REPUBLIQUE DU CAMEROLTN REPUBLIC OF CAMEROON Paix -Travail -Patrie Peace - Work -Fatherland MINISTRY OF PUBLIC HEALTH REGIONAL DELEGATION FOR THE SOUTH WEST Pdoh [email protected]

COUNTRYAIOTF: CAMEROON Proiect Name: SOUTH WEST 1 CDTI PROJECT Approvalyear: 1998 Launchins vearz 1999

Reporting Period: From: January 2010 To: December 2010

APOCfundinevear: (circleone) I 2 3 4 5 6 7 8 9 10 11 (12) 13 APOC Proiect implementation vear report: (circle one) 12345678910 11 (12)13 Date submitted: AUG Partners: 20tt - Ministry of Health - African Programme for Onchocerciasis Control (APOC) - Mectizan Donation Program (MDP) - Sightsavers (NGDO) - 478 communities (meso and hyper endemic) SOUTH WEST 1 CDTI PROJECT

2O1O ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE (TCC)

DEADLINE FOR SUBMISSION:

To APOC Management by 31 January for March TCC meeting

To APOC Management by 31 Julv for September TCC meeting

AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC)

\

( Sightsovers /

CDTI SWI I APOC Technical Report 2010 I

ANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC)

ENDORSEMENT

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

OFFICERS to sign the report:

Country: CAMROON !.-

National Coordinator Name: Dr ter

Signa

Date: fi, $ tl BLl6 qa? Regional Delegate Public Health N .oi. cn r1 w' z5 U) 1 Signature: ..... ) e tt >al Date t7l ;c''lL 7EP NGDO Representative Name: Dr. Oye Joseph -,-.-1 ,,1, Signature:

\.*,-.,,Lf,r;rl.iir.r Date !, >( t:V(2- ... s jft

This report has been prepared by Name: Ms Mah Cccilia

Designation' e. f]C ,,C illJ s ui-[

I tll : ,ll ! Signature ,..,..... i -...\, I

I Date i!t t..t .1 .Z.i:.t t I

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11 CDTI SWI APOC Technical Reporl 2010 Table of contents

v

DEFINITIONS ...... VI FOLLOW UP ON TCC RECOMMENDATIONS I

EXECUTIVE SUMMARY...... )

SECTION l: BACKGROUND INFORMATION ...... 3 l.l . GpNEnel TNFoRMATtoN ...... 3

l.l.1 Description o/'the project lbrie/lil ...... _r 1.1.2. Partnership ...... 5 MINISTRY OF PUBLIC HEALTH...... 6 1.2 PopuuartoN ,.,,,,.7

SECTION 2: IMPLEMENTATION OF CDTI.. 9 2.1. TrivtelrNe oF ACTrvrrrES ,...... 9 2.2. AovocRcv, MoBILIZATIoN, sENSrrrzATIoN AND HEALTH EDUCATIoN oF coMMUNlrrES AT RrSK...... 12 2.3 CovnauNrry TNVoLVEMENT ...... ,..... 13 2.5. CRpRcrry BUILDING ...... 14 2.6. TnERrveNTS...... 16 2.6.1. Treatmenl ./igurc,s ...... t 6 2.6.2 Cuus'es of'ah.senteeism...... 19 2.6.3 Reasons /br re.firsals...... lg 2.6.1 Brie.fly de,scribe all known und verified serious atlverse events (SAE,s) that...... l9 2.6.5. Trend of trealment ac'hievement ./iont CDTI project inception to the c,urrent year ..20 2.7. ORoeRrNc. sroRAcE AND DELTvERv oF TvERMECTTN ...... 21 2.8. ColavuNrry sELF-MoNrroRrNC AND STAKEHoLDERS MeerrNc ...... 21 2.9. SupERvrsroN...... 24 2.9.1. Provide a.flou,chart of supervision hierarchy...... 21 2.9.2. The main issues identified during supervision ...... 25 2.9.3. Use of supervision checklist...... 25 2.9.1. The oulcomes at each level of CDTI implementotion during supervision...... 25 2.9.5. Feedback given to the person or groups supervised...... 25 2.9.6. The.feedback u:;ed to improve the overall performance of the projecl...... 2s

SECTION 3: SUPPORT TO CDTI 25

3.1 . EqureveNr 25 3.2. FtNaNctnl coNTRTBUTToNS oF THE pARTNERS AND coMMUNITTES 26 3.3 ExpENorruRE pER Aclvtrv 30

