I
D E D u D 0 I
_) ORIGINAL: English
COUNTRY/NOTF : Nigeria Proi Name: Benae Stote CDTI Project Approval year: 1999 Launching year: 1999
Reportins Period (Month/Year): October, 2001 - September, 2002
Date Re-submitted z Jonuary 2004 NGDO partner: UNICEF
YBAR 3 PROJECT TECHNICAL REPORT TO I?"-, TECHNICAL CONSULTATIVE COMMITTEE (TCC) f,
-l,CC lf RS C5D CE{ t-o" Brrl i sib i ',!-- RECU ! r 2 6 FEV. 2004 brt APOC/DIR AO t ( AFRICAN PROGRAMME FOR ONCHOCERCTASTS CONTROL (APOci
WI-lOiAPOC. 26 September 2003 ANNUAL PROJECT TECHNICAL REPORT Y TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) ENDORSEMENT
Please confirm you have read this report by signing in the appropriate space.
OFFICERS to sign the report:
country NIGERIAILIBERIA
National Coordinator amu Dr. J. Y. Jiya Signature: .. fut"@ Date:
Zonal Oncho Coordinator Name: Dr. U. E. Udofo
Signature
Date
This report has been prepared by Name : Mrs. Betty Jqnde
Designation : Proiect Coordinstor
Signature E+*ee
Date
2 WHO/APOC, 26 September 2003 Table of contents
Acronyns ..4 Definitions...... 5 FOLLOW UP ON TCC RECOMMENDTITIONS...... t Executive Sum mary...... 3 t SECTION l. Backgt'ound information.,. I l.l. GeNeRalrNFoRMATroN...... 4 l.l.l. Description of the project (brieJly) ..4 I . l . 2. Partnership...... 5 1.2. POPULATION AND HEALTH SYSTEM ..6 SECTION 2: Intplementalion of CDT|...... 7 2.1. Penroo oF ACTIvrrrES ...... 7 2.2. ORoe RtNc, sroRAGE AND DELIvERy oF rvERMECTrN...... 9 2.3, ADVoCACY AND SENSITIZATIoN II 2.4. MosrlrzaloN AND HEALTH EDUCATToN oF AT RrsK coMMUNITIES...... l3 2.5. CovvUNITIESINVoLVEMENTINDECISIoN-MAKING 16 2.6. CRpaclryBUrLDrNG... l8 2.6.1. Training..... t8 2.6.2. Equipment and human resources... 2t CoNorrtoN oF THE EeutpMENT * PLeesg srATE 21 2.8. SupsRvrsroN...... 28 SECTION 3 Support to CDTI .... 29 3.I . FtNRNcral coNTRIBUTToNS oF THE pARTNERS AND coMMUNrrrEs...... 29 3.3. ExpsNorruRE pER AcTrvrry ...... 30 SECTION 4. Sustainabiliry of CDTl.... . Jt 4.1. INrenNal; TNDEIENDENT pARTrcrpAToRy MoNrroRrNG; EvRLuarroN...... 3l 4.2. CouvruNrry sELF-MoNrroRtNGAND STAKEHoLDERSMspTTNc 32 4.4. IxrncRalou 33 4.5 OpenarroNAl RESEARCH 34 SECTION 5: Strengths, weaknesses and challenges. .31
J WHO/APOC. 26 September 2003 Acronyms
APOC African Programme for Onchocerciasis Control ATO Annual Treatment Objective ATrO Annual Training Objective CBO Comm unity-Based Organ ization CDD Community-Directed Distributor CDTI Community-Directed Treatment with Ivermectin CSM Comrnun ity Self-Monitoring DHS District Health Staff HFS Health Facility Staff LGA Local Government Area LG Local Government LOCT Local Onchocerciasis Control Team M&E Monitoring and Evaluation MDP Mectizan Donation Program MOH Ministry of Health NID National Immunization Day NGDO Non-Governmental Development Organization NGO N on-Governmental Organ ization NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force PHC Primary health care REMO Rapid Epidemiological Mapping of Onchocerciasis SAE Severe adverse event SHM Stakeholders meeting SOCT State Onchocerciasis Control Team TCC Technical Consultative Committee (APOC scientific advisory group) TOT Trainer of trainers TV Television UNICEF United Nations Children's Fund UTG U ltimate Treatment Goal VDC Vil lage Development Committee VHC Village Health Committee wHo World Health Organization
4 WHO/APOC. 26 September 2003 Definitions
(i) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking).
(ii) Eligible population: calculated as 84%o of the total population in meso/hyper- endemic communities in the project area.
(iii) Annual Treatment Objective: (ATO): the estimated number of persons living in meso/hyper-endemic areas that a CDTI project intends to treat with ivermectin in a given year.
(iv) Ultimate Treatment Goal (UTG): calculated as the maximum number of people to be treated annually in meso/hyper endemic areas within the project area, ultimately to be reached when the project has reached full geographic coverage (normally the project should be expected to reach the UTG at the end of the 3,d year ofthe project).
(v) Therapeutic coverase: number of people treated in a given year over the total population (this should be expressed as a percentage).
(vi) Geographical coverage: number of communities treated in a given year over the total number of meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage).
5 WHO/APOC. 26 September 2003 FOLLOW UP ON TGG REGOMMENDATIONS
The table below shows a follow up of the recommendations to the project made at the last I TCC meeting.
