RWUMA - WHO/APOC/CDTI PROJECT REPORT OF INDEPENDENT MONITORS OF CDTIACTIVITIES II{ RUVUMA, TANZANIA 15 - 29 SEPTEMBER 2OO2 SUBMITTED TO THE DIRECTOR AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL(APOC) SEPTEMBER 2OO2 I 2TEAM OF MONITORS William Joseph Kisoka, Research Scientist National Institute for Medical Research (NIMR) P O Box 9653, Dar es Salaam, Tanzania Tel: 255 2125083/21307 7 0 Fax:255 222t30660 Email: wkisoka@yahoo.com Oscar Kaitaba, Deputy National Coordinator, National Onchocerciasis Control programme Ministry of Health Tanzania P O Box 9083, Dar es Salaam Tel: 255 22 2130025 Fax:255 222130009 Email : katenga@raha. com Dr Rehmah Maggid, Project Coordinator Tanga CDTI project p O Box 5547 Tanga,Tanzania Tel: 255 27 2G47SB0 Fax: 255 27 2G47943 Email: niduga@yahoo.com Mr.Venancce David District Coordinator, Mahenge CDTI project Ulanga District, P O Box 337, Ifakara Tel: 255 23 2620311 ., TABLE OF CONTENTS E)GCUTIVE SUMMARY. LIST OF ACRONYMS 4 6 7 ACKNOWLEDGEMENT INTRODUCTION -1.1 -G-.P-.qe.P-l.E-ackgr-ssd 12._P..r._oj_e..Et,.Ea.e.kg_r__o_ur.d...... .l..3_Iea.qt ep. mp_ssiti_su .. . ... .l-,4 leu[s.._o..[Refp_.re..tc..e .. 2,A4P_f_H0__D0__1,_o__c__y . . . 8 .8 ...9 ...10 ... l0 .il ..lt ...11 ..12 ... 15 .15 15 16 .17 .19 20 21 .23 .21 28 28 2.1 Study Design2.2 Population ?3 The Sample and Samplins ProcedureInstruments Instrument Sample Treatment Coverage Constraints 4 O CONCLUSIONS 4EXECUTIVE SUMMARY The-GDTI process ofMectizan distribution was introduced in the Ruvuma focus in 199gAt the moment it is in its fifth year. An independent monitoring team of four members carried out an investigation toascertain to what extent the CDTI process had been implemented in the project area. Six endemic villages randomly selected in the project area each sub divided into five subvillages, making a total of thirty were covered during the monitoring exercise. Data wascollected from a representative sampre of the popul#on including r"rruirrirug.leaders/officials, health workers in the communiiies, the cDDs, household members, women, men and youth groups. Policy makers at various levels of the health system andProgramme Managers, .collaborating Ncoor and the wn *... ;ir;ir';;.*"a.Instruments for data collection included in-depth interviews, questionnaires, oflicialrecord/documents and focus group discussion (FGD$ gria.r. The results obtained by the monitoring team indicate that all the villages in our studysample were treated, giving u .o-rnrnity coverage rur. oi too %. rhe decision makingqrolels was largely by the communities in the sJection of the mode of distribution andthe cDDs but the time of distribution was in most cases taken by the health workers. Thehouse to house method was the preferred choice for distribution and height measurement was the form of dosage determination side effects (especially those corisidered severe)were never reported' CDDs were selected and trained in the villages visiteJ. gowever, wenoted that the training period was too short, had_ taken ptu.. u..y long time ago andconsequently they in turn, could not impart the knowleige to the conimunitie"s especiallyin.1h9 aspects of programme ownership, community respionsibility and support for CDDswhich are the key elements for CDTI sustainabilitf rrre team also noticed that there wasgood cooperation and collaboration among the vrinistry of Health, wHo and NGDOpartners, although there is more room for i-mprov"r.ri uy in.r.aring the quatity andquantity of information flow between these very important bodies. community membersexpressed great satisfaction and appreciation foi the prot.urnrn. in the project area, asituation which augurs weil for continuity and programrie sustainability Key Recommendations (a) Training sessions for cDDs and Health personnel should be increased and periodsshould be longer. (b) community education on key issues Iike programme ownership, community responsibility, reporting of side eflects and cJnsus should be stiessed during CDDtraining. (c) An update of community census before the next round of treatment should becarried out. (d) APoc should consider possibilityof extending period of project funding for atleast two more years to enabre project *rtuiruiiiity,-.r.n emphasis being onhealth education and IEC *ut"iiul, developme nt. " I 5LIST OF TABLES TABLE A 1' Divisions wards' villages/Sub-villages covered in the Monitoring ExerciseRuwma Focus...p9 .. . ..13 TABLE 42: Summary of Instruments and Sampling procedures ... .p9 TABLE l: Decision-making process at the village level ........p9 TABLE 2: Treatment Summary-Househord survey and cDD Records .. ...p9. TAB|E.3: Proportion of villages treated and in which CDDs were changed after firstdistribution round t9 TABLE 44: Proportion of villages which received health education and in which health TABLE 48: Length of CDD training. . . ... .......22 TABLE 4C: Issues and Topics covered at CDD Training ..Zz TABLE 5: Input indicators at Community Level . ..24 TABLE 6: Distribution of Imprementation of the components of cDTI by wards ... ....27 l5 t6 l8 l. 6LIST OF ACRONYMS AIDS Acquired Immune Deficiency Syndrome APOC African Programme on Ochocerciasis ControlCDTI Community Directed Treatment with IvermectinCDD Community Directed Distributors HH Housed Hold FGD Focus Group Discussion IEC Information Education Communication IMA Interchurch Medical Association NGDO Non Governmental Development Organization NOTF National Onchocerciasis Task Force PHC Primary Health Care SSI Sight Savers International VETA Vocational Educational Education Training AuthorityWHO World Health Organization 7ACKNOWLEDGEMENT The independent monitoring of the Ruvuma CDIT Focus took place between 15-29 September 2002. We wish to express our appreciation to the management of the African Programme for Onchocerciasis Control (APOC) for financial as well as logistic support, the NOTF national oflice for facilitating the smooth running of the exercise-training needs and transport to and from project villages; Dr Joseph Okeibunor, who facilitated in the training sessions provided template reports and instructed on the use of Epi Info 6.0 soft ware We also extend our sincere gratitude to Dr. Saiduni Kabuma, Regional Medical Offrcer for Ruwma, and Doctors John Budottela, E Mhonzwa and Anthony Mashinda, District Medical Officers for Songea, Ludewa and Mbinga districts, respectively, who agreed to be interviewed and answered all questions put across. We also acknowledge the support from Messrs John Ngatunga, E B C Haule and S L Mpangala District Ochocerciasis Coordinators for the Ruvuma Focus, whose role as field assistants and knowledge CDTI activities within their respective villages simplified the fieldwork in all districts. All omissions and errors remain the responsibility of the authors 8INTRODUCTION 1.1 General Background onchocerciasis remains a serious public health problem in large parts of tropical Africawhere some l8 million people are affected It is mainlya pubilc irealth p-ut.,, in ruraltropical populations, which live in river valleyr, *h..e the back fly ,ectors are found.The disease is chronic, non - fatal but causes a wide - spectrum of skin lesions, fromintense itching to gross changes in skin elasticity, resutting in hanging gioinr, lizard -like skin appearance, and color changes such as patchy depigmentation ,,leopard skin,,The most severe manife-stations prJviourty r..olrlrla were those associated withdamaged eye tissues, which may lead to serioJs visual impairment and ultimateblindness, hence its common name river blindness. onchocerciasis in Tanzania is endemic in fourteen districts out of more than a hundred.characteristic of the East African endemic countries it is found in discrete foci, mainly onremote mountain slopes, from where occasionally it spreads up to the rolling plainsextending from the.foothills. Apart from small -r.ui. opeiations to control onchocerciasiswhich relied largely on vectoi control operations based on aerial larviciding in westAfrica, there used to be virtually no onchoierciasis control in the country until 19g7 whenMectizan (Ivermectin) *ls registered for the treatment of human onchocerciasis. Thesubsequent availability, free of ,hurge, of this safe and effective microfilaricide haspresented an opportunity to control the disease as a public health problem in endemicareas. rnTanzania the current mass treatment using Mectizanstarted in l992in Ruvuma regionwhen.7,830 people received the first cycle. The activitf was under the River BlindnessFoundation (RBF) which provided financial and logistic support up to 1995. operationsfor the 1996 and 1997-were supported by funds p.*il by the Inter-church MedicalAssistance (IMA) and Sight Servers Internationar 1'ssq respectively in collaboration withthe Tanzanian Ministry of Health (MoH) APoc h.,raing ro. the establishment of GDTIprocess started in 1998. The control of onchocerciasis used to be vertically designed in Ruvuma and Mbeyarunning parallel with other health services, until 1995 when the National onchocerciasiscontrol Program G{ocP) was established with the major-goarto eliminate onchocerciasis as a disease of public health importance and obstacle tt solcio - economic development inthe country in the period or is - 20 years. The broad objective of the Nocp is toestablish, within the period of twelve years (1997 - 2008), effective and self - sustainablecommunity-Directed Treatment with Ivermectin (cDiI) throughout endemic areas ofTanzania and where possible, to eliminate the vectois of onchocerciasis by usingenvironmentally safe methods in selected foci. I 91.2 Project Background Ruvuma Focus The Ruvuma GDTI project is composed of three adjoining districts of Songea andMbinga in Ruvuma Region and Ludiwa in Iringa Region. It is often referred to as theRuwma Focus. The three districts.hu.u.. u totui popflation of 767,461 inhabitants (according to the1988 census) with 17 administrative divisions, 75 wards and2g6villages. Songea District Songea is one of the 4 districts which make up Ruwma Region and is the main town inthe region' It houses all the regional administrative functions. The district has 2 hospitals, 9ne i9 owned by the government and the Roman catholic church owns the other. It has 7health centers, 53 dispensaries and 39 village health posts (vHp). It covers a total area of34,193km3' The total population-of the distictistzz,gii. rni, gives a population densityof approximately 8.9 people Km2 The district is about 1,000 km from Dar es Salaam, serviced by an all-weather tarmachighway' The nearest railway station is at Makambako in Iringa Region, iot t, r.o,Songea town' Currently the town is not linked to the national airline network. There areoccasional air characters into the town. Administratively, Songea district has 7 Divisions(Ruwma, Mputa, Namtumbo, Ludewa, Madaba, Muhuiuru and Mkong o),22wards, andI l9 villages. The district borders with Ulanga district which is within the Mahenge Focus to the east,Ludewa and Njombe districts to the north, Mbinga district to the west, and Tundurudistrict and a neighboring country-Mozambique CNJnrr.r" province) to the south. Mbinga District: Mbinga district is the .second project area in the Ruwma Focus. The district has 4hospitals one is ow19d by the gou.ir."rt a1{the rest by NGos. It has 5 health centers,49 dispensaries and 7l^village health posts (vHP). It covers a total area of ts,iTg lrrrf"'The total population of the district is :^:Z,ZSd. The administrative. offrces for Mbinga district are in Mbinga town; which is 100 kmsfrom the regional headquarters in SJngea. The road is partly tarmac (i.e 20 kms fromSongea) and the rest is gravel with permanent bridges. The main means of overland traveloutside the district a-re through Songea. The secon-d alternative is by boat from MbambaPort to.Itungi Port, Kyela district in Mbeya Region. Administratively, Mbinga district has-6 diiisions (Mbuji, Mbinga Mjini, Rahekei, -N31swe9, Mpepo and Ruhuhu), 33 wards, and ll4villages.Mbinga borders with Ludewa district (Iringa negiorf tf,the north, Songea district to theeast and Mozambique's Northern Provin.. 