Consultation mission on Community Self-monitoring (CSM): Burundi, from 5th to 10 th July 2010

By: REPORT Mrs AKAME Julie, Programme Officer at HKI/ Gameroon M. AKONGO Serge,Tehcnical Adviser /ApOG Dr NDIKUBAGENZ! Jacques, Vice-Dean Facutt6 de M6decine, Universit5 de Buiumbura t;li I oN GoMMUNTTY SELF-MOilITORING (CSM) Dl, fmm Sth to lOth July 2O1O ?'l \ l' I =t*'4 -i rf 't" .J !\. r-\ E f -l \\ IF, I ;i &r ffi'j ..V'IfhI \' t I I -Y Table of contents I.INTRODUCTION Background and rationale ................ General information about Burundi. Short presentation of Cibitoke-Bubanza CDTI Project III. DIFFICULTIES ENCOUNTERED IV. RESULTS OF THE CONSULTATIONS ON CSM 1. lnterview with the national coordinator of the NOCP and the coordinator of Cibitoke-Bubanza Planning of CSM ... ..4 L 2 3 4 5 6 7 8 8 II. WORKING METHODS D 2 Solutions recommended............... lncentives for CDDs Meeting with Health District and Health Area Responsibilities in CDTI implementation...... health staff . 8 8 9 9 9 9 Training received on CSM ls CSM useful for your work? Planning of CSM the last 2 years Problems and solutions raised by the CSM reports lncentives for CDDs... Synthesis of group discussions amonB community members Knowledge and information on the programme, the disease and the treatment Structural and dynamic organization in the communities........... lntroduction and implementation of CSM in the communities... Obstacles to the implementation of CSM............ 10 .. 10 ..11 ..11 ..11 ..11 t2 L2 ... 13 13 10 10 Participation in a community meeting following the campaign for the distribution of Mectizan 10 Encourage communities to use CSM for other health programmes Difficulties in introducing CSM in the Hills.. Solutions recommended............... 3 2 ...13 lncentives for CDDs V. CONCLUSION AND DISCUSSIONS OF THE RESULTS...... VI. RECOMMENDATIONS.. To APOC..... To the Ministry of Health (Central level) To Health districts......... To health areas ANNEXES 13 L7 L7 L7 17 18 3 ..15 ............17 I. INTRODUGTION {. Background and rationale The African programme for onchocerciasis control (APOC), in order to achieve its main goal which is to eliminate onchocerciasis as a public health disease in the endemic zones by 2015, has defined the sefting up of sustainable onchocerciasis contro! programmes in all African onchocerciasis endemic countries, as one of the specific objectives. This objective requires the empowerment and the ownership of the CDTI activities by the affected communities. Operational studies and experience have shown that communities are capable of ensuring the monitoring of its own activities, a task that has been looked at, until now, as the duty of the health staff. CSM is therefore a process through which the community undertakes to evaluate its own performance regarding CDTI (or any other activity that benefits from community participation), in order to ensure that the programme's activities are implemented in line with the expectations. This exercise encourages the community ownership of the programme and its suggestions for adjustments if need be, based on the feedback of the monitors' report (who are themselves members of the community). The feedback meeting is the place where the community is informed of the treatment with ivermectin in their village, and in which it discusses the results and reaches realistic solutions by consensus to the problems encountered. lt is a community-directed activity that should be encouraged as such. Despite the efforts made by APOC, most CDTI projects delay in implementing this activity. Faced with such shortcomings, the management of APOC undertook to organize some consultations in some countries in order to identify the obstacles to its implementation. Burundi is the 1't country to have initiated these consultations whose results, drawn from the opinions and suggestions of health workers, community leaders and community members, will contribute to the improvement and to the introduction of CSM in all endemic areas. Moreover, the issue of incentives for CDDs is a major challenge that most CDTI projects should take up and constitutes not a negligible a threat to the attainment of the objectives of the programme. This is a great opportunity to discuss the issue with those working in the field and particularly with the communities for whom this exercise is planned. The objectives of the consultations are: ldentify the obstacles to the implementation of CSM and the strategies to address them; ldentify the obstacles related to the incentives for CDDs and the strategies to address them; ldentify strategies that could encourage first line health staff and communities to use the CSM forum to discuss other concerns related to community health; Use the lessons learnt from these consultations to develop a guide that will be used at countries level. 