North Cameroon NOTF/WHO APOC project yearly technical report Mectizan distribution: May 1998- April 1999

I I t I NORTH CAMEROON NOTF/ITHO _ APOC PROJECT YEARLY TE,CHNICAL REPORT MECTIZAN DISTzuB UTION MAY 1998 _ APRIL 1999 MAY 99 I t. REgU "'j, o'/ '3 I MAt t999&npoc / PM2 EXECUTIVE SUMMARY The Northern Province covers 65 000 km', with an estimated population of about 1 200 000 inhabitants. It is divided in four Administrative divisions made up of twelve Health Districts and seventy two Health Areas. The Foulbe constitutes the dominant ethnic group. The displaced population from the Extreme North Province and the Refugees from Tchad are the cause of constantly changing population figures. Nodule Prevalence Surveys carried out in 1992 revealed that onchocerciasis was primarily endemic in the Southern part of the Province in 6 Health Districts out of 12, namely TCHOLLIRE, TOUBOURO, REY BOUBA, POLI, LAGDO and TOUROUA. A year later, Mectizantreatment started in 1993 in 2 Health Areas under the auspices of River Blindness Foundation. During the third and the fourth year, five more Health Areas were recruited still by the River Blindness Program. In 1997 Global 2000 took over and the treatment was extended to 6 more Health Areas with APOC assistance in 1998, the distribution was extended to 14 more Health Areas Currently 27 Health Areas are receiving either active or/and passive distribution in 431 communities. In accordance with Cameroon National Policy, only poorly accessible communities or communities with shortage of Health personnel were qualified for CDTI implementation for the first year. Out of 431 endemic communities, 33 were selected in the Districts of TCHOLLIRE, TOUBOURO, REY BOUBA and POLI. Officially the CMRNPVAPOC Project was due to begin in May 1998. However to ensure the continuity of the activities, namely the treatment cycle which is primarily imposed by the weather and behavioural pattem, the activities were prefinanced by GRBP. The following activities have therefore been carried out last year : FEBRUARY - Shipment of Mectizanto the Project Site - Advocacy meetings with the Governor and his associates APRILTMAY - Procurement of Project supplies and capital items. - Training of the District teams and CDDs. - Mobilization and IEC of 431 communities including the 33 CDTI communities. MAY - DECEMBER - Mectizan treatment rn 425 communities (Treatment not administered in 6). - Monitoring and Supervision of the treatment zone including the 33 CDTI communities. The achievements of the project are the training of 15 Districts teams members,32 Health Areas members, 33 CDDs, the treatment of 104 290 person in 425 communities, of which 4543 were treated by CDDs in 33 communities, mobilization of 425 communities for to adhere to the program. The strengths of the CDTI implementation process include improved coverage rate in poorly accessible communities, the strengthening of dialogue structures, easy integration of the CDTI within Primary Health care, general support by local authorities. Inadequate supervision of CDDs due to poor accessibility of these communities Insufficient incentives and lack of commitment by some communities may jeopardize the success of the program. In the second year the Project intends to extend the utilization of CDDs in 30 Yo of the communities, to intensifr supervision and monitoring of CDDs to ensure proper record keeping mobilization, and to aggressively mobilize and sensitize target communities. The Project plans also to carry out operational research on cost recovery. g G**oQ,+ aow,L t \'v .1 f rJ z1 J-\ r- 2\ u) 1 PRO\T'ICE DU NORD CARTE SAI.IITAIRE ; HE,qt-a!4 kR rF.l ',-)) District de 61- 6} ALFA 64 Lr!6Eri{G 6t 6& NGAI.LARA Touboro 6 N EcldIc Lr 0{0 0O0 0 IOa Kru lOistricl de Mayo€uto District de Figuit Dist. de Garoua rural District de Poli I . DOUN,IO 1G LAiI 32- BASCHS0 €. POLi 2. GUIIVIZA 17. FIGUIL 33. Dat,BO 27. vC<O 3. DOUREEY: 1& BIDZAR 3+ GiSCHIGA 4& FIGIICLE 4- tvtAYO-OULC 1g BAOAOJI 3' BARIIOAKg t r,r.ANcAt,LA District de BiMml 3+ BANLI 5+ TCHAMEA & u/AFO A} BIBEMI 37. DJAVBOUTOU 51- WAlrGAr District de Guider 2r- PAOERT,!E 3& NASSARAO 52. SALKOSSA 7. GAVAL 2..HOULA 3+ DJALIIJGO 53. BEKA & I,,IOUSGOY Z} ADOUIJRI 4(r TOUROUA ll iri 9- lllATAFAL 24 NOIAM.BADI 41- NGONG 54- TCIIOLLTRE 67. YATJLI 1G OOUROUT{ 2' OENGUI District qe Lagdo 5a soRor,r8Eo 6& TOUBORO I 1. LItsE District de Pitoa 42. GONOUGOU 5+ MAOINGRIT,JG 69 IJ FARE 12. GUIOER 2A PITOA 4} BAME 57- GOR 11i,toRrJA 27. BANAYE 4.