History of ivermectin treatment in communities in Ghana: report on main findings, 2nd -14th November 2007

African Programme for Onchocerclasis Control (APOC) History of Ivermectin treatment in communities in Ghana Report on main findings z"d-l4to November 2007 by Tihman Diana, Social Scienttst Inter+ountry sapport Team (IST)/ Malaria west Af,rica November 2007 1 f Executive summary This report is the result of a study commissioned by the African. Programme for Onchocerciasis Control (APOC) to document the history of onchocerciasis treatment with Ivermectin in Ghana, against the background of an alleged resistance to Ivermectin treatment reported by medical jouinal Lancet in some communities in the country' The study was conducted with national experts as field assistants. The study team used mainly qualitative research methods - interview of key informants and the main actors in the implementation of onchocerciasis control from the national to community level; observation, and review of records on the treatment, mainly at community level. The study covered 21 villages, including 20 villages referred to in the Lancet publication, and one secondary village. The study team used questionnaire to assess ivermectin treatment coverage in the communities. Five individuals were selected randomly from each village to respond to th9 questionnaire and the research method used was difileient from the one on geographical and t^herapeutic coverage developed at the workshop in Ouagadougou 13-16 October 2007 ' The study showed that the implementation of the onchocerciasis control programme in Ghana is facing some major difficulties which are impeding the programme's performance' Treatments carried out annually were ineffective in many of the villages surveyed. Not all eligible individuals were treated, especially those who lived in the hamlets. Some community members have imposed unilateral eligibility oriteria for treatment. These include community membership status, in some cases involving payment in kind for the treatment. In mosi cases, absentees do not benefit from the treatment even after they had returned to the community. These returnees, who were required to receive treatment at the nearest health centre or health post, often did not bother to go for the treatment' It was also observed that many people in the community refused to take ivermectin because of inadequate information abouf ttre drug. There is - even an elroneous belief in some communities that *y on" who took iverriectin in combination with the local gin, (ahpeteshi), would die. Conseqftntly, some individuals had never taken any tablet of ivermectin since the introduction of the drugby the National Onchocerciasis Control Programme in Ghana' Further more, the reported treatment coverage was more or less based on estimates or speculation. The eligible population is not known in most of the communities' Those registered for treatment constitute only a fraction of the population eligible for treatment and in some cases the population registered for treatment is less than half of the eligible population. The settlement pattern and migration also impeded effective coverage in the villages surveyed. This problem equally affects other health interventions such as Guinea Worm Eradilation and ihe Nationai Programme for Tuberculosis Control' It was obvious that community distributors of ivermectin are willing to continue the distribution and all the communities want to be treated regularly. 2 There is therefore the need to improve the implementation of the onchocerciasis control activities in Ghana so that effective coverage could be obtained and sustained. Also, an improvement of the status of onchocerciasis control is required to commit health workers on thir programme at regional, district and community levels. Presently the indicators for assessing the iirplementation of health programmes in Ghana do not include any on onchocerciasis control. ) l.INTRODUCTION Onchocerciasis as one of the principal causes of blindness has been a major impediment to socio-economic development in Africa. The filarial worrn Onchocercavolvulus is transmitted to man by the black fly or sirtlium Datnnosum- A public health programme set up to combat the disease in West Africa - the Onchocerciasis Control programmJ (ocp) -- which started in the 1970s within an initial zone including Ghan4 was later extended to other countries in West Africa. International commitment to prevent onchocerciasis from becoming a public health problem in Africa has resulted in frnancial and technical support from the global community against the disease. The first strategy for onchocerciasis control in Africa was through vector control and for a long time, the riain control tool was larviciding chemotherapy. Another stratery was aimed at arrJsting 'the Ochocercu volvulus by eliminating vector population for the lifespan of the adult worm from human reservoir. The chemotherapy had involved the use of many medicines against onchocerciasis, but ivermectin has since shown its evidence-based effectiveness in the treatment of the disease.It has been possible to use ivermectin supplied free of charge by pharmaceutical company MERCK & Co Inc. for mass treatment with manageable side-effects. At the beginning, treatment with ivermectin was conducted by mobile teams from the national onchocerciasis control programmes in the OCP countries. But after this approactrfailed to achieve the desired objective because of the limited numbers of health personnel, the focus then shifted to the involvement of communities in the treatment of Onchocerciasis, first by a community-based implementation and later the Community Directed Treatment with Ivermectin (CDTI). This strategy was piloted in five countries in 1996 -- Cameroon, Ghana, Mali, Nigeria and Uganda thr;gh u -rlti-"o,rntry study with four sites in Nigerial' The pilot scheme, which showed the CDTI approach as a better option to the mobile-team strategJ, reached the following major conclusions: - CDTI is possible and effective - CDTI has been successful in a wide range of geographical and cultural settings in Africa and is likely to be replicated in other endemic communities in Africa. - CDTI was therefore adopted as a strategy for onchocerciasis control in Africa by OCP and has since become APOC's main strategy A study on sustainability has been conducted in Ghana, Mali, Nigeria and Togo and following this study, sustainability *as established within the context of provision of support for the implemeniation - r"ro,or", for procurement of the drug, side-effect management, Community Directed Distributor (CDDs) support, and other basic programme management needs' , m& OCp, ApOC Communitydirected Treatment with lvermectin Report of a multi-county-study TDR/AFR/RP/96.1 4 The facilitation role of health workers was also evident through meetings, dlug suPPlY, training on record keeping, reporting and interaction with *.-urities as partners2. CDTI is currently being implemented in ex-OCP countries within the context of devolution in APOC countries. In these fo.-.r OCP countries some zones have been selected for targeted interventions and these are known as the Special Intervention Zones ( SZs) Some of these zones are in Ghana. Recent scientific papers published on studies in Ghana claimed the resistance of the adult Oncocerca volvulus-to ivermectin as a result of possible long exposure to the drug. But what is considered as resistance could be related to factors other than exposure of the adult worm to ivermectin. The 2l-village study conducted in Ghana during the first two weeks of November 2007 sought to assess the situation of distribution of ivermectin in the country and also to: o Document the history of ivermectin treatment in communities reported by Lancet as well as in some neighbouring communities; o Report on differenceg if any, between coverage rates provided by community-directed distributors, health personnel and coverage (rates) based on information from communities o Identify endemic communities with low coveragerate, and document reasons for low geographic coverage. A protocol development workshop was held in Ouagadougou in October-2007 to assess .orr.rug. and compliance with the treatment of ivermectin, just before the first phase of the study in Ghan4 which concentrated on geographic and therapeutic coverage. The second phase assessed compliance with the treatment. The study team had a specific task as enunciated above by its terms of reference, and so designed a relevant study protocol for its survey. The team worked within the context of Phase I of the study protocol developed in Ouagadougou. 