West NOTF/WHO-APOC annual project technical report to Techniacl Consultative Committee: January to December 2003

RESERVED Fffi NR@/ilE CT LGGWMEADTNG I OzuGINAL: English riod (Mon$[/Year): January through December 2003 2g!: November 1 ,2003! COIIIITRY/I{OTF: CAMER.OON Prqiect Na.,IiBe: west NorF/wHo - APOC Approval year: 2000 Launch,img vear: 2001 NGDO narfiner: carter center/Gl0bal 2000 1O )r o: ANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC AFRICAN PROGRAMME FOR ONCHOCERCTASTS CONTROL ( tccl$ For Inbrmonon fo'\f^fuF I I?HCU 0 5 FEt/. 2004)'r' 'clDlR 1 r PI il 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 Cameroon National Coordinator Name: ...Dr NTEp Marceiline Signature Date: Provincial Delegate Name: Dr FOPA Amadou Signature Date This report has been prepared by Name : Dr EYAMBA Albert Designation Signature Date ,) 2 I Table of contents ACRONYMS 4 DEFINITIONS........... 5 FOLLOW UP ON TCC RECOMMENDATIONS .........6 EXECUTIVE SUMMARY............... 7 SECTION 1: BACKGROUND INFORMATION....... ......................8 1.1. GeNgnal rNFoRMATroN............. 1.1.1. Description of the project (briefly)....... 1.1.2. oartnership ... 1.2. Popur-ntroN AND Hralru sysrEM......... SECTION 2: IMPLEMENTATION OF CDTI 2.1. PrruoooFAcTrvrrrEs............. .......... 132.2. ORonRnrc, sroRAGE AND DELTvERy oF TvERMECTTN ........... 152.3. Aovocacy aNo SBNslrrzATroN ....... 162.4. MostLrzntroN AND HEALTH EDUCATToN oF AT RrsK coMMUNITIES......................... 162.5. Coupn-wruEs INVoLVEMENT rN DECTsIoN-MAKTNG .....:.:...... 172.6. Cepncrry BUTLDTNG.. ...... 1g2.6.1. Training.... .............. 1g2.6.2. Equipment and human resources ...............22 CoNonroN oF THE EeurpMENT x pLpesp srATE ............222.7. TRnarupNTS.............. .....232.7.1. Treatmentfigures.......... ...........23 2.7.3. Trend of treatment achievementfrom CDTI project inception to the current yearlg 2.8 supnnvrsroN. .........30 SECTION 3 : SUPPORT TO CDTI .................31 3.1 FrNnNcmr coNTRIBUTIoN oF THE pARTNERS AND coMMUNITIES 31 3.2. OrurR FoRMS oF coMMlrNrry suppoRT. . .. . .3.3. ExPENDTTURE pER Acrlvrry. SECTION 4 : SUSTAINABILITY OF CDTI 4.1. INTERNAL ; INDEPENDENT PARTICIPAToRY MoNIToRING ; EVALUATIoN..4,2. CoMMLTNITY SELF-MoNIToRINGAND STAKEHoLDERS MEETING 4.3. susrAINABrLITy oF IRoJECTS : rLAN AND sET TARGETS (veNoaronv ar vn 3)4.4. INrpcRarroN ............ 4.5 OpenerroNAl RESEARCH I SECTION 5: STRENGTHS, WEAKNESSES AND CHALLENGES 39 .8 .8 11 t2 13 32 32 8 8 .32 .34 .34 ..J ..3 aJ Acronyms APOC ATO BASED CAPP African Program for Onchocerciasis Controt. Annual Treatment Obj ective. BAHAI Agency for Social and Economic Development. French Acronym for Centre d'Approvisionnement Pharmaceutique Provincial. Community-B ased Organization. Community Based Treatment with Ivermectin. Community Directed Treatment with Ivermectin. Community Directed Distributors. Community S elf-Monitoring. District Medical Officer. Dialogue Structures. Expanded Program of Immunization. Global 2000 River Blindness Program. Health Area. Health Committee. Health District. Helen Keller Intemational. Head Quarters. lnformation Education Communication. lntemational Eye Foundation. Ivermectin Distribution Pro gram. French Acronym for < lnstitut de Recherche et de D6mographie >. Knowledge Aptitude and Perception. Lions Club International Foundation. Local Government Area. Maternal and Child Health. Ministry of Health. Non-Governmental Development Organization. Non-Governmental Organization. National Onchocerciasis Task Force. Onchocerciasis Proj ect Coordinator. Primary Health Care. Plan of Action for Health. Rapid Epidemiological Assessment. Severe Adverse Event Sight First. Stakeholders meeting. Sight Savers lnternational. Technical Consultative Committee. Trainer of trainers. United Nations Children's Fund. Ultimate Treatment Goal. World Health Organization CBO CBTI CDTI CDDs CSM DMO DS EPI GRBP HA HC HD HKI HQ IEC IEF IDP IRD KAP LCIF LGA MCH MoH NGDO NGO NOTF OPC PHC POA REA SAE SF SHM SSI TCC TOT LINICEF UTG wHo 4 Definitions (i) Total populalSn= the total populatron living in mesp/hyper-endemic communities within the project area (based on REMO and census taking). (ii) Elieible population: calculated as 84uh of the total population in meso/hyper- endemic communities in the project area. (iii) Annual Treatment Objective: (ATO): the estrmated number of persons living in meso/h1per-endemic areas that a CDTI project intends to treat with ivermectin in a given year. (i") 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 expectid to reach the UTG at the end of the 3'd year ofthe project). (v) Therapeutic coveraqe: number of people treated in a given year over the total population (this should be expressed as a percentage). (vi) Geographical coverage: number of communities treated in a given year over the total number of meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage) _5 FOLLOW UP ON TGG REGOMMENDATIONS Using the table below, fillin the recommendations of the last TCC on the project and describe how they have been addressed. TCC session 16th 6 n in the Number of Recommendatio TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT USE ONLY 1 Clear description of the 1.5 adjustment of the IIEA results in the hypo-endemic communities. The 1.5 adjustment of the REA results in the hypoendemic communities was described by Dr WilliamR. Baldwin, Brian O.L. Duke, Edwin M. Jallah, Robert L. Kaiser, Eric A. Ottesen and Hugh Taylor in River Blindness Foundation Technical Manual for Health Professionals and Scientists, published in 1993. That manual was used by the NOTF team during the survey in hypoendemic commrurities. Thrs rapid assessment method allows the inclusion of some of the hypoendemic communities (having the potential to become endemic) in mass treatment , , The remark : "the worrisome