{- |-AGDO 5& GAI,IBA 14 SORAWEL 28. BADJENGO 41 80Kr 1$ TCHONTCHI 29 80ULA.IBr @ EAOJOUMA 3I. TAIJGUI ill tlEEEtlT DE EEfl D 7,. DJOM YEARLY TECHNICAL REPORT ON MECTIZAN DISTRIBUTION I - SECTION I A _ BACKGROL]ND INFORMATION The CMR-Np1/APOC project is located in the Northern Province of Cameroon, covering 65 000 kmr, withLn estimated population of about 1,200,000 inhabitants. The Northern province is divided in four administrative divisions made up of (12) twelve health districts and (70) seventy health areas. It shares boundaries in the North with the Extreme North province, in the East with the Chad Republic and the Central African Republic, in the West with the Federal Republic of Nigeria and in the South with the Adamaoua Province. The Foulbe constitute the dominant ethnic group and forms the indigenous population of the area with other large tribes including the Mboum, the Namji, Moundang, Mafa, and the Mboror0, who are nomadic cattle herders. The dispiaced population from the{xtreme North and the refugees from Tchad are the cause of tonstantly changing population figures. Mectizan distribution here started in 1993, beginning with treatment targeting exercises based on nodule prevalence surveys. The results of these surveys revealed that onchocerciasis was Lndemic in the Southern part of the province in 6 health districts (out of a total of 12 in the province): Tchollire, Touboro, Rey Bouba, Poli, Lagdo, and Touroua. There are atotal of 27 endemic health areas in these districts. The number of hyper/meso endemic communities totals 431 with an estimated total population of 368,243 (Table 1). J Table 1: ENDEMICITY LEVEL # DISTRICTS #oF ENDEMIC HEALTH AREAS TOTAL # OF HYPER / MESO ENDEMIC COMMUNITIES ESTIMATED POPULATION 1 TCHOLLIRE 5 103 44 887 2 TOUBORO 8 1 a) 1 70 190 3 REY BOUBA 3 45 23 294 4 POLI 7 92 35 350 5 LAGDO aJ 35 46 978 6 TOUROUA 1 25 9 173 TOTAL 27 431 368 243 From 1993 to l9g6,the distribution was carried out by The Ministry of Public Health (Min. pH) with assistance from The River Blindness Foundation (RBF). In 1996 the role of RBF was assumed by The Carter Center's Global 2000 River Blindness program (GRBP). This partnership with the Min. PH continued until 1998 when ApOC became apartof it. Until early in 1999, it had been national policy for the distribution of Mectizanto be carried out through outreach strategy from different health centers facilitated by nurses, and assisted by the Village Health Committee (VHC) members. Implementation of CDTI was therefore not accepted in Cameroon .*""pi in poorly accessible communities or in those health areas with shortage of ,,.,.r"r. Taking this into consideration, in 1998 only 4 districts were selected for CDTI implementation, namely Tchollire, Toubouro, Rey Bouba and Poli' Before the ApOC project, communities were receiving ivermectin under the outreach system in Cameroon which relies on the health center and staff for Mectizan distribution. In this case nursign personnel take the drug to the villages and distribute it at a minimal cost. The communities in the treatment area have received treatment (under the above mentioned guidelines stipulated by the MOH) since 1993 (5 times). Community Definition A community refers to a group of persons that settle according to cultural and ethnic affinity, and that has chosen a place as a central meeting point and has a leader approved by all. 4 SECTION 2: Name:NoRTHERNPRovtNCENoTF/wHo_APoC Date of commencement of APoc Assistance : MAY 1998 The technical report covers the period MAY 1993 - APRIL 1999 Activities for the entire year 1998 are provided in this report, although the APOC project has been in operation from May 1998. The provincial action plan was p."pur.a by the provincial and districts teams following the coordination meeting held in Garoua on April 1" and z"d,lgg8. This meeting, held at the health delegation and chaired by the health delegate, was also an occasion to evaluate the previous years activities. That action plan was unique because it took into account the impleme.rtation of CDTI foi the first time in communities with shortage of nurses or i., com.rrunities poorly accessible. Unfortunately, treatment activities due to begin in January were deiayed due to the late arrival of the Mectizan. Only passive distribution was .rtublirh.d throughout the Project from the