CDTI SW II annual project technical report submitted to Technical Consultative Committee (TCC): January 2006 to December 2006

RE^SER VED FOR PROJECT LOGO/HEADING South West 2 CDTI Project Report 2006 - Year 6 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 NIRICAN PROGRAMME FOR ONCHOCERCTASTS CONTROL (APOC) t I rt n7'r;|/ '"i17 I i t o : CAMEROONOTFY/NCO : CDTI SW IIProiect Na me Approval yearz 1999 Launchins year: 2000 Frorn: January 2006Rerrortinq Period: th/Y To: December 2006 Month/Y(circleone) l2 3 4 5 (6)7 8 910Pro ear of tt re Date submitted: Janua 2007 NGDO partner: htsavers InternationalS ( \ ANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) ENDORSEME,NT Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the report: Country: CAMEROON National Coordinator Name: Dr. Ntep Marcelline Signature,. ..,.,,,k Dare: .7 l/p. l/ E (,F Provincial Delegate Name: Dr. Mafany Nji { u4,r,I .r'n;I +',J ,!,+t, :$ r", Signature Date NGDO Representative Name: Dr. Rosa Befidi- + . ,. a\r,-- '-. - ,.-_ -:..--. I ..- '':.+' 't ., )/ Signature: Date: ) Provincial Oncho Coordinator Name: Mr. Signature: Signature Date 3 >--c,o1- go Peter Oponde Date This report has been prepared by Name : Mr. Ebongo perer oponde Designation: SWII ffi H, *vlil* ll \\ HO APOC. ll Norernber l00J D.V. wa[+ Table of contents DEFINITIONS FOLLOW UP ON TCC RECOi\I}IE:{DATIONS EXECUTIVE SUMMARY V SECTION I: BACKGROUND INFORMATTONERROR! BOOKMARK NOT DEFINED l.l. GexeRnltNFoRN{ATtoN.........._.. l. l.l Desutption of the project (briefly,1 . l. 1.2. Partnership 1.2. Popu1nrroN............... SECTION 2: IMPLEMENTATION OF CDTr...... 2.1. TrpreurNE oF ACTrvrrrES ............2.2. Aovocecy 2.3. MosrLtzatroN. sENStrrzATIoN AND HEALTH2.4. CovtvtuNtry INVoLVEIVIENT......... 2.5. CepncrryBUILDrNG.. 2.6. TRenrpreNTs.............. 2.6.1. Treatmentfigures.......... 2.6.2 What are the causes of absenteeism? ...2.6.3 What are the reasons for refusats?....... 22 2.6.1 Briefly describe all knov,n andver 2.6.5. Trend of treatment achievementfrom 2.7. ORoeRruc, sroRAGE AND DELTvERy oF IVERMECTIN 262.8. couvuNrry sELF-rvroNrroRrNG nNo SrarceHoLDERS MEErrNc 282.9. SupeRvrsroN 29 2.9. t Provide aflow chart of supervision hierarc 29 2.9.2 What y,ere the main issues identified dur ing sttpervision? 292.9.3. Was a supervision checklist used? 29 2.9 1. tr|/hat w,ere the outcomes at each level of CDTI implementation supervision? 292.9.5. L[tas feedback given to2.9.6. How v,as the feedback 30 SECTION 3: SUPPORT TO CDTI the person or groups supervised? used to improve the overall performance of the project? 3. l. EqureveNr 3.2. FINeNctel coNTRIBUTIoNS oF THE pAR'rN-ERS AND cor\r\,{L,NITIES3.3. OrHe R FoRMS oF coiulluNrry suppoRT.............3.4. ExpeNotruRE pER ACTIvrry EDUCATION OF AT RISK COMMUNITIES I4 l5 l6 t9 I9 23 30 .................... 30 .................... 30 . ....... .....31 ............. ...,,32 ..,..........,....32 SECTION -I: SUSTAINABILITY OF CDTI 1. I. INTENN,.TIilrr*DEPE)JDENT PARTICIPATORY I\IONITORING: EI'ILURTION 1 l.l ll'as llonitoring'evulunti<tn carrietl out during the reporting periotl'? (tick an1, o./ rhe.lbllowing which are upplicubte).. . . . . ......... . JJJ 1.2. trI'hat tere [he re<.orrtrnendurions? . . . ... . ilJ 1 .3 l{tnr huye the), beerr rtnplenentetl., .. . . Jl1.2. SLs-t-rtr{BIt.tt'\' c)tr prtoJFC rs: pt-.{\ {\D sEl r-ARCETS (\rA\D{'roR\ .\T.............. i+ 'ni) ...... jl ...3{ ,,.34 serious adverse events (SAEs) that... 23 CDTI project inception to the curuent year 25 lu 1 I l. I'lunning ut ull relctunt l.;r'al.s ... . 3l 1 2.2 Futuls.. .. . 3J J 2.3 Tran.sport (rcplacentent <pul mai,?tenunce). ... . ... .. .. ... . Ji 12.J. Other resource.\ Jj 12 5. To :r.hut extent hu,; thc ltlan been intplentented.......... . . ..... .......... Ji4.3. Ixrecn..rrro\ ...... .................. i5 4 3.1. Irermectitt deliverl ntcchunisntr.. ............ . . .... . Jj 13 2. Training. ... ........ Jj 1.3.3. Joinl .supet'vi.sion qnd monitrtringvith other programs....... ... ....... .. 35 4.3.1. Releu.se oJ-funds lor project qctir'ilies ................ 364.3.5. Is CDTI included in the PHC budget? .............. ................. 36 4.3.6. Describe other health prc,grammes th(tt are using the CDTI structure and hov, this v,a.s achiered. Il'hat have been the achievements?............. .. .... 36 4.3.7. Desuibe others i.Esues considered in the integration of CDTI. ..... 36 4.4. OpennTroNAL RESEARCH ..... 36 4.4. 1 . Sumrnarize in not more thcn one half of a pqge the operational research undertaken in the project area within the reporting period. . . . 36 4.4.2. How were the results appiied in the project?............. .................... 36 SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, AND OPPORTUNITIES 37 38SECTION 6: UNIQUE FEATURES OF THE PROJECT/OTHER MATTERS........... l\ Acronyms APOC ATO ATrO CBO CDD CDTI CSM LGA MOH NGDO NGO NOTF PHC REMO SAE SHM TCC TOT UNICEF UTG wHo African Programme [or Onchocerciasis Control Annual Treatment Objective Annual Training Objective Community-Based Organi zation Community-Di rected Distributor Community-Directed Treatment u'ith Ivermectin Communi ty Self-Monitori ng Local Govemment Area Ministry of Health Non-Govemmental Development Organizati on Non-Govemmental Organization National Onchocerciasis Task Force Primary health care Rapid Epidemiological Mapping of Onchocerciasis Severe adverse event Stakeholders meeting Technical consultative Committee (Apoc scientific advisory group) Trainer of trainers United Nations Children's Fund Ultimate Treatment Goal World Health Organization :-'t;l iJ I YDefinitions (i) Total oopulation: the total population livins in mcso/h1'per-endemic communiries within the project area (based on REMO and census taking). Eligible population: calculated as 84/o of the toral population in meso/h5,per- endemic communities in the project area. (ii) (iii) Annual Treatment Objsctive: (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 covera&e: 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). (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 maximise 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) Sustainability: CDTI activities in an area are sustainable when they continue to function effectively for the foreseeable future, with high treatment coverage, integrated into the available healthcare service, with strong community ownership, using resources mobilised by the community and the government. (ix) Community self-monitoring (CSM): The process by which the community is empowered to oversee and monitor the performance of CDTI (or any community- based health intervention programme), with a view to ensuring that the programme is being executed in the way intended. It encourages the community to take full responsibilitl' of ivermectin distribution and make appropriate modifications rvhen necessary. il il \t a FOLLOW UP ON TCG RECOMMENDATIONS Using the table belorv, fill in the recommendations of the last TCC on the project and describe horv thev have been addressed. TCC session 23 r6t i1 1 3. 162. l. TCC agrees rvith the project that continued advocacy is important and suggests that the project makes a request to all partners (government, APOC, NGDO) for funds. The project should look tou'ard funding for key' adyocacv acti!'ities such as developing an advocacy' kit as funds rvill likel.r' not be available for the life of the This u'as done but due to the late submission of the budget to APOC it u,as not given aftention. The request for funds from the rarious partners for this activit)' for 1'ear seven has been done and on tinre. The minister of Public Health has requested tbr the submission o[ budgets of all CDTI activities. Hopefull.r' the governnrent ma.