Report on the Country Monitoring Visit to Tanzania, held from 15-30th October 2008

tWorld Health Organisation African Programme for Onchocerciasis Control -1 T ' q fl\ Report on the Country Monitoring Visit to Ta nzania, held from 15-30th October 2008 DRAFT By: Pius Mabuba Elias Kwesi Ester Mbutole November 2008 lTable of Contents ACKNOWLEDGEM ENTS ........ LIST OF ACRONYMS/ABBREVIATIONS EXECUTIVE SUMMARY..... 1. METHODOLOGY 2. BACKGROUND INFORMATION 3. HOUSEHOLDSURVEY.............. 4. SUCCESS STORIES -SUMMARY................. 5. SUSTAINABILITY 6. CONCLUSIONSAND RECOMMENDATIONS APPENDIX 1 _ TERMS OF REFERENCE OF THE MISSION: APPENDIX 2 _ HOUSEHOLD SURVEY FORM APPENDIX 3 _ LIST OF OFFICIALS AND COMMUNITY LEADERS MET APPENDIX 4 - LIST OF CDDS MET.. List of Charts Fig 1 - REMO Map of Tanzania, 2006 . Fig 2 - Map of Morogoro Region Fig 3 - Percentage of Community Members Treated in 2007. Fig 4 - Gender Disaggregation of Community Members Treated in 2007. Fig. 5 - Percentage of Community Members Treated in 2006. Fig. 6 - Percentage of Community Members with Adverse Reactions in 2007. Fig 7 - Percentage of Checked Household Members Giving lncorrect Answer for Tablets Colour. Fig 8 - Percentage of Checked Community Members Reporting lncorrect Dosage. Fig 9 - Proportions of Community Members not being treated for various reasons in 2007. List of Tables Table 1 - List of Communities (Sub-Villages) Surveyed.. . . .. Table 2: - List of CDTI Projects in Tanzania... ... Table 3 - Population of Districts of [Vlorogoro Region (2002) 2 4 5 ,7 .9 13 25 27 28 30 31 33 34 .9 11 14 15 17 18 19 21 .8 11 12 2 ACKNOWLEDGEMENTS The authors would like to thank the African Programme for Onchocerciasis Control (APOC) for the opportunity to carry out this mission. Particular thanks go to Dr Uche Amazigo, Dr Grace Fobi, Mr Aholou, Mme Patricia Mensah, Mme Antoinette Nana and Mme Emma Kalsany. We also thank Dr Grace Saguti and Dr Ritha Njau of the WHO - Dar office. The mission would not have succeeded without the close support of staff of MOHSW - NOCP especially Dr E. Kirumbi, Mr O. Kaitaba and Mr A. Kamanda, and the Morogoro Focus and Mahenge Focus CDTI project staff, especially Dr Kabodi, Mr Lugata, Dr Kasiga, and Mr Kilimba. To all of them we say thank you for your good job. Several CDTI Project Coordinators attended the focus group meeting organised at short notice during the mission - Dr Maggid - Tanga CDTI, Ms Nguruwe - Kilosa CDTI, Dr Asilia - Tukuyu CDTI, Dr Kassiga - Mahenge CDTI, Dr Kabuka - Ruvuma CDTI, and Dr Kabodi - Morogoro CDTI, the host. Their willingness and commitment is acknowledged. We also wish to thank our families for their moral support. J t LIST OF ACRONYMS/ABBREVIATIONS African Programme for Onchocerciasis Control Council Comprehensive Health Plan Community Directed Treatment with lvermectin Community Directed Distributor District Health Management Team District Onchocerciasis Coordinator District Onchocerciasis Teams District Medical Officer Front Line Health Facility Health Management lnformation System Health Education, Sensitisation, Advocacy, Mobilisation lnter Church Medical Assistance World Health Ministry of Health and SocialWelfare National lnstitute of Medical Research Non-Governmental Development Organisation National Onchocerciasis Control Programme National Onchocerciasis Task Force Project Coordinator Rapid Epidemiological Mapping of Onchocerciasis World Health Organisation WHO Country Representative Sight Savers I nternational Ultimate Treatment Goal APOC CCHP CDTI CDD CHMT DOC DOTs DMO FLHF HM IS HSAM IMA MOHSW NI[/R NGDO NOCP NOTF PC REMO WHO WR SSI UTG 4 EXECUTIVE SUMMARY This is the report of the APOC Country Monitoring Visit to Tanzania held from 15-30th October 2008. The purpose of the mission was to carry out monitoring of lvermectin Treatment in selected communities under Morogoro Focus and Mahenge Focus CDTI projects, and document success stories in the National Onchocerciasis Control Programme (NOCP) in the context of sustainability. The team carried out a household survey of 29 communities in the four districts covered by the two CDTI projects - l/vomero, Morogoro Rural, Ulanga and Kilombero. Discussions were held with NOTF/NOCP staff, regional and districts health officials, District Oncho Teams, comm un ity leaders and Comm u n ity-Di rected Distributors. Onchocerciasis is a major cause of blindness in many African countries. About half a million people are blind or visually impaired due to the disease. Onchocerciasis also causes ugly skin disease with depigmentation and severe unrelenting itching. At the core of APOC's strategy to eliminate the disease is CDTI - community-directed treatment with lvermectin. CDTI relies on active community participation to distribute lvermectin to people who need it. lt focuses on empowering communities to take responsibility for lvermectin delivery - deciding how, when and by whom the lvermectin treatment should be administered. According to the Rapid Epidemiological Mapping of Onchocerciasis (REMO) carried out in 1996-7, onchocerciasis