli (1.158 million), Benghazi (799,000) and Misratah (801,000) are the main population centres.96.6% are Muslim and other 2.7% are Christian.Broad based population pyramid, i.e. 42.34% of the population is 24 years or less, while 47.47% is in the range 25-54 years and over 10% is aged 55 years and above.

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Map of Libya showing migration roads:

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Epidemiological Transition: Disease Threats

Polio free country since 1991Measles: Elimination PhaseMalaria FreeLimited TB MDR CasesBest Immunization ProgramHigh Risk of polio outbreakWitnessed National outbreakRe-emergence of indigenous malaria casesMDR cases on rise having no proper strategy for managing it.Measles, Pertussis, etc. on rise

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Minister

Under SecretaryDirectoratesLegal AffairsMinister ‘s Office OfficesInternational Cooperation

Internal Auditing

Health Information Center

Human Resources Development Centre

National Center for Diseases Control

National Council for Medical responsibilities

Board for Medical Specialties Training

Air ambulance Authority

Libyan board for medical specialties

Medical Supply Organization

Ambulance services Authority

Health Facility Accreditation Centre

Ministry of Health

Health Projects

Admin & Finances

Press & Health Education

Treatment

Affairs

Health Planning

Medical Services

Drugs & Medical Equipment

Primary Health Care

HRH

Medical Insurance Corporation

Central hospitals & Medical Centers

Polyclinics

Primary Health Care Corporation

Emergency

Inspection & Follow up

libyan Centre for Pharmacco vigilance

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Existing Health workforce (Physicians, Midwives/Nurses)8.68/1000 population

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Review of Accreditation Standards of Three Selected Major Undergraduate Medical Education Institutes of LibyaBasic Standards (MUST)

Quality Standards (SHOULD)

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Limited institutional capacityMultiple governments (or areas with none)Health worker density variable and erratic

Non-transparent procurement and distribution system for drugs and suppliesGross disconnect between central and municipal governancePreventive services not supportedLiquidity crisis (little cash available); inflation rate increased by 30%Limited capacity of the health system urged some partners to bypass the system and work with private centers which is not sustainable and cost-effective (TB and HIV).There is an alarming increase of attacks on health care facilities. 11Libya’s health system: challenges

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In 2019, continued conflict and its rapidly shifting lines, migration, displacement and mounting health needs call for an urgent response to strengthen the availability of accessible, equitable, available and sustainable health care services across the country (limited capacities, shortages of staff, medicines, equipment and supplies, lack of investment, and transparency and accountability). Structural challenges:

Fragmentation at all levelsHospital-centric approach Gaps in the medical supply chain management Weak institutional capacity Weak routine surveillance systemsMany people (Libyans and non-Libyans) lack sustained access to primary and secondary health care services. Health is reported in top 3 priorities among refugees and migrants in the West, East and South (source: MSNA).PRIORITY NEEDS

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Health facilities in Libya remain susceptible to regular attacks. Thus far in 2019, there have been 60 attacks on health care. A total of 75 people were killed and 49 were injured in these attacks, compared with two people killed and 15 injured in 2018. 70% of these attacks have occurred in Tripoli and surrounding areas. A high number

of public health care facilities, especially at PHC level, are closed and in need of repair and rehabilitation. Out of 1145 assessed (October 2019) PHC facilities in 21 districts and 85 municipalities in Benghazi, Central, East, South, Tripoli and West, 897 (78%) are open and 248 (22%) are closed. Main reasons for closure: damaged, occupied, under maintenance (both short- and long-term), no access, no staff, no people, being upgraded to a hospital level. Out of 88 public hospitals located in Benghazi, Central, East, South, Tripoli and West regions in 21 districts and 53 municipalities, 78 public hospitals (89%) are open and 10 public hospitals (11%) are closed. Main reasons for closure: “damaged” and “being under maintenance” (both short- and long-term). PRIORITY NEEDS

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The lack of security across the country has hampered the population’s access to health care services and led to severe shortages of medicines, medical supplies, and vaccines. Table 1. Availability of essential services across the public PHC facilities (% of open facilities)

