Report of a technical consultative committee support mission to Littoral II project, Cameroon: October 27 to November 3, 2002

AFRICAIY PROGRAMMX FOR ONCHOCERCIASIS CONTROL REPORT OF A TECHNICAL CONSULTATTYE COMMITTEB STIPPORT MISSION TO LITTORAL II PROJECT, CAMEROON _ October 27 to November 3, 2002 Submitted by Adenike Abiose, Ekanem lkpi Braide and Etizabeth u1+L For lnformotton Tot >1,L,iiIc{.I 2 I H01/. 2002 APOC/DIR For Actron To: 4b CD" cr,t 3rn \vYrtwz ho- Bl-o TABLE OF CONTENTS Table of ContentS........................-......oorfoor.o...o............ii AefOfiyms........-...............-.............. o......................I11 Executive SummarJ.........................o.........................iv ) 7Team Members SECTION 2 TRIP REPORT .4 Aclionowledgement 15 APPENDICES Appendix I Appendix 2 Appendix 3 Appendix 4 Appendix 5' Appendix 6 Appendix 7 Appendix 8 List of persons met Sample of Community register Sample of community register Summary of Register Summary data for the district Request for Mectizan@ Mectizan@ Utilization table List of drugs available at health center for SAE management It APOC BASED CDD CDTI COGEDI COSADI CR CSPSC DMO DPSP HKI IEC IEF LGIF NC NGDO NOTF POC REA SAE TCC TOR UTG wHo WR ACRONYMS African Programme for Onchocerciasis Control Bahall Agency for Social and Economic Development Conimunity Directed Distibutqr ' Comnnmity,Directed Treafinent with Ivermectin District Hospital Management Committee Community Health Committee Country Representative Provincial Chief of service for Community Health Dstrict Medical Officer Provincial Deldgate of Public Health Helen Keller International Information Communication Education International Eye Foundation Lions Club International Foundation National Coordinator N-on Governmental Developmental Organisation ititioi,ii Onchocerciasis Task Force Provincial Onchocerciasis Coordinator Rapid Epidemiological Assessment Severe Adverse Event Technical Consultative Committee Terrns of Reference Ultimate Treatrnent Goal World Health Organization WHO Representative lll EXECUTIVE STINIMAR\ Three members of the TCC visited the Littoral II project in Cameroon from 27 October to 3 November 2002, to review the status of CDTI implementation, particularly in view of the observations made by TCC 12 and 14. These included concerns on data collection and management, training for management of severe adverse events, - r.'community- 'ownership' of' the project, integration ' and movement ' towards. sustainability. During the mission, it was observed that most of the recommendations had been complied with; the project now had fairly accurate information on endemic communities and had done census and REA. Records are generally well kept, ordering delivery, utilization and accountability for Mectizan@ were streamlined and partly utilize existing health channels. Training for management of severe adverse events had taken place and the health staff and health dialogue structure had good recall of the training. Satisfactory arrangements for management of SAE are in p1..", and both geographic and therapeutic coverage had improved significantly during the last treatment rycle to an overall average of lUD/o and 66.6Yo respectively. However, IEC rnaterials had not been produced, there were no onchocerciasis task fgrces at the provincial and district levels and the specific role of each partner in the project wai not clear. Cbrirmuilty hobilization w.Is stili inddequatg and even-thoiigh ' communities understand the philosophy of CDTI, they did not have a sense of ownership of the piogramme. The logistic support to the project is inadequate for thi: difficult t€rrain in which it operates. Although there is struchrlal iniegration of onchocerciasis control into primary health care, functional integration has been hindered by severe adverse events. Addressing these issues will significantly improve the projea and enhance its movement towards sustainability. lv $ SECTION I : INTRODUCTION Background The Littoral Province which is one ol ten prolinces in Cameroon. has four divisions, Nkam. Sana-ea-ivlaritime, Moungo and tVouri (Figure l&2). The first two of these divisions, Nkam and Sanaga-\laritinre constitute the Littoral II Project area, which is one ol flourteen CDTI projects in Cameroon. Littoral II is further subiivided into six health districts, namely Edea, Ndom, Ngambe, Nkondjoc( pouma and yabassi. The Littoral tI CDTI project started in October 1998, with BASED as the NGDO partner. In reviewing the technical.report from the project,- TCC 12 had expressed concern about the fact that 200,000 Mectizan@ tablets had expired The Co4qittee.further noted that the process otreiordihg and forwarding reporti str6uia be improveaupon. --'--- '-'-'-- ' - - TCC 14 noted that a lot of information on CDTI was missing, the number of hyper and meso-endemic communities in the project area were not clearly stated, census had notbeen completed, training was delayed and treatment data were not provided. The committee recommended that an internal team visit the projea to work with the project staffand partners in addressing TCC concerns. . The Broad Objective of this mission was to review the current status of CDTIimplementation particularly in view of the observations made by TCC 12 and 14 and follow-up actions to the APOC/TCC mission undertaken in Oitober 2000. Terms of reference l. Ascertain the number of hyper and meso-endemic communities, report on complbteness of cehsus; the'corrent-status of traifiing and fteatmentj and review data situation in the project area. 2- Assess the current status of delivery, utilization anal accountability for ivermectin. especially in