laborious early CDTI imp lem entatio n p r o c ess with subsequent administrative burden and increase workload for NGDO and MOPH personnel". Thank you for your inquiry. I would like to apologize for the misunderstanding that our reports might have caused to the TCC and APOC Management. Allow me to clarifo the point i was trying to make. At the begurmng of each year the provincial team is planning programs activities throughout the year. This means that each programhas an allocated set period to implement its activities, using the same scarce human and logistrc resources, in an integrated manner. Once that period is passed, you really have to negotlate wrth the MoH personnel already involved with other integrated activities. I hope thrs wrll help in clarifying my comments rn both technical reports (Please add more rows rf necessary,) I fExecutive Sunilmary The Westem Province covers 13870 km', with an estimated population of about 1 571 050 inhabitants. It is divided into 8 administrative divisions, namelyBafang, Bangangte, Mbouda, Foumban, Bandjoun, Mifi and Dschang. These eight administrative units are made of 16 Health Districts and212 Health Areas with 216 Health facilities of which Jl are private. From the Rapid Epidemiological Assessments carried out throughout the Project zone,2343 communities out of a total of 2503 were found to be endemic in all 16 Health Districts. With the refinement and the completion of the enumeration of the population throughout the project zone, the total population was found to be 1 326 541. For the year in review, our Annual Treatment Objective was 1 061 398 and the Ultimate Treatment Objective was 1 148 136, which will be our Annual Treatment Objective for 2004. 1 089 389 persons were treated in 2343 communities, which represents 82.14 o/o of therapeutic coverage and 100% of geographic coverage. People living in Western Province are semi-Bantou of mixed races, living between the Bantu of the forest region in the south and the Sudanese of the grass land in the North. That ethnic group comprises two tribes : the Bamileke who are larger in number, including people of Bafoussam, Bafang, Bangangte, Dschang, Mbouda, Bandjoun districts and the Bamum including people from sudanic and from Bamileke origins found in Foumban and Foumbot. Fluctuating population is well documented in Districts of Dschang, Santchou and Foumbot with a definite increase during the farming season. 10In 2003,353 training sessions were undertaken throughout the project zone. Ten TOTs were trained as well as 78 district staff 370 health area personnel and 5225 CDDs. In additi on 12 Lab technicians were retrained in SARs management. In general, most NGDOs did abide by the development phases of the National Plan of Action. ln order to optimize resources, in spite of the important population involved, WEST I and WEST II were launched the same year as a single project. The Westem Province Project is characteized by a very dense population difficult to reach in several districts. In Foumban, Foumbot and Malantouen, cornmunities are far apart, reaching sometimes a distance of 170 kilometers and becoming completely inaccessible during the rainy season. Several communities in District of Dschimg are accessible only through difficult roads requiring the usage of a 4 x 4 vehicle. ln the District of Santchou, niurow roads and steep valleys make it impossible to reach most of the communities in the mountain areas, unless you trek or use a 4 x 4 wheel drive. An acquisition of a second 4 x 4 wheel drive, will enable safe and efficient implementation of program activities. That need has become urgent now because the two 5 years old Sight First pick up cars have depreciated and their maintenance cost has grown beyond the affordable rate. ln compliance with CDTI strategy, and taking into account TCC concerns about some areas of high risk with regards to loiasis in which full TCC/MEC recommendations should be executed, we felt obliged to alter our field treatment activities. We had decided to phase CDTI activities starting in the seven districts newly classified to be at highest risk for Loa loa. This has allowed the concentration of most project activities and surveillance efforts in those districts, and has maximized treatment coverage there during the early part of the APOC project. A REA Survey funded by APOC was carried out in these districts to identify the communities qualified for mass treatment. This was very helpful because several cases of SARs that had occurred during the early phase of program implementation were properly managed. 7 SEGTION {: Background information 1.1. General information 1.1.1. Description of the project The Western Province project covers 13 870 km', with a total census population of 1326 547 persons. The province is devised in 8 Administrative Divisions made up of sixteen Health Districts and 212 Health Areas with 216 Health facilities of which 71 are private. See table 1. It shares boundaries in the North with the North West Province in the West with the South West Province, in the South with the Littoral and Centre Provinces and in the East with the Centre and Adamaoua Provinces. People living in the West are semi-Bantu of mixed races and that ethnic group comprises two tribes : the Barnileke rvho are larger in number and the Bamun. Table 1 : Project zone. West Province NO Flealth Iir,.i.,, #ofHA #of Communities Population I pafang 8 100 64 961 2 paham 9 7T 43 08i 3 pamendjou 8 51 37 t22 4 pandja 6 57 3t 170 5 pandjoun 13 116 86 814 6 pangangte t7 z0s 78 709 7 patcham t2 t07 73 102 8 fioumban 24 221 t37 7649 fioumbot 24 201 ttt 474l0 ftekem 6 78 32 33811 plalantouen 15 i9l 64 59912 ffibouda 18 307 r70 05713 Min 13 198 205 027l4 penka-Michel 13 191 84 398 l5 lsantchou 5 62 23 514l6 pschang 21 t87 82 417 [rorer 212 2343 1 326 547 While the male who are breadwinners leave their families behind and move out of the province in search of areas of greater econonric pronrise, women and children spend most of the day in the fields, kilometers arvay from homes and return only in the evening. This pattern of activities explains why urban onchocerciasis is found rn the Western Province, and high prevalence in female. In general the distances betrveen communities are sl-iort and the roads are good during the dry season. In Districts of Foumban, Foumbot arid Malantouen. communities are far apart and inaccessible during the rainy season. In distncts of Dschang and Santchou, several communities are accessible through narrow roacls. bordered bv steep valleys. 