North West CDTI annual project technical report submitted to Technical Consultative Committee (TCC): January 2012 to December 2012

aI t i\ t;i' $_' : : + 1;. aI i--- -NoRtHWESTC-DnFRbiEef; ----i LIBERIA i , TECHNICAL REPORT 2012 II : ntds.liberie_f_n9h_@_y_il_9_9:c_9_1l__ : ORIGINAL : Enslish COUNTRY/NOTF: Liberia Proiect Name: North West CDTI Project Approval vear: 1999 Launchinq vear: 2000 Reportinq Period: From: January 2012 To: December 2012(Month/Year) ( Monthf/ear) AEOe_ii1 {!$g_Earr (circleone) 1 2 3 4 5 4i . - . fl-rqte-gl,,rl*!@ (circle one) le 6 7 89 10 11 123456 12 7 138 I 10 11 Date submitted: Partners: - Ministry of Health and SocialWelfare - African Programme for Onchocerciasis Control (APOC) - Mectizan Donation Program (MDP) - Sight Savers lnternational - Communities ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHN|GAL CONSULTATTVE COMMTTTEE (TCC) DEADLINE FOR SUBMISSION: To APOC Management by 31 Januarv for March TCC meeting To APOC Management by 31 Julv for September TCC meeting AFRTCAN PROGRAMME FOR ONCHOCERCIASTS CONTROL (APOC) LForAction To: ?R,.o Forlnfomrtion)iR. Cs\ tt )3^l"6ni- RECU LE APOC/Oln I 2 FEV. 20t3 ANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) ENDORSEMENT Country: I-iberia NTDs Prograrn Director Nanre:K. KarsoT&$llie Signature:-. Wg Dare: . J, tr,'irr,,.,6... 1.,. .ep. l.i Sightsavers Country Director Name:Mrs. Adoley Sonii S ignatlrre: ./.'.:.'..rl l.i:g--r:: ! },:. 'q?Fr#E#rsl This Report has been prepared By Name:NOTF Liberia Designation: NOTF Chail_ si*nu,u.. $1?, Date . .:- cw4[+l i Flease confirm you have read this report by signing in the appropriate space. OFFICERS to sign the Table of contents il ACRONYMS................ ............ v DEFINITIONS........... ..............vI FOLLOW UP ON TCC RECOMMENDATIONS ......................... I EXECUTM SUMMARY.......... ................2 '1.1 Geruenal tNFoRMATtoN............. .......... 31.1.1 Description of the project (briefly) ........ 31.1.2. Paftnership .........4PopuunrtoN ................ ............................... 6 SECTION 2: IMPLEMENTATION OF CDTI......... .....................7 2.1. Trlrlrrue oF ACTtvtlES ................ ....................12.2. Aovocncy ...................92.3. MoatLtzRttoN, sENStrtzATroN AND HEALTH EDUCATToN oF AT RrsK coMMUNrrES. g2.4. Conllvururry INVoLVEMENT................ ............. I I2.5 CRpncrry BUILDING.... ..................122.6 TRERTverurs................. ............... 142.6.1. Treatment figures....... ........ t42.6.2 What are fhe causes of absenteeism?........ ......... tg2.6.3 What are the reasons for refusals?...... . . ......... tg2.6.4 Briefly describe all known and verified serious adverse events (SAEs) that Occurred during the reporting period and provide (in tabte 8) the requiredlnformation when available. ............. IB x........... .. ........ I2'6'5. Trend of treatment achievement from CDT| project inception to the currentyear.......... ...... 202.7 . ORoeRrruc, sroRAGE AND DELtvERy oF tvERMECTtN .......212.8. corun,lururrv sELF-MoNrroRrNG Ruo srRxeHoLDERS Meerrruc .........232.9. SupERv1sroN................. ...............232.9.1. Provide a flow chart of supervision hierarchy. ....................... 232.9.2. what were the mainissues identified during superuision?..................... 232.9.3. What were the outcomes at each level of COfi imptementation superuision?...... ..... .... .......................242.9.4. Was feedback given to the person or groups superuised?..................... 242'9'5' How was the feedback used to improie the overall performance of theproject? 24 3.1. Eourplerur ................243.3. OrHen FoRMS oF coMMUNtry suppoRT................. ......... 303.4. ExperuorruRE pER AcTtvtry .............................................. 30 SECTION 4: SUSTAINABILITY OF CDTI.. ............30 4.1 . lrureRruRt; TNDEpENDENT pARTrcrpAToRy MoNrroRrNG; EvRluRrroN................... 304'1'1 Has the proiect ever been evaluated/monitored? (Tick any of t6efollowing which are applicable)............ ............... 3t4.1.2. What were the recommendations? ....................... 3t4.1.3. How have they been implemented? ..... .. ..... .......314.2- SusrRrruRarlrry oF eRoJECTS: eLAN AND sET TARGETs (l,rnruonroRy AT............. 3 rYn 3)......... ..........314.2.1 . Planning at all relevant levels.... ......... 3 t4.2.2. Funds........ ........ 