Mahenge CDTI annual project technical report submitted to Technical Consultative Committee (TCC): January 2008 to December 2008

THE UNITED REPUBLIC OF TANZANIA MINISTRY OF HEALTH AND SOCIAL WELFARE RECU LE APOC / DiR .t For To: fi'o CRJE^PI 3ltnffi/'S icclg cs_\ coP C/ro '{o co BrDft for hbrndon Tor }14 fl.Bq\<ocro 1 COUNTRY/NOTF : TANZANIA Proiect Name: MAHENGE CDTI Aprrroval year:1997 Launchingyear: 1998 Reporting Periqll: From: JANUARY 2008 To: DECEMBER 2008 Proiectvearofthisreport: (circleone) 1 2 3 4 5 6 7 8 9 (10) O"t. rrn.ru: 3'd MAY2008 NGDO pattner: INTERCHURCH MEDICAL ASSISTANCE (IMA) I zCCSI AOUI WHO/APOC, 24 November 2004 IANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) DEADLINE FOR SUBMISSION: To APOC Management by 31 January for March TCC meeting To APOC Management by 31 July for Sentember TCC meeting AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) 2 WHO/APOC, 24 November 2004 II I IANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE, (TCC) ENDORSEMENT Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the report: Country: TANZANIA Ag. National Coordinator Name: Dr. Edward Kirumbi Signature Date Zonal Oncho Coordinator Name: Dr. Frida Mokiti Signature Date NGDO Representative Name: Dr. Daniel Nyagawa Signature Date j This report has been prepared by Name: Dr. George Kassiga i and Mr. Alfred Kilimba J i Signature WHO/APOC, 24 November 2004 Date: Table of contents DEFINITIONS.......... 7 FOLLOW UP ON TCC RECOMMENDATIONS .........8 EXECUTTVE SUMMARY......... ..................... 8 SECTION I: BACKGROUND INFORMATION........ ...................10 ; ;;: ; ;|; i i *, ;; ; ;: ; ;dl,:i. ::::::' ::::': :?: :'t':\ 2.1. TrvelrNB oF ACTIVITIES .14 2.2. Aovocncv. ........ Ennrun ! SIcNer NoN DEFINI. 2.3. Moett-zertoN, sENSITIZATIoN AND HEALTH EDUCATIoN oF AT RISK coMMuNtnes 15 1.1. GpNener. INFoRMATIoN............. l.l.l Description of the project (brieJly)......... 1.1.2. Partnership 1.2. Popu1euoN............... 2.4. CouuuNIry INvoLvEMENT......... 2.5. CepncrrvBUILDING.. 2.6. TnenrueNTs..................... 2.6.1. Treatmentfigures..... .16 .17 .20 .20 2.6.2 What are the causes of absenteeism?.......... ......-......-..- 20 2.6.3 What are the reasonsfor refusals?................ ..-.--.........21 2.6.4 Briefly describe all known and verified serious adverse events (SAEs) that Erreur ! Signet non diJinl 2.6.5. Trend of treatment achievement from CDTI project inception to the curuent year 23 2.7. ORoenrxc, sroRAGE AND DELIVERY oF IVERMECTIN ......-....25 2.8. CornrNauNlIry sELF-MoNIToRING eNp SrerpHoLDERS MeerNc ............26 2.9. SupenvtstoN.... ....26 Provide aflow chart of supervision hierarchy . Erreur ! Signet non difinl Wat were the main issues identified during supervision? . Erreur ! Signet non Was a supervision checHist used? ..,......Erreur ! Signet non diJini. Wat were the outcomes at each level of CDTI implementation supervision? Erreur ! Signet non ddftnl Was feedback given to the person or groups supervised?... Erreur ! Signet non How was the feedback used to improve the overall performance of the project? Erreur ! Signet non difinl SECTION 3: SUPPORT TO CDTI 2.9.1. 2.9.2. diftnL 2.9.3. 2.9.4. 2.9.5. ddJinL 2.9.6. 3.1. 3.2. J.J. 3.4. EqurrueNr... FnraNcw- coNTRIBUTIoNS oF THE pARTNERS AND coMMUNITIES Oruen FoRMS oF coMMLINITy suppoRT ............... ExprNotruRE PER ACTIvITY 27 27 28 28 29 29SECTION 4: SUSTAINABILITY OF CDTI........ WHO/APOC, 24 November 20044 4.1. INrenNer.; TNDEIENDENT pARTrcrpAToRy MoNrroRrNc; EveluerroN........ Ennrun ! Srcxrr NoN DEFrNr. 4.1.I Was Monitoring/evaluation caruied out during the reporting period? (tick any of thefollowingwhich are applicable)............ ...........29 4.1.2. Yfhat were the recommendations? ............. 29 4.1.3. How have they been implemented? ............. ................. 29 4.2. SusrerNesrLrry oF IRoJECTS: ILAN AND sET TARGETS (MANDAToRv AT.... Ennnun ! SrcNBr NoN DEFrNr. Yn 3) Ennrun ! SrcNBr NoN DEFrNr. 4.2.1. Planning at all relevant levels... .................30 4.2.2. Funds....... ............... 30 4.2.3 Transport (replacement andmaintenance)........ ....30 4.2.4. Other resources ...... 30 4.2.5. To what extent has the plan been implemented................ .............. 30 4.3. INrpcRauoN............ ......30 4.3.1. Ivermectin delivery mechanism,s ................ .................. 30 4.i.2. Training.... ..............30 4.3.3. Joint supervision and monitoring with other programs........... ...... 31 4.3.4. Release offundsfor project activities ........31 4.3.5. Is CDTI included in the PHC budget?............ .............31 4.3.6. Describe other health progrommes that are using the CDTI structure and how this wos achieved. What have been the achievements?............. .................... 31 4.3.7. Describe others issues constdered in the integration of CDTI. ..... 3l 4.4. OppnarroNAl RESEARCH Ennpun ! StcNBr NoN DEFINI. 