is endemic in 14 out of the 120 districts of Tanzania. This was updated in 2006, and it is now estimated that o The number of communities in meso/hyper endemic areas is 5723 o The total population in meso/hyper endemic areas is 2,072,914 Morogoro Rural CDTI Project was launched in 2003 and implementation of CDTI activities commenced in 2004. The ultimate treatment goal (UTG) is 288,833. The sustainability evaluation was carried out in October 2008. Mahenge Focus CDTI Project was launched in 1907, with the sustainability evaluation undertaken in 2002.lts UTG is 390,870. The linvestigations at household level focused on various aspects of treatment with lvermectin including - continuity of treatment, therapeutic coverage in the last two treatment rounds, adverse reactions, dosage, and reasons for not being treated. It has been found that the overall therapeutic coverage in the communities surveyed in the two projects was 73.82o for 2007 and 68.2% for 2006. However, the community level disaggregation shows wide variations of between 45.2o/o and 94.4% in 2007 . This suggests that there is need for targeted action e.g. HSAM to ensure sufficiently high coverage for all com m un ities, particu larly targeti ng problematic households. There is also variation in therapeutic coverage in relation to gender - being consistently higher for females than for males - showing that it is important to take gender issues into consideration while implementing CDTI. This means that the different needs of women and men are considered at all stages of planning, implementing and evaluating CDTI activities. 5 The team met over 40 CDDs for both Morogoro CDTI and Mahenge Focus CDTI. They gave useful comments about CDTI such as importance of targeted, refresher training, need for continued HSAM at community level, and incentives. A focus group meeting of key NOCP and CDTI projects staff was held to discuss issues of sustainability in the programme, and identify key success stories The key success stories pertain to successful implementation of the national onchocerciasis control plan developed in 1997, co-implementation of CDTI with other health programmes, government financial contribution to the programme, inclusion of onchocerciasis control in district annual plans, and continuity of CDDs. However there is need for greater emphasis on sustainability, particularly in mobilizing financial and other resources necessary for CDTI after the APOC exit. Finally, the report makes a number of recommendations focussing on the key areas such as susta inability, improving thera peutic coverage and commu n ity ownersh ip. 6 1. METHODOLOGY The mission was carried out from 15-30th October 2008 as per the terms of reference shown in Appendix 1. At the beginning of the mission, a meeting was held with WR to brief him about the purpose of the mission. The Household Survey was carried out for 29 communities in the four districts covered by the Morogoro CDTI Project and Mahenge CDTI Project, namely Morogoro Rural, Mvomero, Ulanga and Kilombero. One community in Mvomero could not be surveyed due to time constraints. These communities were randomly selected based on information provided by the two projects. A focus group meeting was held with Project Coordinators of Tanga CDTI, Kilosa CDTI, Tukuyu CDTI, Mahenge CDTI, Ruvuma CDTI and Morogoro CDTI, together with the Acting National Onchocerciasis Control Programme Manager. lnterviews were held with the NOCP staff, Regional Medical Officer/District Medical Officers (or their representatives), and some DOTs, Discussions were also held with community leaders and CDDs during the visits to households in their communities The team also studied key reference documents listed in the report to get a full picture of the onchocerciasis control activities in the study area and in the country generally. 7 @Fo d, 9, o oz Jf z o Jf(L o(L s$ O) (f) f-oN N rtr)t- o(o(o N o, r @ O)(o $ roN o,N ro F zf = =oo o oz oYz N I.JJJ I.JJN 5 o c0 oJ - c) (,l = uJ LU LtJ =z =-O o(, Jl o{-rm< == o d o o o E, uJ o =oJ = z o F Jf o. o o- N O) ry r oo O) o rf- lO(o N @s@ co lr) (oo ro @o cf) F zf, = =oo m m Y = fF o v tJJJfY oz o (, @6 o(, z o E, oYfJ IUJ ,_ <-# 6*N= afY Fo e. 9,o otr o(, ot o = z o F Jf o- o o- NO NsN (o tr,N !t o) r tr) @$N ro(olo F zf = =oo LIJ TU =uJ o UJF - tU d) = (, z tu(, z YfJ =J zf lY =mv TU = m f LL Fo E, o o oE u.t =o = z o J :) o- o(L @$N Nt- @s o@ r N cf) CO o, cf) F zf = =oo V u I oo <= <-Y- >= J = Y co I O =N z = E o o) z)a a o(,, s I -of U) a .q .