SECTION 4: SUSTAINABILITY OF CDTI...... 30

4.1. INreRNnr-: TNDEpENDENT pARTtctpAToRy MoNrroRtNc: EvnlunrloN...... 30 1.1.2. recommendations...... 30 1. t.3...... 31 All of the above have been addressed but./br afew point which will be checked during supervision by the region. 31 4.2. SusrerNRsrLrry oF pRoJECTS: pLAN AND sET TARGETS (MANDAToRy AT 3l Yn 3)...... 3l

lll CDTI SWI APOC Technical Report 2010 4.3. INrEcRerroN...... 31 1.3.1. Ivermectin delivery mec'hunism.r...... 31 1.3.2. Training...... 31 Training of health sta/fs and CDDs were integraled inlo other health at the level of the districts and health areqs:...... J1 1.3.3. Joint supervision and monitoring with other programs...... 31 1.3.1. Release of .funds /br project activities ...... 31 1.3.5. Is CDTI included in the PHC budget? ...... 31 1.3.6. Other heolth programmes that are using the CDTI struclure and how...... 32 this v,as achieved...... 32 1.3.7. Describe others' issues consirJered in the integration oJ'L'DTL ...... 32 4.4. OpeneroNA L RESEARCH 36 1.1.1. Summurize in not rnore lhan one half of a page the operational research undertaken in lhe project urea y'ithin the reporling periocl...... 36 1.1.2. Hou,v,ere the resulls upplied in the proiecl'/...... 36 SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, AND OPPORTUNITIES 37

SECTION 6: UNIQUE FEATURES OF THE PROJECT/OTHER MATTERS 4t

lv CDTI SWI A POC Techn ical Report 20 I 0 Acronyms

APOC African Programme for Onchocerciasis Control ATO Annual Treatment Objective ATrO Annual Trairring Objective CBO Commun ity-Based Organ ization CDD Commun ity-Directed Distributor CDTI Commun ity-Directed Treatment with Ivermectin CSM Commun iry Self-Mon itori ng LGA Local Governmerrt Area MOH Ministry of Health NGDO Non-Governmental Developnrent Organ ization NGO Non-Govern menta I Organ ization NOTF National Onchocerciasis Task Force PHC Primary health care REMO Rapid Epidemiological Mapping of Onchocerciasis SAE Severe adverse event SHM Stakeholders meeting TCC Technical Consultative Committee (APOC scientific advisory group) TOT Trainer of trainers UNICEF United Nations Children's Fund UTG U lti mate Treatment Goal wHo World Health Organization

CDTI SWI APOC Technical Report 2010 Definitions

(i) T, poDu roll: the total population riving in meso/hyper-endemic communities withirr the pro.iect 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) ual (ATO): the estimated number of persons meso/hyper-endenric living in areas that a CDTI project intends to treat with ivermectin given year. in a

(iv) Ultimate Treatment Goal (UTGI calculated as the maximum number of people to be treated annually in meso/lryper endemic a.reas within the project area, ultimately to be reached when rhe pro.ject rras reached fuil geographi. .J";;;e (norrnaly the projecr should be expected ro reach the UTG at the e]rd Irri.'. i,Jr"urlrrrr" project).

(v) Therapeutic coverag€=-number people of 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 of rneso/hyper-endemic communities lYTb:t as identifieo uf freHao in the project area (this should be expressed as a percentage).

(vii) Integration: delivering additional health interventions (i.e. vitamin A supplements, albendazole for LF, screening for cataract, etc.) through CDTI (using the same systems, training, supervision and personnel) in order to maximiso cost-effectiveness and empower communities to solve more of their health problems. This does not include activities or interventions carried out by community distributors outside of cDTI.

(viii) Su-stainabilitlz: cDTI activities in an area are sustainable when they continue to function effectively for the foreseeable future. with high treatment .ou.rug.. integrated into the available healthcare service. with strong community ownership, using resources mobilised by the community arrd the goventment.

(ix) C The process by which the communitv is empowered to oversee and rnonitor the performance of CDTI (or any community-based health interventiorr programme). with a vrew to ensuring that the programme is bei ng executed in the way interrded. It encou rages the community to take full responsibility of ivermectin distribution and make appropriate modifications when nece ssary

VI CDTI SWI APOC Technical Report 20 t0 FOLLOW UP ON TCC RECOMMENDATIONS

Using the table below, fill in the recomrnendatiorrs of the last TCC on the project arrd describe how they have been addressed.

TCC session 30

Number of TCC RECOMMENDATIONS ACTIONS TAKEN BY FOR TCC/APOC Recommendatio THE PROJECT MGT ASE ONLY n in the Report 12. I Reinforce community participation and All have been address in improve on CDD ratio per population. plans of action for 201 L II Reinforce Advocacy and Supervision, All have been address in

Monitoring and Evaluation at all levels. plans of action for 201 I . III Reactivate operational research and All have been address in

implicate Lecturers frorn FMBMSs. plans qf action for 20 I I . IV Spot check and verify data collected at all All have been address in

levels. plans of action for 201 I . v Put in place all strategies in preparatiorr ilt All have been address in moving from control to elimination of plans of action for 201 l. Onchocerch iasis.

CDTI SWI APOC Technical Report 2010 E.recutive Sumntory

l. Background on treatment and population data - Total communities, communities treated, total population, UTG, ATO and persons treated. The l2tr'year of Mectizan distribution cycle haslrrie,ia"o with much improvement on the performance on treatment figures and general out put on results. This good impact was as a result of the siate payment of CDDs motivation owed them frorn 2006 and 2007. The state has promise to complete rest of funds due CDDs in upcoming 20ll distribution cycle. Continuous health education and sensitization of communities and willingness the of CDDs to distribution Mectizan has also cause the number of refusals and absentees to dropped drastically. more people are encourage to take the drug especially as many have discovered that Mectizan intestirral kills worms, produces rninimal side effects and'their malaria episodes have reduce or completely disappear. All rumours that surrounded Mectizan programme have completely died away many people are willing to take the drug. This year distribution started early as planned because Mectizan arrived early in the drug store in the Region.

