Independent participatory monitoring of East Bahr El Ghazal CDTI proiect in South Sudan

! I * Independent Participatory Monitoring of East Bahr El Ghazal CDTI proiect in South Sudan Draft Report Submitted to: By Asaph Turinde, IGbali (Team Leader) Abraham Chol Manyiel ]oseph Apec Majok MartinMajok Both Chuol Contact Emai[ rindekabali@hotmail.com Phone: +256752285904 October,2009 I aAPOC ATO CBM CBOs CDDs CDTI CHWs DGHS EPI FGDs GOSS KIIs MoH NGDO NGO NOTF OCP OV PHC REMO SAEs SMoH SSOTF TCC UTG wHo WRs African Programme for Onchocerciasis Control Annual Treatment Objective Christoffd Blinden Mission Community Based Orgnn i zxg[e1s Community Directed Distributors Community - Directed Treatment with Ivermectin Community Health Workers Director General of Health Services E:panded programme for Immunization Focus Group Discussions Government of South Sudan Key Informant Interviews Ministry of Health Non-Governmental Developmental Organization Non Governmental Organization National Onchocerciasis Task Force Onchocerciasis Conrol Programme Onchocerca volvulus Primary Health Care Unit Rapid Epidemiological Mapping for Onchocerciasis Serious adverse events $gx1s ffiinistry of Health South Sudan Onchocerciasis Task Force Technical Consultative Committee (Iltimate Treatment Goal World Health Organization World Health Organization Representatives 2 n !l Acknowledgements I am profoundly grateful to all people and organizations who in one way or the other contributed in the completion of this assignment. I may not be able to mention all by name and their specific contributions. However, I feel indebted to mention a few. I gratefully acknowledge APOC Management for giving us this oppornrnity to undertake this mission and for the financial and logistical support without which this mission would not have been possible. In a special way, I appreciate all the members of the monitoring team for their hard-work and commitment that enabled the successful completion of this task. I owe a lot to Mr. Lazarus Nweke, the APOC / WHO Technical Advisor to South Sudan for sparing his valuable time to share his knowledge about CDTI strategy with team members during the training and preparation for this exercise. Special mention also deserves of IvVs. Agnes Wanyoike of WHO office for South Sudan in Nairobi for her part in ensuring that all the logistics for this exercise were in place whenever we needed them. To Mr. Chol Manyiel, project coordinator, many thanks to you for the good organisation which ensured that we reached all the sampled communities. Last but not least, I appreciate the wonderful cooperation of all the people we talked to during field data collection. I thank them very much for sacrificirg their time to share with us their experiences regarding the implementation of the project. Asaph Turinde, IGbali Team Leader J aP Table of Contmts Acronyms ..2 Acknowledgements.... Asaph Turinde, Kabali Executive Summary... SECTION ONE..... INTRODUCTION 1.1 Context of the East Bahr El Ghazal CDTI project 1.2 Background to monitoring the East Bahr El Ghazal CDTI project...........'.... 1.3 Main objective of the mission SECTION TWO METHODOLOGY....... 2.1 Introduction.... 2.2 Areas covered by the monitoring exercise and sampling procedure 2.2.1 Sample sizes 2.3 Meeting with WHO South Sudan Country representative and MoH - GOSS ..1 I 2.4 Meeting with State MoH and other partners 11 2.5 Monitoringlnstruments 1l 2.6 Data Analysis t2 2.7 Limitations encountered during the monitoring exercise.......'..........'.....12 SECTION THREE RESULTS AND DISCUSSION 3.1 Introduction............. .3 .3 l5 l5 5 8 8 8 9 9 10 10 l0 l0 l0 29 29 29 29 30 JJ .....15 3.2 Indicators on community participation and project ownership .. ... .... ..... 1 5 3. 3 Indicators on Mectizan supply, collection and distribution........... .......-.-17 3.4 Indicators on coverage ........... l9 3.5 Work of CDDs ....20 3.6 Health education, mobilization and sensitization........... ..............21 .223.7 Gender issues and minority grouP's indicators 3.8 Training, monitoring and supervision.'........... 3.9 Integration indicators .24 25 3.10 Partnership with NGDOs, CBOs, Districts, sub-counties or health sub-..'26 districts 26 26 27 3.1 I Contribution of resources (finances and others) by partners 3.12 Communiry self -monitoring 3.13 Review of data entry temPlates for the independent particiPatory monitoring exercise of CDTI projects. .......27 SECTION FOUR CONCLUSIONS RECOMMENDATIONS 4.1 Introduction................ 4.2 Conclusion 4.3 Recommendations References 4 !Executive Summary Introduction: This report presetrts the results of an independent participatory monitoring exercise conducted for East Bahr El Ghazal CDTI project in South Sudan to assess the extent to which the project is in line with the CDTI principles and suggest feasible recommendations to achieve and sustain high Onchocerciasis treatment coverage and project sustainability. It was conducted in three purposively selected counties - Yorol West, Cuibeit and Rumbek East, taking into account Onchocerciasis prevalence levels (hyPer and meso endemic areas), securiry concerns and accessibiliry. The exercise w:rs conducted between 13m - 28,h of September 2009 by a team of monitors comprising of one external and three internal monitors. Methods: This exercise employed a combination of qualitative and quantitative methods of data collection including communiry meetings, FGDs, KIIs, document / records review and household interviews with a random sample of 150 respondents from households. The participants included; household heads, project management both at national and State levels, village chiefs, CDDs, health workers, county and Payams supervisors. Key findings: There was little community participation and ownership of the project mainly because of lack of awareness on part of the community to participate and firlly drive the process. This is compounded by the fact that there has also been little ad on the to enhance these aspects. Consequently, m6st still look at the project as either a government or NGDOs project where they do not perceive themselves playing an important role other than swallowing the drugs when brought to them. This partly also explains why few women and other minority groups were involved as CDDs and a significant number of people who did not know about Onchocercisis and its control activities in their localities. Nonetheless, involvement of some community leaders in community mobilization and activeness of I should be The supply of Mectizan has not only always been late but it is also often not enogg! and this has negative implications on its distribution as some communities remain untreated either because of inadequate drugs or due to floods which cut off some communities and yet treating everybody is critical in the control and elimination of Onchocerciasis. A delay in the release of funds to the project, ,r"grti""ty ffi" V 5 implementation of planned activities aI *k CDDs were playing a significant role in the disuibution of Mectizan in villages where there were available although some villages did not have them because people did not want to work voluntarily. While CDDs were quite knowledgeable about the right doses for the different categories of people and the eligibility criterion were well undentood among those interviewed. There was clear evidence of inadequate monitoring and supervision of CDTI activities at all levels due to; understaffing and poor facilitation including lack of transport means among key project staff. The monitoring orercise revealed very little integration of the project with other existing health prograrnmes in the area and /et this is critical if sustainability is to be achieved. The project was nrnning as an independent Programme. For example, procurement and delivery of Mectizan was done independently of other programs and the staff are not yet absorbed by the State Ministry of Health (SMoH). It is still seen as an independent donor driven project without any govemment