Technical report of CDTI activities in Enugu/Anambra/Ebonyi project: September 1998-February 1999 submitted to African Programme for Onchocerciasis (APOC)

I- TECHNICAL REPORT OF CDTI ACTIVITIES IN E IIU GU/ANAMBRA/I, B ONI-YI PRO JE C T SEPTEMBER 1998 - FEBRUARY 1999 SUBMITTED TO AFRICAN PROGRAMME FOR ONCHOCERCIASIS (APoC) MAY, 1999 1EXECUTIVE SUMMARY The implementation of CDTI in Enugrr/Anambra/Ebonyi States Project commenced in September, 1998, even though APOC money came in January, 1999. Before this date, Global 2000 was the NGDO providing the necessary fund for all the activities. The project has an estimated population of about 7.5 million persons. CDTI implementation started with macro-level advocacy to the states and local goveflrment areas. The objective was to sufficiently educate and mobilize groups to provide the financial, logistic and human resources for CDTI activities. The project undertook a total of 52 advocacy visits to 24 LGAs, conducting 144 trainings at three levels namely: State, LGA, and community. A total of 276 TOTs, 120 DHS, 120 ADHS and 5,285 CDDs were trained on CDTI. A total of 1,767 villages were mobilized and provided with health education. Twenty-one [21] Ministry of health staff and one [1] NGDO staff were involved in the mobilization exercise at LGA level. Treatment has been concluded in only 1,398 villages out of the total 1,767 villages that collected drug. Active treatment was the case in all the villages and a total of 660,039 eligible persons were treated out of a total [census] population of 990,056 giving a treatment coverage of 66.67%o ard costpertreatment of 0.24 US $. From the progress made so far, there are indications that CDTI approach will be successful and sustainable. Finally, the project is being saddled with some immediate attention and these include, provision vehicles, more motorcycles and bicycles. J problems which need of new field project .TYPICAI, BREITDIN(; Sll'l! I0R Ili,ACKEi,Y IN NKANiI LGA. I AR0Vl, AIIROh'S S1l0l,r:. I)II IiANK Ii ICIIAIiI)S DR ]i. S. illTlll IIRII 't'tll, 1'lir\L)ll'l()N',1, Iitll,l,llS ()j; O7.hl,l,A (l()l'll'ltlNl'l'\ PROJECT ADTIINl S'I'R.\]'()R IIOR L]N/AN/]iI]ONYI .STAl'Ii. SP0 ENTJGU S'L\Iii SPO ANA}{BRA STAl'I, SPO IiBONY I STA'tli SO(l'l' lljl){i-llrll,-l l,'()ii ).r Cll/'\\/\.il ltllr\/l,tiOIi'i I l, {','r'l l lt ,{, t*'f t.iY- .\ ms , !*A,' 3.a *'liit,'i.1":'"{ '{,trilI;*'',,r.3q',1r:lir, 1;,ll'.:iiil' r.:""1';'.i, l: +v"'i lpy t.\'t.rl ( 4} I):; -.d,>; I I- / ir."'. J.rl SECTION I BACKGROT]ND INTRODUCTION: Enugu, Anambra and Ebonyi States are among the seven South Eastern States of Nigeria benefiting from the Lions Clubs/Global 2000 River Blindness Programme. The programme started in 1995 with two States, Enugu and Anambra, before Ebonyi State was created later in1997. The project area is located between 5o43' and 8'30'N with a combined populationof 7 .5 million inhabitants [Enugu 2.5 million, Ebonyi 1.8 million and Anambra 3.2 millionl. It has a total of 51 LGAs out of which, 38 are hyper/meso endemic for onchocerciasis, [see map 2]. This giant project received APOC funds in January 1999 and had long commenced operation with three project officers each directing the operations in each state. ti) The total number of communities in the hyper and districts/LGAs The total number of villages in the hyper and meso-endemic [Enugu : 1,331, Ebonyi : 1,160 and Anambra : 1,0621. meso-endemic LGAs is 3,553 tii) How many villages were receiving ivermecfin before and how many are now included in APOC project? A1l the 3,553 villages have been receiving Mectizan before the introduction of the Community Directed Treatment with Ivermectin [CDTI] approach, and all are included in APOC project. COMBINED MAP SHO\A/II'.iC EIJHh,IICI"I.Y SlAI"US IN THE THREE STATES. N)Z b7 aw F lr1ZtrI \\J 5s trI -rWI11 azin ,4 l"*{ r:lr-Irl-_l I Tc Z-oZ. m 7\ TTI(n 'TiOrfin h-a r 5{iii} The number of times the communifies/villages in the Project area have received treatment Any other additional information will be helpful The project commenced in 1995 but all the villages did not start receiving Mectizan in the same year. While some villages are currently in their 5ft yetr, others are either on the 3'd or 4ft year of treatment [see map I]. {iv} If you ore using the term community or village, deftne what constitute the communily or village This will help the TCC reviewer understand the protile of the project ore& A village is a group of houses which forms the smallest unit of Local Government. With this, therefore, a group of villages makes up a community a! Administrative Structures in the Project Area: STATE COMMUNITY VILLAGEVILLAGE IIOUSEIIOLDS GOMMUNITY STRUCTURE lN EN UGU/ANAMBR/A/EBONYI STATES I $ \o VILLAGE HEALTH GOMMITTEE VILLAGE HEALTHVILI.AGE HEALTH , 'l couurree cus 7SECTION 2 The overall shategy for