Report of independent monitors of CDTI activities in Montserrado county: Liberia December 2.21, 2002

tt MONTSERRADO COUNTY - WHO/APOC/CDTI PROJECT REPORT OF INDBPBNDENT MONITORS OF CDTI ACTTVITIBS IN MONTSBRRADO COTINTY, LIBBRIA 2-2t DECEI\rBER 2002 SABMITTED TO THE DIRECTOR AFRICAN PROGRAMME ON ONCHOCERCIASIS CONTROL (APOC) DECEIVIBER 2OO2 lp 1: RECU 2 3 JAltl. 2003 APOC/DIR -) t TEAM OF MONITORS The rTonitorrng of the Lofa, Bong, Montserrado. Nrmba cDTI project rvas carrted out tiom December 2 to December Zl,ZOOZ.ln N{ontserrado County' the exercrse was conducted with the full participation of the following persons .Mr'EviniCyrilleThierry,programoftrcerHelenKellerlnterttational c o*.roo n, i-mail : g-Ylnj*i::riile'.'#l:Qt mail L'om' team lead er . Mrs Bendu A. TulaY . Dr Mei Mei DukulY ' . Mr Nmah BroPleh . Mr Larry Gee All fiorn the Ministry oiHealth and Social Welfare' Liberia Nl the abor.'e persons took active part in the three phases that composed this exercrse including a Preparatoryworkshopaimingatfamiliarizingmonitorswiththeprocessofthe nronitoringprocess(objective,strategy'activities'toolstobeused) Data collection in the two districts of the Montserrado courttY wiiere cDTl a actr\ittes are being imPlernented Data entry, analysis and report writing .l , .l n TABLE OF CONTENT , TEAM OF MONITORS TABLE OF CONTENT LIST OF TABLES LIST OF ACRONYI\4S . ACKN OWLEDGEMENT. EXECUTIVE SLMMARY INTRODUCTION . I I Generiil Bacliground 1.7 Countr Background l.J Team ComPosition.. l.l Terms of Ref'erettce. l0 l{) lt ll ll ') METHODOLOGY Studt Design....... .... .. Pollulation The S:rmple and Samllling Procedure tl lr lr li 2.1 2.2 2.J l?J RESLJLTS 4 O DISCUSSION AND CONCLUSION 5 O RECOI\iN4ENDATION -lU ll J 1 6 1 8 lLIST OF TABLES Title of table Distribution /Clans/towns to be covered in Montserrado CountY Tabte2 i Treatrnent stttrunary Num table Table Al P-eg-e 14 l6I Table A2 Tablel Table3 Table 4 io clianged after villages treated and in which CDDs were the first treatment propoftion of villages that recelve d FtE and ir-r which health care personnel supervised CDDs Input indicators i 1') ' L:- ,23 on of Table5 Table6 i24 I --,---.1,,- ---, -----,,-- Distribution of irnpleur entation of the colnponents of CDTI b-v Clan TableT i Quat ity of CDD training in category A villages 21 28 Surnmary of instruments and samp ling issues Decision-rnaking process at village leve LTST OF FIGURES Titte of figures i PageNum figures Figurel i Wtro decides on the Period of treatment l8 Figure 2 I Who decides.gn the rnode of distribution Figure 3 o selected the CDD gure 4 Weight of absentees as ;"i"p;;a i; tt ; ii.i, r.;i.d I populatrons l -,.. -- _.- -__,- --- - - -- --- --- ---- --,-t --------i------ -.lFigure5 iActual ;.'#s;l"G;Fif ;b;;i'; ii;i;d i 2i i ; 19 l9 ) 6APOC wHo CDD CDTI CBIT REMO OSD NOTF NOCP CFTI) PHC GOL MCH orc NID EPI NGDO DALYS C/DOT FGD CI-IAL LIST OF ACRONYMS Africa Programme for Onchocerciasis Control World Health Organization Community Directed Distributor Community Directed Treatment with lvermectin Community Based lvermectin Treatment Rapid Assessment Method for Onchocerciasis Onchocercal Skin Disease National Onchocerciasis Taskforce National Onchocerciasis Control Programme Community Health DePartment Primary Health Care Government of Liberia Maternal and Child Health Officer-In-Charge National Immunization DaY Expanded Programme of Immunization Non-governmental D evelopmental O rga ni z'at ion Disability-adjusted life Year County/District Onchocerciasis Team ' Focus GrouP discussion Christian Health Association of Liberia 1ACKNOWLEDGEMENT We would like to extend our profound gratitude to the African Program for Onchocerciasis (ApOC) for commissioning the Independent Monitoring Exercise fbr the Onchocerciasis Program in Liberia. Indeed such a worthwhile initiative u'oulcl give us an insight into the strengths and rveaknesses of the program since its inception three Years ago We rvould also tike to thank the Monitors and the Local Guides for their dedicated and sacrificial servic'es to help complete the exercise on schedule. It was a rewarding and challenging experience. our special thanks go to the local authorities in Montserrado county, especially the Superrntendent, Mr-Julius S Parker, for allowing us to visit the targeted Villages and towns and to talk to the people. We must admit that without their patiellce and commitment, r.ve would not have achieved our objectives' Finally, we rhank the entire staffof the onchocerciacis Program of the Ministry of Health and Social Welfare for their numerous contributions to make our work easier The chairrnan of the NoTF. Dr Nathaniel S. Bartee, deserves our special commettdation we hope that the results of the Monitoring Exercise would serve as a basis fbr the improventent of the ONCHO Program in Liberia' 2EXECUTIVE SUMMARY Having realized the magnitude of the River blindness disease in rt's counrry. the Governmerrt of Liberia launched an onchocerciasis project in four endemic countres rncluding Montserrado, Bong, Lofa and Nimba in 2000 The project is berng implemented by the GOL with the technical and financial assistance of the Christran Health Association of Liberia (CHAL), a local NGO representing SSI and is benefiting front the financial and logistical assistance from APOC. To ensure that the project is moving towards its set objectives, the National Onchocerciacis Task Force Commissioned with the approval of APOC decided to conduct an independent participatory monitoring exercise. The terms of Reference of the said exercise carried out in Montserrado County are as follows: Succinctly document how ivermectin treatments were undertaken in a sarnple of Communities with approved CDTI project in Montserrado County, I-iberia Assess comLirunity involvement in drug collection, decision making ort the perrod and modes of distribution, the selection of distributors, and the willingness of the conirnunity to accept and bear these responsibilities designed in the CDTI process. Document community perceptions of CDTI processes especially the issue of ownership, and expectations for Onchocerciasis control, based on these perceptions and expectations determine the degree of satisfaction of the conrn-runity with the different program activities and outcomes Assess the quality of training received by CDDs and health personnel involved rrr the project. Examine the record books of the CDDs and assess the quality of record lceeprrtg and their ability to keep accurate records. The same applies to the health serv'ices staffon the project. Deterrnine the number of communities and eligible treated and compare findinqs with records of the CDDs and the records at the other levels (Clan and Tou rr - level records. ) Determine whether the health personnel participated in iverrnectin distrrbutrort and assess the degree and quality of supervision by health staff (and the qualrtl and orientation of the health staffto the CDTI) Identify constraints in the distribution and recommend appropriate measures to APOC management and Liberian NOTF to be taken belore the nert round ol treatlnents. Discuss the prospects of sustainability based on the findings above After a careful and thorough monitoring of the oncho activities in N{ontserrado Countv the five-menrber team findings and recommendations have been fully noted in the presertt reporr A total of 28 out of 30 planned villages were visited,29 CDDs out of 30 erpected J 4 5 6 7 8 9 !