financial contribution other than one NGDO namely; Christian Blind Mission which participates routinely in planning, budgeting and resource contribution. One other area that was noted weak is records management. Record keeping was poor and no where did the team come across complete records of the previous treatment especially at community level. The results of this monitoring exercise should be understood in the context of a post conflict situation in which activities do not move fast like in situations that have relatively been stable. There are many challenges, for example, in some ateas there are no roads at all. It will therefore take some bit of time for this project to incorporate all the basic principles of CDTI. Notwithstanding however, there is a lot of optimism as most people were positive about the project and are willing to swallow Mectizan as long as it is available in their midst. Recommendations:(1) The project management at various levels should pursue it as a goal to enhance of not the community but and local NGOs Y ostakeholders at those levels including government, and CBOs for their involvement and ownership of the project ownership. Advocacy and lobby meethgs should be held at various levels to get all the key actors on board. The pqoject management at various levels should intensify efforts to sensitise people about CDTI. This will not only enhance suPPort but will also increase uptake of the Mectizan among those that did not know about the treatment. A strong educational campaign guided by a well designed communication sUategy that takes into account how best to reach out to the various sections of the society is recommended. As much as possible 6 efforts should be made to utilise the locally available channels of information dissemination such as, religious gatherings, local FM radio stations, schools, commudty gatherings, community leaders, CDDs, health workers and use of printed materials such as; posters, brochures and leaflets. (3) All the project management staff right from the State level (coordinator) to county, Payam and Buma supervisors should be facilitated with transPort means to enable them execute their expected roles. For example, the coordinator does not have a vehicle as the old one has been grounded for more than a year. The county supervisors need to be facilitated with motorcycles while both the Payam and Buma suPervisor could be given bicycles. (4) APOC and other partners should ensure timely release of funds and logistics to the project to ensure CDTI activities are implemented as t/ planned. (5) Mectizan supply should not only be timely but also adequate enough to treat everybody in all the endemic communities because some communities were reported not treated partly due lack Mectizan and flooding. The preferred period for distribution of Mectizan throughout the project area is th" dry season. (6) In a bid to reduce demand for an incentive from CDDs, there is need to reduce on the workload by mobilizing and sensitizing the communities to have more CDDs such that the workload is shared. Each CDD at least should handle between 20-30 households. (7) Worlshops and seminars should be organised for various actors in CDTI including CDDs on the importance of records and good record-keeping practices because complete records are important to inform many Processes in CDTI implementation including Mectizan procurement among others. hl A /V,ilf,/,,*, v /-u,* K r."( l-ill- ^4 lPTW* ' ar* f'u/ W tbl, {<a qrptu' /k*' /1,-. 'll-/1,0"i*t n^/ t'- fr* /'^h 'l- ,r-'+"-( ' 1t'; /" tt fu'h' )-P,'i' F ^;fr,/o aSECTION ONE INTRODUCTION 1.1 Context of the East Bahr El Ghazal CDTI project East Bahr El Ghazal CDTI project is comprised of the whole of Lakes state and parts of Warrap and West Equatoria states with currently twelve counties as new counties have been formed from the old ones. Lakes State itself has 8 counties; Rumbek North (Maper) Rumbek Central, Rumbek East, Rumbek South (Wulu), Cueibet, Yirol East, Yirol West and Awerial. While the Warrap State has 3 counties under the project ie. Tonj South, Tonj East and Tonj North while West Equatoria state has only one county under East Bahr El Ghazal CDTI project namely; Mvolo county. The project covers 2,513 communities and is bordered by; Unity state in the North, Warrap and West Bahr El Ghazal states in the west, West and Central Equatoria states to the south. While in the East it shares the boarder with |onglei State. Map of South Sudan shou'ing the location of East Bahr EI Ghazal CDTI project lrlr The East Bahr El Ghazal CDTI project is in the fifth year of African Programme for Onchocerciasis Control (APOC) fuoditg phase. It is also being supported by Chirstoffel Blinden Mission (CBM), an International NGDO co-ordinating CDTI in collaboration with South Sudan Onchocerciasis Task Force (SSOTF). The project has an estimated population of 1,729,275 with at- risk total population of 927,285 (53.62%) for Onchocerciasis infection. The dominant ethnic group are the Dinka who are agro-pastoralists whereas the minority fur BeI are 8 East Bahr El Ghazal CDTI ProJcct lllt .B lRfd tirlir agriculturalists. But through socio-economic interactions, the communities have gradually begun to e:rcrt influences otr one another although there are tribal conflicts between Jur Bel and Dinka. According to available information (TCC report 2008), only 1,970 communities were treated thus grl iog a geographic coverage of 78.4o/o and a total of 570,530 persons were treated with Mectizan. This treatment figure represented a therapeutic coverage, IJIG coverage and ATO coverage of 61.50/o, 73.3o/o anrd 86.20/o respectively in 2008. Data on the number of health staff involved in CDTI shows that only few 372(37.8olo) health workers were involved in CDTI activities out of 1,275 avatlable health staffin the project area. 1.2 Background to monitoring the East Bahr El Ghazal CDTI project In a bid to control and eliminate Onchocerciasis in endemic countries in Africa, the Onchocerciasis Control Program (OCP) and the African Program for Onchocerciasis Control (APOC) have initiated a number of strategies. At the heart of all these, has been the Community - Directed Treatment with Ivermectin (CDTI) - an approach that promotes active communiry participation in Ivermectin distribution and instils a sense of community ownership of the process. In the CDTI approach, the communities plan their own distribution systems and make decisions on who should distribute the drug and the method; (house-to house, central location or at chiefs compound, school or church etc). The community collects ivermectin from a collection point if it is located far from them and decides when to distribute it. The CDTI approach has been hailed as an effective strategy (Amazigo et a1.,2002) and over 25 million people globally were treated through CDTI in the year 2002. Several shrdies (Braide et a1.,1990; Katabarwa er a1.,2000 and others) have demonstrated the success of this strategy as not only ensuring equiry and wider treatment coverage among the poor and "hard"to reach areas or communities but also guarantee sustainability. 1.3 Main objective of the mission The main objective of this mission was to conduct an independent participatory monitoring of the East Bahr El Ghazal CDTI project in South Sudan and assess the extent which the project is in line with the CDTI principles and suggest feasible recommendations to achieve and sustain high Onchocerciasis treatment coverage as well as project sustainability. Note that this was the first monitoring exercise undertaken on this project since its inception about five years ago. Consequently, this monitoring exercise did not address itself to the extent to which recommendations of the previous monitoring or evaluation exercises were implemented since there has never been any. 9 ISECTIONTWO METIIODOLOGY 2.1 Introduction The monitoring exercise for this project was undertaken between 146 - 28n of September 2009 by team of six including; one external monitor, three internal monitors, the Project Coordinator and one communiry member. 