Joint WHO/APOC/NGDO visit to Liberia 4th-12th June 2000: trip report

WORLD IMALTH ORGAMZATION AFRTCAN REGION ORGANISATION MONDIALE DE LA SANTE REGTON DE L'AFRIQI,E DIR/APOC/RAP.OO5 23t06t2000 1 d AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONIR,OL (APOC) B;:9,3ffi,HH3$:TIffitr:,?iH^,:l?J3$13ffi333.", T€1; Q26) 30 23 Ol - 34 29 59 - 34 29 60 Tdlex: ONCHO 5241 BF Fax: (226) 34 28 75 In reply please refer to: Pri0re de rappeler la r6f€rence: JOINT WHO/APOC/NGDO VISIT TO LIBERIA 4n - 12tt',JUNE 2000 TRIP REPORT Members of the delegation : Dr. A. S6k6teli, Director of the APOC Programme, Head of delegation ' Dr. J.B. Roungou, WHO/AFRO Regional Adviser on Other Tropical Diseases Ms. Lydia Clemmons, Community Ownership and Partnership Officer of APOC Ms. Pamela Drameh, NGDO Coordinator for Ivermectin Distribution Mrs. Verda Tarpeh, Project Officer, Sight Savers International APOC CDD CDTI CHAL LF MOHSW NDS NGDO NOTF REMO SSI UNDP UNICEF wHo WR a.i. ABBREYIATIONS African Programme for Onchocerciasis Control Community-Directed Distributor Community-Directed Treatment with Ivermectin Christian Health Alliance of Liberia Lymphatic Filariasis Ministry of Health and Social Welfare National Drug Service Non-Government Development Organization National Onchocerciasis Task Force Rapid Epidemiological Mapping for Onchocerciasis Sight Savers International United Nations Development Programme United Nations Children's Fund World Health Organization World Health Organization Country Representative (ad interim) .\ TABLE OF CONTENTS i L rnACrCnOUND......... .......................1 It/. Socio-oolitical History and Economic situation qf Liberia ................1 '8. Previous APOC Missions to Liberia...... .........1 I III ,OBJECTIVES.. ................2 iIII. DESCRIPTION OF ACTTVITIES, OBSERVATIONS, AND KEY TSSUES RAISED....2 iia. ARRIVAL oF DELEGATTDN IN MoNRowA (June 4n) ........... ...................2 '1fi,. MEETING TI1ITH THE MINISTER OF HEALTH AND SOCIAL WSLFARV.....,,........2 'gune ln)......... .. ...............2 ' c. MEETTNG WITH wR aL (June 6).............. ...............:....................3 I 'D. MEETING lllITH NOTF - LIBERIA (June 6) .............. .................4 E. MEETING I|'ITH CHAIJSSI .......................5 i F. coMMUNITy vrsITS..... ...........6 ',G. MEETTNG WITH THE NorF (June g).............. .......7 i i H. MEETING II/ITH NOTF MEMBERS ON INTEGRATION OF ONCIIO CONTROL ! 'WITH OTHER DISEASES (June 9)............... ......................7iI. pngs^s 1DNFERENCE ..............8 i L MEETTNG vITH NATToNAL DRUG sERVrcE ........ ..................8 | 6. DEBRIEFING ILITH WR aL (June 10)............ ........8 I 'L. MEETTNG WITH DR. BOLAY, WHO/LTBERIA ..........9 i ry. MAIN CONCLUSIONS AIID RECOMMENDATIONS.. ...............9 I1: BuocerREvrsroNs .........9 2. DRuc Pnocunsr\4ENT AND DIsrNsurIoN ............ ................9 3. Couvnnurv Owrvenssp............... .....................9 i,3.1. Retigion ............... ........9 ' 3.2. Gender ......................10 ' 3.3. CDDs : Selection process and incentives.............. ........11 5. CDTI, '?BncE eNo RTcoNCILIATIoN", AND Aovocecv .....................13 6. PlRrNrRsnrp .................. ................13 I v. |APPENDTXES.. ...............14 I '' A. MAp OF LIBERIA ...................... /5 i B. Facts About Liberia .....................16 I ' C. Itineraryfor the APOC/SSI mission to Liberia: June 2000...........:...... .............17 i O. wOfp Meetiltg Attendance List (June 5,2000) .............18 ', E. NOTF MEETING: JUNE 5. 2000 ..... ...........19 I,F. STATTIS REPORT PRESENTED BY NOTF COORDINATOR......... .......,.....20 i,G. cHRrsrrAN HEALTH ASS0oIATIoN oF LIBERTA LEAFLET. ................21 I. BACKGROUND A. Socio-political History and Economic situation of Liberia Liberia lies on the bulge of Africa between Sierra Leone and Cdte d'Ivoire, it also shares a border with Guinea. Liberia was founded by the American Colonization Society in an attempt to return freed slaves to Africa. It is the oldest independent country in Afric4 with a landmass of 43,000 square miles. Politically, the country is divided into 13 sub-divisions referred to as counties, and has 16 major linguistic groups. The civil war in 1989-97 has destroyed much of Liberia's economy, especially the infrastructure in and around Monrovia. Many businessmen have fled the county, taking capital and expertise with them. The democratically elected government, installed in August 1997, inherited massive intemational debts and currently relies on revenues from its maritime registry to provide the bulk of its foreign exchange eamings. A map of Liberia is included in Appendix A, and a brief list of socio-demographic statistics are included in Appendix B. B. Previous APOC Missions to Liberia The first APOC mission to Liberia was conducted from 18-30 October 1998 and allowed the visiting team to : (D assess the situation of onchocerciasis and the need for the mapping of the disease ; (ii) prepare the ground for the development a national onchocerciasis control programme and CDTI project proposals ; and (iii) identify and sensitize keys parhrers for ivermectin distribution in endemic communities. The mission noted the eagerness of the MOHSW of Liberia to wage the fight against riverblindness as well as the existence of an effective local NGO (CHAL) willing to link up with Sight Savers International (SSI) to support ivermectin distribution in Liberia. At the request of the NOTF, APOC management sent a consultant to Liberia in December 1998 to help the health authorities conduct a nationwide Rapid Epidemiological Mapping of Onchocerciasis. The exercise was succesfully completed and areas needing mass treatment with ivermectin were determined. From 2- 6 february 2000, the Administrative and Finance officer of APOC visited Liberia and conducted a training session for the accountants (national and peripheral levels; MOHSW and SSVCHAL) on the administrative procedures of managing APOC trust funds money as well as the use of the WHO imprest account system. SSI also made several trips to Liberia within the framework of the APOC partnership, and has contributed to (i) the development of the national oncho control programme and the CDTI project proposal covering Lofa, Bong, Nimba and Montserrado counties, as well as to (ii) the training of trainers for CDTI implementation. Dr Gemade of UniceflNigeria also went on mission to Liberia and contributed to the development of the proposal