4 2. General information about Burundi Map: Location of Cibitoke-Bubanza project (Republic of Burundi) Burundi is located in the East Central part of Africa between latitudes 2'20' and 4"27' South. lt straddles the 30th longitude East. lt is a landlocked country in the Great Lakes Region that shares borders with the Democratic Republic of Congo to the West, Tanzania to the East and South and Rwanda to the North. Burundi is located at 1.500 kms from the lndian Ocean through the shortest commercial road that runs from Dar-Es-Salam to Bujumbura (the Capital City). lt is a country with an uneven relief whose altitude varies from 770 m near Lake Tanganyika to more than 2.000 m on the plateaus. The area is 27,834 km2 excluding the Burundi part of Lake Tanganyika. The country prides itself with a tropical climate with an altitude that varies from 800 m to 2000 m; the rainfall varies from 1000mm to 1400mm with an average temperature of 20'c. Above 2,000 m on the Congo-Nile watershed, the rainfall is abundant (+l-1400 mm) with an annual average temperature of 17" C. The climate is marked by irregular rainfalls distributed between two seasons (dry and rainy seasons). The hydrography of Burundi is characterized by two sides: the Nile basin and the basin of the Congo River formed by all watercourses located to the west of the Congo-Nile watershed and by those located in the eastern depression to the South and that flow to the Atlantic Ocean to the West. The last general population census carried out in August 2008 estimated the total population at 8,038,618 inhabitants. The population was estimated at 8,271,738 inhabitants with an annual increase of 2.9o/o in 2009. This population is rural (93%) and very young. 48.8o/o are less than 15 years old and the population is scattered on top of hills. Finally, it should be noted that women represent 51.38% of the total population. r-It At the national level, the administration of the country is run by a government who implement a comprehensive policy of the country. The country is divided into 17 provinces subdivided into 129 communes led by communal administrators. The communes are also subdivided into zones. The zones are made up of hills. The hills are led by chiefs. With regard to the Bujumbura City Council, the communes are subdivided into suburbs led by suburb chiefs. The hill and the suburb constitute the principal administrative units whose number is about 3060 all over the country. With regard to health care, the country is divided into 17 health provinces each of them managed by a Province Medical Director, 43 health districts managed by a district head Doctor, and707 health care facilities managed by an incumbent. The policy of the Ministry of Public Health consists in setting up health districts in all the provinces. These districts constitute the most operational periphery level and are meant to replace health sectors. 3. Short presentation of Cibitoke-Bubanza GDTI Proiect Onchocerciasis is an issue of public health in Burundi. The government, via the Ministry of Health, instituted since 2005 mass treatment with Mectizan in the provinces of Bururi, Bubanza, Cibitoke, Makamba, and Rutana where the disease is endemic. 3 CDTI projects were, therefore, set up: the Cibitoke-Bubanza CDTI Proj6ct whose activities started in 2005, and the Bururi and Rutana projects whose activities began in 2006. These consultations were mainly carried out in the first project. The area of the Cibitoke-Bubanza project is inhabited by the Bantu, Bututsi, and Batwa (pygmies); three ethnic groups with the same culture and speaking the same language: Kirundi. The majority of the population in the CDTI area is sedentary and relies on agriculture and stock-breeding. A small part of the population living along the rivers mentioned earlier also rely on gold mining, particularly in Cibitoke and Mabayi's health districts. Onchocerciasis control activities are taking place normally in this project area and a significant progress of the therapeutic coverage rate has been noted as the years go by (See the table below). Table: Development of coverage rates Years Total population Population treated Rate of therapeutic coverage Number of hills Rate of geographic coverage 2005 448,417 164,079 35.758 157 75.48 2006 656,947 472,274 71.89 208 100 2007 722,083 523,906 72 55 208 100 2008 752,107 536,1 36 71 .15 208 100 2009 794,907 607,862 76.47 209 100 6 Major problems encountered by the project coordination team are as follows: - The disatisfaction of CDDs due to lack of incentives , - The uneven topography and the roads that are impracticable during the rainy SCASONS ; - Larger area covered by some health care facilities, i.e., 10-13 hills per CDD requiring a-four hour walk or more; - lnsufficiency of logistics : most nurses perform supervision or other community health activities on foot - The Mectizan distribution periods coincide with farming and rainy season in the province of Bubanza. II. WORKING