Assessment of the CDTI program (CDTI-Community Directed Treatment with Ivermectin): April 26 - May 12, 1998)

JUN 24 ,98 g3:A5PM HB AFTF3 ONCHO UNIT 2AZ 5??3L57 AFRICAN PROGRAM FOR ONCHOCERCIASIS CONTROL(APoc) P,?,/L5 SDV / T. Aprricio-Grbara ASSESSMENT OF THE CDTI PROGRAM (CDTI-Communlty Dlrected Treatment with Ivermectin) ' (APril26 - MaY L2,1998) JUN 24 ,98 g3:ESPM t{B EFTF3 ONCHO UNIT 242 5??3757 Backgrourtd for the APOC Program 1. The African Program for Onchoceroiasis Conkol (APOC) is designed to be a cost- effective, regionalprograrn with a defined end-point. It involves up to 19 oounhies in Africa w6ere the disease Onchocerciasis (river blindness) is still endemic, The World Health Orga:rization (WHO) is the executiug agenoy of tlte program, and the Bank has tIe role of dotror coordination. T[e rnain prograrn activity involves distribution of Ivermectin (the drug that protects against the disease) by communities, with assistanoe from primary health care workers sn d Non-Goys1n1n ental Developtn etrt Orgsnizations (NCDOs), Z. APOC is a rnultiple partnership involvirtg participating governments and their affectcd communities, NGDOs. WHO, World Bettk, and other UN Agencies, In all APOC assisted counhies, the partnership is operationalised tJrrough the NOTFs in where governments and their pertners are all represented. The NOTFs should ellsure a tnitrimum coverage of 65% in keated communities to achieve elirnitration of Ouchocerciasis as a public health problern. 3. The program airns to: (i) distribute the drug Ivertnectin (Mectizan) to 50 million people, thereby protecting them from the devastating cotrsequenccs of the disease; and, (ii) establish sustainable comrnunity directed drug delivery systerns in each of the target counhies, Sustainabilify is particularly irnpoftant to this program, because tlte drug needs to be distributed annually for a minim ,,tm of 20125 years in order to maxirnize its effect against transmission of thc disease, thereby protectittg future generations against this disease. 4, CDTI is a r)ew approach for the delivery of Ivermectin to eligible persons. The CDTI approach coufers projcot ownership to the affected communities/villages. CDTI Workshop in Nalrobl 5, Among the main objcctives of the APOCNOTF Workshop were to: (i) provide a forum to discuss the philosophy of APOC and the coucopt of CDTI; (ii) agree on the modalities for establishing CDTI projects and discuss national plans fot CDTI; (iii) reach a common understalding on how to establish sustainable CDTI projects intogratcd into the existirtg healtlt care systcms of each oountry represented in the Wotkshop. 6, The APOC management made commeod&blo efforts to bring together different stakeholder groups from differeut partioipating countries despite tho very difficult prevailing conditions in sorne of the coqntries, mostspecially in southern Sudru, Groups of stakeholders included e.g,, government officials, NGOs, NGDOs, community health workers, medical docto16, and representatives frorn international institutions, 7. The workslrop was conducted professionally and in a highly participatory manner. All participants were very enthusiastic throughout the Worl<shop and perforrned all assigned tasks by the facilitators. t. In light of the proceedings of the Workshop, the recommendations to be made to the APOC Management arc the following. P.3/L5 2 JUt.l 24 '98 03:g7Pl1 tJB QFTF3 OtlcHo UllrT 202 5??3L57 Recommendations to APOC Management a To provide conrinuous guidance to atl APOC Proiects oil the CDTI approach, as well as lo privide technical support to the NOTFs in re-directing exisling progrants and/or establishing ney)s olles, To encourage the NOTFs to underline the imporlance oJ'gender in the proiects and to etnploy local women groups when possible and where available to slrenglhen womeh's Pdt/ticiPdtiok in the proiects; To minitor the intplementaliott of CDTI proiects in eqch of the counlry'members, o / /ac a Misslon to Malawi 9, The missiorr to Mala',vi rvas a follow-up to the APOC rnjssion to Uganda which l undertook in OctoberA,trovernber 1997. Both these missions were financed by thc Danish and Svvedish Trust Funds respeotil'ely, 10, The mission visited Malarvi between April 26 - May 7,1998, to pilot the use of participatory paethodology in the context of Ivermectin distribution within the generaI TOR of t]re mission. The team was composed of Dr, N. Baturnba, Medical Doctor / Ophthatmologist (Consultant); Ms. Lucy Chipeta, Sociologist, (Consultant); tvt.. A.F. Macheso, Public Health Specialist, (Milistry of Health / Consultatrt); and; Ms, J. Msuya, Health Specialist, (AFTF3)' I was tho team leader of tlie Mission. Gpneral urd specific TORs for the mission are included in Annex I . Reports sn fr,,[ission findings by each of t]re team members are included in Annex 2. ll. The Mission was assisted by APOC's NOTF Secretariat staff comprising Mr. P. Tambala. APOC's NationaI Coordinator; Mr. L.Sitirnn, pcputy Coordinator; Mr. F.Nkhotna, TrairringManager/SupervisorlandthreeFieldofficers,Mr'Makina,Mr.MpcrriandMr.Mizati. I2. The missiol held meetings with public hpalth institutions