submitted for funding to the US committee for Unicef by the country Representation of Unicef in Liberia. II OBJECTIVES A joint mission was conducted in Liberia from June 4th to 12th, 2000. The delegation was composed of iepresentatives of WHO/APOC Management and WHO/AFRO, NGDO Coordination Group (NGDO Coordinator), and Sight Savers Intemational (SSI). A representative of the World Bank was,unfortunately unable to participate as planned as a member of the delegation. I Therobjectives of the mission were to: I I(1) ; Meet with the National Onchocerciasis Task Force (NOTD to discuss implementation of the CDTI program. (2) | Discuss project proposals for endemic counties not yet covered for CDTI. (3) , Observe progress made in the counties supported by CHAL/SSI. I (4) i Ctari8, the role UNICEF would like to play in the APOC partnership. i ur. I DEscRIprIoN oF ACTIvrrrEs, oBsERvATroNs, AND KEy IssuES RATsED I A. i ARRIvAL oF DELEGATToN rN MoNRovIA (June 4th) Theidelegation was met upon its arrival at Roberts International Airport by the NOTF Chair, Dr. Nathaniel Bartee, members of the NOTF (CHAL/IVHO), and a protocol officer from the Ministry of Health and Social Welfare (MOHSW), who facilitated transit through immigration and customs. Mrs. Verda Tarpeh, Project Officer of SSI based in Accra, Ghana, joined the delegation immediately following her arrival in Monrovia. t' I An informal welcome and briefing, organized by the NOTF, was held at the delegation's hotel lodgings in order to review and amend the itinerary for the mission. The itinerary developed by the NOTF was well-rounded, including meetings with Ministry of Health officials, the NOTF, NGDO partners, and communities in three counties. The detailed revised itinerary of the mission in Liberia is iriAppendix C. , During the briefing, the delegation was informed that the WR was out of town, and that the UNDP Representative was acting on his behalf. I I B. i MEETING wITH THE MINISTER OF HEALTH AND SOCIAL WELF.ARE I Oune st") I The NOTF Chair and the delegation met with the Honorable Minister of Health and Social Welfare, Dr.'Peter S. Coleman, who welcomed the delegation. Dr. A. S6k6t6li, Head of the delegation, thanked the Minister for the impressive welcome organized for the delegation at the airport and informed him of the objective of the mission, raising the following key issues: 1. ii. iii. The need to report to the Committee of Sponsoring Agencies (CSA) on UMCEF's role in Liberia Clarification of the roles of CHAL and its relationship with SSI Role and efficiency of the WHO office in Monrovia The Minister responded positively to the issues raised, and noted the following: i. UMCEF submitted an onchocerciasis control project, which was approved for funding. There is a need to clarify the roles of the different implementing parties in this project. ii. The budget of the original CDTI project proposal submitted to APOC was understated. It was subsequently revised and re-submitted to APOC Management. He hoped that the revised budget will receive favorable consideration. iii. There was no budget line for the census. Nevertheless, it is being implemented by CHAL/SSI. Thus far, 200,000 people have been counted and registered. iv. He agreed that the role of CHAL must be well-defined and appreciated that an SSI representative was a member of the delegation to help clariff this issue. There has been a lot of confusion between UMCEF, CHAL and the NOTF roles, with the NOTF role seeming to be absorbed by other parbrers. v.' Liberia is a post-war country with serious economic problems and a need to build capacity at the central level. There is a need for more haining of senior staff, who have had little opportunities for professional growth as a result of the war. Training and capacity-building should include exchange visits betrveen NOTF members.within the sub-region. vi. There is a need to speed up administration and communications within the WHO system. For example, email and fax transmissions do not work well , and so the NOTF will need to find ways to by-pass these problems. vii. The Minister assured the delegation that the security situation in the areas where the field visits would be conducted was good. He also-ippreciated the presence of a high-profile representative like the APOC Director, for it sends a positive message to the international community, particularly when the Director makes field visits outside the capital. The meeting was followed by a quick visit to the NOTF secretariat offices, currently being returbished by the MOHSW. C. MEETING WITH WR a.i. (June 6) The delegation met with Mr. John O. Kakonge, Resident Representative (Res. Rep.) of UNDP, and acting WR. The Head of the delegation explained the objectives of the mission and asked for information concerning the involvement of UNDP in the countrlr, and in particular with regards to its role in onchocerciasis control activities. The delegation described the APOC partnership model, which was of great interest to the Res. Rep. Key issues raised by the Res. Rep were as follows: 1. The Liberian government may be unable to raise counterpart funds, due to issues related to the post-war situation and the economic depression, which he outlined as follows: i. In 1998, UNDP organized a donors' meeting in which the Liberian govemment present a budget of 400 million US dollars that included renovating war-torn buildings, water sources, electricity and other infrastruc'fure. 2. ii. The conditions imposed by the donor community to consider the government's i proposal, which were to be followed up in a 6-month review were to: Improve its human rights record; ' o Address the problem of public intimidation by the Liberian government's I recurity forces;| . Repay at least 50,000 US dollars each quarter towards the 3.3 billion US dollar debt. . Break the monopoly on petroleum products, rice and other products; , . Develop of a functional civil service and minimizing comrption. i iii. Unfortunately, for various reasons, intemational aid has not been forthcoming as had i Ueenhoped. i Civil servants are extremely demotivated, with their salaries ranging from $3 to $25 US dollars. The current annual budget is 64 million US dollars, zls compared to the pre-war annual budget rof 500 million US dollars. The illiteracy rate is 80%, while the employment rate is 85% with ,about 80% of the population living below the poverly line. The cost of living is high in Liberia. y75Yo of the infrastructure