4.4.1. Summarize in not more than one half of o page the operational research undertaken in the project area within the reporting period..... Erreur ! Signet non ddJinL 4.4.2. How were the results applied in the project? ........... Erreur ! Signet non ddJinl SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES' AND OPPORTUNITIES.... . ERREUR ! SIGNET NON DEFINI. SECTION 6: UNIQUE FEATURES OF THE PROJECT/OTHER MATTERS...........32 5 WHO/APOC, 24 November 2004 Acronyms APOC ATO ATrO CBO CCHP CDD CDTI CSM HSAM LGA MOH NGDO NGO NLFEP NOTF PHC REMO SAE SHM TCC TOT UNICEF UTG wHo African Programme for Onchocerciasis Control Annual Treatment Obj ective Annual Training Objective Community-Based Organization Comprehensive Council Health Plan Community-Directed Distributor Community-Directed Treatment with Ivermectin Community Self-Monitoring Health Education, Sensitization, Advocacy and Mobilization Local Government Area Ministry of Health Non-Governmental Development Organization N on- Governmental Organization NATIONAL Lymphatic Falariasis Elimination Programme National Onchocerciasis Task Force Primary health care Rapid Epidemiological Mapping of Onchocerciasis Severe adverse event Stakeholders meeting Technical Consultative Committee (APOC scientific advisory group) Trainer of trainers United Nations Children's Fund Ultimate Treatment Goal World Health Organization 6 WHO/APOC, 24 November 2004 Definitions (iv) (i) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking). (ii) Eltelble population: calculated as 84o/o of the total population in mesoftryper- endemic communities in the project area. (iii) Annual Treatment Objective: (ATO): the estimated number of persons living in meso/hyper-endemic areas that a CDTI project intends to treat with ivermectin in a given year. Itimate Treatment Goal calculated as the maximum number of people to be treated annually in mesoftryper endemic areas within the project area, ultimately to be reached when the project has reached full geographic coverage (normally the project should be expected to reach the UTG at the end of the 3'o year of the project). (v) Therapeutic coverage: number of people treated in a given year over the total population (this should be expressed as a percentage). (vi) Geographical coverage: number of communities treated in a given year over the total number of meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage). (vii) lntesration: delivering additional health interventions (i.e. vitamin A supplements, albendazole for LF, screening for cataract, etc.) through CDTI (using the same systems, training, supervision and personnel) in order to maximise cost-effectiveness and empower corrununities to solve more of their health problems. This does not include activities or interventions carried out by community distributors outside of CDTI. (viii) Sustainability: CDTI activities in an area are sustainable when they continue to function effectively for the foreseeable future, with high treatment coverage, integrated into the available healthcare service, with strong community ownership, using resources mobilised by the community and the government. (ix) Community self-monitorine (CSM): The process by which the community is empowered to oversee and monitor the performance of CDTI (or any community-based health intervention prograrnme), with a view to ensuring that the programme is being executed in the way intended. It encourages the community to take full responsibility of ivermectin distribution and make appropriate modifications when necessary. 7 WHO/APOC, 24 November 2004 FOLLOW UP ON TGG REGOMMENDATIONS Using the table below, fill in the recommendations of the last TCC on the project and describe how they have been addressed. TCC 2 ear 9 Technical re ort 8 FORTCC/APOC MGT USE ONLY ACTIONS TAKEN BY THE PROJECT Number of Recommendation in lhe Reporl TCC RECOMMENDATIONS 158 The TCC accepted the report with thefollowing recommendations and for for improving project implementation: Improve number of health staff in project area involved in CDTI (ATOs at district and health posts) (i) The numbers of health staff involved in CDTI have been increased in both districts. Kilombero from 42 to 96. Ulanga from 40 to 90 Ratio for CDD have been improved Kilombero district have reached the CDD ratio of 1 :1 10. Ulanga reached l:120 Improve CDD: Population ratio to I :100 (ii) Mop up treatment successfully treated all temporary excluded persons and absent i refusals (iii) Ensure treatment of pregnant women post delivery The fully implemented the TTC recommendations (iv) Project to tully complete implementation of TTC recommendations Intensiff health education and mobilization to address refusals (v) Extensive health education and mobilization was conducted in all project area and now refusals and absentees have diminished.