AFRICAI{ PROG RAMINE FOR O]ICHOCERCIASIS CONTROT (APoc) COIIIfrII'NITY DIRECTED TREATI}IENT WITTI IUERIIIECTIN (cDn) zAftIFARA STATE, NIGERIA REPOE] OF THE INDEPENDEilT frIONITORI}IG TEATI SEPIEIT|BER 11 - OCTOBER i 1t 2OOO RECU I q il0l/. 2000 APOC/DIR Annreciation - The members of the monitoring team hereby acknowledge with gratitude the opportunity given to them by APOC to participate in the CDTI monitoring in Zamfara State Nigeria. The team is also grateful to all those who conffibuted to the success of the exercise, particularly the National Coordinator, NOCP Nigeria, state and LGA officials. -/ TABLE OF CONTENTS l) 2) 3) 4) s) 6) 7) 8) e) l0) I r) t2) l3) l4) Appreciation Team Members Executive Summary Intrcduction Terms of Reference Zamfara State Profile Methodology Results Results & Discussion Shengths (Best Practices) Weaknesses Unique features of the projec! Area Recommendations Annexes Pagc lt lv t2 l8 38 39 4t 8 8 vl ll 27 40 List of Acronyms NPI - National Programme on Immunisation APOC - African Programme for Onchocerciasis Control SSI - Sight Savers International LGA - Local Government Area CDD - Community Directed Distributor CDTI - Community Directed Treatment with Ivermectin NOCP - National Ouchocerciasis Cunirol Programme ,' SOCT - State Onchocerciasis Control Team LOCT - Local Onchocerciasis Control Team PHDC - Pubic Health Services and Diseases Control Team NGDO - Non - Governmental Development Organisation. r) Members of the Monitoring Team Patricia Ogbu Pearce (Internal Mottitor) National Onchocerciasis Control Programme Zonal Coordinator (North East) Federal Ministry of Health, Jahun Road Bauchi, Bauchi State, Nigeria Tel.077 - 540091 Yemi Qlaoye (Internal Monitor) National Onchocerciasis Control Programme Oyo State Coordinator Ministry of Health Ibadan, Nigeria Tel.02-8107266 3) Hajiya Bilkisu (Principal Mortitor - Team Leader) Citizen Communications Ltd., 4, Sultan Road, G.R.A. P.M.B. 2334, Kaduna, Nigeria Tel.052'23A165 E-rnail : b i I kis ttY@1t dh o o' c orr t 2) The Monitoring Team was assisted by the following persons Remi Fayomi - Data Assistant Ajiboye D. David Isiyaka Idris Aliyu Muhammad Maidabo Muhammed Bello R/Gero Suleiman Moldmmed Umaru Bala Abubakar Shehu Computer Operator Field Assistant Field Assistant Driver Driver Driver State Oncho Coordinator and several SOCT and LOCT members II I I 1j I Executive Summary An independent monitoring team was appointed by APOC to monitor CDTI implementation in Zamfara State Nigeria covering the period September ll to October 11,2000. Members of the team were Pafficia Ogbu - Pearce, Yemi T. Olaoye and Hajiya Bilkisu. The purpose of the exercise was to assess the implementation of CDTI in the Zamfara project. The monitoring team using APOC designed monitoring instruments obtained information on the methods used in selection of CDDs, and other aspects of community participation. Other information obtained are the treatment procedure, community perception, quality of record keeping and health education given to the community, coverage of treatment, integration of CDTI into the PHC, strengths weaknesses and prospects for CDTI sustainability. The team observed that CDTI has been integrated into the PHC and Onchocerciasis officials at the state level are solely devoted to CDTI. The government officials also indicated governments readiness to continue to pay its counterpart funding. The communities did participate in decision making but the team observed that village meetings where all citizens participated were not the rule. Rather there was palpable influence of village leaders in decision making such as selection of CDDs. APOC guidelines on drug collection and community selection are the major components of the CDTI that have taken off. Record keeping is quite poor. The 1999 round of treatment took place in July but some CDDs had tro record to treatment for that year in their treatment registers. The team visited 23 villages. Thc lcst category "A" village was inaccessible. In all the villages visited, record keeping was quite poor, a situation compounded by the practice of CDDs sharing one register with two or three surrounding villages. There were difficulties in completing summaries, determining drug requirement, recording absentees, treating adverse reactions. It was also difficult to dssess treatment coverage as the men collected ivermectin for their wives. This treatment by proxy is difficult to measure particularly when the men also insisted on responding to the household questionnaires on behalf of other family members. Although all the communities said they had received health education and were h"ppy with the CDTI interventions there was little or no community support for the CDDs as most of the community members admitted in the FGDs that they were not aware that they should support the CDDs. Although some CDDs complained of lack of incentives, all the CDDS interviewed were willing to continue to serve. Another strength in the CDTI implementation is the small number of CDDs that have been changed although this might also be due to the fact that educated CDDs are difficult to find. All the CDDs visited in the 23 villages had been trained but the team observed that the level of knowledge and supervision of CDDs needed upgrading. The team observed that the strengths of the CDTI implementation in Zamfara are the willingness of govemments to continue to pay their counterpart funding. The low attrition rate of CDDs and the community acceptance of ivermectin reflected in their willingness to continuc to take thc drug. The weaknesses of the programme are poor record keeping, low input of community in a really participatory decision making, complete marginalisation of women in all CDTI processes and their reduction to passive recipients of a drug, the use of which they only vaguely know. The issue of gender is particularly important for the success of CDTI. In a statc wherc sharia is bcing practiced, male CDDs can not treat women and women CDDs do not exist.'fhe Zamfara CD'II is in its third year; urgent steps must be taken to ensure success. The team suggests that massive enlightenment programmes should be organised, CDDs and health officials retrained, selection of more CDDs, and supervision of CDDs should be intensified. 7 1.2 Introduction Backsround The African Programme lbi Cncirocerciasrs Control (APOC) was established in December 1995 with the specific objecrive to set up an effective and self-sustaining programme of community-directed ivermectin treatment for onchocerciasis throughout ihr-fq endemic countries in tropical Africa where 50 million people are at risk of the disease. Onchocerciasis is a major public health problem in Nigeria with over a million persons estimated to be infected and nearly 30 rnillion persons at risk. A field survey showed that the communities at risk are capable of managing ivennectin trgatment. APOC projects are therefore designed to inrplement this Community-Directed Treatment with Ivermectin CDTI. The drug, Mectizan (ivennectin) is donated ty Merck and Company, Inc and APOC, working in paftnership with National Onchocerciasis Control Programmes (NOCPs) and several Non-govemmental Developmelt Organisations (NGDOs) has established a community base for participation in the tieatment. Each project is funded for a maximum of five years and over the five year period, it is expected that APOC will reduce its support and the devolution of project would have been achieved and they would continue to effectively manage the CDTI processes in partnership with states and local govemments for the next 15 years. The self sustaining component which is critical to the success of the APOC programme is community ownership. Under the CDTI, the Communities selected bommunity Directed Distributors, CDD who are then trained to manage drug distribution. The communities are also expected to decide the point for drug collection, the mode of drug distribution, determirre the date with CDD keeping adequate records of treatment to ensure success of the prograrnme. This community input is expected to reduce the cost of treatment by 90 percent and thus enhance sustainability . Thus the CDTI approach is designed to empower the communities to transfonn their lives by ilcreasing tlicii dccision u:rking and problerr". solving capacity. This community participation clearly distinguishes CDTI from the fomrer Comntunitv Based Treatment with Ivermectin CBTI. Regular monitoring and subsequent review to finetune inrplementation are critical to the success of such an innovative approach to disease control. APOC has been monitoring CDTI implementation in Nigeria, Uganda and Sudan, an exercise that has proved urifut in assessing the prospects and constraints of the CDTI approach. This ieport is a component of the regr.rlar APOC nronitoring of projccts in endenlic conrnrunitics in Nigcria. 1.3 Terms of Reference . Succinctly docurnent how ivemrectin treatn'Ients were uttdeftaken in a number of communities in the Zamfara State CDTI project' Assess community involvement in drug collection, decision making during the period and the mode of distribution, selection of distributors, and the willingness of tommunity to bear these responsibilities as designed in the CDTI project. a 8 a Document community perceptions of CDTI processes, especially the issue of ownership and expectations for onchocerciasis, and based on these perceptions and expectations, detennine the degree of satisfaction of the community with the different programme activities and outcomes. Assess the quality of training received by comnrunity selected distributors (CDDs). Examine the record books of the CDDs and assess the quality of record-keeping and their ability to keep accurate records. The same applies to the health services staff on the projects. Determihe the number of community and eligible persons treated and compare your findings with the records of CDDs and the records at the other level (e.g. district). Determine whether health personnel participated in ivermectin distribution, and assess the degree and the quality of supervision by health staff (and the quality of training and/or orientation of such staff to CDTI). Identify constraints in the distributions and make recommendations to the NOTF and management of APOC on corrective measures necessary before the next treatment. Discuss the project sustainability based on the findings above a a a o a o 9 Man of Zamfara State: cl KM --- 0?oL} imi 'Iso ro .Kwqli ,Dutsi e rml filo rodunTolotor Moforo . Kogoro .Nomod Adebko nko Bogego .Rogom ngl Moje. , Tofo Sodou a ulbi .Donfoso ebe tGt'rci'oi,t M . Rcnko .! .Kwio Mohongo.Yqr 'Sengiokun 10 2. Zamfara State Profile Zarnfara State, the area of focus for the year 2000 CDTI monitoring has 14 Local Government Areas. It was created in October 1996 out of the fonner Sokoto State which lies within the North Westem zone in Nigeria. The State is bordered by Sokoto State and Niger Republic in the }iorth, I(ebbi State irr the Wcst, Katsina State in the East and Kaduna and Niger States in the South. Zarnfara has a population of 2 million, with 80 percent of the people residing in the rural areas. The people are mainly farmers with a small populatid of artisans and traders. It has vast agricultural land, an endowment that is currently under utilised, due to decreasing rainfall, under developed infrastructure, particularly the road network that is vital for evacuation of fann produce. A substantial number of rural roads are not accessible during the rainy season. The rainy season in Zamfara begins frorn April but is heaviest between June and September. The annual rainfall is about 1300mrn and temperatures fluctuate between the hot and the cold season with the highest temperature recorded in tl-re months of March and April, just before the rains. The cold season which begins in November and ends in February is characterised by the prevalence of cold and dusty harmattan which results in a thick fog that impairs visibility and disrupts flights. The vegetation of the state is Sudan and grass savanna to the South and Sahcl savanna to the North. The Rirna river is the major water shed with its tributaries rising frorn the South Eastern part of the state and the neighbouring Kaduna State. The Zantfara and Isa tributaries flow westwards to join the Rima river. Zatnfara State derives its namc frorn a tributary of the P.irna river. Some of thc iivers are s.rasonal, with roduction in the volume of water they dry up in the dry season, and flooding and destroying fannlands and homes at their peak in rainy season. Zamfara experienced a serious floods a few weeks before commencement of this monitoring of CDTI. The area lies within the four health zones delineated for the Onchocerciasis Control Prograrnme. The programme began in 1996 with support from Sight Savers Intenrational using the Community Based Trcatmcrit witft Ivermectin (CBTI) and covering 5 Local Govemment Areas. It was a collaboration between Sight Savers Intemational, the State Ministry of Health and the Local Governments. Underthe CBTI,78,553 persons were treated in 1996 while 84,180 werc ll treated in 1997. Currently distribution of Ivermectin is being implernented through a collaboration between the Zamfara State government, APOC and a local Non- governmental NGDO, the Sight Savers International. The CDTI strategy of Onchocerciasis control was introduced in 1998 when APOC support began. The first instalment of APOC funds was received in December 1998. In that first CDTI year, 96,513 persons were treated. This was increased to 108,092 persons i1 1999. Treatment is implemented in 108 meso endemic communities in 5 local Govemment Areas (LGAs) out of the 14 LGAs in the state. A total of 312 Cornmunity Directed Distributors frafe been trained for CDTI implementation in the areas being treated. 3. Methodology 3.1 Training The monitoring team members comprising two Onchocerciasis coordinators and an independent scientist brought with them substantial experience of CDTI rnonitoring. Two of the team members had three monitoring experiences and both had participated in either in country training and out of country development of the monitoring instruments. A one day training was organised for the two field assistants in Gusau the Zantfara State headquarters on September 18 before field visits commenced the following day. 3.2 Sampling The 5 LGAs were identified and all the endemic villages were listed. They were classified into those with and those without healthy centres. The distance between t6e villages and the headquarters were also a criteria for selection. The multistage sampling was used after listing all the villages. The absence of a map at the sampling stage was a temporary constraint. Sampling was done with assistancc of the SOCT and LOCT members by choosing areas using the multi stage sampling of outlined directions in the location of the villages. The initial plan was to cover all the 5 endemic local government areas. It was envisagetl rhat this would provide a balalced sample of 6 category "A" villages viz:- 2 with health centre and far from headquarters. I with health centre and far from headquarters. t2 I without health centre and near to headquarters. However, this plan was modified when it still did not make it possible to select a village that would have met one of criteria set for the study, i.e. a category A village without health centre and near to headquafters. This could not be rigidly applied in Zamfara. The rationale behind this was to cxplorc thc possibility that distance, communication and transport problems lniglrt irnpact ot'l supervision and prompt distribution of Ivermectin in remote communities. Our findings did not reflect this concem as the outcome of the survey testifies. The sanrpling therefore produced 5 category "A" villages and 22 category "B" villages. Some the villages ./ selected were not accessible due to the heavy rain which had washed away the earth bridges. They were in some cases swapped with others (see Table l). Two category A villages were selected from Bukkuyurn LGA which has the biggest land mass and twice as many endemic communities as any of the other four LGAs. For each category "A" village, four category "B" villages were selected and relative proximity of these settlements to the "A" villages was the major determining factor. 3.3 Limitation in Sampling The absence of a detailed map of project area at the sampling stage was an initial constraint in selection of "A" villages from 3 LGAs only. In order to represent the entire state, a commercially produced map was used to cover north, central and southenr part of the state. Our core "A" villages therefore came from 4 LGAs instead of three. The other limitation as stated earlier was the distance between villages which made it impossible to select a category "A" village that was near to headquarters and without health facility. Where such exists, there would have been no surrounding category "8" villages to survey. To avoid a distortion of the sarnple this last category was abandoned. The inaccessibility of some B villages led to their being swapped with others. In a particular case, a category "A" village chosen during stratification and surveyed was discovered to have two inaccessible category "B" villages when the two nronitoring teams set out to commence field work. l3 Map of Zamfara State: Showing villages visited during monitoring of CDTI project in September 2000 Yqmmq odo NKA OYor Tosho OYor Motonkqri ODqn ODoko ibe Gidon Zollo Dostri KEYfDogon tloji MARU ingi ,A'Vi llages o"d'vt [tages !'li.rngo Moni KM -r-l on$ Orsitigui OBirnin w jc ODongururnfo OMosomor Mudi M Bowqn 9o Mofofo t4 3.4 Instruments All the six APOC monitoring instruments were used to generate information in both category A and B villages. They are the Indepth Interview questionnaire admirristered to the Community Directed Distributor CDD in category "A" village; the indeptlt intcrvicw questionnaire for the village leader in category A village; Focus Group (FGD) discussion questionnaire which was used to extract information from male adult groups cornprising at least 6 to 8 men, female adult groups. female youth groups, and male youth groups. In ./ all, four focus droup discussions i,verc organised in each cltegory "A" village. The FGDs were recorded on audio tapes, labelled and transcribed on paper (attached as appendix). Where more than one CDD was available, two were interviewed separately. However, one peculiar phenomenon were two category B villages where the village heads were also the CDD. In each categoly "B" village, the village lread and CDD werc intcrvicwcd using a modified version of the instruments administered in the category "A" village. This set of instruments were not as detailed as the ones designed for the "A" villages. Thc health personnel were also interviewed to collect information on CDD training and the role played by the health centres in the storage and distribution of Ivennectin. In each category "A" village, Household survey forms wcre adnrinistered irr 15 households. Tlrc absence of a household census in all the treatment registers made random selcction of houses the only option. All the six instruments used are attached as appendixes. Thc measurilrg dcvice was inspected, information on left over dmgs collected and records of treatment recorded in the registers were examined. The LOCTS and SOCT, NOCT and representatives of NGDO were interviewed using the interryiew guide for policy makers. Limitations The administration of these instruments were hampered by socio-cultural practicbs. The research procedure for administration of the Household Survey requires that all the members of each selected household should be listed and asked individually to respond to questions on the administration of Ivennectin within their household. In all the villages l5 visited and indeed all project areas, only the household head (husband and/or father) responded on behalf of other household members. Due to the socio-cultural practice of kulle (purdah) the women are secluded in the houses and the men did not give pennission for researchers to interview them. Another limitation was the practice of using one CDD to distribute ivermectin in two or three villages and/or villages sharing one treatment register. This made record keeping very difficult as separate records of drug administration in the villages treated were not kept. In addition record keeping was poor and scanty and lacked focus, and uniformity. It r'' was therefore impossible to complete that segment of the CDD questionnaire which required examination of village record to extract the following vital informatiorr: o Total Population . Age composition of people below .5 years and ahove . Sex composition of the population (male, female) . Number of persons treated (male, female) o Number of persons under 5-years who received treatment o Number of refusals o Number of absent during last treahnent o Number with severe side effects o Number of tablets received o Number of tablets used o Number of tablets left in the drug kit 7. Results Highlight Number of Local Govemrnent Areas visited - 5 Number of category "A" villages visited - 5 Number of category "B" villages visited - l8 Number of inaccessible "B" villages - 6 Number of key Informant Interviews with village "A" Leaders - 6 Number of key Informant Interviews with village "B" Leaders -17 Number of Indepth Interviews with village "A" CDDs - 6 Number of Indepth Interviews with village "B" CDDs - l3 Number of Inten iews with health personnel - 3 Number of Household Surveys - 75 l6 TABLE l: VILLAGES COVIIREI) Total:5 Category'A' Total:24 Category'B' KEY WHC - With Health Cerrtre WOHC - Without Health Centre NHQ - Near to the Headquarters FHQ - Far from the Headquarters Local Government Area Category'A' Status of Village Category'Bt Maru LGA Bingi WHC FHQ Tugan Mani (7) Dogon Daji 'fugon Arno (Not ttcccssiblc) Birni (Not acccssible) Kaq'a Ttufut n (Not occessible) Mallonnv'a (Notoccessible) Gobiya (Not accessible) 3 Village Heads I Health Personnel No H/H Forms Bungudu LGA Gidan Zalla WOHC FHQ Kwatta Yamma (4) Kwatta Gabas Dashi Ribe 5 Village Heads 5 CDDs Village B I Health Personnel l5 H/H Forms Anka LGA Yar'Tasha WOHC FHQ Doka (5) 'Yar-Matankari Gidan Naboro Dan Daura Bagada 6 Village LIcads I CDD Village A 15 H/H Forms Bukkuyum LGA Masamar Mudi WHC FHQ Sabon Tunga (4) Tungar Bawa Mafara Garanje Dangurumfa I Village Head I CDD Village A 2 Health Personncl 15 H/H Forms Bukkuyum LGA Tsiligidi WOHC NHQ Tudun Gandu (4) Birnin Waje Inwala B asa nson ( Not acccss ible) 4 Village Heads I CDD Village A 3 CDD Village B l5 H/H Forms t7 f@- = *.opoftion and number of rarget communities which decided on period and method of treatment' F, _ 2_ Proportion and number of target communities where the ..community,, selected their own CDD' TABLE 2: DECISION - MAKING PROCESSES AT TEE COMMUNITY LEVEL Question Villagellleeting Village Elders Vitlage Chief Health Worker Vitlages Committee 0ther Total Village Lcader- .rArr 68'' * Who decides onthe month of distribution * Mode of distribution + Selection of CDDs 1o (4s.4s) e (37.s) 6 (25) l (4.s4) 1 (41.67) 3 (12.5) 0 6 Qs) lo (41.67) e (40.e1) 5 (20.83) 3 (12.s) 0 0 0 2 (e.oe) 3 (12.s) 2 (E.33) 22 24 24 CUn Vinage uA' and *Bt' * Time of distribution * Mode of distribution * SelectionofCDD 2.s (33.33)3 (s0)3 (42.86) 7 0 0 .3 I (16.67) J 2.3 0| (14.2e) 0 0 0 2 2 2 (28.s7) 6 6 7 Group Discussion Village uAnz * Time of distribution * Mode of distribution * Selection of CDD No No No No No No No No No No No No No No No No No No No No No CHART - I tEdCfi L/hfing Fess - IIOIIH OF DSIEB'IION \flagpi/bciqg Ots 995vil<PomitE 096 lF% l'di\nbdq 41% \flarCt*{ Gf, Vl{eEhs 5% \a€r l\rl{p tr\,resp Fdt Itr/bdi]€ l EUtts ct*, \nHs OflritE rg I4 CHART - II Declslon Making Process - MODE OF DISTRIBUTION trVilhg. Mcctins rvilhgo EHGrs ovilhs. chi.f trHcallh \Itbrkcr rMlhgc Commitbc trotrcr Vilhgc Commitbc Hcellh lllhrkcr 21% Health Worker 13% Otrcr 134 Mlbgc Chicf ?5% Vrllage Commfttee o% 8'/. Mllagc McGting 37% Mlhgc Eldcrs 4% CHART III Dcclslon tr/hklng Process - SELECTION OF CDD Other trVrllage Meehng lVrllage Elders trVrllage Chref oHealth Worker IVrllage Commrttee trOther Vrllage Meeting 25% Elders Vrllage Chlef 41% l9 137o On decision making process at the community level the monitors found that 45.4o/o of the communities decided on the month of distribution at village meetings while in another 40.9I% of the communities had the health worker deciding for them according to the village leaders. For the distribution, 37 .5o of the leaders clairned the mode was decidcd 50% of the CDDs confirmed this (table 2) 25% of the village leaders claim that CDDs were selected at the villages meetings and this is collaborated by the CDDs in 42.860/o. But from the Focus Group Discussions (FGDs) not one group confinned any of the earlier mentioned claims. (No village meetings were held it seems). There was no palpable community involvement in the decision on when treatment took place although 45 percent was recorded. However, the decision to cornbine CDD training with. drug collection period was the key determinant of when treatment commenced. The local programme managers who took this decision are convinced that this arrangement ensures prompt and effective treatment for following reasons. First, the CDD's zeal to implement what has just been leamt from training is high. Secondly, collection of drug after training reduces the risk of late drug disbursement where CDD would have otherwise been preoccupied with other pursuits. Since the communities are expected to donate to support CDD's trip to collect drugs, resources are conserved in combing training with drug collection underscoring the proverbial "killing of two birds with one stone". The communities also made some input into selection of CDDs because it was obvious that CDDs were not selected by outsiders. However, the village head actually conducted the selection in most of the places visited. Indeed some village heads were CDDs and some selected their sons and wards. The concept of a really participatory selection process in which many people participated was not practiced. TABLE 3: ABSENTEES AND REFUSALS Village 'A' category Absentee Refusals (Summary) Houshold survey Absentee Household survey Refusal 'frca ted Bingi (Maru LGA) 65 17 0 0 68 Gidan Zalla (Bungudu) 25 2 0 0 84 Yar'tasha (Anka) -1 7 4 0 43 Masamar Mudi (Bukkuyum) 3 4 8 0 39 Tsiligidi (Bukkuyum) 4 5 43 20 CHART -IV Total Number d Absentees and Refusals 70 q) 50 g o 840 o. o a,n E30 ,z n 10 0 Tsiliglli f Absertees rRefusals OUTPUT 0-1- Proportion and number of refusals two months after distribution O-2- Proportion and number of absentees later treated From the very scanty record available for the year under review, (Table 3) it was impossible to get accurate figures of total number of absentees and refusals during treatment period 1999. 