throughout the country has been destroyed. There is no investment in the private sector. He estimates between 300 and 400 million US dollars will be required to bring eleckicity to Monrovia. ,tt " irrt"r.rational donor community is reluctant to fund the Liberian government. There is little I partnership in terms of financial assistance. Few NGDOs are involved, and USAID has stopped its funding. I I ,The UNDP has been emphasizing increased understanding and commitment to the concept of partnership in Liberia through a workshop devoted specifically to this topic. I UNDP prepares quarterly economic reports, and has also conducted an in-depth socio-economic analysis of the situation in Liberia. The Res. Rep. offered to share these reports with ttre 'delegation, and indeed later gave copies of the following reports for the delegation, which were: Liberian Economic Review. Economic Unit, UNDP/Liberia. November, 1999. Liberian Economic Review. Economic Unit, UNDP/Liberia. March 31, 1998. i LiberianEconomicReview. Economicunit. UNDPiLiberia. February2OOO.I ffion courrt.u A.."rr*"rrt. volr-" lt tr itrnE, rogrrftrrlo, 't ord D"u"loP*"rt. I Ii MEETING WITII NOTF - LIBERIA (June Q : 'Agenda: The agenda of the NOTF meeting attended by the delegation is included in Appendix D. lAttendance: 'NOTF members present at the meeting were from the MOHSW, CHAL,.WHOlLiberia" and UMCEF. A list of those attending the meeting is attached in Appendix E. 3. 4. 5. D. 1. 3. Regrettably, Mr. Juan Ortiz, the LINICEFlLibeiaHealth Officer, attended the meeting only briefly, departing and returning on two separate occasions. His limited presence during the meeting prevented the delegation from getting complete information on UNICEF's intentions for its role in onchocerciasis control in Liberia. tv. Key points raised during the meeting: The NOTF Chairman opened the meeting and began with a general description of the difficulties that the project has had in start-up, due to difficulties in communications between NOTF and APOC. He stated that the Mectizan distribution programme would be launched within the next few weeks. The NOTF Coordinator read a status report on progress made in the project since its start-up (a copy of the entire report is provided in Appendix F). The Acting Accountant for the NOTF presented a financial status report. The APOC Director clarified information on the issues raised in the status report, particularly those related to the census, the roles of the partners with the MOHSW having the ultimate responsibility for implementing the programme, distinguishing between therapeutic and geographic coverage rates, the CDTI treatment areas following the REMO exercise, and accounting systems. The NOTF Chair requested from APOC management a detailed map in color showing areas for CDTI implementation. Other NOTF members also requested CDTI manuals, CDTI training videos and APOC leaflets. The APOC Director promised to send a fax to request these items from the Ouagadougou office. Mr. Pewu gave an update on UNICEF's activities in onchocerciasis control. The UNICEF project, which has received funding for three years by the US Committee for UMCEF, was launched in January in Rambasa, Magibi, Bomi and Cape Mount counties. An additional two years of funding could be provided following a satisfactory evaluation. Twelve health workers have been trained as trainers in CDTI at the county level. The next step will be to train at the district and community levels in either the last week of June or the first week of July. Training will be followed by a census conducted in the four districts. UNICEF has provided four motorcycles, one for each county, and has procured Mectizan, which arrived in Monrovia two weeks ago. Mr. Pewu said he was not the appropriate person to answer the questions raised by the delegation. The NOTF agreed that by 31 December 2000, a proposal for the four counties supported by UNICEF would be submitted to APOC Management. MEETING WITII CHAL/SSI The delegation had a briefing from the Executive Director of CHAL, Mrs. Ellen B. G. Williams, on CHAL's organization and activities. A leaflet on CHAL is attached in Appendix G. CHAL's role in the NOTF and its relationship with SSI were discussed. In line with the NGDO Coordination Group's criteria for the involvement of local NGDOs, CHAL provided the delegation with the following documentation: - Notary certificate ll. iii. v. vl. E. - Annual reports, including annual independent auditor's report - Agreement between CHAL and SSI I CHAL was encouraged to conduct a KAP survey, making use of APOC's operational research budlet. The delegation then had a tour of the CHAL offices. I F. COMMUNITY VISITS l I The delegation was accompanied by NOTF members and an EU Representative to three counties: Moritserrado (Nyehn town-in Todee dishict), Bong @alama town in Jokole district), and Nimba(Camp 4 in Sanniquelleh-Mah district). MOHSW, CHAL, WHO and the EU each provided a vehicle to transport members of the delegation and the NOTF. The delegation spent the night in Bong county at accommodations arranged by the County Health Officer at Phebe Hospital. I The delegation spent at least two hours in each community visited, discussing onchocerciasis and the CDTI process with Community-Directed Distributors (CDDs) and communit5r members. The Officers In Charge (OICs) accompanied the delegation during the community visits. I I Montserrado countE I o In Nyehn, the Paramount Chief, the District Commissioner, the Township Commissioner, the Chairman for the Health Committee, other health workers and CDDs participated in a meeting i"ittr tt " delegation. The delegation noted that there was a strong representation of women among the CDD since some communities had selected one man and one woman CDD for every 250 residents. From the animated discussion, it was apparent that the haining had been both informative and motivating for the CDDs in this area. I o The SSI representative and the APOC Community Ownership and Partnership Officer visited a household located about 500 meters from the meeting held between the delegation and the CDDs, in order to informally assess the appropriateness of a poster adapted from one developed in Nigeria. The four women present in the household complained of onchocerciasis symptoms (itching, vision problems, nodules) but did not know about the cause or transmission of the disease. Although the women said that some people had recently visited their household