2.2 Areas covered by the monitoring exercise and sampling procedure As earlier noted the East Bahr El Ghazal is made of 12 counties and out of these 3 counties were purposively selected taking into account among other things; Onchocerciasis prevalence levels (hyper and meso endemic areas), security concen$ and accessibility. In each of these counties, two Payams were selected yielding an overall total of 6 Payams as illustrated in table I below. Table 1: Counties and Payams covered during the monitoring exercise of the East Bahr El Ghazal CDTI project 2.2.1 Sample sizes In each Payam, 5 villages were randomly selected. While the monitoring guidelines provide for at least 10 household interviews per village / community, this was not possible due to time corstraint and therefore only 5 interviews were possible in each village / community yielding a total of 150 household interviews. ln terms of deployment, in each village / selected, there would be one member of the monitoring team and after conducting the village chief and Communiry Drug Distributor (CDD) interviews, he would randomly interview 5 households per village, systematically picking every third household until 5 households were covered. In cases where there was no eligible respondent in the sampled household, the next household would be selected. Whereas also the monitoring guidelines provide for 30 interviews for both communiry leaders as well as CDDs, this number could not be raised because Name of the County Rapid Epidemiological lrlappiog for Onchocenciasis (REMo) Name of the Payams Cuiebet Meso-endemic zone Abiriu Maloupec Rumbek East Meso-endemic zone Atiaba Malengot Yirol West Hyper-endemic zone Abang Genggeng l0 some villages did not have CDDs at all while in some villages or communities, the chiefs could not be traced or were not in the village, and since no call backs were made due too time coDstrairt, only 23 atd22 interviews were obtained for CDDs and villages chiefs respectively in the 30 villages or communities covered during this monitoring exercise. In addition to individual interviews, 6 Focus Group Discussions (FGDs) were held with groups of women with one exclusively for women in the cattle carnp (hard - to -reach group). There were also 4 community meetings held in 4 villages / communities to understand communities' views about CDTI implementation, their involvement and sustainability of the project. 2.3 Meeting with WHO South Sudan Country representative and MoH - GOSS While the guidelines provide for meetings with head of World Health Organization (W"HO) South $udan, Ministry of Health -Government of South Sudan (MoH-GOSS officials and the NGDO Coordinator on arrival in the country for a briefing about the mission, this was not possible due to tight air travel schedules / bookings. However, they were de-briefed about the key findings of this after field work. During the de-briefing, we also had oppornrnity to follow on some issues that had emerged from this monitoring to get their point of view. Their views however, were more general about the overall CDTI implementation in South Sudan than East Bahr El Ghazal CDTI project that was the focus of this monitoring. 2.4 lv[ggting with State MoH and other partners In the Lakes State at Rumbek, meetings were held with the Project Coordinator, the acting Director General, the out-going State Minister of Health and the W.HO/APOC Technical Advisor before field work to brief them about the mission. During these meetings were also interviewed on a number of issues that were of interest in this monitoring exercise and as provided in the guidelines. However, they were not de-briefed about the key findings of this monitoring exercise mainly because they were not in office on scheduled date as the Director General of Health Services (DGHS) had lost a sister and most of them had accompanied him for burial in Yirol West County. We could not re-schedule because the external monitor was leaving the rext day and most of the members of the monitoring team were also departing the next day for a workshop in |uba. 2.5 MonitoringTnstrurnents This monitoring exercise utilised 7 instruments as provided in the guidelines and included; o Interview guide for community leaders o Focus Group Discussion guide . Communiry Meeting Guide lt o CDD Interview Questionnaire . Household Survey Qpestionnaire o Health Personnel Interview Questionnaire o Interview Guide for Policy Makers 2.6 Data Analysis (a) Qgditative data One important feature of qualitative inquiry is that data gathering and analysis are simultaneous activities. In this particular exercise, the initial stage of analysis was a quick analysis of data emerging from key informant interviews, FGDs as well as community mgstings to identify emerging issues for the debrief of key stakeholders. Data analysis nurs concrurently with fieldwork in a reflexive and iterative process. A more comprehensive data analysis took place after field work The hand-written notes were assembled together and typed into a word processing program - Microsoft Word. The data was thoroughly read and manually analyzed for content and recurrent themes in the texts based on the key indicators for this monitoring exercise. Key phrases or statements on these indicators have been quoted verbatim and integrated into this report. O) Quantitative data Quantitative data on the other hand, was entered in the computer using standard templates of Epi lafo version 6provided by APOC. Data analysis was also carried out using the same software. Frequency tables, descriptive statistics and charts have been used in the presentation of this data. 2.7 Limitations encountered during the monitoring ocercise This exercise was executed within certain limitations, which however, did not significantly affect the key findings of this exercise. o In the fust place, there were no reliable and up-to-date sampling frames in all the sampled villages / communities. Indeed this is very common problem especially in the rural settings. Nonetheless, a random sampling strategy was used in which a bottle was spinnsd in the centre of the village and take the direction which it has pointed and systematically interviewing every 3.d household until the five households were covered. Note that in case there was no legible respondent at home at the time of the interview, it would be substituted with next one because there was no time for call backs. . Related to the above, was also the limitation of poor accessibility. Most of the roads were in bad shape and this meant spending a lot of time on travel Ieaving little time on part of the team to carry out field activities. In t2 aa o addition, this exercise was also conducted during the rainy season and some areas were completely cut off due to flooding. However, in where zuch villages / communities were sampled, we replaced them with the ones that could be easily accessed. Scenes like in the photographs below are very common during rainy seasons and greatly affect the distribution of Mectizan as many places cannot be reached. Roads either become completely cut offdue to flooding or are impassable. Inability on part of the team leader to speak the local language was yet another limitation because he could trot freely interact \{rith the communities. However, through an interpreter he could get a feel of what it was even though it may have been difficult on the part of the team leader to attach meaning to some of the participants' views or resPonses. As earlier noted, the team did not make call backs due to lir1g senstraint and this therefore meant that respondents that were not at home at the time we visited were missed and yet their views could have contributed to the pattern of the findings of this exercise. Insecuriry was yet another limitation during the execution of this assignment. South Sudan is a hub of inter - tribal conflicts and at one point one of the core members of team had to be evacuated to |uba because his Iife was in danger following an incident in which a senior Dinka military officer was murdered by allegedly people of his tribe and feared for revenge. Indeed the previous evening people came to our hotel and began questioning him. His evacuation did not increase workload on Part of the l3 :ll'r. '.t. s1 *r d&'' r$ .Lt" r(n -n .1. -/\ *ry.rr, . ' Sriri{ *..t -.. tr"f,t _-. *.,1i.