8 Like in phase I and II, census exercise rn districts of phase III revealed a substantial decrease of population figures as compared to estinrates. This r.r'as also the opportunity to refine the number of communities. (See table 2). Table 2 : Population change 2002-2003 Districts of phase III Health Districts Estimated population Census population Population GAP o//o change Baham s0 163 43 081 7 082 t4% Bamendjou 48 69s 37 t22 lt 573 23,80 Bandjoun l 16 089 86 814 29 275 1< 10,/LJlL /O Mifi 228 362 205 027 23 33s 10,20/o Penka Michel 89 20t 80 206 8 995 t0% Total 532 s10 452 250 80 260 r5% Following the approval of the Western Province CDTI Project in 2000, a three years CDTI transition plan was designed beginning with the high risk districts the first year, where full TCC/MEC recommendation were implemented. We had decided to phase CDTI activities beginning in the seven districts newly classified to be at high risk for Loa. This did help to concentrate most project activities and surveillance efforts in those districts, and maxrmize treatment coverage there during the early part of the APOC project. In addition that transition was necessary because extended sensitization/mobilization, training and supervision were needed to ensure adequate monitoring and full adherence to the new strategy. In 2003, we have reached full geographic coverage by enrolling the last five district, namely Baham, Bamendjou, Bandjoun, Mifi and Penka Michel. Table 3 and Graph 1 shorv the number of communities and population involved in each phase. () 4I Table 3 : CDTI Implementation Plan *Cumulative figures Graph 1 : CDTI Transition Plan West Province 2500 2000 1 500 # of Communities r000 500 0 2001 2002 YEARS 2003 NO Health Districts #of HA # of endemic communities Populatron #ofCDTI. communities Population lnvolved in CDTI 2001 2002 2003 2001 2002 2003 1 Bafang 8 100 s6636 100 100 100 s6636 57793 6496t 2 Bandia 6 57 28322 57 57 57 28322 28322 3t170 aJ Bangangte t7 205 69902 205 205 205 69902 69902 78709 4 Foumbot 24 20r 8734t 20t 201 201 87341 96096 ttr474 5 Kekem 6 78 31647 78 78 78 31647 32807 32338 6 Malantouen 15 191 61601 191 t9l 191 61601 61601 64599 7 Santchou 5 62 225tt 62 62 62 225r1 22258 23514 8 Batcham t2 t07 88854 107 t07 64290 73t02 9 Foumban 24 22t 185236 227 221 96196 137764 10 Mbouda 18 307 t9t429 307 307 144047 170057 11 Dschang 2T 347 215071 r87 r87 90184 824t7 t2 Baham 9 7T 50163 7t 43081 Bamendiou 8 51 48695 51 37t22 Bandjoun 13 116 1 16089 116 86814 15 Mifi 13 222 228362 198 205027 t6 Penka- Michel 13 I 9 1 8920t 1 9 1 1) 84398 TOTAL 212 2527 1571050 894 t716 2343 357960 763496 t326547 353% 74,lYot' l00o/o* 22,80o/o 66,1%or' l00%o* 10 -,'. : , ritlr..{.t1 1.1.2. Partnership Ivermectin distribution was funded in the West since September 1,996 by the Lions Clubs lnternational District 403 B, in partnership with the Ministry of Health of Cameroon and the Carter Center/Global 2000. To achieve the initial objectives, while adjusting to the new program demands, the Lions Club International Foundation approved a five years extension in 2001 integrated with APOC funding, to offset costs. The program activities are integrated within the Provincial Health Delegation activities with full participation of all partners, in planning, advocacy, sensitization and supervision. The training is carried out by the MoH and NGDO personnel at the Provincial and District level. Health Area and Community level training as well as supervision are carried out by the MoH persorurel. During the sustainability plan, partners had pledged contributions at different levels for the implementation of the program. These contributions have been monitored by local committees. a. 11 a ot q) clo 6l 6 €ll 6, a0 () q) F.: iaittr(]= €rE 0c) q)6l crtx cl- tr9tg; :C)ra OE6l^E -o' o0 hr 6l E= 6t= Cll q) iok GIL 6t= =a!9c loo rgo.:B' cll^ 6a9e ;400t) i!= Er OJO !..r .= oaj Aa_ =HPo,BDE cla o. e! CL U o a =Rl a/ GI(D L GI q)(u La q) L o (.) 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Our objective for this year was to implement CDTI strategy in all endemic communities in the project zone. This represents about I 326 547 persons spread out in 2343 endemic communities. The following is a summary of activities carried out since January 1't,2003. February 13th and l4th,2Oo3 Coordination meeting at the provincial level Training of the trainers. March l7'h -March 2}th,2OO3 Funds advance to districts for training of Health Area teams March 2003 - August 2003 Mobilization and sensitization of communities March 19th and }O'h,2oo3 Training of District teams (phase III) , March 27th,2003 Retraining session of district teams (phase I and phase II). March 2003 Procurement of equipment/Material and drugs for management of S ARs/Distribution/IlSAM. April 3'd and. 4'h,2}o3 TrainingiRetraining of Journalists, radio and TV presenters. April 7th and 8th,2003 TraininglRetraining of Physicians and Laboratory Technicians on the management of Severe Adverse Reactions. April2003 Selection/Training of CDDs April 2003 - July 2003 o Census enumeration o Distribution o Monitoring and supervision in CDTI districts (phase I, phase tr, phase III) May 2003 Mid-term evaluation. July 2003 - August 2003 Reporting and final evaluation. Estimation of needs and Mectizan Order 13 o IA P (D a o EE U El F] P F]p FID jp F]Fi F]p F]p F] -tD FI FlD FTP FTp FTp F]P iD Pr !:. E d= U& 2 Iil lla U& 2 U& a U& a U& 2 U4 2 (.)il A Q & a Q& z QI a Uil z Q4 a Q/ z Qil z (J 4 z U4 taa o ! 