TCC session 16
Number of TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR Recommendat TCC/APOC ion in llrc MGT USE Report ONLY 65 Inadequate comtnitment by State, The State and Local Government SOCT & LGAs authorities are being sensitized. An advocacy workshop for policy makers at State and LGA levels was held but attendance was poor. Information with the project indicates that a total of :N:405,000 ($3,I90) was given by the LGAs in 2002. At State level the government released only N73,000. Advocacy visits were paid by NOCP and UNICEF officials. To yield the required results advocacy visits is requested from the highest level. 67 iii Evidence of implementation of The project has done the following with the recommendations of the respect to recommendations: independent monitoring undertaken in August 2001 has been brought to the attention of the different stakeholders in the State.
more attention is given to LGAs that are not performing well.
million tablets) has been collected and distributed to the LGAs for treatrnents in the communities. More could have been procured from NOCP but the project was faced with tirne constraints and wanted to ensure that huge balances are not carried over to the next treatment cycle.
mobilized in all the treated LGAs, and most of them went back to mobilize their communities.
stakeholders meeting at the community level was initiated in 30 communities in 3 LGAs. These were carried out with UNICEF funds and in collaboration with NOCP.
been to address record
WHO/APOC. 26 Septernber 2003 keeping at the community level.
guides have been produced to enhance CDD training.
produced with the sum of :N:220,000 as part of efforts to address poor health education. They were then distributed to the various LGAs.
LOCTs was held to assess implementation of activities/ recommendations.
from NOCP for use during visits to the communities. 67 vii Provide the UTG Although the project has some tentative data on target population for all the areas it is treating, a good population update is yet to be done. A general population census update is being planned. Once this is done the project shall be able to provide the UTG. 67 viii Collate outstanding treatment All treatment data for the year has been data and complete and provide collected and collated. They are presented UTG in the report. The issue of UTG has already been highlighted. 67 ix Subrnit a Year 2 technical report A technical report using the old format had been submitted at the tirne it was demanded for, and forwarded to APOC Management. Efforts has been made to prepare and submit a revised Year 2 report using the new repofting format. A lot ofgaps are apparent as data was not collected for some indicators.
2 WI-tO/APOC. 26 September 2003 Executive Summary
I Benue State is located in the central part of Nigeria. The vegetation is forest to the south, with forest - savannah mosaic and mixed savannah grassland in the northern areas. Estimated population of the State is put at 3.9 million. The major ethnic groups are the Tiv and ldoma. Settlement pattern is largely dispersed. Movement of whole communities or large numbers of persons is common due to inter ethnic clashes or fear of reprisals from the army authorities. Roads between major cities are in good condition, but access roads to most of the endemic communities are in poor shape.
The State consists of 23 local government areas but CDTI is currently being implemented in 2049 communities in l8 LGAs. Target population is 1,374,276. All communities were reported to have been covered but total number of persons treated stands at 824,271 thus achieving a 60%o therapeutic coverage.
Eleven (l l) SOCTs and 180 LOCTs, were formally trained on CDTI. The same number of SOCTs and LOCTs in 3 LGAs were trained on CSM and SHM. Though 540 health facility stafl 540 others and 3,000 CDDs were planned to be trained, these could not be done due to lack of funds. However, 186 CDDs were trained by various LOCTs at their own initiative.
A total of 234 district chiefs participated in advocacy workshops organized by the project. An advocacy workshop was also held for policy makers at State and LGA levels. The outcome of these includes the release of bicycles by some LGAs forCDDs as a form of encouragement. Some community leaders who had disallowed their communities from taking Mectizan on account of side reactions were encouraged not only to allow its distribution but also to support the programme. This followed testimonies from satisfied users at the meeting. This facilitated compliance within the project area.
The project has succeeded to some degree in empowering communities to consider and determine their own health needs. There are committed staff at LGA and State levels. A reasonable level of awareness of the magnitude of the Onchocerciasis problem exists at various levels.
The major challenges facing the project include inadequate understanding of communities of their roles under CDTI, inadequate commitment of some health staff due to non - payment of salary arrears, frequent change of policy makers, obtaining an authentic and reliable estimate of the total population of endemic communities and ensuring proper record keeping at all levels and getting the State and LGAs to release counterpart funds.
Other challenges are:
work load on existing CDDs and help reduce demand for financial compensation by CDDs.
State and LGA levels
J WHO/APOC. 26 September 2003 SEGTION i: Background information 1.1. General information
l. l. l. Description of the project (briefly)
leographicol location, topography, climate Benue State is located.in the^cential part of Nigeria. The State lies between longitude 6030, and 8020'East and latitude z'So'und qb3;: N;";i:lrlr'UJrrO"d on the North by Nasarawa State, North west by Plateau State, Enugu State on the South, Kogi State on the southwest, and Cross River State on the east.
The vegetation is forest to the south, with forest - savannah mosaic and mixed savannah grassland in the northern areas. The terrain comprises undulating hills which occasionally reach 4'000 feet above sea level, to bare flat plains along the Benue River, with an altitude above sea level ofabout 300 feet. In the eastern part ofihe project area there are steep hills, cut by swift flowing streams whose banks are densely foresied. The rainy season begins in March and ends in october while the season dry lasti from November to February. The State has an annual rainfall of 1200 - 9g00mm.
Population: activities, cultures, language Estimated population of the State put is at 3.9 million. The major ethnic groups are the Tiv and ldoma. There are other smaller groups such as Etulo, offi;h and Jukln, *ho tiu. in Tiv areas; while the Igede and Agatu live in areas inhabited by the ldoma. The major languages spoken are Tiv, Idoma and Hausa. The major occupation of trr. population is farming, including growing of yams/cassava and cultivation of cotton and beniseed. Fishing along the riverine areas is widespread. Crafts such as blacksmithing, *earing of cloth etc are practised. Some also keep domestic animals. Settlement pattern is lirgely dispersed. Movement of whole communities or large numbers of persons is common-due to inter ethnic clashes or fear of reprisals from the army authorities. Maybe apart from the Niger Delta area genue State is one of the states of the federation with heavy military and polici presence.
