Enugu/Anambra/Ebony CDTI project technical report submitted to Technical Consultative Committee (TCC): January 2008 to December 2008

T"cc q.9 lL., .tD - - -Q.oo-rl.-..- lNG- 7RC J U ENUGU STATE CDTI YEAR 10 CAL REPORT ORIGINAL : English ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATI\TE COMMITTEE (TCC) DEADLINE FOR SUBMISSION: To APOC Management by 31 January for March TCC meeting To APOC Management by Ugly for September TCC meeting AFRICAI\ PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) COUNTRY/NOTF:NIGERIA ENUGU/ANAMBRAIEBONYI NOTF/APOC.WHOPROJECT Proiect Name: Launchinq vear:1998Approval vear:1998 Reportine Period (MONTH/YEAR): JANUARY - DECEMBER 2008 Proiectyearofthisreport: (circleone) I 2 3 4 5 6 7 8 9 NGDO partner: Global 2000Date submitted: 29th December 2008 Ru.-; l4/08/oS WHO/APOC, 24 Novemb er 2004 3a&. P ANNUAL 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: NIGERIA National Coordinator Name: PatriciaOgbu-Pearce Signature Date Zonal Oncho Coordinator Name: John Eluwa Signature: Date: NGDO Representative Name: E.T.Alo Signature Date: ... . This report has been prepared by Name : Attamah-Isiani E.R (Mrs). Designation : State Oncho . Coordinator Signature: Date 29ft December, 2008 t 2 WHO/APOC, 24 November 2004 Table of contents ACRONYMS ........... .......................5 DEFrNITIONS......... ....................... 6 FOLLOW UP ON TCC RECOMMENDATIONS .........7 EXECUTI\TE SUMMARY........ .. ERREUR ! SIGNET NON DEFINI. SECTION 1: BACKGROUND INFORMATION....... ....................11 SECTION 2: IMPLEMENTATION OF CDTI....... .....16 1.1. GpNpRalNFoRMATIoN......... 1.1.1 Description of the project (briefly) 1 .1 .2. Partnership 1.2. Popu1auoN............... 2.1. Tttvtpl-lNp oF ACTIvITIES 2.2. Aovocecv 2.4. CoNaNauNIry INVoLvEMENT....... 2.5. CepecrrvBUrLDINc.. 2.6. TRearupNTS............... 2.6.1 . Treatment figures 2.9.1 2.9.2 2.9.3 3.1. 3.2. J.J. 3.4. Yn 3)... 4.2.1. .... 1 t .... I I ,.,.12 .... t4 .................... 16 .................... 18 20 22 26 26 ....37 ....38 ....39 ....39 40 40 41 2.3. MosLzetloN, sENSTTIZATIoN AND HEALTH EDUCATToN oF AT RISK coMMUNITIES 18 2.6.2 Wat are the causes of absenteeism?.......... .................29 2.6.3 What are the reasons for refusals?................ ............... 292.6.4 Briefly desuibe all lcnown and verified serious adverse events (SAEs) that ... 29 2.6.5. Trend of treatment achievementfrom CDTI project inception to the current year jl 2.7 OnoeRmc, sroRAGE AND DELIVERv oF IVERMECTIN ... 32 2.8 CovrvtrNrry sELF-MoNIToRING AND STAKEHoLDERS MrerrNc . .................33 .................34 ................. -35 ................. -r5 ................. 35 2.9. SupnRvrsroN 2.9.4. What were the outcomes at each level of CDTI implementation supervision? 35 2.9.5. Was feedback given to the person or groups supervised?................................ 362.9.6. How was the feedback used to improve the overall performance of the project? 36 SECTION 3: SUPPORT TO CDTI ..............37 Provide a/low chart of supervision hierarchy...... .. .... . .. Wat were the main issues identified during supervision? Was a supervision checklist used? EqurruENr..... FrxeNcnr- coNTRIBUTIoNS oF THE pARTNERS AND coMMLrNITIES........... Ornen FoRMS oF coMMUNITy suppoRT ............... ExpENorruRE pER ACTIVITy ........ i i,"-ti " i );; ;i t ;: ; i ;;;;; i;; ; i ; SECTION 4: SUSTAINABILITY OF CDTI....... ..........39 4.1. INrERNer.; TNDEnENDENT pARTICIpAToRy MoNIToRINc; Eve1uerloN.................... 39 4.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable)........... ........ Erueur ! Signet non diftnl4.1.2. Wat were the recommendations? .........Erueur ! Signet non diJinl 4.1.3. How have they been implemented? ............. Erueur ! Signet non diJini 4.2. SusrarNeerI.rry oF IRoJECTS: ILAN AND sET TARGETS (MANDAToRv AT................ 40 4.2.2. Funds WHO/APOC, 24 November 20043 4.2.3 Transport (replacement and maintenance) . . ......... ......................41 4.2.4. Other resources ......41 4.2.5. To what extent has the plan been implemented................ ..............41 4.3. INrrecRAnoN............ ......41 4.3.1. Ivermectin delivery mechanisms............... ...................41 4.3.2. Training.... ..............41 4.3.3. Joint supervision and monitoringwith other progroms........... ......42 4.3.4. Release offunds for project activities ........ 42 4.3.5. Is CDTI included in the PHC budget? ............ .............42 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. Wat have been the achievements?............. ....................42 4.3.7. Describe others issues considered in the integration of CDTI. ..... 43 4.4. OppnarroNAl RESEARCH .....43 4.4.1. Summarize in not more than one holf of a page the operational research undertaken in the project area within the reporting period. ........ 43 4.4.2. How were the results applied in the project?............. ....................43 SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, AND OPPORTUNITIES.... . ERREUR ! SIGNET NON DEFINI. SECTION 6: UNIQUE FEATURES OF THE PROJECT/OTHER MATTERS...........45 4 WHO/APOC, 24 November 2004 Acronyms APOC ATO AtrO CBO CDD CDTI CR CSM cwo DHA FMOH GPS HFS LDC LF LGA LOCT MDG MOH NGDO NGO NIGEP NOTF PA PATHS PHC RBM REMO SAE SHM SOCT SPO TCC TOT LINICEF UTG wHo ZOTF African Programme for Onchocerciasis Control Annual Treatment Objective Annual Training Objective Community-Based Organization C ommunity-Directed D istributor Community-Directed Treatment with Ivermectin Country Representative C ommunity S elf-Monitoring Christian Women Organization District Health Authority Federal Ministry Of Health Global Positioning System Health Facility Staff Local Development Center Lymphatic Filariasis Local Government Area Local Government Onchocerciasis Control Team Millennium Development Goal Ministry of Health Non-Governmental Development Organization Non-Governmental Organization Nigeria Guinea Worm Eradication National Onchocerciasis Task Force Project Administrator Partnership for Transformation of Health Systems Primary health care Roll Back Malaria Rapid Epidemiological Mapping of Onchocerciasis Severe Adverse Event Stakeholders Meeting State Government Onchocerciasis Control Team State Project Officer Technical Consultative Committee (APOC scientific advisory group) Training of trainers United Nations Children's Fund . Ultimate Treatment Goal World Health Organization Zonal Onchocerciasis Task Force 5 WHO/APOC, 24 November 2004 Definitions (i) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking). (ii) Eligible population: calculated as 84oh of the total population in meso/hyper- endemic communities in the project area. (iiD Annual Treatment Objective: (ATO): the estimated number of persons living in mesoftryper-endemic areas that a CDTI project intends to treat with ivermectin in a given year. (iv) Ultimate Treatment Goal (UTG): calculated as the maximum number of people to be treated annually in meso/hyper 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'd 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) Geoqraphical coverage: number of communities treated in a given year over the total number of mesoftryper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage). (vii) Integration: delivering additional health interventions (i.e. vitamin A supplements, albendazole for LF, screening for cataracl, etc.) through CDTI (using the same systems, training, supervision and personnel) in order to maximise cost-effectiveness and empower communities to solve more of their health problems. This does not include activities or interventions carried out by community distributors outside of CDTI. (viii) Sustainabilitv: 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-monitoring (CSM): The process by which the community is empowered to oversee and monitor the performance of CDTI (or any community-based health intervention programme), with a view to ensuring that the programme is being executed in the way intended. It encourages the community to take fulI responsibility of ivermectin distribution and make appropriate modifications when necessary. 