All 5 types of essential services are offered only in 121 (13%) out of 897 open PHC facilities.No services are available in 230 (26%) of open PHC facilities. Table 2. Availability of specialized services across the public hospitals (% of open facilities)All 6 types of essential services are offered only in 5 (6.4%) out of 78 hospitals; 2 types of services in 13 (16.7%) hospitals; 1 type of service is offered in 9 (11.5%) hospitals and no services are offered in 7 (9%) hospitals. PRIORITY NEEDS 

Antenatal care

Immunization services

Preventive and curative services (under 5 years old)

NCD services

Surgical services

Essential services

70%

49%

59%

42%

74%

 

Delivery services

CEmONC

Child Health

Mental health

Emergency

Major surgery

Essential services

61%

49%

72%

14%

63%

52%

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Table 3. Availability of essential medicines (top 20) in PHC centers and hospitals (% of open facilities)

PRIORITY NEEDS PHCHospital

Zero available essential medicines

33%

 

1-5 of essential medicines

39%

18%

6-10 of essential medicines

25%

47%

11-15 of essential medicines

2%

24%

16-20 of essential medicines

0.3%

9%

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The conflict has also highlighted regional disparities in health care. Table 4. Regional disparities: Non – availability of services, vaccines and medicines across open PHC facilities (% of open facilities)

PRIORITY NEEDS Antenatal care

Immunization services

Preventive and curative services (under 5 years old)

NCD services

Surgical services

No essential services

Vaccines (Hexa and MMR)

Zero available essential medicines

Benghazi

61

34

53

28

77

15

40

31

Central

69

40

73

46

62

13

87

18

East

60

41

43

25

60

25

59-60

77

Tripoli

62

51

44

22

78

17

62

27

West

83

64

73

57

84

42

64

20

South

80

28

75

57

55

14

32-64

32

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The key findings of 2019 PHC level assessments (source: IMC) demonstrate:Staff lacks the needed trainings…A PHC lacks specialized response in terms of the reproductive and mental health capacity…. There is a shortage of staff with no general or specialist doctors, psychologists, midwives…There is no capacity for ante-natal, pre-natal care…A PHC lacks a proper referral system and ambulance services…

Lack of data for evidence backed nutrition programing…Similarly, the key findings of hospital (Teaching Hospital and Medical Center) level assessments identify: Shortage of trained staff, medication and medical supplies, lack of proper maintenance led to non-functionality of a larger number of equipment… This may lead to the referral of a large number of trauma and emergency related patients to other institutions…In addition, this may serve as a reason for closing down the inpatient department… Lack of comprehensive nutrition program in health facilities (timely identification and appropriate treatment) ...PRIORITY NEEDS

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Health needs are increasing in conflict areas. There are insufficient numbers of mobile clinics/teams to meet essential health care needs.The continued fighting has restricted the movements of health workers

and of people seeking health care services in conflict affected areas. The most requested needs for medical specialty are general and specialized surgeons; orthopedic specialists; imaging, CT and MRI personnel; anesthesiology; and pediatry. In addition, the needs for dermatology, neurology, ENT, general practitioner, gynecology and obstetrics, ICU, endoscopy, urology, infectious specialists. Care for patients with chronic diseases (cardiovascular, cancer, diabetes, etc.) and disabilities are also compromised. Cardiovascular disease are major killer (35%) followed by cancer (12%), diabetes (3%) and chronic obstructive lung diseases (3%), while other NCDs cause 18% of the deaths (source: MoH). More than 20% of migrants reported having been diagnosed with chronic illnesses. Female migrants get more diagnosed with chronic illnesses compared to males (source: IOM). 19 PHC facilities surveyed in Tripoli, Misrata, Sabha, Alshati, Benghazi did not have the required stocks of NCD medicines (source: IOM). Implementation of a comprehensive evidence based nutrition program focused on vulnerable population to prevent all kinds on malnutrition. PRIORITY NEEDS