=,iLd&is#, *#hxw*- - remaining team but also made us fear for our lives which in a way psychologically demorel i sed us. Despite these, limitations, the team was more committed to accomplish the task at hand. t4 SECTION THREE RESI'LTS A}.ID DISCT.JSSION 3.1 Introduction This sectiotr preserts results of the monitoring exercise for East Bahr El Ghazal CDTI project in South Sudan from primary data sources as well as review of important documents that relate to this project. The results are discussed simultaneously as they are presentd. In more specific terms, the chapter presents results on performance of the key indicators of CDTI in this project and examines the extent to which these indicators have been achieved or in the process of being realised and the challenges encourtered in trying to achieve these indicators. The section concludes with a review of the data capturing templates used in this monitoring exercise. 3.2 Indicators on community participation and project ownership One of the core indicators of CDTI is the level of community participation and ownership of the project. This monitoring o<ercise however, found little of this in the East Bahr El Ghazal project as illustrated in box I below. Box I 3.2.1 Proportion and number of target communities, which decided on the period, or method of treafrnent.T (33.3o/o) of the community leaders -reported that the mode / method of treatment was decided upon at village meeting), while only 14 (11.7o/o) of the people interviewed at household level reported that they were involved in deciding the mode of treatment. Similarly, during an FGD with women in Nyangkot village a woman observed, "The commwity did not take any decision on the mode of distribution. The drugs are just brought to us eyery year and we take them" 3.2.2 Proportion and number of target communities where the "community' selected their own CDDs.7 (33.3o/o) of the community leaders interviewed reported that the CDDs were selected at a village meeting in their respective villages while 16 (13.3olo) of the people interviewed at household level acknowledged having participated in the selection of CDDs. " The one distributing the drugs here is Abraham but I don't know how he got that job. May be men know about it"observed a woman in an FGD in Nyangkot village. 15 3.2.3 Proportion and number of target communities where aII segments of the community (including minorities) are involved in implementation. There wi$ no reported community where all segments of the community including minority groups such as; (people living in the cattle camps) were involved in the implementation' 1.1.1 Proportion aad number of communities where community members carry out mobilisation, distribution and reporting. There was no reported community where community members carry out mobilization, distribution and reporting. 1.1.2 Proportion aad number of target communities which collected ivermectin from collectionpoint/the health ceatre.5 (22.7o/o) of the communiry leaders reported that any of their communiry member collected ivermectin from the collection The noted poor community participation in the project is due to a number of factors including lack of awareness on part of the community to participate and drive the process especially at community level. The monitoring exercise found that most people still look at Onchocerciasis control programme as either a govemment or non Sovernmental organization (NGO) Programme where they do not have to play any role other than swallowing the drugs when brought to them. In short, communities just see themselves at the receiving end without playrng any role. This could also be due to the fact that there has been little effort to sensitise the communities about their expected roles in Onchocerciasis control. Moreover, the project coordinator himself acknowledged that he was never oriented on CDTI but only read about it in reports. "I came to know about CDTI last year and I read it from rePofis and I was also briefed by the NGDO coordinator Mr. Fasil Chane", he observed. Due to little exposure to CDTI, he may therefore not fulIy appreciate the need to frrlly involve the community in the project or the important role the community plays in CDTI. The other factors affecting community sensitization and mobilization for people to participate are; understaffing and lack of Uansport as the clurent project coordinator's vehicle has been grounded for over a year now. The project coordinator is currently using a motorcycle which he claims Puts his life at risk due to tribal conflicts earlier noted in this report. He therefore does not often move out to the communities to carry out the necessary advocacy and mobilization. Nonetheless, this monitoring exercise noted some instances of community involvement and participation in the project as follows; t6 Whereas most CDDs were already working as community health workers (CHWs) either at the Primary Health Care Unit (PHCU) or with the NGDOs working on Onchocerciasis control such as; CBM, ACROSS, International Rescue Committee etc in some villages, commurrities reported having been involved in the selection of CDDs for their respective villages. Community leaders were involved in mobilizing the community for treatment especially when the Mectizan arrives. Meetings were reported held in the villages to inform ,rr4 pefilize the people for treatmett. 'We call them for a meeting to inform them and othen about the treatmenr", observed one village chief in an interview. In addition, village chiefs were also reported not only instrumental in convincing those who refuse the drug to accept it but also encouraging CDDs to work on voluntary basis because they have a social responsibility to serve their communities. It was noted that this in a way has kept some CDDs working despite demand for incentives. 3. 3 Indicators on Mectizan supply, collectiou and distributiou According to interviews with project management at State level, the preferred period for distribution of Mectizan is the dry season ie |anuary - Aprit. However, this has not always been the case as Mectizan is always supplied and delivered late. For example, it was during the monitoring period (September 2009) when Mectizan was received at lakes State Ministry of Health. Late supply of Mectizan was noted very problematic because during the rainy seasons some communities get completely cut off because of the floods and therefore remain untreated not because the drugs are not available but because such areas become inaccessible until the next dry season. A case in point was Rumbek North County where the drugs were available at the State Ministry of Health Stores in 2008 but could not be delivered until |anuary 2009 due to floods that completely cut off the road to these communities. This problem is not only in Rumbek North County but in 3.3.1 Proportion and number of communities/uillages that experienced late of ivernectin. 