2.8. Supenrision
2.8,1. Supervision of health personnel
Supervision of health personnel was done at different levels, depending on activity being carried out. Health district staff were supervised by the provincial and NGDO staff during training / retratning of health area nurses and health area sub-supervisors. Most of these trainings were carried out at the various district health services following their pre-prepa-red plans of action. Another health district activity that was supervised by the province and NGDO was the appraisal meetings that held after the distribution exercise. During distribution of Mectizarr@ the provincial and NGDO staff also did spot checks in some health areas and even villages to see how CDDs were supervised by their nurses and to see how side effects were monitored and managed. These spot checks took place in Mamfe, Mundemba, Ekondo Titi and Fontem health districts. During these spot checks the supervisors joined the health area staJf in giving health education to the villages visited and this helped a lot in increasing uptake of the drug. In Mamfe health district for instance the supervision team happened to be in Bachuo Akagbe health area during the National Youth Day Celebrations (l ttt, February 2003). The whole population that came out for the Youth Day celebrations at the ceremonial grounds was addressed and educated on the ongoing CDTI. A very interesting question and answer session followed.
Another level of activities carried out by health personnel was the trainings of CDDs and community members. Most of these trainings were carried out at the leading health centres of the health areas. Here the health area nurses were routinely supervised by the health district staff. Occasionally the project co-ordinator at the provincial level made spot checks to problem health centres to witness the trainings and reinforce the training team. Supervisions by health districts were greatly handicapped by the lack of means of transport. Apart from Fontem, no other health district has a vehicle that can be used for supervision.
Supervisions carried out by the health district \f,rere generally integrated, though during Mectizarr@ distribution more emphases were laid on CDTI. NGDO supervisions and spot checks were not integrated as NGDO sta-ff are generally not involved in other health programmes.
2.8.2. Superuision of CDDs and distributions
Community CDTI activities (those carried out by CDDs within their villages) just like those carried out at the level of the heatth areaand health district were carried out according to pre-made plans of action. After training /
27 retraining of CDDs they carried out registration updates in their different villages. This was then followed by Mectizan@ distribution. Apart from the case of Ekondo Titi Health District where treatment went on for over 5 months, in most villages Mectizan@ distribution generally lasted tor 7 to 14 days. During this period the health centre nurses visited each village daily to supervise CDDs as well as monitor and treat any side effects. During these daily supervisions the nurses took along with them drugs for treatment of minor side effects which they treated on the spot. This year's distribution was door-to-door in most of the villages, as was the wish of the community members. No case of severe side effect was recorded within the whole project area.
2.t.3, How quality of records was ensured
During training / retraining of health centre nurses and CDDs recording and reporting was greatly stressed upon. Practical sessions on these were even included in the training programmes. Recordings in the registers (registration / registration update and Mectiz,arr@ distribution) done by the CDDs, were routinely supervised by the health area nurses and occasionally by the district staff. At the end of the exercise the CDDs together with the health centre nurses filled the individual community/village treatment forms. These were then crosschecked during the health a.rea appraisal meetings. Also during supervision and spot checks from higher levels, recording and reporting was one of the points dwelled on.
2.8.4. How the results of supervision were utilized
During supervision issues found were dealt with on the spot; weaknesses were pointed out and mistakes corrected. Merits were also given for good performances and strong points. Supervision findings were usually listed out in the trip report, and resolutions made. These then served as action points for improvement of implementation of field activities.
28 SEGTIOII 3: Support to GDTI
3.{. Financlal contributions of the partnens and communlties
The table bellow shows the financial contributions of each of the project partners.
The main funding partners are APOC and Sight Savers International. These two partners provide direct financial support. The Ministry of Public Health also funds this project but its contribution is difficult to assess. It does not provide direct financial contribution. Its contributions are mainly personnel, infrastructure and "running credits' which are funds for running of all health activities. Last year the Ministry purchased a lap top computer and desk jet printer. CDDs'motivation for the year we are reporting on is to be provided for by funds from the Ministry of Health.
At the end of yea.r one activities the project had under spent and over 30 million francs CFA were left in the account. This amount was rolled over into the next year. As a result the amount of funds spent during year 2 exceeded the amount of funds APOC released during that year.