\' h'uraber ol Recommendoti sn in lhe R cport TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR TCC/APOCMGT USE ONLY The resubmitted report is j improved; was fairly well-written I and mostly complete, but a few I inconsistencies remain. The project staff and NOTF should ensure that in future a thorough review ofthe report is done before sending it to TCC. The project should make an effort to collect and report the financial data more completely so that a cost per treatment can be calculated. The project should verify and provide updated total population and treatment data considering that they noted some CDDs with held data when back-incentives rvere unpaid. The late reception of reports in year 5 from the lower levels was responsible for the inconsistencies found in the report. Since time was running out the provincial level hurried over it and NOTF was left with no time to cross check it. During a planning meeting in January 2006 involving all stakeholders as well as during supervision of CDTI activities in May 2006, emphasis was laid on prompt reporting and submission of accurate data. We have put in all efforts to ensure that this report does not have such inconsistencies. The report was not a resubmission. It must been mistaken for the South West I report. Health Districts were also requested during the above meeting in January 2006 to submit financial expenditure analysis after each activity to the project's Finance Officer. The finance officer was also requested to ensure that this is strictly followed. The OPC during his supervision stressed on documenting financial expenses incurred by the Health districts as well as motivation in kind or cash by the communities to CDDs. This remark was never made in South West II report. South West I project might have made the remark. reacI rtrve -t I I project ) i One CDD1267 people is not i enough. TCC suggests that the project recruit and double the number of CDDs, with a focus on finding and training more female CDDs. The NGDO coalition has developed an adr.ocacl'kit to parliamentarians for CDTI activities in the countrv. During the District Appraisal Meetings of year 5 (in 2005) anended bv the OPC SWtl, time rvas taken to calculate the number of CDDs per community for all the communities. One CDD for at most 125 persons was agreed upon. This year (2006), despite all efforts made to recruit more CDDs only 824 accepred to be trained and work, giving a ratio of I CDD to 280 population. Recruitment of female CDDs remains a problem. The health centre chiefs of posts have promised to continue sensitizing the community leaders to persuade females to get involved. Most males would not allow their wives to do mectizan distribution because they think it takes too much of their wives time and them to other men il i) t't .J I 63. ) I l. TCC agrees with the project that continued advocacy is important and suggests that the project makes a request to all partners (government, APOC, NGDO) for funds. The project should look forward refining their advocacy messages and strategy and develop tools that can be used for the years ahead. One CDD 1267 population seems an inadequate number of CDDs. TCC suggests that the project recruit and double the number of CDDs, with a focus on finding and training more female CDDs as only l57o of communities currently have female CDDs. This may reduce the workload and increase the satisfaction of the CDDs. Accepted. We shallwork with the supporting NGDO team to refine our strategies and messages. Already treated above (162.2) 2 1 I Executive Summary Prepare an Executive suntmory of the report in not more than one page. I . Background on treatment ond population data - Totol communilies, contmunities treated, total population, UTG, ATO and persons treated. 2. Background on population movements. 3. Training data - cDDS, heqlth workers, Total population (community) per cDD trained. 4. Challenges qnd how they were overcome. CDTI SWII project area has 7 health districts. The districts were increased from 5 to 7 in September 2005. The two new districts are Eyumojock and Wabane created from Mamfe and Fontem health districts respectively. We are therefore reporting on 7 districts distinctly unlike we did last year because the creation of the two new districts took place after treatment had taken place. The year 6 CDTI activities started with a 2 daysjoint planning and appraisal meeting in January 2006 at the Provincial Delegation of Public Health, Buea involving all District Medical Officers, Chiefs of Bureau Health, Chiefs of Bureau Administration and Finance, Provincial Team and the NGDO (SSI) staff. The participants were drawn from the two projects of CDTI SWI and SWII. After evaluating the ,activities of 2005, a plan of activities was drawn up for 2006. A total of 506 communities exist in the project area as against 504 reported last year due to a counting error. All the communities were treated giving a geographical coverage of IOO%. The population census update carried out by CDDs this year revealed a total population of 231,109 persons with 173,521persons treated in meso lhyper endemic communities giving a therapeutic coverage of 75.1%o against 72.9% last year. Also a total of 5,703 persons were treated in hypo endemic communities The Annual treatment objective and ultimate treatment goal was 184,887 and I 94,132 respectively. Population movements rvere minimal this year. This is because those areas where people move to other places for tbrming purposes were treated before they moved. Also in the plantations of Pamol Ndian, there r.r'as a change in management that adopted a policy reducing movement of labour staff. Training of health staff and CDDs took place in all the health districts. The training rvas along side that of primary eye care fbr both CDDs and nurses just as rvas done last year. This w'as intended to strengthen the integration of CDTI and Ey'e Care. Not as unexpected. some CDDs boy'cotted training. Others retirsed to carry out mectizan distribution even after training. Theirproblem uas late and inadequate financial motivation. \\/hen the government I J \ I moti\ation arrived. though late. somc CDDs returned to sork after thel's'ere paid for the t*'o previous )'ears. Some health districts like. Fontem had to retrain CDDs at different times i.e. after succeeding in convincing some of those rvho had boycotted. A total of 824 CDDs w'ere trained (727 males and 97 females). The total population per CDD stood at I CDD/280 persons as against lCDDl267 last year. We still did not meet the target of ICDD/ 125 persons. The challenges obsen ed or reported about during supervision were attrition of CDDs, insufficient funds, poor means of transportation and bad weather / roads. The payment of the 2004 CDD motivations and pre-financing of 2005 motivation packets by some Health Districts helped to reduce the rate of anrition of CDDs. Also prompt intervention by district .and provincial teams helped to persuade some CDDs to go back to work. It was very difficult to increase CDDs or replace some of those who boycotted. The available Sightsavers funding was used to offset some of the CDDsAIurses expenses during the training, although this was insufficient. The available motorbikes provided by the CDTI project and used for all health activities were repaired with the meagre health centre goverrrment funds and funds from other health projects. The early onset of the rainy season in some health districts affected the distribution of mectizan because farmers were busy trying to get certain jobs done in order to catch up with planting time. Insufficient staffing was a handicap in the implementation of activities as one staff was expected to carry out all the activities of the health area. This was partly responsible for late reporting of CDTI activities as most health area staffs were overwhelmed with the workload. Supervision of activities at all levels was greatly hindered by limited funds from goverrunent sources, given that the project is already in the post APOC funding period and is supposed to be sustained by local and not external furrds. However, some integrated supervision was carried out with funds from other health programmes and the NGDO when ever this was available. ''t ! l I ,J I 4 1 SEGTION {: Background information {.1. General information l.l.l Description of the project (briefly) - Geographical loccttion, rcpography, climate Population: act ivities, cuhures, Ianguage Communication systems (roads ... ) Adminis trot io n s truc ture Health system & health core deltvery (provide the number of health posts/centers in the project orea if the information is available) Number of heolth staff in project area and number of heatth staff involved in CDTI activities. Location The South West Two (SW II) Project Area is made up of three administrative divisions(Ndian, Manyu and Lebialem) of the South West Province of the Republic of Cameroon. It now covers seven health districts (Mundemba, Ekondo Titi, Fontem, Mamfe, Akwaya, Eyumojock and Wabane). The last two health districts were recently created by a Ministerial Order. Most of this project area is characterised by dense and luxuriant equatorial forest except for part of Akwaya Health District especially towards the border with Njikwa in the North West Province and the border with the Republic of Nigeria, which has Savannah vegetation. SW il has a very harsh topography with many rolling hills and valleys. This renders the tenain very rough making accessibility difficult. In most of these valleys run fast flowing streams, providing good breeding grounds for the black fly, simulium. This area has two seasons; the hot dry and the wet seasons. The rainy seasons are usually long (April to mid November) during which the streams get flooded. The road network is very poor rvith all roads being earth roads. These roads get very slippery and muddy during the rainy season making work in the field difficult even with a four-wheel drive vehicle. To get to Akrvaya one has to go through the Republic of Nigeria and drive across large streams with no bridges and rough mountainous terrain. The main economic activity in this area is farming. Males are more concerned with cash crops, planting cocoa. coffee, and oil palms. The common food crops include plantains, cocoyams, cassava. yarns, groundnuts, maize and a rich varietl, of fruits and vegetable grorvn mostly by women. l I , l i l 5 !1 ( Toblel.I: Shouing administt'ottve units, heotth districts ond health oreas. Su bdivision/District Health District Health Area Ndian Ir'lundemba Isangelle Kombo ltindi Kombo Abedimo Idabato Toko Mundemba Mundemba Lipenja Madie Ngolo Isangelle Kombo Itindi Pamol Kombo Abedimo* Idabato* Ekondo Titi Bamusso Dikome Balue** Ekondo Titi Ekondo Titi Kumbe Balue Bamusso Bafaka Bissoro Bekumu Lobe Bekora Illor Manyu Mamfe Upper Banyang Eyumojock Mamfe Eyumojock Bachou Akagbe Kajifu Kendem Mamfe Tali Afap Ekok Eyumojock Kembong Ogurang* * * Akrvaya Akwaya Akwa Akwaya Amassi Bagundu Lebialem Alou Fontem Wabane Fontem Wabane Fontem Azi Essoh Attah Fonjumetarv Fotabong Menji Takwai Bamumbu Bechati Fotang Kupe / Muanenguba Nguti Mbetta* * * * Njungo**** *Kombo Abedinto and ldabato are health areas that are non-functional as the areas are fbund in disputed Bakassi arL'A \\ere occupied onlr br soldiers. No etfective cir ilian activit)' goes on there. Division it l ) I j 'l 6 ,'1 i 1 il 1 Ilosercr in.