20 (87o/o) of CDDs interviewed reported ie 2008 andof dmgs 15 (65.20/o) of CDDs were not supply or shortage that tfrere was late l7 other counties as well. The only difference here is that what is cut off may not be the entire county but some villages. Below is picnrre showing the Rumbek - Yirol road having been cut offby floods during one of the rainy seasons. While this monitoring exercise could not accurately ascertain the percentage of Mectizan shortage, there was a general feeling among project management as well as members of the community that the drugs supplied are not enough. For example, at household level, 414 (54.1o/o) of the people did not receive treatment and the main reason given was that dmgs were not brought to their communities 167 (40.3o/o). The shortage could also be a result of more people coming back to settle in their villages (retu::rees) after many years of conflict and the Proiect may not have catered for such people during the ordering time of Mectizan thus resulting into shortages as some people remain untreated. The monitoring exercise also observed that Mectizan supply is not informed by the census of the errpected population to swallow the drug or previous treatment returns / records because there is no system to collect and analyse them. The ordering process is therefore based on what we could call 'guess work'. It is therefore not surprising that shortfalls in Mectizan supply have always been experienced. It was reported that each year, there is a significant shortfall in Mectizan supply ]gxding to some communities remaining untreated as earlier noted. The monitoring exercise also noted two significant ways in which Mectizan is collected or it gets to the CDDs. Most CDDs pick it from the Payam supervisor often at PHCU. However, at times and depending on convenience some Payam l8 ffi -*FqtDE:-;t -*k--, u I tr- !a 't i supervisors may deliver it to CDDs in their homes to distribute to members of the communiry. The main mode / method of distribution is 'house -to- house'which was reported is decided upon by mainly the supervisors. 3.4 Indicators on coverage It was found that less than ha]f 351 (45.9o/o) of the people in 150 households covered in this monitoring enercise received Mectizan, but more 414 (54.9o/o) ild not receive it. There were a number of reasons as to why, these people did uot receive / take Mectizan and prominent among these were; drugs were not brought 167 (40.3o/o), absent 134 (32.4o/o), child below 5 years 47 (ll.4o/o), not informed 44 (10.6), pregffmt 14 (3.4o/o), sick 7 (1.7Vo) and refusals I (0.2olo)' Whereas there was only one person who deliberately reported having refused to swallow Mectizan, review of the TCC report 2008, revealed a significant number of people who refused to take the drugs as illustrated in box 3 below. Box3 Sowce: TCC report 2008 There were basically two reasons noted by this monitoring exercise as to why some people refuse to take Mectizan and they include; a A belief that because they do not have appiuent symPtoms of Onchocerciasis they do not see any reason why they should take the tablets. "Some people who do not take Mectizan claim they do not have Onchocerciasis and therefore do not see any rationale to take Mectizan", observed one participant at a communiry meeting. a Some people experience serious side effects and therefore next time when they are asked to swallow the same drugs they refuse. But we think the most important reason relates to litde health education (awareness) going on in the communities. As earlier noted, some people do not even know about the disease and the drugs, therefore many people are not aware of what they should expect when they swallow Mectizan and how it works. 3.4.1 3.4.2 3.4.3 Proportion and number of refusals two months after distribution. (497). Proportion and number of absentees that were later treated**'* Proportion and number of at-risk uillages treated (L,970, villages for the year 2008). Proportion and number of pefions 5 years and above who teceive ivermectin (570,630) 3.4.4 t9 Wtrile there are deliberate refusals to take Mectizan even when it is available in their midst as revealed by the TCC report 2008, a significant number of people are not treated because they do trot have access to the dmgs either because they do not have CDDs to give it to them or their areas are cut off due to flooding and insecuriry as earlier reported. It was noted that some villages do not have CDDs because people do not want to work voluntary and people including village chiefs, supervisors and health care managers interviewed argued that the government or NGOs should remunerate them. ?eople cannot work for free. They have beea volunteering all the conllict years and are really tired', observed one County Supervisor. Indeed all interviews conducted among CDDs, revealed a high demand for incentives. Despite the high demand for incentives among CDDs, majority of them were willing to continue to serve because they feel a social responsibility. Another reason why some villages are not covered is because Mectizan supplied is often not enough. 3.5 Work of CDDs CDDs were reported playing a significant role including distribution of Mectizan in villages where there were available although their interest in the job was more do with helping their communities as earlier noted than what the role offers to them as individuals because they were working voluntarily - a reason often cited as to why some people refused to take up the work / role. Even some CDDs were reported to have dropped off due to lack of incentives. The demand for incentives by the CDDs was high. Even the county supervisors intimated to us that the 120 United States dollars was not enough to motivate one to do a good job. The challenge of incentives is also compounded by lack of harmonization on incentives - different programs pay differently for examle; Expended Programme for Immunization (EPI) etc. Height measurement using locally calibrated stick was the main method for dosage determination. CDDs seemed knowledgeable about the doses and the eligibility criterion was well understood. Whereas there were attempts to follow up on those who miss treatment, inadequate supplies of Mectizan were the main limitation. Therefore, those who miss often wait until next supply which is usually after one year. Some CDDs and supervisors were not residents of those villages and only go there to perform their roles when it is time. Below is a summary of performance of this project in as far as key indicators on work of CDDs are concerned. 3.5.1 Proportion and number of communities where CDDs were changed by the community after treatnlenr. Out of the 23 communities where we obtained interviews with the village chiefs, majority 15 (68.20lo) had not changed the 20 CDDs, 5 (22.7o/o) were unaware whether the CDDs have ever been changed while only 2 (9.7o/o) reported having ever changed the CDDs. 3.5.2 Proportion and aumber of CDDI with measuring deuice for height. Whereas more than half 13 (56.50/o) had measuring device for height, a considerable number l0 (43.5olo) did not have it. 3.5.3 Proportion aad number of communities with accurate treatment registers Similarly, more than half 13 (56.570) of the CDDs had a treatment register which however had gaps - some information was lacking such as, number of tablets given, etc. Like for the measuring device for height, a significant number of CDDs l0 (43.5o/o) did not have a register at all and the main reason reported for this was that they were not given. 3.5.4 Proportion and aumber of CDDs who had stopped carryiag out CDTI actiuities. Interyiews conducted among CDDs themselves, villages chiefs, health workers and project staff indicated that some CDDs though not many have ceased to carry out CDTI activities and the main reasons were; migrated or gone back to school. However, there were also those who felt cannot work for free. 3.6 Health education, mobilization and sensitization This monitoring exercise found little health education. According to interviews conducted at household level, only 40 (33.3olo) reported having received health education because there has been little effort geared towards this by the project and because of this, some people do not actually know including k"y implementers about the principles of CDTI. This monitoring exercise found that some did rot even know of the Onchocerciasis disease popularly known as OV and Mectizan as well. Some people were leaving as if nothing was happening in their communities regarding distribution of Mectizan. 