2. METHODOLOGY The study team combined qualitative and quantitative methods for the study, although greater emphasis was placed on qualitative method using interviews at different levels: 2.l.Interviews at national level. The interviews were conducted with: professional staff of the National Onchocerciasis Control Programme on the support provided to the implementation of onchocerciasis control in Ghana, challenges faced in the implementation of the programme and suggestions to improve the implementation of the prograrnme. professional staff of other disease control programmes in Ghana such as Guinea wofln, and tuberculosis on the challenges in the implementation of these progftLmmes. a a 'LINDp/World Banl/WHO Implementation and susAinability of Community-Directed fieifment of Onchocerciasis with lvermectin: A multi+ountry study TDR/IDE/FP/CDTU00' I 2000 5 o professional staff of the National Census Secretariat on demographic matters with regard to migration in the country to determine regions and districts with high migration rates 2.2.lntewiews at regional level involved Regional coordinators of the onchocerciasis control programme on the support obtained from the national level, support provided to districts for the implementation of onchocerciasis control programme, the number of communities affected by onchocerciasis in the regiorq implemertutio, challenges and suggestions to improve the implementation' 2.3.Interviews at the district level with: Directors of district health services on population dynamics in the districts, the number of communities covered by the progrllmme, the support provided to the health staff involved in the implementation of onchocerciasis control programme, support provided to the CDDs, and suggestions for the improvement of the implementation o status. Z.4.lnteruiews at the community level involved: o Village chiefs, community leaders, representatives of community associations and comriunity members, on first year of-treatment, last year of treatment, number of rounds of treatment and reasons for no treatments in some years. The interviews also covered stock out of drug during treatment, number of stock out of drugs, change of the CDDs, number of changes of tfr. CDDs, changes in village leadership, mode of treatment (location), and chinge in the mode of treatment and reasons for change. The other elements were on consumption of drug (direct observed or not, given to head of the household or somebody else), community role in the distribution of ivermectin including procurement oi drug, incentives to CDDs, monitoring of the treatment, treatmeni coupled with village events and which events; refusal of treatments, exclusion from treatment and which group; nuisance from black flies ( in the village, at work place and period); perceived benefits of ivermectin treatment in the village; major probl".r faced in the distribution of ivermectin in the last ten years; actions to solve ihese problems; willingness to continue to take ivermectiq and suggestions to improvi the implementation of onchocerciasis control in the community. Other elements were added based on the information provided. A specific exchange was arranged with new comers in the villages, to ascertain the periods of migration; the type o-f migration (individual or family); area from which individuals migrated; .u*j.."nt o1 treatment of migrants; management of treatment of absentees; existelnce of hamlets, fishing locations or new locations of the population; farming activities and treatment periol; migrations out ofthe village; periods of migration; and management of the treatment of migrants ZonalCoordinator, on the support provided to the CDDs, the challenges faced by the coordinator in hiVher worlg^ihe hlahh programmes in which he/she was involved; willingness to continue; and suggestloni to improve the implementation of onchoierciasis control in the ,ore. The study team met only one Zonal coordinator' 6 o o CDDs were asked about new comers in the village, the periods of migration in the villages; the type of migration (individual or family); the area where individuals migr:ated from; ^*unug"rri"nt of tieatment of migrants; management of treatment of absentees; existence o=f hamlets, fishing locations or new locations of the population; farming activities and treatment period; migration out of the village; periods of migrati,on; management of the treaiment of migrants; mode of distribution; period of diJributioq durition of distribution; shortage of drug during distributioru actions taken with regard to shortage; support from the communities; support from the health personnel; suiervision and-period of last supervision; issues discussed during the last supervision; number of CDDs, refusal of treatment;willingness to continue to work as CDD, involvement in other health programmes, suggestions to improve the treatment in the community. o The interview with the CDDs had a second component on treatment records and other health programmes. A quantitative method was used for two aspects of this study involving: 2.5. Questionnaire on the treatment In each community, five members were selected randomly either in the household or in the streets but at different localisations. The individuals selected were given a short questionnaire. The inforrnation collected included on: full names of the interviewee, name of the head of household; male or female; treated for onchocerciasis or not; if treated, an assessment of the treatment for the last three years, how long the individual had been living in the community; if not a native of the community, places where the individual migrated from and their locations and the duration at each place- A short migratory biography was compiled from this exercise which was smooth-sailing in all but one coirmunity *h* u Uay decfined to answer the questions, insisting that she was not from the "o*-,rrity and couldiherefore not understand why she should be involved in the health survey. She was promptly replaced with another interviewee, also randomly selected. It was discovered that the assessment of individual treatment history was carried out in 2004, 2005 and 2006. That for 2007 was still on going when the study visited. But additional assessment was carried out for 2007 since treatment for 2007 was conduced for some communities. The year 2007 was also used to assess the treatment of the absentees mainly because this treatment was administered in most cases for more than three months. It was believed that this could help in the triangulation of information on the treatment of absentees. 2.6. Cross checking of CDDs records This was to assess o The individual treatment history over the last three years with records related to the treatment in other Years. o The update of the population eligible for treatment with regard to new settlers in the community in order to capture events related to the treatment o The time reference with regard to the treatmerft of community members o The recording as a requirement for the treatment to facilitate the management of the treatment by the CDDs. 7 o The completeness of records and the compliance by members of households to treatment and duration of treatment in the community' o The summary report on the treatment o The effectiveness of supervision (the summary report provides one page for remarks by the supervisors on the information obtained from the supervisory visits. o The way the documents were kePt The cross-checking process was conducted with one of the five community members surveyed randomly. The random selection was because the cross-checking could be a time "orruring activity for large communities. It should however be emphasized that this process was not to assess ,or.rugJ, but the procedures related to information on the treatment and on the activities of the CDis. Duringthe cross-checking (for periods where the records were available), the CDD or CDDs were on standby for interviews by the study team. 2.7. Feed back on the cross checking euestions were asked to assess the frequency of supervision during supervisory visits or if sirpervision took place without *y r""oid prepared by th-e_ supervisors, Duling the feedback session the CDD or CDDs were encouragedto continue with the record keeping as required. Where any lapse was observed appropriately advice _was given with emphasis on the importance of records and record keeping as proof of work' The CDD or CDDs were encouraged to ask questions with regarilto any aspect of record keeping. The cross-checking exercise-equally provided an opportunity foi feeaUact to the CDDs. The study team also arranged foi e*ltarrges between firc ro-.unity members selected randomly and the CDDs' TherJwas informati-on for instance about cases where individuals failed to take treatment while the CDDs also talked about the challenges of their work. The methodology d.esigned by the study team ensured that there were several sources of obtaining a partlcuhr i"nformatioq andthis provided a good opportunity for tiangulation and some times for additional cross-checking. For the interviews at community level, two field assistants handled the translation. In some cases the study team was obliged to seek the support of other members of the community in case the field assistants were not fluent in some of the languages spoken in some communities. All the interviews with community leaders, community representatives and community members were recorded. 3. MAIN HNGINGS This is a comprehensive report with detailed information including some time quotes from the community members or the CDDs. 3.1. Onchocerciasis control: Implementation environment and challenges A national Onchocerciasis control programme is in place in Ghana and is being implemented with professionals at different leveis. Rt ttr. national level seven professional staft, including two senior professionals are in charge of nation-wide implementation' The support provided from the national level consists of logistics, resource mobilisation, capacity building for the key staff in the regions, provision of tools, forecasting, ordering and pror*.-.nt of i-vermectin, -and advocacy for more support at regional and district levels so that these levels could have a budget line for onchocerciasis control. 