remaining tablets from the previous year. Treatment activities for 1999 are scheduled to begin in May. In the meantime, training and re-training sessions have been conducted in all APOC project areas in preparation for treatment. TRAINING The North province CDTI project had an objective to train 66 CDDs ( 2CDDs per community) during this period. Shortly after the coordination meeting (April 18"' and May 30'h,1998; 12training sessions were held as shown in table 4: The sessions 33 CDDs,32hea\th center staff, 16 district staff, and 5 TOTs were trained in all 6 endemic districts. A11 33 CDDs were trained to serve the CDTI areas (table 2 &.3), while the other health personnel were trained to carry out Mectizan distribution activities in areas not eligible for CDDs. Training sessions were centered on identification of the disease, Mectizan distribution, management of mild reactions, referral of severe reactions and reporting. Insufficient funds resulted in the training of only 50oh of the CDD training objective. As with other activities, funding for the training activities were advanced by GRBP. Until recently, in compliance with Cameroon policy mandating community treatment by health professionals, the Min PH allowed the utilization of CDDs only in poorly accessible communities or communities with shortage of nurses. Now this policy has been changed, and plans are being made to implement CDTI broadly throughout the area. The following is a summary of activities carried out in 1998: 5 Februrary: - Shipment of Mectizanto project sites - Advocacy meetings April/1V[ay: - Procurement of supplies and capital items - Training of district teams and CDDs - Mobil izationand IEC of 431 communities including 33 CDTI communities May- December: - Mectizan treatment in 425 communities (treatment was not done in the remaingn 6 communities) - Monitoring and supervision of the treatment zone including the 33 CDTI communities Tabte 2: IMPLEMENTATION OF CDTI (1998) - MAJOR ACTMTIES Numbers of communities Paying CDDS in cash or in krnd 8 Districts Numbers of communities Numbers of communities which selected CDDS Numbers of communities which collected Drug Numbers of communities that decided on method of Distribution Numbers of communities that decided on month of Distribution Numbers of communities which trained CDDS TCHOLLIRE 103 8 8 8 0 8 TOUBORO 131 9 9 9 0 9 9 REY BOUBA 45 J J J 0 3 aJ POLI 92 13 13 13 0 13 J LAGDO 35 0 0 0 0 0 13 TOUROUA 25 0 0 0 0 0 0 TOTAL 431 33 33 33 0 33 33 6 Table 3: TRAINING OF CDDs 1 1 1 1 1 1 i 1 I 1 I 1 1 1 1 1 33 DISTRICTS HEALTH AREAS VILLAGES # OF TRAINEES TCHOLLIRE Tchollir6 Doudia I Hormbali 1 Gop 1 Sassa I Dowan 1 Baoussi 1 Gamba Lac6rd I Saki6 1 POLI Poli Gar6 I Mango 1 Volko Mana 1 Wangai Nakalba 1 Sabtou I Malkossa Laro 1 Malkoga 1 Gamo 1 Fagnol6 Paks6 Sika Yobo Dioumte Farkomo TOUBORO Djom Wantounou Ngay Boko Bono Vozgom Kaon Ndock Foumbang Maroum Bidam - Ndourou REY-BOUBA Alpha Tatou Nassarao Mbaila Dami TOTAL 10 33 7 I TAbIC 4: TRATNTNG OF THB DIFFERENT LEVELS OF STAFF INVOLVED rN CDTI TMPLEMENTATION (1998) DISTRICTS Number Of Training undertaken Number of TOT Trained Number of District Staff trained on CDTI Number of Health Center Staff Trained On CDTI Number of CDDs Trained TCHOLLIRE 2 I aJ 5 8 TOUBORO 2 1 aJ 8 9 REY BOUBA 2 2 5 J POLI 2 I aJ 9 13 LAGDO 2 2 4 0 TOUROUA 2 2 2 I 0 TOTAL t2 5 15 32 33 These meetings and training sessions provided the opportunity for district teams (physicians, nurses, and health committees) to sensitize the local administrative, tiaditioral, and political authorities about the new CDTI strategy. Table 5 provides details of the contents of the training sessions. The CDDs performed well as expected. With the timely release of funds, training sessions would be more comprehensively conducted. 