0-3- Proportiorr and number of at risl'^ villagcs treateC. 0-4- Cost per person (Beyond the seope of the sturly) TABLE 4: TREATED POPULATION Engi (tutaru LGA GitanZalh Yailasha Catcgory'A Mll4e Trcdr:nt Rc$ster lvhsanar Village 'A' category Total Pop. Male Female Treated Total Pop. Treated Male Treated Female Binei (Maru LGA) 1004 475 s29 600 238 299 362 Gidan Zalla (Buneudu) 2417 r250 tt67 1125 826 Yar'tasha (Anka) 632 319 218 368 '120 248 Masamar Mudi (Bukkuyum) 50r 332 169 436 327 109 Tsiligidi (Bukkuyum) 2l CHART -V Treded fug.{atim as a peter* of total fuptltim o CL o o o. o on E =z 3m0 2ffi m0 15m 1m0 5m 0 Tddtup. ]VHE . Fende TrdedTdd fop. Trded tVHe tVldesand FerndesTredd in C#ogcyA Mll4es EEr(i 0t nuLGA) lG&nZalh OYar'Tda trlt/krslrtd Treatment Coverage Assuming, the census figures given are correct, (Table 4) the geographical treatment coverage is 59.76%o in Bingi (Maru L.G.A.) 46.5yo in Gidan Zalla (Bungudu), 58.23Yo in Yartasha Anka. These are very low when you consider that treatment has been going on here for a few years before APOC's CDTI. Number and percentages of absentees are recorded in four of the five "A" villages to show that 9614554 (2.1%) were away during distribution (Table 4). There were only 30/4554 (O.07%) who refused treatment. There are no records of treatment of these groups in any community. Though these percentages are small, when they reoccur in many communities it means there is a human reservoir present making the distribution meaningless. TrEded Fende 22 I 0-5- Proportion and number of communities where CDDs were changed by the community after first treatment Table 5 shows that for the proportion and number of communities where CDDs were changed by community after the first treatment (0-5) there were only 3 (15%). TABLE 5: CDD CHANGED LGA Number of )illages Village Names CDD Changed Reply from Village Leader CDD Changed Reply fronr CDDA & CDDB CDD Changed Treated Maru LGA 3 Bingi Tugan Mari Dogon Daji \, ]r{, ]r{, o o o No No No 0 Yes (3) Bungudu 5 Gidan Zalla Kwatta Yarma Kwatta Gabas Dashi Ribe i.lo No No No No No No No No Yes 1 Yes (5) Anka 6 Yar'Tasha Doka 'Yar-Matanliari Gidan Naboro Dan Daura Bagada No No No No No No ? Yes No No I Yes (6) Bukkum 5 Masamar Mudi Sabon Tunga Tungar Bawa Mafara Garanje & Dangurumfa No No No No N N ? ? o o 0 Yes (5) Bukkum (Tsiligidi) 4 Tsiligidi Tudun Gandu Birnin Waje Inwala No No No No No No Yes No I Yes (4) TOTAL 23 3 23 23 CHART - V Number of CDDs changed in all villages 10 Maru LGA Bungudu LGA furka LGA Bukkuyum LGA Bukuyyum Tsi Local Government Areas 9 8 7 6 5 o oElg o t E =z 4 3 2 1 0 rcoo tr Total 24 0 - 6- Proportion and number of communities in which CDDs were supervised by health care system. O - 7 - Proportion and number of target communities which received education about importance of extended ivermectin treatment TABLE 6: CDD SUPERVISED AND TIEALTfI E,DUCATION RECEIVED CDDs Sunervision The team found only 14129 (48.25%) of the CDDs who said they had been supervised during the distribution. This is very low considering that most treatments are by proxy. When you take a closer look at specific village CDD responses, it is not certain that even LGA Number of Villages Village Names CDD supervised Received Health Education CDD supervised Received Health Education Maru LGA 3 Bingi Tungan Mani Dogon Daji Yes Yes Yes No No No 3 0 Bungudu 5 Gidan Zalla Kwatta Yarma Kwatta Gabas Dashi Ribe Yes Yes Yes Yes Yes Yes No No ? Yes 5 2 Anka 6 YartTasha Doka 'Yar-Matankari Gidan Naboro Dan Daura Bagada Yes ? ? Yes Yes Yes Yes Yes ? Yes Yes No 4 4 Bukkuyum 5 I Masamar Mudi Sabon Tunga Tungar Bawa Mafara Garanje & Dangtrrumft, Yes Yes ? , t Yes Yes Yes Yes 2 4 Bukkuyum (Tsiligidi) 4 Tsiligidi Tudun Gandu Birnin Waje Inwala No No No No No ? ? No 0 0 TOTAL 23 l4 l0 25 the 'yes' is actually a yes if in other cases the CDD is not sure whether he was supervised. Health Education Received Again one is not sure if health education was actually given, only 'yes' answers were gotten from the 29 CDDs. From the responses directly during FGDs, the level of health education is very low, you had to probe hard to get any answers. Not Much of IEC materials were seen in the communities by the team. crt'anr- vr It{rrhrcf CtDs srperuised ard }balfi Blrcaliqt Eeived 10 9 I 7 6 5 4 o o CD .B 5 o olt E =z 3 2 1 0 Ivlrr.rLC* ATEdILGA Arl€LGA BlduyunLcA AioryyrnTd Ld BrcmrrntArc rCDDs+erutsed lFbdh Ed.rdim Redved ow+toa 26 Table 6 shows that 14 out of 29 CDDs, 48.2 percent said they have been supervised while l0 said they have received health education. However, the FGD showed that some health education was conducted in the communities. All the target communities received health education about the importance of ivermectin treatment. But the quality of education is quite low because not all the segments of target communities could readily give answers about the drug. One had to pr6U" further to know what knowledge they had. The CDDs had ample knowledge followed by the adult men. The male youths also had some knowledge. However, the female youth and adults know nothing about the drug. The FGDs were quite revealing. ,F ..We do not know its uses, we just take the drug. You can not refuse people's recommendation". Fentale youth in Bingi village in Maru Local Goventntent during FGD. 6.We do not know who brings the drug into the community. Our men give us the drug and we swallowed itt' Adult women at Tsiligidi village in Bukkuyum Local Governntertt in FD. ..We are inside the house,. How can we know who selected the CDD. It's men's affairrr. ,.We do not know those who brought the drug. How can a woman know another man who is not her husband? We did not know the programme's aim'" Our husband sent a man who is our son." Adult women at Bingi village in Maru Local Government Area during FGD. INPUT - Results and Discussion 1-l Training of CDDs The results showed that 18 out of 22 (81.8%) CDDs interviewed have been trained and re-trained, further probing revealed that thc annual rc-training was quitc short, ranging from one day, half a day to three hours for most of the CDDs. Given their low level of education, the CDDs would require a more intensive and practical training' 1-2 Drug Delivery and Distribution Method The established pattern for drug delivery inZamfara state is for the NOCP headquarters to collect ivermectin for onward delivery to the NGDO working in the area, Silht Savers International (SSI). The NGDO then allocates the required number of drug to the SCOT and LOCTs who transport the drug to the collection points, usually health centres in each district, where training of the CDDs are also organised. The CDDs from the various 27 communities collect ivermectin after the training and comnrence distribution. This complies with APoc guidelines for drug delivery and distribution. About 50 percent of leaders said that they did not experience late supply of ivermectin because they did not determine the time of drug delivery. With no community input into the timing of supply, the drug is always supplied to them whenever their CDDs were invited to attend training. Indeed some of the leaders said they did not know whether drug was promptly supplied. (Table 5). .r' 28 TABLE 7: INPUT INDICATORS CHART - VIII TreffiHFier IvEadrgEbice dedinfunRit Dreffi l-#S{dy TrdrEdCrrE fiqrfiuqrcRs o o CI .9t E 432 5 60 1 ttlrrEd\tllEes EBrgtdr l[,tru trRta trafOeryr,m laftuFm Summary formin district office Treatment Register available Measuring device for heig[tt available Collect from a point Late Funds Drug Shortage Late Supply Trained CDDs v I L L A G E LGA N o YYesYes NoNoN o YesNo YesYesYes NoNoNo YesYes 0NA00 55I 4NA44 I0 155Brmgudu 00 NA1 J2112 NA2 1I3 0JMaru 0NA4 ,,20 40NAI 50 606 4Anka 0NA0I 4JI 3NA44 00 044Bukkuyum 0NA4 030 I4NA0 4I J04 2Bukkuy'um (Tsiligidi) Side readio n record availat le I C C C C C ffi F 2q ,ll i:. 1 1; 1, r+1rr'1il\ 'u- , -,,;; -, l- 11 1-3 Drus Shortase Similar results were obtained for adequacy or shortage of drug supplied to the communities. CDDs did not calculate the accurate number of ivermectin required for their communities. First in all the villages visited the registers did not lrave calculations for future projection of under aged children who would be eligible for the next round of treatment. Secondly, even the number of eligible dwellers of the villages were not recorded no. Gr. their drug requirement calculated by the CDD. In the absence of this vital information the supervising LOCTS with the assistance of health workers use an estimate of the community's population, number of CDDs and/or expanse of area treated to allocate dnrgs to'the distributors. It was also observed that all the LOCTs kept an exercise books in which they recorded the quantity of drugs supplied to each CDD who in tum were made to sign and tltus certify that they had actually collected. Since no census was conducted prior to distribution, any quantity of ivennectin provided to CDDs is used up and request for additional supply is rarely made. In Tugan Mani, which is an unusual example, the CDD who is also the village head was given only two bottles of ivermectin and he complained in the presence of the monitors that his request for additional drug was not granted. Further probe revealed that he did not know the number of eligible persons being treated in his community, the number of households, the underaged nor could he determine the number of drug required for the next round of treatment 1-4 Late supply of funds This component of the survey did rrot yield any mcaningful respoltsc from thc communities as they were not concemed with it. However, interviews with NGDO policy makers and the SOCT revealed that there was delay only in the release of the second instalment of funds from APOC for Year I and Sight Savers International, thd NGDO paftner provided funds for commencement of distribution. Interview with SSI showed that subsequent delays experienced in the release of fund should be blamed on the state which did not submit retirement of funds already expended on time. They attributed this 30 to the unfamiliar APOC method of accounting which differs markedly with what the state officials are used to. 1-5 Drug collection fronn a Central pqiut Only seven viliages collected tireir drugs from uuc ceutral point which is the Local Government headquarters. The others collected at the second central point which is the health centre that is often closer to them. This indicator is a measure of the communities commitment to CDTI process. The rationale is that in those communities where the "r feeling of ownership is strong and communities have imbibed the CDTI philosophy, collection would be arranged by them rather than wait for ivermectin to be delivered to them. l-6 Measuring device for height The CDDs had measuring device produced from neem tree branches with the measurements etched on the bark of the tree. The measuring device was presented for inspection by 15 of the CDDs (68.18%). The FGDs however, showed that in several cases, particularly in the case of women the CDDs did not use the measuring device for determination of dosage. The majority of adult women and female youth interviewed were not measured by the CDDs. Husbands collected the drugs for their families and determined the dosage, a practice that must have resulted in several cases of administratiqn,of ,wrong dosage. Two oregnant women in Bingi village were given ivermectin to swallow by their father inlaw. Oirc swallowcd thc drug and the other did not. "Pregnant women take it. I took it while pregnant. I was given three tablets." Afennle youth at Bingi village in Maru Local Govenunent. 1-7 Availability of Treatment Registers Treatment registers in the approved APOC/NOTF format were available and 20 out of the 22 (90.9 percent) were able to present them for inspection. 3l 1-8 Summary Form in District Offiee There were no summary forms available at the Local Government for monitors to inspect What was presented as summary forms were often ivermectin allocation to CDDs. l-9 Side Reaction Record The health centres did not record cases of severe adverse reaction nor did the CDDs. Observations Communities' Perceptions. Expectations and Satisfaction The FGDs reveal varying level of community knowledge of the disease that is being treated. The majority of adult men and youth know that onchocerciasis is dangerous because it leads to blindness hence the name "nruganin ciwort ido" tneaning the drug that cures eye ailment given to ivermectin. Some women also know that the drug has something to do with prevention of blindness iu spite of their scant knowledge of any thing associated with the project. Knowledge of the dosage and exclusions was better among the adult men and youth. A few even mentioned that seriously sick people and very old ones slrould be excluded. Although some women do know that pregnant women and children are excluded, several times disagrccrnents developed d'.ripg FGDs when attenrpts were made to define the exact age limit for exclusion of children. There is palpable indifference on the part of adult women that should be attributed to their level of ignorance of the programme. "We are not told anything. We do not know where it (the drug) is collected. We are inside the house. We do not know who brings it to the community. We swallow it since we are asked to do so." Adult women at Bingi village during FGD in Maru LGA. However, there is an appreciable level of satisfaction with the effect of the drug. "\ile are healthy, so we know the programme is good." Female youth at Gidart Zalla village, Bungudu LGA .during FGD. "We feel strong and healthy" Adult men at Tsiligidi village in Bukkuyum LGA. during FGD "The drug is good for our body" Male youth at Yar'tasha village in Anka LGA. during FGD 32 Communities' perceive the programme as another govemment health progralnme atrd among some women at Bingi village, it was even conflused with tltc imtnunisatiott programme for childhood disease (NPI) which is fully sponsored by govemrrrent. Two women named a wonlan who is the NPI distributor as an ancho CDD. In a statc whcrc there are no female CDDs this was a novelty and the monitor sent for the woman. When she came she revealed that she was only an NPI distributor. The people are totally unaware of their critical role in a programme that is designed to be community focussed. During the FGDs none of the community members noticed any change frorn the previous CBTI to the CDTI. They view the CDTI programme as a local government health initiative and the CDDs as their paid drug distribution agents. On being told that the CDD is not paid they responded that they were not aware that they are supposed to support the CDD. "Actually we do not give CDD anything at all. We pray for him. We are willing to take the medicine as long as government brings it to us. If you say we shtrulri take over the responsit,ility, we sitsll Lry." Male youth dt Yar'Tasha village of Anka LGA during FGD. Communitv Involvement in CDTI The whole concept of CDTI has not taken off in Zantfara. There is an urgettt need for thc community to know their role in CDTI implementation because they are cunently unaware of APOC philosophy. The communities simply do not know that they are supposed to play a crucial role in decision rnaking such as selection of CDD, deciding the time and mode of distribution, supporting the CDD, rnobilisation and community self monitoring. This underscores the fact that the community education and mobilisation is defective. The decision rnaking process is exclusive and not participatory as the CDTI demands. Although the people said that they selected the CDD, the truth of the matter is that the village head selected sometimes in consultation with elders. Wlrere village meetings were said to have been held, the same group constituted "the viliage." The feudal institutions are slow in responding to change and the village head still reserves the prerogative of arrogating to himself, cornmunity power by solely deciding who becomes JJ CDD. In some cases, the village heads are the CDDs as the team discovered in Tugan Mani and Danjikko villages in Mam Local Govemmeut. Often the CDDs are also sons or wards of village heads. This feudal line of authority solely revolves arouud nlen and totally excludes women. The communities did not know that they were supposed to nlake ipput into decisions by establishing village comrnittees or holding parrticipatory villagc meetings with all community members attending. "We the elders and Chief selected (CDD) usually at a meeting" Adult nten during FGD at Masanmr Mudi village in Bukku),um LGA. "CDDs were chosen by village head at village head's palace". "The community does not decicie -whcn drutgs should be deli','ered so we de not know if it is Iate or timely." Male youth in Bingi in Maru LGA village during FGD. Ivermectin is not kept in the communities and even village registers are not kept in the village head's house as the CDTI guidelines demand. They are sometintes kept in the health centre as was observed in Bingi Maru LGA where rcgisters wcrc only retuntcd to three CDDs in the presence of the monitors. "We do not know rvhether the drug came on time since we do not know when it is supposed to be givert to us" Female youth at Gidcm Zalla village during FGD However, the communities expressed a desire to participate in CDTI when it was explained to thern. 