{,ugust 2006. the dispute betrreen Cameroon and Nigeria orer (he disputed area \\as resolred. Negotiations are going on to get the area become functional for all social activities. Because of,their maritime nature REA rvould need to be carried out to find out if oncho is actuallv a problem. **Dikume Balue is under Kumba Health District in South \\'est I Project Area. **+Ogurang health area is the onll' health area without a functional health unit in Eyumojock health district. lt has no motorable roads. The area can ontl' be accessed by trekking through dense equatorial forest across large streams. Health interventions in this area are done only through outreach and mobile health teams from the district health service at irregular intervals; mostly in the dry season. ****For the purpose of proximity' and accessibility, Mbetta and Njungo health areas in Kupe/Muanenguba division are administered by Fontem Health District in Lebiatem division. SW II is situated between latitude 5o 72' and 6o 30' north and longitude 8o 30' and 9o 45' east. As mentioned above this project area spans in three administrative divisions, consists of 7 health districts and 40 functional health areas. The health districts do not strictly follow the administrative units such that a health district or health area can cover more than one division or subdivision. The administrative headquarters of the province is Buea, situated in South West One (SW D Project Area SW I shares boundaries in the west with Nigeria, in particular Cross River, Taraba and Benue States. In the north it shares boundaries with the North West Province; in the east with the West Province; in the southeast with SW I and is bordered in the south by the Atlantic Ocean. 1.1.2. Partnership Partners involved in the implementation of South West II CDTI Project are the Government of Cameroon (Ministry of Public Health [MOH]), African Programme for Onchocerciasis Control (APOC), Sightsavers International and the Community. These partners all work in harmony for the smooth rururing of project activities. Table 1: Number of health staff involved in CDTI DistricULGA Numbcr of health staff involved in CDTI activities, Total Number of health staff in the cntire project rrea Br Number of health staIT involved in CDTI B2 Percentage Br=Brl Br *100 AXWAYA 28 I t2 42.86%62 EI(ONDO TITI 62 l8 29.0% EYTA{OJOCK 15 8 53.3% FONTEI\,I 52 30 57.6% NTAIUFE 5l 22 I I 13.L% IUUNDEIVIB.{ Gi 23 3{.396 \\'^{8.{\E IJ ll l00eo Total 289 t2i 4J.9ou 7 ) t.l. t 0Partnership - Indicate the partners intolved in project implementation at all levels [MoH, NG D Os hat io na l/ i nt e r nat io nol ), c om ntunit ies, I o cal or ganizat ions, e t c. J The partners involved in project implementation are the Community. Ministry of Health. Sightsavers International. APOC and Mectizan Donation Foundation. Describe overall working relationship ctmong partners, clearly indicating specific oreas of project qctivities (planning, supervision, advocacy, planning, mobilization, etc) where all partners are involved. THE COMMUNITY Community Leaders select CDDs in preparation for mectizan distribution and sensitize the population on the importance of taking mectizan. CDDs who are also community members mobilize, sensitize and distribute mectizan to their respective populations. Some communities pay transport fare for their CDDs to attend training sessions and motivate them in cash or kind. Either the CDD or a community member goes to the Health Centre to collect mectizan for its community just before mectizan distribution. The community members and especially CDDs participated in reporting side effects due to mectizan ingestion. For the last two years, some CDDs have also carried out visual acuity in their communities to detect community members with poor vision. They then referred cases with poor vision to their leading health centres for eventual follow up of the patients by the nurses/or ophthalmologists. THE MINISTRY OF HEALTH The Ministry of Health staff at all the levels (Health Area, Health District, Province and Central) do planning, advocacy, mobilization, sensitization and supervision of the Community Directed Treatment with Ivermectin (CDTI) activities. These write reports of all the activities carried out. At the end of the treatment period appraisal meetings are held at Health Area, District and Provincial levels. This year, however reporting from the health area and district levels was very slow. This also affected reporting from provincial level to the central level. At provincial level all requests of mectizan from the Health Districts were synthesized and forwarded to NOTF. NGDO Sightsavers International participated mainly in planning, advocacy and supervision of project activities. During the last provincial appraisal meeting in November 2006, the supporting NGO equally parti cipated actively. The Mectizan Donation Foundation supplied the quantity of mectizan requested for by the project and on time. Considering that APOC financial contribution ends in the fifth year of the project, financial contributions from APOC rvere minimal. The budget tbr year 6 indicated that APOC was going to finance some activities (trainings and supervision) most probably because she failed to finance some of those activities in 1'ear 5. Unfortunately, even this 6th year she still failed to make arailable all the budgeted tirnds. Houever. timds u'ere nrade available fbra computer that $as requested in the budget. I I I .) II I ) i 8 I I I I The relationship between the partners is quite cordial State plos, ,f *ry, to mobilize lhe state/region/district/LGA fucision-malcers, NGDOs, NGOs, CBOs, to assist in CDTI implementation For 2OO7 distribution period, the Health Distrias and Province intend to assist in intensifuing Health Educatioq Sensitizatiorl Advocacy and Mobilization (HSAM) in the I 12 communities wilh therapantic coverage of less thua 65%. It has been noticed tha there are communities which have persistently not improved their coverage for the last six y%rs. Considering that the health areas are poorly statred and have a lot of activities to @ver, support from the health districts and province in the area of mobilization and sensitization is expected to improve on the coverage. The Ministry of Public Health in Cameroon has identified areas of financing CDTI activities and instnrcted all the CDTI projects in the country to come up with budgeted plans of action for the financing of CDTI. During the joint CDTI Provincial Appraisal meeting held at in Buea for the two projects in the province on 3d and 46 November 2B6,the information was circulated to all the health districts. The health districts were requested to prepare budgeted plans of action with their heahh area personnel following the instructions of the Mnister of Public Health. The date line for zubmission ofthese budgeted plans of action is December 3f 2006. The health districts and health areas during their appraisals meetings discussed at length with community members on the role of each partner in the implementation of CDTI. Appeals were made to community members to ste,p up their motivation to CDDs and the District and Heahh teams to use all available resources in an integrted manner so as to achieve the expected rezults for all planned activities in their areas ofjurisdiction. 9 ?l \ : u 9 g\ i, -c, q) .is9ot\ q)\ '=r 1)v-sn.i !! .s\ '= ar :t! 