6 WHO/APOC, 24 November 2004 FOLLOW UP ON TCC RECOMMENDATIONS The 2007 technical report was not submitted before the September 2008 TCC meeting by the former state Oncho coordinator hence there was no TCC recolrunendation but that of TRC which came in 2009. Using the table below, fill in the recommendations of the last TCC on the project and describe how they have been addressed. 7 Number of Recommendati on in the Report TRC RECOMMEN DATIONS ACTIONS TAKEN BY THE PROIECT FOR TCC/APOC MGT USE ONLY To diversifu method of sensitization and mobilization Two new major strategies in sensitization and mobilization were adopted. 1.We initiated yearly flagging -off of Mectizan distribution at state and L.G.A levels in 2008. This is aimed at increasing Mectizan awareness among the people. 2. Visit to CWO during their August meeting to solicit for their support for the welfare of CDDs and also for the participation of their members as CDDs. This resulted in the increased number of women CDDs in the state. Train all health staff to address the issue of frequent transfers. The training was done but could not go round all the health staff in all the facilities due to inadequacy of training fund. There were employments of new health staff and this lead to existence of many untrained staff. We trained more than estimated but still need to train more. The project will still want to complete the training if more fund is made available. To scale-up CSM and SHM 1. This we are addressing by involving more Community Self Monitors though not yet fully trained. 2. We have finished all a:rangements to be have meeting of Oncho stakeholders once ayeat at the LGA level while communities WHO/APOC, 24 November 2004 have it twice a year. Fund is the only thing delaying its take off. Oncho being one of the issues discussed during community and village health committee meetings is already on. At state levels the SOCTs and LOCTs do meet every third week of every month to discuss problems, way forward and make retrieval of data. To advocate for more support from state, L.G.A and communities Advocacy made by the project to Hon. Commissioner of health resulted in instituting annual state flag-off of Mectizan distribution. The project also went round and met all the L.G.A chairmen and also met several times with Hon. Commissioner for ministry of local government. We convinced him to write all the L.G.A chairmen mandating them to release a minimum of Nl0,000 monthly to their Oncho team. All L.G.As complied but for few months. The little that was released helped to ease monitoring and retrievals at L.G.A level. The project met again with traditional rulers in the state and discussed a lot ofissues that hinged on sustainability. We are looking forward to seeing the benefits in the communities next year. Conduct operational research Not yet carried out. We have plans to implement it in 2009 8 WHO/APOC, 24 November 2004 Executive Summary This report is aimed at covering activities executed by the project in 15 out of 17 LGAs in 10ft year of CDTI from January to December 2008. The partners for the CDTI implementation were the APOC, Global 2000, health services at the federal, state and LGA levels and the Oncho affected villages. The activities which were implemented during the period under review include Advocacy, Sensitization, Mobilization/ Health education, Training, Drug distribution, Monitoring and Supervision. The population of the state was estimated to be 3,381,697 people with only 994,643 people registered for Ivermectin treatment. A total of 1373 hyperlmeso endemic villages were under treatment. Village was used as a basic unit for the selection of CDDs in Enugu State. All the 1373 villages were treated with Ivermectin and this represents 100% geographic coverage. The Ultimate Treatment Goal (UTG) same with Annual Treatment Objective (ATO) was 804,043. A total of 801,947 people were treated in 15 LGAs. Therapeutic and geographic coverage were 80.602 and 100% respectively. A total of 2,379,240 of Mectizan tablets were received by the state project for active treatment during the period under review. 74 tablets were wasted while 226 tablets remained. There was no report of any case of serious adverse events (SAEs) from Mectizan treatment. The ratio of CDD to registered population is 1:100 while the cost of treatment is $0.057. For trainings, 90 L.G.A staff were targeted but 60 were trained representing 66.7%. 519 Health facility staff was the ATrO but we trained 724 staff representing 1395% because the need arose. ATrO of 9,858 CDDs, were targeted and trained representing (100%). Major challenges facing the project include coping with repeating advocacy at LGA level due to their frequent change, continuous health education and mobilization for a long term compliance to treatment, incomplete training of all LGA Health staff in the state, increasing the level of participation and ownership of CDTI and gross inadequate counterpart funding of the project in both state and LGA. In any case, the project tried to take a few steps towards solving the problem. In the case of frequent change of LGA executives, we embarked on advocacy visits to both elected and appointed LGA chairmen. All SOCTs, LOCTs and trained Health Facility staff were involved in health, mobilization and sensitization. These were aimed at letting people know the need to 9 WHO/APOC, 24 November 2004 continue taking mectizan even when you feel alright. We are appealing to APOC to please, help us sponsor the training of the remaining Health staff in the LGAs. Increase in the level of community participation is being addressed by ensuring that communities understand and adopt the concept of Community Self Monitoring (CSM). As regards community ownership of the programme; series of meetings the project had with different people including community groups have made them realize more, what Mectizan can cure and or protect them from, thereby making them fell eager to play their own part more than before. Counterpart fund issue was discussed at the meeting with the Commissioners for ministries of health and local government affairs, their permanent secretaries and some directors in the two ministries as well as during advocacy meetings with LGA policy makers. 10 WHO/APOC, 24 November 2004 SECTION 1: Background information 1.1. General information 1.1.1 Description of the project Enugu State is geographically located in the Southern Zone of Nigeria between 7o 10'N and 7o 45'N of equator, and on longitude of 7.4878"E and latitude of 6.4231"N. Enugu state is bounded on the North by Kogi/Benue States, on the South by Abia/Imo states, on the East by Ebonyi State and West by Anambra State. The topography of the state has two marked zones, hilly or mountainous and flat zones The hilly zone stretches through six LGAs (Awgu, Udi, Ezeagu, Oji-River,Uzo- Uwani and parts of Igbo-Etiti) while the flat zone covers the remaining part of the state. The hilly nature of the areas mentioned above gives rise to rapids and waterfalls that exist in most rivers especially Oji, Ogurugu, Ajali, Duu and Kalawa rivers. This favours the breeding of Simulium damnosum, which transmits river blindness. The bioclimatic zone is rainforest in nature with annual rainfall between 152 cm and 203cm. T he climate is comparatively equable and the temperature ranges ftom72.4"F (22.2'C) to 87.5oF (30.6'C). It is the humidity rather than the temperature that causes discomfort to newcomers and is between 78Yo and 95%. It is generally cool during the rainy season while the mean temperature in the hottest periods of February and April is about 30.6'C. The state has a land area of 7,617.82 squile kilometers and a population of 3,289,589 people. The activities of the population of Enugu state are farming, fishing, hunting, petty trading, wine tapping, basket making, poultry keeping and rearing of domestic animals. With regards to the main occupation, which is farming, the periods of major commercial activities run from November to February, which is the period for harvesting and land clearing for cultivation. The people of Enugu state are of Igbo ethnicity hence speak Igbo language. It is a tribe with homogeneous cultural and linguistic origin. 