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COUNTRY/NOTFz Proiect Nanqez CDTI Proiect Approval year: 1999 Launching year: 1999

Reporting Period (Month/Year) z October, 2000 - September, 2001

Date Re-submitted: January 2004 NGDO partner: UNICEF

YEAR 2 PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) t-.-_ .)

I CL ! l3 I C,oorb I r5L I CEv CDf Bth BEt RECU --l I lt , t, 2 6 FFV. 2004 tc, \tR. i A\i APOC/DIR I i ( AFRICAN PROGRAMME FOR CONTROL (APOC) ff,iaM ONCHOCERCTASTS I i i ,i

WI-lO/APOC. 26 September 2003 ANNUAL PROJECT TECHNICAL REPORT { TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) ENDORSEMENT

Please confirm you have read this report by signing in the appropriate space.

OFFICERS to sign the report:

country NIGERIA/LIBERIA

National Coordinator Same: Dr. J. Y. Jiya t/r,,rnurur" \

/e Date:

Zonal Oncho Coordinator Name: Dr. U. E. Udofo

Signature

Date: ...

This report has been prepared by Name '. Mrs. Betty Jande

Designation : Proiect Coo rdi nator

Signature

Date

2 WIIO/APOC. 26 September 2003 Table of contents

Acronyms...... 1 Definitions...... 5 FOLLOW UP ON TCC RECON|MENDATIONS I 2 Execut ive Sum mary...... SECTION l: Background information J l.l. GeNsRalINFoRMATIoN...... 3 .3 I . I .l. Desuiption of the project (brieJly) l. 1.2. P artnership...... ,4 1.2. POPULATION AND HEALTH SYSTEM...... 5 SECTION 2: lmplementation of CDT|...... 6 2.1. Psntoo oF ACTIVITIES ...... ,6 2.2. ORopRtNc, sroRAGE AND DELIVERY oF IVERMECTIN ....'...' .8 2.3. AovocRcv AND SENSITIZATIoN l0 2.4. MOSILtzRttON AND HEALTH EDUCATION OF AT RISK COMMUNITIES..... ll 2.5. CoTUvuNtltESINVoLVEMENTINDECISIoN-MAKING l4 2.6. CRpactrv BUILDING 16 2.6.1. Training..... 16 2.6.2. Equipment and human resources..- I9 CoNotrtoN oF THE EQUIPMENT * PLeesg srATE 19 2.8. SupsRvrstoN...... 25 SECTION 3 Support to CDT|...... 26 3.1 . FtNRNCtaL CONTRIBUTIONS OF THE PARTNERS AND COMMUNITIES...... 26 3.3. ExpgNottuRE PER AcrlvlrY 27 +Lxpenditure included under IEC materials...... 27 SECTION 1: Sustainability of CDTI.. 27 4.1. INTpRNR1; INDEPENDENT PARTICIPATORY MONITORING; EvalUarlON...... 27 4.2. CouuuutrY sELF-MoNIToRING AND STAKEHoLDERS MpertNc 30 4.4. INrpcRRuoN 3l 4.5 OppnaloNAl RESEARCH 32 SECTION 5 Strengths, weaknesses and challenges.. JJ

3 WHO/APOC. 26 September 2003 Acronyms

APOC African Programme for Onchocerciasis Control ATO Annual Treatment Obj ecti ve ATrO Annual Training Objective CBO Community-Based Organ ization CDD Commun ity-Directed Di stributor CDTI Community-Directed Treatment with Ivermectin CSM Community Self-Monitoring DHS District Health Staff HFS Health Facility Staff LGA Local Government Area LG Local Government LOCT Local Onchocerciasis Control Team M&E Monitoring and Evaluation MDP Mectizan Donation Program MOH Ministry of Health NID National Immunization Day NGDO Non-Governmental Development Organization NGO Non-Governmental Organ ization NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force PHC Primary health care REMO Rapid Epidemiological Mapping of Onchocerciasis SAE Severe adverse event SHM Stakeholders meeting SOCT State Onchocerciasis Control Team TCC Technical Consultative Committee (APOC scientific advisory group) TOT Trainer of trainers TV Television UNICEF United Nations Children's Fund UTG U ltimate Treatment Goal VDC Village Development Committee VHC Village Health Committee wHo World Health Organization

4 WHO/APOC, 26 September 2003 Definitions

(i) Total population: the total population living in mesoihyper-endemic communities within the project area (based on REMO and census taking)'

(ii) Elieible population: calculated as 84Yo of the total population in meso/hyper- endemic communities in the project area.

(iii) Annual Treatment Objective: (ATO): the estimated number of persons Iiving 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 maximum number of people to be treated annually in meso/hyper endemic areas within the project area, ultimately to be reached when the project has reached full geographic coverage (normallythe project should be expected to reach the UTG at the end of the 3'o year ofthe project).

(v) Therapeutic coverage: number of people treated in a given year over the total population (this should be expressed as a percentage)'

(vi) Geographical coverage: number of communities treated in a given year over the total numUer of meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage).