to write their names in a book (i.e., register them for the census), they lacked information about the CDTI program and did not know about the CDDs and the training they had received. The !om"n had great difficulty interpreting the poster, but were able to understand it when the images and words were explained to them. Bong countv: I The delegation arrived behind schedule in Balama town, due to a late start from Monrovia and a long stay in Nyehn. The meeting wzls held in a church. Many people from neighboring bommunities, who had been waiting for the delegation for hours, had already left by the time the delegation arrived. Nevertheless, there was a good iepresentation of the community participating in the discussion. Women seemed to have less active involvement in the program in Bong county. Both men and women, during discussions, cited household and farming work as obstacles to women's participation as CDDs. Several women said that they would have liked to participate in the CDD training, but had too much work and too little time. Other women in the communities said that I their participation would be to prepare meals for the (mostly male) CDDs during their training, and also when they distributed the drug. o During discussion about how to identiff pregnant women and advise them against taking Mectizan during the mass dishibution, an elderly midwife informed the delegation that she knew nothing about the program, but would be glad to be involved and provide assistance in identifying and advising pregnant women. She pointed out that she could not become involved, however, if she was not informed. Nimba countv: . The meeting was held in the town of Yekeba (Camp 4) in ihe township commissioner's court, opening with a prayer led by the Reverend Jenkins. No training of the CDDs had been conducted yet in this community. The knowledge of the community on the disease and on Mectizan was very poor. Many attributed their symptoms to bathing in cold water, working in or near swamps, drinking unclean water or palm wine, and heredity. A number of people said that they had purchased tablets (possibly Mectizan) from neighboring Guinea, while a woman said that she had purchased Mectizan from a local YMCA health clinic. o During the meeting, there was an animated debate among the community members over the kind of incentives to provide CDDs, suggesting that the community had not reached consensus on this issue. The community, however, expressed willingness to contribute incentives to CDDs and offered numerous ideas for incentives. G. MEETING WITII THE NOTF (June 9) The NOTF was honored with the presence of The Honorable Minister of Health and Social Welfare throughout the meeting. The Director of APOC reported on the field visit and debriefed the Minister on the delegation's key conclusions and recommendations. He also made particular reference to the presence of the EU Representative during the field visit and emphasized the need to keep the EU informed given that it has not as yet made any financial contribution to the APOC Trust Fund. This debriefing report was followed by a detailed response from the Minister to each point raised. He informed the NOTF that he had met with the President to brief him on the APOC mission. The President intends to launch the programme next week whilst on his farm in Bong County. He stressed that the Government is very committed to APOC and that the MOH would ensure that the requisite staff are in place and that it plans to donate another vehicle to the progmmme. He assured the delegation that Liberia would be submitting a proposal to APOC before 3l't December 2000 for the South East part of the country. He further stated that he was personally going to take up the issue with regards to UNICEF's role with the Country Representative on her return and if necessary with the Regional Director. He further stated that CHAI has a long-standing partnership with the MOH, and that CHAL has been an active and serious partner in health care delivery in Liberia for the past 30-40 years. H. MEETING WITH NOTF'MEMBERS ON INTEGRATION OF ONCHO CONTROL WITH OTHER DISEASES (June 9) Members of the NOTF requested information on whether other filarial diseases e.g. lymphatic filariasis could be included in onchocerciasis control activities. The MOHSW of Liberia intends to integrate mass treatment of onchocerciasis with mass treatm'ent for Lymphatic Filariasis using 7 Ive/mectin and Albend azole.It also intends to modify the composition of the NOTF and expand its *urldut" to enable it deal with the two aforesaid diseases. During a meeting Dr Roungou treld wittr Dr Bartee and Dr Boley, Dr Bartee requested on behalf of the MOHSW that AFRO provide assistance to Liberia for LF elimination aitirities. It was therefore agreed that the first step in that t"gird would be to conduct a mapping exercise to determine the dishibution and the intensity of the disdase so as to delineate the areas where mass treatment with Ivermectin and Albendazole wil1be implemented. It was agreed that the MOHSW will submit a proposal for the mapping of the disease to AFRO through Dr. Roungou as soon as possible. Dr Roungou promised to forward to WHO/Liberia examples of proposals prepared by other endemic countries to guide the NOTF of Libbria in the preparation of its proposal. The second step agreed upon was the development of a national plan for LF elimination which will be submitted to the Programme Review Group for conbideration. i II. i PRESS CONFERENCE i I tfrJ Uinister and the APOC Director held a press conference immediately after the NOTF meeting. ThJ national radio and newspapers reported the information provided during this press conference ovei the next few days. I J. i naBBuNG wITH NATIoNAL DRUG SERYICE Thd National Drug Service G.IDS) is a public not-for-profit organization having the MOHSW (retriresented in the Government group) and CHAL (represented in the Users Group) as members on its Board. it is worth noting here that NDS is represented on the NOTF. Who would take on the reslonsibility of paying the cost associated with transporting Mectizan to the counties is an issue of concern. Up until recently, NDS was able to cover the cost of transporting drugs from frrnding from the EU. This funding which has now come to an end. I I The delegation noted that Mectizan (for both SSVCHAL and UNICEF supported areas) has arrived in Monrovia and is ready for distribution. Expiration date of the Mectizan sent in the