RESERVED FOR PROTECT LOGO/HEADING
COUNTRYAIOTF: CAMEROON Proiect Name: CDTI SW 2
Approval vearz 1999 Launchins vegr: 2000
Renortins Period: From: JANUARY 2008 To: DECEMBER 2008 (Month/Year) ( Mont!{eq) Proiectvearofthisrenort: (circleone) I 2 3 4 5 6 7(8) 9 l0
Date submitted: NGDO qartner: "l"""uivFzoog Sightsavers International
South West 2 CDTI Project Report 2008 - Year 8. ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATTVE COMMITTEE (TCC)
DEADLINE FOR SUBMISSION:
To APOC Management by 3l January for March TCC meeting
To APOC Management by 31 Julv for September TCC meeting
AFRICANPROGRAMME FOR ONCHOCERCTASTS CONTROL (APOC)
I
I
RECU LE
I S F[,;, ?ur], APOC iDIR ANNUAL I'II().I Ii(]'I"IIICHNICAL REPORT 't'o TECHNICAL CONSU l.',l'A]'tvE CoMMITTEE (TCC) ENDORSEMENT
Please confirm you have read this report by signing in the appropriat space.
OFFICERS to sign the rePort:
Country: CAMEROON National Coordinator Name: Dr. Ntep Marcelline
S l) u b Date: . ..?:.+/ c Ail
9ou R Regional Delegate Name: Dr. Chu + C( z z a tu Signature: n rJ ( Date 6t @
RY oF I DE LA NGDO Representative Name: Dr. Oye Joseph E
Signature: .... Date:' g 2 JAN. u0g Regional Oncho Coordinator Name: Mr. Ebongo Signature: Date: 51-.12-Z This report has been prepared by Name : Mr. Ebongo Peter Designation:.OPC SWII Signature: *1.-
,l
1l Table of contents
Acronyms .v Definitions vi FOLLOW UP ON TCC RECOMMENDATIONS. 7 Executive Summary.. 8 SECTION I : Background information...... 9 1.1. GrrueRruINFoRMATroN...... 9 1.1.1 Description of the project...... 9 Location..... 9 1. 1. 2. Pa rtnership ...... It 2. PopuurroN...... l3 SECTION 2: Implementation of CDTI 15 2.1. Tnmrnm oF ACTIVITIES...... l5 2.2. Aovocacv l6 2.3. MoaruzetroN, SENSITIZATToN AND HEALTH EDUCATIoN oF AT RISK COMMUNITIES ...... 16 2.4. ColryruurY TNVoLVEMENT.... l8 2.5. CepaCrrv BUILDING l9 2.6. TRraflqrNTS...... 22 2.6.1. Treatment figures 22 2.6.2.1 What are the causes of absenteeism?. 25 2.6.2.2 What are the reasons for refusals?...... 25 2.6.4.1 Briefly describe all known and verified serious adverse events (SAEs) that occurred during the reporting period and provide (in table B) the required 25 2.6.5. Trend of treatment achievement from CDTI project inception to the current ...... 27 2.7. Onoeruruc, sroRAGE AND DEuvERy oF rvERMECTIN...... 28 2.8. Cot4t"tur{rry sELF-MoNrroRrNG ano SrerEHoLDERS Mernruc...... 30 2.9. SupeRvrsroN...... ,,, ...... 30 2.9.1. Provide a flow chart of supervision 30 2.9.2. What were the main issues identified during supervision? 3l . Poor filling of registers and treatment reports ...... 31 2.9.3. Was a supervision checklist used? 3t Supervision check list was used in some health districts, though no routinely 3I 2.9.4. What were the outcomes at each level of CDTI i m plementation su peruision ?...... 31 2.9.5. Was feedback given to the peuon or groups supervised?....st 2.9.6. How was the feedback used to improve the overall performance of the project? 32 SECTION 3. Support to CDTI...... 32 3.1. Equnurrur...... 32 3.2. Fruerucml coNTRTBUTToNS oF THE pARTNERS AND coMMUNITTES ...... JJ 3.3. OrnrR FoRMS oF coMMUNrry suppoRT...... 34 3.4. ExpelrorruRE PER AcrrvrrY...... 34
I SECTION 4: Sustainability of CDTI 35 4.1. Irurrnruel; INDEPENDENT PARTICIPATORY MONITORINC ; EvalunrloN ...... 35 4.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable) -----...... 4.1.2. What were the recommendations 4.1.3. How have they been implemented?...... 4.2. SusrarrunBlllTy oF eRoJECTS: PLAN AND SETTARGETS (uaruoeroRY AT Yn 3) 4.2.1. Planning at all relevant levels?...... 4.2.2. Funds... 4.2.3 Transport (replacement and maintenance) 4,2.4. Other resources...... 4.2.5. To what extent has the plan been implemented 4.3. IrurrcRRrtoN-. . .,. .. 4.3.1. Ivermectin delivery mechanisms.. 4.3.2. Training. 37 4.3.3. loint supervision and monitoring with other pro9rams...... 38 4.3.5. Is CDTI included in the PHC budget?...... -r8 4.3,6, Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? ...... -38 4.3.7. Describe other issues considered in the integration of CDTI. 39 4.4. OprnATroNAL RESEARCH ...... 39 4.4.1. Summarize in not more than one half of a page the operational research undertaken in the project area within the reporting period.... 39 4.4.2. How were the results applied in the project? SECTION 5: Strengths, weaknesses, challenges, and opportunities...... SECTION 6: Unique features of the projecVother matters.. Acronyms
APOC African Programme for Onchocerciasis Control ATO Annual Treatment Objective ATrO Annual Training Objective CBO Community-Based Organization CDD Community-Directed Distributor CDTI Community-Directed Treatment with Ivermectin CSM Community Self-Monitoring LGA Local Government Area MOH Ministry of Health NGDO Non-Governmental Development Organization NGO Non-Governmental Organ ization NOTF National Onchocerciasis Task Force PHC Primary health care REMO Rapid Epidemiological Mapping of Onchocerciasis SAE Severe adverse event SHM Stakeholders meeting TCC Technical Consultative Committee (APOC scientific advisory group) TOT Trainer of trainers UNICEF United Nations Children's Fund UTG Ultimate Treatment Goal wHo World Health Organization Defin itions
(,) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking)
(ii) Eligible population: calculated as 84%o of the total population in meso/hyper- endemic communities in the project area.
(iii) Annual Treafinent Objective: (ATO): the estimated number of persons living in meso/hyper-endemic areas that a CDTI project intends to treat with ivermectin in a given year.
