African Programme for Onchocerciasis Control (APOC) Programme africain de lutte contre I'onchocercose

JOINT ACTION FORUM JAF-FAC FORUM D'ACTION COMMUNE Office of the Chairman Bureau du Pr6sident

JOINT ACTION FORUM JAF4/INF/DOC.7 Fourth session ENGLISH ONLY Accra. 9-11 December 1998 October 1998

Provisional agenda item 14

INDEPENDENT MONITORING OF CDTI IN September 17 - October 5

COUNTRY REPORT CONTENTS

1. INTRODUCTION 2

2. METHODOLOGY 2

J RESULTS 3 3.1 rndicatoror"n tioicori . : . . : 3 3.2 The number or proportion of target communities that decided on the criteria for CDD selection 4

3.3 How ivermectin treatment was done . 4 3.4 Coverage of the communities 5 3.5 Percentage of the target community treated 6 3.6 Reactions reported from the household survey of sampled communities 7 3.7 Input indicators 8 3.8 Quality of training 9 3.9 Record keeping 9 3.10 Quality of drug supply 9 3.11 Health personnelparticipation 9 3.I2 Management of side effects 9 3.13 Willingness of the community to bear the responsibilities involved in the process of CDTI: prospects of sustainability of CDTI 9 3.L4 Perception of the process . . . 10 3.15 Generating indicators of success of the programme 11

4 CONCLUSION 11

5 RECOMMENDATIONS 11

Appendix 1 TERMS OF REFERENCE t2

Appendix 2 RESEARCH INSTRUMENTS USED ON THE FIELD 13 JAF4/INF/DOC.7 Page 1

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1. INTRODUCTION

Three out of the four states in Nigeria which had received APOC funding in 1997 for Community- Directed Treatment with lvermectin (CDTI) have been monitored by independent team. The monitoring instruments were developed in Ouagadougou by some of the team members who had met to discuss monitoring exercises in Sudan, Uganda and Nigeria. The instruments were developed based on a set of monitoring indicators (appendix 1). The group members for Nigeria acted as team leaders for the States and they were joined by Nigerian counterparts.

Pre test was organized by each team on the field before the main survey. List of research instruments and instructions are included as appendix 2.

Detailed report of each of the States is available.

2. METHODOLOGY

In each State, four villages/communities were selected as the main target villages for the bulk of the research instruments. In addition, twenty communities around the four selected communities were visited to assess the coverage of communities with treatment. Record reviews were carried out regarding the activities of Community-Directed Distributors (CDDs) and at all levels of Ivermectin distribution.

In every state, the process of the review was initiated with a visit to the LGA headquarters for briefing and a request for a guide. In the target village, the chief was briefed and interviewed using 'key informant ' interview guide, another village leader was also interviewed using the same instrument. All the CDDs in the village were interviewed using 'in-depth interview guide for the CDDs, group discussions were held with three groups of community members, adult males, women, and the youth. In addition household interviews involving about 10 - 15 households were done to cross check on the performance of the current ivermectin treatrnent. Selection of the target villages was based on distance from the headquarters of the selected Local Authorities, (near, midway, and far).

At the end of the monitoring, feedback was given to the organizers of Ivermectin distribution at the state level and at national level including the WR (WHO representative) in Nigeria. JAF4/INF/DOC.7 Page 3

3. RESULTS

3.1 Indicator of effect of CDTI

The number or proportion of target communities which decided on the period or method of treatment

Table L

Results of key informants interview (village leaders)

Taraba Cross Kogi River

Response

Q3 How was CDD selected

at village meeting 7 t4 28 health worker selected 2 4 village chief-leader 6 t3 village elders only J other 5 4

Q4 How was the date for distribution decided

at village meeting 4 8 25 health worker selected t2 2 2 village chief-leader J 1 t2 village elders only 1 1 8

other J 6 1

Q3 How was system of distribution decided

at village meeting 3 t2 32 health worker selected 9 1 2 village chief-leader 9 7 village elders only 1 2 other 2 4 5 JAF4/INF/DOC.7 Page 4

In , it was mostly the health worker (onchocerciasis control officer) who decided on the dates (52.8%) of the communities, and the method of distribution(39.IVo). However, in both and , the decision on date of distribution and mode of distribution were undertaken by the community. The health worker did not take the decision (< ZVo).

