Annual technical report of CDTI activities in Enugu/Anambra/Ebonyi CDTI project: October 2000 to September 2001 (Third year)

M*q ,l err *. _.l o qy For Tor(n rLo ANNUAL TECHNICAL REPORT OF CDTI ACTIVITIES IN E N U G U/ANAM B R/A/E BO NYI CDTI PROJEGT OCTOBER 2OOO . SEPTEMBER 2OO1 (THIRD YEAR) N ,/ SUBMTTTED To: AFRIGAN PROGRAMME FOR oNcHocERcrASrs coNTRoL (APOC) E{i(t 25, cr.os. n*. vi tv"r+. c (,,1t{ t't t a' LIST OF ACRONYMS APOC - African Programme for Onchocerciasis Control CDDs - Community-Directed Distributors CDTI - Community-Directed Treatment with lvermectin DHS - District Health Supervisors HFS - Health Facility Staff LGA - Local Government Area LOCTs - Local Government Oncho Control Team Members NGDO - Non-Governmental Development Organization PHC - Primary Health Care SOCTs - State Oncho Control Team Members TOTs - Training of Trainers VHC - Village Health Committee i- I EXECUTIVE SUMMARY The implementation of CDTI under APOC started in Enugu/Anambra/Ebonyi States' Project in October 1998. This report covers activities carried out during the third technical year which began in October, 2000 and ended in September, 2001. Mobilization continued with advocacy visits to State, LGAs, and Community policy makers to re-sensitize them and re-solicit their continued support in CDTI implementation. Sensitization workshops were organized for stakeholders at State, LGA and Communities. These workshops not only serve as a fora to keep the participants abreast of the current situation, but also offer them the opportunity to come together and deliberate on issues bordering on partnership, organization and effective planning of CDTI to achieve sustainability. Mobilization at village level was very intensive and emphasis was on the of sustainability of CDTI. A total of 15 TOTs (SOCTS) , 252 LGA staff (LOCTS and PHC Coordinators), 1,O45 Health Centre/Post Staff (DHS and HFS) and 7,325 CDDs were trained between October 2000 and September, 2001 (Tables 3 & 4). A tota! of 3,412 targeted villages were mobilized and health educated 4on the importance of receiving extended treatment with ivermectin (Table 5). A total of 3,412 villages also selected CDDs, collected drugs, and decided on the method of treatment (Table 2). A total of 3,304 villages decided on the month of distribution, and 2,012 villages compensated their CDDs in either cash or kind (Table 2) valued at N1 ,477,830.00 (Table 8). A total of 1,891,401 persons were treated from a total population of 2,904,422 persons giving 65.120/o treatment coverage (based on tota! population) and from an eligible population of 2,304,786 persons giving 82.060/o treatment coverage (based on eligible population). See Table 7. Treatment has been completed in all the 3,412 villages. Evidently, self- sustainable Mectizan delivery system has proved feasible and effective in the project. The states and local governments have continued to complement the efforts of external donors through release of counterpart funds and continuous payment of salaries of their staff involved in the programme. t' SECTION I BACKGROU N D INTRODUCTION ENUGU STATE Enugu State is located between 70 10' and 7' 45'N. lt is bounded on the North by Kogi and Benue States, on the South, by Abia State, on the East by Ebonyi State, and on the West by Anambra State. The population of the state is about 2.8 million and made up of seventeen (17) local government areas (LGAs). Sixteen (16) of these seventeen LGAs are under CDTI (Table 1) spread over a landmass of over 25,200 square kilometers. The bio-climatic zone is rainforest in nature with annual rainfa!! between 152 cm and 203 cm. The climate is comparatively equable and the temperature ranges between 22.2oC and 36oC. lt is the humidity rather than the temperature that causes discomfort to newcomers, and this between 78o/o and 95%. lt is