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Trauma patients add to the burden on hospital staff. Lack of ambulances and proper emergency referrals are reported. This directly affects normal delivery and neonatal care services (source: IMC). Murzug clashes clearly indicated a very high toll of casualties (95-105 killed and 220-270 injured) within a period of 2-3 weeks. Armed conflict reportedly resulted in some 3,000 casualties. Reproductive health services are

inadequate: Apart from Emergency Obstetric and Newborn Care (EmONC) and antenatal care services (with an alarming increase in C-sections), the remaining SRH services are scarce or unavailable. For instance, postnatal care, family planning, management of sexually transmitted infections, prevention of mother to child transmission of HIV and voluntary counselling and testing are collapsed in the public health system. Specialized health workforce and midwives are unavailable not only in southern Libya but other conflict-affected areas. RH commodities and medicines are unavailable or mismanaged leading to a drastic increase in out-of-pocket expenditures.There have been different reports of vaccine stock-outs across the country. Vaccine (Hexa) is not available in 558 (62%) of open PHC facilities. Vaccine (MMR) is not available in 541 (60%) of open PHC facilities. This poses a threat of outbreaks of vaccine preventable diseases such as measles and polio. Most districts and municipalities have seen a spread of preventable infectious diseases such as tuberculosis, leishmaniosis, acute watery diarrhea, measles, pertussis and acute respiratory infections. Increasing electricity cuts have affected equipment and services in health facilities. Maintenance of medical equipment is inadequate. The disease surveillance system lacks sustainable technical and financial support with its current 125 sentinel sites. The rapid response capacity is challenged by the limited capacity and lack of recurring support. PRIORITY NEEDS

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A specific focus on migrants and refugees: Top 4 most common barriers accessing health care are lack of money, distance, lack of staff, no health facilities to accept refugees/migrants (source: MSNA).71% of migrants reported to be able to access health facility partially (reasons related to high cost for services (47%), lack of safety (20%), bad quality of services (15%) while only 26% reported to have full access to health facilities without constraints. This remains similar for Libyans with undetermined legal status.

In detention centers people with special needs, people with mental health issues, and people chronic illnesses are in critical need of healthcare support. There is a considerable decline in the overall health status of the individuals due to overcrowded living conditions, bad hygiene practices and unsafe water, nutrition status which additionally contribute to the spread of infectious diseases (source: IOM). 32% of surveyed migrants reported not taking any medication if suffering from acute diseases. 13% of migrants who had suffered from a health condition reported no treatment being received. 26% of migrants received treatment at private hospitals/clinics and 53% directly utilized services of a pharmacy. 33% given birth in the last 2 years - of them 93% used Breast Milk Substitute before 6 months of age.PRIORITY NEEDS

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Libya is a middle TB burden country. However, the country is hosting migrants and refugees from low- and middle-income countries with higher burdens of TB. Data for Libya in 2018 show that the number of notified TB cases increased by 33% between 2017 and 2018, suggesting a serious worsening of the problem.According to NTP, 1815 TB cases were registered in 2018, of which 10 are multi-drug resistant (MDR) or rifampicin-resistant (RR) organisms. Migrants from low- and middle-income countries with higher burdens of TB accounted for 22% of all 1815. Between

January and June 2019, 1066 new TB cases were registered. Data from NTP in September 2019 show that the number of either MDR or RR were 23 cases.As of August 2019, there had been six deaths from MDR TB.PRIORITY NEEDSBacteriologically confirmed pulmonary TBClinically diagnosed pulmonary TB

Extrapulmonary

TB

Libyan

Male

159

Libyan Male

75

Libyan Male

 

130

Libyan Female

84

Libyan Female

40

Libyan Female

191

Non Libyan Male

130

Non Libyan Male

100

Non Libyan Male

116

Non Libyan Female

16

Non Libyan Female

8

Non Libyan Female

17

TOTAL:

389

223

 

454

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PRIORITY NEEDSIn 2018 number of TB-HIV cases were 22 cases (21 Libyan & 1 non Libyan).Number of TB cases <15 years in 2018 were 75 cases (64 Libyan & 11 non Libyan).

In 2019 from January-June, TB cases <15y were 42 cases. 22As of August 2019, there had been six deaths from MDR TB.Approximately 700 migrants (of whom half are living in communities and the other half in detention centers) are being treated for TB.

