Technical report of CDTI activities in Enugu/Anambra/Ebonyi states project : October 1999 to September 2000

at TECHNICAL REPORT OF CDTI ACTTVTTIES IN EIIUGU/ANAMBRA/EBONYI tr STATES PROJECT OCTOBER 1999 TO SEPTEMBER 2OOO (SECOND YEAR) SUBMITTED TO: AFRICAN PROGRAMME FOR ONCHOCERCIASIS coNrRoL (APOC) December 2000 \_ a t NOTF NOCP ZOTF CDD PA SPO SOCT LOCT LIST OF ACROI\YMS National Onchocerciasis Task Force National Onchocerciasis Control Progralnme Zonal Onchocerciasis Task Force Community Directed Distributor Project Administrator State Project Offrcer State Onchocerciasis Team Member Local Government Onchocerciasis Control Team Member Community Directed Treatment with Ivennectin African Programme on Onchocerciasis Control Local Government Areas Global 2000 River Blindness Programme State Ministry of Health Federal Ministry of Health Village Health Committee Primary Health Care Nongovernmental Development Organization District Health Supervisor Health Facility Staff CDTI APOC LGA GRBP SMOH FMOH \rHC PHC NGDO DHS HFS L. 2 ( \EXECUTIVE SUMMARY: The implementation of Community Directed Treatment with Ivermectin (CDTI) under the African Programme for onchocerciasis Conhol (ApoC) in Enugu/Anambra/Ebonyr project started in September 1998 and entered its second year in October 1999. Advocacy visits were made to states, LGA5 and community policy makers to solicit their support in CDTI implementation. The state minist'ies of Health also organized sensitization workshops for state, LGA and village members with a view to keeping them abreast of the current situation as it concerns CDTI implementation in the country. A total of 14 SOCTs, 229 LOCTs/PHC Coordinators, 882 Health Facility statr(Itr's),215 DHS and 6,829 cDDs were hained between october lggg to September, 2000. A total of 3,466 targeted villages were mobilizsd an6 health educated on the importance ofreceiving extended fieatnent with ivermectin. A total of 3,444 villages selected CDDs, and,3,293 villages collected drug. 3,217 villages decided on the month of distribution, while 3,248 villages decided on the method of distribution. A total of 1,952 villages compensated their CDDs in either cash or kind valued at about Nl million. A total of 1,092,071 persons were treated from a total population (in heated villages) of 2,165,029 gnlrrrg 50.44% treatuent coverage. Treatrnent has been completed n2,717 villages. From all indications, self-sustainable mectizan delivery system is seen to be feasible in the project. The states and Iocal governments have thrown their weight behind the programme by making their arurual counterpart contribution to complement the efforts of J external donors. Also the communities have continued to offer their own support to CDTI. Some of the challenges the project faces include the need for motorcycles and bicycles. In Ebonyi State, there is still a need for a generators and a desktop computer. The absence of these equipment adversely affect the performance of the projects. 4 SECTION 1. BACKGROUND INFORMATION: State: Enugu state is located between 7" lo'N and 7" 45'N. It is bounded on the north by Kogi and Benue states, on the south, by Abia State; on the east by Ebonyi state and on the west by Anambra State. The population of the state is about 2.7 millron and made up of 17 Local Government Areas (LGAs) spread over a landmark of over 25,200 square kilometers. Sixteen of the LGAs are endemic and are supported by APOC. The bio-climatic zone is rainforest in nature with annual rainfall between 152 and203. The climate is comparatively equable and the temperature ranges between 22.2c and 36"c. It is the hunidity rather than the temperature that causes discomfort to newcomers, and is betweenTSo/o and95%o. It is generally cool during the rainy season, while the mean temperature in the hottest periods of February and April is about 36c. The topography has two marked zones, hilly or mountainous and flat zones. The hilly zone stretches through Awgu, IJdi,Ezeagu, Oji River, Uzo Uwani and part of Igbo Etiti LGAS. The hilly nahre gives rise to rapids and waterfalls that exist in most