6'We can support CDD. We can give money.We can also mobilise". Adult wonten at Tsiligidi tluring FGD. '6We are ready to undertake collection and distribution and even raise funds to do so. We want CDDs to be supported to collect drugs," Female youth at Gidan Zalla village durittg FGD. Training Almost all the CDDs 18 out of the 22 interviewed (8 l'h) have been trained. Hoivever, the quality and duration of training needs to be improved upon and extended as some CDDs displayed ignorance of some basic elernents of the programme such as CDTI, use of measuring device, treatment of adverse reactions and dosage determination. The training 34 obviously did not exteld beyond the technics of causes of disease and drug distributiop' Important topics such as advocacy aud contmunity mobilisation, fund raising and gender equity should be incorporated into future programmes ' Record keeping APOC approved registers were available but record keeping was poor both at the household level and the local governments when the records were available' It was irnpossible to detemrine whether hotrseholds were properly treatecl' Thcrc wcrc no ccllsus figures available during monitoring. Although the teatn later leamt that census was conducted this year, the outcome was not known. There was no household numbering' cases of adverse reaclions wete nt t Jec')lde!'l 't ail lc'"els' In Tsiligidi village in Bukkuyum, LGA, treatment tigures were not recorded for 1998' 1999 and for 2000 although treatment for the year being mouitored was conrpleted ill November 1999 and July 2000 for tl're following year' In Maru LGA no treatment figures were recorded for 1999. The widespread confusion in some places where treatment figures were tecorded was compounded by an attempt by the Ribe village CDD to correct wrong entries and by the practice of three CDDs who are treating separate villages sharing one register. It was difficult to demarcate where treatment for one village endecl and the other began. This was the casc in Tsiligidi, a category "A" village where the CDD shares one register with two other CDDs of Tudun Gandu and Basansan villages' Inaccuracy of dosage was reflected even with the scant records available indicating that several cases of overdose rnight have occttrred without being docurnented' In Bungudu LGA, an eleven year-old was given 4 tablets, a 10 year-old was given 4 tablets in Bukkuyum LGA. The ineligible sucl-r as pregnant and underaged childrcn, tl"re absentees and refusals were not properly recorded for category B villages not to talk of trying to cross-check whether absentees' c.ases qqre rcvistcd )lc summaries were avbilable although the team was told that the CDDs did not do the summaries because the LOCT supervisors have taken up the responsibility of doing so. The only surnntaries the LOCTs 35 kept was that of the drugs collected by CDDs. In short, poor record keeping constitutes the greatest obstacle to monitoring CDTI implementation in Zamfara. Coverase The treatment figures are very low for a state that begarr treatment a few years before APOC introduced CDTI. For example, if the assumptiou is that the census figure given are correct, the geographical treatment coverage is 59.7 percent in Bingi (Maru LGA) 46.55 percent in Gidan Zalla (Burrgudu LGA) 58.2 percen[ iu 'Yartasha (Anka LGA). Number and percentages of absentees are recorded in four of the five "A" villages the team visited. This shows that 9614554 2.lo were away during distribution. There were only 30/4554 (0.07 percent) who refused treatment. There was no record of a review of their cases. Although these percentages are comparatively stnall, when they reoccur itl many communities, it irrdicates that there is a huntan reservoir that nrakes the dnrg distribution ineffective. Suoervision of CDDs The team discovered that only 14out of 29 (48 percent) said that they were supervised during distribution. Supervision was found to be inadequate because superuision seems to be limited to the drug distribution period. Supervision rate is rather low givcn that tnost treatments, particularly for women is done by proxy (ltusbands or father's in-law). A critical examinatioin of CDD responses also casts doubts on the "yes" altswers several of them gave. These was obvious lack of superuision as their poor record kccping alrcl follow up of treatrnents portray. Integratiou into Primary Heatth Cere The team observed that there was evidence of integration of the CDTI into the existing Public Health and Diseases Control Deparlment. Indeed CDTI is a section under the Public Health and Diseases Control department. All the SOCT and LOCT ,rre,rrb"., o." staff of the various PHDC department at state and local govenlment level. The SOCT staff are exclusively for CDTI with other PHC assignments. An outstanding contponcllt that is yet to be integrated is treatment of adverse reactiotls in PHC centres while the PHC 36 staff such as the CHEW ought to collaborate with the communities in the supervision of CDTI. Sustainability Success and sustainability of the CDTI are hinged on the effective education and mobilisation of the communities to imbibe the APOC philosophy of promotirrg community ownership of the programrne. The health workers and NGDOs who are in charge of the programme must focus or-r this crr.rcial aspect of the CDTI which is currently unknown to the communities. It was obvious from FGDs that CDTI has not taken off in Zatnfara state in spite of the three years of project irnplementation. The communities are not aware of the role they are expected to play in decision making as regards volunteering to be CDDs and/or supporting the CDD with cash or kind. They do not know that they have to play a role in deciding the mode of distribution, when and where to collect invermectin. All these are cunently being decided by the health workers as the FGDs shows. A vital aspect of sustainability which the team observed is tlie political will on the part of Zamfara state govemment to fund CDTI. All the local governments do contribute their counterpart funding. Maru contributed 31,450 Naira while Bukkuyum gave 150,000 Naira an amount that is in excess of the 51,000 Naira allocated to it. The LOCTs are also happy with the financial support they receive from the Local Government and the SSI the NGDO. They irowt)V€t, conrplarned. about cieiays iri lei3ase of funJs. "We know that the programme is useful and we shall support it." Zantfura State Conuniss ioner for Healt h. "The state and local governments will continue to fund Onchocerciasis control programme" Zantfara State Director of Public Health Services and Disease Control. Another critical aspect to sustainability is designing and implementilrg a gcnder component for CDTI which is currently lacking. Women who constitute half of the population in Nigeria are not involved at any level, making a sham of comrnunity participation and sustainability. In all the villages visited, the husbands collected 3l ivermectin for their wives and detennined the dosage. The women are denied health education arrd participatiori irr deci-sir.rli making. Tire l,ealth workers attribute the non- involvement of wolnen to the absence of educated women and youth and the cultural practice of purdah. However, in Gidan Zalla vlllage the FGD conducted had female youths in attendance, 4 were secondary school students and two were school leavers with one of them working as a primary school teacher. '6We are ready to undertake collection and distribution altd cven raise funds to do so." Female youths at Gidan Zalla village during FGD. As for the adult women, they had this to say; "We want to be involved (Ana yi da kai yali ba'a yi da kai) meaning being a participant is better than being a bystander". Adult women tu Gidan Zalla village during FGD. The CDDs who are supposed to be the most knowledgeable in CDTI nranagentent in the communities have not fully grasped the CDTI concept. In Dashi village of Bungudu LGA where the monitors were interviewing the village leader, one of the CDDs requested one of the monitors who speaks fluent Hausa to address the gathering outside on the role of the CDD as a volunteer worker. He said the people did not believe that he was not being paid for ivermectin distribution. The team observed, in all the villages visited that CDD support was meagre ci totally lack;ng a dcvclopmcnt mosi cf the participants in the FGD's attributed to ignorance of the fact that they were supposed to support them. "We do not support CDD. We can contribute to support distribution of drug if we are told." Adult nrule of Birtgi village during FGD. "We do not give anything but the men just give them 10 Naira in appreciation" Fenrule youtlt at Gidan Zalla village during FGD. Strengths (Best Practices) . State and Local Governments' commitment to continue to fund CDTI o Integration of Onchocerciasis into Public Health Services and Diseases Control. o The team observed the willingness of the community to continue to take the drugs and the appreciation of its benefits. 38 a Very high CDD retention rate. Very few had been changed. However, the fact that the people are happy with the CDD does not mean that CDD are correctly inrplenrenting CDTI. Weaknesses o Inadequate training of CDDs. It was obvious that community education and mobilisation was not adequately treated as a component of CDD training. . The teanr observed that supervision of CDD was inadequate and usually limited to distribution period. o Deficient record keeping by the CDDs was observed by the team, a factor that made through assessment of CDTI implernentation impossible. o Over concentration of decision making powers in the hands of the village heads who then amog:te to themselves the prcroga.tive of selecting themselves as the CDD or selecting their sons or wards. o Where the village head is also the CDD they waited for the people to come and collect the drug instead of distributing at household level. . Sharing of registers by three CDDs treating different villages conrplicated record keeping. a a a The practice of using one CDD to cover three separate villagcs made effcctive coverage difficult. It was observed that such CDDs were selccted by a district head to cover villages under his domain. The absence of female CDDs is a serious defect in CDTI implementation in communities where adult men including CDDs are barred from entering households. The team observed that treatment by proxy, whereby husbands collect drugs for their wives encourages over dosing and false trcaturcnt coveragc figures bccau,se drugs collected may not be used. The team also observed that CDDs often used visual assessment to detenninc dosage. The relucrancr) of the CDD-s to usc ihe rlreasuli,rg device all the tirne would also Iead a 39 to wrong dosage being administered as some cases recorded in the treatment registers confirm. o The team found that there was no anangement made for treatment of adverse reactions. The health workers interviewed had no record of cases of severe reactions either. o It was observed that the concept of CDTI has not taken off as tlte programrne is sti ll seen as government funded and government directed. Comnrunity support for CDD is poor and. the only asnect of CDTI that is being irnplernented is drug collection from some health centres anci seieciiorr or" sorne CDDs in sorue villages. Plans for community monitoring do not exist. o The team obsered that there was paucity of IEC materials. A few flip charts used for training were seen at the health centres, a few posters in the village head's house in Bingi village and at the state r-ninistrl' of health. None were seen in the other places within the comnrunities. o It was observed that there was difficulty in finding educated and willing CDDs. . The team found that in sorne LGAs (for example) Bungudu, the LOCT ntembers cornplained of lack of LGA Support for the fueling of their nrotorcycles to enable them undertake supervision tours of treatnrent areas. They havc to depend sorely on APOC and SSI although the LGAs arc supposed to fund such expenses too. They also contplained about delay in the release of LGA's countetpart [urrding. At the timc oI rnonitoring funds for 1999 had not beerr paid. a Unique Features of the Project Area Zamfara statc-was thc first to rnnour.ce and bcgi:r thc f;ll in'rplementation of sharia law - the legal Muslim.code. While it is recognised that implementation of sharia law varies from one country to another, within Nigeria, variations also exist in the mode of implernentation of sharia in the different states. One of the tenets of the sharia law being implemented in Zamfara is to discourage unnecessary mingling of rnen and wonteu. This should necessitate the promotiorr of educatiorr for all, mcrr and worl'rcn lrccause cducatiort is contpulsory in Islam arrd it is infact a prc-requisite lor implenrcntation of sharia. Full 40 implementation of sharia therefore requires a public life role for wottcn who should be seen attending schools to acquire knowledge, perlonniug social developlttent rolcs in all relevant sectors and specifically serving other wonlen. Sadly, the team observed that there were no women CDDs in a state that claims that it is implerrrentirrg sitaria, a praciice that clearly negates iite conccpt of sharia. This issue was raised by women during FGDs. They criticisd their marginalisation and uon involvement in CDTI. "We want women who are our compatriots to come into our houses and educate us. Some houses prohibit men from entering. If the man who is the head of the house is not around a man can not enter but if it is a woman, she can entcr without any prohibition or hesitatiolr." Adult wonrcn in Gidun Zalla village in Bungudu LGA cluring FGD. "We have no information. We need information. Government has tried. We need to have women to distribute drugs to women, we know they are those who can do it well. But how can a man do this effectively? Sharia is practiced in Zamfara state and it demands that women should attend to women. Some lvomen are nervous witlt any man who is not their husband. Women must attend to women and men should attend to men. FGD v,ith adult v,onten in Bingi villoge in Moru LGA. Recommendatious Zatnfara state is in its third year of CDTI implenrentation. It should have overcome the transition problems from CBTI to CDTI. With two more years to institutionalise the CDTI which has not really taken off, urgent actions must be taken. The following actions are recommended as irnperative for CDTI's success in the next few years. l) A massive enlightenment campaign should bc organised to enlighten tlre poople on the CDTI and their role in CDTI implementation. Various civil society groups such as CBOs, interrnediary NGOs, trade groups, professional associations, self help and youth groups, women's organisations etc should be used as an cntry point for the enlightenntent campaign. 4t al aa A special advocacy package on how to mobilise muslim women using religious g.o,,pr especially the neighbourhood Islanriyya schools, preachers, particularly at the grassroots should be designed and irnplernented. The Zarnfara Govemment's weekly preaching events should focus on the educatiott of women and their public life role irr lslam. Based olr outcome of thcse, lcgal ruling, fatwa, pamphlets and other IEC should be produced and widcly distributed to givc religious support to an otherwise contentious issue. . More IEC should be produced and distribr.rted, but thc regular IEC conccpt should bc broadened to include use of altemative media, such as sollgs, dranta, poetry and school based enlightenment programmes. 2) More CDDs should be selecterJ anci the criteria for selection of CDDs should be participatory. There should be the standard ratio of 2 CDDs for every 250 people. Guidelines should include permanent residency rvithin the comtnunity, gainful employrnent and willingness to promote community service. 3) Women CDDs should be selected in the courmunities whcre there are willing and capable women. 4) More trainings and re-training for CDDs and health workers should be conducted. The duration of training should be increased. CDDs and supervisors should be rc- trained before the next distribution exercise. 5) The content of the training should be expanded to include colllltlltllity advocacy and rnobilisation skills. Record keeping, drug distribution and management of adverse reactions should be incorporated into practical sessions and group work. 6) More supervisors should be appointed to cover areas tltat are underserved. 7) Supervision of CDDs during distribution and afler should be intensificd using NOTF and APOC checklist on the job training for CDD should fonn ;rart of thc supervisiou. 8) The use of one register for several villages should be discouragcd. 9) A seminar on CDTI should be organised for policy makers. 10) To ensurc the sustainability of CIITI. communities should be educated on the ueed to support the CDD and encouraged to provide cash and other incentives to them. 11)The communities should be educated on the need to establish participatory mechanisms which are critical to the success of CDTI such as hosting village meetings, establishment of village development committees which lvould enhance community participation and self monitoring. 42 12)The statcs and local govenlnrents sliculd release the countetpart funding as ancl whcn due. 13)Given the difficult rural temain they have to cover, more n-totorcycles artd vehicles should be provided to the SOCT and LOCTs to facilitate supervision. 14) The census issue should be revisited, thc one conducted should bc relcascd with thc expectation that corrections arc madc wlrcrc ncccssary bclorc tltc ncxt clistributiolt. 43 Appendix Persons Met 1) Dr. Jonathan Jiya - National Coordinator, FCT Abuja Tclephonc debricfirrg in Lagos NOCP office. 2) Dr. Y. Fayomi - Zonal coordinator NOCP -- Kaduna 3) Dr. Elizabeth Al-Hassan - Sight Savers Intemational, Kaduna 4) Alhaji I{assan }.{ohammad - Ifon. Cornmrssioner fbr Health, 'Zantfal.a State, SMOH, Gusau 5) Dr. Umar Muhammad - Director Public Health Dept - SMOH Gusau 6) Malam Yahaya Bawa - Deputy Director Public Health Dept - SMOH Gusau 7) Malam Abubakar Shehu - State Coodinator Oncho SMOH - Gusau 8) Malanr Mani Mohanrmed DPHC/HOD Bungudu LGA 9) Malam Aliyu - Deputy HOD Bungudu LGA l0) Malam Bello Kadiri Ahmed LOCT - Bungudu LGA 11) Malam Kabiru Garba LOCT - Anka LGA 12) Malarn Lawali LOCT - Bukkuyurn LGA l3) Malarn Halilu Salihu Kanoma LOCT - Maru LGA l4) Malam Muhammadu Mairago Deputy Village Head - Yarlasha Anka LGA l5) Malam Rabiu Dogo - CDD Yartasha, Anka LGA 16) Malam Tudu lbrahim -.uillage I-ead.cr, Yar \,Iata-nka.i Anka LGA 17) Malam Abubakar Wakili- Village Leader, Bagada Anka LGA 18) Malam Ibrahim Abubakar - CDD - Bagada, Anka LGA 19) Malam Sani Mohammed - Village Leader - Dan Daura - Anka LGA 20) Malam Hamidu Musa, CDD Dan-Daura, Anka LGA 2l) Village Leader, Doka, Anka LGA 44 22) Yrllage Leader, Gidan Nabardu, Anka LGA 23) Malam Mohammed Bello - CDD, Gidan Nabardu Anka LGA 24) Malarn Liman Muhtari - Deputy Village Leader, Masamar Mudi, Bulkkuyunr LCA 75) Malanr Lawali Garba- CDD, Masarlar Mucli, Bukkuyyurn LGA 26) Malam Hakimi Mamrnan - Village Head, Tungar Bawa - Bukkuyyum LGA 27) Malam Linrarr Musa - Villagc l{cad, Sabon Tunga - Bukkuyyurn l-GA 28) Malam Garba Mala - CDD, Sabon Tunga, Bukkuyyurn LGA 29) Village Head, Marafa Garowge, Bukkuyyurn LGA 30) Malam Lawali Umaru - Oncho Coordrnator, Senior Cormnrunity Flcalth Extension Worker, Bukkuyyum LGA 3l) Malam Garba Bala - Officer i/c CHEW, Bukkuyyurn LGA 32) Alhaji Muhammadu Dandabai- Village Leader, Tsiligidi Bukkuyyunr LGA 33) Malatrr Sahabi Bala, CDD Tsiligidi, Bukkuyyurn [-GA 34) Malam Wakili Dan Balarabe - Village Leader, Tudurr Gandu, Bukkuyyurrr LGA 35) Malarn Mohanrnrad Dan-Iya CDD Tidinr Garrrdi. Bukkuyyurn LGA 36) Malam Abubakar Hakimi - Village Leader, Inwala - Bukkuyyurn LGA 37) Mohatrrmadu Umar - CDD - Inwala, Bukkuyyunr LGA 38) Malam Abubakar Miagari - Village Leader Birnin Waje, Bukkuyyurn LGA 39) Malam Abubakar Salisu - CDD - Birnin Wajc Bukkuyyurn LGA 40) Malarn Abubakr Sabongari - Ajiya rcprcscrrts Villagc Lcadcr, Birrgi, Maru LCA 4l) Malam Lawali Lumu - CDD Bingi, Maru LGA 42) Mohammed Abubakar - CDD - Bingi. Maru LCA 43) Malam Salihu Bako - Village Leader Tugan Mani, Maru LGA 44) Village Leader above is also CDD of Tugan Mani, Maru LGA 4-5 r( (4a 2_ INr)r(iz\'r'() rts rr()r( r Nl.)riI,tiNr)r,:N,r, I r ( )Nr,r.( ) It I N ( i EIIITtrC'I' E-l ta- 2 lr::ffi:il:t and rrtrrrr[)cr'ol'tarSet c()ilrilr'rriti(:s \vlriclr tlccirlctl on tlrc pt:r.iorl ()r.rrcrlr(](l ol l)rollorlion iuld nlultl)cr. ()l own cDD. (ilIgc( c()illtrrrrrrilics \vllctc llrc,,cprprlrrrrilt,..st.lt,c(crl Ilrcir OU'I'I'U'I' 0-l o-2 0_3 X o-+ 0-5 Pr.Portiorr arrrr nurrrtrcr 0[ refrrsars rrvo rrrorr(rrs ilftcr rr is(r irrrrriorr l)roll0rtiorr arrtl rrtrtrrIrcr 0[ ullserrlccs tltitt \\,cr c lalcr tr cirlcrl Proportiotr arrd nurrrlrcr oI a(-risk vilt;rgcs tr ca(cd Cost ller l)cr.son treirtctl Proportiorr arrtr lrtrrrbcr <l[' c.rr,l^rrritic$'*,rrcr c CDI )s r',cr c crrarrgc<r rrt, rrrcaftcr tlrc flr..st trca(rrrcrr(. Proltortion antl rrurrrllcr ol. corrrrnulritic.s irr rylriclt tlrc CI)l) i.s srrpcr viscrl lr1, tlrc Itcaltlrcare sys(enl Prolrorti,lr arrd lrurrrtrct.o['rirrgct c'rrrrrrrrli(ic. ,r,r,i.r, rcccivctr cdrrcinll)orlilllcc of extcrrdcd ivcr rrrcc(in IIcilInt(.nl. Proportio, arrtr rrttrrrber o[,crsorrs -5 yc;,s irrrtr abrve *,rr, rccei'cd corrrntrrrrill, 0-6 o-7 0-8 INI'UT l-l t-2 t-3 t-4 irliorr about I)rollortiorr and rrurrrtrcr o{ corrrrrruriirics \\,illt.(rlt Proportiolt altd tttt|ttllcr ol r.rr,,,,.,,.,r,: ,b r l' corrrnrrrnitics/pr o;ccl.s .shrlrtagc o[' ivcnrrcctirr. tvctntcctilt irrcrl C'l) I).s (ltirl c.rpcr icrrccrl lrrtc strpply or tl l;rtc su1rp11,9l lirrrrls c'ollcclcrl iycr rrk,clirr lrorrr I)rollortiorr alrd rrurrrber rrl.projccls rvlricli crpcr icncc Prtlllorl iott attd rru rrrbcr,I r. rgr.( currrr r rrrr ri ( ics rvlr iclr collcction poirrf/rlre lrealtlr ccntIe. * It i's suggesterr trrat AI'oc r\I:rrr:rgt'lrrelrt corr.sitrur-*,,,r,t,-".r.ri,rg rrri5 irrrricirror.sr.plrr.lr(cr1. I -5 proporriolr arrd lrurrrrrcr .r ar ) [)s 1f i11, rrrc.:1srrr irrg dcvicc firr Ircigrrrl-(r I)rolltlrtitttt alttl tttltltlrct' ,l'crrrrrrrrrrritics r'itrr trcilrrlerr rcgistcrsl-7 I)roportir.lrr arrtr rrurrrlcr. uI trcir(ctr c,rrrrrrrrritics r'itrr s . gl'llce. ""r"r"ilLi \t rtll tlllllllil tl' lirr ttts lr( llrc rlisrr ict lrlorrilor irrl, llr\tr u,tt.nl\ li :rrr r;,;1 l,; I N l:t). l,)rr() 1l TI t I T I I T T T I I T T T T I T I T a77 *sfia *.? rr. o tn 'rl Z vt$Is (ra (D 2.,<BegcE-(fil [gHdSsEtJ p G I.t< tr tre :"1.' g H'lE,E5(DnFHif ' E-o -oC rr, a./)Ioz qe.{83!( < (D crbo o E A gE €\<h oE o9 5.lRt aJ(| (D ='Jd F':1, a I Ell ilt..J j- z<8 99 <U$If .,*s u '\) { = ='!cPpoioiltro-^os -d 8E g 3 ? S. =i.rc =< o EaE* =u, =.p* o-- -5 €Go.= .r, rn(n t] o aC rrl L/1Jo = =ATFEEE i [ &* "" z<* 3.6 SE;Eil [ (! 5 do ,f D)$I=.,8 E-E g 6 "t.+ dE ; zo -lo oC rrl(/,l z<* 9X S uillt9(liirDa-o-r.ti'B.<E 3 X 9oI rpF oC ra lt1Jo z Ir..J E=>c= r)Frfi o< 'o H'S',rrqsgE TU x;;= o*3-F E q fi,eig,r E."ii I i=o F q oh tt2-9F:E5 'H 6'soa--:a3 =.E E I JrugQ 6€ d o Pni oh5o -6rDliEXEs5r--C -, -z' 3-9=.9 o Ca -='ti.e dP-b''6-s - -l6xJr(3.E c -5 3'z "'PAto= .-oH 5. B, 3,: .Eq E ;€ ,D' ' , '- (D3 o- 2 o 9i5'g3 6 71J,<s#'o I5 t(D 3 E :E E'=ga2H :.='+> 6-'J= ==J9e E:{Hai&c-;q r<fDr-: DF'+6 =6 m8* FE (D-Hn Z->Ar(D6'>hNirD 16 h 3O O'O cf '.9 a :NJ- r.JJ ajft=- :og d':E !--U arOcn?6 oI.9udi oU,O P d3f1 aFl = 5'9 JHod!ia*i-mJ =Hd -5:E 'O+Gq 5BdE g 3o= 3,o 6 o- S. 'r' -6j OI"q6- o re rrrO =.>d=-oo- >n o >1 It o Ut @ rJo (! (D(t l!F rD A) .D(t D' IJ DJ E'a 9.o tr o o0- o ;i UA(D Z o, 3(D ;i UA o o o o. o t 7 o = o N 2 rDq, j (D I oCq o g o- E z 9 I o(,q A) 3(! 3 !. g ol E e ct5 xIt Iit E\o i { D = L f\x a l^., 1..'; t' E t-. I aa \r3l, I' tl' | .t' \l , l. I ) I ' 0l ) (l '! .-l "l ,r .LJ -. qr 'l :< _:" , L) .3 tj l'o(:\ _l ) .'; ) l o t.: t\, lrl al r) ; ( !)( ,) a: -'1 E g .2-, .9 oo E :z 7 = e 3 al =C 9 E o o .tl C'q o ac (JPIL ^C,I8 .=E cro .lJ $.1oEf8t * -.; ll ,63ggr.E 'E ll.+E i\ :i,Eri €.oI fg[€;** (n ., llil3!'6 .9u _-E E ll tr g-tootr x ll -E b:E r E HE3qEEO (r..T'oq, I * \iOr-ll oqc o\ ooll O o\ c, q .ll . .J F " ll8'=.q E . e? $s E #,f Bi E =.q b s > = (! oJ.E o6 E E,g 5 c o-iOOI I ";S *X oC> tt tt U E.E T, 8E s p.S.= S -EEeEEE -l I I !-. 1 I IA () (-' '1 ^i I ir 0, I t' t; .U r-) I I I rIteflqfornrant Inten' g.t_[.etdc_f.! \'illrrgeN.u'..-.VillngeCorle:---I)istrict/l,(iA:-- ('otrtttrt': I)nle of lnst tlislrilrrrlion I)lcasc tell us about any progratnnlc conccrrrirrq orrclroccrciitsis lrcaltttcnt irl llli\ r'illlrcc'l (PLEASE NOTIj TIIAT Tlllr fOLt,OwlNG I.SSUITS AIlll At)l)ltl:SSI:l)) rvho brought tlre itlca oI thc onclrocerciasis proerantntc lo lltis vill:rtc'] u'hen did tltc pcrson(s) ct'rtttc talk s'itlr ytrtt alrotlt ottcltoccrci:tsis'l did thc persorr(s) ntect rvitlt you alttl othcr villngc lcadcrs lirsl'l rvhat did lre tcll you? (l'rohc for contntuttilv orvnersltip oI Protrlllllllle ltttl cottttttttttitv rcsponsibility) Did he ask for you to arrang,e a nrcctingl) 2. llorv rvas the tirne (rnontlr/scrson) lor distrilrution tlccitlctl'l al a villatc nlceting - evcr\'(rnc discussetl village cldcrs villagc clricf/lcatlcr health s,orker village conrnrit(ec othcr (spccify)- 3. \\'lrat mcxlc of distribution was dccidcd'l housc-to-house ccntral plrrcc (spccify botlr housc-to-lrousc and ccntral lllucc otlrcr ( ) 4. llorv was the modc of tlistribution dccidcdl) at a villagc nlecting - evcr\'onc discussed villagc cltlcrs villagc clricf/leatlcr Itcultlr rt,orkcr villagc comnrittce othcr 5. llow many frcrsons in this villagc (CDD) givc out the tlrug frrr orrcllxcrcilsis'' I 2 3 4 I 7 3 4 5 6 I 2 3 4 5 6 VII.LACE A-l.l:At)l:R -'fOOl.- I )l (). llotv nruny rrralcs'l llow nrany lcnralcs'l 7 . llorv rvcrc thc llcrsons (CI)D) sclcctctJ to do tlrc rvork'l ut a villugc nlcctlug - cvcr)'onc drscusscd vrllugc cldcrs vrllagc chicl/lcadcr hculth rvor Lcr t illagc corrrnrittcc rlt lrc r S. \\'lry drd you clttxrsc tlrcsc pcrson(s)'/ (l'rotrin!, lor crrlcru) 9. lluvc thc Ct)Ds rcccrvcd any trarnlng'J I. \'cs 7. Ntl 3. Can't rctttctttbcr Itt ll'rcr trr Qt), rrlrcrr tlr.l thcl' rcecrvc tr:unlnli.) IJulorc tlrc lrr st drstributrorr Durrrrg drstrrbutrorr .Sorln ultur tlrr: lrrsl drstrrllutrort [ )tlrr' t [.rrtlrr'/Curr't rcrrrcrtrllcr IL llorv wcll huvc thc Ct)Ds tlonc thc wurk'] l. vcry s'cll 7. l'uir 3. lloor ( l:rpluin) ll. lllvc you clrangcd your CDD'I l. ycs 2. No 3. Dorr't knorv t-l. ll 1cs to QI2, rvhyi lr ll.rrc 1uu ltlte e()nulruntt) ) rcccrvr.rl cducatrort ()lr tllc ullx)rlJnec ol l;rkrttg trr:rtttccttll taltlcl :rrrrrullll' lirr scr crlrl 1'c.rrs l l. \'cs 2. Nrr J. ('urr't rcrrrcnrtlcr I 2 3 { 5 (l I 2 -1 { I 7 -1 .t Vll l.ACl: A-[-l:Al )l:l( -'l (X )t.