1r.ilnuoring country) to the south. on thewestern side it borders with a neighbouring rourtiy-Malarwi (Lake *ru*l -- Ludewa District: Ludewa district is also within Ruwma onchocerciasis Focus, but administratively is partof Iringa region where there are 6 districts. The district rras : hospitals one owned by thegovernment' There are 5 health centers, two of which are owned by the Roman Catholicchurch and about 34 dispensaries and 50-village rr.urtr, post. It covers a total area of8,397 km2. The total popuiation of the district is ioo,zto r 10 The district is administered from Ludewa township, which is accessible along a windy allweather gravel road. Its location makes it a relatiirlry ..*ot. site even from its regionalheadquarters at Iringa' The main means of travel to and from the district are by road or byboat from Lake Nyasa frgm Lupingu to Itu.nsi rort, rfeta district in Mbeya Region. Thedistrict is divided into 4 divisiom iryfl.ungui, "tutu*.ngi, rurururi and Mwamb ao), zowardsand 63 villages Ludewa borders'with t1e districts? Songea in the east, Mbinga andKyela in the south, Njombe and Makete in the north and Malawi (Lake Nyasa) in thewest. The main ethnic groups in the project area include the wangoni, wamatengo, wabena,wamanda, wapangwa and othei migrants. Despite some minor differences in their socio-cultural characteristics, these tribes mix without tension. peasant farming forms themainstay of income generating activities in the three districts where crops such as maize,banana, beans, rice, cassarra ard potatoes are grown as staple foods while tobacco, teaand, to a lesser extent, timber are cash crops. ih... is atso small scale fishing along therivers and lakes' Border as well as highwaytrade is also existent in the p-j..i u..u. 1.3 Team Composition The independent monitoring team was composed of Mr william Kisoka, ResearchScientist in the department of health systems and policy research, National Institute forMedical Research, Tanzania, as the Principal tvtoritor. the other monitors included Mr.oscar Kaitaba, Deputy Nocp coordinator, Dr. n.rrrnu Maggid, Tanga CDTI Focuscoordinator and Mr venance David, District oncho coordinitor for iJlanga District,Mahenge Focus. Members of the ornrr in Ludewa, s;rg., ;;'dtr;;iirt.i.t, ,rroparticipated in the exercise within their respective -Jo.nairs. Two jrive.s, namelyAbdallah Nuhu and Kurwa Issa of the Ruwma and ranga'projects respectively facilitatedtransport during the whole monitoring exercise. 1.4 Terms of Reference The team was constituted with the following terms of reference: l ' Succinctly document how ivermectin treatments were undertaken in a sample ofcommunities with approved CDTI project in ranla focus, Nigeria- 2 Assess community involvement in drug collection, decision making on the periodand modes of distribution, the selectioi of distributors, and the willingness of thecommunity to accept and bear these responsibilities oesigneJ -i.,- the CDTIprocess. 3' Document community perceptions of GDTI processes especially the issue ofownership, and expectations for onchocerciasis control, based on theseperceptions lnd expectations determine the degree of satisfaction of thecommunity with the different programme activities and outcomes. 4' Assess the quality of training received by cDDs and health personnel involved inthe project. I 56. 7 8 l1 Examine the record books of the CDDs and assess the quality of record keeping and their ability to keep accurate records. The same applies to the health services staffon the project. Determine the number of communities and eligible treated and compare findings with records of the CDDs and the records at the other levels (District, Division Ward - level records.) Determine whether the health personnel participated in ivermectin distribution and assess the degree and quality of supervision by health staff (and the quality and orientation of the health staffto the CDTI) Identifu constraints in the distribution and recommend appropriate measures to APOC management to be taken before the next round of treatments. 9 Discuss the prospects of sustainability based on the findings above. 2. METHODOLOGY The methodology used for the selection of the villages and sub-villages was a modified form of the methodology that was developed during the meeting of the nine monitoring team members in Ouagadougou in 1998. In a review of the tools, in a tool development workshop in Kabale, this was further refined to include a few of the things that were not previously taken into account. The entire endemic villages were included in the sampling frame irrespective of levels of endemicity and closeness to the health facilities in the areas studied. This simplified approach merely selected villages by a simple random sampling approach. 2.1 Study Design For the monitoring conducted in Ruwma Focus of Tanzania September 2002, a cross- sectional research design was adopted. This design was considered the most appropriate to generate the needed data and meet the study (monitoring) objectives. The data collection exercise consisted of a triangulation of qualitative and quantitative instruments designed to collect information from different segments of the target population 2.2 Population The target population for the monitoring exercise consisted of four broad groups. These include: l) Health Personnel involved in the CDTI process at various levels; 2) Village leaders; 3) Community Directed Distributors (CDDs); 4) Household members in the hyper/meso endemic. \ L2 In addition, policy makers in the areas where CDTI is implemented were interviewed to gauge their plans for sustainability of CDTI in the future as well as their policy direction with special reference to their current support for CDTI. 2.3 The Sample and Sampling Procedure A study sample of thirty villages was chosen using a simple random sampling procedure. However, the sampling process began with stratifying the divisions and wards in the district by levels of endemicity. Since treatment focus is prioritized based on hyper and meso, the hypo endemic divisions and wards were excluded from the sampling. Consequently, six hyper/meso endemic wards were chosen through a simple random sampling process (balloting), from three divisions, one division each from the three districts under the Ruvuma project. The chosen wards included Lugarawa and Mavanga in Ludewa district, Mkongo and Matimila in Songea district while Kilimani and Kiangimahuka were sampled from Mbinga district. The villages in the selected wards were listed on pieces of paper and six of them randomly selected by balloting. The villages sampled through this process were Myombo, Mjimwema, Karibuni A, Masimango, Kilimani and Dodoma in the order mentioned above. Category A and B Villages: Having selected the six villages, one from each of the earlier sampled wards to be visited, the sub-villages in the chosen villages were listed. Thirty sub-villages were randomly selected from this list. Another random sample of six villages out of these thirty sub-villages chosen earlier were taken as category "A" villages while the remaining twenty four villages became the category "B" sub-villages for the monitoring exercise. Unfonunately these villages could not be classified into hyper or meso because the information was not available The only information available helped in eliminating the hypo endemic areas from the etcercise. The list of divisions, wards, villages and sub-villages that were visited for monitoring purposes is summarized in the table below. \ 13 Table A1: DivisionsAilard s/Villages and Sub-Villages Covered in Ruvuma ect Focus: Households: In each Category "A" sub-village sampled, fifteen households were chosen. To do this,the sub-village was carved inio threl clusters grid;;-;; the village head and Iocalguides' The systematic sampling approach was thin uppri.a to select ive dwelling unitsfrom each cluster' .The sampli,rg inie*als were dete#ined through a quick estimationof the number of dwelling units in each village-cluster- This differed from one sub-village-cluster to another' In each sampled dw"ellin! unit one household was randomlychosen for the treatment coverage study. nurtherm"ore, io check on the correctness oftreatment, one household was randomly chosen, and'the dosage fo. one householdmember, randomly selected and crosschecked, Districts Division Wards "A" Sub-Villages ttBtt Sub - Villages I.LUGARAWA I MYOMBO lAMKATWEND E 2SONGAMBELE 3MWENDAPOLE 4 MJIMWEMA I.LUDEWA I.LIGANGA 2 MAVANGA 2 MJIMWEMA 5 MGOIv{BESI 6 USHINDI 7 MANNZESE 8 MBUGANI 3 MKONGO 3 KARIBLTNI A 9 KARIBUNI B IO ULAMBONI 1I MABATINI l2MWEMBECHA I 2.SONGEA 2. MKONGO 4 MATIMIRA 4 MASIMANGO 13 MPINGI B 14 MULTNGANO 15 LIZABONI 16 MOTOMOTO 5.KILIMANI 5 KILIMANI 17 NJOOMLOLE 18 KILIMANI KATI 19 MAHUKA 20 MAPINDUZI 3.MBINGA TOTAL 2. MBINGA MJINI 6 A 6 DODOMA 2I LUSAKA 22 KIVTIKONI A 23 KIVIIKONI B 243 6 6 24 l4 CDDs and Village Leaders: In each Category "A" sub-village sampled, the sub-village leader was purposively selected and interviewed. The sub-village CDD was alsJ purposively sampled andinterviewed. In cases where there were two cDDs both of thlm were interviewed, butwhere there were more than two cDDs, only two were selected by balloting Similarly, the sub-village leaders of the Category "B" villages were purposively chosenand interviewed. The sub-village cDD, *..f uiro pr.posively chosen and interviewed where the CDDs were two or less. In somc sub-villages with more than two CDDs, twowere randomly selected for the category ,,B,, sub-vill-age cDD interview. Health Persorutel and policy Makers; various cadres of health personnel involve.d in GDTI process were purposively selectedand interviewed. These included Supervisors, District onchocerciasis Team (DoT) members and Coordinators. The Coordinators of Primary Health Care and Healthofficials at the District and ward levels, involved in the CDTI p...r" *ere alsopurposively selected and interviewed. The purpose of these interviews was to examinethe orientation to CDTI. process and provide information on the records and quality oftraining they receive andlor give on th; CDTI process. Policy makers at these levels of the health. systems' operations were also purposively selected and interviewed to give idea of the support or tn. policy makers'for GDTIimplementation as well as theii prans for the sustainability of theprogru*... - 15 Instruments Eight instruments were used to gather information from both categories ,,A,, and ,,B,,sub-villages as well as at the oistrict and ward levels. copies of these instruments areincluded as appendices to this report. Table A2: Summary of Instruments and Sampling Issues Instrument Category of Sub-villages and Unit Sample Sampling Procedure In-depth interview & Record review with CDD A&B | -2per sub-village Purposive (Simple random, where there are more than 2 CDDsHousehold coverage survey A 15 households per sub- village Multi-stage (i.e. cluster, systematic and randomKey informant interview of vil leaders A&B I village leader per sub- village Purposive Group discussion A 3 groups per sub-village (i.e. 1 male and I female adult, and I female or male youth groups), 6-g in each Convenience Health personnel interview A I PHC coordinator 1 Oncho coordinator I DMO per District I LOCT member t health centre staff Purposive Programme manager/Policy maker interview Project, District & National levels 1 NOCP Staff I Project Coordinator, 1 Supporting NGDO staff Purposive Ho --oc6 ,- ?z ooo o\ o\ o\N c.l c.l ^^ooooOO- vvOr\o \o (\ OOOooo \o \o\o t-o €o t-a -F-tr)NO OOO \o \o \o I c)'=o0Hcgc 5-Y o) ^.