(iv) Ultimate Treatment Goal (UTG): calculated as the ma (") Therapeutic coverage: number of people treated in a given year over the total population (this should be expressed as a percentage). ("r) Geographical coverase: number of communities treated in a given year over the total number of meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage). (vrD Integration: delivering additional health interventions (i.e. vitamin A supplements, albendazole for LF, screening for cataract, etc.) through CDTI (using the same systems, training, supervision and personnel) in order to maximise cost- effectiveness and empower communities to solve more of their health problems. This does not include activities or interventions carried out by community distributors outside of CDTI. (viiD Sustainability: CDTI activities in an area are sustainable when they continue to function effectively for the foreseeable future, with high treatment coverage, integrated into the available healthcare service, with strong community ownership, using resources mobilised by the community and the government. (ir.) Community self-monitoring (CSM): The process by which the community is empowered to oversee and monitor the performance of CDTI (or any commturity- based health intervention programme), with a view to ensuring that the prografirme is being executed in the way intended. It encourages the community to take full responsibility of ivermectin distribution and make appropriate modifications when necessary. FOLLOW UP ON TCC RECOMMENDATIONS Using the table below, fill in the recommendations of the last TCC on the project and describe how they have been addressed. TCC session 26 Numher of TCC ACITONS TANEN BY THE PROJECT FOR rcC/APOC Recontnend RECOMMENDATT MGT USE dioninthe oNs ONLY Report Scale up Discussions have been held with NOTF and (i) advocacy even letters have been written to the towards Minister of Health on this issue. This is an government to ongoing activity and results cannot be take care of measured immediately. CDD incentives (!t ) Scale up The health districts and health areas advocacy educated on the impoftance of CSM. They towards were also refreshed on carrying out the communities to activity. Despite these however CSM was make CSM still not done. lust like CDDs monitors are effective requesting for financial motivation. Even health staff do not seem interested in this activity. (iii) Take concrete The region during planning meetings with actions to the health districts pointed out those increase communities with low therapeutic coverage. therapeutic This was to enable the districts intensify coverage in sensitization in these communities. areas where However, it was discovered during the performance is supervision that this had not taken place low yet. The coordinator then visited communities with low coverage in Afap, Mkpot and Bakwelle in Afap health areas (Eyumojock Health District). It was agreed at the end of the treatment rycle that Mectizan@ tablets be returned to the concerned communities for treatment to continue for another week. The Regional Delegate of Public Health officially requested the district medical officers of Eyumojock and Ekondo Titi to do everything to increase therapeutic coverage in the villages with low coverage rate. (tv) Undertake The re-evaluation was finally carried out from project L4 - 28 April 2008. evaluation, Amongst others, the main finding was that the after several project was making good progress towards postponements sustainability but much still needed to be done in the areas of funding for the project and provision of transpoft facilities. 7 Executive Summary Preparations for CDTI activities for 2008 started in the late part of 2OO7 (December) with the training of health district staff and chiefs of centers. The trainings were organized in all health districts. The provincial project coordinator supervised only those districts that needed support. These included Eyumojock, Mamfe, Fontem and Wabane. A total of 29 (96.60/o) out of 30 and 91 (97.8olo) out of 93 health district and health centre staff respectively were trained. A total of L,92O CDDs were planned to be trained. However just 986 (5t.4o/o) were trained between February and April 2008. This gave a CDD to population ratio of 1CDD to 241 persons against 1CDD to 225 persons in 2007. Distribution of Mectizan@ started in most health districts in March. Out of a total of 506 meso and hyper endemic communities in the project area, only 500 were treated, giving a geographical coverage of 98.Bolo. This drop of geographical coverage from LOOo/o as was the case last year was due to the following; o Inter-tribal war in Akwaya health district leading to the burning down of 4 communities. While some of the community members lost their lives in this conflict, others fled into neighbouring Nigeria (Benue State) for safety. . In Mamfe health district, one community was not treated because of attrition of its CDDs. Efforts to get a new one trained failed. o In Eyumojock, one CDD left his treatment register after dlstribution to a colleague who has disappeared from the village since then. The records cannot be traced. From a total population of 238,163 persons registered, lB7,B99 persons were treated in meso/hyperendemic communities. This gave a therapeutic coverage of 78.9o/o against 76.20/o in 2OO7. The annual treatment objective was set at 190,530 while the Ultimate treatment goal at 200,057. In hypo-endemic communities, 7,738 persons were treated. As already indicated above, the main challenges were coping with attrition of CDDs who demanded payment of arrears of their financial motivation. In Mamfe for instance, rumours that CDDs in the neighbouring district of Akwaya had been paid arrears of their motivation caused them to go on strike. In some other districts, CDDs with held their treatment results. Late reporting by the districts was of great concern, making it difficult for the Regional levels to report promptly as well. HSAM was continued and hopefully 2009 will be better in reporting. HSAM was also targeted to the government to improve its support to the CDTI project. 8 SECTION 1: Background information 1.1. General information 1.1.1Description of the project Location SW 2 Project is situated between latitude 50 t2'and 6o 30' north and longitude Bo 30' and 9o 45' east. It is made up of three administrative divisions (Ndian, Manyu and Lebialem) of the South West Region of the Republic of Cameroon. It now covers eight health districts (Akwaya, Bakassi, Ekondo Titi, Eyumojock, Fontem, Mamfe, Mundemba and Wabane) split up into 40 functional health areas. Bakassi health district was created in December 2006; Staff to take care of the health district have been posted there already. The health map does not strictly follow the administrative ffidp, such that a health district or health area can cover more than one division or subdivision. The administrative headquarters of the province is Buea Most of this project area is characterised by dense and luxuriant equatorial forest except for part of Akwaya health district especially towards the border with Njikwa in the North West Region and the border with the Republic of Nigeria, which has Savannah vegetation. The Project shares boundaries in the west with Nigeria, in particular Cross River, Taraba and Benue States. In the north it shares boundaries with the North West Region; in the east with the West Region; in the southeast with SW 1 and is bordered in the south by the Atlantic Ocean SW 2 has a very harsh topography with many rolling hills and valleys. This renders the terrain very rough making accessibility difficult. In most of these valleys run fast flowing streams, providing good breeding grounds for the black fly, simulium. This area has two seasons; the hot dry and the wet rainy seasons. The rainy seasons are usually long (April to mid November) during