98% of the population practices Christianity as their major religion while the remaining belongs to the idol worshipers and other religious sects. The main communication systems in the state are by road and air. Others are through post offices, courier services, telephones and internet services. Within the state, the only means available is road. Most of the roads are inaccessible especially during the rainy season. 80% of the villages exist in remote areas, which are difficult to reach. The state has 17 administrative local govemment council areas (LGAs). Of these, 15 LGAs are hyper/meso endemic for onchocerciasis and the remaining two are hypo endemic. Additional functional 39 Local Government Development Centers (LDC) were created out of 17 LGAs by the State Government. Each LGA consists of communities with administrative head called Igwe or Traditional Leader. Further, community consists of several villages with administrative head called village head. The basic administrative structures are the State, LGAs, Communities and Villages. The state health care system is built on the basis of the responsibilities for state and local governments. In Enugu state, the health system has evolved into district health system. ll WHO/APOC, 24 November 2004 This district health system is made up of 7 District Health Authorities (DHA) but still based on Primary Health Care (PHC). The 7 District Health Authorities (DHA) are Enugu metro (Enugu South, Enugu North and Enugu East LGAs), adi (Ezeagt and Udi LGAs), Isi-Uzo (Isi-Uzo LGA), Enugu-Ezike (lgboeze North, Igboeze South and Udenu LGAs), Agbani Q.lkanu East and Nkanu West LGAs) and Awgu (Aninri, Awgu and Oji- River LGAs). The state govefirment upholds the system as the main focus of government intervention for meeting the health care needs of the majority of the people without under rating the inter-linkages with secondary and tertiary health care levels. The PHC system operates at state, local government, district and community levels hence the integration of onchocerciasis control activities into the system. PHC services in Enugu state are delivered through health posts, health clinic and health centers in 17 LGAs. In the project area, there is a total of 382 health centers/posts/clinics. Table 1: Number of health staff involved in CDTI LGA Number of health staffinvolved in CDTI activities. Total Number of health staff in the entire project area Br Number of health staff involved in CDTI Bz Percentage B3=B2lBr *100 Aninri 53 46 86.8% Awgu 111 88 79.3% Enugu East 83 69 83.r% Ezeagu t43 I I J 79% Igbo-Etiti 160 135 78.1% Igboeze North t07 86 80.4% Igboeze South 74 54 73.0% Isi - Uzo 86 6T 709% Nkanu East 105 94 895% Nkanu West 78 74 949% Nsukka 115 96 66.% Oji River t20 97 725% Udenu 115 92 7t.3% udi t39 rt2 73.4% Uzo Uwani 158 r29 62.7% Total 1647 1346 80,h 1.1.2. Partnership t2 WHO/APOC, 24 November 2004 Four partners are involved in implementation of CDTI project in Enugu State. They are APOC (external donor), Global 2000The Carter Center (NGDO), health services (Federal, State and Local Government levels) and oncho affected villages (1373 in number) The overall working relationship zlmong all the partners was satisfactory as evidenced in the success of the distribution during the period under review. The specific areas of project activities where all the partners were involved are planning, training, mobilization, advocacy, drug procurement and storage, distribution, supervision and record keeping and reporting. There is a plan to continue mobilizing the decision makers at the state and LGA level including credible NGOs such as Global health awareness and Research Foundation (GHARF), Women for Women, influential and reputable persons in the community through advocacy. l3 WHO/APOC, 24 November 2004 + O ct L(.)p C) o z +N d o Or B $ 0) o H o () Gotr 0)Lr k c.) o B oli Iq) q) L q) O Jtn tr 6 o(,) cltr OU N N t-- cn o\ co € s$\o \o C.Itri o\$ ( ca oo o\ o\ c.)$ oo$ r- o\ \o ra) oo$ t1 N \o ra) $F- ca\o\o ooca \o o\ c.tt- c.la.| oo (a$ = € Er;) TF EE3 F-\o \o $ oo \o r- c.l\o \ ra) oo o\\o oo t--$ € o\ c.) a.)\o aa o\ <f,\o ( N o\ c* (ai\o =o\ o\ +i il5 .6) -oo .= aN " -?.e!\ E F EE Eo) $(a) \osr* oot- \o F- o\t-- cn $ \t oo o\tr- \otns \o ca t-- co t-- ca\o \o o\F-(\ o\\o o\\o(\ c.)\o $ € o\tr- \olri+ \o o\\o oo tr-$ ca o\ t\o c.l o\ tr- o\inNiar-t .,.g8*EF?-otrEe):\ fit E gE" $\ottr- oo t-- \o tr- t €(.t o\ in o\r- c..lrnt cor- c.)F- c.)\o \o o\(-* o.l o\\o o\\o c..l cn\o tr- c.I\o € oo o\ cn ao\0 cl Fr o ;ead 9; Bgsi o\ oo $ \o ca $ ca tr-tr- o\ car* \o\o € (a r- ra +_ il C) o r(9 =Laj:90 o -N at)q) (a) oo cn c.) $N o\$ o\ \o\o oo =tr- e) U.E E o.- c)J o)q)9:e- )iN a oo cn I $N o I c.) I o\$ o\oo $ \o ao $ c.) tr- tr- car- o\N\c trl -lo)l Ed6l >l\t2o C,) o L 4) z H.: E ;:d F is #si t o\\oN c.t\o t--N\o oo o\\o oot'-$ oo o\ co ca\o c.t o\ $\o r.1 c.1 t-- (a$\o =o\ o\ - F6) oo= .-LLY -.i -!-?i E.i| *o 9' -v9lits aE a v \ost-- € F- \o(-- o\F- c.l ra) sf $ € o\F- \o ra)$ \o c.tt- ca tr- co\o \o o\r*cl o\\o o o 00 tr z oN C) o -obo oa C)No o oo oN D I V) (t) IJ] (0 I z a o B cg -vz c0 & a z rro & ;T o D D oN D j F t'r O c.)sq) =ic'- gE)OI<Ec 'c) o0B rh ttl bo r! 00(s C)N E] I I I I $ c-l L c) -o () z$N o.{ o q) Lq) c) I U' +. GoL 6l II L q) CE q 0) oE cl ?hq) Lq) o cl t- L c) 6l q)lrq) an+ A ! c)9 *j= oJ1c)tr r- -C,o '+jLtrgo- e) g,rE(! axtr'r6t=?Ee)tr L() -(Be+r c)v 's)rh .Z .'= olia0 '=Gtr arCg trE .Eotrtr =,1 a C-) E-iodet od ig vo c€ =9 rhtr o()e-q 6l cn 'Yoos q) dFI o.i -w-,:.-i- - Ia--L >:to <t:tb 'i3 .- CJ ;^tr ox a '!a-E E.?E o}Y VIHQ) €qr AUU b Hiei6aq) =tr.j =tra0.F*t 9! .tP!9aico - G) HagiEE 69o-Ct EE cv.-(' - -.v€Ei .E s (.) c) an oOlr) o U) Lro () op Cd C) -o CB q) CB O +r o o C) o(n() U) CB B zqi o z --7 a c.) c. L c) OD L q o)L q) 00 L q) E q) q) fr I L# ah an q) I G ah c! k_ L $!0 .A .\ OT =^.E'{l!k- .S r-.siS$ *Q)s^sbt i:!.*Pv .\\ Y \.) \qiP*\.s eU =s :a)\8 .s*sa)$q)\^oS "r.. bs *tS>6B qi o'S\ .Sp SH ss vo $:pL\J qrP .sa oa S, 'Y:a "Ss$\b.\o :* boq)\ ss s9 ).r % UU ra :e :SJ B\:sSSrsiuilt $ rr.t \\r'U*l-Bs)5 P{ (-) I I I I I I I I I I U) U) o() CB o CB7. 0)oLL ;.0)d> * SECTION 2: Implementation of CDTI 2.1. Timeline of activities Fill in table 3, timeline of activities for areas treated in current year, indicating when the key activities were implemented by the month they began and the month they ended. 2008 CDTI activities commenced Enugu state in January and ended in December. Timeline of activities vary from LGA to LGA as can be seen in the detailed Table in the next page. 16 WHO/APOC, 24 November 2004 $ c.l L() .o C;) o z tN o r U) o q) o CB IAtr U) tr 0) U) )r o C) Cg (! +.i(€ (r) (€ o) 4v) s= c)q; o! zD t)dtr c)E =bo r.C ='E 6c GIO c)-otrO dtr -6 *2,nbr cd555ad;ie= >,L o-oqf ir .'!EE6 = E'5 90()h trEX="o;s.=G) aH56o .Z Q o=EEEZIE p9cl /.E lt(EOd: .rL-L a\ v LE X SEcc:-:o .9 [i 5u 9Ui. -.rHr .=.2.9 I a):iE5E :iS l-ql ".Y =oJ-_r- =; s-t\rl (.) fr o O OI Cg O v) olr(6 C) .oH t,(D o(B(+i o C) q) t oo o 0) oo oq) oo o z oo o z o a): oo o z oo o z @ o z oo o z oo o z € o z € o z € o z oo o z oo o z oo o z oo (d z o ah P 0)o a E!.c?E cr: oo L oo E6 <rz 00o (U oo 3r o o: oo o z oo z oo o z € o z oo o z ooo z oo o z oo o z oo o z €o o z oo o z oo o 0.) l-.,t oo o 0.) t-l oo o z oo o z o L o at tr P.c 1!-tr € -7 7 oo z oo cB <rz oo -7 a 6 z oo o C) o oo o z oo o z o o= € o z 00 o z 00 o z €o o z oo o z oo o z oo o z € o z € o z oo o z oo o z oo oo t-l q) 6 o t) q)I P= lJtr c:(n- oo L 7 -7 € (d z @ trd z oo L € >a z oo oo h €o h € o! €o o0 a 00 oo >') oo oo bo ooo o h 00 00 o:qo @ oo oo 00o 0) oo h oo L 00 s c) tu € (d a oo il(B 00 c)L ad z € so € o d oo u! 6lL t't .Htftr 6: ooo ild 2 -7 €o o -7 @ CN a oo c) @ d -7 € o € d z -7 € o ,- 7 o= € 6 z -7 @a L:O .E'= s= oolr()a S.e IPE 6: ri) - € i(€ z -7 7 -7 oo € C) Er oo (d a 00 l.: CE a € o (6 a oo ljo trr ooo o CU a oo F] oo B (t)(! r! bo rrl oo(€ oNI! C) o bo li o z oN C) o .o ao oa C) Noosbo N I o aA r! z v) 0) }( z -vj IA z Lo ,8. o' o D D (d D oN D 2,2. Advocacy The project mobilized some key policy makers at the state level, which included the Speaker Enugu State House of Assembly, State Traditional Rulers Council, Hon. Commissioner for Local Government Affairs and his permanent secretary, Hon. Commissioner for health and his permanent secretary, directors of Public health services, personnel / management and finance/supplies of the ministry of health etc. At the LGA level, 15 elected LGA chairmen plus 33 newly appointed transitional Local government Development Center (LDC) chairmen were mobilized. The reasons for undertaking the advocacy are as follows . T o brief them on the sustainability plan developed by both the state and the LGAs and their roles and responsibilities in CDTI. . To seek for their supports towards fulfilling their own part of the sustainability plan. Outcomes of the advocacy are: 1. The project succeeded in getting financial supports from both the state and some of the LGAs for implementation of CDTI activities. 