8 Table 5: ofT MAJOR CONTRAINTS FACILITATION TEAM TYPE OF MATEzuAL USED TOTAL TRAINED TYPE OF TRAINING - Long distance to cover - Security - Material inadequacy Provincial Team Flip Charts Posters Manual and writing materials 15PROVINCIAL TRAINING - Long distance to cover - Security - Material inadequacy District Team + Oncho Supervisor 32 Flip charts Posters Manual and writing Materials DISTRICT TRAINING - Material inadequacy - Insufficient resources Health Area Nurse + Oncho Supervisor JJ Posters Treatment books Tapes Measuring rods chalk CDD TRAINING 9 Districts Numbers of communities Mobilized Number of target communities which received HE about importance of extended treatment Number of Advocacy visits to State or Regional Director of Health Number of MOPH staff involved in Mobilization Number of NGDO StAff Involved in Mobilization TCHOLLIRE 8 8 I 8 I TOUBORO t7 l'7 I ll I REY BOUBA ) J 1 7 POLI 15 15 l2 I LAGDO 0 0 I 6 TOURAOUA 0 0 1 3 AR I 1 TOTAL 43 43 6 47 5 TAbIC 6: MOBILIZATION AND EDUCATION OF TARGET CDTI COMMUNITIES Mobilization at the community level was aimed at ensuring community involvement with emphasis on their : - Attitude and acceptance of the project. - Nomination of CDDs. - Creation of functional VHCs' - Timely collection of Mectizan from agreed points' - Payments of incentives to cDDs selected by the community. - Decision on the mode of distribution. - Educate communities on the disease and its treatment . - Importance of extended treatment. l0 I {The mobilization and IEC in the endemic communities was best achieved through the involvement of administrative and traditional authorities, focus groups, and outreach by public health nurses to the communities. Posters and flyers developed during previous years were also utilized as tools for health education. Table 6 above details the mobilization activities that took place. The mobilization efforts were encouraging, especially the involvement of traditional and political authorities which continues to bring about positive attitudes and acceptance towards the program. They continue to attend mobilization meetings. The communities seem to be responding well to the new approach (CDTI), and as a result have taken charge of their own distribution. For the first time, communities arranged for the collection of their drug by their CDD. TMPROVING MOBTLIZATTON OF TARGET COMMUNITIES To further improve mobilization of target communities there is a: - need for more posters in both French and Arabic since Arabic is widely spoken and understood in North Province. - need for more flyers and brochures targeted at local authorities and opinion leaders. - need for more flipcharts for use in health centers and target communities. - need to increase awareness by having an Onchocerciasis Week. At the time the Northern province project was approved by APOC, the procurement and distribution of supplies and Mectizan was assisted by GRBP. Unfortunately delays of APOC funds have threatened to interfere with the well-established treatment cycles that are rarely dynamic. To ensure the continuity of the treatment activities, GRBP provided advanced funding to assist with the design and production of IEC materials for use during mobilization and sensitization campagins (treatment books, posters, individual treatment cards). Some CDTI materials from the Douala and Nairobi seminars including the CDDs field book were also used to introduce the new concept to local authorities and target communities. Capital equipment such as 2 Mitsubishis DL 4x4,4 motorcycles, one desk top computer and peripherals were made available in preparation to the commencement of CDTI implementation in the project area l1 THE COST RECOVERY SYSTEM: Although Onchocerciasis has been recognized as an important public health problem in Cameroon, large scale vector control has been considered feasible due to cost and logistical barriers. Mectizan treatment has been accepted as the principle strategy in the national onchocerciasis control policy. In 1992, however, with the assistance of the European Union, UNICEF, and The World Bank, the MOH implemented a change in the design of its Primary Health Care system. The process, called re- orientation, is based on two principles: that the health center is the basic unit of care that will serve a health area (5-10,000 population), and that a mechanism for cost recovery will be put in place for all services offered through the health center. Mectizan distribution in Cameroon is integrated into this system, which differs slightly from the CDTI strategy in the followign ways: the health center personnel dislribute the drug through an outreach program (rather than the primary distributors being villagers), and for each Mectizan treatment 100-200 CFA (about US$ 0.20) is charged to cover the costs of drug distribution. The money is used to pay for supervision, maintenance and fueling of motorcycles, and other costs. The funds from cost recovery are managed by the MOH and health committees. In August,lg9g, the program will conduct