rivers especially oji, ogurugu, Anambra, Ajali and Duu which form conducive breeding sites for simulium damnosum. The main occupation of the people is fanning and hading. There are a total of 16 endemic LGAs ard 1,377 villages in this state (Table l). E \ 5 Anambra State: Anambra state is bounded on the north by Kogi state, on the south by Imo State, on the east by Enugu and on the West by Delta. It is located between 5" 43'N and 6" 48' and has a population of approximately 4 million and made up of 2l LGAs, out of which l6 are endemic. The state derives its name from the placid Anambra River which is a tributary of the River Niger. The land has an undulating configuration and generally slopes from the north to the south and from east to west into the River Niger which is the major drainage channel. The highest level is about 400 meters above sea level. The state falls within the south equatorial rainforest region which passes through the tropical forest and great oil palm belt of Nigeria, then thins out into the savannah area with drrmps of trees. The rainfall is relatively high at about 2050mm average. The highly fertile arreas of Oji and the Manu rivers are also established breeding sites for Simulitrm damnosum. There are a total of 16 endemic LGAs and 1,062 villages in this state (Table l). Ebonvi State: Ebonyi State is one of the states in the South EastemNigeria. It is bounded on the North by Benue State, on the East by Cross River State and on the South by Abia State. The state has a total of thirteen (13) Local Government Areas, out of which ten (10) are under APOC. It has an approximate population of 1.85 million based on the l99l National Population Census Estimate. However, the total population in oncho endemic communities is 689,987 persons. The Igbo language spoken in the state has over six different dialects. 6 The topography consists of undulating elevation of approximately 500m above sea level in the south and extends to the rugged terrain of the central part of the state. The northern part is characterized by uriform landscape with intennittent escapement. The Cross River terrain is mainly an alluvian table which favours most agricultural activities. The vegetation arrangement consists of mangrove forest sparsely distributed around the Cross River basin of the boundary of the state, with a mixture of the decidious and evergreen types of trees. There are atotal of 10 endemic LGAs and 1,027 villages in this state (Table 1).t \- 7 TABLE 1. TOTAL NUMBER OF ENDEMIC VILLAGES IN THE PROJECT STATE TOTAL NO. OF LGAs ENDEIIIC LGAs Hyper- Endemic Villages Meso- Endemic Villages Total No. Villages ENUGU 17 16 818 559 1377 ANAMBRA 21 16 282 780 1062 EBONYI 13 10 240 787 1027 TOTAL 51 42 2,126 3,4661,340 (SECTION 2 IMPLEMENTATION OF CDTI: The overall sfrategy for the control of onchocerciasis through chemotherapy revolves around the implementation of community based sustained programme for the distribution of Mectizan to all individuals either infected with river blindness or at the risk of infection. Emphasis is therefore, placed on establishing an Ivermectin Delivery Programme in which the primary responsibility for obtaining the required mectizan, distributing it to the at- risk population, supervising the activities of the CDDs and keeping relevant record will be devolved to the communities themselves. In addition, the communities are responsible for taking decisions on selection of CDDs, method of distibution, month(s) of teafinent and remuneration of distributors (Table 3). 2.I. TRAINING: Training of staffinvolved in CDTI implementation was conducted at three separate levels. [a] State level - for training of SOCTS tbl LGA level - for fraining of LOCTs, District Health Supervisors (DHS) and Health Facility Statr(ItrS) [c] Community level - for taining of CDDs In view of the high number of cornmunity drug distributors to be tained in the project area and the need to reduce the burden of cost to the community, CDDs fraining is done at the cornmunity level. Each LGA is divided into five districts and each with a District Health Supervisor and her assistants {Health Facility Statr}. Basically, a minimum of six trainings were undertaken in each LGA {one at LGA 'r- 8 { @t- m N - =! zin m=zmCZPil =-l10Fz =oE .TI E8m=I!oozc) -.oU,. TDqs UE Q:Ya -imT{ m =E m7 NooI e sr E ig e. g1 8 EE ,z].