Report on the 1999 independent monitoring of CDTI projects in Tanzania

African Programme for Onchocerciasis Conlrol Programme africain de lutte contre I'onchocercose JAF-F'AC It ) JOINT ACTION FORUM Office of the Chairman JOINT ACTION FORUM Fifth session The Hague.S-10 December 1999 FORUM D'ACTION COMMUNE Bureau du Pr6sident JAF5/INFiDOC.4 ORIGINAL: ENGLISH September 1999 REPORT ON THE 1999 INDEPENDENT MONITORING OF CDTI PROJECTS IN TANZANIA t I I REPORT OF INDEPENDENI' MONIf'ORTNG OF CDTI PROJECTS IN TANZANL{ : THE RUWMA PROJECT August 16 - September l(t, 1999 IAIDS APOC CBTI CDTI CDD CSD EPI HH IEC IMA KAP MCH MOH NGDO NOTF PHC REA REMO SODA SSI TOl' wHo LIS'[ OF' ABBREVIA'TION S Acquired Immune Deliciency syndrome African Programme on Onchocerciasis Control Community Based Treatment with lvermectin Community Directed Treatment rvith Ivermectin Community Directed Distributors Cornmunity Selected Di stributors Expanded Programrne on Immunisation House Hold Information Education Communication Inter-church Medical Association Knowledge Attitude and Practice MaternalChild Health Ministry Of Health Non Governmental Development Organisation National Onchocerciasis Task Force Primary Health Care Rapid Epidemiological Assessment Rapid Epidemiological Mapping of Onchocerciasis Songea Development association (A local community development agency) Sight Savers International T'raining of Trainers World Health Organisation I ll a TABLE I.O TABLE I.I TABLE I.2 TABLE I.3 TABLE I.4 TABLE 2. I T ABLE 2.2 TABLE 2.3 TABLE 2.4 TABLE 2.5 TABLE 2.6 TABLE 2.7 TABLE 2.8 TABLE 3. I TABLE 4.1 TABLE 4.2 TABLE 4,3 TABLE 5.I TABLE 5.2 TABLE 5 3 LIST OF TABLES Decisron making process at village level Mode of distribution by source of information Who distributed Ivermectin Treafinent summary from household survey Refusals and absentees by village Length of CDD training Issuesitopics covered at CDD training What the communities were told about Ivermectin treatment Horv Ivermectin dosage was determined Existence of treatment registers Quality analysis of treatment registers Communities receiving health education x form of CDD supervision H/Education recipients Whether CDDs had been changed Forms of support received by CDDs Activities integrated with CDTI Opinions of CDDs on community response whether community members collected the drug from a collection point Constraints in supervision Constraints in getting the drug Constraints in the distribution of drugs by CDDs tEXECUTIVE SUMMARY The independent nronrtorinq of the CDTI process of Ivermectin distribution in the ltuvuma Project area of Tanzania rvas carried out by a four-man team drarvn trom Nigeria, Uganda and Tanzania. The monitoring exercise rvas undertaken to ascertain the extent to rvhich the CDTI process was follorved during the first year of operation of the programme which started in 1998. The monitoring exercise covered 30 endemic villages in trvo randomly selected districts- Songea and Mbinga- in the project area. Data were collected from a cross section of the village population including village leaders/officials, health workers in the communities, the CDDs, household members, the youth, men and women groups. Policy makers and Programme Managers at various levels of the health system, the collaborating NGDOs and the World Health Organisation(WHO) were also covered. Instruments for data collection included in-depth interviews, questionnaires, observations, official records/documents and focus group disc ussi ons. The major findings of the monitoring team include that all the sampled villages were treated. This implies a coveraqe rate of 100%. While the CDTI decision-making process was largely (67%) followed in the selection of CDDs, it was not adhered to in deciding the time and mode of Ivermectin distribution. The health workers made these decisions mosl of the time. Central location was the prefened mode of distribution. The training of CDDs rvas deficient especially in the areas of census-taking, record-keeping and proper completion of the treatment register. Dosage determination was by height measurement but a disturbingly high inaccuracy rate of 40% was found. Severe side effects of the drug rvere generally not reported. Community education on CD'l'l did not deal with the major issues of programme ownership, community responsibilitv and material support for the CDDs. 'fhere was'good cooperation and collaboration among the Ministry of Health, WHO and NGDO partners. Shortage of drugs and delay in supply of drugs and funds rvere not experienced during the vear. There was general satisfaction wrth and appreciation for the programme in the project area and the prospects for sustainability is verv good. Kev recommendations include a) A retraining of both the health personnel (trarners) and the CDDs before rhe next distribution. b) A fresh community education exercise in all villages before the next distribution c) A census of villages to be carried out. d) APOC to cntically evaluale the system of school-based distribution fourid in the project area and take policy decisions on it. e) Elnployment ol an accounts of ficer at the NOTF t<l handle financial and accounting matters. ill ! .I"ABLE OF CONTENTS l'ctgc LIST O}- ABBRE\/IATION LrsT oF TABLES_ __ ii EXEC UTI \/E SU ]\{ I\IAR}' lll I I I I I.O INTRODUCTION l. I Country background 1.2 Project background 1.3 Terms of refbrence 2.0 METHODOLOGY 2.1 TargetPopulation 2 2.2 Sampling---------- 2 2.3 Monitoring Instruments--------- 4 2.4 Linitations-------- 5 3.0 RESULTS 3.1 Indicators-- 3.2 Quality ol'implementation of CDl'l--- -------------1 3.3 Communiw Perception------- -----------1 3.4 Sustainabilitv------ 3.5 Constraints-------- 3.6 Unique features of the proJeo----- --- 24 4.0 DISCUSSIONS AND CONCLUSIO 5.0 RECOI\{MENDATION 25 ANNEXTS 1. Team membership 2. Time frame 3. Charts and Graphs 4. [nstruments 6 0 6 8 1) 24 tI.0 IN]'RODTIC]'ION l.l Country Background l'anzania has a rvell established Pnmary Health Care system(PHC) which provtdes communiry health services and programmes such as water & sanitation, Child survival, Family Planning and AIDS educatron. There is an established network for the distribution of essential drugs from district pharmacies, village health posts and health units. The various levels of Government, the NGDOs and the churche$ are actively involved in both health and other community development programmes and projects (Ruvurna Focus CBTI Project, 1998: 7-8) 1.2 Proiect Background The Ruvurna CDTI Project area, often refened to as the Ruvuma Focus, covers three adjoining districts within the southern highland Zone of Taruania. The districts are Songea and Mbinga in Ruvuma Region and Luderva in lringa Region. Songea, the headquarters of the Ruvuma Region, is located 1,000 km southwest of Dar es Salaam, the capital city. The Project area has a total population of 761,461 inhabitants (198S census) organised into 17 Administrative Divisions, 75 Wards and 296 Villages or autonomous comtnunities. Songea district has ll9 villages, Mbinga has ll4 rvhile Ludewa has 63 villages. Each village is administered by an elected village committee headed b1- a chainnan Ivermectin distnbution for the treatment of Onchocerciasrs was started in the project area in 1992 by the River Blindness Foundation (RBF) which provided financial and other logistical support up to 1995. Operations for 1996 and 1997 were supported with funds provided by the Inter-church Medical Assistance Inc (lMA) and Sight Savers lnternational (SSI) respectively in cooperation rvith the Tanzanian Ministry of Health. APOC flnding for the establishment o[the CDTI process started in 1998. 1.3 'ferms of reference 'fhe terrns of ref'erence set by APOC fbr CDTI independent monrtoring teams are as lollows. l. Succinctly document horv ivermectin treatments u,ere undertaken in a number of the communities in Ruvuma Focus. 2.. Assess community involvement in drug collectron. decisron rnaking during the period and the mode of distribution, selection of'distributors, and the willingness ol'the comrttunifv Lo lrear these responsibilitres as dcstgned rn the CDTI Pro.lects. ,) t- 3. Documcnt cornrnunrlv pcrccptrons ol'CD'l-l l)roccsscs, cspcciallv thc issuc of ownership and expectations for onchocerciasis control, and based on these perceptions and exlrctations, detennine the degree of satistactron of the community rvith difttrent pro$amme activities and outcomes. 4. Assess the qualrty of training received by Community Directed Distrrbutors 5 Examine the record books of the CDDs and assess the qualiry of record keeping and their abilrt,v to keep accurate records. The same applies to the health services staffon the projects. 6. Determine the number of community and eligible persons treated and compare your findings rvith the records of CDDs and the records at the other levels (e.g. district) 7. Determine whether health personnel participated in ivermectin disnrbution, and assess the degree and quality of supervision by health staff ( and the quality of training and/or onentation of such staff to CDTI). 8, Identify constraints rn the distributions and rnake recommendations to the NOTF and management ol'APOC on corrective measures necessary belbre the next treatment. 9. L)iscuss the Project's sustainability based on the findings above 2.0 METHODOI,OC\ 2.1 Target Pollulation An endemicity assessment of the Project area conducted by the Tanzanran Mrnistry of Health using both REA and REMO methods identified a total ot'132 hyperimeso endemic villages rvith an estimated population of 350,473 inhabitants (based on 1998 census). This constitutes the target population. The 132 villages in the arca are di stributed as fol lows: a : I iI iJ il I ll rJ .\ t Songea District Mbinga District Ludewa District 79 vrllages 22vrllages 3 I villages I 2.2 Samnline A multistage random sarrrplrng method rvas follou,ed a) I)istnct l-rvo drstrrcls '.