relation to the changing policy of cost-recovery.3 Rel'iew the process of recording and forwarding reports.4 Assess progress made towards 'sustainability' and 'integration'5. Review the current situation with respect to SAEs such as: i) existing knowledge about SAEs and/or their identification ii availability of appropriate IEC material iii) SAE management iv) existing mechanisms of feedback to individuals, their families and the communities; v) availability of skilled personnel to handre cases, guidelines, etc. 6. Review the quality oftraining of health personnel, CDDs on: a. The management of SAEs b. Implementing CDTI in general I 7. Review the status of community ownership of CDTI- i) Find out whether community leaders and members including women, youths, disabled participate in CDTI ii) Whether these groups of people own the program 8 Document any other worthwhile experiences to CDTI Nlethods Documents provided to the team included the following: a.) Technical and Financial Reports for years 2 and3 b.) Report of Joint APOC/TCC MisSion df 2000 ' . ' c.; extiaas-of TCC 12 and l4'Reporis oh'Littoral II : d.) List of Communities and their endemicity level e.) Detailed record of Mectizan@ receipt, allocation and usage in2O02 f.) Training manuals and reports for all levels for the last dosing exercise g.) Completed forms for observed SAEs in2002 treatment cycle h.) List of drugs available in health facilities for SAEs i) National, provincial and district summary of treatment data for 2OO2 The team held meetings with the NOTF, BASED, WHO, Provincial Delegate for Liuoral, Head of Provincial Service for Community Health for Littoral, Dstrict Medical Officers and their staff, Health center staff and Dialogue Committees for Yabassi, Nkondjoclq Edea and Pouma Districts. The team also visited three communities, Ekite, P-oukack tr and Songbengue. The names and designation of people met during the mission is provided in Appendix I. Some family members of SAE patients, health staff and-CDDs were also interviewed. Findings and re-commendations contained .in this report. werb -derived from information obtained during meetings and interviews, observations made durihg field visits and from documents examined. Team Members Professor Adenike Abiose (Team Leader) Sightcare International, Kadun4 Mgeria Professor Ekanem Ikpi Braide (Team Member) Department of Biological Sciences University of Calabar Calabar, Nigeria Dr Elizabeth Elhassan (Team Member) Country Representative Sight Savers International Kaduna" Nigeria ' I 2 Schedule of Activities October 27 October 28 October 29 October 30 October 31,2002 November I November 3 Arrival of team in Yaounde Meeting with NOTF Meeting with BASED Meeting with WHO Administrator Departure for Douala Meeting with Head of Provincial Service for community Heatth and his team Meeting with the Provincial Delegate of public Health, Littoral Meeting with: the 'Manager of the provincial centre for Pharmaceutical Supplies Departure for Yabassi Meeting with the District Medical Officer and his team Departure for Nkondjock Health District Meeting with the District Health Services and team and members of the dialogue structure Departure for Douala Departure for Edea Meeting with the Dstria Medical Officer and his tearn, in Edea Visit-to Ekite village in Edea District YT,hg yttr the_District Medig4l Officer, tus.teqnL and members -of the dialogue structurd in Pouma Visit to Poukack II and Songbengue in Ngambe District Departure for Douala Debriefing of the Provincial Delegate of public Health Littoral and the Head ofProvincial Service for community Health Littoral Departure for Yaounde Debriefing of the WHO Administrator , Debriefing of the BASED Team (The chairman ofNOTF was not available for debriefing.) Departure from Yaounde 3 tr, 7!tt LI H TI ni.l fl U f, il H GJ nii r! rj fT i; SECTION 2:TRIP REPORT Meeting with the NOTF The team held discussions with the chairman of NOTF, National Coordinator/Executive Secretary foi Onchocerciasis Controt, chairperson of NGDO coalition, BASED and other NGDO members of the task force (Appendix l). During the meeting, the team presented the objectives of the support mission as specified in the TOR and iiie issues wlre freely discussed. The following information was given to the team during the meeting: : The- policy_on- cost tecovery changed.in MaylJune'2}}Z'.such that peisoris receiving Mectizan@ no longer have to'pay-during distribution-of the ditrg. Government will pay incentives to CDDs and estimates are being collated for inclusion in the national budget. o I budget of CFAI3O million has been provided for onchocerciasis in 2003, relative to CFA I l0 million for mrlari4 emphasizing the priority being accorded onchocerciasis control. ' ' Training for SAEs has being intensified at all levels. A core team of trainers has been constituted and at least three of its members must be present at any training to ensure quality ilssurance. o The occrrrence of SAEs has retarded community participatiorq is partly responsible for low coverage figures, has led to specifii ,*ra campaigns foi distributing Mectizan@ (September g-29 n zCfl}) and has not allowed the NOTFto focus yet on progralnme sustainability. For the same reasorL integration is . being addressed with cautiorL so its not to jeopardize other programmes. o BASED has diposited-cFA I million'*ith-the ororn;jtpi31inar"*i.a services, and CFA 50,000 at each district referral center to @ver cost of drugs,hospitaliiation and iransportation that may bb necessary for the treatment "oi 'SAEs ' census was done in 2000 and is being updated by districts . Coverage has improved o NOTF is rearranging NGDo areas 