=c J E E oo o ,o -J I r o -ooF 2. BACKGROUND INFORMATION Onchocerciasis - or'river blindness' - is a parasitic disease caused by the filarial worm Onchocerca volvulus. lt is transmitted through the bites of infected Simulium blackflies, which breed in fast-flowing streams and rivers. Onchocerciasis is a major cause of blindness in many African countries. About half a million people are blind or visually impaired due to the disease. Onchocerciasis also causes ugly skin disease with depigmentation and severe unrelenting itching. The disease is chronic, nonfatal but causes a wide spectrum of skin lesions, from intense pruritis to gross changes in skin elasticity, resulting in hanging groins, lizard-like skin appearance, and colour changes such as patchy depigmentation "leopard skin" and dispigmentation. The most severe manifestations previously recognised were those associated with damaged eye tissues, which may lead to serious visual impairment and ultimate blindness, hence its common name "river blindness". As a public health problem, the disease is most closely associated with sub-Saharan Africa, but it is also prevalent in Yemen and Latin America. ln the past, fear of blindness led people to move away from the fertile river valleys in the African savannah, reducing agricultural productivity and increasing poverty Efforts at onchocerciasis control in Africa began with the aim of eliminating the disease through vector control. as a collaboration between WHO, the UN Development Programme, the World Bank, and the Food and Agriculture Organisation, using aircraft to spray pesticide over the infected areas. under the then Onchocerciasis Control Programme (OCP), launched in 1974. The African Programme for Onchocerciasis Control (APOC) was set up in 1995 to eliminate onchocerciasis as a disease of public health importance in endemic African countries that had not been included in the OCP. At the core of APOC's strategy to eliminate the disease is CDTI - community-directed treatment with lvermectin. CDTI relies on active community participation to distribute lvermectin treatment to people who need it, focusing on empowering communities to take responsibility for the medicine's delivery - deciding how, when and by whom the medicine should be administered, National Context Tanzania has a population of 34,443,603 according to the2002 population census. The country is divided into 26 administrative regions (21 on the Mainland and 5 onZanzibar) and 130 administrative districts. Each district is sub-divided into divisions, wards and villages. There are approximately 9,000 registered villages. According to Rapid Epidemiological Mapping of Onchocerciasis (REMO) carried out in 1996- 7, onchocerciasis is endemic in 14 out of the 120 districts of Tanzania. Based on this itwas estimated that the Ultimate Treatment Goal for the whole country is 1,310,000. This was 9 updated in 2006. and it is now estimated that . The number of communities in meso/hyper endemic areas is 5723 . The total population in meso/hyper endemic areas is 2,072,914 Characteristic of the Eastern African endemic countries, onchocerciasis in Tanzania is found in discrete foci, mainly on remote mountain slopes, from where it occasionally spreads onto the rolling plains extending from the foothills. The map below shows the endemic areas of the country. ! ir".+r .d lrr.HtlrtHl !;iwb*{{ rr grp {r h +d lre *!.'' rtir f FiJri rrn 'htsr wuecr I 6 fl e I}* PF .G-ltq,**:e?, '"m t$ir Figure 1 - REMO Map of Tanzania, 2006 The Tanzania National Onchocerciasis Control Programme was established by the Ministry of Health in 1997. The current list of onchocerciasis control projects in Tanzania is as follows l0 I .t , \'''r ' .;TEI L ttrrl rI " . -'"*"*""-=.d' ' r', a {-'"I n - Table 2: List of CDTI Projects in Tanzania Project Start of Mass Treatment Start of APOC Funding NGDO Partner Ruvuma 1992 1 998 SSI Tukuyu 1996 2000 SSI Kilosa 2001 2001 SSI and Rotary lnternational Morogoro Rural 2004 2003 SSI Tanga 2000 2000 HKI Mahenge 1992 1997 IMA Tunduru 2000 2004 SSI Morogoro Region: Morogoro region is located in the eastern part of Tanzania. The region comprises of six districts namely; Morogoro Rural, Kilosa Ulanga, Morogoro Urban, Kilombero and Mvomero. According to the 2002 National Population Census, the region had an estimated population of about 1,759,805 people with a growth rate of 2.60/o annually. Table 3 shows the population of each district. @ ilomber itosa Moro go vome Figure 2 - Map of Morogoro Region l1 Table 3 - Population of Districts of Morogoro Region (2002) Male Female Total Mvomero 131,256 129,269 260,525 ltlorogoro Urban 113,639 115,224 228,863 Ulanga 95,915 98,294 194,209 Kilombero 162,942 159,837 322,779 Morogoro Rural 129,285 134,635 263,920 Kilosa 244,201 245,312 489,513 Total 877,238 882,571 1,759,809 Morogoro Rural CDTI Project which covers two districts of Morogoro Rural and Mvomero is in its third year of CDTI activities implementation. The project was launched in 2003 and implementation of CDTI activities commenced in 2004. The total population in the project area is 594,066 while the population living in hyperand meso endemic areas is 328,814. The ultimate treatment goal (UTG) is 288,833. The sustainability evaluation was carried out in October 2008 Mahenge Focus CDTI Project was launched in 1997 and covers two districts - Ulanga and Kilombero. The total population of the affected area is 449,640 and the UTG is 390,870. The sustainability evaluation for this project was undertaken in2002. t2 3. HOUSEHOLD SURVEY The survey was conducted in 29 communities in Morogoro Focus and Mahenge