\'ere selected for cttYerale/assessment uslng str]l:ric random t sarnpling method 'l-he i'hosen distncts rvere Son;-ca and Mbinga I I I ^t 3I tr) Catesory "A" villages. Considering that 79 out of l0l (78%) villages in the two chosen districts are in Songea, it rvas decided that category "A" and "8" villages be sanrpled in the ratio of 2:1. Consequently, fbur category "A" villages were sampled tiom Songea district rvhile hvo were sampled from Mbinga distnct. Before carrying out the sampling, all the villages in each district were grouped by distance from health faciliry" into near (rvithin 5 km) and far (beyond 5 km) as rvell as by level of endemicity thyper or meso). Within each stratum, the required number of villages rvere chosen by random sampling process. Followrng this procedure, four category "A" villages (Madaba, Kilagano, Mdunduwalo and Mugagura) were chosen from Songea District "vhile two villages (Ruanda and Mkako) were chosen from Mbinga District making the six category "A" villages required. c) "B" vil Following the desigr, tbur villages adjacent to each chosen category "A" village were selected giving a total of 4x 6 : 24 category "B" villages. The listing of sampled categorl' "A" and category "B" villages by districts is presented in the table belorv. Sarnpled category "A" and "B" villaqes bv Districts Districts SONCEA MBINGA "A" villages Madaba Kilagano Mdunduwalo Magagura Ruanda Mkako "B" villaqes Mahanje Lilondo Lutikila Mkongotema Lugarara Mungano Zomba Mtrepai Mngazini Maposeni Litowa Parangu Mpandangindo JKT Mlale Masanga Litapwasi Ngahokora Ndongosi Paradiso Kingole Litumbadrosi Kilimani Lipumba L.ukarasi Amanimakoro 4d) Households. Households (defined as a group of persons who cook and eat from the same pot) covered in the exercise rvere chosen by first going to the 'centre' of the village and spinning a bottle to choose a direction. Each dwelling unit in the chosen direction was vrsited until l5 households were interviewed. Where there were more than one household in a drvelling unit, one was chosen by balloting. Where there rvere tw'o sets of inteniervers operating in one village, once a direction rvas chosen, the interviewers moved in opposite directions, one covering eight and the other seven to make the fifteen households required. 2.3 Monitorinq Instruments Altogether eight monrtoring instruments provided by APOC rvere employed in the exercise. The instruments were: ct) Key mformants questlonnarrefor "A" villages This 28-item questionnaire was administered to the chairman of village committees in category "A" villages. It is intended to provide the view of the community leadership on the CDTI process and also to confirm the information given by the health personnel and the CDD. b1 Key tn/orntunt,\ questt<ttttzutrc.f bt' "8" vtlluges l'hrs shortened version ot'the above (a) instrurnent was administcred to thc chainnen ol village committees in category ''8" villages mainly to ascertain rvhether the CDTI was irnplemented in those villages. c') ()roup cltscttsstctn gutde tn cale4on' "A" vrllage.s I-hrs gurde was used to conduct fbcus group discussion sesslons alnong communtty members. In each category "A" yillage, one male and one female adutt (25years and above) group discussions were held, In three category "A" vrllages, group discussions were also held for female youth (15 - 24 years), whrle in the remaining three vrllages they rvere held for male youth. Each group, which contained 6 to 8 persons discussed, among others tssues, the community understanding and perception of the CDTI; community particlpation and prospects for programme sustainabiliry The village chairmen assisted to rdentifu and assemble group members. dl ln-depth tntervtcvl, gurdc fttr vtlluge "A" (''l)D:; Thrs instrument *'as adnrrnrstered to trvo CDDs (CSDs) rn categor) "A" vrllages. The detarled rnteryre\\ cor,cred such issued as lrorv the CDL) was selecied. r'easons fbr hrs chorce. hrs trarnrng, hcalth sYstem collaboratron, supervision. community support, perceptlon of the Dr(),lratnme . constrarnts and sugqeslrons for suslatnabitity. It also I 3 n ,l rl -l I I 2 I 5I t entailed close supen'ision ol'the CDDs measuring device, census and treatment registers and abstraction of summary statrstics fiom them. c) ln-deplh tntervtav, gwdc /itr village "8" ('1.)l)s This modified and shortened version of instrument (d) above, was administered to two CDDs in category "8" r'illages. The tu,o instruments seek essentially the same information. /) Household Sum'cv l.-ornt l'his instrument was administered in l5 selected households in each category "A" village. In each chosen household, the head was requested to list all members of the household. Each member was then called upon to respond to a number of questions on his,/her involvement in the last ivermectin distribution. This instrument helped to estimate coverage rates, monitor CDD training and performance as well as community acceptance rates, defaulter rates and incidence ofsevere side effects. g) Quest ionnaire for Heulth Personnel This instrument was administered to selected health personnel directly involved in the CDTI process. It sought information on the role of health personnel in community mobrlisation, CDD training, supervision, managernent of severe side effects and record keeping. h) lntervicy, gude.for polic), ntukers l'his is a guide for inten-rervs rvith policy makers in the Ministry of Health, Programme Managers and Coordinators, Representative of the WHO and Representatives of NGDOs involved in CDTI. 2.4 Limitations One obvious limitation of the data collection exercise was the language problem. While the monitonng instruments rvere wrinen in English, they had to be administered in Srv36i11. As we moved from one district to another, and from one village to another, it became clear that the standard Srvahili translations had to be rendered (translated) in local dialects for the villagers to follow. In the process of translation and retranslation, there were chances of misinterpretation and misunderstanding of certain concepts and ideas. (l 3.0 RESTII, S 3.1 [ndicators 3.1.1 Indicators of effect of CDTI In thts exercise, etl'ect indicators measure the extent to rvlrrch the CDTI process has been lollowed in ivermectin treatment in ihe Project area. I'hree CDTI ke1; processes were used in this assessment, namely: . How the date or period of distribution (treatment) was decided. . How the mode of distribution was decided. . How the CDDs rvere selected. Table 1 presents the field data as rvell as the effect indicators on these three CDTI decision-making processes: TABLE.I.O DECISION MAKING PROCESS AT THE VILLAGE LEVEL I , .ltJ 3 Process/ Data sourte Decision on date/ time of distribution. i)Key informants (A&B) ri)CDDs (A)* + No. of targct villages 1 Lerder H. n rkcr olxnmr Effect Indicator 8/30= 26.7% I I t'.2- 8 3o,ir I i/30: 36 T/o 5lt2= 4t 794 vitviL atcc 28l0 1 r ll -5 29 I 6 4 4 52l ')l 2J J I Questions about how decision was taken on tinre and mode of distribution were not included in village "B" CDD interview schedule The table indicates that the decisron on thr: rlme or penod of treatment was mostli,made by the health tvorkers in the Ruvuma fbcus .According to the viilagc leaders in l3 out ol 30 communitres (J3 3%), the health u'orkcrs took the decisron; rrhile in 9 out ol- l2 vrllagers (7594). tirc CDDs rcported thirt thr'decisron rvas nrade by irealth u,orkers The vit Mc.cting viI cldcrs ViL H ittc= Made other Decision on mode of distribution. i)Key informants (A&B) J I 0 2ii)CDDs (A)* il 5 Selection of CDDs i)Key informants (A&B) ii)CDDs(A&B) 60 30 20 37 ) J 20130= 66 7% 37160= 6t 7% rl comm 7I I elfect indicators on horv the period of treatment rvas decided is therefore26.T0/o (village leaders) and8.3Yo (CDDs).lt was also found that only in 4 out of 18 (22.2o2t) focus group discussion sessions that mernbers agreed that the decision on time rvas made at a village meeting. Three of those four sessions were male groups. Majority of the groups agreed that health workers made the decisions on time/period of treatment. With regard to decisrons on mode of distribution, the table shows that the village leaders agreed that more oflen, the decisions were not made at village and sub-village meetings. The effect indicators on decision on mode of distribution are 36.7% accoding to vllage leaders and 41.75% b1'CDDs. Five of the eighteen group discussion sessions (27.8%) agreed that the decision was made at village or sub-viliage meetings. Of these five, foui rvere male and only one was a female group discussion session. On the method of selection of the CDDs, the table indicates a general agreement among both village leaders, the CDDs and the group discussants that most of the time the selection was at a village meeting. The effect indicators on selection of CDD are 66.7%o (village leaders and 61.7% (CDDs). Twelve of the eighteen group discussion sessions (66.7%) agreed that the CDDs were chosen at village meetings. Eight of these twelve groups (67%) were males rvhile four were females. Summarv of E Indicators Code Description #of Target vil./ #of Vil. meeting decisions o//o E-l Proportion and number of target Communities which decided on the Period or method of treatment E-2 Proportion and number of target com munitic:s where the 6community" selected their ou'n CDD 830 30 20 26.7 66.7 3.1.2 Mode of lvernuctin distribution 'fhe table belorv presents data on the system of Ivermectin distnbution rn the Project area based on information from the village leaders in both A and B villages and the focus group discussion sessions. UTABLE I I MODE OF DIS'TRIBU-TION BY SOURCE OF INI.ORMATIOI{ Mode of distribution Source Leaders Discussion 4 (22.2%) t3 (72.2%) s.6% l8 The table shorvs that in 73.4% of the vrllages, the mode of distnbution was from a central location according to village leaders. Thirteen out of the eighteen discussion groups (72.2%) also indicated that central place distribution approach was followed in their communities. Such central places for distribution included village centers, health facilities and the village chairman's house. In many villages, distribution was also done in schools for pupils and teachers only. This mode of distribution is a peculiarity of Tanzania and will be further discussed under the section on unique features of the project area. 3.1.3 Wto distributed the lvermectitt rc,BLE _l_2_ WHO DI STRIBUTED I VERMECTIN The person Percentage I -T h iJ I Il CDDs (CSDs)* Village leader CDD anct Village leader CDD and Health Worker Not stated l4 I I I I u l8 778 5.6 5.6 5.6 5.6,,1 TOTAL 100.0 *In the project area, CDDs are called CSDs (Community selected distributors) to distinguish rhenr fronr family plannrng service workersrry_ha_arc-qa-llc_d cDDs (Contaceptive Drug Distributors) The table above presents the data on rvho carried out the actual Ivermectin distnbution according to participants in the erghteen focus goups discussion sessions. The table shows that while in a large majoritl, of the cases (78%) distribution was done by CDDs, there were nevertheless ferv instances rvhere the village leader or health rvorker participated directly in Ivermectrn distribution. We also found that the number of CDDs employed in each village varied greatly rangrng from 2 to 27. There were a total of 73 CDDs in the six category "A" villages. Of this number. 39 (53.4%) were females w,hile 34 (46.60/o) rvere nrales. 