$ ^f-#aa c\$+ a.l OO- OOO po -'=ooti HCU: - -cBEFP-Q o-rr'iri ui () ca N I-*H \O C.l \oo +Oca OOO Li -E o) € -lZ cd=0.)-v oo= aO i-^Ycn v Ocacarncor c. cil tf, --O \o \o o o0 r-tcoi cO t-t -c.lo O-co OOO o oo !na6 =-o>tr OOO ooo OOc.)l.) ra) aa cacoN a)sbo,= -:() -6)5> /-\# OH$o\ \iN \oO\#(tl ,^. a C.lcao\oI Y);' c\coi \o\oo -#c.) t) o U) a.) e-caxY q.Y X ^*-r-- ^!/!ra ^p#He v !.i 7\q, ur.9 EYh qE.3Hv9. -.rHV ,\ A . Fv.VqE€: ? 3li^{i-]1O s5 E ! *S>rZa = A Fq t tr{tavb -='- ^ €EEtl . XSIJ 7'E:e -- !: 0q vor, vPI ts E ,, ij = o-:, o air>,; Uo.o 6-Ck.E.g^ =9L! )^trjrriiH o.i LL/ 'z a Ez -v-c,r <- rtl x .h;^(JYvAo.lgEO.E E* -:i=lvdJaaL vaoo \o ca aq96s.s oXN- -ll o\ll PN EOll() tro ts in/1 +l o-Cl,li\J9i cio36r o o= q) .F Ot6tr-o--E ,99 €= I cao)o-<r) E 3'>-, '08EgE = €otr(J'-a -= (JE 'Yaa(Da u)g(D(D+jSSe == (l) 'a .- .,qa>> C) U) Chooo trtrtr oooooo(H (r (Hooo I<Lrl<oo() -o.o.o E.OE(o(g(o ooo LLLoooo. a. o.oooLr li li0iAOi o U)q) 6,) CEtr q) q) t] o o0 c) qE U2 .r) O o a0 & c! I o ar) I(l) o) cl t-r auLrLt- O F-CE a.Y r.1 EfrE (\t I rq I f-l 4?a t7 Decision Making Process for CDTI Implementation The decision making process on the implementation of CDTI as indicated on table 1 above were largely done by the communities. Interviewed leaders in both category "A" and "B" villages overwhelmingly 26 out of 29 (about 90%) reported that the decisions on the persons responsible for distribution of drugs had been taken at village meetings while decisions on the time and mode of distribution that were taken in the same manner were reported by nine and twelve leaders respectively. The village committees were also involved in a number of decisions especially those on the mode of distribution. Health workers were mostly involved in decisions on the time of distribution against APOC directives that these decisions be left to communities apparently because of the need to distribute the drugs as soon as they arrive. The same results were obtained from CDDs interviewed. One third (2 out of 6) and half reported that the decisions on the timing and mode of distribution respectively were taken at village meetings while l8 CDDs reported that they had been selected in the same manner. In the group discussions participants gave a slightly different observation, as village elders were reportedly responsible for most of the decisions on the time and mode of distribution. However, they too affirmed that they participated in the selection of CDDs. "Meetings were held at sub villages where we nominated names for further steps by the leadership" according to one old man in Mavanga much to the agreement of others during an FGD session. Women in Kilimani echoed the same observation when they submitted that they too were involved in the selection of their CDDs " I remember we held a meeting at our chairman's house and selected those two young people to do the distribufion" However, sessions involving youths indicated a glaring deficiency on the awareness about what went on in the introduction of the projects within their respective areas. This may partly be explained by the fact that most of the youth discussants in the FGDs were still school children at the time the project was initiated in the project area. This demonstrates the need for urgent introduction of IEC materials especially in schools which serve as separate entities in Mectizan distribution. oo E 0)(n() Lr o. C)t< o Cdoli € €o ti € U) oa(€(l)L (H o3aOO \^S\648Hr< ca(I) o- ll(l).= SPt-o 9Li@tro:!-ts 3aS a ,, 'r)EJJ ll H-.9;J. c,X>U.{ (DtE 'E rr'8 € E €* :QilkPp-CLtsU)di;s Eg3E'6 6 x I -.-o fi .Y X LU(UrVAi VH c = (Dr ^*x EbEE(ts O g .^9- E-E E E o-E [j ,d.>P^ -- E i 3-0)r<2C,l(/) -Eo dEH *ts6nvc*E AA?, :.ts' 9€ 8.tr^ (H(Hq< ='o o o o 'hQ)t<LL .'ts(l)0.)o) =;\ -o-o.oEtr trtrtr!HHH ue))):otrtrtr "F EEE&sr EEEE6 trtrtr -c oooO) P .-.n.- != +{ l- l- L-Ho oooo. o- o-EE PP9!9AAA.iHHH €l- orQ -tr :+ t-( 61 6ErYllri E ooo 54( rh 6)\J bo{ 5'= =iEL =.1a av OI!& \oo\ ; z I I I a ,\n c- Orozc caN caN FRH\i @FS' -f,sra \- g( rh 6)u,/ 0!<s -? -a O14F F( c.r O ..oz, O ot\o ooQ N9 $9*:./ 2or+ (-- o ..oza o .f,C.) ooPa.l \i ;s r.- PSV z 5q{ rt 6)t/ 0!<s r->FIA -a \o @ c.l C) H& O ro'Ze> o o\ F- N a tr) @N oot- ooa N\J 2air 0O dGz?> O caca F-N $N co t- cn r-.\o o\ ra) g{ rh G)l/ oo{E,s .l?b tr€E>da I O IJ]& O.ozc I I a^ ,+ C-' Oroza t-- !t N t-- ao ca co c'l tr-\o l-. w 9(U t!<{ S'= 'i ?.o F r'sa av HsC( o.l Orozc ca orRco$ o.l ' -f, ii sa 3rrtsli O\ Oroze) O l*-t-- c.l ci cil aa $ o\ ca O\o @lr) 54{rr 0) -\J O! =t<SEIFl 't ali;si 9^lrJ tr)fi\o Orotz o\ O \o\o t-- o\$ ,nQ F8 2a/< 00 .o o\ o z l-r \o o\ r- \oN caN co t-- lr)\o * d F an G U) (uil arlq) o {) U)E (,Lo q) q,) L o z o 6!otr Fi U) U, o) (D c( Fr \o P, cq o (l) G(D 3 6l €) E CE Fr I I t9 Treatment Coverage The treatment coverage as shown in table 2 above indicates a fairly high compliance rate of Mectizan treatment among communities. The proportion of eiigible p..rom treated, according to the household survey and records obtained from treatment registers is close to seventy percent well above that recommended by APOC. The proportion of refusals in both studies is almost nil, while the proportion of persons absent duiing distribution who later received treatment is about sixteen percent. The observed findingJabove indicate an increasing acceptance of Mectizan treatment by the communiti., oui time, a signal that the project will eventually be sustained. This observation is shared by CDDs interviewedin category A sub villages in which hundred percent expressed their opinion that community response to CDTI programme was posiiive because of the benefits offered by Mectizan. Participants in the focus group discussions (FGDs) gave similar observations with regard to drug acceptability. In a session involving young men at Kikunja one member suggested "Many people have reslized that theie'drugi are benejicial that is why a lot of them are asking when they witl he brought" In agioup of woriren the same observation was made, "previously people were afriid of drig riactions but after we were informed that the reactions were a sign of infections and that the diug was effnctr:1many peolle are demanding" (Shaurimoyo) Young women in the ,u-. uillug. hinted that they had assembled in that group ressioo because they knew whenever thiy saw the vehicles with WHO logo it meant Mectizan was in it "this is why we are here,,.However, in another village participants believed Mectizan *as drug to cure eye infections and as such "why should we take it when we have no eye problems" (Men,Kilimani). This misconception may partly be explained by the name of the disease used before "usubi" was introduced. Previously the nime "upofu mto", a direct translation of river blindness, was in use, hence the misconception. Table 3:Proportion of Villages treated and in which CDDs were changed after thefirst treatment o-3 Proportion and number of at-risk villages treated : 30 (100%)O-5 Proportion and number of communities where CDbs were changed by the community after the first treatment: 1 (3.3%) Wards Sub-villages (Both A and B) Treated CDD changed Lugarawa 5 100% 0 Ma 5 100% 0 5 l0jyo 0 Matimila 5 100% 1 Kilimani 5 100% 0 Kiangimahuka 5 100% 0 Mkongo 20 community Geographicar Coverage and CDD performance The proportion of villages receiving treatment in the Ruwma focus as presented in thetable above indicates. a satisfactory g.og.uphical treatment coverage as all the villagesvisited acknowledged to have recelred treatment in the previous distribution round th..g9y.attaining a hundred percent geographical cove.age.In addition to the high geographical .ou..ug. attained thi proportion of cDD change wasalmost nil of all the villages that were visited, only in one villagslas there areplacement of the cDD_following the marriage olthe fo.."r. The major reason givenfor not .changing.*the CDDs aJ given by -community leaders was satisfaction ofcommunities by cDD performance, About .ignty three percent of leaders in category "1" sub-villages rated their performance u"r iood and 17% rated as fair. Theirobservations were grounded on commitment to iro.l, ,lility to educate communities,high coverage attained and trustworthiness. Also a hundred percent of the CDDsinterviewed in category A villages affirmed their willingness to continue with their work,the major motivation being community_trust, porriul"r,ty for more opportunities andcommitment to serve their people. This observation was shared in the gffi-air.ussions across all villages where FGDs were conducted. The following .frnu.'t succinctlysummarizes the sentiments across the group sessions " these people-move from house to\?!:" slving drugs, sometimes walkiig long distancn fiyng n'persuadi even the mostdfficult men. we surely appreciate ilr"tilr"y ao. y i, were to give them marks Iwould suggest a hundre_d percent,'(women, kimnla;. ihe aboue f;;dir;.rgur we1for the sustainability of the distribution proce-ss as it signifies continuity. However, thereis a need for community sensitizationtothe fact that tlie distributors are doing voluntarywork and it is the responsibility of the communities to motivate their distributors as itseems communities are not informed of this fact. -In a group session involving youngwomen this came out as follows "It is impossibte for a iormal person to work so hardand with such commitment for free. Tlise rylt; be paid I think by those who bingthese drugs, otherwise they wouid not le working ,ohird" (young woman, Kikunja).This observation explains why cDDs do not ,...iu. ury ,rppon from the communities as none acknowledglo to....iu" ury. a2l Table 4a: Proportion of villages which received health education, and in which health care personnel supervised CDDs Wards Sub-villages (Both A and B) Received health education (Yes/No) CDD Supervised by health system T ugarawa 5 100% t000h Mavanga 5 r00% 100% Mkongo 5 t00% 100% Matimila 