Focus CDTI Projects using the standard survey form which is shown in Appendix 2. Following are the results of the survey: (i) Continuity of treatment: lvermectin treatment was provided in Morogoro Focus communities in 2004,2006 and 2007. The break in 2005 was due to unavailability of funds. lvermectin treatment for Mahenge Focus communities has been provided continuously since 1997, except for 2002 when there was a problem of clearing the drug for all CDTI projects to change in tax regulations regarding donated drugs (iii) Therapeutic Coverage: The percentage of household members treated in 2007 (last round of treatment) based on the household surveys is as follows: District Percentage Treated Mvomero 78.54 Morogoro 77.32 Morogoro Focus - Average 77.87 Kilombero 64.46 Ulanga 74.70 Mahenge Focus - Average 69.80 Overall - Average 73.82 The above treatment figures correspond wellwith the reported treatment coverage data for the two CDTI projects for2007, which wereT5o/o for Morogoro Focus CDTI and74o/ofor Mahenge Focus CDTI. This is based on the Annual Technical Reports of these projects for 2007. The percentage treatment for each community is shown in the chart below, which shows that the percentage varies from 45.2o/o and 94.4oh. Efforts are needed to make sure that treatment coverage for each community is above 65% l3 o o = =Cz = 1' m ao mz o m 1 m il o =Noo{ o N5o)@ONoooooo PERCENTAGE 'tr(a (.) I !o ts oI qr ao o o o 3 3 i'\ =o3o o a +o o o a. S Noo\5 %4.:,3 4rr,uO%* .w^ {; .'{;z :#, 7;: '^*; "& ,"$" "*% ,,, ((iv) Gender-disaggregated Treatment Coverage: Based on the gender distribution for the 2007 round of treatment in the Morogoro Focus communities, 76.5% of male members were treated compared with 78.5% for females. For the Mahenge Focus communities, the percentage of males treated was 71.3% while that for females was 73.6 percent. Overall for all communities, the percentages for males and females treated were about equal at74.2o/o and 75.9o/o respectively. 82.00 80.00 78.00 76.00 74.00 72.00 70.00 68.00 66.00 64.00 62.00 60.00 r PERCENTAGE MALES TREATED r PERCENTAGE FEMALES TREATED l MVOMERO MOROGORO KILOMBERO ULANGA OVERALL Figure 4 - Gender Disaggregation of Community Members Treated in 2007 l5 (v) Therapeutic Coverage in 2006: The percentage of household members treated in the 2006 round of treatment based on the household surveys was70.4o/o for Morogoro Focus CDTI communities and 66.6 for the Mahenge Focus communities, with an overall average of 68.2o/o. The community treatment data are shown in the figure below l6 .It Q ; I !o o oI 0r(a o o oo 3 3 \ =o3r o\6 :ldo o a. S Noo o){ PERCENTAGE TREATEE o JJ NSo)@ONoooooo o o C zI DCIVIA MKATA KIJIJINI MIIAIVIA CI-{AMBIKA MINIAZINI TVIAHARAKA JITEGEMEE NG\AAMBE LUKANGE TVIALANI MKUYUNI KIB\A'AYA MFUMBE MKAI\BA B KIDATU A IKULE ll m v o m zt o m o -Tl o o =CzI m @ m va -{v m -l m o =Nooo SAGATVAGANGA LUKOROT{GO MIALE ztGt{ALt MKUSI NKONGO I\AA'AYA IIZ;ELEZI CHILCMBOIA E\AI.JGA NIAIAENGE VIGO CHINI MBAGI.JIAJUU Cl\/ERALL ! m ! I --T F - - - -Fr- - n TT r-l I ITI !- m J. .! ,j E - E - ivi) Adverse reactions: The adverse reactions usually expected are itching, dizziness, headache, vomiting, swelling, or multiple reactions. Of the household members surveyed, about 2.4o/o had adverse reactions, mainly mild, and none had severe reactions requiring hospitalization. PERCENTAGE OF HOUSEHOLD MEMBERS WHO REPORTED GETTING ADVERSE REACTIONS DISTRICT Fig. 6 - Percentage of Community Members with Adverse Reactions in 2007 (vii) Response about colour of the drug (Mectizan) swallowed: Of the household members surveyed, about 1.1o/o gave an incorrect response regarding colour of the drug. However, it was realized by the monitoring team that many of those that got it wrong were confusing it with the colour of Albendazole and Vitamin A tablets which were also distributed during the year. 3.5 3 2.5 2 1.5 1 0.5 0 ]U(9 Fzt IJJotr lJJ o. .nso "f.FV .,P &o -ra$ .^oo-\\- =\o- -," l8 Ol n3[ P6f;O=ZFZJL-At lUB rfl3p6rt@{rjafr sfi6Pni EHEmlo o=mZnaa (Jlo PEFTCENTAGE N(,So o m n o o n o o o n o o @r nz 99 x F o @ m n o o T l .Ir Q\ I\o o=o q) Qo o -ro{ oo\o o.Iof co o J o o- o 35o a o s.5Q 5oo\ QJo 5q Eo d'\ i{G o U, oo os \o (viii) Correctness of Dosage: Of 255 household members checked for correct dosage based on their height, overall about 3.9% seems to have been given an incorrect dosage based on their response. However, it was pointed out that some of them may have forgotten the number of tablets given to them during the distribution, so this should not really be a cause for concern. The table below shows the number of people checked. 20 =oo frH l1'! n -oomo1 fiH =988s= #=rE IE4?Cn- g_= -rSqs =rD =mHd c)E .