3. l. 4 Comntu niq, coyerage All the cotnmunittes vrsited rn both category "A'' and "B" r,rllages received lvermcctrn treatment The coverage rates for e ategory "A" villages obtarned from our sample survev of horrseholds are as follorvs t LHouse to House 2.Central Place 3 Both l&2 4 Other 4 (t3.3%) 22 (13 4%) 4 (13.i%) TOTAL 30 000%) a I 9TABLE I 3 I'REATMENT SUMIUARY FROM HOUSEHOD SURVEY 65 8% 50.0% 34 3% 67.0% 56 5% 74.3% i TP=Total Population T..T=Total Treated R=Refusal A=Absent P=Pregnant S=Sick TCR=Total Coverage Rate When the CDD treatrnent records were exarnined, we found that only in one of the six category A villages (Mkako) were the records adequate for computing the treatnent coverage rates. None of the other five villages had data on total number of persons treated. For Mkako village, total population was 1870 and total no of persons treated rvas 1333. This gives a coverage rate of 71.3o/o. This compares very favourably with the coverage rate of 74.3o/o shorvn in the table above for the same village. From the above table also, it is possible to derive the rates of refusals and absentees during the last distribution. IABI-E-!: Dnta from HII Su Data from CDD Records Village Population Abscnt No. 'h Madaba Kilagano Mdunduwalo Magagura Rtranda Mkako Table 1.4 shou,s a total of 23 refusals and 42 absentees giving a 4.7o/o refusal rate and 8.6% absentee rate derived from the household surve),data. Only two villages, Kilagano (16.3%) and Mdundurvalo (12.8%) reported refusals, while all the other villages reported absentees ranging from 3 (3.5%) in Kilagano to 12 (14.1%) in Ruanda. On the other hand rvith the only exception of Mkako with a high absentee rate of 16.0% (299), the CDD records in all the villages did not include information on refusals and absentees. This underscores the poor record keeping among CDDs. 85 86 70 88 85 14 160% Village TP' TT' UNTREATED <5 R' Ar Pr sr Other 56 43 24 59 48 55 l4 l-3 IO l-, l:i IO 0 l4 9 0 0 0 8 J 7 5 t2 7 I 2 { 0 I I 0 2 1) I 0 6 8 '15 9 ll l0 TCR' Madaba Kilagano Mdunduwalo Magagura Ruanda Mkako 85 86 70 88 85 74 TOTAL 4EE 285 i 73 23 42 9 6 50 58.40h Refusals No. o/o Absent No. Y" Refusals No t/" Population 00% t1 t6.3% 9 lZ.fi" 0 U/o 0 ff/n 00% 8 9.4%3 3.s% 7 10.tr/o 5 5.7/o t2 t4.t% 7 940h I 870 il o6y, | 4asTOTAL 23 4.70/, 42 8.6Vo 1t) 3.2 Oualitv of CD'tl Imnlementntion 3.2.1 CDD Training In all the villages (both A and B) covered, rve fbund that the CDDs had recerved some training on the CDTI process. The length of training varied significantly among the CDDs ranging from less than one day trainrne in Mugarura to seven days in Madaba. TABLE 2.I LENGTH OF CDD TRA]NING /o 83 50.0 t6l o.J 16.7 100 0 The modal training period reported lvas one day. This rvas rather too short to ensure adequate and proper training of CDDs. As regards rvho trained the CDDs, eleven out of the twelve CDDs inrerviewed (91.7%) reported that they u'ere trained by Health Personnel/Onchocerciasis Coordinator. The remaining CDD from Irzladaba indicated that he was trained bv an official of the community development agency, SODA. The table belou' sututtrarises the inlbrmation on rvhat issues and toprcs rvere covered at the training scssions as stated by the CDDs. TAB LE 2. 2 : IS SLIEVTQPI C S COVERE D AICDD_IBAINING I ssues # saying Yes /o A. Aboul Onchocerciasis I Cause 10. Symptoms I I Socioecononric rmportance I 2. Community nrobilrsatiorveducation 13. Ivermectin needs long time treatment B. About the Drug Treatment duratron Coverage of dr stri bur ion Dosage determination Drug expiration Treatment oI AbsenteeVrefu sal s Side effects counscl i ngy'referral Exclusion cr rlerrz, Record keelrrrre Census talrlru_, . f_1 rl ) rlil H r^l I I 2 J 4 5 6 7 8 9 : I .1 1 it '1j ! I l ! lr l2 l l0 lr 8 t2 l2 I il l2 l2 II t2 917 t00 0 5E3 83i 917 667 r00 0 r00 0 83 917 100 0 r00 0 917 r00 0 _t l2 _i No. of Davs Response I 2 ! 7 Less than I I 6 2 I 2 TOTAL t2 TOT t00 0 ;i 11 l'able 2.2 shou's that the only one issue apparently not covered during the training was expiration of Ivermectin after removing the container seal. Socioeconomic importance of Onchocerciasis rvas covered only in about half of the training exercises. On the whole, coverage of issues at training was good but we found sufficient reason to worry about how rvell some of the topics were covered and understopd by the CDDs. 3.2.2 CommunitT, education and nnbilisation Under the CDTI process, health personnel and the CDDS provide community education on Ivermectin distribution. AII the health workers interviewed confirmed that the communities were provided with education on the importance of treatment with Ivermectin tablets. Similarly, 1l out l2 CDDs, (91.7%) in category'A'villages agreed that they provided their communities rvith education on Ivermectin treatment. Only one CDD (8.3%) in Magagura village admitted that he did not provide the community rvith education on Ivermectin treatment. TABLE 2.3: WHAT TF{E COMMUNITIES WERE TOLD ABOUT IVERMECTIN l.Taking Ivermectin treatment annually for several years 2. Benefrts of treatment 3. Community responsibility 4. Side effeos 5 Other 81.8 90.9 18.2 72.7 9.1 TOTAL CDDs 100.0 'table 2.3 shorvs that the cornnrunities were least educated on community responsibiiity. Only l8o/o of the CDDs reported educating their communities on this very important issue. This finding was confirmed by village leaders. When asked what they were told about communih- responsibility ( see key informant interview : village 'A' Question l6c.), half of them (509i,), the village leaders said that they were told nothing about community responsibility. This, no doubt, has some adverse effects on the implementation of CDTI in the area. 3. 2.3 Dosage deternination Ivermectin dosage determination is one of the key tasks the CDD must learn to perform correctly. Table 2.4 presents the data on horv the CDD performed this task. TABLE 2.4. HOW IVERMECTIN DOSAGE WAS DETERMINED Process o/o I By height measurement 2 Use weight 3 Visual Observation 4. Age 5 Other (prevrous e.rpcrrence) t2 I I 2 I 100.0 8.3 8l t67 8i se # ofCDDs a//o 9 l0) 8 I t2 'Ycst# of CDDs l:\'f S t2 r00 0 ! iI il I iI t'2 The table indrcates that all the CDDs (100%) use height measurement, although three ol- the CDDs emploved weight measurement, age and visual observation (experience) as well. All the CDDs have measuring devices which in all cases but one, rvere available for inspection. The CDD who did not present his device explained that he came to the interview fiom another engagement away fiom his house rvhere the measuring device rvas kept. Dosage occurlcv check A dosage accuracv check performed on l5 randomly selected I{ouseholds revealed 9(60%) correct dosages and 6 (40%) incorrect dosages of Ivermectin given. This is an alarmingly high percentage of enor. 3.2.4 Record keeping and reporting Another rnajor task required of operators of the CDTI process is proper record keeping and reporting. As a form of self evaluation of this task, the CDDs were asked if they had problems with record keeping (interview schedule for village 'A' CDD Quest. 39). In response, 6 of them (50%) admitted having problems with record keeping while the other half denied having any problems. As for the nature of problems being experienced, only two were metttioned namel-v; insulficicnt forms and absence of proper hard back big note books to be used as registers instead of loose sheets of paper being used conectlv Horvevel, our observation is that their problem with record keeping is much deeper thalr that. 'fhis rvill be discussed later. ('cnsus llccttrtls On the issue of census taking, tive out of six (83.3%) category 'A' village leaders indicated that census of their village was undertaken. One village leader denied this. Horvever, no census register could be produced for inspection. 'l'reatment l?egtsler The treatment register is one of the most irnportant CD'l'l record. [nformation on its existence as obtained from the village leaders and CDDs in category A & B villages is summarised belorv. TABLE 2 5 EXISTANCE OF TREATMENT REGISTERS Source of information Stat us Village Leaders (A & B). N=30 CDDs (A & B) oho//o N=60I Register seen 2 Exists but nor scen 3 Does nol exrst 23 4 J I 6 lo/o l]3% I 3oto 45 8 6 16 3Yo 13.60/o l0.lYo TOTAL RESPONDI]NTS 30 100% :e r000% 13 The table shows that all logether there were three villages which had no treatment registers tbr 1998 lvermectin distribution The villages are Ruanda, Amanimakoro and Lutumbadiosi, all in Mbinga district. This yields a defaulter rate of 30o/o for Mbinga district and l0o/o for the entire project area. Explaining why there was no treatment register, one of the CDDs for Amanimakoro said: " No regtster hus becn opencd for the 1998 treatment cycle because the trealmenl .forns y:ere collected by the Dtstrict Onchocerctass Coortltnator and he has not returned them." A further analysis of the 45 treatment registers seen and inspected reveals some serious problems in record keeping attributable, in mosl part, to poor training and supervision. TABLE 2.6: OUALITY ANALYSIS OF TREATMENT REGISTERS TOTAL More than half (53%) of the trealment registers were in such poor state that no meaningful statistics could be extracted from them. A third of the registers however rvere well kept. None of the 45 records examined follorved the recommended practice of organising treatnrent registers on household basis and giving each household a separate page. This will prermit updating of registers. Side e.ffect.r records Treatment records rvere available and inspected in 23 villages but none recorded any side effect information as required. Further, of the four Health Personnel seruing as CDD supervisors who rvere intervierved, none had records of severe side effects available lbr inspection. The impression given was that none suffered any side effects from the drugs. However, dunng fbcus group discussions, partrcipants gave examples of individuals rvho suffered severe side effects. For instance a male, 25+ years discussant in Mdundurvalo village said, " I was espectally the mam vtctim. M1t /ace got swollen to the extent that I could not .see for tv,o day:;. " Another female discussant of under 25 years of age focus group, in Mkako village, Mbinga district oted one person who had srvelling and severe itching of the rvhole bod1, rvhich necessitated going to hospital for treatment where lre r.r,as qiven tranquiliz-ers 'l'his, accordrng to hrm, created l'ear among community members. Assessment No. Yo Good Fair Poor Very bad 14 7 t4 l0 3t.t% 15.6% 3t.t% 22.zYo 45 100.0% 14 3.2.5 ,Supervision of CDDs Our dau show tlrat lourteen (23 39/o) of sampled CDDs in both category A and B vrllages had not been supervised by any one This means that seven villages were not supervised since two CDDs were taken from each village. Trvo vrllages were supervised by non- health personnel while 2l villages (70%) were supervised by health personnel as prescribed by the CDTI process. Table 2.7 classifies communities rvho received health education on Ivermectrn (see 3.2.2) by fbrm of CDD supervisron TABLE 2 7. COMMUNITIES WHICH RECEI\ED HEALTH EDUCATION X FORM OF CDD SUPERVI S ION FI/EDUCATION RECEIPIENTS 3.2.6 Perlormance and change of CDDs When asked to evaluate the performance of CDDs, allthe village leaders (1007i,) returned the verdict that the CDDs had done rvell. We are inclined to agree rvith their assessment and to attribute a number of lapscs identified in their performance, especially record keeping, to poor training and supen,isron. As a follow up on the issuc of pertbnnance, both thc vitlage lcaders and the CI)l)s u,ere asked if there had been any,change of CDDs sincerhc last <irugdistribution. 