=C1 = **= fl sdE Eg : $ = ;= !i !, E, q'9 E + € E-e 6 iL -a, die gF ; Bg s* 6 Eo 9: r -{ es { Eo .-- m c\ ot 5J = oa ir € ;E d3 ; : a $[ s Ee gS 3 EF e: fi $E ie I ss ES :s. a; ET 3 gE "m Y oI l!!s @ O$ g€ $ -He :s.; 9. ,!r EA S. m: FT E gE BH- 8 E(o 6X' T 9S TE ' Bil T: i EH iA F fE xa o g = d5 o g# ia F s ' o.9. cL =A'=. = o.i9 d l6= = o96' ci I6'f E dfGt o {o{ t- m @oz z (D v mzC oC (.,b o) o) 'o N) -o o, N) -(r, o)b55 -o o(,t .1, -o O)N .G' (.) i.)(0 o, -t 'o o(,t (o N '(^.) o) J,.)N .A{ (o5o (o5@ '(^, N)(o J^)N5 CX' (o N)s (o5@ G)o) J,' OJ(ll(0 .l -o o(,t (o N\ .G.) !\ (o(,t I\) o)(,t(,r s(,t{ @5o i- a) b) c) d) 0 s) h) e) i) headquarters for LOCTs and DHS, one or more for IIFS in the districts and the rest for CDDs in the communities. TRAINING ACHIEVEMENTS : The annual training objective for CDDs in year 2000 was 10,983 lri.42 LGAs. In Enugu state2,444 CDDs were hained (59% of their ATO), in Ebonyi state, 1,931 (65W and Anarnbra,Z,454 (84%). See Table 4. The low training objective was due to the high rate of atkition of CDDs as a result of the inability of some communities to compensate them. The annual taining objectives were 237 for LGA staff (,OCTs/PHC Coordinators) and715 for health centre/health post sffi. Achievements were 229 (96%) ard 1,097 (153%) for LOCTs/PHC Coordinators and health centre/health post stafftrained respectively. There was an underestimate of the number of people to be hained here that is why the achievement is far more than target. TRAINING MATERIALS: The following is the list ofmaterials developed and used for training of health staffand CDDs and for education on CDTI Post and pre-test documents Training manuals for LOCTs and DHS Brochure on CDTI for LOCTs, DHS, FIFS and CDDs Pocket treaftnent guide Flip chart and posters Samples of measuring sticks Village treafinent registers (samples) Mectizan sunmary sheets, reaction guides and duty specifications for each cadre of health staffand CDDs Mectizan transfer forms 9 \ f o) 3(, o) m =c(o C mf, :f mI m(, of =. -9(o @ G) J' -1, .s(,t JJ)N@ ct) .}(,l(,lN Ot{o -t(oo -\(Jt(Jt NN(rt J5 (,t s (,r NN(C) (,ro @(o (oo ll-o(o{ LsN' .-\{ ct) c('N(c) J, -(o G) -\ N -s (,ts J\)s .rs { zcF of; 9s+ irmz _=Zztrogio =>-dbl+S:H ie= FdH>mztro{ ?qH;cit,9@ O{mT -3a s* tD rim-7tz s5ot- .9ffi tf -|-{o GlO =q,5's = o 'u oo ao !, I tt ll (t +ho 'tt C) (l?dd3!cL-qlC) IOaro o CL3!, o a O(,rar =-lX{zo., -*Sis=:srmsa = *o<t68 f..ri 6' == =o,Jtcr{ oggd3=+a6E sbdx ..O ooi J(DJ tp cL p.cooo oo. Caa o= eGl =qil o diCtr69o+o:3GrI!, =or-o 3r oo6d3:. cL@ =3.Dt,O(DSol 3f!roE;)o =6s3io og oooa o a Jg a o o 3 3cf 6-6 -,:( :b' lg, \rl : ,- TABLE 4. DETAILED BREAKDOWN OF TRAINING ACTtVtTtES (OCTOBER {999 - SEPTEMBER 2000) SOCT 5 5 LOCT/PHC COORDINATORS 96 90 DHS 80 75 HFS 240 0 ENUGU CDDS 4,131 2,444 TOTAL 4,552 2,614 SOCT 4 4 LOCT/PHC COORDINATORS 96 89 DHS 80 90 HFS {80 327 CDDS 2,926 2,454 TOTAL 3,286 2,964 SOCT 5 5 LOCT/PHC COORDINATORS 45 50 DHS 45 50 HFS 90 192 EBONYI CDDS 2,960 1,931 TOTAL 3,145 2,229 \. ANAMBRA 100% 94o/o 94% 0% 59o/o 57olo 100% 93% 113o/o 182% Molo 9A% 100% 111o/o 111o/o 213% 65% 71o/o a) b) c) 2.2. The use of the above materials was significantly result oriented. The performance of the CDDs indicates that they understood their roles in the CDTI implementation. This can be seen in their improvement in recording and reporting of inforrnation. They are also able to caliberate their sticks used in determining dosage. SUGGESTIONS FOR IMPROVEMENT OF QUALITY OF TRAINING OF HEALTH STAFF AND CDDs The following need to be done to improve the quality of raining of health staff and CDDs: Provision of adequate training materials Use of posters printed in local languages Constant review of taining curriculum and yearly updating of knowledge MOBILIZATION AND TIEALTH EDUCATION: Atotal of 3,466 villages were mobilized during this reporting period. In