\vere,rter\re\\,ed. l8 out of l8 FGD were held in 6 drfferent vrllages,23 r,'rllage leaders out of 30 erpected were intervrewed as r.vell as health statT dcsignated to supen'ise tlte CDDs rnterviewed 89 households were visited during the exercise Also. prolect leaders such as the NOCP and NOTF chairman were interviewed so were some top rankrtrc admrnistrative and health officials of the visited county The tearn observed that one major of the project has been to make the dru1; ar''arlable to rhe rargeted poputations despite the many constraints that it has to face including the r,e$ rnstable socio-political enviionment within which it has to be implemented, the lack of Government counterpart funding amongst many others. The program has succeeded rn building the drug demand among the community which is now overwhelming as the .o***iti.s are willing to take the drug and continue to do so as long as it will be made available to them Ho*,eyer.. the team's findings also revealed that there has been very little real shrfting tior1r the tradrtional opprou.h of health serv'ices detivering to cDTl nlostll' due to poor trarnlng ot'OlCs that in turn has resulted to poor trarning of CDDs and poor supen'istott of cDDs The heatth staff still plays a too much pervasive role in decisron makrng rvhere as the communities will still need to be empowered through health education so as to allow them play their role and by so doing ensure that the program is sustarned throughout the yearS Record keeping is stilt a weak point that will need to be urgentlt' acldressed in the Very short terrn The NOTF will have to advocate so as to ensure that policl, ntakers u.tuilly provide the necessary counterpart funding expected [lor-Il the GOL A ptan for susiaining the program is to be developed in the short ternl Finalli'' based on its findings uia observations, the team strongly recommends APOC manasement to keep a'nd if possible enhance its present financial assistance to the NOTF of Liberia and, that more technical assistance be provided to the NOTF of Liberia gir err tlreuniquesocio-politicalsituationprevailingintheCountry lo TNTRODUCTION I I General Background Onchocerciasis, otherwise known as river blindness, is one of the devastating diseases, which continues to affect the health of people in Africa lts effect on the health and socio- demography of the people is considerable in magnitude is rightly noted It has been found our that the affected persons suffered from physical discomfort, anxiety, embarrassment. inconvenience, lack of confidence and depression. It has been observed that such persons were stigm attzed, miserable and generally pitiable, and deserving help and sympathv They were avoided by even clo.se friends and relations, a situation which affected their marital life and general well being. The economic importance of the disease has also been recognized by a number of operation researches on its social and economic impact For instance, outright blindness associated with the savannah strain of onchocercizlsts has been kn0wn to cause visual impairment resulting rn economic disability of the infected Concern is also raised about the economic impact of the non-blinding straln ol onchocerciasis, which is prevalent in the forest zones Studies in Uganda, Ethiopia and Nigeria have demonstrat;d that onchocercal skin disease (OSD) has direct and indirect costs as well as impact on school attendance of children, and the computation of disability-adjusted life years (DALYs) . N,tass distribution of Mectizant liuer*.ctin) is known to have signiticant impact orr morbidity caused by onchocerciasis. Thus APOC, a health partnership, has adopted the .u,r-,,.,.,rniry directei treatment with ivermectin (CDTI) as its main strategy for ensurirtg mass distribution of ivermectin in the onchocerciasis endemic communities in the nineteen countries that were not covered under the onchocerciasis control progralllnle (OCP) The CD f I project proposals based on a partnership between APOC, the Natronal Prosrarnmes'and ,"r.rul NGDOs were submitted for APOC support Each approved proftct is funded for a maximum of five years. During this period, it is expected that ApbC supporl will decrease proportionately to that of the other partners and that the cost of treatnrent per individual will reduce by 90 per cent ln addition, it is erpected that the Natiopal Opchocerciasis Control Programme (NOCP) will continLle to manage thett' CDTI acrivities for up to l5 years after APOC, in order to guarantee effective control of Onchocerciasis. ApOC's philosophy for CDTI is to ensure that the recipient conlmurlities owrt the programme in oider to sustain it The communities tliemselves determine the actir.ities ttrei, deterrline where to obtain their mectizan@, when and how to distribute it Ther select their cornnrunity directed distributors (CDDs), collect information about coVeraqe that help the determination of programme success. Unlike the community based iverrne6in rreatmenr (CBIT), the CDTI is a process building up based solely on the erperience of the community members, and consequently, enhancing the decision nlaking and problem sotving capacity of the communities ll MontserradclCountyissituatedinthe.Northwesternl'T:fLiberia.TheEntrreCountY hosts approximately 1,3 ;illi;"t inhabitants with an estimated 35000 living within Todee and St Paul fuver Districts which .on,tit"t the project area' The project area therefore covers two of the three districts .o*poring Montierrado county, up1l.,l'-o' Greater Monrovia ff.re aisrici, ur. f.rnt,.r divibed in-to clans' towns and communities Based on the 1998/1999 REMo results, Uon,r.r,ulo County isbelieved to be 100% Mesoendentrc Numerous rivers and tributaries rravers;;;" a"r;y. The St Paul River traverses both St Paul and Todee districts' St P.aul R"t;; k*;i"-5:l*eding site for the black flv Hamlets, villages and towns dominate the settlement pattern' cDrI activities *t"lt'"'t'ta in roatJ.;]!;;;i; i:I^?ooo with support from APoc' SSI and CHAL. These activities covered 5l communities in the year 2000 and included training of CHos' then trainilg 9f Orct';; ^C^D-? followed by the distribution of lvtectizan@ to 11,904 people. Beg]gn;iooi, corl aaivities expanded to rnclude St paul District F"r;;. i*r'zoor, bDtl"u"tivities were implemented in 132 comn'rurlrlres arrd tkre totnl nu*b'l, J#;rt; 1*q; ;q*^ll:,?yo' activities were launched in April 2002 *,itt tnJ ,iui,ii"g'or olcs-frollowed cDD training Distribution actrvrtres were carried out liom May to September. T;;;.p*, for the 2002 distribution round rs not vet 1.2 CotrntY Background available 1.3 Team ComPosition drtver l.