-] l ) t5 ll'yes to Ql4. ask: Wlrcrr tlitl vou rcccivc thc ctlrrcaliorr,l ('l.ick lrll tlrlt lr|plr,) L During tlrc firs( lncctint 2. Rclrrrc thc first tlistrihution 3. During tlisrrihution 4. .Soon aftcr distrihurion 16. lIycs to Ql4. s,hat \\,crc vou told,l (probc lor ilnnual trealmenl frlr s$,eral yclrrs benefits conrmunity responsihil ity t7 g slrotrltl he collcctctl [rrrrrr a collcctionpoinr'l l. Ycs2. No l. I)ort'l k rrorv lll. [)id alry nrcnrhcr of thc conrrrrtrnitv collcct rhc tlrrrt frorn a collsq.11,,,,, p(rn]t.] l. Yes 2. No 3. Don't krrorv 19. lf no ro Qt8, why'l 20. Whcre is thc collection poinr,.) 2r I)id you cxpcricnce latc srrpplv oI tlruu tlurirrg tlrc l:rst tlistrilrrrtrrrr., l. Yes 2. No 3. Don'r knorv Plcasc explain 22. Ditl you expcrience slrortate of tlrugs rlrrrirrg r1e l:rst rlisrrihuri...., l. Ycs Z. No 3. Don't knorv t 23. If ycs to Q22, lrow rvlrs rhc prohlcrrr.solvcd,l Docs (lrc comlrrunity havc a trclltnlent rcgisrcr,f 3. l)orr't knorv fl h c Was tlrcrc any conlmunity tlecision on horv the dru 24 L Ycs2. No Vll.l.AGl: A.l.l:At)l:t( .'t (X)t.-.'t t I ).,.) -) 25. Il'ycs to Q24, rvhcrc is thc rcgislcr kcpt'l .ltr. \\'lrut utu )'(rut sug.[,cstl()ns trrr llrlrv llrc corrrnrunily cuuld bc ruorc irtvolvcd itt trcattttg ils tttctttItr:r's tvillt it,crrtrcctirr lirr scvr:r:rl ycurs'l 27, ls tlrcrc unytlling you will likc to tcll/ask us? Vll.l.AUl: A-1.IAl)l:l( -'l ()OI--4 cx{-i ilH,rl ",I 'i:i How J ,t Jtt J> t.I roult "A" viiluges. lnrctview 2 CDDs lter vtlltt1,,t: if tlrct e 1t.e ptot ttlte lttlCt'r'tctv tt.rk tlrc distt'ibrttor ttt lct 1,11,,.r,,,,clntg if it it tltc cttsa se cotle. ltfttlte r Ittrtlr iltlc vlter tc.tl)ouJc.t, tk) ttol [ot.11ct toC ttltlt t'rt1t t.ittl e Itts ttlttl.s; tt'tcu.\ut ttrt, l)ltl (t ( tt clc ilt0ttttrl ctt, it ,::.i:ilh:lirl .,l' ,,rfil : i$. t:Ir.. ., ri. 'rf, \[prc or Viillgr utricUstatc Villagc cuJc: .--subcourrry/LCA \fl;rc or CDI> Scx: l. l;crrralc 2. M;rlc $lu occupariorr ]{ Y,fl,,,, atr<l year o[.r.sr CD'l.l disrriburiurr irr ltrc village --/_Morrtlr arid year of lasr CD.l.l disrritrurrurr irr rhc village _/_ l. How vlas tlrc tirrrc (rrrr,.,tlr/seas orr) [or rlistrihrrliorr rlcc irlcrl'fl. at a villugc n tccting2, viil ttgc cltlt:rs' rrrcct ir,1:3, viilage chic[/lcar,lcr 4. lrealtlr wtirkc r5. viilagc lrcalrl t conlrr:it(cc6. viila gc cuilulti(ec rrrct:(ir7. orhc r(spccify) lr ,, Irl , ii ,j i\r rA ,'2 'I ij ;,.,il,,r, r!lorJc of tlistriburiurr was tlccirJcd.r t houuc.tu.lruusc 2,, scrrtrol ltlncc (sgrccify)3. llurtr I tousc-to-housc hri tl ccrrtr,,t lltnc.4. olhor (rpcclfy) was tlrc rno<Jc si distriburiorr clccirtct,l,/ t. 2. 3. 4, 5. 6. 7. nt a vill:rgc trrcctirrr, ,illr*" cttJcrs.,,,"i,,,g villugo clric[/lcrrrlcr Ircgltlr worker ,lllrU" heultlr corrruritrr vtllage corrrrrri((ec rrrccr olhcr (sgrccify) 'c lirrg .t I 'i I rt il, i, ri t.: d, I 3. I l.t!l ,'' I 1:i :l,l t.,:, I wt lr ' Jll', ,', It, ,.- I:' ,- r,, I l'r i.' r'' t" I (, '- ti. A lrrttltor rrrg ft 13lrrrrrrrrll Xrnprlr, Mry I 999 ,( ' ,1li I )i.t I .:iisi' f I t. r i l\'I i i'ii ,l llorv rvcrc lou lclectctl to rlo tlrc wttrk,l I'l I t. 2 3. 4. 5. 6. 7. ul u viltugc rrrcclirrg ,]llnr" clders' rrreetirrg vtilage chief/lcader Ircttlllr workcr village lrealrh conrruiltee !o'h' kd,. 5 6 7 ,l'las arry cDD bccn crrarrgcd arrcr trrc rirsr distribu tit:u), [, yes Z. No 3. Don,l kuoy. lf YES to e5, Why was rhc CI)D ctrarrgcd? / villagc corrrrrrirtcc ltrcct irrg otlrc r (spcc il'y) l'lavc yg11 evcr bcerr supervisctl I 2. No 3. Dorr'l krrow llealrh .sraff : Villagc healtlr corrrrnittec nrerrrlxr NCO pnrrrrcr Cornrnulr ity rrrcruber/clrie fOtlrcr (specrl'y) l. Yes l. i I I rl l1 t, I t I 8a.'lf ycs to e7, rul,,,..r):lIy!:crt y*r ? (tF NAME WA.s MriNT.lON'DI D ENTtTy/posrTlo N/!rlr.u s'o I, ri i p.'p clrso N) l'l.F.A.SI A.SK Ir()R l, 2, 3. 4. 5. t'. 8t:. Whar rJid thc supervisor doir l. Cf yccfer] rhe iv.cnrrecrirr irrvenrory ,Z. Clre.ckcrl tlre recor<ls/lrent,ltcnt regislcrl. Cr.lllatcd rlle reports4. Advise<l orr tlrc trealnlcnl oI nllserrlees5. orher (spccify) 9. At rvltat occasiotts were you su,crvisctl? (ClltcLE, ALL Tll^.f AI,l,Ly) L Belore tlistributiorr 2 [)rrrirrg rli:rlr ilrrrtinrr 3. Soorr afrcr rJisrribufion NoNo 2No 3, Cntt'l rcrrrcrrrlrer Mnnirorirrg lrrstpnE1|1! Krnpoh . Moy 1999 l. )'es l. Ycs? l, Yes2 '7.. No ''^' 'fnlil 1::'::i;11:::lf:1,.," tltc i,r1,orra,ce orrakirrg i,errrrecrirr rar,rer.s ,.1 \5 Ycs lr, .: I I rJ*.4,1&l4r,. r, lt 3d l0b. lf yes, what,wcrezysu rrrlrlJ provrde [lre corrrmu,ity witrt cducario,'rr ivcrrncctilr trea(rrerr(? 12, lt ycs to Ql l. when rti,l r,,,,, h-....: ,rrli n,)i,rri"r, ditr you providc trrc educatir, ro rtre co**uni(y? (cr*cLE A r-L I l. Dir! you 13. lf yes ro Q l. Yes l. Ycs Otlrcr (spccily) lu trairrir lg-_ Lsst trai l. Ycs I , )'cs l. Yesl. Yes ALL TIIA 2. Nr.r 2. No 2. No ?.. No T, APPLY) Yes 2Ycs zYcs z)'es Z. 2. No 2. Nd I . Duting thc first tnecting2. Ucf<rrc tlrc firsf dlsrriburl<lrrj. uuilng dislribution l. lo.on aftcr <tistriburion5. Orlrcr (slrccify) I l, what did you rclt tlrc conrnrurrity? (CtRCLE .l faking iu..,n""ti,, ,rtnuatty ftrr several years : Bclrcfi(s r.l[ (rcatulentS.,Corrrrnurriry re..,ss151L1111y4. Sidc cffects6. Orhcr (sgrcciiy) No No No No 14. Did l5 vou receive ally rrairritrg ort lrow to trea( cottrrrrurrity rrrerrrbers? lf Yes to Ql4, rvlrcrr ditJ ),ou rcccive traiuing? 16. WJ,o rrainecl you? I 2 3 4 I'lcal tlr pcrsorrrrc l/Orrc I rvc oo'siniil;:, r; "" c'rord irtaror Arrothcr CDD =- 17. l{orv long <lirJ rlre rrairring lal,r? l, trainirrp arrl . . tl.t]illlltlr Lrst .trai,,h-,i|.- l.lorv rrrorry CDDs \vcrc tl;nrrcd togctlrcr (Slzc of llrc gruup).r .t*..,"...,*.^ l8 l.i' ,1, il lr.trrrrrrrrrllsl lnrlrunrrrll Karrlrlr. Alry l ggg I 'ii :l 'rt I Y,, ,,1' ,;' J,fi" ,}: I, li,, fr. fir il .f#,r ,!L 19, Where was tlre vcrrue oI rlrg last rrairrirrg? l, Witlrirr llre corrr '1. 0utsldc rltc curr3. Hcal(hcare facill. Otlrer (spccity) 20 Ycs 2. Nr.r rrrurr ity ttrrtrrr ity ity/lruspir:r II I I ,'l,l ,l ,il Was tlte vcrruc of training rrcar lo your conltnurrity? f1 , a,l r^lt "l 2t wl'lr wc'c yr)' r'*r,rrr rrrrrirrp. rrrrirrirrl, 'rr*ir.rrr.rrrx:crt:i,*iri ((-rttcr,ri Ar,r..r.rA,l.n 't,r.\,)I . Cuusu 2, .Syrnp(otrrs 3, Socio.ecr.lrrorni, 4. Corrrrrrrrrrity rrrr5. lverrrtectin as r6. Otlrcr (sPcclly) ,) wltat rvcrc you tauSlrl ab.ut tlrc .rug? (cll(cLE ALL'l.l.lA.l. Alrl,Ly) Duration of trcirtrrrerrI Covcrngc of rlistrilrrrr iorr c iruportarrcc rlrilis;rtion :urr l p1111q.11 i1111 realrucnt for :r lortg tirttc l. Ycs l. Ycs l. Ycs | \'cl l. Ycs L Ycs l, Ycr l. Yes l. Ycs L Ycs | . Yr:r l. Ycs I Ycr L Ycs l. No ?.. N, 2. No 2. No 2. No 2. Nrr 2. No 2. Ntr 7 N,t 2. No '). No 2. No 2.. Nrr 2. No Yus Yes Ye.s I 2 3 ,4 5 6 7 8 9 t. 2. :1, 4. .5. 6. , Dosage dcterrrrirration by rrrcasuring hcigtrfExpiraliorr oIrJrug nfter rcrrrovirrg fontairrc.r sc:rlI tcilullcn( ul itUsclltccs utrd rcl'usals Sirlc c[fccts (corrrrsclirr;1 nrrtI rr:[crrrrl) Exclusiorr crircria Ilecortl.kee^ini Certsus I 0. Orlrer (specifl,).*.. 7.1 wlr*t wcrt: y., rrrgrrr ub,rrr rcpur tiru'r (uil(cl.tj.Ar.L .t.ilA.r. n r,r,L.y) Nurrtbcr of pcrsurrs tr culc(l Nuurber o[ relusals Ntrttrlx:r of nlrsciltccs Nurnber of exclutle<J l)ersolt:iNtrrnkr tvitll sevcrc si<lc r.[[r.t.ts Other (s1>ccity) Did arry rrrcrrrbc?'f rrrc corrrrrurrity c,rrect (rrp.rrrrrg fr,trr rr carccr.tltc last distributiorr.l ,,yy.,,,,s urril i oil troil Poirrr tlurirrg l. \,cs 2. No 3. l)orr.l klrow '1.5. l[ "no" lo e]4, wlry,/ Al,lrrror llg tlrr,.rrrllt X orr,1,6pa.i Alrv lllrrr Yy 2. Nr-r 2.' No .) Nl, r 2. 'No ) N,' l- 2,1 i,; I l,l, i" I I I i' t::*' l).)' ':'i iIil l i I I I I I l' L t I i I l I i I I I I l :i ":i+f1:. :-G! " -+*t) i,-i;:',i. :s{d '-ri. v ).(' '2t 7fi 2yb 30. llow do 't'ilA llttw {s ye11 lrcaliltellt? Dld you cxperi '1. yes | . \'r.s lf ycs, pleasc e.rlllarrr Wlrclc is tlrc eollcctrurr lrurrrr/ crrcc lalc sul)pty of drugs rJurilrg (hc last distriburiorr? 2. No Plerse explnirr rt,rw rr, y(,,, ,(,rrr,.ry rrcrcr,,,,,,"',;';:::;;;,;;;,,,r,, ,".,,,,,".,.,r:," *,,,,,,,,,, j1 I . Ccnsu.s,,rcgistratiun record2, t'tcvrr.rr, :i.lt ctllrrrcrtl tcc(,t.ds3. By cour rting lhe rrurrrbcr oI lrou.sclrold,s4. orlrcr ( slrcclly) hy't l . Ycr 2. lJol. Yes Z. Nol. Ycs 2. Nul. Ycs Z. Nol. Yes ?, No 29a Did you e.lpcricrrce slrortagc o f drugs durirrg the tasr tJi.strilrrrtiorr? 2 l.trr 'lT,ffi:i,'j"ne rhe nurrrr)er of rabtcrs ro givc ro arr Take lrcight nleasurenlcrrl Urc wciglrr Visual obscrvatiorr Agc Otlrcr'(spccify J l. Wlrat do you rjo about irrclivi<Iu nls who arc abserr( rJurirrg lrorrrral rlistriLruti 't , 2. 3. 4. 5. l. Ycsl. ycc l. Ycsl. Yes wcck (rclor r: tlrs(ribu rlurr inrlividual? (ClR(.t.t1 AI,l- 2. No,, '), Nu 2, No 7. No on pcricld?)2. Wlrut do you ,__- 'r :l Wlriclr crrlcgor ics rrf AI'I'LY) Irtrllv irlrrnls lrclow Pregnalrt wotnen .5 ycnr r of nge/ Lrcluw gOcrrr Worrrqr wlru dclivct.ctl lc.s,, 111;111 s11cSick in<JivitJuals Vlsitors Ottrer (.spec i l-y).-_.__ rjo atruut lrrtjivitluall, wlro rctusc llcilltnsn(,/ pcogrlc worrlrl yorr tror givc rlrc lrrLtc(s (t,LljAljU Cll(CLlj ALL .l.lln,l I 2 l 4 5 6. :t4 ir cnsutc tlrrrl llrclc elltc6(l,lc! (rf 1,tcu1tlc cvcil(u0lly r.ccclvc MorrilorirrT lr,ltrrrr*nu Xrnprlr tMal lgt)g r8 t i, t; IIt ,,1,i ,t 1 I l,:'.tl i .t't ,l,til,, ',hl S:i' ,l l 'i "ij ,Nt Ui trt / 35a."1'low lorrg'r.tbigou nonnar,ry kccp trrc tnbrcrs irr rhc corrrnurrrity,/ 35b. tlow rnarry days tritr you takc tru corrplete trre last distributiorr?ul .r1r -, 36. Whcrc tlo you rronrmlly kccp thc tablcrs? 37r. Do you,lrave rJrugs to rake clrc of irrirror sidc cffccrs? l. Ycs 2. No 38. What kirrd of suppor( do you rcceive frolrr tlre conllluuity? ;rlP,rlr arrrl y,.,r, ',^ 1 'r).1... ,;., 'l'rarrsportatiorr for ttrug collcctiorr Incentivcs (spccify) Othcr (spccity) 1i ht(':.... L F [liurri,, \., I 2 3 l,ir, 39. Do yoq have rrroblerns witlr rccor<l kceping? l. Ycs "' 2. No 40. If ycs to e39. pteale expla ,+t, plcasc,telt us lrorv you feelubou '| ' ,,t t tlre progrdrrrrrre with resl)cct to: a) sustairrrrrg tlre prograrrrtrrc lr) conrnrurrity response c) corrstrairrts 41. Wlrat tlo y<tu tlrirrk slrotrltJ bc tlorrn lo irrrpruvc tlrc lrrugr:rrrrruc,/ 43. Arc you willirrg ro conrirruc as a CI)D./ I r l. Yes 2, No /ll Plense explairr ilirtj;ififififiou RECrsTER ^ND ME^suRrNc Dr:vr.sri'r'o lnovrr)ri Fo;r_owrN(; 44n. ls rrrcnsurirrg rJcvicc lor hciglrr prcscrrt? , I I [lortllorrrrg ltrrtrunEnlr Karllpoh , lvloy lr)99 I I I I I I l i I I I . ."# ,,i,$ir :;l: i: 1il.it iil , li'li hI' I, l1 l:t I l 1""-- F l, .Ycg, 5cgi1 2. Yor, I'ut trol rccrr (lixgrluirr) +1 r,lr.rrl.r.,Nrl,.Uxlllairr f'rr' lluw rlo 1'r,, usc il? I 5. Is lrcatlllcnt rc!,ster prcscrrt?. . Ycs, scclt t . Ycs, [rut ll(JI scclt (Uxlrluirr) , N0, cxltluirr lr Q,I.5 i.s "Ycs, sccrr" ItXAMINF.'t'REATMENT REolsrER AND ourAlN t.ilEr:oLLowlNc lNFot(MA,l.loN oN: Totnl populatiorr Agc courposiriurr of pcoplc: l}clow 5 y.curs_ S years.arrd above Scxcorrrposiriorrol'tlrc.pulrulurlu,,:Mul". -l1ilil,.Nulnbcr of pcrsorrs trcatcd____Male Fcrrrale N u r r r bc r o f pc r so us ur r..t. r - 5-ffi1ilhu rcfr:li"Jf[,, ;, ; ;, ;' - Nrrrrrlrcr of rcfrrrnll t-" -NUillucr abscil( durittg lilst trcuirrrcut Nurrrlrcr rvillr scvcrc rirlc e[fcr,ts Nurnbcr of tablcrs rcccived lU, Nurrrlrcr of tubtcrs uscrl I I . Nurrrlrcr of rab lcts lc[r irr .,rc tlrug kit ';t,4 ,; I t, i, ,l l,l 4 i !l. lt, I ir'.t j I i-,t, t,, ,' 1. i I 2 3 6 t. 2. l. dt 5, 6, 7. 8, 9, Murilur lrrl lrrltr urrrlllr Kurlrlr , M ry I U9u Itrt. I i ) $r r: Lr I l 'i 5 t a i I !' t LEfI I.( i. t.' l, k" ti-. $i F-. H rrj I I I I i t l I I i I I i I i I i i I I ; I i I ,I I I I I I 4Nxexr- q L Yes l. Yes 5. Have you rec scvcral years? 3. Dou't krrow/carr't rerrrenrber 3. Dorr't krrow Fo ,> 'To'be athninistered o.rtly in grortp "l)" villages. ltttervictv 2 cDDs p.cr village i,f there ore ilrcre tlmtt otte',cDDs' At tttc end of ttie ittirviir, ,ir iii ,iistritt,,ti, ii toi yii, see ri.t troti, ,,iriruring dcvise, registers,runaitittg'dnry if availqblc' whctt a qt,ostio,t.req,ri,'c, ,,i,itii,t, rcsr)ottses, au ,:,ri'lorgct to prt <t circrearowrd each appricabre response ,oau, ii,it* tvrrcrc (u,r)r(4)ri(tte. ...i District/State. Narrre of CDI),t I _ Sex: l. Fernale 2. Malc r, ,-MainOccupation: \i. Morrth and year of tast distribution ,./ ,i l. l'low were you selec(ed to tJo thc work? at a village rrrcetirrg village elders' nrcetino village chferlead; " lrcalth,wor[cl, village healrh'cornrnittee village cr:rrrrriiuec nree(iug other (specit-y) 2' llas a.y cDD beerr crrarged after trre {rrst dis(ribu(iorr? l. z. 3. 4. 5. 6. 6. 3. l{ave you ever bccn sullcrviscrl ? 2. No Z. Nr.r 4' lf ycs to Q3' wrro superviscrr yt'ru ? (r1 Nly-!-wns'MEN'r'roNIrD, I'LEASE ASK I;Or(lDENrrry/po'srrrorursiiiij; on l rE pEnsoN) l. I lialtlr statf2 Village lrcaltlr conrruittcc rrrcrrrbcr3. NGO parrner : Cornurunity.rrrerrrbcr/chieI). Other (specify) eived educalion on (lre irrrllortarrcc of takirrg ivcrrrrcclin tablcts arrrrually [or i. Yes Z. No 3. Carr'l rcrrrqrrrber ti, Did you receive any lrainirrg orr irow ro r| ..,, . q.,,r, 6 uil l t (rca( conuttunity tttctrrbcrs? 2. No t\l l. Yes Morritorlng lnstrurEntr Kortrpolo . Moy 1999 t7 ls rrrcasuring dcvicc for lrciglrt llrcscrr(./ | . Yes, secrr)lttr 1rr,il,, at, '21 Yes,:',[gl11rut seen (Exgrlairr), 17istl.i1,rr ,rr3l.;rNo,itExp lnirr) ol)1rr rr llill trt l.r:{rril \r,r1 1r\, + !(ii 8. Is lreattllctrt register pre ,r.rrttt r',r..' ',,. sent? l. Yes, seen , 2. yes, but uot seen (Explairr)3. No,'(explai Nunrber rvittr sevcrc side cl'l.ccrs Nurrrber <lf taLrlers receivetj Nurrrber or taL,lcrs usc..i' Nurrrber of lablcts.left irr the drug kit Update oI recorcls 9 ifll8;l,itlfiir;fflTJi,i lif^ r MEN r r{uGIs rurr ^Nr) oB r^IN ,ilrE l.-l'otal popu!atio 2.Age conrllosition of lleoplc: Uctow 5 ycars 5 ycars arrd above 3. Scx conrposition of rhe population: Male Nu.rber of pcrsorrs trcatetl_lvlale.-- l;crrrale - Nurrrbcr of perso.s agetr 5 years alrd ab,vc rvrro recciveu ,r*,,** - Nurnber of Lefusals 7 Nunrbcr abserrt tJurirrg last treatrrrerrt I;errrale 4 5 6 8 9 l0 u l2 "tf )' .: t,'l'rlliil,,l,. ;.!,t.r,.,r, L 1., lrlrttUlrrri::., lil(lllrrrx.rr,r. r ,,,rl.t . [1.\. Ir,rrr) ,1, . ' I ', ,I, 'r : ,,,r, {'". [., i[ '-i i[,t ' ;I !t +* ANnr c-xe (, .,.' -i /'. .'j: r. : ; ,, OUESTIONNAIRD FOII IIEALT'I I I' EIISO NN DI- ?'ltis tyrcstiotumirc .is afutinistered ot auy hcaltlr t,orkcr irr tlrc arcu who is diractly itrvolt,cd ilt CD'l'l progroilunc i,e tlrc health sluff ucurest lo tltc t,illogc.'fltc ttutttbcr o[ l.tc<tltlt ltersorttrel to be itilerviewe<! dcpen<ls otr tlrc situatiott ou tlrc growtd. A ttrittittttutt of 3 lrcaltlt persoturcl wlrc arc srq,rcrvisors of CDDs slrould be tnterviewed witltitt tlrc project arca. After the intert'iew ask tltc lrcdth persoturcl for tlrc docuntettr.s usad lor CDTI activilies. LGA/Subcourrty Statc/DiSirict_ Country Natrreoflrealtltpersonllel-Scx:l.Malc2'l:clttale No. of O,:"1,o..Villages No. of CDDs in villagcs covercd Position:\l Quali[ication 'ltcsponsibilities irr Orrclro con(rol Progranrnrc: I Ouclrl Courdirrator 2 CDD sullcrvisur' 3 o(lrcr (specily)_ 1. Did you receive arry general oricnratiorr on CD'l'l? , l. ,Yes 2. No 2a. Did you receive trainiug ou horv to (rain CDDs? l. Yes 2, No 2b. Ifyes, how loug?--' 2c. List the rrrairr topics covcrcd 2d. Wcre,you taugltt trorv severc sidc cflccts shoultl bc uranagccl? l.' Yes 2. Nr.r - -3iPleaselell us wltar you krtow about tlre CDTI l)rogralunre rvirh respccr to 1. Cornnrunity responsibility 2. irrvolvenrcnt of the liealtir sysrenl irr CD'l'l 4i Was tltete an initial rneeting with the coullnunity rvlrcre CD'l'l rvas inrroduced'/ l. Yes 2. No Morritoring lnstrunrnls Klnrpaln , May l99g +i N:,,'j-ftj,liiQ4' rvhat r.le tlitl the lrealth sta[F ntrry irr :rrrarrgirg frr rrre first ^reerirrgr tcrnr-ca nLij, '+. il.'5i ,;, I;acilitated the rucet irrg Met with village leatler to arrangc [r-rr tlre rrreetirrgOther (specify) 6 Wlro led the facilitating tearn to tlre coirrrrrulriry? Irealth stal'f govenul)cnt adrrrirristrativc sta[[ (norr_lrealf tr)NCDO sraff othcr (specity) NobuJy Xffi,ji" cottttttutrities (rvltere you wr-rrked) cducatcd orr rrrc i,,,porro,,.. oI treatrrrent witrr iverrrrectin l. Ycs 2. Ncr 3. Dorr't krrorv 8 Il'yc.s ro Q7, rvtrat rverJ rlrey rotd? (cillcLE At-'L TilA.l.ApPLy) Arrrrutrl trcatlllcllt for scvcrlrl yeurs lJenellts of treatrrrerrt Cournruuity responsibiliry Others (specity) I 2 3 t. 2. l. 4. 5. I ,l t!;. Il ':(, llt:l 't \r'' '/r.i .rftl r, rliz,', : rtlJ'- 1 1 2 2 4 l. Ycs I . Yc.s 1.. Ycs 2. No 2. No 2. No 9 wcrc cDDs irl (ltc corttttturtities (rvlrcrc yotr rv'rkctl) rrairrcd lor tlrc CD.l'l ,rograrrrrr:c? 1. Ycs 2. No 3. Don,t krrow I0:r Il 1,q.,,, Q9, did yorr parriciparc irr rlrc (rairrirrr ol"Cl)t)s,/ l. Ycs Z. No t0tr ll'ycs. lrorv lo11g did rlris tmirrirrg se.ssiorr last./ Initial trar Itetrairrirr irr ing-- t! I ll. Wlro supervisccJ the CDDs I . N0t sullerviscd 2. Villagc lrcad 3. Village lrealth c<lrnnrittee ruerrrller4. lrealth ltersonrrcl5. Orlrcr lllr li'strllcrvised, lttlrv tttalty cDDs did yorr.strpervise tlrrrirrg (lrc Ias( disrributiorr? l2 ll'rror supcr viscd, rvlry?. At rvlriclr occasit-rrr.s tritr you visir trre cDD,/ (cil{cLE ALL.r.ilA.r.AI,pLy) l. Ycs 2. Nt-r :- i .hl I ., I i,.,, .t:(.1. )l'-l,i- i, .t | .'] I llc[orc rli.strilltrtiorr NlorriIrrirrg l[5ln[tEnls Krrrrn.rlr . lvlr1, l9r)g I i P6 During distributiorr Soon alter dis(ribution Collection of unused drugs after distribution Review of records Marragerrrcnt of si<Jc eflects Supervision of drug rjisrributiorr l. No constrainB 2. irradequate/lack of rnearrs of trarrsport/fuel3. Too rnuch work 4. Inadequate/lack of supcrvisir,lrr allowarrcc5. Inacccssibiliry 6. Othcr (spcci l6a. llavc tlrcre been arry ctelays irr receivirrg ivcrrrrectirr,/ Il Yes l6b. If ycs, explaiu 2 3 4 l. Ycs 2 I. Ycs 2 No Nr.l 1., Othcr (specity) l4' Whatfluttc(iotrsdoyoupcrl<;nrrtJuriDgyourvisirrorlrcCDD,/(cll(cLEAI-Ll.llATAppLy) I ., 3 4 5 l. Yes 2 l. Ycs Z I. Yes 2, l. Yes 2, No No No NoOther (speci [ 15. wlrnI con.straiilrs do you hirvc irr suPclvi.sirrg rrrc cDD? (cillcr-E n Lr- .1 IA.r. A ppLy) L Yes l. Yes l. Ycs I. Ycs l. Ycs 2. No 2. No 2. No 2. No 2. Nt-r 2. No [6c' l'lave tltcrc bccrt arty clclal's irr collectirrg ivcrrrrec(iu by.rlrc crrrrrrurrity? l. Yes 2. No 17. If ycs to el6c, pleasc expla llt 18. Wlrar cousrrairrrs havc you expericlcccl in get(irrg rlre tlrug,/ (CIIlCLlj AI.L.fl IAliApl,l,y) l. Noue 2. Transport problenr 3. lrradequqte supply4. Dclay iu suppty 5.. Ottrer (spccify) Yes Yes Ycs Yc.s 2. No 2. Nu 2, No 2. Nrr 19. I{ow rJo you eslilllate tlle quarrrity of rlrug requirctl? t. 2. 3. 4. 5. Not responsible Nunrber used durirrg last treattrrcnt Based orr requests.frorrr tlre CDDs 1'otal population (with rhe forrnula Other (specify 20. Did yuu get lhc rJrugs whclr rcquir.ccl? l. Ycs Z. No lvltrrikrr irrg l[str ullEnts Klrrlrlll . lvlrry I r)r)r) i ! r) t{ I --'tl I, I 21. tf 'ro ro eZO, why? i. "illll,llf l,i',lii;f-'o,,aI Ievc, .J. Ortrer (specify) 22., Do you have facility for.storage of iverrnectin,/ i i i F I t, I I i i. t t l. yes 2. No Whar orher lrcalrh acriv.i,j::do you corrrbirrc rvirlractiviries'(pttollE FOR I.tEALTII nCt.rutlry tN 27. How <Jo you feel about tlre CDl.l prograrnrue? 3, Dolr't krrorv Wcie cases of severe side effects reported to you,/ L Yes 2. No L .Available 2. Not available (cr.tECK AVA il_ABTL|TY) 9,fi ';.H: " iif ililli, or,, 23. IIave you experienced, loss of ,tablcts <Jue to pilli:rage,/ l. Yes Z. No 3. Dorr,t krrorv 24 25. 2(t fu1il11i1111;;* lntlnrtx:,ll( Knrplr;11;1, A,l.r\. l,),)() Arvx<-xc & I t n'rcttvt nw G UIDtr For( pol.r cy-MA l(rins/ lvno r( Eprt risriN'l'ATrvr/pno c rrn Nr M Ii I\,IANAG EITS/ COOITDINA'rORS SECT|ON A: PROGITAMME MANAGERS/ ONCI{O COCr(DTNATORS .l' Pleasc describe ltow tlte CDTI prograrnrue is beirrg irrrplcnlellted irr your area PROBE FOR 2 :1. The approaclr,used lbr introducirrg cD'l'l to tlre corrunurrities b. Eletnents of collal-rr.rratibu trctween Couuuuuity, llealth systenl arrd NGDOs (IDENT'IFy SPECtFtC ROLES) c. Gettcral re-orietttatiott of lrealrh Jrcrsorrrrcl [owards CD'l'l prograrrrrrrc d. Mobilisation of rhc conrnrunities c. Trairring of hcalrlr staff as trainers Please.exlllain proccss oI rcceivirrg ivcrrrrectirr. PROBE FOII : il. Delays iu sirulriy . at wltat lcvel and rvhy'? c. Adcquacy of tlrc quantiry reccivctl/slrortlgc rl. Sturage e. Distributioil to corrrruunities l. Constraints (srora-uc, transjrort, ctc) S. Pilferage FUNDINC: Please probe tor a. Delays in etrdorsenrcllt of lcttcrs of agrccrrrcrrt, 5t T'ltis ilueruicw is a&ninistered oil Co-ordinators, Prograttutte nkutr.gers) represeilatives of NGDOs ittvolvetl it1 CDTI, Mitristry of health ltolicytttakcrs otul tlrc WIIO rcprcsetttiltiva itt tlrc coutrtry. Ir is sitrtilctr to t1e . i,ile,'view of lrcattlt personnel. Doctunetils sac/t ru rcgisrcrs sitotdd be requcsrecl befoie tlrc fornutl irttcryicrt,\, so tlmt infonuatiotr can be utracted {ot- the report ,; [" I I l. I /{ t':!f ir IIr,t I I !, I ,l.it + Jrl i h, t. l I ) ?. i i., a l i. tll J b WIry? Delays irr receivirrg luntls . il( wllat level arrrl rvlry? Dclays irr disburscrrrcrrt oI furrrls . At what levet and wily? sr I'J,rrrilurirrg lnslrunEnts Karrr;xrla . May l99g c 45 d. Inadequacy of previous budget c Fuur, aduri'istratiorr: ,lcluys i. subrrissiorr. uI hrrarrciirr reports,disbursernelrt and reti retrient procedures, rlelays iir feeub.act< rrorir nt;oc t,.o,qunr,.r, r.rrr firrarrciar reports I)lensc describc trre ,rograrrrrrrc's llrarrs ror irrrprbvirrg sustnirrarririr.y 6 Xlfil;:J'tt ltealttt activities do tlre,o.iho suPcrvisors co'rbirre witrr rrreir orrcrro corrrror prograrrrnre -wruld you please ex-llrairr trre ;lr<lgra.urrc s rccortr kccpirrg llroceduresEXAMTNE 11rE FOLLOWINb RACOROS Surnruary sheers: l. AvailaLrle 2. Not available IJXTI{ACT INFOI{NIA'I'ION oN 'I'IIE I,'oLLoWING (retare to rhi level o[ o,erario. e.gst:rtc arrd LCA) a. Total Iropulariorr b. Nurrrber of villages in tlre arca_ c. Nurrrber of villagcs rvith surrrrrrary forrrrs d. Nunrl-ler of villaues treatetl 7 I I rl' ,'i ). e Nunrl-rer rvi(h severe side eflects Evidence of report ulldate (check anlrual retuurs alter tlistribution) I. Updated 2. Not updated SECTION B: tvlOIl POLICY iUAKERS ( Pertttarterrt Secrctary/Director Disease Ccrrrtrr:l) :l;ilrJr:ir:,1,1::,;",i^,'"rtal Plart [or tlte control of orrchocerciasis ( Probe [or rhe i,rnporrarrce auactred ro 8b. what kirtd of support do vou provide for Orrcho. Corrtrt-rl activities (pltOBE'FOII FINANCIAL INPUT) 9 tlow do you perceivc the CD'l'l strategy of AI'OC ( Probe for persorral opiniorr and officinl policy on CDTI) l'0 Is the Ortclto Progratttttte iutegratecl irrto the ltcaltlr systctrr ( Probe for aclivities rvhiclr irrdicate irrtcgratiorr aud owrrerslrip/ Ptans for sustairraLrility. I r I s I ,+ , i ri t' lr ,.i -'. , I r . Moniloring lnstrurrEnts Kcrnpaln , May l9t)9 1 ,,1. ,MAP OF ZAMFARA STATE OF MGERIA KM -t--=-- 0 20 lr0 ISA .Golod .Dole . Isq MARADUN RA ro. Rogo ' ALATAR'Bukkuyum .Gwoshi a 'Rog 'Bokuro . Donk o Adebko ANKA .Bogego BAKUR A Tototor Mof shebowq' rZurmi ZURMI odo _v--_ rngr UN GUDU a K.I,IAMODA .K .Lqngol CHAFE .'No GUSAU ,Rqnlo .Don SodouMARU Mohongo dq ,Yor rSengiokun \