generally cool during the rainy season, while the mean temperature in the hottest periods of February and April is about 36oC. The topography has two marked zones, hi!!y or mountainous and flat zones. The hilly zone stretches through Awgu, Udi, Ezeagu, Oji River, Uzo Uwani and part of lgbo Etiti LGAs. The hilly nature gives rise to rapids and water- falls that exist in most rivers, especially Oji, Ogurugu, Anambra, Ajali and Duu which form conducive breeding sites for Simulum damnosum. ANAMBRA STATE Anambra State is bounded on the North of Kogi State, on the South of lmo State, on the East by Enugu State and on the West by Delta State. It is located between 5o 43'N and 6o 48'N, and has a poputation of approximately four million and made up of twenty-one (21) LGAs, out of which sixteen (16) are endemic. The state derives its namefrom the placid Anambra River, which is a tributary of the River Niger. The land has an undulating configuration and generally slopes from the North to the South and from East to West into the River Niger, which is the major drainage channe!. The highest level is about 400 meters about sea level. The state falls within the south equatorial rainforest region, which passes through the tropical forest and great oil palm belt of Nigeria, then thins out into the savannah area with dumps of trees. The rainfall is relatively high at about 2,050 mm average. The highly fertile area of Oji and the Manu rivers are also established breeding sites for Simulum damnosum. There are a tota! of sixteen (16) endemic LGAs and 1 ,O62villages in this state (Table 1). EBONYI STATE Ebonyi State is located between longitude 70 45' and 8o 3O'E and latitude 5o 40' and 7o 00'N of the equator. lt is bounded on the North by Benue State, on the East by cross River State, on the South by Abia State, and on 7the West by Enugu State. The State has a total of thirteen (13) Local Government Areas. lt has an approximate population of 1.8 million based on the 1991 National Population Census Estimate. There are over six different dialectic local languages in the State. However, based on the population update/registration of CDTI communities, there are about 700,000 persons living in onchocerciasis endemic villages in the state. The topography consist of undulating elevation of approximately 500m above sea Ievel in the South and extends to the rugged terrain of the Central. The Northern part is characterized by uniform landscape with intermittent escapement. The Cross River terrain is mainly an alluvia table land which favour most agricultural activities. The vegetation arrangement consists of mangrove forest sparsely distributed around the Cross River basin of the boundary of the State, with a mixture of the deciduous and ever green types of trees. There are ten CDTI LGAs in the State consisting of two hyper and eight meso-endemic (Table 1). ENUGU/ANAMBRA/EBONYI APOC PROJECT The Enugu/Anambra/Ebonyi CDTI Project is the largest project in Nigeria being a combination of three states. The three states have a total of 51 LGAs out of which 42 are hyper/meso endemic for onchocerciasis and therefore approved for CDTI implementation. 8Each state has a Coordinator and five SOCTS, while the Project has one Project Accountant. Every LGA health department is headed by a PHC Coordinator hence, there are 42 PHC Coordinators in the CDTI Project. There are also 210 LOCTs in the project (five LOCTs per LGA). For the purpose of effective implementation of CDTI, each LGA is divided into five Oncho health districts with a district health Supervisor (DHS) in-charge of a district. There are therefore a total of 210 health districts and corresponding district health supervisors. Each health district has a number of health facilities (Health Centres/Posts) from where CDDs collect their drugs. The number of health facilities