-t Terms of Reference The independent monitoring team_that was constituted by NOTF, Liberia, on behalf ol APoc to visit vroni""uao- corr p'"j;;:i;l'-l'^1,^?,"""'oer 2002' had rvlr Errnr ei; ; in,.,o,,.'Jffi ,jJ g*,*F il'X "i).: i#,.H-:'* :'iil' ;i'*lThe other tllonltor: Bropteh, Mr r-ur.y e;;;;i working *i,r1 it. Liberian Ministry of Health and Socral welfare in various capacities. The team uiro nua members of the Districts Medical reanr as well as community members who ^.i"J .t r"cal guides Finally' the team had one The team was constituted with the following terms of reference: ]Succinctlydocumenthowivermectintreatmentswereundefiakeninasarnpleof communities with approved cofr project in Montserrado cou ty' Liberia 4AssessCommunityinvolvem.entindrugcolle.ctio.n,decisionmakingontlrr:perrod and modes of disiribution, the ,.i..ii""" of distributors, and the rvillingness of the community to accept una u.ur-itr.r. ,.rponsibilities designed in the cDTl process tl J 4 _5 6 7 9 Document community perceptions of CDTI processes especially the issue of ownership, and expectations for Onchocerciasis control, based on these perceptions and expectations determine the degree of satisfaction of the community with the different programme activities and outcomes Assess the quality of training received by CDDs and health personnel involved trr the project Examine the record books of the CDDs and assess the quality of record keeprng ancl their ability to keep accurate records. Tlte same applies to the health seruices staffon the project Determine the number of communities and eligible treated and compare findrngs with records of the CDDs and the records at the dther levels (Clan and Town - level records. ) Deter.mine rvhether the health personnel participated in ivertnectin distributrorl attd assess the degree and qualitl, of supervision b1, health staff (and the tlualrtl. and orientatroit of the health staffto the CDTI) Identifu constraints in the distribution and recotnmend appropriate measures to APOC management and Liberian NOTF to be taken before the next routtd ol treatments I Discuss the prospects of sustainability based on the findings above Ir 2. METHODOLOGY The methoclology used for the selection of the villages and sub-villages u'its a modrfred form of the methodology that was developed during the meeting of the nine tttonitorrng team members in Ouag-aiougou in 1998 In a review of the tools, in a tool development workshop in Kabale, ttris wai further refined to include a few of the things that were not pre,'iousi1, taken into account. The entire endemic villages were included rn the samplrng iio,r.,. rrrespective of levels of endemicity and closeness to the health facilities rn the areas studied. This sirnprtified approach merely selected villages by approach simpte random samPlinua 2.1 Study Design For the. monitoring conducted in Montserrado county of Liberia in December 2002 a cross-sectional research design was adopted This design was considered the ntost appropriatu to generate the needed data and meet the study (monitoring) objectives The data collection .*.rlir. consisted of a triangulation -of qualitative and cluantitati\e instnrments designed to collect information from different Segments of the tarqet popu lation 2.2 PoPulatiort The target population for ihe monitoring exercise consisted of four broad groups These include Healrlr Personnel involved in the cDTl process at various levels' Town leaders, Comrnunity Directed Distributors (CDDs); Householdmembersinthehyper/mesoendemicDistricts/clanscontairtedrntlre REM0 result for Montserrado Countv I 2 -) 4 ln addrti91. polrct,rlakers in the areas where cDTl rs inrpletnented rtere tnterrierved tt'r gauge therr plans lor sustainability of cDTl in the future as well as their polrcl' dtrecttort iu,tti sp.ciol reference to their current support for CDTI 2.3 fhe Sample and Sampling Procedure A study santple of thirty towns was chosen using a simple random sampling procedure The sanrpting pro..f, was to begin with stratiS'ing the Districts and Clans in the Count' b), ler.'els of endemicity Since treatment focus is prioritized based on hyper and meso' the hypo endemic divisions and wards were excluded from the sampling Montserrado Countv having only two districts covered by the project' the trvo were directtv included in ll tlie sa*ple. The Clansr in the two Districts were listed on pieces of'paper arld three ('larrs Ner.e randontly selected tbr each of the drstrict to make tt srx clans in total (ctegttr'.1'A and B I'illages: Having selected the six clans, three.from each of the earlier sampled District to be 'isited. the Towns i' the chosen uiitug.t were listed Five towns were rattdonll' selected flrorn this tist of towns in each C-lan' Another random sample of one Tow'tt out of these five chosen earlier were taken .t *r.g""y "A" Town whiie the remairring four' Towns hecame the category "B" Towns for the monitoring exercise' in each of the srr Drstricts This gave o tot-ol of six category A Towns and twenty-four Category B Towns TableAl:DISTRICTS/CLANS/TOWNSCOVEREDINMONTSERRADo PROJECT Distrrcts I ST PAIJI 2 TODEE ..8'' TOWNS I Grantl. Parker Corner 2 BillY's town J Jah tono Town 5. Pleemu 2 Esatt totr n 2 2 Wilson Corner i Jones tottn J Dttdtt totttt I Ktttuara tort tt \ e [O\\ ll I Coubalt (ott tt + e to\\ ll I Massa 2 Jahrua I Jalttotto -l Gaut I Bahr totttt Gor,th li-rrrtt I -i Grree lorrtt I { Morris torl rl I I Gbotott to\\ tl I 2 Kolleh 71121111 tQu ll I Karloe tort n + Sackte to\\ ll I l Nret toun I 2 Blackre ttltttt i Zore I 2 cl .tLCC I 216 ttA" TownsCLAN I VOA Road 3 Vouzon 4 Goba town4. Fahnseh 5 Pleemu 6 Zingbor townMount Coffee6 6TOTAL I**t.,*.,r*t. ",,* *,t,.