operational research on the cost recovery system to evaluate the impact of the system on overall coverage. SECTIONS 3 A . ACHTEVEMENTS A total of 4,543 persons were treated in the 4 districts under the CDTI/APOC strategy in Northern Province of Cameroon. The CDTI districts include: Tchollire, Toubouro, Rey Bouba, and Poli. A total of 33 communities are involved in these districts. The overall coverage rate in the CDTI areas was 38.7o/o (using total population), and 48% (using eligible population). Table 7 summerizes the treatment and population data. Treatment activities are yet to begin for 1999. Currently all training activities have been completed. Training is scheduled to begin in May/June in these districts. o Treatment coverage rate : 38.7% o Total (Census) Population : 11,935 . Eligible population . Coverage rate (eligible) 9,388 48.39% l2 I DISTRICTS NUMBER OF TARGET COMMUNITIES TOTAL POPULATION OF TREATED COMMUNITIES NUMBER OF ELIGIBLE PERSONS TREATED COST OF PER PERSON TREATED cov oh H REFUSED OR ABSENT POP PER CDD TCHOLLIRE 8 3199 tt27 N/A 35.2 2072 399.7s TOUBORO 9 3248 1068 N/A 32.9 2180 360.8 REY BOUBA 3 972 tl5 N/A 79.4 199 324 POLI l3 4316 1575 N/A 36.s 2741 332 TOTAL 33 11,735 4,543 N/A 38.7Y. 7192 Table 7:Mectizan treatment summary in 33 CDTI treatment communities: During this reporting period, the Mectizan tablets arrived at the WHO office early in January and were flown by air to the project site by the GRBP Country Representative. To minimize further delay, these tablets were taken to the CAPPI for further delivery to different health areas for active distribution. It is at this level that the tablets are collected by the CDDs. The community had already decided on the time of distribution and mode of distribution. Although the CDDs were selected by their own communities, some abandoned the program because they felt the level of motivation was inadequate. The remuneration of CDDs was 20 o/o of the amount collected but not exceeding 2000 Frs per distribution session (following the cost recovery policy). This amount seems insufficient given the fact that the distribution lasts all year. These CDDs have to give up their activities without any compensatory gains. Shortening the distributions period might be the solution to this problem. Some of the difficulties encountered were the lack of motorcycles in some health areas, a shortage of treatment cards because of a steady migration of populations from the extreme North in search of fertile land for farming. This has resulted in frequent fluctuations of census data in many areas. In the same 4 districts, a total of 7 ,192 persons (over 50%) of those eligible for treatment, either refused or was absent during treatment. This is higher than expected, ' CAPP* : Provincial Drug Agency l3 The most common reasons for absenteeism were : - students in school during treatment - farmers in farms during treatment - poPulation is very mobile These communities did not experience difficulty with refusals to take Mectizan. However , day such incidents were associated with rumors about the drugs effects. To reach defaulters the program continues to provide the necessary health education to the community, while r.iking the support and endorsement of opinion leaders, and traditional leaders. Mobilization and sensitization activities need to be intensified further. To reduce absenteeism: - The treatment period should coincide with when most people are home - Mop-up treatments should be scheduled on non-farming and school days MONITORING AND SUPERVISION Supervision exercises were carried out at two different levels: 1. The district level was supervised every 3 months by the provincial team (Dr. Abdoulaye and Dr. Djibrila). They were charged with ensuring that the procedures had been followed as planned, and that the objectives had been reached. 