5 100% r00% Kilimani 5 100% r00% Kiangimahuka 5 t00% t000A 0-6 Proportion and number of communities in which the CDD is supervised by the health care (communities scoring 5O%o and above): 30 (100) o'7 Proportion and number of target communities which received health education : 30(100) Community Health Education and CDD Supervision The proportion of villages receiving health education and those whose CDDs were supervised by the health system as presented i4 the table above indicates that ahundred percent of communities acknowledged to have received health education and that in 67yo of the communities the health workers did the supervision while in the rest 33%o it was the village health committee member who supervised the CDDs. In most occasions the supervision entailed checking the treatment books during and soon after the distribution. However, while all CDDs admitted to have been taught on all aspects of onchocerciasis and the drug, the quality of education imparted to community members needs to be improved as it was limited to the information given orally mLstly during distribution times. Hence it only focused on the drug benefits and side effecti There were no IEC materials to be seen. In the group discussions this was repeatedly put forward as a special request across all the groups. The complaint was " We need to be given these seminarc as frequently as possible. You see for the short time that you havi been with us today we have gained a lot in terms of knowledge about these ihings,, (young women, T,imamu). Young men in Kikunja echoed the same request "We iay haie been told of the things that you are asking but we do forgel You should come-more frequently ir ifpossible bring the posters for they are more informative comparecl to virbai information" The tables below summarize the information on the number of days, issues and topics that were covered at the training sessions as reported by cDDs in sub-villa ge,, A,, 22 Table 4b of CDD Table 4c: Issues/To ics Covered at CDD Trainin Sessions t iqyt Response % Les 1 2 J s than I J J 0 0 0 50 50 0 Total 6 100 Issues Yes# % A. About Ochocerciasis Cause Symptoms Socioeconomic importance Community mobilization/education Ivermectin needs long time treatment B. About the Drug Treatment duration Coverage of distribution Dosage determination Drug expiration Treatment of Ab sentees/refu sals S ide effects counseling/referral Exclusion criteria Record keeping Census taking 6 6 6 6 6 6 6 6 6 5 6 6 6 6 100 100 100 100 100 100 100 100 100 83.3 100 100 100 100 TOTAL 6 100 23 Table 5: rnput indicators (community level) (oh in parenthesis) Treatmen Register 5 100 5 5 100 5 100 5(100) I-t r-2 t-4 I-5 I-6 l-7 Proportion and number of communities with trained cDDs : 30(100) Proportion and number of communities that experienced late supply of ivermectin = 3(10) Proportion and number of communities that experienced shortage of ivermectin = 1(3 3) Proportion and number of target communities which collected ivermectin from a collection point or health center:30(100) Proportion and number of cDDs with measuring device : 30(100) Proportion and number of communities with treatment registers : 30(100) Proportion and number of treated communities with rrrrnrury form ai the district oflice:30(100) Community Level Input Indicators Community level input indicators as presented in the table above indicate that hundred percent of communities reported to have trained distributors. All the CDDs interviewed in both category A and B sub villages acknowledged to have attended some form of training on how to treat community members. Differences in the length and number of sessions regarding training were reported although they were insignificant. Moreover, the reported differences reflected differences in perception. For instarice one CDD observed that he had attended only one training session *t ich entailed going to another village while another observed that the last session was not training be.uur. the trainers riere in the village for four hours only. The number and proportion of communities that experienced late supply of drugs wereinsignificant as only three representing ten percent bf dl ,ornrnunitiii visited reported to have experienced late supply of drugs. All the rest said that the drugs arrived as expected.Likewise for those who reported to have experienced shortage of dirgs was only one village representing three percent. The main explanation given for thJ observed shortage was that people from a neighbour village which was not in the programme came for treatment thus the number of people exceeding the drugs estimiteJto treat the particular village. The proportion of communities that collected ivermectin from a collection point (health facility) represented a hundred percent of all visited villages. However, in some uillug., Wards Sub- villages(A&B) Trained CDDs Late Supply Drug Shortage Collection from a Point Measuring Device LUGARAWA 5 s(100) 0 0 s(100) s(1 00) MAVANGA 5 s(100) t(20) 1(20) s(100) s(100) MKONGO 5 5(100) t(20\ 0 s(100) s(100) MATIMILA 5 s(1 00) 0 0 s( I 00) 5(l0o)KILIMANI 5 s(100) 0 0 5(100) s(100) KIANGIMA HUKA 5 s(100) r(20) 0 s(100) s(100) I 24 CDDs interviewed were adamant when asked if a member of community had collected Mectizan from a collection point. In most cases they replied that only CbOs did the collection, indicating some misunderstanding about whither they could be regarded as community members. In all the focus group discussions participants described the process of collecting the drugs from the health facilities, mostli dispensaries, to the final destination, that is, the villagers within their hamlets. With regard to other input indicators, the proportion of communities with measuring devices, treatment registers and treatment summary forms at the district offices were hundred percent for each indicator. All CDDs interviewed had brought in their measuring and rightly described how they used them. Likewise all the CDDs piesented their treatment registers from which information about community treatment could be extrapolated, indicating good record keeping in many villages. However, in some of the villages, record keeping still poses some problems. For insLnce in one (bodoma) sub village the treatment register listed only the names of household members and ,.v,, or,,x,, marks to indicate treated or not treated respectively AII the three District Medical Officers (DMOO interviewed reported to have seen treatment summary forms shown to them by the District Oncho Coordinators (DOC) within their respective domains. Constraints At the managerial level the project reported some problems with respect to finances. In the first place, funds were delayed at the World Health Organization, country office inDar es Salaam last year and, secondly, funds for year foui were inadequate as money released for project activities in the year were not in accordance with that budgeted foi. Therefore, they were exhausted well before the following distribution. Technically, the major constraint experienced relates to the topographical features of some project areas. Typical of onchocerciasis endemic areas, rorn" uitluges are located in remote, hilly and rough terrain, thereby making them inaccessible to pro]ect stafffor various activities. According to the Songea District Coordinator, it takes more than twelve hours walking to some of the villages during data collection This may pose serious problems in undertaking other CDTI activities. Community Perception Three key issues regarding community perieption of COft were discussed during FGD sessions. These include ownership of the programme, expectation and community responsibility in the programme. Ownership Community responses with regard to who owns the programme indicate that theinformation in this respect was very limited, if at all it was givIn. only on. jroup replied that the programme belongs to the communities while 1ne maloiity m"entioned thegovernment and donors. In the majority of the discussions, however, dir.urrurts were completely ignorant of this issue as captured in this remark 25 "We were told the drugs are being distributed but we don,t know where theyc_omefrom" ( Female youths, Karibuni A) It is evident from the above statement thaithe village was not educated on the ownershipof the programme The expectation of the communit, "" *'Jli:r*}. was that it will eradicate the diseaseafter.sometime, given that the drug will ue maae available regularry " Because we have t""n-to*b signs-9{recovery we are certain that in the long runthe disease will be completely eradic;ted,,(Men, OoOornul I vr-a z v< -q !) =!- O O'O =lG---tr(g(gn(g ,i-4H.. H /\ U ! 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()+ 0)H o0 i'= o.tRl (vcdP>- *7^!4 EE;E 5f BE .q9EE9srEee -:EfEAE.EH-EE E aE E E B p(J'"s q-8E Its L Q.9i I € Eg ;EREf r E E€Eg=5 $H* $H3'E H+L )>a! -gA a)'!!-- ' ;i v P a *\J O { C)l j(! '= > ,.',= x = Y'= .Y EqgrEEEYU*^aL HE H-q U E# 0 J1 o (.) (!(.)E o oo ;5EEE$;,5:H IJ*Fsif€i;it ; .o tr V) lE H "i I >.!g - E d"_3ljaHi€EgE _.E --9;0! n, Q- .9E .9E Er q k -o.ts(u(g(B/>; :.:oE-leRP9i2. n h o o tr SEcB HE f E E€E:lHE EHHa--*O. 'jl tr ^ c.> ..3 €€e 3,e str do (co H -H;HIEE.Etq *5t aE;f €5 *g€ EE r H3'B PE:,P - f EUIU,-J ijBo .E v5 o- E-C 0 -VC)Ho-.:.<'5 .r H sEssf,t fsE €,f; € EE$:"H:Hs3 € "AEEHe ;s* rE*l€J$E€ s L (r.) E s d E x-3; e,()'--Cl3b. ltr e cd C)'ri -d)_lZ I -.= EViO!., Q- .9E .9E 9P q P 9.=(g(g(82)a .. = -- i e i =!-9 >X F b I E ,9€cA HE AE €EEEE$;"H:H ,,H € "AgEgs ;s * rs i;r Jigt op HIo 'o H E H.B'H - o'- -cii. !F H -9E - s H $ HE *: f;5f,tBE P o I(B oH € Eo o() .: oo Eo UE o\ a.] 27 Table 7: Quality of CDD Training in Category ,,A', villages('/o in Parenthesis) Ward No. of CDDs No. Trained Length of Traini No. Trained in a session LUGARAWA 10(100) 10(100) 2days 10MAVANGA 10(100) 10(100) 2days 10 MKONGO 10(100) l0(100) 2days 20MATIMILA s(100) s(100) 2days 20KILIMANI 10(100) 10(100) 2days 20KIANGIMAHUKA 10(100) 10(100) 2days 20 Tables 6-8 take a summary look at the quality of the implementation of CDTI in theproject focus. While Table 6looks atthe implementation of component, of -Cbrr atthe ward levels, Table 7 builds up information fr-om FGDs with the different segments of thepopulations in the category A sub-villages. The later gives qualitative aid contextualflesh to the data presented so far in su.pport of the argiments on the quality of CDTIimplementation in the Ruwma focus, *t,irt currently rafes satisfactory in all respects. 28 4.0 CONCLUSIONS Our conclusions are as follows: 1. While the CDTI process of decision making was generally observed in the selection of CDDs, it was not followed in deciding the time and mode of distribution. Decisions on these aspects were largely by health workers. 2. Community education on CDTI was limited to benefits of Mectizan. Community responsibility and ownership of the programme is deficient and this being the fifth and final year for APOC funding, it seriously affects community preparedness to take over control of project activities. 3. The CDTI training of health workers who trained the CDDs was sufficient in all aspects of census taking, proper record keeping and using symbols to indicate reasons for non-treatment as well as severe side effects. However, the CDDs in turn could not impart this education to community members. 4. The CDTI is fully integrated into the Primary Health Care system which augurs well for project sustainability. 5.0 RECOMMENDATIONS 1. A retraining programme for
