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I African Programme for Onchocerciasis Control (APOC) Programme africain de lutte contre I'onchocercose JOINT ACTION FORUM JAF-FAC FORUM D'ACTION COMMUNE Office of the Chairman Bureau du Pr6sident I JOINT ACTION FORUM JAF4/INF/DOC.8 Fourth session ENGLISH ONLY Accra. 9-11 December 1998 October 1998 a Provisional agenda item 14 INDEPENDENT MONITORTNG OF CDTI PROJECTS IN UGANDA September 14 - October 3 SUMMARY COUNTRY REPORT I I CONTENTS Pages 1 INTRODUCTION .1 f .i. Background on APOC .1 1.2. Country Background .1 1.3. Terms of Reference .J 2. METHODOLOGY ,4 2.1. Population .5 2.2. Sampling .5 2.2.I. Category A Villages .5 2.2.2. Category B Villages .6 2.2.3. Health Personnel . , .6 2.3. Instruments.... .6 2.4. Procedures .7 2.4.1. TimeFrame..... .8 2.4.2. Team Memberships .8 3 SUMMARY OF MAIN FINDINGS .8 3.1. Hoima District .9 3.2. Masindi District .9 3.3. Kisoro District 10 4. CONCLUSIONS AND RECOMMENDATIONS 11 JAF4/INF/DOC.8 Page I I. INTRODUCTION 1.1. Background on APOC The African Programme for Onchocerciasis Control (APOC) was established in December 1995, with the objective of setting up effective and self-sustainable community-based ivermectin treatment for onchocerciasis throughout 19 endemic countries in tropical Africa where 50 million people are at risk of onchocerciasis. APOC is based on the Mectizan @ (ivermectin) Donation Programme of Merck and Company, Inc., and awarded its first country project grants in 1997. To date 45 projects have been approved, 36 of which are specifically devoted to field operations for Community Directed Treatment with Ivermectin (CDTI). Field project proposals are based on a partnership between APOC, the National Onchocerciasis Control Programmes (NOCPs) and several Non-Governmental Development Organizations (NDGOs). Each project is funded for a maximum of five years. Over this time it is expected that APOC support will decrease proportionately to that of the other partners, and that the cost per individual treated will reduce by 90%. Once this has been achieved, it is expected that the particular National Onchocerciasis Control Programmes (NOCPs) will continue to manage their own CDTI activities for upwards of 15 years to guarantee effective control of onchocerciasis. CDTI is an approach to community involvement in disease control that was field tested with support from the UNDP/TVorld Bank/WHO Special Programme on Research and Training in Tropical Diseases (TDR). With CDTI, communities obtain their ivermectin from the health service, select their own distribution agents, or Community Directed Distributors (CDDs) for training, determine both the date for and mode of distribution, and through their CDD, gather information about the coverage that helps determine programme success. The TDR projects found that communities were capable of managing their own ivermectin distribution with 1-acilitative support from the health services and achieved as good tf not better coverage than distnbution activities organized by dishict health services centrally. It was concluded that CDTI offered the best hope for sustainable onchocerciasis interventron at the community level, and was thus adopted by APOC as its central strategy. CDTI can be contrasted with the former approach of Community Based Treatment (CBTI). CBTI is a procedure wherein health providers determine the steps and the schedule to be followed. Activities are based in the community but not owned by the community. In contrast, CDTI is a process built on the experience of community members and thus enhances decision making and problem solving capacity. Activities are both in and of the community. 1.2. Country Background Countries with the earliest approved CDTI projects, and thus locations where implementation would have been ongoing for at least one year, include Malawi, Uganda, Nigeria and Sudan. The current Independent Monitoring exercise is focused on the latter three. This report describes the experiences and findings of the four teams that visited Uganda. Important background information is that Uganda had started community nass distribtttiort o1-ivcrnrcctitr sincc 1992. ThLrs CDTI nas not introduced in a \.acLnur. but u,as adaptcd to rvhat \\'as olt thc gt'ttund. l'rvo NGDOs collaborated in those early e1'lorts and cor.rtir.rr-rc ttt be ini,olved, Sight Savers hrternational (SSI) and Global2000 River Blindness Program (GRBP). Table 1.1 traces the history oltrcatment in lltc iirLrr original chstricts. and those included rn this study. JAF4/INFiDOC.8 Page 2 Table 1.1. Treatment History in Phase I Districts District Number Treated per Year 1992 1 993 1 994 1 995 1 996 1997 1 998 Hoima 1 5,1 00 34,378 40,274 42,637 nla 49,780 42,954 Kisoro 8,916 10,362 13,879 12,262 12,142 ',l3,653 Kasese 32,135 37,615 49,307 48 059 46,935 started 9/98 Masindi 29,300 31,825 35,833 37,771 nla 37,268 36,877 TOTAL 44,400 107,254 124,084 