vary from state to state, LGAs to LGAs and communities to communities. Currently, there are 874 health facilities in the project. One health facility staff is selected per health facility. There exists different administrative structures in the area, but the basic operational leve! is the village. lt is the immediate smallest functional administrative unit of a community larger than a hamlet with a village head and made up of many households. Hence, the term village will be more often used in the report except where the application of the term 'Community' becomes more relevant. SEGTION II IMPLEMENTATION OF CDTI Community Directed Treatment with lvermectin (CDTI) is aimed at institutionalizing Community-based lvermectin delivery to members of the community. Consequently, emphasis is therefore placed on establishing ivermectin delivery programmes in which the primary responsibility of collection of the mectizan distribution, supervision of CDDs and record keeping will be devolved to the community members themselves. lt is still the additional responsibility of the community to decide on CDDs selection, time and method of treatment as well as CDD compensation. The CDTI activities executed within the period under consideration are discussed below: TRAINING: Personnel involved in CDTI implementation were trained at different levels as shown below: (a) State Level - for training of SOCTs (b) LGA Level - for training of LOCTs, DHS and HFS (c) Community Level - for training of CDDs ln view of the high number of community drug distributors to be trained in the project area and the need to reduce the burden of cost to the Jtl 10 community, ten to fifteen (10 - 15) CDDs were put together and trained per training session at village squares and health posts/health centers. The LOCTs after their training, proceed to train the Health Facilities staff who in turn train the CDDs. TRAINING ACHIEVEMENT The total annual training target and corresponding achievement for year 3 is as follows (Tables 3 & 4): Gadre SOCTs LOCTs Tarqet Achievement 15 15 210 210 42 210 210 874 835 7,626 7,325 8.977 8.637 PHC Coordinators 42 DHS HFS CDDs Total The variation in the targeted personnel to be trained against the actual number trained is because the number of CDDs to be trained was over estimated by the project. 1l TRAINING MATERIALS The list below are materials developed and used for training of health staff and CDDs and for education on CDTI: (i) Post and pre-test documents (ii) Training manuals for LOCTs and DHS (iii) Brochure on CDTI for LOCTS, DHS, HFS, and CDDs (iv) Pocket treatment guide (v) Flip chart and posters (vi) Samples of measuring sticks (vii) Village treatment registers (samples) (viii) Mectizan summary sheets, reaction guides and duty specifications for each cadre of health staff and CDDs (ix) Mectizan transfer forms Observations from the trainings conducted indicate that the CDDs understood their roles as evidenced in their improvement in recording and reporting of information. Most of the CDDs were able to calibrate their sticks used in determining dosage. MOBILIZATION AND HEALTH EDUCATION Continuous and effective mobilization and health education at all levels formed an integral part of CDTI activities within the period under review. t2 As contained in Table 5, a total of 3,412 villages were mobilized in the Project. Advocacy visits were made to top state and LGA government officials to acquaint them with the problem of onchocerciasis and the need for government at all levels to support the programme in various ways. Mobilization was carried out with the assistance of District Health Supervisors, Health Facility Staff, the CDDs and members of VHCs. USE OF MEDIA AND/OR OTHER LOCAL SYSTEMS The channels used for disseminating information in the Project varied from community to community and village