Morogoro focus CDTI project v/s VAS proposal submitted by National Onchocerciasis Task Force & nutrition program

MOROGORO REGION OFFICE SUPPORT PROPOSAL FOR CDTI V/S VAS INTEGRATION SUBMIîTED BY NATIONAL ONCHOCERCIASIS TASK FORCE & NUTRITION PROGRAM Sustainability will be enhanced through integration of VAS-CDTI focusing on the use of approach that leads into community ownership, efficiency and cost effectiveness. @ÿ I PROPOSAL OUTLINE Title Linking Vitamin A Distribution to Community Directed Treatment with lvermectin (CDTI) at Morogoro Region Level in Tanzania Prepared by (Region officers and partners) Submitted to The African Program for Onchocerciasis Control (APOC) General Objectives of Programme 1. To enhance the sustainability of the CDTI framework by demonstrating its abiliÿ to deliver Vitamin A to children 6 - 59 months and post partum women. 2. To contribute to decreased child mortality in Kilosa, Kilombero and Ulanga District in Morogro region by providing Vitamin A supplements to children 6 - 59 months. 3. To lay the foundations for extending CDTI+VA to adjacent communities Specific Objectives 1. Reaching postpartum women with VAS 2. Attain >75 o/o lvermectin Treatment 3. To reach 20% of children between 6 - 59 months. 4. Allof the above in a sustainable manner. Target Groups: Children 6 - 59 months, post-partum women Mahenge focus CDTI (Kilombero, Ulanga) Kilosa CDTI Time Period: 3 years Estimated Budget:YEAR ONE Tshs. 50,194,000/= Sustainability will be enhanced through integration of VAS-CDTI focusing on the use of approach that leads into community ownership, efficiency and cost effectiveness. Definitions Communiÿ- Directed Treatment with lvermectin (CDTI). A strategy whereby communities are empowered to make decisions on their health including selection of the place, mode and time of distribution, and support to lvermectin d istributors. Therapeutic coverage rate Number of people treated x 100 Total population living in meso- and hyper endemic communities in the project area Geographical coverage rate Number of communities/ villages treated x 100 Total number of meso- and hyper endemic communities as identified by REMO in the project area 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 communiÿ ownership, using resources mobilized by the communiÿ and the government." Cost per person treated with lvermectin ( based on amount released from APOC Trust Fund only) Annualcoverage with vitamin A (VA) Number children aged 6 - 59 months who have received two doses of VA in a one year period. t I I Total number children 6 - 59 months APC. Additional person covered cAPC. Cost per additional person covered. Sustainabiliÿ will be enhanced through integration of VAS-CDTI focusing on the use of approach that leads into communiÿ ownership, efficiency and cost effectiveness. round Tanzania has a population of 35 million people. The country is divided into 119 districts. ln Tanzania vitamin A deficiency has long been recognized as a major public health problem affecting both children and women. The national prevalence study, 1997 (UNICEF and TFNC) in mainland Tanzania showed that24 percent of children under five years and about 69 percent of lactating women have vitamin A deficiencies. lt was found that the problems were severe in dry regions and areas where the availabiliÿ of food reach in vitamin A is seasonal in particular. The lnfant and Under-Five Mortaliÿ Rates are high at 98 and 150 per 1,000 live births respectively (MICS 1998). There has been an upward trend in mortaliÿ rates over the last few years since 1992. More than 75 per cent of infant and child deaths are attributed to common illnesses, which are easily preventable through low cost interventions (HMIS, 1997). About 84 per cent of child deaths occur at home and 60 per cent of them without any contact with formal health services (AMMP, 1997). A mixture of different approaches such âs, disease targeted approach, routine supplementation, integrated Vitamin A supplementation with SNlDs, has been put in Tanzania to reduce the severiÿ of vitamin A deficiency. Since June 2001, the children aged 6 months to 59 months are being supplemented with two doses of vitamin A using community based supplementation during child days i.e. around the Day of African Child June 16th'and the World AIDS Day in December. Since then the national coverage, including children in refugee camps has been over 80 percent (source- national implementation reports). ln a few districts Vitamin A is supplemented with other interventions such as ITN distribution and dipping, growth monitoring and promotion. This has opened a window of opportunity to reach children with integrated services, and also acted as a channe! for reaching children and community at large with the global themes. Supplementation of two doses of vitamin A in June and December is in the process of being institutionalized but needs to be strengthened further. In this regard government's commitment has been very strong. Despite positive changes in terms of high national coverage among children and attainment of the national target, vitamin A supplementation at individual level still remains a challenge for future because: Sustainabiliÿ will be enhanced through integration of VAS-CDTI focusing on the use of approach that leads into communiÿ ownership, efficiency and cost effectiveness. (i) (ii) The current high coverage reflects the national average only. There are several pockets/areas within districts with coverage far below the national coverage. ldentification and reaching these pockets with effective supplementation program is a challenge as the districts are not constantly the same; Raising vitamin A supplementation coverage to post natal mothers will continue to remain a challenge unless faciliÿ based deliveries are increased significantly from their cunent level of only 44o/o of deliveries or alternative approaches are adopted to reach them; The population at risk of onchocerciasis in Tanzania is estimated at 2.7 million persons. Currently there are five functioning APOC CDTI projects in Kilosa, Mahenge, Ruvuma, Tanga, and Tukuyu districts. The current