arrd visitcd local villages in trvo dislicts: Thyolo and Mwanza, out of tle seven districts affected by Onchocerciasis (Thyolo, Mwanza, Mulanje, Phalombo, part of Chirhdzulu, patt of Blantyre and part of Chikwawa districts). The mission met with Dr. J. Chinkhumba, DHO, and Dr, Somanje, DHO, and members of thoir district health managemetrt teams in Thyolo and Mwanza districts respectively. The mission also tnet with Dr. Miller, Tea Estatesl Medical Adviser, and with Mr. Barrow, Programs Director for International Eye Foundatiotr flEF). Methodology 13. The goal was to pitot the use of partioipatory rpethodology in the context of Ivcrmectin distribution. This approach was Eeen as a potentialrleans of building ownership of the APOC Program at the communify Ievel within the CDTT approach, 14. The rrrethodological frunework of tho mission was rnultidisciplinary and interdisciplinsry. Pafticipatory Monitoring & Evaluation (PM&E) methods aud tools were used- including: (i) revierv materials and background information ott participatory Processes and publio involvernent in the project; (ii) consults.tions rvith representatives of allstakeholder groups'of the projecti (iii) participant and non-participarrt observation techniques io the field; (iv) 3 I Th" T.a Estatcs is a major tea factory in the region JUN 24 '98 A3:ABPN t^IB FFTF3 ONCHO UNIT ZAZ 5??3L57 methodologioal tools from participetory rural appraisal (PRA) in the field; and, (v) discussions wiflr key-informants, and gender selected groups, 15. For cornpsrative purposes and similarly to the APOC mission in Uganda, the APOC mission in Malawi concentrated mainly on the four followitlg issues in connection to Ivermectin distribution irr local communitiesr (i) inoentivest (ii) supervision; (iii) informal health systems; and, (iv) repoding. 16. The communities visited by the mission were selocted according to the follorving ctiteria: (i) rnore/less cxposed; (ii) latger/smaller commuuities; (iii) more/less experience in the d istribution of Ivertnectin. 1'7 . Upon completion of fields visits, tnission preliminary fiudings were presented and discussed at wrap-up seminars in the districts, wjth the participation of stakeholder groups, Au Aid-memoire wss presented to the World Bank Resident Mission at tlte end of the Mission. 1t. As stated iu the TOR, atrd provided funding is made avsileble, findings of both the Uganda and the Mslarvi missions will be presented and discussed at a Iater stage in a one-day workshop in APOC headquarters iu Ouagadougou. Workshop participants to include: representatives of stakeholder groups including iruplemcrrting and funding agencies, health workers, NGOsNGDOs, and local/district level representatives. Onchocerclaels ln Malawi 19, Malawi, witii a population of I I million is estimated to have 600.000 people infected with Onchocercia'sis. The rnissiolr visited communities in two identified oncho-foci in the Southern region, encircling Thyolo and Mwanzs Distriots, Both Thyolo and Mwanza, ih southeast and southwest of Mslawi respeotively, are oncho-endemic border distriots along the international boundary with Mozambique, which is also a member of APOC, Tho largest number of population foeus at risk from Onchocerciasis in Malawi is in Thyolo district: 367 .985 (out of fi93a9; and that of Mwanza district is estimated to be at 48.859 (out of 50.130). APOC aud the CDTI approach ln Malawi 20. Iu the early 1980's authorities at tho tea cstates in Thyolo reported to the Minisky of Uedtm about increased incidence of human biting by the black flies, Theee fliee were known to be the vectors for Onchocerciasis infection. In I983, a WHO consultant carried out surveys to detertnine the extent of Onchocerciasis infection in Thyolo district. Results ef fl1e 5upveys showed that the propottion of the population infected by Onchocerciasis in Thyolo ranged from 40 - 72yo. Further studies in Neno, Mwanza district confirmed that local trarrsmission of Onchoceroiasis occured in that area. ?-7. Between l9Et and 1991, Community-based Ivermestin trials showed that the drug was highly efficacious in clearing parasite Ioad and relieving the signs and symptoms relating to Onchocercissis. The Intornationa[ Eye Foundatiotr started community based Treatment with Ivermectin in (CBTI) Tltyolo following these findings. 22. Following an invitstion by the Africar: Programme for Onohooerciasis Contol (APOC), Malawi joined the otgsnisation.in December, 1995. A NationalTask Force was formed and fuuds were secured frorn APOC for the enhancing implernentation of community based mass treatment P.5/15 4 JUN 24 '98 A3I18PI1 I^]B AFTF3 ONCHO UNIT ZA2 5??3757 using Ivermectin. Specifically, APOC advocates community directed rreatmgnt with Ivermectin (CDfI). Between December 1997 sfidJanuary 199t, the sum of US$30,000 was received to start CDfi aotivities. The Primary Heglth Care (PHC) syctem ln Malawi 23. In MalawiPrirnary Health Care (PHC) is seen as the basic philosophy behind health service delivery thus maintainiug hospital service as an integralpart of this systern, Accorrding to MinisUy of Health services u." froviJud at five levels: community, rural lrealth facility, distict hospital central and special servioes at community level which include training of village volunteers dealing with simple healtlr problems. 