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Q & raa Qil z U c z Qil 2 (Jil \-a (J 4 \-r a. (, & a Uil a Qil z (Jil ta2 U& a Iil i!,{a (n I Lr t, r r') z fJr ca a FA - t-] z s.l z FA a e z H z;) t-.,1 z H gl F r>) z t z ca a OF P z Oa ! z H D o fJr F" g o tu z M tr.] V z rI] oF z J z t-.1 (-) o A tu z F.l O a4g z r:lA P\_, OFz a F] Fr Fr $ -.A B V1 aaq)() q) S 14} o a)L o t B q) V'2 \D E L(o q) >' d 0.)Ll-i)(.) o o () H CN clq) Ld c) Lr(tr CA C) o (H o() o tr F. ,;i1 0)I -oldt F-l 2.2. Ordering, storage and delivery of ivermecffn Mectizan@ ordered/applied for by - Qtlease tick the appropride answer) ./MoHtr wHoN UNICEFtr NGDoV Other (please specify) Mectizan@ delivgred by - Qtlease tickJhe MOH NT wHoE/ -,/NGDO\ appropriate answer) UNICEF ! Other (please speciff) Please describe how Mectizan@ is ordered and how it gets to the communities Mectizan needs are submitted to the NGDO by the provincial team. These needs take into account the adjusted total population of the different communities for the previous distribution campaign. The order is finalized by the NGDO. After the approval of thebrder by MDP, Mectizan is cleared by MoH and WHO. It is picked up by the NCOO and delivered to the Drug Procurement and Delivery Agency responsible for getting it to the Health Area, where it will be picked up by the CDDs. Mectizan@ add more rows if State activities under ivermectin delivery that are being carried out by health care personnel in the project area. Any other comments Number of Mectizan@ tabletsHealth Districts Requested Received Used Lost Waste Expired BAFANG ts9 392 158 392 160 670 2O BAHAM 104 059 104 059 t06 762 BAMENDJOU 97 000 97 000 91 085 BANDJA 70 897 70 897 7t 4s2 BANDJOUN 2t3 042 2t3 042 212 876 BANGANGTE t87 4tr t87 4tl 190 237 BATCHAM l6t 743 161 743 16s 895 DSCHANG 237 t}r 237 t}r 202 8s1 FOI.IMBAN 296 215 296 2T5 298 064 FOI-IMBOT 259 360 2s9 360 264 328 KEKEM 78 043 78 043 77 966 MALANTOUEN 135 261 r35 261 r34 043 MBOUDA 402 980 402 980 406 794 MIFI s18 715 5t8 7 15 520 620 PENKA MICHEL t97 s00 197 500 t86 526 SANTCHOU 65 249 65 249 60 660 TOTAL 3 182 968 3 182 968 3 150 829 15 I 2.3. Advocacy and Sensitization State the number of policy/decision makers mobilized at each relevant level during the current year; the reasons for the sensitization and outcome. Describe difficulties/constraints being faced and suggestions on how to improve advocacy. At the beginning of the campaign, an Advocacy and Planning meeting was held by the Governor, the Provincial Health Delegate and the Carter Center Country Representative. An Advocacy and sensitization meeting was held subsequently in the Governor's office. The attendees included all District officers, the Provincial Team and the Carter Center personnel. Each of the District Officer convened a meeting at the District level. The attendees included the Sub District Officers and the Health District Team. The reason for the sensitization and Advocacy in cascade was to inform and sensitize the authorities at all levels in order to empower them and to make them responsible for the mobilization of the Community Leaders and Community members. The major constraint remains the increased demand for fueling the authorities vehicles for the mobilization campaign as well as increased demand for incentives by the other partners and lack of transportation. We can improve advocacy by carrying out a National inter sectorial campaign, with the participation of several Ministries involved in the process. 2.4. Moblllzatlon and health education of at risk communltles Provide information on : - The use of media and/or other local systems to disseminate information - Mobilization and health education of women and minorities - method and response - Response of target communities/villages - Accomplishments - Wealmesses/Constraints - Suggest ways to improve mobilization of the target communities. New IEC adapted and harmonized materials were used for sensitization and mobilization sessions throughout the project zone. In addition, Radio Spots and specific programs were broadcasted throughout the province. Prior to these activities, journalists and Radio/TV presenters were trained by the provincial team. Mobilization at the community level was aimed at ensuring community involvement and ownership. Focus groups and out reach of women associations by Public Health Nurses were used to mobilize and health educate women. The mobilization effort was encouraging and continues to bring positive attitudes and acceptance toward the program. 16 a Egt r =EfE E = t,z i'} o oo o "Q = .9,tr6 o,- .oUtr b.0 z? o\ o\ € s € 6\ 6 o\ o\ \o t-- o\r o\6l o\ I o\ N o\$ o\ c.l \o t-.r+ o\ t-- + t--$ \o <tr-- co @ \o N a.l F-. o\6 \o co 9qc!otr^ O r\ =Lt2t) E oF ZZ6v l/ .E o= otr4E EO z ..1 N = N :1- a1 € N r Ir- oot$ t-- $ <f s e.lo\ c-.te.l N N t-.$ m \oo\ \o@ 01 \o o\ \o a] C\ a- cl -t t- Ir- 6l N F- a\ N 00 $ \o @ <l N \o co co o\ oo i" >o oo- Uc l:o EO e= -oE ze 0) oo 5 >,s q ?'i t .Z a:P> -atr=): zucq ?oci.: L o)E'EEI - = qJ: 6rquX E E€'F o f- o t z * I \a o \o N t-- t- F-@ a\lN N € a- o\ t-- 00 o\ o\ e.l 6s e{ F U o .o qE C! o z E! c)I q) 0. o\ o\ r\ ca \c N r\|r) \o ,i t-- o\ 09 v t o\<- o\r- e.l o\\f F- o\ o\ o\ U \c 00 c.l F-. \o \o c.i n o\ o.l !Eu19!-lel=E oFf!!Sia =-z.= LE o fib =.: 9J -!!-r !X-q- FEE.:.1 =:!! o .-.c.