3.2 The number or proportion of target communities that decided on the criteria for CDD selection

In all the states, Taraba, Kogi, and Cross River, using results of the key informants in the four main villages selected for the monitoring, the community decided on the criteria for the selection of CDDs. The criteria include experience or exposure to similar book keeping elsewhere, people seen as hardworking, self sacrificing, committed to community work and some level of education. In Taraba State, students were used as CDDs and that might have accounted for high drop out rate

3.3 How ivermectin treatment was done

Table 2. Drug to CDDs and mode of distribution

State Local Govt How Drugs are Mode of obtained distribution

TARABA All LGAs Sent to CDDs House to house

CROSS RTVER LGAs CDDs collected House to house drugs

Nyo-Ika CDDs Central location collected drugs

KOGI Olonaboro Drugs are House to house(66%) collected by Central (33%) CDDs from LGAs.

In some communities, the nearest health centre was used.

Ida House to house

otu House to house(60%) Central (407o)

West Yagba House to house(99%) Central (IUVo\ JAF4/INF/DOC.7 Page 5

In all the states, prior to distribution, there was mobilization, most of the respondents in the study areas indicated that meetings were held in their areas. The people were sensitized to the socio-economic importance of taking ivermectin. All the communities indicated that the State Onchocerciasis Coordinator, the Local Onchocerciasis Coordinator, and the participating NGOs briefed them on the CDTI prograrnme.

It is evident that, in Taraba State, CDTI process is yet to be fully installed. What is happening is more Community Based Distribution (CBD). In the other two states, CDDs collect drugs for distribution. It must be stated that where training precedes treatment, the CDDs are given drugs and would go for more drugs when needed from the health centre or at the local government office.

The major mode of distribution of drugs within the communities is house to house. However, in a few communities especially in Kogi State, central location was used.

People were measured before being given the ivermectin and exclusion criteria were observed.

3.4 Coverage of the communities

All the villages around the selected villages had been treated or were being treated at the time of the survey in Taraba State.

Table 3. Percentage treated household suryey

TARABA CROSS KOGI RIVER

Total population 406 284 394

Treated 300 2r0 37t

Under age 34 40 15

Absent 37 13 T7

Pregnant 5 6

refusal 2 13 4

Not informed 10 J

Sick 5 5 1

Others 3

Vo tteated 73.8 73.9 94.t

Percentage treated (88.3%) (84.7%)* (87.e%) (from records) JAF4/INF/DOC.7 Page 6

3.5 Percentage of the target community treated

The proportion of the target population treated according to the survey sample was 73.8% for Taraba statewhichcomparestothefigure of 88.3Vo fromtherecordsof theStateof Taraba. Ingeneralall the figures were comparable indicating good to reasonable coverage of ivermectin treatment in the states monitored. The overall estimates from the survey for Cross River was 73,9% compared to 84.7 Vo and in Kogi state, the estimate was 94. I7o comparcd, to 87 .9%. It must be noted that using the definition of coverage of treatrnent, that is the denominator should be the total population, it would not be possible to have coverage rates greater than 80% in view of the size of the ineligible population.

Table 4. Proportion of target communities treated

STATE COMMUNITIES FROM SAMPLED COMM. FROM RECORDS %

Pop Treated %

TARABA Dingding 70 56 80.0 76.t

Popule 92 54 58.7 94.7

Karamti 83 68 81.9 51.5

Ashuku 161 t22 75.8 69.t

CROSS Mbarakom 47 37 78.7 61.3 RIVER

Duwanga 75 62 82.6 45.7

Aningeie 58 4t 70.7 80.5

Busi 3 44 40 90.9 76.2

Ketting 64 30 46.9 72.7

KOGI Olomaboro t02 1 0 1 99.0 84.7

Idah 76 74 97.3 91.8

otu t42 t26 88.0 91.8

Yagba West 74 70 94.5 85.0

For Taraba State, the proportion of community members that had been treated ranged from 58.6% in Popule village in LGA to 8I.97o in Karamti village of LGA. The survey results did not match very well with data from the state records. The data for Dingding , Zrng LGA were for 1997 treatment period since the community was being treated at the time of the monitoring. JAF4/INF/DOC.7 Page 7

In Cross River State, the proportion of the communities in the sample villages that had been treated was high with the exception of Ketting community. However, information from members who were not physically present at the time of the survey was not taken into consideration, whilst in the other states, information on persons not present was obtained from household records at the houses or from the head of household.

In Kogi State, virtually all the sampled community members had received treatment. In Kogi, the sample information on proportion treated coincided with the results of the state records.