to vi!!age. The methods used were: Radio, television, posters, brochures, newspaper publications, pictures or photographs, flipcharts, handouts, handbills and calendars, town criers, church announcement, schools announcement, village/community Heads/C hiefs, vi I lage meetings/g roup meetings. RESULTS OF MOBILIZATION Mobilization was very effective and gave satisfactory resutt in the target villages. This effectiveness is evidenced in the commitment of the community leaders and distributors and the high degree of involvement of the communities and their willingness to commit available !oca! resources to the distribution process. 13 sEcfloN ilr TREATMENT COVERAGE Tables 6 and 7 show a tota! of 1,891,401 persons treated in 3,412 villages with a population of 2,9U,422 persons, giving an average geographical coverage of 65.12o/o and chemotherapeutic coverage of 82.060/o. The total registered population of endemic villages in the project area was 2,904,422 persons. Geographical coverage rate was based on the census population of the villages. t4 SECTION IV STRENGTHS AND WEAKNESSES OF CDTI IMPLEMENTATION GDDs'CHOICE Communities were opportuned to choose the type and number of CDDs from their rank based on CDTI criteria. So far, most of the CDDs chosen have demonstrated competence in the performance of their tasks. There is marked increase in coverage achieved and the CDDs demonstrated apparent competence in the skills acquired. METHOD OF DISTRIBUTION. MONTH OF DISTRIBUTION AND CDD COMPENSATION Communities were allowed to decide on the month and method of distribution. They were also given free hand to decide whether or not CDDs should receive incentives and in what form. COMM U NITY PARTICIPATION Many villages have shown a lot of commitment and involvement in CDTI process. These communities continued to plan and collect their drugs at the drug collection center. The increase in the number of CDDs has reduced the area and population covered by one person. The use of more CDDs definitely accelerates the time of distribution and coverage is enhanced. However, the level of community input in some villages is still l5 low despite our mobilization efforts. Nevertheless, the project had planned other strategies to improve its mobilization efforts. MECTIZAN MANAGEMENT AT THE COMMUNITY LEVEL CDTI strategy provides for appropriate and accurate mectizan inventory down to the household level. The flow of mectizan had been streamlined and made efficient as drugs were speedily delivered to the consumers as and when due. The communities feel more fulfilled as they participate more actively in the planning and execution of the distribution process. They now determine the quantity of their own drugs and are willing to collect them. There were no difficulties in sending reports/records back to the ivermectin collection centres since the centres are closer to the CDDs. The communities are also happy to take custody of their drugs. Although the health staff does supervision, the Village Health Committees (VHCs) assist in the component since the CDTI approach provides participatory opportunity to al! segments involved in programme implementation. LEVEL OF INVOLEMENT OF THE STATE AND LGAs IN CDTI Despite the fact that the various partners are aware of their expected inputs to the implementation of CDTI, government counterpart funding at state and LGA levels sti!! need improvement. The contributions from the state l6 and Local Governments are shown in Table 6. Local radio stations in the state support community mobilization through airing of jingles and radio discussions. MAJOR ACHIEVEMENTS OF THE PROJECT (a) lntegration of CDTI into PHC system particularly at LGA level for sustainability. (b) Communities now select their CDDs and take vital decisions in im plementation process. (c) lncreased coverage of