2003 5 WHO/APOC. 26 September FOLLOW UP ON TCC RECOMMENDATIONS

The table below shows a follow up of the recommendations to the project made at the last TCC meeting.

TCC session 13

Number of TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR Recommendot TCC/APOC ion in the MGT USE Report ONLY 34 (i) Conflicting information on annual This is clarified in Table l0 treatment obiective 34 (ii) Complete infonnation on Table 3 Cost per treatment could not be ofthe report calculated. There was no community where CDD is a health worker. The health workers supervised all the distributors in the communities. 34 (iii) Provision of a plan of action for The present leadership did not meet any expansion Year 2 Plan of Action in the files, but it is aware that treatments were expanded from the l4 LGAs originally approved to l8 (with the addition of 4 new LGAs namely:Tarka, Obi, & Logo. 34 (iv) NOCP to ensure adequate The national office is trying its best to monitoring of CDTI monitor the activities of the project implementation 34 (v) Treatment figures should be Complete summary treatment figures provided from January to provided in Table l0 December 2000 and not only for January to September 2000.

WHO/APOC. 26 September 2003 Executive Summary

Benue State is located in the central part of Nigeria. The vegetation is forest to the south, with forest - savannah mosaic and mixed savannah grassland in the northern areas. Estimated population of the State is put at 3,802,500 persons. The major ethnic groups are the Tiv and Idoma. Settlement pattern is largely dispersed. Movement of whole communities or large numbers of persons is common due to inter ethnic clashes or fear of reprisals from the army authorities. Roads between major cities are in good condition, but access roads to most of the endemic communities are in poor shape.

The State consists of 23 local government areas but CDTI is currently being implemented in 2049 communities in l8 LGAs. Target population is 1,243,525. All communities were reported to have been covered but total number of persons treated stands at 696,460 thus achieving a 56%o therapeutic coverage.

During the course of the year I I SOCTs, 72 LOCTs 180 other LGA health staff, 540 health facility staff and 3,451 CDDs were trained on CDTI. One SOCT underwent computer training. These represent achievements of 33% for LGA staff, 60% for health facility staff and 345% for CDDs with regards to AtrOs.

A total of 1390 community leaders, 221 opinion leaders and 584 primary school teachers were mobilized to support CDTI. The policy makers at State and LGA levels were visited to solicit for financial support to the project and to enlighten them on their roles. This has resulted in some communities forming Mectizan distribution monitoring committees. Moreover, in some LGAs drama groups are being formed to further highlight the socio - econmic importance of the disease using the local dialects. Some schools have formed health clubs. These have resulted in increased awareness of the communities of the benefit of Mectizan, and the need for its continual intake over a long period of time.

The project has succeeded in creating awareness in communities that the programme belongs to them. It has tried to some extent in empowering communities to consider and determine their own health needs. There are committed staff at LGA and State levels.

The major challenges facing the project are:

communities and ensuring proper record keeping at all levels.

State and LGA levels

2 WHO/APOC, 26 September 2003 SECTION 1: Background information

1.1. General information

1.1.1. Description ofthe project (briefly)

Geographical location, topography, climate Benue State is located in the central part of Nigeria. The State lies between longitude 6030' and 8020' East and latitude 7080' and 9035' North. It is bounded on the North by Nasarawa State, North West by Plateau State, on the South, on the Southwest, and Cross River State on the east.

The vegetation is forest to the south, with forest - savannah mosaic and mixed savannah grassland in the northern areas. The terrain comprises undulating hills which occasionally reach 4,000 feet above sea level, to bare flat plains along the Benue River, with an altitude above sea level ofabout 300 feet. In the eastern part ofthe project area there are steep hills, cut by swift flowing streams whose banks are densely forested. The rainy season begins in March and ends in October while the dry season lasts from November to February. The State has an annual rainfall of 1200 - 9800mm.

Population: activities, cultures, language Estimated population of the State is put at 3,802,500 persons. The major ethnic groups are the Tiv and ldoma. There are other smaller groups such as Etulo, Offiah and Jukun, who live in Tiv areas; while the Igede and live in areas inhabited by the Idoma. The major languages spoken are Tiv, Idoma and Hausa. The major occupation of the population is farming, including growing of yams/cassava and cultivation of cotton and beniseed. Fishing alongthe riverine areas is widespread. Crafts such as blacksmithing, weaving of cloth etc are practised. Some also keep domestic animals. Settlement pattern is largely dispersed. Movement of whole communities or large numbers of persons is common due to inter ethnic clashes or fear of reprisals from the army authorities.

Communication system (road...) Roads between major cities are in good condition, but access roads to most of the endemic communities are in poor shape. Some are not passable during the rainy season. Despite this transport by road remains a major means of communication among the communities. The electronic and print media are also veritable channels of communication. Within the communities the town criers and announcements in churches/mosques are preferred means of communication.