In year 2 (2OO1) and year 3 (2OO2l Sight Savers International budgeted additional funds for support of the project. Additional support funds for 2OOl were under spent. This was as a result of the fact that district temporar5r staff on whom part of this money was to be spent were recruited after the year's CDTI activities. So funds meant for paying them were not used.
Sta-ff cost borne by SSI for its stalf are also not shown on this table.
29 o o @ z o l, o 6' L o o c< o, o=: H o 3 J. 0 J-(/l B o 3 o o. o o G -{ c o- E' a o 0, =o o F. oe 6' f o = \) 6' =q) th I cr -Tt o o (D c E (tt o, o 5 L a a T { o. t @ o, ) I o c,o = tr o, I ta.ll F cr R (.,N (r)N c (,l o.{ (D o -(ri a(oo q, 'o o) o gl Ctl c-- I o @ o.tsd or- $ t& 5 5 =. B \ d _o (D "(., -coo (r, aE. il (., o (r) ON G .@ _o I -oo s 3a'd lc CD o o) G o o o 8. Bq n 8* il d oo,3; @ 34 a e qB N (o N 6B -(., _o) J\) _{ (r) o, o* 9G N o) o (,l 'n o :/.^{ !., J.) N _{ o (., o o, Ctr o o, (,l @ o. \l @ N I g c I (o (o cL{ J\' N ."E I> 5 (Os (o@ (o & 18* CL p* N l' or o J$ -(,l I 'or o) (o o o) s c-> -5 _5 -(oA --l $E. 3E Ot o (,l d o €g!,N d. 5:N @ oo E 8< I fl oo' N or==o !P nr .CD -- -(rio (D. Ng @ o @ 'TlC) iD-' -o _(,l _o) o =!L o ('l 9.5 @ (I, (oo N (,r o, (O o- If problems are being encountered in getting counterryrtfundingwhat plans are being made to address the situation
Government funding is being advocated for from the Ministry of Public Health and the HIPC initiative. Requests are being made for a budget line to be created at the district and provincial levels for onchocerciasis control activities. This has started yielding fruit as last yetr the Ministry of Public Health purchased some equipment for the project.
!.2. Other forms o,f communlQr support a Describe (indicateforms of in-kind contributions of communities if any)
Generally there is little or no community support of this programme. Very few villages provided food to the CDDs while carrying out their activities. It has been very difficult to make the community understand and actually take the project as theirs. Despite the amount of sensitisation carried out all through it has still not been possible making the community members providing substantial support to the programme. We hope with sustained sensitisation this will be achieved gradually.
3.3. Go6t per activityl - Indicate the cost o/the activities below in US dollms using the curuent United Nations exchange rate to local currency
Tablc 73: thoutlrtg prcteci expendldtre per c,L4foltg ltstcd Activity Ertimatcdcort($US1 AFOC ssr Drug delivery from NOTF HQ to central collection pgi4l of tle communit5r 100 Mobilisation and health education of communities and IEC materials L,742 1,833 Training of CDDs 2,262 Training of health staff at all levels 8,233 3,384 Supervising of CDDs and distribution 6,256 - treating hard to reach communities (Lm loa testing and Mectizan distribution) 5,707 8,212 Internal of CDTI activities tt,526 13,091 visits to health and authorities Total 27,?p,f, 35,137 Crtand Totd 62,3,46 o Comments Much was not spent on Mectizan@ delivery to the community. What went on this year was as follows; drugs were collected from WHO Yaounde premises after being signed out by the NoTF. These drugs were then taken to SSI country oflice in Yaounde from where they were transferred to the provincial 3l delegation of health in Buea. At the provincial delegation the drugs were kept by the provincial co-ordinator. The DMOs then collected consignments for their various districts when they came for a routine (not CDTI) meeting at the delegation. Supplementary quantities were supplied the districts by the provincial co-ordinator during supervision visits. Supplies from the province to the communities were not paid for as such. Supplies were always linked to an activity that was sponsored already.
Advocacy visits to health and political authorities was budgeted for under mobilisation and health education, and expenditure was made as such.
SEGTIOI{ 4: Sustalnabltlty of GDTI
4.11. lnternal; independent partlcipatoryr monitoring; Evaluation
If there has been an operational research carried out within the project area, please describe how the results have been applied
This project has never benefited from an operational research but internal evaluations are carried out each year.