Communication system (road...) Roads between major cities are in good condition, but access roads to most of the endemic communities are in poor shape. Some are n^ot passable during the rainy season. Despite this transpot't by road remains a major means of communication Lrong thl communities. The electronic and print media are also veritable channels of communication. Within the communities the town criers and announcements in churches/mosques are preferred means of communication.
Ad m i n istrot io n st r uct ure The State consists of 23 local government areas with the chief administrative officer being the Chairman' A legislative arm made up elected councillors from various wards supports him. At the State level the Executive Governor is the head of administration. There ur. judicial thl legislative and arms. The capital of the State is located in Makurdi.
Health system & health care delivery There is an official PHC policy and structure in the project area. It is a system of health care services where community participation forms the mairlstay with ,rpport from the State, Local Government and NGOs. Levels of functionality howeve r vary across the State. scattered throughout the State are various health faciiities ranging irom health posts to hospitals. There are 1,296 health facilities in the State, butt,i2l in the Ig LGAs covered.
4 WHO/APOC. 26 September 2003 1.1.2. Partnership - Indicate the partners involved in project implementation at sll levels (MoH, NG D O s -natio na l, inter nat io nal) - Describe overall working relationship among partners, clearly indicating specific oreos of project activities (planning, supervision, advocacy, plonning, mobilization, etc) where all partners are involved. -State plans d any to mobilize the state/region/district/LGA decision-makers, NGDOs, NGOs, CBOs, to assist in CDTI implementotion.
The partners involved in project implementation in Benue State are UNICEFA{igeria, NOCP (National &Zonal offices), the State Government, the various localgovernments and the endemic communities. In Kwande Local Government area St. Monica's hospital is assisting in the distribution of ivermectin to some of the communities.
UNICEF is mainly involved in planning, occasional advocacy and training. It makes funds available through the zonal offices to the project to carry out several activities. The NOCP zonal office is empowered to act for UNICEF in terms of supervision and technical support. The NOCP national office has also been involved in supervision/monitoring, advocacy and provision of technical support to the project. The State, Local Governments and the endemic communities carry out their various responsibilities under CDTL
Partners are working together in relative harmony although there are problems with release of approved funds due to delay in approval of applications by UNICEF. Several proposals have been submitted to the UNICEF zonal office and only a few were approved.
There was no conscious effort made by the project within the reporting period to get additionalNGOs and CBOs to support the implementation of CDTI.
5 WHO/APOC, 26 September 2003 €.a N F oL o- E o^ () c- .: o t! a I c.l oo 00 o\ t'- a-t co \o \o :iv + @ .+ f-- o\ =f a.l oo r\ N oo + t-- a5 N $ o\ t-- $ $ ro. q t-. @ c- .! qQ a.l -eo r- 00 $ tr- .+ \o oo ca \o @ t $ $ \o s s r- i! U c-.1 ? .e, S^o o :! oo a .:E SE o c F o :d YL B
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2.1. Period of activities
Insert Plan of action indicating activities by month, which were implemented
7 WHO/APOC, 26 September 2003 a.l
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=o L E 63 F (n -] () I c.ir (o 0) -o o0 $ar -o .V o n! orl d ! a- cd s(d -v () a cd d o .v E o q o r o o0 .o o- -V ! -o (n o o -o o0 .v -V a lJo co v v J \J o c IJ (-., - F D f, 2.2. Ordering, storage and delivery of ivermectin
Mectizan@ ordered/applied for by - (please tick the appropriate answer) ./rvrosrnocfl wHotr uNrcEFtr NGDotr Other (please specify)
Mectizan@ delivered - Qtlease tick the appropriate answer) r/tvto wHotr UNICEFtr NGDOtr Other (please specifu):
Please describe how Mectizan@ is ordered and how it gets to the communities
The quantity of Mectizan@ required by the project is calculated based on treatments and total population from the last cycle. NOCP processes the data after receiving information from other UNICEF - assisted States and submits re - application to the MDP. On approval the drugs are shipped to the country and UNICEF facilitates clearance and storage. The State or the Zonal office picks up its consignment from NOCP and releases to the LGAs through the LOCTs. LOCTs release drugs to the district health supervisors or the health facility staff who in turn make them available to the communities.
FLOW CHART OF MECTIZAN DELIVERY
MDP UNICEF/ Nigeria Reporting flow
NOCP
I Zonal Oflice
Delivery process
STATE
LGA
District Health Facilities
Communnities
9 WHO/APOC. 26 September 2003 Table 3: Mectizan@ Inventory
State/District/ Number of Mectizant tablets LGA Requested Received Used Lost Waste Expired Ado r 33.000 133,000 132.233 702
Buruku 54.000 54.000 53. I 35 204
Gboko 209.249 718 2 r0.000 2 r 0.000 Gwer West 104,603 387 r05,000 r05.000 Guma 95.17 5 414 96,000 96,000 Katsina-Ala 84.236 132 85,000 8s,000 Konshisha 60.s34 90 60,000 60.000 Kwande r6r.978 s02 r 62.000 162.000 Logo 48.865 r35 50,000 50,000 obi 114,546 154 1 15.000 I15,000
139,93 r 69 Ogbadibo r 40.000 r 40.000 66.410 90 Ohimini 67.000 67,000 r0s.000 oiu r 05-000 105.000 104.906 r50 Okpokwu 105.000 r0s.000 104.840 r60 Otukpo r 05,000 105,000 69,514 85r Tarka 70.000 70,000
59,35 r 8 79.369 Ukum 60.000 60.000 139.512 488 Ushongo 140.000 140.000 1 7 6.7 44 256 167.000 REF. CENTRE 80,000 80,000 .TOTAL I I,942,000 1,942,000 7,930,762 5,510 246,369
Stule activities under lvermectin delivery tltat are being carried out by health care personnel in the project oreo.