9f actMty to improve management and the need to maximize the use of potential strength of variols partners ii recognizedo The information was given that Merck is funding a Technical Advisory post to address SAEs in Cameroon o New IEC materials are being developed centrally and funding from ApOC isbeing expected to conclude this. Planning is done under NorF with all partners in a collaborative way Tlp_th." meeting with BASED, detailed information was obtained on implementationof CDTI in Littoral lland additional data and documentation were obtained which werefurther investigated during the field visit. fi. 4 In the absence of the WR, who w'as away on official duty, the Administrator of \l'HO' Mr Rene Boungou, was briefed on the purpose of the mission. Meeting with the Provincial delegate of public Health for Littoral The provincial delegate was briefed on the purpose of the mission and he confirmed the involvement of policy makers, and health staff at all levels in CDTI and SAE management. : Meeting with Head of Provincial Service for Community Health and his team The newly appointed Provincial Onchocerciasis Coordinqtor and the BASED Technical Adviser p.rticip"t.a in the m-eeting. Points that emerged amonliothers-were that.- - - o Definition of a community was not yet clear' o Arrangements for SAE management had improved this year o Although there is collaborative planning, the role of partners was not clearly . defined in relation to various aspects of CDTI implementation o Role of the BASED Technical Adviser was not clear o CDDs view CDTI as a job and expect renumeration These and the other issues will be discussed in detail in the findings. Meetings with District Medical Officers and their teams, some CDDs and members of the dialogue stlucture in Yabassi, Nkondjong, Edea and Pouma Discussio-ns were held duryrg -thpre. meetings-o-n.CDTl implementation and SAE .*ug.r*nt and the community registers from two districts were examinrjd. Various terms of reference were freely discussed. Details of the- findings ryrll be r€ported in the findings under relevant TORs. Discussions with communities in Ekite Poukack II and Songbengue Community perception of CDTI and their views on SAEs and their management were freely disiusied with these communities. The team used the opportunity to educate 'communities on issues raised and encourage them to support and motivate their CDDs. Details will be captured in the section on findings- a 5 GT FI ,;l iJ rn [,1 77It il1-I a{>l iJ EI il . i"t-';iI$ ftti( f,-. n 'r-i f-, n ii f ,.- Lt i-r- LJ SECTION 3 : FINDINGS AND RECOMNIENDATIONS TOR I Ascertain the number of hyper and meso-endemic communities, Report on the completeness of census, the current stafus of training and treatment, and review data situation in the project area. : TOR 3 Review the process of recording and forwarding reports. ; TOR 6 Review the quality of training of health personnel, CDD on: .. - ..' b) Implementing.CD-Tlin general . FINDINGS REA has been conducted and villages have been delineated into hypo, hyper and meso endemic communities. A list of all communities qualified for CDTI in Littoral ll is available at the national office and corresponding lists are available at the provincial office, District offices, and communities. However, there is a need to further review and update the existing 'lists. A slight discrepancy was observed in nvo versions of a list of villages obtained from Pouma Dstrict. One list had 8 hyper endemic and 12 meso endemic villages while the other list had t hyper endemic and 7 meso endemic villages. Total number of villages in Littoral'rl is given as 453 in the text and 326 inthe summary - table of the sitdation riport on COtt in tittorhl'tr Piovince datit' Oaob er 2g, ZAOZ. Thb District -Onchocerciasis control team pointed out- the need to repeat REA in some communities in Edea- These villages designated as hlpo endemic may indeed be either hlper endemic or meso endemic since'at the time REA was conducted, mainly youths were present and examined. The Nkondjock Dstrict Oncho control team indicated that delineation of villages is yet to be completed in Ndobiame, an area *ith difficult terrain. The Provincial Delegate @ublic Health) also observed that some villages, merged during REA and enumeration (census) because of lack of a unified definition of a villagg would have to be separately assessed and listed. Enumeration (census) has been conducted in all villages. Final population figures are available for most villages and are being collated for the remaining villages. These figures will have to be revised after,refinement and confirmation of the list of CDTI 6 t .'trJ r-ttil il I .l Li il il -1 :l ll n i.J villages. It is now possible to set the Ultimate Treatment Goal (UTG) flor each community, Disirict, and the Province. Treatment registers are available for all communities being treated The format in the registers is appropriate, and the summary page provides space for re,"ording number of under fives and breastfeeding mothers, as well as absentees, refusals. the sick, and pregnant women. Eleven treatment registers were examined and quality of records kept by the CDDs was found to be fairly high. It was observed however that in most registers, only.the treated . .wOre registered and i-here weEe no r@ords of under-fivesand the untreated (Afipendix 2,3' -'&a). This omission makes it impossible to accurately calculate therapeutic coverage and *ul"r it difficult to follow up the untreated. Cycle of treatment was not indicated in most of the registers and no provision is made to record treated persons who develop reactions after treatment. . With regards to recording