Highlight the recommendations of the most recent internol or independent participatory monitoring or evaluation of project sustainabilily and describe the extent to which they have been implemented.
The project however had a mid term sustainability evaluation this year. The recommendations made as well as their level of implementation so far are as follows:
Tablc 14: Shorlag Recommendrtionr of thc mid-tcrm surtelaebility cvaluatlon rnd thcir lcvcl of implcmcntetlon Recommendetioa Lcvel of lmplcmentatlon Plannina The Province should draw the attention of all CDTI This has been done already. partners (communities; NGDOs; APOC and MOH), to their roles based on the proposal document and lessons learned to date in the implementation of CDTI. Already done (April 2003)
All health districts should have comprehensive work plans showing that CDTI is integrated into the ottrer To be addressed from when health programs of the district year four activities commence. However a few Census taking and distribution of Mectizan by CDDs use this method in CDDs should be undertaken during the same their villages period. Immediate action should be taken by project to improve the participation of communit5r leadership in assisting.lCDDs to mobilise and educate members. Leadership District Health Management Tearns should Usually action plans are immediately retrain health area sta-ff and empower prepared during appraisal
32 them to prepare and implement their own action meetings of the preceding plans according to the needs of the communities in year. They are done at each their catchment areas. level. Fourth year training will pay particular attention Communit5r leadership should be urgenfly be visited to this. and empowered about their roles and responsibilities in CDTI. They should understand the communities have the powers to select CDDs and change those not performing well. Communities should decide the timing and method of distribution. Monitorino and sp erui,ston There should be an element of quality assurance in Still to be done place as a mechanism for assessing tlle skills and quality of performance of the Districts level stalf following training activity.
All transmission of reports should be paid for with funds from the goverrrment partner and the communit5l.
Integrated superwision check list should be Mectizan@ requests are established and utilized in atl health districts usually based of census Mectizan@ requests and supply should be based on figures which emanate from FLHF and community requests, which in turn data from FLHF. should be based of census records.
The project should devolve tlre pa5rment of the DTS DTS are not permanent staff, to the govemment partner to ensure efficiency and neither are they government sustainability of the process. From the fourth year employed. They only senre of prograrn implementation, health area sta-ff should as back up for the deficiency be trained to carry out supervision of CDTI in an in health stafl in our healt]r integrated manner. DMOs should routinely send facilities. Dwolving their letters of commendation to chief of posts and payment to the government communities. will be dilfrcult as they are not government employed. Also the ministry of health has started employing addition personnel. When this exercise is over there may be no need to have DTS within the project.
To sustain the interest of CDDs, project should Being done already. Needs to sensitise communities to provide adequate support be intensified to their CDDs
Medizan@ hocurement and Di,stribution It is recommended that the NOCP should ensure Arangements have been that the procurement, storage and timely delivery of made (July 2OO3)with the Mectizan@ tablets be done within the existing health Drug prograrnme in Buea so systenqs from the national level to the entire project that Mectizan@ is procured
JJ areas. Secondly, a standardised method of and delivered like other Mectizan@ requirements estimation should be essential drugs in the stricfly followed. province. This will take effect as from the next round if Mectizan@ distribution.
The duration of distribution should be extended From year four of Mectizan@ in all communities. Mectizan should be left with distribution this will be done. CDDs for about two weeks after the community distribution in order to allow enough time for absentees to receive treatment. This recommendation will improve treatment coverage. Tlainirw and HSAM HSAM should be intensffied at district level. The district management teams should empower tJre FLHF to identi$z training needs
Health education, sensitization, mobilization and This will be particularly communication messages should provide considered during this communities with specific information to deal with oncoming fourth year of identified problems. In ttre fourth vear proiect activities. manaeement should tarqet traininq of chiefs of post. The educational background of the chiefs of post should be considered in planning targeted retraining sessions.
To strengthen HSAM, community and social Social mobilisation agents mobilisation officers and health educators should were used during the third be co-opted to assist tJ:e project and improve the year and this is probably one effectiveness of HSAM on the benefits of long-term of the contributing factors to compliance and ownership of CDTI. improved treatment coverage.