population. (d) lmproved commitment of state and LGA level personnel (e) There is now adequate sensitization of endemic communities on CDTI thereby leading to increased awareness of the disease and its treatment. CONSTRAINTS (l) Late release of funds by APOC management (ll) lnadequate commitment to programme by some LGA staff due to non-release of counterpart funds by their LGAs resulting in poor attitude towards effective supervision. (!ll) lncrease in the number of cDDs is a burden on the communities in terms of compensation. t7 (lV) Non-release of counterpart fund by states and LGAs (V) Unstable political situation. (Vl) Inadequate motorcycles and bicycles CHALLENGES FOR THE NEXT TREATMENT CYCLE 1. High turnover of CDDs which demands for more training poses a challenge to the programme. 2. The greatest challenge for the next treatment cycle is to solicit for increased involvement of the State, LGA and Communities in the programme. TYPES OF ASSISTANCE NEEDED FROM: (a) The Government: (b) APOG Manaoement: and. (c) Other parties to be able to improve the GDTI Process next vear (a) From The State and Local Governments: Make as a matter of policy, annual budgetary provision and actual release of funds towards onchocerciasis control. (b) From APOG Manaqement: (i) Timely release of funds to the project is required (ii) Provide more motorcycles and bicycles to improve g rassroots mobi I i zation and supervision l8 (c) Other Parties: NGDOs To assist in advocacy and mobilization at State, LGA and Community levels. GONCLUSION The challenge of establishing effective and self-sustainable community based ivermectin treatment throughout the endemic areas in the three states is strong, but the strength of CDTI in the project area lies in the commitment of all those involved in the project and an excellent top-level advocacy strategy. Training and skill transfer to CDDs by health staff and the active participation and involvement of health establishment in CDTI management at the district level is a sine-qua-non to the success of sustainability. The issue of transportation which is the greatest problem militating against effective supervision at LGA level is yet to be solved since the project needs about ten (10) additional motorcycles to complement the already supplied ones. The p@ect has 42 LGAs and only 32 motorcycles have been supplied thus leaving a balance of ten (10). The increase in the number of CDDs resulting from the shift to CDTI strategy demands for increase in training and supervisory responsibilities. The project is the largest single project being a combination of three states. APOC t9 management should realize this and give us enough share of funds, materials and logistics commensurate to the size of the Projects. TABLE 1 rOTAL NUMBER OF ENDEMIG VILLAGES AND CENSUS POPULATION IN THE PROJECT COMMENT: There are a total of 3,412 endemic villages in the project area that require mass treatment. ,) 3,412 STATE TOTAL NO. OF LGAs NO. OF ENDEMIC LGAs TOTAL NO. OF ENDEMIC VILLAGES TOTAL POP, OF ENDEMIC VILLAGES ENUGU 17 16 1.377 1 .105.458 ANAMBRA 21 16 1.062 1.089.449 EBONYI 13 10 973 709,515 TOTAL 51 42 2,904,422 TABLE 2 IMPLEMENTATION OF CDTI IN ENUGU/ANAMBRA/EBONYI STATES' CDTI (OCTOBER 2000 - SEPTEMBER, 2001) COMMENTS: * ln Enugu, Anambra and Ebonyi States, all the villages selected their CDDs, collected drugs and decided on the method of treatment' * gg.11olo of villages in Enugu , gg.Z4o/o in Anambra, and 92.39% in Ebonyi States decided on month of distribution * gg.11% of villages in Enugu, g6.s1% in Anambra, and 85.5% in Ebonyi States decided on month of distribution - * Allthe villages in the Projec't have trained CDDs. ; NO. OF VILLAGES WITH TRAINED CDDs NO. OF VILLAGES PAYING CDDs IN CASH OR KIND STATE NUMBER OF VILLAGES NO. OF VILLAGES WHICH SELECTED CDDs NO. OF VILLAGES WHICH COLLECTED