AFRICAI{ PROG RAMINE FOR O]ICHOCERCIASIS CONTROT (APoc) COIIIfrII'NITY DIRECTED TREATI}IENT WITTI IUERIIIECTIN (cDn) zAftIFARA STATE, NIGERIA REPOE] OF THE INDEPENDEilT frIONITORI}IG TEATI SEPIEIT|BER 11 - OCTOBER i 1t 2OOO RECU I q il0l/. 2000 APOC/DIR Annreciation - The members of the monitoring team hereby acknowledge with gratitude the opportunity given to them by APOC to participate in the CDTI monitoring in Zamfara State Nigeria. The team is also grateful to all those who conffibuted to the success of the exercise, particularly the National Coordinator, NOCP Nigeria, state and LGA officials. -/ TABLE OF CONTENTS l) 2) 3) 4) s) 6) 7) 8) e) l0) I r) t2) l3) l4) Appreciation Team Members Executive Summary Intrcduction Terms of Reference Zamfara State Profile Methodology Results Results & Discussion Shengths (Best Practices) Weaknesses Unique features of the projec! Area Recommendations Annexes Pagc lt lv t2 l8 38 39 4t 8 8 vl ll 27 40 List of Acronyms NPI - National Programme on Immunisation APOC - African Programme for Onchocerciasis Control SSI - Sight Savers International LGA - Local Government Area CDD - Community Directed Distributor CDTI - Community Directed Treatment with Ivermectin NOCP - National Ouchocerciasis Cunirol Programme ,' SOCT - State Onchocerciasis Control Team LOCT - Local Onchocerciasis Control Team PHDC - Pubic Health Services and Diseases Control Team NGDO - Non - Governmental Development Organisation. r) Members of the Monitoring Team Patricia Ogbu Pearce (Internal Mottitor) National Onchocerciasis Control Programme Zonal Coordinator (North East) Federal Ministry of Health, Jahun Road Bauchi, Bauchi State, Nigeria Tel.077 - 540091 Yemi Qlaoye (Internal Monitor) National Onchocerciasis Control Programme Oyo State Coordinator Ministry of Health Ibadan, Nigeria Tel.02-8107266 3) Hajiya Bilkisu (Principal Mortitor - Team Leader) Citizen Communications Ltd., 4, Sultan Road, G.R.A. P.M.B. 2334, Kaduna, Nigeria Tel.052'23A165 E-rnail : b i I kis ttY@1t dh o o' c orr t 2) The Monitoring Team was assisted by the following persons Remi Fayomi - Data Assistant Ajiboye D. David Isiyaka Idris Aliyu Muhammad Maidabo Muhammed Bello R/Gero Suleiman Moldmmed Umaru Bala Abubakar Shehu Computer Operator Field Assistant Field Assistant Driver Driver Driver State Oncho Coordinator and several SOCT and LOCT members II I I 1j I Executive Summary An independent monitoring team was appointed by APOC to monitor CDTI implementation in Zamfara State Nigeria covering the period September ll to October 11,2000. Members of the team were Pafficia Ogbu - Pearce, Yemi T. Olaoye and Hajiya Bilkisu. The purpose of the exercise was to assess the implementation of CDTI in the Zamfara project. The monitoring team using APOC designed monitoring instruments obtained information on the methods used in selection of CDDs, and other aspects of community participation. Other information obtained are the treatment procedure, community perception, quality of record keeping and health education given to the community, coverage of treatment, integration of CDTI into the PHC, strengths weaknesses and prospects for CDTI sustainability. The team observed that CDTI has been integrated into the PHC and Onchocerciasis officials at the state level are solely devoted to CDTI. The government officials also indicated governments readiness to continue to pay its counterpart funding. The communities did participate in decision making but the team observed that village meetings where all citizens participated were not the rule. Rather there was palpable influence of village leaders in decision making such as selection of CDDs. APOC guidelines on drug collection and community selection are the major components of the CDTI that have taken off. Record keeping is quite poor. The 1999 round of treatment took place in July but some CDDs had tro record to treatment for that year in their treatment registers. The team visited 23 villages. Thc lcst category "A" village was inaccessible. In all the villages visited, record keeping was quite poor, a situation compounded by the practice of CDDs sharing one register with two or three surrounding villages. There were difficulties in completing summaries, determining drug requirement, recording absentees, treating adverse reactions. It was also difficult to dssess treatment coverage as the men collected ivermectin for their wives. This treatment by proxy is difficult to measure particularly when the men also insisted on responding to the household questionnaires on behalf of other family members. Although all the communities said they had received health education and were h"ppy with the CDTI interventions there was little or no community support for the CDDs as most of the community members admitted in the FGDs that they were not aware that they should support the CDDs. Although some CDDs complained of lack of incentives, all the CDDS interviewed were willing to continue to serve. Another strength in the CDTI implementation is the small number of CDDs that have been changed although this might also be due to the fact that educated CDDs are difficult to find. All the CDDs visited in the 23 villages had been trained but the team observed that the level of knowledge and supervision of CDDs needed upgrading. The team observed that the strengths of the CDTI implementation in Zamfara are the willingness of govemments to continue to pay their counterpart funding. The low attrition rate of CDDs and the community acceptance of ivermectin reflected in their willingness to continuc to take thc drug. The weaknesses of the programme are poor record keeping, low input of community in a really participatory decision making, complete marginalisation of women in all CDTI processes and their reduction to passive recipients of a drug, the use of which they only vaguely know. The issue of gender is particularly important for the success of CDTI. In a statc wherc sharia is bcing practiced, male CDDs can not treat women and women CDDs do not exist.'fhe Zamfara CD'II is in its third year; urgent steps must be taken to ensure success. The team suggests that massive enlightenment programmes should be organised, CDDs and health officials retrained, selection of more CDDs, and supervision of CDDs should be intensified. 7 1.2 Introduction Backsround The African Programme lbi Cncirocerciasrs Control (APOC) was established in December 1995 with the specific objecrive to set up an effective and self-sustaining programme of community-directed ivermectin treatment for onchocerciasis throughout ihr-fq endemic countries in tropical Africa where 50 million people are at risk of the disease. Onchocerciasis is a major public health problem in Nigeria with over a million persons estimated to be infected and nearly 30 rnillion persons at risk. A field survey showed that the communities at risk are capable of managing ivennectin trgatment. APOC projects are therefore designed to inrplement this Community-Directed Treatment with Ivermectin CDTI. The drug, Mectizan (ivennectin) is donated ty Merck and Company, Inc and APOC, working in paftnership with National Onchocerciasis Control Programmes (NOCPs) and several Non-govemmental Developmelt Organisations (NGDOs) has established a community base for participation in the tieatment. Each project is funded for a maximum of five years and over the five year period, it is expected that APOC will reduce its support and the devolution of project would have been achieved and they would continue to effectively manage the CDTI processes in partnership with states and local govemments for the next 15 years. The self sustaining component which is critical to the success of the APOC programme is community ownership. Under the CDTI, the Communities selected bommunity Directed Distributors, CDD who are then trained to manage drug distribution. The communities are also expected to decide the point for drug collection, the mode of drug distribution, determirre the date with CDD keeping adequate records of treatment to ensure success of the prograrnme. This community input is expected to reduce the cost of treatment by 90 percent and thus enhance sustainability . Thus the CDTI approach is designed to empower the communities to transfonn their lives by ilcreasing tlicii dccision u:rking and problerr". solving capacity. This community participation clearly distinguishes CDTI from the fomrer Comntunitv Based Treatment with Ivermectin CBTI. Regular monitoring and subsequent review to finetune inrplementation are critical to the success of such an innovative approach to disease control. APOC has been monitoring CDTI implementation in Nigeria, Uganda and Sudan, an exercise that has proved urifut in assessing the prospects and constraints of the CDTI approach. This ieport is a component of the regr.rlar APOC nronitoring of projccts in endenlic conrnrunitics in Nigcria. 1.3 Terms of Reference . Succinctly docurnent how ivemrectin treatn'Ients were uttdeftaken in a number of communities in the Zamfara State CDTI project' Assess community involvement in drug collection, decision making during the period and the mode of distribution, selection of distributors, and the willingness of tommunity to bear these responsibilities as designed in the CDTI project. a 8 a Document community perceptions of CDTI processes, especially the issue of ownership and expectations for onchocerciasis, and based on these perceptions and expectations, detennine the degree of satisfaction of the community with the different programme activities and outcomes. Assess the quality of training received by comnrunity selected distributors (CDDs). Examine the record books of the CDDs and assess the quality of record-keeping and their ability to keep accurate records. The same applies to the health services staff on the projects. Determihe the number of community and eligible persons treated and compare your findings with the records of CDDs and the records at the other level (e.g. district). Determine whether health personnel participated in ivermectin distribution, and assess the degree and the quality of supervision by health staff (and the quality of training and/or orientation of such staff to CDTI). Identify constraints in the distributions and make recommendations to the NOTF and management of APOC on corrective measures necessary before the next treatment. Discuss the project sustainability based on the findings above a a a o a o 9 Man of Zamfara State: cl KM --- 0?oL} imi 'Iso ro .Kwqli ,Dutsi e rml filo rodunTolotor Moforo . Kogoro .Nomod Adebko nko Bogego .Rogom ngl Moje. , Tofo Sodou a ulbi .Donfoso ebe tGt'rci'oi,t M . Rcnko .! .Kwio Mohongo.Yqr 'Sengiokun 10 2. Zamfara State Profile Zarnfara State, the area of focus for the year 2000 CDTI monitoring has 14 Local Government Areas. It was created in October 1996 out of the fonner Sokoto State which lies within the North Westem zone in Nigeria. The State is bordered by Sokoto State and Niger Republic in the }iorth, I(ebbi State irr the Wcst, Katsina State in the East and Kaduna and Niger States in the South. Zarnfara has a population of 2 million, with 80 percent of the people residing in the rural areas. The people are mainly farmers with a small populatid of artisans and traders. It has vast agricultural land, an endowment that is currently under utilised, due to decreasing rainfall, under developed infrastructure, particularly the road network that is vital for evacuation of fann produce. A substantial number of rural roads are not accessible during the rainy season. The rainy season in Zamfara begins frorn April but is heaviest between June and September. The annual rainfall is about 1300mrn and temperatures fluctuate between the hot and the cold season with the highest temperature recorded in tl-re months of March and April, just before the rains. The cold season which begins in November and ends in February is characterised by the prevalence of cold and dusty harmattan which results in a thick fog that impairs visibility and disrupts flights. The vegetation of the state is Sudan and grass savanna to the South and Sahcl savanna to the North. The Rirna river is the major water shed with its tributaries rising frorn the South Eastern part of the state and the neighbouring Kaduna State. The Zantfara and Isa tributaries flow westwards to join the Rima river. Zatnfara State derives its namc frorn a tributary of the P.irna river. Some of thc iivers are s.rasonal, with roduction in the volume of water they dry up in the dry season, and flooding and destroying fannlands and homes at their peak in rainy season. Zamfara experienced a serious floods a few weeks before commencement of this monitoring of CDTI. The area lies within the four health zones delineated for the Onchocerciasis Control Prograrnme. The programme began in 1996 with support from Sight Savers Intenrational using the Community Based Trcatmcrit witft Ivermectin (CBTI) and covering 5 Local Govemment Areas. It was a collaboration between Sight Savers Intemational, the State Ministry of Health and the Local Governments. Underthe CBTI,78,553 persons were treated in 1996 while 84,180 werc ll treated in 1997. Currently distribution of Ivermectin is being implernented through a collaboration between the Zamfara State government, APOC and a local Non- governmental NGDO, the Sight Savers International. The CDTI strategy of Onchocerciasis control was introduced in 1998 when APOC support began. The first instalment of APOC funds was received in December 1998. In that first CDTI year, 96,513 persons were treated. This was increased to 108,092 persons i1 1999. Treatment is implemented in 108 meso endemic communities in 5 local Govemment Areas (LGAs) out of the 14 LGAs in the state. A total of 312 Cornmunity Directed Distributors frafe been trained for CDTI implementation in the areas being treated. 3. Methodology 3.1 Training The monitoring team members comprising two Onchocerciasis coordinators and an independent scientist brought with them substantial experience of CDTI rnonitoring. Two of the team members had three monitoring experiences and both had participated in either in country training and out of country development of the monitoring instruments. A one day training was organised for the two field assistants in Gusau the Zantfara State headquarters on September 18 before field visits commenced the following day. 3.2 Sampling The 5 LGAs were identified and all the endemic villages were listed. They were classified into those with and those without healthy centres. The distance between t6e villages and the headquarters were also a criteria for selection. The multistage sampling was used after listing all the villages. The absence of a map at the sampling stage was a temporary constraint. Sampling was done with assistancc of the SOCT and LOCT members by choosing areas using the multi stage sampling of outlined directions in the location of the villages. The initial plan was to cover all the 5 endemic local government areas. It was envisagetl rhat this would provide a balalced sample of 6 category "A" villages viz:- 2 with health centre and far from headquarters. I with health centre and far from headquarters. t2 I without health centre and near to headquarters. However, this plan was modified when it still did not make it possible to select a village that would have met one of criteria set for the study, i.e. a category A village without health centre and near to headquafters. This could not be rigidly applied in Zamfara. The rationale behind this was to cxplorc thc possibility that distance, communication and transport problems lniglrt irnpact ot'l supervision and prompt distribution of Ivermectin in remote communities. Our findings did not reflect this concem as the outcome of the survey testifies. The sanrpling therefore produced 5 category "A" villages and 22 category "B" villages. Some the villages ./ selected were not accessible due to the heavy rain which had washed away the earth bridges. They were in some cases swapped with others (see Table l). Two category A villages were selected from Bukkuyurn LGA which has the biggest land mass and twice as many endemic communities as any of the other four LGAs. For each category "A" village, four category "B" villages were selected and relative proximity of these settlements to the "A" villages was the major determining factor. 3.3 Limitation in Sampling The absence of a detailed map of project area at the sampling stage was an initial constraint in selection of "A" villages from 3 LGAs only. In order to represent the entire state, a commercially produced map was used to cover north, central and southenr part of the state. Our core "A" villages therefore came from 4 LGAs instead of three. The other limitation as stated earlier was the distance between villages which made it impossible to select a category "A" village that was near to headquarters and without health facility. Where such exists, there would have been no surrounding category "8" villages to survey. To avoid a distortion of the sarnple this last category was abandoned. The inaccessibility of some B villages led to their being swapped with others. In a particular case, a category "A" village chosen during stratification and surveyed was discovered to have two inaccessible category "B" villages when the two nronitoring teams set out to commence field work. l3 Map of Zamfara State: Showing villages visited during monitoring of CDTI project in September 2000 Yqmmq odo NKA OYor Tosho OYor Motonkqri ODqn ODoko ibe Gidon Zollo Dostri KEYfDogon tloji MARU ingi ,A'Vi llages o"d'vt [tages !'li.rngo Moni KM -r-l on$ Orsitigui OBirnin w jc ODongururnfo OMosomor Mudi M Bowqn 9o Mofofo t4 3.4 Instruments All the six APOC monitoring instruments were used to generate information in both category A and B villages. They are the Indepth Interview questionnaire admirristered to the Community Directed Distributor CDD in category "A" village; the indeptlt intcrvicw questionnaire for the village leader in category A village; Focus Group (FGD) discussion questionnaire which was used to extract information from male adult groups cornprising at least 6 to 8 men, female adult groups. female youth groups, and male youth groups. In ./ all, four focus droup discussions i,verc organised in each cltegory "A" village. The FGDs were recorded on audio tapes, labelled and transcribed on paper (attached as appendix). Where more than one CDD was available, two were interviewed separately. However, one peculiar phenomenon were two category B villages where the village heads were also the CDD. In each categoly "B" village, the village lread and CDD werc intcrvicwcd using a modified version of the instruments administered in the category "A" village. This set of instruments were not as detailed as the ones designed for the "A" villages. Thc health personnel were also interviewed to collect information on CDD training and the role played by the health centres in the storage and distribution of Ivennectin. In each category "A" village, Household survey forms wcre adnrinistered irr 15 households. Tlrc absence of a household census in all the treatment registers made random selcction of houses the only option. All the six instruments used are attached as appendixes. Thc measurilrg dcvice was inspected, information on left over dmgs collected and records of treatment recorded in the registers were examined. The LOCTS and SOCT, NOCT and representatives of NGDO were interviewed using the interryiew guide for policy makers. Limitations The administration of these instruments were hampered by socio-cultural practicbs. The research procedure for administration of the Household Survey requires that all the members of each selected household should be listed and asked individually to respond to questions on the administration of Ivennectin within their household. In all the villages l5 visited and indeed all project areas, only the household head (husband and/or father) responded on behalf of other household members. Due to the socio-cultural practice of kulle (purdah) the women are secluded in the houses and the men did not give pennission for researchers to interview them. Another limitation was the practice of using one CDD to distribute ivermectin in two or three villages and/or villages sharing one treatment register. This made record keeping very difficult as separate records of drug administration in the villages treated were not kept. In addition record keeping was poor and scanty and lacked focus, and uniformity. It r'' was therefore impossible to complete that segment of the CDD questionnaire which required examination of village record to extract the following vital informatiorr: o Total Population . Age composition of people below .5 years and ahove . Sex composition of the population (male, female) . Number of persons treated (male, female) o Number of persons under 5-years who received treatment o Number of refusals o Number of absent during last treahnent o Number with severe side effects o Number of tablets received o Number of tablets used o Number of tablets left in the drug kit 7. Results Highlight Number of Local Govemrnent Areas visited - 5 Number of category "A" villages visited - 5 Number of category "B" villages visited - l8 Number of inaccessible "B" villages - 6 Number of key Informant Interviews with village "A" Leaders - 6 Number of key Informant Interviews with village "B" Leaders -17 Number of Indepth Interviews with village "A" CDDs - 6 Number of Indepth Interviews with village "B" CDDs - l3 Number of Inten iews with health personnel - 3 Number of Household Surveys - 75 l6 TABLE l: VILLAGES COVIIREI) Total:5 Category'A' Total:24 Category'B' KEY WHC - With Health Cerrtre WOHC - Without Health Centre NHQ - Near to the Headquarters FHQ - Far from the Headquarters Local Government Area Category'A' Status of Village Category'Bt Maru LGA Bingi WHC FHQ Tugan Mani (7) Dogon Daji 'fugon Arno (Not ttcccssiblc) Birni (Not acccssible) Kaq'a Ttufut n (Not occessible) Mallonnv'a (Notoccessible) Gobiya (Not accessible) 3 Village Heads I Health Personnel No H/H Forms Bungudu LGA Gidan Zalla WOHC FHQ Kwatta Yamma (4) Kwatta Gabas Dashi Ribe 5 Village Heads 5 CDDs Village B I Health Personnel l5 H/H Forms Anka LGA Yar'Tasha WOHC FHQ Doka (5) 'Yar-Matankari Gidan Naboro Dan Daura Bagada 6 Village LIcads I CDD Village A 15 H/H Forms Bukkuyum LGA Masamar Mudi WHC FHQ Sabon Tunga (4) Tungar Bawa Mafara Garanje Dangurumfa I Village Head I CDD Village A 2 Health Personncl 15 H/H Forms Bukkuyum LGA Tsiligidi WOHC NHQ Tudun Gandu (4) Birnin Waje Inwala B asa nson ( Not acccss ible) 4 Village Heads I CDD Village A 3 CDD Village B l5 H/H Forms t7 f@- = *.opoftion and number of rarget communities which decided on period and method of treatment' F, _ 2_ Proportion and number of target communities where the ..community,, selected their own CDD' TABLE 2: DECISION - MAKING PROCESSES AT TEE COMMUNITY LEVEL Question Villagellleeting Village Elders Vitlage Chief Health Worker Vitlages Committee 0ther Total Village Lcader- .rArr 68'' * Who decides onthe month of distribution * Mode of distribution + Selection of CDDs 1o (4s.4s) e (37.s) 6 (25) l (4.s4) 1 (41.67) 3 (12.5) 0 6 Qs) lo (41.67) e (40.e1) 5 (20.83) 3 (12.s) 0 0 0 2 (e.oe) 3 (12.s) 2 (E.33) 22 24 24 CUn Vinage uA' and *Bt' * Time of distribution * Mode of distribution * SelectionofCDD 2.s (33.33)3 (s0)3 (42.86) 7 0 0 .3 I (16.67) J 2.3 0| (14.2e) 0 0 0 2 2 2 (28.s7) 6 6 7 Group Discussion Village uAnz * Time of distribution * Mode of distribution * Selection of CDD No No No No No No No No No No No No No No No No No No No No No CHART - I tEdCfi L/hfing Fess - IIOIIH OF DSIEB'IION \flagpi/bciqg Ots 995vil<PomitE 096 lF% l'di\nbdq 41% \flarCt*{ Gf, Vl{eEhs 5% \a€r l\rl{p tr\,resp Fdt Itr/bdi]€ l EUtts ct*, \nHs OflritE rg I4 CHART - II Declslon Making Process - MODE OF DISTRIBUTION trVilhg. Mcctins rvilhgo EHGrs ovilhs. chi.f trHcallh \Itbrkcr rMlhgc Commitbc trotrcr Vilhgc Commitbc Hcellh lllhrkcr 21% Health Worker 13% Otrcr 134 Mlbgc Chicf ?5% Vrllage Commfttee o% 8'/. Mllagc McGting 37% Mlhgc Eldcrs 4% CHART III Dcclslon tr/hklng Process - SELECTION OF CDD Other trVrllage Meehng lVrllage Elders trVrllage Chref oHealth Worker IVrllage Commrttee trOther Vrllage Meeting 25% Elders Vrllage Chlef 41% l9 137o On decision making process at the community level the monitors found that 45.4o/o of the communities decided on the month of distribution at village meetings while in another 40.9I% of the communities had the health worker deciding for them according to the village leaders. For the distribution, 37 .5o of the leaders clairned the mode was decidcd 50% of the CDDs confirmed this (table 2) 25% of the village leaders claim that CDDs were selected at the villages meetings and this is collaborated by the CDDs in 42.860/o. But from the Focus Group Discussions (FGDs) not one group confinned any of the earlier mentioned claims. (No village meetings were held it seems). There was no palpable community involvement in the decision on when treatment took place although 45 percent was recorded. However, the decision to cornbine CDD training with. drug collection period was the key determinant of when treatment commenced. The local programme managers who took this decision are convinced that this arrangement ensures prompt and effective treatment for following reasons. First, the CDD's zeal to implement what has just been leamt from training is high. Secondly, collection of drug after training reduces the risk of late drug disbursement where CDD would have otherwise been preoccupied with other pursuits. Since the communities are expected to donate to support CDD's trip to collect drugs, resources are conserved in combing training with drug collection underscoring the proverbial "killing of two birds with one stone". The communities also made some input into selection of CDDs because it was obvious that CDDs were not selected by outsiders. However, the village head actually conducted the selection in most of the places visited. Indeed some village heads were CDDs and some selected their sons and wards. The concept of a really participatory selection process in which many people participated was not practiced. TABLE 3: ABSENTEES AND REFUSALS Village 'A' category Absentee Refusals (Summary) Houshold survey Absentee Household survey Refusal 'frca ted Bingi (Maru LGA) 65 17 0 0 68 Gidan Zalla (Bungudu) 25 2 0 0 84 Yar'tasha (Anka) -1 7 4 0 43 Masamar Mudi (Bukkuyum) 3 4 8 0 39 Tsiligidi (Bukkuyum) 4 5 43 20 CHART -IV Total Number d Absentees and Refusals 70 q) 50 g o 840 o. o a,n E30 ,z n 10 0 Tsiliglli f Absertees rRefusals OUTPUT 0-1- Proportion and number of refusals two months after distribution O-2- Proportion and number of absentees later treated From the very scanty record available for the year under review, (Table 3) it was impossible to get accurate figures of total number of absentees and refusals during treatment period 1999. 