A dministrat io n str uct ure The State consists of 23 local government areas with the chief administrative officer being the Chairman. A legislative arm made up elected councillors from various wards suppofts him. At the State level the Executive Governor is the head of administration. There are the legislative and judicial arms. The capital of the State is located in .

Health system & ltealth care delivery There is an official PHC policy and structure in the project area. It is a system of health care services where community participation forms the mainstay with support from the State, Local Covernment and NGOs. Levels of functionality however vary across the State. Scattered throughout the State are various health facilities ranging from health posts to hospitals.

3 WHO/APOC. 26 September 2003 I.1.2. Partnership - Indicote the portners involved in project implementation at all levels (MoH, NGD Os -natio na l, i nter nat i o nal) - Describe overall working relationship among parlners, clearly indicating specific areas of project octivities (planning, supervision, advocacy, planning, mobilization, etc) where all partners are involved. -State plans tf any to mobilize the state/region/district/LGA decision-mokers, NGDOs, NGOs, CBOs, to assist in CDTI implementation.

The partners involved in project implementation in Benue State are UNICEFAIigeria, NOCp (National & Zonal offices), the State Government, the various local governments and the endemic communities. In Local Government area St. Monica's hospital is assisting in the distribution of ivermectin to some of the communities.

UNICEF is mainly involved in planning, occasional advocacy and training. It makes funds available through the zonal offices to the project to carry out several activities. The NOCP zonaloffice is empowered to act for IINICEF in terms of supervision and technical support. The NOCP national office has also been involved in supervision/monitoring, advocacy and provision of technical support to the project. The State, Local Governments and the endemic communities carry out their various responsibilities under CDTI.

Partners are working together in relative harmony although there are problems with release of approved funds due to delay in approval of applications by UNICEF.

There was no conscious effort made by the project within the reporting period to get additionalNGOs and CBOs to support the implementation of CDTI.

4 WHO/APOC. 26 September 2003 e(, c\l F so () I -o .s 6 oE bo .= o- s.= (.) :E a co a @ @ $ @ \o a.l \o \o \o + a.l ia c- o\ \o N @ € o\ a{ c\ al ca v'I o\ t-- 6 ':e o Ar o G! EE o 60 o ^E o O i9e! o t L $ + c.l F- \o F- F- N + \o o\ L ':e ''= @ \o o\ F- € \o \o r- N r- \o F.- t 00 t E -f O 6l E o \H or q) q =o H N io cn o- \o 6 E (r) !o ! il tq C) F := o d ri bIJ o Po o c? .o z z z z z z z z z z Z Z Z =l q) EN z z z z z SYo F L \o c! f, E (] q) o \- oL Lo oC @ E e-UE E =o $: o o z o t\ s.r!\ vs C) t. 9a { =! C) :o z z z Z z z z z z z z z z z z Z z z G9ss Eo E .9! 1-7 o E tl. g.? Bsu=o ' -= o EA G is .- -V )u r o -do- h o. o o\ ,= o (n L NO uu f 9 I .9. e: o a, O': Q L co ca @ co s @ \o c.t \o $ N ia t E= p- t! \o a- o\ c.l 00 \o € o\ c{ c.l N qd .\c =o€^ (E F- ro- c.l F- rA -g o EO q s q q v- Q- G E=t E :o=-t> za q oX ! u C= (! :s o N 5 O si o o (J (d =fr a= o o = !{ o -V o E & L d tr (! o cn .v () (d o .v .v F N F o ox -o o. ! ! -o -o o0 .5z (! :2, o L9' F (, I co \J r-) V v J o 5 o o F D f F F* 5\ SECTION 2: Implementation of CDTI 2.1. Period of activities

Insert Plan of action indicating activities by month, which were implemented

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Mectizan@ ordered/a for by_- (ltlease tick the appropriate answer) r/tvt wHOL-l UNTCEF,tr NGDOI Other (please specify)

Mectizan@ delivered by - Qtlease tick the appropriote answer) ./ruosrNocfl wHotr uNrcEFn NGDOtr Other (please specify)

Please describe how Mectizan@ is ordered and how it gets to the communities

The quantity of Mectizan@ required by the project is calculated based on treatments and total population from the last cycle. NOCP processes the data after receiving information frorn other UNICEF - assisted States and submits re - application to the MDP. On approval the drugs are shipped to the country and UNICEF facilitates clearance and storage. The State or the Zonal office picks up its consignment from NOCP and releases to the LGAs through the LOCTs. LOCTs release drugs to the district health supervisors or the health facility staff who in turn make them available to the communities.