=B-x mg o PERCENTAGE otuso)@ o m no oTo o o vo o cnF v=9v x o (D m7o o mn T I I r I I I I I I TI Q a Ito dof, a)Qo o ai oJ ooxo o. ool 3 s5 ofu o a ToE of, =Q 5 ooto Uo U, o)Qo NJ (ix) Reasons for not being treated: Of those not taking the tablets in 2007, the highest proportions were for'Under 5' children (40.4%), absentees (25.4o/o) and refusals (15.2%) overall, as depicted in the graph below. The team found a few cases of whole households who did not take the tablets during 2007 and 2006 refused to take the drug for some for personal reasons. Some Morogoro CDTI community members reported getting adverse reactions such as swelling and itching in the first round of treatment in 2005 and decided not to take the drug in subsequent rounds. There is need for targeted sensitization to brig such household members on board. U) o J- m Jo o on .Tt ov v m @ oz CN '1'l o7 z o -{ @ m =o J n m -tm o z Noo -.t oo s PERCENTAGES FORVARIOUS REASONS FOR NOT BEING TREATED (o os @o s ..l os O)os rEt zoroo6J 'xfr1nov m o (,os IIDD o>.I,n -(pf,rm =cDmalbmoczz? -r>>zt -t so s (/) o s N)osos o s o mvo ovo o ovo o=6b =fidg C Fzo o m n l-r- tt TI(o (o It db of, o5(.r, o\ ool 3 J = o f,G o a =o o o 5Qtq) o o. d.' q) =.of U, d 0) U) of, u, =\)oo\ N)(/) L (x) General Observations: . Funds provided by the District Councils are not adequate for implementation of CDTI activities. . Onchocerciasis is not listed among the top ten priority disease in Morogoro region. . lnsufficient HSAM at community level, o There is inadequate sense of ownership in some communities manifesting in lack of incentives for CDDs . CDDs & FLHF staff are sometimes overloaded by the many parallel programmes . Both projects have competent and very committed staff; building up their capacity in critical areas will benefit the programme. . Some household members were absent during the visits and the team had to rely on the feedback provided by their parents. o Morogoro CDTI Project was undergoing sustainability evaluation at the same time so the host DOTS and PC were burdened by two teams of visitors. However, they coped quite well and went out of their way to successfully accommodate both missions. (xi) Comments by CDDs: The team met over 40 CDDs for both l\Iorogoro CDTI and Mahenge Focus CDTI. The team found nearly all of them to be very enthusiastic about their work as CDDs. Some of their comments and observations are given in the text box below. a CDDS COMMENTS: The work is tough as you have to convince people to take the drug and sometimes they are away in the farms and we follow them there The community leaders give me support which makes the work easier We need regular visits from FLHF staff to help explain some things to the community The government should consider providing us with bicycles to help us move around especially for large and widely-flung villages The project should give us posters and T-shirts as they are help us to disseminate information about Oncho APOC should continue bringing the drug as it is very beneficial. Some community members eagerly await arrival of the drug as it helps remove fungus and skin infection Need for increased advocacy at community level to continue support and incentives e.g. T-shirts, rain coats, umbrellas, etc More sensitization is required to tackle misconceptions IEC materials are needed Some of us have to cover large areas so more CDDs should be trained to share the work We need refresher training to keep us updated about CDTI and to be to explain to the community when asked We are faced with a challenge to reach school children as they are supposed to get the tablets ain the community, not the schoolas it was previously. a a a a a a a a a a 24 4. SUCCESS STORIES - SUMMARY The following success stories were identified during the focus group meeting of Project Coordinators and the NOCP staff: (i) The National onchocerciasis control Plan developed in 1997 has been successfully implemented, with 9 projects having been started. REMO has been completed in all oncho suspected areas. The CDTI projects were developed started as follows: Mahenge Focus - 1997; Ruvuma Focus - 1998; Tukuyu Focus - 2000; Tanga Focus - 2001; Kilosa - 2002; Morogoro Rural - 2003; Tunduru Focus -2004.1n addition, the Tukuyu Vector Elimination project started in 1999. (ii) The Ministry of Health and Socialwelfare has been allocating funds for onchocerciasis control at national level consistently for the last 6 years as follows 2001:50 million 2002:70 million 2003: 100 million 2005/6: 150 million 200617:120 million 200718:92 million (US$=Tanzania Shs 1 300) (iii) Kilosa CDTI Project has succeeded in maintaining their CDDs without any drop- outs over the last two years 2005-7. This is attributed to good selection procedures and motivation provided by the community. ln addition, the DOTs make a point of making close follow up of communities during distribution to provide support to the CDDs. The project has around2140 CDDs. (iv) There has been successful co-implementation of CDTI with bed nets in Kilosa CDTI in three wards - Zombo, Ulaya, and Kimamba in collaboration with Rotary lnternational and NIMR; and also for Vitamin A and Deworming in Zombo in collaboration with NIMR; Co-implementation with LF is in 37 wards; and for Zithromax distribution it is in all wards of the districts since 2004. (v) CDTI has been incorporated in all districts'Comprehensive Council Health Plans in Ruvuma CDTI Project for all