METHODS The methodological approach selected consisted in organizing meetings with health staff at the level of projects coordination (National Coordination and CDTI projects), Health District (District Medical Officer) and Health care facilities (lncumbent nurse of health care facilities) on the one hand, and in organizing group discussions with community members, on the other hand. This way, 4 hills (villages) were first selected for this exercise (Giserema and Miremera in the provinces of Cibitoke and Rugeyo, and Butembe in the province of Bubanza). Because of inaccessibility, insecurity and the limited time allocated to these exercises, group discussions only took place in 2 hills ( Miremera in Cibitoke and Rugeyo in Bubanza). The following tools were used: - An interview guide with projects coordinators (national coordinator and Cibitoke- Bubanza project coordinator). - An interview guide with health staff (levels of Health care Facility and Health District) - An interview guide for group discussion with communities. Prior to the visits in communities and after the courtesy visits to political and administrative authorities, a briefing was given to other partners involved in the management of community-based development programmes. They are: - Agriculture extension worker - SocialWelfare worker - Community mobilization worker. These parties participated in the discussions at community level and expressed their opinions on the implementation of CSM in the communities. Moreover, a meeting took place at the central level with the other health programmes and partners of the Ministry of Public Health in order to sensitize them to the use of the CSM forum in order to engage and encourage the communities to discuss other community health problems. 7 lnformation gathered from the interview guides that express the health workers' opinions is presented in the first 2 items of the results and the one from community discussions is synthesized by discussion topic and presented in the third item. III. DIFFIGULTIES ENGOUNTERED Short time period for carrying out this mission (4 days out of which 2 days for field trip) Choice of communities to visit made on very remote and hard-to-reach villages (hills). ln consequence, much time was used for travelling. The atmosphere of insecurity that prevails in the country IV. RESULTS OF THE GONSULTATIONS ON GSM {. lnteriew with the national coordinator of the NOGP and the coordinator of Gibitoke-Bubanza proiect Relationship with other health programmes At the central level, the NOCP is part of the programmes under the authority of the Division of Neglected Tropical Diseases (NTDs). The planning of activities at the central and province levels is done in consultation but the implementation is specific for each programme. A good collaboration exists between the projects coordinators and the managers at the level of province health districts. However, compartmentalization and the vertical management of programmes were noted. They led to a large number of interventions at community level that apply different strategies, contradictory sometimes, and that use "community implementers" each time differently from one programme to another ( different system of incentives in CARE GROUP and Volunteering in CDTI). - Planning of CSM The National Coordination of the NOCP has initiated a training of health facilities heads based on availabte documentation and on how the activity is understood. Their understanding of the activity led these staff members to conduct monitoring missions to organize meetings with the CDDs in order only to collect treatment data at the end of the distribution campaign. This activity has therefore been planned to be conducted by the head nurses of health care facilities. lt has never been planned to be introduced in the communities, and to be monitored and encouraged, as an activity conducted by communities on their own. 8 - Solutionsrecommended The Coordinators recommend that training sessions be organized on CSM from the central level and these sessions continue to reach each level of the health pyramid (provincial, health district and health care facility. The introduction guide to CSM should be made available at all levels, notably at the level of the health care facilities as an absolute necessity. The organization of community meetings to discuss CSM should be a priority for the staff of health care facilities. Good sensitization of the populations and good mobilization of hills chiefs may contribute to an effective implementation of this activity at the level of each hill. lncentives for CDDs The Coordinators, firstly, noted the difficulty related to the presence of several community health implementers in charge of specific health activities to which the programmes apply different strategies of incentives. Some leads for solutions were suggested regarding the incentives for CDDs. Among others, there were free medical treatments of CDDs (upon presentation of a CDD lD card) or exemption from administrative fees for CDDs who need services at the level of the communes or city halls. None of these suggestions has been applied. The solutions that seem to be chosen by the Ministry of Health are probably harmonizing the strategies and setting up a unique structure at the level of each hill that is made up of the most active community implementers, who may benefit from the incentives from one or several programmes, when it is possible. A study commissioned by the Ministry of Public Health to address this issue is on-going. 