Enugu state, 1,377 villages were mobilized, Anambra state (1,062 villages) and Ebonyi state (1,027 vrllages). Successful mobilization and health education were crucial activities which created awareness of the problem of onchocerciasis at the state, LGA" community and village levels, as well as solicit support and patronage of the entire citizens towards effective implementation of the confiol prograrnme. The ultimate aim was to have a sustained high demand for mectizan tablets for prevention of blindness due to onchocerciasis. Advocacy visits were made to top state and LGA govemment officials to acquaint them with the problem of onchocerciasis and the need for goverrment at all levels to support the programme in various ways. l0 \: Communities were mobilized wrth the help of District Health Supervisors, Health Facility Statr, the CDDs and members of VHCs using all available avenues both formal and informal and appropriate health education messages conveyed by use of a variety of culturally relevant media. The following measures are suggested to improve the performance of the project: (a) Continuous community mobilization (b)More realistic targets should be set for all components of the programme taking all negative influences into consideration. USE OF MEDIA AND/OR OTHER LOCAL SYSTEMS Inforrnation is said to be effectively disseminated when the message relayed or transmitted has been coded {heard accepted} and the receptor {village} elicits a positive response. The channels used for disseminating information in the project varied from community to community and village to village. The methods used were: Ra dio, Television, Posters, B ro chu res, Newspa per publications, Pictures or photographs, Flipcharts, Handouts, Handbills and Calendars, Town criers, Church announcement, School announcem en t, Vilta ge/Co m munity Hea ds/Ezes, ViIIa ge Meeting/Grou p Meetin gs - RESULTS OF MOBILIZATION EFFORTS: The use of media and other local systems of disseminating information were very effective and gave satisfactory results from the ll t target villages. The effectiveness is reflected by the increased commitnent of the commrurity leaders and distributors and the high degree of involvement of the communities and their willingness to commit available local resources to the distribution process. Furthermore, there were increased responses from isolated fiemlets, which hitherto were not reached in the past. SUGGESTION FOR IMPROVEMENT ON MOBILIZATION: a) Increased logistic support particularly motorcycles for LGA staff participating in CDTI implementation. b) Provision of bicycles for health center staffinvolved in the CDTI implementation to enable them cover the villages more effectively. c) use of mobile public address system for better ouheach of the population. t2 \- SECTION 3. TREATMENT COVERAGE: As shown on Table 6, a total of 1,092,071 persons were treated in 2,717 villages with a population of 2,165,029 persons, giving a coverage of total population of freated villages of 50Yo. Treatnent is still ongoing and large quantrty of drugs are stifl in the field. The total population of endemic villages was obtained as 2,165,029 persons from a recent census that was conducted this year. The result of the census exercise is still being validated. Total eligible population is 1,67 4,983 persons, based on the data from fueahent sunmary fonns. LEVEL OF ABSENTEEISM: The proportion of absenteeism and refusals is lower than expected in all the project ireas. This situation is atfributed to the aggressive mobilization of the communities, perceived benefits of ivermectin and the high demand for it in all the endemic villages. In addition, the ability of the comnlrnities to recogntze problems with distribution methods and modifr the methods accordirgly contributed to low absenteeism recorded so far. REASONS FOR ABSENTEEISM: For those that are absent during treatment, the most corlmon reason given by them is 'farming activity" which keeps them away from the community during distribution period. SUGGESTIONS ON ACTIONS TO BE TAKEN TO REACH ABSENTEEISM AND DEFAULTERS: There is need for the project to adjust the distribution period in line with the tradition of the area to avoid its coincidence with the fanning season. Where this is not possible, arrangement will be made to treat l3 t. them in the farm settlements. This arrangement is bound to be very successful and the project suggests that it should be applied in other projects. The issue of defaulters is more difficult to handte. Defaulters should be traced back to their residents for freatrnent if they are still within the project area. But where they leave the area entirely for far away cities, it becomes very difficult to follow them up because of consfiaints of tansportation cost involved. There are also some people who refuse the drugs for some reasons. For this group of persons, continuous education and mobilization will be applied. l4 \headquarters for LOCTs and DHS, one or more for IIFS in the districts and the rest for CDDs in the communities. TRAINING ACHIEVBMENTS : The annual haining objective for CDDs in year 2000 was 10,983 l.ri.42 LGAs. In Enugu state 2,444 CDDs were hained (59% of their ATO), in Ebonyi state, 1,931 (65"A and Anambra,2,454 (84yA. See Table 4. The low training objective was due to the high rate of athition of CDDs as a result of the inability of some communities to compensate them. The annual raining objectives were 237 for LGA staff (LOCTs/PHC Coordinators) and 715 for health centre/health post staff. Achievementswere 229 (96yAandl,097 (153%) for LOCTs/PHC Coordinators and health centre/health post stafftrained respectively. There was an underestimate of the nunber of people to be hained here that is why the achievement is far more than target. TRAINING MATERIALS: The following is the list ofmaterials developed and used for fraining of health staffand CDDs and for education on CDTI Post and pre-test docunents Training manuals for LOCTs and DHS Brochure on CDTI for LOCTs, DHS, FtrS and CDDs Pocket treatrnent guide Flip chart and posters Samples of measuring sticks Village treatment registers (samples) Mectizan summary sheets, reaction guides and duty specifications for each cadre of health staffand CDDs Mectizan transfer forms a) b) c) d) e) 0 s) h) i) 9 :f 0) 3q -lID rn =E(o c m :f f, mI moo :f, =. -o(o @(.r) J' -\s(,l JJ) N) @ o) .}(,t(Jl N Ot{o -\(oo -\(n(Jt N) N)(,t J5 (Jt s (,t NN(l) (rlo @(o (oo l-lo(c){ I @N(o L (o (.r) -1, Nb(,ts I\) -s 5s { zcFql =* mzsz ?3>'n{-r 9* Efid* TD iTIfl zvl =mzC oC z =TD ?gH;citq(/,o{ ITI .n -3o s*tDtm-7tz B5or .9ff o II-{o 6)O =gs,$a o 'u oo 0l !l Iltll a -bA 'nC)(l3dd =!cL-glC)rc)(r, o o EL =!l o a I9!c) -:OL, :*=jP.= :Srmg.a = +o<r,68 e..ri 6' =:, =oGrtog .gdOEC'-4.^5E-t$Bd oJ(}T J o=te o.9.cooo oq. fao=s6qr ot6t d9o+o33Gr =E')o Jct Ettoo ctA9-{ o-@sBo!,oeEgJJorog6 aJO =J1 =_Dt31(Dog o c,(f a o Jg. a o o 3 3 : 6'o TABLE 4. DETAILED BREAKDOWN OF TRAINING ACTtVtTtES (OCTOBER {999 - SEPTEMBER 2000) SOCT 5 5 LOCT/PHC COORDINATORS 96 90 DHS 80 75 HFS 240 0 ENUGU CDDS 4,131 2,444 TOTAL 4,552 2,614 SOCT 4 4 LOCT/PHC COORDINATORS 96 89 DHS 80 90 HFS 180 327 CDDS 2,926 2,454 TOTAL 3,286 2,964 SOCT 5 5 LOCT/PHC COORDINATORS 45 50 DHS 45 50 HFS 90 192 EBONYI CDDS 2,960 1,931 TOTAL 3,145 2,228 100% 94% 94% 0% 59o/o 57olo 100% 93% 113% 182o/o 84% 90% 10a% 111% 111o/o 213o/o 65o/o 71% ANAMBRA t a) b) c) 1',' The use of the above materials was significantly result oriented. The performance of the CDDs indicates that they understood their roles in the CDTI implementation. This can be seen in their improvement in recording and reporting of inforrnation. They are also able to caliberate their sticks used in determining dosage. SUGGESTIONS FOR IMPROYEMENT OF QUALITY OF TRAINING OF HEALTH STAFF AND CDDs The following need to be done to improve the quality of training of health staffand CDDs: Provision of adequate training materials Use of posters printed in local languages Constant review of haining curriculum and yearly updating of knowledge MOBILIZATION AND HEALTH EDUCATION: A total of 3,466 villages were mobilized during this reporting period. In Enugu state, 1,377 villages were mobilized, Anambra state (1,062 villages) and Ebonyi state (1,027 villages). Successfirl mobilization and health education were crucial activities which created awareness of the problem of onchocerciasis at the state, LG& commtrrity and village levels, as well as solicit support and patonage of the entire citizens towards effective implementation of the confrol prograrnme. The ultimate aim was to have a sustained high demand for mectizan tablets for prevention of blindness due to onchocerciasis. Advocacy visits were made to top state and LGA goveflrment officials to acquaint them with the problem of onchocerciasis and the need for govemment at all levels to support the programme in various ways. l0 \-, Communities were mobilized with the help of District Health Supervisors, Health Facility Statr, the CDDs and members of VHCs using all available avenues both formal and informal and appropriate health education messages conveyed by use of a variety of culturally relevant media. The following measures are suggested to improve the performance of the project: (a) Continuous community mobilization (b)More realistic targets should be set for all components of the prograrnme taking all negative influences into consideration. USE OF MEDIA AND/OR OTHER LOCAL SYSTEMS Inforrnation is said to be effectively disseminated when the message relayed or transmitted has been coded {heard accepted} and the receptor {village} elicits a positive response. The channels used for disseminating information in the project varied from community to community and village to village. The methods used were: Radio, Television, Po sters, B rochu res, Newspaper pu blicatio ns, Pictures or photographs, Flipcharts, Handouts, Handbills and Calendars, Town criers, Church announcement, School announ cem ent, Vilta gelCo m munity Head slEzes, Villa ge Meetin g/Group Meetings RESULTS OF MOBILIZATION EFFORTS: The use of media and other local systems of disseminating information were very effective and gave satisfactory results from the I ll target villages- The effectiveness is reflected by the increased commitnent of the community leaders and distributors and the high degree of involvement of the communities and their willingness to commit available local resources to the distribution process. Furthermore, there were increased responses from isolated hamlets, which hitherto were not reached in the past. SUGGESTION FOR IMPROVEMENT ON MOBILIZATION: a) Increased logistic support particularly motorcycles for LGA staff participating in CDTI implementation. b) Provision of bicycles for health center staffinvolved in the CDTI implementation to enable them cover the villages more effectively. c) Use of mobile public address system for better ouheach of the population. t2 t. SECTION 3. TREATMENT COVERAGE: As shown on Table 6, atotal of 1,092,071 persons were treated in 2,717 villages with a population of 2,165,029 persons, giving a coverage of total population of heated villages of 50Yo. Treatnent is still ongoing and large quantrty of drugs are still in the field. The total population of endemic villages was obtained as 2,165,029 persons from a recent census that was conducted this year. The result of the census exercise is still being validated. Total eligible population is 1,674,983 persons, based on the data from treatrnent sunmary forrns. LEVEL OF ABSENTEEISM: The proportion of absenteeism and refusals is lower than expected in all the project areas. This situation is athibuted to the aggressive mobilization of the communities, perceived benefits of ivermectin and the high demand for it in all the endemic villages. In addition, the ability ofthe communities to recognize problems with distribution methods and modifr the methods accordingly contributed to low absenteeism recorded so far. REASONS FOR ABSENTEEISM: For those that are absent during freatment, the most corlmon reason given by them is "farming activity" which keeps them away from the community during distribution period. SUGGESTIONS ON ACTIONS TO BE TAKEN TO REACH ABSENTEEISM AND DEFAULTERS: There is need for the project to adjust the distribution period in