the project districts - Mbinga, Namtumbo, Songea Rural and Ludewa. This achievement is based on effective sensitization of council leadership done as part of the Sustainability Evaluation in 2003. Now all the districts are routinely allocating and releasing funds for CDTI activities. The total amount released in 2007 for all four projects was around $10,250. (vi) Tanga CDTI has successfully integrated implementation of CDTI with LF control for the 3 districts of Muheza, Korogwe and Lushoto since 2004. A total of 44l villages are covered by the joint programme, of which only 1 47 are Onchocerciasis- endemic (32%). The same team of health staff are responsible for both programmes. l.e. Project Coordinators and DOTs. ln the three districts, joint sensitization meetings are held for CDTI and LF which translates into efficient use of resources. Other districts with joint LF and CDTI have tried to learn from the 25 good Tanga experience. One of the challenges is to set and agree with the community on the time of distribution, and ensuring that the two programmes are ready at that set time. (vii) Morogoro CDTI Project has been holding Annual Mectizan Day celebrations every year since 2004. The celebrations are held at community level to launch each year's round of distribution, with a very senor government official being the guest of honour. This has proved very successful in sensitizing the government and community members. (viii) ln Morogoro region - which has 3 CDTI projects (Mahenge Focus, Kilosa Focus and Morogoro Rural Focus) - a region-wide Annual Oncho Review Meeting is held every year under the chairmanship of the Regional Administrative Secretary, bringing together representatives of all the three CDTI projects, together with the senior district officials. The meeting is functioning as a regional onchocerciasis task force mirroring the National Onchocerciasis Task Force. (ix) Full devolvement of the management of CDTI activities has been successfully done for Mahenge Focus CDTI Project, with each of the two districts - Ulanga and Kilombero - fully responsible for programme activities. This has promoted full programme ownership by the district councils. Previously, the Project Coordinator based in lfakara was managing the project directly. There has also been good public-private partnership in CDTI project management in Mahenge Focus CDTI, with St Francis Hospital (private) involved in project management and financial administration. 26 5. 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 health care service, with strong community ownership, using resources mobilized by the community and the government. With APOC's mandate due to end in 2015, every effort is being made to ensure that the substantial investments and progress made towards eliminating onchocerciasis in Africa are sustained for the future. By 2015, APOC aims to transfer full responsibility for onchocerciasis control to ministries of health, to encourage the ministries to provide ongoing financial support, and to encourage non-governmental development organizations (NGDOs) to continue to play their critical role. lt is judged that projects will be more sustainable if the following aspects are present - lntegration, Resources, Efficiency, Simplicity, Health Staff Acceptance, and Community Ownership. ln the context of the Tanzania NOCP and Morogoro Focus CDTI and Mahenge Focus CDTI projects, CDTI activities are fully integrated into the government health system at national, regional, district and local facility level. The key stakeholders are MOHSW, APOC, NGDO partners (Sight Savers lnternational and IMA World Health) and communities, and between them, they provide the necessary resources for the programme. All four districts implementing CDTI in Morogoro Focus and Mahenge Focus - Morogoro Rural, Mvomero, Ulanga and Kilombero - have included CDTI in the CCHPs but the funds allocated/released annually are not adequate. Geographical coverage is 100%, and the overall therapeutic coverage is high (above 65%). However, treatment coverage at community level varies a lot, and focused HSAM is required to bring up the coverage in all communities. The attitude of health staff at all levels is very positive and most of them are committed and very hard working. The RHMT and CHMTs provide close support. Community ownership needs to be strengthened particularly in regard to provision of motivation for CDDS. ln summary, the following are major impediments against programme and project sustainability that need to be addressed: - Onchocerciasis is not considered as a priority disease as it does not cause mortality; for example it is not included in the official HMIS. - The NOCP is still perceived as a donor-funded programme; there is therefore limited involvement of RHMTs and CHMTs - lnadequate allocation of funds at district level - lnadequate sense of ownership in some communities - lnadequate capacity of NOCP and DOTs. 27 6. CONCLUSIONS AND RECOMMENDATIONS The monitoring team successfully visited Morogoro Focus and Mahenge Focus CDTI Projects