the control of onchocerciasis through chemotherapy revolve around the implementation of community-based sustainable programmes for the distribution of mectizan to all individuals either infected or at the risk of infection. Emphasis is therefore placed on establishing Ivermectin delivery programmes in which the primary responsibility of obtaining the required Mectizan, distributing it to the at-risk population, supervising the activities of the CDDs and keeping relevant records is that of the communities themselves. In addition, the communities are responsible for taking decisions on selection of CDDs, remuneration method of distribution, month[s] of treatment and remuneration of distributors, [see table 1,2,3 e q. Training of staffinvolved in CDTI implementation was conducted at three separate levels. These are: td The state level training for the SOCTs tiil LGA level training for LOCTs and District Health Supervisors [DHS] tiiil Community/Village level training for Community Directed Distributors [CDDs], Village Health Committees [VHCs], Assistant District Health Supervisors [ADHS] and local leaders. In other words, whereas the state and LGA level trainings are for TOTs, the community/village level ftainings are for CDDs and Assistant District Health Supervisors [ADHS]. In all the States, 12 SOCTs were trained [i.e. 4 SOCTs per state]. Table 5,6,7 & 8 show training of different levels of staff involved in CDTI implementation. TABLE l: IMPLEMENTATION OF CDTI (SEPTEMBER, 1998 - FEBRUARY, {999) IN ENUGU/ANAMBRA/EBONYI STATES' CDTI \ * ENUGU 687 687 687 687 299 687 353 \NAMBRA 492 492 492 492 257 492 274 EBONYI 588 588 588 588 273 588 195 EN/AN/EB. 1,767 1,767 1,767 1,767 829 1,767 822 Jr FIG. 1 1,900 1,600 1,400 U'u o JJ lr o ciz 1,200 1,000 800 600 400 200 0 ABCDE KEY: A,B,C,D,E,F,G, REFER To TABLE I tlz a TABLE 2: IMPLEMENTATION OF CDTI (SEPTEMBER, 1998 - FEBRUARY, 1999) IN ENUGU STATE FA * ANINRI 52 52 52 52 15 52 32 IGBO-EZE NORTH 39 39 39 39 12 39 18 AWGU 113 113 113 113 54 113 78 OJI RIVER 43 43 43 43 15 43 18 JDI 142 142 142 142 62 142 84 =ZEAGU 112 112 112 112 56 112 51 GBO-ETITI 99 99 99 99 49 99 43 NSUKKA 87 87 87 87 36 87 29 TOTAL 687 687 687 687 299 687 353 a ffit-"sf :i\ :' "l $i i ilii i::;S..:.l:.:::i...i;;.:..::: iLi{iri11$11!.$\tig-:i1p$,,;rl,ln}ii;,,,i$ FIG. 2 700 600 500 400 300 200 100 0 BCDEF KEY: A,B,G,D,E'F,G, REFER To TABLE 2 ENUGU STATE '1. h t TABLE 3: IMPLEMENTATION OF CDTI (SEPTEMBER, 1998 - FEBRUARY, {999) IN ANAMBRA STATE t4 r qGUATA 90 90 90 90 51 90 18 CRUMBA NORTH 35 35 35 35 20 35 35 NNEWI NORTH 36 36 36 36 18 36 10 IHIALA 24 24 24 24 19 24 23 EKVVUSIGO 26 26 26 26 16 26 8 IDEMILlNORTH 58 58 58 58 25 58 58 ANAMBRA EAST 5 5 5 5 5 5 3 CNITSHA NORTH 14 14 14 14 8 14 5 AYAMELUM 54 54 54 54 24 54 22 ORUMBA SOUTH 85 85 85 85 40 85 45 AWI(A SOUTH 65 65 65 65 31 65 47 TOTAL 492 492 492 492 257 492 274 ! I l!E] iNli .i.:i:::.:ii li&i\.!:,=.i::, $-tii,=.....,ii r) -1i.. i,: =i(l w ,il N{*;S*NN :..'i\\\\\\\t t, "!-:;::::::: i i[* ll.r:=-ii\i =i'.ffi N I --J I I --J ) FIG. 3 IMPLEMENTATION OF CDTI TSEPT. 1998 . FEB. 1999 tN ANAMBRA STATE (r, IJJ o JJ =lJ.o c,z 500 450 400 350 300 250 200 150 100 50 0 CDEF KEY: A,B,C,D,E,F,G, REFER TO TABLE 3 T6 _l "*] TABLE 4: IMPLEMENTATION OF CDTI (SEPTEMBER, {998 - FEBRUARY, 1999) IN EBONYI STATE t- I I I ,J - I I -.] I I -..| I i , _t o i3 it FIG. 4 rHpLEMENTATTON OF ClTt rsEpr. lqgs - FEB. lsest tN EBONYI STATE 600 500 €t\ TJ.J(5 J 5 [L U d5 400 300 200 100 0 S1 KEY: A,B,C,D,E,F,G, REFER TABLE 4 .l- .s 't IN CDTI IMPLEMENTATION TABLE 5: TRAINING OF THE DIFFERENT LEVELS OF STAFF INVOLVED 6.) * rt , t tr I yirt lrl t I:I: r-l I't:t:t I-l TABLE 6: TRAINING OF THE DIFFERENT LEVELS OF STAFF INVOLVED IN CDTI IMPLEMENTATION IN ENUGU STATE 9 Et tJti i $ffi ffi t1 ;1,,s r'1:$r: N.9, "ffi,, . i,;t-il.iin.on.;, rr i. rffi rp#ffit ;:iIr*#.qffi ffi #i,wi if.j"*I,F.qi{ii f,.{trryi-sj"iffi 'l:t'1ff Sffiii{.iffi 'ir,irirf ]rTffi l,itiil,-Y{ \NINRI 6 11 6 10 247 GBOEZE NORTH 6 11 6 10 186 AWGU 6 11 6 10 84 CJI RIVER 6 11 o 10 207 UDI 6 11 6 10 473 :ZEAGU 6 11 6 10 394 IGBO-ETITI 6 11 6 10 359 NSUKI(A 6 11 6 10 192 IOTAL 48 8I3 48 80 2,142 tl f--) f-- r-! ' ! I r , ! F TABLE 7: TRAINING OF THE DIFFERENT LEVELS OF STAFF INVOLVED IN CDTI IMPLEMENTATION IN ANAMBRA STATE : Fj--I ,., ._".',1t,'il.,,l,li: ,. :" r .e . ir;;.. '.:. '."LGA ' "', ,, , ,;,,.,,.1f,,' :,,."11'uI ,-.. f ,f l{ 1'. "' ,, i-. .l ,,,'r]",1'., ||; ,i:i, wi .;, NO. OF CDDS TRAINED D E AGUATA 6 11 6 10 198 ORUMBA NORTH 6 11 6 10 234 NNEWI NORTH 6 11 6 10 94 IHIALA 6 11 6 10 96 EKWUSIGO o 11 6 10 90 EDEMILI NORTH 6 11 6 10 258 ANAMBRA EAST 6 11 6 10 46 ONITSHA NORTH 6 11 6 10 28 AYAMELUM o 11 6 10 126 ORUMBA SOUTH 6 11 6 10 162 AWKA SOUTH 6 11 o 10 148 TOTAL 66 121 66 110 LJ,499.,..