(vi) Carry out mop up treatment to improve therapeutic coverage Done and we were able to reach 81oZ therapeutical coverage(vii) Involve more women and youth, existing cultural groups, schools and religious sectors in CDTI All were involved WHO/APOC, 24 November 2004 Executive Summary Mahenge Focus was launched on lst July 1997 covering two districts namely Kilombero and Ulanga; it is in the 10th year of CDTI implementation. The project operates in 531 communities that are defined as hyper and meso- endemic with a total population of 453,426 people. In this reporting period the project focused mainly on the components training, monitoring, sensitization and mobilization. During the sensitization meetings community members were told to add the number of CDDs in large communities so as to reduce workload. Policy maker were informed on the withdrawn of APOC hence to incorporate fully CDTI activities in the CCHP. All communities have received treatment in the year being reported and decision making process is largely manned by the communities in the selection of time, mode of distribution and the selection of CDDs. Treatment in the affected communities commenced in November 2008 and ended in December 2008 whereby 378,413 people were treated and this makes the Therapeutic coverage to be 83.4. The project has reached full geographic coverage of 100%. Ultimate Treatment Goal (UTG) was 380,877 people and the Annual Treatment Objective (ATO) was 317,867 people. The project managed to conduct re-training and training to 1,551 CDDs and 134 FLHF staff. The project received 817,103 tablets of Mectizan in 2008 adding to the remained 427 ,483 (2007) resulting to a total of 1,244,586 Mectizan drugs through the NLFE Program and was at once distributed to all Central Collecting Points (Hospital, Health centers and dispensaries). CHMT members who were traveling for various activities in the district observed that Mectizan drugs are delivered and received for distribution in the affected communities. The partners of sustainability plan contributed to their commitment by remitting funds for CDTI are the Government Authority: US$ 42,509 (100%),Interchurch Medical Assistance (IMA), the NGDO partner: stopped funding Mahenge Focus since 2007. However, IMA released the 2007 funds approved in 2008: US $ 7,527 (100%), The National Lymphatic Elimination Programme US$ 8,580 (100%) and African Programme for Onchoceciasis Control (APOC) contributed US $ 14,721.3 (76%). Challenges: exit situation existing in our project since 2007. or cap with slogans for CDTI. activities. 9 WHOiAPOC, 24 November 2004 SEGTION {: Background information 1.1. General information ULANGA Ulanga District is located in southern part of Morogoro Region, 324Km from Morogoro town has a total population of 223,691. It has 5 divisions, 24 wards, 65 villages and 308 communities. Ulanga has an area of 24,560 sq. km. It is a diverse and variegated area embracing many climatic zones and geographical variations from low land swamps to mountain as high as 3500 meters above sea level. [t also comprises of 3 agro ecological zones; hot lowly flood plain, undulating Savannah miombo grassland and cool mountains with rain forests. The telephones and other forms of modern communication are present; but there are difficulties during rainy season due to frequent electrical blackout hence affecting telephone communication. The main ethnic groups in the project area are Pogoro, Ndamba and Ngindo and the newly migrating Sukuma from Lake Zone. The Pogoro tribe still forms the majority in the district. Despite of the varied tribe languages, Kiswahili, which is the national language, is spoken by all ethnic groups. Ulanga CDTI project operates in 4 divisions, namely Vigoi, Mwaya, Lupiro, and Mtimbira having 52 villages comprising 257 sub village communities that are defined as hyper and meso endemic. All sub village communities have received ivermectin since the commencement of CDTI project in 1997. KILOMBERO Kilombero District is among the six district forming Morogoro Region. It covers an area of 14,918Km. is bounded by Morogoro district to the east, to the west there is Mufindi district, while to the south is Ulanga district and to the north the district bounded by Kilosa district. Most of the district lies along the Kilombero valley (part of Rufiji basin) which extend below the Udzungwa mountains. The district has around 38 permanent rivers which provide high potential for hydroelectrically power plants and large irrigation scheme. There is also a Udzungwa national park and Selous game reserve which is attractive area for tourist. The district divided in 5 division, 19 ward, 81 villages and 365 sub villages with total population of about 404,672. Climatic condition of the district is mild Temperature ranges from 20 degrees centre grade as the lowest to 32-degree centre grade as the highest. Rains start in early November and end in May. It ranges from l300mm up to 1600mm. Forms of communication available include; landline and mobile telephones, fax, and Internet / e-mail. However, difficulties in communication do arise frequently due to fluctuating and or power cut-out. 10 WHO/APOC, 24 November 2004 The main ethnic groups in the project area are Wapogoro, Wandamba, Wangindo,Wasukuma, Wabena and Wahehe. This ethnic groups; although they