as planned. The household survey was mad in 29 communities in the 4 districts covered by the projects. The visit also provided an opportunity for sensitization of various government officials about CDTI, as well as health workers, CDDS and community members in all the four districts. The projects have in place the necessary institutions and partnerships for ensuring continued distribution of the drugs to the endemic communities with support of the NOCP and Ministry of Health and Social Welfare. However there is need for greater emphasis on sustainability, particularly in mobilizing financial and other resources necessary for CDTI after APOC exit. It was found that for both projects, there was a break of one year in the treatment due to, on the one part, funding bottlenecks, and on the other, delay to a change in tax regulations that imposed charges on imported drugs. This emphasises the importance of continued resource mobilization and high level advocacy for CDTI. Continuity of treatment for 15* years is a requirement for breaking the cycle of infection from the community. The survey found that the overall average therapeutic coverage in the communities surveyed in the two projects was 73.82% for 2007 and 68.2% for 2006 which are above the minimum threshold of 650/o. However, the community level disaggregation shows variations of between 45.2o/o and 94.4o/o in 2007. This suggests that there needs to be targeted HSAM to ensure sufficiently high coverage for all communities, particularly targeting problematic households. The variation in therapeutic coverage in relation to gender - being consistently higher for females than for males - shows that it is important to take gender issues into consideration while implementing CDTI. This means that the different needs of women and.men are considered at all stages of planning, implementing and evaluating CDTI activities. More male-targeting HSAM is also necessary in view of these findings. The presence of mass media e.g. radio, newspapers can e used for effective dissemination of information. The survey found very few cases of adverse reactions suffered by the community members for the 2007 treatment cycle. However, there were numerous cases in the earlier rounds - mainly swelling and itching that subsided after a few days, but none that required hospitalization. Some members who had such reactions in the 2006 round in Morogoro Focus communities decided not to take the drug in 2007 fearing that they would have the reaction again. There is need to sensitize such community members so that they 'rejoin' the treatment programme again. Nlost of the respondents answered correctly about the colour of the Mectizan tablets implying that they had seen and swallowed the tablets. However, a small number were getting it wrong especially in Morogoro district, but the team attributes this to confusion with the colour of Albendazole and Vitamin 'A' which have also been administered with CDTI. Although approximately 3.9% of those checked reported getting a dosage which was incorrect based on their height, the survey team attributes most of these cases to forgetting 28 rather incorrect dosage. The CDDs met seem to be well acquainted with the correct of the measuring stick. The categories of absenteeism, refusals and 'not informed' constitute quite a high percentage of those not taking the drug in 2007. There is need for more targeted HSAM at community and household level to reach these members. CDDs are knowledgeable about their role in CDTI, but more advocacy and sensitization is needed for communities to provide them with appropriate motivation. The National Onchocerciasis Control Programme technical staff play a critical role in supervising and supporting the CDTI projects in the country as well as the general national eye activities. Currently they are somewhat stretched due to some key members having taken on other assignments. Efforts are needed to strengthen the unit and build its capacity as per emerging needs. The main recommendations are as follows o There should be targeted and effective HSAM about CDTI at all levels. At community/household levels, this will help overcome any fears and misconceptions that lead to a higher number of absentees and refusals, and promotion of community ownership. Greater community sensitization needed to facilitate provision of appropriate incentives for CDDS such as exemption from community work, etc . Specific advocacy at national/regional levels directed towards greater RHMT/CHMT lnvolvement, and encouragement and support for the Regional Onchocerciasis Task Force o lnclusion of Oncho Data ln 'HMIS' - will help to integrate onchocerciasis control in mainstream reporting at district and regional level o There is need for APOC technical support to continue as long as there is distribution of Mectizan even after end of direct APOC support o Partners should support capacity building for NOCP and NOTF based on emerging needs . More operational research on CDTI issues is required . Monitoring of the lmplementation of the Sustainability