and reporting of treatment data, the CDD completes the "orn nunity treatment register during distribution and submits it to the District field officer who collates data for the entire District (Appendix 5). Thereafter, the registers are kept in the Districts till next distribution period. This means that th-9 CD-Ds have no continued a@ess to the treatment registers. This arrangement will not allow for recording follow up treatments, on-the-job retraining of CDDs during visits by the supervisor, as well as discussion of treatment data by the village dialogue structufe- Treatment records should ideally be colleaed from the Distria by the Provincial coordinatOr-and forwrded-to NOTF; but-afterthe last distribution, in orderto beatthe deadline for submission, this was done by BASED. The Head of Provincial Service for Community Health.indicated ttnt it would be best for CDTI data to be released by the Delegation. as is the case with other health programmes. Though treatment records are reviewed at NOTF meetings, there is presently no forum for discusdion and review of treatment data at the Oistrict and Provincial levels. To ensure continuity and sustainability, as well as consistency of data, treatment reports should be forwarded through exiJing Government structures, with all stakeholders particiPating within a Task Force, in the review of treatment data and discussion of the reports. It was observed that geographic and therapeutic coverage has improved tremendously in all districts visited. C"ogi"phic coverage is reported to be l00o/o in Yabassi, Nkondjoch poum4 and Edea pistriits. this will have to be revised after lists of villages qualified for CDTI have been reviewed and confi.rmed. Comparison of Therapeutic coverage for the yqars 2001 and20O2 shows improvement from 36Yoto 66.6% for the entire province of Littoral I I 32Yoto 59/ofor Yabassi District 6OYoto TlYo fot Nkondjock District 43Yo to 56ob for Puoma District 24Yo to 57.7Yo for Edea District I l U .. a 7 il fl il U il iJ il _l ,H kJ ilti t:l .:J !t;-t n :i;.'i, rl LI t:rtt ,, IiJ .: 'i1'ti I.I t-li]$ r.l rii! rt a-1 t_; t!!a l:Li The team in Edea and Puoma indicated that shortage of Mectizan@ affected coveraqe in the Districts. It is necessary to validate these therapeutic coverage rates as these rvere collated from treatment registers, some of which have incorrectl.v calculated coverage(eligible used as denominator). It is evident that CDDs, field officers, health personnel and members of dialogue structures have received training on CDTI in general. Topics covered include causeVtransmission /manifestations of onchocerciasis, APOC philosophy, role ofpaptners' community mobilization and adverse reactions. Judging from quality of existing records' the CDDs and field officers have been fairly well t.ain.a but furthei training oi record k*pilg is required to solve the problem of poor lecord keeping by some CDDs - - rrho afe unable to accurately complete treatment registers.' . - Supervision seems to be limited to distribution periods of one month. Last distribution was within the period September 9-29,2002. Two of the three Terms of Reference in the supervision check-list address data issues. Supervisors are required to examine and validate treatment records in treatmerit registeis, check the accuracy of dosage, and evaluate contribution of communities to collection of Mectizan@ and submission of report. RECOMMEIYDATIONS I Project should conduct REA in each of the villages that were aggregated/combined during first REA and repeat REA in "hypo eniemic" vittagesihi" onry youths were examined for nodule rates.t Projea should conclude enumeration (census) in all villages qualified for CDTI after review and ddnfiimation of list of villiges quain.a roi 6ori. rnir *ili Ue ,ir*alvdone if all CDDs--are requested to update thlir records by registering all members ofhouseholds including the untreatedI Treatment register should be kept in the villages with either the CDD or the chief orthe head of the dialogue structure. TheJe are about i-6 sheets of thi summary page in each booklet. Carbon paper should be provided so CDD can make duplicate copy ofthe summary page for each treatment iound .The supervisor/field officer should tear offand take away the duplicate copy after validation oientries. ,o Supervisors and CDDs should advise communities to select more CDDs in order to reduce burden of record keeping on each CDD. At the optimum ratio of 2 CDDs to250 persons, there will be, fewer requests for incentivei, faster distributioq more careful and accurate record keeping and more effective follow up of the urtr.ut.a. ' Project should T"tt1" CDTI implementers at all levels on record keeping. CDDsshould be retrained to effect complete registration of each household, Ld make ' accurate entries on the summary page. Project should set Ultimate Treatment GoalGI[G) for the Province, Districts and villages. ' District Medical Officers, field officers, and C-DDs should make arrangements for the siclg breastfeeding mothers, pregnant motherq absentees and converted refusals to betracked and later treated. An extension of the treatment period, as *"ti as piouirion or 8 Mectizan@ at the health center will allow for follow up and treatment of most of the untreated. o Project should initiate Stakeholders meetings and Community Self Monitoring after appropriate training. These will provide opportunity for critical assessment of treatment data, enhance supervision and ease follow-up tracking of the untreated. o To ensure continuity and sustainability as well as consistency of data, treatment reports should be forw.arded through eisting Government structures, with