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'-) , v Vl, = iL- - -z ., I I I u.,l at I a z = z = ,r' 1 Iilrl il Ii1 2.2. AdyoeecT Stote the mrmber of pokcy/decision makers mobilized at each relevort level during the current leor; lhe reason(s) for underaking the advrcaqt otd the outcome. Describe difianlties/constratnts beingfaced od rugestions on how to improve advxaq,- In the CDTI SWII project area, advocacy this year was geared towards administrdive (Senior Divisional Offrcers (SDOs) Divisional Officers (DOs), Mayors), Political, Religious Lraders, and Chiefs of Serrrices of various departments and vitlage chiefs. These live within the implementation area and have direct influence on their populations. All the 7 heahh districts including the health areas carried out mobilization of their decision makers. This was done during celebnations such as Youth day, Women's day, National Day, Chiefs meeting cultural festivities etc. Apart from Akwaya and Ekondo Titi health distrids that specified the number of persons mobilized during ttrose occasions, the rest of the heatth districts indicated only the categories of personnel mobilized as mentioned above. Akwaya and Ekondo Tito mobilized +f ant tOO persons respectively. It should be noted that it has become a routine for health districts to use the above occasions to disseminate information concerning all heahh activities about to take place during those periods. At provincial level, the Provincial Delegate of Public Health addressed all village chiefs of the South West Province during an annual conference held in Kumba on 24t November 2006. During that conference, the Provincial Delegate reiterated amongst other things, ttre role of chiefs and their communities in the CDTI and eye care prograrnmes; selection of CDDs for training on CDTI and pnmary eye care, motivation of CDDs, community mobilisation for upake of Mectizan@ and eye care services given their present accessibility and affordability. He appealed to the chiefs to collaborate with the staff of the health units in all health programmes, especially during outreach activitieg health campaigns etc for their own good. The reason for the advocacy is to continue to increase awareness on the importance of mectizan and so reduce refusals. When leaders of communities are convinced about an idea, it becomes easy for them to persuade their communities to buy the idea. Although refusals are still registered in all the communities, there is a gradual trend towards an increase number of people taking mectizan. This can be proven from the fact that we registered an over all coverage of 75.loh as against 72.9/o last year. This increase has been steady since 2003. This year an absolute figure of over 17.610 new people were treated. However, it was not easy to arrive at the above results. The perennial problems of insufficient funds and staff continue to linger on. The lack of means of trarsport is another headache especially now that the APOC, MOH and Sightsavers supplied motorbikes are old and breaking down very frequently. The integration of advocacy talks into routine occasions of community celebrations and meetings cuts down on financial expenses involved in the several movements to be done to meet the individuals concerned. Consequently this method shall continue to be used for advocacy ofthe category of personnel mentioned above. Funds that will be made available at all levels for health activities shall be used to maintain the motorbikes while hoping that APOC, MOH, and SSI shall support the project with new motorbikes, l3 -l i I 2.3. Mobiliz-ation, sensitization and health education of at risk commirnities Provide information on: - The use of media and,'or other local systems to disseminate information - Mobilization and health education of communities including women and minorities In most communities in this project area, mobilization, sensitization and health education of at risk communities was carried out in churches, social groups and during national and international events such as youth day, (l lth February) national day, (20th May) Women's day (8th March) chiefs meeting grouping large numbers of the population. nuring these eventi, either direct contact is used to pass on information, use of megaphones etc were used to mobilize and sensitize the population. In health districts like Mamfe and Akwaya a good number of people were treated during those occasions. During non-eventful days, town criers were used to rnobilize the population for sensitization. However, in Mamfe health district, there exists a local radio station (Voice of Manyu) which serves the main town and neighbouring villages. This radio station was very instrumental during this round of mectizan distribution in Mamfe town, especially towards the end of the distribution when it was used to inform the population that in two weeks mectizan would be withdrawn from the communities as the distribution period would have come to an end. Those who had not taken mectizan had to wait for the CDDs in their last round within the communities or meet them in their houses for their dose of Mectizan@. Because sensitization is carried out mostly where groups of people meet, women and minorities are reached similarly. Each group is targeted during its meeting time. School children and their teachers for example are met and sensitized in their various schools. - Response of target communtties/villages Most communities reacted positively to the sensitization although not all individuals come out at the same time to listen to messages. Because it is difficult to bring people together for health education the methods described above to meet the communities were employed in order to reach them. During these sessions a lot of questions were asked for clarification. All members of the community listen to announcements made by the town criers and sometimes ask them questions about the activity where information is not clear. - Accomplishments From the treatment data indicated in this report, there is every reason to think that the mobilization bore fruits as there is improvement in both the geographical and therapeutic cqverage. - Suggest v'qys to improve mobilization and sensitization of the target communities. For the 2007 mectizan distribution period. intensive HSAM should be carried out especially in the communities not yet achieving treatment coverage of 65%o. It has been obsen'ed that u'here the health area teams fail to convince people on the importance of mectizan, the district or provincial teams succeeded. The district team is most often handicapped to follorv-up the difficult communities because of lack of transport means. The provincial team has alr,r'ays succeeded in persuading communities to change their attitudes. The district and provincial teams have theretbre agreed to intensit-r' HSAIVI provided the means are available. Request tbr firnds for HS..\M have been tbruarded to APOC tbr tunding and that to the government rrill - I I l l I l+ ,-, l, I I soon be completed. It should be noted that APOC indicated that she can fund HSAI\,I actrr ities. 2.4. GommuniQr involyement Table 4: Communities participation in the CDTI Comment on: - Attendance offemale members of the community at health education meetings - In general, how do you rqte the participation of female members of the community meetings when CDTI issues qre being discussed (ottendance, participation in the discussion etc). - Incentives provided by communities for the CDDs - Attrition of CDDs Is attrition a problemfor the project? If yes, how is it addressed? - Other issues Generally speakin,e it was difficult to rally most of the communities in a single hall for health education. Women in particular find it difficult to mix with men in large groups to be talked to. Consequently occ4sions like womep's-day are used to educate the women. The churches and other social associations of rvomen r,vere used to address them. When met in these groups the women participate activelv. They ask questions and they are generally more receptive than the men. Up-till this moment, the issue of incentives to CDDs by the communities remains a hard nut to crack. Manl'communities believe that CDDs are adequately motivated by the government or other partners of the project. It has been rerv difficult to persuade most communities that CDDs are not ernplolees of government or c-rther partners. Hou'ever few'communities (in i!{amt-e and Erumujock health districts) have begun sivin-q incentives to their CDDs in the tbrm of cash. pa,r.ment of transport to meetincs. drinks. and exemption tiom commtrnitl' labour'. In Afap village (E5-trmojock health district) the CDDs are motivated at the -t i I -.) I Li rr :l I DistricULGA Numbcr of com munitics/villeges with community members ls supcrvisors Number of CDDs end thc communities involved Numbcr of communitics /villeges with femele CDDs Totel no. communities in the entirc project area I Numbcr with Percentage community mcmbers rs su pervisors B. Bs Be= By' ti. rl00 NI rlc CDDsl I Fcmale T'otel CDDs B7 Br Bt= B?+Br Number of communities with femelc CDDs Bro Pcrcentage Brr= Bto/8.