2. Awareness and popularity about the CDTI activities in the state have continued to increase. Difficulties/Constrained bein g faced r Frequent change of policy makers at LGA levels. . Inadequate fund to fuel project vehicle for repetition of visits at the LGA level Suggestion on how to improve advocacy r Repeat visits to the decision makers whenever there is a change of leadership at LGA and state levels. . Sustained high level advocacy visits by various partners - APOC, Lions Club and NOCP to the state governor and top government officials at the state and LGA levels to encourage support for the programme 2.3. Mobilization, sensitization and health education ol at risk communities The use of media and/or other local systems to disseminate information During the period under review, radio was the media employed for information dissemination, especially Enugu State Broadcasting Service and Federal Radio Nigeria Enugu during the state flag-off ceremony of commencement of Mectizan distribution in April 2008. Other local systems that were used in disseminating information at 1373 villages were town criers, church announcements, school announcements, village/community heads, villagelgroup meetings and market announcements. These were usually used at the beginning of the distribution or at any stage of the distribution where necessary. The types of IEC materials used during the period under review were posters, flipcharts, handout and handbills from APOC. l8 WHO/APOC, 24 November 2004 Mobilization and health education of communities including women and minorities Women groups in religious and political orgarizations were targeted to increase women participation in CDTI activities. During August meeting 2008, the project from state level joined the L.G.A teams and visited some branches of the Christian Woman Organization (CWO) in the communities soliciting for their support and participation in the project. We also met with the women wing of the political groups in about four LGAs. This brought about an increased number of women participation in the state. Before the commencement of drug distribution, intensive mobilization and health education were carried out in all the villages particularly through the health facilities staff. The aim was to elicit their interest in participation by sending their CDDs for drug collection/distribution, support the CDDs and actual intake of the drug. Also, the adverse reactions issue was addressed and how best to manage them. Women were charged to encourage their children to participate in the yearly treatment. They were educated about who is eligible to take Mectizan. They were funher reminded that pregnant women and lactating mothers should participate after exclusion period had elapsed and that sick persons should also take Mectizan as soon as they recovered. Response of target communities/villages There was high turnout of target villages for the treatment. All the villages ensured that they received treatment by sending their CDDs and some villages also replaced some old CDDs particularly those CDDs that have left the programme for greener pastures. Household heads ensured that their household members received treatment. Lactating mothers and pregnant women later sought received treatment after expiration of exclusion period. Some villagers who considered it unnecessary to receive treatment because they were no longer having the infection saw the need and also submitted themselves to treatment. Accomplishments . The project attained a therapeutic coverage of 80.6% during the period under review. A total of 801,947 persons were treated out of 994,643 persons registered in all 1373 Mobilized villages. r Successful hosting of first ever State Flag-off of Mectizan distribution . l00oh geographic coverage was attained as all 1373 villages received treatment. r Improvement in Compliance rate to receive treatment after the expiration of exclusion period by lactating mothers and pregnant women. Suggest ways to improve mobilization and sensitization of the target communities . Provision of T-shirt, caps, bags etc. r Promotion of use of video films for health education at community level. r Use ofjingles on the radios and TV, radio and TV discussion, increase in news commentaries. . Provision of incentives to local town criers. . Meeting with more women groups especially the CWO during August meetings and other groups during any other meeting would really have a positive impact on the project . Educating the school children would also help. l9 WHO/APOC, 24 November 2004 2.4. Communityinvolvement Table 4: Communities participation in the CDTI Comment on: - Attendance of female members of the community at health education meetings The Female members were found to attend the health education meetings whenever it was held and this accounted for overwhelming female intake of Mectizan, and their participation in the prograrnme this year. A Number of communities/villages with community members as supervisors Number of CDDs and the communities involved Number of communities /villages with female CDDs Total no. communiti es in the entire project area Bt Number with community members as supervisors Bs ge Bo= BslBe *100 Male CDDs B7 Female CDDs Bg Total Bs= B7*Bg Number of communit ies with female CDDs Bro Percentag e Blt: Bro/Br*100 Aninri 85 85 100 387 245 632 69 8r.2% Awgu 130 130 100 504 358 862 106 8t.5% Enugu East 31 31 100 211 213 424 23 74.2% Ezeagu t24 r24 100 443 356 799 91 73.4% Igbo-Etiti 100 100 100 514 216 730 86 86% Igboeze North 49 49 100 346 1 2 1 467 42 85.7% Igboeze South 89 89 100 326 318 644 69 775% Isi Uzo 40 40 100 286 178 464 32 80% Nkanu East t36 136 100 391 345 736 102 7s% Nkanu West t34 134 100 456 386 842 99 73.9% Nsukka 77 77 100 319 282 601 49 63.6% Oji River 59 59 100 252 251 503 45 76.3% Udenu 73 73 100 345 234 579 56 76.7% udi t66 t66 100 688 305 993 137 82.5% Uzo Uwani 80 80 100 298 284 582 62 775% TOTAL 1373 1373 l00o/o 5766 4092 9858 1068 77.8o/o 20 WHO/APOC, 24 November 2003 In general, how do you rate the participation of female members of the community meetings when CDTI issues are being discusses (attendance, participation in the discussion etc). High number of female members participated. This reflected in the number of female CDDs in 2008 and women who received treatment after one week of delivery. The Christian Women Organization (CWO) in some communities have taken upon themselves to take care of the welfare of CDDs in their communities while a good number volunteered to become CCDs. Incentives provided by communities for the CDDs Incentives were given to some CDDs by their communities, especially some Traditional Rulers, elected councilors and some women groups. The Christian Women Organisation (CWO) in some communities have taken upon themselves to take care of the of CDDs in their communities while a good number volunteered to become CDDs. At village level, 688(50. l%o) out of 1373 villages supported their CDDs. The number of CDDs that received support varies from villages to village. 12.7 % CDDs (1250 out of 9858 CDDs ), were supported in Enugu state with a total of N635,500 by 688 villages. This represents an average amount of N500 per CDD. Is attrition a problem for the project? If yes, how is it addressed? Although attrition of CDDs is a continuous phenomenon and challenge to CDTI, it was not a serious problem for the project. Each village has more than one CDD and as such, the project always resorts to the services of the remaining CDDs while waiting for a replacement by his village. And in villages where the kindred system has commenced, there was a pool of CDDs where the replacement could easily be effected. . 