The Project area is divided into l0 health districts which are further broken down into 75 health areas having a total of 478 meso and hyper endemic communities.

Information on communities treated 478, Total CDTI population update :472906,UTG: 397 241,,\TO: 31g325, Persons treated: 391703. Annual coverage: 82.83oh,. In the hypo communities, a total of 93727 persons were treated. It is worth noting that. the project will be moving from control to elimination of Onchocerciasis and we will be working with the entire population of the project zone projected from 2005 national population census in 201 l; will not take into consideration the hypo, meso and hyper community,s population figures.

2. Background on population movements. Population movements are not a big problem in the project zone. These take place around the fishing ports of the coastal areas of Tiko and Limbe. These population movements do not affect the project significa"nily as these coastal areas are basically hypo endemic.

3. Training data - cDDS, health workers, Totar popuration (community) per cDD trained. The project zone had l0 health districts and 75 health areas: Sighisavers provided funds for targeted training of Nurses and CDDs: in all a total of I05 health staff were refreshed frorn health district and health areas andll0l CDDs trained. Another training that was organised and carried out was on corlrnunity self monitoring in 3 pilot health districts (Kumba, Konye and Mbonge).26 health areas and 223 cornmunities were selected. A total of 3 district medicalofficers, 3 chief of bureau health,26 nurses and further 223 monitors were selected and trained.The carried their task and reported on CSM.

4. Challenges and how they were overcome.

The CDTI SW I project is depending entirely on Government funding for its key activities like transportation of Mectizan, HESAM, training, supervision. monitoring and evaluation, distribution of Mectizan, monitoring of severe adverse effects, reporting and motivation of CDDs. We all know the impact what it means for a project to depend entirely on Government funding. This has reduced the performance of both the health staff and the CDDs in carrying CDTI activities. Many districts integrated CDTI key activities with other health programmes and this cut dawn the cost and delay in time Iirre for imprementation and ieporting.

Some 62 communities spread in between Kumba. Mbonge and Konye are still not achievin gg1%therapeutic coverage rate. After the midterm evaluatiotl meeting it was recommended all these communities thal have not been able to attend 80% therapeutic coverage rate should go back for catch up Mectizan treatment.

2 CDTI SWI APOC Technical Report 2010 SECTION l: Brckgrountl idormotion l.l. General information

l.l.l Description of the project (briefly) Geographical location, topography. clirnate South West I is part of the South West Region of Cameroon. It lies between 5o20 and 4oN and g"45 E. CDTI SW I includes 3 adrninistrative divisions. g.r\o, Kupe Muanegouba. Meme). These divisions are made up of about l0 subdivisions. Buea in the Fako Division hosts the aldministrative headquafters of the SW Region is bordered to the 'SWl Nofth by the SW administrative divisions of Lebialem and Manyu, to the South by the Atlantic ocean. to the East by Liftoral and west Regions and to the west by the RLpublic of Nigeria. FromthehealthpointofviewSWl isdividedintol0healthdistricts(Bangem,Buea,Konye,KumbaLimbe, Mbonge, Muyuyka, Nguti, Tiko and Tombel).which are subdivided into Tihealth areas.

SW I project area has a diversified landscape with the predominant vegetation being the Equatorial Rain Forest' Besides this main type of vegetation, there is mangrove veget;tion along the coastal areas. The Rft-umpi hills occupy the whole of Meme Division. The altituie ,ung.. from 0 metie on the coastal areas to 4095 metres on Mount Cameroon in Buea with a multiplicity of srnall hills. The Cameroon Development Corporation (CDC), an agro-industrial unit has put iis stamp in this region with its numerous large plantations of rubber, tea, oil palms and banana.

CDTI Sw I project area has a very rich network of drainage system most of which flows from high altitude are interrupted by nunlerous 11d cascades. rapids and *aterfalls. These streams provide breediig sites to Simulium vectors.

The rainy season stafts from mid-March to rnid-October with its peak around July and August. The dry season goes from rnid-October to mid-March. Farming is practised all through the year, the highest activity being registered around March and April at the beginning of the rainy season.

Population: activities, cultures, language The surface area of CDTI project Sw I rone.is approximately 14300 km2 and the total population of the entire project (hyer, zone meso, hypo communitiesj for oncho is estimated at962 9g6 inhabiiants following extrapolations from the 2005 national population census. There are 478 meso/hyper endemic communities in the project area.

The most important economic activity of the inhabitants of this project area is farming. They grow cash crops like cocoa, coffee and oil palrns. Agro-industrial institutions"in the project area arc the Cameroon Development cooperation (CDC). the Cameroon Tea Estate and Pamol piantations Limited. They grow rubber, tea, banana and palms oil most of which is forexport. Subsistence farming is also done with-miinly foodstuff and fruits. grown for livelihood and excesses being sold to the local irarkets and neighbouring towns and Countries. Cash crop f'arnting is dorre rnostly by rnaLs while the females are more engaged in food crop farming' Most the of CDDs are engaged in farming activities, which explain the reasons for low participation of female -replacement CDDs, rapid drop out and slow by communities. Sometimes they abandon their activities during the peak of Mectizan@ disiribution. A small population is engaged in administration (white collar jobs) and small scale trading.