=; rc c.l $t-- \t c.] 6l ri- @N N r N 00N t--\o a- N$ $ !j' \o \o + aa <fN s o oo$ =l- \o C! ol ol \o a.l @ N \o $ $<f @cl :'i 4 o z tL a ca f o Zq.l q ! z zf Z c0 t!F O z (, Z c0 OF c0 (, z Qa t-.1 z m f, o tu Fo EO ) oE. F.] V 14v Z rrl)(-,Fz I o tt\ t\ J IJ.] Q 2 V z rr.lA OFz a v)& r! 3 6(F (-- -\t \Jqq U U\ p \\ QJq q) E F oU() o (d o Lr(n aq) oQ r-t orl (dt FI o E a-I IE EI E .9 o .I(, o! .E +, E o E o E ,-E o ot- +. .E f E E o(, a u) !N 2.6. Capacity building 2.6.1. Training The training session of the Provincial team followed by the Program Review were held in Bafoussam on February 13th and l4th,2OO3. The attendees included the Health Delegate, the two Onchocerciasis Project Coordinators, the Carter Center Administrator, the Carter Center Program Officer, the West Province Project Accountant, the provincial Chief of Service for Drug Procurement and Delivery and the Provincial Chief of Service for Hospital Medicine. The meeting was chaired by the Carter Center Country Representative assisted by the National Onchocerciasis Coordinator. The training was about the CDTI strategy including APOC Administrative and Technical procedures and guidelines. That gathering was also an opportunity to review and evaluate past year activities and to recommend solutions for identified constraints and weaknesses. Following the fraining of the provincial team in Bafoussam, the training of district teams by two members of the standardized training team was held in Bafoussam on March 19th and 20th,2003. The training was about the implementation of the new CDTI strategy for Districts of phase III, with emphasis on APOC Administrative and Technical procedures and guidelines. On the second day, the training was about the management of Severe Adverse Reactions. That gathering provided also an opportunity to identiff constraints and achievements of last year campaign. On March 27th, 2003, retraining session of District teams of phase I and II was held throughout the project zone. The training/Retraining of journalists and radio/TV presenters was organi zed in Bafoussam on April 3'd and 4'h, ZOO3. On April 7th and 8'h , Laboratory Technicians from selected referral hospitals were trained on LoiasfB'slide preparation and interpretation relative to managemeni of Severe Adverse Reactions. Training of CDDs was scheduled from April 15'h to May 2"d , 2003. The number of trainees and type of training are shown in tables 8 and 9. The apparent low achievement rate in CDD training is due to the impact of mass distribution in urban communities where drug was distributed primarily by Health professionals and members of Dialogue structures. a l8 \o 6 (! o l.] H - (h z -lo o lnz X ? o T IJ - 7 L., r- - z{ C Lrlz 5 rn Xln o C (, ,-J z ao z -Jo 7 z z -.1 t tl ED z C2 z ln FIz o \ z(-., - -J{ 5 5 \] l..J -J +- -- (,J O (.) 5 A 5 { ! UJ (, s \.1 a G- € b i tt z .! o tDr) - 0 l, A) hJUI (,(, {6 A s s + 5 A O 5 o\ \] s a (! o t! tJ -I NJ NJ\o UJoa @ 5 t\.)@ N)UJ NJ N) a a z (D (D oo (! l, !l (! A{ tJ N)(, (, -t o\ 5 N) O N) \o \o UJ N) UJ NJ NJ .----t UJ @ NJoo A UJ NJ (,J @ N)! (J) @ A O N) oo N) oo l.J t! oo { _iOI N) =l t! t! F € b E l. \v r! (! (D O O <) Ii" [- O O O O O O z s z .io !9 'l 8o' .o viED)0. ='(D 0 o l't-- 5 O O O O O O o\ (! (! (! -(,l -It) s o\\o o\ 5\o N) v UJ ! N co N) NJ\o\o 5{ @ UJ o\ O o\ UJ oc O NJ co NJ co\o NJ UJs N)(! tJ o\ N) a -t6 OD (,A -.t (,l}J h.JUI \o N) \o NJ A\o A 5s 5s @ N.) \] O s! 55 oo O \o \o (, UJ c'. ! O \]\o -J\o o UJ NJ 5 NJ A N) N) ooN O @ l.J NJ UJ N) l-l IIDl(' lo lco ;F.t 0a !J CD (D' -(D o @ (h ot o U -l o @ A) e t)(\ N !\G\ o q \ G n C- C) \.) z o{ Fo t o FD FO CD Ft o o- .D ol o '-t(D U) o 0a A) z xo th f-t o A) oFt (D th o o CD o o oal \o z tD o 0 A' o F a g -J E Trainees Type of trainins CDDs Other Community members e.g Community supervisors Health Workers (frontline health facilities) MOH staff or Other Adm-rnistrative and political leaders Journalists radio and TV presenters Laboratory Technicians Program management x x x x x x How to conduct Health education x x x x x Management ofSAEs x x x x x x CSM SHM Data collection x x x Data analysis x x Report writing x x x Others (speci&) x x Table 9: Type of training undertaken (Tick the boxes where specific training was carried out during the reporting period) - Any other comments The training material has been developed but has not yet been harmoruzed.In the meantime, APOC manuals and tapes have been used for training sessions. Some CDTI materials from previous seminars have been used to introduce the new concept to local authorities and target commafrities. These training sessions and meeting provided opportunity to district teams, namely physicians, nurses and health committees to sensitize the local administrative, traditional and political authorities about CDTI strategy. The training sessions were centered on the disease and its public health and socio-economic impact, Mectizan distribution, program ownership and community participation, management ofadverse reactions, reporting and census. Our Annual Training Objectives in general did take into account past year performance as well as human resources and logistics available at the district level. The ATO was set such as to allow : The training of all district leading teams including at least one district hospital physician. The training of at least2 nurses per Health Area. The training of at least 1 CDD for 125 persons. In summary 266 training seslions including the provincial session were held throughout the project zone. During these sessions 10 trainers of trainers including the provincial supervisors, 20 t 78 districts and 370 health Area staffs were trained. A total number of 5225 CDDs was trained in CDTI districts and they were all selected by their communities. These CDDs were selected by their communities, they did coilect their own drug from the Health Area Health Center, did decide on the mode and time of distribution. Eventhough distribution weeks were decided by the communities, the overall distribution period was decided by the MoH because of reporting deadline requirements. Communities have used some type of combination but the door by door mode of distribution was preferred. 