21 WHO/APOC, 24 November 2004 co ON E 0) € (.) o zs a.l U o Or oir B N(\ iEEuEEiE€eoE6 si X ; #3EE= si ! .; uEEEE sg .E ; o HEET ES E g Eil;i EE ; ; EiEEE rS g i EEiE6 it E E 5 tEE- E$ e ** EaEt# ;$ € E€ t[uEE :E 1 +!=-5g?: f $ s gE8'jEEEt e: E =-pE:E'=PFo., Hs F -.=iEfsE,E i€ b LE{F igtp ;S ? gfE? *t€E ;$ E frEqE ;i+iEEiEf,TEE:E EE[Eg f$S E:€E#E EEH;E EiI EE#EE*Eoexoi ,l$ EE#:*iE :=E?; ;!t gEHE€*EQqtc ^ c = *EilEE EEs EEEiEi; si[sr ES$ EE;ieEE ilI;$EiigtgEEeI iiEtEEI$EiiE+EE E Ei ; t E a, 0)() Lrd F ,h H() 'odF 0') dH F(J a^ tr JA H vd(t l-rA €(d !t vlro oo oPd I U) C) d I I O cr7 .lkA dF vo ts .O rlD pEe acdO)P -V) -vcE ,q! -LG -0)LPc)co -) - - A UXorHtrE -trft ->o) ;' ^-!:cl L./0)AhivEaq)0) --!€ - V .! €oq clq:.iEBE cq ot .-HL - v aP kg =-5 ,_. -o C)r--rdbD t o::t i= >(€ E .)-9>cB = 5 5Ir \ 5-E>i! B 3-X .B '6 ip;c, G yii, IE li. ridF E er.9eo o €s9 - , oiI o)<rr .und^d ul t=i6i N ', < 6 *N Lq) ! 0) o z$ c\l O { N ; o CB o (.) a F Oqr o cn o (.) I ()H ,()ltrH E (B o0 l.rF a; o -o cdF 6 a,n6 o\ (r)ia €\t) c.t € c.l oo o\ o\ co N ca\o N$l o\ c.l\o oo N \o \oN s c.t$ \oN ca oo o\ clt'- c{ o\ o\ tt- t--N ra) ca : oo : c.l o.l F-\o : tr- : *f,s\o $ : o\ s\o$ € o\ \o\o c.t c.l c.l \o ca(-r $ ca$ cl$a $$tr) € o\cl \o oo\o cn cn$ oo c.l ( (-r co ca rr) \o o\(--( oo + t1 c.t c.) cn o\ o\ oo \o cBll +h!9ir € riCc't \) R +.q U ta (a inci -cr eoft-r t _-__--! ( 2 r' el. Et 6DJx(D e sN(o @ sN$ O) o,r\ o(f, F- t-(o$ $s(o s(os (o cf)t- Ns@ o(o (f)olr) o, F- LO (f) o) O) N @ rf) 0) L o Q L 0) z Q L3 N(f)(o €in € o\ in \o GI |,a \o t\ $|r) r sflo NN NN No No (o rN (f) N rfO s@ (f, Nr (f) N r- l- (f) @ c\N @NN (o NN @NN t- rf) I\ tr) (o (f) (o (Y) N rtr) N ro $@N s(oN (o (o dll + :dcr F ciCu S.; S U > = ex q) I q) o -oc\ (a N s@ (ac! t- (f) r oNN (o NN t- rO @(f) r N 1() s(oN r @ tsa?aO- h.i Eb e8 EE =dzl t'( 6(J s ro NN No r in \e GT o\ ra $GIt-: ca ao ca ra)l co aa c-r tr- : co o.l s (a) c.l ca c.)l $ C\.l c.) r- : s \o co N : Nl $ -* $ c.lEs"to +.U' .q) = NU 6\) C.l co t- ca c.)t (\ : $ o\ : co $rn c.l : ao c.) \o € .f, o\ : co r.1 *i- ca in (\I o\ ca c.t c.) ca co c.) rc.l c.lc.) (\ c.) \o c.) c.l$ $ s o\(.) -6i c) 0) q) 9 s o c) OE(Jq) dli o- L 0) z t'r Q N c.]c.) o\cl (\$ oo$ o\tn o\o in$ $ : s co $ c.) $ cn $ c.t s ca $ co s ao s c.) s c.t $ co $ ca s c.) $ ca $ aa ta \o \o\o \o \o \o \o \o \o \o \o \o \o \o o :] 3a9o) Ec! od 6o z s ss dLEr +.q ,N:q)k (h t! (! z 0 o cc .v z (! II 0 z L C) .z& :a C) D D 6 D oN D 3 tr q) o o) o s o\ s r-. \o\o Fl C' L o L oo U)(d tr.l 00 bo oN rI] C) o -obo ii o z 0)N C) os oo o(n oNo oo oN th $ c{ Lq) ! (.) o z sN s et Table 6: Type of training undertaken Any other comments No 2.6. Treatments 2.6.1. Treatment figures The project has continued to sustain a therapeutic coverage of above 65oh as well as 100% geographic coverage for over six years now. Trainees Type of training CDDs Other Community members e.g Community supervisors Health Workers (frontline health facilities) MOH staff or Other Political Leaders Others(specif v) Program management ./ { How to conduct Health education ^/ ,{ { Managemen t of SAEs { CSM ./ ./ SHM ,v { { Data collection { { ,v Data analysis { Report writing { ,v Others (specify) 26 WHO/APOC, 24 November 2003 t o c.l Lq) 0.) o z <f c-l s o r a.l O o ^€!? -c '= gEeEEg= E 6 s1* e EL-e. cn o tr c)a (: L(.)I z o EiEd2Z o r- ca r- co tn +cn o\ +$ tr) \o t(v)s .axox 0.) E"gz€ sc.l o\N carn (nol anc.) C-l $ cO tal \o $ \a oo \o TA g,-EnE,E E" g; E I E N + \o \.) sa oo s crl o\f- scj @ sN ci@ s oo oo s c.l @ o\@ oo s n € -o -o o\ o\ v1 c.) €€ scl Orr- s\ € s n € s\ oo s9 € =oC;)bo O. da BggE F() si .L s oo \o\o ol €$ $r- o\la) ta \o o\@o\ -\Oco O\r.} olo\orn \o o\ oo @r\ e.t Or € \.) t- co\.} tat $\o oo T.) r-t o\ 6 00) =E -o=c) E"HE z o'ij r olrn$ \o o\c\\o \o $N o\(n ca co *\o \atrc! o\ <t' \otr\ o\\ Or cat €t r\ o\ \o\a oo+ \r) c-n + -[\\o cao\o\n \o oocn \o rr) rf1 o\ cor- (n C\l cO oo\.) (.Jt t € Eo d o.= < s*' r- \o \o $ oo \o t- cn o\\.} co oo $+\o \o ol( o\+ la) co € o\(n sla)\o+ c- oo tr- \ot- o\ c-N(r)$ $ oo Orr\ \o rns \o car- car- ca\o \o o\f\ ol Or\o o\\o c\l co\o ta) #f- r)NH\o oo o\\o @r- =l' € o\ c.t co\o c.) o\ +\o (n c.l o\ r\ ?a$\o t o\ o\ o (d g o (H AL -E Eg."Ese<E Ei -a rE* LAL oo o o ll * oc) =9pSHaFacEo lJ(d r a co cn $ o.l o\+ o\ao t \o co $ ca f- -[\ o\\.} cor- \o\o oo (.) r-(r) b= rr tr bO!o=cB92 J h- (d uts-Lioa-zoo rn € co cn *ol o\$ o\€ o$ \o co $ca f- -f: o\\n cof- \o\o € (r) r-(a E 0.) EE*Ui9 5\r: t- \, d IA 0) ol cd tA C) oO ..ra! -=-= o !a o v:Anq.- h J_=_c;-'- 6?EE:=€EAF E-<.= r E *F6[J E' \.)€ oca c.l sc.t Or$ o\€ $ \o ca +co r-if\ Orrn car- \o\o oo ?.)F- ?.) I fi )b0 B U) rrl ot r! b0(! oN rrl o 3 o0 (.) N c:)-E -o_ tiOI) Fz oN(I)-g s# oN) U) ah d rrl (! J1 z t)o = sl,tr-v(!JYu)zz Ho & 5 oE oN F] tr Er s U) tr (! v)(B q) Lr cB CB F] a tr U) U)H a C) CS(.)lr F- to N 0.) -o 0) z sl N (J > € N Ci{E$ *[s ss .s {}oo 1:rB x. I .s ss .S E*\E IL : q,s)T SSx s* .ti!S N'E5 Eq) E \TS BT\\ q),Y Ei!E \tu ^,'13.P ST\ SS F EEv ,.P: NT: Eq) = r'rs t '=\ b-\i rs s tRs €s.I st *' .s t'5 rSE\AE L U\s-s Ps .i \; S)s ss:: s! BES .\r (s :r S'A- r tHn :r\ sq *E :\E Sa)S 'T.SE SE $U6s sdH Fr'sil ll EA. f\ \)H ('F.'\ b\ F (.)lr(i Q c.) 'a Lrq o B th(!() L(6 o (,) o Itr a)a >) o ar) o C) CO ar G) -l ! -l o.rxls -l o .91 c-,3lErl Iol q .il (! =1 o6l -otr c.) ul S ol tr 6-)l i- -ol -trlE =l ozt? OIOI *l c.rxl.z EI E CBI .=Elx c)l : ol 0)ol tr()t -Eal idul ()'ol. r-l '9lE Hc =l czl< oLr(s o() 'a lia o o z lJ.,l >.p o H (.) v)(B th() F E o() o q) () IL(.) >' U)(,) qr o tr 0) F X (.) CBoL U)(.) OI(B cr',(,) o C) +i o lr(,) z (.)E oq) La() U)o o o () o ILr(.) >, o v)() bo aoa (! oF OI ^t -lXI cl 0) doLP 6) o1 o +i tr() z (,) C) o F s o Cd! (,) bo Oro > 9-. () F (,) dlr o bodH() (.) (! .9a :\v O. </(dL oo oo O (clr 0) bo(s H(.) o C) O^ !j \oJo\6)vq(nli C,) F (hl ol o0 63i bl BI :ldl ol OJ cBlLl o0 ol()l oo 'oltrl(BI ol ,l C)l ol cdlLI()l -ql -J il 9l o.t EI ol ol *.1 €t ,ol =lEI l-r I ol r!l 2.6.2 What are the causes of absenteeism? Farming activities by villagers outside their villages without coming back during the period of Mectizan distribution. Migration of villagers to township probably in search ofjobs or for higher school. Traveling to townships in order to visit newly delivered children of their daughters or daughters in-laws. 2.6.3 What are the reasons for refusals? r Due to either adverse reactions one suffered or seen in someone after taking ivermectin. r Due to one's religious faith Inadequate health education by health workers or CDDs to community members concerning the Mectizan. Fatigue in taking the drug since he/she is no longer having the symptoms 2.6.4 Briefly describe all known and verified serious adverse events (SAEs) that occurred during the reporting period and provide (in table 8) the required information when available. There was no case of any known serious adverse events during the reporting period. In case the project did not have any cases of serious adverse events (SAE) during this reporting period, please tick in the box. No SAE case to report ! I { ^/ 29 WHO/APOC, 24 November 2004 n n *c.l L a.)s q) z t c.l (-) o o > s q) k- L\) $\q)4 l( Hoq oo L (,) l-r c) b0 L C)l<Lr oo o cn a U) o q) O U) l-iO 6 U) o lrOq) qi o Ch c)(r)(s O #r ol -ol ,csl oqx w>d): <.E E E !P PEU.iH .!Pdjj (d -::ctr <) q) = =tspl00)ai) .E - E.gIL] Ooou) C).2E?,OEgoo itr. ts(Joo. L qi* C) 0* b oijY a(hl) E?*bo.9 -tr -3o tr c== E€EEE . o-c .li'= P -oiiES or'i a2 5e:-.1d-=- oA !J E,Cg - lU.- - (! *:.8 TEfisEf: (n E oq xa il tl. O e. rrlZ<l- tiaO -x hC)=o) €E6dF(a=O # E H'c dN 'nAaqEQbAS:r qr o oooe cg .; =oo>6 Xoa () a0 Ax obo P Es -oO t'-s € c-q € € 9 o\& o\ e.i o\ TA oq o\ c.tcl N o\ c.lq r o\ tr-9 \a1 o\ .r; o\ o Cd o ll -O k5 ri *- rd C) o Boo F C)o\< B- o Ns o\ c.l € t- oo e o\ o\ cn n oo o\ (..) ,r; o\ *I Fi ll - 6 rd'tr E9o Sg BSo >v .EoFo q(.-\o rtq ra)\o \ F-\o oo oe c- co c.l oor- c.l $ oo n$ oo \q N oo \q o\t-- \o oo a rd +io --bFE JqacdEb9 = Q.!z €N o\ \o $$ o\ € c.l c- c!\r $ cat'- o\ o\$s c- €\NIr) cr $tr-\o \al tr- \o$ €r-tr- c.t$ €^ co € trr c.) oo oi r-.t-' t*$ o\ oo rri tso d o.