proposed project, 'CDTI + VA In Africa', will pilot the addition of Vitamin A to the communiÿ distribution networks already established in Mahenge and Kilosa projects. The Kilosa project started in 2001. The Mahenge project started in 1998 and is now in year six and will receive no additional APOC funding apart from that provided for the replacement of capital equipment. As VA supplementation coverage in both project areas is high, and child health days are well institutionalised and included in district strategic plans, adding VA to community distribuüon networks may have very marginal benefits in terms of additional VA coverage in Tanzania The inclusion of this small Tanzania sub-project in the overall program proposal is strategic. The objectives of this project are . To support initiatives in three other countries - development of mapping, surveillance and monitoring tools that can be extended and adapted to other countries o Reinforces achievement of Millennium Development Goals . May increase coverage of VA in hard to reach populations, and especially post partum women . Sustainability of CDTI by the end of the project in two years in Kilosa and ensure sustainabitid in Uanenge which is in 6h year of funding. This project was extended as sustainabiliÿ was not assured . Support strengthening of districts in developing own plans for disease priorities and service delivery . Strengthening accurate data collection for VA programme with use of village registers and accurate denominator data. MOROGORO REGTON PROFILE Morogoro region has a total of five districts namely Kilosa, Morogoro Mvomero, Kilombero na Ulanga;with a total population of1.8 million The Region is divided into three geographical'zones known as: -Mountainous or Highland Zone (25%) Covering Uluguru Mountrains located at an attitude of 1200-2000m, above sea level with the clay type of soil. The zone is suitable Sustainabiliÿ will be enhanced through integration of VAS-CDTI focusing on the use of approach that leads into community ownership, efficiency and cost effectiveness. for the production of maize, beans and horticultural particularly Mediterranean types of fruits. -Semi-Mountainous/Low land zone (20%) This zone covers most of the southern part of region, at an altitude of 800-1200m above sea level with sandy clay loam type of soils. The zone is suitable for the production of maize, cassava and sorghum as staple food crops. -savannah zone (55Yo) This zone is located at altitude of 600-800 meters above sea level; with same clay loamy ÿpe of soils. The zone is suitable for paddy, maize and cassava, for both food and cash crops; and also suitable for sugarcane, cotton and sisal as cash crops. Part of south east of the zone falls under Selous National Park; further, the region has big valleys and numerous fast running rivers such as Mngeta, Ruvu and Wami-Luhindo. The temperature ranges between 20"c up to 28 'c. Rainfall ranges from600 mm in the:- -Savannah areas up to 1600mm in the mountainous areas. -Rainy season: February-May -Dry season: June-January. Population at risk for Vitamin A deficiency- 505,834 -<5 mortality - Children under five years of age=360,000. -Post partum Women =73,824 -Pregnant women=72,01 0 -Ranking in terms of child mortaliÿ-Malaria, Pneumonia, Diarhoea, Malnutrition, Anaemia, PTB, Poisoning, Sickle cetldisease Challenges of Mtamin A o lnadequate skilled personnel o lnadequate knowledge of health workers on the importance of vitamin A o Hard to reach areas . Misinterpretation: instead of vitamin A supplementation they call immunization and is linked it to injection o lnadequate and delayed funding o Time of distribution interferes with other field activities . Sustainability o Coverage of PPW is not known Possibilities of integration: VAS & CDTI a CDDs are the same o No need of specialized skills o CDDs are knowledgeable of their population o Both drugs (Vitamin A & Ivermectin) are easy to handle Sustainabiliÿ will be enhanced through integration of VAS-CDTI focusing on the use of approach that leads into community ownership, effrciency and cost effectiveness. Simplifies monitoring and supervision Regional Strategies to address Challenges to integration of VAS and CDTI CHALLENGES CONTRIBUTING FACTOR SOLUTION Misconception: instead ofVAS, termed vaccination which is linked to iniection Formerly done in line with inj ectable vaccination FLIIF workers be clearly told about the difference between VAS and vaccination. Interference with community field activities Top down decision making Communiÿ to decide on the convenient time of imolementation Increased workload to CDDs Increased number of interventions -Increase number oI CDDs - provide them with simplified data collection format Poor support by community leaders Not involving them right from the start Involving community leadership from the start Inadequate incentive to CDDs Poor arrangement for provision of incentives -Mobilise communiÿ initiation of CHF -Councils to incorporate CDDs incentives into CCHP 7 Sustainabiliÿ will be enhanced through integration of VAS-CDTI focusing on the use of approach that leads into community ownership, effrciency and cost effectiveness. Change of leadership and dropout of CDDs Due to election and change of activity, shifting, etc Sensitise incoming leadership and recruit new CDDs Delayed implementation Delayed release of funds and suoolies Timely release of funds and supplies. 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EgEË tgl= o à12 à, c .o G c o,ccb.go(uto '- d) o -_L e.E EE 'E "98Ë*I §È s -o-hE E6 E.boc oF -cEa .E Ë E_I xx E ;EâË ^6>O,v>drô-C4' o)E C' É8ç .\É.ë =€EëasoP I alr -= .> REGIONAL OFFICE SUPPORT CDTI/ VAS PROJECT: BUDGET SUMMARY BY PARTICIPATING PARTN ERS AND ACTVITIES NO ACTIVITY APOC ssr RMO TOTAL 1 L.2 2,880,000.00 2.880.000.00 2 1.3 9.800,000.00 9,800,000.00 2.2 2,880.000.00 2,880,000.00 4 3.1 3.330.000.00 3.330.000.00 5 4.L s.432.000.00 5.432.000.00 6 5.1 12.000.00 12,000.00 7 5.2 60,000.00 60.000.00 8 5.3 25,800.000.00 25.800.000.00 TOTAL 43,912,000.00 2,880,000.00 3,402,000,00 50,194,000.00 Percentage (%) contribution by each oartner 87.48o/o 5.74o/o 6.78o/o 100.00o/o