1O 2t Source Type of Equipment APOC MOH DISTRICT/ LGA NGDO Others Condition of the equipment * Please state 1. Vehicle 1a la etZb 2. Motor cycle l6a,2b, et Ic 6a et 4b 1Computers 3a Ia 4. Printers 3a 5. Fax Machines 1b 6. Others a) Photocopier 2a !) UPS 3a la c)- 2,6.2. Equipment and human resources Table 10: Status of equipment (Please add more rows if necessary) *Condition of the equipment (Functional ** a) Functional , Currently non-functional but repairable, Written off). b) Cunently non-functional but repairable c) written off. How does the project intend to maintain and replace existing equipment and other materials? There will be an elaboration of equipment replacemenuacquisition plan. Each vehicle or motorcycle will have a maintenance board and a procedure manual available to all users. -t - Describe the adequacy of available knowledgeable mimpower at all levels. Even though the Government has not been hiring for the past years, we have been having substantial number of personnel recruited this year from Poverty Eleviating Fund. In general the personnel is qualified and in adequate number. - Where frequent transfers of trained staff occur, state what project is doing or intends to do to remedy the situation (The most important issue is what measures were taken to ensure adequate CDTI tmplementation where not enough lmowledgeable manpower was available or staff often transferred during the course of the campaign). In the Western Province, all 16 Heatth Districts are currently imptementing CDTI. Therefore even when there is personnel transfer, most of the time the reappointment occurs within the province. From time to time, the new personnel is coming fiom a none CDTI zone but this is no longer of common occurrence. 22 2.7. Treatments 2.7.1. Treatmentfigures A total of 1 089 389 persons were treated in 194 003 households and 2343 communities, out of a total census population of | 326 547 persons. This represents a coverage rate of 82,14 yo of total population and 102,6 0Z of our ATO. See Table 1 I and Graphs 2 and 3 . oo 23 t OJ (g OJIr (/) oHH trI H\o }.Qa rf)-6 d'e o\$ d's\o s ro FT \D H a6 s H noq)}uES Iaq)uAI P{uad IJII^I PpnocuAI uanoluulehl rua{a>I loqrunoc uPqruno{ Sueqcs6 ltrEq)lPg alSueBueg tmofpueg efpueg nofpuarueg rtrEqPB 3ue;eg !f, c.l c.t ONt o) a (n t) IA cq&o 0)o l-{p< U)o ? :l oldt lil ot :<Yltilvxxx-x><><-:<-K5tstsV rr r-r OJ({ q,) o) .E othLi o) r-r "=SE The application of the adjusted CDTI strategy in urban communities and the refinement of CDTI process in general were conducive to optimal coverage ratqs in 2003. See graph 3. Graph 3 : GRBP Treatment (1996-2003) GRBP TREATMENT ACIUTES (1 996-2003) 1 089 389 Persons treated 1200000 1000000 800000 600000 1996 1997 1998 1999 2000 YEARS 2001 2002 ,Q003 25 .t tt'l^.i:i..) ,t 1. ,: ,,,/ l-l l*-IQ l.Dt*t- ; o 3 o (h rl'ra o- Ch Ft o l- FD to >.t o U) TD (, 7( e a U, G \\ !\a\ 6 GGq 14 F.l H F a z -lo (- It z X o lnF rl o (J z - z -lo C F1z 5ln5 rrJ? ,n o ? o .l o ? TD z ao z -lo ? c! z z .a ln w z o z w z lrjz H o z o !a' r .1. ,o NJ 5t, o\ N) \o \ooo \) \o -]oo N.) l!NJ co -l { l!O { { O 6,i N =.,' =;oa =;J<6JN "< - f + =ara^ o CD c/) !D oa CD cn tJ UJs(JJ o\ NJ \o \oco UJ{ \o {co tJ NJN) oo\] -l N)O -J -J -r -l ,;; > o5= ?99ar_ l'.J(,s o\N) \ooo { {oo N) l'.JNJ @ -J -J l.)O -] { O o oa -<Jco =J I *6; Xii Q ='ro:L o o o O O O oQ ^:0asq-E rb5o6'g UJf.) o\(,5{ N) 5 oo5 UJ\o oa l..J N) \,1 { O{ o\5 (,t\o\o (/J NJ oo 5{s ! -.t 5 @ l..J 5 \] \] UJ N) \] @ -lO oo o\ @ :- { -JNNJ 5 = A \o -l6^- oi;^- oai9. N; o = Or': o (,\o ooa 6 o\\o o\ o\(,t o oo N) o\@@ N \o\o\o \.1A5 N)\.) \) oo \o UJ oo \o o { o\ oo 5 s (}) \o co l..J @ O N) U N) L' @ o\ 5 ;O s @ 5 -ia s': d fo:=oi= :gg o\(, @ NJ 5 o\ 5 {5 \o 5 O @ 5@ { f.) -J \ @\o o\ \o -.1 o\ UJ l.J{s o\ o,5 @ !tJ{ NJ l..J NJ 5 oo -J 5 (,.l 5 O UJ z4E c OI:Do+ hi 9o u- o oo J., 5 oo l.J oo o\ oo(Jr l, oo N) {5 @(}) \o *J @ \) o\ o\ @5 N) oo UJ o\ @ N) t, @ UJ\ oo o\ co N) \o oo N) hJ @(, @ -lo5Oa -6^ No\ X'6v0, O0atr o -i. o N)(n o\ N) N) oo o\ 5N) t.J @ co{ \o(Jlt, ())UJco @\:{ oo\o 5 \'l (, N) NJ O { gr,E52 a +a -J aX o Xo _- = i d 5{ @ \o co5 o\\o UJ oo NJ 5 s @ t-J @ NJ N)\o (.J UJ @ @\o @5 NJ55 \.1 {s z B t=3 ^i^6 =,;=-at)O o O az a=>a .rlX o O z 5 o o P E.E sa-a;+o = o-- o a - - V)a9.5-6 >E r: =fi N) o\ If the project is not achieving 100% geographical coverage and minimum of 650/o therapeutical coverage rate or coverage rate is fluctuating, state reasons and plans being made to remedy this. 2.7.2 What are the causes of absenteeism? Students out for vacation. Farming activities. 2.7.3. Briefly describe all known and verified serious adverse events (SAEs) and provide in table 9 the required information when available. N/A 2.7,4. In case the project has no case of serious adverse event (SAE) during this reporting period, please tick in the box No case to report qO 27 l-Jla) lo-tE l.Dt- lx.; o fJa oa -r) a o - a o '1a r! o .D Ch (u Frl a oo H -.i o- rt J 0a ! o .Dr5 -t oa .D: o o- -L\ G q rs S a_ a- G\o Ga a(aq C.^ G.\ s o 't s. ! G oao xa --t--- i l I I l I I l l -,1 i l I l l l-- I l l I t- -, Ci@E 6; O -l- 7-da- a Z--:D (D t) - A e P N vY (o 5 D - =' Pr .'1 -,)-t =o =.o -No^< -@ e 3 (A ox (h 3 :a aa J. -,0a= o o € <p :8X *F' -l l I I l a :.:oho raa A*N, atlq - cG O- r.n T'C'\ tn; 6'@ N'I =, .).)H e:5 ci o @ON 5:.5 ^ =t6id 0o :- -i=P =.D9 N) oo Ir-- -- l o\N (J y L 1^ Pa i) o\ t-- oo \o o\ t u ^on(rs- F tlr o a o\ o\ @ o\ s' o\ \o c...1O O 6^0!:rc L>voo F o\ l-r c] N oo cl c\ @ ,o u9 4- CL p. t ao F-\o N \o o\ o\ c.l\o aa oo 00O o a .i rQD FU \o o\ o\ a{ .i' c.l \o @ o\ \oO 1O O l+r ^ .r 6*::o = a =6 I ?u -o \o o\ f-- oo \c) l-- Ir-$ \o N : o vi:= c) O O = N- 6^ bo )'1 o o: o - >v OO O = v = o_ o =:1iJOaj q= Nt!