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PRIORITY NEEDSTB in Detention CentersMigrants are often kept in unventilated, and overcrowded hangars, creating conditions for the spread of TB

.In 2018, there were 250 TB cases in detention centers. As of October 2019, this number had already risen to 423.Humanitarian organizations are responsible for providing health care services for migrants in detention centers and for reporting TB cases to the NTP for inclusion in national statistics. However, they don’t have regular access to the detention centers.The lack of clarity over the roles and responsibilities of different agencies working in the detention centers has resulted in duplication and overlap in the provided services.23

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PRIORITY NEEDSGaps and challenges with TBInadequate screening for the early detection of people with TB in detention centers

and host communities. Severe shortages of X-ray machines, laboratory equipment, diagnostic tests and trained staff to diagnose patients with TB.The lack of a national strategy and inter-ministerial approach to manage TB patients among migrants and refugees both inside and outside detention centers.Lack of isolation units, and severe shortages of second-line medicines to treat patients with MDR-TB.No mechanism to refer migrant and refugee TB patients who require hospitalization. Currently these patients are being referred by humanitarian organizations to private clinics on an ad hoc basis, at considerable cost.24

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In Libya, mental health is a chronically neglected field, with very limited mental health and psychosocial support and rehabilitation services (source: 2015). The country does not have a Mental Health Policy or legislation with insufficient trained staff in the field of mental disorders and disabilities. The conflict increased the proportion of the population in need of acute psychosocial support.

There is an existing gap for mental health patients to receive care, with most of them applying to private health facilities while capacity of public health is not adequate and sufficient. There are only two Mental Health hospitals (Tripoli – Benghazi). Two mental hospitals have the capacity of 700 beds (12 beds per 100,000 population). No beds available exclusively for children and adolescents.There are no services for child psychiatry, Forensic psychiatry or Geriatric psychiatry.Mental Health services in PHC is extremely limited.PRIORITY NEEDS

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The total Mental Health workers per 100,000 is 8.1. The breakdown according to profession is as follows: 0.97 psychiatrists, 0.16 other doctors, 5.3 nurses, 1.04 psychologists and 0.58 social workers. The number of psychiatrists working in private and public mental health practice is around 60 psychiatrists in all Libya.There is a remaining high level of “mistrust” to health facilities due to lack of medicines, supplies and updated equipment needed to treat MH problems. Various barriers to access to formal care for people with MH problems, existing stigma towards them are common. The key coping mechanism remains minimizing exposure to community (source: HI).

There is no public addiction centre in Libya (there are 2 private addiction centres).Lack of physical rehabilitation services factored by: lack of access to essential services; lack of availability of essential services; and lack of information about available services (source: HI).PRIORITY NEEDS

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Mental Health Needs in LibyaBuilding capacity of the Mental Health workers.Establishing addiction centers, and psycho-trauma centers due to the increasing needs of the country during and after conflict for the affected people.

Implementation of schools mental health programs.Create mental health information system.Reactivate the previous National campaign for raising awareness of mental health in the country.Integration of Mental Health Services in primary, secondary and tertiary y general hospitals through Mh-GAP to help pts with mental health problems without Stigma.PRIORITY NEEDS

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Health sector methodology: 3,970,842 people as number of people in need of health assistance.Acute PIN in health:

Severity scale 4: 1,662,586 peopleSeverity scale 5: 122,485 peopleTotal: 1,785,072 people People in need GroupsPeople in Need Inter-SectorTarget Inter-SectorPeople in Need in Health

Target in Health

IDPs

219,142

93,558

128,090

56,156

Returnees

74,314

67,768

42,903

38,679

Non-displaced

256,013

48,880

151,621

29,190

Migrants

299,782

84,037

184,202

50,090

Refugees

48,215

48,215

28,472

28,472

TOTAL:

897,465

342,452

535,287

202,587

OCHA methodology:

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SEVERITY SCALE

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30

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High level of trauma and burns related injuries. Vaccine Preventable Diseases: Measles and Rubella outbreaks reported in some areas in 2019. There were total of 164 measles cases confirmed by lab, and 38 confirmed rubella cases registered in January-September 2019 (source: Measles Elimination Program). 384 reported cases of pertussis could lead to further complications, deaths and disabilities (source: EWARN

