TUNDURU - WHO/APOC/CDTI PROJECT
REPORT OF INDEPENDENT PARTICIPATORY MONITORING OF CDTI ACTIVITIES IN THE TUNDURU CDTI PROJECT, TUNDURU DISTRICT TANZANIA 2-14 AUGUST 2007
Community Members and CDTI Monitors in Ligoma Village, Tunduru District, Tanzania
SUBMITTED TO
THE DIRECTOR AFRICAN PROGRAMME ON ONCHOCERCIASIS CONTROL (APOC)
AUGUST 2007 Independent Participatory Monitoring of Tunduru Focus CDTI Project ii Tanzania, 2-14 August 2007
TEAM COMPOSITION
PRINCIPAL INVESTIGATOR
William KISOKA Social Scientist National Institute for Medical Research (NIMR) Dar Es Salaam, Tanzania [email protected] +255 755 096080 (cell)
INVESTIGATORS
Dr. Deborah KABUDI - Project Coordinator, Morogoro Rural CDTI Project, Tanzania P.O. Box 110, Morogoro Email: [email protected] Tel: +255 784 351 200 (cell)
Harriet HAMISI – Project officer, Helen Keller International, Tanga Region P.O. Box 5547, Tanga Email: [email protected]; Tel: +255 27 264621; +255 784 381521(cell)
Oscar KAITABA - National Onchocerciasis Control Programme, Tanzania Ministry of Health and Social Welfare, P.O. Box 9083, Dar es Salaam Email: [email protected]; + 255 22 213009; +255 754 889 390 (cell)
Sebastian MHAGAMA - Mbinga District Onchocerciasis Coordinator, Tanzania P.O. Box 42, Mbinga, Tel: +784 8273 86
Dr. Wade A. KABUKA - Project Coordinator, Ruvuma Focus CDTI Project, Tanzania P.O. Box 5, Songea, Email: [email protected]; Tel: +255 25 2602048, +255 754 899941 (cell)
FACILITATOR
Joseph Chukwudi OKEIBUNOR Department of Sociology/Anthropology University of Nigeria, Nsukka, Enugu District, Nigeria [email protected] +234 806 329 0671 (cell) Independent Participatory Monitoring of Tunduru Focus CDTI Project iii Tanzania, 2-14 August 2007
ACKNOWLEDGEMENT
The team would like to extend its sincere gratitude to all those that assisted it during this mission. Of special mention are the following:
. The Director, Dr. Amazigo, and staff at APOC Headquarters in Ouagadougou for making available the necessary financial and logistic requirements for the success of this assignment . Dr Mohammed Belhocine, the WR, Dar es Salaam and his staff provided support, which contributed to the smooth functioning of the monitoring Team . Dr Grace Saguti, National Onchocerciasis Control Programme Coordinator, and her team facilitated the smooth take off of the exercise in Tanzania . The District Executive Director, District Planning Officer, District Medical Officer and District Health Management Team for their cooperation . The district Onchocerciasis Control Coordinator, Gaufrid Mville, made all possible arrangements for the team to meet with all those that were required . Health workers and community members who provided important information and contributed to the success of the mission . Last but not least immense gratitude to the team of accommodating drivers who drove the monitoring team over several kilometres of very demanding roads and terrain under tough conditions Independent Participatory Monitoring of Tunduru Focus CDTI Project iv Tanzania, 2-14 August 2007
LIST OF ACRONYMS
APOC African Programme for Onchocerciasis Control
CCHP Comprehensive Council Health Plan
CDD Community Directed Distributor
CDTI Community Directed Treatment with Ivermectin
CHF Community Health Fund
CHMT Council Health Management Team
CSSC Christian Social Service Commission
DED District Executive Director
DMO District Medical Officer
DOC District Onchocerciasis Control Coordinator
DOT District Onchocerciasis Control Team
DPLO District Planning Officer
FGD Focus Group Discussion
HKI Helen Keller International
HS Household Survey
IDP Ivermectin Distribution Programme
IEC Information, Education and Communication
NGDO Non Governmental Development Organization
NOCP National Onchocerciasis Control Programme
NOTF National Onchocerciasis Task Force
PHC Primary Health Care Independent Participatory Monitoring of Tunduru Focus CDTI Project v Tanzania, 2-14 August 2007
RBF River Blindness Foundation
REC Record (CDD Treatment Record)
REMO Rapid Epidemiological Mapping for Onchocerciasis
RMO Regional Medical Officer
SSI Sight Savers International
VHW Village Health Worker
WHO World Health Organization Independent Participatory Monitoring of Tunduru Focus CDTI Project vi Tanzania, 2-14 August 2007
EXECUTIVE SUMMARY
Introduction
Tunduru Focus CDTI project commenced mass treatment with ivermectin, with funding and technical support of the APOC trust fund in 2005. It had its second distribution in 2006 and is planning for the third round of distribution later in 2007. As is customary with the APOC partnership, CDTI projects undergo independent participatory monitoring after one or two distributions. This is aimed at ensuring adherence to the CDTI process, early in the age of the projects.
APOC Management constituted the Independent Participatory Monitoring Team APOC Management to visit Tunduru District Community Directed Treatment with Ivermectin (CDTI) project, Tanzania, from 2-14 August 2007. The team had William Kisoka of the National Institute of Medical Research, Dar Es Salaam as the Principal Monitor. Other team members include Dr Wade Kabuka of Ruvuma Focus CDTI, Dr Deborah Kabudi of Morogoro Rural CDTI project, Oscar Kaitaba of the National Onchocerciasis Control Programme in Dar Es Salaam and Mr. Sebastian Mhagama of Mbinga District CDTI project as well as Harriet Hamisi of HKI Tanga. Dr Joseph Okeibunor of the University of Nigeria Nsukka facilitated the team. The team had the Tunduru District CDTI members as local guides.
The assignment commenced with a briefing of the District authorities and health management team on the terms of reference of the Independent Monitors and the areas where their cooperation would be required. The methodology and instruments adopted were the same as those developed in Ouagadougou and finalized in Kabale, Uganda. The objectives were equally left as in Kabale, Uganda.
Six Category A and 24 Category B sub villages were selected through a multi stage random sampling procedure. A total of eight instruments were employed for data collection during the monitoring. Policy makers and programme implementers within the project area were interviewed for their roles in the implementation of the CDTI. At the community level, village leaders and their CDDs were interviewed for their roles in the implementation of CDTI within their villages. Ivermectin intake by household members was ascertained through household treatment survey while FGDs were held with community members to ascertain their knowledge, attitude and perceptions of onchocerciasis, the control programme and ivermectin, as well as their willingness to support the programme in their respective communities. Independent Participatory Monitoring of Tunduru Focus CDTI Project vii Tanzania, 2-14 August 2007
Findings
The key findings in Tunduru CDTI project include the following:
• CDTI has taken off in all the villages.
• Treatment coverage is high and actually on the increase from seventy percent in 2005 to seventy-one percent in 2006 for the entire population. Similarly, there was a rise from 70.2% to 79.5% in the sample population. Over thirty-seven percent of those who did not take the drug in 2005 took it in 2006. On the other hand, just about two percent of those who took it in 2005 did not take it in 2006.
• Refusals and absenteeism constituted very low proportions of reasons for not taking the ivermectin in 2006. Temporary ineligibility such as pregnancy and childhood were the main reason for not being treated. This is true of the CDD record as well as the household treatment coverage survey.
• The programme is integrated in the District health system. District authorities have included CDTI in the Comprehensive Council Health Plan (CCHF) and budgeted for it against the 2007/2008 fiscal year. Moreover, the government has also planned to increase funding for CDTI through the Community Health Fund (CHF). They are thus planning to sensitize the communities to set funds aside for implementation of CDTI and other health programmes in the communities.
• Drug and reports pass through the routine health system. For instance ivermectin is stored in the District Pharmacy. The District Pharmacy controls the issuance of drug to the DOT as is the case with other programmes in the District
• Communities are however, currently ignorant of their responsibilities in CDTI. This is attributable to the poor community mobilization, health education and empowerment.
• Community members do not know why they should take ivermectin beyond the fact that it prevents blindness and skin diseases. Due to the low level of health education, community members confuse onchocerciasis control drugs with drug for trachoma initiative since both function to prevent blindness
• District Health Officers dictate timing and mode of distribution to communities. In some FLHF staff selects CDDs for the communities.
• Senior members of the Council Health Team lack knowledge of the APOC philosophy and the driving principles of the CDTI strategy and as such encourage the use of health related personnel for the distribution of ivermectin as a solution to the demand of incentives by CDDs. Independent Participatory Monitoring of Tunduru Focus CDTI Project viii Tanzania, 2-14 August 2007
• Some CDDs were not fully conversant with the CDTI concept. This could be an element of quality of training and supervision.
• The training and retraining of CDDs are inadequate both in duration and content. In all the cases encountered, CDDs were trained for only 2-6 hours. This period is just enough to give them instructions to go house to house and administer the drug. They are not health educated and not told why they are involved in the programme.
• Health workers made up for the deficiency in training with supervision of CDDs during treatment. However, supervisory checklists were not seen.
• New CDDs were not trained.
• Treatment was late in coming to the communities in 2006. Treatment took place in November/December, which was very inconveniencing to the people because of their farming activities
• Some communities experienced shortage of drugs.
Generally, CDTI programme implementation in Tunduru District is commendable, particularly with respect to the high and rising coverage as well as the attitude of the Council Health Team and the level of integration. However, level and nature of implementation at the community level needs improvement in the form of community mobilization and health education as well as training of CDDs, else the current coverage may not be sustained for a long time. Moreover, some of the leaders in the Council Health Management Team lack knowledge of the APOC philosophy and principles behind the CDTI strategy. The concerns with the Tunduru project are particularly worrisome when it is realized that the project will soon be going through the third round of treatment and is mature for sustainability evaluation.
Based on these concerns the following recommendations are proposed to enhance CDTI implementation in this project area:
• Continued reorientation, training and involvement of the health service personnel at policy and implementation levels on the APOC philosophy and their roles in the CDTI as well as its integration into the CHMT system should be intensified.
• Adequate time should be devoted to the project for proper dialogue with community leaders on the benefit of the Ivermectin treatment, their roles and commitment in the long-term sustenance of the treatment process. They should be made to be aware of their ownership of the programme and right to make the necessary decisions.
• The CHMT should ensure that communities are empowered to make decision on implementation especially with respect to timing. The CHMT should endeavour to treat when the communities expect to be treated. Independent Participatory Monitoring of Tunduru Focus CDTI Project ix Tanzania, 2-14 August 2007
• Training and retraining of CDDs should be improved by increasing the number of days, for comprehensive training to cover all aspect of the CDTI strategy and APOC philosophy instead of only emphasizing the drug aspects.
• A deliberate attempt must be made to improve the quality of record keeping at all levels of the CDTI implementation in the District.
• The district should have a plan in place to train new CDDs
• CHMT should endeavour to retire funds early in order to access more funds for distribution activities.
• Finally, and perhaps more importantly, the APOC and the NOTF should arrange technical support for Tunduru CDTI as they plan for the next round of distribution. The Project Coordinator for Ruvuma Focus CDTI, Dr Wade Kabuka and the Assistant Coordinator Mr. Oscar Kaitaba could be mobilized to assist the Tunduru in Training and reorientation of health workers on APOC philosophy and CDTI process as well as guide the third year implementation. The process is currently health system driven. This undermines community ownership and threatens project sustainability.
Debriefing
In response to the debriefing on the findings of the monitoring exercise, partners (SSI, NOCP and WHO) expressed genuine concerns and pledge to address that issues that arose from the exercise. It is important to mention that the partners did not find the results surprising. Both the NOCP Coordinator and the WHO DPC blamed the situation on the changes that have occurred both in the NGDO circle and at the District levels. The NOTF therefore plans to conduct health education in response to the requests of the communities as well as a re-orientation programme for the major players.
The Regional and District authorities saw the results of the monitoring exercise as a challenge and promised to work towards changing the situation. Independent Participatory Monitoring of Tunduru Focus CDTI Project x Tanzania, 2-14 August 2007
TABLE OF CONTENTS
ACKNOWLEDGEMENT ...... iii
LIST OF ACRONYMS ...... iv
EXECUTIVE SUMMARY ...... vi
TABLE OF CONTENTS ...... x
LIST OF FIGURES ...... xii
1.0 INTRODUCTION...... 1 1.1 General Background ...... 1 1.2 Tunduru District CDTI Background ...... 2 1.3 Team Composition ...... 3 1.4 Terms of Reference ...... 3
2.0 METHODOLOGY ...... 5 2.1 Study Design ...... 5 2.2 Population...... 5 2.3 The Sample and Sampling Procedure ...... 5 2.4 Monitoring Instruments ...... 7
3.0 RESULTS ...... 10 A Indicators ...... 11 B Constraints ...... 21 C Community Perception ...... 21 D Quality of implementation of CDTI ...... 22 E Unique Features of the Project Area ...... 35
4.0 DISCUSSION AND CONCLUSION ...... 38 4.1 Discussion ...... 38 4.2 Conclusion ...... 39
5.0 Feedback from Debriefing Sessions with DMO, DED, RMO, NOTFs and Country WRs ...... 40
6.0 RECOMMENDATION ...... 42 6.1 To the Project: ...... 42 6.2 To National Onchocerciasis Taskforce ...... 44 6.3 To APOC Management ...... 44
REFERENCE ...... 46
APPENDIX ...... 47 Independent Participatory Monitoring of Tunduru Focus CDTI Project xi Tanzania, 2-14 August 2007
LIST OF TABLES
Table A1 Villages and Sub-Villages Covered
Table A2 Summary of Instruments and Sampling Issues
Table 1 Decision-making Process at the Community Level (% in Parenthesis)
Table 2 Treatment Summary (% in Parenthesis)
Table 3 Proportion of Sub-Villages treated and in which CDDs were changed after the first treatment
Table 4 Proportion of Sub-villages which received health education, and in which health care personnel supervised CDDs
Table 5 Input indicators at Village level (% in Parenthesis)
Table 6 Distribution of implementation of the components of CDTI and Villages
Table 7 Some Community Responses on Issues Raised during Focus Group Discussions
Table 8 Quality of CDD Training in Category “A” villages (% in Parenthesis)
Table 9 Treatment Coverage for 2005 and 2006 Independent Participatory Monitoring of Tunduru Focus CDTI Project xii Tanzania, 2-14 August 2007
LIST OF FIGURES
Figure 1 Decision making in Village Meeting and Source of Information Figure 2 Treatment Summary in Each Village by Source of Information Independent Participatory Monitoring of Tunduru Focus CDTI Project 1 Tanzania, 2-14 August 2007
1.0 INTRODUCTION
1.1 General Background
Onchocerciasis, otherwise known as river blindness, is one of the devastating diseases, which continues to affect the health of people in Africa. Its effect on the health and socio- demography of the people is considerable in magnitude. Affected persons suffered from physical discomfort, anxiety, embarrassment, inconvenience, lack of confidence and depression. Such persons were stigmatized, miserable and generally pitiable, and deserving help and sympathy. They were avoided by even close friends and relations, a situation which affected their marital life and general well being. The economic importance of the disease has also been recognized by a number of operation researches on its social and economic impact. For instance, outright blindness associated with the savannah strain of onchocerciasis has been known to cause visual impairment resulting in economic disability of the infected. Concern is also raised about the economic impact of the non-blinding strain of onchocerciasis, which is prevalent in the forest zones. Studies in Uganda, Ethiopia and Nigeria have demonstrated that onchocercal skin disease (OSD) has direct and indirect costs as well as impact on school attendance of children, and the computation of disability-adjusted life years (DALYs).