have their tribe languages all of them speak mainly Kiswahili, the National language. Seasonally there is migration of cattle herders; the Mang'ati and Masai from central Tanzania. Most of the communities are involved in subsistence farming of rice, maize and beans. The main cash crops are also rice and sugar cane. The cattle farming also have emerged recently as one of the cash earning activity in these two districts. Table l: Number of health staff involved in CDTI 1.1.2. Partnership o The APOC funded the project for advocacy and mobilization activities and the rest of activities were funded by the Kilombero District Council (KDC) using the Basket Fund. o The Mahenge Project merged CDTI activities with Lymphatic Filariasis Elimination Program 6FEfl activitieJfrom December 4th, 2007. These programs are now using CDTI staffs, infrastructure, the CDDs and other community volunteers for the current Mass Drug Administration of Mectizar,and Albendazole. Overall working relationship among partners: 1. DISTRICT COUNCIL 2. APOC/WHO & OTHER INTERNATION PARTNERS I I WHO/APOC,24 November2}D4 District Number of health staff involved in CDTI activities. Total Number of health staff in the entire project area B1 Number of health staff involved in CDTI B2 Percentage BFBzlBl *100 ULANGA 274 90 32 KILOMBERO 250 96 38 Total 524 186 70 3. COMMUNITY. t2 WHO/APOC, 24 November 2004 $ oN Lo -o (J o zsN U o. o Jr > ca q) q) \I U q) L q) -as aU 8X Ss .S\\\ LB!$9 Brtil$q) '5-Sy!t\-\o'q)* -q) .t q: .\ .s >G rr s-v$F\L\GtsJ SS \U up $o *xs'd O()!a q)gF.rt .S qr ^-a =-: =*t 'r-. U <.\ L\ *qr .Q\ a\i\' *x =t!\s\s,\v .tsb s.9 =-s .FL 5bou6 iB"Y+ B\ +r, q) \!):!\ .li q. lt Erh q)X'n' !\ F-. (\l & oo rh Lq) -7 U en o q) q) G .= ^r Z6r u" c)LL =61AO)d> o tr o 0r (, Fr o;r =EcEEE6iJL oO r- F-r-r- o\ N rrF-a € ?a + I\o .q)rltr :4)O .= QN - hc.l ci E.-! +a\ Ei r€ -c) o\\o" caON tr} ca\ o\ .+ N \o GT -.t^ ?atf')t q) .'.9€:r-v-C)EEC):!6fit: gHo N (n C.lc\ oo o\ lr) t-- co \o ca \o $ ?o(\I d I rrc,rE f,l.-i.af --Ltr-EH!J€.T ga t t'= 'sx. \o\o$(n \o c.l c.) \o(\I6 € ot E q) e a0 6l anq) oI lr o)E z .q)l1 tr -C)O .= QiN - ). q.; 9\a Ei r3 rc) r,-tr) c.l $t--N rala N d)rr<) =c)i x'-_ 8..: i p ff,E I -Fq \o cn h \oa ol a):: c)E i r.aIi €E;EA t t'= ,RE. N $N intal ocl ali6) .9:E! 6*, E+iits a.= o. o\\o c.t NN c.lr-\o .+ r+ ra\o m € .I\o E,t -98 o) ;trEd 5{ f H - 9'sE'A oz F.l o&Ho a F.l V Fl t'{ o Fr .U o li(D a o0 tr o a.(l)lr 0) o0 l_r .d 9o ko (.) (d C)Lr oH x(.) Lr() 0) c,q) L GI Iq) oLa q) L tq) o JI(/) lr 6J o (d q og (! ar) C) E.:OE fltrGE -Hf!o. \Jt:t Nbt r (dliF Fl * t+o c.l k C) -o E 0) o z$ c.l O o Or{ o t+ th(d (d c/) d 0)k cd I o o a U)(d o ) k!(n E 0.)o o ,trq) V) c.)oo U) U) th l-r(.) .o do x oo(H o o CUN (/) trotn (d >.o(o>o;>oo r>.db -;> rt) E c) o U t-<(g 0.) >' o E o() tr C) (d(.) L{I (/) 63olr(E() l-r € U)q) o(B(* q) () H F ..i r 6)l -ol(dt FI o o +, '5 o G rF o o .= o EarF a F aN Fa(, lF o tr o .I *, G +. tr o Eg c .E aaN z 9F(J lrl o .t L e) a o ot BOEE o(.) ooq U rrl o @ Or! o .i'e?tr c(: rh- €q F(-) o 00 J D fr a bx tr oE trtr ooq o z @ O frl o a0EE1itr (i) - @ FO o € o z q) cll an q) q)(.) .9 -E 3E Er\ E @ e o z € D a0 .E€1itr (i) - 00 FO o € J AT E GL Fr o9 lJr OEE o U coq F O € z En*1-tr (h- @q o. IJ]a oo FU o =(l) .Etr s= &Eoo =9a a o (l)! IJr OEE o Q 00 ri D € o z 3',r 1!.ti c!= €O nJ € J tI I L U) a o z J o& sI ca z -l V Fl tr otr 2.2. Advocacy This was done at community level as it is a Front Line Health Workers led activity, undertaken to sensitize the community serve by the health facility. The new formation of the Ward Health Committees expected to assist us more from next year round of distribution. The CHMT did the district level part to the govemment leaders, Politicians and other influential people and local partners and the integration of projects were emphasized for cost efficient in its implementations. While, the Frontline health workers did within the community encouraging community meetings for CDTI sustainability, community self monitoring and ownership. 2.3. Mobilization, sensitization and health education of at risk communities The media used to disseminate information were; school health programs, village mass meetings, church, mosques and through Community Own Resource Persons (CORPs). Methods used in mobilization and health education of women and minorities are Reproductive Child Health (RCH) clinics, Out Patient Clinics, and Outreach RCH clinic Weakness/Constraints - Lack of funds to procure Information Education and Communication (IEC) materials. Suggested ways to improve mobilization and sensitization of the target communities are:- To involve more women and youth, existing cultural groups, schools and religious sectors in implementing CDTI. To produce local and cheap IEC materials and disseminate in all endemic areas. a l5 WHO/APOC, 24 November 2004 c.)OoN k()p 0) o z *N O(J P o \o q) G OEEEE!'Ef5? E }R| 7 oz\) .f E c)Zaoo, CJGI ll ':t- =co c = cl c)c)(.)boL() Fr O O r EE () ra f; EEEE E E aecrZE r-tr} C\ + t-- c.l ra rn c)trEi6l !?CrZ R3lJ5 (,)EEEtroac) z TII FOc( o Fr $ (n \o(r) r-\o q 2-c{6EAG) r\ -+( c.l tr-s\o o\ -. ania lr l.iaa) \oN o\ tr) o\\o F- ah 0)hiaHcr =">q) drtriro?trtso5-u) E=+ ,*Aototr 6(,) z "6A=dBioq)Pbo(t) ri .Br ?9-E6 A EEEE*Tz EE 7 r--tr)N .