'We do not know about OV treatment program. We have never taken those dtugs"rroted a male participant at a community meeting in Makral in Rumbek East County. Similarly, there has been little advocacy done to stakeholders at various levels. During fieldwork for this monitoring, the team did not come across any printed materials including leaflets and posters about Onchocerciasis and CDTI and yet these would go a long way to inform the people including stakeholders about the project. The project coordinator partly attributed lack ofhealth education to understaffing, lack of transport and poor faciJitation to the few staffavailable. 2t 3.6.1 Proportion and number of communities which received education about importance of extended iveraectia teafrnenL Thfuty three point three percent (33.3olo) of the people interviewed reported h"tirg received health education about CDTI. 1.1.1 Proportion and number of commuaity leaden that have been mobilized for CDTI actiuities. Out of t}ne 22 village chiefs interviewed, majority 16 (72.7o/o) acknowledged having received health education while 4 (18.2o/o) could not remember and only 2 (9.1o/o) reported not to have received any education about the importance of extended Mectizan treatment. 3.6.3 Proportion aad number of distict/LGA poficy makers who have been sensitized on CDTI. The monitoring exercise noted that the project conducted advocacy at state level although not all the stake holders at state level were contacted other than the State Minister of Health and Director General who were met by the APOC technical Advisor and the Project Coordinator which has resulted into incorporating CDTI into the health system. Whereas there were also attempts to carry out advocacy at county level, the commissioners were not found because of their frequent travel to others counties to mediate peace and reconciliation. 3.6.4 Proportion and number of community leaders that are involved in mobilisation /health education / superuision for CDTI actiuities. All the 22 (100o/o) villages chiefs interviewed indicated that they were involved in community mobilization to take the drugs. 3.7 Gender issues and minority group's indicators This monitoring exercise observed that few women are involved in the project as CDDs because they do not only have so many duties at home to allow them time outside the home but also because they have to work voluntarily and their husbands cannot allow them to work for free. 'A man cannot accePt his wife or daughter to work for {ree. May be, if there was something, they would be allowed. Daughters are a wealth to be Ieft to move freely like that", commented one Payam supervisor in an interview. Below is a summary of key indicators on gender issues and minority groups. 3.7.1 Proportion and number of communities where there are female CDDs. Majority 15 (75o/o) of the communities covered during this monitoring did not have female CDDs. Only 3 villages (150/o) had one female CDD while 2 villages (10o/o) had 2 CDDs and according to TTC report 2008, there were a total of 2,034 CDDs of which only 136 were females accountingfor 5.4o/o. Table 2 below adopted 22 from the TCC report 2008, presents community participation in CDTI activities including CDDs who are females. Table 2: Communities in the CDTI Source: TCC report 2008 3.7.2 Proportion and number of health workers who are females. As illustrated in table 3 below, there were few (39.5olo) health workers involved in CDTI although, this monitoring could not ascertain the proportion and number of these who were females. Table 3: Number of health staffiuvolved in CDTI Disuict/IGA Number of heelth rtrffinvolved in CDTI ectivities. TmlNumbcrof hedth *rffiu the entire p,roiect eree Br Number of heelt rnff invohrcdinCDTI Bz Perceutege B=B/Br'100 YIROUAWERIAL 473 175 37.0o/o RI.IMBEK 514 154 30.0olo CI,EIBET 288 tt2 38.9/o TOr.U 276 148 53.60/o MVOLO 40 40 10@/o TOTAL 1,591 629 39.5Vo Numberof coumunitier AriUegelwith ftmdr CDDI Number of communitierfuilleger with commuaity uembcrr rs rup€rvil@r Nunber of GDDr end thc conunitier involved Br Femrle CDDI Br Bz+Br Totrl Bro Numberd coumuritieg with ftmrle CDDs Perccutrge Brr= Brol&1(X) Br Totel no, comnunitie r in the entile project rree Bs Numberwith community memberr rs Pcrccnagc 86= By'B{'lm MdeCDDI Bt 634 37 4.7o/oYiroVAwerid 912 47 2Wo 604 30 Rumbeh 694 4t ll.2Vo 551 55 606 3s 5.V/o 27 8.60/oCueibet 314 264 12 276 438 30 8.U/oTonj 373 36 14.4Vo 408 30 7 3.2o/oMvolo 220 4 29.1o/o 70 l0 80 2034 r35 5.4%Tot l 2513 168 16.896 1897 137 Source: TCC report, 2008. 23 DiraictrI.GA .7.3 Proportioa and number of women that attend health education meetings. Majority 18 (81.8olo) of the community leaders reported that women also attend health education mggtings and only 4 (l8.2Vo) noted tfrat women do not. 1.1.1 Proportion and number of women who were treated during the last distribution Overall, a total of 570,630 people were treated. However, it was not easy to tell how many of these were women. 3.7.5 Proportion and number of health workerc who participated in selecting the CDD. None of the health workers were reported involved in the selection of CDDs in the 30 villages covered in this monitoring. 3.7.6 Proportion and number of women who participated in deciding the day of distribution Whereas this monitoring noted that somehow communities are involved in major decisions relatirg Mectizan distribution, it was not easy to quantiff the proportion and number of women who participate in some of tlese decisions including deciding on the day of drug distribution. The low participation of females / women in the project was attributed to a number of factors including; o In Dinka culture, men do not want their wives orposed into public life. They are highly treasured and a source of wedth and cannot therefore be Ieft to move around. o Have a lot of work at home to dlow they take on public roles. o Culturally, women do not have a voice. They do not have an opinion of their own. They are controlled by their husbands who often want them confined to domestic duties only. o There are not educated as their male counter parts. Nonetheless, this trend is likely to change in the years to come because females are also currently enrolling in schools there are also many women advocacy NGOs such as; W'omen to Women International, Black company - a micro finance institution etc. 3.8 Training, monitoring and zupenrision These were noted as not adequate. Most CDDS were reported to have had the initial training when they were being selected and have not had subsequent / refresher trainings which is supposed to be the case before every distribution. The budget for training have not been forthcoming and sometimes the materials for training are delivered late. Like this year it came with drugs. Similarly, monitoring and supervision has not been forth coming due to inadequate staff, lack of facilitation, means of transport, ard sometimes delays in the release of training materials. For example this round, the training and mobilization materials were 24 delivered at the same time with drugs instead of being delivered earlier to enable training of the CDDs as well as community mobilization for treatment. Below are the findings on key indicators on training, monitoring and supervision revealed by this monitoring exercise. 3.8.1 Proportion and aurnber of commuaities with tained CDDs. All the CDDs interviewed reported having been trained on CDTI. Consequently, all the 30 villages/communities covered had trained CDDs. The monitoring exercise reveals that indeed most CDDs were giving appropriate doses of Mectizan to the people. For example, for all the 15 cases where an attempt was made to verify the accuracy of the dosage given, the results indicate that they were all correct. 1.1.1 Proportion and number of communities whose nearest health facilities have 'bevere adverse reaction" records. None of the communities visited had records ot "severe advetse reaction'. 1.1.2 Proportion and number of target communities that were superuised/monitored during the last Mectizan distribution All the 23 CDDs interviewed revealed that they had ever been supervised. However, this monitoring could not capture, those CDDs that were supervised / monitored during the last Mectizan distribution exercise. 