Ivermectin has been noted to have significant effect on the microfilarial worms that is largely responsible for the onchocerciasis conditions in an effected person. However, it requires that people in endemic communities take it once every year for a prolonged period. The challenge therefore is the distribution of the drug in all the endemic communities in Africa. Results of studies conducted by the Tropical Disease Research unit of the World Health Organization however showed that communities are capable of treating themselves with ivermectin if they are empowered to take lead role in the process of distribution. This gave birth to the innovative approach in health care delivery called community directed treatment with ivermectin (CDTI).
The African Programme for Onchocerciasis Control, which was established with the mandate of instituting structure for sustainable distribution of ivermectin, thus adopted the CDTI approach as its main strategy. The CDTI project proposals are based on a partnership between APOC, the National Programmes and several NGDOs. The first grants were awarded in 1997. Each project is funded for a maximum of five years. During this period, it is expected that APOC support will decrease proportionately to that of the other partners and that the cost of treatment per individual will be reduced by 90 per cent. In addition, it is expected that the National Onchocerciasis Control Programme (NOCP) will continue to manage their CDTI activities for up to 15 years after APOC exit, in order to guarantee effective control of Onchocerciasis.
APOC’s philosophy for CDTI is to ensure that the recipient communities own the programme in order to sustain it. The communities themselves determine the activities. Independent Participatory Monitoring of Tunduru Focus CDTI Project 2 Tanzania, 2-14 August 2007
They determine where to obtain their mectizan®, when and how to distribute it. They select their community directed distributors (CDDs), collect information about coverage that help the determination of programme success. The CDTI is a process building up based solely on the experience of the community members, and consequently, enhancing the decision making and problem solving capacity of the communities.
1.2 Tunduru District CDTI Background
Tunduru District is the extreme southeastern district of Ruvuma Region. It is located between 10º15’ and 11º45’ south of the equator and longitudes 36º30’ and 38º east of Greenwich. Tunduru District borders with Namtumbo District to the west in Ruvuma Region, Liwale District to the north in Lindi Region, Nachingwea District in Lindi Region and Masasi District in Mtwara Region to the east, and the Republic of Mozambique to the far south. Its population of 219,000 lives in a land area of 18,778 sq. km, resulting in a population density of 11.7 people per sq.km. Tunduru town, the administrative centre of the district, is 264 km from Songea, the regional capital of Ruvuma and approximately 1,150 km from Dar es Salaam. The road from Dar es Salaam to Songea is a well-maintained tarmac and suitable for driving at all times of the year. However, the road from Songea to Tunduru is an earth road that is not well maintained and not easily passable during periodic heavy rains. Administratively, Tunduru District is comprised of seven divisions, 24 wards, and 107 villages averaging 2,000 persons each. There are two hospitals, five rural health centres and 35 dispensaries.
The Tunduru Focus CDTI Project covers the district of Tunduru in Ruvuma Region in the far southeastern part of the region. The total population of the district is approximately 219,000 people, and it is estimated that approximately 52,757 people are in hyper- and meso-endemic villages. The region has an area of 18,778 square kilometers. It was not included in the Ruvuma Focus CDTI Project because of its great distance and isolation from the rest of the region. Administratively, Tunduru is the most difficult district in the region where communication is poor and where the road network deteriorates periodically in the rainy season to a point where road traffic comes to a standstill. It was for these reasons that Tunduru CDTI was established as a separate project for APOC support.
Ivermectin had been distributed in Tunduru District since 1994, originally supported by the River Blindness Foundation (RBF) and more recently, since 1998, by the Christian Social Services Commission (CSSC). The highest number of people receiving treatment occurred in the year 1997 when 27,663 received tablets. The CDTI project was approved for support from the APOC Trust Fund in 2005 with SSI as the NGDO partner. The project has had two rounds of distribution and APOC management considers it timely to ascertain the level of compliance with the CDTI process. Independent Participatory Monitoring of Tunduru Focus CDTI Project 3 Tanzania, 2-14 August 2007
1.3 Team Composition
The independent monitoring team had William Kisoka of the National Institute for Medical Research Dar Es Salaam. The other monitors included Dr. W. Kabuka of the Ruvuma Focus CDTI, Songea, Dr Deborah Kabudi of Morogoro Rural CDTI project, Harriet Hamisi of the HKI Project Office in Tanga, Oscar Kaitaba of the National Onchocerciasis Control Programme in Dar Es Salaam, Sebastian Mhagama of Mbinga District CDTI. The team also had members of the Tunduru CDTI as local guides. Dr J. Okeibunor of the Department of Sociology/Anthropology facilitated the team on the monitoring exercise.
1.4 Terms of Reference
The team was constituted with the following terms of reference:
1. Succinctly document how ivermectin treatments were undertaken in a sample of villages with approved CDTI project in Tunduru District.
2. Assess community involvement in drug collection, decision making on the period and modes of distribution, the selection of distributors, and the willingness of the community to accept and bear these responsibilities designed in the CDTI process.
3. Document community perceptions of CDTI processes especially the issue of ownership, and expectations for Onchocerciasis control, 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 CDDs and health personnel involved in the project.
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 health services staff on the project.
6. Determine the number of communities and eligible treated and compare findings with records of the CDDs and the records at the other levels (FLHF and District – level records.)
7 Determine whether the health personnel participated in ivermectin distribution and assess the degree and quality of supervision by health staff (and the quality and orientation of the health staff to the CDTI) Independent Participatory Monitoring of Tunduru Focus CDTI Project 4 Tanzania, 2-14 August 2007
8. Identify constraints in the distribution and recommend appropriate measures to APOC management to be taken before the next round of treatments.
9 Discuss the prospects of sustainability based on the findings above. Independent Participatory Monitoring of Tunduru Focus CDTI Project 5 Tanzania, 2-14 August 2007
2.0 METHODOLOGY
The methodology used for the selection of the villages1 and sub villages was a modified form of the methodology that was developed during the meeting of the nine monitoring team members in Ouagadougou in 1998. In a review of the tools, in a tool development workshop in Kabale, this was further refined to include a few of the things that were not previously taken into account. A simplified approach that merely selects villages by a simple random sampling approach was adopted in this exercise.
2.1 Study Design
For the monitoring conducted in Tunduru District, Tanzania, a cross-sectional research design was adopted. This design was considered the most appropriate to generate the needed data and meet the study (monitoring) objectives. The data collection exercise consisted of a mix of qualitative and quantitative instruments designed to collect information from different segments of the target population
2.2 Population
The target population for the monitoring exercise consisted of four broad groups. These include: 1) Health Personnel involved in the CDTI process at various levels; 2) Village/sub village leaders; 3) Community Directed Distributors (CDDs); 4) Community members in the hyper/meso endemic Villages/sub villages contained in the REMO result for Tunduru District.
2.3 The Sample and Sampling Procedure
A study sample of thirty sub-villages from 6 villages was chosen using a simple random sampling procedure. However, the sampling process began with stratifying the villages by levels of endemicity to focus on the hyper and meso endemic villages. Six villages
1 Villages, here refer to the equivalent of community in Nigeria, for instance. In this sociopolitical unit, we have a collection of sub villages, each with its political organization with links to the village leadership. The sub villages usually maintain their own Mectizan® distribution structure but the CDDs are supervised by the health worker in the FLHF at the village level. Independent Participatory Monitoring of Tunduru Focus CDTI Project 6 Tanzania, 2-14 August 2007 were chosen through a simple random sampling process (balloting), The chosen villages included Marumba, Masuguru, Namasakata, Ligoma, Nampungu and Hulia.
Category A and B Villages
Having selected the six villages, the sub-villages in the villages were listed. Thirty sub villages were randomly selected from this list. Another random sample of six sub villages out of these thirty villages chosen earlier were taken as category “A” villages while the remaining twenty four villages became the category “B” villages for the monitoring exercise. See Table A1 for the sampled villages and sub villages.
Table A1: Villages and Sub Villages Covered
Villages “A” Sub Villages “B” Sub Villages MARUMBA Muhimbili Zimanimoto Muungano Uzunguni Upendo MASUGURU Mwandile Misri Mbale Mchaka-mchaka Motomoto NAMASAKATA Mapambano Mageuzi Afya Ujenzi Ushirika NAMPUNGU Ushirika Kawawa Msikitini Mashine Mkoma LIGOMA Barabara Kuu A Barabara Kuu B Rahaleo Shuleni Naidingo HULIA Misufini Misheni Michungwani Majengo Madukani
Households
In each Category “A” village sampled, fifteen households were chosen. To do this, the sub-village was carved into two clusters guided by the sub village head and CDDs. The systematic sampling approach was then applied to select seven or eight dwelling units from each cluster. The sampling intervals were determined through a quick estimation of the number of dwelling units in each village-cluster, using the CDD register. This Independent Participatory Monitoring of Tunduru Focus CDTI Project 7 Tanzania, 2-14 August 2007
differed from one village-cluster to another. In each sampled dwelling unit one household was randomly chosen for the treatment coverage study. Furthermore, to check on the correctness of treatment, one household was randomly chosen, and the dosage for one household member, randomly selected and crosschecked.
CDDs and Sub-Village Leaders
In each Category “A” sub-village sampled, the sub-village leader was purposively selected and interviewed. The sub-village CDD was also purposively sampled and interviewed. In cases where there were two CDDs both of them were interviewed, but in Muhimbili, where we had four CDDs, only two were selected by balloting.
Similarly, the sub-village leaders of the Category “B” sub-villages were purposively chosen and interviewed. The sub-village CDDs were also purposively chosen and interviewed where the CDDs were one or two.
Health Personnel
Various cadres of health personnel involved in CDTI process were purposively selected and interviewed. These included Supervisors, District Onchocerciasis Control Team (DOT) members and Project Coordinators. The District Medical Officer (DMO) at the District level was also purposively selected and interviewed. The purpose of these interviews was to examine the orientation to CDTI process and provide information on the records and quality of training they receive and/or give on the CDTI process.
2.4 Monitoring Instruments
Eight instruments were used to gather information from both Categories “A” and “B” villages (see Table A2). Copies of these instruments are included as appendices to this report. Independent Participatory Monitoring of Tunduru Focus CDTI Project 8 Tanzania, 2-14 August 2007
Table A2: Summary of Instruments and Sampling Issues
Instrument Category of Sample Sampling Sub Procedure Village/Unit In-depth interview A & B 1 – 2 per village Purposive (Simple & Record review random, where there with CDD are more than 2 CDDs) Household coverage A 15 households per village Simple random survey Key informant A & B 1 village leader per Purposive interview of village village leaders Group discussion A 3 groups per village (i.e. Convenience 1 male and 1 female adult; and 1 female or male youth groups), 6-8 persons in each group Health personnel A 1 DMO coordinator Purposive interview 1 Oncho coordinator 1 health centre staff per village Programme Project, 1 Director, Disease Purposive manager/Policy District & Control maker interview National 1 NOCP Staff levels 1 SSI staff
Two sets of semi structured interview guides were employed in collecting information from the community directed drug distributors (CDDs). One set, with extensive questions on the CDDs training, health system’s supervision of CDDs as well as CDD performance was administered on CDDs in the category “A” sub-villages. An abridged version of the CDD interview guide was administered on CDDs in category “B” sub- villages.
The household coverage survey instrument consists of structured questions designed to collect information on ivermectin in-take in households. It gives information on the treatment coverage in communities and also ensures information for non in-take of ivermectin.
Two sets of semi structured key informant interview guides were employed with two categories of community leaders. The first and more detailed was employed with leaders in category “A” sub villages while the abridged version was employed with leaders in category “B” sub-villages. The instruments ensured information on community involvement in the CDTI process as well as community perception of the CDTI process. Independent Participatory Monitoring of Tunduru Focus CDTI Project 9 Tanzania, 2-14 August 2007
Still on the need to establish the level of community involvement in the CDTI process as well as community perception and ownership of the CDTI project, focus group discussion (FGD) guides were employed in conducting discussions with community groups. The discussions focused on decision making processes for CDTI implementation in the communities, community perception of onchocerciasis and ivermectin as well as the preparedness of the communities to own the programmes. It also allowed information on the inputs of the health systems with respect to community health education, sensitization and mobilization for the control of onchocerciasis in the communities.
Two other sets of instruments, one for health workers at the first line health facilities and another for programme managers were also employed to gauge the orientation of these groups on the APOC philosophy and the basic principles of the CDTI strategy. It is also ensured information on the inputs from these groups for the implementation of the CDTI project. Independent Participatory Monitoring of Tunduru Focus CDTI Project 10 Tanzania, 2-14 August 2007
3.0 RESULTS
The results presented here derive from the analysis of data collected from a mix of instruments administered on key players at the different levels of implementation of Tunduru CDTI project between the 2nd and 9th of August 2007.
For comprehension of the findings, the results are grouped and presented to reflect the keys issues in CDTI implementation such as indicators resources (funding and human resources), indicators of activities that support CDTI (health education, sensitization and community mobilization, ivermectin procurement, leadership and ownership) as well as indicators of results achieved (treatment coverage) with the implantation of the CDTI projects. There is also the indicator of effects of the process of implementation (ownership and sustainability potentials).
Beyond the analysis of the findings on the key implementation indicators, this result section also reviewed the quality of implementation of the project, community perceptions of onchocerciasis and ivermectin and analyzed the managerial and technical constraints for the implementation of the project. A SWOT analysis of the project was also undertaken to understand that unique features of the project setting and guide recommendations.
Frequency distribution tables and graphic illustrations were employed in the presentation of the key findings from the quantitative data. Ethnographic summaries of the qualitative data were developed in the form of prose supported with illustrative quotes. Independent Participatory Monitoring of Tunduru Focus CDTI Project 11 Tanzania, 2-14 August 2007
A. Indicators
Table 1 Decision-making Process at the Community Level (% in Parenthesis)
Questions Village Village Village Health Village Village Other Total Meeting Elders Chief Worker Health Committ Number Committ ee ee Village Leaders “A” “B” • Who decides on the month for distribution 5 (17.2) -- -- 14 (48.3) -- -- 10 (34.5) 29 (100) • Mode of distribution 17 (58.6) 1 (3.5) 7 (24.1) 3 (10.4) -- 1 (3.5) -- 29 (100) • Selection of CDD 15 (51.7) -- 13 (44.8) -- 1 (3.5) -- -- 29 (100) CDD Village “A” & “B” • Time of distribution 3 (50.0) 1 (16.7) 2 (33.3) 6 (100) • Mode of distribution 4 (66.6) 1 (16.7) 1 (16.7) 6 (100) • Selection of CDD 18 (60.0) 1 (3.3) 10 (33.3) 1 (3.3) 30 (100) Group Discussion “A” • Time of distribution -- 6 (100) 6 (100) • Mode of distribution -- 6 (100) 6 (100) • Selection of CDD 5 (83.3) 1 (16.7) 6 (100) E-1 Proportion and number of communities (sub-villages) which decided on the period of treatment = 5 (17.2%) Proportion and number of communities (sub-villages) which decided on the method of treatment = 18 (62.1%) E-2 Proportion and number of communities where the “community” selected their own CDD = 29 (100%)
Independent Participatory Monitoring of Tunduru Focus CDTI Project 13 Tanzania, 2-14 August 2007
The decision-making processes on issues of timing and mode of distribution as well as CDD selection were employed to gauge the level of community involvement and ownership of the programme that exist in the villages. Here, decisions that were reported to have been taken in village meetings or by village health committees were taken as indicative of the ownership of the programme.