24, The PHC is seprnunity based a1d involves provision of services for mothers snd children and a range of services concerned with nutrition arrd child spacing and a range of priority disease prog6r,.". such as AIDS, It also provides oo-ordination between all parfiers in the heslth sector. tlr" ,ou".uge of the PHC should include the Orrchocercissis programme. Sitrce the programme is co-ordinsted by APOC, it should be incorporated within the PHC system.In this case PHC instruments could be utilised to sensitise the commurrity on the Oncho, Integration of PHC activities and DDTI project willhelp strengthen tho irnplomentation of tho project' ZS, The Ministry of Health and Population of Malawi has a five year Onoltoceroiasis control program, based on it. Cpn approach, to eliminate tlte disease as a public health problern. (See the CDTI structure within the Primary Health Care System (PHC) in Malawi in Annex 3' Integration of CDTI into de the Formal Health Servlce Delivery System ?,6. Integration of CDTI re quires a shift from implementatiott of activities in a vertioal fashiou. It alio calls for i[volvement of all the relevant health psrsofluel irr the official health system. Except for the fact that the Thyolo and Mwanza District Health Officers arc msrnbers of the CDTI Task Force aud that the Thyolo Dishict EnvironmentalHealth Officer @EHO) ie the primary Health Caro and CDTI Co-ordinator, their invotvcmont in planning and implementation of CD{I appear to be very limited. In atl the health facilities visited, thero have been expression of concern that nurses and clinical health personnel ate not involvcd in CDTI aotivities. 27, Ordering and delivery of the drug to the CDDs is cunently,dircctly fiom the CDTI searetariat to the community, ffiey are not deliverod through the dishiot pharmacy and the health cen6es. In addition, taining activities for the different cadres in both Thyolo and Mwanza districts are carried out by members of the CDTI seuetariat and the field officers' Zt, Although the DEHO is the CDTI co-ordinator, he does not receive reports about CDTI gctivities, The DBHO is not involved in supervisory aotivities relating to CDTI. Between 1991 and I 995, there had been a steady increaso in treatment covcrage from 2.5Yo irt l99l to t7 ,44Yo in 1995. However, during 199?, treaftnent coverage decreased by 2l%. This decrease is thought to be due to the fact that Medipal Assistants / Clinioal Officers in Charge of health cenhes witliheld the drug apparently beosuse they wore rrot involved in CDTI activities. This is a good signal of the need to integrate and involve health personnel in tlte health system, P.6/75 5 JUN 24 '98 E3:11PI'1 I^IB AFTF3 ONCHO UNIT 242 52?3L57 Recommendation a CDTI activities should be integrated into the health dellvery system; the disnlct health *oiogr^rrt ledils should be given more role to plan and conduct CDTI activities, the Field Offtcirs and members o/the NOFT secretariat should onlyfacilitale od suppott disttict activities. P.7/15 CDTI and Stakeholder grouPs Zg, The APOC proposel shows that the four major players in the CDTI ProEta.mme are the Ministry of Health, Internetional Bye Foundation, the tea estates and the Christian Hospital Association of Mslawi (CHAM), ffrere appears to be close collaboration betrveen the national task force and the tea estates in irnplementation of activities, but there is very limited involvement of the other partrrers. The involvement of CTIAM is limited to proviaion of wotking base for the health s,r.rr"illuno. assistants. The International Eye Foundation worked closely with the rninistry of healtS and population in developing APOC proposal. However, there sre indications that the organisation'6 aoiivities in the Onchocerciasis control, including CDTI are boing scaled down. 30. A structure exists which can facilitate flow of information from the community to the district and the other health delivery levels. But there eppesrs to be no data reported on routine basis in both Thyolo and Mwanza which would be useful for determining the burden of Onchocerciseis, Nlumger oiolinical cases of Onchocerciasis in the districts is not kuow. Prevalence of blindncss related to Onchooerciasis is a.lso not known. However, the Dermatology MA at Thyolo indicated that up lo 30Y" of the ca-ses in his clinic is related to Onchooerciasis infection, A similar picture was rePofted for Neno area of Mwanza diskict' 31, IEF program director , Mr. John Barrow, infotmed the mission that thete is a partnership between the M,O,H., the NGDO, and the recipient communities. The role of eaoh of the Partners, ttowever, does not refleot cloarly in the financo contribution, planing, daily running, af,d implemeutstion of the Program. 