'fhe result is summansed belorv. lADr-E z s wrcrHER cpps [Ap_DE_ENCuaNGep Sourte Response l il :I i^I 'l There had been change No change Don't know Village Ieaderc N=30 (6 7%) (e3.3%) 0% CDDs Nd0 58 I 59 2 28 0 (0ei'o) (98 3%) I 70h 096) Reasons given for the two changes repo(ed by the village leaders were (a,y Lack of commitment and seriousness: (b) being too busy rvrth his other personal engagelnenrs /rvork Supervision by 'farget villages CDDs th Health personnel Others Not supervised 2t 2 7 42 4 l4 10.0% 6 1o/o 23.3oto TOTAL RESPONDENTS 30 60 100 0oz6 TOTAL RESPONDENTS r00.0%30 I t 15 Summary of output indicators Code Descrintion No. Ponulation 7o 0-l Refusels two months after distribution 23 488 4.7 Absentees that were later treated 0 At risk villages treated 30 r00 0-2 0-3 0-5 0-6 0-7 0-8 M Communities where CDDs werr Changed after the fint distribution Communities in n'hich the CDD was Supervised by tbe health personnel Target communities which received education about importancc of cxhnded Ivermectin treatmenL Persons five years and abovewho Reccived Iverrrectin 2 7l 30 285 6.7 6.1 100 s8.4 042 30 30 30 30 4E{t Cost per person treated $31000/122"559 = 50.29 I Ii { ii ,I 16 3.0 Conrqrunity I'crecDliett 3.3 I Communitr perception o[ CDTI Prograntme o) Ownersrp o/ l)rogruntnrc Evidence fiom tntervrer.r,s rvith village leaders, the CDDs and focus group discussion sessions shows that tlrroughout the project area, community members were not able to distinguish the CDTI process from any other community health programmes of the Government. The Programme was taken as just another disease control activity of the Government. They did not perceive the Programme as their own but that of the Government and perhaps the donors. The main reason for failure of the communities to exhibit the expected CDTI perspective was due to inadequate community education. In all the focus group .sessions, the participants stressed that no one ever told them rvhat their role and responsibility in the programme should be. h) Usefulness lntportance of CDT'I Focus group discussion participants (Women, 25+ years, Madaba, Songea district) put their viervs on usefulness of the CDTI Programme this way: "ln./act v'c ure happvwith this Prograntnte andwe thanktho.se u,ho gavc u,t the drugs" Male (25+yearsl discussants in Mdunduwalo village elaborated turther "People arc reultstngthe benefits of'tlrc drug. Prior to the u,se of tfu,r drug, they dul not knov, what to do aboul the disease, and now tlrut they lruve recerved lhem]br ntore than lwo round:;, they appreciate" c) (.ommuntly, c-\pe(:lat ton. The expectation and the desire of the communlty members rvas that the Programme should not come to an end. According to one of the group discussants, Covernment should ensure thal the drug supply continues until when they know that the disease has been completely eradicated. d) An apprehenstotl Focus group discussants expressed some apprehension and fear about tablets kept in homes of CDDs rvhere sanitary conditrons n'ere drfficult to guarantee 'l-hev feared that sonte tablets might gel contarnrnated and suggested that the unuseci drugs be kept at the nearest health lacilitres a 17 a) Communilt' usscssntent d ('l)DtOD'l'l When asked how rvell the CDDs had done therr rvork, all the village leaders tntervierved responded in the af firmative - They had done rvell. Participants in focus group discussion sessions horvever felt that it was too early to assess the Progtamme having completed only one year. They agreed that within the year, CDDs had done well. 3.3.2 Commaniq, Responsibili$ As shown in table 2.3 (see P.l0), community responsibility under CDTI process was the least ffeated topic during community education and mobilisation and the least understood aspect of the CDTI process. According to Madaba adult males group discussion participants, " Community ctlucation was reslricted to the need for annual treatment of lvermecttn for several years. The contnrunily was not informecl of therr responsibility antt how they are supposed to ensure they sustain the programme after five yelrs." Some key elements of community responsibility under the CDTI are discussed below a) lrnsuring contntunih' compliance ln most communities in the project area, communitv responsibility is understood to mean "going for treatment whenever the drug is brought to the village." A number of communities were prepared to ensure that every member took part in srvallowing the drug. Rules had been made which impose penalties on defaulters. b) Support./br the ( DD.r. ln the course of our investigation, CDDs rn category A villages were asked what kind of support or assistance they received from their communities. The results is summarised belorv TABLE 3.I: FORMS OF SUPPORT RECEIVED BY C_DDS ln cash or kind Provision of transport Community mobi I isation I3xemption from communrty rvork l;nsuring compliance None at all '1 _-5 12 0 0 0 0 _s8.i% 41 7o/o H lt//oSupport TOTAL RESPONDITNTS r00 0% Ir) Thus as tar as the CDDs were concerned, the only lbrrn of assistance glven to them by the communitl, was using the existing administrative structure to ensure that community members took the drug. The absence of material incentives was emphasised b1, male (25+years) group discussants fiom Mdunduwalo village. Songea District when they stated: "7'o sat,the lruth, u,e don'l gn,e lhem even on ounce ty' salt." However, group discussants from Madaba had this to say: "7.he only ^support given to CDDs b), the communiyt is e-rentplutn front contmuniry, work. However, thts exemptton is n()l re.etrrcled to those engoged tn oncho conlrol sen)tces bul tt is extended to all tho.se tm,olved in otlrcr Prtmary Health Care (PHC) activrlies" From the foregoing, we conclude that the forms of community support received by the CDDs are Exemption from community rvork ii) Ensuring compliance i ii) Communit_v mobilisation c) CDD Supervision Another aspect of community responsrbilrty under the CDl'l is supervision of the CDDs by the conrmunity members. Unfbrrunately, community leaders and members were not properly educated on this, hence thrs lunction was not prcrformed in rnost of the communitics visited Village leaders u,ere specitically asked how they were involved in CDTI supervision (See key informant interview schedule for village 'A' item 26). ln response only I out of six (16.7o/o) specificallv mentioned supen'ising the activities of CDDs in the communit\,. 3.4 Programme Sustainabiliw 3.4.1 Communiq, sr+'r.rship ol the Programme This is also a ke-v element in the future sustainability of the CDl'l Programme. But as stated earlrer (see 3.3.1), the communities had not been educated to see the CDTI Programme as their own. It is ver1, important to instill this community perception of the Programme so as to ensure sustainabilrty. 3.4.2 Integration iruo ilrc health system Three ofllcrals tntervrerved at the natrorurl level (MOH, SSI and NGDO rcpresentatrve at the NOTIr) rndrcaled that Onchocercrirsis control is rvell integrated into the Health care system. A special unrt for the coordrnatron of eye care and Onchocerclasls activities lras I it I il 1 I i) 1 I I t tq i 19 been established at the MOH headquarters and is administered under the Directorate of Preventive sen,ices. The unit, which receives its financial and other support from Government, has a National Onchocerciasis Control Plan in place. At the distnct level, integration of Onchocerciasis control activities is a key strategv being promoted as stated by one MOH official; "cli,ylrtcts are bemg empow,ered to conttnue the programme by integrating onchocercias is tttlo P HC act ivrt rcs"' Of the four health workers intervies,ed, all indicated that they were responsible for other activities besides CDTI progmmme activities. The table belorv summarises the other activities carried out by the health rvorkers involved in CDTI activities; TABLE 4.I ACTIVITIES INTEGRATED WITH CDTI The table shows that the main activity with rvhich CDTI is being integrated u'ith in 75% of respondents is MCHiEPI. All the three health rvorkers who reported this are health personnel based in the peripheral health uruts (Health centers and Dispensaries;. The trvo health workers.(50%) who reported carrying out Eye carelVitamin A supplementation activities, are the District Onchocerciasis Coordinators who are based in the Songea Regional Hospital and Mbinga District Hospital and work in the Eye Care departments of these Hospitals. Also, the Project Coordinator for the Ruvuma focus, himself a full time employee of the MOH, is responsible for eye care services in the Songea Regional Hospital. The other activities with which CDTl activities are integrated with are Curative (50%), Health education (25%) and Home visits (25%). 3.4.3 Willingness to contribute (Community Response) Evidence of the community response and willingness to contribute to the CDTI Programme was gathered dunng our interviews with the CDDs, the village leaders and droup discussion sessions with various segments of the population. CDDs in category 'A' vrllages were asked to say what they t-elt about the Programme rvith respecl to "community response'' (CDD A Questionaire, item 4l(b). Their vietvs are summansed belorv Activitics carried out # Yo Curative Eye care/Vitamin A supplementation MCH/EPI Home visits Health Education ,) ) 3 I I 50.u/o 50.v/o 75.0% 2'5.0% 25.0% TOTAL RESPONDENTS 4 100.0plo Opinion # o//o a) Community very positive enthusiastic and eager b) Good response, active participation c) Like the Programme to continue d) Willing to attend meetings and to take the drugs e) Very responsive, rvitling and supportive 0 No Answer J 2 I 2 2 2 250 16 7 8i 167 161 161 TOTAL RESPONDENTS t2 100 0 20 TABI-E 4 2 OPTNTONS OF CppS ON COMMUN_IIY_BESPQNS! As shorvn in the table above, all the opinions were very positive and supportl\e; no negative views were expressed. Similarly, women (25+years) group discussants in Madaba village, Songea District had this to say "14/e will listen to what they advice us and y,e will do wlatever they tell us even if nteans contributing ntoney" Village leaders were also asked if any member of the community collected the drug from a collection point to demonstrate practical support for the programme. Their response is shown in the Table below TABLE 4 3 WFTETHER COMMTD{ITY _MEM_BE&S_COLLECTEp THE pRUG FROM_ A CoLLECTTNG POrNf vit. A vit B AL t\, I Ii.l nseRes rlil ,1 i I [J[) r.) 20 tlt The table shorvs that community members collected their drugs in 80% of the rarget villages while in the remaining twenty 20o/o,the drugs were delivered to the communit), by the health staff. 