* 100 AKWAYA 101 68 67 .3o/o 110 11 12r 10 9.9% EKONDO TITI 40 0 o% 69 16 85 13 32.5% EYUMOJOCK 32 0 Oo/o 57 6 63 4 t2.5% FONTEM 97 0 Oo/o 202 24 226 20 20.6% MAMFE 102 0 Oo/o 99 t2 111 t2 tt.7% MUNDEMBA 90 0 0o/o 88 10 98 10 lI.lo/o WABANE 44 0 o% ro2 18 t20 8 18.r% Total 506 68 13.4% 727 97 824 79 I5.6% I 2sp€cial functions for the community- In Fontern and Wabane health districts, community leaders in 8 health areas out of the I I either contributed money or gave food/or drinks to their CDDs. The rate of attrition of CDDs is increasing. The situation would have been worse had governmert not made available their incentives for 2004 shortly after training had taken place in the project area. [n 2005, it was planned to increase the number of CDDs to be trained for 2006 Mectizan distribution. This increase was going to be 1CDD to 125 persoilr to be treaed. Unfortunaely this objective cotrld not be dtained because of the plan by the CDDs to massively boycott CDTI activities if their motivation for 2OO4 and 20O5 were not paid. The payment of the 20O4 incentives and later that of the 2005 saved the situation. Some districts to prw{npt this scenario in the coming year, the 2005 incentive has been preserved to paid just before the 2007 mectizan distribution period. Also during the HSAM the aspect of communities motivating their CDDs will be an area to lay emphasis on. Communities would also be sensitized on the importance of respecting the mectizan distribwion days set aside so as to shorten the time to be taken by CDDs to treat their communities on time. The notion that CDDs are reasonably compensated by the government has to be wiped out. fupeals to governmed to pay the 20O6 incentives before the next disnibution tn 2AO7 would be made. Efforts would continue to be made to convince the communities to select more CDDs in order to s.rt down on the workload of CDDs treding more than 125 persons. It has been agreed with the hedth area and district teams that CDDs should be used for other heatth activities where incentives are paid as an encouragement for them to continue working. - Other isszes. The late payment of CDDs by government and non motivation by most communities makes the selection of New CDDs very dfficuh. No one would wart to go where others are refusing to work because of lack of incentives. The difEcult times and the emergenc€ of the purzuit for economic development and improvement of life styles is beginning to wipe away the lofty ideas of sacrifice that used to blossom in the villages. As already mentioned above, the cosmopolitan nature of the communities is beginning to erane community spirit and free services for the general good. 2.5. GaprciQl building Describe the adequacy of availoble loowledgeable manpower ot all levels Since the economio crisis showed its ugly face in Cameroon in the early nineties, the country stopped employment of heahh staff. Some staffwere even retrenched and those who went on retirement were never replaced. It was only three years ago that a few health staff were recruited as a result of acute shortage of staff Even this recruitment did not solve the problem of acute short4ge of staff. The problem of shortage of staff is more pronounced at the heahh uea level were the actual implementation of CDTI takes place. At the district and provincial levels, the situation is not so acute. As far as CDTI is concernd the available staffare quite knowledgeable at all levels. This is because the staffwere tained at the inception of the project and are retrained each year at the beginning of the distribution period. Any new stafftransferred to the project area is quickly trained and brought to the level of the colleagues. l I ) l I t6 j r-1 I ll'here frequenl lransfers of trained staff occur, state y'hat rhe project is doing, or itltends to do, to remedl'lhe situcttion Ohc most imporrant issue to describe is rrhar nlcasurcs \\crc taken to ensure adequate CDTI intplementation rrhere not enough knorrledqeable manporrer \\'as available or if staffs are frequentlt,transferred during the course of the campaign). This project does not suffer from frequent transfers of staff. Transfers have hardly taken place fo^r a p-1eny long time now. The main problem as already mentioned above is thit of shortage of staff at health area level. In Wabane health district however, a new District Medicil Officer (DMO) was transferred there when this district was created last year. He has never taken up duties there since then. Two health centre staff of Bamumbu health area in the same health district u'ere also transferred and replaced by one only. This staff is also always absent from her post. [n order to cover the district adequately for CDTI this year, the DMO of Fontem lrom rvhere Wabane health district was carved out has been assigned by the Provincial Delegate of Public Health for the South West to cater for all health activities of that district. During mectizan distribution this year, the DMO assigned a staff from Fontem health district to assist in CDTI activities in Bamumbu health area. il 17 rl @:E En B Eti;;?i€:X c 'ra t -iEoe9o ooi n=E E€€ ii;:EE€ BH€:IEE ETEEEE€ :EEf; EHE E t -e r i r..Hg EE ET E ESstE€ EE5s E be t o E gEEE }E I€EA gEE E BUF s aEg : .E: E;'5 f,8T€€€ BEo E 2eiE sr e*5 FE EE:EETi E€€E gE E5f EH 5E: EEEEEiE ;EEEEEE T;;E:gH EEEgg3g E5;;ErE; E X E S e t:a orsE r;6 + p c o o I s I oast- o *p 6u l6G s s o g\\\ o +l C, o E C) a F oo(g o rr, o ru IdoL. .luI+{(}. 1, q)E G, u)d c dLF .iir ol -olcllFI c{ -o r-GI o Jtr!lE-:+lt-v-X :l Is.iqv t------. !r :6 oa \c o -a r-6t & o oct O6t o 'ta aU o Lco EI z l) tr G:L e:t<u t- a{ o@ oo6l 6{t ao 't ar- o\c(\ .t(\t6 s9(p .(l €\oF \o vl Etu E a) a) AC' sv?c\\o o i * Fd I?rU6-=+hv.? ct o o o o o o o o ts---- o o o o o o o o (r) GI o u,LI .4G al L{gb r. Fr()l vq,oo :.E r- clOLAP a z U e tr .+ o o o o o ! EIt E a) 6) Eo s sG GI o\ $sq di* Es5 oo \o c.l c.l o\ (-. + + .f, o.l Gl \, \c 6l .+ t- C{\o o\ 'EloaElgd 4lrrd)f rf; oql EF 2A c)o 0tr U o\ <f € E €) E o) €) Ao s \a tt roO\ c\ 6t N ra-) Y-)F sq 6i{ ETYF-(5 aa \c \c a.t o F---- -----t tq + :f iGI (r) Gl E cl O ta o Fl 8t9a, E'e5! o L a)Eai zl U?F = .+ -.f t-cl o -l <) L G a >v IF F o o z o v s.l t{Fzo Er lrlz o > FI l-{ oF a o, E a) a) 4(, s s €(p C) -I I Table 6: Type of training undertaken - Any other comments No training on CSM took place for district and health area staffthis year. This is because it would have needed at least an extra day for this training and there were insufftcient funds for even the two day training on CDTI and Eye Care. There seems to be need for retraining to be carried out for this activity as almost all the districts except Akwaya did not make any effort to conduct meetings at community level. Even in Akwaya were some supervisors held some meetings with theircommunities, the communities were not ready to carry out community self monitoring. It may be necessary to have the health area staff trained again as it seems that they have forgottenthe approachtowards community self monitoring. 2.G. Treetments 2.6.1. Treetment figures If th.e prcject is rwt orhi.euing 100% geogaphiral aueroge and o minimum of 65% therapedic couero.ge or tlrc couera.ge rate is fluctuating, state th.e rectsotts and the planw being made to remedy this. In 2003 and 2004 the project achieved a l00%o geographical coverage. In 2005 it dropped to 99.8Yo geographical coverage. This year it has again returned to 10ff/o geographical coverage. I I I I Trainees Tpe of training CDDs Other ICommunity 1 members e.g Community supsrvisors Heahh Workers (frondine hcatfr h,cilities) MOH staffor Other Political [-eaders loor.rt"r""im Program EqnaP,€,lxrent x x x lbw to conduct Iftalth education x x x Management ofSAEs x x x csM x x x SHM Data collection x x x Dafaanalysis X x Report writing x x x Otters (specifir) I9 1 Regarding the therapeutic coverage. the project has steadilv maintained an ups'ard trend since 2003. Houever, nol all the health districts have maintained this trend. llundernba health district dropped fromT3oh coveraqe last year to 68.4% rhis vear. At the health area and community' levels also, there are communities that have never achieved 65% therapeutic coverage. The reason for this is persistent refusals due to cultural beliefs. hose communities (e.g Kotto Balue, Kumbe Balue etc in Ekondo Titi health district and Akpasang, Bekoko etc in Mundemba health district) belief that mectizan kills witches and wizards. In some other communities many people find it difficult to give up alcohol for 24 hours to enable them take mectizan. As a remedy to this situation, it was agreed during all appraisal meetings that all levels have to continue Health Education, Sensitization, Advocacy and Mobilizalion (HESAM). The province will assist the districts with poor perfiorrnance especially those that have never attained a therapeutic coverage of 65Yo. With financial assistance from govemment and APOC for this activity at all levels. it is hoped that there shall Be remarkable improvement. l j .i i l 20 oo c o EEE EE?EEA.EEtz cil sq(a o\ lt aFllI rlg |l) ct o oo Gt (l) oo oF ll) (rlk od) clk(, oo C,o E, o.