). Outbreaks of VPDs is expected due to: Recurrent interruptions of vaccine supplies. Cold chain problems due to long hours of power outage. Continuous influx of migrants from endemic areas. Poor performance of EPI program in the hard to reach areas.Water borne diseases: In 2019 the risks for hepatitis A or E, and shigellosis outbreak were high. The circulation of acute Jaundice syndrome continued (1119 suspected cases) affecting children in most municipalities (source: EWARN). 1500-2000 cases of acute diarrhea get registered every week. The possibility of cholera outbreak occurrence continues to be very high in Libya considering the migration flows from the neighbouring countries and problems in WASH sector.Vector-borne Diseases: Cutaneous leishmaniosis is spread across the western region and Nafosa Mountain. In October 2019 a total of 3660 cases were registered (source: EWARN). Similarly visceral leishmaniosis is spread across the southern Libya with patients traveling to the north, Benghazi area. Scabies have re-appeared in Libya. CHANGES IN 2019

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Surveillance system: The disease surveillance system lacks sustainable technical and financial support with its current 125 sentinel sites. Rapid response teams: The rapid response capacity is challenged by the limited capacity and lack of support. Child health:

About one-third of municipality facilities provide a very limited package of child health care, focusing on diagnosis and treatment of diarrheal diseases and respiratory tract infections. The well baby clinics and the growth and development monitoring are almost non-existent.Sexual and Reproductive Health and gender-based violence services: Sexual and reproductive and GBV health services are facing alarming accessibility, availability and quality issues. Birth spacing component of the family planning services remain basically non-existent in the public facilities, but is mainly offered by private sector. Access to public GBV services by female refugees is highly challenged. CHANGES IN 2019

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60 attacks on health care, killing 75 and injuring 49 people. 23-25% of assessed 1145 public PHC facilities are closed. 0% of essential services are available in 230 (26%) of open PHC facilities. All 6 types of essential services are offered in 6% of open 78 hospitals. 33% of open PHC centers do not any of the required (list of 20) essential medicines. 9% of open public hospitals have the required list of essential medicines. 83% of open PHC centers in the West region and 80% in the East region do not have the required antenatal care services.

64% of open PHC centers in the West region and 51% in Tripoli region do not provide immunization services. More than 73% of open PHC centers in the Central, West and South regions do not provide preventive and curative services (under 5 years old). More than 75% of open PHC centers in Benghazi, Tripoli, and West regions do not provide NCD and surgical services. 25% of open PHC centers in the East and 42% in the West regions do not have provide any of 5 essential services. 77% of open PHC centers in the East and 32% in the South regions do not have any of the required essential medicines. Vaccine (Hexa) is not available in 558 (62%) of open PHC facilities. Vaccine (MMR) is not available in 541 (60%) of open PHC facilities.700 migrants (both in communities and in the detention centres) are being treated for TB.KEY FIGURES/TRENDS

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Specificity of the health sector composition – 34 actors (6 UN agencies, 13 INGOs, 2 NNGOs, 2 National Authorities, 7 Donors, 4 observers). Only 10 are active in a regular information sharing. A strong lack of national NGOs with potential or current health projects. The present distribution of humanitarian assistance and operational presence is

largely disproportional while mainly focusing on Tripoli and Benghazi areas. The predominant number of other districts and municipalities remains non-covered by humanitarian health services for various reasons, including security, lack of funding, while health needs are well-recognized in those areas. Health sector earlier developed and agreed upon on a number of preparedness and response documents, where roles and responsibilities were assigned and all related points covered, including: Scenario-based Contingency Plan, Annual Emergency Preparedness and Response Plan, Health Sector Response Strategy, Minimum Health Service Package. The health response has been limited until now to the national, local health authorities and a few humanitarian agencies and organizations. A number of present health sector organizations have not demonstrated the expected flexibility to shift operational response. RESPONSE ANALYSIS

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A better dialogue is necessary with the national authorities on exchanging information on levels of provided assistance while fully recognizing the leading role of the authorities in support of referrals/evacuation, delivery of health supplies, enabling vaccination response, continuation of care for patients with chronic needs, provision of approvals for humanitarian organizations, etc. Rapid response mechanism should be more effectively continued via different modalities, including replenishment of health supplies, support to the referral hospitals, and deployment of specialized health teams, especially for post-surgery care.