3.4.4 Community readiness to take over CDTI In 29 of 30 A and B villages visited, CDDs had been chosen and trained. The exception was Mlale JKT, an Army camp where the drug distribution rvas carried out b1, health personnel who themselves are soldiers. The number of CDDs per village varied from 2 to27 depending on the size of the villages. Of the 12 CDDs interviewed in core'A' villages, ll(91.7%) indicated that they were willing to continue working as CDDs The major reason given by 5 of I I (45 4o/o) for rvillingness to continue serving the communiq, rvas "l lrkc the u'ork/Job'' The other reasons given rvere enhanced positron in soclel)', garnrng expcnence, and rvanting to ensure that their atlected lamrlies continue getrrng rhe drug. 1'hrs .'\as the case rnsprte of the fact that all of the trvelve CDDs (100%) stared tlrat they uere netther receiving rncentrves nor transport support from their respeclrve Yes No Don't know 5 I l9 5 24 6 TOTAL RESPONDENTS 6 24 30 100 00,'o j 21 communities indicating a stronB lei,el of voluntarism in these communities rvhich is important fbr CDTI Programme sustainability. lnspite of these findings however, only 4 of I8 (22 2% ) focus group discussions stated that they were prepared to take over and sustain the programme. Six of the l8(33.3% ) focus groups said they would still need support, 5 groups (27.5%) had not heard that it is the community responsibility to sustain the Programme rvhile three out of the 18 groups (16.7%o)not answer the question about communiw responsibility in sustaining the Programme. 3.4.5 Collaboration with NGDOs. Collaboration arrangement betrveen the health system and the NGDOs at the National level is coordinated through NGDO representation at the NOTF. The MOH ofticial interviewed expressed that a close rvorking relationship between the MOH, the NGDO representative at the NOTF and WHO exists. The monitoring team did observe this to be the case during the one month stay in-country. "Through this collaboration arrangement, the NOTI; has joinrly carried out a number of activities mcluding production of IEC materials, KAP study, detelopittq a training manual for TOt and conducling advocacy and .\ens r I i:al ion meel ings. " At the district level, Sight Savers international the NGDO partner, was involved in the planning stages of theproject and has participated in review meetings. SSI implementing partner of the prqect is Paramiho Mission Hospital, a 350 bed hospital, located about 20 km in the outskirts of Songea town, the Ruvuma Regional headquarters. Although the monitoring team was not able to interview the relevant persons in Paramiho Mission Hospital, rve observe that the involvement of such a well established institution located rvithin the project area in the CDTI activities is an important feature of sustainability 3.5 Programrye Constrainls Three categories of respondents \\'ere intervierved on constraints being experienced in supervision, obtaining the drug, distribution of the drug and constraints being experienced at the national level. The four health rvorkers inten,ierved on constraints in supervision reported as follows, TABLE 5.1 :CONSTRAINTS IN SUPERVISTON # of times mentioned No constraint Lack ol trarrsport lnadequate/l-ack of al lowances lnaccessibrlrtl' 0 ? J I 0 0% 5096 75% 250 0%Ma ent of srde effects Ii I 2'2 The most reported constraint bcing cxperienced by health u,orkcrs in carrying out supervision is inadequate or lack of allorvances l75o/o), followed by lack of transport(50%). Inaccessibiliry of the project area was repofied by only one of 4 (25%) of the health workers rvhile nranagement of side et]'ects was not a constraint as reported by the health workers. The Health workers rvere also interv'ierved on constraints in gettrn-q the drugs. The fbl lorving summarises the fi ndings; TABLE 5.2 . CONSTRAINTS IN GETTING THE DRUG o//o 0% 100% 50% 250h All the health workers (100%) stated that lack of transport was a constraint in getting the drug while inadequate supply was reported by 2 of a Q5%) health workers. Delay in getting supplies was reported by only one (25%) of the health workers. Constraints being experienced by the CDDs rn the distribution of the drug as reported by the twelve CDDs intervierved in category 'A' villages were: TABLE s.3 CONSTRATNIS rN THE DTSTRIBUuQLLQF pRUG By CppS Response # of tinrcs m to No constraints Distribution period rvas shorr Lack oftransport Lack of community suppon S of Seven of trvelve CDDs (58%) reported that they, did not have an,r- constraint in the distribution of Ivermectin. However,4 ot'thel2(33 3%) CDDs said that lack of financial or transport support from the community was their major constraint. Lack of transport was reported by 2 of 12 (16.7%) while onlv one(8.3%) CDD reported that distribution period rvas short and one (8.3%) said that shortage of drugs had been experienced. The MOH official interviewed and the NGDO representatives interviewed stated that there were no constraints experienced in either transportation or storage of the drug. They sited only trvo constraints that have been experienced. There were however three areas of constraints reported, a) Some constraints rn the cleanng of drugs orr landing at Dar es Salaam. This was due to some disagreement benveen the (iovernment and the donor/shrpper on whose agenl should handle ir l'hrs has norv been iesolr ed b) Constraints rn rccord keeprng and proper repofirng liom the I)istrrct and local levels. This is being improved upon and rectrfied ilil 3 i i 2 .l I 58.3% 83% 16.7o/o i3.30io 83% 1 ; _t Response # of times nrentioned No constraint Lack ofTransport Inadequate supply Delay in supply 0 4 2 I rlr il I iI 23 c) A ma-;or constraint in preparing the national Programme account to APOC. This is due to absence of a permanent Accounting Officer charged with such responsibility. The problern persists and increases unless a solution is found by ernploying an Accounting Offlcer at a competitive and attractive remuneration rate to attract and retain an appropriately qualified person. Summarv of Input Indicators Code Descriotion # Pooulation 'h l-l Communities with trained CDDs t-2 30 30 30 30 30 60 30 30 30 100.0 13.3 80.0 r00.0 90.0 r00.0 Co m m u n ities/Projects that experienced Late supply or shortage of Ivermectin Projects which experienced late supply of funds 0 4 0 1-3 t-4 Target com munities which collected Ivermectin from collection point /H.centre 24 1-5 CDDs rvith measuring device for height 60 l-6 Communities with treatment registers 27 t-7 Trcated communities with summary form At thc District office l-8 Communities whose nearest health Facilities have "severe adverse reaction Records 0 30 0 aj I I ltl 3.0 ti nt o ue feature of the Proiect area 3.6.1 School based distribution of lverntectitt This is a system rvhereby school children and teachers receive their Onchocerclasrs treatment in schools and not in family groups. This system is unique because it rvas not recommended or considered in the APOC manual and it has not been reported in other countries implernenting the CDTI. Three models of school based distnbution were encountered in the Project area a) The elected CDD and the health rvorker appoint one teacher in each school as a "sub distributor" to undertake Ivermection distribution in that school They also "train'' the teacher locally b) The official CDD goes to each school in the community on an appointed day to distribute the drug to pupils and teachers. c) School teachers match their pupils to the distribution centre on the distribution date and line them up to receive treatment betbre the rest of the comnrunity and retum to school. Approach (a) above has very serious implications for proper training of the teacher- distributor and all the three approaches present problems for record keeping and propcr maintenance and updating of the treatment and census register. A proper evaluatron of this system needs to be urrdertaken and a tbrmal directive issued. 4.0 CONCI,USIONS Our conclusions arc as lbllows I While the CDTI proccss of decisron making was generally observed in the selecrron of CDDs, it u'as not followed in decrding the time and mode of Ivermectln distribution Decisions on these trvo issues are generally nrade bi.,the health worker 2. The communiq'education on CDTI was deficient on communitv responsibiliq' as it affects orvnership of the programme; support ibr CDDs. supervision of CDDs. preparedness to take over. 3. The CDTI trainrng of health workers rvho trained the CDDs ivas deficient especialli, in the areas of census taking, proper keeprng of rreatment registers using appropriate symbols to indicate reasons for non-treatment as well as severe stde effects. Because of this deficiency in their training, the health workers rvere unable to train and supervise the CDDs properly. 4. The I'ears expressed about possible contarnlnation of unuscd tablets kept rn CDD's homc rvere genur;te and nced to be addrcs;cd. I I Jj 25 5. 'fhe CDTI is fairly u,ell integrated into the Primary Health Care (PHC) system and this enhances the prospect of future sustainabrlity of the programme. 6. The absence of a qualified accounting staff to handle tjnancial matters at the NOTF level has become a hinderance to smooth and efficient operation of the programme. 5.0 RECOI\{MENDATIONS l. A retraining programme for both health personnel and CDDs should be carried out before the next round of distribution. The retraining exercise should pay special attention to census taking, record keeping and reporting. 2. Community education especially on the responsibility of communiry members in CDTI should be carried out before the next distribution. 3. A fresh census of all the villages under the programme should be organised before the next distribution exercise. 4. Special drug kits (containers) should be provided for CDDs to keep unused drugs in their homes u,ithout being contaminated. 5. A qualified accounting officer should be enrployed to take charge of financial matters at the NOTF level. r'! ANNIIX. I ]!TEMI}ERS OF THE MONITORTNG TEAM E.\1'ERNAI, MONITORS I . Professor Dan S. Obikeze i University of Nigeria, Nsukka - Nigeria 2. Dr.Johnson Ng'orok Sight Savers International, Kampala, Uganda 4. Mr. Willianr Kisoka Medical Research Institute, Dar es Salaam, Tanzania Member GUIDI'S Nir Llcnson Nyirenda Drstnct Oncho Coordinator, Songea N4r Sebastian Mhagama Drstrict ()ncho Coordinator, Mbinga I-eader Member ll INTgRNAL MONITORS 3. Dr Mposhi Ruhiso Tukuyu Focus Project co-ordinator, Mbeya, Tanzania Member iJ il L] l I ,l t I I I ) J ) SCIIEI) ANNEX 2 ULE OF AC'IIVITIES OF TH MONITORING TEAM AUG _ SEPT. STIN MON TTIES WED THTI FRI SAT August l5 At Dar l6 prelirninar y meeting t7 I8 TrainingTra n ng l9 Leave for Songea 20 arrive Songea, meet with officials 2t orientation meeting 22 site visits 23 -do- 24 -do- 25 -do- 26 -do- 27 -do- 28 -do- 29 -do 30 -do- 31 -d<l- Sept. I -do- 2 -do- 3 -do- 5 Travel to [)ar 6 TraveliArr ival to Dar 7 Analy,sis 8 -do- 12 Report production l3 -do- l4 debriefing l5 Submit report 9 Report Writing t6 -do- r999 4 End of site visits. Debriefing II -do- l0 -do- 17 Departure Mode of Distribution by Source of lnformation rs I t, Bo960 640g20to 123 45678 Mode of Distribution 9 10 11 ! ! l I 1 I -t IJ '',13. 