The practice of intensified health education strould continue and strengthened. Health education, sensitization and mobilization materials should be made available in sufficient quantity to support the work of chief of posts and CDDs in mobilizing communities. Financinq The evaluators are concerned t]'at the Government Though still small has not fulfillsd her obligations as highlighted in the government's direct financial project proposal and the endorsed letters of contribution to this project agreement for the project implementation. It is has started coming. recommended ttrat government take action to Advocating for increased comply with the obligation to ensure sustainabilit5r financial support from the of CDTI whose success is of great importance to the government needs to be people of Carneroon. intensified.
Government funding of CDTI activities should increase. A budget line for CDTI should be created at this level
34 NOTF should urgenfly sensitise the national, provincial and district governments to immediately assume their appropriate responsibilities. Governments should cover the costs of Mect2an@ procurement and delivery to health areas, supervision, advocacy and transmission of reports to districts.
Immediate changes a-re necessary in order for This is usually done during communities to appreciate the tasks of CDD as training and re-training their own responsibilities. The Provincial delegate sessions that go on yearly. It and NGDO partner should as a matter of priority will be reinforced this year. organizn the health personnel at districts and health area levels and embark upon immediate sensitization of the leaders and communities on the responsibilities as the lead partner in CDTI. This is very crucial for sustainability of long-term treatment.
The present complicated financial management of An account for the project APOC funds should be simplified as follows: has already been opened at . The project should have its primary Bank BICEC bank Buea. The Account in the town where the project is located account at Standard or the nearest convenient location where funds Chartered Bank in Yaounde can be withdrawn easily. is in the process of being closed. The APOC finance a The Delegation team (MOH) should take full oflicer has already assumed control of the day-to-day management of APOC duty at the provincial funds, while the facilitating NGDO is expected to delegation of health Buea. provide the needed technical support and financial control. The NGDO should remain a mandatory signatory to all cheques. a The present Finance Oflicer being paid with APOC funds under technical assistance should relocate to the project office in Buea and work under the direction of the Provincial Delegation (MOH). This arrangement should continue until the delegation is in the position to absorb the Finance Officer.
35 Tlansport and othq Materiol Resources To ensure sustainability of CDTI, government and APOC should ensure replacement of transport before APOC support ends.
Log books should be used routinely in all districts This needs to be done and and they should contain routine maintenance reinforced. schedule in order to extend the life span of the vehicles. Necessar5r health education materials should be Adequate IEC materials will made available in all districts in adequate quantities be made available but time next year's CDTI activities take off.
From the fourth year of implementation, district This will be advocated for as funds should be used to support travel costs of from the oncoming fourth chief of posts for the collection of Mectizan from the year. districts. Human Resources Provincial, District and Health Area staff should be Community sensitization is trained on community sensitization and usually an important mobilization. And this includes utilization of IEC component of the yearly re- materials. This is an essential ingredient to irnprove trainings that take place at treatment coverage. the onset of CDTI activities. Appropriate and suflicient number of training and This will continue to be done HSAM materials should be made available to health yearly. areas before the next distribution to enhance the efforts of chief of posts, and sustain communit5r interest in taking Mectizan that seem to have been achieved only during the last distribution
The ratio of CDDs per population should be The communities will be reviewed and ratilied before the next treatment. asked to select more CDDs so Communities should be encouraged to select as as to reduce their workload many CDDs as possible so that one CDD will treat a m€udmum of 5O people and their work reduced to 2- ! !qys. CDDs should also work in pairs. Coueraqe Coverage has been generally low since the project Therapeutic coverage has inception, although the third year has seen improved considerably improvement over the first two years. The level of during this third year. This coverage should be raised and maintained to ensure needs to be maintained. maximum benefit to the eligible population. Geographical coverage is at Therapeutic coverage rate should increase to at IO0P/o and needs to be least 657o in all communities of t] e health district. maintained too. Geographic coverage should increase to 1007o in all the health districts
The duration of distribution in communities is of concern and should immediately be reviewed upwards to the range of 4 weeks, to reflect APOC CDTI guidelines and the wishes of the communities.
36 4.2. GommuniQr self-monitoring
Tablc 75: Up scallng Communltg self-monttortrtg Totd # of No of Communities No of Communities that Health District communities/villages in that carried out self conducted stakeholders the meso/hyper-endemic monitoring meeting areas Akwaya 79 0 0 Ekondto Titi 36 0 0 Fontem 116 ll6 37 Mamfe 135 0 0 Mundemba 89 0 0 TOTAL 455 116 37
Describe how the results of the community self monitoring and stakeholders meeting have affected project implementation or how they would be utilized during the next treatment cycle. Apart from in Fontem health district community self monitoring and stake holders meetings were carried out in no other place. Even in Fontem where it was done, it was more like an activity imposed on the community. They still need to understand the importance of self monitoring. Results of this activity have therefore not affected project implementation significantly. Before onset of year four activities the health district and health area staff will have to be refreshed in the whole activity.