*u.u.r,.ities in Nrgena and else.uhere rthrle the torrlls are eqtll\'llcnt lo rrll.rgcs l. co.llli.u*,.r,,, ul"O rn Nigerra and otiicr places rrrtS srrnilar usagc lor t1e cottccpts I I I I I I I I ti Hotrseholcls ln each Category "A" Town sampled, fifteen households were chosen To do tltis the Torvrr rvas carved into three clusters guided by the Town leader and local guides Frr,'e dw'elhng unrts from each cluster were randomly selected. In each sampled dwelling unit one household was randomly chosen for the treatment coverage study. Furthermore, to check on the correctness of treatment, one household was randomly chosen, and the. dosage for one household member, randomly selected and crosschecked. ('DD: attd Tavtr Leaders In each Category "A" Town sampled, the Town leader was purposively selected and interviewed The Town CDD was also purposively sampled and interviewed ln cases where there were two CDDs both of them were interviewed, but where there were more than two CDDs, only two were selected by balloting. Srmilarty, the Town'leaders of the Category "B" Towns were purposively chosen and interviewed The Town CDDs were also purposively chosen and interviewed where the CDDs \\,ere two or [ess. In some sub-villages with more than two CDDs, two \^/ere randomly selected for the Category "B" Town CDD intervierv H atrlth Parvtttrtal utrcl Prtlrc'l' Maker's" Various cadres of health personnel involved in CDTI process were purposivety selected and interviewed. These included Supervisors, County/District Onchocerciasis Tearn (C/DOT) members and Coordinators. The Community Health Department (CHD) Director at the County level as well as officer in charge (OIC) at the District level inyol1,ed in the CDTI process were also purposively selected and interview'ed The purpose of these interviews was to examine the orientation to CDTI Process and prov'rde inforrnatio6 on the records and quality of training they receive and/or give on the CDTI process Policy makers at these levels of the health systems' operations were also purposivell' selected and interviewed to give idea of the support of the policy makers for CDII irnplenrentation as well as their plans for the sustainability of the programme l6 Instrumehts Eight rnstruments were used to gather information from both Categories "A" and "8" sub-villages as well as at the District and ward levels. Copies of these instruments are included as appendices to this report Table A2: Summary of Instruments and Sampling [ssues lnstrunlent Sampling Procedure i ln-depth interview i & Record review ivith CDD Group discussion Programr-ne rnanager/Policy nraker interv'iew Purposive (Simpl random, where there I are more than 2 CDDs Multi-stage (i t: cluster, systenratrc and sim le random Purposive Convenience Purposive Purposrr e ei Category of Towns and Unit Sample A&B | -2per Town Household co\/erage survey A l5 households per Town Key, iplot*on, interview of villaee leaders A&B I Town leader per Town (30 in all) A 3 groups per Town (i e I male and I female adult; and I female or male youth groups), 6-8 persons in each group Health personnel rnten,lew A I Ct{D Director I Oncho coordinator I OIC/I health centre staff Project, District & National levels I Director, Disease Control per District I Supporting NGDO staff ^r- -gr- , --DC .U 0-) !- L_: ts 'rj iJc), O-. :-c 6 0() -_ dir u(,)_c: u(:^v o",n -fi) : -O a) '>-.u-tlj _Ooo=0)-o = !o= >2) ^1) .)U-:0 irr () I -- - .U --- 2 '/, tt '1,O()'J L L L)) Fts- --*t- occUOO ,*,*.* 'JVJ L L :.CJ O i,) .--c - - -)) UUJ E'JJ ePP L.L!OOC -^- L L L ^A^ (.) G)L x (J d) oI] (/ qJ bo ( I I o) a i-- -J =a tn a{ I : I ":.1 0/ \O \O -O\O 'O e'l co oo oo(.l N C'l o) _.o oft-'z $ a.) = o l, c.l .D c^t \o o= :Dtr 2(J o) a.) ,^ aa \o c\l c.l c.l tr- c'.1 a -'= :=oo",i-, >J\-/ O) OO;-'(J9O \O \D \D (.- .a O\DO t*- = c. o\ $ tr- $ r/', -0)i -v. da C\ c- (\ 0_) :t'l ,+6.9 '=s >(, aa r^, @ Nc'lW c.1 t-- (\ u'o\ ,r-:'o 3(c0) /J) r-. F- CO \c)vv v-[- ' t--O^ v\o r- t-- $. \o .{- : 5')0)c)0.5(ciD =0) CICY';n :-ou ::e 0J-Y -Y'eC'e: l- 2 'tt aaa q q <) o -\ .Y;^ ?50 : o.9 dJ-Pp U .==6)?- 2 crt aaa q) ofJ U € C o(J (F o 9 O 1) -oa a COC0.) .- ^ _.o =aL:Y a ."-.! ,-to-o.= o o'*o.)! c -o_c (J o?-a L'J aa ()J CIJ a - 0) a Montserrodo moniloritt g report, December 2002 t8 CDTI is supposed to be a community initiative with the entire community fully taking active part in all decisions that aretaken. An analysis of the table above reveals that while the village leaders tend to think that the period of distribution, the mode of distribution and the selection of CDD were done during town meetings, town people attending FGD thought that all decisions in relation with the above topics were taken by the health worker and imposed on them. Even 50Yo of the 6 CDDs interviewed in towns A think that the period of distribution was decided by health workers. . TTMY DID TI{EIR OWN THING, DECIDING ON HOW THINGS WERE GOING.TO HAPPEN, WHEN TTMY WERE GOING TO HAPPEN AND WHO WAS TO DO WHAT" Town chiefs need more education and sensitization in order for them to fully be in control, otherwise, the health worker who has the 'know how' will take advantage on them and have them depending on him. Chiefs tend to think that once they have been involved in the process, the entire community has. This is a serious issue as the gap between what town leaders, CDD think and the FGD is so wide that this shows that if communities were more involved, a lot the problems encountered during CDTI implementation process would have been solved. This can be explained by the fact that village chiefs tend to politicize the answers they were giving while people in FGD spoke out freely Figl: Who deceides on the period of distribution '(, o! o 3 o @o o,o c oo o(L 100 BO 60 40 20 0 ooa trMllage Meeting lMllage Elders trMllage Chief trHealth Worker IMllage Health Committee EMllage Committee EOther .d .d ..1} +ts ;$ -"tP- L{? t' sF ,f" a-"" "d- Groups interviewed lll on ts e rr a do m on ito rin g repo rt, D ecem ber 2 00 2 t9 EMllage Meeting IMllageElders uMllage Chief trHealth Worker I Mllage Health Commiftee IMllage Committee IOther Fig2: Who decides on the mode of distribution? 100 90 E80oP70(E360(U .tt 50o E', 40630 E20 ,'10 0 Mllage CDDs FGD leaders interview Groups interviewed Fig3: Who selected the CDD EoE L(E = (U oo(,,(g EooL(I) TL 100 90 80 70 60 50 40 30 20 10 0 EtVillage Meeting IVillageElders trVillage Chief tr Health Worker I Village Health Committee IVillage Commiftee !Other ar€ j.