which the streams get flooded. The road network is very poor with all roads being dirt earth roads which get very slippery and muddy during the rainy season making work in the field difficult even with a four-wheel drive vehicle. To get to Akwaya one has to go through the Republic of Nigeria and drive across large streams with no bridges and rough mountainous terrain. The new district of Bakassi is in the maritime region of Ndian division. It can only be accessed via Mundemba by boat. The main economic activity in this project area is farming. Males are more concerned with cash crops, planting cocoa, coffee, and oil palms. The common food crops include plantains, cocoyams, cassava, yams, groundnuts, maize and a rich variety of fruits and vegetable grown mostly by women. Fishing is also carried out in the maritime area and in some streams that drain the area. 9 Tablel.l: Showing administratiae units, health districts and. health areas. Division Subdivision/District Health District Health Area Ndian Mundemba Mundemba Mundemba Toko Tipenja Madie Ngolo Pamol Ndian Idabato Bakassi Idabato Isangele Isangele Kombo Abedimo Kombo Abedimo Kombo Itindi Kombo Itindi Ekondo fiti Ekondo Titi Ekondo fiti Bamusso Kumbe Balue Dikome Balue** Bamusso Bafaka Bissoro Bekumu Pamol Lobe Bekora Illor Manyu Mamfe Mamfe Bachou Akagbe Upper Banyang Kajitu Kendem Mamfe Tali Eyumojock Eyumojock Afap Ekok Eyumojock Kembong Ogurang*** Akwaya Akwaya Akwa Akwaya Amassi Bagundu Lebialem Alou Fontem Azi Fontem Essoh Attah Fonjumetaw Fotabong Menji Takwai Wabane Wabane Bamumbu Bechati Fotang Kupe / NSuti Mbetta**** Muanenguba Fontem Njungo**** **Dikume Balue is under Kumba Health District in South West 1 Project Area. l0 ***Ogurang health area is the only health area without a functional health unit in Eyumojock health district. It has no roads. Only trekking inside dense equatorial forest across large streams accesses the whole area. Health interventions in this area are done only through outreach from the district health service at irregular intervals. ***{rFor the purpose of proximity and accessibility, Mbetta and Njungo health areas in Kupe/Muanenguba division are administered by Fontem Health District in Lebialem division. L.7..2. Paftnership Partners involved in the implementation of South West 2 CDTI Project are the Government of Cameroon (Ministry of Public Health [MOH]), African Programme for Onchocerciasis Control (APOC), Mectizan Donation Programme (MDP), Sightsavers International and the community. These partners all work in harmony for the smooth running of project activities. Planning is done with the full pafticipation of the MOH, Sightsavers and the community. Together, they also carry out supervision, mobilisation and monitoring of side effects during Mectizan@ distribution. Advocacy is usually reserved for personnel of MOH and Sightsavers. Plans of action are usually drawn at the beginning of each distribution round, specifying which of these partners does what and at what time. The working relationship of partners in the implementation of CDTI activities has remained very cordial all through the B years of this project's Iife. Each partner has assumed her responsibilities; the communities selected and replaced CDDs that abandoned Mectizan@ distribution. They are also through the CDDs mobilizing communities on the importance of Mectizan@ and when to take it. A few of them motivate their CDDs in diverse ways. Health staff as usual trained the different levels and assisted in the sensitization of hierarchy and communities on the round of the present distribution of mectizan. The provincial team also made sure that Mectizan@ reached the health districts and health areas on time. The NGDO partner has always been available to give both financial and technical support. In July for instance the NGDO (Sightsavers) team was in the region for integrated superuise CDTI and Eye Care activities. Sightsavers also made available funds for district and health area superuision of CDTI activities. APoc has continued to support the project in various ways as well. In 2008 APOC provided funds for trainings / re-training as well as travel at the different levels of the project. This enabled the different levels to carry out supervision and training of CDDs. APOC also sponsored the external evaluation of the project in April 2008. This evaluation has once more brought to light the strengths and weaknesses of the project and the way forward. Mectizan@ Donation Foundation as usual made available sufficient quantities of Mectizan@ at the end of February 2008 for the year's distribution. These drugs came into the country through the WHO country representation in Yaounde. 1l A five-year sustainability plan drawn after the external evaluation of the project in April 2008. This plan took into consideration issues to be addressed by the government, Sightsavers and APOC. All that is left now is to effectively implement the plan. This will take effect as from 2009. Also, exhaustive health district development plans were elaborated and submitted to government for funding by the Sector Wide Approach. This plans when approved will go operational in 2009 as well. Table 1: Number of health staff involved in CDTI Numbcr of health staff involved in CDTI activities. Health Total Number of Number of heelth Percentage Distict health staffin the stafrinvolved in entire project area CI'TI Br Bt BrB'/B' *lfi) AKWAYA 28 L2 42.9o/o BAKASSI 15 8 53.3o/o EKONDO TITI 63 15 23.8o/o EYUMO]OCK 13 L2 92.3o/o FONTEM 55 31 56.4o/o MAMFE 2L 16 76.2o/o MUNDEMBA 68 22 32.4o/o WABANE L2 7 58.3olo Total 275 L23 44.7o/o According to the table above just 44.7o/o of health staff were involved in CDTI activities. Ekondo Titi and Mundemba had the lowest percentage of staff working in CDTI. This is as a result of the fact that these health districts have big private (owned by an agro industrial institution, Pamol Plantations Limited) hospitals whose personnel do not actively take part in CDTI activities. This agro industrial institution appointed just two nurses each to take part in CDTI activities in their health area. t2 E e s. 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G^ r!< Ei 7i r1 g I ?l $i"*[e sXS --E o ii sl i +J H =! sl U !:(!Et =' (DA] Ai *Fi-5 qql -ad f Eia? ^ 6 15 td citr=(D a o N \t @ { N N' @ o Nx (O (n (, u, @ E'=. o $ s o (D J m€ B$5 $3 u, ri. =.S Fl - gE cN o o ^(\ r!P p t) oe 1' =*# II (D -l g$BEc (DJ ra lt o ss EE Er 5.= ts F=n (\os=. P d'g o (\D + NQ t+o E!J $t* s Rd P EE o gu?E;gq .od UI ts H o Y- o s @ o \o (, $ o - P S.c) tD lJ o I o o 5 P N) N' o ro P o H; H s# ds \ N,-Z O E' HE Ha HE HE HE HE HE HE *B ------OQ 0e a U) NU! N(' NLO N(n NU) NU) rl orn om orn orn om om o ct OE H8 H8 o! o-u OE O! OT' EE @-l c(r-r crt.' @{ oo{ @{ @-{ @{ 9lc :t6 o o N, -ll N, -TI otporn o(pom a9 HE HE HE HE HE HE @- @- E4 U) r - - - - - 'oo+E !