The health personnel at the various levels have been responsible for the following:
l0 WHO/APOC, 26 September 2003 2.3. Advocacy and Sensitization
Stute tlte number of policy/decision mskers mobilized at each relevant level during the current year; the reasons for the sensitization and outcome. Describe dfficulties/construints being faced and suggeslions on how to improve advocacy.
At the State level an advocacy workshop for State and LGA policy makers was organized but attendance was not encouraging. The aim of the workshop was to create more awareness of the project and solicit better financial support. Part of the reason for the poor attendance was the various political meetings holding in preparation for the 2003 general elections. At the LGA level advocacy meetings were held with LGA Chairmen and selected district/clan heads on CDTI implementation. See table below on participants that attended the meetings. The objectives of the meetings held at the various LGAs were:
emphasis on the role of the communities
project and request for their assistance in proffering and implementing solutions.
Outcome
has been evidenced in the release of funds for various activities by some LGAs
Mectizan on account of side reactions were encouraged not only to allow its distribution but also to support the programme. This followed testimonies from satisfied users at the meeting. This facilitated compliance within the project atea.
community members to suppoft the implementation and the distributors.
allayed.
NIDs. This has been implemented in some communities in the LGA.
dropped or to support the existing ones. However, though new CDDs were selected in several communities the issue of compensation led to some of them dropping out.
Constraints/Diffi culties
preparation for the general elections
the meetings which could have been used to create greater awareness
ll WHO/APOC. 26 September 2003 )> Inability to follow up adequately on promises made by the district chiefs and LGA policy makers to financially support the GDTI process due to inadequate funds at project level.
Suggestions
meeting particularly in the area of press coverage.
LGA level.
LGAs and feedback given as a way of engendering competition.
Table 3B
LGA Chairman/Other District/Clan LOCTs/Health Total District/LGA Policy Makcrs Heads Workers Others Ado I l,l { l9
Buruku I t4 2 2 r9
Gboko l5 2 2 t9
Gwer West I t5 4 4 24
Guma l2 2 l4
Katsina-Ala l4 2 4 20
Konshisha t4 2 t6
Kwande I l5 3 J 22
Logo I lt J l6
obi l5 2 t7
t5 2 t7 Ogbadibo 2 t5 2 l9 Ohirnini l3 4 2 l9 oju
Okpokwu t2 J l5 Otukpo ll 2 l3 Tarka I t5 J J 22 Ukum
t4 J I l8 Ushongo
l
ltt 8 234 45 309 Total
12 WHO/APOC, 26 September 2003 2.4. Mobilization and health education of at risk communities Provide information on : - The use of media andlor other local systems to disseminate information - Mobilization and health education of women and minorities - method and response - Response of target communities/villages - Accomplishments - Weaknesses/Constraints - Suggest ways to improve mobilization of the target communities.
Tlte use of media and,/or other local systems to disseminate information
During the reporting period the project made use of the following media for the mobilization of the people: (l) The electronic media - radio and television. This was done principally during the National Oncho Day celebrations, and few other times important visitors who paid advocacy visits to the State were interviewed. (2) Community heads, including district chiefs and opinion leaders. (3) Town criers - this is the principal means of information dissemination at the cornmunity level. (4) Health education meetings with community members by health personnel from the LGAs or CDDs. (5) Church announcements - This medium had been used in some areas to mobilize the people especially during the Onchocerciasis day celebrations.
Mobilization and heolth education of women and minorities - method and response
In the State where the people were mobilized, there is an active participation of female members of the community at meetings. Women are always in attendance at health education meetings, and sometimes are in greater numbers. In several places the women are assertive and can demand that their views be listen to, respected, and decisions reached based on what they have suggested. Generally in decision - making women make inputs before decisions are reached. In some communities women are part of those who make the actual decisions as they hold traditional titles. In some communities women are selected or have volunteered their services as CDDs. There are no problems with ethnic minorities living in the community.
Response of target communities/villages
Communities have responded by coming forth to collect their Mectizan tablets. Members have expressed willingness to comply with Mectizan treatment though there are reservations in some areas on account of reactions experienced by some in past treatment cycles 3 - 4 years back. The communities have selected their CDDs and in many places determined the rnode of distribution agreeable to them. But a lot of community members are unaware of their roles under CDTI.
Accomplishments
From the few health education and mobilization activities that have been carried out. the following have been achieved:
over a long period of time is being sustained.
l3 WHO/APOC. 26 September 2003 support is yet to realistically determined. Health workers at the LGA level are reluctant to disclose the exact amount the LG authorities have been giving out to assist in the implementation of CDTI
W e a k n e s s e s/C o ns t r a i nts
There are several constraints facing the project with respect to mobilization of the endemic communities. These include:
reduced level of activities considerably.
programme. By the time a parlicular set of policy makers are enlightened on the burden of the disease there is a change and new persons are sworn in. The entire process of creating awareness and soliciting for support begins all over.
demoralized. In some LGAs health workers are being owed up to 5 months.