The local dialects are widely spoken within the clans and tribes in the project area. The language commonly used during communication (lingua franca) is Pidgin English. The literacy"rate is very high ,ilth"rury people being capable of expressing themselves in English and ale* in French.

The village traditional administration is headed by a paramount chief who heads the tribe. He controls the sub or second class chiefs who are the heads of the clansor big villages that make up that tribe. These chiefs and their councillors make traditional laws, protect and uphoi-d traditional beliefs. Iaws and taboos. Traditional ceremonies like, rnarriages. deaths, festivals and births are celebrated according to the norms and standards of each tribe' They all have one belief in cornmon. the pouring out of libation to appease the spirits and the ancestors to intervened for their wellbeing. Traditional authority is not highly respected as in the grass land of the North West and Western regions of Cameroon some of these cultures are a hindrance to a lot of health tnterventron.

J CDTI SWI APOC Technical Report 2010 Communication systems (roads...) The roads in CDTI SW I project area are rnostly un-tarred. They are generally practicable during the greater part of the year, with only about 3 months (July, August, and September) when they are most difficult to ply. During this period of the year movement of Comrnunity Directed Treatment with Ivermectin personnel should be reduced and oriented towards areas where the roads are practicable. Despite every oathi with the use of four wheel drive car a person can still make a successful.iourney within the project zone.

Administration structu re The Governor is the administrative head of the region. The Senior divisional officers head the six divisions. The Divisional officer heads the 70 sub divisions

Health system & health care delivery (provide the number of health posts/centers in the project area if the information is avai lable).

Table I showing number of health posts/cerrtres in the project area.

Health System - Health Care Delivery No No Administrative Technical services Intermedia level Regional delegation of public Regional Hospital Limbe. health for the Southwest Regional Hospital Annex Buea

University of Buea reference I Laboratory Peripheral level Health district services r0 District hospitals (Publ ic) 9 Private hospitals t4 Centres medicaux 8 d' Arrond issement (CMA) Health areas 15 _Ugelh centres (Publ ic) 82 Qommun ities meso/hyper 478 Health centres Private 71

4 CDTI SWI APOC Technical Reporr 2010 I Table 2: Number of health staff in project area and number of health staff involved in CDTI activities

Number of health staff involved in CDTI activities.

Total Numberof health staff Number of health staff Percentage in the entire project area involved in CDTI

Br B2 District/LGA I B3=B2l Br *100 BANGEM 50 I 4 28.0% BUEA 84 24 28.6% KONYE l8 t4 77.8% KUMBA 96 32 33.3% LIMBE 36 34 94.4% MBONGE 4t 28 68.3% MUYUKA 99 24 24.2% NGUTI 59 l3 22.0% TIKO 65 35 s3.8% TOMBEL 66 25 37.9% REGIONAL 35 DELECATION ls 14.3% Total 649 248 38.2o/o

NB: The total numbers of these health staff are drawn from state, private and confessional structures

1.1.2. Partnership

African Program for Onchocerciasis Control (APOC) o Role: Finances planning meetings, trainings, and HESAM. o Achievements: Active funding of training CDDs and community self monitors greatly created awareness and involvement of the community in lrealth programmes. o constrains: Funds this year were disbursed into the project accounts late. o Proposal: Supporl funds for key CDTI activities should be increase and disburse early into project accounts in 201 l.

Mectizan@ Donation Program, a Role: Purchase and deploymerrt of Mectizan to the project. o Achievements: The consistency in the availability of Mectizan in sufficient quantity since onset of programme has really curved down the prevalence of Onchocerciasis in the region. Constraints: ' Periodic delays in the supply of Mectizan due to late reporting from the field. o Proposal: Mectizan should be readily available at alltimes and reporting should be timely and properly done.

Sightsavers o Role: Provides logistic, technical and financiar support to the project

5 CDTI SWI APOC Technical Report 2010 a Achievements: Contributed to the successful establislrmerrt of the SWI CDTI project. lntegration of eye care into CDTI. o Constrains: The change in Sightsavers strategy from charity to developmentalorganisation has reduce their financial suppor-t to the project, and direct government funding is not forthcoming. o Proposal: Carry out advocacy towards direct government funding for the project.

Ministry of Public Health o Role: Putting in place of lrealth structllres, allocation of personnel. formulation of health policies. provision of rnaterial and financial resources. planning and execution of supervision, monitoring and evaluation and search for new partners to support CDTI activities. o Achievements: Scale up of CDTI activities geographically, decreases prevalence of Onchocerciasis in amongst the masses' empotvernterrt of health personnel through trairrings and workshops, payment of CDDs.

o Constrains: Irregular payment of CDDs. absence of direct project funding for CDTI, inappropriate personnel deployrnent.

o Proposal: Funds for CDD motivation should be included into the budget of the district health services, There should be direct government funding of CDTI activities, Integration of CDTI with Lymphatic filariasis control and de-worming programmes.