(It L{o tU() c) e(uq) cl c) o(.1 o C)a eO F soo s ror- lt 8t ;l els EI xl *la stil Iil 39E; AO o oo o o o o o ;i l7rot€6t o\ca\o otr(n oo6t 6l(,lrGI t-r-rfl \o€(nGl o\tl('r(!t E a'Ee @6t6t o\ra € rn -t o\ c-\os GI6 r ca \o$ € al caiatt+ (a !GI s I ki e €P" gs 10c\e!+t.- 16o\ o\t-t- s € +rr \oo\ n € s ,.i r- s9 @\o s .,1 o\\o s Y)F €oE d,(\t d Eer 6rt r+ + an €6 dt o(r)q tfo o\ o\9 € c7) \o\o e.l|.) €6vl 6t at GlVI ctF AEE$ atfq c.t c.t c.t6 + o\ oc\ \o\o + c?i oF-\ort \ot-t e r* o *q \oC\ F.6(D !t G' o €ct)eoA A E. gE g€ EEF EBF o a od ca \t rrl at (.) .+ c! tal 6l r-o\N!+ (tr\oq olrl r.| o\c!(\l a\ ora(n ei c7) o\o ('l at I a d o I A cl .9o 'H p^ f,gE6oo 1Oo\oo \o €\oo soo \oo\oo 1Co\oo \oo\oo r€o\oo soo A r=B EE#E o o+ clo oo\ { = (\t(') r-o\ \oc 11 aEEs o o .+ o,lta t-6 clo Oo\ .+!f \aoYI a, 6) o06l I act o) +a tr E A o() EEg$E o * 6l c.t c- o\ (\lo o\ t.+ \oc Y') EO i5< t_ IE loozoV EI z trlt-2oll. Fl H otr I jz rn L GI <n c,oL. GI c, tr od6 liPv) € >rp ra EI aEcd c(t) E GIq)LF n-t ol -.ol(rtl FI '! 6lt-t A] frl l u) P a t< frl Fltr t'i z Nl,lh(J H E E oilH lek{a ,)z ot- ctl ra) @ €t- r.| \ot(t ti @ €t- tl@ r- az oa ffnFrF' .- t{53/il El tr tebla b)z ca 6 H tt)\o .+ @@s $ o\ r.|(\l (aoI.r|f) trUl-{ilH(n lriA tr F{ rf rdtr t-r F oozo M rq M() eo FH a EI t-{zo fr.{ FI E e a'1 Ell al EI frlil < .H() fElh oilr o (n ol c.t $ rn Fl Ho t< aa) a) S sSa o s{ q) ISS .lE' q) s ltq) A .s' llp D - E E FiaElrio Et e, ,tt tr .Cg fri .! lrlr 'b \ +ss\tErEtiEsaEsIS *€tll E!f,lr tortSE E$ i:.EE Sth. iS{ e EEs Ett , $E$EI $ST $r$it - .s 3ES s^t " EEi $E$E !:B t stA E E}E Eir"g f 3s "? q ss il il I I I I I I 2.6.2 Srbrt rre 6c ceus d ebrrtccirm? r Farming outsid.e their health ilistrict . Movement out of the district for business puq)oses . Fear of side effects causes some people to leave their houses during the distribution period. 2.6.3 Whet rre ttrc nerton3 for refusals? , Fear of side effects . Beluctance to stop alcohol even for one day. , Fear that mectizan kills witches and wizards ' Rumours that mectizan provokes the appearance of other diseases 2.6.4 Briefly describe all known end vcrified serious edvcrsc cvcnts (SAEs) that occurred during the rcporting pcriod end providc (in teblc t) thc rcquircd infomation when evailabla No SAEs occurred in the project area this year ln case the project did not have any cases of serious adverse everts (SAE) during this reporting p€riod, please tick in the box. 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'4.) ,o&O 5^F5S 00 F \o c'! r- \c &. \o 9 \c \o o\ n r- \oq(.l r- \o rir- LJ 'o ,o o<tq9 o52oEC50z2'o o- o c! o.\o aq oo o s \o \ 00s o\ (\q.l c.)r- rd =oE 6.2 c cl,= <.e A'rv oo 09 o s a.l n N .f n o\ rt\o c.l \o c.lr- 09 r- r- oo oo + oo aqe *E €.X o bo .od4<'=ll]t-= - o ts' d. 3: o .f F-- e 6 \o q c..l t-t \o \ oo co n @ c.1 € €q 6 N o\ - N o @(! = (.) '= E tr o(-) oo I Ll ti I o e s:;rl Oo\< e-o \o 6\ ,a; o\ \o c_) o\ o\ o\o o\ \o 09 o\ o\ \o EoQ $s g s't OoEl -o o\ ri o\ s n o\ o\ \oo\ o\ \o 09 o. o\ \o tIl o::3_ E 5 COE trtr=ii =E-i!z3- c.l €$ I c.l $ (\ v $ \o I! -= oE 5.2 j!-fl' -v oo @ s c! v (\ $ .(l O \o :o =4 -rd!>-oc> 9 a: +ui>. ll a='4.,.) - F'J ')= =!c? 3J € € $ o.l $ cl v tL] a.t (\ N a.l C.l rC c\l (-.1 6l F- C e'l 2.7. Ordering, storage and dclivery of ivermectin Mectizan@ ordered/applied for by - (please tick the qpr-opriate orswer) MOB UNICEil CIher (please sp€ciry) Mectizan@ delivered by - (pleas tick the appropriate answer) MOH tr I,NICEIt] NGDCI Other (please specifu) Pl.eose dzscribe lww Mectizan@ rs ord.ered and lww it gets tn the cornmunities Mectizan stock required for the year was calculatcd by level (health area and district). Collations of the provincial needs were made at the level of the province. This was then charnelled to the NOTF in Yaounde through the supportins NGDO. the NOTF then mad.e a combined ord.er for the countr5r, taking into consideration needs of this project area. The consiguee of this mectizan wa.s WHO WR in Yaounde. When the dmgs they are deared. from the port by WIIO and handed to the NOTF who then chan',els them to the provincial esseutial drugprogramme through the supporting NGDO. Table 10: Mecliun@ Inventory x WHOD NGDCI .t :i Stetc/District/L GA Number of Mcctizrno tablcts Rcqucsted Reoeivcd Ulcd Mem/hyper Used Evpo Lost Wrstcd Epircd f,3prining AKWAYA 7',1,417 77,417 74,315 o 155 0 0 2,947 EKONDO TITI 54,6E5 54,6E5 6,790 5,370 73 2,452 0 o E'TUMOIOfi( 47,(rco 47,ofi) 4t,ot7 5,7E8 t95 0 0 FONTEM 96,232 96,232 88,380 3,46t 426 0 0 MAMTE 109,308 109,36 9E,336 2,7E8 2U 0 0 7,920 MT,JNDE,IBA 60,000 60,000 45,591 83 t7E 2,441 0 11,707 WABAI.IE 55,124 55,t24 52,t39 0 101 0 0 2,884 TOTAL 49D,76 499,76 446.rffi flr4m t3e2 4#93 0 29,423 o 3,965 COMMENTS: 26 I l 't I 2 Total Mectizan received from MDP at start of 2006 419.000 Total balance of mectizan at end of 2005 distribution 94.691 Total tablets available at beginning of 2006 513.691 Total mectizan distributed in meso/h1per communities 44$.5G8 Total tablets losU 1.392 Total tablets wasted 4,893 Total tablets distributed in h1ryo communities 17,490 Totel teblets remeining at cnd of 2fi)6 distribution 4334t It should be notcd that while 29.423 teblets arc in the health districts, 13.925 tablets erc rt thc dnrg Progremme How are the rcmaining ivermectin tablets collected and where are they kept? Remaining tablets of ivermectin were collected from CDDs by the health centre nurse and returned to the heahh district. This year all tablets lspaining after distribution have been left in the health districts. List md brietly describe the activities uder ivermectin delivery thot are being cqried out by health care Wrsormel in the project uea. Provincial Lcvel: At this level, the Manager of the Essential Drug Programme (EDP) organised for the collection of Mectizan from the supporting NGDO to the provincial central drlg store at the project site. The cost of transporting these drugs from the NGDO office in Yaounde to the Essential Drug Programpe was bome by the NGDO. From this level, the districts were informed of the presence of mectizan in the province. The Essential Drug Programme then ensured the delivery of the mectizan to Health districts through the essential drug delivery system. Ecatth District Level: This level makes its request to the EDP and is supplied through the progremme's routine drug distribution system. Ilds level in turn informs the health area level of the availability of mectizan at the district service. Hcdth Arca level: The nurse in charge of the hedth area with his/her request goes and collects her mectizan from the health district. She in tum informs her communities of the availability of mectizan.at the health centre. Ihe nurse in turn supplies to CDDs the quantity requested for. At all the levels, a record is kept indicating the quantities supplied. The EDP even keeps a stock card for mectizan supplied to the project area and the health districts. Any other comments The community assigus their CDD to collect mectizan from the health centre I I I 27 n ll 2.8. CommuniQr self-monitoring and Stakeholders Meeting Has an1' training (of traincrs) for comrmrniq' sclf-monitoring bcen done in the projcct area? Yes. If so, When? The last training of trainers for Cummunity self-monitoring (CSM) was done in 2004. The provincial level staff were first trained in April 2OO4 and these trained the district and health area nurses in May and June 2004. The communities were unwilling to execute the activity because the monitors wanted to be paid just like the CDDs by the government. Some were of the opinion that the work the CDDs had done was okay and so was a waste of time for them. This year however, only some CDTI supervisors in Akwaya health district started working with some communities in their health areas and promised to submit the reports of the community self-monitoring which they have not done. A total of 7 communities were said to have been visited by the supervisors for community self-monitoring but no report of what the community did has been submitted up till the time of completing this report. All the communities in the project area are reluctant to carry out this activity. During the last district appraisal meetings, it was agreed that the nurses would be retrained on community self-monitoring as there was the impression that even the nurses had forgotten the steps to follow when carrying out this activity. Table I l: Community self-monitoring and Stakeholders Meeting (Add rows if needed) Describe how the results of the community self- monitoring and stakeholders meetings have affecteil project implementation or how they' v'ould be utilized during the next treatment cycle. lt l I I) District/ LGA Total # of communities/villages in the entire project area No of Communities that carried out self monitoring (CSfvD No of Communities that conducted stakeholders meeting (SIIN'I) AKryA_Y4 EKONDO TITI l0l 40 32 0 0 0 0 0 0EYUMOJOCK FONTEM 97 0 0 MAMFE 102 0 0 MUNDEMBA 90 0 0 WABANE 44 0 0 TOTAL 506 0 0 CSM was not done this I'ear 28 2.9, Supervision 2.9.1. Provide a florr chart of supen'ision hierarchv CENTRAL LEVEL . NOTF o NGDO PROVINCIAL LEVEL o Provincial Delegate o Provincial Chief of Service for Community Health . OnchocerciasisProjectCoordinator . Finance Officer HEALTH DISTRICT LEVEL . DistrictMedicalOfficer o Chief of Bureau Health . Chief of Bureau Administrative and Financial Affairs r Chief Medical Officer of District Hospital HEALTH AREA LEVEL . Health Centre Nurse COMMUNITY LEVEL o CDD o Community members (dialogde structures) 2.9.2. What were the main issues identified during supervision? l. Some CDDs refused to distribute mectizan after training 2. Late reports after activities were canied out at both district and health area levels 3. Checking of visual acuity was either poorly or not done by CDDs 4. Communities are not willing to carry out CSM 5. A reduction in the refusal rate 6. A slight increase in the absentee rate 7. Slight improvement in the motivation of CDDs by communities and the govemment 8. Health districts were generally better prepared for appraisal meetings this year 9. Improved management of mectizan 10. Supervision of activities w'as timid because of insufficient funds I l. Time line of activities was not respected by most healthdistricts. 2.9.3 Was a supervision checklist used? Checklists were used mostly by members of the district team 2.9.4. What rvere the outcomes at each level of CDTI implementation supen'ision? Identified problems rvere rectifled on the spot or later by the actors concerned. Areas of deficiencies u'ere given more attention during training in a bid to avoid past errors. Project activities n'ere u'ell implemented. 1 J 29 7 I 2.9.5. \\'as feedback given to the person or groups supen'ised? I:eedback s'as given to persons or groups supen'ised either r-erballi'on the spot. b1' telephone. text rnessages or bv written letters. Issues obsen'ed during supen,ision rtere reirerated during appraisal meetings. 2.9,5. How was the feedback used to improve the overall performance of the project? The districts reacted and corrected issues that needed correction, e.g. communities that had not been treated in Elumojock by May 2006 were treated after the feedback was given. This improved on the geographical and therapeutic coverage of the project area. Mectizan inventory improved this year compared to last year as a list of mectizan collected in 2006 and that remaining in 2005 was made and distributed to all the districts just before the end of the distribution period. There was an improvement of the coverage this year by 2%. SEGTION 3: Support to GDTI 3.'1. Equipment Table 12: Status of equipment (Please add more rows if necessary) *Condition of the equipment (F=Functional, CNFR=Currently non-firnctional but repairable, WO:Wrinen oft). NB. It u'as reported last )'ear that there u.as a far machine supplied by APOC to this project. \\'e are sorrl' fbr this error. The available fa.r machine supplied b1 APOC was meant tbr CDI-I SWI project. The ,eovernnrent supplied to Ekonclo Titi I'lealth District a brurd nerr 1'o1'ora Hilu.r (double cabin) 4x4 u'heel drive in Nfal 2006. a il t-t 'l I Source Type of equipment APOC MOH DISTRICT/ LGA NGDO Others No Conditron No Cond rtion No Conditron No. Condition No Condition l. Vehicle I F 2 F/CNF R I t F CNFR 0 0 0 0 2. Motor cycle(s) 20 F 7 F l2 3 F CNFR 5 6 F CNFR 3. Computer(s) 2 F 6 F 5 F 0 0 0 0 4. Printer(s) 2 F 5 F 5 F 0 0 0 0 5. Photocopier (s) 2 I F wo F CNFR 5 F 0 0 0 0 .6. Fax Machine(s)- 0 0 _l F 0 0 0 0 0 0 7. Others a) Laptop I F 0 0 0 0 0 0 0 0 b) c) 30 I I I I{ot 'does the project intend to maintain and replace eristing equipment and other matcrials? There is no clear cut policy put in place on replacement of equipment. The provincial level applies for equipment needs of the province on annual basis and waits for supply from the central level. Occasionally, some of the needs may be met rvhile at other times nothing is supplied. This year for instance,a4x4 Toyota Hilux (double cabin) was supplied to Ekondo Titi Health district in the South West II project area. This is first of its kind the project area has received since 1998. Regarding maintenance, the government makes provision for maintenance in the budget of the provincial level and health districts. This provision is however very minimal as cost of maintenance is usually very heavy due to the bad terrain (earth roads which become very muddy during the rainy season) the vehicles/motorbikes are subjected to. These funds plus those from the different health interventions are used for maintenance. The situation in the health areas is even worse as there is no allocation for maintenance. These use health centre fund (cost recovery) and funds from other health activities such as the Expanded Programme on Immunization (EPI) etc. to carry out maintenance of equipment. 3.2. Financial contributions of the partners and communities Table 13: Financial contributions by allpartners for the last three years If there are problems vith release oJ'counterpartfunds, hov'y,ere they,addressed? The onll'problem rvith the release of funds is that funds were released late. I\Iost of the counterpart funds rve leceive come flom the central level (\IoH) Ftrnds from this level cannot be easilr-influenced bv trs. ) I Contributor Yeer 4 (20041 Ycrr 5 (2005) Yczr 6 (2006') TOTAL Cash Budgeted (us$) TOTAL Cash Released (us$) TOTAL Cash Budgeted (us$) TOTAL Cash Released (US$) TOTAL Cash Budgeted (us$) TOTAL Cash Released (us$) MOH (Central + Provincial/State) 428 50,885 514 0 470 MOH (District/LGA) '7 t4 0 714 0 I,000 Local NGDO(s) ( if any) 0 0 0 0 0 NGDO partner(s) 46,486 39,558 26,'77 t 27,964 38,632 20,86 r Others 0 0 0 0 0 0 a) CDD motivation by MoH 0 7,302 o i 7.843 l 0 8.534 b) 0i 0 0 0 0 0 Communities 0 i 'i 0 0 0 0 0 APOC Trust Fund 62,022 5085 7 l8 83 17.t42 34.731 32.699 TOTAL I 08,508 I I 98.859 2 5.819 I 51.177 73.363 63.554 it ' Additionalcontment.s The health districts and health areas used funds from either their government credits or cost recovery. The problem here is that of documentation / allocation of the sums of money used for CDTI activities. lYe would like to recommend to APOC that the funds not released for the last two years be calculated and made available to the project in 2O07. This is because, it was not through the fault of the project that the funds were not released. 3.3. Other forms of community support - Describe (indicate forms of in-kind contributions of communities f ary) As stated before, there was an improvement of CDD motivation especially in kind this year. The communities that motivated their CDDs did so in form of food and drinks during mectizan distribution. 3.4. Expenditure per activityr Indicate in table 14, the amount expended during the reporting periodfor each activtty listed. Lltrite the dmount expended in US dollars using the current United Nations exchange rate to local curuency. Indicate exchange rate used The exchange rate used here is 525 FCFAruS$ a l I I I I .t I 2 _) Table l4: Indicarc hou'much the project spent for each activitv listed belorv during the reporting period Any comments or explanations? It should be noted that CDDs were paid for their 2004 and 2005 mectizan distribution a total of 3.891.130 FCFA and 4.117.500 FCFA at the beginning and at mid year respectively. fl 'l Activity Expenditure (S US) Source(s) of funding Drug delivery from NOTF HQ area to central collection point of c_g,!I!nqnily Mobilization and health education of communities Eeilfng of C!D. th staffat all levels _Qupgrvis_ing CDPq and distribution Internal of CDTI activities 4{yqgegy_visiqlqo_freelthql$_politicalautho_rities IEC materials Summary _(r9p94!go forms for treatment Vehicles/MotoJgy_clel/!i"yc!eS_Bqr!!g_!a!qe LqmeqEgqlpr,ne-n!(..g-"9ltpg!ql!-,ltl1r1ets9l9) I lCommunication 3,277 6,370 1,457 2.756 577 476 95 229 APOC SSI SSI SSI APOC SSI SSI APOC Planning evaluation meetings 2,328 SSI Others Insurance for vehicle Appraisal meetings 3.202 5,632 APOC APOC TOTAL 14,917 17,920 APOC SSI Total number of persons treated Meso/hyper: Hypo : TOTAL = 173,521 5,703 179,224 ) _') t I f, I I SEGTION 4: Sustainabitity of GDTI 4.1. lnternal; independent participatory monitoring; Evaluation 4.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable) Year I Participatory Independent monitoring Mid Term Sustainability Evaluation 5 year Sustainability Evaluation Internal Monitoring by NOTF Other Evaluation by other partners 4.1.2. What were the r€commendations? 4.1.3. How have they been implemented? 4.2, Sustainabillty of projects: plan and set targets (mandatory at Yr 3) Was the project evaluated during the reporting period?_No_ Was a sustainability plan lwitten?