32. In tho past IEF ptayed ths role of sole implementation organ. Later, aftel a bridging role in funding the prrcgram while writing for APOC's funds, the role is now reversed: the MOH implements, and IEF looks at repofts, co-signs chooks, but with no control ovor both the funds and field activities, 33. The role of CIIAM is timited to accommodating/availiug some of the HSAs who will be supervising the yet to train CDD, as well as providirtg room for storage of the drugs, 34, The tole of the Tea EEtEtes is limitcd to distributing tho drug during pay-day, The tea estate authoritics understand the bcnefit of Ivermoctin mass treatment to tho people in the comrnunity and the berrefit of employing healthy poople in regards to their own te& production. They give full support to the distribution by availing the health facilities and health personnel of the tea estate, Initially resistance to tsle the drug was high as the communities believed the drug was & contraceptive, But through health education, understanding of the disease has improved, and so the cornpliance. 6 JUN 24 ,98 A3:13PM L.JB AFTF3 ONCHO UTJIT ZAZ 5??37=7 P.B/75 Recommendation o fhere is urgent need lor the NOFT to PrcPdre q Memorandum of Understanding which will outline the roles onirrsporslbllities olMbHP, IEF, CHAM, Tea Eslate Management and rhe o lher partic iPat in g agenc ies. t The Malawi National Onchocerciasis Task Force (NOTF) need to develop lts own specific plan o/ action, tinking per/ormance to locql monitoring and evalualion indicators to lead to an integrated and sustainable CDTI Progranz' Community Awarenetl and thcir Perceptlon of the Diseage 35. The offrciai name of tfue drug used for rnass treahnent is Ivermeotin (Mectizan). in one of tlre viltages the drug was nickrsrfled"the one and ha{-tablet" referring fp the dosage the drug was adrninisf,red previously, The disease and its Eymptoms has different names in both the local languages and English, e,g, ,,Zokanda,' & "zokaildakanda" (local name describing any itching of the skin) "chipwilatt(local nune for the "simulium dqtnnosum" (black fly)) "mtssna mpcpo" (1ocu.l name describing any skil tash) tfiiphuwa" (local name for nodules) t'nkung4" (local name for blindness) "sungu" (local name for papules) 36, In Ctrichewa lalguage the disease is also known ai t'rtatendq atilariat' , and Onchocerciasis or filaria in the English language. 37. The communities visited in the two districts showed some knowledge of Onchocerciasis disease, however, the degree of awaroness varied arnong ttro people. For example the communities in th" iea estates Thyolo and Chikalema vitlage in Mwanza showed more awareness than Kasaila village in Thyolo. The two disfiicts' sommunitios showed that ttrey know the haditio-nal name for the diseaso. it w"s howover obaerved that the two districh had different locel hames for flre fly th* oause the disease as well as the dieease itself. 3t. The communities in both Mwanza and Thyolo Eeem to have been sware of the various symptoms of Onchocersiasie and associated the black fly bite with the itching disease, The mission also noted that some of the communities espeoially among the Mwanza communities stfiibuted tlle itching problem with etlrnical belief. One of theee beliefs was trrst cettain clans refrained from eating clftdn animals' meat which was regarded as a clan toteth, athibuting the consumption of tzboo-forbidden meats as a csuse of tl:e Onohocerciasis related symptoms. Thus providing oultural misconcsptions of the discase, However, the majotity of the people atttibuted the disease to the black fly. 39, The mission noted that the communitiss visited irr Chikalema village in Mwanzs and Kasarra village in Thyolo were not aware of the new progrenme of the CDTI, This clearly showed that tho progio*rn" had not yet bcen introduced, l'towever, when asked about iq they often confused it with tie existing programme of community based disfiibution directed by the Intemational Eye Foundation, TJre mission learnt that the communifies were very willing to pafticipate if the new CDTI was ingoduced because they thought it would be very convenient for them as the people disrributing the drugs would be right in the village. 7 JUN 24 '98 O3:14PN t-IB trFTF3 ONCHO UNIT ZAZ 5?23L57 P.9/L5 40. The communities were aware that a new system of drug dishibution wa.s in place and will soon be intoduced, and that there will be need to use cornmunity based volunteers and that Orese were to be selected by the community. The communities were willing to seleot the volunteers' In view of this the mission wanted to krrow somc of the qualities that the communify would look for in a volunteer. All the communities indicated the following qualiticsl honcsty, literacy, dedication, friendliness, as well as humbleness. It was noted with pleasure that some of the communities especially at kslaira had already submitted the nqmes of the volunteers for considoration. Tho community atso indicated oagerness towards haining for the new approach, 41. lrr the Tei Eststes and in ths two villages of Kass.ira in Thyolo and Chikalema in Mwanza, the mission noted that there are some cultural beliofs that were either detimental or positive to the irnplementation of the DDTI projeot, From discussion with the communities at all sites it was learned that the communities had misconeeptions