1. Housc to Hous€ 3. Central Place Both 't & 2 Other 7. House to House 8. Central Placc 9. Bothl&2 10. Other I) What the Communities Were Taught About lvermectin Ioao tl- o l- o -o E Jz 12 10 B 6 4 2 0 5421 3 What They Were Taught treatnent annually for several yeers 2. BenefiG oftreatnent 3. Community responsibility 4. Side-Effects 5. Other 1, Taking ivermectin 110 ,l ii,lli, 4 FAIR Quality Analysis of Treatment Reg isters 22o/o 31% 31o/o GOOD VERY BAD I 16% POOR t I I il rl il 1 i i .! t .r. 'i .l .J ij t a Ii t'r _.1 r r lir r-111p1111 t c r r i cu' : \/ il I r_41c't!_l_-cq rl c r' 'l'ltis rttstt'trntuit t.\ Io ltt rtrlttrrttittt'rcrl rttt tli( rilluec ltcrtrl or o tcpt(scnt(ttn'c o.[ tlra ytlleu( ltt'ttrl 7'lra lrcurl crttt trrk ottotltct l)ct'soti tr; a.s.ris; tt'itlr tlte irrtert,rcy,ortd to et,cn ltove o soy rltrritre tlrt, tttt()t'\'t(\t'. I)o ttrtt tefttsc t\4ost o.[ tlte qtrc.<trorts etc stt'u(tttrcd. Circlc eppropiote codcs. [)tt rtot l)tot)tpt Iltc rtsltrtrtscs: tallt(r ollort'tlrc rt's1tr.ttrd0tt lo ettswct'trlttlc you circlc tltc opl)tol)ti(tt(' ol)lio)t to llt( t(.\l)()tt(!(ttl '.\ r//l.rl1'c/ l,t.slctt lLt tltc clttef ottcl cltoose iltttottQ tltc itettts ltrot,i4crl t/ Ira sats.\()tn(tlutl::,lrl/.ctartt stlc,t 'Otltar rttttl ttrite tlre actttal t(spott.\( tesl)onsc ttt Iltc sltttt-1, 1ttovidarl Villltgc Nurrrr': Srr Ilcorrn(.r'/l-G.\ Villagc Coclc District /Statc C--ort rtl.r'r \lorrtlr lrrrrl r t'ru' ol' lrtsl <iistrillir(ion I)lCrrSc icll t:s .rlrrr.tl irll\ i)ro!rarllrlld c()ncr'r:rrrtQ 0ri;lioceIcitiS]s t|eirint('nt trt lirrs '.,illiSt.'(PROBI: I l'll, I'Ol-l-O\ INC ISSiiES AItl: ADDRE,SSED) ',tltrt ltrrtitllii tltt, ttit,ti ol tlta rtttt ltocrlcrn-sis prograt)ttnc lo tltts t,illase',' ',:ltttt rlr<1' tlit'1tttr()titS) (ottt( Io tolk wtlt \'()u ul)Out onaitO<'erctrtsts') l)ttl tltt l)r t,rtiut) rut'L,t \','ttlt \ou tttttl ,ttltct t'rllrtga ltttrlt'ts.fit.ti') l)ttl tltL't 11tl iot \'()tt it) (tt t'on.!c ( ntcctin.u ) t, ltttt tlr ti t ltc,. i al l yt,rr ttlt0ttt (onilttuntt.\' r(51)ott!tbtl fi .\' 2 llou \\'as ll)e rlntc (ntontlt/season) lbr drstrrbutron decrded') .tt a \lllag.e nrccltng r rllaee elders nrcctrnQ vrllace chielileader Irealth rr orker r rllaut ltealth conrntrttec r rllaqe corltnrrttcc ntecttr)u ollier (spccili )_.- -. I 2 l 4 5 6 1 I \\/lrlrt rrrorlr-' ol tlrstr rlltrlrrln rr:rr riccrtlr'rl ) I 2 .1 lrtltrse-lo ll0trst r cr)tral lllacc r r1'lcr rlr') lrrrtlr ltotrsc lrr ltotrst' ,rtlrr'r (\l)L'ctl\ ) rrrrl ccrttrlrl plircc ltL I-lorv rr,:rs llrc rlotlc ol drstrrbution rlccrrictl ) I ar ;r vrllzrqc nteetin{l I vrll.iuc cldcrs ltrcctrrr! 3 r,rllaqc clrre[/leader -l Ircirlth rvttrkcr -i r rllrec Ircaltlr corrrrrrrrtcr,(r r rllaqc collnlttee lncL,llnt 7 olirc-r (sltecifi,) IJo* ,urrtr ,t:rle ( l)l)s) l.l rt* rir:rrtr li,ntalc CDDs? IIOri' rve tc tltr' pgl.rrni ((-l)l)s) Se lce tCtl l11 rjrr litc' \\,Ofk? I .rr .r r rllinc r)tcetint I r rllulc clders ntcettnl .: , r'i.r_!c chre l'lleaclcr -l Ii.'.rlrlt rrorkcl 5 \ rillrr:e lttaltlr contrrrrtrct,(r'r,li.r!e colnn]Ittce n)cetlr)r' ( );i111 (spe6,1'.,;_ I []elore rhc lirsr drstriburrorr 2 Drrr rnl ti rstrrltutrort 3 Soon;tl'rer tltc llrsl drstrrttu(rtlrr 4 [)rrn t l,rrou,/('an t rcntcntl)ct -i llori, rnlr rrr I)!'rsons tCDDs) ul lllts r rllaqe qive out Ilre ririru lrlr onchttcercursrs.) (r 8 \\/ht dtd rotl eil.,,'.. tltr.sc [)erSOr)(S))(l)r.lre i.r critcrra) 9 IJave tlte CI)l)r rr'!cr\e(l arry rrarprnt') I \"cs 2 No 3 Drtrr.r krtrtrr I0 [f 1,s5 to Q9 rr ]rcn ti rrl tlrcr re ccrvc tratr)rnl ) I 2 3 4 I I IIrlrv u,e ll lr,.r q, 1l1q' ('l)l)s clorrc tlte rr orl..,/ I ricll 2 l'trrr i ltoor (Erplirrrr r l-t llttve vr)u tr.lt,-,r(1 .rlt\ ()l Yorrr ( J)l)., i \C\ .l No i I)ol I Inr\\\ I'1,\ (),') \ .l l-1 IIave \ ()tr IIlr.' rvctntee{rrt/rnt'etr -rrrttrtttrrrrl\,) rcccrr ctl e tirrc.urolt on tltc nltl)orl.ulcc ol tlrkrrtt 'ni ()rtclio ttrtllct arrnrnlir lrrr scvcral Ycalsl I \'cs I \rr : I)trt tkrttlri'/Clrrt ttcllr,'ttti)ct I 5 l1' _1'cs to t.) I .l lr L{)lllllltllll I l)trrrn-r: tlrL'lr'.t nrcctrr! 2. Ilclbrc ti)c lr:.r ti istrrbutrort i Dtt rrrrr rl rsrn'.rtrorl 4.,Strtltt lrltr'r tir.:r Il)tlti()rl \\'lrcrr rlrd \'o11 rcccr\t'tl:t'r'tjrrcatrrrn'/ lcrrclc rrll 111,,1 .r1lqtlt') It, l1 \,er trr Ql-.l . rrl,.rt \\cl'c \()u tr)ld) (l)rrrl..- l,,i C lrrtrtulrl lr(.rtnter)l litr severa] r'e ar. bcnclrt: \\/us tltcre .rrrr eollcetron lltlrru' '. r((l)()nsrl)ilitr_ -, )r l)rttur)lt\ (jeclsr()lr 1;r1 i11 rr,, ilte <irLrg sltoLrltl lrr'.,,llcctecl l.rrtrti ir i \ r'. I \,, .l l)rln't l.rtori i:l l)rtj ttrtr tttctttltt't o' l)t'r-ortlrtlul)it\ e(,llce t ti,, rjrrr.. lr()n) lr c()llcLtl()r) lrrr1l it I Ycs I \,r I ) L\ I r\r i)ort ( krtrlu i') ll rroloQI8 ultr -l() \\rlrcr-c rs tltc collct,,()n I)()lltt ) lr I)rcl vou c\pe ltcnLr' l.rtc suppl), ol druc durrrr-! tlrc l.rst rlrstrrltutrorr ) I )'cs 2 \,, .l l)trltlkltttrr I)lclrsc crlll;rrrr l)rtl ,,,rU ( \l).1( - ..1,(rti,tlc trl tllLtus tltr, lt.' rr,, ,,111 rltrtIir(tltrrn) I )ol t Lrtor,. ll tr'' to (.)l-l lt,, tlr,. ltlrrlrlurrr rrrlrr l\j a ,V l.l,r \\ lrs tirc ce nsus ()l \ ()ur r rll.rgc undcrtakcn) I Ye s I No .l l)on'l krrou, lllt I)0es tltc con)nlri nltV IIrr.c lr ttcatlltr'nt rcgtstcr ) I Ycs l it,, I I)orr't krr<lu 2-l ll rcs to Q2{. ulrcle rs rltc relrsrer keprl l-i Ilorr rve l'e \'(ru in\ rrlr t,tl rrt ntottrlisaritrrt, l6 lltlu u'elc you trt\ ()l\ c(l llt \Lll)crylsiop') lii I. llrcre at)\ tl)ln! \ ()ti \\ iil lrllc ro te ll/l:sk us') l7 \\ ll.lt llte \/otl I \LlS!e\tt()n\ ()n ltou, tlte colt)rIunil\ trrrrlci [)e ntorc tr)\'(ri,,,:ti tr r'Den'titcIs ri,itlt tr et ntr.r lilr l'rI sc.r,eral r ears') llt'iltlll'!l ltS lrr Ke1' Infbrrnant Intervierv: Village" B" Leaders 'l-ltis tool is to bc odntitti.stered to the village lrcad or a rcpresentattve o.f'tlre villa7e lrcad itt all cetcgory "B" t,illages. ln tlrc case tlw tlrc village ltead w'ants sottrcone else to ossist tt,ith tlte ittterviey,, do ttot refitsc. Put a circle around the approprtatc respotlse codes. Do trct Protilpt rcsponses and allott, respondent tinrc for answering the questiott. Usa tlte optiott "otlttt" n'ltere tlrc resportse is not liyed but renrcnilter to specify the respotlse itt tlte space provitled. If a village heatl is not available, trtterviev,/tis assisrar:r- or represetttotive. Village Name Village Code:--subcoutrtl'/LGA,_ State/District Country Morrth and year of last distribution _l_ I. Have people in this comrnunity been treated with iverntectin in the past one yearl l. Yes2. No i. Don'tknow IF NO TO QI END INTERVIEW IF YES TO Q1 CONTINUE THE INTERVIEW 2. llow was the tinre (nronrh/seasort) for distribution decided? at a village rneeting village elders' nreeting village chie[/lcader lrealtlr n,orker \ri llage health cornnrittee villac.e cornrnittee meeting other (specr fy)- 3. What nrode ol distributron was decided? Irou se'-to- house central place (specily) botlr house-to-house and central place otlrer (specrfy)_- 4 I-low rvas the nrorle of drstribution decided? at a vrllage rneeting r rllage e.lders' rnceting r rllage chiet/leadcr hc:tlth rvorker \/tllaile lrealth cornrnittec vrllaec conunrl.tec meetrng otlrcr (spccrly) I 2 J 4 5 6 1 I 2 3 4 I 2 3 4 _5 f) 1 Nl,rr i,)|irf 1,,\l[lr])frl\ li..tntP,tl.r \l , l')')') )l 5. I{ow nrany persons rn this vrllage (CDD) give out the drug for onchocerciasis? 7 . Horv rvere the persons (CDD) selected to do the "vork? I z J 4. 5 6. 7. at a village rneeting village elders' meeting village chief/leader health worker village health cornurittee village committee meeting other 7. Have the CDDs received any training? I. \'es 2. No 3. Don't know/ Can t remember 8a. Have you changed any of your CDD? L yes 2. No 3. Don't know 8b. If yes, why? 9. Did any mernber of the cornrnunity collect the drug from a collection point? l. Yes 2. No 3. Don't knorv 10. Did you experience late supplv of drug during the last distribution'J l. Yes 2. No 3. Don't know I I. Did you experience shortage of drugs during the last distribution? I Yes 2 No 3 Don't know 12. Does the cornnrunity have a treaturenr register'? I Yes 2. No 3 Don't knorv \1or)rl()r trg l;rsltunxntr ii..tnrpllr, I'1r;' l9()() 22 OF Wlrcn a question requires ntuhiple applicable response code. Probe whe responses, do not forget to pu a circle around eaclt re appropriate. To be administered only in group "A" vitlages. lnterview 2 CDDs per village if rhere are ntore tlntt one CDDs. At end of the imerview ask the distributor ro let you see his tools; ttteasurirtg devise, registers, renaining drug if it is rhe case. Nanre of Village District/Sute V illage code : _SubcountyilGA Narne of CDD Sex: l. Female 2. Male Main Occupation Month and year of first CDTI distribution in rhe villag e _l_ Month and year of last CDTI distriburion in the villag e _l_ I . IJow was the rirne (month/season) for distribution decided? at a village meering village elders' meeting village chief/leader healrh rvorker village healrh comrnitree village commirree meeting other (specify) 2. What rnode of distriburion u,as decided? house-to-hou se central place (specifl) Both house-to-house and central place other (specitv)_ 3. Horv was rhe rnode of distribution decided? at a vrllage rneering village eldersr rneering village chief/leader healrh worker village health c()mnl(tee villaqe comrnirtee rneeting otlrer (speciiy) I 2 3 4 5 6 7 l. 2. 3. 4. l 2 J 4 5 6 7 i\1(rr I.)|nl' ln\lrUt.DCnl. KrrIg,all N1r\ l,)()r, i,l