all st;keholders participating within a Task Force, in the review of'treatmqnt data and discussion of the reports. TOR 2. Assess the ' current status-. of -delivery' accountability for ivermectin' drugs '6ipecialf :iri changing policy of cost -recovery. FINDINGS utilization and relation 'to''the Meaizan@ ordering and accountability has generally improved. BASED staff explained that the 200,000 tablets of Meaizan@ which were reported to TCC 12 as having expired were a result of ordering tablets based on an inaccurate population figure in the first year of CDTI implementation. The expired tablets have since been destroyed by the Provincial Commission made up of representatives of the Mayor, Provincial Public Health Department, Finance, and Security operatives as per laid down Government procedure. The current status of drug delivery is that BASED applied for 228,500 Mectizan@ tablets from Mectizan@ Donation Programme'forthe 20@ treatnrent.-rotmd. The drugs were sent to WHO Cameroon from where BASED colleded its consignment and delivered it to CAP in Douala. The CAP, Coirseiller technical and the District endorsed requests for drugs from the districts (Appendix 6). The District Medical Officers of the sirdistriAs collected 224,626 tablets based on the census population of the communities under treatment in their distrids. Nurses in charge of health centres collected their allocation from the District Field Officers. The CDDs in turn collected drugs from the health centres. Of the districts visite{ shortage of ivermectin was reported in Edea and Pouma.. Utilization of ivermectin was judicious (Appendix 7). The six districts used lg8,2t5 tablets, being (87%) of the tablets received. Eight hundred and ninety five (895) tablets were lost, noni expired and 15,425 (7%) tablets remained. The new policy which waived cost recovery on Mectizan@ had no effect on drug delivery and seemed to have incpeased drug utilization. Accountability of drug usage was adequate as CDDs reported to the nurses in charge of their health areas. The latter reported to the DMOs. The DMOs either submitted r"po.ts to BASED on request or to the Provincial delegate who submitted to the NOTF. Eich district accounted for losses, damages and balances. Drug balances were returned to o 9 L'j ilil ti H r.l r-l }I jt iJ '11 -iI ii 2aa( E' ri(.t ,;il ni; U I-! ,l ti "ra l: iJ rtfItJ l the nurses at the health areas who retumed them to the districts. The drugs remained at this level as opening balances for the following year. Accountabilitv for dirg usage \\as not adversely affected by the new policy. Recommendation o Project should devise a mechanism for reallocating excess drugs in one district to any other district -where there is drug shortage S-Review the current situation with respect to sAEs such as:i) Existing knowledge about SAEs and/or their identification .' ii) , Availability-of apprapnate IEC mate.rialsiii) Existing mechanisms of feedback to indiiidr.ls, tneir'families and their communitiesir) Availability of skilled personnet to handle cases, guidelines etc 6- Review the quatity of training of hearth personnel, cDD on: a)The management of SAEs. FINDINGS -The project has implemented the recommendation of TCC lz to put in place strategies for management of SAE and train staff for same. Thus, SAEs have beenincluded- in-the training ppgr_am4e. District level and health area health rtur*.i. trained on SAEJ recognition,-r,i*"ill-re, referrai ;Jrid;d;;;il;0i,r -j r.tr.in"a -in .2002- F"rI1h personnel (6 medical doctors, 60 nurses ia I hboratory technicians) in6 hospitals and 25 health @ntres of the 4 districts we visited had been triir"a L ,nurug. cases of SAEs. BASED recruited a part time Technical Advisor for Littoral I I project io support these staff. He provided technical support when the doctor trained in tttonaloctdistria hospital was unavoidably absent (due io itt t eattt ) when an SAEs occurred. Eristing -knowledge on SAEs and /or identification, abilitv to recall knowledge onSAEs and identify SAEs were adequate. The doctors, nurses ind CDD spoken to coulddifferentiate between minor reactioni and SAEs and were not ready to take any risks. rEC materials were not available in most of the distria hospitals visited. of the fivedistria hospitals visited, posters were only seen in Pouma; though more posters were said to^ E in the villages. BASED and the NOTF sought assisiance from HKI in development of'IEC materials for awareness-raising, counselliig and interpersonal communication on management of side effects. It is however awaiting finati,afen of the materials by theNorF. This has been held up as a resurt of delayed dnding from Apoc. L l0 t-{ rIit i] nil fi fi fi FII,: r' (, \.1 r] t-l ?3rj I t o a il.1ai2 rIU EI il il il TIil it l u The existing mechanisms of feedback were through the health personnel who had contact with the individuals with SAEs during the period of the et'gnts' Feedback rvas given mainly to individuals and their fanrilies. Three of the districts said ther prorided feedback to communities. The other district has planned to give feedback to the communities after the immunization programme. In visits to three communities, awareness and mobilization $ere inadequate. People expressed great fears about minor reactions, $AE. and continued treatment. We had -ureat difficulty ionvincing them to continue treatment. Also during the discussions some people who had not receiued treatment during the designated treatment period asked if they could be treated later. . fn" district tearn in Nkondjock.idormed the.team of minor reacti-ons in a Gmonth-old child following maternal treatmeirt with Mectizan@. Investigations