* li ! r ! I r. , , I i"lli{,.i1.,-La' I rr ' TABLE 8: TRAINING OF THE DIFFERENT LEVELS OF STAFF INVOLVED rN cDTt |MPLEMENTAT|ON tN EBONyt STATE , # ltt I a, r. t- ACT|VITTES (SEPT. 1998 - FEB. 1999) ENUGU SOCT 4 4 lO0olo LOCT/PHC COORDINATOR 102 48 47.5o/o DHS 85 40 47.5o/o ADHS 85 40 47.5o/o CDDS 2,154 2,142 99.4% SUB.TOTAL 2,430 2,274 93.6% ANAMBRA SOCT 4 4 100 LOCT/PHC COORDINATOR 114 66 57.9o/o DHS 95 55 57.9o/o ADHS 95 55 57.9o/o CDDS 2,286 1,480 64.7olo SUts-TOTAL 2,594 t,660 64o/o EBONYI SOCT 4 4 100 LOCT/PHC COORDINATOR 72 30 41.660./0 DHS 60 25 41.660,10 ADHS 60 25 41.66% CDDS 2,667 1,663 62.35o/o SUB.TOTAL 2.863 1,742 60.85% EN/ANIEB SOCT 12 12 100 LOCT 288 1M 50% DHS 240 120 50o/o ADHS 240 120 50o/o CDDS 7,1A7 5,285 74.4o/o t1 ts ;iiai=*ffi i,w ffi* s ta a It! II r! ,tr II 'r L t 't I I I i ISEPT. 1998 - FEB. 1999I FIG. 9 0 UJ z. a E,F J UIzz o tJ, ui L lr Gz 8,000 7,000 6,000 5,000 4,000 3,000 BTarget EActual tr% Achievement 2,000 1,000 0 Enugu Anambra Ebonyi En/Ab/Eb. PRO..'ECT ?. ,., !8 ti) Projecfs annual training objective ond the percentage of the objective achieved The project's annual training objective is 7,887 persons. A total of 5,681persons representing 72.0% of the targeted persons were actually trained. Table 9 shows the detailed breakdown of the training activities of each of the three states that make up the project. Similarly, the cumulative training targets and percentage achievement is also included in the table. The low level of percentage coverage as compared with the project's annual training objective is as a result of series of industrial dispute between labour and government in respect of minimum wage which in some states lasted for months. The industrial dispute disrupted trainings, especially at the LGA, district and village levels. It is hoped that with the strike action now over, there will be improved coverage of the project's training targets. {ii} Types of materials develaped and used for training health staff and CDDs. The project also used the APOC approved CDTI training materials such as: 1. CDD training guide 2. Flip chart 3. CDTI Video tape 4. Informationbrochure In addition, the project in collaborafion with NOTF, developed and used the following materials: 1, rr- [a] Post and Pre-test: These are used to assess the effectiveness of communication of trainers on the course of training, and also an instrument for evaluating the knowledge of the trainees before and after training sessions. tb] Pocket Treatment Guide: This is used as a reference material for LOCTs, DHS, ADHS and CDDs with a view to understanding: til What onchocerciasis is Iiil Their roles in oncho control tiiil The CDTI concept [iv] The difference between (iii) above and the system formerly in place [v] Communitymobilizationstrategies [vi] The new 3mg Mectizan formulation [viil Treatment techniques and management of side reactions [c] Samples of measuring stick and village treatment registers. tdl Hand bills in local languages [e] MIS forms tfl Blind walk goggles (to illustrate the challenges to being blind) {iii} The performance of the CDDs, does the pedormance of the CDDs indicate they received and underctood important information about their roles? At the start of the trainia5, d pre test was administered to assess the level of understanding of the CDDs. After the trainiilg, o post test was administered to assess the level of assimilation of the training content. The general observation showed a significant level of improvement. 1, rd l0 The CDDs performance on the field was also encouraging, as there were few errors in: a Health Education messages 0 Dosing t Record keeping t Eligibility criteria o Monitoring and management of side effects o Mectizan inventory control In the light of the above, it is clear that the CDDs received and understood important information about their roles and responsibilities. The CDDs chosen in most communities appreciated the work required of them and were quite zealous in carrying out their tasks. 2.I. MOBILIZATION AND EDUCATION: Successful mobilization and health education are crucial activities, which create awareness of the problem of onchocerciasis at the State, LGA, community and village levels as well as solicit support and patronage of the entire citizens towards effective implementation of the control programme. The ultimate aim is to have a sustained high demand for Mectizan tablets to prevent blindness due to onchocerciasis. Advocacy visits were made to top state and LGA government of;ficials to acquaint them with the problem of onchocerciasis and the need for the government at all levels to support the programme in various til 11 ways. Communities were mobilized with the help of District Health Supervisors and their assistants, the CDDs and members of VHCs. The formal and informal avenues were used to convey appropriate health education messages. Unfortunately, state participation has not been