RWUMA - WHO/APOC/CDTI PROJECT REPORT OF INDEPENDENT MONITORS OF CDTIACTIVITIES II{ RUVUMA, TANZANIA 15 - 29 SEPTEMBER 2OO2 SUBMITTED TO THE DIRECTOR AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL(APOC) SEPTEMBER 2OO2 I 2TEAM OF MONITORS William Joseph Kisoka, Research Scientist National Institute for Medical Research (NIMR) P O Box 9653, Dar es Salaam, Tanzania Tel: 255 2125083/21307 7 0 Fax:255 222t30660 Email: wkisoka@yahoo.com Oscar Kaitaba, Deputy National Coordinator, National Onchocerciasis Control programme Ministry of Health Tanzania P O Box 9083, Dar es Salaam Tel: 255 22 2130025 Fax:255 222130009 Email : katenga@raha. com Dr Rehmah Maggid, Project Coordinator Tanga CDTI project p O Box 5547 Tanga,Tanzania Tel: 255 27 2G47SB0 Fax: 255 27 2G47943 Email: niduga@yahoo.com Mr.Venancce David District Coordinator, Mahenge CDTI project Ulanga District, P O Box 337, Ifakara Tel: 255 23 2620311 ., TABLE OF CONTENTS E)GCUTIVE SUMMARY. LIST OF ACRONYMS 4 6 7 ACKNOWLEDGEMENT INTRODUCTION -1.1 -G-.P-.qe.P-l.E-ackgr-ssd 12._P..r._oj_e..Et,.Ea.e.kg_r__o_ur.d...... .l..3_Iea.qt ep. mp_ssiti_su .. . ... .l-,4 leu[s.._o..[Refp_.re..tc..e .. 2,A4P_f_H0__D0__1,_o__c__y . . . 8 .8 ...9 ...10 ... l0 .il ..lt ...11 ..12 ... 15 .15 15 16 .17 .19 20 21 .23 .21 28 28 2.1 Study Design2.2 Population ?3 The Sample and Samplins ProcedureInstruments Instrument Sample Treatment Coverage Constraints 4 O CONCLUSIONS 4EXECUTIVE SUMMARY The-GDTI process ofMectizan distribution was introduced in the Ruvuma focus in 199gAt the moment it is in its fifth year. An independent monitoring team of four members carried out an investigation toascertain to what extent the CDTI process had been implemented in the project area. Six endemic villages randomly selected in the project area each sub divided into five subvillages, making a total of thirty were covered during the monitoring exercise. Data wascollected from a representative sampre of the popul#on including r"rruirrirug.leaders/officials, health workers in the communiiies, the cDDs, household members, women, men and youth groups. Policy makers at various levels of the health system andProgramme Managers, .collaborating Ncoor and the wn *... ;ir;ir';;.*"a.Instruments for data collection included in-depth interviews, questionnaires, oflicialrecord/documents and focus group discussion (FGD$ gria.r. The results obtained by the monitoring team indicate that all the villages in our studysample were treated, giving u .o-rnrnity coverage rur. oi too %. rhe decision makingqrolels was largely by the communities in the sJection of the mode of distribution andthe cDDs but the time of distribution was in most cases taken by the health workers. Thehouse to house method was the preferred choice for distribution and height measurement was the form of dosage determination side effects (especially those corisidered severe)were never reported' CDDs were selected and trained in the villages visiteJ. gowever, wenoted that the training period was too short, had_ taken ptu.. u..y long time ago andconsequently they in turn, could not impart the knowleige to the conimunitie"s especiallyin.1h9 aspects of programme ownership, community respionsibility and support for CDDswhich are the key elements for CDTI sustainabilitf rrre team also noticed that there wasgood cooperation and collaboration among the vrinistry of Health, wHo and NGDOpartners, although there is more room for i-mprov"r.ri uy in.r.aring the quatity andquantity of information flow between these very important bodies. community membersexpressed great satisfaction and appreciation foi the prot.urnrn. in the project area, asituation which augurs weil for continuity and programrie sustainability Key Recommendations (a) Training sessions for cDDs and Health personnel should be increased and periodsshould be longer. (b) community education on key issues Iike programme ownership, community responsibility, reporting of side eflects and cJnsus should be stiessed during CDDtraining. (c) An update of community census before the next round of treatment should becarried out. (d) APoc should consider possibilityof extending period of project funding for atleast two more years to enabre project *rtuiruiiiity,-.r.n emphasis being onhealth education and IEC *ut"iiul, developme nt. " I 5LIST OF TABLES TABLE A 1' Divisions wards' villages/Sub-villages covered in the Monitoring ExerciseRuwma Focus...p9 .. . ..13 TABLE 42: Summary of Instruments and Sampling procedures ... .p9 TABLE l: Decision-making process at the village level ........p9 TABLE 2: Treatment Summary-Househord survey and cDD Records .. ...p9. TAB|E.3: Proportion of villages treated and in which CDDs were changed after firstdistribution round t9 TABLE 44: Proportion of villages which received health education and in which health TABLE 48: Length of CDD training. . . ... .......22 TABLE 4C: Issues and Topics covered at CDD Training ..Zz TABLE 5: Input indicators at Community Level . ..24 TABLE 6: Distribution of Imprementation of the components of cDTI by wards ... ....27 l5 t6 l8 l. 6LIST OF ACRONYMS AIDS Acquired Immune Deficiency Syndrome APOC African Programme on Ochocerciasis ControlCDTI Community Directed Treatment with IvermectinCDD Community Directed Distributors HH Housed Hold FGD Focus Group Discussion IEC Information Education Communication IMA Interchurch Medical Association NGDO Non Governmental Development Organization NOTF National Onchocerciasis Task Force PHC Primary Health Care SSI Sight Savers International VETA Vocational Educational Education Training AuthorityWHO World Health Organization 7ACKNOWLEDGEMENT The independent monitoring of the Ruvuma CDIT Focus took place between 15-29 September 2002. We wish to express our appreciation to the management of the African Programme for Onchocerciasis Control (APOC) for financial as well as logistic support, the NOTF national oflice for facilitating the smooth running of the exercise-training needs and transport to and from project villages; Dr Joseph Okeibunor, who facilitated in the training sessions provided template reports and instructed on the use of Epi Info 6.0 soft ware We also extend our sincere gratitude to Dr. Saiduni Kabuma, Regional Medical Offrcer for Ruwma, and Doctors John Budottela, E Mhonzwa and Anthony Mashinda, District Medical Officers for Songea, Ludewa and Mbinga districts, respectively, who agreed to be interviewed and answered all questions put across. We also acknowledge the support from Messrs John Ngatunga, E B C Haule and S L Mpangala District Ochocerciasis Coordinators for the Ruvuma Focus, whose role as field assistants and knowledge CDTI activities within their respective villages simplified the fieldwork in all districts. All omissions and errors remain the responsibility of the authors 8INTRODUCTION 1.1 General Background onchocerciasis remains a serious public health problem in large parts of tropical Africawhere some l8 million people are affected It is mainlya pubilc irealth p-ut.,, in ruraltropical populations, which live in river valleyr, *h..e the back fly ,ectors are found.The disease is chronic, non - fatal but causes a wide - spectrum of skin lesions, fromintense itching to gross changes in skin elasticity, resutting in hanging gioinr, lizard -like skin appearance, and color changes such as patchy depigmentation ,,leopard skin,,The most severe manife-stations prJviourty r..olrlrla were those associated withdamaged eye tissues, which may lead to serioJs visual impairment and ultimateblindness, hence its common name river blindness. onchocerciasis in Tanzania is endemic in fourteen districts out of more than a hundred.characteristic of the East African endemic countries it is found in discrete foci, mainly onremote mountain slopes, from where occasionally it spreads up to the rolling plainsextending from the.foothills. Apart from small -r.ui. opeiations to control onchocerciasiswhich relied largely on vectoi control operations based on aerial larviciding in westAfrica, there used to be virtually no onchoierciasis control in the country until 19g7 whenMectizan (Ivermectin) *ls registered for the treatment of human onchocerciasis. Thesubsequent availability, free of ,hurge, of this safe and effective microfilaricide haspresented an opportunity to control the disease as a public health problem in endemicareas. rnTanzania the current mass treatment using Mectizanstarted in l992in Ruvuma regionwhen.7,830 people received the first cycle. The activitf was under the River BlindnessFoundation (RBF) which provided financial and logistic support up to 1995. operationsfor the 1996 and 1997-were supported by funds p.*il by the Inter-church MedicalAssistance (IMA) and Sight Servers Internationar 1'ssq respectively in collaboration withthe Tanzanian Ministry of Health (MoH) APoc h.,raing ro. the establishment of GDTIprocess started in 1998. The control of onchocerciasis used to be vertically designed in Ruvuma and Mbeyarunning parallel with other health services, until 1995 when the National onchocerciasiscontrol Program G{ocP) was established with the major-goarto eliminate onchocerciasis as a disease of public health importance and obstacle tt solcio - economic development inthe country in the period or is - 20 years. The broad objective of the Nocp is toestablish, within the period of twelve years (1997 - 2008), effective and self - sustainablecommunity-Directed Treatment with Ivermectin (cDiI) throughout endemic areas ofTanzania and where possible, to eliminate the vectois of onchocerciasis by usingenvironmentally safe methods in selected foci. I 91.2 Project Background Ruvuma Focus The Ruvuma GDTI project is composed of three adjoining districts of Songea andMbinga in Ruvuma Region and Ludiwa in Iringa Region. It is often referred to as theRuwma Focus. The three districts.hu.u.. u totui popflation of 767,461 inhabitants (according to the1988 census) with 17 administrative divisions, 75 wards and2g6villages. Songea District Songea is one of the 4 districts which make up Ruwma Region and is the main town inthe region' It houses all the regional administrative functions. The district has 2 hospitals, 9ne i9 owned by the government and the Roman catholic church owns the other. It has 7health centers, 53 dispensaries and 39 village health posts (vHp). It covers a total area of34,193km3' The total population-of the distictistzz,gii. rni, gives a population densityof approximately 8.9 people Km2 The district is about 1,000 km from Dar es Salaam, serviced by an all-weather tarmachighway' The nearest railway station is at Makambako in Iringa Region, iot t, r.o,Songea town' Currently the town is not linked to the national airline network. There areoccasional air characters into the town. Administratively, Songea district has 7 Divisions(Ruwma, Mputa, Namtumbo, Ludewa, Madaba, Muhuiuru and Mkong o),22wards, andI l9 villages. The district borders with Ulanga district which is within the Mahenge Focus to the east,Ludewa and Njombe districts to the north, Mbinga district to the west, and Tundurudistrict and a neighboring country-Mozambique CNJnrr.r" province) to the south. Mbinga District: Mbinga district is the .second project area in the Ruwma Focus. The district has 4hospitals one is ow19d by the gou.ir."rt a1{the rest by NGos. It has 5 health centers,49 dispensaries and 7l^village health posts (vHP). It covers a total area of ts,iTg lrrrf"'The total population of the district is :^:Z,ZSd. The administrative. offrces for Mbinga district are in Mbinga town; which is 100 kmsfrom the regional headquarters in SJngea. The road is partly tarmac (i.e 20 kms fromSongea) and the rest is gravel with permanent bridges. The main means of overland traveloutside the district a-re through Songea. The secon-d alternative is by boat from MbambaPort to.Itungi Port, Kyela district in Mbeya Region. Administratively, Mbinga district has-6 diiisions (Mbuji, Mbinga Mjini, Rahekei, -N31swe9, Mpepo and Ruhuhu), 33 wards, and ll4villages.Mbinga borders with Ludewa district (Iringa negiorf tf,the north, Songea district to theeast and Mozambique's Northern Provin.. 