2. Meeting with Health District and Health Area health staff The interview guide for the health staff was administered to the Bubanza provincial medical officer (province of Bubanza), to the Mubayi Health District medical officer (province of Cibitoke), to 3 supervisors of Bubanza and Mpanda Health Districts (province of Bubanza) and Mabayi (province of Cibitoke) and to the head of the Ruhororo Health care Facility (province of Cibitoke). ln total, 6 staff members responded to the questionnaire. Responsibilities in CDTI implementation Out of 6 staff members interviewed, 5 have clearly indicated their responsibility regarding CDTI activities. Only the Mubayi Health District Medical officer (also head medical officer of the district hospital) is not really involved in monitoring CDTI activities. He had been in 9 this position four 6 months and had not yet been trained on CDTI. All other staff members, at province, Health District and Health Area levels, are involved and are familiar with their roles and responsibilities. - Training received on CSM No health staff has received training on CSM, be it at the level of provinces or at the level of Health Districts. The issue was vaguely referred to, but without any documentation during the training of Health care facilities' staff in 2008. ls CSM useful for your work? All the staff members acknowledge the importance of CSM that may make their actions become more effective. The staff, due to the workload they experience, is not always in the position of applying possible solutions to solve problems in the communities. Getting some advice from these communities and relying on them to apply the solutions are necessary and useful. Planning of CSM the last 2 years The introduction of CSM as defined by APOC has not been planned by the health staff. The understanding of this activity at the level of Health care facilities led health staff to conduct monitoring and supervision missions to the hills and to organize meetings with the CDDs for the collection of treatment data. CSM has not been understood as community activity carried out by communities themselves. - Problems and solutions raised by the CSM reports No health staff member has received reports from the communities, given the fact that the activity had not been introduced to them. Participation in a community meeting following the campaign for the distribution of Mectizan No staff member participated in a community meeting following the campaign for the distribution of Mectizan. To their knowledge, no such meetings took place. Health district and Health care facility levels supervisors have mentioned difficulties for travelling and the scarcity of logistics if they were to attend community meetings. 10 - Encourage communities to use CSM for other health programmes Given the fact that the health staff were not familiar with CSM, the way it has been defined by APOC, no indication was given to communities to this end. However, it happens that communities, episodically, get together to discuss clearly defined items relating to the development of the hills, under the initiative of the hills chiefs. Health care staff members would also invite the populations to attend other health activities (Comprehensive lmmunization Programme, Reproductive Health etc.) - Difficulties in introducing CSM in the Hills The lack of information and training on CSM is the 1st obstacle to introducing CSM in the communities. No staff understood it as an activity that should be conducted by the community itself and that should be organized within the community. Documentation required for better understanding of the activity is insufficient if not lacking. The staff members of health care facilities complain about the lack of logistics and about the fact that many hills are enclosed when they have to conduct CSM in each one of them. Solutions recommended All staff members requested a sound training on CSM. Such training should be organized from the central level to that of the health care facility. Furthermore, sufficient documentation should be provided to the health staff so that they may be able to apply the implementation steps and monitor the progress of the activities at the hills. Most staff members want to see a strong involvement