impressive. High level advocacy visit to MOH management (Commissioner, Director General, Director PHC etc.) is required to educate the States on their role in the implementation of CDTI. Some local govemment areas have been quite responsive and most have principally agreed to support the programme and release funds for the project. Provide information on the use of media and/or othq locul systems to dis s eminate info rmation? Information is said to be effectively disseminated when the message relayed or fransmitted has been coded [heard, accepted] and the receptor [villager] elicits a positive response. The channels used for disseminating information in the project varied from community to community and village to village. The methods used were: Electronic media: til Radio: Radio jingles, radio discussions/interviews/broadcast were prepared and aired constantly, especially, during the Onchocerciasis Week observed by the project from lzn - 22"d February 1999. Radio stations in all the states and the National radio stations were involved in the mobilization activities. During this period, radio messages were relayed to the public as news inserts or during important prograilrmes. ta) t2 tiil Television: The television was also used, but coverage was limited by lack of electricity in most of the communities and villages. tbl Print Media: Newspapers and magazines were used for mobilization. [cl Local Systems: These are the fraditional methods applicable to different communities and villages and relate to varied traditions. The local methods include: {i} Town criers: These are persons chosen by the community for the purpose of moving around the villages or market squares with metal or wooden gongs or drums disseminating information to the people. The village or community through their coflrmon purse usually compensates them. They move around the markets during the day, but around the villages at dawn or at night. {ii} Churches: The main religion of the inhabitants of the project area is Christianity. There are churches in all the towns and are built through coflrmunal contribution. They are usually centrally located and important messages disseminated through the churches reach every household. {iii} Schools: Health Education messages are provided through schools during health lessons or drama. Education is one of the valuable assets recognized in the project area. {i"} Village/Community Heads/Ezes - The head of the village or community, convenes meetings of his cabinet chiefs or other members of the community atregtlar intervals. Health Education messages are being passed at these meetings. 13 {v} Village SociaUGroup Meetings:- The project team used social meetings such as Youth Development Associations to disseminate Health Education messages. Tables 10,11,12,13, show mobilization and Health education tnget communities/villages in the project area. {ii} Are you satisftedwith the results of the mobilizafion efforts? The use of media and other local system of disseminating information were very effective and gave satisfactory results from the target villages. The effectiveness is reflected by the increased commitment of the community leaders and distributors and the high degree of involvement of the communities and their willingness to commit available local resources to the distribution process [see pix I, II, III. {iii} Did target communitieshillages respondfavourably? The target villages are responding very well to the CDTI approach as a result of mobilization, all the villages have: o Selected one or more CDDs in each village o Paid CDDs transport fare to collect Mectizan from the district centres o Made cash or in-kind compensations to CDDs 0 Plans to conduct mop-up freatment for absentees t Formed Village Health Committees Some villages also developed workplans for fraining and Mecfizan distribution. {i"} Suggest ways to improve mohilization of target communities. TABLE 10: MOBILIZATION AND HEALTH EDUCATION OF TARGET GOMMUNITIES/ VILLAGES IN ENUGU/ANAMBRA/EBONYI STATES IDP r1 I $ -) ,) I' FIGl O M9BTLTZATTON ANp HEALTH EDUCAT|ON OF TARGET COMMUNIflESMLLAGES IN EN/AN/EB. STATES' IDP N t ffi IJE(8 Itt tvt 0 7, 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 BCD KEY: A,B,C,D,E, REFER TO TABLE 1O t3z TABLE 11: MOBILIZATION AND HEALTH EDUCATION OF TARGET COMMUNITIES IN ENUGU STATE "r, crl ffi tffi."ffi iffi4ffi tiffi Bffi_ffi iISt i,+r-Ltiigi. i"..rr,:: .*i:-,,:;'riai?i!t$aY#,Lii:,ril ,ffi, ANINRI 52 52 2 7 1 IGBO.EZE NORTH 39 ?o 2 7 1 AWGU 113 113 2 7 1 OJI RIVER 43 43 2 7 1 UDI 142 142 3 7 1 EZEAGU 112 112 3 7 1 IGBO-ETITI 99 99 2 7 1 NSUKKA 87 87 2 7 1 TOTAL 687 687 18 7 1 I a FtG. 11 MOBILIZATION AND HEALTH EDUCATION OF TARGET CoMMUNTTIES tN ENUGU STATE o 500 UJ NJ Eg 4oo (t, IJJ o J 300 II o oz 20n BCD KE\'': A,B,fi,n,ffi, REFfiR TAHLH f '! 