= =tr'o =8.9.< 9*' \o $ c- oo ol oo oltr- t-- €$\o$ e- s co c- c\ co c- o\tr- €dt-- c- oo € \o o\tr- t-- co ca o\ oo c.t$ $ oo I6 9<.r EE#EE suF Ql.o', E,Ba E' c-.$ € t,r. o\ € $ rrr\o$$ oo cr e- o\$ s o\ \o o\ € € e- o\ € \nt'-$^ c.l oil o\ oo od$ o\ $ (r) tr- o\ c-)s\o$ o\ o\ (a o b0 t) c) oU * fEl ua c) ^o0I EaF Oo\< >v o o o o. 9- E = 30^ ,, -. 5 ilg i E,r'trI {.(,Err o ri E EEI EbE-EEz E.E r r-tr cn tr- cr c.) c- I'r co c.)(-- co caF. c.} cn t-- co ca(-. c.} c.) t-- c.l co(*- co c.t c- co d rd Eo d 0).= t.uF t-rF-c.l t--F-c.l tr-tr-co c.tt--c.) c.)F-c.) c.tc-c.) c.tt-c.t c.tr-co catr-ca c-tc-co rEc sg+t.: tr X:: A1A\:E+:=0)oEo tr oo? c)F tr C! 9'O8- - 6 tr- tr- aa t- t-- co tr-F- c.) a-t t-- c.) aa r-- c.) car- c.) ca cr ca ca r* c.t an r* ca c.) F- c.) & lrl cr o\ o\ oo o\ o\ o\ o\ o\ c.l N C.l c.l ca c.l s o{ lrr N \o c..l t-- cil € c\ $ c.l L 0) -o () z sN 0. o q) AD c€L o) I rl F GI fr cB o q) q) (A GI oL 00 ah q) ah lslol$lol -l ii c)L cq I c) L q) L Er q) q) e) t) E.9 arS H.E 0.U e E\ a) S. s) !)t +. .=F= = qJ' -v)Vll c)q)i$- 5t5cg e!(l)999 Ei .g s) q) - o.) hi €UX o(t -L 0)rH >' EEIotlH5l ()ol € .BtGo !bot(E9b g5 r-E l: (C EEtr()(l)c -cd .o)ul r:\o e.i o\l arl -ol cdlt-l 2.7. Ordering, storage and delivery of ivermectin Mectizan@ ordered/applied for by - Qtlease tick the appropriate answer) MoH { wno tI UNICEF n Mectizan@ delivered by - (plea,se,tick the appropriate answer) MOH tr WHO ll UNICEF ll ./ NGDO NGDO Please describe how Mectizan@ is ordered and how it gets to the communities It is ordered by the state project by submitting Mectizan requirement to Global 2000 (The Carter Center). Global 2000 orders for Mectizan, collects and stores at its store It is here that the state collects as and when required. LGAs collect from the state based on requests while the health care personnel at health facility level come to the LGAs to collect for the communities under its control. It is from here that the communities collect their requirements through CDDs. Table 10: Mectizan Inventory How are the remaining ivermectin tablets collected and where are they kept? LGA Number of Mectizant tablets Requeste d Received Used Lost Wasted Expired Remainin o Aninri 180,000 t75045 r75025 0 5 0 15 Awgu 180,000 1 79 115 179097 0 J 0 15 Enugu East ll7,96l 1t3620 1 13600 0 20 0 0 Ezeagu 175,000 r92830 t928rl 0 2 0 17 Igboetiti 160,000 149190 r49169 0 J 0 18 Igboeze North 160,000 r76050 t76032 0 5 0 13 Igboeze South 133,000 143550 143540 0 2 0 I Isiuzo 160,000 t64420 t6438s 0 7 0 28 Nkanu East 130,000 145350 145323 0 6 0 21 Nkanu West 150,000 r48t70 1 48 1 5 1 0 2 0 17 Nsukka 210,000 20t350 20134r 0 6 0 3 Oji River 124,000 1 13630 tt3599 0 4 0 27 Udenu 195,000 t52550 r52s20 0 7 0 23 udi 120,000 r 50750 r50736 0 0 0 14 Uzo Uwani 182,000 t73620 t736rt 0 2 0 7 TOTAL 2,376,961 2,379,240 2,378194 0 0 74 0 226 32 WHO/APOC, 24 November 2004 The remaining ivermectin tablets are collected in the reversed order of distribution. The CDDs at the end of distribution retum any unused or remaining tablets to the focal personnel at the health facility, who in turn send them to the supervising LOCT at the LGA. All the unused tablets collected at the LGA level are sent to the state. The state coordinator sends all the remaining tablets to Global 2000, where they are stored. At the end of this year we returned 226 tablets of ivermectin to Global 2000 Enugu office. List and briefly describe the activities under ivermectin delivery that are being carried out by health care personnel in the project area. a Collection of the tablets from the LOCT. The health care personnel collect mectizan from the LOCT after the latter had received from the state. Storage of Mectizan at the health facilitv. After collecting mectizan from the LOCT, the health care personnel store them in the store within the health facility. Communitv mobilization and health education on the availability of drugs and who are elieible to take the drug. The health care personnel send message to community leaders and CDDs for the drug availability. Also, such message is sometime sent through the churches. Trainins/retrainine of selected CDDs from different villaees. New and old CDDs from the catchment villages are trained/refreshed before distribution. The health personnel are in charge of CDDs and ensure that household member' s registration is updated accordingly. Distribution of Mectizan to CDDs based on updated fieures of villages under coverage. Mectizan and necessary reporting materials are issued to CDDs by the health facility staff. Supervision of CDDs. The health staff supervise the activities of CDDs and any village without CDDs. occurs. It is the responsibility of health staff to manage any case of severe adverse events or other minor side effects that may occur after treatment. Collection and collation of Mectizan treatment summaries from CDDs and reportine it to the higher levels. All treatment summaries from CDDs are screened, collected, collated and sent to LOCT by the health staff. Any other comments Sometimes the LOCT used their motorcycles to send Mectizan to health facility staff with a view to speed up drug collection and distribution by CDDs. Also occasionally, State oncho team send the drug to LGA oncho team. 2.8. Community self-monitoring and Stakeholders Meeting Has any training (of trainers) for community self-monitoring been done in the project arez? Yes. a a a a Management of cases of serious adverse events due to Mectizan where it a If so, When? 33 WHO/APOC, 24 November 2004 a r] I learnt that Training of trainers for community self-monitoring was organized by Dr Amazigo (APOC Director) in April/T\4ay 2002 at Global 2000 premises in Enugu for all state coordinators and their assistants in all zones in Nigeria. I was not part of it since I just joined the project in February,2008. Communi and Stakeholders Describe how the results of the community self- monitoring and stakeholders meetings have affected project implementation or how they would be utilized during the next treatment cycle. The CSM enabled the community members to realize the important of compensating the CDDs, which we expect to yield more positive result next year. Monitoring the distribution of Mectizan, owning the programme and to attend SHM was also realized. Therefore, the project intends to use the results to improve and sustain identified strengths. The solutions to the weaknesses/gaps are being discussed and found in such meetings. No of Communities that conducted stakeholders meeting (SHM) LGA Total # of communities/villages in the entire project area No of Communities that carried out self monitoring (CSM) Aninri 85 60 40 Awgu 130 72 67 31 22 T7Enugu East 68Ezeagu t24 88 53Igboetiti 100 72 Igboeze North 49 JJ 23 59 40Igboeze South 89 19Isiuzo 40 25 Nkanu East 136 85 62 81 65Nkanu West 134 Nsukka 77 51 30 37 27Oji River 59 45 38Udenu 73 77udi 166 108 Uzo Uwani 80 40 35 1373 878 661TOTAL 34 WHO/APOC, 24 November 2004 2.9, NGDO Supervision 2.9.1 Provide a flow chart of supervision hierarchy. Below is the flow chart showing supervision hierarchy in the Project NOCP MOH LOCT LGA PHC DEPARTMENT FLHF CDDS COMMUNITY What were the main issues identilied during supervision? . Most LGAs did not budget for CDTI activities! census registration has not been validated and updated in some villages in Enugu State. . Complaints of non-compensation of CDDs. r Some old CDDs have withdrawn from the programme ' Transfer and shortage of LOCT and health care personnel. . Attendance of pregnant women I lactating mothers for treatment after the expiration of the exclusion period J 2.9.1. 2.9.2. Was a supervision checklist used? Yes, the supervision checklist was used. The project developed checklist for all relevant levels. 