2. The district teams, including the Onchocerciasis supervisors, in turn supervised the health area teams once a month. The health area nurses supervised the Dialogues Structures, and the CDDs, twice a month' All trained CDDs performed up to par despite the fact that some of them left. All CDDs had decided on the method of distribution and all had collected their own drugs. t4 I SECTION 4 A- STRENGHTS OF TFIE CDTI IMPLEMENTATION PROCESS For the first time, poorly accessible communities or areas with shortage of health personnel have received Mectizan treatment For the first time, communities have taken charge of their own distribution by collecting their own drug and choosing their own distributors. The empowerment of communities through the CDTI process has strengthened local dialogue structures, rendering them more functional. Local traditional, political, and administrative authorities have already expressed their support of the new strategy by attending most of the mobilization meetings. All primary health care personnel have been trained on the CDTI strategy and are fu1ly involved in the training of CDDs. The CDDs are supervised by the area nurse, and the Onchocerciasis supervisors. The health facilities are used as collection points at health area level. All the above factors make the CDTI stratgey easy to integrate into the PHC system. o o o a o a B - WEAKNESSES OF TFM CDTI IMPLEMENTATION PROCESS . Funding delays resulted in GRBP advancing unbudgeted funds to the APOC program. This results in administrative difficulties on the NGDO side on top of the heavy APOC administrative burden. . Poor data quality and inconsistencies may be increased under the CDTI program, and needs to be carefully monitored. . Inadequate supervision of CDDs due to poor accessibility to some communities. . Insufficient incentives offered by the system resulted in CDDs leaving the program. This was compounded by the lack of commitment of some communities to support their CDDs. o Inadequate CDDs: Population ratio in all target communities. o Prolonged treatment activities in the North since 1993 has created a new class of professional distributors in the Min PH that is not in favor of CDTI. Funding delays: The treatment cycle is naturally short in the Northern Province. It has to begin in February and end around August. To avoid missing this treatment cycle, the activities were pre-financed by GRBP. Unfortunately this MAJOR CONTRAINTS SO FAR IN CDTT IMPLEMENTATION l5 , ao resulted in only 50oh ofCDDs being trained, further compromising the coverage rate. Technical and financial reports and APOC standards are a challenge. Cumbersome bureaucratic problems have not always allowed a coordinated, harmonized planning of activities . The national policy until recently did not allow drug distribution by non-health professionals. Even though the policy has changed, CDTI implementation demands a change in Min PH culture to the lowest levels of the system. Such change will take time. Lack of adequate CDTI IEC materials to the project has hampered effective and efficient implementation of activities such as training, mobilization and Health Education. O TMPROVING THE IMPLEMENTATION PROCESS o The adoption of CDTI as an acceptable distribution strategy by the Government of Cameroon has resulted in an upward adjustment of the CDD training objectives (a 30o/o increase) in the second year. This will assist the selection process by having more trainees to pick from, and also facilitate full adhesion of communities and local authorities to the program due to increased involvement.Getting more literate community members involved in the program'will improve the quality of reporting and monitoring. o Continuous mobilization of target communities for more support to the program and particularly to CDDs remuneration. o Design of APOC/CDTI IEC and training materials o Program advocacy could be improved significantly with the addition of an Onchocerciasis Week. During this time, goverrlment authorities can be sought to ensure mobilization by all the tiers of the administration. . The distribution period should be shortened to 3 months at most. TYPES OF SUPPORT NEEDED a) From Government: o Increased counterpart funding o Involvement at the highest level for full mobilization of all tiers of government . Ensure that project vehicles and equipment are used exclusively for the intended purpose t6 oa O c) a o b) From APOC: Timely release of approved funds to enable coordinated and harmonized planning of activities. Reduction of reporting demands There should be fewer intermediaries for direct communication with the NOTF. From the Communities Communities should be more active in selecting and motivating their CDDs Personal involvement to CDTI activities t7 ,{tU ;? ,/:"i:t i.:;-':. ''.. :'l :i'- . "i r,; i: i; ) r I;-..1r ,ftl'r i._ _ .,..;, ,,' , .t-l,.* 1-.".; \..-f.. r-r-i. ,asJ ,,. ;:tr-1 r:;,--r ':-. \,- .- ,-.", t i: '.-I ;'. ',;(.-,:,;1'rr i.-; li i,.;l i:'.: {..