could not be carried out due to transportation difficulties, a non-functional laboratory and the absence of a technologist. Systems put in place for management of SEAs were effective and efficient. A drug lisi for management of SAEs was available at each level (Appendix 8.)' BASED provided CFA lmillion to CAP for procurement of drugs and consumables and CFA 50,000 to each hospital as additionaL support. Apart from these, the cost of transportation of individuali with SAEs and those accompanying them to hospitals/health centres was to be reimbursed by BASED. Fifteen persons were hbspitalised following treatment with Mectizan@. According to the national coordinator, only five were SAEs, and of these five, one consumed alcohol and the other was epileptic. A checklist for monitoring was available and used by the health personnel. However it did not-providefor SAEs ard mino.reactions: Logistic support (motorbikes) provided to ' - the project was inadequate and seemed to have made supervision difficult- Recommendations The project should develop IEC materials targeted at SAEs for use during community education and mobilization. Intensive health education and mobilization using IEC and the media should be used to promote awareness on the benefits of onchocerciasis control and allay the fears of the people. Provision should be made by the partners to ensure that absentees, refusals and ineligibles not treated during designated treatment periods are treated within the year. The policy of free treatment of individuals with minor reactionVSAEs occurring within oni week of treatment should be reviewed to take care of recurring minor reactions (probably due to co-endemicity of loasis). The project should gve feedback to the communities as a means of encouragement, motivation and reassurance in the management of SAEs and reactions. t t! ir - ll 5 a o L' n I"J r-l U F.? IJ EI F] Fiil FI E] FI tr EI E:Tl.t E-i :.tr: ti Ff i:Li lr-ii LI r?t! EJ The project stafr partners and communities should be trained on Community Self IUonitoring and Stake Holders Meetings with a view to using these to improve management of SAEs and minor reactions. Communities should be empowered to increase the CDD/population ratio to 2..250 as a means of improving monitoring of SAEs. The project should request additional logistic support (motorbikes and bicycles)for health workers, from APOC to enable them to improve health educatioq supervision and marlagement of SAEs. l TOR I Apsess progress made towards'sustainability' and'integration'a. . I a . - --,.ToR 7 Review tf,e status of community ownershfp of CDTI iridicating whether i) community leaders and members including women, youths, disabled participate in CDTIii) these groups of people own the program ln discussions held at the distria level, and with the communities, it was observed that communities have been involved as partners in the implementation of CDTI. The program relates to the communities through the dialogue stmcturg which consists of theDistria Health Committee (COSADI) and the Dstrict Hospital Management Committee(COGEDI). These committees are fully involved in all aspects oI Cpn, including planning, decision-making on'time (in a limited way) and rnoi. of distributioq eleaioi Non-health structures like education, communi.ty leaders, lraditional healers, womengroups and religious organizations are involved in CDTI. The team met one pastor _who is a CDD, and who l-ed us to Ekite. The -l<nowledge of CDTI by communities is impressive, one member asking aboutpossible sanctions which could be imposed on community members who refuse treatment and therefore constitute a threat to the rest of the community in terms of continuinginfection and risk of transmission of disease to other co.-unity members. Althougf, criteria for election of CDD are clearly understood by the dialogue structure, inadequaie numbers are elected, !h9 CDD to population ratio being as high; l:1000 people in one community; in spite of the community deciding on a house to house mode ofiistribution. There are very few female CDDs, the ratio being 13 female out of a total of I 12 CDDs inNkondjoclq one of the females being the chiifs wife. In Pouma, a member of thedialogue structure considers 'ur'omen's'heads not big enough' to unierstand CDTMheCPPt are respected in the communities and in some districts are involved in other activities like immunization and non-onchocerciasis mobilization activities. a o a r.- t2 l..l il r.1 II il iltI II ii r-ttt i,j n .J :! !r fi- ,i IJ ri IJ EI il iI it U it ;lLI il ti il Although the representatives on the dialogue structure are well intbrmed about CDTI. and theie is active communit-y participation, it would appear that the communities have not been adequately sensitized on the need for them to accept responsibilitv lbr supporting/motivating the CDD and own the programme in the long term. There is consequently no sense of community ownership. The dialogue structure members were advised to emulate the initiative of Edea district medical officer to hold a feast for CDDs and give prizes to the best CDD as an e\ample of non-monetary CDD motivation. Although the.technical report to TCC 12 had not provided information on integration and sustainabitity, there is evidence of structural integration of onchocerciasis control at all levels of the health service and especially at the district lev'el. The district medical officers are in charge of onchocerciasis control among other diseases, and function in ...f"o Litl Uirt iJ"onqtocerciasii'coordinatcir: Oth& tiuff.t the district and lower level, accept responsibility for onchocerciasis control. Even though mectizan is procured by