@'$ ^"t* "^$"{\-' 6P" (ct Groups intervierarcd o\ c..l\o s c1 ll C; O .o o o'Ff,^E .o 0) .a c- '- II N,E OoO C) '-sDO Jll L : O.C €F, -.6> -Y-o oILP G d) '" =o:C>CC O*,tl ^+d) >-tl ''i gn' chcla '=oc(uL2- Z ,)eL .xoo) 'Yco q- (F '+ooo LLL .)C)o -o -o -cEEE) ) ) -o'o -o - - - ccc999 gLL UUUo- o- o-occ L L L C 0)a 0)rG 0)I ! 0) (c() L o L € a C .t O ,+ o a o 5D(c C 0)oL 0) o- o -cF L 0) () o 'r -o 0)0.)i(v() 0.)L 50 PC ts o.r -- -o d- aaEcoo ,q)e(d ,o C)L -c 0) O>. _o E. tt 0) o(c -.c o) OPeo ac ,0) o)5r o!L,+0)^ -.c. ,'J OJ o-, R xO- - a.l OOttr \c EEJ \ <: N Z Qr!d .+ >< ozOo.. U) f c{ 6ir- * t-. a.l e.l :if& (\ $ 1\ 5,C' ,> .:- ,: :\ oZ 't) uld c'a * s ZN@ a -+(\ a{ v r- a.l a- <f -i' ro rr i-\ri<:J: -a s l Z l) u.ld ll, r'r zoo a 6l * r- c^, a.l al ir.l - >\ ; Z U uld <t o] .\ : z a I N a\ -l a! (Jj <s 'r \.) -\: s Z l) d a * al r,(\ \' i/ oz C\ sa + r- ,n =J n <t a{ <s >N s oZ (-/ LL) d c.]i- ciZ\o@ </) :E r- *r- r'- * r- () * '= oF () o F o) () oZ q c) o ()() =q)q -o o.) Al \- a 0.) {,, N I Montserrado moniloring report, December 2002 2l Out of a 520 population sample, 324 paple got treated representing a therapeutic coverage rate of 62.3yo which is still low compared to the "at least 65Yo" expected. It is clear that this coverage would have been higher if there were a strategy to treat the people found absent during the treatment. In fact, out of the 196 people not treated, 68 were absent, representing about 35Yo of all that didn't get treated. On the other hand, all the people who were reported absent are willing to get treated which implies that there is a need for the supervisors and CDDs to work out a plan to capture the absentees, especially since most of them are farmers or rubber plantations workers, because, for the sample taken, had these absentees got treated, the coverage rate would have been around 75Yo. AIso, for those reported absent because of war, there is a need at central level to work out a national plan aiming at treating people in displaced camps. Also, the supervisors need to make sure that, in cases where CDDs are non residents of areas they are supposed to be treating, they actually go there to treat people, otherwise, these people will not get treated. Figure4: W of absentees/not treated %oh 62.Th Population treated 47.3% Population rot treated other reasons for not taking the drug 65% Absentees during treatment Fig5: actual coverge, coverage if absentees treated 100 BO 60 40 20 0 tr Total population rrATO trCoverage trCoverage if absentees treated 1 ff The table also reveals the poor record keeping from the CDD In most cases, r5ere was no treatment book When it happened, the information contained was completely Lrnreliable Therefbre, tliere rs a need to train CDDs with tbcus on record keeping Table 3 Proportion of Villages treated and in which CDDs were changed after the first tt'eatment -3 Proportion and number of at-risk villages treated :25(89.3oA) Proporlion and number of conrmunities where CDDs were changed [n, the communrt),after the first treatment : 5(20%) -5 Eren though the geographic coverage expected is I00% of the targeted communrties, the proportion of at risk villages treated is good. This shows that a lot of communiries targeted for CDTI are receiving the drug. However, some comrnunities did not receive cornmunities even though they were ready and willing to take the drug " the CDD whiclt wus ttssigned to our town conrc with u stick trul et'en took our nu,nei rlown. pruttnisi'ng to conrc bnck with the drug. [.lntil now, tve hut'en't heurrl of'him r41itt." The cluestrr-lrr here wh5, n66 a number of answers can be thrown in includrng . Lacl</poor supervision by OlCs . Too much towns to be covered by the same CDD This is an issue that needs to be addressed as some of these communities feel that tlrer.' have been abandoned for some unknown reasons Orr the other hand. the proportion of CDDs changed seems reasonable given the socro- ecottonttcal-political situation of the country ln lact. some CDDs got interested thrrrkrnq that thet' had found a job until they realized that it wasn't a cash-paying job and decided to quit The supervisors based on their poor performances changed others o o CLAN Sub-villages (Both A and B) Treated CDD changed Parker Corner 5 4 (80) 2 (s0) Billy 5 4 (80) r (2s) Jah tono J 2 (66 7) 0 (0) Pleernu 5 s( l 00) r (20) IVIount Coffee 5 s( r 00) 0(0) Fenseh 5 s( l 00) l (20) lTable 4 Proportion of villages which received health education, end in rvhich health care personnel supervised CDDs Clan Sub-villages (Both A and B) Received health education (Yes/l'{o) CDD Supervised by health system Parker Corner 5 3 (60%) 3( r o0%) Billy 5 4 (80% 4( I009,t,) Jah tono Pleemu J 2(66 7%) 2(100%) 5 5(r00%) s(r0o%) Mouut Coffee .5 s(r00%) Fenseh 5 5 100% s( r00%) 0-6 Proportion and number of clans in which the CDD is supervised by the healttr care (clan scorin g 50% and above) : 24(100%) o-.tProportionandnumberoftargetclanswhichreceivedhealtlieducatton=24 (100%) Not all the visited communities received health education But' all that got health education are those that received supervision by health system This means that' the more you supervise, the more cDD will provide health education to the communities and er,,etl' tltenroretlret,willbecoveringthecommunitiestobetreatedasshownbytablesland] trre crarrs trlar got att their communities treated are the same that received hearth educatro. and supervision, in other words, the level of education given to communities and the understanding of the onchocerciasis program conc.epts reflects in the degree of acceptance and participation rate, also, the iutput of those implementing the progranl Is basrcatty relative to supervision they receive s(100%) J a! o\ tr- r./-r @ vs C\ il L 0) €c C)o -c!E 0) -C L(J \oo\ CO '=v -^ (, \e .6 ^ U?i+;; lS!-.9 Ir- o.r fi ,Y vXtEll coi Etril o '-= (.) r)iJ.E - 'E()PE co-':cnT 9E NEotrF- ^>i-CU.a .- ar .; tfr --C @ ^.- i'S.E E c.N ;vs0)()o\llE r\ = (c'- co g'* srP.'av.rl o E d.r I a 'e=PaJqrdXstE.rr IoeO B 85 9? - Er) o o o.= = =cc->;iE d) d)'- ():-r0.)'i-'i-.Y ! c .= .5 E Q€ cots 3S ??>.E E .' * oi oi k: -.9U)eu -==='ZcnZ'= rw(w._6._L >-c-c C o > l --/,-664-*6 .o.9.9 E-c 9 E !iret:pe- cccO>co = = = o'=* CCCeaCX LLL^IALE E E 5oH E ELH.\0) oooi:U(J=(* (+- q- '* (! '* '!ooooooo LLLLLLL()0)oC.)o0)a) -o ,o _o -o -o -o -.oEEEEEEE))))))) - - - - -()'O -O'O'lf,'c,']C ccccEcc(Edd6id(c(c 9 9.9.9 9 9 9 LLt-LL-LLoooooooo-o-go-o-o-o_oooooooLLLLLLLo-o-o-o-o-o-o- o,) \- q.) 4) E U lft F $uf\cr-lttl ), (ft AlL a \oo'o o \o o .o o\ O \o o\ O o \oo\o O o\ O O !'J vY> A L< \o o c\ = \o o\ NY \o O o o\ (..l = .o o\ O o.lY \o o\ \o ZZ \o Oo \oo\O @ ri- aa .o o\o @ $ \oo\ \oo\oO :I =9 >o \o O\o aa \ao\ O @ .f, -o o\ t--- \o\o N \o oo $ o\o = -o o\o = :A 'J- \o o\ O - \oo-C co v \oo\ tr- \o\o c.l o\ @ s- -o o\ co $ o\ C .J :t :IE -vEG \o o\ C.