line with the tradition of the area to avoid its coincidence with the fanning season. Where this is not possible, arrangement will be made to treat l3 \... them in the farm settlements. This :rrrangement is bound to be very successful and the project suggests that it should be applied in other projects. The issue of defaulters is more difficult to handle. Defaulters should be traced back to their residents for freatnent if they are still within the project area. But where they leave the area entirely for far away cities, it becomes very difficult to follow them up because of conshaints of tansportation cost involved. There are also some people who refuse the drugs for some reasons. For this group of persons, continuous education and mobilization will be applied. t4 { <E l-ti' rnD <rro..rn-@= =8mF ='- =NbT E9f,z E6ZI HErpiO-1m -g e5I= ve Eq6i 3fr d l1'!(o- rQ@omz3= .'c 8= tffi- a :i E il59S E €}E9, : -trF; E * €B = t ;=o O =o$siE{ 6 dr 3 3 *iq 6 sii E srI * 3q5 J :rg!.$r+f a 3 F3 = :i EEu : &=I 5 *: = C) cod. e :6q + :3r t E; fr i $sd 6 oH = = +=g &q(DN = =oq 8td rL'g +tsoo =0roI 3a{ ror -= o6I =.n(cI oo ( L, mzc oC rn(D ozI z TD7 {o{ r -to o)N (,{{ G' -s ct) ct) -1,o N){ l- o N){ l_(,{{ o O) N) I I I r., -5 (r) ct) N)o Ct)N) G)@(oo A ..4 -\, -.\ _\ r+1::E--. _- {o+ l- m TD ozI z TD7 mzCoC !.,{ ..1{ (o @N (Jt G)@ -1, -\(o -l o(0 No{ -l F -o @ o) N5p N N) 5 o)5ie o, G) o- o oo -l ='(Do o- o-(D +Joo 3.< ='(D(D o. o. o )oo -l+ ='oo o. (,t zr z t- (,t J,)(.,{5 o N)b(,ts (o N)o N\t -l{ (o @ N) (Jt (l) @ (o{ -l .A -l(o(lr N) o)(,r(x 5(,t ! @so -i -l Jot\t o 5O;< 3 rn= o c\ i=J 3 EE E= = $dE =F1, Gl .gAl.DI\t A*cLUE g.8[] =:t=I H.goQo JL' o3.'+i s !lo(D33.oOat -cr A-T'Oo!l -=Esd.* xOgag =cct { TDt- _mz9 m- =6o+cm D# EE rD=VcnD- s8 ed2wJ6@v{-rDto{<o m(oU, I -a omU!{ Noog { Ipr m J ={mvzrn o=r-S E2z, -l =orDogo EH8n16 (oA-rilci{ammU,!cilY= -: ID m n Noos { o{ r m @ oz z (p 7 mzC oC N{ .J{ (o @lv (,t (,*) @ .l(o ! N -l o) JrtoN(l) o)@ so(o @! (Jlo .} o) o)@ (o osos -lb,{ .}(0 @(..) (Jl !\)Io O) (.r) @o bo(rtO .F .s o(o !eo{ s .-\, -\b@ o) N)A o) \N N) 5(-r)5 il> o) G) ()to ss\o 6\ (Jt sc(rt @s s 90 @(o s 5FN(,t s {. L. llil tSECTION 4: STRENGTHS AND WEAKNESSES OF CDTI IMPLEMENTATION: HOIY CDDs PERFORM THEIR TASKS: From the progress made so far, CDTI approach is the only shategy that has addressed the declaration at AIma-Ata on Primary Health Care (PHC). Significant progress has been made in CDTI. CDDs CHOICE The CDTI approach gave the communities the opportunity to choose the type and number of CDDs required based on APOC criteria. So far, most of the CDDs chosen have demonstrated competence in the performance of their tasks. There is marked increase in coverage achieved and the CDDs demonstated apparent competence in the skills acquired. However, some CDDs were unable to cope with the training and illiterate ones were disqualified outright. The project has therefore taken necessary steps to provide guidelines to the corununities for selection of CDDs. C OMMU NI TY PARTI CI PATI O N There is increased willingness and involvement of many communities/villages to commit available local resources to the CDTI process. These communities happily plan and collect their drugs. The increase in the mrmber of CDDs has reduced the area and population covered by one person. the use of more CDDs definitely accelerates the time of distribution and coverage is enhanced. However, the level of commrmity input in some communities/villages is still very low even though they were involved right at the planning stage. There are also complaints about increased burden of compensation on the entire community as a result of increase in the number of CDDs involved in L- l5 the process. Furthennore, there is already growing rivalry and leadership problem in some communities arnong the multiple CDDs now being used per village. MECTIZAN MANAGEMENT AT THE COMMUNITY LEWL In terrrs of mectizan management, CDTI strategy provides for appropriate and accurate mectizan inventory down to the household level and the communities feel more flrlfilled as they now participate more actively in the