FLOW CHART OF MECTIZAN DELIVERY

MDP UNICEF/ Nigeria Reporting flow

NOCP

I Zonal Office

Delivery process

STATE

LGA

District Health Facilities

Communnities

8 WHO/APOC, 26 September 2003 Table 3: Mectizan@ Inventorv

State/District/ Number of Mectizan tablets LGA uested Received Used Lost Waste Expired Ado 5 r,340 99,936 r 82,3 l0 102,230 Guma I 09,000 Katsina-Ala 139,932 68,278

Kwande 204,3s4 Logo 21.962 obi 78.809

Ogbadibo r37.5 t9

Ohimini 34,896 oju 99,256

Okpokwu 70.000

Otukpo 136.456

Tarka 26,213

Ukum 77,761

Ushongo t3I,098

REF. CENTRE

TOTAL 1,771,250 The new lead ership did not meet any records on tablets given to the LGAs within the reporting period, despite series of efforts

state octivities under-Ivermectin delivery thar ore being caruied our by healtlt care personnel in the project areo.

The health personnel at the various levels have been responsible for the following:

9 WHO/APOC, 26 Seprember 2003 2.3. Advocacy and Sensitization

State the number of policy/decision makers mobilized at each relevant level during the current year; the reosons for the sensitization and outcome. Describe dfficulties/constraints being faced and suggestions on how to improve advocacy.

The policy makers at the State and LGA levels were sensitized during advocacy and routine visits by SOCTs and visitors to the project. These were geared towards creating more awareness of the treatment programme, define roles/responsibilities of the various tiers of governments and solicit for financial support. Advocacy workshops for district heads, selected opinion leaders and some primary school teachers were held to mobilize them to support the CDTI process either in form of supervision, health education/mobilization of endemic communities or financial support for CDDs/collection of Mectizanlreturns rendition. See table below for number of participants.

Outcome

has been evidenced in the release of funds for various activities by some LGAs

communities. Once Mectizan was available the CDDs were dispatched to collect their consignments. We see more communities picking their Mectizan from the collection centers.

aware that some did give financial incentives to their CDDs the level of support could not be ascertained. CDDs were unwilling to give specific details of incentive received thinking that it may jeopardize further assistance from the project to them.

Co nstra i n ts/D i ffi c u I ti es

for CDTI.

LGA policy makers to financially support the CDTI process due to inadequate funds at project level.

Suggestions

LGA level.

proposals submitted to UNICEF zonaloffice is a cause of great concern.

l0 WHO/APOC, 26 September 2003 Table 38

District/Kind red Primary Opinion Leaders School Total Heads Teachers

District/ LGA Ado 86 l5 40 t4l

Buruku 72 l0 40 122

Gboko 90 10 40 140

Gwer West 78 l0 40 t28

Guma 85 20 40 145

Katsina-Ala 84 l0 40 r34

Konshisha 72 l0 80 t62

Kwande 72 l0 40 122

Logo 62 t0 0 72

obi 56 t0 0 66

93 23 40 156 69 l0 Ohimini 0 79 oj, 84 l5 40 139 90 r0 40 140 90 t8 40 r48 75 l0 0 Tarka 85 l2 10 40 122 60 t0 24 94

I,390 22t 584 2,195 Total

2.4. Mobilization and health education of at risk communities Provide information on : - The use of media andlor other local systems to disseminate information - Mobilization and health education of women and minorities - method and response - Response of target communities/villages - Accomplishments - Weaknesses/Constraints - Suggest ways to improve mobilization of the target communities.

ll WHO/APOC, 26 September 2003 The use of medio and/or olher local systems to disseminate information

The project made use of the following media for the mobilization of the endemic communities: (l) A team comprising officers from the State Ministry of Information, Health Education department of the Benue State University and Health Education unit in the Ministry of Health went round to some LGAs to mobilize school children on onchocerciasis control. (2) Personal visit of the Honorable Commissioner for health to some communities. (3) Production and airing ofjingles as well as health talks on onchocerciasis through the electronic media - radio and television. (4) Production and distribution of thousands of IEC materials, particularly posters to the endemic communities. (5) Community heads, including district chiefs and opinion leaders. (6) Town criers - this is the principal means of information dissemination at the community level. (7) Health education meetings with community members by health personnel from the LGAs or CDDs.

Mobilization and health education of women and minorities - method and response

In the State where the people were mobilized, there is an active participation of female members of the community at meetings. Women are always in attendance at health education meetings. and sometimes are in greater numbers. In several places the women are assertive and can demand that their views be listen to, respected, and decisions reached based on what they have suggested. Generally in decision - making women make inputs before decisions are reached. In some communities women are part of those who make the actual decisions as they hold traditional titles. In some communities women are selected or have volunteered their services as CDDs. There are no problems with ethnic minorities living in the community.

Response of target communities/villages

Communities have responded by coming forth to collect their Mectizan tablets. We see more communities sending the CDDs to pick Mectizan from the collection centers. Members have expressed willingness to comply with Mectizan treatment though there are fears of reactions. The communities have fulfilled most of their responsibilities under CDTI such as selection of their CDDs, giving some incentive to some of them and determination of the rnode of distribution.

Accomplishments

The following has been accomplished

importance of the disease using the local dialects.

over a long period of time is being sustained.

12 WHO/APOC. 26 September 2003 We a k n es s es/C o n s tr a i nts

There are several constraints facing the project with respect to mobilization of the endemic communities. These include:

of the role of UNICEF's zonal office in CDTI.

salaries. This has had a demoralizing effect on health workers.