first shipment is June 2001. The Director of NDS informed the delegation that he was awaiting instructions from the NOTF on the distribution list before contacting the counties to ask them to make arangements to doflect the tablets. With regards to the UNICEF consignment, he has received inskuctions that the tablets should only be handed over to Mr. Moses Pewu. DEBRIEFING WITH WR a.i. (June 10) The delegation debriefed the Res. Rep. on the outcome of its mission and asked that he convey its coricern about UMCEF's reluctance to discuss its role in the APOC partnership with the delegation. The APOC Director expressed his strong dissatisfaction with the attitude of the UMCEF Health Officer during the NOTF meeting. The Res. Rep. assured the delegation that its concems will be conhmunicated to the WR and the UMCEF Rep. on their return and that he will ensure that appropriate actions are taken. At the delegation's request, the Res. Rep. also agreed to forward to APOC Management: 1i. areport of a symposium on partnership recently organized by UNDP/Liberia; ii. a copy of a KAP survey (possibly funded by USAID and/or conducted by Africare). K. L. MEETING WITH DR BOLAY, WHOILIBERIA The APOC Director clarified a number of points related to the smooth functioning of the WHO office in its role in facilitating APOC's funding and logistical support in Liberia. IV. MAIN CONCLUSIONS AI\D RECOMMENDATIONS 1. Budget revisions Conclusion and recommendation: The original budget submitted for approval was grossly underestimated and needs to be reviewed to include the following: (i) strengthening the Secretariat;(ii) purchasing a second vehicle;(iii) IEC equipment (TV, VCR, camera, portable generator, and an overhead projector) and(iv) increasing the visibility of CHAL by adding a column showing its contribution. 2. Drug Procurement and Distribution 2.1. Conclusions : Storage conditions at the NDS are satisfactory, ffid drug procurement and delivery to Monrovia appears to have occurred without difficulty, even though shipments must pass through Abidjan. The drug is ready for hansport to the project area and distibution Communities are eager for the arrival of Mectizan and made pleas to be treated as soon as possible. Recommendations: The NOTF should assure that the drug is completely distributed prior to the expiration date of June 2001 for the first shipment ofMectizan. 3. Community Ownership Community ownership is the comerstone of CDTI and an important factor in sustainability. During the mission, the delegation noted the following key issues that could pose challenges to achieving fuIl community ownership for CDTI in the project area: 3.1. Religion 3.1-1. Conclusions: i. The delegation appreciated the integnty of CHAL's mission to provide health.services to all people, regardless of their religious beliefs and practices. Nevertheless, the pivotal role played by CHAL, combined with the practice observed during the mission of praying at the 11. beginning of community meetings, gives Christianity a very high profile within the CDTI program. Given this high profile, and the absence of people of other faiths in leadership roles within the program, the delegation was concerned that non-Christians in the target communities will perceive themselves as simply beingpassive beneficiaries rather than as active owners of the CDTI progam. 3. 1.2. Recommendations : i The NOTF should: Conduit public information campaigns to assure that communities perceive the CDTI program as being owned by people of all religions, faiths, or beliefs (including Muslims, animists, and others). Identiff ways to encourage non-Christians to be actively involved in directing the CDTI program alongside Christians at all levels (national, county, distict, and community), and apply these measures with the shortest possible delay. I3.2. Gender 3.2. 1. Conclusions: Women's heavy workloads at home and in the fields pose important obstacles to their active participation in the CDTI program as CDDs. The reluctance of husbands or other men, and other socio-cultural barriers may also prevent women from participating fully in discussions and decision-making related to the selection of CDDs, the type of distribution, and the period of dishibution. In spite of these obstacles, women in the communities visited during the mission expressed their desire to be actively involved in the CDTI program. Women who had been selected and trained as CDDs demonstrated that they had leamed just as much as the men and were equally committed to the program. In Nyehn, communities selected one man and one woman as CDDs. This approach may or may not be appropriate or possible for all communities. t. 3. 2.2. Recommendations : I I TheNOTF should: i. i Invite a gender specialist to attend one of the meetings and/or provide technical advice or i other assistance to help the NOTF to identiff ways to: . increase women's active involvement in community decision-making about the CDTI project; o increase women's access to training and to other opportunities provided by the project; t I .l 1. I I I I I I i ll. ; I I 11. 111. t0 . increase men's support of women's active involvement and access to oppoifunities in the project. ii. Where possible and appropriate, increase the gender balance within the NOTF (specifically, increase the number of women who are members of the NOTF). 3.3 CDDs : Selection process and incentives 3.3.1 Conclusions: It is apparent that many community members are not actively involved in discussion and decision-making for the selection of CDDs. Instead, a community leader, as in the case of Camp 4, or a small group of community leaders had the responsibility of selecting the CDDs. ii. Communities appear willing and eager to discuss ways to motivate CDDs and during discussions with the delegation, identified a number of alternatives for incentives. 3.3.2. Recommendationsfor community involvement in CDD selection and incentives: i. The NOTF should identiff strategies to increase the participation of as many community members as possible in discussion and decision-making about the selection of CDDs as well as about any incentives to provide to them. An example of a possible strategy to increase the involvement of all community members is to hold separate assemblies for men and for women, and/or separate assemblies for youth and elders, so that each group can discuss ideas and reach consensus. The separate assemblies could be followed by a general assembly for the entire community to discuss the decisions taken during the smaller assemblies and to reach a final consensus. ii APOC Management should send reference materials containing ideas for motivating CDDs for the NOTF to review and consider using in its project activities. 