+ r--Ct ?ara a gEi nE e iE;EgH r-(n o.l $t-.N ?ara d -o) 0'E =c!dFoFEa ovLtr6)'-81,Eq) =iz? I ca=dD r cl q)(') lioo)Er U0 N ca € c-) la?a I.E EFttriF =E;;vZZ .E.E o\ \oo\ \o € s;=EE*€gs $r--N Otr)C\ tNin r}1 i.I q) L rn z -l c&r! FA zo r-l M G o Fr FiF (J o fl+trZo.=EtrL-o.n o'5 Ld *, c) E.EJ-ts=EtrEEo-o:. +l .qltbtr (tr|NFI Comments on rate of the participation of female members of the communify meetings when CDTI issues are being discusses (attendance, participation in the discussion etc). There was an observation for continual increase of female attendance at health education meetings which was now 6lYo and that is leading to more volunteering to become CDDs. Their participation is an active one hence also a number of them are elected to become community leaders. Current attrition of CDDs is not a problem however; more CDDs are expected to be chosen and trained in this coming financial year to lessen the workload. More females are among the expected volunteers for Mectizan distribution. It should be noted here that Village Health Workers who are two in each Village Government are now assisting in CDTI, distributing Mectizan and making follow ups to those absent during distribution in their respected communities; 2,5. Gapacity building Adequacy of available knowledgeable manpower at all levels. The project has 186 FLHF staff and 1,670 CDDs in 531 communities who are well trained on the implementation of CDTI activities. Most of the CDDs are willingly to continue with their job even though there is no incentive given to them. lYhere frequent transfers of trained staff occur, state what the project is doing, or intends to do, to remedy the situation. Normally transfer occurred within the project area where training has been already been done hence they do continue to implement CDTI activities at their new stations. Moreover the project have at least two health staffs who were trained at each Front Line Health Facility therefore, incase there is a transfer implementation of CDTI activities will continue as planned. t7 WHO/APOC, 24 November 2003 c.) c.l ko -o 9 o z tN O O^r o > oo .9(/) 'Eo(-, (')inAA EF EcdO) .,6=5J( :L 5Bo ?,)o-\ -o^ =(JB 0., rhPboctro) '4:# 'eq Lreo()€ E.E H orlqHlI c.lqY ! o-rq u?tb€ IEatriSs, L.1 'jf (d e 8=Y>> ::€6sur4 2oH(1)E =C)dtrcc) .^5bogEs cB a:dI o)EEi -o(gH€} 96(glEr E.r s '628 t88 arl< Oe'5 -tEx 't o-r H3 N\,/!5 r .b 2,; .9bc E GA bI) 9Ai xP^o)- =d9!Hq)H C'G)!Ydl<9E bo,, d"> .j u)'=:bEEEg a O.I te.so'E a *= g()tr< a FJ .rH-! 8€ i o (B io 0)q tr F oO(H o lr)() o) tr(,) t-r .(l)H () I d oo (n L<F .iir orl -oldtFI q) clL U) a aU o Lo E Z E tt+- s € cSOt-' U U *. a< > * -+ c.t $o \olr) oo(.} trt oo o\lrl t- ra €\o\o (\l r- trq) Eq) q) (.) x U otr3 $c.l \o r t- ?n U)L c) .=6 crt f-rr-i r. F-ro: yrA oq) .c) r- c! oli EO Z E t!., +- =irJcSo S *. > * (n tr) ra in q) q) 6) I ^\o\U Llo O (r} ra c) cdL0)? i!E 33 tr: .roZ2 0) c) S r+ -l/-6€r\i UU-, NU EU +- a< > * \o o\ N$ +\n \oe Nt t\o E o) q) q) e,) sU LIo O \oo\ \o t) c3a9q) Uc Tuocl q) z E"*5u $ $ ,L\$'q a)R o rn\o rn lr) \o ra ra IN c () q) q) q) o\ U oL Fr (n\o rn\o () rl I L t) n oz Fl o& rI] t+l a o -l V hl F oF $oo C.l rq) ! 0) o z$ c.l (J L,/p. o > o\ q-{ o C)O. 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(B Lr 0) F tr- (-- @ oo R ra € r b 2r -ox(l)'iqv€E"HE Z or+i cn\o € t-- cl oo\ o\ o\ ?.) $ €F- ?a \o ts o.rE 6.2Itr'oE H.qj 9-o' Fq/ O tr* t-rr-\ o\ C\ tr-F- €_ o\ € ca ra E 8-.9 EEgS€ HF *o E U dvt A.El< o\\o c.tON (n eo r-- oi+ C..l \o ol _t- ra rn!+ (D C) o0d .n C) € i) H )r oO rL>= eo"- Eoo, bo cB- cSa Fo'fr b So - >voooo O 'E q) li .'r (-)otrooE -o5dq) EEE=Ez 5> "oc) r-.\n c.l $r- c-l ra ra dEE;8,<F o r-r) N $r-N ?ara Si EE'+;E sE;; e^ t--ra)cl $t-rc.l rain o-n ;q o z Fl o& rI] ca =z o Fl V Fl F oF N .vi V) lr Cd U)(d(.) L Cd (d o F.l o Lr (/) 0vc)\ h0a -{aa9o P(g 9E -r o) .d!-l (D 9Fr\ ..F-l orl -oldtFI o# E o E +a G oLF d c,i 2.6.2 Causes of absenteeism. In the project area most of absentees are people who are migrants, business people and some who go away from their villages and even districts for preparation of farming seasons. 2.6.3 Reasons for refusals. Ignorant to few people about Onchocerciasis and Mectizan drug especially to those who don't attend community meetings tend to amplify the diminishing rumors as yearly compliance to Mectizan drugs is on increase. 2.6.4 No serious adverse events (SAEs) that occurred during the reporting period. 2t WHO/APOC, 24 November 2004 l+ o ct L c) -o C) z$(\ O o Or NN q) q) o' L s) .a \l L q l+ r'\ q 4q) q) 4: o s. q)\o t q) 4 q) E .o o k o)q bo L oao L< o bo l<) c.)Htr ooo (d t)H a V)I o (l) G) V)l< 0.) CB (n o Lr C)tt)(rr o (/) o v, CdO <iir o-,l -oldtFI o9X -ta-o=Iqib= <.E E E S HHt Es(g ot II e5 EaEB,, o.9E8EF,E.'. I(Joo, HHt E .!)* a /hge(.)(/)904gE Eqao.2 -cFo C c==!kHi.r -s.9 e u 9IJEG.C+: ri o_cts7ta()'= q= E€;E z CdE .