0-3- Proportiorr and number of at risl'^ villagcs treateC. 0-4- Cost per person (Beyond the seope of the sturly) TABLE 4: TREATED POPULATION Engi (tutaru LGA GitanZalh Yailasha Catcgory'A Mll4e Trcdr:nt Rc$ster lvhsanar Village 'A' category Total Pop. Male Female Treated Total Pop. Treated Male Treated Female Binei (Maru LGA) 1004 475 s29 600 238 299 362 Gidan Zalla (Buneudu) 2417 r250 tt67 1125 826 Yar'tasha (Anka) 632 319 218 368 '120 248 Masamar Mudi (Bukkuyum) 50r 332 169 436 327 109 Tsiligidi (Bukkuyum) 2l CHART -V Treded fug.{atim as a peter* of total fuptltim o CL o o o. o on E =z 3m0 2ffi m0 15m 1m0 5m 0 Tddtup. ]VHE . Fende TrdedTdd fop. Trded tVHe tVldesand FerndesTredd in C#ogcyA Mll4es EEr(i 0t nuLGA) lG&nZalh OYar'Tda trlt/krslrtd Treatment Coverage Assuming, the census figures given are correct, (Table 4) the geographical treatment coverage is 59.76%o in Bingi (Maru L.G.A.) 46.5yo in Gidan Zalla (Bungudu), 58.23Yo in Yartasha Anka. These are very low when you consider that treatment has been going on here for a few years before APOC's CDTI. Number and percentages of absentees are recorded in four of the five "A" villages to show that 9614554 (2.1%) were away during distribution (Table 4). There were only 30/4554 (O.07%) who refused treatment. There are no records of treatment of these groups in any community. Though these percentages are small, when they reoccur in many communities it means there is a human reservoir present making the distribution meaningless. TrEded Fende 22 I 0-5- Proportion and number of communities where CDDs were changed by the community after first treatment Table 5 shows that for the proportion and number of communities where CDDs were changed by community after the first treatment (0-5) there were only 3 (15%). TABLE 5: CDD CHANGED LGA Number of )illages Village Names CDD Changed Reply from Village Leader CDD Changed Reply fronr CDDA & CDDB CDD Changed Treated Maru LGA 3 Bingi Tugan Mari Dogon Daji \, ]r{, ]r{, o o o No No No 0 Yes (3) Bungudu 5 Gidan Zalla Kwatta Yarma Kwatta Gabas Dashi Ribe i.lo No No No No No No No No Yes 1 Yes (5) Anka 6 Yar'Tasha Doka 'Yar-Matanliari Gidan Naboro Dan Daura Bagada No No No No No No ? Yes No No I Yes (6) Bukkum 5 Masamar Mudi Sabon Tunga Tungar Bawa Mafara Garanje & Dangurumfa No No No No N N ? ? o o 0 Yes (5) Bukkum (Tsiligidi) 4 Tsiligidi Tudun Gandu Birnin Waje Inwala No No No No No No Yes No I Yes (4) TOTAL 23 3 23 23 CHART - V Number of CDDs changed in all villages 10 Maru LGA Bungudu LGA furka LGA Bukkuyum LGA Bukuyyum Tsi Local Government Areas 9 8 7 6 5 o oElg o t E =z 4 3 2 1 0 rcoo tr Total 24 0 - 6- Proportion and number of communities in which CDDs were supervised by health care system. O - 7 - Proportion and number of target communities which received education about importance of extended ivermectin treatment TABLE 6: CDD SUPERVISED AND TIEALTfI E,DUCATION RECEIVED CDDs Sunervision The team found only 14129 (48.25%) of the CDDs who said they had been supervised during the distribution. This is very low considering that most treatments are by proxy. When you take a closer look at specific village CDD responses, it is not certain that even LGA Number of Villages Village Names CDD supervised Received Health Education CDD supervised Received Health Education Maru LGA 3 Bingi Tungan Mani Dogon Daji Yes Yes Yes No No No 3 0 Bungudu 5 Gidan Zalla Kwatta Yarma Kwatta Gabas Dashi Ribe Yes Yes Yes Yes Yes Yes No No ? Yes 5 2 Anka 6 YartTasha Doka 'Yar-Matankari Gidan Naboro Dan Daura Bagada Yes ? ? Yes Yes Yes Yes Yes ? Yes Yes No 4 4 Bukkuyum 5 I Masamar Mudi Sabon Tunga Tungar Bawa Mafara Garanje & Dangtrrumft, Yes Yes ? , t Yes Yes Yes Yes 2 4 Bukkuyum (Tsiligidi) 4 Tsiligidi Tudun Gandu Birnin Waje Inwala No No No No No ? ? No 0 0 TOTAL 23 l4 l0 25 the 'yes' is actually a yes if in other cases the CDD is not sure whether he was supervised. Health Education Received Again one is not sure if health education was actually given, only 'yes' answers were gotten from the 29 CDDs. From the responses directly during FGDs, the level of health education is very low, you had to probe hard to get any answers. Not Much of IEC materials were seen in the communities by the team. crt'anr- vr It{rrhrcf CtDs srperuised ard }balfi Blrcaliqt Eeived 10 9 I 7 6 5 4 o o CD .B 5 o olt E =z 3 2 1 0 Ivlrr.rLC* ATEdILGA Arl€LGA BlduyunLcA AioryyrnTd Ld BrcmrrntArc rCDDs+erutsed lFbdh Ed.rdim Redved ow+toa 26 Table 6 shows that 14 out of 29 CDDs, 48.2 percent said they have been supervised while l0 said they have received health education. However, the FGD showed that some health education was conducted in the communities. All the target communities received health education about the importance of ivermectin treatment. But the quality of education is quite low because not all the segments of target communities could readily give answers about the drug. One had to pr6U" further to know what knowledge they had. The CDDs had ample knowledge followed by the adult men. The male youths also had some knowledge. However, the female youth and adults know nothing about the drug. The FGDs were quite revealing. ,F ..We do not know its uses, we just take the drug. You can not refuse people's recommendation". Fentale youth in Bingi village in Maru Local Goventntent during FGD. 6.We do not know who brings the drug into the community. Our men give us the drug and we swallowed itt' Adult women at Tsiligidi village in Bukkuyum Local Governntertt in FD. ..We are inside the house,. How can we know who selected the CDD. It's men's affairrr. ,.We do not know those who brought the drug. How can a woman know another man who is not her husband? We did not know the programme's aim'" Our husband sent a man who is our son." Adult women at Bingi village in Maru Local Government Area during FGD. INPUT - Results and Discussion 1-l Training of CDDs The results showed that 18 out of 22 (81.8%) CDDs interviewed have been trained and re-trained, further probing revealed that thc annual rc-training was quitc short, ranging from one day, half a day to three hours for most of the CDDs. Given their low level of education, the CDDs would require a more intensive and practical training' 1-2 Drug Delivery and Distribution Method The established pattern for drug delivery inZamfara state is for the NOCP headquarters to collect ivermectin for onward delivery to the NGDO working in the area, Silht Savers International (SSI). The NGDO then allocates the required number of drug to the SCOT and LOCTs who transport the drug to the collection points, usually health centres in each district, where training of the CDDs are also organised. The CDDs from the various 27 communities collect ivermectin after the training and comnrence distribution. This complies with APoc guidelines for drug delivery and distribution. About 50 percent of leaders said that they did not experience late supply of ivermectin because they did not determine the time of drug delivery. With no community input into the timing of supply, the drug is always supplied to them whenever their CDDs were invited to attend training. Indeed some of the leaders said they did not know whether drug was promptly supplied. (Table 5). .r' 28 TABLE 7: INPUT INDICATORS CHART - VIII TreffiHFier IvEadrgEbice dedinfunRit Dreffi l-#S{dy TrdrEdCrrE fiqrfiuqrcRs o o CI .9t E 432 5 60 1 ttlrrEd\tllEes EBrgtdr l[,tru trRta trafOeryr,m laftuFm Summary formin district office Treatment Register available Measuring device for heig[tt available Collect from a point Late Funds Drug Shortage Late Supply Trained CDDs v I L L A G E LGA N o YYesYes NoNoN o YesNo YesYesYes NoNoNo YesYes 0NA00 55I 4NA44 I0 155Brmgudu 00 NA1 J2112 NA2 1I3 0JMaru 0NA4 ,,20 40NAI 50 606 4Anka 0NA0I 4JI 3NA44 00 044Bukkuyum 0NA4 030 I4NA0 4I J04 2Bukkuy'um (Tsiligidi) Side readio n record availat le I C C C C C ffi F 2q ,ll i:. 1 1; 1, r+1rr'1il\ 'u- , -,,;; -, l- 11 1-3 Drus Shortase Similar results were obtained for adequacy or shortage of drug supplied to the communities. CDDs did not calculate the accurate number of ivermectin required for their communities. First in all the villages visited the registers did not lrave calculations for future projection of under aged children who would be eligible for the next round of treatment. Secondly, even the number of eligible dwellers of the villages were not recorded no. Gr. their drug requirement calculated by the CDD. In the absence of this vital information the supervising LOCTS with the assistance of health workers use an estimate of the community's population, number of CDDs and/or expanse of area treated to allocate dnrgs to'the distributors. It was also observed that all the LOCTs kept an exercise books in which they recorded the quantity of drugs supplied to each CDD who in tum were made to sign and tltus certify that they had actually collected. Since no census was conducted prior to distribution, any quantity of ivennectin provided to CDDs is used up and request for additional supply is rarely made. In Tugan Mani, which is an unusual example, the CDD who is also the village head was given only two bottles of ivermectin and he complained in the presence of the monitors that his request for additional drug was not granted. Further probe revealed that he did not know the number of eligible persons being treated in his community, the number of households, the underaged nor could he determine the number of drug required for the next round of treatment 1-4 Late supply of funds This component of the survey did rrot yield any mcaningful respoltsc from thc communities as they were not concemed with it. However, interviews with NGDO policy makers and the SOCT revealed that there was delay only in the release of the second instalment of funds from APOC for Year I and Sight Savers International, thd NGDO paftner provided funds for commencement of distribution. Interview with SSI showed that subsequent delays experienced in the release of fund should be blamed on the state which did not submit retirement of funds already expended on time. They attributed this 30 to the unfamiliar APOC method of accounting which differs markedly with what the state officials are used to. 1-5 Drug collection fronn a Central pqiut Only seven viliages collected tireir drugs from uuc ceutral point which is the Local Government headquarters. The others collected at the second central point which is the health centre that is often closer to them. This indicator is a measure of the communities commitment to CDTI process. The rationale is that in those communities where the "r feeling of ownership is strong and communities have imbibed the CDTI philosophy, collection would be arranged by them rather than wait for ivermectin to be delivered to them. l-6 Measuring device for height The CDDs had measuring device produced from neem tree branches with the measurements etched on the bark of the tree. The measuring device was presented for inspection by 15 of the CDDs (68.18%). The FGDs however, showed that in several cases, particularly in the case of women the CDDs did not use the measuring device for determination of dosage. The majority of adult women and female youth interviewed were not measured by the CDDs. Husbands collected the drugs for their families and determined the dosage, a practice that must have resulted in several cases of administratiqn,of ,wrong dosage. Two oregnant women in Bingi village were given ivermectin to swallow by their father inlaw. Oirc swallowcd thc drug and the other did not. "Pregnant women take it. I took it while pregnant. I was given three tablets." Afennle youth at Bingi village in Maru Local Govenunent. 1-7 Availability of Treatment Registers Treatment registers in the approved APOC/NOTF format were available and 20 out of the 22 (90.9 percent) were able to present them for inspection. 3l 1-8 Summary Form in District Offiee There were no summary forms available at the Local Government for monitors to inspect What was presented as summary forms were often ivermectin allocation to CDDs. l-9 Side Reaction Record The health centres did not record cases of severe adverse reaction nor did the CDDs. Observations Communities' Perceptions. Expectations and Satisfaction The FGDs reveal varying level of community knowledge of the disease that is being treated. The majority of adult men and youth know that onchocerciasis is dangerous because it leads to blindness hence the name "nruganin ciwort ido" tneaning the drug that cures eye ailment given to ivermectin. Some women also know that the drug has something to do with prevention of blindness iu spite of their scant knowledge of any thing associated with the project. Knowledge of the dosage and exclusions was better among the adult men and youth. A few even mentioned that seriously sick people and very old ones slrould be excluded. Although some women do know that pregnant women and children are excluded, several times disagrccrnents developed d'.ripg FGDs when attenrpts were made to define the exact age limit for exclusion of children. There is palpable indifference on the part of adult women that should be attributed to their level of ignorance of the programme. "We are not told anything. We do not know where it (the drug) is collected. We are inside the house. We do not know who brings it to the community. We swallow it since we are asked to do so." Adult women at Bingi village during FGD in Maru LGA. However, there is an appreciable level of satisfaction with the effect of the drug. "\ile are healthy, so we know the programme is good." Female youth at Gidart Zalla village, Bungudu LGA .during FGD. "We feel strong and healthy" Adult men at Tsiligidi village in Bukkuyum LGA. during FGD "The drug is good for our body" Male youth at Yar'tasha village in Anka LGA. during FGD 32 Communities' perceive the programme as another govemment health progralnme atrd among some women at Bingi village, it was even conflused with tltc imtnunisatiott programme for childhood disease (NPI) which is fully sponsored by govemrrrent. Two women named a wonlan who is the NPI distributor as an ancho CDD. In a statc whcrc there are no female CDDs this was a novelty and the monitor sent for the woman. When she came she revealed that she was only an NPI distributor. The people are totally unaware of their critical role in a programme that is designed to be community focussed. During the FGDs none of the community members noticed any change frorn the previous CBTI to the CDTI. They view the CDTI programme as a local government health initiative and the CDDs as their paid drug distribution agents. On being told that the CDD is not paid they responded that they were not aware that they are supposed to support the CDD. "Actually we do not give CDD anything at all. We pray for him. We are willing to take the medicine as long as government brings it to us. If you say we shtrulri take over the responsit,ility, we sitsll Lry." Male youth dt Yar'Tasha village of Anka LGA during FGD. Communitv Involvement in CDTI The whole concept of CDTI has not taken off in Zantfara. There is an urgettt need for thc community to know their role in CDTI implementation because they are cunently unaware of APOC philosophy. The communities simply do not know that they are supposed to play a crucial role in decision rnaking such as selection of CDD, deciding the time and mode of distribution, supporting the CDD, rnobilisation and community self monitoring. This underscores the fact that the community education and mobilisation is defective. The decision rnaking process is exclusive and not participatory as the CDTI demands. Although the people said that they selected the CDD, the truth of the matter is that the village head selected sometimes in consultation with elders. Wlrere village meetings were said to have been held, the same group constituted "the viliage." The feudal institutions are slow in responding to change and the village head still reserves the prerogative of arrogating to himself, cornmunity power by solely deciding who becomes JJ CDD. In some cases, the village heads are the CDDs as the team discovered in Tugan Mani and Danjikko villages in Mam Local Govemmeut. Often the CDDs are also sons or wards of village heads. This feudal line of authority solely revolves arouud nlen and totally excludes women. The communities did not know that they were supposed to nlake ipput into decisions by establishing village comrnittees or holding parrticipatory villagc meetings with all community members attending. "We the elders and Chief selected (CDD) usually at a meeting" Adult nten during FGD at Masanmr Mudi village in Bukku),um LGA. "CDDs were chosen by village head at village head's palace". "The community does not decicie -whcn drutgs should be deli','ered so we de not know if it is Iate or timely." Male youth in Bingi in Maru LGA village during FGD. Ivermectin is not kept in the communities and even village registers are not kept in the village head's house as the CDTI guidelines demand. They are sometintes kept in the health centre as was observed in Bingi Maru LGA where rcgisters wcrc only retuntcd to three CDDs in the presence of the monitors. "We do not know rvhether the drug came on time since we do not know when it is supposed to be givert to us" Female youth at Gidcm Zalla village during FGD However, the communities expressed a desire to participate in CDTI when it was explained to thern. 