4. How were you selected to do the rvork? l. at a village meering 2- village eldersl meering 3. village chief/teader 4. healtli rvorker 5. village health commirtee 6. village committee meeting '1 . other (specify) _ 5. FIas any CDD been changed after the firsr distribution? l. Yes 2. No 3. Don't know 6. If YES to Q5,' Why was the CDD changed? 7. Have you ever been supervised ? l. Yes Z. No 3. Don,tknow 8a. If yes ro Q7, who supervised you ? (rF NAME wAS MENTIoNED, PLEASE ASK FoRTDENTITY/PoSITIoN/STATUS OF THE PERSON) I . I-lealth sraff 2. Village health committee member 3. NGO parrner 4. Comrnunity member/chief 5. Other (specify)_ 8b. Whar did rhe supervisor do? l. Checked rlie ivermectin inventory 2. Checked rhe records/treatment register3. Collared rhe reports 4. Advised on rhe treatment of absentees 5. other (specifo) 9. At what occasions were you supervised? (clRCLE ALL THAT Appl-y) I Before distribution l. yes Z. No2. During disrriburion l. yes2. No3. Soon afrer <lisrriburron I. yes2. No l0a' Ijave you received education on rhe importance of taking iverrlectin tablets annually for scveraI years? I . Yes 2. No 3. Can't re rlernbcr f,1(\lr(olilli, lil\tl(rrilcnl\ Karrr|.rll i\1rY l,).) ) li l0b. If yes, whar were you rold? I l. Did you provide the cornmuniry with education on ivermectin treatment? Yes 2. No 12. lf yes to Qll, when did you provide the education to the comrnunity? (CIRCLE ALL THAT APPLY) l. During the first meeting l. Yes 2. Before the first distribution l. Yes 3. During distribution l. Yes 4. Soon after distribution l. Yes 5. Other (specify) _ 2. No 2. No 2. No 2. No t 3. If yes to Ql i, what did you tell the community? (CIRCLE ALL THAT APPLY) Taking ivermectin annually for severaI years Beneflts of treatment Cornmunity responsibility Side effects Other (specify) 14. Did you receive any training on how ro rreat cornmunity members? l. Yes 2. No I-5. If Yes to Q14, rvhen did you receive rraining? I6. Who trained 1,ou? Healtlr personne[/Oncho coordinator NGDO staff (specify) Another CDD Other (specify)_ I1 . Horv long did the trarning lasr? l t' traintng_ 2''d trairring Last trarning l8 Horv rnany Cl)Ds r.,'ere (rarned together (size oI the group)? l t' trarrtrng_ Last trarning I 2 J 4 6 Yes Yes Yes Yes 2. No 2. No 2. No 2. No I 2 J 4 N4onrtonng ln\lrLnrnls Krnrpala. trlay I099 t6 19. Where was the venue o[ rhe last training? Within rhe community Outside the community Healthcare facility/hospital Other (specify) 20. Was the venue of trarning near to your community? l. Yes 2. No 21 Wltat were you taught during training about onchocerciasis (CIRCLE ALL THAT Appl-y) I 2 J 4 I 2 3 4 5 6 Cause Symptoms Socio-economic importance Communiry mobilisation and education Ivermectin as treatment for a long time l. Duration of treatment 2. Coverage of disrribution 3. Dosage determinarion by measuring height 4. Expiration of drug after removing container seal 5. Treatment of absentees and refusals 6. Side effects (counseling and referral) 7 Exclusion criteria 8. Record keeping 9. Census 10. Other (specrfy) l. Yes l. Yes l. Yes l. Yes l. Yes L Yes l. Yes 1. Yes l. Yes l. Yes I. Yes l. Yes l. Yes l. Yes 2. No 2. No 2. No 2. No 2. No 2. No 2. No 2. No 2. No 2. No 2. No 2. No 2. No 2. No Other (specify) 22. what were you taught about rhe drug? (clRCLE ALL THAT AppLy) 23 wlrar were you rausht abour reporting? (clRCLE ALL THAT Apply) I . Nurnber of persons treated 2. Number of refusals 3. Nurnber of absentees 4. Number of excluded persons 5. Number rvirh severe side effects 6. Other (specify) l. Yes l. Yes l. Yes l. Yes l. Yes 2. No 2. No 2. No 2. No 2No 24 Did any tttetnber of tlte cotnmunity collect the drug frorn a collection poinr during the last distriburion, Yes 2 No 3. Don'r knou Nlrrnrloilng. Insiruntcnls Kanrpl'.r, \4.rr lc)99 l 25 Il "no" to Q24, rvh\,') 26. Where is rhe collecrion point? 21 Did you experience late supply ol drugs during the last distribution? 1. Yes 2. No Please explain 28. How do you norrnally determine the quantity of drugs required by the conrmunity? Census/registration record Previous treatment records By counting the number of liouseholds Other (specify) 29a. Did you experience shortage of drugs during the last distribution? L Yes 2. No 29b. If yes, please explain 30. How do you determine the number of tablets to give to an individual? (CIRCLE ALL THAT APPT-Y) l. 2. 3. 4. l. Take heighr measurernent 2. Use u,eighr 3. Visual observation 4. Age 5. Other (specify)_ Yes Yes Yes Yes Z. No 2. No 2. No 2. No 3l . What do you do about individuals rvho are absent during norrnal distribution period? 32. What do you do abour rndividuals who refuse rrearrnent? 33 Whiclr categories ot'people would )-ou nor grve rhe tablets (PLEASE CIRCLE ALL THAT APPLY) l. Individuals below 5 years of age/ below 90cm 2. Pregnant wonten 3. Wourerr who delivered less rhan one rveek before distribution 4. Sick indivrduals 5. Visitors(r. Other (specrt1,)' 34 I-lurv do you ensr.rc that these catesories ol people eventually recel\/e L Yes 2. No l. Yes 2. Ncr l. Yes 2. No l. Yes 2. No I Yes 2. No trca(lltent? Monrtorrng l;rstrurrxnts Kanrpala. Mrv 1999 Iii 35a. Horv long do you normally keep rhe tablets in the cornmunity? 35b. Ilow rnan1, days did you take ro complete the last distribution? 36. Where do you norrnally keep the tablers? 37 . Do you have drugs ro take care ol minor side effects? l. Yes Z. No 38. What kind of support do you receive from the community? Transportation for drug collection Incentives (rp..ify) Other (specify) 39. Do you have problems wirh record keeping? l. Yes 2. No 40. If yes to Q39, please explain 41. Please tell us how you feel abour rhe programme with respect to: a) sustaining the program-rne I 2 3 b) cornmunity response c) constraints 4t What do you think should be done ro inrprove the programme? 43. Are you willing ro conrinue as a CDD? I Yes 2. No Please explarn_- PLEASE A.SK FOR REGISTEIT AND \4IIASURING DEVI.:^E TO PROVIDE FOLLOwtNc INFORMATION 44a. Is ureasLrrrng dcvrce for height presenr? llonrlonnlt 'runrt)l\ Krrnprla, Nlrt l9i)() l9 I . Yes, seen 2. Yes, but not seen (Explair) 3. No, Explain 44b. How do you use it? 45. Is treatrnent register present? I 2 3 Yes, seen Yes, but not seen (Explai No, explain 46. lf Q45 is "Yes, seen" EXAMINE TREATMENT REGISTER AND OBTAIN THE FOLLOWING INFORMATION ON: Toul population_ Age conrposition of p."pl., B"l"* 5 years- 5 years and above Sex composition of the population: Male_ Female- Number of persons treated_Male_ Female- Number of persons under-S years who received treatment_- Number of refusals Nunrber absent during last treatment_ Number rvith severe side effects Number of tablers received 10. Number of tablets used I l. Number of tablers left in the drug kit-- I 2 3 4 5 6 7 8 9 l!1or'rrtcnng instrrrnrcnts Kanrprlrr , \1.rv I9()9 20 R w VILLAGE " To be adtnitistered only in group "B" villages. lnteryiew 2 CDDs per village if tlrcre are nore tlnn otte CDDs. At tlrc end of the interview ask tlrc distributor to let yott see his tools: nrcasuring devise, registers, rennining drug if available. Wten a question requires nrultiple responses, do not forget rc pw u circle orourtd eaclt applicable respottse code. Probe where appropriate. Name of Village District/State Village code: _ subcounty/LGA Name of CDD Sex: l. Female Main Occupation 2. Male Month and Year of last distribution I I. How were you selected to do the work? at a village meeting village elders' meeting village chief/leader health worker village health committee village committee meeting other (specify) 2. Has any CDD been chansed afler the first distribution? l. Yes 2. No 3. Don't know/can't rernember 3. Have you ever been supervised ? l. Yes 2. No 3. Don't knorv 4 If yes to Q3, who supervised 1,ou '? (lF NAME WAS MENTIONED, PLEASE ASK FOR TDENTTTY/POSITION/STATUS OF THE PERSON) l. Health staff 2 Village health committee member 3. NGO partner 4. Cornmunity rnember/chief 5. other (speciry)- 5. Have you received education on the importance of taking rvermectin tablets annually for scveral years? )'es 2. No 3. Can't renrerlber (r Did ),ou reccive arry trairting ort how to treat corlrnunity rnernbcrs'J l, \'cs 2 No I 2 J 4 5 6 6 91 [s rneasuring device for lieiglit presenr? l. Yes, seen 2. Yes, but not seen (Explain) 3. No, (Explain) 8. Is treatrnent register present? L Yes, seen 2. Yes, but not seen (Explain) 3. No, (explain) If Q8 is "Yes, seen" EXAMINE TREATMENT REGISTER AND OBTAIN THE FOLLOWING INFORMATION ON : l.Total population_ 2.Age composition of people: Below 5 years_ 5 years and above_ 3.Sexcompositionofthepopulation:Male-Female- 4 Number of persons treated_Mate_ Female_ 5 Number of persons aged 5 years and above who received treatment 6 Number of refusals 7 Nurnber absent during last treatment_ 8 Number with severe side effects_ 9 Number of tablets received l0 Number of tablets used I I Number of tablets left in the drug kit 12. Update of records fr: ot" U x 6', T#*=11 "o?2D)^=r =oX:ic)r)nrer)U-ft il ?;o9 = J-: rc* @ UaOPrDO 65hZ-6(D;,t-J,aJ n =q="i"o 5-.='<F q=.,g ^U7^rL6 =;>a' A) 'a = al7 q'"€ 6: -:tE a $ z-= c. "=Y - =- ,,^6- ON:.= - o c ov' -C)F-^O-=-L) -ri3.PE ^lD_G5 6 a-2P o c J6 A()(!61l<- a=:i o : 19 J L -;9'E '9-- += b wYao ='-tP -- -l= -)?^)-i? x(D"d ^.t!tr:Eai& )v;4tav :1 < rD<6 Fa-m '_?o(r?o-;o(DX6A rD-- o, E #3oDIo r6;3?1xr .y6n -(Do N'n -o -f -lor5:; :(Dl3c Doc 1-6 ^<(D\/lJUoa 9-uo P :(D'119b-l _F_ -='o =Y- =b>O*a -o^3u:J =86 IrOF(D() a.orau^ 6Re 'r^4 = +rEU o-S.- vfiC =rq rD.D= --Cj->u ri o-; 5 o, oa rD z 3 CD !-. ;itri cD() oo(D I I I I 7 C (t (l (l C U.(D z o b rD =J>9E>1E <5 TrnJ ?ao-c - - o m 't7Ln llttx tJ ,, Oc rD z<;Agi;iut, il C, o c-!? b c r.J - c {.'< q oc ='35 P X g65o- -n=.DJ(D -aC tlJa -t o z E,€6=:E < G C'A) O E a E-.: €\<O o =rl rr,6to aC G'a -j = o9=t9t d =.Y.A 9 d5rDlltt N- z<s =2 <ort lt g(D s P dN)-(D=- ;AU .\, 1 Yq:o *rD -r)LL ,o- iv2A-/r =: t ii{ t a '-rc=<o=trx =a =.=* o- 5 { ='CD =.+sex53 N -c): -o--ito.-(z '! -'t =r i d e +x -* o z -J o a rrl U1i z<=3.i=E:Eil il CD 5 5(D isq)r r S c) =O (D <r.Jl-l:_rcogro:id o '7,1d =< 3- ilil?oiJ(Da u-]i'- 6.-< >:2X('o =. :l(D'o XGn =- o_ii -,G rD o arl v) *l a) z t\) ts=> a): -O--'ha= ,() ,C :to.:1 5 5 +rD ='() o o r)0rl':5r-O EH;safr)qll;-="i T ss & UU-ll! ilil . OO:-9 ; IF: e * 'O ll -- rD z-(rc ;"BsEgACD :j9=u,ll tt "- 3''\oott@\O Ooa ll - Iio -9 * * .)o !q +oiXO rD =o5a q5'll 9::oa .sil= ll -ai- :i. rD =il',i r...1 il * __ D) *3E3E;Edfir-;q:5E?41?5,r:rlt O'r-l.J(-)JrAlt = -rl fDgo-n ll tr'L^ llj- J+ .r( *C)trOa)ro aD*O(D v.e rt 6 c) o- oq rD il c a f -/ I lrL GROUP DISCUSSION GUTDE AMONG COMMUNITY MEMBERS:VILLAGE A Itt each cateSory A village, one Male and. one Fennle adult group d.iscussion must be cottducted. In three of he sk category A viltages, group d.iscussions nrust be conducted witlt rtnle youtlts-and in the renruining three villages, discussions nrust be hetd wittz femalg youths. For tnonitoring CDTI projects, yowhs are defined as individuals between l5 and 24 years. . Tlte CDD nrust arrange for a comfortable place tlrut offers some privacy and enough places to sit . Each group trtust consist of 6-8people. Depending on culture, tlrc group discussiorts may need separate meeting placefor nule andfenrule so that peopteian speak freely. One of ilte internal nrcnitors should be rhe facilitator while a local guide. takes notes (recorder). The group discussion must be tape-recorded. At the end of the i'eision, play backthe rapefor afew minutes to be sure that rhe discussion was properly recorded. hbel tlrc cassette/Notes (Name of the vittage, the group identiiy, datel. TARGET GROUPS: ADULT MALES; ADULT FEMALES; YoUNG MALES oR FEMALES Please tell us what you know about the onchocerciasis rrearnlenr programme (pLEASE PROBE FOR THE FOLLOWING TSSUES.) the person(s) who brought the idea of the onchocerciasis programme to this village the time when rhe person(s) came to talk with you abour onchocerciasis whether rhere rvas a village meeting at that tirne Issues rhat were discussed at the meeting . ownership of the programme . expectation from the programme - . responsibiliry of the community 2 Please describe how the community took decision on the time (rnonth/season) and mode of distriburion. PLEASE PROBE FOR: Persons involved in decision-rnaking Time of distribution Why the time was chosen Method of distriburion Why the rnethod of distribution was chosen Please dcscribe ltow the community took decision on the persons responsible for distributing the druqs ro comrnuniry members. PLEASE pROBE FOR: . Persons involved in decision-making . Who will be responsible for drstriburron 3 lrl 0tttlor rrrl', lilstl utrK.trts K.rrrryrr lr, M,ly I ()()() 1l 4a . [-low the persons were selected . Why the persons were selected . Method of drug collection Has there been any change in tle person responsible for drug distribution (CDD) since the beginning of the prograrune? (PLEASE TELL US WHy) 4b. Has there been any change in the programme? . Who brought the change . What was the change 5 What were,you told about the need for community rreatment witlr FOR ANNUAL TREATMENT FOR SEVERAL YEARS, THEOF INFORMATION, COMMUNITY RESPONSIBILITY ivermectin? (PROBE BENEFTT, S_OgBg=E AND HEALTH EDUCA 6. Horv is the drug normally brought into the communiry and distributed to community rnembers? PROBE FOR o point of collection . person responsible for bringing it to the community, . person responsible for distribution rvithin the community . rnode of disrribution . when rvas rhe drug swallowed 1 . Would you please tell us those who should not be rreated with iverrnectin (exclusion criteria)? 