Table 1 shows that only a total of 29 sub-village leaders in categories A and B villages were entered in the analysis because one of the sub-village heads visited was away and could not be interviewed. CDDs in categories A and B villages were interviewed. Focus group discussions (FGDs) were also held with people in category “A” villages.
Table 1 shows varied responses on who decided on the mode and timing of distribution as well as selection of CDDs. For instance, less than two-thirds (62.1%) of the sub- village leaders reported that sub-village meetings or health committees took the decision on mode of distribution. In 48.3% of the cases, health workers took the decision on timing of distribution and in 35.4% of the cases the timing depended on arrival of the drugs. CDDs were however mostly selected in village meeting (51.7%) and/or village heads (44.8%).
From the FGDs, where different segments, namely, adult males and females as well as young males and females were involved, it is observed that CDDs were selected in community meeting in 5 of the 6 category “A” sub-villages. In the sixth sub village, participants in the FGD sessions indicated that health worker selected CDDs. The results of the FGDs also indicated that health workers took decisions on mode and timing of distribution in category “A” sub villages where FGD sessions were held. The female and male groups irrespective of age indicated that the communities did not take any decisions on the distribution process. According to a participant in FGD with adult females,
we do not take any decision. I think the decision is made from the District and they just come and ask us to take the drug without telling us anything
This is a typical Fig. 1: Decision Making in Village Meeting and Sources of Information expression of the level of involvement of the community 90 83.3 members on the mode 80 66.6
) and timing of 70 58.6 60 % ( 60 51.7 50 distribution across n
o 50 i
t groups of FGD. r 40 o p
o 30 r 17.2 P 20 The responses of sub- 10 village leaders were 0 0 0 employed in Village Leader CDD FGD measuring the Sources of Information indicators (E-1 and E- 2). This is because the Time Mode Selection of CDD Independent Participatory Monitoring of Tunduru Focus CDTI Project 14 Tanzania, 2-14 August 2007 sub-village leader information appeared more representative by virtue of its geographical coverage of categories “A and B” villages, and the three subjects, namely, decision on mode and timing of distribution, as well as the selection of CDDs. The FGDs were limited to category “A” villages, while the category “B” village CDD interview did not ensure information on the timing and mode of distribution.
Following from this therefore, it is observed that 17.2% of the sub-villages indicated that the decision on timing of distribution was taken in village meetings. About half each (58.6% and 51.7%) indicated that the decision on mode of distribution and selection of CDD respectively were taken in the village meeting. See Figure 1 for pictorial presentation of the results on E-1 and E-2.
The process is health system driven. Most decisions come from the District level and are simply passed down while compliance is expected from the community. Senior members of the Council Health Management Team lack knowledge of the APOC philosophy and the driving principles of the CDTI strategy and as such encourage the use of village health workers, instead of CDDs, for the distribution of ivermectin as a solution to the demand of incentives by CDDs. For instance, during an interview with a senior member of the council health team, he asserts that,
We do not need the CDDs to implement the programme in the communities. In every community we have the village health workers. These are people selected to assist with health issues in the communities. Every village (a collection of sub-villages) has one village health worker. These village health workers can be mobilized to implement CDTI and are paid by the health system. This will also save us of the demand for incentives by so many CDDs.
With the same orientation and lack of powers, and seeming submission to the whims of the health system, in the implementation of the programme, which is perceived as on of the traditional government programmes in the communities one community leader said,
I communicate with the people to know if there are problems…. When there is problem I refer such problem to the health officer who decides how to resolve the problem and ensure that distribution continues…. Independent Participatory Monitoring of Tunduru Focus CDTI Project 15 Tanzania, 2-14 August 2007
Table 2: Treatment Summary2 (% in Parenthesis)
MARUMBA MASUGURU NAMASAKATA NAMPUNGU LIGOMA HULIA (Muhimbili) (Mwandile) (Mapambano) (Ushirika) (Barabara Kuu A) (Misufini) HS REC HS REC HS REC HS REC HS REC HS REC Total* 71 467 71 215 78 257 84 234 76 155 65 413 No. (%) No. No. No. No. No. No. No. No. No. No. No. (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Refusals 0 (0.0) 1 (1.4) 0 (0.0) 0 (0.0) 6 1 (1.1) 0 (0.0) 2 (4.2) 0 (0.0) 0 (0.0) 0 (0.0) 6 (2.2) (33.3) Absentees 0 (0.0) 21 1(7.1) 14 2 41 2 19 2 6 5 2 (0.7) (28.8) (26.4) (11.1) (46.6) (13.3) (39.6) (13.3) (15.8) (23.8) Others 8 (100) 51 13 39 10 46 12 27 12 32 16 266 (69.9) (92.9) (73.6) (55.6) (52.3) (86.7) (56.3) (86.7) (84.2) (76.2) (97.1) Not treated 8 (11.3) 73 14 53 18 88 15 48 15 38 21 274 (15.6) (19.7) (24.7) (23.1) (34.2) (17.9) (20.5) (19.7) (34.5) (32.3) (66.3) Treated 63 394 57 162 60 169 69 186 61 117 44 139 (88.7) (84.4) (80.3) (75.3) (76.9) (65.8) (82.1) (79.5) (80.3) (65.5) (67.7) (33.7) O-1 Proportion and number of refusals two months after distribution = 6 (6.5%) O-2 Proportion and number of absentees that were later treated = 12 (13.2%) O-8 Proportion and number of persons 5 years and above who received ivermectin = 354 (79.6%)
2The total here refers to the sum of the ‘treated’ and ‘not treated’. However, the percentages of reasons for not treated represent proportions of those ‘not treated’ by the reasons for not being treated. Independent Participatory Monitoring of Tunduru Focus CDTI Project 16 Tanzania, 2-14 August 2007
The Table (2) above presents a definite pattern in the comparison between the results from the sample survey of household treatment and the treatment summary from the CDDs’ records. In all cases the records show lower proportions than the sample survey results.
The picture comes out clearer with the picture in Figure 2 below. Treatment records were generally poor. In Hulia treatment summary was about half the result of the survey. However the treatment record results seem to be generally slightly below the household survey results in other cases.
Fig. 2: Treatment Summary in Each Village by Source of Comparing the Information reason for non HH Survey CDD Record treatment in the 100 household survey 90
d 80 and the treatment e t
a 70 records of the CDDs e r
T 60 showed very slight e
g 50 disparity. For a t 40 n
e instance, the
c 30 r
e 20 difference in P 10 proportions reported 0 to have refused
a u a treatment in all cases r a u a li b u t g m u m g ka n o u u a u g H r s s p i were not statistically a a a m L M M m a a N significant. N However, the CDD Source of Information (HH Survey and CDD Records) record captured more absentees than the household survey. All the same a significant finding is that, with the exception of Hulia, both sources of information indicated high treatment coverage in the project area. Most of the untreated population is due to such other reasons as the exclusion criteria of age, pregnancy status of women and breast feeding mothers. This thus points to the level of acceptance of the programme in the project area. Independent Participatory Monitoring of Tunduru Focus CDTI Project 17 Tanzania, 2-14 August 2007
Table 3 Proportion of Sub-Villages treated and in which CDDs were changed after the first treatment
Villages Sub-Villages (Both Treated CDD changed A and B) MARUMBA 5 5 (100.0%) 2 (40.0%) MASUGURU 5 5 (100.0%) 3 (60.0%) NAMASAKATA 5 5 (100.0%) 3 (60.0%) NAMPUNGU 5 5 (100.0%) 1 (20.0%) LIGOMA 5 5 (100.0%) 3 (60.0%) HULIA 5 5 (100.0%) 0 (0.0%) O-3 Proportion and number of at-risk sub-villages treated = 30 (100.0%) O-5 Proportion and number of sub-villages where CDDs were changed by the community after the first treatment = 12 (40.0%)
Table 3 above shows that treatment has taken place in all 30 at-risk sub-villages visited. It also shows that CDDs have been changed in 12 (40.0%) of the sub-villages after the first treatment. The reasons for the change of CDDs were however reassuring of the welcome the programme has received among the people. The people were able to evaluate the situation confronting them and move to find new CDDs. Some of the reasons for changing the CDDs include the change in marital status of the female CDDs and consequent relocation out of the community or the movement of the male CDDs to greener pastures outside the village. According to a village leader in Ligoma, “one of our CDDs got married and moved to her husband’s village so we had to get another CDD…”. In Masuguru, the village leader noted that, “…the CDD left this village so we had to get new CDD to distribute the drug for us…”. In all the cases, none of the replacements was attributed to incompetence or unwillingness to continue with the distribution of the drug in the community.
Ironically, the acceptance of the programme seems to be at variance with the quality of implementation for of the CDTI project in the project area. For most cases as will be seen in the data that will be presented hereunder, the implementation falls short of the principles of CDTI. The Regional Medical Officer attributed the acceptance of the programme and consequent compliance with treatment to the fact that,
the programme deals with a vital organ of the body, the eye, which the people would do anything to protect at all time. Once you tell the people to take this drug to protect them from getting blind they will go for the drug Independent Participatory Monitoring of Tunduru Focus CDTI Project 18 Tanzania, 2-14 August 2007
Table 4 Proportion of sub-villages which received health education, and in which health care personnel supervised CDDs
Villages Sub-Villages Received health CDD Supervised (Both A and B) education by health system MARUMBA 5 5 (100.0%) 5 (100.0%) MASUGURU 5 2 (40.0%) 2 (40.0%) NAMASAKATA 5 2 (40.0%) 2 (40.0%) NAMPUNGU 5 4 (80.0%) 4 (80.0%) LIGOMA 5 5 (100.0%) 4 (80.0%) HULIA 5 3 (60.0%) 4 (80.0%) O-6 Proportion and number of villages in which the CDD is supervised by the health care (villages scoring 50% and above) = 4 (66.7%) O-7 Proportion and number of target villages which received health education = 4 (66.7%)
Table 4 above shows that more than fifty per cent of the sub-villages visited received health education. It has to be noted, however that the data here were collected from the CDDs, who indicated that they have received health education. This is because the analytical guide directed that such information be collected from both categories A and B villages. Thus while CDDs may have received health education during their orientation by the first line health facility (FLHF) staff the community members may not have been health educated. Data from FGDs seem to support the later possibility. In all the FGD sessions, the people did not only demonstrate poor knowledge but actually indicated that they were not told anything. According to one of the participants in the female youth group, “the people were not told anything. They just bring the drug and ask us to take it”. This typifies the position among other FGD participants.
For the female youth, all they know is that,
“when he (the CDD) comes asks us to swallow the drug”.
The results also show that the CDDs are not supervised in some sub-villages. In more than fifty percent of the sub-villages visited in Masuguru and Namasakata there was no CDD, who indicated that s/he was being supervised by the health personnel. This is a serious lapse in view of the fact that this project has gone through two rounds of treatment now and should have put the CDTI process in the right footing now as it prepares for the third round of treatment later in the year. Independent Participatory Monitoring of Tunduru Focus CDTI Project 19 Tanzania, 2-14 August 2007
Table 5: Input indicators at Village level (% in Parenthesis)
VILLAGE Sub- Trained Late Drug Collection Measuring Treatment Side reaction Summary Villages CDDs Supply Shortage from a Point Device Register record Form at (A & B) Available District office MARUMBA 5 5 (100.0) 2 (50.0) 1 (25.0) 5 (100.0) 5 (100.0) 5 (100.0) 0 (0.0) 5 (100.0) MASUGURU 5 5 (100.0) 3 (60.00 1 (20.0) 5 (100.0) 5 (100.0) 5 (100.0) 0 (0.0) 5 (100.0) NAMASAKATA 5 4 (80.0) 1 (20.0) 1 (20.0) 5 (100.0) 5 (100.0) 5 (100.0) 0 (0.0) 5 (100.0) NAMPUNGU 5 5 (100.0) 0 (0.0) 0 (0.00 5 (100.0) 5 (100.0) 5 (100.0) 0 (0.0) 5 (100.0) LIGOMA 5 5 (100.0) 1 (20.0) 1 (20.00 5 (100.0) 5 (100.0) 5 (100.0) 0 (0.0) 5 (100.0) HULIA 5 5 (100.0) 3 (60.00 0 (0.0) 5 (100.0) 5 (100.0) 5 (100.0) 0 (0.0) 5 (100.0)
I-1 Proportion and number of sub-village with trained CDDs = 29 (96.7%) I-2 Proportion and number of sub-villages that experienced late supply of ivermectin = 10 (34.5%)3 Proportion and number of sub-villages that experienced shortage of ivermectin = 4 (13.8%) I-4 Proportion and number of target sub-villages which collected ivermectin from collection point or health center = 29 (100%) I-5 Proportion and number of CDDs with measuring device = 30 (100%) I-6 Proportion and number of sub-villages with treatment registers = 30 (100.0%) I-7 Proportion and number of treated sub-villages with summary form at the district office = 30 (100.0%)
3 Information on drug shortage, lateness of drug supply and collection of drug from agreed point by community members were extracted from the interview with sub-village leaders. One sub-village leader was missed thus bringing the denominator for these indicators to 29 instead of 30 cases. Independent Participatory Monitoring of Tunduru Focus CDTI Project 20 Tanzania, 2-14 August 2007
Table 5 shows that in Namasakata, one of the sub-villages visited has CDDs that are not trained. Incidentally, this is one of the communities where CDDs were replaced because of the relocation of former trained CDDs. New community members were selected to distribute the drug without any training.
Though the table shows that in all the villages visited drugs were collected from agreed designated points, drug shortage was reported in a few villages in the project area. Four (13.8%) of the sub-villages visited reported drug shortage. However, in all group discussions, participants were of the opinion that there were no communities that had experienced drug shortage.
With respect to the timing of distribution, ten (34.5%) of the twenty nine village leaders interviewed reported late supply of drug to the community. For most others, who did not report late supply, however, the reason is that the communities did not decide the month of distribution in the first place. According to one of the village leaders, “we take the drug anytime it arrives”. All the same, those that indicated lateness of the drug based their judgment on the fact that they took the drug earlier the previous year. Others argued that the drug was distributed as late as November or December when they are attending to their farms.
The monitoring team however noted that the lateness was at the District level. The NOCP representative noted that all drug arrived early in the country. The District Onchocerciasis Control Team (DOT) members blamed the late distribution on availability of funds. Both the NOCP and DOT agreed that funds for distribution arrived late from APOC due to late retirement of funds for the previous distribution period. The Council Health Team (CHMT) had to get funds from other sources to ensure distribution though late. It is however delighting to note that following the experience the CHMT now incorporated onchocerciasis control activities in the Comprehensive Council Health Plan (CCHF) for 2007/2008 fiscal year to ensure funds for prompt distribution in future.