1r.ilnuoring country) to the south. on thewestern side it borders with a neighbouring rourtiy-Malarwi (Lake *ru*l -- Ludewa District: Ludewa district is also within Ruwma onchocerciasis Focus, but administratively is partof Iringa region where there are 6 districts. The district rras : hospitals one owned by thegovernment' There are 5 health centers, two of which are owned by the Roman Catholicchurch and about 34 dispensaries and 50-village rr.urtr, post. It covers a total area of8,397 km2. The total popuiation of the district is ioo,zto r 10 The district is administered from Ludewa township, which is accessible along a windy allweather gravel road. Its location makes it a relatiirlry ..*ot. site even from its regionalheadquarters at Iringa' The main means of travel to and from the district are by road or byboat from Lake Nyasa frgm Lupingu to Itu.nsi rort, rfeta district in Mbeya Region. Thedistrict is divided into 4 divisiom iryfl.ungui, "tutu*.ngi, rurururi and Mwamb ao), zowardsand 63 villages Ludewa borders'with t1e districts? Songea in the east, Mbinga andKyela in the south, Njombe and Makete in the north and Malawi (Lake Nyasa) in thewest. The main ethnic groups in the project area include the wangoni, wamatengo, wabena,wamanda, wapangwa and othei migrants. Despite some minor differences in their socio-cultural characteristics, these tribes mix without tension. peasant farming forms themainstay of income generating activities in the three districts where crops such as maize,banana, beans, rice, cassarra ard potatoes are grown as staple foods while tobacco, teaand, to a lesser extent, timber are cash crops. ih... is atso small scale fishing along therivers and lakes' Border as well as highwaytrade is also existent in the p-j..i u..u. 1.3 Team Composition The independent monitoring team was composed of Mr william Kisoka, ResearchScientist in the department of health systems and policy research, National Institute forMedical Research, Tanzania, as the Principal tvtoritor. the other monitors included Mr.oscar Kaitaba, Deputy Nocp coordinator, Dr. n.rrrnu Maggid, Tanga CDTI Focuscoordinator and Mr venance David, District oncho coordinitor for iJlanga District,Mahenge Focus. Members of the ornrr in Ludewa, s;rg., ;;'dtr;;iirt.i.t, ,rroparticipated in the exercise within their respective -Jo.nairs. Two jrive.s, namelyAbdallah Nuhu and Kurwa Issa of the Ruwma and ranga'projects respectively facilitatedtransport during the whole monitoring exercise. 1.4 Terms of Reference The team was constituted with the following terms of reference: l ' Succinctly document how ivermectin treatments were undertaken in a sample ofcommunities with approved CDTI project in ranla focus, Nigeria- 2 Assess community involvement in drug collection, decision making on the periodand modes of distribution, the selectioi of distributors, and the willingness of thecommunity to accept and bear these responsibilities oesigneJ -i.,- the CDTIprocess. 3' Document community perceptions of GDTI processes especially the issue ofownership, and expectations for onchocerciasis control, based on theseperceptions lnd expectations determine the degree of satisfaction of thecommunity with the different programme activities and outcomes. 4' Assess the quality of training received by cDDs and health personnel involved inthe project. I 56. 7 8 l1 Examine the record books of the CDDs and assess the quality of record keeping and their ability to keep accurate records. The same applies to the health services staffon the project. Determine the number of communities and eligible treated and compare findings with records of the CDDs and the records at the other levels (District, Division Ward - level records.) Determine whether the health personnel participated in ivermectin distribution and assess the degree and quality of supervision by health staff (and the quality and orientation of the health staffto the CDTI) Identifu constraints in the distribution and recommend appropriate measures to APOC management to be taken before the next round of treatments. 9 Discuss the prospects of sustainability based on the findings above. 2. METHODOLOGY The methodology used for the selection of the villages and sub-villages was a modified form of the methodology that was developed during the meeting of the nine monitoring team members in Ouagadougou in 1998. In a review of the tools, in a tool development workshop in Kabale, this was further refined to include a few of the things that were not previously taken into account. The entire endemic villages were included in the sampling frame irrespective of levels of endemicity and closeness to the health facilities in the areas studied. This simplified approach merely selected villages by a simple random sampling approach. 2.1 Study Design For the monitoring conducted in Ruwma Focus of Tanzania September 2002, a cross- sectional research design was adopted. This design was considered the most appropriate to generate the needed data and meet the study (monitoring) objectives. The data collection exercise consisted of a triangulation of qualitative and quantitative instruments designed to collect information from different segments of the target population 2.2 Population The target population for the monitoring exercise consisted of four broad groups. These include: l) Health Personnel involved in the CDTI process at various levels; 2) Village leaders; 3) Community Directed Distributors (CDDs); 4) Household members in the hyper/meso endemic. \ L2 In addition, policy makers in the areas where CDTI is implemented were interviewed to gauge their plans for sustainability of CDTI in the future as well as their policy direction with special reference to their current support for CDTI. 2.3 The Sample and Sampling Procedure A study sample of thirty villages was chosen using a simple random sampling procedure. However, the sampling process began with stratifying the divisions and wards in the district by levels of endemicity. Since treatment focus is prioritized based on hyper and meso, the hypo endemic divisions and wards were excluded from the sampling. Consequently, six hyper/meso endemic wards were chosen through a simple random sampling process (balloting), from three divisions, one division each from the three districts under the Ruvuma project. The chosen wards included Lugarawa and Mavanga in Ludewa district, Mkongo and Matimila in Songea district while Kilimani and Kiangimahuka were sampled from Mbinga district. The villages in the selected wards were listed on pieces of paper and six of them randomly selected by balloting. The villages sampled through this process were Myombo, Mjimwema, Karibuni A, Masimango, Kilimani and Dodoma in the order mentioned above. Category A and B Villages: Having selected the six villages, one from each of the earlier sampled wards to be visited, the sub-villages in the chosen villages were listed. Thirty sub-villages were randomly selected from this list. Another random sample of six villages out of these thirty sub-villages chosen earlier were taken as category "A" villages while the remaining twenty four villages became the category "B" sub-villages for the monitoring exercise. Unfonunately these villages could not be classified into hyper or meso because the information was not available The only information available helped in eliminating the hypo endemic areas from the etcercise. The list of divisions, wards, villages and sub-villages that were visited for monitoring purposes is summarized in the table below. \ 13 Table A1: DivisionsAilard s/Villages and Sub-Villages Covered in Ruvuma ect Focus: Households: In each Category "A" sub-village sampled, fifteen households were chosen. To do this,the sub-village was carved inio threl clusters grid;;-;; the village head and Iocalguides' The systematic sampling approach was thin uppri.a to select ive dwelling unitsfrom each cluster' .The sampli,rg inie*als were dete#ined through a quick estimationof the number of dwelling units in each village-cluster- This differed from one sub-village-cluster to another' In each sampled dw"ellin! unit one household was randomlychosen for the treatment coverage study. nurtherm"ore, io check on the correctness oftreatment, one household was randomly chosen, and'the dosage fo. one householdmember, randomly selected and crosschecked, Districts Division Wards "A" Sub-Villages ttBtt Sub - Villages I.LUGARAWA I MYOMBO lAMKATWEND E 2SONGAMBELE 3MWENDAPOLE 4 MJIMWEMA I.LUDEWA I.LIGANGA 2 MAVANGA 2 MJIMWEMA 5 MGOIv{BESI 6 USHINDI 7 MANNZESE 8 MBUGANI 3 MKONGO 3 KARIBLTNI A 9 KARIBUNI B IO ULAMBONI 1I MABATINI l2MWEMBECHA I 2.SONGEA 2. MKONGO 4 MATIMIRA 4 MASIMANGO 13 MPINGI B 14 MULTNGANO 15 LIZABONI 16 MOTOMOTO 5.KILIMANI 5 KILIMANI 17 NJOOMLOLE 18 KILIMANI KATI 19 MAHUKA 20 MAPINDUZI 3.MBINGA TOTAL 2. MBINGA MJINI 6 A 6 DODOMA 2I LUSAKA 22 KIVTIKONI A 23 KIVIIKONI B 243 6 6 24 l4 CDDs and Village Leaders: In each Category "A" sub-village sampled, the sub-village leader was purposively selected and interviewed. The sub-village CDD was alsJ purposively sampled andinterviewed. In cases where there were two cDDs both of thlm were interviewed, butwhere there were more than two cDDs, only two were selected by balloting Similarly, the sub-village leaders of the Category "B" villages were purposively chosenand interviewed. The sub-village cDD, *..f uiro pr.posively chosen and interviewed where the CDDs were two or less. In somc sub-villages with more than two CDDs, twowere randomly selected for the category ,,B,, sub-vill-age cDD interview. Health Persorutel and policy Makers; various cadres of health personnel involve.d in GDTI process were purposively selectedand interviewed. These included Supervisors, District onchocerciasis Team (DoT) members and Coordinators. The Coordinators of Primary Health Care and Healthofficials at the District and ward levels, involved in the CDTI p...r" *ere alsopurposively selected and interviewed. The purpose of these interviews was to examinethe orientation to CDTI. process and provide information on the records and quality oftraining they receive andlor give on th; CDTI process. Policy makers at these levels of the health. systems' operations were also purposively selected and interviewed to give idea of the support or tn. policy makers'for GDTIimplementation as well as theii prans for the sustainability of theprogru*... - 15 Instruments Eight instruments were used to gather information from both categories ,,A,, and ,,B,,sub-villages as well as at the oistrict and ward levels. copies of these instruments areincluded as appendices to this report. Table A2: Summary of Instruments and Sampling Issues Instrument Category of Sub-villages and Unit Sample Sampling Procedure In-depth interview & Record review with CDD A&B | -2per sub-village Purposive (Simple random, where there are more than 2 CDDsHousehold coverage survey A 15 households per sub- village Multi-stage (i.e. cluster, systematic and randomKey informant interview of vil leaders A&B I village leader per sub- village Purposive Group discussion A 3 groups per sub-village (i.e. 1 male and I female adult, and I female or male youth groups), 6-g in each Convenience Health personnel interview A I PHC coordinator 1 Oncho coordinator I DMO per District I LOCT member t health centre staff Purposive Programme manager/Policy maker interview Project, District & National levels 1 NOCP Staff I Project Coordinator, 1 Supporting NGDO staff Purposive Ho --oc6 ,- ?z ooo o\ o\ o\N c.l c.l ^^ooooOO- vvOr\o \o (\ OOOooo \o \o\o t-o €o t-a -F-tr)NO OOO \o \o \o I c)'=o0Hcgc 5-Y o) ^.