Endemic Communities o Roles: sensitizatiolr of fellow members, selection of CDDs. collection and distribution of Ivermectin, motivation of CDDs, distribution, reporting and evaluation. o Achievements: increased awareness and Mectizan acceptance amongst other members. o Constraints: Lack of transportation means. no motivation immediately after distribution, untimely delivery of reports after distribution. o Proposal: Reinforcement of HESAM and provision of transportation means, regular motivation of CDDs by communities should be greatly encouraged.

The Community Directed Distributors (CDDs): o Collected Mectizan@ frorn the Health centre. o Ensured storage and safety of Mectizan@ within the communities. o Carried out registration update of their communities. o Distributed Mectizan to community members. o Measure visual acuity of cornmunity members alongside treatment. Refer those who could not count fingers at three metres to the health centre for further evaluation and ' management. o Monitor for Mectizan side effect. o Assist the nurse to sumnrarise treatment reports at the front line health facility.

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2.1. Timeline of activities

Fill in table 4. timeline of activitiesfor areas rreuted in current year,indicating when the key activities were implemented by the month they began and the month they ended.

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2,2. Advocacy, mobilization, sensitization and health education of communities at risk

Advocacy was dotte at the regional level during the General assernbly of the Drug Fund and the madden tour of the regional delegate of public health in all the health disiricts of the relion. The chiefs and most decision makers were in attendance.

The reason(s) for undenakirrg the advocacy, mobilization, sensitization and health education of communities at risk

The reasons for HESAM, was to create awareness on the importance of Mectizan intake and Eye care within the community. increase therapeutic coverage as compare to last year, inform the community of their role ownership of of the project and the challenge to sustain it, lnform the community on the distribution strategy and finally to nrinirnise the numbeiof refusals and absentees.

The chiefs, Community leaders and CDDs are very commented in Mectizan distribution Willingness to take Mectizan. Some CDDs continue working despite irregular motivation. Mectizan awarelless is high in the regiorr. Active involvement of all stakeholders in the project. Reduction in the number of refusals and absentees in treatlnent repofts of 20 I 0.

When comes it to planning. decision rnaking, leadership and ownership they feel is another person.s role to play in CDTI and the COCs always srep in to fillihis gap cDD attrition, some refusals and absentees are seen in some oirtri.tr. Most communities not motivating CDDs ; Under utilization of local radio stations and national language broadcasters to reduce the rate of refusals and absentees Ineffective implementation of HESAM plan. Insufficient resources, human financial and material. Development of health education massages. Under utilization of schools. teachers and pupils.

To improve advocacy, mobilization, sensitization and health education of communities at risk;

To advocated from Mayors Health budgets from councils . Use Structured socio-cultural grouping existing in the community. Use existence of community leadership, e.g elites Politicians Church leaders and chiefs Use of local radio stations in some districts in the region. Use of national day celebrations. e,g. national day women day etc Produce and supply of HESAM materials. Improve Training on HESAM for health staff and some communities. Use of local & national language broadcasters and journalist in the region Developed simple massages formulated in the dialect of the people. Use of simple and meaningful drawings on posters; Use of Community base organisation.

ll CDTI SWI APOC Technical Report 2010 2,3 Community involvement Table 5: Communities pafticipation in the CDTI

Num ber of com m un ities/villages Number of CDDs and the with community members as supervisors communities involved I Total no. Number Percenta Male Female Total communitie with ge CDDs CDDs s in the community entire members as project supervisors area Be= Bg Be= B7+Bs B< B

l 32 0 0 i BANGEM I l 49 J 52 0 0% t3 BUEA 0 0 44 43 87 0 0% KONYE 54 0 0 78 89 t2 22% KUMBA r03 0 0 t32 8 I 2t3 52 50%

l LIMBE 6 0 0 48 48 96 0 0% MBONGE 66 0 0 t07 46 t53 t4 2t% I MUYUKA 45 0 lo 65 l0 75 l3 29% NGUTI 84 0 0 88 89 0 0% l l5 TIKO 0 0 l 55 r03 r58 6 40% % TOMBEL 60 0 0 8l 26 107 t4 23 Total 478 0 0 73t 370 Ir0t ill 23%

Comment on: - Attendance of female members of the community at health education meetings Cenerally the; attendance of female members of the community at health educatio"n meetings vary per community. ln some communities is very high and low in some. Usually the female always dominate in health discussions In general, - how do you rate the participation of female members of the community meetings when CDTI issues are being discusses (attendance, participation in the discussion etc); Female are less in decision makirrg than males - Incentives provided by communities for the CDDs Community mutuality and voluntary services offered to CDDs is not a common practice and this makes it very difficult for community members to assist CDDs in kind or cash to carry out their task. Attrition of CDDs. Is attrition a problem for the project? If yes, how is it addressed? Attrition is still common in 3 health districts in project zone.