as regards the use of tho drug, Some expressed fcars that the drrrg was interrdpd for birth control or likely to csuse impotency and infeftility. These were the initial sentiments of the community but it was learnt that after a few had taken the drug rnany more began to accePt it, 42.. T}e mission also observed that thosc that had taken the drug any got better acted as tools for installing change of attitude towards the drug in flre community. It wal DJso noted tltat some people accepted the drug not as a curotive or preventive drug for Oncho but as a multipurpose drug' One may understand that witir AIDS epidemic people take aay drug hoping it will ease theit ailment regardless of what it is. 43. It was generally observed thst there is vory liffle o-ordinstion between the stakeholdcrs involved in the healtlr related issues, lt has also been observed that flre CDDs are not yet in place in rnany ares.s Co-ordination between the stakeholdors should be strengthened and the CDDs instituted and trained to ensure a smooth implementation of the CDTI progammc, 44. The community's knowledge of the drug used in the mass heatmont, as well as the signs and symptoms of Onchoe€rciasis and modo of transmission is low. Evcn in the well experienced village, only a few individuals appeared to have some knowledge. If the targot population is not aware about thc disease, it is unlikely that they would partioipate in the mase hestment with enthusiasm. 45. It was roported that the HSAs in the tea estatee deliver health education talke eepecially during the time preceding drug disribution. The Chipwita Band is reported to be instrumontal in health education activities. However, it is not known how well theso sossions are conducted. At all the health facilities visited, there were no IBC matorials on Onchocerciasis. The mission suggests to conduct I(AP exercises in thc communities relating to Onohocerciasis sfld use the findings to develop IEC materials, Other ways of disseminating information should likewise be explored and used. Incidence of Ocular Oncho in the communlfies 46. Blindness to the level of social dependen* is very rarely seen sincc the year 19t3. But many people in the community hsve yarious degtee of visual impairment: Inoluding severe visual irnpairment. (On the weekly routine rryork visit to the rural health centots, the DHO confirmed E JUN 24 '98 A3:16PI1 I^IB FFTF3 ONCHO UNIT 2AZ 5??31.57 P.7A/75 that the ophthalmic medical assistant gets usually lnoro patients with eye problem than the Dr would get during the same visit). 4j . One of the field workors observed that despite gettiug many people with ,isutl impairment, they do not detect the oculsr Oncho diseaso, but the ophthalmic specialist when available froquently sees the worm in the oyc and other ocular manifestation. 4t. Usual[y only 3Yo in forest Oncho (5-10% in savanna Oncho) of the Oncho infected population devtlop irreversible ocular cornplioations, On the oflrer hand it requires semi soit isti"at"d ophihatmio iltstruments (special tools e.g. Field portable slit lamp) and expertise to deiect the microscopic ocular changes. No epidemiological data were available on prevalenoe of uveitis and corneal oPacitY. Distribution of Ivermectin 4g. Two methods are used for distributions of the drug, either the people are given the drug at a gatSering^ or the drug is given at horne wlren the CDD malies a house to house distribution, Bot5 methodi app"u. to be working well and are useful considering the different types of settlement of the target pdpulation. The house to house distribution may be useful in the local villages arrd in t]re residential compounds of the tea estates. In the villages, house to house distribution may be the most.suitable irr order to maximise treatment ooverage, S0. For an effective mass distribution of Ivermectin in the communities co-operation between the various organ-isations dealing with health issues and integration of all stgkeholders in the programme is required, 51. The Ministry of Health plays a co-ordinsting role betwoen the donor community aud flre NSTF snd also assists in the provision of staff suoh as tlre Eovironmen6l Health Inspootors, Healtlr assistants, Health Surueitlance and office space and other services. Howovq it has been noted that it is not all the health personnel dealing with curative and prcvcntivc teafiuent that are involved. From the meetings with the District Heatth personnol it was obeerved that Eome of them, such as nufses and clinical personnel, are not involved in the CDTI ptoject. In some instances the drug is not even available and y"t theso mcdical staffcome across pationts with Oncho in their work and would need to tr€at them. Sz. CHAM provides heslth servioos in Malawi. Malanrulo hospital provides office accommodation for the project officer at a cost, but apart ftom this service CHAM plays a Passive role in the programme. It is suggestod that lvermectin is supplied to them for curative putPoses; tSeir involvement in the program woutd also help to dieseminate information about the Oncho disease to their patients' 53. The rolc qf the InternatioualEye