-9 7ai, $ oo \o r- ca <1- c! 4 9-o'-- v o\ @ r- .a w a.l O,J a o ,= (, aI) a =a :-- ^, o 9) Oa!'asL-vUi + co \o t-- ti- N d q r- co a o\ N N N O c.l OO a\t $OON Oa.l \o N F- a.l ooOON c..t O N q) ! q) G aoq) (h F U = 0,, /.u 90- =q)OL $ o.rtro) :e()tr d -() (, 6l EtrI o0)l L;I *61 =olaJ >lE -ol9o)ioo e0) tln utrec) Q(!LC) ,F ci r- cal .-tNI d)I ^l cdlFI 2.8. Supervision 2.8.1. Provide a flow chart of supervision hierarchy. Supervisions are targeted and each level is supervising the level directly below unless a specific problem is identified. a, CDDs 2.8.2. What were the main issues identified during supervision. No involvement of all members of provincial team. No integration of supervision. 2.8.3. Was supervision checklist used ? No 2.8.4. What were the outcomes at each level of CDTI implementation supervised It was always an opportunity to discuss about issues and definitely this has improved the performance of the project. 2.8.5. Was feed-back given to the supervised, and how was the feedback used in improving the overall performance of the project Yes feed-back was given to the supervised. Recommendations wgre made and there was a follow up on these recommendations. Central team Provincial team District teams Health Area team 30 SECTIS{ 3: SttBport to GDTI 3.'1. Financial contributions of the partners and communlties Table 14: Financial contributions by all partners for the last three years Ministry of Health (MOH) Local NGDO(s) ( if any) If there are problems with release of counterpart funds, how were they addressed? There are definitely problems with release of counter part funds. The NOTF through the Executive Secretary and local committees have continue to advocate and monitor the release of the funds. Contributor Year | ('provide the period') Year 2 ('provide the period') Ycar 3 ('provide the period') TOTAL Budgeted (us$) TOTAL Released (us$) TOTAL Budgeted (US$) TOTAL Released russ) TOTAL Budgeted rus$) TOTAL Released (us$) 93 320 125 921 I 54 593 NGDO partner(s) 224 474 215 400 l 69 888 133 021 194 762 250 800 District/LGA , , Others a) b) c) Communities APOC Trust Fund 292 234 281 870 194 722 196 750 t62 138 150 135 TOTAL 610 028 497 270 490 53 I 329 77t 5tr 493 400 772 31 t I - Comments 3,2. Other forms of community support Describe (indicate forms of in-kind contributions of communities if any) Eventhough communities have been contributing with coffee breaks, food, drinks, shelter or halls for discussion or meetings, these have not been valued. 3.3. Expendlture per activity - lndicate the expenditure on activities below in US dollars using the current United Nations exchange rate to local currency. Table 15: Indicate how much the project spent for each activity listed below during the reporting period. * Partial amount. SEGTIOil 4: tucfta,Jnab,lfitrty @f GETI 4.,1. lnternat; independent partlcipatory monitortrng; Evaluatlon 4.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick where applicable) Year 1 Participatory lndependent monitoring Mid Term Sustainability Evaluation Activity Expenditure Source(s) ($ us) APOC NGDO MoH Drug delivery from NOTF HQ area to central collection point of community 196 196 Training of CDDs Training of health staff at all levels 52 590 49 729 2 86r Mobilization and health education of communities 43 545 31 952 ll 593Supervising CDDs and distributio:t Internal of CDTI activities visits to health and authorities IEC materials ,) forms for treatmentSummary Vehicles/ maintenance 16 600 52 579 27 }io 16 600 22 586 3 263 18 755 etc)Office e. Housing/utilities/communication 7 975 21 850 CDDs Motivations Personnel/Benefit rt5 332 t6 t46 99 186 TOTAL 308 692 *137 013 *171679 Total number of persons treated I 089 383 32 5 year Sustainability Evaluation I Internal Monitoring by NOTF Other Evaluation by other partners 4.1.2 What were the recommendations? Recommendation for the provincial level All partners should participate in the elaboration of work plans. Onchocerciasis program should be integrated within provincial health activities. Provincial supervisions should be targeted according to specific needs. The personnel should be stable and in sufficient number for efficient implementation of activities. The population enumeration should be assessed through quality assurance to ensure the treatment of all eligible persons. Equipment and Funds should be managed properly at the District level. Capacity building should focus in resource mobilization as well. Recommendation for District level ,,) - A11 districts should have participatory, comprehensive work plans reflecting needs at the community levels. - Communities should participate and contribute to CDTI implementation. - Supervisions of health areas should be targeted. - Log books should be used routinely in all Districts and they should contain routine maintenance schedule of vehicle. Recommendation for Health Area Level Oncho Program should be integrated in the Health Area overall plan. Mectizan Needs should be estimated in terms of tablets, based on the population enumeration. Training needs should be identified during field activities and targeted training should be carried out accordingly. Detailed financial report should reflect the contributions of different partners. Motorcycles and other equipments should be maintained properly through the utilization ofLog books. Recommandation for Communitv level - Communities should be sensitized about their roles and responsibilities to support CDDs 4.1.3 How have they been implemented? See # 4,3.5 JJ District/ LGA Total # of communities/villages in the entire project area No of Communities that carried out self monitoring (CSM) No of Communities that conducted stakeholders meeting (SHM) BAFANG 100 BAHAM 71 BAMENDJOU 5l BANDJA 57 BANDJOI.]N ll6 BANGANGTE 205 Proper documentation Proper documentation BATCHAM 107 Was not done ll/as not done DSCHANG 187 FOUMBAN 221 FOTIMBOT 201 KEKEM 78 MALANTOUEN l9l MBOUDA 307 MIFI 198 a, PENKA MICHEL SANTCHOU 191 62 TOTAL 2343 4.2. Gommunityl self-monitoring and Stakeholders Meeting Table 16: Community self-monitoring and Stakeholders Meeting (Please add more rows if necessary) 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. Community self-monitoring and stakeholders meetings have allowed the involvement of traditional and political authorities, which has brought positive attitudes, acceptance toward the program and ownership. 