6'We can support CDD. We can give money.We can also mobilise". Adult wonten at Tsiligidi tluring FGD. '6We are ready to undertake collection and distribution and even raise funds to do so. We want CDDs to be supported to collect drugs," Female youth at Gidan Zalla village durittg FGD. Training Almost all the CDDs 18 out of the 22 interviewed (8 l'h) have been trained. Hoivever, the quality and duration of training needs to be improved upon and extended as some CDDs displayed ignorance of some basic elernents of the programme such as CDTI, use of measuring device, treatment of adverse reactions and dosage determination. The training 34 obviously did not exteld beyond the technics of causes of disease and drug distributiop' Important topics such as advocacy aud contmunity mobilisation, fund raising and gender equity should be incorporated into future programmes ' Record keeping APOC approved registers were available but record keeping was poor both at the household level and the local governments when the records were available' It was irnpossible to detemrine whether hotrseholds were properly treatecl' Thcrc wcrc no ccllsus figures available during monitoring. Although the teatn later leamt that census was conducted this year, the outcome was not known. There was no household numbering' cases of adverse reaclions wete nt t Jec')lde!'l 't ail lc'"els' In Tsiligidi village in Bukkuyum, LGA, treatment tigures were not recorded for 1998' 1999 and for 2000 although treatment for the year being mouitored was conrpleted ill November 1999 and July 2000 for tl're following year' In Maru LGA no treatment figures were recorded for 1999. The widespread confusion in some places where treatment figures were tecorded was compounded by an attempt by the Ribe village CDD to correct wrong entries and by the practice of three CDDs who are treating separate villages sharing one register. It was difficult to demarcate where treatment for one village endecl and the other began. This was the casc in Tsiligidi, a category "A" village where the CDD shares one register with two other CDDs of Tudun Gandu and Basansan villages' Inaccuracy of dosage was reflected even with the scant records available indicating that several cases of overdose rnight have occttrred without being docurnented' In Bungudu LGA, an eleven year-old was given 4 tablets, a 10 year-old was given 4 tablets in Bukkuyum LGA. The ineligible sucl-r as pregnant and underaged childrcn, tl"re absentees and refusals were not properly recorded for category B villages not to talk of trying to cross-check whether absentees' c.ases qqre rcvistcd )lc summaries were avbilable although the team was told that the CDDs did not do the summaries because the LOCT supervisors have taken up the responsibility of doing so. The only surnntaries the LOCTs 35 kept was that of the drugs collected by CDDs. In short, poor record keeping constitutes the greatest obstacle to monitoring CDTI implementation in Zamfara. Coverase The treatment figures are very low for a state that begarr treatment a few years before APOC introduced CDTI. For example, if the assumptiou is that the census figure given are correct, the geographical treatment coverage is 59.7 percent in Bingi (Maru LGA) 46.55 percent in Gidan Zalla (Burrgudu LGA) 58.2 percen[ iu 'Yartasha (Anka LGA). Number and percentages of absentees are recorded in four of the five "A" villages the team visited. This shows that 9614554 2.lo were away during distribution. There were only 30/4554 (0.07 percent) who refused treatment. There was no record of a review of their cases. Although these percentages are comparatively stnall, when they reoccur itl many communities, it irrdicates that there is a huntan reservoir that nrakes the dnrg distribution ineffective. Suoervision of CDDs The team discovered that only 14out of 29 (48 percent) said that they were supervised during distribution. Supervision was found to be inadequate because superuision seems to be limited to the drug distribution period. Supervision rate is rather low givcn that tnost treatments, particularly for women is done by proxy (ltusbands or father's in-law). A critical examinatioin of CDD responses also casts doubts on the "yes" altswers several of them gave. These was obvious lack of superuision as their poor record kccping alrcl follow up of treatrnents portray. Integratiou into Primary Heatth Cere The team observed that there was evidence of integration of the CDTI into the existing Public Health and Diseases Control Deparlment. Indeed CDTI is a section under the Public Health and Diseases Control department. All the SOCT and LOCT ,rre,rrb"., o." staff of the various PHDC department at state and local govenlment level. The SOCT staff are exclusively for CDTI with other PHC assignments. An outstanding contponcllt that is yet to be integrated is treatment of adverse reactiotls in PHC centres while the PHC 36 staff such as the CHEW ought to collaborate with the communities in the supervision of CDTI. Sustainability Success and sustainability of the CDTI are hinged on the effective education and mobilisation of the communities to imbibe the APOC philosophy of promotirrg community ownership of the programrne. The health workers and NGDOs who are in charge of the programme must focus or-r this crr.rcial aspect of the CDTI which is currently unknown to the communities. It was obvious from FGDs that CDTI has not taken off in Zatnfara state in spite of the three years of project irnplementation. The communities are not aware of the role they are expected to play in decision making as regards volunteering to be CDDs and/or supporting the CDD with cash or kind. They do not know that they have to play a role in deciding the mode of distribution, when and where to collect invermectin. All these are cunently being decided by the health workers as the FGDs shows. A vital aspect of sustainability which the team observed is tlie political will on the part of Zamfara state govemment to fund CDTI. All the local governments do contribute their counterpart funding. Maru contributed 31,450 Naira while Bukkuyum gave 150,000 Naira an amount that is in excess of the 51,000 Naira allocated to it. The LOCTs are also happy with the financial support they receive from the Local Government and the SSI the NGDO. They irowt)V€t, conrplarned. about cieiays iri lei3ase of funJs. "We know that the programme is useful and we shall support it." Zantfura State Conuniss ioner for Healt h. "The state and local governments will continue to fund Onchocerciasis control programme" Zantfara State Director of Public Health Services and Disease Control. Another critical aspect to sustainability is designing and implementilrg a gcnder component for CDTI which is currently lacking. Women who constitute half of the population in Nigeria are not involved at any level, making a sham of comrnunity participation and sustainability. In all the villages visited, the husbands collected 3l ivermectin for their wives and detennined the dosage. The women are denied health education arrd participatiori irr deci-sir.rli making. Tire l,ealth workers attribute the non- involvement of wolnen to the absence of educated women and youth and the cultural practice of purdah. However, in Gidan Zalla vlllage the FGD conducted had female youths in attendance, 4 were secondary school students and two were school leavers with one of them working as a primary school teacher. '6We are ready to undertake collection and distribution altd cven raise funds to do so." Female youths at Gidan Zalla village during FGD. As for the adult women, they had this to say; "We want to be involved (Ana yi da kai yali ba'a yi da kai) meaning being a participant is better than being a bystander". Adult women tu Gidan Zalla village during FGD. The CDDs who are supposed to be the most knowledgeable in CDTI nranagentent in the communities have not fully grasped the CDTI concept. In Dashi village of Bungudu LGA where the monitors were interviewing the village leader, one of the CDDs requested one of the monitors who speaks fluent Hausa to address the gathering outside on the role of the CDD as a volunteer worker. He said the people did not believe that he was not being paid for ivermectin distribution. The team observed, in all the villages visited that CDD support was meagre ci totally lack;ng a dcvclopmcnt mosi cf the participants in the FGD's attributed to ignorance of the fact that they were supposed to support them. "We do not support CDD. We can contribute to support distribution of drug if we are told." Adult nrule of Birtgi village during FGD. "We do not give anything but the men just give them 10 Naira in appreciation" Fenrule youtlt at Gidan Zalla village during FGD. Strengths (Best Practices) . State and Local Governments' commitment to continue to fund CDTI o Integration of Onchocerciasis into Public Health Services and Diseases Control. o The team observed the willingness of the community to continue to take the drugs and the appreciation of its benefits. 38 a Very high CDD retention rate. Very few had been changed. However, the fact that the people are happy with the CDD does not mean that CDD are correctly inrplenrenting CDTI. Weaknesses o Inadequate training of CDDs. It was obvious that community education and mobilisation was not adequately treated as a component of CDD training. . The teanr observed that supervision of CDD was inadequate and usually limited to distribution period. o Deficient record keeping by the CDDs was observed by the team, a factor that made through assessment of CDTI implernentation impossible. o Over concentration of decision making powers in the hands of the village heads who then amog:te to themselves the prcroga.tive of selecting themselves as the CDD or selecting their sons or wards. o Where the village head is also the CDD they waited for the people to come and collect the drug instead of distributing at household level. . Sharing of registers by three CDDs treating different villages conrplicated record keeping. a a a The practice of using one CDD to cover three separate villagcs made effcctive coverage difficult. It was observed that such CDDs were selccted by a district head to cover villages under his domain. The absence of female CDDs is a serious defect in CDTI implementation in communities where adult men including CDDs are barred from entering households. The team observed that treatment by proxy, whereby husbands collect drugs for their wives encourages over dosing and false trcaturcnt coveragc figures bccau,se drugs collected may not be used. The team also observed that CDDs often used visual assessment to detenninc dosage. The relucrancr) of the CDD-s to usc ihe rlreasuli,rg device all the tirne would also Iead a 39 to wrong dosage being administered as some cases recorded in the treatment registers confirm. o The team found that there was no anangement made for treatment of adverse reactions. The health workers interviewed had no record of cases of severe reactions either. o It was observed that the concept of CDTI has not taken off as tlte programrne is sti ll seen as government funded and government directed. Comnrunity support for CDD is poor and. the only asnect of CDTI that is being irnplernented is drug collection from some health centres anci seieciiorr or" sorne CDDs in sorue villages. Plans for community monitoring do not exist. o The team obsered that there was paucity of IEC materials. A few flip charts used for training were seen at the health centres, a few posters in the village head's house in Bingi village and at the state r-ninistrl' of health. None were seen in the other places within the comnrunities. o It was observed that there was difficulty in finding educated and willing CDDs. . The team found that in sorne LGAs (for example) Bungudu, the LOCT ntembers cornplained of lack of LGA Support for the fueling of their nrotorcycles to enable them undertake supervision tours of treatnrent areas. They havc to depend sorely on APOC and SSI although the LGAs arc supposed to fund such expenses too. They also contplained about delay in the release of LGA's countetpart [urrding. At the timc oI rnonitoring funds for 1999 had not beerr paid. a Unique Features of the Project Area Zamfara statc-was thc first to rnnour.ce and bcgi:r thc f;ll in'rplementation of sharia law - the legal Muslim.code. While it is recognised that implementation of sharia law varies from one country to another, within Nigeria, variations also exist in the mode of implernentation of sharia in the different states. One of the tenets of the sharia law being implemented in Zamfara is to discourage unnecessary mingling of rnen and wonteu. This should necessitate the promotiorr of educatiorr for all, mcrr and worl'rcn lrccause cducatiort is contpulsory in Islam arrd it is infact a prc-requisite lor implenrcntation of sharia. Full 40 implementation of sharia therefore requires a public life role for wottcn who should be seen attending schools to acquire knowledge, perlonniug social developlttent rolcs in all relevant sectors and specifically serving other wonlen. Sadly, the team observed that there were no women CDDs in a state that claims that it is implerrrentirrg sitaria, a praciice that clearly negates iite conccpt of sharia. This issue was raised by women during FGDs. They criticisd their marginalisation and uon involvement in CDTI. "We want women who are our compatriots to come into our houses and educate us. Some houses prohibit men from entering. If the man who is the head of the house is not around a man can not enter but if it is a woman, she can entcr without any prohibition or hesitatiolr." Adult wonrcn in Gidun Zalla village in Bungudu LGA cluring FGD. "We have no information. We need information. Government has tried. We need to have women to distribute drugs to women, we know they are those who can do it well. But how can a man do this effectively? Sharia is practiced in Zamfara state and it demands that women should attend to women. Some lvomen are nervous witlt any man who is not their husband. Women must attend to women and men should attend to men. FGD v,ith adult v,onten in Bingi villoge in Moru LGA. Recommendatious Zatnfara state is in its third year of CDTI implenrentation. It should have overcome the transition problems from CBTI to CDTI. With two more years to institutionalise the CDTI which has not really taken off, urgent actions must be taken. The following actions are recommended as irnperative for CDTI's success in the next few years. l) A massive enlightenment campaign should bc organised to enlighten tlre poople on the CDTI and their role in CDTI implementation. Various civil society groups such as CBOs, interrnediary NGOs, trade groups, professional associations, self help and youth groups, women's organisations etc should be used as an cntry point for the enlightenntent campaign. 4t al aa A special advocacy package on how to mobilise muslim women using religious g.o,,pr especially the neighbourhood Islanriyya schools, preachers, particularly at the grassroots should be designed and irnplernented. The Zarnfara Govemment's weekly preaching events should focus on the educatiott of women and their public life role irr lslam. Based olr outcome of thcse, lcgal ruling, fatwa, pamphlets and other IEC should be produced and widcly distributed to givc religious support to an otherwise contentious issue. . More IEC should be produced and distribr.rted, but thc regular IEC conccpt should bc broadened to include use of altemative media, such as sollgs, dranta, poetry and school based enlightenment programmes. 2) More CDDs should be selecterJ anci the criteria for selection of CDDs should be participatory. There should be the standard ratio of 2 CDDs for every 250 people. Guidelines should include permanent residency rvithin the comtnunity, gainful employrnent and willingness to promote community service. 3) Women CDDs should be selected in the courmunities whcre there are willing and capable women. 4) More trainings and re-training for CDDs and health workers should be conducted. The duration of training should be increased. CDDs and supervisors should be rc- trained before the next distribution exercise. 5) The content of the training should be expanded to include colllltlltllity advocacy and rnobilisation skills. Record keeping, drug distribution and management of adverse reactions should be incorporated into practical sessions and group work. 6) More supervisors should be appointed to cover areas tltat are underserved. 7) Supervision of CDDs during distribution and afler should be intensificd using NOTF and APOC checklist on the job training for CDD should fonn ;rart of thc supervisiou. 8) The use of one register for several villages should be discouragcd. 9) A seminar on CDTI should be organised for policy makers. 10) To ensurc the sustainability of CIITI. communities should be educated on the ueed to support the CDD and encouraged to provide cash and other incentives to them. 11)The communities should be educated on the need to establish participatory mechanisms which are critical to the success of CDTI such as hosting village meetings, establishment of village development committees which lvould enhance community participation and self monitoring. 42 12)The statcs and local govenlnrents sliculd release the countetpart funding as ancl whcn due. 13)Given the difficult rural temain they have to cover, more n-totorcycles artd vehicles should be provided to the SOCT and LOCTs to facilitate supervision. 14) The census issue should be revisited, thc one conducted should bc relcascd with thc expectation that corrections arc madc wlrcrc ncccssary bclorc tltc ncxt clistributiolt. 43 Appendix Persons Met 1) Dr. Jonathan Jiya - National Coordinator, FCT Abuja Tclephonc debricfirrg in Lagos NOCP office. 2) Dr. Y. Fayomi - Zonal coordinator NOCP -- Kaduna 3) Dr. Elizabeth Al-Hassan - Sight Savers Intemational, Kaduna 4) Alhaji I{assan }.{ohammad - Ifon. Cornmrssioner fbr Health, 'Zantfal.a State, SMOH, Gusau 5) Dr. Umar Muhammad - Director Public Health Dept - SMOH Gusau 6) Malam Yahaya Bawa - Deputy Director Public Health Dept - SMOH Gusau 7) Malam Abubakar Shehu - State Coodinator Oncho SMOH - Gusau 8) Malanr Mani Mohanrmed DPHC/HOD Bungudu LGA 9) Malam Aliyu - Deputy HOD Bungudu LGA l0) Malam Bello Kadiri Ahmed LOCT - Bungudu LGA 11) Malam Kabiru Garba LOCT - Anka LGA 12) Malarn Lawali LOCT - Bukkuyurn LGA l3) Malarn Halilu Salihu Kanoma LOCT - Maru LGA l4) Malam Muhammadu Mairago Deputy Village Head - Yarlasha Anka LGA l5) Malam Rabiu Dogo - CDD Yartasha, Anka LGA 16) Malam Tudu lbrahim -.uillage I-ead.cr, Yar \,Iata-nka.i Anka LGA 17) Malam Abubakar Wakili- Village Leader, Bagada Anka LGA 18) Malam Ibrahim Abubakar - CDD - Bagada, Anka LGA 19) Malam Sani Mohammed - Village Leader - Dan Daura - Anka LGA 20) Malam Hamidu Musa, CDD Dan-Daura, Anka LGA 2l) Village Leader, Doka, Anka LGA 44 22) Yrllage Leader, Gidan Nabardu, Anka LGA 23) Malam Mohammed Bello - CDD, Gidan Nabardu Anka LGA 24) Malarn Liman Muhtari - Deputy Village Leader, Masamar Mudi, Bulkkuyunr LCA 75) Malanr Lawali Garba- CDD, Masarlar Mucli, Bukkuyyurn LGA 26) Malam Hakimi Mamrnan - Village Head, Tungar Bawa - Bukkuyyum LGA 27) Malam Linrarr Musa - Villagc l{cad, Sabon Tunga - Bukkuyyurn l-GA 28) Malam Garba Mala - CDD, Sabon Tunga, Bukkuyyurn LGA 29) Village Head, Marafa Garowge, Bukkuyyurn LGA 30) Malam Lawali Umaru - Oncho Coordrnator, Senior Cormnrunity Flcalth Extension Worker, Bukkuyyum LGA 3l) Malam Garba Bala - Officer i/c CHEW, Bukkuyyurn LGA 32) Alhaji Muhammadu Dandabai- Village Leader, Tsiligidi Bukkuyyunr LGA 33) Malatrr Sahabi Bala, CDD Tsiligidi, Bukkuyyurn [-GA 34) Malam Wakili Dan Balarabe - Village Leader, Tudurr Gandu, Bukkuyyurrr LGA 35) Malarn Mohanrnrad Dan-Iya CDD Tidinr Garrrdi. Bukkuyyurn LGA 36) Malam Abubakar Hakimi - Village Leader, Inwala - Bukkuyyurn LGA 37) Mohatrrmadu Umar - CDD - Inwala, Bukkuyyunr LGA 38) Malam Abubakar Miagari - Village Leader Birnin Waje, Bukkuyyurn LGA 39) Malam Abubakar Salisu - CDD - Birnin Wajc Bukkuyyurn LGA 40) Malarn Abubakr Sabongari - Ajiya rcprcscrrts Villagc Lcadcr, Birrgi, Maru LCA 4l) Malam Lawali Lumu - CDD Bingi, Maru LGA 42) Mohammed Abubakar - CDD - Bingi. Maru LCA 43) Malam Salihu Bako - Village Leader Tugan Mani, Maru LGA 44) Village Leader above is also CDD of Tugan Mani, Maru LGA 4-5 r( (4a 2_ INr)r(iz\'r'() rts rr()r( r Nl.)riI,tiNr)r,:N,r, I r ( )Nr,r.( ) It I N ( i EIIITtrC'I' E-l ta- 2 lr::ffi:il:t and rrtrrrr[)cr'ol'tarSet c()ilrilr'rriti(:s \vlriclr tlccirlctl on tlrc pt:r.iorl ()r.rrcrlr(](l ol l)rollorlion iuld nlultl)cr. ()l own cDD. (ilIgc( c()illtrrrrrrilics \vllctc llrc,,cprprlrrrrilt,..st.lt,c(crl Ilrcir OU'I'I'U'I' 0-l o-2 0_3 X o-+ 0-5 Pr.Portiorr arrrr nurrrtrcr 0[ refrrsars rrvo rrrorr(rrs ilftcr rr is(r irrrrriorr l)roll0rtiorr arrtl rrtrtrrIrcr 0[ ullserrlccs tltitt \\,cr c lalcr tr cirlcrl Proportiotr arrd nurrrlrcr oI a(-risk vilt;rgcs tr ca(cd Cost ller l)cr.son treirtctl Proportiorr arrtr lrtrrrbcr <l[' c.rr,l^rrritic$'*,rrcr c CDI )s r',cr c crrarrgc<r rrt, rrrcaftcr tlrc flr..st trca(rrrcrr(. Proltortion antl rrurrrllcr ol. corrrrnulritic.s irr rylriclt tlrc CI)l) i.s srrpcr viscrl lr1, tlrc Itcaltlrcare sys(enl Prolrorti,lr arrd lrurrrtrct.o['rirrgct c'rrrrrrrrli(ic. ,r,r,i.r, rcccivctr cdrrcinll)orlilllcc of extcrrdcd ivcr rrrcc(in IIcilInt(.nl. Proportio, arrtr rrttrrrber o[,crsorrs -5 yc;,s irrrtr abrve *,rr, rccei'cd corrrntrrrrill, 0-6 o-7 0-8 INI'UT l-l t-2 t-3 t-4 irliorr about I)rollortiorr and rrurrrtrcr o{ corrrrrruriirics \\,illt.(rlt Proportiolt altd tttt|ttllcr ol r.rr,,,,.,,.,r,: ,b r l' corrrnrrrnitics/pr o;ccl.s .shrlrtagc o[' ivcnrrcctirr. tvctntcctilt irrcrl C'l) I).s (ltirl c.rpcr icrrccrl lrrtc strpply or tl l;rtc su1rp11,9l lirrrrls c'ollcclcrl iycr rrk,clirr lrorrr I)rollortiorr alrd rrurrrber rrl.projccls rvlricli crpcr icncc Prtlllorl iott attd rru rrrbcr,I r. rgr.( currrr r rrrr ri ( ics rvlr iclr collcction poirrf/rlre lrealtlr ccntIe. * It i's suggesterr trrat AI'oc r\I:rrr:rgt'lrrelrt corr.sitrur-*,,,r,t,-".r.ri,rg rrri5 irrrricirror.sr.plrr.lr(cr1. I -5 proporriolr arrd lrurrrrrcr .r ar ) [)s 1f i11, rrrc.:1srrr irrg dcvicc firr Ircigrrrl-(r I)rolltlrtitttt alttl tttltltlrct' ,l'crrrrrrrrrrritics r'itrr trcilrrlerr rcgistcrsl-7 I)roportir.lrr arrtr rrurrrlcr. uI trcir(ctr c,rrrrrrrrritics r'itrr s . gl'llce. ""r"r"ilLi \t rtll tlllllllil tl' lirr ttts lr( llrc rlisrr ict lrlorrilor irrl, llr\tr u,tt.nl\ li :rrr r;,;1 l,; I N l:t). l,)rr() 1l TI t I T I I T T T I I T T T T I T I T a77 *sfia *.? rr. o tn 'rl Z vt$Is (ra (D 2.,<BegcE-(fil [gHdSsEtJ p G I.t< tr tre :"1.' g H'lE,E5(DnFHif ' E-o -oC rr, a./)Ioz qe.{83!( < (D crbo o E A gE €\<h oE o9 5.lRt aJ(| (D ='Jd F':1, a I Ell ilt..J j- z<8 99 <U$If .,*s u '\) { = ='!cPpoioiltro-^os -d 8E g 3 ? S. =i.rc =< o EaE* =u, =.p* o-- -5 €Go.= .r, rn(n t] o aC rrl L/1Jo = =ATFEEE i [ &* "" z<* 3.6 SE;Eil [ (! 5 do ,f D)$I=.,8 E-E g 6 "t.+ dE ; zo -lo oC rrl(/,l z<* 9X S uillt9(liirDa-o-r.ti'B.<E 3 X 9oI rpF oC ra lt1Jo z Ir..J E=>c= r)Frfi o< 'o H'S',rrqsgE TU x;;= o*3-F E q fi,eig,r E."ii I i=o F q oh tt2-9F:E5 'H 6'soa--:a3 =.E E I JrugQ 6€ d o Pni oh5o -6rDliEXEs5r--C -, -z' 3-9=.9 o Ca -='ti.e dP-b''6-s - -l6xJr(3.E c -5 3'z "'PAto= .-oH 5. B, 3,: .Eq E ;€ ,D' ' , '- (D3 o- 2 o 9i5'g3 6 71J,<s#'o I5 t(D 3 E :E E'=ga2H :.='+> 6-'J= ==J9e E:{Hai&c-;q r<fDr-: DF'+6 =6 m8* FE (D-Hn Z->Ar(D6'>hNirD 16 h 3O O'O cf '.9 a :NJ- r.JJ ajft=- :og d':E !--U arOcn?6 oI.9udi oU,O P d3f1 aFl = 5'9 JHod!ia*i-mJ =Hd -5:E 'O+Gq 5BdE g 3o= 3,o 6 o- S. 'r' -6j OI"q6- o re rrrO =.>d=-oo- >n o >1 It o Ut @ rJo (! (D(t l!F rD A) .D(t D' IJ DJ E'a 9.o tr o o0- o ;i UA(D Z o, 3(D ;i UA o o o o. o t 7 o = o N 2 rDq, j (D I oCq o g o- E z 9 I o(,q A) 3(! 3 !. g ol E e ct5 xIt Iit E\o i { D = L f\x a l^., 1..'; t' E t-. I aa \r3l, I' tl' | .t' \l , l. I ) I ' 0l ) (l '! .-l "l ,r .LJ -. qr 'l :< _:" , L) .3 tj l'o(:\ _l ) .'; ) l o t.: t\, lrl al r) ; ( !)( ,) a: -'1 E g .2-, .9 oo E :z 7 = e 3 al =C 9 E o o .tl C'q o ac (JPIL ^C,I8 .=E cro .lJ $.1oEf8t * -.; ll ,63ggr.E 'E ll.+E i\ :i,Eri €.oI fg[€;** (n ., llil3!'6 .9u _-E E ll tr g-tootr x ll -E b:E r E HE3qEEO (r..T'oq, I * \iOr-ll oqc o\ ooll O o\ c, q .ll . .J F " ll8'=.q E . e? $s E #,f Bi E =.q b s > = (! oJ.E o6 E E,g 5 c o-iOOI I ";S *X oC> tt tt U E.E T, 8E s p.S.= S -EEeEEE -l I I !-. 1 I IA () (-' '1 ^i I ir 0, I t' t; .U r-) I I I rIteflqfornrant Inten' g.t_[.etdc_f.! \'illrrgeN.u'..-.VillngeCorle:---I)istrict/l,(iA:-- ('otrtttrt': I)nle of lnst tlislrilrrrlion I)lcasc tell us about any progratnnlc conccrrrirrq orrclroccrciitsis lrcaltttcnt irl llli\ r'illlrcc'l (PLEASE NOTIj TIIAT Tlllr fOLt,OwlNG I.SSUITS AIlll At)l)ltl:SSI:l)) rvho brought tlre itlca oI thc onclrocerciasis proerantntc lo lltis vill:rtc'] u'hen did tltc pcrson(s) ct'rtttc talk s'itlr ytrtt alrotlt ottcltoccrci:tsis'l did thc persorr(s) ntect rvitlt you alttl othcr villngc lcadcrs lirsl'l rvhat did lre tcll you? (l'rohc for contntuttilv orvnersltip oI Protrlllllllle ltttl cottttttttttitv rcsponsibility) Did he ask for you to arrang,e a nrcctingl) 2. llorv rvas the tirne (rnontlr/scrson) lor distrilrution tlccitlctl'l al a villatc nlceting - evcr\'(rnc discussetl village cldcrs villagc clricf/lcatlcr health s,orker village conrnrit(ec othcr (spccify)- 3. \\'lrat mcxlc of distribution was dccidcd'l housc-to-house ccntral plrrcc (spccify botlr housc-to-lrousc and ccntral lllucc otlrcr ( ) 4. llorv was the modc of tlistribution dccidcdl) at a villagc nlecting - evcr\'onc discussed villagc cltlcrs villagc clricf/leatlcr Itcultlr rt,orkcr villagc comnrittce othcr 5. llow many frcrsons in this villagc (CDD) givc out the tlrug frrr orrcllxcrcilsis'' I 2 3 4 I 7 3 4 5 6 I 2 3 4 5 6 VII.LACE A-l.l:At)l:R -'fOOl.- I )l (). llotv nruny rrralcs'l llow nrany lcnralcs'l 7 . llorv rvcrc thc llcrsons (CI)D) sclcctctJ to do tlrc rvork'l ut a villugc nlcctlug - cvcr)'onc drscusscd vrllugc cldcrs vrllagc chicl/lcadcr hculth rvor Lcr t illagc corrrnrittcc rlt lrc r S. \\'lry drd you clttxrsc tlrcsc pcrson(s)'/ (l'rotrin!, lor crrlcru) 9. lluvc thc Ct)Ds rcccrvcd any trarnlng'J I. \'cs 7. Ntl 3. Can't rctttctttbcr Itt ll'rcr trr Qt), rrlrcrr tlr.l thcl' rcecrvc tr:unlnli.) IJulorc tlrc lrr st drstributrorr Durrrrg drstrrbutrorr .Sorln ultur tlrr: lrrsl drstrrllutrort [ )tlrr' t [.rrtlrr'/Curr't rcrrrcrtrllcr IL llorv wcll huvc thc Ct)Ds tlonc thc wurk'] l. vcry s'cll 7. l'uir 3. lloor ( l:rpluin) ll. lllvc you clrangcd your CDD'I l. ycs 2. No 3. Dorr't knorv t-l. ll 1cs to QI2, rvhyi lr ll.rrc 1uu ltlte e()nulruntt) ) rcccrvr.rl cducatrort ()lr tllc ullx)rlJnec ol l;rkrttg trr:rtttccttll taltlcl :rrrrrullll' lirr scr crlrl 1'c.rrs l l. \'cs 2. Nrr J. ('urr't rcrrrcnrtlcr I 2 3 { 5 (l I 2 -1 { I 7 -1 .t Vll l.ACl: A-[-l:Al )l:l( -'l (X )t.