3.9 Integratiou indicators There has been little integration if *y. Whereas at lower levels, the Payam supervisors as well as the CDDs may work on other health programmes, it is by coincidence but not because it is intended. There has not been a deliberate effort to integrate Onchocerciasis activities with other health activities going on in the project area as illustrated in the key indicators below. 3.9.1 Proportion and aumber health programmes which have adopted CDTI approach to the health seruices. (None). 1. 1. 1 Proportion and number of districts/LGAs that have CDTI integrated into annual plans / budgets. (None). 1.1.2 Proportion and number of health workers who combine CDTI with other health actiuities. All the health workers interviewed noted that in addition to CDTI, there are also involved in other health activities including providing curative services at their respective health units as well as running out reaches for immunization and giving health education on various health activities including water and sanitation among others. 25 1.1.3 Prolnrtion and number of target conmunities which undertook integrated community self monitoring. (None). Despite the relatively poor performance of this project with regard to integration indicators, it was reported that recently it has been recognised as a health prograrnme and hence incorporated and housed in the State Ministry of Health. Interviews also revealed that plans have also been concluded to have all the core staff working on the programme absorbed in the State Mioitt y of Health including payment of their salaries this financial year. It however, remains to be seen how this will play out. 3.10 Partnership with NGDOs, CBOs, Districts, sub-counties or health sub- disuicts There were few partners working with APOC on East Bahr El Ghazal CDTI project As the firrdiog on the key indicators reveal (see the findings on these key indicators below). 3. 10. 1 Proportion and number of local pannen, NGDOs and CBO proniding technical support (training, health education, etc) at different leve,ls. There is only one NGDO Partner ie Christian Blind Mission. 3.10.2 Proportion and number of partners/IvlGDOs participating in routine ptanning and budgeting of CDTI actirzrrbs. There is only one NGDO namely; Christian Blind Mission participating in routine planning and budgeting of CDTI activities. 1.1.1 Proportion and number of pattuerc/IttGDOs carrying out advocacy for CDTI actiuities. There is only one NGDO namely; Christian Blind Mission. 3.11 Contribution of resources (financqs and others) by Partners. According to interviews with the project management at state level, the resources for the project have not only been delaying but dso been inadequate. Instances of where staff spend more than five months without any toP uP Pay were reported. There were complaints that the top is little a reason cited as to why there has been a high turn over of finance officers of the project. There were only two organizations making financial commitments to this project ie. APOC and CBM. There is no counter funding at all from govemment. The project is still seen as an independent separate NGDO or donor Program. The DGHS at State level attributed lack of financial contribution to the project by government to 26 inadequate resources, otherwise there was a will to suppoft the project. He noted that because they have just come out of war, they do not have enough resources. 3.11.1 Proportion aad number of communities that support their CDDs. (None) 3.11.2 3.11.3 Proportion and number of paraerc that contribute cash to CDTI implementation. APOC. This financial year however, Christian Blind Mission will be also making cash contribution to the implementation of this project as indicated in the budget. Proportioa and nu-mber of NGDOs/Govenment Organisations that contributed to fiaances of the CDTI. APOC. This financid year however, Christian Blind Mission will be also making cash contribution to the implementation of this project as indicated in the budget. 3.12 Community self -monitoring Nothing of such is taking place in this project. 3.13 Review of data eDtrry templates for the independent participatory monitoring ocercise of CDTI projects One of the terms of reference for the team during this monitoring was also to review the data capturing templates in a bid to identify the gaps and suggest what needs to be changed to make them suitable in future for this exercise. This was done through a critical review during data entry for the various tools utilised in this exercise For ease of reference, our comments are presented separately for each instrument/tools. a) Household survey form, (cdd.rec template) The template has areas to information on; Sub County / LGA, District/ State and but these are missing on this field data collection and yet there are important variables during analysis if comparisons or presentation of the findings have to be made by these specific variables. We therefore suggest that they should be included on the data collection form. b) Householdmembers'participatiougection (hhpart.rectemplate) While this information is captured together in the household questiornaire, there is no separate template for data entry with all identification fields. We there suggest that this form should be separate and have all the identifiers as for the household snrvey form including the changes we have recommended. c) Questionnaire for frontline health personnel (flhf,rec template) While this data collection form collects data on number of CDDs and of these who are females, there is no provision for this in the data capturing template. Whereas there is provisions in data capturing template for the responsibilities the 27 respondent has with the Onchocerciasis prograrnme, this is missing on the data collection form. For question 6, there is need for a skip to take you to qn. 8 if the answer in qn 6 is no 2. or 3. Question 46 in template is different from what is on the data collection form. There is need to harmonise this. Qn. 52 is not provided for in the data entry template. d) Key Infomant Intenriew: Communityleader (commldr.rec template) Qn. 1 On the data collection form is not provided for in the data entry template. e) In{epth inteniew of the CDD (cdd.rec template) Whereas the template provides a field to captrure country, it is not provided for on the field data collection form. For qn. 5 id the response is 2 or 3, there should be a a skip to take you to qn. 9. 28 SECTION FOIJR CONCTUSIONS RECOMMEI{DATIONS 4.1 Introduction This last section of this report prr'lls sut the key issues emerging from this monitoring exercise of the East Bahr El Ghazal CDTI project. It also presents a number of recommendations not only based on the results of this monitoring but also what is considered feasible approaches and if well implemented would go along way to improve treatment coverage and sustainability of this project. 