Suggest ways to improve mobilization of the target communities,
l. Local NGOs and CBOs need to be sensitized to support CDTI implementation in the State. The project also needs to reach out to religious groups and various community based associations who can effectively take the message to the grassroots. 2. Release of funds by all partners. There is particular need to enlighten the UNICEF Zonal office on its role in the management of APOC funds. With funds SOCTs and LOCTs can be empowered to mobilize difficult cornmunities especially where there are fears of side reactions following drug intake. 3. There will be need to produce jingles and utilize the electronic media more to reach the endemic communities. Radio is an effective means of reaching millions of people in the State. TV sets are common in several communities.
t4 WHO/APOC. 26 September 2003 ca
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2.6.1. Training
During the reporting period eleven (ll) SOCTs and 180 LOCTs were trained/retrained generally on CDTI implemntation. The LOCTs in Kwande, Okpokwu and Oju LGAs were trained with SOCTs on CSM and SHM. The project intended to train/retrain 540 health facility staff,, 540 others and 3,000 CDDs on CDTI but this was not possible due to paucity of funds. The project is however aware that some LGA Oncho coordinators trained some new health facility staff. For example in Buruku LGA t health facility staff were trained. The number of LGAs where this happened is small, and therefore not reported in the table. The project recieved repofts that some LOCTs on their own trained/retrained some CDDs. Officially it was not reported as the number was small, but the project has deemed it fit to make the records available to show some initiative on the part of the Locrs.
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o o J U) o0 -(, ; o o tr q) o 0) D F ; Table 6: Type of training undertaken (fick the boxes where specific training was carried out during the reporting period)
Trainees Health Other Workers Comnrunity (LOCTs. Type members e.g frontl ine MOH staff of training Community health or Other Political CDDs supervisors facilities ) (socr) Leaders Others(specify) Program { management How to conduct .v Health education Management of SAEs CSM { { SHM { ^/ Data collection { { Data analysis
Report writing Others (specify)
Any other comments
2.6.2. Equipment and human resources Table 7: Status of equipment (Please add more rows if necessary)
Source APOC MOH DISTRICT/LGA NGDO Others Type of Condition of the equipment * Please state equipment l. Vehicle ( I ) Functional 2. Motor cycle (l 7) Functional (27) Written off 3. Computers (l) Functional 4. Printers (l) Functional 5. Fax Machines (l) Not available 6. Others a) Photocopier (l) Functional b) Air conditioner (2) To be replaced c) *Condition of the equipment (Functional, Currently non-functional but repairable, Written off).
How does the project intend to maintain ond replace existing equipment ond other materials?
In the interim the project will repair and maintain all capital equipments with the funds provided by APOC, while awaiting the government to release counterpart funds. In the long run it is expected that government will maintain existing equiprnent with some assistance
WHO/APOC. 26 September 2003
2o from IINICEF and few local NGOs. The project intends to request APOC to provide a replacement of most of the equipment supplied.
- Describe the adequacy of available knowledgeable manpower ot all levels.
Adequate manpower to be tapped for CDTI implementation is available, but there is need for training and retraining of health staff and CDDs. Specifically health workers need training in such areas as data management, community self - monitoring & stakeholders Meeting.
- l{lterefrequent tronsfers of trained staff occur, state what project is doing or intencls to do to remedy the situation (The most important issue is what meosures were token to ensure adequate CDTI implementation where not enough knowledgeoble manpower wos ovailable or staff often transferred during the course of the campaign).
There is some stability of staff at State level and at LGA level. Sometimes transfers occur only within the LGAs i.e. from district to district. Where transfers occur and some one new to the programme takes over, he/she is trained either by the SOCTs during the training of LOCTs or by the LGA Oncho Coordinator.
)v WHO/APOC. 26 September 2003 21 I I I I s!Eei ts it E E- >u= d = 2"d=8, a-l ()
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o* ca a.l @ @ ca .+ c.l t-- co 'Eo .+ .+ $ \o $ 500 \o 00 \o ol F- \o oo oo t-- t-- o\ O d^ :: O!:\o d 9o'^ * ooL>v"-- EO F
F- o\ c-l \o co 00 t-- \o o\ + @ .+ o 6_ N oo e.t o\ ca F- \o ca \o F. bEU s a.l .o^ \o c\ 6l o\ o\ o\ o\ q N -o;iE di N 00 oi \o 00 + N c.l .o ! c.l 00 $ $ o1 o\ v C-l .+ sl' c.l el Eb9 6 z= o! :4 O O q o E =oU.U d N oo \ o N @ an ..l .V(, o N l- i c\ \o a o\ 6\ 6\ o\ 5\ o\ o\ o\ (s ^\ ^\ ^\ o\ o\ o\ s o .9c (!L =d^ 602-!v Oo\ uo + + C.l F- \o a- F- c.l t \o o\ oo \o o, U) (s $ v N t't F- t'. a.l $ o\ o o d: co \o o, F- oo \o r\ a.l F- \o F- -, =c oo >c d s v o i: 9 () () - ===+ N =c)=6cc E Foa c t CE () Lo 3fr F (n F ad z 0) o r- t o -o o ti J o\ o ,b .2 ! o o0 U N I .v L d ,6 tr E(! -v,o o. C) (d E }Z o F o L b0 -o o .V k: ! -o (c o o ,o oo x (! .:z q ri q \J (7 v v v -] \J o o e o o F D ) & F Formula for computing therapeutic and geographical coverages Therapeutic coverage rate umber of e (%) Total population living in meso/hyper-endemic communities within the project area Geographical coverage rate Number of communities/villages treated x 100 (%) Total number of meso/hyper-endemic communities as identified by REMO in the project area ATO coverage rate Number of people treated x 100 (%) Annual Treatment Obj ective % UTG achieved Number of people treated x 100 Total number of people to be treated in meso/hyper-endemic areas within the project area (UTG) ATO = The eslinnled number of persons living in nteso/hyper-endemic oreas that a CDTI projecl intends lo treat with ivermectitt in t given year. UTG = The maximum number