(D { NJ U} NU} N, (' N,, U} NJ U) NU} orn orn orn om om orn o ta, OT' HE H8 OT o! o-o o1' o1' 3T c @{ Glt.' @.' @l col @l @-{ @-l iE 2.2, Advocacy At Regional level, the project coordinator carried out advocacy on CDTI and eye care during the General Assembly meeting of the South West Regional Special Fund for Health that was held on January l8th 2OOB. This meeting which was chaired by the Governor also saw the participation of health district health committee chairpersons, heads of services and heads of private health establishments. It was a one day meeting and was adequately covered by both state and private media. As planned, advocacy to poliqf/decision makers was carried out at the district level to administrative personnel (senior divisional officers and divisional officers) of the different administrative units, religious and traditional leaders by health district teams. All the health districts informed their local administrators and other leaders by way of personal contacts and letters. The senior divisional officers and divisional officers on their part informed their collaborators at lower levels. They sent administrative letters soliciting support of the communities and CDDs during Mectizan@ distribution. District Medical Officers also used the routine coordination meetings to advocate for support from all service heads. Advocacy was also done alongside that of EPI immunization campaigns. National celebrations like the Internationat Women's Day (Btn March 2OOB), Youth Day (11th February 2OO9) and the National Day (20th May 2009) were used for advocacy and sensitisation of the community. In Fontem, the Senior Divisional Officer and his entourage launched Mectizan@ distribution by taking swallowing their own tablets in public, in front of the population of Menji town. This was helped to erase negative rumours that had been circulating about Mectizan@. In Mamfe where CDDs attempted to go on strike, the health district team urged quarter heads to replace CDDs who refused to get back to work after persuasion. 2.3. Mobilization, sensitization and health education of at risk communities Provide information on: - The use of media and/or other local systems to dlsseminate information Mamfe and Fontem health districts used their local FM radio stations to disseminate information on Mectizan@ distribution. Health districts also made use of church announcements, announcements in socio cultural meetings and town criers to disseminate information of the year's CDTI activities. As was the case with advocacy, nationa! celebrations were also used for dissemination of information and health education. This year, as a result of the several sessions of National Immunization Days (NID) against poliomyelitis and the disgruntlement of cDDs over the non payment of their incentives, CDTI activities witnessed a late start. During one of his monitoring trips to Mamfe, the coordinator took part in a radio programme at Radio Monaya (a local FM radio station) 16 WHO/APOC. 24 November2}o3 - Mobilization and health education of communities including women and minorities Mobilization and health education on CDTI did not exclude any sections of the community. Women were part of all health education and mobilization sessions. There exist no known minority groups within the South West 2 CDTI project area. - Response of target communities/villages There were various reactions from those who were talked to during community mobilization and health education. Most of them described the benefits they derived from taking Mectizan@. These included disappearance of skin rash "craw-craw", improvement of poor vision, expulsion of intestinal worms etc. Some even requested that Mectizan@ be distributed twice a year. Others questioned why they no longer experience itches as before after taking Mectizan@. A few who still fear to take the drug complain that CDDs were not competent enough to distribute Mectizan@ as they are not trained health personnel. The same category of persons still questioned why scales were not used to determine the Dose of Mectizan@ given to people. Explanations were given to all of their queries to dispel their worries / fears. - Accomplishments Improved Awareness: The population now knows around the period when Mectizan@ is distributed and on their own move to the CDDs or health centres to ask when the drug will be available. This was particularly evident this year as Mectizan@ arrived late. Even the regional level sometimes received telephone calls from both the health districts and health centre nurses requesting to know if Mectizan@ is already available from Yaounde. Therapeutic Coverage: . The therapeutic coverage of this project area has continued to improve since 2003. This year, as already indicated above, it has improved by Z.7o/o. . Communities with coverage less that 650/o are reducing every year. (47 this year against 84 last year). CDDs in some health districts are becoming more organized in spite of poor motivation from both the state and communities. Suggest ways to improve mobilization and sensitization of the ta rget com m un ities. This year particularly, the number of community members invited to attend health district and regional CDTI appraisal meetings was increased. This was a bid to reiterate their roles especially that of mobilization and sensitization. Communities performing well were sited and congratulated t7 openly. Both the community members and the health staff planned for HESAM in 2009 during these meetings. The regional level has also planned to support some health districts by participating in HESAM activities in problem communities, particularly in the health districts of Mundemba and Ekondo Titi. 2.+ Gommunityr involvement Table 4: Communities participation in the CDTI Number of communities Number of communities/villages with Number of CDDs and the community members as supervisors communities involved /villages with female CDDs Total no. Number of Percentage Male Female Total Number of Percentiige Health District communities community CDDs CDDs communaties in the entire with with female proiect area members as Br= Bc= CDDs Brr= Br supervisors Br./ Br *1OO Bt Br B7*Br Bro BrolBr*1OO Bs AKWAYA 101 t4 L3.9o/o L4L 2L L62 I 7.8o/o BAKASSI 9 0 0 10 3 13 2 22.2o/o EKONDO TITI 40 0 0 85 L4 99 4 10.0o/o EYUMOJOCK 32 0 0 63 9 72 3 9.4 o/o FONTEM 97 0 0 250 51 301 11 LL.3o/o MAMFE LO2 0 0 L23 23 L45 7 L2.8o/o MUNDEMBA 81 0 0 72 L4 86 5 6.Lo/o WABANE 44 0 0 84 23 L07 8 L8.lo/o Total 506 t4 2.8o/o 828 158 986 48 9.5o/o Comment on: - Attendance of female members of the community at health education meetings It has been mentioned in previous reports that calling on the population for health education sessions in community halls etc used to pose a tot of problems of attendance to meetings. Most people, be they women or men were not attending as expected. The women especially were not well represented because when they returned from their farms, they were tired and had to prepare dinner for their families or they were not just interested. That is why the strategy was changed to meeting different groups of persons in their respective social gatherings. consequently, the attendance of female members of the community at health education sessions in joint gatherings was addressed. In general, how do you rate the participation of female members of the community meetings when CDTI issues are l8 being discussed (attendance, participation in the discussion etc) Their participation was good. They asked pertinent questions, even more than the men. Since they were met in their social gatherings, the attendance was usually impressive and they participated fully. - fncentives provided by communities for the CDDs Providing incentives to CDDs by the communities is still an outstanding issue. This year Eyumojock was the only health district in which transport cost was reimbursed to CDDs for attending CDTI meetings (training and appraisals). These communities are planning to further motivate their CDDs to the tune of 5000 francs CFA per CDD after Mectizan@ distribution exercise. An insignificant number of other communities occasionally feed or give drinks to their CDDs. - Attrition of CDDs. Is attrition a problem for the project? If yesr how is it addressed? Attrition is still a problem in the project although this year it was not generalized. Mamfe health district topped the list of the number of CDDs that abandoned. CDDs in Mamfe town went on strike because of rumours that CDDs of other health districts had been paid government motivation for 2006 and 2007. The district team intervened by counteracting the rumour. Most CDDs went back to work and those who refused to distribute Mectizan@ were immediately replaced by new ones who received on-the-spot training. During the district appraisal meeting of Mamfe, CDDs were invited. This was to explain in front of everyone that no CDD had been paid for 2006 and 2007. They were once again reminded of their role to their community members and that the government token to them was just an appreciation. They were also informed of the fact that CDDs elsewhere in the project area are forming CDD Associations to handle health problems and other problems affecting them within their communities in a coordinated manner. 