None of the villages reported cases of severe side reaction. According to the DOT “what we have mostly are mild reactions which do not last beyond a day”. The people, in FGd sessions, also indicated mild reactions like itching, swelling, nausea and headache, which do not go beyond one or two days. Further more, the household survey revealed that the people did not have to do anything in response to reaction to treatment.
All the sub-villages visited had treatment registers, measuring sticks for the “pole for dose” treatment of community members. Treatment summaries were also observed in the district office for each of the sub-villages visited. Independent Participatory Monitoring of Tunduru Focus CDTI Project 21 Tanzania, 2-14 August 2007
B Constraints
Management
Support at the District or Regional levels in the past two years was not impressive. Nothing concrete was given to support the implementation of the programme except the provision of personnel. The programme depended entirely on funding from the APOC Trust Fund, thus when the fund was late in coming for the last treatment period, treatment was delayed. Even as they CHMT plans to take on CDTI activities for the future, the Acting RMO noted that the District may not be able to take on all CDTI activities. Thus the CHMT is planning to sensitize the communities to provide support for the programme through the community health funds (CHF). This plan is yet on the drawing table.
Technical
The CDDs interviewed showed poor knowledge of the APOC philosophy and the right process for the CDTI implementation. This may have adverse effect on the quality of CDTI implementation in the communities. The implementing team does not seem to possess the skills and knowledge for the programme. Health education and sensitization is poor. They simply bring the drug and ask the people to take it. This poor implementation creates a situation where the people are asking government or APOC to pay CDDs.
Furthermore, the DOT and CHMT lack skills for prompt fund retirement. This was responsible for late disbursement of funds for the 2006 distribution period and the ensuing late treatment.
C Community Perception
The people showed no clear perception of the CDTI programme. This is true of all the communities visited. Women and youths exhibited total ignorance and lack of knowledge on role of the community in the CDTI process. Even the male adult groups did not show any significant understanding of the programme and their responsibility in it. All the people knew is that they were asked to take the drug to prevent blindness and skin problems. The programme is seen as one of the numerous health programmes brought to the people by government. An example is the Trachoma Control programme.
In all the communities and within the different groups the exact role of the community with regards to ownership of the CDTI programme was still poorly understood. The programme is being perceived as government program, where they can make little or no inputs especially in decision making about the timing of treatment. This is a clear indication of the quality of health education and sensitization that is in place in the Tunduru CDTI programme. Independent Participatory Monitoring of Tunduru Focus CDTI Project 22 Tanzania, 2-14 August 2007
D Quality of implementation of CDTI
Table 6: Distribution of implementation of the components of CDTI and Villages Component MARUMBA MASUGURU NAMASAKATA NAMPUNGU LIGOMA HULIA of CDTI Training of Fair. Health Fair. Health Fair. Health Fair. Health worker Health worker worker worker understands the role Workers understands the understands the understands the of the health system role of the health role of the health role of the health in CDTI. However, system in CDTI. system in CDTI. system in CDTI. health worker was However, health However, health However, health unable to explain worker was worker was unable worker was APOC philosophy unable to explain to explain APOC unable to explain and the CDTI APOC philosophy and the APOC process. philosophy and CDTI process. philosophy and the CDTI process. the CDTI process. Training of Poor. CDDs were Poor. CDDs were Poor. CDDs were Poor. CDDs were Poor. CDDs were Poor. CDDs CDDs trained for only trained for only trained for only trained for only trained for only one were trained for one day and for one day and for one day and for one day and for day and for just two only one day and just two hours, just two hours, just two hours, just two hours, hours, enough time for just two enough time to enough time to enough time to just enough time to to just give them hours, enough just give them just give them give them just give them instructions rather time to just give instructions rather instructions rather instructions rather instructions rather than train them. them instructions than train them. than train them. than train them. than train them. rather than train them. Supervision Good. Health Poor. CDDs are Poor. CDDs are Fair. Health staff Fair. Health staff Fair. Health staff of CDDs staff supervised not supervised by not supervised by supervised most supervised most supervised most CDDs, though health staff in health staff in most CDDs during CDDs during CDDs during supervisory most of the of the villages. distribution. distribution. distribution. checklists were villages. Independent Participatory Monitoring of Tunduru Focus CDTI Project 23 Tanzania, 2-14 August 2007
Component MARUMBA MASUGURU NAMASAKATA NAMPUNGU LIGOMA HULIA of CDTI not seen Treatment Poor. Almost a Poor. More than Poor. More than Fair. Just slight Fair. Just slight Poor. More than accuracy quarter (23.9%) 10 percent 10 percent (15.5%) inaccuracy in inaccuracy in 10 percent of the people was (15.5%) was was wrongly treatment (4.8%) treatment (7.6%) (12.3%) was wrongly dosed. wrongly dosed. dosed. wrongly dosed. Record Good. Treatment Good. Treatment Good. Treatment Good. Treatment Good. Treatment Good. Treatment Keeping and records are well records are well records are well kept records are well records are well kept records are well Reporting kept and kept and and maintained. kept and and maintained. kept and maintained. maintained. maintained. maintained. Storage and There is facility for There is facility for Good facility for Good facility for Good facility for Good facility for safety of storage. storage storage but not storage but not storage but not enough storage but not Ivermectin enough to store. enough to store. to store. enough to store. Availability Available but not Available but not Available but not Available and Available but not Available and and adequate adequate adequate adequate adequate. adequacy of treatment Community Good. CDDs Poor. CDDs (60%) Poor. CDDs (60%) Fair. Communities Good. CDDs reported Poor. CDDs (60%) mobilization reported health reported no health reported no health know their role in health education reported no health and education though education in the education in the CDTI even though though communities education in the education communities know communities. communities. 80% of CDDs know nothing about communities. nothing about their Communities do Communities do not reported that they their responsibilities Communities do responsibilities and not know their know their were health and take no decisions. not know their take no decisions. responsibilities and responsibilities and educated. responsibilities and take no decisions. take no decisions. take no decisions. Integration There is evidence There is evidence There is evidence of There is evidence There is evidence of There is evidence into PHC of integration at the of integration at the integration at the of integration at the integration at the of integration at the District level District level District level District level District level District level Community No community self No community self Community self No community self No community self No community self monitoring monitoring monitoring monitoring monitoring monitoring monitoring Independent Participatory Monitoring of Tunduru Focus CDTI Project 24 Tanzania, 2-14 August 2007
Table 7: Some Community Responses on Issues raised During Focus Group Discussions
VILLAGE INDICATORS FGD Male Adults FGD Male Youth FGD Female Adults FGD Female Youth (Sub Village “A”) MARUMBA Decision Making Timing:-The sub village leader Timing:- Village leaders Timing:-We do not know (Muhimbili) inform us that today CDD will and CDDs take the decision anything. It just came to us come and distribute Mectizan to on timing and method us. CDD Select: CDDs were CDD Select:- Village Mode:-The village leader makes selected through each sub leaders selected CDDs. decision for us. He decided on village meeting house to house CDD Select:- Village leaders select CDDs Knowledge Dosage:-Measuring stick is used. Dosage:-Using a measuring Dosage: By measuring us Expectation:- It will help us with stick, he just measures your with measuring stick problem of eye, skin rashes and height and give you tablets severe itching. written there. Responsibility:- Responsibility: We have to make sure all of us swallow the drug. Benefit/Perception We are ready to take the drug Prevents blindness and skin The drug removes rashes because we have seen the result is problem. People with shin and reduces itching. good problems are ok today Health Education The drug kills worms that cause We were told to take it for The CDD told us the drug night blindness 15 years kills worms and cures rashes. Exclusion Criteria Pregnant women and children Pregnant women; children under 5 years do not receive the under five and very sick treatment. persons Independent Participatory Monitoring of Tunduru Focus CDTI Project 25 Tanzania, 2-14 August 2007
VILLAGE INDICATORS FGD Male Adults FGD Male Youth FGD Female Adults FGD Female Youth (Sub Village “A”) Process Drug Collection:- Treatment:-Everybody is Drug collection: CDD Distribution:- treated collects the drug but we do Treatment:- Nobody missed it No Distribution: The time is not know from where any problem with CDD not good for us because it is Distribution: The drug Problems:- when we are working for was distributed in Sustainability:- agric. It was November November when we are CDD Support:- No support other CDD Support:- No any farming. It is better in than giving him cooperation incentive. July-August during distribution by swallowing Treatment:- Everybody is the drug. treated. Problems: Swollen body, head ache, nausea Sustainability: To continue to educate the people CDD support: We only sit at home to swallow the drug. No support Suggestion We need more sensitization Bring drug timely and transport for Provide transport for CDD CDDs Treat in July-Sept. Give incentive to CDDs MASUGURU Decision Making Timing:- Village leaders, together Timing:- We do not know Timing:- We are not (Nwandile) with health workers make who makes the decision. sure. May be from decision on timing and method of Decision is made by District level. It may be distribution leaders from the District by leaders and health Mode:- They go house-to-house Mode:- We do not know. worker. and that is good for us CDD Select:- Community Mode:- House to house CDD Select:- We sit in the leaders select CDDs CDD Select:- meeting and select the 2 CDDs Community for each sub village. In selecting them we are looking for people with education and permanent residence. Independent Participatory Monitoring of Tunduru Focus CDTI Project 26 Tanzania, 2-14 August 2007
VILLAGE INDICATORS FGD Male Adults FGD Male Youth FGD Female Adults FGD Female Youth (Sub Village “A”) Knowledge Ownership:- Dosage:- He measures our Dosage:-He uses a stick Dosage:- He measures people’s height with one stick to measure our height. height Expectation:-. Expectation:- Expectation:- We don’t know Disease:- The disease how long we are to take the drug causes blindness. It is Disease:- It is skn disease caused caused by blackfly by worm Benefit/Perception Health Education We were told to continue taking In our school, we just the drug because it is good for our talk to each other about eyes and skin the benefits of the drug Exclusion Criteria Pregnant women under age Pregnant women and Pregnant women and children and sick people do not children below 3 years are under aged children do take the drug not given the drug. Very not receive treatment. old people are also not given. Independent Participatory Monitoring of Tunduru Focus CDTI Project 27 Tanzania, 2-14 August 2007
VILLAGE INDICATORS FGD Male Adults FGD Male Youth FGD Female Adults FGD Female Youth (Sub Village “A”) Process Drug Collection:- The drug is Drug Collection:- The Drug Collection:- The brought by the CDD from the CDD gets the drugs from Drug is brought into the Village the Health facility community by the CDD Treatment:- He measures Treatment:- Their work is from health facility people’s height good and helpful to us Distribution:- They go Problems:- No problem in this Problems:- from house-to-house to sub villages. The drug is good for CCD Support:- No any distribute us. incentive Treatment:- They treat Sustainability:- everyone in the sub CDD Support:- Our economic village. status is poor. We cannot afford Problems:- The drug anything so we do not give any caused a lot of itching incentive. after swallowing. Others have skin rashes CCD Support:- We do not give then anything. We just mobilize ourselves to take the drug Suggestion More mobilization and More health education. More health education is sensitization is needed. Give Change the time of needed in the CDD incentives distribution community. Provide transport for CDDs. Independent Participatory Monitoring of Tunduru Focus CDTI Project 28 Tanzania, 2-14 August 2007
VILLAGE INDICATORS FGD Male Adults FGD Male Youth FGD Female Adults FGD Female Youth (Sub Village “A”) NAMASAKATA Decision Making Timing:- We did not take Timing:- We did not fix the Timing:- They just came (Mapambano) decision. It came from the time. They just came and and gave us the drug District started distributing the drug without consulting us. Mode:- Health worker in the Mode:- They to go house- Mode:- They go house-to- village told us about the drug and to-house. house. then CDD distribute the drug CDD Select:- Community CDD Select:- Community house to house selected them. members in the sub village selected one male and one CDD Select:- Community female members in each sub village selected the CDDS. Knowledge Ownership:- We do not know Ownership:- We were not Ownership:- what to do about the programme told. Dosage:- He uses a stick to except taking the drug when it is Dosage:- Before taking the take our height brought to us drug one is measured with a Expectation:-.We were not Dosage:- He measured us and ruler. (one foot ruler) expecting anything. We gave us the tablets. Expectation:-. just took the drug Expectation:- Disease:- When the man Disease:-the disease Responsibility:- We were not told came he just said the drug causes itching of the eyes about community responsibility. kills worms. and body. Disease:- It causes rashes, itching Responsibility: We don’t and waist pain. know. We were not taught about our responsibilities. Benefit/Perception The drug expelled worms. The -- We are happy with the drug made us strong. exercise because the drug is good. Health Education We were told the side reactions -- We were told it is an that could occur. We were told to annual treatment. take it every year but we not told for how long Independent Participatory Monitoring of Tunduru Focus CDTI Project 29 Tanzania, 2-14 August 2007
VILLAGE INDICATORS FGD Male Adults FGD Male Youth FGD Female Adults FGD Female Youth (Sub Village “A”) Exclusion Criteria Pregnant women, breast feeding We were told sick people, Pregnant women and mothers and under age children pregnant women and very children under five year do not take the treatment. little children should not take the treatment. Process Distribution:- He went house-to- Distribution:- He came Distribution:- They house when most of us were not distributed the drug to Treatment:- We take the drug around everyone when they bring it. Treatment:- The last time Treatment:- It is an annual Problems:-.We had no problem as he came without telling treatment. with the distribution. We had no us most of us were not Problems:- The drug problems after taking the drug. around since we were not caused a lot of itching and Sustainability:- We are ready to informed. some people had stomach run the exercise because it helps Problems:-.After taking the upset. Diarrhoea us against this disease. drug some people could not CCD Support:- No CCD Support:-.We support the see very well again. Others support. CDD by making sure everybody had severe itching. takes the drug. We do not give CCD Support:-We did not any financial support. But we give him anything. appreciate their work. It is good for us. Suggestion Give CDD more training. We prefer to fix the time of There should be committee . Continue with the programme. treatment so that we can all in all the sub villages. be around to receive Provide transport for treatment. CDDs. NAMPUNGU Decision Making Timing:- The decision on timing Timing:- The decision on Timing:- The decision (Ushirika) was made from the District level. timing was made from the on timing was made Mode:- The decision was by the District level. from the District level. health worker. Mode:- The decision was Mode:- The decision CDD Select:- CDDs were by the health worker. was by the health selected from the sub village CDD Select:- CDDs were worker. meeting. selected from the sub CDD Select:- CDDs village meeting. were selected from the sub village meeting. Independent Participatory Monitoring of Tunduru Focus CDTI Project 30 Tanzania, 2-14 August 2007