8 Authorities at the national level, which also assist the regions in the education of community members are also in charge of monitoring and evaluation. Evaluatior\ epidemiological and entomological surveys weie usually conducted and both were in process during the period the study team visited Ghana. Ghana has Special Intervention Zones (SZ) and Non-Special Intervention Zones. The SZs receive more external support for the implementation of onchocerciasis control in the country. The Non-SVs arebenedting from the (Lymphatic Filariasis (LF) programme in areas where the diseases are co-endemic. Pru basin is one of the SZs in Ghana. The treatment of onchocerciasis within the context of devolution began in 1993 with some challenges, the major one being the determination of the communities eligible for treatment. At thatlime, the Northern r"gIon which is the biggest in the country came out with a list of communities which was considered "too many" by authorities at the National level- The National Onchocerciasis Control Programme then drew up a list for the implementation of the treatment with ivermectin by the mobile teams, but the professionals on the ground, argued that communities eligible treatment should be more. Thus many communities el[ible for treatment, but were originally excluded were later made eligible f6r onchocerciasis treatment within the context of the implementation of LF progrrrrn" in lggT.Nonetheless, since the beginning of the devolution period the problem of it " number of communities to be ffeated hid been an issue. This has remained a critical question with implications for the geographic coverage. Meanwhile, the study team gathered that gome 3204 communities in Ghana estimated to be covered by the Onchocerciasis Control Programme were being treatment with ivermectin. But this dgrr. has not been updated for some time, and among these communities 247 are within the SIZ. The figure for SZ communities was updated in 2006. While the question about the number of communities eligible for onchocerciasis treatment is unresolved, n"* communities has sprung up over time. In all the region and districts covered by this survey, the number of communities changed from year to year with implications on the implementation of the Onchocerciasis Control Programme. There are also other challenges at the regional, district and community levels.At the regional level an onchocerciasis coordinator is in charge of the implementation of the programme. He is the only professional staffin charge of onchocerciasis control at this level. At the district level the disease control offrcer is in charge of onchocerciasis control. He is also the focal point for all diseases at this level. The professional staff at sub-district level are dealing with all the disease control progralnmes and coordinating healh professionals in the ditrerent health centres at different levels including the community level' So, onchocerciasis is not a vertical programme at the community level. It is only at the naiional level that professional staffare solely committed to onchocerciasis control. This integration of onchocerciasis control into the national health system is proof of the commitment of the national authorities to the devolution of the onchocerciasis control to the countries with the cessation of OCP in 2003. A huge effort has been made in Ghana on the implementation of the Onchocerciasis Control Programme and the LF programme has been an opportunity to extend the geographic coverage of ivermectin distribution' 9 At the community level the distribution of ivermectin started with mobile teams coming from Burkina Faso and thereafter from the National Control Programme. With the adoption of the CDTI as an effective stratery of distribution of ivermectin, CDDs have been selected in the communities and implemeritation activities began with the involvement of health staff and community members. During this study, the implementation of the onchocerciasis control progfamme was assessed at all levels. The team noted that while considerable achievements had been made, the programme is facing some challenges which could adversely affect performance. 3.2. Impediments to effective programme implementation Some of the challenges at different levels include: 3.2.1. National level At the national level it was observed that indicators set up to assess hedth programmes do not have any on the onchocerciasis control. So the status of onchocerciasis control as a public health programme faces problem of implementation. for instance, the performance of a treatttr professional is measured based on hiVher work on HIV/AIDS,-Malaria, Tuberculosis and some other programmes, excluding onchocerciasis control. This situation affects the implementation of onchocerciasis control at all levels, including apathy on the part of some health personnel towards onchocerciasis control. Consequently, the status of onchocerciasis control as a health intervention does not seem to engender the commitment of professional staff in the combat of this disease. It would seem that with the achievement und do.tr.e of OCP, the status of onchocerciasis control has dropped as a public health programme in Ghana. Thisiituation could affect ihe support for and commitment to the control of this disease- Financial support is also a challenge at the national level in Ghana. For instance, in 2005 ivermectin wis made available forbnchocerciasis treatment, but the treatment did not take place in most of the communities because the resources for operational cost on the distribution were not made available in time. Other problems were related to the procurement of drug for the regions, the district and the communities, and training of healthitaff. This situation impacted negatively on treatment in many districts such as Pir, Nkoranza, Kitampo South and Tano South.The non-SZs do not always receive adequate support for implementation activities, so resources for the SIZ were some times deployed to address the needs of non-SZs. Undoubtedly, resource availability constitutes a facilitating factor for the implementation of the onchocerciasis control programme. Meanwhile, the distribution of ivermectin did not appear to be effective in some communities inZOOT,including the first two weeks of November when this study was conducted. At the national level there was also the delay of reports from the regions, so the professional staffof the National Onchocerciasis Control Programme were obliged to travel many times to the regions to get the reports. 10 3.2. 2.Regional and district levels Onchocerciasis control at the national level does not seem to encourage the full commitment of professional staff at regional and district levels, where the programme is seen as a "no man's" affair at the implementation and operational level. Health personnel .o* or less chase after programmes with more financial support, and especiaily because achievements in onchocerciasis control are not used to assess the work of ihe professional staffat regional and district levels' Even when training is undertaken more regularly, the supervision of Onchocerciasis control activities does not seem to be high on the agenda of the health professionals at regional and district levels particularly where accessibiliiy to the communities is diffrcult. For example, travelling to communities which should normally be less than 30 kilometres by road from Salaka the district of Gonja East, entailed crossing at least two other communities thereby making the journey much long.r. In some cases there is no adequate means of movement to some communities. Consequ-ently, supervision which should be a monthly activity has become quarterly in some cases. Evaluation is also seen as a national activity so the professional staff at regional and district levels do not always have the opportunity io know the situation on the ground and to take appropriate actions. The region does not have the capacity to conduct some activities either because the tools required 6r this exercise are unavailable or there are no trained health staff to conduct the activities. By far the biggest challenge to the implementation of the Onchocerciasis programme at regionat and ?-istrict tevels in Ghana remains the constant change in the number of communities. The number changes from year to year and in some cases with entire community moving to a new localion whictr could be in another district. Membership of communities also rhung.r. In some districts the last update was as old as three years ago' There is also the proSlem of migration, with one professional staff in a district saying: ..Communities do .or" at any time to another place which makes service delivery even for immunization, very diffrcult. " At the district level, some community members complained about the shortage of ivermectin in some districts, while in some communities without CDDs, the health personnel are made to take on additional duty of administering the treatment' At the district level health professionals say they are facing what they called "volunteers- fatigue" or "community fatigue for research". A d-irector of a distriit health team summed up the situation saying: "There are too many research activities going on at the same time concerning the same communities. You are the third team in two aiyt -e month ago another research team was here"3' 3 One of tlyee teams mentioned was a team working on coverage. There was also another research team working on treatment of onchocerciasis with another drug. We were informed about this team in four communities and we met the team in one community. The team was involved in a project on the treatnent of onchocerciasis with doxyciclin. 