4. Training and IEC 4.1. Conclusions: The 3-day haining appears to have been effective, for the CDDs were well informed and motivated to begin their work. Training therefore not only increases CDDs' knowledge and skills, it also acts as an incentive. The CDDs clearly appreciate having work tools. They use the brochure as a reference document and also as a reminder tool on what they learned during the training. CDDs like to use the poster as a visual aide to help them inform, educate and communicate about onchocerciasis and Mectizan in their communities. The poster adapted from Nigeria probably has limited effectiveness as a "stand alone" IEC material. It is likely that most people in the target group would have difficulty interpreting the images and the words if they saw the post-er hanging on a wall- unless someone nearby explains the poster to them. ll. 111. 11 4.2. 11. 111. 1V. I I i iv. I I I I The high level of illiteracy in Liberia (estimated at 80%) presents a challenge to the NOTF to identiff appropriate IEC materials for communities. The cost-effectiveness of print materials should be carefully considered prior to making additional investments in them. Alternative means of informing, educating and communicating should be explored, and CDDs themselves suggested including radio, drama, song, and video. The NOTF should seek assistance from local resource people who have expertise in these communication channels to help them develop IEC materials. Recommendations: The NOTF should continue with a 3-day training for CDDs in Camp 4 prior for distribution. CHAL and the OIC should provide additional on-the-job training for CDDs and other health workers in interpersonal communication and in using visual aides to assure that they are able to use the poster appropriately during household visits, individual counseling, ffid community discussions. Since the current poster appears to be most effective when It is uplained, it is best to prioritize its use as a visual aide during educational sessions with community members rather than to simply hang it on a wall or a door. NOTF should consider providing CDDs with something to protect the poster from dirt and water, or else consider developing a visual aide on fabric to make it more resistant to wear and tear. Nevertheless, the NOTF should pretest the poster with communities and modiff it to make it easier for people to understand. The NOTF should identiff local resource people who have experience in pretesting IEC or health education materials to provide technical assistance in this activity. The NOTF should also: a. develop an IEC stategy, with appropriate objectives, messages and materials, to increase community knowledge of onchocerciasis, its cause and transmission, as well as to increase community ownership for CDTI; b. explore other ways to inform, educate and communicate. about Mectizan, including radio, dramq song, and video; and and c. pretest all other IEC or health education materials with their intended target groups to assess their appropriateness and effectiveness, and modiff them as needed, prior to investing in the costs of reproduction. APOC Management should provide technical advice or assistance in IEC if the NOTF cannot identiff local resource persons. CDTI, 66Peace and Reconciliation", and Advocacy The delegation noticed that peace and reconciliation is a popular social theme in the current post-war environment of Liberia. '?ackaging" CDTI within the peace and reconciliation movement could be an effective advocacy strategy at all levels, including govemment, civil society, donors, and target communities. The NOTF should therefore consider : promoting the CDTI approach as a way to support peace and reconciliation because it encourages dialogue, consensus-building and shared ownership among all community members. Modiffing/improving the idea of a theme of CDTI for Peace and Reconciliation and consider involving CDDs, community members, and/or musicians or actors to develop this theme into a slogan, songs, drama, etc. to be disseminated during the drug dishibution period. 11. l. 6. Partnership 6.1. Conclusions: 6.2. 1. Liberia, unlike most of the other APOC partner countries, has a well-established local NGDO. CHAL has all of the criteria necessary to be invited into the NGDO Group as an APOC parbrer. The NOTF needs to speed up the formulation of project proposals to cover all CDTI areas in the country by 31't December 2000 or 31't March 2OOl. The delegation is concerned about the way UMCEFlLiberia is playing its role in the control of onchocerciasis in Liberia and is under the impression that UNICEFiLiberia does not seem to be prepared to be part of the APOC partnership. Recommendations: The NOTF should increase the visibility of CHAL's conkibution as an APOC partner by adding a column to the budget to show this contribution. CHAL should officially request authorization from the MOHSW to tune into the MOHSW radio frequency in order to facilitate communication between NOTF members. To facilitate access to and its use in the project area, the first vehicle that will soon be delivered to the NOTF should be kept on CHAL premises. The NOTF should submit a new proposal for areas that UMCEF has agreed to support to the APOC Management for review and approval. 11. 11. 