^ o oo.Nf E,5.E E0.) ir-i1J4g:EE5S> q) o 0. A xa z iia0) -rYH0)=otsF,,*O # E H'o (s N sE:* qi q)b0c6.; =boao xoa o bI) A* $oo c.l k(,)o tr 6) o z$(\ c) o Or o4)tr cl I cll() caN 3 cl A L cl o Eo q) ar, 6l rt) 6t) c{q)L cl Iq) q) L € oF q) e 6lq) c) ah 6lq) Er ; q) L c! I{) oL q) L 0) (.) k € Ldox LI(Blrl cl o)l (dl ol >l -ol q) bo(dlr C) oo E d l, tro (€ C)LrF O,f o)l -ol cdlFI L q) q) lr () 0) o tr a 0)(,) c)q) tr F nQ E L q) Ea q) o 6l a c€ 0)fr o oL t-r ia \0 OI o bI) P $s -O O N o\ too \c.t € € q co oo $ @ q oo oll -Oe 6Fd H *.'-ri o o Boo ti Oo\< B- C) t--+ \o ca c.l\o o\\o r- oo $oo co 00 Or- n r.- c.l t-- .t F- -q c.t@ ll *ii \o rI] El € frl o '5 q.r = br)O cBa3US ooSc)3 o\ o co N oo co\o co\o oo @ c.l €\(\ c.) c.l c.t '+" 00r- c.) b 9r €.* 5IE"HE Z QP a E] oo('l c.t cl I r- o\ o oir- O\ovl \o r-\o rr *N r-- .o^ co ooN o\F- o" ca c.l c.I C.t c.t r- co =t\ o\ c.) c-t- oo oi oo c.t tsar d ().=zEEll=o < g€'FU l'rri c.)\o +\o c.l c-l r-N o t--c\ t- oo N \o F\o^ o :f, N o\\O- O c.l c.) \o \o\d c.t c.t \o q rn co co o\\ o\ co o n" \o oo N o.l c.)(\l co € oo o\ $ co o\ vl \o @ o.l 6 .o^ co o\ c.) ca c.t\oot o\oc\ r- $ a.ldI oo a.l$ c.)t cor- o- $ .+ os \O" o\$$ \o otq c.t $ o d o IJi I Eg EEEfrE u,;F 0.6 6l cdo oq)g.E r- co o" \a c.t oO oo oo oo oo o O oo o () bo(, !s-ta (D o\4 >v o &a *d ri O o o +!oeru-d H.E I ,sltli.O- U ti Oo O o o o r* c.l ra r-N r-c.llr) F- o,llr} c.t co C4E 'i V) 0)E.9 Etr.E a UP L{ C) -o tr z qi o ri o\ o\ o\ o\ o\ o\ t.-Nr) c-a,l r-Nta) c-c.l co c.l E a.r d ().= =tr'oEE.g < 9*'Ft, Nri F- cl r-(\lr} cn cOo\ o\ o\ rr) r-a.l r-N rr) ob0(c (r) o oO -Dg.'H q< C)E x 6) i E ea*' F- o o.l 00oo a.l r- o\ o\ oo o\ o\ o\ o\ o\ ooN oo c.l c..lo ol c.to c.l t o o{ oo c.l \oo c.l E] & I 2.7. Ordering, storage and delivery of ivermectin Mectizan@ ordered/applied for by - @lease tick the appropriate answer) MOH ^/ wHO tr UNICEF E NGDO tr Other (please specify): Mectizan@ delivered by - Qtlease tick the appropriate answer) MOH { WHO f] UNICEF tr NGDO tr Other (please specify) Description on how Mectizan@ is ordered and how it gets to the communities Projects request for Mectizan from MOH by filling the Re-Application forms then the NOFT sent the form to MDP who supply the drug to Projects through Medical Store Department (MSD) who are the clearing and forwarding of the MOH inTanzaria. When the drugs arrives the MSD notify NOTF who inform RMOs/DMOs in the affected area requesting them to allow the Project Coordinators to come and collect drugs. Mectizan tablets received from MSD are stored in the District Government Health store, thereafter delivered to the FLHFs thorough normal channel of the districts. FLHF, staff informs the village leaders and request them to send one community member or CDD collect drug ready for distribution to community members. Once distributed to all Central Collecting Points (Hospital, Health centers and dispensaries). CHMT members who were traveling for various activities in the district observed that Mectizan drugs are delivered and received for distribution in the affected communities. The in-charges of all Central Collecting Points in the dispensaries and Health centers have been in-powered for closer supervision of CDTI activities. Table 10: Mectizan@ Inventory Activities under ivermectin delivery that are being carried out by health care personnel in the project area. . Ordering of Mectizan@ drug . Training and re-training of CDDs . Conducting monitoring and supervision to CDDs during census update and drug distribution . Data collection and report writing . Conduct feedback meetings to affected community 146,592 District Number of Mectizant tablets Requested Received Used Lost Waste Expi red Remaining District Merck ULANGA 430,000 430,000 400,000 0 1,500 0 28,500 KILOMBERO 814,586 427,483 387,103 667,994 0 0 0 TOTAL 1,,244,596 427,483 817,103 1,067,994 0 1,500 0 175,092 25 WHO/APOC, 24 November 2004 2.8. Gommunity self-monitoring and Stakeholders Meeting Trainings (of trainers) undertaken for community self-monitoring in the project area was done to cover all communities in our project area of Kilombero district. Table I l: Community self-monitoring and Stakeholders Meeting. District/ LGA Total # of communities/villages in the entire proiect area No of Communities that carried out self monitoring (CSM) No of Communities that conducted stakeholders meeting (SHM) ULANGA 257 0 0 KILOMBERO 274 274 255 TOTAL s31 274 255 2.9 2.9.t Superuision A flow chart of supervision hierarchy. RMO Morogoro J Regional Proj ect Coordinator J DMO Kilombero DMO Ulanga IJ District Oncho. Coordinators J DOT'S J FLHW'S t CDD'S I Community The main issue identified during supervision is communities have collected the Ivermectin themselves from central collection points and taking greater responsibility for distribution, supervision and record keeping. However, the treatment registers needs replacements. APOC Supervision checklist was used as a guide during the assessment of CDTI activities at each level. The outcomes at each level of CDTI implementation supervised at various levels of CDTI implementation from the district level to the community are increased community awareness of the disease, the importance of taking Mectizan annually and motivated CDDs with increased mobilization skills, knowledge on the roles and responsibilities hence better performance for higher coverage. 