11 3.2.3.Community level The community is crucial to the success of Onchocerciasis control programme, yet featment coverage is hindered at this level by many factors including: 3.2.3.1. Settlement pattern and migration. Most of the communities have other settlement areas for farming or fishing. These hamlets are considered part of the community but treatment is uncoordinated. o In some cases the settlers are informed on the day of treatment and invited to the main community centre to receive ivermectin tablets. While many of the settlers do not go for treatment, some who turn up complain about not receiving ivermectin tablets due to an apparent shortage of the drug. A community member in Chabon said: "The time they arrive here in the village, they do not get any tablet of ivermectin because of shortage". o Consequently, treatment in many of the hamlets is ineffective. The CDDs do not go to the hamlets and when the inhabitants are asked to come to the main community many of them do not bother to go for the treatment. Also, most of the new comers in the harnlets are not considered eligible for the treatment, even as the hamlets continue to multiply in numbers. For example the Kyingakrom village has more than 10 hamlets. The CDD has no way of knowing if distributed drugs reached the intended hamlets or whether these drugs were taken. In KyingakrofiL many cases of refusal were reported and the Chief of the community was said to be assisting the CDDs in efficrts to address this problem. New settlers in the villages are usually not registered for treatment although community leaders confirmed that new comers continued to settle in the villages every year. In Kyingakrom for instance, treatment is at best, underestimated with the number of eligible individuals for treatment much higher than the number recorded for the treatment. The CDD requested for a bicycle to be able to reach and treat people in the hamlets. Also, treatment coverage is also more or less a distribution coverage estimate.Treatment by CDDs began seven y*r ugo in Kyingakrorn, according to the community leaders. Before therq a rnobile team was coming, but not every year. The study team made the following observations: o CDDs do make efforts to treat inhabitants of the hamlets and neighbouring settlements, but this is not on a sustainable basis because some hamlets are very far from the main community. For instance, a CDD in Mankutwa complained that among the hamlets he had to cover the nearest was 23 kilometres away from the main community, while the most remote was 35 kilometres. o In a few cases drugs meant for the settlers living outside of the main community are sent by the distribitor or given to the head of a household who goes to collect the quantiiy for members of his family. But the CDD has no idea if the drug has been given to the intended reciPients. o In some cases even the hamlet is near the main community, the CDDs do not go there for the treatment. If they do not come in the mother community, the individuals living in the hamlets are not tieated. For example, .a37-year-old man living in Chabon said he had never been treated before he moved in this community. He said he was living t2 in a hamlet called Burayi Ayinfe. When we asked if this hamlet was very far from Chabon he said: "Not far from here, it is just near the rivet''. In some cases for people travelling from the hamlets for the treatment, the distribution of drug is finished by the time they arrive at the main community. This is a recurrent situation in Hiampe. Here the community chief said: 'hre inform those living in the hamlets to come for the treatment. Those who come a little bit late do not get any ivermectin tablet. When they arrive the treatment is always over. In Jagbenbendo, a 25-year-old man said he had been treated twice since he moved into the comiunity. gui he ruid h" was never treated when he was in Banda, a hamlet at less than two miles from Jagbenbendo. A man from Bankaba community who said he had never been treated. "I was born in this village and I live here. But I'm also living in Nandjero some four miles from here. It is my working place most of the time. I was in Nandjero every time they gave the onchoceriiasis medicine in Bankaba. I have never been treated since the beginning". o A lady in Hiampe said she was not treated in2007 . But had received treatment in three previous years, but never in Hiampe. "I'm treated regularly because_my husband is -one of the distributors of ivermectin in Prang. We also live here, but we are not considered to be from Hiampe. Here they refused to give me ivermectin. Every distribution period I go for the-onchocerciasis drug. They do not give me any thing. I was always told that I'm not among the individuals to be treated, that I'm not from here". o The situation in Akrakuka is also very informative. In this community Y G 60 years old was in the village six years ago. He has never been treated. All the numbers of his household are considered-ineligible for treatment. He left his home country Benin a long time ago for Ghana where he moved from different places. In the same village A. UiZ year; old has been living five years ago. He had never been treated. If an individual is not from the community, he may be considered as eligible for some reasons. For example N.T 50 years old was in Alaakuka six years ago. She is a native of pruso as well ui h". brother. But her brother arrived in Akrakuka a long time ago and has been selected as a distributor. She is treated every time the distribution takes place in Akrakuka since she arrived there. She has been considered as eligible- o The individual should be in communities socially eligible to the treatment. In Mepesean B. P aged 18 years and living in this community and K. B 19 years in the village have neve-r been treated. They are considered to be from the households of new settlers. Those in charge of treatment in Mepesean come from outside, and have been given the names of the households to be treated. So some household members ." "i"lud.d from the treatment. M.T 40 years, has never been treated. She arrived two years ago in Bomboi. But she had been moving with here family in Gfiana for a long time. Born in Bobo-Dioulasso in Burkina Faso, she went in Ghana when she got married. She was moving from one place to another in Ghana o In the majority of cases neril comers are not given treatment because of the eligibility criteria set up by some communities. 3.2.3.2. Hidden eligibility During this study the team discovered two eligibility methods set up by community members 13 3.2.3.3. Social eligibitity Living in a community is not always enough to make an individual eligible for treatment. Neithir is staying in t-hat communiiy for more than five years. The personal history or the history of the-ho;sehold of an individual is the first criterion agreed by many communities. Consequently some new settlers in the community are not registered for treatment. Treatment is reserved for the native households, those who are among the first settlers of the communities. On why new comers are not eligible for treatment, a c,ommunity member said: "They can go even tomorrow. You don't know for how long they will stay in the community. Theyare not p"n of us. If they do not feel comfortable here, they just go". A typical case is Ayerede community, where even members of a teacher's household are considered ineligible for the treatment because they are said to be in the community "to work only". Ayerede L r.", only as a duty station. Some communities have also set age criterion, while y.i i, others, people considerld not to be economically active are excluded from the treatment ( Begbemdo). In many communities the treatment has become a socially managed event. But the danger is that since those who are eligible for the treatment and those not eligible live in the same community, the excluded group could become a potential human reservoir for new transmissions of onchocerci*ir. t "ia"ntally the untreated group is usually more in number than the individuals registered for treatment in many communities. 