TUNDURU - WHO/APOC/CDTI PROJECT REPORT OF INDEPENDENT PARTICIPATORY MONITORING OF CDTI ACTIVITIES IN THE TUNDURU CDTI PROJECT, TUNDURU DISTRICT TANZANIA 2-14 AUGUST 2007 Community Members and CDTI Monitors in Ligoma Village, Tunduru District, Tanzania SUBMITTED TO THE DIRECTOR AFRICAN PROGRAMME ON ONCHOCERCIASIS CONTROL (APOC) AUGUST 2007 Independent Participatory Monitoring of Tunduru Focus CDTI Project ii Tanzania, 2-14 August 2007 TEAM COMPOSITION PRINCIPAL INVESTIGATOR William KISOKA Social Scientist National Institute for Medical Research (NIMR) Dar Es Salaam, Tanzania [email protected] +255 755 096080 (cell) INVESTIGATORS Dr. Deborah KABUDI - Project Coordinator, Morogoro Rural CDTI Project, Tanzania P.O. Box 110, Morogoro Email: [email protected] Tel: +255 784 351 200 (cell) Harriet HAMISI – Project officer, Helen Keller International, Tanga Region P.O. Box 5547, Tanga Email: [email protected]; Tel: +255 27 264621; +255 784 381521(cell) Oscar KAITABA - National Onchocerciasis Control Programme, Tanzania Ministry of Health and Social Welfare, P.O. Box 9083, Dar es Salaam Email: [email protected]; + 255 22 213009; +255 754 889 390 (cell) Sebastian MHAGAMA - Mbinga District Onchocerciasis Coordinator, Tanzania P.O. Box 42, Mbinga, Tel: +784 8273 86 Dr. Wade A. KABUKA - Project Coordinator, Ruvuma Focus CDTI Project, Tanzania P.O. Box 5, Songea, Email: [email protected]; Tel: +255 25 2602048, +255 754 899941 (cell) FACILITATOR Joseph Chukwudi OKEIBUNOR Department of Sociology/Anthropology University of Nigeria, Nsukka, Enugu District, Nigeria [email protected] +234 806 329 0671 (cell) Independent Participatory Monitoring of Tunduru Focus CDTI Project iii Tanzania, 2-14 August 2007 ACKNOWLEDGEMENT The team would like to extend its sincere gratitude to all those that assisted it during this mission. Of special mention are the following: . The Director, Dr. Amazigo, and staff at APOC Headquarters in Ouagadougou for making available the necessary financial and logistic requirements for the success of this assignment . Dr Mohammed Belhocine, the WR, Dar es Salaam and his staff provided support, which contributed to the smooth functioning of the monitoring Team . Dr Grace Saguti, National Onchocerciasis Control Programme Coordinator, and her team facilitated the smooth take off of the exercise in Tanzania . The District Executive Director, District Planning Officer, District Medical Officer and District Health Management Team for their cooperation . The district Onchocerciasis Control Coordinator, Gaufrid Mville, made all possible arrangements for the team to meet with all those that were required . Health workers and community members who provided important information and contributed to the success of the mission . Last but not least immense gratitude to the team of accommodating drivers who drove the monitoring team over several kilometres of very demanding roads and terrain under tough conditions Independent Participatory Monitoring of Tunduru Focus CDTI Project iv Tanzania, 2-14 August 2007 LIST OF ACRONYMS APOC African Programme for Onchocerciasis Control CCHP Comprehensive Council Health Plan CDD Community Directed Distributor CDTI Community Directed Treatment with Ivermectin CHF Community Health Fund CHMT Council Health Management Team CSSC Christian Social Service Commission DED District Executive Director DMO District Medical Officer DOC District Onchocerciasis Control Coordinator DOT District Onchocerciasis Control Team DPLO District Planning Officer FGD Focus Group Discussion HKI Helen Keller International HS Household Survey IDP Ivermectin Distribution Programme IEC Information, Education and Communication NGDO Non Governmental Development Organization NOCP National Onchocerciasis Control Programme NOTF National Onchocerciasis Task Force PHC Primary Health Care Independent Participatory Monitoring of Tunduru Focus CDTI Project v Tanzania, 2-14 August 2007 RBF River Blindness Foundation REC Record (CDD Treatment Record) REMO Rapid Epidemiological Mapping for Onchocerciasis RMO Regional Medical Officer SSI Sight Savers International VHW Village Health Worker WHO World Health Organization Independent Participatory Monitoring of Tunduru Focus CDTI Project vi Tanzania, 2-14 August 2007 EXECUTIVE SUMMARY Introduction Tunduru Focus CDTI project commenced mass treatment with ivermectin, with funding and technical support of the APOC trust fund in 2005. It had its second distribution in 2006 and is planning for the third round of distribution later in 2007. As is customary with the APOC partnership, CDTI projects undergo independent participatory monitoring after one or two distributions. This is aimed at ensuring adherence to the CDTI process, early in the age of the projects. APOC Management constituted the