of the administrative authorities (provincial and communal) in the holding of community meetings. Given that the hills chiefs are under their authority, their influence in engaging the chiefs to organize this activity is of chief importance. The issue of logistical support (vehicles and fuel) was also raised by the staff at the level of the Health Districts and Health care facilities. The latter have no means of transportation to reach some hills that are hard-to-reach on foot. At the level of the Health Districts, supervisors are sometimes provided with only one vehicle when the Health District Medical officer is not on mission. lncentives for CDDs lncentives for CDDs remain a big challenge globally at the project area and at the level of all the hills. The health staff finds this problem all the more difficult than different policies and strategies are applied by other partners (For instance, the NGO CONCERN \ /W funds the activities of CARE GROUP community members, set up at the level of the hills l1 and sub-hills, involved in tuberculosis surveillance activities or community health implementers designated in the framework of UNICEF operations, who receive funds from health care facilities' budgets). According to officers at the central level, a study is on-going to find a solution to these diverse approaches. Harmonizing policies is, most and foremost, necessary for the interventions at community level. The merger of the different groups (Care Group, community health implementers, CDDs) operating in the hills is indispensible for effective interventions. The Health District health staff proposes a gratification mechanism (in kind or material) granted by the Ministry of Health at the levels of health care facilities, on the basis of the performance of "community health implementers", (name given to any volunteer designated by the community), depending on performances. 3. Synthesis of group discussions among community members During our consultation mission, we organized 2 Group discussions in the Miremera hills (Cibitoke province) and in the Rugeyo hills (Bubanza province). ln Miremera, 16 community members, among whom were 5 women, participated in the discussions. ln Rugeyo, 30 people, among whom were 10 women, participated in the discussions. lmplementers of associated sectors (A Bubanza Agriculture extension worker, a Social Welfare worker, a Community Mobilization worker) participated in the discussions. Knowledge and information on the programme, the disease and the treatment ,/ Communities are perfectly aware of the distribution of Mectizan and other drugs that are distributed. They are aware of the disease and its manifestations. The distribution of Mectizan has been effective since 2005 and is carried out by CDDs selected per sub-hill and by the members of the sub-hills. Everybody knows the CDDs who distribute Mectizan and most participants in the discussion are aware that the number of tablets is given according to the height. / CDTI was introduced in the communities by the health staff (during a meeting also attended by the community mobilization agent). / The distribution mode in a central point of the sub-hill was decided by the CDDs (Miremera Hill) and by the entire community (Rugeyo Hill). Unfortunately, the results of the campaign are not made known to the population. No feedback is given to the population. Only the hill chief is aware of the results of the mass d istribution campaign. t2 - structura! and dynamic organization in the communities ./ In general, community meetings are called to discuss some aspects and problems relited to living in the hills. The hill chief calls these meetings. He writes a message that he fonraids to the sub-hills chiefs and to the church. The sub-hills chiefs inform the heads of the10 households that get the population informed. Messages are also communicated in the churches. / Women regularly participate in these meetings, even though many women among them preter to take care of other businesses such as farming and other chores. They feel obliged to participate in the meetings called by the hill chief. - tntroduction and implementation of CSM in the communities ./ The communities never received the information on the necessity to hold a meeting at the end of the Mectizan distribution campaign and they were not asked to choose people to check whether everybody was treated. What they know is that the CDDs report on the distribution to the hill chief and to the health care facility nurse. ,/ No meeting took place to discuss the results of the Mectizan distribution campaign or any other health Problem. Obstacles to the implementation of CSM ./ The lack of information is the root cause of the lack of follow up activities that should be carried out by the community. The health staff did not explain to community members that they themselves can evaluate the results of the Mectizan distribution