2.9.3. What were the outcomes at each level of CDTI implementation supervision? SOCTs improved on their attitude in tracking and rapid checking mectizan distribution to the lower levels. SOC 3s WHO/APOC, 24 November 2004 n LOCTs become more aware of the areas they needed improvement particularly in cross-checking summary forms from the CDDs via the health facility staff. Health facility staff better understood the need to reserve drugs after distribution for sick person who recovered, mothers whose lactating period have expired. At the community level, a decrease in the number of people refu sing mectizan intake CDDs agreed to be updating their registers and to go from house to house to treat absentees in order to improve therapeutic coverage. Community members agreed to select new CDDs and they demonstrated more willingness to support the CDDs. Community members became more interested in conducting community self monitoring at the end of distribution. The stakeholder meeting has helped the communities to identi$ their weaknesses and to plan to address them. LGA authority better informed and re-orientated toward the need to budget for CDTI activities. Health facility staff resolved to be counseling the pregnant women and lactating mothers on the need to come for treatment after the expiration of the exclusion period. 2.9.4. Was feedback given to the person or groups supervised? Yes, feedback was given either on the spot through oral communication or in writing on the findings. 2.9.5. How was the feedback used to improve the overall performance of the project? A strong follow - up mechanism was developed to ensure improvement of the overall performance of the project. I 36 WHO/APOC, 24 November 2004 n SECTION 3: Support to CDTI 3.1. Equipment Table 12: Status of equipment * Condition of the equipment (F:Functional, CNFR:currently non-functional but repairable, Wo:Written off). How does the project intend to maintain and replace existing equipment and other materials? The project made provision for the maintenance and replacement of some of the existing equipment and other materials in the sustainability plan for 2009 - 20013. The project has made a budget in this report to APOC with strong justifications for replacement and provision of other essential office equipment. Global 2000 and State are expected to assist in providing other equipment. Source Type of equipment APOC MOH DISTRICT/ LGA NGDO Others No. Condit ron No Condit ion No Condit ion No Condit ion No Cond ition 1. Vehicle 1 F 0 0 0 0 2. Motor cycle(s) 22 15 -F 7- CNFR 2 CNFR 3. Computer(s) 2 1-F 1- CNFR 0 0 0 0 4. Printer(s) 2 1-F 1- CNFR 0 0 0 5. Photocopier (s) 2 l-F l-w 6. Fax Machine(s) 0 0 0 0 0 7. Others(Bicycles) a)Generator 2 F b) rv 0 0 0 I F c) Video 1 F d)) Air conditioner I F e) GPS 1 F 0 0 0 0 37 WHO/APOC, 24 November 2004 Contributor Year 1 -2006 Year 2 -2007 Year 3 - 2008 TOTAL Cash Budgete d (us$) TOTAL Cash Release d (us$) TOTAL Cash Budgete d (us$) TOTAL Cash Budgete d (us$) TOTAL Cash Budgete d (us$) TOTAL Cash Release d (us$) MOH (Central * Provincial/State) 39,062,5 Nil 15,601 .8 1 4,515.63 43478 11304 MOH (District/LGA) 11,718.8 308.6 11,718.7 5 2r0.94 r4783 s826 Local NGDO(s) ( if any) NA NA 0 0 N/A N/A NGDO partner(s) NA 3078.1 NA 2,453.13 NA 8662.6 Others a) NA NA N/A N/A b) NA NA N/A NiA Communities Nil 2972.4 Nil 1,159.92 t79t0 5526 APOC Trust Fund Nil Nil 76,618.9 1 4,209.22 I 5000 15000 TOTAL 50,881.3 6359.r 92,220.72 12,548.84 9l,l7l 46,318.6 3.2. {1 Financial contributions of the partners and communities Table 13: Financial contributions by all partners for the last three years.US$:Nl15 If there are problems with release of counterpart funds, how were they addressed? The state govemment released the counterpart fund as indicated in the table above but late though, through the efforts of the director of public health and the Honorable Commissioner for health. Because of the letter we convinced the commissioner for Local government to write to all the LGA chairmen, the LGAs tried a little to comply but not fully to the instruction of releasing N10,000 monthly to their LOCT which is contained in the letter. We need a high powered advocacy visit from NGDO, APOC and NOCP to state government and LGAs or a written document reminding them of their obligations to the programme. Additional comments The Carter Center assisted the project through its monthly fund release. State Government has been doing quite a lot in terms of road construction and maintenance as well as strengthening the health system. There is hope that the government will in future assist the state project the way it should since the chief executive is a crusader of health system reform. 38 WHO/APOC, 24 November 2004 3.3. Other forms of community support Describe (indicate forms of in-kind contributions of communities if any) CDTI Communities use different ways to support their CDDS apart from the financial aspect. These forms of in-kind contribution include. . Electing some CDDs as village chiefs or councilors. . Communities provide food items such as tubers of yam and entertainment to CDDs during distribution such as soft drinks or cooked food. r Exempting some CDDs from certain corlmunity levies. . Some communities assist their CDDs in farm works during the farming season as compensation for offering free service to the community. 3.4. Expenditure per activity Indicate in table 14, the amount expended during the reporting period for each activity listed. Write the amount expended in US dollars using the current United Nations exchange rate to local currency. Indicate exchange rate used here : Nl15: US$l . Table 14: Indicate how much the project spent for each activity listed below during the Any comments or explanations? Both state and LGA did not support the project as expected Activity Expenditure ($ us) Source(s) of funding 6842.34 MoH & Global 2000 550 29t3 MOTVLGA APOC/LGA 8200 Drug delivery from NOTF HQ area to central collection point of community Mobilization and health education of communities Training of health staff at all levels Supervising CDDs and distribution Trainingof CDDs Global2000 APOC Internal monitoring of CDTI activities 1670.5 2913 LGA 60Advocacy visits to health and political authorities IEC materials l 800 MoH APOC Summary (reporting) forms for treatment 77.76 MoH / Global2000 MoH / Global2000 5000 348 APOC Vehiclesi Motorcycles/ bicycles maintenance Qlftqe Equip*e"t (50 Bic Others ( 1 )Staff support 4063.5 MoFVGlobal2000 (2) Proiect Meetings/ APOC review meeting 6304.5 MOH (3) Maintenance of offrce equipment s00 MOH (4) CDDs support 5526 Community 46,318.6TOTAL Total number of persons treated 801,947 39 WHO/APOC, 24 November 2004 SECTION 4t Sustainability of CDTI 4.1. 4.1.1 Internal; independent participatory monitoring; Evaluation Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable) No Year 1 Participatory Independent monitoring No Mid Term Sustainability Evaluation 5 year Sustainability EvaluationNo 4.2. No No Was the project evaluated during the reporting Internal Monitoring by NOTF Monitoring Implementation of Sustainability Plans in Enugu state by APOC Sustainability of projects: plan and set targets (mandatory at Yr 3) ? No Was a sustainability plan written? When was the sustainability plan submitted? 2007 What arrangements have been made to sustain CDTI after APOC funding ceases in terms of: Through government counterpart funding. 4.2.1 Planning at all relevant levels Sustainability plan was developed by the State and all the CDTI LGAs. State: A stakeholders meeting of all prograrnmes in the ministry of health was held by the State Government, the aim of the meeting was to plan on way forward as regards sustaining CDTI activities. The meeting will be replicated in the Local governments and communities. The State initiated state and LGA flag-off ceremonies of Mectizan distribution in the country and has made it a yearly affair. This is to increase awareness of Mectizan treatment and the gospel of CDTI in general. The project has been able to hold planning meetings at different levels for sustainability. One of the first things we did in 2008 was for the project to identifu and arrange meetings with some categories of people that we need inorder to facilitate our work. The first meeting was with government official i.e. Hon. Commissioners and Permanent Secretaries for ministries of Health and Local Govemment Affairs 40 WHO/APOC, 24 November 2004 respectively. The result of this meeting is that the ministry of Local Government mandated all the LGAs to be giving their LGA Oncho teams N10,000 monthly. They all complied initially but later started defaulting The second was with state council of traditional rulers. This resulted in most of our communities starting to strategize on how to get well involved in CDTI activities. This also resulted in many communities being ready to contribute to the welfare of their CDDs. LGA: All LGAs have drawn their sustainability plan prior to the advocacy visits the project made to the LGA chairmen. Communities: The commurities through the Traditional Rulers and their cabinets, town unions, some women groups etc, depending on the active one in a community are planning on how best to get involved in CDTI activities. 