2.5. Capacity building - Describe the adequacy of available knowledgeable manpower at all levels All levels of the project are proud of knowledgeable manpower. This is because training on CDTI has been going on each year to both old and new staff at all Ievels. The problem is more with the numbers; Although government has been making efforts to recruit new staff the last couple of years, the numbers have been quite small compared to that of those going on retirement and that of those leaving the country for greener pastures abroad. Transfers of health staff was not a problem in this project area in 2008. However when these transfers occurred, this did not affect the project as t9 most of them came from health districts doing CDTI, and had been trained before. However, Mundemba and Fotang health areas in Mundemba and Wabane health districts respectively, suffered from transfers that negatively affected the project; chiefs of centres of Mundemba and Fotang were transferred and replaced with staff who were completely new to CDTI. It was even worse in Fotang where the whole health centre team was completely new. During monitoring trips the regional coordinator asked the district teams to provide support to these health centres. This was done and it is hope that in 2009 these health areas will be able to carry out CDTI activities with minimal support from outside. 20 * H z ? E' rr, rn l-l 5E +g i o C E o F x a litlo: o Ed z o rt N=Q5 H 2 rl z. { ltD E U frl lr, o OJ d z rd lrl ? o't U lu, oo:.s= ]; F rn ? o F o o o :{=u, Q + ED o "-l >'t; oooi X -.i tr) r+lr0t' s 904 0a o \J1J a F) (.) a+ l.f-{r G 5 rj UJ o\ 5 o Ur H o (D a 7. (D r- o- d :/t t! z otrI@ EI !R uI( -o o3 Fto' @o, o- (D ( o o o F LH lJ OE'= \ 95.* (D d d+. tr,'f os. (D oo o x (n IJ (, (Jl (, 5 o (,l 60 9f ar 5 o oL o a +) oar o o o+ \o U go d o.\ Fl t, t.J (J) B \o 5 5 o\ (-) 5 o (,r +:t o oJ o s-l Allts ='oJ a 'o 8.o a (D \o l..J Fl il ArO E (.) \o a o\ (, o\ 5 o (D ,60 Ib B t-'? o,q o .) tD= F' N) 5 d {5 (u \ (! bJ qJ o ul 5 (, o Sr E'A ('D 5 a t o,3 8; \o? F o @x o r{r otE (n i$ c o\ \o x ii *r \t o\ N) -l N..) o o Efl-. d s \o F9=*g 6't.ll qr J \o o s \o \o trL o s -t UJ o\ t.) EE a i+g 'g 6' o 5 () o O ,l z o a 5 o o o o 5 C o s 6 vt ec 6' a € o E !9BT rl rJr r) (! (.) o o o o o o uJ SFs{ i'o o {r c (! 6*r ; rct 5 E (Do '9 f o -* o to E (D=. O O Ab -iq "o o o o o r' S' (U Y't i.J HD' 5 f .J, o =' oz o rto a a--o to (D o 5 o 5 (I, s E o cr(D (o ^lt P. i.J f UI NJ s N) u) \o (, h.J o\ c ,. t+ bJ O-t 6 o tJ s 6 z o .) E (D o (! \o (,) (, N \o (I, (! { (, o -J o\ 5 (€SF o o (D o {r EI U o E' -I b.) @ AX 0 \o 5-I \o{ Ur +(rl u) 5 5 o- Ur @ ;' s, rl o !0 o, Ur (D \o u) g oo \o i'arH+--o o 5 O o\ 5 O N)-I \o (]) o\ o g\ -J o\ N g s .^lt Table 6: Type of training undertaken Trainees Other Health molr Community Workers staff Political Otherc CDDs members e.g (frontline Type or Leaders (specify) Community hcalth Othcr of supervisors facilities) traini Program X X x management How to conduct X X X X Health education Management of X X SAEs CSM x X X SHM x X X Data collection X x x Data analysis X X Repoft writing X X 2.6. Treatments 2.6.1. Treatment figures - If the project is not achieving TOOo/o geographical coverage and a minimum of 65o/b therapeutic coverage or the coverage rate is fluduating, state the reasons and the plans being made to remedy this. It was thought at mid-year that the project was going to achieve 100o/o geographical coverage this year. The Region only learnt later that the inter-tribal war in Akwaya seriously affected 4 villages that could not be treated. One village in Eyumojock health district is yet to submit its treatment results while in Mamfe one village could not be treated because of attrition of its CDD. As a result, geographical coverage fell from 100o/o last year to 98.Bolo this 2008. The overall project therapeutic coverage since 2003 had been on the upward trend. As already mentioned above, there are stil! 47 communities (9.3olo) which have not yet attained 650/o therapeutic coverage. The challenge this project has is to achieve and maintain a minimum therapeutic coverage of 650/o in all the endemic communities. In order to maintain the present progress and improve on the therapeutic coverage of some communities, the communities performing poorly were pointed out during appraisal meetings. The probable reasons for their poor performance were identified and plans to address this problem elaborated by the respective health districts. 22 WHO/APOC, 24 November 2003 Frl Fl z ? lrl ld ED o C o A X h o { l-rl EE 2, z o x t+ o lo H z { lIU = U E rr,'{ U) -U o o rn rrl o U t-ls rO -t z ? a 5a -t o li F EI o o >6' lo a(U lc EE -l ^U t- .) 1.., o---oE o\E-o(D lo h .l :t i. l-, lr. o r) lo o_ o h o lo 1- o lo o o (U o -t l3 UI -t o to 5 @ o \o (, 5 o "B*$ffi+i 3 o (o lc o\ 5 N) -t N) O \o o rO o ld ) o -t l= -t (U ^>J o o a+ ao o (I, o l.* #q5 p5 f, o lj (, o lo 5 @ \o (r) 5 (DH?HE 3 l- o\ 5 N) -l tJ o \o t a lo, + il to rn l(D 9,2 (r)o @ IC q S.E E k+ CF lo $FE'r i l(n lp (, irg a: p lo 5 @ \o 5 \o 0a o- lo lo l= c 5 -I \o t+ (D a lo lo- -t (r) 8l* (l,-lJ l\o L o r)=. ot lr- @ho lo o!! lo lo qr lo \o ^=q9o\HE\oo ;.i r 5l* to \o \o \o * ll vo v. u) lH l- 90 o o P O 9 9 MP o lo lo, 6 O O O \o t o6' lo to s \o \o s s s o\ \o s 0) ll l= 5' Io |d 4d9* o \o !t l9l_ *(D >d I b,J (I, @ ! 1., (.) 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Ed C o -Tl 6S lo ooll il o = -{ z -F -{ rn rfl = lw o o l- o I v1 I. oili s l{+ (U o = o lxl o -t o c)* G r) o o { UI ) (o x --{ F} 6' o -{ F Ei =. 5t -I rn o= o o (U a.s (D o I a. o s =rn si s z I 8t tr z 8E \o z ilc; o { IU iHs !\ rrr ts (, ur @ N - IE ! (^, G UJ N N) ur ! o il I 6 u) @ (, 5 il[6E z, u$ t ^t o 6' s60 rn 1t z H$ I S H F rn fi$ a {@ {@ aO S N) @ H @ o= s-o I o (o (o (o { 9t o o o UI o (, o Sq. ut x (, X l- i=7 o e. \ ts u) ts u, LrJ rrnE s o o 00 i :.J mr)s = _g: o o L^J ts @ s {{E sg lo { Ld ts o @ (aHm C= oo il UT s (, (, (.rI z l il (o gl E} o lo Ia 90 ET3 -l o S^, Ol Ill-1t rn \o N) ln I N I TE o st.) oN o o ot @ h v oo$$ }l} 1ll Fio o = $B vD I x ri H o E: t !o ii6 sg S so- o os aI Qo UI I$ I il .rl $ ils ll. od { rt iu S q,: oO o s il'g o o 'ta ci I E* I da. 0t s*\s a 6g Io rt i o 2.6.2.L What are the causes of absenteeism? o Migration to other communities out of the project area for economic reasons. Students leaving for further studies out of the project area, and still reported as leaving in the project area. o Poor recording. 2.6.2.2 What are the reasons for refusals? . Some people cannot give up alcohol even for a day . Persistent rumours in some communities that Mectizan@ is harmful. . Some people think that because the drug is free, it is not effective. 2.6.4.1, Briefly describe all known and verified serious adverse events (SAEs) that occurred during the reporting period and provide (in table 8) the required information when available, No SAEs occurred during the reporting period. ! In case the project did not have any cases of serious adverse events (SAE) during this reporting period, please tick in the box. No SAE case to report 25 WHO/APOC, 24 November 2OO4 * a t+ z lo, k * t-ls \ lo og r.o 9s o l- ra :S oa r) SP x (U o\ th l.o o< o r+\ a-t a f.ilf(o o z* (D ox o a ur n o (D\=. o--r. o,= o F*Hfiil o r) N) oii'6aa+ c o\ :, o o- P=Bg o- -.