\o o\O O .o o\O O \o o O \o o\r N \oo\O\o -o o\ O c{ : o\o O .o o\o o o\o(\ \o otf, N -o o\O en LHt- r) o\ Oo \o o co v -o o\(-- .o\o N .o o\ o \oo\ O O \oo\OI ' lrot ==4cn>i an (, o U () o o C) C) oU C) () - a{lt 2_i The proportion of trained CDDs in sampled communities is 92 8% It is expected that whenever there is an active CDD, he/she should be trained, which means that the training sesslons to come will have to make sure that all active CDDs are trained ro ensure accuracy in work being done The table also reveals that25o/o of the visited communities experienced late supply in Mectizarr@ delivery, furthermore, 28.6oh experienced shortages in Mectizan@ supplies. this is a serious issue as there is a set time for distribution, so a late supply r.r,ill definrtety be unhelpful to the program. On the other hand, given that the National Coordinator specificallv said that the supply being received from MDP has always been enough, shortages of Mectizan@ can be ju:tified by the following: . Poor census not taking into consideration all the populations to be cov'ered, . Poor sharing of the Mectizan@ at District level, All the above problems can be tackled by regular supervisions bi, Q16t and adecluate sharing of supplies within districts. The table reveals that I8% of the interviewed CDDs lacked measuritrg devrces There rs no reason tbr a CDD not to have a measuring device This can easily lead to either under dosrng or o\/er dosing of the drug, which can be damaging to the program Supen,rsors should alwavs make sure that CDDs have adequate measuring devices each time they visit thern As for the measuring device, treatment registers are key instruments to be used by CDDs Unfortunately, about l5% of the visited towns lacked treatment registers This is a serious issue that should be addressed, as lack of registers will automatically.learl to lack of record k:eeping Finally, the lack of treatment summary at state office (district and County) reveals a lack of close collaboration between OICs and State offices. AII summary forms are given to the rmplementing NGO with no copy to the state offices. There is a need to re-orientate and/or t.rain OlCs on the absolute necessity to provide regular and accurate surnman, of actii,ities being carried out in a given district. I )() B Constraints lVltntgenrcnt . Lack of counterpart funding fiom the county budget to support CDTI related activities . Constant movement of populations running away from fighting areas . Most OICs working to implement CDTI activities are supported by NGO whrch do not always integrate CDTI in their priorities, . Lack of community initiative to support CDDs . I-ack of transportation means for OICs u Tecltnical . Lack of adequate training with focus to supervision . Lack of required skills for record keeping C Community,Perception Even thbugh communities think that this program is important for their health, they har e the perception that it belongs to the government and that they have a very limited role ro plal' That is, irr terms of the drug and its effect, they value it " if it is left r.r,ith me. I rvill take two tablets every night". The populations would like to see the program contlnue providing the drug, "it took out the warms from my stomach, it cleared my skin. I no longer itch myself like I used to, I even wear trousers now.' Some town chief had this to say: "tablet is good. we want more. when I took it, it did well to me" Another had this to say: "we are satisfied with the program, it should continue" "we appreciate treatment with Mectizan@ in our vrllage and hope that it w'ill be sustained by collaborative efforts, that is: . Provision of drug for necessary duration . Support to CDDs" Finall1,, a town chief said the tbllowing to show his appreciation of the program "W'e are blessed to be treat with free Mectizan@, we pray that the donors will continue ro provide ttre drugs. We hope that eventually, river blindness be eliminated tiom Liberia We will continue to be committed and supportive to the program and our volunteer workers. " About the perception that the program belongs to the government, a town chief said the following: "the government should provide support for the program by providing transportations means to its CDDs and health workers to enable them to qo out more often oq) u o : cJ o C) cE o >,/i o () --Ye?.-,iI.,=6-.P - v ) )-a(J !.= '-,==__rrOU,=='-O- u.:=>q--Ya) ai - == = 9* o >a = - 3o:+ >..: : I .! .itg;=t€iE2='E-Zs=;,;=E8 EEn-?l=, *,.E = ="-1tr E; x; = E E rlE! = eE 8: ;: E: S E L@Oo=-o 6oo a)=>. 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() r.: N a (] )a- '- 'J .E ') -a) o .= :iad Y-a)JA;>zx=ootr=oc- :t'J:= = /, -,) - -E=E--o 2EZZn ') "'q '--52:Al0o rn = - - =-F'Jir-r;r € q E E i az 2 ) =-E = E,E e'9 E' E l-gr- s p't i ='T '3 gaS;I--ar:, _ L-lf !r\l ri ?PO=.v=O !D elsEEZEEE2aE d,)9- L/r ,; ? J 'J O o :'O i\E i, 3 i iE- E -UE;Eo=e2=rv- -ne C 5c=E*=?EE i: e I E: B " - = = == 6 =E 53=3:zE7etc>=;?=7 ..1.) J (i ,,= ii a ^.:l -r)Z==-+l=a(l€ if E: E4; a g P )o,. -e1: =.; :i -u ci *,.o ::S* -3UIu ) .r-I -ia: -=o ?'9= = >, >,) =.hat'E (!-o );i a =Y.a-+ E'.YJ '" - r. 5 - -a=JI .,8 = C c-z =2I5 u.t::qEsiE;2=iFi p'* [' T.r! = vt.-9 :o- - o -L-EJ)=\l r:Po=J=cn? tl€ 3 E2EEE2;Z 0/ o ul !;: - gn! 'JXr^: ,J >.-o o o U =,Le vYrO- crx = > D-ox = o oo-=oo- ZEnE€s i=2e 6z a>N-Oij=,) _ -._= _ a =- G._ = n'E i:E e €E a .== -yi -2.; "a= .= i = <t i - .=.= .=_ol=-odp,_=+l-A il es=;€Ei;EEt= Er r $ E x o € :p-o ? E -= a, vtlr.-JUJJ :E 3,8> EEE _Z=9!li=..'" -2'tl ';ji- = .) ' J= 7*, = -gli-o E = ! =-'- =- q.a - * it * 5= - F^i -o"'.rZSl,8 , - F'b ; Po .. = = q.tE€.sE E-)E.Ez6=d r$Exo€'{)'!5o,1 <,X.= i:{U d'- <U.. !Ella"*.iEZt? o*i - t ) ')= ;!-./,?! :., o=;85 '4?l Sl 5 -o ipt-''rin1',7 els: e E i 7 E ='I i 3o?oL!-u- _,J 5r= :O -E) -.E ) tt =ci 9 =,L!P;i3cd e:r-a)J +AL2+1x = o o ^ !- - ,r a E€gE:ei:22 6"= =>N-O;:P) - /= 5q=- ci; -o > : s =F= "2 =oEQ e -oij g' ==-y.!q2.:-):,= . i = o L - .= = =;I = 3qs3's-3A ='lil ei E- ? 3 s gi n =i E I;sl r 5?F€ 222 3 5;- 5 r\l o o >J- A=A q C O O O o tr f $EEO€:p-E 3 7-= I Vlt)-)eJJ3€ *E>EiE E= .. - Y- - = q _ ? l!;l?=s--.e2?" !a->-Jtt.- o.;-O = -= \ = -u:.,- E= E ! 5 : c I tl€;I*E!E32zEa ) = = (.) ? -^ ='!J r- = :I)-(] 2 t '= z.LJJTLL^ V I t - .- ) e J J :).-L:v(iv^ ,E p,zz )=+, _Z= 'J=^." - =i;)3E-l'=A' l5<e - g.= (: - <,= = !^l-JJ2-J) -.giio 7 € 5 :..'- E= H S 5 l.: :l L -'.= ^nJ 'n l) :OSl,P, - F'b;:fo..