of people lo be lrealed in nteso/hyper-endentic areas within the projecl orea, ullimalely to be reaclted when lhe proj.ecl has reachedfull geogrophical coveroge (nornnlly lhe projecl should be expecte(l to reach the IITG at the end of the 3"t year of the project). - If the project is not achieving 100% geographical coverage and minimun, of 65% therapeutical coverage rate or coverage rate is fluctuoting, stote reosons and plans being made to remedy tltis. The project appears to be achieving 100% geographical coverage but due to funds constraints the SOCTs could not validate the figures. We are aware of problems of poor record keeping at all levels, and efforts are being made to ameliorate them. For example the project has produced and distributed 2,000 community registers so that CDDs could ensure proper recording of treatments but there are also problems of CDD incentive. The inadequacy of CDD incentive, the irregular payment of staff salaries and the unavailability/inadequacy of counterpart funds to supervise have demoralized project personnel, and one area where this is evident is poor record keeping. Therapeutic coverage is not optimalas there are still a lot of absentees, some refusals who decline treatmentdueto fearof reactions (but reported as absentees) and in a few places unavailability of Mectizan in sufficient quantities which was not reporled or brought to the notice of SOCTs. The project is also aware that some communities have not been properly mobilized to take decisions on CDTI. This has reflected in lack of decisions on mode and period of treatment. 2.7.2. Thefundamentol couse of absenteeism There are several causes of absenteeism within the project area. These include: not return early for treatment. community members are not available, coupled with lack of follow up. 23 )k WHO/APOC. 26 September 2003 Briefly describe all known and verilied serious adverse events (SAEs) and provide in table 9 the required information when available. At the early stages of the distribution there were reported cases of SAEs, and this is partly the reason why some community members are reluctant to comply with Mectizan treatment. However, in the past few years there were no reported cases of SAEs. 2.7,3. In case the project hos no case ofserious odverse event (SAE) during this reporting period, please tick in the box. No case to report z+ 2{ WHO/APOC, 26 September 2003 otr- sr!E0e o;o dtr= at 2a o ;soB 600 (, o 6 tu =r I r!t^r 5'5 o r\ o.9 Cq q4 9&) q,) U o- q l o- \ b9 ai^ t* U o.= O ()-c tr ^:! \) ai;o- 4 o.9 -q .3 AJ OJ E C= !LL.-d400 a-! .9 L qo VAEP bo \l )a.d oL ^ o- C) L 0) E s.r oo.l \ E :.6.E- q bo 0)s6*g .I La-OJZ. -o t0 Eo L L N o o E o o. (o F ax lr1 tl.] -EP (J!+ o a (dF= q) !o66 o I N==o C) () Y9a a dJy (! o a>, (! q) U') o b0eCJ ()L a) a = o{) (F ='tr?o o 6 0) r. (J q) oI u a a () q) o oo O\l 6rl o \ * _q) -olcdl q FI z a o bo a.t L F oX o. Q (-) o o\ o\ o\ ^\ o\ o\ € ol r-. N (-r!sa^bo F- + oo @ co o- F 6X d )v o o o -o !o o\ o\ o\ o\ o\ o\ fb0 c'l + * oo O d^ + 6o.t€ 90' s0oo F $ s r.. oo s \o r- ,o .?. oo + al Oo F-. @ \o .f a.l a.l o, N o.!: c.l N \o @ (B o o o s ca d =uo.a c.l a.l G s 00 LA oo \o A.16 o\ c{ r- --o C.l a.l +d d.= .. > .+ o a.l t l'- 'EEi€.: r- t-- F- a.t a? G a 3e t) () o () o L \ bo o t- \o o\ o\ o c! ^oo q) (JF- Z Z z 0a r 06\ o -o \0 0 q) C\ 0) o o\ o\ O- =o-6-o- o^bo i^ z z z a.l (.) bD)\ Oo: 0a € o->-^* o\ -o6i L oo () (.) L (E LI o co o (Bl 00 a.l + c.l r-- s o z z Z Fl l- =::Yo a.l (Jt €=-:Eb (dl ='.9 ol p .9 >o6 C! rl .= -ol o\ o\ o\ (o C) E + t 00 E =ob.z z Z z F- (! o E 6i c.l L \) O o { e d.: o < 9f' C) o Fv a5 oo o, o. (.) G o\ all $ $ =a a- t-. t.. tr- El o Q I oi c! 6J *.9 o E = >;; (g 5c-oF o ()d ; i u q€ o L -o F EO o ir o d. ,l r\ @ o\ a{ s \o F- oo o\ ^t o\ o\ o\ (Bt q o\ o\ c- FI N a{ c-.t a-.1 c.l N N c..l c.l c.l c-.t ) 2.8. Supervision 2.8.1. Provide aflow chart of supervision hierarchy LOCT I DHS/HFS I CDDS 2.8.2. The issues identified during supervision included: The SOCTs went on supervisory visits twice within the year due to inadequate funding from all partners. LOCTs went on supervision depending on level of suppor-t from the local government authorities. The following were identified and reported: of salaries for several months. greener pastures. health education of endemic communities. absentees by CDDs communities/ CDDs. This placed a heavy workload on the few LOCTs willing to work. their j obs. 2.8.3. Llas supervision checklist used? Supervisory checklists were not used. 2.8.4. l|/hat were the outcomes at each level of CDTI implementstion supervised? correcting the anomalies. Follow up was however problematic due to unavailability of funds. Moreover, an advocacy workshop was held for policy makers at State and LGA Ievel, but attendance was poor. ax- WHO/APOC, l0 April 2003 27 heads (2nd class chiefs). They went back to mobilize their communities, and some areas where there had been refusals for fear of reactions have started complying to Mectizan treatment. also had audience with several community leaders to solicit for support. They could not follow up on these due to inadequate funding and lack of utilization of health facility staff. payment of salaries arrears is however a big constraint, moreso when LG authorities do not release funds to this level for any pHC activity. organizations to assist in the mobilization and health education of their communities. The project has also encouraged communities to select more cDDs. 2.8.5. LYas feed-bock given to the supervised, and how was the feedback used in improving the overall performance of the project Feedback was given during visits to the communities and during advocacy visits to community leaders. Some of the issues were also raised during the advocacy meetings with district heads and policy makers. The feedback led to some of the outcome describeJ above, particularly at the community level. SEGTION 3: Support to GDTI 3.