Independent Participatory Monitoring Team APOC Management to visit Tunduru District Community Directed Treatment with Ivermectin (CDTI) project, Tanzania, from 2-14 August 2007. The team had William Kisoka of the National Institute of Medical Research, Dar Es Salaam as the Principal Monitor. Other team members include Dr Wade Kabuka of Ruvuma Focus CDTI, Dr Deborah Kabudi of Morogoro Rural CDTI project, Oscar Kaitaba of the National Onchocerciasis Control Programme in Dar Es Salaam and Mr. Sebastian Mhagama of Mbinga District CDTI project as well as Harriet Hamisi of HKI Tanga. Dr Joseph Okeibunor of the University of Nigeria Nsukka facilitated the team. The team had the Tunduru District CDTI members as local guides. The assignment commenced with a briefing of the District authorities and health management team on the terms of reference of the Independent Monitors and the areas where their cooperation would be required. The methodology and instruments adopted were the same as those developed in Ouagadougou and finalized in Kabale, Uganda. The objectives were equally left as in Kabale, Uganda. Six Category A and 24 Category B sub villages were selected through a multi stage random sampling procedure. A total of eight instruments were employed for data collection during the monitoring. Policy makers and programme implementers within the project area were interviewed for their roles in the implementation of the CDTI. At the community level, village leaders and their CDDs were interviewed for their roles in the implementation of CDTI within their villages. Ivermectin intake by household members was ascertained through household treatment survey while FGDs were held with community members to ascertain their knowledge, attitude and perceptions of onchocerciasis, the control programme and ivermectin, as well as their willingness to support the programme in their respective communities. Independent Participatory Monitoring of Tunduru Focus CDTI Project vii Tanzania, 2-14 August 2007 Findings The key findings in Tunduru CDTI project include the following: • CDTI has taken off in all the villages. • Treatment coverage is high and actually on the increase from seventy percent in 2005 to seventy-one percent in 2006 for the entire population. Similarly, there was a rise from 70.2% to 79.5% in the sample population. Over thirty-seven percent of those who did not take the drug in 2005 took it in 2006. On the other hand, just about two percent of those who took it in 2005 did not take it in 2006. • Refusals and absenteeism constituted very low proportions of reasons for not taking the ivermectin in 2006. Temporary ineligibility such as pregnancy and childhood were the main reason for not being treated. This is true of the CDD record as well as the household treatment coverage survey. • The programme is integrated in the District health system. District authorities have included CDTI in the Comprehensive Council Health Plan (CCHF) and budgeted for it against the 2007/2008 fiscal year. Moreover, the government has also planned to increase funding for CDTI through the Community Health Fund (CHF). They are thus planning to sensitize the communities to set funds aside for implementation of CDTI and other health programmes in the communities. • Drug and reports pass through the routine health system. For instance ivermectin is stored in the District Pharmacy. The District Pharmacy controls the issuance of drug to the DOT as is the case with other programmes in the District • Communities are however, currently ignorant of their responsibilities in CDTI. This is attributable to the poor community mobilization, health education and empowerment. • Community members do not know why they should take ivermectin beyond the fact that it prevents blindness and skin diseases. Due to the low level of health education, community members confuse onchocerciasis control drugs with drug for trachoma initiative since both function to prevent blindness • District Health Officers dictate timing and mode of distribution to communities. In some FLHF staff selects CDDs for the communities. • Senior members of the Council Health Team lack knowledge of the APOC philosophy and the driving principles of the CDTI strategy and as such encourage the use of health related personnel for the distribution of ivermectin as a solution to the demand of incentives by CDDs. Independent Participatory Monitoring of Tunduru Focus CDTI Project viii Tanzania, 2-14 August 2007 • Some CDDs were not fully conversant with the CDTI concept. This could be an element of quality of training and supervision. • The training and retraining of CDDs are inadequate both in duration and content. In all the cases encountered, CDDs were trained for only 2-6 hours. This period is just enough