111. vl. t3 APPENDIXES APPENDIX A MAP OF LIBERIA APPENDIX B Facts About Lib Population: 2,923,725 Age structure: 0-14 years: 45Yo (male 656,101; female 649,389) 15-64 years: 52Yo (male 775,429; female 738,904) 65 1),ears and over: 3Yo (male 50,126;female 53,776) Population growth ratez 4.92Yo Birth ratez 41.49 births/l,000 population Death rate: 11.03 deaths/1,000 population Infdnt mortality rate: 100.63 deaths/l,000live births Life expectancy at birth: total population: 59.88 years (male: 57.2 years;female: 62.64 yeais) Ethhic groups: indigenous African tribes 95% (including Kpelle, Bassa, Gio, Kru, Grebo, Mu+o, Krahn, Gola, Gbandi, Loma, Kissi, Vai, and Bella), Americo-Libeiarc2.5o/o (descendants of immigrants from the US who had been slaves) Religions : traditional 70%, Muslim 20Yo, Christian 1 0% Literacy: definition: % of population age 15 and over able to read and write total population: 38.3%o male:53.9% femble : 22.4% (1 995 est.) GDP: purchasing power parity-$2.8 billion (1998 est.) GDP-per capita: purchasing power parity-$1,000 (1998 est.) Population below poverty line: 80% Undmployment ratez 7 OYo Industries : rubber processing, pah oil processing, diamonds Agricultur"-p.odr"ts: rubber, coffee, cocoa, ,i"", "ursaoa (tapioca), palrn oil, sugarcane, bananas; sheep, goats; timber I Source : The World Factbook 1999 - Liberia APPENDIX C Itinerary for the APOC/SSI mission to Liberia: June 2000 SUN JUNE 4TH MON. JTJNE .TH5 TUES. JITI\TE 6TH WED. JUNE 7TH lHURS. JUNE 8TH I{Kl. JI,NE 9TH SAT. JI]NE 1OTH SUN. JUNE 1lTH ArTrval ot delegation in Monrovia Meeting with the Minister of Health and Social Welfare Meeting with NOTF Field visits: Todee district, Montserrado County: -Nyehn town Field visits: Sanniquelleh -mah district, Nimba County: -Yekepa (Camp 4) Meenng with the Minister of HSW and theNOTF Debriefing withWRa.i. Departure of delegation Brietrng with NOTF Chairman Meetmg with WR a.i. Meeting with CHAL/SSI Jokole district Bong county: -Balama town Press Conference with Minister of HSW and the APOC Director ii. iii. iv. v. vi. vii. viii. ix. x. xi. xii. xiii. xiv. xv. xvi. xvll. APPENDIX D I I NO.[F Meeting Attendance List (June 5,2000) PreJent at the meeting were: Dr. Nathaniel S. Bartee, Deputy Minister/Chief Medical Officer, RL, Chairman, NOTF- Liberia Dr.ZoluB. Traub, National Coordinator, NOTF, MOHSW Dr. Azadoga Seketeli, Director APOC Ms. Hawa M. Johnson, Oncho/IVIOHSW Ms. Victoria Ireland, Medical College Rev. Jenkins R. Jorgbor, CHAL Dr. Meimei Dukuly, MOHSW Consultant Ms. Lydia Clemmons, Community Ownership and Parbrership Officer (APOC/IVHO) Dr. J.B. Roungou, WHO/AFRO Regional Advisor for Other Tropical Diseases Ms. Pamela Drameh, NGDO Coordinator, WHO/Geneva Ms. Verda L. Tarpeh, Project Officer, SSI Ms. Fatoma K. Balay, WHO Mr. Bropsey Mniah, Planning/MOHSW Ms. Ellen B.G. Williams, CHAL Mr. Richard B.Zayzay, CHAL Dr. A.B.S. Haidala, MOHSW Mr. Moses Pewu, UMCEF 1. APPENDIX E AGENDA NOTF MEETING: JUNE 5, 2000 Monrovia, Liberia Call to Order Medical Officer, Prayer Welcome Remark/Introduction Reports: Program Status Budget General Constraints Recommendation Dr. Nathaniel S. Bartee, Deputy Minister/Chief R.L., Chairman, NOTF-Liberia Rev. Jenkins Jorgbor PHC Coordinator/CHAl Dr. Nathaniel S. Bartee Dr. ZolaB. fiaub, National Coordinator, NOTF Minishy of Health and Social Welfare Mr. Richard Zayzay, AccountanVCHAL Dr.ZollB. Traub Dr. Nathaniel S. Bartee 3. 4. 19 A?PENDIX F PROGRESS REPORT OF THE NATIONAL ONCHOCERCIAASIS CONTROL PROGRAM OF LIBERIA TheMnister ofPublic Health - Dr. Colernan Dr. Seketeli and Menrbers of his Delegation Me|nbers oftheNofl Ladies and Gentlernen. Overview The tristory of hrrman Ochocerciasis in Liberia ddes back to 1926 when the l{alvard Expedition gave thefrstervidence ofthg diseaseoccuupaocy in the country. Since that time, many studils brougtt topcul a more global picture of Onchocerciasis distribut'ron and associated severe manifestations by late 1980s I I Itr 1991, when hnrmanitarian organizattons and uN Agencies returned to Liberia to assist victims of theongoing civil war d the time,lVHo sawthe need to cater to victims of onchocerciasis atong with other health intervernions. The assistance was in the form of making available in country a stock of Medicine for distrihrtion to clinics forthe treatmrt of onchocerciasis. The effort was complerreuted by the River Blindness Fouodation of the U.S.A, who, through the Christian Health Association of Libbria began distribution ofMectizan to their member-health facilities to treat the disease. I !9 Prgeram of Mectizan distribution to health facilities was intemrpted by one of the e,pisodes(Operation Otopus) ofthe civil war in October of 1992, I I ofttre plight of the larger segment ofthe Liberian population with the diseasg WHO again loo! a bold $ep by urging and encouraging Liberia to become a mernber of the African progrdfor Onchocerciasis Control (APOC), which came into being in 1996. I I The objective of APOC is to establish a zustainable community -directed ivermectin (mectisan) *fo.rYguem^coyoing 50 milli_ on people in 19 counties which fall outside the scope of an ongoingWdst aftican Onchocerciasis Program (OCP). To achieve this objeotivg APOC requires member countries to provide a comprehensive epidemiologcal data generated using a unifonn standard or protocol in any endemic area, a prerequisite for funding treatment progftrm. Although many epidemiological studies have been canied out on onclrocerciasis in Ijberia such a compretrusive epidemiological data was not available Orf-ib_uiauutil lgruary 1999 when APOC sponsored a nationwide Rapid Epidemiologicat Mapping of Onchocerciasis (REMO) December l998-lFebruary 1999. Page I of 7 20 3. Activities Caried out in Preparation for the Launching Of CDTI in Liberia: Liberia attended workshop on the ptrilosophy of APOC in April lggg,Kenya. TheNOTF formation included government, NGDO AI,ID THE United Nation System with the assistance of Sight Savers International. AnaiorwideRapidEpide,miologicalMappi"g of onchocerciasis exercise was carried out in Liberiafrom 29 December, 1998 to February. 1999. The resrlts led to the developmeot ofthe National Plan of Action and Proposals. Sigh Savers Irfiemrional ageed to give its zupport through CHAL under the auspices of the APOC to the CDTI in the West-Central Counties (Bon& Montserrado,Lofa and Nrmba) Counties. The Christian Assoociation of Liberia (CHAL) conducted a workshop on CDTI for the couuty health officers of and community health workers in Montserra, Bong, Nimba and Lofa counties. The purpose was to acquaint the County Heatth Teams with APOC phitosophy on CDTI and to review the draft proposal zubmitted to APOC. CHAL Program Coordinator attended the two-weeks direct observation of the implementation of CDTI projects in the sate of Kogi, Nigeriq May 1999. The Mnistry of Health and Social Welfare received representatives from Sight Savers International. A rumber oft€chnical me€{furgs wqe held with the participation of WHO, LINICEI CHAL, other governmental Mnistries and local non governme,ntal organizations. X'uture Plans Workshops to be held on the implementation of CDTI in January 2000 to invotve the participationofimplementers, WHO, UMCEF communitybased organizations and leaders. Conduct nationwide social mobilization activities to sensitize the population. Lunching of CDTI IN February 2000. Page2of 7 f,i