camPaign. ,/ The late delivery of Mectizan in the hills, at moments close to farming activities, often discourages the members of the community, who end up losing interest in the distribution of Mectizan. ,/ All the members of the community acknowledge that if these meetings had taken place, they would have been provided more information on the programme and on other health-related actions conducted in their hills. That would have helped them solve several problems in the hill, including those related to other development problems in general. r' According to members who participated in the discussions, the hill chief and the sub-hill chiefs are responsible for calling these meetings. lnformation related to them simply needs to be circulated. - lncentives for CDDs ./ The community members acknowledge that there is a problem with the CDDs. According to them many CDDs left because of the lack of incentives. ln addition, they are aware that other community workers benefit from incentives given by other programmes at the end of the activities; the programme must therefore provide the l3 CDDs with incentives. ln fact, no one ever told them that they should provide the CDDs with incentives. Some members argued that the populations are poor and that it will be difficult for them to help the CDDs / After getting some explanation about the necessity to support the CDDs in their duties, the community members stated that all the sub-hills should get together to discuss the issue and find out the best way to help the CDDs. ,/ Some CDDs who were at the discussions suggested that, instead of cash, support in kind would be welcome and would be a proof of acknowledgement by either the community or the health staff. l4 V. GONGLUSION AND DISGUSSIONS OF THE RESULTS Following the different consultations with the Ministry of Health of Burundi and the meetings organized with health administrators at the level of provinces, health districts, communes, health care facilities and administrative and political authorities, followed by the discussions carried out in the 2 hills of the Cibitoke and Bubanza provinces, the following conclusions emerge: On the one hand : ,/ The populations are well sensitized about the onchocerciasis control activities and are appropriately informed of the disease, the treatment, and the instructions on the drug administration. Likewise, the administrative and politiques authorities (Province Governors and communal authorities) have good understanding of the programme and are involved in the mobilization for onchocerciasis control. ,/ CDTI was introduced in all the hills identified as endemic for onchocerciasis by the health care facilities staff that has provided enough information to the communities. A strong commitment of health care facilities staff and a sound knowledge of CDTI and its philosophy have been noticed. ./ A constant increase of the rates of therapeutic coverage since the launching of the project in 2005, in spite of the fact that the minimum rate of 80% has not yet been reached. (35% in 2005 - 75o/o). / A good structural organization of the communities and an effective communication system (from the hill chief to community members via the sub hills chiefs and the heads of the 10 households), facilitating a good circulation of information. The organization, on precise occasions, of community meetings to discuss problems retated to the hills. This good traditional organization and the existence of discussions forums are opportunities to take into consideration in order to introduce CSM in the hills and make a common practice of it. On the other hand / A lack of information and aptitudes among the health staff members for the introduction of CSM in the communities. This misunderstanding of the activity is significant at the level of the national coordination of the NOCP, where CSM is understood as an activity conducted by the health workers. This understanding of the activity was shared by all the health staff members at all levels. / A lack of documentation was noticed. The introduction guide to CSM developed by APOC is not known by the health care facilities staff, let alone the staff at health districts. The popularization of this tool is necessary and indispensable for guiding the staff in introducing this activity. l5 Vertical and compartmentalized health interventions at community level, applying strategies of incentives for implementers often contradictory and making the accepiance and ownership of CDTI by the communities become fragile. The major consequence is that not any hill, let alone any service, provides any support to CDDs. Some solutions leads were recommended but none of them was applied in the field. Based on what is described earlier, some recommendations were made to different partners that will be the basis from which an effective planning of CSM in the hills will be made. l6 VI. REGOMMENDATIONS