3.2.3.4. Economic etigibility A community leader in Asubende said: "I have seen in some cofirmunities, CDDs taking yam tubers from individuals treated. I complained, telling them that ivermectin is free. But the practice continued." This claim could not be verified, but the issue also came up at Hiampe community, where the study team was told that it was agreed by community members as a way to support the two distributors of ivermectin. However, the study team has no evidence that this measure impacted coverageo But at another community, Mankutwa, it was gathered that giving yam tubers to the distributor was not compulsory for treatment. Heads of household do so to express appreciation to the CDD. While communities have been generally encouraged to provide support to the CDDs some kind of support could jeopardize effective coverage. For instance, if payment is introduced for the drug io support ih. -CDDr, prospective recipients of treatment who are economically handicaf,pea co"tO be denied treatment. In an interview with one of the distributors in o In t1e multi-country stgdy conducted in 1996 the overall covexage in the sites of Cameroon was the lowest of alt the shrdy sites. T[e reason was that this counfiy had decided that a cost recovery system should be put in place for ivermectin as it was the case for any drug. Individuals had t9 pay for treament !"1 Tu"y eligible i*pf. failed to go for the treatnent. The second *idero was in in the Bagan village in tvfali: where community^*".Uer. Ua AeciaeO tat for the first round of treafinent each head of household should pay 100 F CFA by individual treated. During that first round Bagan recorded the lowest coverage in lvlali. (Ihe exchange lilte tlrcx was I USD:500 F CFA):Some heads of househotd did not go for treatment for any member of the household cifing lack of money. The money collected was for the distnlbutors of ivermectin Later the same community cfranlea the criterion for the secbnd round treatrnent. Each head of household was charged 100 F CFA for the treatnent of all the members of the household- There was an improvement in the coverage of the treatment compared to the first round- So payment or contribution for the treatnent affected the treatment coverage. t4 Hiampe, he said that some community members failed to go for treatment because they did not want to give yams. It is therefore clear that some community members do not receive treatment because of the criteria set up by the communities, while some eligible community members also refuse treatment. 3.2.3.5. Refusals. Refusal of treatment runs across all the communities, from the interviews with the community members, CDDs and health professionals at district level. The study team observed at least three categories of refusal: 3.2.3.5.1. Individual refusal Individuals who are eligible for treatment may refuse the treatment actively or passively. Actively an individual can refuse when the medicine is given to him or her. In the cases where the CDD treat household by household some individuals refuse to take ivermectin tablets. passive refusal is when distribution is done at a central place and individuals fail to go for treatment or even when they are present during distribution. The refusal in these cases is an individual decision. Individual refusals are many in some communities and up two-fold or threefold in some cases after the first treatment. Also those who experienced side effects often refuse to take the drug. This was observed in communities such as New Longoro; Kyingakrom and Begbemdo where the number of refusals were as many as those who actually took ivermectin' Regarding side-effects in some communities the number of refusals increased from the first round of treatment to the second. The distributor at Begbemdo said: "With the side-effects, I would tell them every thing in the world, but they would vow not to take ivermectin again". 3.2.3.5.2. Hidden refusals. A passive refusal is a hidden refusal as well. But there is another side to the hidden refusal. This involves individuals who go and actually collect the drug but fail to take the drug when they get home. This happer, *f,"r. community members are not asked to swallow the tablets on ii" spot after distriLution. In New Longoro and Kyingalaom these hidden refusals were many, with a community member saying: "They just go for ivermectiq but they are not interested in taking it". This was also where the issue of the traditional drink - akpeteshis - came up. Thesg communities believe that if an individual took ivermectin with akpetesi the individidual would die. If ivermectin + akpeteshi : death, to avoid death community members preferred not to take ivermectin. For this reason, the therapeutic value of ivermectin has not been experienced by many individuals in communities such as New Longoro and Kyingakrom. One regional coordinator said. *Most people do not want to take ivermectin because they *".. told not to drink alcohol with ivirmictin tablets". In Kyingakrom, many individuals equally refused ivermectin because of side-effects. t The local drink is said to be a mixture of sugar and fermented palm wine. 15 While refusals in general constitute a major concern for health professionals involved in the implementation ofinchocerciasis control, a more troubling type is the community refusal' 3.2.3.5.3. Community refusal The study team gathered that some communities refused ivermectin at one time or another' Mepesaen comniunity members refused the drug for four consecutive years because they complained about the issue of weight to height in ihe determination of the dose to be taken by an individual. They wanted to know the reasons or rational rationale behind the changes. The concem about refusal has been addressed in the annual report of the National Onchocerciasis Control of Ghana in 2006. In that year some 2,989 cases of ivermectin refusal were reported with 9lo/o inthe Pru district which -had 2,719 casesu. According to the district health officer, many communities in the Pru district decided to stop taking ivermectin and at the period oi this-rtuav the communities were not receiving ivermectin treatment. They stopped taking the drugtased on the information received from some people that a long term in take of ivermectin iuta lead to long-term negative effects. This situation affects both the geographic and the therapeutic "ou..-rug.. Heatth professional were complaining about refusals. The midwife in charge in Ayerede health centre said: " The main problem we have here is refusal. you send the Irug toihem in the communities, they do not take it. I get here the drug to be given to them. Some communities do not come to collect it". Other factors that impact the coverage 3.2.4. The mode of distribution Three modes oftreatment were observed in the communities 3.2.4.l.Treatment at a unique location. This mode of treatment is in place in most of the communities. [nformation is disseminated on the date of the treatment and the community members are invited to a designated centre to receive ivermectin. In some communities the drug is administered on the spo! but in others individuals take the J-g ho-". Under this mode of distribution heads of household from the hamlets are sometim., firr"n the quantity of drug for members of their households' In same cases drug is iso given to th; head of household for members of the households absent during the period of the treatment. Major fieatment methods observed. 3.2.4.2. House to house treatment Under this mode, CDDs treat community members by households and also move to hamlets to administer treatment. But this is in place in few communities. 3.2.4.3.Treatment at a unique location followed by house to house treatment This mode targets treatment of the maximum number of individuals. But a CDD noted that the system often fell short of ensuring complete coverage' 6 Armual progress Report National Onchocerciasis Control Programme Ghana January-December 20n,6 t6 It was also observed that communities switched from one mode to another. Some changed from designated location to house to house, while others switched from house to house to designateJ location. Unique location followed by house to house mode is likely to achieve better coverage if factors such as refusal do not stand in the way. 3.2.5. Period of distribution Many communities reported that the period of ivermectin distribution changed from year to year. In some communities this takes place during the farming season, !*ing into account the ippur.nt fear of side-effects by community members, who are mainly farmers, and would not want to loose any man-hour. Treatment during periods of the year when many community members are absent would exclude parts of ihe population. In some communities absentees during such periods are more than the individuals present. The absentees could include those who had travelled out or had gone to the farm betause of fear of the side-effects. In Wiae community for example, the ireatment in June recorded more absentees than in April' Generally, the communities would prefer treatment during a convenient period taking into account iocal environmental factors such the farming season. Most communities would want the treatment just before the beginning of farming activities. 3.2.6. Duration of distribution The changing duration of treatment was another concern for the CDDs. In some communities, treatment lasted for just one day. In others it lasted for between five days and one week. tn these cases even veryfew time is given for the treatment of the hamlet, generally not morethan one day. In .orn. oih"rs such as Bankaba it changed from two weeks, one week to five days. In some communities such as Mepesean thetreatment is just for one day and the distributors are coming from another community. This situation has an impact on the treatment of absenteer.-ttr" communities near Mepesean are not treated most of the time' They generally do not come in Mepesean for the treatment. The CDDs are not from Mepesean and retum to their community after the treatment. The duration period should be looked into since this could impact coverage, taking into account the treatment of absentees- 3.2.7. Treatment of the absentees Short duration of treatment could exclude many absentees. Normally, after the period set for the treatment, the CDDs should forward the registers and the remaining drugs to the nearest health centre, where the absentees are t rppot"d to go for treatment. But in most cases the absentees fail to go for treatment. Among the five individuals randomly surveyed in each community those who were not treateibecause they were absent did not go for the drug, even though they were back in the community at the period of this study. This was the case in Ayerede, Nyamebekyere, Begbemdo, Chabon, Jagbenbendo, Akrakuka, Hiampe, Mepesear; gankaUa, Wiae, New Longoio and Kyingakrom, where treatment took place between February and June 2007 . ireatment had not taken place in other communities during thatyear' t'l A review of the records also revealed that absentees were qot treated in General, and some of the communities the absentees were more than those treatedT. One of the five randomly selected members of Bankaba community has never received treatment since treatr"ni b.gu, in the community. He has been absent during each distribution period. 