STTMMARY OT NOIT' ACTIVTIIES DI]RING THE PAST T'OI]R MONTHS. EEBRUARY - MAY,2OOO Training: i i NOIF activities for 2000 began with a three- day workshop for CHAL Staffard NOTF Members. Theltraining was facilitateed by Dr. Elizabeth Elhassarl the Programme Technical Advisor. The ktraining methodology was partioipatory with role plays on dosing treatnent and recording. Participarts were divided into working groups for group work at the end of each topic. During those sessions, each group developed steps they would undertake to implement each of the activities presented. An improvement obsenred in the post-test indicated a high lwel of understanding. ' Twenty-five participants were each gven CDTI training manuals. A total number of thirty-ttuee persbns attended the worlcshop and had the opporarnity to watch the CDTI films t'wice I CoTTNTYHEALTE rEAlt{ A similar worlshop was held for the Cowty HealthTeam (CIITs) of Infa, Bong, Nrmba and Montserrado Counties. This wortshop took place at the Phebe Hospital Campus. The same topics disiussed urd training forrrats used at the above wortshop were covered. Atotal oftwenty-tlree pqticipants attended. They all received the CDTI training manuals and witnessed the CDTI film twice. 1t OXT'ICERS IN CHARGE (OICs): Inthe modls ofldarch and April, the officers in charge ofthe four counties, Lofa, Bong Nrmba and Momserrado received dndlartrafudng Atotalnumber offifty-two officers in ctrarg{OlCs) have been trained representing twenty-six districts. CENSUS: APOC a,sked us to do a cens.rs before disuibution Funds and opert assistance were promised. These are,not yet fortlr-coming. We have managed somehow, to cary on this aspect of the program as best as we can. I CENSUS SUMMARY Bong County Census by District and Community SalalaDisfrict - 10,806 Number of communities - 28 Sanoyea District - 14,603 Number of communities - 32 Zota - 12,401 Number of communities - 25 PageS of 7 1. 3. LL 4. 5. Suakoko Number of Communities PantalKpaai Number ofcommunities FuamahDishict Number of communities 1. Sanniquelle lv[ah Dishict Number of communities 2, ZoeGeh Distict Number of communities 3. TappitaDisfrict Number of communities 4. Gbehlay-Geh Number of communities 15,741 35 15,730 2t 30,551 58 16,5M 16 19,450 26 9,r31 11 Nimba County Census by district and community - 15,661 -17 Lofe County Census by District and Community 1. ZozorDistrict Number of communities 2. SalayeaDistrict Number of communities 3. BelleDistrict Number of communities 4. VoinjamaDistrict Number of communities 5. Bopolu District Number of communities 6. Kolahun District Number of communities - 12,819 -16 - 8,041 -6 - 14,024 -20 - 12,707 -23 - 13,850 -18 - 38,768 -46 Page4of 7 Z3 Bokomu Distric't Number of communities 10,875 26 Montserrado County Census by District and Community 7. 1. TodeeDistrict Number of communities - 13,321 -63 Presently, we are receiving census re,ports from the various endemic communities of the four counties, To datq a total of 270,702 persons have been ce,nsussed. This figure is only a fraction of the total census currently undenray in three districts of Lower Lofa. These cenzussed communities will begin distribution during the second week of fune, They have all ageed on the point of the collection oftheir dnrgs and methods of disfibution AII the endemio communities have selected their CDDs and all have been trained. We,are already frced with questions as to while some communities are censused, leaving out nearby ones. I I MEETINGS: I fUd NOff has continued to meet regularty. At these monthly meetings, decisions for the smoottr implementaionofCDTl have been high. Discnssions ontraining and contact visits,IEC sessions in conrmunities have all been taken during these meetings. I Members ofthe NOTF include the following: Mnistry of Health and Social Welfrre Christian Health Association of Libeda/SSI Liberia Institute of Biomedical Research A. M. Doglotti College ofMedioine UMCEF wHo National Drug Service 3. I Vehicles The motocycles for the health frcilities have been disfributed accordingly. . Sight Savers International purchased 6, while WHO PURCHASD 20. We are indeed grd€ful for these motocycles. They have and continue to be helpful to us for the irnplementation of the CDTI. Page 5 of 7 84 These motor cycles were disributed as follows: Lnfa County Bong County Nmba County Montserrado Total 2. NOTF hopes to come up with the launching date at the next montlrly mmeting. the tablets arrived in Liberia on lday 17,2000. NOTF will meet on fune 6,2000. Contshaints: 1. Iack of srprport for centnal administration- i.e. ince,ntives, vehicles, communications.2. Lack of incentives for CDDS. To datg the vehicle approved for the project has not been received. This development has continueed to pose some difficulties forus. Thebad road conditions in the contry make it diffioilt to ply with old vehicles. Recomm endation/suggestion: We suggest that the Toyota Iand Cruiser approved for the project be made a vailable immediately. This wi[ enable us to speed up the programmed/project. EXECUTTVE ST}MIT,IARY The CDTI project is being implemented by CHAUSSI in Montserrado, Bong Nrmba and I-ofa Courties in collaboraionwiththeNOTF with support from APOC. Thirty-three staffof the Mnistry ofHealtlt, CHAL incfuding the merfte,rs of APOC were trained in CDTI approaches. In addition, 52 officers in charge of various health facilities in the four courrties were trained in CDTI.. Swe'dy-sevenmrnmrnitiesharrebeen reached and fifty comminities selected their CDDs. All ofthe Seventy-swe,n commidties have trained CDDs and there are one huodred and twenty CDDs that were trained by CHAUSSI through the officers in charge. Training aids were dwdoped and used during the training. These materials are presently being used by the CDDs in the mobilizatiou and education of the emnderric communitied. Up to the present, oensus were conducted in 77 cornnrunities in Montserrado County and district in Lofa County. Ce,nzus is presertly being cafiied out in the remaining counties. CONCLUSION WewerecalleduponbytheMnisterofHealtb Dr. Petercolernan, to coordinate theNotional Oncho Conhol Proganl on November 8, 1999. My predecessor had been transfered to another area of practice. Page6 of 7 -10 -8 -6 -2 -26 ei The task has been and is arduous, froth with restraints, constraints, and at times very discourging. This has, however, not deterred any of us fiom carrying out the mandate. 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