Other issues Delayed in motivation of CDDs by the state has affected the malaria program because some CDDs who at the same time actirrg as community relay agents lrave embezzied iunds from the sales of home base malaria treatment drugs.

l3 CDTI SWI APOC Technical Report 20 t0 2.5. Capacity building

There was adequacy of available knowledgeable rnanpower at all levels. This was the l2'r'year of Mectizan distribLrtion in this pro.iect and all health staff are already used to the program already. These health staff has been in project fbr past eight to ten years so tlrey have mastered CDTI as one of the minirnum health package activities.

- Where frequent transfers of trained staff occur, state what the project is doing, or intends to do, to remedy the situation. (The most imporlunl issue lo describe is v'hat measures were taken lo ensure adequate C'DTI implentenlution where not enough knowledgeable manpou)er wos available or if staff are frequently transferred cluring I he course oJ' t he campaign).

Transfer of health staff was not an issue

Refresher training was organise for nurses and CDDs, another training was organized only for community self morritoring in the project area. Three pilot districts (Konye, Kumba and Mbonge) were selected because of high population density that is eligible for CDTI and their past performance in therapeutic coverage's.

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Trainees Other Health Community Workers members e.g (frontline MOH Type Community health staff or Political of training CDDs supervisors fac i I ities) Other Leaders Others(specify) Program x x x management How to conduct x x x Health education Management of x x x SAEs CSM x x x X SHM x x x X Data collection x X X X Data analysis x X

Report writing x X X x Others (specifu)

2.6. Treatments

2.6.1. Treatment figures

Southwest I CDTI project currently has good treatment coverage rates. All health districts did scored above the APOC required minimum of 80% therapeutic coverage. Geographic coverage 100% this year as a result of the commandment of CDDs to cooperate with the chiefs of health centres to cover allendemic comnrunities. See Table below.

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\ 2.7, Ordering, storage and delivery of ivermectin

Mectizan@ ordered/applied for by - Qtleu,se tic'k the uppropriute unsu'er) MOH !tr WHOE UNICEFD NGDO E Other (please specify)

Mectizan@ delivered by - Qtleuse tic'k the uppropriatc unsv'er) MOH Vtr WHOE UNICEFE NGDO E Other (please specify)

Mectizan@ ordered and how it gets to the communities

This year's Mectizan@ for the project was ordered by the NOTF through the WHO office in Yaounde. The drugs were collected from WHO by the NOTF secretariat and handed to the South West regional delegatiorr of health through sightsavers, the supporting NCDO from whom the Southwest Regional essential drug programme collected the drugs. From there the drugs were distributed to the various health districts through the regular drug delivery system. The Nurses in charge of each health area collected Mectizan@ from the districts according to the request by the CDD's of eaclr community. This year drugs were delivered early (March) in the regional drug store.

Mectizan@ Invento Number of Mectizan. tablets Requested Received Used Lost Wasted Expired Remaining

District

BANGEM 63600 63600 60693 46 0 0 2861

BUEA 87000 87000 8r3r4 67 0 0 5619 KONYE 0 0 I 24800 I 24800 t 16328 |2 8360 0 0 KUMBA 390000 390000 385592 r 688 2720

0 0 LIMBE r 09000 I 09000 97597 80 |323

0 0 MBONGE I 80000 I 80000 t72277 89 7634 0 0 MUYUKA t4'7340 147340 r 40873 70 6397 0 NGUTI 73600 13600 69812 t'7 0 37|

TIKO 122200 t22200 108432 199 0 0 13s69

TOMBEL I 19500 I r 9500 I I r082 89 0 0 8329

0 0 TOTAL r 387040 r 387040 r3r4089 2447 70504

Remaining ivermectin tablets collected and where are they kept?

The full bottles of remaining lvermectin tablets are collected and stored in the regionalessentialdrug programme store. The opened bottles are kept in the community pharmacies within the health areas.

2.8. Community self-monitoring and Stakeholders Meeting

Yes

21 CDTI SWI APOC Technical Report 2010

Training was organise and carried out in 3 pilot health districts (Kumba, Konye and Mbonge),26 health areas and 223 communities. Training of Monitors and other Health staff forCDTI in October 20 t0

A total number of 3 DMO. 3 CBH. 26 COPs and 223 monitors were trained on Communiry self monitorirrg.

The objective of training comprised the following topics:

a To revisit the meaning of partnership in CDTI.

a To have a common understanding of community self-monitoring.

a To reinforce the capacity of panicipants in conducting community self-monitoring.

a To elaborate action plans on community self-monitoring.

o Steps to initiate CSM

o Adequate preparations should be rnade prior to meeting with the communities for CSM. o Meeting with Comrnunity leaders and their representatives of community based organizations. o Meeting with the entire community and training of monitors. o Conduction of CSM o A feedback meeting has to be conducted with the monitors and entire community.

It is good to note that CSM will be scale up in all the remaining 7 health districts of the project zone in 20ll distribution cvcle.