=f r E . Mectizan@ ordered/applied for by - MOH I WHON UNICEil NGDil Mectizan@ delivered by - (please tick the appropriate answer) MOH I WHOtr UNICEil NGDd Please describe how Mectizan@ ,s ordered and how it gets to the communities Mectizan@ stock required for the year was calculated from the lower levels upwards (health area then health districts then project). Collation of the project needs was made at the level of the region. The different projects in the country then met in Yaounde were a synthesis for the country was made and channelled to Mectizan@ Donation Programme (MDP) via the NOTF secretariat, who approved, then sent the order through the Cameroon representation of WHO in Yaounde. When the drugs are cleared from the port, they are handed to the NOTF who then channels them to the South West Regional Essential Drug Programme in Buea through the supporting NGDO Sightsavers International. From the Regional level, the Drug Programme sent the drugs to the different health districts, following their orders. The health areas collected their stock of Mectizan@ from the district. The CDDs in turn collected their stock of drugs from the health centres. Table 10 below details Mectizan stock inventory Table 10: Mectizan@ Inventory Health Number of Mectizan@ tablets Used in District Requested R.eceived Used Wasted Expired Remai- hvpo ning AKWAYA 87,877 87,877 87,6L6 0 L42 0 119 BAKASSI 1 1,500 11,500 10,909 0 0 0 591 EKONDO 54,271 54,27t 42,209 3,485 3 0 8,574 TITI EYUMOJOCK 68,885 68,895 51,531 7,803 252 0 9,299 FONTEM 111,780 111,780 98,618 31 13 18 0 10,031 MAMFE LL7,884 Lt7,gg4 100,081 4,334 256 0 L3,213 MUNDEMBA 42,600 42,600 33,235 0 91 0 9,274 WABANE 62,965 62,965 61,285 0 30 0 1,650 TOTAL 557,762 557 t762 48,5,484 18,735 792 o 52,751 Total number of Mectizan@ tablets left in the project at end of zooT distribution 95,623 Total number of Mectizan@ tablets received at the beginning of 2008 516,000 28 WHO/APOC, 24 November 2004 Tota! Mectizan@ tablets at the beginning of 2008 distribution 6tt,623 Total Mectizan@ tablets distributed/lostl damaged etc 505,011 Total Mectizan@ borrowed to SWI project 6,500 Total tablets remaining at the end of 2008 distribution LOO,llz Tablets remaining in the Health Districts in 2008 52,751 Tablets remaining in the Drug Program in 2008 47,36! .BATCH NO. EXPIRY DATE NO. OF REMARKS TABLETS ND113001079596 o2l2oo9 LO,774 Expiring this February 2009 NG26600 /0845820 70/2O7O 89,338 - How are the remaining ivermectin tahlets collected and where are they kept? Remaining ivermectin tablets are routinely returned to the Drug Programme. In 2008 it was agreed that left over tablets are returned to the drug programme. Not more than 1 box of tablets would remain at the referral hospitals for passive treatment, outside the maSS treatment period. The hospitals concerned would account for such Mectizan@ tablets. List and briefly describe the activities under ivermectin delivery that are being carried out by health care personnel in the project area, When ivermectin is received at the regional level, two things happen: . The districts collect it from the Drug programme when they happen to be around. . The Drug Programme takes along the ivermectin to the districts during routine distribution of essential drugs. This year however, most health districts collected their stock of Mectizan@ by themselves from the essential drug programme. At the peripheral level, the health areas were informed of the availability of ivermectin in the health districts, from where each of them came to collect their stock. When Mectizan@ arrived at the health area, the chief of centre then called for the CDDs in his / her health area to come for their drugs. In some places this coincided with training / re-training and the CDDs collected their stock of Mectizan@ just after the training. 29 2.8. Community self-monitoring and Stakeholders Meeting Has any training (of trainers) for community self-monitoring been done in the project area? If so, When? All trainers were trained on CSM in 2004. After this training, staff at different levels received targeted training annually; this year was not an exception. Although a refresher was done in four districts supervised by the project coordinator during health area nurses training, no CSM was carried out in any community. CSM monitors are requesting for payment just like the CDDs. Table 11: Community self-monitoring and Stakeholders Meeting No of Communities Total # of No of Communities Health that conducted com m un ities/vil lages in that carried out self District stakeholders project monitoring (CSM) the entire area meetins (SnU) AKWAYA 101 0 0 BAKASSI 9 0 0 EKONDO TITI 40 0 0 EYUMOJOCK 32 0 0 FONTEM 97 0 0 MAMFE to2 0 0 MUNDEMBA B1 0 0 WABANE 44 0 0 TOTAL 506 o o Describe how the resulB of the community self- monitoring and stakeholders meetings have affected project implementation or how they would be utilized during the next treatment cycle. No CSM was carried out in the entire project area 2.9. Supervision 2.9.1. Provide a flow chart of supervision hierarchy. CENTRAL LEVEL o NOTF . NGDO PROVINCIAL LEVEL . Regional Delegate . Regional Chief of Service for Community Health . Onchocerciasis Project Coordinator . Finance Officer 30 HEALTH DISTRICT LEVEL o District Medical Officer . Chief of Bureau Health . Chief of Bureau Administrative and Financial Affairs . Chief Medical Officer of District Hospital HEALTH AREA LEVEL . Health Centre Nurse COMMUNITY LEVEL . CDD . Community members (dialogue structures) 2.9.2. What were the main issues identified during supervision? o Poor filling of registers and treatment reports . New staff are not yet conversant with CDTI implementation . Late submission of activity and financial reports . Complains from CDDs about the non payment of motivation from government . No reports for some activities said to have been carried out e.g. HSAM. 2.9.3. Was a supervision checklist used? Supervision check list was used in some health districts, though no routinely. 2.9.4. What were the outcomes at each level of CDTI implementation supervision? . Financial justifications and reports were written and transmitted to the regional level, though not often on time. . Issues concerning delayed payment of CDD motivation were clarified, though this had very little influence on attitude of CDDs towards the programme. . The provincial coordinator visited some difficult communities for sensitization and community mobilisation. This improved treatment compliance. . Weak health area teams were identified and the district teams advised to provide them support. . On the spot training was done and this improved staff performance. 2.9.5. Was feedback given to the person or groups supervised? Feed back was given routinely on the spot to those supervised. A meeting with the supervisee or supervisees was held after supervision to give a feed back of the supervision. 3t 2.9.6. How was the feedback used to improve the overa!! performance of the project? Feedback points were routinely and immediately applied by the supervisees in their implementation of CDTI activities. The improved therapeutic coverage is evidence that the feed back contributed to improve the overall performance of the project. Absentees and refusals dropped this year by 3738 and 2610 respectively. SECTION 3: Support to CDTI 3.1. Equipment Table 12: Status of equipment Source & APOC MOH DISTRICT NGDO Others Type of equipment No. Condition No. Condition No Condition No. Condition No. Condition 1. Vehicle 1 CNFR 1 F 3 F 1 F 7 F 2. Motor 20 WO 0 0 8 F 15 WO 11 WO cycle(s) 4 CNFR 3. Computer(s) 1 CNFR 6 F 7 F 1 F 0 0 4. Printer(s) 1 F 5 F 7 F 0 0 0 0 5. Photocopier 2 F 2 WO 5 CN FR 0 0 0 0 (s) 1 WO 6. Fax 0 0 1 F 0 0 0 0 0 0 Machine(s) 7. Others a) Laptop 1 WO 0 0 0 0 0 0 0 0 b) c) xCondition of the equipment (F=Functional, CNFR=Currently non-functional but repairable, WO=Written off). NB. How does the project intend to maintain and replace existing equipment and other materials? There is no clear cut policy in place on maintenance and replacement of equipment. The regional !eve! applies for equipment needs