Suggest woys to improve mobilization of the target communities.

UNICEF Zonal office should be made to realize its role in the funds release process. 2. Partners should be sensitized to fulfilltheir financialresponsibilities to the project so that more interactions with the communities could take place. J Local NGOs and CBOs need to be sensitized to support CDTI implementation in the State. The project also needs to reach out to religious groups and various community based associations who can effectively take the message to the grassroots.

l3 WHO/APOC, 26 September 2003 6l

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2.6.1. Training

During the course of the year I I SOCTs,72 LOCTs 180 other LGA health staff,540 health facility staff and 3,451 CDDs were trained on CDTL One SOCT underwent computer training. Materials used in the training sessions for CDTI include CDD training manual, flip charts in the indigenous languages, various types of posters, community logbooks, and Mectizan (3mg) treatment charts.

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p' o a bI '.] ; E o F q) o f, F ; C) Table 6: Type of training undertaken (fick the boxes where specific troiningwas carried out during the reporting period)

Trainees Other I lealth Community Workers nrembers e.g ( frontline Type Community health MOH staff Political of training CDDs supervisors fhcilities) or Other Leaders Others(specify) Program management How to conduct { .{ Health education ^/ Management of { { SAEs CSM SHM Data collection { { .v Data analysis

Report writing Others (specify)

Any other comments

2.6.2. Equipment and human resources Table 7: Status of equipment (Please add more rows if necessary)

Source APOC MOH DISTRICT/LGA NGDO Others Type of Condition of the equipment * Please state equipment l. Vehicle (l) Functional 2. Motor cycle (17) Functional (27) Written off 3. Computers (1) Functional 4. Printers (l) Functional 5. Fax Machines (l) not in use 6. Others a) Photocopier (t) b) Air conditioner c) *Condition of the equipment (Functional, Currently non-functional but repairable, Written off).

How does the project intend to mointain and replace existing equipment and otlrer materials?

In the interim the project will repair and maintain all capital equipments with the funds provided by APOC, while awaiting the government to release counterpart funds. In the long run it is expected that government will maintain existing equipment with some assistance from UNICEF.

WHO/APOC. 26 September 2003 t3 - Describe the adequacy of available knowledgeable manpower at ull levels.

There is enough available manpower for CDTI implementation. The project however needs to train more health facility staff and ensure CDTI is part of their routine responsibilities.

- lYherefrequent transfers oftrained staffoccur, state what project is doing or intends to do to remedy the situation (The most importont issue is what measures were taken to ensure adequate CDTI implementation where not enouglt knowledgeable monpower was available or slaff often transferred during the course of the campaign).

There is some stability of staff at State leveland at LGA level. Where transfers occur and some one new to the programme takes over, he/she is trained either by the SOCTs during the training of LOCTs or by the LGA Oncho Coordinator.

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Therapeutic coverage rate Number of le treated x 100 (%) Total population living in meso/hyper-endemic communities within the project area

Geographical coverage rate Number of communities/villages treated x 100 (%) Total number of meso/hyper-endemic communities as identified by REMO in the project area

ATO coverage rate Number of people treated x 100 (o/o) Annual Treatment Obj ecti ve

% UTG achieved Number of peoplq treated x 100 Total number of people to be treated in meso/hyper-endemic areas within the project area (UTG)

ATO = The eslimated number oJ persons living in meso/hyper-endemic areas that a CDTI project intends to treat with ivermectin in a given yeor,

UTG = The maximurn number of people lo be trcoted in meso/hyper-endemic areas within the project area, ultimately to be reaclted when lhe proj.ecl hos reaclrcdfull geographical coverage (normally lhe projecl should be e:rpected to reoch the IITG at lhe end of the 3"t year of the project).

- If the project is not achieving 100% geogrophical coverage and minimum of 65% theropeutical coverage rate or coverage rate is fluctuating, stote reosons and plons being made to remedy tlris.

The project appears to be achieving 100% geographical coverage but due to funds constraints the SOCTs could not validate the figures. We are aware of problems of poor record keeping at all levels, and efforts are being made to ameliorate them.

Though the project recorded a therapeutic coverage of 56% more could have been achieved but for the short supply of Mectizan. Many communities could not get sufficient Mectizan since the project did not get enough from NOCP. In some communities there are some refusals who decline treatment due to fear of reactions.

2.7.2. Thefundamentol cause of absenteeism

Some causes of absenteeism include the relocation of some farmers to their farm houses during the farming season, displacement of communities during communal clashes and abstinence of some from community treatments for fear of reactions.

Briefly describe all known and veri/ied serious adverse events (SAEI ond provide in table 9 the required information when available,

At the early stages of the distribution there were reported cases of SAEs, and this is partly the reason why some community members are reluctant to comply with Mectizan treatment. However, in the past few years though there were minor reactions there were no reported cases of SAEs.