$ ^f-#aa c\$+ a.l OO- OOO po -'=ooti HCU: - -cBEFP-Q o-rr'iri ui () ca N I-*H \O C.l \oo +Oca OOO Li -E o) € -lZ cd=0.)-v oo= aO i-^Ycn v Ocacarncor c. cil tf, --O \o \o o o0 r-tcoi cO t-t -c.lo O-co OOO o oo !na6 =-o>tr OOO ooo OOc.)l.) ra) aa cacoN a)sbo,= -:() -6)5> /-\# OH$o\ \iN \oO\#(tl ,^. a C.lcao\oI Y);' c\coi \o\oo -#c.) t) o U) a.) e-caxY q.Y X ^*-r-- ^!/!ra ^p#He v !.i 7\q, ur.9 EYh qE.3Hv9. -.rHV ,\ A . Fv.VqE€: ? 3li^{i-]1O s5 E ! *S>rZa = A Fq t tr{tavb -='- ^ €EEtl . XSIJ 7'E:e -- !: 0q vor, vPI ts E ,, ij = o-:, o air>,; Uo.o 6-Ck.E.g^ =9L! )^trjrriiH o.i LL/ 'z a Ez -v-c,r <- rtl x .h;^(JYvAo.lgEO.E E* -:i=lvdJaaL vaoo \o ca aq96s.s oXN- -ll o\ll PN EOll() tro ts in/1 +l o-Cl,li\J9i cio36r o o= q) .F Ot6tr-o--E ,99 €= I cao)o-<r) E 3'>-, '08EgE = €otr(J'-a -= (JE 'Yaa(Da u)g(D(D+jSSe == (l) 'a .- .,qa>> C) U) Chooo trtrtr oooooo(H (r (Hooo I<Lrl<oo() -o.o.o E.OE(o(g(o ooo LLLoooo. a. o.oooLr li li0iAOi o U)q) 6,) CEtr q) q) t] o o0 c) qE U2 .r) O o a0 & c! I o ar) I(l) o) cl t-r auLrLt- O F-CE a.Y r.1 EfrE (\t I rq I f-l 4?a t7 Decision Making Process for CDTI Implementation The decision making process on the implementation of CDTI as indicated on table 1 above were largely done by the communities. Interviewed leaders in both category "A" and "B" villages overwhelmingly 26 out of 29 (about 90%) reported that the decisions on the persons responsible for distribution of drugs had been taken at village meetings while decisions on the time and mode of distribution that were taken in the same manner were reported by nine and twelve leaders respectively. The village committees were also involved in a number of decisions especially those on the mode of distribution. Health workers were mostly involved in decisions on the time of distribution against APOC directives that these decisions be left to communities apparently because of the need to distribute the drugs as soon as they arrive. The same results were obtained from CDDs interviewed. One third (2 out of 6) and half reported that the decisions on the timing and mode of distribution respectively were taken at village meetings while l8 CDDs reported that they had been selected in the same manner. In the group discussions participants gave a slightly different observation, as village elders were reportedly responsible for most of the decisions on the time and mode of distribution. However, they too affirmed that they participated in the selection of CDDs. "Meetings were held at sub villages where we nominated names for further steps by the leadership" according to one old man in Mavanga much to the agreement of others during an FGD session. Women in Kilimani echoed the same observation when they submitted that they too were involved in the selection of their CDDs " I remember we held a meeting at our chairman's house and selected those two young people to do the distribufion" However, sessions involving youths indicated a glaring deficiency on the awareness about what went on in the introduction of the projects within their respective areas. This may partly be explained by the fact that most of the youth discussants in the FGDs were still school children at the time the project was initiated in the project area. This demonstrates the need for urgent introduction of IEC materials especially in schools which serve as separate entities in Mectizan distribution. oo E 0)(n() Lr o. C)t< o Cdoli € €o ti € U) oa(€(l)L (H o3aOO \^S\648Hr< ca(I) o- ll(l).= SPt-o 9Li@tro:!-ts 3aS a ,, 'r)EJJ ll H-.9;J. c,X>U.{ (DtE 'E rr'8 € E €* :QilkPp-CLtsU)di;s Eg3E'6 6 x I -.-o fi .Y X LU(UrVAi VH c = (Dr ^*x EbEE(ts O g .^9- E-E E E o-E [j ,d.>P^ -- E i 3-0)r<2C,l(/) -Eo dEH *ts6nvc*E AA?, :.ts' 9€ 8.tr^ (H(Hq< ='o o o o 'hQ)t<LL .'ts(l)0.)o) =;\ -o-o.oEtr trtrtr!HHH ue))):otrtrtr "F EEE&sr EEEE6 trtrtr -c oooO) P .-.n.- != +{ l- l- L-Ho oooo. o- o-EE PP9!9AAA.iHHH €l- orQ -tr :+ t-( 61 6ErYllri E ooo 54( rh 6)\J bo{ 5'= =iEL =.1a av OI!& \oo\ ; z I I I a ,\n c- Orozc caN caN FRH\i @FS' -f,sra \- g( rh 6)u,/ 0!<s -? -a O14F F( c.r O ..oz, O ot\o ooQ N9 $9*:./ 2or+ (-- o ..oza o .f,C.) ooPa.l \i ;s r.- PSV z 5q{ rt 6)t/ 0!<s r->FIA -a \o @ c.l C) H& O ro'Ze> o o\ F- N a tr) @N oot- ooa N\J 2air 0O dGz?> O caca F-N $N co t- cn r-.\o o\ ra) g{ rh G)l/ oo{E,s .l?b tr€E>da I O IJ]& O.ozc I I a^ ,+ C-' Oroza t-- !t N t-- ao ca co c'l tr-\o l-. w 9(U t!<{ S'= 'i ?.o F r'sa av HsC( o.l Orozc ca orRco$ o.l ' -f, ii sa 3rrtsli O\ Oroze) O l*-t-- c.l ci cil aa $ o\ ca O\o @lr) 54{rr 0) -\J O! =t<SEIFl 't ali;si 9^lrJ tr)fi\o Orotz o\ O \o\o t-- o\$ ,nQ F8 2a/< 00 .o o\ o z l-r \o o\ r- \oN caN co t-- lr)\o * d F an G U) (uil arlq) o {) U)E (,Lo q) q,) L o z o 6!otr Fi U) U, o) (D c( Fr \o P, cq o (l) G(D 3 6l €) E CE Fr I I t9 Treatment Coverage The treatment coverage as shown in table 2 above indicates a fairly high compliance rate of Mectizan treatment among communities. The proportion of eiigible p..rom treated, according to the household survey and records obtained from treatment registers is close to seventy percent well above that recommended by APOC. The proportion of refusals in both studies is almost nil, while the proportion of persons absent duiing distribution who later received treatment is about sixteen percent. The observed findingJabove indicate an increasing acceptance of Mectizan treatment by the communiti., oui time, a signal that the project will eventually be sustained. This observation is shared by CDDs interviewedin category A sub villages in which hundred percent expressed their opinion that community response to CDTI programme was posiiive because of the benefits offered by Mectizan. Participants in the focus group discussions (FGDs) gave similar observations with regard to drug acceptability. In a session involving young men at Kikunja one member suggested "Many people have reslized that theie'drugi are benejicial that is why a lot of them are asking when they witl he brought" In agioup of woriren the same observation was made, "previously people were afriid of drig riactions but after we were informed that the reactions were a sign of infections and that the diug was effnctr:1many peolle are demanding" (Shaurimoyo) Young women in the ,u-. uillug. hinted that they had assembled in that group ressioo because they knew whenever thiy saw the vehicles with WHO logo it meant Mectizan was in it "this is why we are here,,.However, in another village participants believed Mectizan *as drug to cure eye infections and as such "why should we take it when we have no eye problems" (Men,Kilimani). This misconception may partly be explained by the name of the disease used before "usubi" was introduced. Previously the nime "upofu mto", a direct translation of river blindness, was in use, hence the misconception. Table 3:Proportion of Villages treated and in which CDDs were changed after thefirst treatment o-3 Proportion and number of at-risk villages treated : 30 (100%)O-5 Proportion and number of communities where CDbs were changed by the community after the first treatment: 1 (3.3%) Wards Sub-villages (Both A and B) Treated CDD changed Lugarawa 5 100% 0 Ma 5 100% 0 5 l0jyo 0 Matimila 5 100% 1 Kilimani 5 100% 0 Kiangimahuka 5 100% 0 Mkongo 20 community Geographicar Coverage and CDD performance The proportion of villages receiving treatment in the Ruwma focus as presented in thetable above indicates. a satisfactory g.og.uphical treatment coverage as all the villagesvisited acknowledged to have recelred treatment in the previous distribution round th..g9y.attaining a hundred percent geographical cove.age.In addition to the high geographical .ou..ug. attained thi proportion of cDD change wasalmost nil of all the villages that were visited, only in one villagslas there areplacement of the cDD_following the marriage olthe fo.."r. The major reason givenfor not .changing.*the CDDs aJ given by -community leaders was satisfaction ofcommunities by cDD performance, About .ignty three percent of leaders in category "1" sub-villages rated their performance u"r iood and 17% rated as fair. Theirobservations were grounded on commitment to iro.l, ,lility to educate communities,high coverage attained and trustworthiness. Also a hundred percent of the CDDsinterviewed in category A villages affirmed their willingness to continue with their work,the major motivation being community_trust, porriul"r,ty for more opportunities andcommitment to serve their people. This observation was shared in the gffi-air.ussions across all villages where FGDs were conducted. The following .frnu.'t succinctlysummarizes the sentiments across the group sessions " these people-move from house to\?!:" slving drugs, sometimes walkiig long distancn fiyng n'persuadi even the mostdfficult men. we surely appreciate ilr"tilr"y ao. y i, were to give them marks Iwould suggest a hundre_d percent,'(women, kimnla;. ihe aboue f;;dir;.rgur we1for the sustainability of the distribution proce-ss as it signifies continuity. However, thereis a need for community sensitizationtothe fact that tlie distributors are doing voluntarywork and it is the responsibility of the communities to motivate their distributors as itseems communities are not informed of this fact. -In a group session involving youngwomen this came out as follows "It is impossibte for a iormal person to work so hardand with such commitment for free. Tlise rylt; be paid I think by those who bingthese drugs, otherwise they wouid not le working ,ohird" (young woman, Kikunja).This observation explains why cDDs do not ,...iu. ury ,rppon from the communities as none