-] l ) t5 ll'yes to Ql4. ask: Wlrcrr tlitl vou rcccivc thc ctlrrcaliorr,l ('l.ick lrll tlrlt lr|plr,) L During tlrc firs( lncctint 2. Rclrrrc thc first tlistrihution 3. During tlisrrihution 4. .Soon aftcr distrihurion 16. lIycs to Ql4. s,hat \\,crc vou told,l (probc lor ilnnual trealmenl frlr s$,eral yclrrs benefits conrmunity responsihil ity t7 g slrotrltl he collcctctl [rrrrrr a collcctionpoinr'l l. Ycs2. No l. I)ort'l k rrorv lll. [)id alry nrcnrhcr of thc conrrrrtrnitv collcct rhc tlrrrt frorn a collsq.11,,,,, p(rn]t.] l. Yes 2. No 3. Don't krrorv 19. lf no ro Qt8, why'l 20. Whcre is thc collection poinr,.) 2r I)id you cxpcricnce latc srrpplv oI tlruu tlurirrg tlrc l:rst tlistrilrrrtrrrr., l. Yes 2. No 3. Don'r knorv Plcasc explain 22. Ditl you expcrience slrortate of tlrugs rlrrrirrg r1e l:rst rlisrrihuri...., l. Ycs Z. No 3. Don't knorv t 23. If ycs to Q22, lrow rvlrs rhc prohlcrrr.solvcd,l Docs (lrc comlrrunity havc a trclltnlent rcgisrcr,f 3. l)orr't knorv fl h c Was tlrcrc any conlmunity tlecision on horv the dru 24 L Ycs2. No Vll.l.AGl: A.l.l:At)l:t( .'t (X)t.-.'t t I ).,.) -) 25. Il'ycs to Q24, rvhcrc is thc rcgislcr kcpt'l .ltr. \\'lrut utu )'(rut sug.[,cstl()ns trrr llrlrv llrc corrrnrunily cuuld bc ruorc irtvolvcd itt trcattttg ils tttctttItr:r's tvillt it,crrtrcctirr lirr scvr:r:rl ycurs'l 27, ls tlrcrc unytlling you will likc to tcll/ask us? Vll.l.AUl: A-1.IAl)l:l( -'l ()OI--4 cx{-i ilH,rl ",I 'i:i How J ,t Jtt J> t.I roult "A" viiluges. lnrctview 2 CDDs lter vtlltt1,,t: if tlrct e 1t.e ptot ttlte lttlCt'r'tctv tt.rk tlrc distt'ibrttor ttt lct 1,11,,.r,,,,clntg if it it tltc cttsa se cotle. ltfttlte r Ittrtlr iltlc vlter tc.tl)ouJc.t, tk) ttol [ot.11ct toC ttltlt t'rt1t t.ittl e Itts ttlttl.s; tt'tcu.\ut ttrt, l)ltl (t ( tt clc ilt0ttttrl ctt, it ,::.i:ilh:lirl .,l' ,,rfil : i$. t:Ir.. ., ri. 'rf, \[prc or Viillgr utricUstatc Villagc cuJc: .--subcourrry/LCA \fl;rc or CDI> Scx: l. l;crrralc 2. M;rlc $lu occupariorr ]{ Y,fl,,,, atr<l year o[.r.sr CD'l.l disrriburiurr irr ltrc village --/_Morrtlr arid year of lasr CD.l.l disrritrurrurr irr rhc village _/_ l. How vlas tlrc tirrrc (rrrr,.,tlr/seas orr) [or rlistrihrrliorr rlcc irlcrl'fl. at a villugc n tccting2, viil ttgc cltlt:rs' rrrcct ir,1:3, viilage chic[/lcar,lcr 4. lrealtlr wtirkc r5. viilagc lrcalrl t conlrr:it(cc6. viila gc cuilulti(ec rrrct:(ir7. orhc r(spccify) lr ,, Irl , ii ,j i\r rA ,'2 'I ij ;,.,il,,r, r!lorJc of tlistriburiurr was tlccirJcd.r t houuc.tu.lruusc 2,, scrrtrol ltlncc (sgrccify)3. llurtr I tousc-to-housc hri tl ccrrtr,,t lltnc.4. olhor (rpcclfy) was tlrc rno<Jc si distriburiorr clccirtct,l,/ t. 2. 3. 4, 5. 6. 7. nt a vill:rgc trrcctirrr, ,illr*" cttJcrs.,,,"i,,,g villugo clric[/lcrrrlcr Ircgltlr worker ,lllrU" heultlr corrruritrr vtllage corrrrrri((ec rrrccr olhcr (sgrccify) 'c lirrg .t I 'i I rt il, i, ri t.: d, I 3. I l.t!l ,'' I 1:i :l,l t.,:, I wt lr ' Jll', ,', It, ,.- I:' ,- r,, I l'r i.' r'' t" I (, '- ti. A lrrttltor rrrg ft 13lrrrrrrrrll Xrnprlr, Mry I 999 ,( ' ,1li I )i.t I .:iisi' f I t. r i l\'I i i'ii ,l llorv rvcrc lou lclectctl to rlo tlrc wttrk,l I'l I t. 2 3. 4. 5. 6. 7. ul u viltugc rrrcclirrg ,]llnr" clders' rrreetirrg vtilage chief/lcader Ircttlllr workcr village lrealrh conrruiltee !o'h' kd,. 5 6 7 ,l'las arry cDD bccn crrarrgcd arrcr trrc rirsr distribu tit:u), [, yes Z. No 3. Don,l kuoy. lf YES to e5, Why was rhc CI)D ctrarrgcd? / villagc corrrrrrirtcc ltrcct irrg otlrc r (spcc il'y) l'lavc yg11 evcr bcerr supervisctl I 2. No 3. Dorr'l krrow llealrh .sraff : Villagc healtlr corrrrnittec nrerrrlxr NCO pnrrrrcr Cornrnulr ity rrrcruber/clrie fOtlrcr (specrl'y) l. Yes l. i I I rl l1 t, I t I 8a.'lf ycs to e7, rul,,,..r):lIy!:crt y*r ? (tF NAME WA.s MriNT.lON'DI D ENTtTy/posrTlo N/!rlr.u s'o I, ri i p.'p clrso N) l'l.F.A.SI A.SK Ir()R l, 2, 3. 4. 5. t'. 8t:. Whar rJid thc supervisor doir l. Cf yccfer] rhe iv.cnrrecrirr irrvenrory ,Z. Clre.ckcrl tlre recor<ls/lrent,ltcnt regislcrl. Cr.lllatcd rlle reports4. Advise<l orr tlrc trealnlcnl oI nllserrlees5. orher (spccify) 9. At rvltat occasiotts were you su,crvisctl? (ClltcLE, ALL Tll^.f AI,l,Ly) L Belore tlistributiorr 2 [)rrrirrg rli:rlr ilrrrtinrr 3. Soorr afrcr rJisrribufion NoNo 2No 3, Cntt'l rcrrrcrrrlrer Mnnirorirrg lrrstpnE1|1! Krnpoh . Moy 1999 l. )'es l. Ycs? l, Yes2 '7.. No ''^' 'fnlil 1::'::i;11:::lf:1,.," tltc i,r1,orra,ce orrakirrg i,errrrecrirr rar,rer.s ,.1 \5 Ycs lr, .: I I rJ*.4,1&l4r,. r, lt 3d l0b. lf yes, what,wcrezysu rrrlrlJ provrde [lre corrrmu,ity witrt cducario,'rr ivcrrncctilr trea(rrerr(? 12, lt ycs to Ql l. when rti,l r,,,,, h-....: ,rrli n,)i,rri"r, ditr you providc trrc educatir, ro rtre co**uni(y? (cr*cLE A r-L I l. Dir! you 13. lf yes ro Q l. Yes l. Ycs Otlrcr (spccily) lu trairrir lg-_ Lsst trai l. Ycs I , )'cs l. Yesl. Yes ALL TIIA 2. Nr.r 2. No 2. No ?.. No T, APPLY) Yes 2Ycs zYcs z)'es Z. 2. No 2. Nd I . Duting thc first tnecting2. Ucf<rrc tlrc firsf dlsrriburl<lrrj. uuilng dislribution l. lo.on aftcr <tistriburion5. Orlrcr (slrccify) I l, what did you rclt tlrc conrnrurrity? (CtRCLE .l faking iu..,n""ti,, ,rtnuatty ftrr several years : Bclrcfi(s r.l[ (rcatulentS.,Corrrrnurriry re..,ss151L1111y4. Sidc cffects6. Orhcr (sgrcciiy) No No No No 14. Did l5 vou receive ally rrairritrg ort lrow to trea( cottrrrrurrity rrrerrrbers? lf Yes to Ql4, rvlrcrr ditJ ),ou rcccive traiuing? 16. WJ,o rrainecl you? I 2 3 4 I'lcal tlr pcrsorrrrc l/Orrc I rvc oo'siniil;:, r; "" c'rord irtaror Arrothcr CDD =- 17. l{orv long <lirJ rlre rrairring lal,r? l, trainirrp arrl . . tl.t]illlltlr Lrst .trai,,h-,i|.- l.lorv rrrorry CDDs \vcrc tl;nrrcd togctlrcr (Slzc of llrc gruup).r .t*..,"...,*.^ l8 l.i' ,1, il lr.trrrrrrrrrllsl lnrlrunrrrll Karrlrlr. Alry l ggg I 'ii :l 'rt I Y,, ,,1' ,;' J,fi" ,}: I, li,, fr. fir il .f#,r ,!L 19, Where was tlre vcrrue oI rlrg last rrairrirrg? l, Witlrirr llre corrr '1. 0utsldc rltc curr3. Hcal(hcare facill. Otlrer (spccity) 20 Ycs 2. Nr.r rrrurr ity ttrrtrrr ity ity/lruspir:r II I I ,'l,l ,l ,il Was tlte vcrruc of training rrcar lo your conltnurrity? f1 , a,l r^lt "l 2t wl'lr wc'c yr)' r'*r,rrr rrrrrirrp. rrrrirrirrl, 'rr*ir.rrr.rrrx:crt:i,*iri ((-rttcr,ri Ar,r..r.rA,l.n 't,r.\,)I . Cuusu 2, .Syrnp(otrrs 3, Socio.ecr.lrrorni, 4. Corrrrrrrrrrity rrrr5. lverrrtectin as r6. Otlrcr (sPcclly) ,) wltat rvcrc you tauSlrl ab.ut tlrc .rug? (cll(cLE ALL'l.l.lA.l. Alrl,Ly) Duration of trcirtrrrerrI Covcrngc of rlistrilrrrr iorr c iruportarrcc rlrilis;rtion :urr l p1111q.11 i1111 realrucnt for :r lortg tirttc l. Ycs l. Ycs l. Ycs | \'cl l. Ycs L Ycs l, Ycr l. Yes l. Ycs L Ycs | . Yr:r l. Ycs I Ycr L Ycs l. No ?.. N, 2. No 2. No 2. No 2. Nrr 2. No 2. Ntr 7 N,t 2. No '). No 2. No 2.. Nrr 2. No Yus Yes Ye.s I 2 3 ,4 5 6 7 8 9 t. 2. :1, 4. .5. 6. , Dosage dcterrrrirration by rrrcasuring hcigtrfExpiraliorr oIrJrug nfter rcrrrovirrg fontairrc.r sc:rlI tcilullcn( ul itUsclltccs utrd rcl'usals Sirlc c[fccts (corrrrsclirr;1 nrrtI rr:[crrrrl) Exclusiorr crircria Ilecortl.kee^ini Certsus I 0. Orlrer (specifl,).*.. 7.1 wlr*t wcrt: y., rrrgrrr ub,rrr rcpur tiru'r (uil(cl.tj.Ar.L .t.ilA.r. n r,r,L.y) Nurrtbcr of pcrsurrs tr culc(l Nuurber o[ relusals Ntrttrlx:r of nlrsciltccs Nurnber of exclutle<J l)ersolt:iNtrrnkr tvitll sevcrc si<lc r.[[r.t.ts Other (s1>ccity) Did arry rrrcrrrbc?'f rrrc corrrrrurrity c,rrect (rrp.rrrrrg fr,trr rr carccr.tltc last distributiorr.l ,,yy.,,,,s urril i oil troil Poirrr tlurirrg l. \,cs 2. No 3. l)orr.l klrow '1.5. l[ "no" lo e]4, wlry,/ Al,lrrror llg tlrr,.rrrllt X orr,1,6pa.i Alrv lllrrr Yy 2. Nr-r 2.' No .) Nl, r 2. 'No ) N,' l- 2,1 i,; I l,l, i" I I I i' t::*' l).)' ':'i iIil l i I I I I I l' L t I i I l I i I I I I l :i ":i+f1:. :-G! " -+*t) i,-i;:',i. :s{d '-ri. v ).(' '2t 7fi 2yb 30. llow do 't'ilA llttw {s ye11 lrcaliltellt? Dld you cxperi '1. yes | . \'r.s lf ycs, pleasc e.rlllarrr Wlrclc is tlrc eollcctrurr lrurrrr/ crrcc lalc sul)pty of drugs rJurilrg (hc last distriburiorr? 2. No Plerse explnirr rt,rw rr, y(,,, ,(,rrr,.ry rrcrcr,,,,,,"',;';:::;;;,;;;,,,r,, ,".,,,,,".,.,r:," *,,,,,,,,,, j1 I . Ccnsu.s,,rcgistratiun record2, t'tcvrr.rr, :i.lt ctllrrrcrtl tcc(,t.ds3. By cour rting lhe rrurrrbcr oI lrou.sclrold,s4. orlrcr ( slrcclly) hy't l . Ycr 2. lJol. Yes Z. Nol. Ycs 2. Nul. Ycs Z. Nol. Yes ?, No 29a Did you e.lpcricrrce slrortagc o f drugs durirrg the tasr tJi.strilrrrtiorr? 2 l.trr 'lT,ffi:i,'j"ne rhe nurrrr)er of rabtcrs ro givc ro arr Take lrcight nleasurenlcrrl Urc wciglrr Visual obscrvatiorr Agc Otlrcr'(spccify J l. Wlrat do you rjo about irrclivi<Iu nls who arc abserr( rJurirrg lrorrrral rlistriLruti 't , 2. 3. 4. 5. l. Ycsl. ycc l. Ycsl. Yes wcck (rclor r: tlrs(ribu rlurr inrlividual? (ClR(.t.t1 AI,l- 2. No,, '), Nu 2, No 7. No on pcricld?)2. Wlrut do you ,__- 'r :l Wlriclr crrlcgor ics rrf AI'I'LY) Irtrllv irlrrnls lrclow Pregnalrt wotnen .5 ycnr r of nge/ Lrcluw gOcrrr Worrrqr wlru dclivct.ctl lc.s,, 111;111 s11cSick in<JivitJuals Vlsitors Ottrer (.spec i l-y).-_.__ rjo atruut lrrtjivitluall, wlro rctusc llcilltnsn(,/ pcogrlc worrlrl yorr tror givc rlrc lrrLtc(s (t,LljAljU Cll(CLlj ALL .l.lln,l I 2 l 4 5 6. :t4 ir cnsutc tlrrrl llrclc elltc6(l,lc! (rf 1,tcu1tlc cvcil(u0lly r.ccclvc MorrilorirrT lr,ltrrrr*nu Xrnprlr tMal lgt)g r8 t i, t; IIt ,,1,i ,t 1 I l,:'.tl i .t't ,l,til,, ',hl S:i' ,l l 'i "ij ,Nt Ui trt / 35a."1'low lorrg'r.tbigou nonnar,ry kccp trrc tnbrcrs irr rhc corrrnurrrity,/ 35b. tlow rnarry days tritr you takc tru corrplete trre last distributiorr?ul .r1r -, 36. Whcrc tlo you rronrmlly kccp thc tablcrs? 37r. Do you,lrave rJrugs to rake clrc of irrirror sidc cffccrs? l. Ycs 2. No 38. What kirrd of suppor( do you rcceive frolrr tlre conllluuity? ;rlP,rlr arrrl y,.,r, ',^ 1 'r).1... ,;., 'l'rarrsportatiorr for ttrug collcctiorr Incentivcs (spccify) Othcr (spccity) 1i ht(':.... L F [liurri,, \., I 2 3 l,ir, 39. Do yoq have rrroblerns witlr rccor<l kceping? l. Ycs "' 2. No 40. If ycs to e39. pteale expla ,+t, plcasc,telt us lrorv you feelubou '| ' ,,t t tlre progrdrrrrrre with resl)cct to: a) sustairrrrrg tlre prograrrrtrrc lr) conrnrurrity response c) corrstrairrts 41. Wlrat tlo y<tu tlrirrk slrotrltJ bc tlorrn lo irrrpruvc tlrc lrrugr:rrrrruc,/ 43. Arc you willirrg ro conrirruc as a CI)D./ I r l. Yes 2, No /ll Plense explairr ilirtj;ififififiou RECrsTER ^ND ME^suRrNc Dr:vr.sri'r'o lnovrr)ri Fo;r_owrN(; 44n. ls rrrcnsurirrg rJcvicc lor hciglrr prcscrrt? , I I [lortllorrrrg ltrrtrunEnlr Karllpoh , lvloy lr)99 I I I I I I l i I I I . ."# ,,i,$ir :;l: i: 1il.it iil , li'li hI' I, l1 l:t I l 1""-- F l, .Ycg, 5cgi1 2. Yor, I'ut trol rccrr (lixgrluirr) +1 r,lr.rrl.r.,Nrl,.Uxlllairr f'rr' lluw rlo 1'r,, usc il? I 5. Is lrcatlllcnt rc!,ster prcscrrt?. . Ycs, scclt t . Ycs, [rut ll(JI scclt (Uxlrluirr) , N0, cxltluirr lr Q,I.5 i.s "Ycs, sccrr" ItXAMINF.'t'REATMENT REolsrER AND ourAlN t.ilEr:oLLowlNc lNFot(MA,l.loN oN: Totnl populatiorr Agc courposiriurr of pcoplc: l}clow 5 y.curs_ S years.arrd above Scxcorrrposiriorrol'tlrc.pulrulurlu,,:Mul". -l1ilil,.Nulnbcr of pcrsorrs trcatcd____Male Fcrrrale N u r r r bc r o f pc r so us ur r..t. r - 5-ffi1ilhu rcfr:li"Jf[,, ;, ; ;, ;' - Nrrrrrlrcr of rcfrrrnll t-" -NUillucr abscil( durittg lilst trcuirrrcut Nurrrlrcr rvillr scvcrc rirlc e[fcr,ts Nurnbcr of tablcrs rcccived lU, Nurrrlrcr of tubtcrs uscrl I I . Nurrrlrcr of rab lcts lc[r irr .,rc tlrug kit ';t,4 ,; I t, i, ,l l,l 4 i !l. lt, I ir'.t j I i-,t, t,, ,' 1. i I 2 3 6 t. 2. l. dt 5, 6, 7. 8, 9, Murilur lrrl lrrltr urrrlllr Kurlrlr , M ry I U9u Itrt. I i ) $r r: Lr I l 'i 5 t a i I !' t LEfI I.( i. t.' l, k" ti-. $i F-. H rrj I I I I i t l I I i I I i I i I i i I I ; I i I ,I I I I I I 4Nxexr- q L Yes l. Yes 5. Have you rec scvcral years? 3. Dou't krrow/carr't rerrrenrber 3. Dorr't krrow Fo ,> 'To'be athninistered o.rtly in grortp "l)" villages. ltttervictv 2 cDDs p.cr village i,f there ore ilrcre tlmtt otte',cDDs' At tttc end of ttie ittirviir, ,ir iii ,iistritt,,ti, ii toi yii, see ri.t troti, ,,iriruring dcvise, registers,runaitittg'dnry if availqblc' whctt a qt,ostio,t.req,ri,'c, ,,i,itii,t, rcsr)ottses, au ,:,ri'lorgct to prt <t circrearowrd each appricabre response ,oau, ii,it* tvrrcrc (u,r)r(4)ri(tte. ...i District/State. Narrre of CDI),t I _ Sex: l. Fernale 2. Malc r, ,-MainOccupation: \i. Morrth and year of tast distribution ,./ ,i l. l'low were you selec(ed to tJo thc work? at a village rrrcetirrg village elders' nrcetino village chferlead; " lrcalth,wor[cl, village healrh'cornrnittee village cr:rrrrriiuec nree(iug other (specit-y) 2' llas a.y cDD beerr crrarged after trre {rrst dis(ribu(iorr? l. z. 3. 4. 5. 6. 6. 3. l{ave you ever bccn sullcrviscrl ? 2. No Z. Nr.r 4' lf ycs to Q3' wrro superviscrr yt'ru ? (r1 Nly-!-wns'MEN'r'roNIrD, I'LEASE ASK I;Or(lDENrrry/po'srrrorursiiiij; on l rE pEnsoN) l. I lialtlr statf2 Village lrcaltlr conrruittcc rrrcrrrbcr3. NGO parrner : Cornurunity.rrrerrrbcr/chieI). Other (specify) eived educalion on (lre irrrllortarrcc of takirrg ivcrrrrcclin tablcts arrrrually [or i. Yes Z. No 3. Carr'l rcrrrqrrrber ti, Did you receive any lrainirrg orr irow ro r| ..,, . q.,,r, 6 uil l t (rca( conuttunity tttctrrbcrs? 2. No t\l l. Yes Morritorlng lnstrurEntr Kortrpolo . Moy 1999 t7 ls rrrcasuring dcvicc for lrciglrt llrcscrr(./ | . Yes, secrr)lttr 1rr,il,, at, '21 Yes,:',[gl11rut seen (Exgrlairr), 17istl.i1,rr ,rr3l.;rNo,itExp lnirr) ol)1rr rr llill trt l.r:{rril \r,r1 1r\, + !(ii 8. Is lreattllctrt register pre ,r.rrttt r',r..' ',,. sent? l. Yes, seen , 2. yes, but uot seen (Explairr)3. No,'(explai Nunrber rvittr sevcrc side cl'l.ccrs Nurrrber <lf taLrlers receivetj Nurrrber or taL,lcrs usc..i' Nurrrber of lablcts.left irr the drug kit Update oI recorcls 9 ifll8;l,itlfiir;fflTJi,i lif^ r MEN r r{uGIs rurr ^Nr) oB r^IN ,ilrE l.-l'otal popu!atio 2.Age conrllosition of lleoplc: Uctow 5 ycars 5 ycars arrd above 3. Scx conrposition of rhe population: Male Nu.rber of pcrsorrs trcatetl_lvlale.-- l;crrrale - Nurrrbcr of perso.s agetr 5 years alrd ab,vc rvrro recciveu ,r*,,** - Nurnber of Lefusals 7 Nunrbcr abserrt tJurirrg last treatrrrerrt I;errrale 4 5 6 8 9 l0 u l2 "tf )' .: t,'l'rlliil,,l,. ;.!,t.r,.,r, L 1., lrlrttUlrrri::., lil(lllrrrx.rr,r. r ,,,rl.t . [1.\. Ir,rrr) ,1, . ' I ', ,I, 'r : ,,,r, {'". [., i[ '-i i[,t ' ;I !t +* ANnr c-xe (, .,.' -i /'. .'j: r. : ; ,, OUESTIONNAIRD FOII IIEALT'I I I' EIISO NN DI- ?'ltis tyrcstiotumirc .is afutinistered ot auy hcaltlr t,orkcr irr tlrc arcu who is diractly itrvolt,cd ilt CD'l'l progroilunc i,e tlrc health sluff ucurest lo tltc t,illogc.'fltc ttutttbcr o[ l.tc<tltlt ltersorttrel to be itilerviewe<! dcpen<ls otr tlrc situatiott ou tlrc growtd. A ttrittittttutt of 3 lrcaltlt persoturcl wlrc arc srq,rcrvisors of CDDs slrould be tnterviewed witltitt tlrc project arca. After the intert'iew ask tltc lrcdth persoturcl for tlrc docuntettr.s usad lor CDTI activilies. LGA/Subcourrty Statc/DiSirict_ Country Natrreoflrealtltpersonllel-Scx:l.Malc2'l:clttale No. of O,:"1,o..Villages No. of CDDs in villagcs covercd Position:\l Quali[ication 'ltcsponsibilities irr Orrclro con(rol Progranrnrc: I Ouclrl Courdirrator 2 CDD sullcrvisur' 3 o(lrcr (specily)_ 1. Did you receive arry general oricnratiorr on CD'l'l? , l. ,Yes 2. No 2a. Did you receive trainiug ou horv to (rain CDDs? l. Yes 2, No 2b. Ifyes, how loug?--' 2c. List the rrrairr topics covcrcd 2d. Wcre,you taugltt trorv severc sidc cflccts shoultl bc uranagccl? l.' Yes 2. Nr.r - -3iPleaselell us wltar you krtow about tlre CDTI l)rogralunre rvirh respccr to 1. Cornnrunity responsibility 2. irrvolvenrcnt of the liealtir sysrenl irr CD'l'l 4i Was tltete an initial rneeting with the coullnunity rvlrcre CD'l'l rvas inrroduced'/ l. Yes 2. No Morritoring lnstrunrnls Klnrpaln , May l99g +i N:,,'j-ftj,liiQ4' rvhat r.le tlitl the lrealth sta[F ntrry irr :rrrarrgirg frr rrre first ^reerirrgr tcrnr-ca nLij, '+. il.'5i ,;, I;acilitated the rucet irrg Met with village leatler to arrangc [r-rr tlre rrreetirrgOther (specify) 6 Wlro led the facilitating tearn to tlre coirrrrrulriry? Irealth stal'f govenul)cnt adrrrirristrativc sta[[ (norr_lrealf tr)NCDO sraff othcr (specity) NobuJy Xffi,ji" cottttttutrities (rvltere you wr-rrked) cducatcd orr rrrc i,,,porro,,.. oI treatrrrent witrr iverrrrectin l. Ycs 2. Ncr 3. Dorr't krrorv 8 Il'yc.s ro Q7, rvtrat rverJ rlrey rotd? (cillcLE At-'L TilA.l.ApPLy) Arrrrutrl trcatlllcllt for scvcrlrl yeurs lJenellts of treatrrrerrt Cournruuity responsibiliry Others (specity) I 2 3 t. 2. l. 4. 5. I ,l t!;. Il ':(, llt:l 't \r'' '/r.i .rftl r, rliz,', : rtlJ'- 1 1 2 2 4 l. Ycs I . Yc.s 1.. Ycs 2. No 2. No 2. No 9 wcrc cDDs irl (ltc corttttturtities (rvlrcrc yotr rv'rkctl) rrairrcd lor tlrc CD.l'l ,rograrrrrr:c? 1. Ycs 2. No 3. Don,t krrow I0:r Il 1,q.,,, Q9, did yorr parriciparc irr rlrc (rairrirrr ol"Cl)t)s,/ l. Ycs Z. No t0tr ll'ycs. lrorv lo11g did rlris tmirrirrg se.ssiorr last./ Initial trar Itetrairrirr irr ing-- t! I ll. Wlro supervisccJ the CDDs I . N0t sullerviscd 2. Villagc lrcad 3. Village lrealth c<lrnnrittee ruerrrller4. lrealth ltersonrrcl5. Orlrcr lllr li'strllcrvised, lttlrv tttalty cDDs did yorr.strpervise tlrrrirrg (lrc Ias( disrributiorr? l2 ll'rror supcr viscd, rvlry?. At rvlriclr occasit-rrr.s tritr you visir trre cDD,/ (cil{cLE ALL.r.ilA.r.AI,pLy) l. Ycs 2. Nt-r :- i .hl I ., I i,.,, .t:(.1. )l'-l,i- i, .t | .'] I llc[orc rli.strilltrtiorr NlorriIrrirrg l[5ln[tEnls Krrrrn.rlr . lvlr1, l9r)g I i P6 During distributiorr Soon alter dis(ribution Collection of unused drugs after distribution Review of records Marragerrrcnt of si<Jc eflects Supervision of drug rjisrributiorr l. No constrainB 2. irradequate/lack of rnearrs of trarrsport/fuel3. Too rnuch work 4. Inadequate/lack of supcrvisir,lrr allowarrcc5. Inacccssibiliry 6. Othcr (spcci l6a. llavc tlrcre been arry ctelays irr receivirrg ivcrrrrectirr,/ Il Yes l6b. If ycs, explaiu 2 3 4 l. Ycs 2 I. Ycs 2 No Nr.l 1., Othcr (specity) l4' Whatfluttc(iotrsdoyoupcrl<;nrrtJuriDgyourvisirrorlrcCDD,/(cll(cLEAI-Ll.llATAppLy) I ., 3 4 5 l. Yes 2 l. Ycs Z I. Yes 2, l. Yes 2, No No No NoOther (speci [ 15. wlrnI con.straiilrs do you hirvc irr suPclvi.sirrg rrrc cDD? (cillcr-E n Lr- .1 IA.r. A ppLy) L Yes l. Yes l. Ycs I. Ycs l. Ycs 2. No 2. No 2. No 2. No 2. Nt-r 2. No [6c' l'lave tltcrc bccrt arty clclal's irr collectirrg ivcrrrrec(iu by.rlrc crrrrrrurrity? l. Yes 2. No 17. If ycs to el6c, pleasc expla llt 18. Wlrar cousrrairrrs havc you expericlcccl in get(irrg rlre tlrug,/ (CIIlCLlj AI.L.fl IAliApl,l,y) l. Noue 2. Transport problenr 3. lrradequqte supply4. Dclay iu suppty 5.. Ottrer (spccify) Yes Yes Ycs Yc.s 2. No 2. Nu 2, No 2. Nrr 19. I{ow rJo you eslilllate tlle quarrrity of rlrug requirctl? t. 2. 3. 4. 5. Not responsible Nunrber used durirrg last treattrrcnt Based orr requests.frorrr tlre CDDs 1'otal population (with rhe forrnula Other (specify 20. Did yuu get lhc rJrugs whclr rcquir.ccl? l. Ycs Z. No lvltrrikrr irrg l[str ullEnts Klrrlrlll . lvlrry I r)r)r) i ! r) t{ I --'tl I, I 21. tf 'ro ro eZO, why? i. "illll,llf l,i',lii;f-'o,,aI Ievc, .J. Ortrer (specify) 22., Do you have facility for.storage of iverrnectin,/ i i i F I t, I I i i. t t l. yes 2. No Whar orher lrcalrh acriv.i,j::do you corrrbirrc rvirlractiviries'(pttollE FOR I.tEALTII nCt.rutlry tN 27. How <Jo you feel about tlre CDl.l prograrnrue? 3, Dolr't krrorv Wcie cases of severe side effects reported to you,/ L Yes 2. No L .Available 2. Not available (cr.tECK AVA il_ABTL|TY) 9,fi ';.H: " iif ililli, or,, 23. IIave you experienced, loss of ,tablcts <Jue to pilli:rage,/ l. Yes Z. No 3. Dorr,t krrorv 24 25. 2(t fu1il11i1111;;* lntlnrtx:,ll( Knrplr;11;1, A,l.r\. l,),)() Arvx<-xc & I t n'rcttvt nw G UIDtr For( pol.r cy-MA l(rins/ lvno r( Eprt risriN'l'ATrvr/pno c rrn Nr M Ii I\,IANAG EITS/ COOITDINA'rORS SECT|ON A: PROGITAMME MANAGERS/ ONCI{O COCr(DTNATORS .l' Pleasc describe ltow tlte CDTI prograrnrue is beirrg irrrplcnlellted irr your area PROBE FOR 2 :1. The approaclr,used lbr introducirrg cD'l'l to tlre corrunurrities b. Eletnents of collal-rr.rratibu trctween Couuuuuity, llealth systenl arrd NGDOs (IDENT'IFy SPECtFtC ROLES) c. Gettcral re-orietttatiott of lrealrh Jrcrsorrrrcl [owards CD'l'l prograrrrrrrc d. Mobilisation of rhc conrnrunities c. Trairring of hcalrlr staff as trainers Please.exlllain proccss oI rcceivirrg ivcrrrrectirr. PROBE FOII : il. Delays iu sirulriy . at wltat lcvel and rvhy'? c. Adcquacy of tlrc quantiry reccivctl/slrortlgc rl. Sturage e. Distributioil to corrrruunities l. Constraints (srora-uc, transjrort, ctc) S. Pilferage FUNDINC: Please probe tor a. Delays in etrdorsenrcllt of lcttcrs of agrccrrrcrrt, 5t T'ltis ilueruicw is a&ninistered oil Co-ordinators, Prograttutte nkutr.gers) represeilatives of NGDOs ittvolvetl it1 CDTI, Mitristry of health ltolicytttakcrs otul tlrc WIIO rcprcsetttiltiva itt tlrc coutrtry. Ir is sitrtilctr to t1e . i,ile,'view of lrcattlt personnel. Doctunetils sac/t ru rcgisrcrs sitotdd be requcsrecl befoie tlrc fornutl irttcryicrt,\, so tlmt infonuatiotr can be utracted {ot- the report ,; [" I I l. I /{ t':!f ir IIr,t I I !, I ,l.it + Jrl i h, t. l I ) ?. i i., a l i. tll J b WIry? Delays irr receivirrg luntls . il( wllat level arrrl rvlry? Dclays irr disburscrrrcrrt oI furrrls . At what levet and wily? sr I'J,rrrilurirrg lnslrunEnts Karrr;xrla . May l99g c 45 d. Inadequacy of previous budget c Fuur, aduri'istratiorr: ,lcluys i. subrrissiorr. uI hrrarrciirr reports,disbursernelrt and reti retrient procedures, rlelays iir feeub.act< rrorir nt;oc t,.o,qunr,.r, r.rrr firrarrciar reports I)lensc describc trre ,rograrrrrrrc's llrarrs ror irrrprbvirrg sustnirrarririr.y 6 Xlfil;:J'tt ltealttt activities do tlre,o.iho suPcrvisors co'rbirre witrr rrreir orrcrro corrrror prograrrrnre -wruld you please ex-llrairr trre ;lr<lgra.urrc s rccortr kccpirrg llroceduresEXAMTNE 11rE FOLLOWINb RACOROS Surnruary sheers: l. AvailaLrle 2. Not available IJXTI{ACT INFOI{NIA'I'ION oN 'I'IIE I,'oLLoWING (retare to rhi level o[ o,erario. e.gst:rtc arrd LCA) a. Total Iropulariorr b. Nurrrber of villages in tlre arca_ c. Nurrrber of villagcs rvith surrrrrrary forrrrs d. Nunrl-ler of villaues treatetl 7 I I rl' ,'i ). e Nunrl-rer rvi(h severe side eflects Evidence of report ulldate (check anlrual retuurs alter tlistribution) I. Updated 2. Not updated SECTION B: tvlOIl POLICY iUAKERS ( Pertttarterrt Secrctary/Director Disease Ccrrrtrr:l) :l;ilrJr:ir:,1,1::,;",i^,'"rtal Plart [or tlte control of orrchocerciasis ( Probe [or rhe i,rnporrarrce auactred ro 8b. what kirtd of support do vou provide for Orrcho. Corrtrt-rl activities (pltOBE'FOII FINANCIAL INPUT) 9 tlow do you perceivc the CD'l'l strategy of AI'OC ( Probe for persorral opiniorr and officinl policy on CDTI) l'0 Is the Ortclto Progratttttte iutegratecl irrto the ltcaltlr systctrr ( Probe for aclivities rvhiclr irrdicate irrtcgratiorr aud owrrerslrip/ Ptans for sustairraLrility. I r I s I ,+ , i ri t' lr ,.i -'. , I r . Moniloring lnstrurrEnts Kcrnpaln , May l9t)9 1 ,,1. ,MAP OF ZAMFARA STATE OF MGERIA KM -t--=-- 0 20 lr0 ISA .Golod .Dole . Isq MARADUN RA ro. Rogo ' ALATAR'Bukkuyum .Gwoshi a 'Rog 'Bokuro . Donk o Adebko ANKA .Bogego BAKUR A Tototor Mof shebowq' rZurmi ZURMI odo _v--_ rngr UN GUDU a K.I,IAMODA .K .Lqngol CHAFE .'No GUSAU ,Rqnlo .Don SodouMARU Mohongo dq ,Yor rSengiokun \