DRUGS NO. OF VILLAGES WHICH DECIDED ON MONTH OF DISTRIBUTION NO. OF VILL. WHIGH DECIDED ON METHOD OF TX. A B c D E F G ENUGU 1,377 1,377 1,377 1,351 1,377 1,377 853 ANAMBRA 1,062 1,062 1,062 1,054 1,062 1,062 561 EBONYI 973 973 973 899 973 973 598 EN/AN/EB 3,412 3,412 3,412 3,304 3,412 3,412 2,012 ffiffi 'i3:.?.S#l TABLE 3 TRAINING OF DIFFERENT LEVELS OF STAFF INVOLVED IN CDTI IMPLEMENTATION tN ENUGU/ANAMBRA/EBONYI STATES'CDTI (OCT. 2000 - SEPT., 2001) only LGA Staff LOCTs and PHG Coordinatons Health Centre HFS and DHS COMMENTS: * T2}training sessions were undertaken in the project during the reporting period while 8,637 persons were trained; 96.210/o of the training objective was achieved. STATE TRAINING TARGET NUMBER OF TRAINING UNDERTAKEN NUMBER OF TOTs TRAINED NO. OF LGA STAFF TRAINED ON CDTI NO. OF HEALTH CENTRE/POST STAFF NUMBER OF GDDs TRAINED A B c D E ENUGU 3,245 182 5 96 395 2,845 ANAMBRA 3,386 338 5 96 355 2,881 EBONYI 2,346 200 5 60 295 1,599 EN/AN/EB 8,977 720 15 252 1,045 7,325 s a TABLE4 : r;21,, TRAINING OF DIFFERENT LEVELS OF STAFF INVOLVED IN CDTI ITIIPLEMENTATION tN ENUGU/ANAMBRA/EBONY| STATES', CDTI (OGT. 2000 - SEPT., 200{) STATE CADRE TARGET ACTUAL % ACHIEVEMENT SOCT 5 5 100.00% LOCT/PHC COORDINATORS 96 96 100.00% ENUGU DHS 80 80 100.00% HFS 310 315 101 .60% CDDs 2,754 2.845 103.30% TOTAL 3,245 3,341 121.300/0 SOCT 5 5 100.00% LOCT/PHC COORDINATORS 96 96 100.00% ANAMBRA DHS 80 80 100.00% HFS 279 275 98.50% CDDs 2,926 2,881 98.460/o TOTAL 3,386 3,337 98.55% SOCT 5 5 100.00% LOCT/PHC COORDINATORS 60 60 100.00% EBONYI DHS 50 50 100.09% HFS 285 245 82.30o/o CDDs 1,946 1,599 98.460/o TOTAL 2,346 {,959 83.50% TABLE 5 ,IVIOBILIZATION AND HEALTH EDUGATION OF TARGET COMMUNITIES lN ENUGU/ANATUIBRA/EBONY! STATES' CDT| (OCT. 2000 - SEpr. 2001) GOMMENTS: * All the 3,412 villages were mobilized for treatment between October 2000 and September, 2001. * Advocacy visits were made to LGA policy makers and the PHC Coordinators to heigthen interest in CDTI . Ministry of Health staff were also involved in CDTI mobilization and health education STATE NO. OF VILLAGES , MOBILIZED NO. OF TARGET VILLAGES WHICH EMPHASIZED IMPORTANGE OF EXTENDED TREATMENT NO. OF ADVOCACY VISITS TO LGA POLICY MAKERSIPHC GOORDINATORS NO. OF LGA MIN, OF HEALTH $TAFF INVOLVED IN MOBILIZATION NO. OF NGDO STAFF INVOLVED IN MOBILIZATION A B c D E ENUGU 1,377 1,377 52 6 1 ANAMBRA 1,062 1,062 32 6 1 EBONYI 973 973 30 6 1 EN/AN/EB 3,412 3,412 114 18 TABLE 6 TREATM ENT IN ENUGU/ANAM BRA/EBONYI STATES' CDTI (OCTOBER 2000 - SEPTEMBER, 2001) STATE NUMBER OF VILLAGES TREATED NO. OF PERSONS TREATED COST PER PERSON TREATED US$ NO. OF VILLAGES WHERE CDD IS A HEALTH WORKER NO. OF DISTRIBUTIONS SUPERVISED BY HEALTH WORKER NO. OF TREATED VILLAGES WITH SUMMARY FORMS A B c D E F ENUGU 1,377 730,415 o 0 1,377 1,377 ANAMBRA 1,A62 691,803 Iltz = t 0 1,062 1,062 EBONYI 973 469,1 83 trtF ltJo 3 973 973 EN/AN/EB 3412 1,891,401 oz 3 3,412 3,412 COMMENTS: * ln Enugu, Anambra and Ebonyi States, 3,412 distributions were supervised by Health workers and all the villages treated had summary forms for proper record keeping. TABLE 7 TREATMENT IN ENUGU/ANAMBRA/EBONYI STATES' CDTI (ocToBER 2000 - SEPTEMBER, 2001) STATE NO. OF VILLAGES TREATED TOTAL CENSUS POPULATION ELIGIBLE POPULATION POPULATION TREATED TREATMENT COVERAGE RATE o/o A B c D E ENUGU 1,377 1 ,105,458 885,876 730,415 66.07o/o ANAMBRA 1,062 1,089,449 917,086 691,803 63.49% EBONYI 973 709,515 601,824 469,1 83 66.12o/o EN/AN/EB 3,412 2,904,422 2,304,786 1,991,401 65.12o/o a, a\. ffi TABLE 8 FUND (in NaiTa) RELEASED BY STATE, LGA AND COMMUNITIES FOR CDTI IMPLEMENTATIoN OCTOBER 2OOO . SEPTEMBER 2OO1 ANAMBRA EBONYI 614,200 EN/AN/EB a AMOUNT RELEASED BY THE STATE AMOUNT RELEASED BY THE LGA ENUGU 250.000 425,900 571.550 NIL 25,000 564.425 2,000,000 341,855 2,250,000 1.065.000 1.477 .830 \