=ortE € 2 a ;. € = z 6 a o (l bnr r q.) OOOL e-- ! ^ = 'r >i '-D ti ') -.Ttt C .J V =,uEr-;l'J.i Xi='rJx r.)JU9oE=oo- A ?'J Ei ? a 3'= '{ a = 4o= .J'J= C,n -- ci .Y H .->N--cij-;'-)\ / = - 0 =- Ct; - J .\ L - -o > i = =7 = r:,? =o:Q 9 =I .€ .==-y.iqi.;-1,= .= .: = o t - .=.= .=-oI = 9gs3'e-ZE ='2il n E - : Li = eZ J = ? = P ;sl r5=g;!2e=6r,*3d\l o o 7J- )'=..O.n a o O C o - trr^ UU i.5 .E'q E E.s =L-Gc': u O O:\JtrO) i! lt I Table 7: Quality of CDD Training in Category "A" villages (oh in Parenthesis) Clans No. of CDDs No. Trained Length of Training No. Trained in a session Parker Corner 5 s ( 100%) J 30 Billy 5 4(80%) J 25 Jah tono 2 2(to0%) 3 30 Pleemu 5 s(100%) 3 30 Mount Coffee 5 s(100%) 3 30 Fenseh 5 s(100%) J 30 Er,en though the duration and ratio per session seems reasonable, the question rests uith the content of the training. There is aneed to adaptthetraining content to the real need of the trainees Also, it is vital that these training sessions be closell' supervised and fotlowed up by on -the-job training. l() The compopents here above can be grouped into five categories Categor.y I 'frarntng ct/ health v,orkers, tratltng of CDDs, Supert,r.sron o/ ('DD.t The trainrng of health workers has not been consistent, as a result of this, the tratnrrtg and supen,ision of CDDs were done in a very approximate manner. The trainrng/refresher course is being done irrespective of the level of knowledge of CDTI principles New attd old trainees are all grouped and undergo the same training. The r,'ery few OlCs existtng and willing to supervise go out without really knowing what to look at since there is no supervision checklist that would have enabled them to improve on CDDs' perflormances Category2 . Treatntertt ,rr,,rory', Record keeping and repctrting, slorage and sc1/t:11 tl clrttg This section looks at CDDs performances While treatment accuracy and storage and sat'ety of drug score good grades, record keeping and reporting is still a weakness Most of the time. CDDs give the right doses and keep the drug in good places, thev still need to be taught the rmportance of good record keeping and adequate repofiing Thts ts atl orrgoing process that can be addressed in the corning training sessions, now that there is littie to be taught oli treatment accuracy and other related topics. AIso, there is a need to improve on the actual treatment registers so that they include all the necessary data and. rnore important. that a summary sheet be attached to it instead of the actual flying paper which is presently being given to CDDs at the end of the treatment period This summan' shcer could be done in double so that one be removed and sent to the superv'isor rvhile thc' second wrll rentain within the register So aS to keep track of annual results Category3 . Availabrliqt and adequaqt of treatmenl This is a component that does not need a lot to be added to the existing The druq r: ordered I adequate quantities However. it will be necessary to ensure. throttgh rnore regular ald eflectrr,'e supervision that the drug is adequately redistriLruted to t he cornmunities rn need so as to avoid frustrations Category 4 C o nr nt r t n t 11.' tn ob i I t zal t on and edt r cati ott lvlost targetect communities were mobilized to receive the treatment Hower"er, thete ts a need to ensul'e that conrmunities receive the appropriate educational messages relatlnc, to collntut-ltt\r responsibitit), towards the program, the necessity for the commttnrtY to take ovunershrp of the program and the reason to ertsuring its continuity after the erterrlal fundrng ceases Cateqor"v5 . Integranon mto PHC Fr"* th. "ounty level all the way down to the community level. it is absolutell' essential tSat emphasis be put in making people understand that the program will not sull'l\e urrless rt is fulli, integrated into the PHC This is very important especially gir''en to soci- politrcal environment prevailing in the country t2 E UNIQTIE FEATURES OF THE PROJECT AREA Given the prevailing socio-political environment in the entrre project area makes it so that it is a permanent challenge to have the program running I'lad the people implementing it (OICs, CDDs and the NGO) not been committed to have it achieve its objectives, had they not shown a lot of enthusiasm. the project would have collapsed before it reaches its third year Community acceptance towards the project is another demonstration that rt they were fully mobilized much progress would have been achieved Strengths a Weaknesses a t I a The absence of community initiative created gab between the CDDs and the commuhity. The lack of counterpart funding from the governlnent to help support the proJect There is absolutely no plan for sustaining the program a { 4.0 DISCUSSION AND CONCLUSION Three years after its launching, it is encouraging to see that the onchocercrasis control program has succeeded in making the drug available to most of the affected communrtres desprte the numerous daily challenges it has been facing As the benefits of the trearmenr are easily noticeable, the program has succeeded in building the community dernand of the drug During the present monitoring exercise, all the visited communities w'ere ready and willing to take the drug and continue to do so throughout the years Hourever, there rs strll worll to be done as far as sustainability is concerned. The NOTF has to lobbt, towards a stronger national commitment. It has to ensure that the Government which has already has a very good appreciation of the CDTI approach and has shown good signs bv including the oncho control program into its national budget tbr the year 2002-2003 actually steps in by going beyond good intentions The program needs to be made rnore r rsrble so that all the cornmunities and other stakeholders become more a\\are of tlre oncho problem in Liberia The capacity of all internal implementers has to be burlt by providing with the opportunity to attending workshops where they would learn frorn other cr-runtries' experiences. Liberia has to be considered a 'specral case' and nrore tlrrancral and technical assistance should be provided to enable the proeram achreve rts ob.lectir,'e 9 a It 5.0 RECOMMENDATION I To the Project: General recommendation: Given that the project document was prepared based on sometimes-anecdotal information, it is necessary that it be revised so as to ensur6 that it reflects the scientific evidence existing on the field. Also, this document should be made available .to all the stakeholders involved in the project implementation. This documdnt should clearly state the role of each of the sta keholder. Also, there is a need