{. Financial contributions of the partners and communities ble I : Financial contributions all for the last three Year I (1999/2000') Year2 (2000/2001) \/ear 3 (2001/2002) TOTAL TOTAL TOTAL TOTAL TOTAL TOTAL Budgeted Released Budgeted Released Contributor Budgeted Released (us$) (us$) (us$) (us$) (US$) (us$) Ministry of Health (MOH) t2.832 14,785 2.8 r8.9 13,065 574.8 LocalNGDO(s) ( if any) 45.01 NGDO partner(s) 5 40.300 63.63 5 42.t43 District/LGA 66.586 I 74.852 3.1 88.98 Others a) b) c) Communities I APOC Trust Fund 98.360 | 75.r47.U r06.965 ISZ.Z:S-S6 90.390 s7.738.86 l TOTAL r 98,350 75,247.88 228,636 78,066.78 241,942 61,502.64 NB: For APOC and TINICEF amount stated as budgeted above does not include what were budgeted for capital items just as amount released does not include expenditure on capital items. For MoH/LGA, amount stated as budgeted does not include personnel costs 29- WHO/APOC. 26 September 2003 2g If there are problems witlt releose of counterpart funds, how were they addressed? There are problems with release of counterpart funds at both State and LGA levels due to several reasons. These include: Some advocacy visits have been paid to LGAs, but the political instability and short tenure of political office holders is a big constraint. At the State level several advocacy visits were paid by both the NOCP and UNICEF officials as well as evaluators/independent monitors during which they solicited for financial support at all levels. An advocacy workshop was held for policy makers at State and LGA levels. There may be need for a high - powered advocacy visit to the executive governor of the State. 3.2. Other forms of community support Some communities support their CDDs by helping them on their farms especially during the planting season. Others support in some ways such as 3.3. Expenditure per activity - Indicate the expenditure on activities below in US dollars using the current United Nations exchange rate to local curuency ($ - :N:127.00) Table l2: Indicate how much the project spent for each activity listed below during the reporting period Expenditure Source(s) of Activify (s us) funding Drug deli very from NOTF HQ area to central collection point of 574.8 community MoH Mobilization and health education of communities* Training of CDDs 6,062.99 Training of health staff at all levels Supervising CDDs and distribution 4,000.38 APOC Internal monitoring of CDTI activities Advocacy visits to health and political authorities 2,122.05 UNICEF IEC materials 4,330.71 APOC Summary (reporring) forms for treatment Vehicles/ Motorcycles/ bicycles maintenance 311.02 APOC Office Equipment (e.g cornputers, printers etc) + office supplies 3.397.64 APOC Others 9,162.6** APOC TOTAL 29,962.2 APOC Total number of persons treated 824,271 Commenls *Amounts spent by the LGAs were not available. **A total of $8.513.34 was expended on managerial allowances. x WHO/APOC. 26 September 2003 2g SEGTION 4: Sustainability of GDTI 4.1. lnternall independent participatory monitoringl Evaluation 4.1.1 lYas Monitoring/evaluation corried out during the reporting period? (tick where applicable) _Year I Participatory Independent monitoring Mid Term Sustainability Evaluation 5 year Sustainability Evaluation -V Intemal Monitoring by NOTF Other Evaluation by other partners 4.1.2 llhat were the recommendations? l. 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 PHC system should be intensified. 2. Adequate time should be devoted to the project for proper dialogue with community leaders on the benefits of the ivermectin treatment, theirroles 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. 3. More personnel from other components of the PHC, media and educational institutions with skills in health education, mobilization, and gender issues should be co-opted in CDTI implementation activities at all levels. Steps should be taken to increase publicity of the CDTI programme as in other disease control programmes. 4. A deliberate attempt must be made to improve the quality of record keeping at all levels of the CDTI implementation in the State. 5' The UNICEF Program Officer should be made to see the need for prompt release of APOC funds for the CDTI activities in the State. 6. The SOCTs need reorientation and should change their attitude to the programme. 7. The State authourities should be made to show more responsibility forthe success of the programme in their domain. 8. There is need for a high - powered advocacy to the State authorities for more deliberate commitment to the implementation of CDTI according to APOC philosophy in the State. The Committee will also try to resolve the bureaucratic issue that may stall the conscientious implementation of CDTI in the State. 9. Areas of differences and breaks in communication among the necessary actors should be resolved quickly to make for a common purpose for efficient implementation of CDTI in the State 10. APOC funds meant for CDTI activities should be released once project activities are developed in line with APOC approved programme activities. 4.1.3. How have they been implemented? The project has tried to implement the recommendations by doing the following .2t- WHO/APOC, 26 September 2003 30 o With resources made available some health personnel from SOCTs to LOCTs have been trained/ retrained on APOC philosophy and their rotes in CDTI implementation. See section on training. Health facility staff willbe trained/retrained once funds are made available. tr There have been several advocacy meetings with and visits to quite a number of community heads. These activities have been reported in the earlier sections of the repoft. A lot of follow up is however necessary, but this is consequent to the availability of funds. tr A multi - sectoral, multi - disciplinary committee on health education and mobilization has been set up atthe State level and there were ideas of setting similar ones at LGA level, but funds is a constraint in making these functional. o There are plans to devote time on record keeping during training sessions. In the meantime 2,000 registers have been produced to step up quality of record keeping at the community level. o The project is aware of several persons who have gone to see the UNICEF Zonal officer to advocate for prompt release of funds. The project is awaiting a change. o Some NOCP officers and independent scientists have had sessions with SOCTs and had emphasized on the need for a shift in paradigm. It is hoped that these will bear the needed result. tr Advocacy visits have been paid to policy makers. In one instance the national coordinator was able to meet with the executive governor of the State. An advocacy workshop was also organized by the State. The project is however yet to see a definite taking on of more responsibilities by the State government. o Efforts are being made by the Permanent Secretary in the Ministry of health to resolve any bureaucratic issue and areas of differences among the necessary officers that may hinder CDTI implementation. 