4.2 Condusion This monitoring exercise has revealed little community participation and ownership of the project mainly because of lack of awareness on part of the community to participate and fully get involved and drive the process especially at communiry level. In addition, there has been little advocacy going on by the project management and therefore most people still look at Onchocerciasis control programme as either a govemment or NGOS progftrmme where they do not have to play any role other than swallowing the drugs when brought to them. In short, communities and other key stakeholders perceive themselves at the receiving end without plafng any role. This may partly elqlain why few women and other minority groups were involved as CDDs to melilisg communities for treatment and distribute Mectizan. Similarly, there were few health workers involved in CDTI although, this monitoring could not ascertain the actual proportion and number of those involved. Nonetheless, involvement of the community leaders in communiry mobilization as well as CDDs accepting the roles despite the demand for incentives is a positive step and should be encouraged. Mectizan has always come late and is often not enough although data at the national office indicate that drugs have always been enough and often with surpluses. This has negative implications as some communities remain untreated either because drugs are not enough or they have been cut off due to floods as clearly demonstrated by this monitoring exercise, and yet treating everybody in the endemic communities is critical in the control and elimination of Onchocerciasis. A delay in the release of funds to the project negatively affects the implementation of planned activities. CDDs were playing a significant role especially in the distribution of Mectizan in villages where there were available although some villages did not have them because people did not want to work voluntarily. For the active CDDs, their interest in the job was more do with helping their communities than what the role offers to them in terms of incentives. Nevertheless, CDDs were quite 29 aknowledgeable about the right doses for the different categories of people and also understood the eligibility criterion for treatment. This monitoring exercise also revealed inadequate monitoring and supervision of CDTI activities at all levels due understaffing and poor facilitation including transport means. Similarly, there has been little integration if *y. Whereas at lower levels, the Payam as well as the CDDs may work on other health programmes, it is by coincidence but not because it is intended. There has not been a deliberate effort to integrate Onchocerciasis activities with other health activities going on in the project area. There were few Partners working with APOC on East Bahr El Ghazal CDTI project. It is only one NGDO namely Christian Blind Mission participating in routine planning, budgeting and resource contribution to the implementation of CDTI. In conclusion, the results of this monitoring exercise should be understood in the context of a post conflict situation in which activities do not move fast like in situations that have relatively been stable. There are many challenges, for example, in some areas there are no roads at all. It will therefore take some bit of time for this project to incorporate all the basic principles of CDTI. Nonetheless, there is a lost optimism as most PeoPle are positive about the project and are willing to swallow Mectizan as long as it is available in their midst. 4.3 Reconrmeudations In light of the above key findings, the following recommendatiohs are proposed' (l) This monitoring e:rercise has revealed little participation not only by the community but also other key stakeholders at various levels in the project. It is therefore important that the project management at various levels should pursue it as a goal to enhance participation of not only the community but also other key stakeholders at those levels. The project management at various levels should carry out advocacy and lobby meetings to get key actors on board for support and ownership of the project which will ultimately translate into project sustainabiliry. (2) All the project management staff right from the State level (coordinator) to counfy, Payam and Buma supervisors should be facilitated with transPort means to enable them execute their expected roles. Lack of transport means does not only impact on project implementation but also supervision and effective monitoring of the project. For example, the coordinator does not have a vehicle as the old one has been grounded for more than a year. The counry supervisors need to be facilitated with motorcycles while both the Payam and Buma supervisors could be given bicycles' 30 a(3) It was also established by this monitoring exercise that there has always been delays in the release of fu:rds to the project which affect implementation of planned activities. It is important that APOC and other parhers should ensure timely release of funds and logistics to the project so that CDTI activities are implemented as planned. (4) Mectizan supply should not only be timely but also adequate enough for the treatment of everybody in the eudemic communities. This is because some corlmunities/ people remain untreated either because Mectizan is not enough or due to flooding. The preferred period for distribution is the dry season because there are no problems of access usually common during the rainy season as clearly demonstrated by this monitoring exercise. (5) The monitoring exercise did also reveal very little integration if any of the Onchocerciasis programme with other existing health prograrnmes in the area and yet this is critical if sustainability it to be achieved. The project runs an independent progr.rm. For example, Procurement and delivery of Mectizan is done independendy of other Programs, the staff are not yet recognised and absorbed by i6g Ivlinistry of Health (MoH). The program is still seen as an independent donor driven one without any government financial contribution. Whereas there were reports that the State Ministry of Health had included the salaries of the project staff in the coming budget, it remains to been seen how this will work. It is therefore recommended that the project intensifies its advocacy to enlist more support from not only the government but also other stakeholders insluding donors and local NGOs for support. (6) The issue of CDDs demanding for incentives remain critical and in a bid to reduce it, there is need to reduce on the workload by mobilizing and sensitizing people on the need to have more CDDs such that the workload is shared. Each CDD at least should handle between 20-30 households. (7) This monitoring exercise also found a significant number of people who did not know about Onchocercisis and its control activities in their areas. They were living as if nothing was happening. This calls for increased and sustained efforts by the project management to sensitise people about CDTI as this will not only enhance support but also will increase uptake of the drugs for those who did not know and therefore were not making any effort to take the (drugs). A strong educational campaign guided by a well designed communication strategy that takes into account how best to reach out to the various sections of the society is recommended. As much as possible efforts should be made to utilise existing channels of information dissemination such as, religious gatherings, FM radios, schools, community 3l to (8) gatherings, community leaders, CDDs, health workers, posters, brochures and leaflets. One other area that was noted weak is records management. Record keeping was poor and no where did the team come across complete records of the previous treatment especially at community level. It is therefore recommended that seminars appropriate and importance of record keeping should be conducted among various actors at all levels including CDDs. This will greatly inform mary processes including procurement of Mectizan. 32 ?t References Anfiral technical report on East Bahr El Ghazal project to Technical Consultative Committee (TCC),2008. Amazigo UV, Obono M, Dadzie I(Y et al. Monitoring community -directed treatment programmes for sustainability: lessons from African Programme for Onchocerciasis Controt (APOC). Aruals of Tropical Medicine and Parasitology; 96 (suppl. 1), S75-S92, 2002. Braidel El, Obono MO, Bassey SA Community participation in the control of Onchocerciasis in Cross River State, Nigeria. Acta Leiden, 59, 427-32,1990. Kaabarwa NM, Mutabazi D, Richards, FO fr . Controlling Onchocerciasis by community - directed ivermectin treatment programmes in Uganda: why do some communities succeed and others fail? Annals of Tropical Medicine and Pa s ra si tology;. 9 4, 343-52, 2000. 33 \ Fa a AI.INEKES 1. List of indicators 2. List of Instruments 3. Guidelines 4. Other attachments including graphs, charts, histograms, maPs 5. Debriefing sessions with NOTFs and Country WRs 34