2.7.3. In case tlte project hos no case of serious adverse event (SAE) during this reporting period, pleose tick in the box No case to repoft {

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I 2.8.1. Provide a flow chart of supervision hierarchy '1"

LOCT I DHS/FIFS I CDDS

2.8.2. The issues identi/ied during supervision included:

Issues identified during supervisory visits are:

health education of endemic communities.

2.8.3. Ll/as supervision checklist used?

Supervisory checklists were not used.

2.8.4. what were the outcomes ot each level of CDTI implementation supervised?

At the State level, review meetings were held with LoCTs. They went out later to rectify some of the anomalies. LOCTs went back to some communities to mobilize and health educate them. They also had audience with several community leaders to solicit for support. Health facility staff have been trained to be involved in CDTI. At the community level the project has encouraged leaders to assist in supervising CDDs.

2.8.5. LYasfeed-back given to the supervised, and how was thefeedback used in improving the overall performance of the project

Feedback was given during visits to the communities and during advocacy visits to community leaders. Some of the issues were also raised during the advocacy meetings with district heads and visits to policy makers.

25 WHO/APOC. l0 April2003 SECTION 3: Support to CDTI

3.1. Financial contributions of the partners and communities

Table I l: Financial contributions all rtners for the last three ars

Year I (1999/2000') Y ear 2 (2000/200 I ) TOTAL TOTAL TOTAL TOTAL Budgeted Released Budgeted Released Contributor (US$) (us$) (us$) (us$) Ministry of Health (MOH) 12.832 14,785 2.8 r8.9 LocalNGDO(s) ( if any)

NGDO partner(s) 45,0r 5 40.300

District/LGA 42,t43 66,586 Others a) b) c) i Communities

APOC Trust Fund 98.360 75.247.88 r 06.96s 57.73 8.86

TOTAL r98,3s0 75,247.88 228,636 78,066.78

NB: For APOC and UNICEF amount stated as budgeted above does not include what were budgeted for capital items just as amount released does not include expenditure on capital items. For MoH/LGA, amount stated as budgeted does not include personnel costs.

If there ore problems with release of counterportfunds, how were they oddressed?

There are problems with release of counterpart funds at both State and LGA levels due to several reasons. These include:

Advocacy visits were paid to LGAs, but only very few responded, at least from the information available to us. The LGA contributions were well reported, and we are encouraging LOCTs to be more comprehensive - allaying fears of any audit. This is the reason why no amounts appear for LGA in the table above. At the State level NOCP and UNICEF officials have paid advocacy visits to policy makers but not much has come out of it

3.2. Other forms of community support

Some communities support their CDDs by helping them on their farms especially during the planting season. Others support in some ways such as

26 WHO/APOC. 26 September 2003 3.3. Expenditure per activity - Indicate the expenditure on activities below in US dollars using the current United I Nations exchange rate to local curuencJ ($ - :N:127.00)

Table l2: Indicate how much the project spent for each activity listed below during the reporting period

Expenditure Source(s) of Activitv ($ us) funding Drug delivery from NOTF HQ area to central collection point of 2.81 8.9 community* MoH Mobilization and health education of communities** 289.76 Training of CDDs 2,039.8 Training of health staff at all levels 2,347.32 Supervising CDDs and distribution 10,262.05 APOC Internal monitoring of CDTI activities Advocacy visits to health and political authorities UNICEF IEC materials 28,438.92 APOC Summary (reporting) forms for treatment+ Vehicles/ Motorcycles/ bicycles maintenance 3,898.79 APOC Office Equipment (e.g computers, printers etc) + office supplies 1,360.56 APOC * ** Others 8,944.55 APOC TOTAL 60,400.65 Total number of persons treated 696,460

Comments *Some of the funds were used for supervisory visits +*Amounts spent by the LGAs were not available. ***A total of $7,208.04 was expended on managerial allowances +Expenditure included under IEC materials

SECTION 4: Sustainability of CDTI 4.1. lnterna!; independent participatory monitoring; Evaluation

4.1.1 lVas Monitoring/evaluation csrried out during the reporting period? (tick where applicable)

{_Year 1 Participatory Independent monitoring

Mid Term Sustainability Evaluation

5 year Sustainability Evaluation

Internal Monitoring by NOTF

Other Evaluation by other partners

27 WHOiAPOC. 26 September 2003 4.1.2 Whal were the recommendations?

1. To the Project

Training of Health Staff o The initialtraining should be for a minimum of 3 days, whilst retraining should be for 2 days. During the trainin g, a day should be set aside for practical work and assessment. o A schedule with the content for training of health personnel, as well as for training of CDDs should be made available. The content of the training should include sessions on the APOC philosophy, techniques on advocacy, mobilisation and health education, with special emphasis on community responsibilities as well as the specific roles of other partners in the CDTI process, supervision, recording and reporting to effectively address the requirements for CDTI implementation. o More health staff should be trained on CDTI programme to further enhance integration in PHC.