Pourdation (IEF) in the distribution of Iverm"cfu is more of an administrative natrue and it does not, as in the past, pafiicipates in the planning and implementariorr of the project. It is suggested that IEF be.fuIly involved in all activities, 54. The linking of the distribution of tho drug to a pay-day in the Tea Estates gavc a first improssion ttrat the distributiou was forceful, However, wiflrout rejecting tlte element of coerciorL ftre delivery is wcll done and in an orderly manrer by a team of estate nursing staff with good recordirrg. The distribution appeared wcll eusteined and fully integrated in the heslth delivery 9 JUN 24 '98 A3:17PN I^IB FFTF3 ONCHO UNIT ZOZ 5??3T57 system of the tea estate, The coercion wes thought justifiably by the fact that tlro Tea Bstate authorities understsnd the benefit of mass treutrn"ni to the people in the.com_munity ard the t"nufit of employing healthy people in regards to their own tea production' In Tea Bstates' Ivermectin is iistriuuica *ortly by health surveillance assistante, It is understood flrat the HSAs trained volgnteers who assist witir drug distribution in the estate compounds. In the villsges, selection of community directed distributort has just began, Irr K-asaila village, for cxamplc, E Cppg(4 males and 4 fernales) were appointed by fellow community members in February, 1998, after a low turn up at a meetfurg. Thesl have formed a CDD committee in a village with a village trealth committee. The plan is to have one CDD for evcry 250 persons of the target PoPulation' In Mwanza, the selection of the CDDs ltas not yet been made' 55, In t6e past,lvermectin tablets came in 6 mg preparation, This has since changed to 3 mg tablets, The later preparation may be better bscause there will be no need for breaking the tablots for the youngor age groups. These tablete are paskaged in bottles containing 500 tablets. Tllese have to be used within two months after openiug the bottle foil, after this period, the tablets loose potehoy, This calls for well planned distribution to minimise drug wastage. 56. Initiatly, at the time community based activities were implemented, flre dose of Ivermectin was calculated based on the weight of the pstient. 20 standing scales c-clibrated in pounds (lb) were used. But this was replaced by dose based orr height; a measuring stick was used to r,easure qre height of the peopie, But this was also discontinued after receiving reports of misconception from the community. The current practice is to calculate the dose using a more subjective measure of physical aPPeararce' 57 , One rnajor obstacle to effeotive delivery of Ivermectin especially during the first round of distribution is flie misconception that tlre drug is a contraceptive and./or sterilizer, Because of this. many poople refuse to take the tablets especially during the firat round of distribution in aa area, However,-resistance decline during subsequent rounds of dishibution' Supervirion of co mmuntty-di rcctod dletrlbutorr (CDDo) 58. The supervision is pcrceived as being still very low in both Kasaira Village in Thyolo and Chikalemgvillage in Mwanza whcre CDDs exist and have beeu dishibuting Ivermectin for 3 years under IEF support. 59, Supervision of the CDDs is required to make suro that Ivermectin is dishibutod to the whole commurity and thet records arc updated. 60. In the Tea Estates, Ivermectin is administered under supervision, Howsver, in ttre villages tlre teblets are distributed to be swallowed at home. All patients receiving the drug are regisiered, but no rocord is maintained indicating whether or not treatment is taken under supervision 6l . Based on the current plans, implementation of CDTIs will be in the Onchooerciasis endemic areas of Tfiyolo and Mwanza districts. In Thyolo alone, the eetimated population at risk is 500,000. In order to implement community bssed activities efliciently, there is need to do so in phases. Cu6ent implernentation plans do not appesr to have planned implemontation in a phased fashion. P . tt/L5 10 JUN 24 '98 A3:19PM I^IB trFTF3 ONCHO UNIT 2AZ 5??3157 P. L?/75 62. The mission suggests that effective monitoring/supervision mechanisms be put in place to ensure that the whole community receive tlre drugs. Monitorlng meihanisms of actually following up whether the drug has beon distributed and swallorved should be done from time to time. Recommendatious . To mmimise coveldge, consideration should be made to disfiibule lvermeetin at the heailh facilities in the target areas. In addition, ef.forrc should be made to always have lvetmectin for treating clinical cases in the endentic areas. Tlrc cohilnutti$ should be allowed to use the distribution method mosl convenient to them. . There is need to ensure that lyermectin is Mken in presence o/ the CDD. In addilion, it is necessdry that o column be added i4 the lreatnrcnt registel indlcating whether or not the veAtment has been taken under supervision. Informel Health Syrtems 63. Although most of the cbrnrnunity rnelnbers ste"ted thst there were no kaditional healers a1d gaditional birt.h attendants in both Thyolo snd Mwanza districtu, it is believed that these cadres exist in tfiese communities. It does lrot seem that these have any rolo in the keatment of Onchocerciasis. Training f,ctivitles 64, Training aotivities have been conducted for preparing the providers in commu:rity-bssed activities. The training has involved HSAs and the community providers, The HSAs receive 8 weeks of training before qualiffing as health sutveillance assistsnts. Itr- service training has been organised for HSAs and the duration of tlte course has been 2 - 3 days. The Field Training Officer is the person responsible for organising urd conducting training relating to CDT[. The Training Officer and the three Field Officers are allHealth Surveillance Assistants. 