To APOC Provide technical support to CSM training for programme managers at the central level in the Ministry of public health; ./ Provide logistical support to health care facilities involved in onchocerciasis control; / Provide support to the training of coordinators on resources mobilization; / Grant more time to CSM consultants to enable a more in-depth analysis of the causes of the shortcomings of its implementation; To the Ministry of Health (Central level) './ Promote the integration of the activities of other health programmes in the CDTI approach; / Reinforce the capacity of Health Districts staff on Community-Self- Monitoring (CSM); '/ Promote integrated community self-monitoring; ,/ Go thoroughly into and decide a harmonized policy of incentives for CDDs/ community health workers. To Health districts / Reinforce the capacity of health workers at the level of the health care facilities for the implementation of CSM in the communities; ./ lntegrate the monitoring of CSM implementation process in the minimum activities package. To health areas / lntroduce the integrated CSM in CDTI community (encourage communities to use this forum to discuss other health problems); ./ lntegrate the monitoring of CSM implementation process in the minimum activities package; ./ Capitalize on communities' inclination (Good structural organization and community meetings organized in the hills) in order to introduce CSM successfully. t7 ANNEXES PROVISIONAL WORKING AGENDA OF THE CONSULTATION MISSION ON COMMUNITY.SELF MONITORING (CSM) IN THE REPUBLIC OF BURUNDI FROM 5 - 10 JULY 2OIO DATES ACTIVITIES Monday 5 Jull' Arrival of external consultants Visit to WHO Office in Bujumbura Meeting "vith the Director in charge of NTDsMeeting with the deputy-Director in charge of the NOCP Drafting of detailed programme of field activities Submission for security clearance Meeting with facilitators and development of information gathering tools Tuesday,6 July Meeting with the WHOiBurundi Representative Security briefing Finalization of information gathering tools Wednesday, 7 July Field trip Meeting with Cibitoke administrative authorities Meeting with Mabayi health district head (Cibitoke) Visit to Giserama community (FGD) Visit to Miremara community (FGD) Back to Buiumbura (security instructions) Thursday,8 July Field trip Meeting with the administrative authorities of Bubanza Meeting with Musigati health district head (Bubanza) Visit to Rugeyo community(FcD) Visit to Butembe community(FcD) Back to Bujumbura Friday,9 July Meeting with Director of Disease control Programmes' meeting on CSM Briefing WHO/Burundi Representative Drafting mission report Saturday, 10 July Departure of external consultants 18 CoNSULTATTON MISSION ON COMMUNITY SELF-MONITORTNG (CSM) Burundi, from 5 to 10 July 2010 INTERVIEW GUIDE WITH HEALTH STAFF (District and Health Areas levels) Fottowing the meeting with the lrcalth staff, the facilitator nrust ,nake sure that the staff members understand their role and responsibilities regarding the CDTI, their role in the introduction and trtonitoring of the implententatiott of CSM by contmunities, the necessity to promote the use of CSM in other progranunes that integrate community participation, which encourages the interaction benueen health services and conunurtities, and contribute to the success of healtlt programmes ot conmuutit.t level. Health zone of: Health Area Project Country l- What are your responsibilities in CDTI implementation? 2- Have you been trained in CSM? 3- Do you think CSM can improve your work (planning etc.)? 4- Have you planned it the last 2 years? in how rnany villages? 5- Have you received CSM reports? What were the main problems raised by communities in their reports? What rvere the solutions suggested by communities? 6- Have you ever aftended a community feedback rneeting? lf not, why? Do you etlcourage communities to use this kind of rneeting for other community health programmes? Have you ever received reports that deal with other health problems in additiorr to CDTI? 8- Have you faced difficulties in introducing CSM in the communities? Which ones? 7 9- What solutions do you recommend? 19 CoNSULTATION MISSION ON COMMUNITY SELF-MONITORING (CSM) Burundi, from 5 to 10 July 2010 INTERVIEW GUIDE WITH CDTI PROJECTS COORDINATORS (National and Provincial level) l - Relationship maintained with other programmes 2- Planning of CSM (Was CSM planned during the training sessions of the staff? was its introduction planned in the villages?) lf no, what are the reasons? 