Health sector funding under 2019 has reached only 23% (out of 45 million USD). In 2019 there was a need of continuous advocacy at all levels for: Securing access for supplies (medicines, consumables and medical equipment) and medical teams to meet critical needs across the country.Securing an effective system for referral and evacuation of critical medical cases to medical facilities across the country.Agreeing on a more effective system for protection of medical facilities and workers across the country.RESPONSE ANALYSIS

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2020 health response will address: Insufficient number of mobile clinics/teams to areas of acute emergency needs. Disrupted emergency referral system in public health care facilities, preparedness and response levels to improve the management of trauma patients. Lack of medicines, equipment and supplies to support diagnostic and treatment services (including cold chain) in health care facilities and mobile teams/clinics.

Deficient reproductive health services: A five-year Reproductive Maternal Newborn Child and Adolescent health (RMNCAH) strategy for Libya was approved in December 2018. The strategy is yet to be costed and a task force is to be appointed. Ineffective detection and response to communicable diseases through community health education/promotion; integration of vertical programming with other services. Limited health care for patients with TB, HIV. A potential for increase of vector-borne diseases across the country. Non-continuous and interrupted routine vaccination of children, insufficient number of vaccination teams.Increasing demand for services for patients with injuries: rehabilitation of persons with disability; strengthen capacity for prostheses and rehabilitation.Limited MHPSS activities and services, including community mental health system.Shortage for diagnosis and treatment of non-communicable diseases, as home care for patients with chronic diseasesA high number of public health care facilities, especially PHC level, being closed and in need of repair and rehabilitation.The capacity of health authorities in health emergency preparedness, planning and operational readiness needs to be strengthened.Absence of comprehensive monitoring and evaluation plans to systematically evaluate trends, and weak capacity for data analysis and regular reporting. There are gaps in assessment, supervision, monitoring and evaluation-related activities across the country. RESPONSE ANALYSIS

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As of 30 October, the estimated funding envelope for 2020 HRP is 79,340,000 USD which needs to meet 30,000,000 allocated ceiling for health sector.

RESPONSE ANALYSISOrganization2019 HRP requested amount

Organization

2020 HRP requested amount

WHO

11,464,349.00

WHO

24,000,000

IOM

7,100,000.00

IOM

10,000,000

UNFPA

6,330,118.00

UNFPA

6,300,000

PUI

5,340,000.00

PUI

3,700,000

UNHCR

5,066,635.00

UNHCR

5,000,000

UNICEF

3,858,600.00

UNICEF

3,800,000

IRC

2,599,998.00

IRC

5,200,000

HI

2,483,330.00

HI

2,500,000

TdH Italy

1,460,000.00

TdH Italy

1,500,000

 

 

Emergenza Sorrisi

740,000

 

 

IMC

15,000,000

 

 

Helpcode

1,600,000

TOTAL:

$45,703,030.00

TOTAL:

79,340,000 USD

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Data sources used to inform the 2020 HNO (primary and secondary): Update of key emergency indicators for 2019 (public hospitals and primary health care centers), WHO, 4W health sector 2019, EWARN, selected reports by IOM, IMC, and HI, MSNA, and MoH Libya data. Information gaps (geographic, thematic, population group):Out of 97 public hospitals and 1355 PHC centers assessed by SARA 2017, the 2019 update covered 88 hospitals and 1145 PHC centers. Second phase will be implemented in cooperation with the MoH.

Essential to roll out EWARN across the country (only 125 sentinel sites) and the detention centers. Despite the rolled out and updated health sector assessment registry, the response remains low. Challenges related to the analysis of the needs data, the reliability or availability of the data: Frequently quoted and largely invested DHIS tool has not yet yielded the expected results with no clarity of the mechanism of information sharing for health sector partners. The much requested feedback on the levels of the national health response remains unanswered while the authorities are committed to cooperate. There is no dedicated information management unit within WHO Libya as health sector lead. Funding available only until the end of 2019. There are noticeable difficulties in accuracy of data collection under the current 4W matrix (listing more than 60 different type of activities). Absence of IM reporting officer within the most of health sector partners while this function is being carried by other staff. A high turnover of staff and mix of functions almost every 2 or 3 months. DATA SOURCES AND INFO GAPS