4-2- Gommunity self-monitoring and stakeholders Meeting Table l3: Community self-monitoring and Stakeholders Meeting (Please add ntore rows if necessary) District/ LGA Total # of communities/villages No of Communities that No of Communities that in the entire project area carried out self conducted stakeholders monitoring (CSM) meeting (SHM) Kwande 33s t0 t0 Okpokwu 73 l0 l0 oju 124 l0 l0 TOTAL 532 30 30 Describe how the results of the community self- monitoring and stakeholders meetings have affected project implementation or how they would be utitized during the next treatment cycle. These were initiated by NOCP with funds from UNICEF. Some of the decisions at the stakeholders meetings include provision of IEC materials for health education and creation of awareness, formation of sub - committees in the Village Development Committee (VDC) or Village Health Committee (VHC) to oversee CDTI at community level and sanctions to be meted out to community members who refuse or abstain from Mectizan treatment. More IEC materials have been produced by the project and distributed, although there is need to produce y WI-lO/APOC. 26 September 2003 34 more. The project has however been unable to follow up on other decisions and the outcome of the community self-monitoring initiated due to inadequate funding. The project is however aware that some VDCs/VHCs are becoming alive to CDTI activities in their communities. 4.3. Sustainability of projects: Plan and set targets (mandatory at yr 3) The project has just started considering issues on sustainability and produced a 4th year plan of action to deal with problems identified and the consolidate strengths. The plan of action is attached as appendix l. 4.3.1. Planning at all levels 4.3.2. Funds 4.3.3. Transport (replacement and maintenance) 4.3.4. Other resources 4.3.5. Please provide a written plan with set targets and achievements for so far. 4.3.6. To what extent has the plan been implemented 4.4. lntegration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration 4.4.1. Ivermectindeliverymechanisms The Mectizan delivery process occurs within the existing PHC structure. Communities pick their Mectizan requirements from the health facilities, except in few cases where the drug is taken to them. During NIDs, for instance, the LGA/PHC staff who come to pick up their vaccines also use the opportunity to collect Mectizan. 4.4.2. Training Some other LGA/PHC Personnel, apart from LOCTs, have been trained on CDTI so that they can assist in training of lower level personnel and supervise CDTI activities.. 4.4.3. Joint supervision and monitoring with other progroms At the State level, there are no plans for joint supervision and monitoring at present. At the LGA level we are aware that some of the LOCTs are involved in other programmes and occasionally use the opportunity of visits to the community/health facility for one programme to look into other programmes which they are handling. At the health facility level, where health personnel are involved in CDTI the situation is even more fluid. Visits to the community are used for several purposes. There are however no integrated supervisory checklists. and none is being planned at the moment. .'') WHO/APOC. 26 September 2003 32 4.4.4. Release offunds In some LGAs imprest is released for PHC activities and is controlled by the pHC director. From there minimal amounts are made available to the Onchocerciasis Coordinator for some routine visits or collection of Mectizan. This practice is not widespread as most LGAs do not have funds for recurrent expenditure. At both State and LGA levels proposals for the release of funds however must pass through the PHC director and other normal channels. 4.4.5. Is CDTI included in the PHC budget? At the State level there is a line item for CDTI in the PHC budget. At the LGA level CDTI activities are subsumed under a general PHC budget. Inclusion of the budget or the existence of a line item does not however guarantee funds release. 4-4.6. Describe other health progrommes that are using the CDTI structure and how tltis was achieved. ll/hat have been the ochievements? None at the moment 4.4.7. Describe others issues considered in the integration of cDTI. 4.5 Operational research 4.5.1 Summarize in not more than one half of a page the operational researclt undertaken in the project area within the reporting period. None was carried out during the reporting period. 4.5.2. How were the results applied in the project? SEGTION 5: strengths, weaknesses and chailenges Strengths Empowerment of communities to consider and determine their own health needs. Committed staff at LGA and State levels Availabil ity of mectizan. Good level of awareness of the magnitude of the Onchocerciasis problem by the community Weaknesses partners Inadequate commitment of some health staff due to non - payment of salary areas Frequent change of policy makers Non involvement of CBOs and other local NGOs Lack of support for CDDs in many communities Poor funding of the programme by government Poor record keeping at all levels Poor utilization of APOC funds due to bureaucratic problems at UNICEF zonal office -Y WHO/APOC, 26 September 2003 33 Challenges communities and ensuring proper record keeping at all levels. work load on existing CDDs and help reduce demand for financial compensation by CDDs. State and LGA levels .+5- WHO/APOC, 26 September 2003 34