00 13.r, TABLE 12: MOBILIZATION AND HEALTH EDUCATTON OF TARGET COMMUNITIES IN.I ANAMBRA STlt.TT l11 er) :t"6*"r!':ffir! _;. - ;_ ; -__./,-;.,.,:i4:k,1i "i t': .rl r' -' :.':ii::.;:l.li .t.l , j:-,r,;;ii ..,'l 1 NO. OF MlN' OF HEALTH SfhFF NO. OF N6DO 8TAFF rWolveo IN MOBILIZAIION -'', Bl G 'ii D E IAGUATA I JORUMBA NORTH lr'r'rewr NoRTH l,*,o* EKWUSIGO IDEMILI NORTH ANAMBRA EAST ONITSHA NORTH AYAMELUM ORUMBA SOUTH AWKA SOUTH TOTAL 90 90 2 7 1 35 35 2 7 1 36 36 2 7 1 24 24 2 7 1 26 26 2 7 1 58 58 2 7 1 5 5 2 7 1 14 14 2 7 1 54 54 3 7 1 85 85 2 7 1 65 65 3 7 1 492 492 24 7 1 & FtG. 12 tli t\.; L ei ! E 350 300 250 200 150- trCD HEY; &,S,C,[],E, F1EFEER TO TABLE .12 TA 13, f TABLE {3: MOBILIZATION AND HEALTH EDUCATION OF TARGET COMMUNITIES IN EBONYI STATE t A 'L- , ,,.i1..;=,1i:] t,.:l' :;l,l#'1 - -,,1 ,, .,:l...rr;..- '" .' ' r1 ;fil; ".-. -.,, -,.,.r,. ,,-,,i,j_ ,l i,;''. NO. OF i:--2,').,, ;- '-:.-i, l.1.nf. NO. OF MIN. OF HEALTH 3,.?r:-..: , ,"ST-,AFf. . *i,ilr, 'lNV9trIED"' :''i ,lN ,-'11 MOBILEAT|oN NO. OF NGDO STAFF INv9LVED -,.1',,'1,,-lN ftrqFrLrzATloN -'., ,,'i'rL,lB; lQ "1,',, D E ISHIELU 111 111 2 7 1 VO 51 51 2 7 1 tzzt 191 191 2 7 1 IKWO 139 139 2 7 1 OHAOZARA 96 96 2 7 1 TOTAL 588 588 10 7 1 l(rl . ,.- -" : 'll) NO. OF , ADVOCACY.' ,J.,t,l';.t'1 , AND HEALTH *! * 4oo J 300 "\ 200 BCD iri,*l.ii.ii,&. HflFf;*& T# 'i.e"\,#i_[ 1:i t) I t4 Ways to Improve Mobilization of Target Communities include: {a} Increased logistic support (particularly motorcycles) for LGA staff participating in CDTI implementation. tb) Provision of bicycles for health centre staff involved in the CDTI implementation to enable them cover the villages more effectively. {c} Use of mobile public address system for better outreach of the population. I'IX I CROSS SEC'|ION OII PAI(TICIPANTS IN AN ORIENTATION MEEI-ING ON CD'TI FOI( WOMEN LI]ADERS FROM FIVE COMMUNITIES OF ONICI.IA LGA OF EI]ONYI ST'A]-E ORGAN IZEDI]Y ONICHA WOMEN DEVELOPKMTIN.T ASSOCIATION. L. -r F,1 :i, 44.,1 .f"*i FJ >.1 :I'IX 2 A CROSS SECI'ION OtI I'AI{-IICIPAN'TS IN A FUNt) ITAISING CEt{t,MONy I.OI{ StJI,pOR't OI;CDTI INt OLO COMMUNTTY, EZ[TAGU LAG. "n{*---- e mL ='q f": v'- ;:""*{lt 'fr-+z- *o ,*,f,$; 4 ll'r, L \l,lx.l COMML]NI'fY AND Ot'INION I,EADERS I'TIESIDING IN A IrtlND I{AISIN(i CL.I{EMONY IrOIt SLJppOR'f O}I CDTI IN OI,0 COMMUNI'I'Y n \ tj \ L' llr.B II #:;t rt\,, i li I i 15 SECTION 3: ACHIEvEMENTS: The project total [census] population is 990,056 persons. The number of persons treated is 660,039. This gives a treatment coverage rate of 66.67Yo. Out of the total population, 815,241persons were eligible. Based on that the coverage rate (eligible) is 81%. {i"} Describe brietly whether the proportion of village/community members who were absent during treatment is higher than upected The proportion of absentees and refusals is lower than expected in all the project areas. This situation is attributed to the aggressive mobilization of the communities, perceived benefits of ivermectin and the high demand for it in all the endemic villages. In addition, the ability of the communities to recognize problems with distribution methods and modifu the methods accordingly contributed to low absenteeism recorded so far. {"} State the most common reasonsfor absenteeism For those that are absent during treatment, the most common reason given by them is "farmin g activity" which keeps them away from the community during distribution period. t"i) Suggest what actions need to be taken by the project to reach ahsentees and defuukers during the nut treatment and if any constraints might prevent their inclusion. There is need for the villages to adjust the distribution period in line with their tradition to avoid clashing with the farming season. Where this is not -16 possible, alrangement should be made to freat absentees/defaulters in the farm settlements. There are also some people who refuse the drugs for some reasons. For this group of persons, continuous education and mobilization is suggested. "i"*t$*fr".[:: i.{: l},#h'{$ffiVHi1#Ufldg^$ [SU[:,'r"lrfuifJE&t t13$]E _ I Ls.*!ru*it r i**# lN ENUGUiANAMBRA/EBONY[ STATE$r, fi E:3[] s \(, STATE NO. OF TARGETED - VILLAGES TREATED NUMBER OF ELIGIBLE PERSONS, TREATED COST PER PERSON TREATED us$ NUMBER OF '- VILLAGES WHHRE cori i$ a'r ' HEALTH wodren G;-,t.' ----'. . r-a=iffi; ::::: NUMBER OF DISTRIBUTORS SUPERVISED BY HEALTH WONKFTT NUMBER OF TREATED VILL. \GES WTH SUM MARY FORMS O. OF VILLAGES PAYTNGI coos i t rN cAsH I oR KIND tr B c D E F G ENUGU 549 306,694 0.17 NIL 2,142 549 I 353 ANAMBRA 432 223,776 0.32 NIL 1,490 432 274 EBqNYI I I -JgIAL-] 417 I"t" --LqgL:l 1?g,qge I ;-;"t 0.25 fi.24 NIL I ;,; I 1,663:--.---..---.1*;L-.r-:;:"E ^., ffi i_;,'i r +,_'. dt il 417; ,3Sf,j i t'195 ;, - _-*,__-___-___Jl II ll .i"n'-, iti sll *- ll a\l TABLE 15: ACHIEVEMENT [SEPTEMBER 1998 'FEBRUARY 1999] {f'l HhXt}G[J $TATffi IDP J Y .;#^-r};*lx ;^,-i,ES ':i. ,;litifil $i,,o[.i;r't;. iG;ETHqilAilEf..' ,.