3.2.8. Drug supply In many communities treatment did not take place for some years, especially in some districts in 2005. Treatment was also characteriz.O UV inadequate supply of ivermectin' Some communities experienced shortages twice during the same distribution period and had to approach other communities for the drug, while in some cases, the shortages were not addressed. A community leader in Begbemdo said. "Even when you go to the health centre to get additional supply, yo,, ur" often tJd there is no more ivermectin. You just go back home"' According to the CDD for Kyingakrom: "The drug for the treatment is not available every year. For some yeilrs there imo ivermectin distribution here. We want the drug to be available every yeat''. The shortage of drug could be the consequence of inadequate estimation of the quantity of ivermectiniequired ior the treatment in a given community. Some times there are no updates on the population and the supply is often based on old figures. In Begbembo , "o.mumty i*a.r said: "At the time of distribution in this cornmunity a daughler who is a native this community but married in another community is not alwaysgi; ivermectin because she is not on the register. But she can have her treatment here even if she is no more here". Many factors can cause population change in a community and if this is addressed shortage of drug could be experienced. 3.2.g. Follow-up of treatment and technical support to cDDs Before the treatment each year, the CDDs are trained and later provided with ivermectin to treat the communities. This happens regularly every year before the distribution of drug. This technical supporr is nigtrry appieciated-uv ttr6 cDDi. IJ was also observed that the training of the CDDs is effective in all the districts covered by the study. This contributes to capacity building for the success of the treatment- However, treatment follow-up is very questionable. From the CDDs registers on supervisory visits over the years no mention was made on treatment' Some CDDs said they had benefited from supervision, but in some cases, this happened when the health personnel"in charge of supervision was just passing through for another activity elsewhere. In some instanJes, the iast supervision took place a lole time ago or when supervision was conducted at ali no specific issrre *"t addressed according to the CDDs' The status of record keeping suggests that supervision is very poor' Sgme times there is no information on the total iopulition. Information is only provided on the number of individuals treated, but without information on the summary report' 7 More details u,ill be provided in the final report 18 3.2.10. Information and communication on treatment In some communities, advocacy and sensitisation activities were conducted in some SZ districts in 2005 for members oi the district Assembly, while some mobilisation and health education activities were conducted in some communities at risk. But these activities were not organised on a sustainable basiss. Also in many communities covered by this study, very few communication activities were conducted. In many of the communities there was no information on decisions related to the change from weight to height, change from the 6mg tablets to the 3mg tablets. Some communities believed that the drug was not the same with this change, with 6mg tablet called the "Burkina drug" seen as stronger than the 3mg tablet which was referred to as the "Ghana tablet". In Bomboi, M.D, a 56-year-old said: "I go for drug whenever the treatment takes place. But the medicine which was brought from Burkina Faso was stronger- The one coming now from Accra is weak. Because of ttrii we are given more tablets" M. D is among the few individuals who received treatment every year from 2004 to2007. In general, there was inadequate information on at least two changes in the distribution in some communities -- change from mobile team with health professionals to the treatment by selected community membirs, the CDDs and the change in the number of tablets to be taken withthe change from 6mg tablets to 3mg tablets. Some community members believed that the increase in the number oT tubl"tr to be iaken during treatment meant that the drug currently being administered was weaker. This might have affected the treatment coverage. A comirunity member who was attended to by a mobile team refused to take the ivermectin afterthe ,irung". According him, since the current drug is not stronger than the first it may not be as efficacious as the first one. This was because he had no information about the rationale behind the change from the 6mg tablet to the 3mg tablet and on the dosage. This lack of information partly responsible for community refusal to take the drug as happened in Mepesean foi foui years. Many communiJies in the Pru districts have also refused to take ivermectin after receiving information from an undisclosed source over an alleged delayed long term effects of ivermectin. Addressing the refusals would require information and sensitisation on ivermectin, including the mode oftreatment, dosage etc. Individuals who expeiiencei side-effects in many communities stopped taking the drug and some communities would want to know why they should take ivermectin every year. The CDD for Begbembo said community members were asking why he was no! grving ivermectin to children,r-rd.r five who had the required height for the treatment, but he had no answer. So, some community members do ask some technical questions in their quest for information to properly situate their involvement in the onchocerciasis control programme. 3.3. Treatment coverage more or less misleading It was discovered that the therapeutic and geographic coverage were estimated- The situation on the ground support evidence that coverige is affected by many factors beyond the figures reported. These factors include: o The hidden eligibility criteria 8 Annual technical report. Special Intervention Znnes. Pru Bassin' 19 . Not all those who meet the criteria of the National Programme of Onchocerciasis Control Programme in a community are registered for treatment. The denominator used to calculate the therapeutic coverage should be revised so that all those eligible for treatment within a community are taken into account. In many communities new settlers are as many and some times even more than the population registered for the treatment . Many eligible individuals currently excluded from treatment should be part of the denomina-tor. The number of households to be treated in many communities is more than the households registered for the treatment. For this reason the therapeutic coverage falls short of the estimate. o The economic eligibility criteria also affect the therapeutic coverage as_some eligible community members miy not go for treatment because they could not afford to donate yams. o Some individuals in the 2l communities had never taken a single tablet of ivermectin since the beginning of the onchocerciasis control programme in Ghana. Among the 105 individuats ranaornty selected in the communities 18 didn't swallow a single ivermectin tablet: 17,146/o. Among those who have been treated many have been treated five times or less times even the community in which they were living had more than l0 rounds of treatments since the beginning of the programme- The number of treatments is in most of the cases less than the number of rounds of the treatment in communities even for communities who began the treatment three and four years ago. Even in a community like Asubende where the community leader said the treatment with ivermectin begana long time more than 15 years, some individuals among the ones selected randomly have been treated less than four times. AF 50 y.".r-old, a native of Asubende has been treated for a total of five times while some other native of the same conrmunity have been treated more than ten times. So every body is not treated every time. Compliance provide more evidence on this issue. But when the number of treatment is more than ten, they just said they didn't know or they have forgotten or they said more than 10 times. o Compliance is a major challenge. Among the 105 individuals of the survey, the "o.iliurr"" from 20b4 to 2006 (three years) was less than 50Yo. The number of individuals treated every year from 2004 to2007 is 2l out of 105, which is about 20lo. The number of males tieated every year from 2004 to 2OO7 is 14 while the number of females treated yearly during the same period is seven which suggests than compliance should be poorer for female. Is this situation due to the status with regard to migration or to the activities? A specific study could provide more evidence. The figures here suggest that if a longer period is taken, 10 years for example, the cJmpliance "ouil-b. very poor. Individuals are not regularly taking-ivermectin at each treatment round. Some u*ng the 105 had been treated only five times or less out of the more than l0 rounds of treatment in a given community o The treatment coverage for 2007 was less than 30%o. As at the second week of November 2007 treatient had not taken place in some coflrmunities and this should affect the coverage. But the programme is making efforts to achieve better coverage. In 2006 the reported coverage wis 63%. But this r,g.rr" could be less when the problem of eligibility criteria is taken into account. The change of the number of population and the change in the number of communities still constitutJa major implementation problem to the onchocerciasis control activities. 