the programme, its storage, accounting and delivery is partly inte-erated into the existing _ drug delivery system. However, CDTI is currently being carried out as a campaign at periods specified by the health authorities, rather than as an integrated activity. This is mainly because of the SAEs and the need for intensive surveillance during the treatment period. The need for functional integration of onchocerciasis with other health activities is however recognized The TOR of the team did not include in-depth assessment of sustainability but observation of so-me of the indicators allowed us to conclude that initial steps towards sustainability have been taken. Notable among these are - structural integration, partjci.palory planning a$ !ryplgmentation of CDTI, improvement in data collection and reportlng, supervrsio-n dna ino*toriirg; im-pioved tiaining'arid mectiiair doverage and - governryent budgeting offunds for the program Some of the aspects that need attention are partnership building and clear definition of roles, mobilization of communities to accept ownership of the programme, amirudinal change to continue CDTI even in the absence of additional material reward and inadequate mobility in terms of motor-cycles and bicycles for srpervision in this very difficult terrain. Recommendations o The district and BASED should improve on the quality of community mobilizatiorL targeting community ownership in relation to long duration of programme, the benefits derived by the communities, the input of government and external donors, and motivation strategy of the distria for CDDs which is n non-financial. Communities should be encouraged to decide on and implement appropriate methods to motivate their CDDs. o The project should intensify Community mobilization efforts and increase its frequency, linking it whenever possible to other health care activities. NOTF stroutd rapidly finalize the IEC materials which are being'developed, ,ensuring l.I:: u l l3 that the messaq,es and materials use the participatory rural appraisal method which take account of community knowledge and culture. The project should encoura,qe communities to improve on the CDD: population ratio to the optimum recommended ratio of 2 CDD to 250 people. Thii should reduce the demand for incentives to a minimum, while at the same time enable higher coverage Communities should be encourased to increase the number o[ female CDD. NOTF should ensure that there is a clear definition of the role of each partner in the project'and effort at partnership building should be intensified through all available channels including stakeholders meetings, provincial and district onchocerciasis task forces. While.acknowledging the need for caution on intcgration at this stage because of the risk of SAEs, ,it is recommended that NOTf ieviews its policy- and-address functional integration as soon as the crisis management of SAEs is risolved. The project should budget for and provide adequate and appropriate mobility(motorcycles and bicycles) in view of the difficult terrain. The project should strenghthen the capacity of non-health partners eg. teachers, religious leaders, for more effective participation in CDTI. TOR 8: Document any other worthwhile experiences PIANMNG a o o a o It was observed that planning is done at the national level in a collaborative andparticipatory manner with all partners involved. An evaluation of past activities precedes planning ' at this' level.' At the Provincial level , plans -are made jointty by the provincial Delegate team ,BASED, and Distria representaiives. At the District-level , the DistrictMedical O-fficer, Oncho Field officer and representatives of the dialogue structures plan together for CDTI. lnvolvement of District Medical Officers in- the planning 'and implementation of CDTI is unique and good for integration and sustainability. Howeveq absence of Task Forces at the Provincial and District levels limits input into the plans. It was observed that roles of partners at all levels are not clearly defined and understood. Though plans seem to have been discussed at these levels, these have not been properly documented- The samples of plans examined contained only list of activities, persons responsible, date of implementatiorL location, cost and observation. Theie is noindication of objectives, stritegies, and funding responsibilities. Recommendation o There is a need for NOTF and NGDO to train all stakeholders on strategicplanning 14 I.' it i1 CONCLUSIONS The overall impression of the team is that all involved in the Litttrral II CDTI project have made a definite effort to address the observations made by TCC l2 and l4 and have addressed in greater part the recommendations of the APOC/TCC mission which was undertaken in October 2000. More efforts, however, need to be made to improve on data management, partnership and team building, community mobilization, information. education and communication and community ownership of the project. The improved geographic and therapeutic coverage which have ;been achieved- should be at least maintained, and improved upon in'areas with unsatisfactory coverage rate. ACKNOWLEDGEMENT . ftet.am-is gatefiI to ih. NOTF; The Prbvincial and Eistrict Staff, BASED Stafl and the CDTI communities visited for their cooperation. The mission could not have been successful without this. The team appreciates the opportunity given it by TCC to undertake the mission. -l I -l I :l t- II I -1 3-! I i:J :-l I;i !'