22 CDTI SWI APOC Technical Report 2010 Table ll: Community self-monitoring and Stakeholders Meeting (Add rows if needed)

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)

BANCEM 32 0 0

r3 BUEA 0 0

54 KONYE 54

r03 KUMBA t03 r03

LIMBE 6 0 0

66 MBONGE 66

MUYUKA 45 0 0

NGUTI 84 0 0 l5 TIKO 0 0

60 TOMBEL 0 0 223 TOTAL 478 223

Activities already carried out in 223 communities and results reflect what CDDs reported on. CSM has empowered some communities in planning, supervision, rnonitoring and evaluation. CSM has improved cornmunity participation in most of health programme.

23 CDTI SWI APOC Technical Report 2010 I 2.9. Supervision

2.9.1. Provide a flow chart of supervision hierarchy.

Central Level - NOTF . NGDO

Intermediary level - Regional delegate of public health - Regional Chief of Service of Community Health - Oncho Pro.iect Coordinator - Finance Olficer

Peripheral Level - District Medical Officer - Chief of Bureau Health - Chief of Bureau of Administration and Finance - Director of District Hospital

Health Area Level - Health centre nurse

Community - CDD - Dialogue structure members - Community members

24 CDTI SWI APOC Technical Reporl 2010 I 2.9.2. The main issues identified during supervision. a Activities did not go on as planned: respect of timing needs to be improved upon. a Prornpt reporting also needs to be routinely rnade for project activities at all levels a Eye care rrot fully irrtegrated into CDTI.

2.9.3. Use of supervision checklist

The systematic utilization on a checklist still needs to be instituted at all level

2.9,4. The outcomes at each level of CDTI implementation during supervision.

Supervision was really effective this year at the level of districts and health areas, because district have learned a lesson that integrating activities is possible and reduce time and cost in implementation and reporting.

2.9.5. Feedback given to the person or groups supervised.

The region did carry out two supervision visits and feedback was given to the district concerned during regional and evaluation meetings.

2.9.6. The feedback used to improve the overall performance of the project.

Feedbacks greatly improve of the census, treatment figures and reporting on CDTI activities.

SECTION 3: Support to CDTI

3.1. Equipment Table l2: Status of ent (Plea.se udd more row:; neces, Source APOC MOH DISTRICT/L NCDO Others GA Type of No Conditi No. Conditi No Conditi No. Conditi No. Conditi equipment on oll oll on on

l. Vehicle I CNFR I CNFR 1 F 7 F 2. Motor cycle(s) 7 r3 F 20 wo 6 wo 3. Computer(s) il F t2 F I F 4. Printer(s) I F ll F t2 F I F

5. Photocopier (s) I CNFR l0 F I F 6. Fax Machine(s) I F 7. Others a) Flip chart stand 3 F b) Overhead proiector c) Lap top computer I F +Condition of the equipmerrt (F:Functional, CNFR=Currently non-functional but repairable, WO:Written offl.

25 CDTI SWI APOC Technical Report 2010 How does the project intend to maintain and replace existing equiprnent and other rnaterials?

Decisions on purchase and replacernent of equipments are made at the ministerial level. The region and the districts need to write and channel their requests to the Minister of Public Health, and wait for the response. The cost of maintenance corres from the state budget of the region and health districts. In most cases the funds are not enough and the cost of mairrtenance is very high due to the bad state of cars and motor bikes. At the level of the health area, the motor cycle is used for all health programmes. There is the principle of risk bearing and cost sharing applied. The health centre chief of post uses health funds and contribution from other programmes to repairthe bike. All these depend much on the willingness and conscience of the staff concern to take good care of the equipments and logistics put at their disposal.

3.2, Financial contributions of the partners and communities

- Fill tables l3a. l3b and l3c

- If there are problems rvith release of counterpart funds. how were they addressed?

- Additional cornments

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Indicateintable l3.theanrountexpendedduringthereportingperiodforeachactivitylisted. Writethe amount expended in US dollars using the current United Nations exchange rate to local currency. lndictate exchange rate used here 442$

SECTION 4 : S ustai nrtbility tt' CDTI

4.1. lnternal: irttleJteltrlelrl pat"lici;l:rtor"-r rnorritol'ing; llraluirliorr

No-YearllPafticipatorylndependentmonitoring

YES_ Mid Term Sustainability Evaluation

YES_ 5 year Sustainability Evaluation

YES lnternal Monitoring by NOTF

YES Other Evaluation by other partners

4.1.2. recom mendations. End of year evaluatiort meeting was held in December 2010 at the region and the following are the recomntendations that we made;

o To reinforce of HESAM in all communities o Selection of CDDs to be done by their communities o To reinforce of capacity of staffs and cDDs on the management of Mectizan o Effective motivation of CDDs o Effectivesupportivesupervision o To ensure good census updates in cornmunities o Data arralysis at district level to mortitor cornmunities with less than 80% therapuetic coverage rate. o To involve community mernbers in coordination meetings. o To institute rnonthly repofting on CDTI activities o To plan and irnplement supervision and monitoring of CDTI activities as for other routine health activ ities. o To be give feedback during district coordinatiorr meetings to health areas with respect to the reports as they find in other repofts o To empower community rnembers through training for CSM r CDDs should be involved in all health activities in the health area (this should be ensured by the district health service o To brief staffs on the prirrciple of integration, o To pool financial resources in one corlmon basket, o To integrate all work plarrs in the districts and health areas

30 CDTI SWI APOC Techn ical Report 20 I 0 4.1.3.

All of the above have been addressed but for a few point which will be checked during supervision by the region.