20 The geographic coverage is also of concern forthe following reasons: o The number of communities is changing from year to year. Members of some recognized new communities are not always registered for treatment. The number of communities to be treated is therefore more than the number reported as was noted in the National Onchocerciasis Control Programme 2006 annual progress reporte. The change in the number of communities also affected the SZs. For example in 2003 the number of communities reported was 316, while h 2004 the number of communities was 26210 o There was also no regular update of the number of communities in endemic areas, so new communities aie not always taken into account. Migration is not only an individual or a household event. A whole community could move for better economic conditions, in this case for farming. This point was stressed during meetings with the health professionals at national, regional and district levels, and it is of concern to effective implementation. Also, because of irregular update of the denominator accurate gmgfaphic coverage cannot be determined. Consequently, the reported therapeutic and geographic coverage rates are more or less estimation and often misleading vii-e-vis the picture on the ground. But in some cases it may not be possible to estimate the therapeutic coverage- In the summary report on the treatment the total population is not always provided, only the number of individuals treated is stated. For some years the therapeutic coverage could only be estimated through surveys because there was no record on the treatment. In some communities there was no record on the treatment after 2001, yet in others there was no record on the treatment from 2004 to 2007. One zone coordinatoi told the study team: "Many drug distributors believe that after they have distributed ivermectin they have done their job". During the feedback to the CDDs, the study team stressed the importance of recording information on the treatment as a means of evaluating the work of CIiDs and as proof of CDDs' commitment to the onchocerciasis control programme. 3.4. Community response to ivermectin treatment The communities appreciate the treatment with ivermectin. They are also playing some roles in the distribution of ttre drug. In some mses community members are supporting the CDDs because they see many benefits in the treatment of onchocerciasis with ivermectin. Some of these benefiis are meniioned in a group discussion in a community like Ayerede. 3.4.1. Community involvement Communities are contributing in the mobilisation for the treatment. They give information on the day or the period of treatment through the gongoner (town crier).They also contribute in the design of the house to house mode oftreatment. But community involvement in the actual treatment is minimal. n Annual progress report Nalional Onchocerciasis Conuol Progamme Ghana January- December 2006. ,o nupport OJU qrati6*e reunion de revue et de planification des activitds dans les zones d'intervention speciales (SIZ) Ouapdougou, du 09 au 11 Novembre 2005. 2l 3.4.2, Support to the CDDs In most of the communities no support is provided to the CDDs, while in some cases as noted above some commuriti., provide'incentives by way of donating yams to CDDs'A head of household or individual could also support the CDD in kind. It must be stressed that this is voluntary and does not affect coverage. 3.4.3. The CDD's work The CDDs were observed to be very happy to do their work even without any support flom the communities. Some of them believe tirat if their work is recognised they could command more respect in the communities- The cDDs were also involved in other health prografirmes, and in some cases served as volunteers for community-based surveillance dealing with EPI, Guinea Worm eradication programrne and the ffi6mentation of the national iymphatic Filariais programme'A good effort is being made to integrate the Onchocerciasii Control Programme implementation activities with the iymphaticiit"riurir Control Programme in Ghan4 such that the summary report on cDDs in" solne communities now p-rid. information for Lymphatic Filariasis nrogramme including the number of elephantiasis and of hydrocele cases' The cDDs are committed to their worh but should be encouraged to recognize the importance of proper record keeping on treatment and on their activities. It was not possible in many cases to estimate the thirafeutic coverage except by going {ro9gh the register' The problem with this method is that some eligible househofds and individuals are not registered, such as in Ayerede community. Also, CDis are not always receiving support from the health personnel ,o.pt for the annual training before the distribution of drug. They also lack 'adequate rup.*iriorq with the page for supervisory remarks of the treatment summary report usually left blank. Since the CDDs are willing to continue their worlg they should be motivated to improve their performance. For instani they should be prwided with transportation -bicycles and motorbikes - to reach the remote parts of the communities. It is also suggested that ivermectin be supplied regularly for treatment every year' 3.4.4.Perceived benefits of treatment with ivermectin Community members mentioned many benefits of treatment with ivermectin. Many said ivermectin has impiored their health siatus and economic life. All the communities are also willing to continue taking ivermectin. The main challenges are the shortage of drug during some treatment period and irregular treatment. one coirmunity leader rad n" did not understand why ivermectin was not being given every year to them. The community members would also want ffeatment Io take plaie at an appropriate time instead of the change from year to year' 3.4.5. Ayerede community members' debate on Ivermectin At a meeting with community leaders in Ayerede, th91e was an isolated case of an individual who argued that ivermectin iould not worl in his village. "Here in Ayerede ivermectin can never work. We are taking it but ivermectin can't work here. The benefit we have from the 22 treatment is very limited," he said. According to him: "Here in Ayerede, we take this rnedicine with dirty watei. Our drinking water iJ very dirty. Any medicine taken with dirty water would not work. We have only one source of pipe-borne water' It is not enough' We need at least a ,.rord pump in Ayeiede. If we take ihe onchocerciasis medicine with clean water it will work better". But another community member countered: "I do not agree him at all. The treatment with ivermectin has broughius good heatth. We no longer have eye problem. I have reasons to say that it (ivermectin) works. In 1980 I went to Kitampo. I was ill. They examined me and they told me I had onchocerciasis. I will never forget this. They decided to treat me. I was given 90 tablets of the medicine. It was called binocidi. I was asked to take it every day. After seven- tablets I gave up. It was very diffrcult to support the treatment. But when the treatment of onchocerciasis with ivermectin began here I-took the tablets every time the treatment took place. Now I'm no longe. suffering-1from the disease). It is not comparable to my situation in 19g0. The treatment with ivermectin is good. Here we see the difference. We now have better health situation in Ayerede. We have bJnefited from taking ivermectin here," he added' Other speakers supported the view that treatment of onchocerciasis with ivermectin had brought many benlhts and they would want the treatment to continue. Also, the need to improve the source of water in tie area and sustaining treatment with ivermectin was stressed' 3.5. Environment and health programme implementation The Onchocerciasis Control Programme is being implemented in Ghana in an environment characterised by complex indivfrual and community migration dynamics. The number of communities keeps ctr-anging from one year to year, with new settlers arriving in areas where the programme is orgoiig.