- NUMBER OF DISTRIBUTORS SUPERVISED "r' BY HEALTH WORKERS NUMEEF OF TREATED ILLAGE$ wlTT " SUiii[tARY'* FORMS NO. OF. VILLAGES PAYING CDDS ' 'tN CASI{. OR KIND .,A B'" c D E F G ii ANINRI 38 36,588 0.18 NIL 247 38 32 IGBO-EZE NORTH 28 18,148 0.36 NIL 186 28 18 AWGU 11 2,768 2.39 NIL 84 11 78 OJI RIVER 32 35,272 0.19 NIL 207 32 18 DI 142 58,735 0.11 NIL 473 142 84 EZEAGU 112 65,187 0.1 NIL 394 112 51 GBO-ETITI 99 49,879 0.1 3 NIL 359 99 43 iry!!5!q 87 40,122 0.17 NIL 192 ..,...=.=. 87 29 TOTAL $l , i.l:I ;i{}[-l t;li]'] ..1. It ,fREhieD I 'T;i#86"".I iEA.fH Wd"CKER TABLE 16: TREATMENT ISEPTEMBER {998 - FEBRUARY {999J IN ANAN'IBRA STATH IDP rrl a = NUMBER OF ,,: VILLAGES WHERE aoug*" ,, , HEALTH WORKER : NUMBEROF ,'' DI$TRIBUTORS . BY :.HEALTH WORKER$ TRFATED . VILLAGES WTH SUMMARY , FOil[/IS. NO, OF VILTAGE$ PAYING CDDS IN CASH OR KIND 1, r lrr i i,rr@,-r;r;r,r ,-"D,i.r*}\M{r&+.a,}ri a-.',4 "rrF,i.j1.r': G AGUATA 30 29660 0.03 NIL 198 30 18 ORUMBA NORTH 35 16,134 0.41 NIL 234 35 35 NNEWI NORTH 36 13,422 0.49 NIL 94 36 10 HIALA 24 13,013 0.51 NIL 96 24 23 r; EKWUSIGO 26 18,249 0.36 NIL 90 26 8 IDEMILI NORTH 58 11,997 0.55 NIL 258 58 58 ANAMBRA EAST 5 1,759 3.7 5 NIL 46 5 3 ONITSHA NORTH 14 14,396 0.46 NIL 28 14 5 AYAMELUM 54 31795 0.21 NIL 126 54 22 ORUMBA SOUTH 85 51 360 0.13 NIL 162 85 45i WKA SOUTH 65 22012 0.30 NIL 148 65 47 l il fOTAL 432 223,776 032 r.ilL .'i'.;'1 15 t:$!.Ji-rdi.E ir. l-i,l;! *\ TABLE 17: ACHIEVEMENTS ISEPTEMBER 1998 . FEBRUARY 1999 IN EBONYI STATE IDP { \o =::::*.:L_a--- .'_=e:---- _ a::-=-la- --- _- :: i.:- - r.,- :-.1 GOST PER PERSON TREATED ..-;r$F,$' - NUI\/IBER OF- VILLAGES UgHEf,E CDD Bh ' HEALTH WONKER '--*ltUMB*Eh-bF "'- DISTRIBUTORS SUPERVISED BY HEALTH WORKERS --rtuixbt-*R"ffi' TREATED VILLAGES WITH SUMMARY FORMS ' "'"N6:bf'"'' VILLAGES PAYTNG GDDS IN CASH OR KINDA B G D E F A(, tzzt 20 15,573 0.42 NIL 553 20 20 ISHIELU 111 36,251 0.18 NIL 242 111 56 IVO 51 3,102 2.13 NIL 110 51 28 KWO 139 39461 0.17 NIL 430 139 66 OHAOZARA 96 35182 0.19 NIL 328 96 25 TOTAL 417 129,569 4.25 Ntt- '1r17 1 {iij3 TABLE 18: TREATMENT ISEPTEMBER 1998 TO FEBRUARY 19991 IN ENUGU/ANAMBRA/EBONYI STATES CDTI 1 48,80 1 la v Ei-;-., -,Jrtr']-:. i, '-, '- ll)'j : =NUGU 549 439.671 338.540 306.694 69.760/o ANAMBRA 432 348.830 327,900 223.776 64.15o/o EBONYI 417 201,555 129.569 64.28o/o H\rfI\r[l{:] 1.398 990.056 815.241 660.039 66.670/o FtG. 18 :'tu&Iffi -: rES. t.Sgqliii- f; il J$tiihEt STATES'IDP o TU IIJ &. wz Q tu tJ- oz 1,000,000 900,000 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 16 ,€ KE r': :,.t,l*l.D,8, :qEFEfq T0 Tliil-i iA TABLE 19: TREATMENT ISEPTEMBER 1998 TO FEBRUARY 19991 IN ENUGU STATE CDTI t Y ANINRI 38 52,401 38,491 36,588 69.82o/o IGBO-EZE NORTH 28 26,410 19.577 18,148 68.72o/o AWGU 11 3,467 2,985 2,768 79.84o/o )JI RIVER 32 51,796 37,543 35,272 68.1 0% UDI 142 79,182 63,1 01 58,735 74.18o/o EZEAGU 112 95,287 73,287 65,187 68.41o/o GBO-ETIT! 99 70,438 56,534 49,874 70.81o/o NSUKKA 87 60,690 47,022 40j22 66.11o/o TOTAL 549 439,671 338,540 306,694 69.760/o E;: . ')s't tt i:1 FlG. 1S TREATUENT rSEpT. 1998 - FEB. 1999t lN ENUGU gt&rf; 450000 400000 350000 300000 250000 200000 1 50000 1 00000 50000 0 ABCDE KE"': 4,8.C i),E, REFER TO TABt_E 't9 I I I td, I TABLE 20: TREATMENT ISEPTEMBER 1998 TO FEBRUARY 19991 IN ANAMBRA STATE CDTI st \ AGUATA 30 48,277 42,871 29,660 61.44o/o CRUMBA NORTH 35 21,099 19,866 16,134 76.47o/o NNEWINORLTH 36 28,512 28,395 13,422 47.07o/o IHIALA 24 16,451 15,570 1 3,013 79.10o/o EI(^/USlGO 26 24,889 22,786 18,248 73.32o/o DEMILINORTH 58 23,778 23,711 11,987 50.41o/o ANAMBRA EAST 5 2,335 2,157 1,759 75.33o/o ONITSHA NORTH 14 21,165 1 8,1 98 14,386 67.97o/o AYAMELUM 54 51,680 48,738 31,795 61.52o/o CRUMBA SOUTH 85 78,250 73,805 51,360 65.640/o AWKA SOUTH 65 32,394 31,803 22,012 67.95o/o TOTAL 432 348,830 327,900 223,776 64.15o/o o UIF IIJ E, U'z o U' E, UJ .L ll. o oz fiii:; :iii TREATMENT ISEPT. 1998 - FEB. 1999I IN ANAMBRA STATE IDP t6,3 200000 1 50000 i'{,.:'l A,B,{),},f, RFF*H'f'} TABI-E 7{) TABLE 21: TREATMENT ISEPTEMBER 1998 TO FEBRUARY 1999] IN EBONYI STATE CDTI o \o tTzt 20 22,357 15,846 15,573 69.66% ISHIELU 111 52,624 37,009 36,251 68.89% tvo 51 6.028 5,147 3,102 51.460/o [( /o 139 68,036 53,786 39,461 58.00% OHAOZARA 96 52,510 37,013 35,182 67.00o/o TOTAL 417 201,555 148,801 129.569 64.28o/o ,. ,-s t FlG.21 TREAI\{_ENT tSEPf, 1ge-8 FEB. 1e9?UN LBONYI STATE 250000 201;555 129,569 64.28o/o 16, tt , a 200000 1 00000 aa- 17 SECTION 4 STRENGTHS AND WEAKNESSES OF CDTI IMPLEMENTATION: {i} How did CDDs chosen by the communities perform their tasks? From the progress made so far, there are indications that the CDTI approach is bound to be more successful and sustainable than any other distribution strategy applied before. Indications of this success