2.9.2. 2.9.3 2.9.4 26 WHO/APOC, 24 November 2004 2.9.5 2.9.6 The feed-back was given to the community members through FLHF staff. Feed back report used to improve the implementation of CDTI activities. SEGTION 3: Support to GDTI 3.{. Equipment able 12: Status of equipment. *Condition of the equipment (F:Functional, CNFR:currently non-functional but repairable, WO:Wriuen off). Source Type of equipment APOC MOH DISTzuCT/L GA NGDO Others No Condit ion No Condit lon No Conditio n N o Condit lon No Condit lon 1. Vehicle 2 CNFR 2. Motorbike(s) J CNFR I wo I CNFR 3. Computer(s) 1 CNFR 2 F I wo 4. Printer(s) 1 CNFR 2 F I wo 5. Photocopier (s) 2 CNFR 6. Fax Machine(s) 1 CNFR 7. Others: a) Bicycles 30 CNFR l0 wo b) c) 27 WHO/APOC, 24 November 2004 3.2. Financial contributions of the padners and communities Table 13: Financial contributions by all partners for the last three years Local NGDO(s) ( if any) NGDO partner(s) I.M.A. * The NGDO partner (I.M.A. Inc.) pulled out funding Mahenge Focus -2007, however the last funds pledged in2007 was released in 2008. 3.3. Other forms of community support In-kind contribution provided by the community such as:- . Financing sub village community meetings in different forms and venues to most of the trainings. . Inclusion of the Village Heatth Workers in CDTI activities to reduce the workload of CDDs. . Collection of Mectizan from the Central Collecting Points to the communities . Using their own means of transport (walk, fare, bicycle etc) . Distributing Mectizan to their communities and follow ups of absentees/refusals. . Health education to their community members . Data follow up, data summary and report writing . Data feedback, inventory control of Mectizan Contributor Year 8 (2006) Year 9 (2007) Year 10 (2008) TOTAL Budgeted (us$) TOTAL Released (us$) TOTAL Budgeted (US$) TOTAL Released (us$) TOTAL Budgete d (us$) TOTAL Released (us$) Ministry of Health (MOH) 3,89 I 3,891 *7,694.7 0 7,614.7 District Councils 27,215 24 ) 993 11,934 17992 16,662 17,614 Others: NLFEP 8,580 Communities In kind ln kind In kind In kind In kind In kind APOC Trust Fund 5,934 5,934 9,950 7,958 19,388 14,721.3 TOTAL 37,040 34,818 29,578.7 25,950 36,050 48,530 28 WHO/APOC, 24 November 2004 Activity Expenditure ($ US) Source(s) of funding Drug delivery from NOTF HQ area to central collection of Mobilization and health education of communities of CDDs & health staff CDDs and distribution Internal monitoring of CDTI activities Ad visits to health and tical authorities IEC materials S @pq4!e) forms for treatment Vehicles/ es/ bic les maintenance Office e. etc Others 4,160 3,724 17,839 2,257 2,000 ____ _lfle 400 479.7 42,800 Councils/LFEP Council/APOC/IMA CouncilsiAPOC/LFEP Councils/IMA Council LFEP/APOC Council Councils Council TOTAL 78,129.7 Total number of persons treated 378,413 3.4. Expenditure per activity Table 14: Indication on how much the project spent for each activity listed below during the reporting period SEGTION 4: SustainabilitY of GDTI 4.1. lnternall independent participatory monitoring; Evaluation 4.1.1 Was Monitoring/evatuation carried out during the reporting period? (tick any of the following which are applicable) NONE Year 1 Participatory Independent monitoring Mid Term Sustainability Evaluation 5 year Sustainability Evaluation Internal Monitoring by NOTF Other Evaluation by other partners 4.1.2. What were the recommendations? NA 4.1.3. How have they been implemented? NA 29 WHO/APOC, 24 November 2004 4.2. Sustainability of proiects: plan and set targets (mandatory at Yr 3) Was the project evaluated during the reporting period? NO Was a sustainability plan written? NA When was the sustainability plan submitted? NA What arrangements have been made to sustain CDTI after APOC funding ceases in terms of: 4,2.1. Planning at all relevant levels CDTI activities are already incorporated into CCHP, now plan is done in a form of bottom up approach and activities are base on the priority to the community themselves 4.2.2. Funds Budget for implementing CDTI activities has been incorporated into Council Comprehensive Health Plans and funds have been released by council. For the past six years, Local Government authority has been supported CDTI activities 4.2.3 Transport(replacementandmaintenance) APOC management has replaced capital equipment in the fifth year and maintenance of that capital is being done by using district council funds. 4.2.4. Other resources The project is mainly depending on Council and APOC 4,2.5. To what extent has the plan been implemented CDTI activities have been incorporated into CCHP since 2003 and all planned activities have been implemented as scheduled. 