planning and execution of the distribution process. They now determine the quantity of their own drugs and are wi[ing to collect them. They also decide on the method of disfribution. There were no difficulties in sending reports/records back to the invermectin collection points since the points are closer to the CDDs. The communities are huppy to take custody of their drugs, but the safety cannot be assured in times of community clashes. Although, supervision is done by the health staff, the village health committees assist in this component since the CDTI approach provides participatory opporhrnity to all segments involved in progrzlmme implementation. Monitoring of village registers is among the tasks perfonned by the VHCs. LEVEL OF IIYVOLVMENT OF STATES AND LGAs IN CDTI: Mobilization of states, LGAs and benefiting villages for acceptance, ownership and involvement in onchocerciasis control has been an integral part of the project's routine activities and has yielded some useful fruits. Despite the fact that the various partners are aware of their expected inputs to the implementation of CDTI, there is still inadequate l6 a) b) c) d) govemment counterpalt funding at state and LGA levels. States and local govemments release their personnel {whom they pay salaries} for CDTI activities. Local radio stations at state level support conununity mobilization. MAJOR ACHTEVEMENTS OF THE PROJECT: A solid fotrndation has been laid at the village level for the sustainabilrty of CDTI Communities now appreciate their roles in iverrrectin delivery More eligible persons are now receiving treatment with iverrnectin There is now adequate sensitization of endemic communities on CDTI CONSTRINTS AND CHALLENGES FOR THE NEXT TREATMENT CYCLE. Adequate training is to be given to the CDDs to enable them monitor and treat side-reactions properly Poor orientation and lack of commitment by some LGA staffdue to non-release of firnds by their LGAS and none/late payrnent of salaries resulting in poor attitude towards effective supervision- Because of the number of years required for unintemrpted treafinent, high attrition of CDDs is likely to be a concern. Villages have an added responsibrlity by involving more than one CDD because the burden of compensation is increased Ensure release of counterpart fund by state and LGAs Unstable politicat situation can lead to changes in political powers The greatest challenge for the next treatment cycle is to increase the coverage rate and level of involvement of the state and LGA in the prograrnme ( i) L ii) iii) iv) v) vi) vii) 17 viit) To increase the level of sensitization of endemic communities on CDTI Types of help needed from: (a) the government (b) A?OC monogement (c) other parties to be able to improve the GDTI process nut yeaf. a) From State Governments: Make as a matter of policy, annual budgetary provision and acfual release of funds towards onchocerciasis control b) From APOC ,) Improve the time release of flrnds to the project ii) More motorcycles and bicycles are needed to improve grass- root mobilization and supervision b) Other Parties: NGDO D To assist in community mobilization ii) To assist in advocacy at the state and LGA levels The aim of CDTI is to establish effective and self-sustainable community based ivennectin treatrnent throughout the endemic areas in the three states, the shength of CDTI in the project area lies in the cornmihnent of all those involved in the project and an excellent top-level advocacy stratery. Also, taining and skill hansfer to cDDs by health staff and the active participation and involvement ofthe health establishment in CDTI management at the district level is sine-qua-non to the success of sustainability. There is need to address the issue of transportation which is the greatest problem militating against effective supervision at LGA level. New project vehicles should be supplied to the project in order to meet up with the additional challenges of training and mobilization. There is also, t8 qurgent need to provide more motorcycles for field staffto enhance their mobilization efforts. \_ 19