can be seen in the way CDDs carried out their tasks in these areas during the period under review: a) Record keeping - Less number of errors are now being recorded than before. b) Correct dosing - It is obvious that even with the change from 6mg to 3 mg tablets, CDDs have adjusted to the new dosing. c) Exclusion criteria - From our experience, CDDs in the project have demonstrated clear understanding of who qualifies to be treated or not. d) Monitoring and management of side effects - A majority of CDDs have also demonsfrated competence in this regard. e) Health Education Most CDDs gave correct Health Education messages to the people. {ii} Willingness or not of communities to participate in CDTI process - to collect the drug and to take charge of dktribution and i* supervision. There is increased willingness and involvement of the communities/villages to commit available local resources to the CDTI process. The communities happily plan and collect their drugs. The increase in the number of CDDs 18 has reduced the area and population covered by one person. The use of more CDDs definitely accelerates the time of distribution and coverage is enhanced. However, there are complaints about increased burden of compensation on the entire community as a result of increase in the number of CDDs involved in the process. However, there is already growing rivalry and leadership problem among the multiple CDDs now being used per village. In terms of Mectizan management, CDTI strategy provides for appropriate and accurate Mectizan inventory down to the household level and the communities feel more sense of fulfillment as they now participate more actively in the planning and execution of the distribution process. They now determine the quantity of their own drugs and collect them by themselves. They also determine the method of distribution. However, there is increased distortion of data, because they now have to pass through multiple hands for verification. There were no difficulties in sending reports/records back to the ivermectin collection points since the points are closer to the CDDs. The communities are happy to take custody of their drugs, but the safety of the Medicine cannot be assured in times of community clashes. Although supervision is done by the health staff, the village health committees assist in this component since the CDTI approach provides participatory opportunity to all segments involved in programme implementation. Monitoring of village registers are .unong the tasks performed by the VHCs. a L9 {iii} Describe the level of involvement of the regionaUstate and district/LGA governments in the activifies including involvement of Sectors outside health in facilitating distribution U any level of govetnment provided funds factual cashJ and/or materiak towards Implementation of CDTI. It is important to state so and how much. Mobilization of states, LGAs and benefiting villages for acceptance, ownership and involvement in onchocerciasis control has been an integral part of the project's routine activities and has yielded useful fruits. The States, LGAs and villages have contributed a total of N816,170. Details of the breakdown are in table 23. The states and Local Governments apart from approving and releasing fund for CDTI activities, also release their personnel whom they pay salaries and other benefits. Similarly, benefiting communities nominate their indigenes as CDDs and also provide funds for their transportation and stipends for distribution activities. Also, other community-based NGDOs like the Sudan United Mission tStIMl of the Netherlands and local radio stations assist at state level to support CDTI in haining, community mobili zation and monitoring of distribution activities. What do you consider the maior achievements otthe proiect Treatment: The project fieated 660,039 persons within the period under review. Training: During the period 120 DHS ,120 ADHS were frained. In the same period, 5,285 CDDs and276 TOT were also trained to lay a sfiong foundation for CDTI take offin the project. Mobilization: 1,767 villages were mobilized during the period covered by this report. {i"} {1} {ii} {iii} Qestron; lf any level of govemment provided funds [actual cash] and or materials towads implementation of CDTI it is importantto state so and how much. TABLE 23 LEVEL OF FINANCIAL INVOLVEMENT OF STATES, LGAS, BENEFITING VILLAGES AND OTHERS" *STATE; TOTAL AMOUNT RELEASED FOR ONCHO D AY CELEBRATION IN116.750 N286,170 N816,170 I , ..1 '- 20 .' {i"} All communities also provided notebooks for their CDDs and took care of transportation for collection of Mectizantablets. {"} Increased awareness about Oncho and its fieatment was achieved. {vi} Increased level of participation of host villages in CDTI. {"ii} Decentralization of the issuance of Mectizan tablets from LGA