VILLAGE INDICATORS FGD Male Adults FGD Male Youth FGD Female Adults FGD Female Youth (Sub Village “A”) Knowledge Ownership:- We were never told Ownership:- We were Ownership:- We were of taking control of the exercise. never told of taking control never told of taking Dosage:- He measures us with a of the exercise. control of the exercise. stick to determine dosage. Dosage:- He measures us Dosage:- He measures Responsibility:- We were not with a stick to determine us with a stick to told. dosage. determine dosage. Disease: The disease is caused by Responsibility:- We were Responsibility:- We black fly not told. were not told. Disease: The disease is Disease: The disease is caused by black fly caused by black fly Benefit/Perception No skin disease since we started to swallow Mectizan Health Education It is to prevent blindness. It is a National prog to The drug prevents eliminate onchocerciasis in blindness. our community Exclusion Criteria - Under 5 years children Under 5 years children Very sick persons Very sick persons Psychiatric patients Pregnant women Pregnant women Process Distribution:- The drug comes Drug Collection:- He gets Distribution:- When the from the District the drug from the Village drug is available people Treatment:- The treatment is office. are informed to stay taken once a year. We taught that Distribution:- The drug is around for treatment. the treatment will be for 5 years distributed house-to-house Treatment:- They bring Problems:- No any problems but Treatment:- We are it once in a year. there was mild side effect like counted first then Supply:- The drugs severe itching, abdominal pain, measured. comes on time and it is nausea. Problems:- After taking adequate. CCD Support:- Community to the drug, our bodies itched Problems:- Dizziness mobilize themselves to take the us a lot. Support:- No any drug. Government should take CCD Support:- No nay support in cash or kind. over on paying CDDs. incentives for CDDs. Independent Participatory Monitoring of Tunduru Focus CDTI Project 31 Tanzania, 2-14 August 2007
VILLAGE INDICATORS FGD Male Adults FGD Male Youth FGD Female Adults FGD Female Youth (Sub Village “A”) Suggestion More education and sensitization More education and The programme is good. about onchocerciasis to the sensitization about Continue with this community and more workshop onchocerciasis to the programme for CDDs. community and more workshop for CDDs. Govt should consider CDD during distributon LIGOMA Decision Making Timing:- No decision was taken Timing:- No decision was Timing:- No decision was (Barabara Kuu on timing. taken on timing. taken on timing. A) Mode:- It is house to house Mode:- It is house to house Mode:- It is house to house decided by health workers. decided by health workers. decided by health workers. CDD Select:- We selected two CDD Select:- Village CDD Select:- We selected people from each sub village. leaders selected CDDS. two people from each sub village. Knowledge Dosage:- It is height that is used Dosage:- It is height that is Dosage:- It is height that is to determine dosage. used to determine dosage. used to determine dosage. Responsibility:- We were not told Responsibility:- We do not Responsibility:- We were what our responsibility is except know. not told what our to select someone to be trained by Disease:- We do not know. responsibility is except to the health staff. select someone to be Disease:- It is caused by black trained by the health staff. flies. Disease:- It is caused by black flies. Benefit/Perception The programme is of benefit We do not know We are cured of the because in our area this insect disease bites us. When we take the drug No more skin and eye we are sure of prevention diseases We are happy with it Health Education We were told that the disease We do not know the causes causes blindness. of the disease and what it causes Independent Participatory Monitoring of Tunduru Focus CDTI Project 32 Tanzania, 2-14 August 2007
VILLAGE INDICATORS FGD Male Adults FGD Male Youth FGD Female Adults FGD Female Youth (Sub Village “A”) Exclusion Criteria Pregnant women and Children under two months. Pregnant women and hypertensive and asthmatic hypertensive and asthmatic patients are usually not treated. patients are usually not Children below 5 years are not treated. treated Process Distribution:- The CDD is Problems:- People Distribution:- The CDD is instructed to go house-to-house. generally suffer nausea, instructed to go house-to- They are doing well. dizziness and vomiting. house. They are doing Problems:- People generally Some complain of severe well. suffer nausea, dizziness and itching Problems:- People vomiting. Some complain of generally suffer nausea, severe itching dizziness and vomiting. CCD Support:- No any support CCD Support:- No any foe CDD in cash or kind. support foe CDD in cash or kind. Suggestion We need more sensitization. We need more sensitization We need investigation to . Make Mectizan available all time know if we are cured or not. We need more sensitization HULIA Decision Making Timing:- We do not fix the time Timing:- We do not fix the (Misufini) for treatment. Decision came time for treatment. from District level. We do not Mode:- Health worker know, we just know that it is decided August to September CDD Select:- Health Mode:- Health worker decided on worker selected CDD house to house CDD Select:- Health worker selected CDD Independent Participatory Monitoring of Tunduru Focus CDTI Project 33 Tanzania, 2-14 August 2007
VILLAGE INDICATORS FGD Male Adults FGD Male Youth FGD Female Adults FGD Female Youth (Sub Village “A”) Knowledge Dosage:- It is our height that is Dosage:- The distributor measured. uses stick to measure our Responsibility:- We were not told height. Disease:- We were not told Disease:- Nobody comes to explain anything to us Benefit/Perception It helps us from skin disease and prevent us from blindness Health Education To prevent oncho disease and other skin diseases Exclusion Criteria Sic persons, Preg. Women and Pregnant women and children under 5 years lactating mother are not treated Process Distribution:- When the drug is Drug Collection:- CDD available we are informed to wait collects the drug from and take the drug health facility. Problems:- We do not have Distribution:- The drug is problems with the drug. It distributed well and there improves our health. are no complains Side effect: Body itching, eye Problems:- People had problem nausea nausea, dizziness and CCD Support:- No incentive abdominal pain. given to CDD. CCD Support:- There is no incentive given to CDDs. We just thank them for their good work. Suggestion More sensitization is needed for There should be more community members sensitization and advocacy CDD training should be for more to support CDDs than 3 days Independent Participatory Monitoring of Tunduru Focus CDTI Project 34 Tanzania, 2-14 August 2007
Table 8: Quality of CDD Training in Category “A” villages (% in Parenthesis)
VILLAGE No. of No. Length of No. Trained CDDs Trained Training in a session MARUMBA 9 9 (100) 1 day 18 MASUGURU 7 7 (100) 1 day 32 NAMASAKATA 10 9 (90) 1 day 32 NAMPUNGU 8 8 (100) 1 day 14 LIGOMA 8 8 (100) 1 day 28 HULIA 8 8 (80.0) 1 day 14
Table 6-8 take a summary look at the quality of the implementation of CDTI in the Tunduru District. While Table 6 looks at the implementation of components of CDTI at the village levels, Table 7 builds up information from FGDs with the different segments of the populations in the category “A” villages. The latter gives qualitative and contextual flesh to the data presented so far in support of the arguments on the quality of CDTI implementation in the District, which currently rates poor, irrespective of the high treatment coverage.
Another issue that came up as an area of concern is the success and sustainability of the CDTI process. This is presented on Table 8 above. The Table shows that the quality of training is generally inadequate irrespective of village. While the number of CDDs trained in each training session may be considered okay, the duration of training is very poor. This affected the content of the training as well. All six villages reported of CDDs having been trained. However, in Namasakata and Hulia we find that some CDDs were not trained.
With regards to the number of CDDs trained in each training session, it was observed that it ranged from 14 to 32 persons per session. No patterned relationship between length of training time and number of participants involved in a training session could be discerned here. The training period was short in all the villages irrespective of number of participants Independent Participatory Monitoring of Tunduru Focus CDTI Project 35 Tanzania, 2-14 August 2007
E UNIQUE FEATURES OF THE PROJECT AREA
• Strengths
There is evidence that CDTI has been introduced in all the endemic communities. Health staff supervised CDDs during distribution. Treatment coverage is high and on the increase in all the villages visited. A comparison of the treatment coverage in 2005 and 2006 shows a 9.5% point increase in coverage over the previous year.
Table 9: Treatment Coverage for 2005 and 2006
2006 2005 Total Treated Not Treat Treated 302 (97.1%) 50 (37.9%) 352 (79.5%) Not Treated 9 (2.9%) 82 (62.1%) 91 (20.5%) Total 311 (70.2%) 132 (29.8%) 443
Further more Table 9 reveals that 37.9% of the 132 household members who were not treated in 2005 received treatment in 2006. On the other hand, only 2.9% of the 311 household members who were treated in 2005 did not receive treatment in 2006. A Mantel-Haenszel non parametric text of difference in proportion (198.71) reveal that the difference in the two treatment periods is highly significant (p<0.00001).
CDTI is well integrated into the health system. Ivermectin, for instance, comes from MSD and is stored in the District Drug Pharmacy. The DOT then collects Ivermectin as needed for the communities and accounts to the District Pharmacist.
The programme is integrated into the CHMT. The CHMT recognized the problems with the programme and has made plans to correct them in the future by making provisions to fund distribution activities in the future.
• Weaknesses
One major weakness of the CDTI implementation in Tunduru District is that senior members of the Council Health Team lack knowledge of the APOC philosophy and the driving principles of the CDTI strategy and as such encourage the use of health related personnel for the distribution of ivermectin as a solution to the demand of incentives by CDDs.
Another major weakness is the training and supervision of CDDs as well as health education and mobilization of communities. Communities are not made aware of their responsibilities in the CDTI process. This affects the principles of community ownership very adversely. Health workers, especially from the District dictated the timing and mode of distribution. In some cases, the health Independent Participatory Monitoring of Tunduru Focus CDTI Project 36 Tanzania, 2-14 August 2007
system, rather than communities selected CDDs. Even where communities were empowered to select their CDDs, they were not informed that they could select as many CDDs as they wished in order to reduce the work load for the CDDs. The communities were restricted to selecting one male and female CDD each.
The frequency and duration of training needs a lot of improvement. In both training and retraining, the duration was short. Though the population of CDDs per training session may be considered okay with less than 40 in each case, CDDs were trained and retrained in two hours. This time is only sufficient to give CDDs instructions to start distribution and how many tablets to give per pole measurement. It does not allow time enough to train CDDs to give health education, recognize side effects and refer to health facility and other ideas required in the process. No wonder therefore a number of wrong dosing was recorded in some of the villages. Worse still, where new CDDs were selected to replace the CDDs who may have relocated from the village, such CDDs were not trained. The health workers, from the District however tried to make up this deficiency with supervision during distribution.
Put succinctly, the implementation of CDTI in Tunduru District seems health system driven and the players in the health system have not sufficiently embraced the CDTI approach in health care delivery.
Distribution came very late last year. This was due to funding constraints for that year. The DOT lack skills for prompt retirement of funds and as such could not access APOC funds for the next year. This also brings to mind the over dependence on APOC funding for the project.
• Opportunities In recognition of the problem of over reliance on APOC funds, which led to the late treatment for last year, the CHMT has pragmatically identified the possibility of accessing funds from the community health funds in financing CDTI activities. Plan are thus in top gear to sensitize the communities to meet their responsibilities in the CDTI process from the community health fund.
Further more, the funding system in the country affords the Districts the opportunity to meet their responsibilities in the CDTI process. Funds come directly to the District from the Central Government.
• Threats
The poor understanding of the APOC philosophy and CDTI strategy among senior health personnel as well as the resolve of the health system to drive the process of implementation is a threat to project sustainability as much as it undermines community ownership of the programme. This is irrespective of the current high treatment coverage. Both the National Coordinator and the Independent Participatory Monitoring of Tunduru Focus CDTI Project 37 Tanzania, 2-14 August 2007
DPC/WHO blamed the unfolding situation on the changes that have taken place in the system. New NGDO administrators have been appointed and new District officials are now at the helm of affairs.
The major threat here is the activities of other health programmes and NGDOs operating in the District. Some of these groups have incentive systems that are at variance with the incentive systems of CDTI for community volunteers.
The people also confuse Trachoma drugs for Onchocerciasis control drugs as both are directed to preventing blindness.
However, in spite of this apparent threat, the National Coordinator sees a big opportunity in the co-implementation of Trachoma and onchocerciasis control programmes. According to her,
we introduce the idea of CDI to our partners as the Trachoma programme started expanding. As a person, I see it (CDTI) as a good strategy for strengthening the health system. What is needed is educating the communities and implementers to use the local people for giving education on the availability of services. The major issue is implementation at the community level. The community members are requesting more health education. So we have to get the DOTs to use their local communication media to educate the communities
Debriefing of Stakeholders
The monitoring team debriefed the major stake holders. During the debriefing sessions, the sustainability of the programme was a major concern for the stake holders. The concern was informed by the lack of adherence to the principles of CDTI, irrespective of the high coverage. All the stake holders, namely Ministry of Health, WHO and SSI officials pledged commitment to addressing these issues as soon as they receive the report. The main plank of action proposed is the re-orientation of the health workers at the District and Health Facility levels. It was observed that a good number of these key players are new. Independent Participatory Monitoring of Tunduru Focus CDTI Project 38 Tanzania, 2-14 August 2007
4.0 DISCUSSION AND CONCLUSION
4.1 Discussion
All District officials, especially the DMO, DED and even the District Planning Officer (DPLO) appreciate the importance of the programme and wish that it succeeds in the District. At the district level plans are made to sustain the programme at the community level. Following the lateness of treatment in 2006, the District authorities identified funding as the main problem. Since APOC funds were late at coming and the District hitherto depended on only APOC funds to implement CDTI, the District now decided to plan within its resources for CDTI implementation. Budgetary provisions were made for CDTI in 2007/2008 fiscal year. Further more, the District plans to sensitize communities to set aside funds, from the community health fund for the implementation f CDTI and other health programmes at the community level.
CDTI is well integrated into the routine health system. This is evidenced in the inclusion of CDTI in the Comprehensive Council Health Plan (CCHP) as well as the integrated implementation of CDTI activities with those of other health programmes to share resources. Another evidence of the integration of CDTI in the health system is the management of ivermentin and submission of reports. Ivermectin is stored in the District drug pharmacy and the District Pharmacists controls the stock. The DOT accounts on the use of drug to the District Pharmacist. Activity reports are submitted to the DMO, as is the case with other programmes, SSI and APOC.
Coverage is high and the demand for the drugs by the communities is also high. Many more people are now receiving ivermectin in the villages. All the endemic villages are covered with ivermectin treatment. However, it is feared that the high treatment coverage may not be sustained for a long time because the community members seem to be taking the drug without knowledge of why they have to take the drug and their responsibility in the CDTI process. The high coverage outside the CDTI process may not be sustained for a long time, especially as CDDs begin to demand compensation.
The RMO, in explaining the superficiality of the high treatment coverage noted that the programme targets an essential organ of the body (the eye). The community members will take the drug once it is linked to the prevention of blindness. But CDTI goes beyond just getting the people to swallow the drug. It is important for them to know the nature of the disease, the full benefits of the drug, the socioeconomic and physiological importance of controlling the disease as well as their roles in the CDTI process. All of these are designed to achieve community ownership of the programme.
As it is now, the community members perceive the programme as one of those government programmes. They are not empowered to direct the implementation of CDTI, and of course stay aloof to the programme implementation. In the FGD session, Independent Participatory Monitoring of Tunduru Focus CDTI Project 39 Tanzania, 2-14 August 2007 some of the discussants noted that, “they did not tell us anything. They just bring the drug and ask us to take it”. Decisions are not taken by the communities in respect of timing and mode of distribution. These “decisions are taken by the health workers and District authorities” say some of the participants in FGD sessions. The process, which is key to successful CDTI implementation, is lacking and this is threat to the project sustainability irrespective of the high treatment coverage.