Training and Supervision of CDDs o This should continue within the communities. Initial training should be for at least three days, while retraining activities can be for two days. During the first three days training, a day should be set aside for demonstration on record keeping, aensus taking and reporting. o More CDDs should be enlisted and trained to ensure adequate coverage of all the communities. . The current trainee-trainer ratio should be encouraged and sustained. o The involvement of literate members of the communities, such as teachers and retired civil servants CDTI implementation at the community level should be encouraged, to help re-enforce training and record keeping at community level. o More attention should be paid to the aspects of record keeping and reporting during training, particularly with regards to household composition and documentation of colour for easy assessment of treatment accuracy. o Training and supervision checklists should be made available and used to assist in these activities. o Supervision should be emphasised at all levels, especially during and immediately after distribution for the CDDs.

Record keeping and Reporting o The quality of record keeping at all levels of CDTI implementation in the State still has room for further improvement. o Review of the process of census taking in the villages to determine accurate population to enhance adequate planning for ivermectin procurement and distribution as well as effecti ve d ete rm ination of treatment coverage. o Adequate training on household recording and recording of treated persons immediately after administration of the drug should be emphasized.

Approaching the Health Services and the Community o To ensure a proper transition from CBIT to the CDTI approach by the project, precise and concrete steps must be taken to conduct proper orientation of the health personnel and community. It is recommended that the project intensify the following: o Training and orientation of health personnel on the policy and implementation of the APOC philosophy and their roles in CDTI should be encouraged. More health personnel

28 WHO/APOC. 26 September 2003 at all cadre, should be involved and made to understand that more training, supervision, monitoring and reporting of CDTI activities. a Continued dialogue should be held with community leaders on the benefits of ivermectin treatment, their roles and commitment in the long-term sustenance of the treatment process should be emphasized. a Mobilisation should continue to target everybody, including women, youths and religious groups, as they have been found to lack good knowledge of the CDTI philosophy and process. a More personnel from the components of the PHC, media and educational institutions with skills in health education, mobilisation and gender issues should be co-opted into the mobilisation of communities and introduction of CDTI activities to this level of partners. a Supervision of the community by village leaders and health personnel should be directed more to periods during and after distribution. These supervisors need training for at least 2 days as TOT and supervision in CDTI/

Integration of CDTI into the PHC Systems o The current level of integration of CDTI into PHC in Benue State is good for this early stage. o CDTI activities should be included in the PHC budget plans at State and LGA levels.

To State: a The State must be very active to ensure that the facilitate role of APOC is felt in the first and second years of implementation of CDTI. This will afford a great opportunity of re- orientating the CBIT programme into CDTI. a In this early stage of funding from APOC, the State must ensure that APOC funds are rapidly utilised to train CDDs. If this is not done, there will be great variation of entry of CDTI and exit of CBIT in the different LGAs. Some LGAs. Some LGAs have had no training using APOC funds. Training of CDDs should be budgeted for in the APOC budget, ifnot already done. a Supervision should be enhanced and budgeted for in the APOC budget, if not done already. a State should make proposals to purchase more durable motor cycles and bicycles to enhance supervision and monitoring by health personnel and district health supervisors respectively.

4.1.3. How hove they been implemented?

tr Duration of training and training of additional health staff suggested shall be done when funds are available. o Various training materials have been produced. tr During the last training sessions the various topics recommended were covered. tr Communities have been encouraged to select more CDDs, but the problem has been the issue of incentives. tr Efforts are being made to improve record keeping both by devoting some time during training sessions and by making corrections during supervisory visit. o Supervision is being emphasized, and acclaimed to be important in project implementation, but project is being constrained by inadequate release of funds by all partners. In the meantime teachers have been mobilized to assist in supervision at the community level.

29 WHO/APOC, 26 September 2003 o Training and supervisory checklists have been procured from Nocp, the ones developed at Kabele, Uganda. tr The project is aware of problems relating to getting accurate population figures of a endemic communities, and will address it thoroughly when funds are available. A comprehensive census update is being planned as a separate exercise. o Project recognizes the need for continuous dialogue with communities on CDTI but it is being constrained by inadequate funds. Meanwhile there have been several advocacy meetings with and visits to quite a number of community heads. tr A multi- sectoral, multi- disciplinary team comprising officers from Ministry of Information, Health Education Depaftment of Benue University and Health Education Unit, Ministry of Health mobilized school children in some LGAs. o The project is aware of several persons who have gone to see the UNICEF Zonal officerto advocate for prompt release of funds. The project is awaiting a change. tr There is a line item for CDTI at the State level and in one LGA. o Proposal for l0 additional motorcycles was made for the second year, but the number was reduced to 5. The project made a proposal for additional 3 in the third year, and this has been approved. Supervision and CDD training were all included in the budget proposals both for the 2nd and 3'd years. The problemis however that of funds release. o Some NOCP officers and independent scientists have had sessions with SOCTs and had emphasized on the need for a shift in paradigm. It is hoped that these will bear the needed result. o Advocacy visits have been paid to policy makers. In one instance the national coordinator was able to meet with the executive governor of the State. An advocacy workshop was also organized by the State. The project is however yet to see a definite taking on of more responsibilities by the State government. tr Efforts are being made by the Permanent Secretary in the Ministry of health to resolve any bureaucratic issue and areas of differences among the necessary officers that may hinder CDTI implementation.