4.2.2 Funds Adequate plan has also been made for fund release by the State and LGAs. Meanwhile, it is contained in the State budget-rolling plan for the next 10 years.. Our partner, Global 2000, is expected to continue her support to the project. 4.2.3.1 Transport (replacement and maintenance) Replacement and Maintenance of logistic (transpon) are expected to be carried out through the fund provision in 4 2.2 above. Also, LGAs are expected to provide necessary fund to maintain and replace motorcycle. 4.2.4 Other resources The human resource is expected to be stable in the near future. 4.2.5 To what extent has the plan been implemented Many of the planned activities in the APOC post sustainability plan for 2008, have been touched but a lot still have to be done especially in the area of CDDs training for the smooth take-off of the kindred system in the state. Assistance in the area of hosting of more stakeholders meeting would really help in implementing and sustaining the system. 4.3.Integration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration: 4.3.1. Ivermectin delivery mechanisms At the state level, Onchocerciasis control is part of the Public Health Services Department in the State Ministry of Health. Our main distribution route is still the 4l WHO/APOC, 24 November 2004 way it use to be, i.e. from state to the LGA, from LGA to the health facility and then from health facility to the community and the individuals. Another is that the state started free maternal and child mobile clinic in remote communities in all the LGAs of the state. The LOCTs then link-up the CDDs in such community with the mobile team each time they are going. This give the people the opportunity to ask questions and receive answers from people they see as experts and of course receive Mectizan treatment if not treated before. Full integration in terms of delivering other commodities along with Mectizan has not commenced in the state. 4.3.2. Training Training by different programmes is integrated as much as possible. During trainings at each level, other topics related to other diseases- are included in the training contents especially when they are handled by the same person. For example, the state Oncho coordinator who is also the programme officer for LF and Schistosomiasis mentions these diseases during during Onho trainings This level of integration is what we practice for now and it is seen more in the LGAs where one person handles two to four programmes at a time, 4.3.3. Joint supervision and monitoring with other programs Joint supervision and monitoring with other prograrnmes are regular features of CDTI implementation in the project. Those officers involved in Oncho progralnme while supervising Oncho activities also supervise and monitor activities of other prograrnmes in which they are involved. 4.3.4. Release of funds for project activities In addition to the existing budget line for onchocerciasis in the budget, funds released by the government at state and LGA levels for health activities are sometimes (not a regular future) shared among programmes based on need. 4.3.5. Is CDTI included in the PHC budget? Yes, it is included in the PHC budget at state and LGA levels. 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? The use of CDTI structure for other health prograrnmes have not yet been fully implemented in the state. There is plan to use the CDTI for administration of vitamin A supplement, distribution of ITN and control of HIViAIDS in the state. This approach is part of the method of building sustainable ivermectin distribution system. In immunization, many LGAs are using some CDDs as guides duringNIDs, while Roll Back Malaria (RBM) makes use of Oncho health facility staff and LOCT for their drug and ITN distribution. 42 WHO/APOC, 24 November 2004 a4.3.7. Describe others issues considered in the integration of CDTI. 1. In integrating LF into CDTI, how and where do we get the ITN to distribute to the communities from 2. For integration to kick of well, there is need for cascaded trainings. 3. Also for integration of Vit A, where do we get the capsules to administer from. 4.4. Operational research 4.4.1. Summarize in not more than one half of a page the operational research undertaken in the project area within the reporting period. No operational research was undertaken in the project area within the reporting period. 4.4.2. How were the results applied in the project? Not applicable SECTION 5: Strengths, weaknesses, challenges, and opportunities STRENGTHS CDDs in particular towards Mectizan distribution even without monetary incentives from their communities. levels. WEAKNESSES conduction of CSM and CDDs compensation. List the challenges and indicate how they were addressed. CHALLENGES r Repeating advocacy visits to LGA policy and decision makers due to their frequent changes. 43 WHO/APOC, 24 November 2004 . Continuous health education, mobilization and sensitization for long term compliance and sustained enthusiasm to treatment despite improved health status. . Completion of Training of health workers in the LGAs occasioned by the LGA creation and staff transfer. . Increasing the level of community participation and ownership of CDTI . .Problem of non release of counterpart fund by the state Government and some LGAs.. . Training of many more CDDs and community supervisors as to help us start off the kindred distribution system. Solutions The state project embarked on advocacy visit to both the elected and appointed LGA chairmen to brief them on CDTI prograrnme and also solicit for their financial supports Health education, mobilization and sensitization were carried out by the SOCTs, LOCTs and health facility staff to educate community members on the need to continue receiving Ivermectin yearly to prevent the possibility of one becoming a reservoir of infection to others in future and thus waste the gains already made. The project is pleading with APOC to help us in funding the training of the remaining Health Staff. Increase in the level of community participation is being addressed by ensuring that communities understand and adopt the concept of Community Self Monitoring (CSM). As regards community ownership of the programme; series of meetings the project had with different people including community groups have made them realize more, what Mectizart can cure and or protect them from, thereby making them fell eager to play their own part more than before. Counterpart fund issue was discussed at the meeting with the Commissioners for ministries of health and local government affairs, their permanent secretaries and some directors in the two ministries as well as during advocacy meetings with LGA policy makers. For more trainings, we are by this forum appealing to APOC for more sponsorship on trainings for all Health Facility Staff to enable us solve the problem of staff transfer. Opportunities We have been reaching out to private organizations like 7-UP bottling company for assistance in some areas like mobilization and sensitization which is yet to yield fruit. SECTION 6: Unique features of the project/other matters . Introduction of yearly state and LGA flag --off ceremony of Mectizan distribution. . GPS mapping of all the health facilities and high expectation of take-off of state wide introduction of kindred system of distribution. . Use of churches in addition to town criers to announce arrival, venue and dates of distribution. . High number of women volunteering to distribute Mectizan not considering incentives first. a I 44 WHO/APOC, 24 November 2004 D45 WHO/APOC, 24 November 2004 a aa 46 WHO/APOC, 24 November 2004