for the project leaders to work out a strategy ainring at treatirlg the displaced in camps as these people constitute a big portion of he targeted poulations. Trainins 0f Health Staff As these people are key players in CDTI implementation process, it is essential that there trainrng be set as high priority. Therefore, considering their fair performances nou'. tt is highty recommended that their training be strengthened in terms of quality. There should be an assessment on what is expected from health worker based on which the training conrent will be defined. Finally, there is a need to provide for additional training davs of training for the OICs joining the program for the first time instead of having to undergo the same training Trainins and Sunervision of CDDs There is a need to strengthen CDD training with great emphasis on basic operational principles of the program. CDDs must be trained in simple language u,ith emphasrs put on practical exercises during the training sessions. Training content will have to answel' the tbll orvrng questions . Program: What does a CDD need to know about the progrant Partners, role of partners . Onchocerciasis: What does a CDD need to know about Onchocerciasis its causes, symptoms and consequences if not treated . Mectizan@ What does a CDD have to tell the people about the treatment \\ rth Mectizan: benefits, duration of treament . Census Why shoutd a CDD do an exhaustive census of his population? How does a CDD do the census? . Treatment and record keeping: Who is to be treated with Mectizan? How many tablets does a CDD give to the people to be treatede Why does the CDD have to keep track of all the informations he/she col lects') How and where records? (hrtrcrship The conrmunity' should begin to appreciate the prograrn and planning and irnplementation stages in order to sustain it. does a CDD keep his/her Once the training over, there is a need to ensure that frequent and effective super-r,ision visits are paid to CDDs This should be done by o Providing OlCs with sufficient resources to effectively carry out supervisions to CDDs o Developing a simplified checklist to guide OlCs during supervision visits BCgg,'d keepins and rep There is an urqent need to impr.ove on the record keeping aspect of the project The follcr.ving measures should urgently be implemented. . Inrprove on the census and treatment registers that need to be combined ir)to one census/treatment register. The same register should also have a summar-Y sheet attached to it The inside cover of the register can be used as a reminder to CDDs . The community census/treatment summary sheet should be filled out ttl two coples. one that is sent to the OIC, one that will remain attached to the regrster . [t has to be made clear to both OICs and DHO that summary sheets need to get to both the supporting NGO and County health authorities. These sumnrary sheets need to be sent along with narrative report of the area covered. o Regular feed-back has to be provided to people implementing the program, Approaclting the Health Services and the Communitv As the project intends to strqngthen the health and social structures in p lace, all atternpts ro approach the community or the health services must be done in fuil respect ot' the existrng hierarchical structures. This will ensure full participation of all the partners and at the same titne ensure sustainability of the program Itrtegl'atiott rl ('DTI irtto the PHC Sysrent It sliould be considered a priority progranr and integrated at all levels It is now a publrc healtI coltcer.n that needs to be given serious attention like any other program as tnalarta. and diarrhea To District t be totalh' inv'olr,'ed both in Mo h i I i zal i ort and sensi I i zal i on Local authorities should be involved as mobilizes and develop and dissemtnate appropriate messages through local media such as "talking drums, town criers, Coprliemorati\e ON('HO Day should be declared to demonstrate the itnportallcc of the d rsease l6 (- o r r r r te rpat.t fu ndmg Approprrate allocation should be made to facilitate the work of the program vanousstakeholders in the district should be encouraged to provide minimum funds towards theproJect Provision of logistics Adequate logistics such as vehicles, stationery, motorbikes should be provided by allstakeho[ders to ensure effective implementation of project activities P |an.: f or .\t t.tta t tta b r I t 6; A three-year sustainable plan that would contain every shades of community involvementshould be developed. ltrteg'otiott tttto lhe rotrline healfh .sS;slent Tlre project should be rnade visible in alt facet of the health system Thar rs thecornntunity should be fully aware of the existence of the project either at the conrmunrr' and facility Ievels. To National Onchocerciasis Taskforce ( \r'trer.shrp The program should be regarded as a national program Decision and policy rnakersshotrld be committed and accept the program as any other health p1-ogra, such asN'lalaria, TB/Leprosy and Environmenial Health. Budgetary approprration should bemade to enhance the work of the program. lvlob i I r zcr ti cttr orcl se nsi Ii zaI i ort The Taskforce should use all available media (print and electronic, row. crier) anddevelop appropriate message for dissemination to th. target popuration (- o t r n t e rpo r. t ./indi n g Approprrate budgetary allocation should not only be made but be disbursed ro rheprogram NOTF should continue to advocate to ensure the disbursement of the funds P t'ot't.t't rt t of I ogt sn c.s The taskforce should ensure that adequate logistics are provided by advocatrng tbrappropriate funding in the national budget. P I on.: .fb t' s t r s.t cr t rta b t I i ry; The NoTF should develop a three year plan involving all stakeholders and rar-cets to beachieved as well commitment of various partners. lntegration rnlo the rotttine health syslenl NOI'F should advocate that the program be incorporated into the overall health s)'stenr at all levels To APOC Management Prrt,rsron rl' logrstrcs and capilal equipntents As the project presently operates exclusively on APOC funding and in order to keep growing the present noticeable results, the team encourages APOC to increase tts financial supporr to the NoTF.pf Liberia to facilitate the work being done to get the Mectizan@ to the suffering communities of Liberia' Provi sr ctrt oJ' techni cal assi slance The team strongly recommends APOC management to allow that enhanced technical assistance Ue prouiaea to the NOTF of Liberia given the unique socio-political environment in which it has to operate f a