- ,:i:;, :' ,_ Fl'Jt)Ulli-!GUE iiii i:it; i'-.; '-)1., 1': 1,1 II.jl$'i=1.lij ri-r' Li 1!i I,:'.-., :',.;i-:.:,-:i 0rrc.ti.',p 8.2. .179.1 \' .',5,r{^ '[cl : '-C ,0.12 l ?0 5f i,j '.; ( :r] :i i2 \',^'Oljl!l-)i, I.'2l O(l.i i ,rr:r;; l')',il ( i h irY \,'ot lc nrcti,rgc I)ortc rr:f . 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Cortirirc l':rn;icc dcrlrcrc, llr rioilrtrcrr s,tr.r lr,rlsfclrcc urr Cr\l)I)-NOILl) . qtlt s( cl'ltrglr,t ric l'apltrovrsionncniclrl dcs Arrcs r],: r;:rlrli sous lll Coolclr:tl.trorr (lcs co,li(lrrtatcu.s J)i-ovrr.ar:trrr ci rlu [)rrcctcrrr du I)rograrrrr:tc. .lc YrrUS lllrc cgalcrncnt dc brclr lrouYcr ('n iirina\c l\/,:t \,/ Ic t,t;.11,11'1 (iL.:: ilcli\'rl({s dc lri)rtcl'.,'i,' nl:;rie:, itu courS dc I'anncc 9S . lr'Ic,ir-.,lcrrr. r,ctrrllcz agrccr l'cxprcsston dc rna srncttrc colll,bor.;rllorr CC Arclrrvcs \ , -' ( .( . '- 1.... Dr A-lirirr I-\'iiir il lA DIRECTITUR DE C.\iT'I'fJI1 CL:].J-f E11 ONE COPEN.i,,..L - ATLANTA. GEORGTA - USA 30307. TEL. (404) 420 - s160 - FAX (404) 420 _ 5196 / 404 _ 874 _ 5s15 Antcnnc,ic Ga;oua :-:l /Fa^ : 27.31.13 Antcrlne cle Eafoussani rl P- 1f .i4 /Tdl.:.i4.63.21 0 , .rrl Global 2000 OPERATIONAL RESEARCII PRE-PROPOSAL TO TCC: The Impact of changes in Ministry of l{ealth policies on Cost Recovery on Treatment Coverage in North Province of Cameroon Problem Statement: It is unclear rvhat effect, ifany, the cost recovery system and health center outreach systems being used in Mectizan distribution activities in Cameroon has on overall treatment coverage rates, which have been low in North Province. Although some believe that the cost recovery system contributes most to the low coverage rates, others argue that the outreach policy using nurses from health centers (instead of community-based or community-directed distributors) is the principal factor influencing coverage rates. In fact, it is probably a combination ofboth policies that result in treatment coverages ot30-40%' eligible population in some villages. In 1998, several changes have taken place. Firs! the cost recovery payment criteria have been modified, with reductions in costs. Second, the ministry of health is relaxing is policy on CDTI even in areas rvhere the health center system is strong. Lastly, APOC programs in North are being implemented, rvith reorientation of a long-standing progftun to the CDTI approach. In this dynamic environment, we propose to focus on the impact of the cost recovery system on opinons about the program, and coverage- Our results rvould not only be important to Cameroon. There has been considerable discussion about whether in order to ensure sustainabilitl,that, along rvith community participation, a cost-recovery system should be estabtished as part of APOC in line rvith the Bamako Initiative. Since there is no charge for the Mectizan itself, cost recovery under thrs system (in this case of the order of I 00 CFA per treatment, or about 20 US cents) would cover the costs of distributing the drug. In this rvay the IDP becomes integrated with the PHC system. Objective To evaluate the impact of cost recovery on Mectizan treatment coverage rates in the North Province of Cameroon. Hypothesis: Despite implementation of CDTI, a cost recovery policy will continue to prevent achievement of maximum coverage. Methodology We propose: ' the use of KAP studieVquestionnaires to determine knowledge, attitudes, and practices related to the cost recovery system (ex. is it a barrier to seeking treatment?) ' the use of focus group interviews to evaluate community support and awareness of the Mectizan distribution program, with specific emphasis on the cost recovery system . Interviervs rvith key informants and opinion leaders in the community to understand the prevailing attitudes, and evaluating the likelihood of compliance/non-compliance with the current system t Careful analysis ofcoverage data to determine past and present coverage rates, and look for changes in coverage in thrs dynamic situation. Outcome Measures The main outcome measures will be: . Results from questionnaires and interviews . coverage rates over time Costs: Personnel/Consultants (to conduct KAP study) Perdiem Travel Focus Group Meetings Communications (local calls, faxes, publication of results) Office Supplies TOTAL s 3,000 $ 2,100 $ 3,300$ 300$ 700$ 600 $10,000 GIobaI 2OOO Rlver Bllud trmail' rrrhn/d)e :mnof rm aess Program BP 4794 yaound6 T612l ZS 26 Fax: 20 SO lz