4.2. Gommunity self-monitoring and Stakeholders Meeting

Table l3: Community self-monitoringand Stakeholders Meeting (Pleose add more rows if necessary)

District/ LGA Total # of communities/villages No of Communities that No of Communities that in the entire project area carried out self conducted stakeholders monitoring (CSM) meeting (SHM) Not done

TOTAL

Describe how the results of the community self- monitoring and stakeholders meetings have affected project implementation or how they would be utilized tluring the next treatment cycle"

30 WHO/APOC, 26 September 2003 4.3. sustainability of projects: Plan and set targets (mandatory at yr 3)

4.3.1. Planning at all levels a_ 4.3.2. Funds ( 4.3.3. Transport (replacement and maintenance)

4.3.4. Other resources

4.3.5. Please provide a written plan with set targets and achievements for so far.

4.3.6. To what extent has the plan been implemented

4.4. lntegration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration

4.4.1. Ivermectindeliverymechanisms

The Mectizan delivery process occurs within the existing PHC structure. Communities pick their Mectizan requirements from the health facilities, except in few cases where the drug is taken to them. During NIDs, for instance, the LGA/PHC staff who come to pick up their vaccines also use the opportunity to collect Mectizan.

4.4.2. Training

Some other LGA/PHC Personnel, apart from LOCTs, have been trained on CDTI so that they can assist in training of lower levelpersonnel and supervise CDTI activities..

4.4.3. Joint supervision and monitoring with other programs

At the State level, there are no plans for joint supervision and monitoring at present. At the LGA level we are aware that some of the LOCTs are involved in other programmes and occasionally use the opportunity of visits to the community/health facility for one programme to look into other programmes which they are handling.

4.4.4. Release offunds

In very few cases where there are releases of fund, imprest is released for PHC activities and is controlled by the PHC director. From there minimal amounts are made available to the Onchocerciasis Coordinator for some routine visits or collection of Mectizan. At both State and LGA levels proposals for the release of funds however must pass through the PHC director and other normal channels.

a 4.4.5. Is CDTI included in the PHC budget?

At the State level there is a Iine item for CDTI in the PHC budget. At the LGA level CDTI activities are subsumed under a general PHC budget. In one LCA CDTI has a line item in the budget.

3l WHO/APOC, 26 September 2003 4.4.6. Describe other health programmes thot ure using the cDTI structure antl how this wos ochieved. Whst have been the achievements?

None at the moment

I 4.4.7. Describe others issues considered in the integration of CDTI.

4.5 Operationa! research

4.5.1 Summarize in not more than one half of a page the operationol researclt undertuken in the project oreq within the reporting period.

An operational research on < Evaluation of the Factors that Influence CDD Performance in CDTI Implementation >> was conducted in Bauchi and Benue States by Prof. O. Akogun. The research was sponsored by UNICEFA.,ligeria. Reproduced below is an extract from the executive summary of the repoft as it pertains to Benue State.

'The Benue team has made commendable achievement within one year of CDTI and has raised community ownership to25o/o. The State has very effective information, Education and Communication strategy and a very impressive level of advocacy such that the communities are highly mobilised. However there are frequent request for motivation from the CDDs leading to household contributions of between =N:10 and =N:20 to the CDDs during distribution. Supervision and training are important components of the programme but restricted to the State team and local Oncho Coordinators. The training method is a combination of demonstration (60%) and talk chalk(40%). Record keeping is poor as CDDs only keep record of those treated and not all members of the household thus making estimation of coverage very difficult.

The most important factors which influence CDD performance are team management style, supervision, practicaltraining, interest of superiors in CDD activities and recognition by the community and those in authority.

UNICEF should intensify reorientation of health workers to the concept of community service and fashion out some means of getting communities to contribute to the programme either by direct cash without CDDs abusing the process.'

4.5.2. How were the results applied in the project?

o CDDs have been retrained on CDTL The project intends to devote more attention to practicals in future training sessions tr The project has tried to mobilize traditional and opinion leaders to supervise CDDs. This, it is hoped, will complement the supervision by the health staff as wellas let CDDs know of the interest of superiors in CDTI implementation. This will raise not only their personal perspective on CDTI but also their social status as community leaders pay attention to what they are doing. a o Health facility staff has been trained and teachers mobilized to assist in the supervision of CDTI at community level. o Poor funding has limited the number of health workers at the LGA level that could partake in supervision.

32 WHO/APOC, 26 September 2003 SECTION 5: Strengths, weaknesses and challenges

Strengths: L. t.

Weaknesses

partners

release of approved funds.

funding from all partners

Challenges

communities and ensuring proper record keeping at all levels.

State and LGA levels

a

33 WHO/APOC. 26 September 2003