Some senior members of the health system demonstrate lack of understanding of the CDTI process and APOC philosophy. As a way of addressing the apparent difficulties in CDTI implementation they advocate the use of conventional health delivery systems, which rely on the use of village health workers. While this line of action solves the problem of incentive for many CDDs, it is important to reiterate that it undermines the CDTI process. CDTI is an innovative approach to health care delivery. It is built on partnership with strong, if not disproportionate, emphasis on community ownership as a solution to generating sustainable health care systems, especially in the far and hard to reach communities. The success of this system over the traditional mode of health delivery, especially in rural areas has been phenomenal. The community decides collectively when and how treatment with ivermectin is to be done and who in the community will be responsible for the distribution of the drug. This approach has been very effective (Amazigo et al. 2002). Using this approach, the affected communities in Africa treated over 34 million people in 2004 (APOC, 2005, http://www.apoc.bf/en/cdti.htm). This is contrary to the fears expressed by Blas and Sommerfeld (2004) about the negative impact of health sector reforms on the access of poor and vulnerable populations to infectious disease prevention and treatment intervention. CDTI strategy has been effective in delivering ivermectin to over 90000 communities including those beyond the reach of health services (APOC, 2005).
4.2 Conclusion
In conclusion, it thus follows that in order to sustain the recorded success in health care, the re-orientation of the health system within the Tunduru project area needs to be intensified. This is a necessary first step to achieving community ownership and sustainability of the CDTI process in the project area. The observed high coverage not withstanding, the current orientation of the health system is a threat to successful CDTI project implementation in Tunduru District.
It is commendable that the district council has noted this deficiency and decided to take it as a challenge that needs to be addressed with the urgency it deserves. Independent Participatory Monitoring of Tunduru Focus CDTI Project 40 Tanzania, 2-14 August 2007
5.0 Feedback from Debriefing Sessions with DMO, DED, RMO, NOTFs and Country WRs
The DMO and DED were briefed on our findings. In attendance, during the debriefing of the DED was the District Planning Officer (DPLO). The results of the monitoring exercise were very well received. In the words of the DPLO, “this is a challenge to us. We are going to work with the results and make sure we change all that needs to be change for improved outing next time”. At this level, thoughts are already directed towards ensuring community input to the programme. As noted earlier, the District authorities is now budgeting for CDTI and the acting DED promised that this will be upheld.
At the regional level, the RMO was delighted to note that treatment coverage was high. He however shared the fear that high treatment coverage without the CDTI process may pose a challenge in future. He also traced the high coverage to the importance the community members place on issues affecting the eye. “They will take any drug so long as it is meant to protect them against blindness”. That notwithstanding, he agrees that it is important to get the CDTI process right and as such suggested health education and sensitization.
Debriefing sessions were held separately with the Director Preventive Services at the Ministry of Health, the Country Representative SightSavers International and the WHO Country representative in Dar es Salaam.
The Director of Preventive Services Dr Don Mbandon was delighted to receive the team and desire to disseminate the findings of the monitoring exercise. The Director commended the team and expressed the desire to correct the information, education and communication gaps in the project.
At the Sightsavers International Office (SSI), the Country Representative, Dr Ibrahim Kabole who was just two months in that position expressed pleasure at he working relationship between SSI and the Ministry of Health which he described as very cordial and warm. He expressed the need to align Trachoma Initiative with CDTI. He promised that he will take on the recommendation of transport facilities for the Cascade supervisors and the FLHF facilities. He also wanted to know if the team identified operational research issues that needed addressing so that such issues could be included in the current workplans. The two teams of monitors discussed and came up with some issues for operational research. These are listed in the recommendation to the project.
The National Coordinator, NOCP responding to the findings of the monitoring exercise noted that gaps in human resource adequacy and skills are the key challenges to the activities of the onchocerciasis control. She observed that the NOTF has not been very active as it should and used to be because of the frequent changes in both the Ministry and the leadership of the partner NGOs. The NOCP will call for a meeting of the NOTF where the findings of the monitoring exercise could be discussed and the sustainability of Independent Participatory Monitoring of Tunduru Focus CDTI Project 41 Tanzania, 2-14 August 2007 all projects can be planned in a holistic manner that will enable the partners to support the districts to carry on their activities. She noted that there is much to learn and pass on to others about the CDTI strategy particularly the empowerment of communities.
The Acting WHO Representative was pleased with the achievement of the project within a short period and hoped that all partners will continue to play their roles to ensure sustainability of the project. Independent Participatory Monitoring of Tunduru Focus CDTI Project 42 Tanzania, 2-14 August 2007
6.0 RECOMMENDATION
6.1 To the Project:
Training of Health Staff
• The initial training should be for a minimum of 3 days, whilst retraining should be for 2 days. During the training, a day should be set aside for practical work and assessment.
• 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, mobilization 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.
• More health staff should be trained on CDTI programme to further enhance integration in PHC.
• The orientation of health personnel at all levels in the District on APOC philosophy and CDTI should be given priority attention
Training and Supervision of CDDs
• 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-day training, a day should be set aside for demonstration on record keeping, census taking and reporting.
• 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
• 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.
• Training and supervision checklists should be made available and used to assist in these activities. Independent Participatory Monitoring of Tunduru Focus CDTI Project 43 Tanzania, 2-14 August 2007
• Supervision should be emphasized at all levels, especially during and immediately after distribution for the CDDs.
Record Keeping and Reporting
• The quality of record keeping at all levels of CDTI implementation in the district still has room for further improvement.
• 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
To ensure a ownership and sustainability of 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:
• Training and orientation of health personnel on the principles and implementation of the APOC philosophy and their roles in CDTI should be encouraged. More health personnel, at all cadre, should be involved and made to understand that more commitment is expected of them with respect to mobilization, health education, training, supervision, monitoring and reporting of CDTI activities. The project Coordinator of Ruvuma Focus CDTI project and the Assistant National Coordinator, Dr Wade Kabuka and Oscar Kaitaba should be consulted to help the Tunduru CDTI project on these issues as they prepare for the third year treatment round and before they are evaluated for sustainability.
• 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.
• Mobilization 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.
Integration of CDTI into the CHMT System
• The current level of integration of CDTI into CHMT is good and should be encouraged. Independent Participatory Monitoring of Tunduru Focus CDTI Project 44 Tanzania, 2-14 August 2007
Operational Research Issues The following operational questions should be addressed through a well articulate Operational Research the results of which will be useful for improving the project implementation 1. Documentation of the role of the community leadership style (popular/unpopular, charismatic/uncharismatic, young/old, laise fair/goal directed etc) and the community performance indicators of sustainability (ownership, awareness, responsiveness) 2. Document the impact of transport and motivation on project performance and the frontline health facility level. 3. Community perception of the CDTI process, Onchocerciasis and Ivermectin vis- à-vis other health programmes in the communities
6.2 To National Onchocerciasis Taskforce
• NOTF should ensure greater monitoring of the Tunduru CDTI project to ensure that they conform to agreed guidelines and processes.
• NOTF should send technical support to the Tunduru focus CDTI project to properly sensitize the authorities and CHMT on the APOC philosophy and CDTI strategy. This will go a long way to elicit corporate support and promote sustainability.
• Greater efforts should be put into plans for mobilization of the communities to take ownership of the programme.
• During the debriefing sessions, it was observed that the NOTF is now weak due to changes that have taken place over time. We now have new Director and Chairman, new authorities in the NGDOs among others. It is thus necessary to reposition the NOTF by holding an orientation programme for the new members. The NOCP could request assistance from APOC management on this.
6.3 To APOC Management
• Provision of appropriate means of transport to FLHF supervision of CDDs and for community mobilization activities
• APOC should consider supporting technical assistance for the Tunduru focus CDTI project now that it is about to go for its third round of treatment. The technical assistance should focus on re-orientating the health system on the APOC philosophy and CDTI strategy as well as sensitize and mobilize communities to take ownership of the programme. Independent Participatory Monitoring of Tunduru Focus CDTI Project 45 Tanzania, 2-14 August 2007
• Such technical assistance can be locally drawn. See suggestions made under recommendation to the NOTF. Independent Participatory Monitoring of Tunduru Focus CDTI Project 46 Tanzania, 2-14 August 2007
REFERENCE
Amazigo UV, Obono M, Dadzie KY, Remme JHF, Jiya J, Ndyomugyenyi R, Rougon JB, Noma M, Seketeli A. 2002. Monitoring community-directed treatment programmes for sustainability: lessons from the African Programme for Onchocerciasis Control (APOC). Annals of Tropical Medicine Parasitology 96 (Suppl 1), S75-92.
African Programme for Onchocerciasis Control 2006. Community Directed Treatment with Ivermectin. http://www.apoc.bf/en/cdti.htm, 9 February 2006
African Programme for Onchocerciasis Control 2006. Sustainability/Ownership. http://www.apoc.bf/en/sustainability_ownership.htm, 9 February 2006
Blas E. Sommerfeld J. 2004. Editorial. Int J Health Plann and Mgmt, 19 (1):S1-S2. Independent Participatory Monitoring of Tunduru Focus CDTI Project 47 Tanzania, 2-14 August 2007
APPENDIX
Appendix 1: Independent participatory monitoring of the Tunduru and Morogoro CDTI projects in Tanzania.
Interview of the NGDO partner
Sight Savers International is the NGDO partner for the two CDTI projects undergoing independent participatory monitoring. The interview was done by Dr Grace Fobi on 10, August 2007. It took place in the SSI head office in DAR ES SALAM. Present at the meeting were: Dr Ibrahim Kabole, SSI Country representative Dr Sixbert Mzee Mbaya, SSI Programme manager Mr David….., SSI Finance and Administrative Officer Dr Grace Saguti, National Coordinator for Onchocerciasis Control Dr Grace Fobi, APOC Management
It is to be noted that all the above SSI staff have been in office for less than six months.
Dr Ibrahim Kabole explained that during the short time he has been in office he has come to value the good working relationship that exist between SSI Tanzania and the NOCP in particular and the Ministry of Health and Social Welfare in general. SSI is a partner in Oncho control in Ruvuma, Kilosa, Morogoro Rural, Tukuyu and Tunduru districts. There are three main domains in which SSI supports the MOH. These are:
Comprehensive eye care services: eye care services, education and rehabilitation Onchocerciasis control project Coordination at national, regional and district levels
The new strategy is to support eye care and onchocerciasis control under the same programme; this will be piloted in the Kilosa district through the new SSI strategic plan.
SSI gives both technical and financial support (training of NOCP on computer skills, training of health staff at national, regional and district levels, co-financing the launching of treatment days etc)
The SSI Country representative describes CDTI in these words “The APOC strategy is good since it empowers the communities to be in the driving seat…”
Challenge will be to: Reinforce coordination amongst partners in order to avoid duplication of efforts Institute Community Self Monitoring (CSM) in the SSI pilot project in Kilosa. Currently it is not done though the manual has been translated into Swahili. use the CDTI and CDDs net work for Comprehensive eye care services Independent Participatory Monitoring of Tunduru Focus CDTI Project 48 Tanzania, 2-14 August 2007
Appendix 2: Monitoring Instruments
Key Informant Interview: Village “A”Leader
This instrument is to be administered on the village head or a representative of the village head. The head can ask another person to assist with the interview and to even have a say during the interview. Do not refuse. Most of the questions are structured. Circle appropriate codes. Do not prompt the responses; rather allows the respondent to answer while you circle the appropriate option to the respondent’s answer. Listen to the chief and choose among the items provided. If he says something different select ‘Other’ and write the actual response response in the space provided. ______
Village Name:______Village Code:____
Subcounty/LGA ______District/District:______Country: ______
Month and year of last distribution______
1. Please tell us about any programme concerning onchocerciasis treatment in this village? (PROBE THE FOLLOWING ISSUES ARE ADDRESSED)
who brought the idea of the onchocerciasis programme to this village?
≅ when did the person(s) come to talk with you about onchocerciasis?
- Did the person(s) meet with you and other village leaders first?
≅ Did they ask for you to arrange a meeting?
≅ what did they tell you about community responsibility
2. How was the time (month/season) for distribution decided?
1. at a village meeting 2. village elders meeting 3. village chief/leader 4. health worker 5. village committee meeting 6. other (specify)______
3. What mode of distribution was decided?
1. house-to-house 2. central place (specify) ______3. both house-to-house and central place 4. other (specify)______Independent Participatory Monitoring of Tunduru Focus CDTI Project 49 Tanzania, 2-14 August 2007
4. How was the mode of distribution decided? 1. at a village meeting 2. village elders meeting 3. village chief/leader 4. health worker 5. village committee meeting 6. other (specify) ______
5. How many persons (CDDs) in this village give out the drug for onchocerciasis? ______
6. How many male CDDs?______How many female CDDs? ______
7. How were the persons (CDDs) selected to do the work?
1. at a village meeting 2. village elders meeting 3. village chief/leader 4. Health worker 5. Village health committee 6. Village committee meeting 7. Other (specify)______
8. Why did you choose these person(s)? (Probe for criteria)
1.______2.______3.______4.______
9. Have the CDDs received any training? 1. Yes 2. No 3. Don’t know
10. If yes to Q9, when did they receive training?
1. Before the first distribution 2. During distribution 3. Soon after the first distribution 4. Don’t know/Can’t remember
11. How well have the CDDs done the work?
1. well 2. fair 3. poor
(Explain)______
12. Have you changed any of your CDDs? 1. yes 2. No 3. Don’t know
13. If yes to Q12, why? ______Independent Participatory Monitoring of Tunduru Focus CDTI Project 50 Tanzania, 2-14 August 2007
14. Have you (the community) received education on the importance of taking ivermectin/mectizan/ Oncho tablet annually for several years?
1. Yes 2. No 3. Don’t know/Cant remember
15. If yes to Q14, ask: When did you receive the education? (circle all that apply)
1. During the first meeting 2. Before the first distribution 3. During distribution 4. Soon after distribution
16. If yes to Q14, what were you told? (Probe for:
a. annual treatment for several years______b. benefits______c. community responsibility______
17. Was there any community decision on how the drug should be collected from a collection point?
1. Yes 2. No 3. Don’t know
18. Did any member of the community collect the drug from a collection point?
1. Yes 2. No 3. Don’t know
19. If no to Q18, why?______
20. Where is the collection point?
______
21. Did you experience late supply of drug during the last distribution?
1. Yes 2. No 3. Don’t know
Please explain______
22a. Did you experience shortage of drugs during the last distribution?
1. Yes 2. No 3. Don’t know
22b. If yes to Q22, how was the problem solved?______23a. Was the census of your village undertaken? 1. Yes 2.No 3. Don’t know
23b. Does the community have a treatment register? Independent Participatory Monitoring of Tunduru Focus CDTI Project 51 Tanzania, 2-14 August 2007
1. Yes 2. No 3. Don’t know
24. If yes to Q24, where is the register kept? ______
25. How were you involved in mobilisation? ______
26. How were you involved in supervision? ______
27. What are your suggestions on how the community could be more involved in treating its members with ivermectin for several years?
______
28. Is there anything you will like to tell/ask us? ______Independent Participatory Monitoring of Tunduru Focus CDTI Project 52 Tanzania, 2-14 August 2007
GROUP DISCUSSION GUIDE AMONG COMMUNITY MEMBERS:VILLAGE A
In each category A village, one Male and one Female adult group discussion must be conducted. In three of the six category A villages, group discussions must be conducted with male youths and in the remaining three villages, discussions must be held with female youths. For monitoring CDTI projects, youths are defined as individuals between 15 and 24 years.