3- Solutions recommended 4- lncentives for CDDs 20 aCoNSULTATION MTSSTON ON COMMUNITY SELF-MONITORING (CSM) Burundi, from 5 to l0 July 2010 GUIDE FOR DISCUSSING WITH COMMUNITIES Before the meeting of the group discussion, explain to the participants that the objective is not to detect shortcomings in what has been done in the community bttt to improve the global process of implementing CDTI The participants should therefore be encouraged to.freely express themselves during the meeting and all contributions ore v,elcome. After the administration o.f this discussion guide, the facilitator .shoulcl allow the participants to ask questions. Make sure, at the end of the discussion, that they quite well understand the necessity of having a good therapeutic coverage each y'ear, of having several CDDs (depending on neecls) and that they are supported by their communily, and finally, that communig, meetings should be called at the end of each Mcctizan distribution campaign so that the entire community should discuss the results andother health i.ssrres. andalso discuss about life in lhe village. Village: Health Zone Project Country Number of participants Number of women 1- Knowledge and information about the programme, the disease and the treatment Are communities informed about the Mectizan distribution? (who talked about it? Control o.f which disease? how long has the distribution taken place? u,ho distributes Mectizun? hou,many are they? v,ho selected thent ? does everybody knou, the CDDs in the village ?) How is the Mectizan distribution carried out in the village? (who chose the distribution mode ? when did the last distribution take place ? v,hat were its results? 2- Community structural and dynamic organization Does the village often hold meetings to discuss issues relating to the village life? Who calls these meetings? How are people called for the meetings? u,here do they take place? do women attend these meelings?) 2l a3- Introduction and implementation of CSM in the communities Has the nurse talked to you about meetings that should take place at the end of each Mectizan distribution campaign (CSM)? when did that happen? have there been any meetings since then? If meetings were organized ' How did they go? what did the discussions refer to? . What issues were raised at the last meeting? What problems were solved at that meeting? Are there any reports from this meeting ? . Has this meeting been useful to the village? do you think this meeting may contribute to discussing other health problems of the village? which ones for example? . Are you happy with the way it took place? Are there things that y'ou wish to improve? 4- Obstacles to CSM implementation If meeting were not organized . Do you think this kind of meeting is useful to the village? . What difficulties do you face in organizing this kind of meeting? ' What do you propose to get these meetings take place? 5- Incentives for CDDs - [s the village organized to encourage the CDDs in their work? If yes, how? If no, Why? - What does the village intend to do to encourage the CDD? 22 aConsultation mission to Burundi on CSM Report of the meeting with the programme managers and partners from the Ministry of Health On 9 July IOLO, a meeting with the managers of other health programmes and the partners took place in the conference hall of the ministry of Health. The meeting aimed, on the one hand, at sensitizing these managers in order to use the CSM forum and encourage community members to discuss other health problems, on the other hand, at contributing to an effective implementation of CSM in the communities. The meeting was attended by: The National Coordinator of the NOCP of Eurundi The provincial coordinator of the Cibitoke-Bubanza CDTI project The Advisor in the Department for the promotion of health, hygiene and sanitation The Manager of Monitoring and Evaluation at the Direction of NTDs control The deputy- director of PEV (Comprehensiv6 lmmunization Programme) The head of IEC Service at the Ministry of Public Health The Manager of IEC and Mobilization at the Direction of NTDs control The Manager of prevention and management at the Direction of NTDs control At this meeting, the participants were given the following presentations Short background of CDTI and CSM Summary of the field work After these two presentations, the participants acknowledged that CSM is a very important exercise that is necessary for engaging communities to discuss their own health problems and get the ownership of the programmes. A series of comprehension questions were asked and responses were provided by both the consultation team and the national coordinator. Ending the meeting, the participants made the following recommendations: APOC's support for the organization of training on CSM in Burundi ; Extension of CSM training to other programme managers ; APOC's support for the organization of a workshop on resources mobilization in Burundi to ensure the continuation of the programme ; Quick steps to be taken by the Ministry of Health to come up with a tangible conclusion on incentives for < community implementers > based on different actions undertaken. Necessity to set up a process of integration of health activities at community level. a a Bujumbura,9 July 2010 23