65. Some oommunity mombors at the Tea Estates indicated that the HSAS failed to answer technioal QUostions adequately. And the HSAs indioated that the 2-3 days of in service taining in Onchocerciasis for thc HSAs was not enough, 66. Training activities are not integrated. It appears ftat all the training is conducted by the NOTF secretsriat porsonnel and the Field Officers. For exarnple, tho training for HSAs conductsd in Mwanza was conducted by the Thyolo-based Field Officers. It is not clear whether or not training manuals are available for use during the hainirrg, 67, There appears to be s lotrg period fcir preparing and conducting training aotivify. In Kasaila village, for example, CDDs were appointed in February and 6re ready to sLart working but training has not yet taken plaoe. Recommendatlon . Arrangement and conduction of training should be speeded. Trainlng olTlainers should be conducted to allow each district have its own team of trainers: Tlaining nalerlals should be preparedfor use during fie training. 11 JUN 24 '98 A3I?APN HB AFTF3 ONCHO UNIT 2AZ 5??31'57 P.73/L5 Incentives 63. The District Health Management Team and the Onchocerciasis Control personnel indicated that policy on incentives for the cDDs should follow the polioy of the Government of Malawi, In the past, whon IEF was fully supporting tlre p1og1am, the organisation was providing walking allowance of K2O to the CBDs during dru! aietribution. This sPPearE to have been ,,"pp.i The DHMTs indicated that CDDs and other volunteers are told not to expect incoutives from outside their communitY. 69. The missio' wanted to know whether the communities would give any inoentives to the CDDS, The communities indicated that thoy would provide the incontives depending on the situation. Workers in the Tea Estate irdicsted that they pieferred the government to assist in form of sash to help the volunteets. .lo. All communities indicated their willingness to provide some foffn of incentives for the CDDs when neoessarY' jl. The role of the CDDs during the 10 - 1l rnonths following drug distribution is not clearly defined. In addition, it is not clear wliat the expectations of the cDDs will be for their participatio,. Information is also lacklng'to indicate what factors would contribute to retention or drop orrt of the CDDs. 72, As much as possible, CDD8 ("dispenscrs"2; should conrbine rhe role of Ivermeotin distribution and treatnent ofthe other illnesses, this will ensure that the cDD is active throughout the yearl, Reporting 73, The HSAs and cDDs have bocn compiling toPorE ospecially on the number of pople treated. These ,*porr, have bcon sent to the Intemationat Bye Foundation through the Field Offriors who are bascd a Malarnulo. A sampte of the registration and monthly summary forms wcre secn at one of thc Tec EEtates in Thyoio, The Thyolo and Mwanza distict hoalth ms'sgernent tesms do not recoivc any reports about Onohocsrciasis control activities in their ."rp.Jtiro districts. All thc reports go to tho IEF via the Field Officere' 74. It is suggeeted fltat the communities should bo assisted to develop meohanisms fot reporting progrEsE of implementation. Reports will have to be prepared and sent to the NOTF thiougir th" looal health facility and distriot health offioe' 2 At distriot level CDDg should be called 'dispcnsers' becsuse of thc fotlowing' At I rocent (Fcbruary 1998) symposiurn on fffi,-ttr" Oovernment oiVelawi decided to usc the term 'dispenssr' for community mcmbers storing and dispcnoing drugs' 12 JUN 24 '98 A3IZ?PY L-]B RFTF3 ONCHO UNIT 2AZ 5".?*3157 a Monitoring & Evaluation 75, Considering that the ultimate goal of APOC is to eradipate Onchocerciasis, monitorittg and evaluation s[ould be an important compohent of CDTI Programme. As muoh as possible, evaluation of the progralnme should be cotrduoted by independent ovaluators' ProceES' outcome and impact indicators should be developed and used to monitor Progfess of programme implemontation. 