The CDD must arrange for a comfortable place that offers some privacy and enough places to sit . Each group must consist of 6-8 people. Depending on culture, the group discussions may need separate meeting place for male and female so that people can speak freely. One of the internal monitors should be the facilitator while a local guide. takes notes (recorder). The group discussion must be tape-recorded.
At the end of the session, play back the tape for a few minutes to be sure that the discussion was properly recorded. Label the cassette/Notes (Name of the village, the group identity, date).
TARGET GROUPS: ADULT MALES; ADULT FEMALES; YOUNG MALES OR FEMALES ______
1. Please tell us what you know about the onchocerciasis treatment programme (PLEASE PROBE FOR THE FOLLOWING ISSUES.)
the person(s) who brought the idea of the onchocerciasis programme to this village
the time when the person(s) came to talk with you about onchocerciasis
whether there was a village meeting at that time
≅ Issues that were discussed at the meeting • ownership of the programme • expectation from the programme • responsibility of the community
2. Please describe how the community took decision on the time (month/season) and mode of distribution. PLEASE PROBE FOR:
⋅ Persons involved in decision-making Time of distribution Why the time was chosen Method of distribution Why the method of distribution was chosen
3. Please describe how the community took decision on the persons responsible for distributing the drugs to community members. PLEASE PROBE FOR:
• Persons involved in decision-making • Who will be responsible for distribution • How the persons were selected • Why the persons were selected Independent Participatory Monitoring of Tunduru Focus CDTI Project 53 Tanzania, 2-14 August 2007
• Method of drug collection
4a. Has there been any change in the person responsible for drug distribution (CDD) since the beginning of the programme? (PLEASE TELL US WHY)
4b. Has there been any change in the programme?
• Who brought the change • What was the change
5. What were you told about the need for community treatment with ivermectin? (PROBE FOR ANNUAL TREATMENT FOR SEVERAL YEARS, THE BENEFIT, SOURCE OF INFORMATION, COMMUNITY RESPONSIBILITY AND HEALTH EDUCATION)
6. How is the drug normally brought into the community and distributed to community members? PROBE FOR:
• point of collection • person responsible for bringing it to the community, • person responsible for distribution within the community • mode of distribution • when was the drug swallowed
7. Would you please tell us those who should not be treated with ivermectin (exclusion criteria)?
8. How was dosage determined by the CDDs during the last distribution? PROBE FOR MEASURING DEVICE
9. What problems have you had with respect to the distribution of the drug? PROBE FOR
• timeliness of supply to the community • adequacy of supply • storage
10. What problems have you had after taking the drugs?
11. How prepared is the community to take control of ivermectin distribution programme? (How does the community intend to sustain the exercise for several years?)
12. What support has the community given to the CDD? PROBE FOR :
• Incentives in cash or in kind • Provision of means of transport • Mobilization of community • Ensuring compliance
13. Could you please tell us how you would measure the success of the CDTI programme? Independent Participatory Monitoring of Tunduru Focus CDTI Project 54 Tanzania, 2-14 August 2007
14. How well has the CDD performed? (PROBE FOR ATTITUDE).
15. What suggestions do you have to improve the programme? Independent Participatory Monitoring of Tunduru Focus CDTI Project 55 Tanzania, 2-14 August 2007
IN-DEPTH INTERVIEW OF VILLAGE “A” CDD
To be administered only in group “A” villages. Interview 2 CDDs per village if there are more than one CDDs. At end of the interview ask the distributor to let you see his tools: measuring devise, registers, remaining drug if it is the case. When a question requires multiple responses, do not forget to put a circle around each applicable response code. Probe where appropriate.
Name of Village ______Village code: ____Subcounty/LGA:______
District/District______
Name of CDD ______Sex: 1. Female 2. Male
Main Occupation: ______
Month and year of first CDTI distribution in the village ___/_____
Month and year of last CDTI distribution in the village ____/______
1. How was the time (month/season) for distribution decided? 1. at a village meeting 2. village elders’ meeting 3. village chief/leader 4. health worker 5. village health committee 6. village committee meeting 7. other (specify) ______
2. What mode of distribution was decided?
1. house-to-house 2. central place (specify) ______3. Both house-to-house and central place 4. other (specify)______
3. How was the mode of distribution decided?
1. at a village meeting 2. village elders’ meeting 3. village chief/leader 4. health worker 5. village health committee 6. village committee meeting Independent Participatory Monitoring of Tunduru Focus CDTI Project 56 Tanzania, 2-14 August 2007
7. other (specify) ______
4. How were you selected to do the work?
1. at a village meeting 2. village elders’ meeting 3. village chief/leader 4. health worker 5. village health committee 6. village committee meeting 7. other (specify) ______
5. Has any CDD been changed after the first distribution?
1. Yes 2. No 3. Don’t know
6. If YES to Q5, Why was the CDD changed?______
7. Have you ever been supervised ?
1. Yes 2. No 3. Don’t know
8a. If yes to Q7, who supervised you ? (IF NAME WAS MENTIONED, PLEASE ASK FOR IDENTITY/POSITION/STATUS OF THE PERSON)
1. Health staff 2. Village health committee member 3. NGO partner 4. Community member/chief 5. Other (specify)______
8b. What did the supervisor do?
1. Checked the ivermectin inventory 2. Checked the records/treatment register 3. Collated the reports 4. Advised on the treatment of absentees 5. other (specify) ______
9. At what occasions were you supervised? (CIRCLE ALL THAT APPLY)
1. Before distribution 1. Yes 2. No 2. During distribution 1. Yes 2. No 3. Soon after distribution 1. Yes 2. No
10a. Have you received education on the importance of taking ivermectin tablets annually for several years? Independent Participatory Monitoring of Tunduru Focus CDTI Project 57 Tanzania, 2-14 August 2007
1. Yes 2. No 3. Can’t remember 10b. If yes, what were you told?
11. Did you provide the community with education on ivermectin treatment?
1. Yes 2. No
12. If yes to Q11, when did you provide the education to the community? (CIRCLE ALL THAT APPLY)
1. During the first meeting 1. Yes 2. No 2. Before the first distribution 1. Yes 2. No 3. During distribution 1. Yes 2. No 4. Soon after distribution 1. Yes 2. No 5. Other (specify)______
13. If yes to Q11, what did you tell the community? (CIRCLE ALL THAT APPLY)
1. Taking ivermectin annually for several years 1. Yes 2. No 2. Benefits of treatment 1. Yes 2. No 3. Community responsibility 1. Yes 2. No 4. Side effects 1. Yes 2. No 6. Other (specify) ______
14. Did you receive any training on how to treat community members?
1. Yes 2. No
15. If Yes to Q14, when did you receive training? ______
16. Who trained you?
1. Health personnel/Oncho coordinator 2. NGDO staff (specify)______3. Another CDD 4. Other (specify)______
17. How long did the training last?
1st training______2nd training______Last training______
18. How many CDDs were trained together (size of the group)?
1st training____ Last training______
19. Where was the venue of the last training? Independent Participatory Monitoring of Tunduru Focus CDTI Project 58 Tanzania, 2-14 August 2007
1. Within the community 2. Outside the community 3. Healthcare facility/hospital 4. Other (specify) ______
20. Was the venue of training near to your community?
1. Yes 2. No
21. What were you taught during training about onchocerciasis (CIRCLE ALL THAT APPLY)
1. Cause 1. Yes 2. No 2. Symptoms 1. Yes 2. No 3. Socio-economic importance 1. Yes 2. No 4. Community mobilisation and education 1. Yes 2. No 5. Ivermectin as treatment for a long time 1. Yes 2. No 6. Other (specify) ______
22. What were you taught about the drug? (CIRCLE ALL THAT APPLY)
1. Duration of treatment 1. Yes 2. No 2. Coverage of distribution 1. Yes 2. No 3. Dosage determination by measuring height 1. Yes 2. No 4. Expiration of drug after removing container seal 1. Yes 2. No 5. Treatment of absentees and refusals 1. Yes 2. No 6. Side effects (counseling and referral) 1. Yes 2. No 7. Exclusion criteria 1. Yes 2. No 8. Record keeping 1. Yes 2. No 9. Census 1. Yes 2. No 10. Other (specify)______
23. What were you taught about reporting? (CIRCLE ALL THAT APPLY)
1. Number of persons treated 1. Yes 2. No 2. Number of refusals 1. Yes 2. No 3. Number of absentees 1. Yes 2. No 4. Number of excluded persons 1. Yes 2. No 5. Number with severe side effects 1. Yes 2. No 6. Other (specify)______
24. Did any member of the community collect the drug from a collection point during the last distribution?
1. Yes 2. No 3. Don’t know
25. If “no” to Q24, why? ______26. Where is the collection point? ______
27. Did you experience late supply of drugs during the last distribution? Independent Participatory Monitoring of Tunduru Focus CDTI Project 59 Tanzania, 2-14 August 2007
1. Yes 2. No
Please explain______
28. How do you normally determine the quantity of drugs required by the community?
1. Census/registration record 2. Previous treatment records 3. By counting the number of households 4. Other (specify) ______
29a. Did you experience shortage of drugs during the last distribution?
1. Yes 2. No 29b. If yes, please explain______
30. How do you determine the number of tablets to give to an individual? (CIRCLE ALL THAT APPLY)
1. Take height measurement 1. Yes 2. No 2. Use weight 1. Yes 2. No 3. Visual observation 1. Yes 2. No 4. Age 1. Yes 2. No 5. Other (specify)______
31. What do you do about individuals who are absent during normal distribution period? ______
32. What do you do about individuals who refuse treatment? ______
33. Which categories of people would you not give the tablets (PLEASE CIRCLE ALL THAT APPLY)
1. Individuals below 5 years of age/ below 90cm 1. Yes 2. No 2. Pregnant women 1. Yes 2. No 3. Women who delivered less than one week before distribution 1. Yes 2. No 4. Sick individuals 1. Yes 2. No 5. Visitors 1. Yes 2. No 6. Other (specify)______
34. How do you ensure that these categories of people eventually receive treatment?
35a. How long do you normally keep the tablets in the community?______
35b. How many days did you take to complete the last distribution? ______Independent Participatory Monitoring of Tunduru Focus CDTI Project 60 Tanzania, 2-14 August 2007
36. Where do you normally keep the tablets? ______
37. Do you have drugs to take care of minor side effects?
1. Yes 2. No
38. What kind of support do you receive from the community?
1. Transportation for drug collection 2. Incentives (specify)______3. Other (specify)______
39. Do you have problems with record keeping?
1. Yes 2. No
40. If yes to Q39, please explain______
41. Please tell us how you feel about the programme with respect to:
a) sustaining the programme
b) community response
c) constraints
42. What do you think should be done to improve the programme?
43. Are you willing to continue as a CDD?
1. Yes 2. No
Please explain______
PLEASE ASK FOR REGISTER AND MEASURING DEVISE TO PROVIDE FOLLOWING INFORMATION
44a. Is measuring device for height present?
1. Yes, seen 2. Yes, but not seen (Explain)______3. No, Explain______
44b. How do you use it? Independent Participatory Monitoring of Tunduru Focus CDTI Project 61 Tanzania, 2-14 August 2007
45. Is treatment register present?
1. Yes, seen 2. Yes, but not seen (Explain)______3. No, explain______
46. If Q45 is “Yes, seen” EXAMINE TREATMENT REGISTER AND OBTAIN THE FOLLOWING INFORMATION ON:
1. Total population______2. Age composition of people: Below 5 years______5 years and above______3. Sex composition of the population: Male______Female______4. Number of persons treated______Male______Female______5. Number of persons under-5 years who received treatment______6. Number of refusals______7. Number absent during last treatment______8. Number with severe side effects______9. Number of tablets received______10. Number of tablets used______11. Number of tablets left in the drug kit______Independent Participatory Monitoring of Tunduru Focus CDTI Project 62 Tanzania, 2-14 August 2007
Key Informant Interview: Village” B” Leaders
This tool is to be administered to the village head or a representative of the village head in all category “B” villages. In the case that the village head wants someone else to assist with the interview, do not refuse. Put a circle around the appropriate response codes. Do not prompt responses and allow respondent time for answering the question. Use the option “other” where the response is not listed but remember to specify the response in the space provided. If a village head is not available, interview his assistant or representative.
Village Name:______Village Code:____subcounty/LGA:______
District/District______
Country: ______Month and year of last distribution______/______
1. Have people in this community been treated with ivermectin in the past one year?
1. Yes 2. No 3. Don’t know
IF NO TO Q1 END INTERVIEW
IF YES TO Q1 CONTINUE THE INTERVIEW
2. How was the time (month/season) for distribution decided? 1. at a village meeting 2. village elders’ meeting 3. village chief/leader 4. health worker 5. Village health committee 6. village committee meeting 7. other (specify)______
3. What mode of distribution was decided?
1. house-to-house 2. central place (specify) ______3. both house-to-house and central place 4. other (specify)______
4. How was the mode of distribution decided?
1. at a village meeting 2. village elders’ meeting 3. village chief/leader 4 health worker 5 Village health committee 6 village committee meeting 7. other (specify) ______5. How many persons in this village (CDD) give out the drug for onchocerciasis? ______
7. How were the persons (CDD) selected to do the work? Independent Participatory Monitoring of Tunduru Focus CDTI Project 63 Tanzania, 2-14 August 2007
1. at a village meeting 2. village elders’ meeting 3. village chief/leader 4. health worker 5. village health committee 6. village committee meeting 7. other ______
7. Have the CDDs received any training?
1. Yes 2. No 3. Don’t know/ Cant remember
8a. Have you changed any of your CDD? 1. yes 2. No 3. Don’t know
8b. If yes, why? ______
9. Did any member of the community collect the drug from a collection point?
1. Yes 2. No 3. Don’t know
10. Did you experience late supply of drug during the last distribution?
1. Yes 2. No 3. Don’t know
11. Did you experience shortage of drugs during the last distribution?
1. Yes 2. No 3. Don’t know
12. Does the community have a treatment register?
1. Yes 2. No 3. Don’t know Independent Participatory Monitoring of Tunduru Focus CDTI Project 64 Tanzania, 2-14 August 2007 HOUSEHOLD SURVEY FORM (category A villages only)
Instructions to The Monitor - The Following Questions Should Be Answered by Every Member of The Household. First Ask The Head of The Household or His/her Representative to List The Names of All The Members of The Household. Next Pose The Following Questions to Each Household Member And Record The Answer in The Appropriate Column. Select 5 persons in three (3) villages treated by a particular CDD (not more than 1 per household) determine the accuracy of number of tablets given. If accurate code as “1” but if not accurate code as “0”
For those not selected, leave blank and do not code.