3.6 Reactions reported from the household survey of sampled communities

Table 5.

REACTIONS Taraba Cross River Kogi

Number % Number % Number Vo

Itching 11 36 2t 44.7 JJ 37.0

Dizziness 2 6.7 2 5.0 4 4.5

Headache 2 5.0 5 5.6

Swelling 5 16.7 l7 36.2 15 t6.7

Nausea/vomiting 2 6.7 I 2.5 3 3.4

Many reactions 1 3.3 2 5.0 25 28.1,

Feeling better 1 2.5

Others 9 30 1 2.5 4 4.5

Total 30 47 89

The most common reactions reported in the survey in all the states were itching and swelling

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3.8 Quality of training

The in-depth interviews with the CDDs in Taraba State revealed that the quality of training was good. The methodology was participatory, involving practical, problem solving and active participation of trainers. The contents of training was found to be adequate through the knowledge displayed by the majority of the CDDs on the disease, dosage determination, criteria for treatment and duration of treatment with ivermectin.

3.9 Record keeping

Examination of record kept by the CDDs showed that a good understanding of the recording and reporting procedures, the data types such as name, sex, number of tablets and ineligibles were included. In both Kogi state and Cross River state, there was a suggestion for the inclusion of column to record measurement of height since this is required to assess whether the correct dosage was given or not. In Yaba West and Ida villages in Kogi State, CDDs were found not conversant with recording.

3.10 Quality of drug supply

The comments from the interviews indicated that there was no problem with the quality of drug supply. However, all the remaining drugs after treatment was collected from the CDDs and the LOCTS. It was suggested that it should be possible to leave some drugs in the villages for those absent during treatment.

3.11 Health personnel participation

In Kogi and Cross River states, health personnel are involved in the treatment of the communities. Most CDDs were supervised by health personnel. The only constraints to the health personnel have in supervision are transportation and inaccessibility of the communties. However,in Taraba state, health personnel have just been trained but they are yet to be involved in the process of CDTI. The prograrnme has developed maps for the Local Government Areas, identified collection centres and health facilities to be involved in the ivermectin treatment.

3.LZ Management of side effects

The monitors in Cross River said many villages had mobile drug kits for the management of side effects. Side effects were not adequately managed in several of the communities.

'We expect a drug that would cure our diseases but not bring us reactions. I felt unwell for somedoys so I have refused to take it now. " 'Ilouse to house mode of distibution was done but side effects were not managed by CDD who only told us to go to the hospital"Women FGD Taraba State.

3.13 Willingness of the community to bear the responsibilities involved in the process of CDTI: prospects of sustainability of CDTI

The majority of the community members said they were poor and would prefer the existing system where Government delivered the drugs to their villages. Others said that if they had been informed that they were supposed to collect the drugs, they would have made some arrangements to do so. Many did not know that as a community, they could play a role in the selection of distributors and mode of treatment. JAF4/INF/DOC.7 Page 10

'We are ready as a community to organize treatment for several years if and when LGA fficials inyolve us and seek our views etc. If enlightenment continues and the LG's involye us we cdn do it and organize transponation to collect drugs. Now the LGA's disseminate the information and do everything" Focus group, Taraba State.

All the communities had trained CDDs. Were aware that ivermectin was free and the drug is to be taken once yearly for about 10 to 15 years.

The community does not seem to be ready to maintain the CDTI even though some support is given during ttre distribution to the CDDs, yet they would want the Government to still continue to deliver the drugs to them. They claim to be poor.

However, in Cross River State the monitors concluded that all communities are willing to sustain the programme and provide material and financial incentives for their CDDs. The following statements from group discussions underscore this conclusion:

" We are ready to buy drug kit from government to keep the drug for future use". 'We have seen the usefulness of the drug, people were ready and willing to work for their communities " 'tsenefits from the drug are multifurious. We are prepared to contribute money to secure it even if it means going to Calabar to secure it" 'We will continue to give our support and assistance to handlers of these drug; we are therefore prepared to pay their transport to Calabar for the drugs ". Women FGD Cross River State.

All the CDDs said they were interested to continue with the work but most of them wanted to be remunerated by the LGAs. However, since the process of CDTI has not been fully implemented in all the States visited, it may not be fair to infer whether the communities are able to sustain the CDTI. In Cross River State, all the communities expressed and trusted their ability to manage the CDTI in future. It is important to note that in Cross River State, distribution activities were not seen as government program and a lot of assistance was given in cash and in kind.