-The programme activities are not reaching the new comers' In additid the hidden iigib'irity criteia set up by communities are affecting both therapeutic and geographical coverlg.. Th"r" is no doubt ihat these socio-economic and environmentai facto"rs lre^impacting tfrZ implementation of not just the onchocerciasis, but other health programmes i, Ct ana. For effective implementation these factors must be addressed' ^Esintialy, the National Onchocerciasis Control faces additional challenge of inadequate financial support, especially in the non-SZs. 23 CONCLUSION The implementation of the National Onchocerciasis Control Programme in Ghana is facing some problems which are hindering the achievement of the programme's objectives. Many factors constitute obstacles to the achievement of the level of therapeutic coverage for the elimination ofthe disease as a public health problem in the country. The estimated therapeutic and geographic coverage are misleading because of distortions created by socio-economic and environmental factors. The programme lacks adequate financial support. The SZs enjoy more financial support than the non-SZs and so the implementers try to use part of SIZs resources to support activities of the struggling non-SZs. Also, onchocerciasis control as a national programme does not engender commitment on the part of health staff at operational and implementation levels, because the performance of these health workers is not assessed based on their work on the onchocerciasis control, but on other health intervention programmes. The problems of implementation also affect other health programmes operating under the same environmental and socio-economic system. There is a need to revitalize onchocerciasis control in Ghana for better coverage. Currently, the treated communities live in the same environment with untreated communities raising the risk of transmission. In most of the communities covered by this study the nuisance of black fly is evident in the villages and there is a potential human reservoir for possible onchocerciasis transmission and new infections. This situation if not addressed, could jeopardize the gains and achievements of more than 30 years of onchocerciasis control in Africa. The epidemiological situation could be adversely affected if urgent steps are not taken. For instance, in 2005 an epidemiological evaluation was conducted in nine communities in the Pru Basin. Among the I187 individuals examined 126 were positive. Four out of the nine communities had a prevalence of 5Yo which constitutes a clear indication that all the communities are at risk of onchocerciasisll. Some concerns raised ten years ago with the treatment of onchocerciasis in Ghana with the mobile teams still persist, such as the treatment of the absenteesl2 . The Community-Directed Treatment of onchocerciasis with Ivermectin is not always implemented fully in many communities. The global community should strengthen its support for and commitment to Onchocerciasis control in Ghana to ensure that all the zones benefit from financial resources to ensure the elimination of the disease. It is recommended that all the onchocerciasis zones in Ghana be classified as Special Intervention Zones for at least five more years. Data from this study also suggest that Ghana should be declared a Special Intervention Country (SIC) for onchocerciasis and enjoy substantial technical and financial support. The communities surveyed want ivermectin treatment to continue, and cannot understand why they are not getting the drug. They fear there could be an abrupt end to the control programme. At a meeting with community leaders in Bankana, the chief of the village underscored this fear by saying: "They will not come againr" a veiled but symbolic message to the implementers of onchocerciasis control programme in Ghana. "Rupport de la quatidme r6union de rerrue et de planification des activitds dans les zones d'intervention speciales (SZ) Ouapdougorl du 09 au ll Novembre 2005. 12 Biritium RB. Sillah M and Diarra T. : Evaluation of ivermectin distribution in Ben[ C0te d'Ivoire, Ghana and Togo : Estimation of coverage of treatrnent and operational aspects of the distribution system, Annals of tropical Medicine andParasitology, Vol 91, No 3,297-305 (1997) 24 RECOMMEI{DATIONS Based on the key findings of this study the following recommendations should be taken into consideration: o a o a a a There is a need for the national authorities to improve the institutional status of the Onchocerciasis Control in Ghana by identifring indicators for the assessment of health programmes' performance in the country and therefore in the evaluation of the performance ofhealth professionals at different levels. Financial support should be provided by the Government of Ghana, APOC, WHO/HQ and WHO/AFRO for the implementation of onchocerciasis control activities at all levels in Ghana. Strong regional teams including demographers and specialists in health education should be put in place in all endemic areas in addition to the health stafffor a limited time to be determined based on the magnitude of the situation. The demographers should be in charge of yearly update and mapping of the communities to be treated: the specialists in health education should address all the concerns related to the achievement of effective coverage mentioned in this study. The epidemiological situation should be globally assessed to determine the burden of the disease in each community and to tailor the number of treatment to be given each year to the situation. A new Rapid Epidemiological Mapping of Onchocerciasis (REMO) could be carried out. llamlets should be considered as treatment site as well as the mother communities to improve both therapeutic and geographic coverage. Mechanisms should be put in place to ensure effective treatment of the population living in the hamlets and in smaller settlement areas of one household or one individual. Ghana should be a Special Intervention Country for Onchocerciasis control for a limited period so that the communities which are not adequately treated do not constitute a potential human reservoir for transmission and new infections thereby putting all countries at the risk of loosing the benefits and achievements already made in more 30 years of onchocerciasis control in Africa. Economic organisations in West Africa, the African Union and the global community should commit resources to Ghana as a Special Intervention Country for the elimination of onchocerciasis. Community involvement should be reinforced using the CDTI approach and implementation of the onchocerciasis control in Ghana o o a 25 REFERENCES TD& OCP, APOC Community-directed Treatment with Ivermectin Report of a multi- country- stu dy TDR/AFR/RP/96. UNDPAtrorld Bank/WHO Implementation and sustainability of Community-Directed treatment of Onchocerciasis with ivermectin: A multi-country study TDR/IDE/RP/CDTUOO. 1 2OOO Annual Technical Report - Special Intervention Zones @ru Bassin) Annual progress report National Onchocerciasis Control Programme Ghana January- December 2006. Biritium R. B. Sillah M. and Diarra T. - Evaluation of ivermectin distribution in Benin, C6te d'Ivoirg Ghana and Togo : Estimation of coverage of treatment and operational aspects of the distribution system, Annals of tropical Medicine and Parasitology, Vol 91, No 3, 297-305 (tee7) Rapport de la quatriime r6union de revue et de planification des activit6s dans les zones d'intervention sp6ciales (SZ) Ouagadougou, du 09 au I I Novembre 2005. 26 ANNEXES 27 AnneX 1: List of villages surveyed on the history of ivermectin treatment in communities Brong Ahafo Region I(tampo district Dwere Gomboi Kyingakrom NewLongoro Bole district Bamboi* Nkoronza district Ayerede Nyamebekyere Pru district Akrakuka Asubende Baaya Beposo Fawomang Hiampe Mantukwa Mepesean Senyase East Gonja Bakanba Begbomdo Chabon Jagbenbendo Wiae * Secondary communitY 28 EJ - -tD N s.) {ort ,\0t" - ) ?Dg Its tD .Aoc F ao5 o Ht! E E -lo D t0o E. F V U B.{p Ht! z EI For :l z b o.o6 ?1 aro a ro H tll E rA c B b B, z ; @ x H tt, z o EIE oo F b s o U ;xD mE H ta, E E' t{o tr,3. m U ID ci. H ta, E o{ POAFFlx Eg <H v-i lr, E 2r. OE 6i35EtNOp^ Pv "+ !J + &1c !0 ++d{'rf6EE s:€ =.Bo \o +E E +rd E U a -t +FlJ tlttl<q4Hr.7\cJ EI U E'IA oz iJ E I Jfop N A, N +g. t D +cnj-6 o-ggE T'G + .l s +>FFcdAE ss Podtd + rt E N@ t\){ - --t UhI lu Foo tn(A u) z o 4 ? \o zro e K& }J + &lt E -I + dx FEBg"E vl9 + SFde 8ra +> .oH 5d cp' €9: 5 e E -{ U H EFoo lr,(A(n z o tr,D a oz o\ lrl B o oz -l tt a oz { rn B o o z { ln oo z -l 5G- EE -t U F] E oo td U) a) z o Fl tr, <r z o\ + lrl oo z -J t!D a oz { F o z *I tr, oo z A --l E<tsu -l U PE Foo t!, rr) V) z o TDo o 6 IUo o € x EoE 1o o X E o {o e >> 3o\ t a N.)\o oAnnex 3: List of professionals met during the mission Odame Asiedu, National Onchocerciasis Control Programme Bright Alomatu, National Onchocerciasis Control Programme Ofori Antony, Regional coordinator for Onchocerciasis Control Brong Ahafo Region Salamatu P. Ibrahim, Acting Director of District Health Services. Principal Nursing Ofiicer Public Health Kitampo Simon Owusu Agyekum, Technical officer disease Control Kitampo Charity Mensah, District Nutrition Offrcer Kitampo A. G. Amofah Senior Technical officer Kitampo Victor Abagre Accounter District health Services Kitampo Alice Vorlefo District Public Health Nurse Nkoranza Asem Livingstone District health Information officer Nkoranza Mercy Adjeiwaa Midwife in Charge Ayerede Prince Kouassi Director District Health Services of Yejy Gilbert Dery Regional coordinator for Onchocerciasis Control Northen Region Seydu Andrew Koko National Coordinator Guinea the Programme ofEradication of Guinea Worm Sakode James Director district medical services Solaka East Gonja Mariama Katrigi Midwife Bamboi a .Annex 4: List of CDDS met during the mission Samuel Okra Kwabna Kyingakrom SF Hansin Ayerede Daniel Jinedu Nyamebekyere Steven Nakibi Beposo Joseph Nanpare Senyase Collins Kogma Senyase Sito Atali Mantukwa John Kowa Fawomang George Lamptey Bamboi Nyibinyi Oyon Hiampe Andris Kouakou Bankaba Amale Kouakou Bankaba Mpetribiwu Diko Wiae John KbnaMensah Wiae Asung Mathew Zonal coordinator wiae supervisor of the cDDs Meitheio Tideing Chabon Bingo Mafune Begbomdo a t 3l