Village Name ______Village code______Month of last treatment______Household ID No. ______CDD’s name ______
Accuracy of VILLAGE: Sex Age QUESTION IF YES TO QUESTION 1 IF NO TO QUEST. 1 QUESTION 2 number of M=1 1 tablets F=2 Is the NAMES of During the How What Did How did If unwell Why did Have you Did you take number of household last general many color You it affect within you not taken the tablets the tablets given members treatment, tablets were swallow you?* two receive the these year before by CDD did you were you they? the days, tablets at tablets the last correct by receive given White=1 tablets? what did that since distribution? the height of tablets? Other=2 Y=1 you time?*** then? Y=1 the person? Y=1 N=2 do?** Y=1 N=2 N=2 N=2 Correst =1 Incorrect= 0 Independent Participatory Monitoring of Tunduru Focus CDTI Project 65 Tanzania, 2-14 August 2007
*codes: **code: nothing=1, ***code: child<5=1, ****code: incorrect dose= 0 not treated =00, swelling=05, modern medicine=2 absent=2 correct dose = 1 no reaction=01, nausea/vomiting=06, traditional medicine=3 pregnant=3 itching=02, many reactions=07, others=4 refusal=4 dizziness=03 feeling better=08, not informed=5 headache=04, others=88, sick=6 no response= 99 others=7 Independent Participatory Monitoring of Tunduru Focus CDTI Project 66 Tanzania, 2-14 August 2007
IN-DEPTH INTERVIEW OF VILLAGE “B” CDD
To be administered only in group “B” villages. Interview 2 CDDs per village if there are more than one CDDs. At the end of the interview ask the distributor to let you see his tools: measuring devise, registers, remaining drug if available. When a question requires multiple responses, do not forget to put a circle around each applicable response code. Probe where appropriate.
Name of Village ______Village code: ___ subcounty/LGA:______
District/District ______Name of CDD ______
Sex: 1. Female 2. Male
Main Occupation: ______Month and Year of last distribution_____/____
1. How were you selected to do the work?
1. at a village meeting 2. village elders’ meeting 3. village chief/leader 4. health worker 5. village health committee 6. village committee meeting 6. other (specify) ______
2. Has any CDD been changed after the first distribution?
1. Yes 2. No 3. Don’t know/can’t remember
3. Have you ever been supervised ?
1. Yes 2. No 3. Don’t know
4. If yes to Q3, who supervised you ? (IF NAME WAS MENTIONED, PLEASE ASK FOR IDENTITY/POSITION/STATUS OF THE PERSON)
1. Health staff 2 Village health committee member 3. NGO partner 4. Community member/chief 5. Other (specify)______
5. Have you received education on the importance of taking ivermectin tablets annually for several years?
1. Yes 2. No 3. Can’t remember
6. Did you receive any training on how to treat community members?
1. Yes 2. No
7. Is measuring device for height present? Independent Participatory Monitoring of Tunduru Focus CDTI Project 67 Tanzania, 2-14 August 2007
1. Yes, seen 2. Yes, but not seen (Explain)______3. No, (Explain)______
8. Is treatment register present?
1. Yes, seen 2. Yes, but not seen (Explain)______3. No, (explain)______
9. If Q8 is “Yes, seen” EXAMINE TREATMENT REGISTER AND OBTAIN THE FOLLOWING INFORMATION ON:
1.Total population______2.Age composition of people: Below 5 years______5 years and above______3. Sex composition of the population: Male______Female______4 Number of persons treated______Male______Female______5 Number of persons aged 5 years and above who received treatment______6 Number of refusals______7 Number absent during last treatment______8 Number with severe side effects______9 Number of tablets received______10 Number of tablets used______11 Number of tablets left in the drug kit______12. Update of records ______QUESTIONNAIRE FOR HEALTH PERSONNEL
This questionnaire is administered on any health worker in the area who is directly involved in CDTI programme i.e the health staff nearest to the village. The number of health personnel to be interviewed depends on the situation on the ground. A minimum of 3 health personnel who are supervisors of CDDs should be interviewed within the project area. After the interview ask the health personnel for the documents used for CDTI activities.
LGA/Subcounty: ______District/District______Country ______
Name of health personnel______Sex: 1. Male 2. Female
No. of Oncho. Villages______No. of CDDs in villages covered_____
Position: ______Qualification: ______
Responsibilities in Oncho control Programme: 1 Oncho Coordinator 2 CDD supervisor 3 other (specify)______
1. Did you receive any general orientation on CDTI?
1. Yes 2. No
2a. Did you receive training on how to train CDDs?
1. Yes 2. No
2b. If yes, how long?______
2c. List the main topics covered
2d. Were you taught how severe side effects should be managed?
1. Yes 2. No
3.Please tell us what you know about the CDTI programme with respect to:
1. Community responsibility______
2. Involvement of the health system in CDTI ______Independent Participatory Monitoring of Tunduru Focus CDTI Project 69 Tanzania, 2-14 August 2007
4. Was there an initial meeting with the community where CDTI was introduced?
1. Yes 2. No 5. If yes to Q4, what role did the health staff play in arranging for the first meeting? (CIRLCE ALL THAT APPLY)
1. Facilitated the meeting 2. Met with village leader to arrange for the meeting 3. Other (specify) ______
6. Who led the facilitating team to the community?
1. health staff 2. government administrative staff (non-health) 3. NGDO staff 4. other (specify) ______5. Nobody
7. Were the communities (where you worked) educated on the importance of treatment with ivermectin tablets?
1. Yes 2. No 3. Don’t know
8. If yes to Q7, what were they told? (CIRCLE ALL THAT APPLY)
1. Annual treatment for several years 1. Yes 2. No 2. Benefits of treatment 1. Yes 2. No 3. Community responsibility 1. Yes 2. No 4. Others (specify)______
9. Were CDDs in the communities (where you worked) trained for the CDTI programme?
1. Yes 2. No 3. Don’t know
10a. If yes to Q9, did you participate in the training of CDDs?
1. Yes 2. No
10b. If yes, how long did this training session last? Initial training______Retraining______
11a. Who supervised the CDDs
1. Not supervised 2. Village head 3. Village health committee member 4. health personnel 5. Other Independent Participatory Monitoring of Tunduru Focus CDTI Project 70 Tanzania, 2-14 August 2007
11b. If supervised, how many CDDs did you supervise during the last distribution? ______
12. If not supervised, why?______
13. At which occasions did you visit the CDD? (CIRCLE ALL THAT APPLY)
1 Before distribution 1. Yes 2. No 2. During distribution 1. Yes 2. No 3. Soon after distribution 1. Yes 2. No 4. Other (specify)______
14. What functions do you perform during your visit to the CDD? (CIRCLE ALL THAT APPLY)
1. Collection of unused drugs after distribution 1. Yes 2. No 2. Review of records 1. Yes 2. No 3. Management of side effects 1. Yes 2. No 4. Supervision of drug distribution 1. Yes 2. No 5. Other (specify)______
15. What constraints do you have in supervising the CDD? (CIRCLE ALL THAT APPLY)
1. No constraints 1. Yes 2. No 2. inadequate/lack of means of transport/fuel 1. Yes 2. No 3. Too much work 1. Yes 2. No 4. Inadequate/lack of supervision allowance 1. Yes 2. No 5. Inaccessibility 1. Yes 2. No 6. Other (specify)______
16a. Have there been any delays in receiving ivermectin?
1. Yes 2. No
16b. If yes, explain ______
16c. Have there been any delays in collecting ivermectin by the community?
1. Yes 2. No
17. If yes to Q16c, please
explain______
18. What constraints have you experienced in getting the drug? (CIRCLE ALL THAT APPLY)
1. None 1. Yes 2. No 2. Transport problem 1. Yes 2. No 3. Inadequate supply 1. Yes 2. No 4. Delay in supply 1. Yes 2. No 5. Other (specify) ______Independent Participatory Monitoring of Tunduru Focus CDTI Project 71 Tanzania, 2-14 August 2007
19. How do you estimate the quantity of drug required?
1. Not responsible 2. Number used during last treatment 3. Based on requests from the CDDs 4. Total population (with the formula) 5. Other (specify)______
20. Did you get the drugs when required?
1. Yes 2. No
21. If no to Q20, why?
1. Shortage at District, regional level 2. Means of transport 3. Other (specify) ______
22. Do you have facility for storage of ivermectin?
1. Yes 2. No 3. Don’t know
23. Have you experienced loss of tablets due to pilferage?
1. Yes 2. No 3. Don’t know
24. Were cases of severe side effects reported to you?
1. Yes 2. No
25. RECORDS OF SEVERE SIDE EFFECTS (CHECK AVAILABILITY) :
1. Available 2. Not available
26. What other health activities do you combine with Oncho Control Programme activities (PROBE FOR HEALTH ACTIVITY IN THE CDTI COMMUNITIES)? ______
27. How do you feel about the CDTI programme? Independent Participatory Monitoring of Tunduru Focus CDTI Project 72 Tanzania, 2-14 August 2007
INTERVIEW GUIDE FOR POLICY-MAKERS/ WHO REPRESENTATIVE/PROGRAMME MANAGERS/ COORDINATORS
This interview is administered on Co-ordinators, Programme managers, representatives of NGDOs involved in CDTI, Ministry of health policymakers and the WHO representative in the country. It is similar to the interview of health personnel. Documents such as registers should be requested before the formal interview so that information can be extracted for the report
SECTION A: PROGRAMME MANAGERS/ ONCHO COORDINATORS 1. Please describe how the CDTI programme is being implemented in your area PROBE FOR
a. The approach used for introducing CDTI to the communities
b. Elements of collaboration between Community, Health system and NGDOs (IDENTIFY SPECIFIC ROLES)
c. General re-orientation of health personnel towards CDTI programme
d. Mobilisation of the communities
e. Training of health staff as trainers
2. Please explain process of receiving ivermectin. PROBE FOR :
a. Delays in supply
• at what level and why?
c. Adequacy of the quantity received/shortage
d. Storage
e. Distribution to communities
f. Constraints (storage, transport, etc)
g. Pilferage
3. FUNDING: Please probe for a. Delays in endorsement of letters of agreement
Why? ______
b. Delays in receiving funds
• at what level and why? Independent Participatory Monitoring of Tunduru Focus CDTI Project 73 Tanzania, 2-14 August 2007
c. Delays in disbursement of funds
• At what level and why?
d. Inadequacy of previous budget
e Fund administration: delays in submission of financial reports, disbursement and retirement procedures, delays in feedback from APOC headquarters on financial reports
4. Please describe the programme’s plans for improving sustainability
5. Which other health activities do the Oncho supervisors combine with their Oncho Control Programme activities?
6. Would you please explain the programmes record keeping procedures EXAMINE THE FOLLOWING RECORDS
Summary sheets: 1. Available 2. Not available
7 EXTRACT INFORMATION ON THE FOLLOWING (relate to the level of operation e.g. District and LGA)
a. Total Population ______
b. Number of villages in the area______
c. Number of villages with summary forms______
d. Number of villages treated______
e. Number with severe side effects______
f. Evidence of report update (check annual returns after distribution)
1. Updated 2. Not updated
SECTION B: MOH POLICY MAKERS ( Permanent Secretary/Director Disease Control)
8a. Do you have a national Plan for the control of onchocerciasis ( Probe for the importance attached to onchocerciasis control
8b. What kind of support do you provide for Oncho. Control activities (PROBE FOR FINANCIAL INPUT)
9 How do you perceive the CDTI strategy of APOC ( Probe for personal opinion and official policy on CDTI) Independent Participatory Monitoring of Tunduru Focus CDTI Project 74 Tanzania, 2-14 August 2007
10 Is the Oncho Programme integrated into the health system ( Probe for activities which indicate integration and ownership/ Plans for sustainability.
SECTION C: WHO COUNTRY REPRESENTATIVE
11.What is your perception about the APOC strategy for ivermectin distribution ( Probe for feasibility of the CDTI approach in solving other health problems) Independent Participatory Monitoring of Tunduru Focus CDTI Project 75 Tanzania, 2-14 August 2007
APPENDIX 3: LIST OF PEOPLE MET DURING THE MONITORING OF TUNDURU CDTI PROJECT.
DISTRICT HOSPITAL 1. DR. A NDUNGURU ACTING DISTRICT MEDICAL OFFICER 2. MR. GAUFRID MVILLE DISTRICT ONCHO COORDINATOR
DISTRICT COUNCIL OFFICE 1. MR. CHARLES NGONYANI ACTING DISTRICT EXECUTIVE DIRECTOR 2. CONSTANTINE MUSHI DISTRICT PLANNING OFFICER
COMMUNITIES • MARUMBA 1. HASSAN SAID VILLAGE CHAIRMAN 2. ABDALLAH SADIK VILLAGE EXECUTIVE OFFICER 3. SAIDI MPENDA CDD SUPERVISOR 4. MOHAMED ISSA CDD 5. ASHA KISASI CDD
• MASUGURU
1. SHAIBU KANDURU CDD SUPERVISOR 2. HAMED KASSIM CDD 3. LYANDUNGU MUSA VILLAGE EXECUTIVE OFFICER
• NAMASAKATA
1. YASIN ISMAIL VILLAGE CHAIRMAN 2. SEIF YUSUF VILLAGE EXECUTIVE OFFICER 3. CECILIA FUSI HEALTH STAFF 4. AMINASA SAIDI NURSE ASSISTANT 5. SYLVANUS NCHIMBI CLINICAL OFFICER IN CHARGE 6. HABIBA KWIKANDE CDD 7. TIMAMU OMARY CDD 8. SALUM YUSUF CDD 9. SOFIA OMARY CDD 10. ISSA ZUBERI CDD 11. MAIMUNA HAMIS CDD 12. FATUMA CHANDE CDD 13. BONOMALI YAHAYA CDD 14. HASSAN OMARY CDD 15. SOFIA KOLO CDD Independent Participatory Monitoring of Tunduru Focus CDTI Project 76 Tanzania, 2-14 August 2007
• NAMPUNGU
1. MOHAMED SALUM HEALTH WORKER 2. SAIDI SAIDI VILLAGE EXECUTIVE OFFICER 3. SAIDI ALLY VILLAGE CHAIRMAN 4. LIMBE MOHAMED CDD 5. MOHAMED ATHUMAN CDD 6. MWANAHAWA SWALEEHE CDD 7. RASHID RASHID CDD 8. ASHA KAROLO CDD 9. DAUDI MAKARANI CDD 10. MOHAMEDI SHAIBU CDD 11. ASHA HASSAN CDD
• LIGOMA 1. ZAWADI ABDALLAH VILLAGE EXECUTIVE OFFICER 2. ALADO HAMIS VILLAGE CHAIRMAN 3. AMINA MATUMLA HEALTH OFFICER IN-CHARGE 4. AISHA LAUMU CDD 5. MWAJUMA SAIDI CDD 6. HALIFA LUFAJI CDD 7. ALLI DAUDI CDD 8. MKOCHA YUSUF CDD 9. MWANAHAMIS HASSAN CDD 10. AUSI KANYATA CDD 11. HALIMA MARTIN CDD
• HULIA 1. SAIDI HASHIM VILLAGE CHAIRMAN 2. SONGO ABDULRAHMAN VILLAGE EXECUTIVE OFFICER 3. AMINA RAJABU HEALTH WORKER 4. NYENTE SAIDI CDD 5. ZIADA MKWINDA CDD 6. FATUMA KASSIM CDD 7. CHRISTOPHER NIPALA CDD 8. MARIAM GERVAS CDD 9. JUMA MILLANZI CDD 10. TECLA RAFAEL CDD 11. ISSA SAID CDD