3.14 Perception of the process

The people saw the prograrnme as a preventive measure designed to improve their health. They want it to continue but with minimum side effects. They perceive the programme as a Government programme designed to help the community and they want the Government to continue with such a programme that would bring health benefits.

The women saw it mainly as a prograrnme involving the men and wanted it to be more participatory

'We know that people were measured, their ages taken and number of drugs given --We did not see the distributors. Only the men saw them. Our men brought the drugs, that is wlry we did not see the distributors or know anything about the drugs. "Women FGD Taraba State

The people do not feel that they can own the process of drug collection because they have not been informed. JAF4/INF/DOC.7 Page 11

3.15 Generating indicators of success of the programme

(i) General improvements in the health of the villagers, i.e worms are expelled, lice eradicated, few people with eye problems, improved eye sight and eradication of blindness. (ii) Quality of drug supply and drug distribution and few side effects. (iiD People expressing appreciation to all those involved in the project. (iv) Willingness of the community members to contribute towards the programme. (v) Change in skin condition of the people, rashes to disappear. (vi) Non-patronage of native doctors who have taken so much of our money in time past,

4. CONCLUSION

The team found out that in all the communities, there was ample evidence of positive awareness of the disease and the knowledge of the people about the dosage and benefits of the control programme was very satisfactory.

The CDDs have been adequately trained and are willing to continue with treatment. Though changes in CDDs were reported by some communities as a result of CDDs finding jobs elsewhere or going back to school, the communities did not find it difficult selecting CDDs and giving them some token rewards. CDDs performance was found to be very good in all the respective communities.

Almost all projects reported delays in release of funds. However, none of the projects reported shortage of drugs. Lack or inadequate counterpart support from the state as well as local government was identified in all the project areas.

Transportation problems were cited by all the States

5. RECOMMENDATIONS

Projects should be encouraged to complete their budget plans on time to ensure that funds are made available to them on time. In Cross River state, it is recommended that funds should be kept at programme site and not at the zonal level.

Taraba State should implement the CDTI approach as soon as possible to enable the assessment of community ownership of the progralnme.

The communities should be made aware of the need to support the CDDs and initial support should be given by the Local Government system.

The recording or the management information system of the projects was found to be excellent and well kept in several sites however, it is being suggested that column be provided to record height to assist in supervisory activities.

Several of the communities were found to be inaccessible during most of the time and support for appropriate means of transport must be given.

The need for counterpart support from both the state and the Local Government to sustain the programme.

Accountant to manage APOC funds should be employed in areas where they are not currently available.

The traditional leaders should develop their own monitoring systems to ensure accuracy in dosage and recording. Attention must be given to the management of side effects. JAF4/INF/DOC.7 Page 12

Appendix 1: TERMS OF REFERENCE

I Succinctly document how ivermectin treatments were undertaken in a number of sampled communities/villages in Districts/Local Government Areas with approaved CDTI projects.

2 Assess community involvement in -drug collection, decision making on the period and mode of distribution, the selection of distributors, and willingness of the community to bear these responsibilities as designed in the CDTI process.

J Document community perceptions of CDTI processes, especially the issue of ownership, and expectations for onchocerciasis control, and based on these perceptions and expectations, determine the degree of satisfaction of the community with the different programme activities and outcomes.

4 Assess the quality of training received by community selected distributors (CDDs).

5 Examine the record books of the CDDs and assess the quality of record-keeping and their ability to keep accurate records. The same applies to the ealt services staff on the project.

6. Determine the number of communities ans eligibles treated and compare your findings with the records of the CDDs and the records at the other levels (e.g. district, central). 7. Determine whether the health personnel participated in ivermectin distribution, and assess the degree and quality of supervision by the health staff (and the quality of training and / or orientation of such staff to CDTD.

8 Identify constraints in the distributions and make recommendations to the NOTF and the Management of APOC on corrective measures necessary before the next treatent.

8. Discuss the prospects of sustainability based on the findings above JAF4/INF/DOC.7 Page 13

Appendix 2: RESEARCH INSTRUMENTS USED ON THE FIELD

Taraba Kogi Cross River

1. In-depth interview of CDD 8 6 t3

2 Household survey of category 26 48 22 B villages

3 Household survey of category 65 45 54 A villages

4. Key informants village leaders 8 8 7

5. Health personnel 4 6 4

6. Focus group discussions 8 8 5