4.3. SuStalnablllty of projects: plan and set targets (mandatory at Yr 3) What arrangements have been made to sustain CDTI after APOC funding ceases in terms of 4.3.I Plaruring at all relevant levels. Arrangements have been made for work plans elaboration by all provincial and district members taking into account community needs, with the participation of all partners. 34 I 4.3.2 Funds Provisions have been made for local and central Government contributions as well as community contributions, including councils. Committees were appointed for the monitoring of these contributions. 4.3.3 transport (replacement and maintenance) Log books have been made available and have been used at all levels for all vehicles and motorcycles and they contain routine maintenance schedule of vehicles. Replacement plans should be put in place for all equipments at all levels and should be completed before the distribution campaign. 4.3.4 other resources A system conducive to proper and efficient management of others resources has been put in place. This includes the utilization of log books and inventory lists. Targeted supervision should be carried out to ensure that the system is functional. o 35 I(-J (/, o a o I o o { >1 o 0J Lr)o -,1 oq .D a D) o- o (D o (/) o'Ft a o + FD.H (n U) DO 6(h .l (t o (J) o\ Jt a -l:1 oa 0o'Uz V.) OCDr r'.Di\i .DJ:(< (e) .o oa -o I o a Z-l 'do ;. u)Ntro) -r;(D ='(DP:i o) ;t;() og i.J v 5pD o ch ot (D .Do N (D 0aNo:1<!]HEE 5!loiOa o NFOVoa:1XE 6'X'5 cr(<9t.' 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U) o Ft (D J o 0q>r ID o 3 o .D a OD (D o(D -o c o o ts CD o -t CD o o ;J CD toa FO r-.1 @ t0 .D CD Ft m oFt(, (D i- z i 1l a o .D CD oo CD o aF1 o a oFn o o >1 cn o o o=7 ^ (9 --LtsQo ;) v t-] -o !s.)6-Y A Ooj!5u aD H.+- oxQa *!) aaw'i^Ttv =-J+or(D :l6rq(9 ; A 6'- a to(?a o FD J TD oa -t o 3 ! (D TD oo (h o rD rD n CD r) @ ch =o -to o oa tD o oo ao >1 0a o a .) N - 0a Ftl) ,@ dNJ l\et9 o\ !Joo fD'+<5(Dn o- F0 laJ!: Aa\< 6'Ro o 0qo .6 o\ _F) 0ao oa - o o .D '-1 0ao PJ - .D = 0a A) o -o o>r o- .D (D l o+) H o 3 oa q .1 o c0 PD CD o o ? o CO o o UJ{ a 4.3.6 To what extent has the plan been implemented By the end of the distribution campaign, the plan would be implemented fully 4.4. Integration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration Ivermectin delivery mechanisms Ivermectin delivery mechanisms have been Fully integrated within the Provincial essential drug distribution system. Training Training is carried out essentially by the MoH personnel under the supervision of the oncho Program Coordinators and the Carter Center Personnel but it is not integrated with the other programs. Joint supervision and monitoring with other programs Joint supervision and monitoring with other programs is carried out but proper documentation is not done. A supervision check list has been designed and is going to be used. 4.4.4. Release of funds once released, funds are advanced for planned activities up to Health Area levels. 4.4.s Is CDTI included in the PHC budget? Yes. 4.t.b. Describe other health programs that are using the CDTI structure and how this was achieved. What have been the achievements? Mass immunization and HIV programs have been using cDDs as social mobilizers. Priority is given to best CDDs so this opportunity can be used as an incentive. They are given a training prior to the beginning of activities. 4.4.7 Describe others issues considered in the integration of CDTI. CDTI has been a real opportunity for capacity building in the project zon.q and has served as a model to other programs. 4.5 Operatlonal reGearch 4.5.1, Summarize in not more than one half of apage the operational research undertaken in the project area within the reporting period. None 4.4.1 4.4.2 4.4.3. I How were the results applied in the project? None ' 4.5.2 38 SEGTION 5: Strengrths, wealrnesses and challenges List the strengths and weaknesses of CDTI implementation process List the challenges and indicate how they were addressed. A - Constraints Insufficient or late payment of incentives offered by the system and resulting in CDDs leaving the program, which can be compounded by the lack of commitment of some communities to support their CDDs. Increased demand for incentives by community members, Health personnel and local authorities. Ongoing restructuring of Health areas and frequent appointments and reappointment of Ministry of Public Health personnel, which interferes with data collection process, leading to a lack of continuity. Inaccessibility of Several Communities in the project zone. ,, Insufficient transportation for the implementation of the activities. B - Challenses Poor counter part financing by the MoH. o a o o o a a a a C - Achievements o Secured and reliable motivation for CDDs. o Capacity building for MoH personnel and community members at all levels. Refinement of CDTI strategy in urban communities Program integration Utilization of CDDs for other programs Capacity building with regard to logistics acquirement in the project zone. Program Recognition by the partners and other programs Successful CDTI transition of all phases with full implementation of TCC/MEC recommendation and optimal coverage. o aa 39 I o