headquarters to the district. {"} The constraints and the challenges for the netct treatment cycle. {a} Villages have added responsibilities by involving more than one CDD and the burden of compensation is increased. {b} With more than one CDD, there is the tendency for contention for leadership among the CDDs, resulting in negative consequences for the work. {c} Frequent changes in government leadership, requiring more advocacy visits. {"r} Clearly state what types of help you need from: [aJ the government [h] APOC Management [cJ other parfies to be able to improve the CDTI process next yean A From State Government: ti) Non-diversion of project vehicles and equipment should be strictly enforced. {ii} States should demonstrate commitment to CDTI by releasing counterpart funds on time. {iii} Advocacy visits to the LGAs are required. {iv} State Government should solicit for support from elecfronic and print media for enlightenment on Oncho activities. 2t {"} They should restrict frequent and disruptive transfers of Oncho personnel at LGA level. B From Local Government Area {i} Exclusive use of project motorcycles should be enforced. {ii} LGAs should be committed to CDTI by timely release of budgeted funds. {iii} Advocacy visits to traditional rulers should be embarked upon. C. From APOC Management: {i} APOC management should release its counterpart funds on time to the project. {ii} Release of project annual funds in two installments will be appreciated. {iii} Three new vehicles will be required to run the project. This is because the vehicles earlier provided by Lions Club International are too old and therefore, breakdown very frequently. {i"} 120 ADHS will require a bicycle each for effective supervision in their respective districts. {"} For effective supervision, motorcycles will be needed in 51 LGAs covered by the CDTI project. D. Other Parties: ti) Advocacy visits by the Federal Government to the States will be necessary. I _l 22 {ii} Compensation for CDDs by the communities is a major concern. We therefore, expect District and Village Health Committees to play a major role in this respect. -a Appendix 1 ORGANIZATIONAL SETUP Organizational Structure of Community-Directed Treatment with lvermectin ZZ,I Procurement of Mectizan Policy formulation Formulation of National Plan Of Action, Monitoring, Supervision and Evaluation NOCP Steering Committe Non-Govern mental organization (Country Representative - Global 2000) (Asst. National Director, Mectizan Manager) Collection of Mectizan from Lagos Supervision of State Project Officers and SOCTs Monitoring and Evaluation of lvermectin Distribution Advocacv and Mobilization of Policv Makers State Onchocerciasis Control Team(Sfafe Coordinator, SOCT, Director PHC, pHC Coordinator) Collection of Drug from NGDO Training of SOCTs, & Operation Research Supervision of SOCTs and LOCTs Monitoring & Evaluation of ivermectin Distribution Advocacy and Mobilization of Policy Makers, and Private Sector Local Government Onchocerciasis Control Team(Locrs Leader, Locr, PHC coord., Health superuisor, District supervisor) Colleciion of Drug from the State Advocacy and Mobilization of LGA policy Makers Training of CDDs, & Mobilization of endemic Communities Monitorino & Evaluation of ivermectin Distribution Community-Directed Treatment with lvermectin(Community Leader(s) Viliage Health Committee, Community members, CDDs) Collection of l/ectizan from LGA Headquarters lvermectin Distribution Supervision of Commurrity Distribution Activities Managemeni of Adverse Reaction and referral Funds for transport anrj distribution activities to CDDs NGDO L- NOCP fa' Appendix 2 - MAGRO FLOW.CHART FOR SUPERVISION AND MoNtToRING oF:GDTI AGTIVITIES ]N STATE PRoJEGT GRBP QUARTERLY MONITORING ZONE, STATE, LGAs, AND COMMUNITIES ,i NOCP I 'l I + GLOBAL 2OOO I I GRBP OFFICE, ENUGU I I Y STATE ONGHOCERgIASIS GONTROL TEAM (SOGTS) PROJECT OFFIGE MONITORING AND SUPERVISION OF STATE' LGAs AND GOMMUNITIES ROUTINE MONITORING AND SUPERVISION OF LGAs AND SPOT CHECK ON COMMUNITIES VHGS AND GOMMUNITY LEADERS AND GDDS I +I h l { : LOCAL GOVERNMENT ONCHO. CONTROL TEAMS (LocTs) ZL, U '\,r.. iAppendix3 ,, ,!tt \,.r \a . .-UFINANCIAL FLOW.CHART OF APOC FUNDS IN . ENUGU/ANAMBRA/EBONYI STATES NOCP.HEADQUARTERS NOTF ACGOU NT SIGNATORIES : -WR . NGDO CHAIRMAN NATIONAL ONCHO COORDINATOR GRBP OFFIGE ENUGU PROJECT AGCOUNT SIGNATORIES: . PROJECT ADMINISTRATOR . ZONAL COORDINATOR NOCP . STATE ONCHO COORDINATOR ENUGU/ANAMBRA/EBONYI STATE ONCHOGERGIASIS CONTROL UNIT EN UGU/ANAMBRA/EBONYI PROJ ECT SITES ACGOUNT SIGNATORIES: - DIRECTORS OF PHC/DC STATE PROJECT OFFICER ENUGU, ANAMBRA & EBONYI LL, Z Map'l COMBINED MAP SHOWINC TREATMENT ROU}IDS IN THE THREE STATES. 1 Appen dix 4 I z wfr lItur+\Nr - e ^d 8x e9=1 :LIUVU Lz-, q / .t r {'Y .//, ,oj' / -) a 4,, \,- i fti -rt I t rnZC n -1 Ijl EJ w 2 F{ \