Plans is required at3-4 Years intervals. o Need for mufti-sectoral collaboration and involvement of all key stakeholders in planning, implementing and funding of CDTI activities at all levels, based on the principle of public-private partnership which is part of the National Health Policy. . Need for review of the NOCP strategic plan to make it more realistic and reflect the APOC exit philosophy. Similar strategic regional and district-level plans are required. . The CDTI projects should consider increasing the number of CDDs to improve CDD ratio and lessen the work-load and distances covered by each one. 29 t7. APPENDICES APPENDIX 1 - TERMS OF REFERENCE OF THE MISSION o Brief WR about the purpose of the mission . Document success stories, challenges and provide technical advice on the sustainability of CDTI . Documents lvermectin treatment coverage in 20-30 communities for 2007 and 2008 o Document when treatment started and whether lvermectin treatment has been provided continuously . Hold meting with some CDDs to document their experiences 30 aoq >ro H+!o =!<ES ,E*aeEgti d zo F U) P o 8t * E - od E6uQ;: ;E liEEs F U) El o oF oz l& 9 E B! 3t-aETEi HEJ!* = -$ = ItOYo + 9istEe 2o F CAq oF cr') EI E o .=ic E 5E o EE =1.c E E€E 3€ - ot 'Erodi !c.o3 - 5= -9-dY o; o! I Ia> 455>Z ?n E a er! Et= u o-= , u '€ro 5 >h.EeEo (! u >EES}5b 7 FH ch HDo oE - €bE E'$fi5iIn'asE€g.st2 q @ rlii u) ZIL z) E.' 8E gE frE E > 8t<rb zE c APPENDIX 2 - HOUSEHOLD SURVEY FORM ra o E ug ooI iD bog o 5g o !tr E aq E:58ET oi EE fieco9E -.troEL ,EO "dFEcOE o.r!E tZ <E a9 'E'€xo5EOots9o EE ooE 5l 32 eq8:Err -t9 H EE P 9=(A Og a >r,d ;utr 56rrl ,v3 HE9 3tr 9l A,E, #e Ht .=6 Ei(IE BCtrH 5_roe -on 9o :E EE -oE€trti o5 €g99 EE E$EPbrEO 8 CI so > i P 3 E E q E6tr3 o 8 I oz e 'o E 8a E I I _ttro E o ad E E tro "lEo x a E E O o E €z$ B E E Q o xo6 aood o P Eo oE t o e & E € g o E 9 E!.ioE -E8 oO 'EeHoo.E 6E .oC E.Lo- E83, {Ia I .s€ IEi dEE Eo6 6E3 2 ,EE E .si g o5 -fr'- LEr '9 b 3l n Ioo E o o! t * + t lt o o € ao E o o ll ! a o 8 U e _t o ' € E E EI a iiEIEs _oIEv E o --!l5 iTTPH"$sE5X9 ^Tu5 €ET :E€ !E EE j I bD a o U a, o \d E?I ? .e E o oSEEE";E - ht E"HT F e; HBit: d.-i {Es?ti g Ei'H{I O O q.: O * E tr.=€E 32 oAPPENDIX 3 - LIST OF OFFICIALS AND COMMUNITY LEADERS MET 1. Dr Martins - OlC, WHO Dar es Salaam 2. Dr Ritha Njau - WHO, Dar es Salaam 3. Dr E. Kirumbi- Acting National Onchocerciasis Control Programme Manager, MOHSW 4. Mr O. Kaitaba - Deputy National Onchocerciasis Control Programme Manager, MOHSW 5. Dr Mbena - District Medical Officer, Morogoro 6. District Medical Officer, Kilombero 7. Dr G. Kasiga - Mahenge Focus Project Coordinator 8. Dr Kabodi - Morogoro Focus Project Coordinator 9. Dr W. Kabuka - Ruvuma Focus Project Coordinator 10. Ms R Nguruwe - Kilosa Focus Project Coordinator 11. Dr Asilia - Tukuyu Focus Project Coordinator 12.Dr R. Maggid - Tanga Focus Project Coordinator 13. Mr Lugata - District Onchocerciasis Coordinator, Morogoro 14.Mr Kilimba - District Onchocerciasis Coordinator, Ulanga 15. Dr Sewando - District Onchocerciasis Coordinator, Mvomero 16. Mr Jayambo - Assistant District Onchocerciasis Coordinator, Mvomero 17. Mr Omari Kombo - Village Executive Officer, [/ilama 18. Mr Halfani Abdalla - Village Chairperson, Milama 19. Mr Ramadhani Kabezi - Village Chairperson, Mvomero Village 20. Mr Michael Kilumanga - Health Cascade Supervisor, Mvomero 21.Mr Hamis Kizigo - Health Cascade Supervisor, Mvomero 22.lrtr Ally Lusewa - Clinical officer, Duthumi Health Centre JJ oAPPENDIX 4 . LIST OF CDDS MET 1. Mwajuma Shabahi - Jvlkata, Mvomero 2. Mpaka Donald, Maharaka, Mvomero 3. Maria Stefano - Milama, JVlvomero 4. Esta Yovine - Ng'wambe, Morogoro 5. Abdala Ngereko - Chambika, Mvomero 6. Hadija Simba - Chambika, Mvomero 7. Charles legele - Minazini, Mvomero 8. Selina Peter - Minazini, Mvomero 9. Emily Mvuona - Ng'wambe, Morogoro 10. Lucian Mpeka - Lukange, Morogoro 11. Omari Mangode - Jitegemee, Morogoro 12. Halima Mshimba - Jitegemee, Morogoro 13. Huseni Ngalawa - Mkuyuni, Morogoro 14. Ms Levina - Malani, Morogoro l5.Amadeus Octavian - Malani, Morogoro 16. lssa Kondo - Kidatu A, Kilombero 17. Oswald Katwatwa - Kitadu A, Kilombero 18. Mr Timotheo - lkule Maendeleo, Kilombero l9.Zaituna Kayombo - Mkusi, Kilombero 20. Flowin ltlakelo - Mkusi, Kilombero 21. Joshua Gideon - Sagamaganga, Kilombero 22.Falma Ngonani - Sagamaganga, Kilombero 23.Adriano Saluyu - Lukorongo, Kilombero 24.Peter Kilumuka - Lukorongo, Kilombero 25. Stan Mlipuka - Miale, Kilombero 26. Haruna Mfaume - Zignali Mbalaji, Kilombero 2T.Marcelline Maganga - Zignali Mbalaji, Kilombero 28. Selemani Libukula - Nkongo, Ulanga 29. Saida Lyawala - Nkongo, Ulanga 30. Hassani Simba - Mwaya, Ulanga 31. Bulubo lteke - Mzelezo, Ulanga 32.Avelina Mgomba - Mzelezi, Ulanga 33.Zamda Sengerere - Chilombola, Ulanga 34.Thabit Nambelimbili - Chilombola, Ulanga 35.Asia Majiji- Euga, Ulanga 36. Scola Kimbole - Euga, Ulanga 37. Albertina lVlaumba - Nawenge, Ulanga 38. Mr Mtoro - Nawenge, Ulanga 39. Deodatus [t/gala - Vigoi Chini, Ulanga 40.Therezia Mbalagi - Mbagala Juu, Ulanga 34