_ When was the sustainability p lan submitted? What arrangements have been made to sustain CDTI after APOC funding ceases in terms of: 4.2.1. Planning at all relevant levels Staffs at all levels have been trained to carry out planning. This is done from bottom to top that is, health area, health district and provincial levels on annual basis during appraisal meetings. The sustainability plan that was prepared in 2003 after the mid term evaluation covered three years, 2004, 2005 and 2006. The plans were revisited each year and revised were necessary. Planning has already become part and parcel of the health system and is carried out for all other activities and is likely going to continue. 1.2.2. Funds All the levels at provincial level are being instrtrcted to use the available government resoul'ces and resources from other programmes to carr)' out j1 il 1 a C ,activities in an integlated tnanner. Recentll', the Minister of Public Health instructed all tlie different levels in the countr]- to preparc budgeted plans of action for CDTI and submir to him. 4.2.3 Transport (replacementand maintenance) As already mentioned above under replacement of equipment, the situation is no different here. 4.2.4. Other resources 4.2.5. To rvhat extent has the plan been implemented Irrespective of the frnancial difficulties faced this year, the plan was implemented completely. All the activities planned were carried out except for community self- monitoring. 4.3. lntegration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration: 4.3.1. Ivermectindeliverymechanisms Ivermectin delivery system has already been explained elsewhere. However it should be noted that the essential drug programme is responsible for the collection of mectizan from Yaounde and distributed to the health districts through the same delivery mechanism used to deliver other drugs to all pharmacies in the province. From the health district, the health areas collect and distribute to CDDs who collect for their communities. 4.3.2. Training For the last two years, CDTI and Eye care training have usually taken place at the same time. Information about other programmes such as malaria control, EPI, Leprosy and Tuberculosis control are usually transmitted during this training session. There were times when coordination meetings were called in which all PHC activities were discussed and feedbacks given for any necessary improvement. This scenario is beginning to be practiced more frequently because of the limited staff available and workload they have to perform. 4.3.3. Joint supervision and monitoring with other programs Integrated supervision was observed in all the*health districts this year. Due to Iimited resources from Government coupled with insuffrcient staff, the districts and health areas carried out supervision of all activities in an integrated manner. This year in particular there were very little funds available for CDTI activities, hence funds allocated for supervision of other activities such as EPI, Leprosy and Tubercr.rlosis control were put in a common basket and used for joint supervision of activities. At the provincial level, the OPC used APOC and Sightsavers funds to carrl' out integrated supervision. I l 'l a 35 4.3.4. Release of funds for proiect activities The N,loH directll' releases no funds for CDTI implementation. APOC and Sightsavcrs funds rrere released from project sire. As mentioned above APOC funds released are not up to the total funds budgeted for the project. 4.3.5. Is CDTI included in the PHC budget? For now CDTI has not been included in the PHC budget at the implementation levels. The Minister of Health has however given instructions to all levels to come up with budgeted plans of action for CDTI and submit to him before the end of this year. 4.3.6. Describe other health programmes that are using the CDTI structure and horv this rvas achieved. What have been the achievements? The Eye Care programme started using the CDTI structure to reach the population via CDDs for checking of poor vision two years ago. The CDDs were trained at the same time with CDTI for eye care. During mobilization, sensitization, registration update and mectizan distribution, CDDs also sensitize and carry out visual acuity to detect poor vision and refer them accordingly. Other programmes such as Expanded Programme on Immunization (EPI), Leprosy Control, Tuberculosis Control, Malaria Control, HIV/AIDS etc use CDDs to enter the community and execute their programmes. The motorbikes supplied by APOC and SSI are used for the implementation of all health activities. The same motorbikes are maintained using the funds from the various programmes. The APOC Toyota 4x4 wheel drive allocated to the CDTI programme at provincial level was used by other programmes for supervision, transportation of equipment such as fridges, mosquito nets, and bicycles etc to the health districts in the province. Photocopiers supplied to the project at provincial level are used by the entire delegation of public health especially as that of the delegation is beyond repairs. The achievements have been quite wonderful. Cooperation between programme managers has improved; reaching the communities through CDDs has become easier for new programmes such as malaria control especially. All activities especially at health area level are easily executed because of the existence of the CDTI bikes. 4.3.7. Describe other issues considered in the integration of CDTI. At national level discussions are going on to introduce Sector Wide Approach '- -'(SWAp). This approach aims at putting togettter all -resources available for execution of all health activities. This would mean that no project suffers from Iack ofresources. 4.4. Operational research t.4.1. Summarize in not more than one half of a page the operational research undertaken in the project area u'ithin the reporting period. 1.1.2. Horr sere the results applied in the project? 6 l 1 36 I) o ,} SECTION 5: Strengths, weaknessesr challengest and opportunities List the strengths and v'eaknesses of CDTI implemenlcttion process List the challenge.s and indicate hou' they tere addressed. STRENGTHS More people are taking mectizan Government has paid CDD motivation up-to-date The integration process is beginning to take root. The project is recording an improvement in therapeutic coverage every year WEAKNESSES Community support to CDDs still very low Distribution of mectizan takes too long because of lack of cooperation from the community Failure of APOC to supply all funds budgeted for the project. Insufficient funds supplied by MOH Attrition of CDDs I Insufficient IEC materials for sensitization and health education. Many communities with less than 65% therapeutic coverage still exist. CHALLENGES: =+ Starting the distribution with little funds + Convincing of CDDs and supervisors to go ahead with activities while waiting for funds + Getting reports written and forwarded in time to the different levels + Improving on therapeutic coverage of communities that have never achieved 65% = Because of dwindling frnancial lesources, it is becoming more and more difficult for supervision to take place at all levels leading to sluggishness in implementation of activities. The above challenges were addressed as follows: Most health districts either pre-financed the activities while waiting for available funds or managed to convince the implementers to go ahead with their activities while waiting for funds. Government later paid CDDs their over due motivation and I good number of them decided to do distribution. During supervision by the district and province, emphasis was laid on the impoitance bf prompt reporting, type of reports expected and information required. Health area supervisors were requested to pay more attention to communities with low therapeutic coverage during their supetvision. Integrated supervision was done by district and provincial supervisors to cut down cost. For instance the OPC SWII supervised CDTI and Eye Care when using either funds from Eye Care or CDTI programme. The health districts also used any available funds to supervise all other activities at health area level. The hitch here is that the funds especiallf if coming from one programme ale usually insuffrcient to do effective supen'ision. I I a 37 1 I : SEGTION 6: Unique features of the proiecUother matters From 26-27 September 2006, African Ministers of health attended a special summit of panners of the African Programme for Onchocerciasis Control held in Yaounde, Cameroon to discuss the future of river blindness control in Africa. In compliance to the recommendations of that meeting the Minister of Public health of Cameroon has issued instructions to provincial and district levels to come up with budgeted plans of action for CDTI activities in the country and submit to the Minister. It is our hope that government shall respect these budgets. Once the government budgets for this programme, it will be the light of day for sustainability to gain grounds. f I ) -1 I t i8