-'l il ar L., t i-l J iI J 'l il il l -J .J l il l5 o-!: chq)() oL.A oo o GI Q u t, (6 q) t5 U7 "Bq,(l) .V GIJ TI <tq) d € a o c0 (\l o GIz tr EI il fl il il Ds rli lr iltJ nT:' FItrii fi ttl{ii -n u tl iJ E fl IJ fl il l l l E l, a a , o t 7I -g .Irts oL o- 'L' {-,tr rTJ oo ! z o ot IJJ =o a Glq)L CE() .Et GI Lr!a0 .ItI a- aF - - ,l( B a, a a a a o 7E at a ,a *. 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IJ t5ii E-i r{\,;i;.t PERSONS MET DURING THE MISSION NOTF CAMEROON Dr Basile KOLLO Dr Marcelline NTEP Mr NJOMBINI Desire Mrs Naz Yeganeh Dr Rosa BEFIDI-MENGUE BAKER, Shawn K Mme Coste Dominique Mme Nancy HASELOW DrAlbert EYAMBA Mr Patrice NKWELE BONGAY!Soni6 iusti& WORLD HEALTH ORGANISATION Mr Rene Boungou DOUAI.A PROVINCIAL MEETINGS Dr SOLLE Jeremie Dr Bita Fondu Ande Demango Ngange Dr EI(AMBI Ndema Armand Dr BIKOTI Joseph Tarie drAL DSC/MSP Chairman NOTF National Coordinator/Executive Secretary Oncho Coordinator BASED Director BASED CR SSYChair NGDO Coalition HKI RegionalDirector LCIF Sight First HKI Country Representative Director, Carter Centre/Global 2000 IEF ProjectAdvisor ' ' BASED .. Administrator DPSP, Provincial Delegate of Public Health Littoral province CSPSCL, Head Provincial Service for Community Heatth Provincial Onchocerciasis Coordinator Lift oral Technical Adviser Littoral ll Manager FSPS Pharmaceutical Stores Littoral M,r YABASSI Dr Mboka Mr Ndock ' - Oistrict Medical Officer Oncho Coordinator NKONDJOCK Dr Magny Tiam Eric Mr Mbang Jules Mr Mpong Mbenga Mr Samba Nyame Jacques Mr Eyengue Nkocie Jean-M Mr EDIM Dim Gilbert Mr Bingue Joseph POUMA Dr Ntengue Joel Mr Biyik Jean Chief Yem Bekok Bieurem Mr Nzeuldng Simon Mr Ngom Benga Piene Mr Massing Louis Medecin Adjoint Nurse l/c Field Health Traditional Chief Community Delegate Delegate COSADI Chief Admin & Finance COSADI Pdf. COSADI District Medical Officer Treasurer Distric{ Hospital Management Com m ittee Cashier District Hospital Management Committee Chief Health Bureau, Pouma District President COSADI- Secretary General COGEDI \g t, il LI il I \p*a-* I uo".t.. EDEA Mr Salifou MKPONWONPIEKO Rev Alphonsi Nkwori Mr MWAHA Jean Piene Mr BEHAI-AL ISAAC Dr NKIGOUM NANA Achille SONGBENGUE VILI-AGE Mr Tonye Jacques Mme UGO Uyaga Cecile Mr ONBONG Guillume Mr Kaljob ll Martin Mr Bonga Westor DMO Edea CDD Field Health Officer Administrative and Finance Officer HD Edea Secretary CDD COMMIS Treasurer COGEDI President COGEDI Assistant a l'l :l :l :! :l tI J l' : t. :t I 1, ': 'l -i 't 'I Ll il il J 3 J ,J -i il t ? rq I II t! .P \\) Y X LJ I p I N I \c 6\c 90 -J 9. i { o\ N5 19P N" Ord F... ht.'kt)F, l,^ F S=JrS]I] Ln'E h FSt-\Fts\ N NS F't F, s 5l\- F: lt' R- \fq -i ill\t\iS\lI tr F It+1 FI P $ It.st: FIrl^'l D^t N kb --\5 e ilS r N] ,l tn 5 P F- cs F&. ^\] lu,p N,p Fis * t =:\\i I I lF;ls\|qtr $I$..; \ N\\ + \Nr\ N. le, E &.R$\ \\5 S'l N] $! 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I I ET l 'i ,$J Ir fr trr II t Ann6e : Zoo?- Rapport de campagne du Distributeur commun autaire ldentificatibn Disrricr de Sanr6 Villa-ee: Aire de santi <-5c>" c{O lVlinistirc de la santd publique Progranrmc Nationat de Lutte contre I'Onchocercose Dcldgation Provinciale de la Santd publique du Littoral -a Cyctederaitemenr : L,fiJ, 6 7 8 9 to u .tzjr:(Encercler le cycle correspondant) *lfiWL>t,X ll R6pubtique aJCr*"-un paix-Thavail-patrie Recen Traiteme-nt ent des co0tS Effets 2d Total Grand Total TUI Grand Total N, il:#:::: ;:H.*"9,* Nombres d.absenrs: O Nombre de mara&s O Taux de couvenure ( Grand ,ra*r**C.-d total recensemenr) x l00J Total des flonds recouvr6s: Nombre d'Effets secondaires l6gers: Nombre d'Effets secondaires graves pagnd {'un rapport si-end d'une autoritd locale Signatures Infirmier Superviseur \J Hommes Femmes0 - 4ans 5ans et + 0 - 4ans 5ans €t: Hommes Femmes5 - l5ans l6 ans + 5 - I5ans l6ans ct+ t Nombre de compri mes restanr i la fin de la campagne Nombre de mes de I'infirmier Nombre de 0compn * Accom ':\ gL L il { ri st {t iil ,il li a{il llc,tt:, IJ fr [: ii quantit6 El; ., lws,luryrK13 Rdpubllque du Camemun Paix-Tbavail-Patrie e nili.l FNr.lil TiI -:liJ rl Ll -! ::i-l :'l ij a-.! 'i lll--r ii -i :J ' Iilinistlrt de la sant6 Publique Programme National de Lutte contrc l'Onchocircose D6l6gation Provinciale de la Sant6 Publique du Littoral ldentification District de SantC : Villagc: Cyclc de traitemcnt : I .5.6 7.E.9.10 li t2't3 (Encercler le cyclc Ann6e, 2D O X., ' RapBort de campagne du Distributeur Communautaire ED Airede,*n gyuT#ei 6 I ! Traitemenl Recouvrement des co0ts ' Etfets 2d Total Grand Total Total Grand Total Nombre de retus ' ,)3 Nombre dc femmcs cnccintcs: Nombrps d'24y abscnts: 2]44 Nombre'dc ^*, 13I5flr+STaux de couvcffure ( Grand traitcmentrGrand total recenscment) x 100 Total des fonds recouvr€s: / Nombre d'Effets secondaires tege.s, .L' 3 L. 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I r.tr -tri P,tlrrq t 959r 1 356, I 960, 477 2?.79r I 6gd 2t7 1 2075' 5008, 19219 DATE P DATE pppr Frl i( .)t (,\\lFIl(r()\ PC,r.. \L.rr'" [- rllrCrl.rt(l 4068i 8 1'3, 5882', I r 7$r | 4301 2 96, 851 3, 1 7.06, 508d t0 16, 7431 I 4 96, 6224. 12 44 I 502t 30 0d L t-in.cj rhE. [:b Eir Ei EJki.tr. Fitr H H H [: EJ il *' E$ G.Et ri.,45+ \ll\l\ II ill t)f r :.i \ il I'l Il, la)r I \ll\l\l[]\ r/r -l tll rr llt,\l rll 2877' 5 75, , a t)il t(,.\rtr)\ PRr)\ t\( t.\t f l')r lrrT()R,\l rl P rir, r,:l t.. ',, r,/, l. I - /..r l.r. l_. -/. lrr [)()l \l \ AIRE DE SANTE EEON NGONGA I 370r MAKONOC I 937 LOGEADJECK 2801 OEHANE 681 MALIMBA 4054 9IZANGUE 2421 ELOGBELE 3539, PLATEAU ADMIN 296d DELANGUE 7 155 TOTAL 27 t06 SIGNATRUE DU CAPP pRr)\l\( I \t i)f I f (,-\ rlr)\ Fr)R rllf I lrt'r){] .\i P () [lor. lrr/, ':l .l] -", /il, l-' l- r'lt Frr t'-,.t" f)(rl -\l .\ Pop. Totale eoir. Erigiore - .Cbinpiirhds - 'iBoites 494 338; r016, 2 O32' oArE o! 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