76. At t5e ,noment tfie Mission took place, names'of the people reoeiving the drug were entcred in a register for a data sheet maintained by the CDDs, Iuformatiou collected does not include observations regarding whetlrer or not the drr.rg is taken under suPervision. In addition, there appear to be not simpte methods of detecting Ivermectin rnetabolites in the urine which coutd be of much use for monitoring compliatrce , Summary of flte numbers of people treated are prepared and sent to IEF tlrrough tlie Field Officers. '11. Morritoring aotivities should include treatment coverage aud monitoring tJle side effects of Ivermectin. It is understood that forms for motritoring drLrg reaction ate availablo but these were not seen. Recommendatlon o Indicators should be developed/or monitoring implententation of the proiect,'Ihe monitoring should include compliance with h'eatment and impact of the activities on lhe disease. "Include drug taken ukder suPervision = YN. " Concluslons & Recommendations 7t. In the oommunities that the mission visited it was observed that they were not fully involved in the previous system because it was not community directed. This does not neoc'ssarily givo a sense of respotrsibilities to the community. It is expectod that the new approao6 of Cpff will be ableio involve the community as the approach is community dirocted. 79. For the community to be fully involved it is necesesry for it to bc cngaged in the planning process o.g. in the selection of the CDDs, implementation through suPervision 9lth.9 CDDS in ihe distribution of Iverpectin, as woll as orgauisation of the community in the distribution oamPaigns. 80, The CDTI progr&m has not yet fulty started, however mechanisms are sst on the ground to have it taking ofi' u.g. selsction of CDD candidates in some of thc areas, initialtraining of some of the HSAs .upurriroru. There is need for urgent and energetic start of the CDD training. 8l Main recommcndations: The process of implementqtion should be speeded up, e.g. training o/trainers, selection and training of CDDs', etc. Currenrly only the Environmetttal Health personnel are involved in CDTI activities. The mission lecommends that implementation of acrivities should also involve other health cadres than lhose involved. The dtvision oJ labor and responsibilitie,r wtthin the NOTF Secretarilt should be clearly deJined. P . t4/15 a a 13 JUN 24 '98 B3:31PI{ L,IE RF-TF3 ONCHO UNIT ZEZ 5??3L57 . A\OC rnanagemenf is b provide conlinuous guidance lo all APOC proiects on the CDTI ipproa"h, ai well aa to provide technical support to the NOTFs to re'direct eristlng programs and/or lo establish news ones, . lpoc management is to encotn.age the NoTFs, to wderline tlte importance of gender in lhe proJects ,nifo use local women groups phen posstble and Where available to Sl''onglhen womeil's parlicipation in the proiects' t2. Other recotnmendations inoluded in this repoft are: o CDTI actlvities should be integrated into the heqlth delivet! system; the district health mandgemenl leams should be given rtore role to plan and conduct CDTI aclivities. the Fleld O!ficirs and members of the NOFT tu"rrtartat shoultl unlyfacilitate and support district activities s There is yrgent need foT the NOFT ta prepare a Memorandunt ol Understanding which will outline the roles rrirurponribllities o/MOHP,IEF, CHAM, Tea Estate Management and the other p ar t ic ipattn g agenc i es, o To ffiaximise "ouJr{u, consideratlon should be made to dislribute lvennectirt ar lhe heallh facilities ln the targit dreds. Jn addition, eJforls should be nzade rc nlway,l have lvermealn 'Jor treating ctinicil cases tn the endemic areas, The communlty should be allowed use lhe distrlbution method mosl convenient lo thent' o There is need to ensttre that lvermectin is taken in presence of the CDD' In addition' it is nccessqry thal a colunm be adcled in lhe lreqlment register indicating whether or nol lhe fiedtmenl has been taken under superVislon . Arrangement and conducf ion of training should be speeded, Tlaining of Trainers should be cortdrctud to allow each district hatte ils own teant of tainers. Tlaining tfldterlals should be preparedfor use during the training. One appropriate namefor rhe bluckfly and/or the dlsease respectively should be identifled and promoted, t Jndicators should be developed for monitorilry implementation of the proJecl, The t monitoring should include compliance with treatment and impact of the qctivities on the disea.se. "Include drug laken under super'llslon = YN." . Decduse of CDTI is a new approach aimlng bolh to rcoilent existing projects attd to eslablish new ones, the APOC management needs lo npnitot the lmplementation of CDTI projects in 'each of the country-members. Next Steps 83. To enhance long-term susts,insbility of the progrsm, the Oncho-Unit irt cortjuuction with thc APOC rnEnagemont, HD units at tho Bank, and other partners, ehould continue to actively support rnonitoring and evaluation activities, lu support of an integrated and sustainable Program, best CDTI practices and lessons learnt from Malawi, will bc conveyed to APOC Partners at upcoming meetings related to CDTL E4, The focus will be on: (i) health education including training: (ii) program management including financisl srrsngoments; (tii) internal and external monitoring and evaluation; (iv) inclusivJness of partners i1CDTI;(v) integration of CDTI a"tiriti"s iuto existing health systems; (vi) communify ownership of the program from planning to reporting; (vii) gender aspects and involvement of women in CDT should be further explored. ? .I5/L5 14