acknowledglo to....iu" ury. a2l Table 4a: Proportion of villages which received health education, and in which health care personnel supervised CDDs Wards Sub-villages (Both A and B) Received health education (Yes/No) CDD Supervised by health system T ugarawa 5 100% t000h Mavanga 5 r00% 100% Mkongo 5 t00% 100% Matimila 5 100% r00% Kilimani 5 100% r00% Kiangimahuka 5 t00% t000A 0-6 Proportion and number of communities in which the CDD is supervised by the health care (communities scoring 5O%o and above): 30 (100) o'7 Proportion and number of target communities which received health education : 30(100) Community Health Education and CDD Supervision The proportion of villages receiving health education and those whose CDDs were supervised by the health system as presented i4 the table above indicates that ahundred percent of communities acknowledged to have received health education and that in 67yo of the communities the health workers did the supervision while in the rest 33%o it was the village health committee member who supervised the CDDs. In most occasions the supervision entailed checking the treatment books during and soon after the distribution. However, while all CDDs admitted to have been taught on all aspects of onchocerciasis and the drug, the quality of education imparted to community members needs to be improved as it was limited to the information given orally mLstly during distribution times. Hence it only focused on the drug benefits and side effecti There were no IEC materials to be seen. In the group discussions this was repeatedly put forward as a special request across all the groups. The complaint was " We need to be given these seminarc as frequently as possible. You see for the short time that you havi been with us today we have gained a lot in terms of knowledge about these ihings,, (young women, T,imamu). Young men in Kikunja echoed the same request "We iay haie been told of the things that you are asking but we do forgel You should come-more frequently ir ifpossible bring the posters for they are more informative comparecl to virbai information" The tables below summarize the information on the number of days, issues and topics that were covered at the training sessions as reported by cDDs in sub-villa ge,, A,, 22 Table 4b of CDD Table 4c: Issues/To ics Covered at CDD Trainin Sessions t iqyt Response % Les 1 2 J s than I J J 0 0 0 50 50 0 Total 6 100 Issues Yes# % A. About Ochocerciasis Cause Symptoms Socioeconomic importance Community mobilization/education Ivermectin needs long time treatment B. About the Drug Treatment duration Coverage of distribution Dosage determination Drug expiration Treatment of Ab sentees/refu sals S ide effects counseling/referral Exclusion criteria Record keeping Census taking 6 6 6 6 6 6 6 6 6 5 6 6 6 6 100 100 100 100 100 100 100 100 100 83.3 100 100 100 100 TOTAL 6 100 23 Table 5: rnput indicators (community level) (oh in parenthesis) Treatmen Register 5 100 5 5 100 5 100 5(100) I-t r-2 t-4 I-5 I-6 l-7 Proportion and number of communities with trained cDDs : 30(100) Proportion and number of communities that experienced late supply of ivermectin = 3(10) Proportion and number of communities that experienced shortage of ivermectin = 1(3 3) Proportion and number of target communities which collected ivermectin from a collection point or health center:30(100) Proportion and number of cDDs with measuring device : 30(100) Proportion and number of communities with treatment registers : 30(100) Proportion and number of treated communities with rrrrnrury form ai the district oflice:30(100) Community Level Input Indicators Community level input indicators as presented in the table above indicate that hundred percent of communities reported to have trained distributors. All the CDDs interviewed in both category A and B sub villages acknowledged to have attended some form of training on how to treat community members. Differences in the length and number of sessions regarding training were reported although they were insignificant. Moreover, the reported differences reflected differences in perception. For instarice one CDD observed that he had attended only one training session *t ich entailed going to another village while another observed that the last session was not training be.uur. the trainers riere in the village for four hours only. The number and proportion of communities that experienced late supply of drugs wereinsignificant as only three representing ten percent bf dl ,ornrnunitiii visited reported to have experienced late supply of drugs. All the rest said that the drugs arrived as expected.Likewise for those who reported to have experienced shortage of dirgs was only one village representing three percent. The main explanation given for thJ observed shortage was that people from a neighbour village which was not in the programme came for treatment thus the number of people exceeding the drugs estimiteJto treat the particular village. The proportion of communities that collected ivermectin from a collection point (health facility) represented a hundred percent of all visited villages. However, in some uillug., Wards Sub- villages(A&B) Trained CDDs Late Supply Drug Shortage Collection from a Point Measuring Device LUGARAWA 5 s(100) 0 0 s(100) s(1 00) MAVANGA 5 s(100) t(20) 1(20) s(100) s(100) MKONGO 5 5(100) t(20\ 0 s(100) s(100) MATIMILA 5 s(1 00) 0 0 s( I 00) 5(l0o)KILIMANI 5 s(100) 0 0 5(100) s(100) KIANGIMA HUKA 5 s(100) r(20) 0 s(100) s(100) I 24 CDDs interviewed were adamant when asked if a member of community had collected Mectizan from a collection point. In most cases they replied that only CbOs did the collection, indicating some misunderstanding about whither they could be regarded as community members. In all the focus group discussions participants described the process of collecting the drugs from the health facilities, mostli dispensaries, to the final destination, that is, the villagers within their hamlets. With regard to other input indicators, the proportion of communities with measuring devices, treatment registers and treatment summary forms at the district offices were hundred percent for each indicator. All CDDs interviewed had brought in their measuring and rightly described how they used them. Likewise all the CDDs piesented their treatment registers from which information about community treatment could be extrapolated, indicating good record keeping in many villages. However, in some of the villages, record keeping still poses some problems. For insLnce in one (bodoma) sub village the treatment register listed only the names of household members and ,.v,, or,,x,, marks to indicate treated or not treated respectively AII the three District Medical Officers (DMOO interviewed reported to have seen treatment summary forms shown to them by the District Oncho Coordinators (DOC) within their respective domains. Constraints At the managerial level the project reported some problems with respect to finances. In the first place, funds were delayed at the World Health Organization, country office inDar es Salaam last year and, secondly, funds for year foui were inadequate as money released for project activities in the year were not in accordance with that budgeted foi. Therefore, they were exhausted well before the following distribution. Technically, the major constraint experienced relates to the topographical features of some project areas. Typical of onchocerciasis endemic areas, rorn" uitluges are located in remote, hilly and rough terrain, thereby making them inaccessible to pro]ect stafffor various activities. According to the Songea District Coordinator, it takes more than twelve hours walking to some of the villages during data collection This may pose serious problems in undertaking other CDTI activities. Community Perception Three key issues regarding community perieption of COft were discussed during FGD sessions. These include ownership of the programme, expectation and community responsibility in the programme. Ownership Community responses with regard to who owns the programme indicate that theinformation in this respect was very limited, if at all it was givIn. only on. jroup replied that the programme belongs to the communities while 1ne maloiity m"entioned thegovernment and donors. In the majority of the discussions, however, dir.urrurts were completely ignorant of this issue as captured in this remark 25 "We were told the drugs are being distributed but we don,t know where theyc_omefrom" ( Female youths, Karibuni A) It is evident from the above statement thaithe village was not educated on the ownershipof the programme The expectation of the communit, "" *'Jli:r*}. was that it will eradicate the diseaseafter.sometime, given that the drug will ue maae available regularry " Because we have t""n-to*b signs-9{recovery we are certain that in the long runthe disease will be completely eradic;ted,,(Men, OoOornul I vr-a z v< -q !) =!- O O'O =lG---tr(g(gn(g ,i-4H.. H /\ U ! 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E s d E x-3; e,()'--Cl3b. ltr e cd C)'ri -d)_lZ I -.= EViO!., Q- .9E .9E 9P q P 9.=(g(g(82)a .. = -- i e i =!-9 >X F b I E ,9€cA HE AE €EEEE$;"H:H ,,H € "AgEgs ;s * rs i;r Jigt op HIo 'o H E H.B'H - o'- -cii. !F H -9E - s H $ HE *: f;5f,tBE P o I(B oH € Eo o() .: oo Eo UE o\ a.] 27 Table 7: Quality of CDD Training in Category ,,A', villages('/o in Parenthesis) Ward No. of CDDs No. Trained Length of Traini No. Trained in a session LUGARAWA 10(100) 10(100) 2days 10MAVANGA 10(100) 10(100) 2days 10 MKONGO 10(100) l0(100) 2days 20MATIMILA s(100) s(100) 2days 20KILIMANI 10(100) 10(100) 2days 20KIANGIMAHUKA 10(100) 10(100) 2days 20 Tables 6-8 take a summary look at the quality of the implementation of CDTI in theproject focus. While Table 6looks atthe implementation of component, of -Cbrr atthe ward levels, Table 7 builds up information fr-om FGDs with the different segments of thepopulations in the category A sub-villages. The later gives qualitative aid contextualflesh to the data presented so far in su.pport of the argiments on the quality of CDTIimplementation in the Ruwma focus, *t,irt currently rafes satisfactory in all respects. 28 4.0 CONCLUSIONS Our conclusions are as follows: 1. While the CDTI process of decision making was generally observed in the selection of CDDs, it was not followed in deciding the time and mode of distribution. Decisions on these aspects were largely by health workers. 2. Community education on CDTI was limited to benefits of Mectizan. Community responsibility and ownership of the programme is deficient and this being the fifth and final year for APOC funding, it seriously affects community preparedness to take over control of project activities. 3. The CDTI training of health workers who trained the CDDs was sufficient in all aspects of census taking, proper record keeping and using symbols to indicate reasons for non-treatment as well as severe side effects. However, the CDDs in turn could not impart this education to community members. 4. The CDTI is fully integrated into the Primary Health Care system which augurs well for project sustainability. 5.0 RECOMMENDATIONS 1. A retraining programme for