4.3. lntegration The extent of integration of CDTI into the PHC structure and the plansfor complete integration: 4.3.1. Ivermectindeliverymechanisms Ivermectin is delivered within normal government system using the existing structure. Mectizan tablets are delivered to the FLHF in Onchocerciasis endemic area, together with other essential drugs/drug kit and vaccines by the CHMT member. The FLHF in charge and his/her subordinates are responsible to all medical drugs and equipment brought to them from DMO's office including Mectizan. The FLHF staff informs the community members on the arrival of Mectizan. The communities select a member among of them or CDD to go to the FLHF to collect Mectizan ready to distribute to the community members. 4.3.2. Training Training on the implementation of CDTI last year goes together with the implementation of LF in our project though the distribution of Albendazole was done at the end of December. 30 WHO/APOC, 24 November 2004 4.3.3. Joint supervision and monitoring with other programs Supervision and Monitoring of CDTI activities are integrated within system. Therefore at District supervision is done by joint team using the developed checklist. The team includes medical staff and program staff. 4.3.4. Release of funds for project activities Funds are released through normal channel according to budget line item and every responsible part plays its role. The responsible part in our budget is APOC, Council and Government. NDGO partner has withdrawn its support in Mahenge CDTI Project. 4.3.5. Is CDTI included in the PHC budgetr Yes 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? Other programme that is using CDTI structure is Lymphatic Filariasis Elimination Programme, Malaria control, TB and Leprosy control and Mental health services Achievements are: Cost and time effective : Many people are served within short time. .Ownership is high .Increase sustainability 4.3.7. Others issues considered in the integration of CDTI. CDTI activities in both districts are integrated into health system; supervision of Oncho activities is included in the Comprehensive Supportive Supervision conducted regularly by CHMT team. In addition, CDTI have merged the Lymphatic Filariasis Elimination Program (NLFEP) activities with no difficulties. Lymphatic Filariasis Elimination Program is using the CDTI structure for identification and treatment of Lymphatic Filariasis and de-worming activities targeted to persons; 5 years and above covering the whole villages in the districts. Achievements: There is full political and government support at all level of implementation in our districts, this is, from; the district council level to the community and individuals. Oncho and Lymphatic Filariasis Elimination have been integrated at district up to community level. 4.4 Operational research Not done during the reporting period. SEGTION 5: Strengths, weaknesses and challenges List of strengths of CDTI implementation process o District Councils supports implementation of CDTI activities. 31 WHO/APOC, 24 November 2004 oa Council Health Management Team (CHMT) and FLHF staff works together on management of CDTI activities. Increased coverage in knowledge of Onchocerciasis disease, drug, side effects, in the communities Communities are getting used to collect drugs themselves from the nearby FLHF in both districts Villagers are taking greater responsibility for distribution, supervision and record keeping teady increase in therapeutic coverage in the communities annually. a a Weakness Threat a a o Delay of community leaders in selecting the additional CDDs for training according to their need at the implementation level o Shortage of staffs at the FLHF level that restrict the CDTI health staffs working with CDTI and work overload to the existing ones. o Inadequate Basket funds to effect trainings reaching the 2:250 population ratio of CDDs in this year, with current cease of funding from NGDO partner. o Still some community members still fear the side effects of ivermectin. o Lack of incentive from the community to their own Community Directed Distributors. Worn out project capital equipment such motor vehicles, Motorcycles and bicycles as transportation equipments for sustaining CDTI and co implementation with other Mass Drug Administration activities such as NLFEP and NTDs. Luck of Information, Education and Communication materials to support CDTI and other education campaigns. providing incentive to FLHF staff and CDDs. List of challenges addressed during training and stakeholders meeting support CDTI and other education campaigns. control to the FLHFs. SEGTION 6: Unique features of the proiecUother matters The project is progressing well following the implementation of the sustainability plans; l. Integration of CDTI into Lymphatic Filariasis Elimination and NTDs Program. 2. CDTI activities are being fully funded and included into Comprehensive Council Health Plan (CCHP) in both districts. 32 WHO/APOC, 24 November 2004