from the central level on annual basis and waits for the response. Sometimes, some of these needs are met. In 2008 the government provided credits for the purchase of vehicles for four health districts (Eyumojock, Mamfe, Mundemba and Bakassi). The credits reported withdrawn in the mid term report have now been released. It is now just a matter of time to clear administrative procedure for all the vehicles to be acquired. Five motorbikes were also procured by the government and supplied to the 32 health districts of Mundemba, Ekondo Titi, Mamfe, Eyumojock and Akwaya. With regards to maintenance, the government makes provision for maintenance in the budget of the regional delegation and the health district. This provision is however usually insufficient as cost of maintenance is usually very heavy due to the bad terrain on which these vehicles are used. These government funds plus those from the different health interventions are used together for maintenance of vehicles and other equipment. At the health area leve!, there are no funds allocated for maintenance of equipment and vehicles. At this level they are obliged to use health centre funds (from cost recovery) and funds from other health activities such as the Expanded Programme on Immunization (EPI). Vehicles that belong to other programmes listed under "others" above are usually maintained by the programmes. The South West Regional Special Fund for Health (Drug Programme) has a plan for maintenance and replacement of its own vehicles. This structure is run jointly by the government and community representatives. 3.2. Financial contributions of the partrters and communities Table 13: Financial contributions by all partners for the last three years YeplG (2006) YearT(2007) Yars (2008) TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL Cash Cash Cash Cash Cash Cash Budgeted Released Budgeted Released Budgeted Released (us$) (us$) (us$) Contributor (us$) (us$) (us$) MOH (Central + 16,628 6,402 21,972 21,972 56,708 45262 ProvinciaVState) MOH (District/LGA) Local NGDO(S) ( if any) NGDO partner(s) 35,693 34,562 49,754 48,634 48,315 48,315 Others a) b) Communities APOC Trust Fund 18,035 13,505 16,808 1 6 ) 808 TOTAL 52,321 40,964 89,761 84,111 l2l,83l 110,385 JJ If there are problems with release of counterpart funds, how were they addressed? When noticed at the beginning of activities that APOC funds were not going to be available on time, the project applied to APOC to approve pre- financing of CDD training by Sightsavers. The application received timely approval, pre-financing was done and CDD training carried out. Releasing government funds for CDTI project activities continues to be a serious challenge. 3.3. Other forms of community support - Describe (indicate forms of in-kind contributions of communities if any) As already mentioned before, very few communities motivated their CDDs any form. A negligible few did provide food or drinks to some of their CDDs. This was reported more in Akwaya. 3.4. Expenditure per activity Indicate in table 74, the amount expended during the reporting period for each activity listed. Write the amount expended in US dollars using the current United Nations exchange rate to local currency. Indicate exchange rate used here: Table 14: Indicate how much the project spent for each activity listed below during the reporting period Expenditure Expenditure Expenditure ($ MoH) Activity ($ APOC) ($ ssD Drug delivery from NOTF HQ area to central collection point of community Mobilization and health education of communities 5,079 Training of CDDs 8,234 5,284 Training of health staffat all levels 3,729 Supervising CDDs and distribution 2,208 4,480 Inlernal monitoring of CDTI activities 3,250 1,690 Advocacy visits to health and political authorities IEC materials 34 4,692 Summary (reporting) forms for treatment 3.753 22,781 Vehicles/ Motorcycles/ bicycles maintenance Office Equipment (e.g computers, printers etc) *SIDE effect drugs *Personnel 20.770 2,956 3,284 *Evaluation 10,800 6,897 *Office Stationeries and supplies 1,684 *Registers *Communication 487 *Bank charges 352 2tt Others 268 TOTAL 16,408 45,262 51,219 Any comments or explanations? o Health staff were trained in December 2OO7 with funds that arrived late in 2OO7 for training of CDDs. . SSI supplied IEC materials at the beginning of this treatment period . The funds spent by MOH are mostly from the health districts and health areas. Expenditures at regional level is mostly on maintenance of the car SECTION 4: Sustainability of CDTI 4.L. Internal; independent pafticipatory monitoring; Evaluation 4.1.1 Was Monitoring/evaluation carried out during the repofting period? (tick any of the following which are applicable) Year 1 Partici patory Independent monitoring Mid Term Sustainability Evaluation Y,FC 5 year Sustainability re-Evaluation 35 Internal Monitoring by NOTF Other Evaluation by other partners 4,7,2, What were the recommendations? The main issues were: . Improving on government funding of CDTI activities o Motivation of CDDs by communities . Improving and sustaining therapeutic and geographical coverage . Putting in place a maintenance and replacement policy for vehicles/equipment . Appointment of a government staff as finance officer of the project o Intensification of HSAM especially in communities with low therapeutic coverage. o All partners in the Regional Delegation should have knowledge on the working of the project. 4,7.3. How have they been implemented? A 5 year sustainability plan (2OO4 - 2008) was drawn up and had been in implementation since then. However addressing all the recommendations to the fullest has been a big challenge. Treatment coverage has greatly improved and there has been marked improvement in integration of CDTI into the minimum package of activities. The finance officer was moved to the project site in Buea. This plan aimed at addressing all the above. 4.2. Sustainability of projects: plan and set targets (mandatory at Yr 3) Was the project evaluated during the repofting period? The project was re-evaluated in April 2008. It was found to be making satisfactory progress towards sustainability. Was a sustainability plan written and submitted? _ A sustainability plan (2009-2013) was elaborated and submitted to APOC management. This plan addresses issues like CDD motivation and intensification of HSAM to maintain good coverage rates and improved government funding What arrangements have been made to sustain CDTI after APOC funding ceases in terms of: 36 4.2.1. Planning at all relevant levels? Plans (sustainability plans) have been drawn to cover health areas, health districts and the Region for 5 years with the government expected to fund most of the activities and the communities to get more involved in the implementation of CDTI. 4.2.2, Funds Health District Development Plans have been drawn up and submitted to government for study and eventual allocation of resources (financial included) using the Sector Wide Approach. This approach encourages the putting of all financial resources together and used from a common basket to finance all district activities without discrimination. It is hoped that this will become effective from the beginning of 2009. 4.2.3 Transpoft (replacement and maintenance) The government has begun to supply/replace vehicles more regularly now than ever before. This year, 5 motorbikes were supplied to five health districts. Four vehicles have been allocated to some health districts, out of which one has already been procured. The project has requested for the replacement of its project vehicle and motor cycles which are old and now have a high maintenance cost. 4.2.4. Other resources 4.2.5. To what extent has the plan been implemented The current plan's implementation is soon to commence. As soon as funds are available, activities will start. 