4.3. Sustainabtlity of proiects: plan and set targets
South West Two Project is at the end of its third yetr. APOC funding is still expected for two more yea.rs. Nevertheless the following sustainability plans have been made for the project; i) Fltndirry: Government funding during the post APOC funding period will be from government "running credits" of the different health facilities. So far some funding from the government for CDTI activities was made available last yetr from special disbursements of the Ministry of Public Health, used for the purchase of a computer and printer. Plans are also underway for extra funds to be mobilised from the Highly Indebted Poor Country (HIPC) Initiative. Budgets for HIPC initiative funding have already been submitted to the Ministry of Public Health for year 4 activities. ii) Tfar*port: No plans have been made yet for replacement of existing means of transport yet. However maintenance and repairs will be done with funds provided by the goveflrment for running of the health facilities. iii) Otlrcr Sources of Funding: Funding from SSI will still be avaitable but would not replace APOC funds. Most of the financial support will have to come from the Ministry of Public Health and the community. iu) Sustainabilitu Plan: South West Two Project had a sustainability evaluation in April this year. At the end of the evaluation
37 sustainability plans were drawn up by each of the five health districts. Copies of the sustainability plans are attached to this report. The plans are still to be implemented in their entirety when year four activities effectively take off later this year.
4.4 lntegration
Outline the extent of integration of CDTI into the PHC structure and the plansfor complete integration
So far CDTI is being integrated in the minimum package of health care activities at all levels. This integration is however not complete yet as some health sta-ff still find it difficult integrating CDTI activities with other community health activities they carry out. At the provincial and district levels supervisions are fully integrated. Although trainings are not fully integrated yet, during CDTI trainings information on other health programmes was occasionally passed on to the trainees. Fully integrating trainings may confuse the trainees, considering the level of health staff we have in our health facilities. Also this may pose a problem as different health programmes have different focal persons with different plans of action.
Describe other health programmes that are using the CDTT structure and how thiswas achieved. lthat hove been the achievements.
Other health programmes like measles and polio immunization campaigns make use of both human (CDDs) and material resources (vehicles) put in place by CDTI but the programmes are not community directed. Instead they are health intervention programmes. So far the achievements of these other progra.mmes have been good.
38
\ SEGTIOII 5: Discussion, Gonclusions & recommendations
Discuss the strengths andweaknesses of CDTI implementation process.
South West Two CDTI Project has just rounded up its third yetr activities. Compared to the preceding two years this year's performance has been good. Activities were better carried out and treatment coverage rate has increased considerably.
Merits should go to this programme as it has brought to light the fact that the community could be made to take interest and take care of issues concerning their health. It is a leading project as far as community activities are concerned.
Through this project interaction of health personnel and the community has been greatly increased. This has greatly facilitated implementation of other community health programmes. CDDs who are the main CDTI field actors are now used not only for CDTI but for other community health programmes oNational like the Immunization Days against poliomyelitis" and "Measles elimination programme'.
Thanks to the CDTI project transport facilities have greatly improved in the project area. Apart from making available a four wheel drive vehicle at the provincial level, every health area with a motor-able road has at least a motorcycle to boast of. These vehicles are not only used for CDTI but for all health programmes within the province.
CDTI has rekindled the spirit of project planning and budgeting which had almost died out since the withdrawal of GTZ support to health activities in the province.
More and more people are becoming aware of the importance of treatment with MectLan@ as they notice improvement in poor vision, improvement if skin infections and elimination of intestinal worms and lice.
As weaknesses, this project has never been able to fully function within the limits of its planned period.
Some communities still do not see the importance of their full involvement in matters that should, according to them concern only health care professionals. This is probably one of the reasons why their involvement in CDTI activities is lower than expected.
CDTI activities are very involving and have a lot of paper work. This coupled with the poor staffing situation of the health flacilities makes execution oi CDTI itself and other health programmes tedious.
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