143,594 146,125 Table 1.2 shows current programming information on the four districts where the teams visited, that is Hoima, Masindi, Kisoro and Kasese. Prior to the teams' visits, the NOCP in Uganda reported for 1997, that in 373 hyper- and meso-endemic communities, 148,709 eligible persons had received treatment. This figure is adjusted from the figure of 151,911 available at APOC. Prior to APOC, Onchocerciasis control activities based on mass distribution of ivermectin began in Uganda in 1991, with assistance from the German development agency, GTZ.. Over the ensuing six years, annual treatmenr rose from 3,5215 individuals to967,183 (1996). The targetpopulation is estimated to be 1.3 million people. At present, four NGDOs are involved in the NOCP including Sight Savers International (SSI), Global 2000 River Blindness Programme (RBP) (The Carter Centre), Christofell Blinden Mission (CBM) and World Vision International (WVD. On the local level, The East Ankole Diocese of the Church of Uganda is also involved. The NOTF progress report dated 13 February i998, noted that CDTI had not acnrally been applied in the four districts during the 1997 distribution due to, "delay in receiving funds from APOC." An attempt at CDTI was apparently undertaken in Kasese, but due to instability and insecurity in the area, people treated were based in camps. This concentration of people may have made it easier to undertake CDTI and may also have accounted for the extra people present to yield a coverage of 109%. The Onchocerciasis Coordinator from Kisoro explained that distribution was undertaken in early 1997, using the previously established procedures even though funds had not arrived, in order not to disappoint the community. A challenge to the Monitoring Tearns was to learn whether, in the ensuing months since February 1998, CDTI had been instituted in the community. JAF4/INF/DOC.8 Page 3 Table 1.2. Summary of 1997 Programme Activities in Four Phase I Districts Frorn February 1998 DISTRICT Total Progress Report Hoima Masindi Kisoro Kasese Number of 119 98 31 t25 315 Communities Coverage Rate 75% 80% 75% 109% 86% (reported by NOCP) Supervisors Trained 10 11 8 11 40 Number of CDDs 266 268 1 1 5 324 973 Trained* NGDO SSI SSI RBP RBP *at least one CDD per community At the present time, 19 Districts are under treatment from Phase I through Phase IV. Ten of those districts receive NGDO assistance from GRBP, 4 from CBM, 3 from SSI and 2 from GTZ. Other areas of the country do not appear to be endemic from the REMO maps. Most of the endemic areas are in the west, with the exception of Mbale in the east. 1.3. Terms of Reference At present, TDR is sponsoring additional research to identify potential indicators for sustainability of CDTI. The monitoring of ongoing APOC projects in the field offers another avenue for determining the factors and processes that enhance implementation and sustainabiliry of CDTI. With this potential in mind, APOC set the following terms of reference for the monitoring teams: (i) Succinctly document how ivermectin treatrnents were undertaken in a number of sampled communities/villages in Districts/Local Government Areas with approved CDTI projects. (ii) Assess communiry involvement in - drug collection, decision making on the period and mode of distribution, the selection of distributors; and the willingness of the community to bear these responsibilities as designed in the CDTI process. (iiD Document communify perceptions of CDTI processes, especially the issue of ownership, and expectations for onchocerciasis control, and based on these perceptions and expectations, determine the degree of satisfaction of the community with the different prograrnme activities and outcomes. (iv) Assess the quality of training received bv communiry selected distributors (CDDs) (v) Examine the record books of the CDDs and assess the quality of record-keeping and their :rhili11, to keep accurate records. The same applies to the health services staff on tl.r' project. JAF4/INFiDOC.S Page 4 (vi) Determine the number of communities ad eligibles treated and compare the findings with the records of the CDDs and the records at the other levels (e.g. district, central). (vii) Determine whether the health personnel participated in ivermectin distribution, and assess the degree and quality of supervision by the health staff (and the quality of training and/or orientation of such staff to CDTD. (viii) Identiff constraints in the distributions and make recommendations to the NOTF and the Management of APOC on corrective measures necessary before the next treatement (ix) Discuss the prospects of sustainability based on the findings above It should be noted that items (iii) and (ix) were added to the original terms at a planning and instrument development meeting of the Independent Monitors on 14-15 September 1998, in Ouagadougou, Burkina Faso, headquarters of INDICATORS FOR INDEPENDENT APOC.