4.3. Integration- Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration: 4.3.1,. Ivermectin delivery mechanisms This year, an Eye care team on a trip to Yaounde transported Mectizan@ to the drug program at the regional delegation in Buea. The drug program in turn dispatched the Mectizan@ to health districts through its routine distribution mechanism. Some DMOs also collected their mectizan during their trip to the regional delegation of health for any official matter. The integration of mectizan into PHC took effect in 2OO4 and has been going on smoothly. 4.3.2. Training All the training (Nurses and CDDs) for CDTI were integrated with Eye Care. This year, almost all the health districts organized their training of CDDs to coincide with the preparation for Local Immunization days that took place in April 2008. All the districts organized coordination meetings 37 during which period they examined the progress of all activities such as CDTI, EPI, Tuberculosis, Leprosy, Roll Back Malaria, HIV/AIDS etc. 4.3.3. Joint supervision and monitoring with other programs From the regional to health area level, it has become routine to carry out CDTI activities in an integrated manner. The provincial coordinator for example carried out spot checks of CDTI and eye care activities during the supervision of National Immunization Days in April and May 2008 in the distrlcts of Eyumojock and Mamfe where he worked. The district and health area levels used these days to ensure that CDTI activities were faring on. Once a staff was on the field for superuision, he/she supervised all the programs irrespective of the source of the funds. HSAM was equally carried out at the same time in communities with poor Mectizan@ distribution results. 4.3.4. Release of funds for project activities The project is not receiving sufficient funds from government at all levels for project activities. The different levels occasionally chip in what they can from their credits, but this is usually small. When government health institutions release such funds for CDTI project activities, they do not document them properly, making reporting on them difficult. APOC released funds late this year, contributing to delay in implementing project activities. It is hoped that the awaited Sector Wide Approach in 2009 may contribute in solving the problem of funding of CDTI, as all funds will be put in a common basket for the benefit of all project activities. 4.3.5. Is CDTI included in the PHC budgetz There is no budget line for CDTI at any level. 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? Programs such as Roll Back Malaria, EPl, HIV/AIDs, Leprosy, and Tuberculosis etc used the CDTI structure to enter the community. They used the CDDs for social mobilization, treatment of mosquito nets, and raise awareness on the importance of voluntary testing for HIV, encouraging pregnant women to attend clinics where they can be checked for HIV, sensitizing people on free treatment of Tuberculosis, Leprosy and HIV/AIDs. The impact of this is that community awareness has improved, leading to more people using the available health programs. In EPI and HIV for instance, parents refusa! to vaccinate their children is no longer a problem and the number of persons voluntarily testing for HIV is increasing steadily. Mosquito nets are now impregnated with insecticides 38 at village Ievel by community members trained to do so. During an integrated monitoring exercise carried out in October 2008 in some health districts in the region, CDDs were at hand as dialogue structure members to find solutions to some of the problems identified in the implementation of most health interventions. 4.3.7, Describe other issues considered in the integration of CDTT. In the regional planning meeting at the beginning of this year, all the regional supervisors where requested to submit their supervision checklists to the unit in charge of supervision. This unit intends to strengthen integrated supervision by ensuring that all supervisors use these checklists when on supervision trips. A briefing of all supervisors on the various programs, of course, will precede this. For the first time, the regional level including some district medical officers formed teams of integrated monitors who carried out integrated monitoring in L4 health districts. This exercise was very enriching and it is expected that future monitoring and supervision will be integrated especially if SWAp is put in place in 2009. 4.4. Operational research 4.4.7.. Summarize in not more than one half of a page the operational research undeltaken in the project area within the reporting period. No operational research was carried out. 4.4.2. How were the results applied in the project? No operational research was carried out. SECTION 5: Strengths, weaknesses, challenges, and opportunities List the strengths and weaknesses of CDTI implementation process, Strengths . Formation of associations by some CDDs to improve on the implementation of their CDTI activities and even includes hygiene and sanitation in their communities. . Use of CDDs for other health interventions. . Steady increase in the therapeutic coverage of the project and drop in the number of communities with low coverage. . Improved awareness of CDTI e.g. Spontaneous requests by communities for Mectizan@ . Refusals and absentees are on the decline. 39 Weahnesses o Late reporting by the district and health area levels o Existence of pockets of communities with therapeutic coverage less than 650/o . Delayed motivation of CDDs by the state . Communities not carrying out all their roles . Insufficient financing of CDTI activities by the state List the challenges and indicate how they were addressed, . Existence of pockets of communities with therapeutic coverage less than 650/o . Delayed motivation of CDDs . Communities not carrying out all their roles o Insufficient financing of CDTI activities by the state . Lack of interest the implementation of CSM by the communities. During the district and regional appraisal meetings, plans were drawn with community members to improve on the therapeutic coverage of communities with low coverage. The issue of CSM was discussed intensively with the community representatives and also included in the plans. Regarding CDD motivation and state contribution to CDTI, it is hoped that SWAp may resolve this problem in 2009 as District development plans have elaborated and submitted including CDTI. SECTION 6: Unique features of the project/other matters In a presidential decree of 12th November 2008, the President of the Republic changed the names of the provinces to Regions. From thence, the name province has been replaced by Region. The Regional Delegate of Public Health retired in November and was replaced by Dr. Chuwanga John Ndengue. As already mentioned above, the project area suffered the loss of 4 villages in Akwaya health district due to inter-tribal war which took place there in December 2OO7 and continued into the early part of this year. The villages were completely burnt down with their inhabitants fled for refuge to neighbouring Nigeria where some of their relatives live. The new district of Bakassi created at the end of 2006 became operational in 2008 with the appointment of a medical officer in charge. As already reported before, the health district is predominantly maritime. It has four health areas. Two of the health areas (Isangele and Kombo Itindi) were carrying out CDTI under Mundemba health district while the other two (Idabato and Kombo Abedimo) have never been involved in CDTI before as a result of the Bakassi border crisis with Nigeria. Just when the Region was planning to train the district team on CDTI, assassination of the divisional officer of Kombo Abedimo and 5 military men by unidentified 40 persons took place in the Bakassi area thus disrupting planned activities in the area. 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