8. How was dosage deterrnined by the CDDs during the lasr disrriburion? PROBE FOR MEASURING DEVICE 9. What problems ltave you had with respecr to the distriburion oltlre drug? pROBE FOR tirneliness of supply to the communiry adequacy of supply storage 10. What problerns have you had after taking the drugs? I l. How prepared is the community to uke control of rvermectin distrrbutron programrne')(How does the cotntnunity intend to sustain the exercise for several years?j 12. what supporr has rrre cornmuniry given ro the cDD? pRoBE FoR : Incentives in cash or in kind Provision of n:eans of transport N,lobilizatron of communirv a a o a a Monrtorrng InstrrnEr,ts Kanrpala , lt4ay 1999 t2 Iinsuring compliance 13. Could you please tell us how you would rneasure the success of rhe CDI'l programrne? 14 How well has rhe CDD performed? (PROBE FOR ATTITUDE). l5 What suggesrions do 1,ou have to improve the programme? tt N1(,ilrloilill' ltt,,lrrrrrr rrls f..rrl11.r r f\llr\, l()()(/ li 0UESTION IIIE I;OII IlDALTH PDRSOAINEL '['lris qrtetiortttaire is ctcttttttristercd on any hcaltlt x,orkcr in Ihe urea rt,ltr,t ts tlirccrly involt,c4 irt CD7, l)togt'otttttt( i.c the lteoltlt slaff ttaurest to lhe village. Tlte ttutttber of heoltlt ltersottttel to be irtrc^,ietvc4 rlcpcttds ott tltc situatiort on thc ground. A rrtinitttrtnt of 3lrcaltlt persotrncl v,lto ara supervisors of CDDs sltotrld bc ittlct'ttiett'ed v'illtin tlte proiact area. Aftct' the itrten,ier.'osk tltc lrertltlr ltctsottne I for rhe docrtrttetrts rrs'cd for CDTI activitics. I-C A /Sultcou nrv State/Districr Courttrv Nanie ol' healrh personnel Sex I . lr4ale 2. Fenrale No o1'Onclio \rillages No. of CDDs rrr villaqes covered Posrt iotr Qualification Rcsponsrttilitics in Orrcho conrrol Proqramnte: I Oncho Coordirraror 2 CDD supel'\/rsot 3 other (specifi,) 1 Drci \t)u pr6gj1,g artr; es11s12l orrentation on CDTI? IYes2No llr Dicl lou rcceive rrainine on llorv to train CDDs? I \c' 2 No -lll ll' r'cs. lrrlrr lont'.) It Lrst tlrc ntaln tol)lcs covercd 2rl \\/e'c r <lu rauglrr l)or' se*ere side effects should be rrra,agccl .) | \'es 2 No I I)leasc tcll us r'hat },ou knorv about rlre CDTI prograrnnre,,vitlr respecr ro 1 ('orrrntLrnitl rcsponsrltilrrl, 2 lrtr trlr e rncr)l rtl the ltculrlt svs(cn) rn CI) I'l I \\,r'. Iltr'tt' .rrr rrtrtt,rl rtrcclrrt! rvrtlt rlte c6t)tpttrrtrly rrllerc ('l)-l I \\,.t\ 1lt.rlrrrr.Ll) L \1" .) N,t \i , ,ll,r| 1,, ll t,!itr( t,l l,,rtrr1r rl,r I \ l')')' -5. Il'yes to Q4, rvhat role rlid the hcalth stal-i pla1, in arranging lix the l'rrst nreeting? (Cll{LCIr ALL TIJAT N PPL\') Facilitated the nteering Met rvith village leader to arrange for the ureeting Other (specify) (r Who led the facilitatin-e rearn to the cornrrunity? health staft' govenrnrent adnrinistrative stall (non-health) NGDO stal'f other (specitr,) Nobody 7 \\rere the conrr.r.runitres (rvlrere you rvorked)educared on (he irnpoltancc'ol'rrearlr)ent rvith ivernrectirr tablets? 1 2 .) .J I I 7 J 4 -5 8 If 1'es to Q7, u,lta( u'ere thev told? (CIRCLE ALL THAT APPL\') LYes2No I IJe lorc tlrrltrlrrnr,rrr 3. Don't knorv 1 . Annual rrearrnenr lbr several 1,ears 2. Berrellts ol' rrcarnrenr 3. Conrurulrirl, responsibilirl, 4. Others (specili,)_ l. \'es r . \'es l. Ycs 2 Nrr 2 Nrr 2 Nrr 9 \\/ere CDDs in thc corrrr:iunitres (rvlrerc rou rvorked) traiued fbr thc CD I-l prouraurrne'? 1 \'es 2 No i Don'r knorv I()a. Il'res ro Q9. drd vou parricipare tn rhe lrarnlr]e of CDDs? I Ycs 2 No l()b It' r es. ho*' lonq drd rhrs trainins session last? lnitial traininc. Retrainin,u_ I la. \\/ho supervised rhc CDDs L Not supervrsed 2.. \rrllaqe head i. \rillage healrh cortrrnitree rnernber 4 healrlr personnel 5 Otlrcr' llb It sultervrscrl llori,ntirnv CDDs drd you suJ)crvlse durrrrg tlte last tl rstrrirLrtron') l. rr lrr' )I I Il rr<lt sultcrvrscd li r\t ul11g11 oLLir\r()n\ ti rrl rrrrr vrsrt (lrc ('l)l), (('llt(.t-l.r Al-l_'l'll,\ I \l,l'l \ ) I|erI\o 2-) { Durins. disrributiorr Stlon uller distribution IYcs 2 lYes2 No No Other (s1:ecifu)-- l4 Wlrlr lLrrctions do you pertbrnr durrrrq your visit to rjre CDD? (CIRCLE ALLTIIAT AppL\,) L Collection o[ unused drugs airer disrributiorr 2. Rcvierv of records 3 N4anagerrenr of sidc cl'fecrs 4 Supervision of druc drstl'iburion -5 Orher (speci[,) I No constraints 2. rnadequate/lack of uteans ot' rransporr/fuel 3 'foo uruch rvork 4 Inadequate/lack of supcrvrsion allorvance ,i Inaccessibilio, (r. Orher (speci[,)_ I. Yes 2 IYes2 l. )'es 2 I )'es 2 No No No No l5 \\/lrat coustraiuts do ),ou have rrr sultc'r'r,isine rlie CDD? (CIRCLE ALL THAT APPLY) Yes 2. No Yes 2. No Yes 2. No )'es 2. No Yes 2 No l(ra. Ilave tlrere been anv delavs rrt receiving iverntectin? I Yes 2. No l6tr ll' r es. e xplain l(rc l-lavc tltere bcen attl,delays rrt cclllcc(rrtrl iyerrttectin by tlre Cgrr"rptr.rprty') I )'es 2. No I 7 ll ves ro Q l(rc. please cxplarrr_- l8 \\/ltat constrairtts ltave )'ou e\pencnced rrr gerring the drue'l (CIRCI-E ALL THAl'APPL\') 2. -) 4 5 None Trarrsport problent Inadequate supplv Yes Yes Yes )'es 2No 2. No 2No z l\o ) Delay in supply Other (specifu) l9 I-l<lrv dct )/ou estillate tlle quanrlry of <lrug required'l N<lt rcsponsrble Nurubcr used durrnq lasl rreatnten( Based on reque srs lrorn tlrc ('DDs liltal populatrtrrr (rvrrlr rlrc lrlrnrula) Otlrer' (spccil'l ) _- -l() [)rrl r orr ucl lltc clr.uqs u,lrcrr re rlurlr,(i ) I Yt'r I Nrr I 2 .) J 4 5 ,,' lr ,tr , ttt. l,.rrr|r,,i \l rr ,','r'\l D rl 2l. If no to Q20, u,lr1,'i Shortage at state, regional level Means of transport Otlrer (specif1,) 22. Do you have facilrry lor srorage of ivennectin? l. Yes 2 No 3. Don'r knorv 23. Ilave you expcnenced loss of tablets due ro prlfcrage? I. Yes 2. No 3. Don't knorv 24 \\/ere cases of severe srde effects reported ro You? I. Yes 2. No 25 RECORDS OF SE\/ERE SIDE EEFECTS (Cr{ECK AVAILABTLn-\') l. Available 2. Nor avarlable 26. Wltat otlter healtlt acttvittes'do 1'ou conrbrne rvrth Oncho Control Progranrntc activities (PROBE F'oR HEALTH Acrl\/ll-\' IN THE CDTI CoN4N4tJNIt-rES)? 27 'llow do 1,ou l-eel abour rhe CDTI programrnc? I z 3 f \1o[rlorr]!: I rr Ir ,i l..,rrrr,r.rl,r N1J\ l')(){) INl'IlR\iIEW GUIDE FOR POLICY.MAKERS/ \\/I{O ITEPRESENTATIVTiPITOGRAI\,IN,IB I\{ A NAGERS/ COORDINAl'ORS Tltis itrtcrview is adnitislcred ott Co-ordinators, Progratttnte nmnogct's, reprcscntatit,cs of AtGDOs ittvolved in CDTI, Mittistry of healfi policlunkers and rhe l|tHO represetilotive in the courttD,. lr is sirtilar to the ittten'ictv o.f ltealth personrrcl. Docunterils such as registe rs sltoukl be requested before the forttnl itile n,ictt, .ro tltot irtfonnatiott can be extracted for tlrc report SECTION A: PROGRAMN4E I\4ANAGERS/ ONCHO COORDINATORS l. Please describe horv the CDTI programlne is being iurplenrented in your area PROBE FOR The approach used for rntroducing CDTI ro rlre cournrunities Elements of collaborarron between Cotrrnrunrr),. Ilealth sysrent and NCDOs (IDENTIFY SPECIFIC ROLES) General re-orienrarion of health personnel rorvards CDTI progralnnte Mobilisarion of rhe conununities Training of lrealrlr sralf as rrainers Please explain process of receiviric ivermectin I)ROBE FOR : Ir lr b C d 2 C d c lr lr Delays in supplr . a[ n,l]at level ltnd rvhr,) Adequacv of tlre quanrir), r"a.'radrslrortase Storage Distribution ro corrrrnuniries Constrainrs (s(orase rransport, etc) Delays irr recervrrr_t tunds . a[ \\/l]a( level irrrcl rr,ltr,) I)elays irr ri rsbrr rsente nt ol funds J g Pilferaee FUNDING: Please probe tbr a Delays in endorsernent of letters of aqreerrrenr why?a a At rvlurt Icr 1'l ,1111J 1yl1v') i , r lr rr rr I r, I [\lr iil] ), rtl,, | ,,r) I,r \. r c n !. L' Inadequacl, of' prcvlous budget e Fund adrninistrario,: dela)/s in submission of financial reporrs, disbursement and retirernent procedures, delays in feedback lronr APoC headquarters on fi,ancial reports 4 Please describe the prograurrne's plans for irnproving susrainability -5 \\/hich other health activitres do the Oncho supervisors cornbine with their Oncho Control Progranrrne acriv ities? \\/ould you please explain rhe programme s record keeping procedures EXAI\,1lNE THE FOLLO\\/ING RECORDS Surlrnary sheets I Available 2. Nor available EXTRACT INFORI\'IA1'ION ON THE FOLLO\\/ING (relare to the level ol'operarion e.g srate arrd LGA) Total Populatron b Nurnber of villales ur the area Nunrber of vtllaces rvirlr summary forrns_ d Nuurber of vill.rees rrcarcd e Nuntber rvrth scvcre side effects d 6 d 1 d i Evidence ol r e p.r r updare (check annual rerurns afrer distribution) l. Updared 2. Not updared SECTION B: i\{OH POLIC\' I\1,'\KERS ( Permanent Secretary/Direcror Disease Corrrrol) 8a Do -you have a natlottal Plalt lor the control of onchocercrasis'( Probe for tlre rnrporrance attac5ed to t)r'rclrnce t'c rasis control 8t) \\rlrat kind of supporl do rou provide for Oncho Control activities (PROBE FOR FINANCIAL INPUT) 9 Ilorv do you perceive tlre C'Dl-l strategy of APOC ( Probe for personal opinron arrcl offlcral polrcy o1CDTI) I al0 Is rhe Orrcho Progranrnrc rrtrerrared lnto the healrh s_r,srent ( probe for acrivrrrcs rvlriclr irrdrcare irttcrration and ownershrp/ 1>1..,,,. for sustainabiliry \i,: lrltriln! Instrunttrtl\ K.rIrp.rlr \lJ\ l,),)r) 2 a SI:CTION C: \\/IIO COUNTRY REPRESENTATI\/E ll.Wlrat is 1'ottr l)erception about thc APOC srraregy for ivernrecrin disrriburiorr( ProLrc lbr lcasibility oI the CDTI ap1;roach in solving orher healrh proble rns) 12. What is tltc relatiortsltip betwecn tlrc \\/liO of'flcc and rhe Narional Onchocerciasis l'ask Irorce (NOTIT) u'itlt rcspcct to CDI-l irnplcrnentation. (l)roirc for issues rclatin!, to traltsl-cr ol lunds, supporr ro NO1p arrd rnortitorrnu) a i I rt. l..rIr;r.rl.r \ I.r\ | r)r,'{