4.2. Sustainability of projects: plan and set targets (mandatory at Yr 3)

I Was the project evaluated during the reporting period? NO

Was a sustainability plan written? _Not applicable_ When was the sustainability plan subnritted? _Not applicable_

What arrangements lrave been rnade to sustain CDTI after APOC funding ceases in terms of:

4.3. Integration

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

4.3.1. Ivermectindeliven,mechanisms

The delivery mechanism of Mectizan@ is alrnost completely managed by the staff of the Ministry of Health. From when the tablets got the South West Regional. they were stored and managed by the Regional essential drug programrne just as is the case with the other essential drugs. At the end of the distribution campaign, left over tablets of Mectizan@ in full cups are forwarded back to the drug programme vial the various health districts and open cup are left in the community pharmacy.

4.3.2. Training

Training of health staffs and CDDs were integrated into other health at the level of the districts and health areas;

4.3.3. Joint supervision and monitoring with other programs

lntegrated supervision can only be possible at the health district and health area levels where few staffs are called upon to carry out all health programmes.

4.3.4. Release of funds for project activities

Sighsavers secured some funds for activities and they were release early but APOC funds approved arrived Iate in the region. The state did respect its promise to rnotivate CDDs for the past 2006 and 2007 years.

4.3.5. Is CDTI included in the PHC budget?

In the state budget. there is no line for CDTI: However, the districts and health areas carry out expenses on CDTI either directly or indirectly from other budget lines. One of such budget line is "supervision of health activities". ln health areas. especially those not allocated any runnirrg credit from the government. health centres funds (collected from services the render to the public) are used to finance CDTI activities. The government is now advocating for a "common basket". whereby funds for all community health programmes are pooled together and used together from a common basket in an integrated manner. The difficulty in instituting this is the fact that different programmes have different calendar for activities, they have different donors each of whom wants financial j ustifications in a d ifferent way.

3l CDTI SW I APOC Technical Report 2010 4.3.6. other health programmes that are using the GDTI structure and how this was achieved.

a Fill tables l4and l5andprovidedescribeotherprogrammesthatareusingtheCDTl structure and how this was achieved. See table below.

a What have been the achievenrents?

Most CDDs are now implicated in other health intervention in the communities and this reduces spending on capacity, building. Cornmunity rnernbers can now take decisions on health issues CDDs know their communities and population better than before.

a For each intervention listed in table 15. explain what were the roles played by the CDDs (census. rnobilization, distribution, data collection. storage. collection of drugs, referral of SAEs, etc ...)? See table below.

a Explain what are the combinations of interventions co-implemented?

The strategy for Mectizan distribution is doorto door. this opportunity permit's the CDDs to treat mosquito bed needs, rnobilised the community forother health programs, identify and refer cataract . Tubercolsis. Leprosy. Burulli ulcer cases to the health staffs.

c How were the interventiorrs irnplemented? (At the sarne time?)

The interventions are planned in annual districts and health areas plans of action

4.3.7. Describe others issues considered in the integration of CDTI.

Implementation of sector wide approach system and state budget. Institution of common financial basket that is funds are pool together from all funding bodies and uses as need arise in programme implementations.

The service of supervision. monitoring and evaluation has developed a tool for integrated SME activities in the region and CDTI is one of the programmes.

32 CDTI SWI APOC Technical Report 2010 0)

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4.4.1. Summarize in not more than one half of a page the operational research undertaken in the project area within the reporting period.

No research carried out.

4.4.2. How were the results applied in the project?

Not applicable.

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o! p i.; \ ,rr'1- ;.9 0 otr=E.t'= 6 E= ??y c! o 0) .B La 6t a (J E tr'= G ql rGlH f.l o! 0) q,ah Etc G SECTION 6: Unique./entures rfthe project/other mufters

Four pilot districts have been selected fbr the implementation of Sector wide approached (common managerrlent for all health basket in financiai intervetttiotts). Soon SWaP will be scaled up region. in ail'the health districts of the south wesr

out come from end of year evaluation rneeting, was the decision to push forward the epidemiological evaluation impact of the treatment with Ivermectine of the onlhe population from May and June 2011. Following nationalconsultation meeting the reports of th€ on the Elimination oithe infection and transmission place of onchocerca volvulus, which took in Mbalmayo on the Il l3llol2olo,the communities - should not receive treatment within months last treatment or before the evaluation. ll afterthe During the annual regional e^valuation/ planning meeting held on the observed -started l5rr,- l6,h December 2010 in Buea, it was that the treatment for the last round in 2010 in both project zones from April and extended october/lrJovember' This was partly because tc of late arrival of lvermeJtine. considering the criteria epidemiological evaluation. the inter;al set for of ll morrths will not be respected if the evaluation The evaluation has takes place as scheduled been postponed to February-M arch 2012. In planning the for 2011, distribution is scheduled for March - April 20 | I irr both project zones.

41 CDTI SWI APOC Technical Reporl 20lC