3 t ilt 4.2.3. Other resources .........,......324.2.4. To what extent has the plan been implemented.............. ...... 324.3. lrurecRnrroN ................ ................324.3.1. lvermectin delivery mechanisms................. . . ..... 324.3.2. Training..... ........ 324.3.3. Joint superuision and monitoring with other programs ......... 324.3.4. Re/ease of funds for project activities.... ............... 324.3.5. ls CDTI included in the PHC budget? ............... ..... . .... ..... .. -rj4.3.6. Describe other health programmes that are using the CDTI structure and how fhis vyas achieved. What have been the achievements? ....................... 334.3.7. Describe othersissues considered in the integration of CDT\............... -r34.3.7. Describe othersissues considered in the integration of CDT1............... 33 4.4. OpennloNAL RESEARCH. ................364.4.1. summarize in not more than one half of a page the operational research undertaken in the project area within the repofting period..................... 364.4.2. How were the results applied in the project? ...... 36 THE RESULT OF THE KAP WILL F'EED INTO THE DEVELOPMENT OF NATIONAL NTD COMMUNICATION AND PLAN AND DEVELOPMENT OF IECMATERIALS.............. .............36 SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, AND oppoRTUNrTIES..... ............. 36 SECTION 6: UNIQUE FEATURES oF THE PROJECT/OrHER MATTERS...........36 IV Acronyms APOC African Programme for Onchocerciasis ControlATO Annual Treatment Objective ATrO Annual Training Objective CBO Community-Based Organization CDD Community-Directed Distributor CDTI Community-Directed Treatment with lvermectinCSM Community Self-Monitoring LGA Local Government Area MOH Ministry of Health NGDO Non-Governmental Development OrganizationNGO Non-Governmental Organization NOTF National Onchocerciasis Task Force PHC Primary health care REMo Rapid Epidemiorogicar Mapping of onchocerciasisSAE Severe adverse eventSHM Stakeholders meeting TCC Technical Consultative Committee (APOC scientific advisory group)TOT Trainer of trainers UNICEF United Nations Children's FundUTG Ultimate Treatment Goal WHO World Health Organization CHT County Health Team OIC Officer -in charge MERLIN Medical emergency relief internationalCRC Cavalla rubber corporationCHAL Christian Health Association CO County Onchocerciasis supervisorCHDD Community Health department DirectorCHO County Health officer BPHS Basic Packages of health services NECP National Eye Care program LISGIS Liberia lnstitute of Statistics and Geo lnformation Services Definitions (i) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking). (ii) Eliqible population: calculated as 84o/o of the total population in meso/hyper-endemic communities in the project area. (iii) Annual Treatment Obiective: (ATO): the estimated number of persons living in meso/hyper-endemic areas that a CDTI project intends to treat with ivermectin in a given year. (iv) Ultimate Treatment Goal (UTG): calculated as the maximum number of people to be treated annually in meso/hyper endemic areas within the project area, ultimately to be reached when the project has reached full geographic coverage (normally the project should be expected to reach the UTG at the end of the 3'o year of the project). (v) Therapeutic coveraqe: number of people treated in a given year over the total population (this should be expressed as a percentage). (vi) Geooraphical coveraoe: number of communities treated in a given year over the total number of meso/hyper-endemic communities as identifiedby REMO in the project area (this should be expressed as a percentage). (vii) lnteqration: delivering additional health interventions (i.e. vitamin A supplements, albendazole for LF, screening for cataract, etc.) through CDTI (using the same systems, training, supervision and personnel)-in order to maximize cost-effectiveness and empower communities to solve more of their health problems. This does not include activities or interventions carried out by community distributors outside of CDTI. (viii) Sustainabilitv: CDTI activities in an area are sustainable when they continue to function effectively for the foreseeable future, with high treatment coverage, integrated into the available healthcare service, with strong community ownership, using resources mobilized by the community and the government. (ix) communitv. self-monitorinq (csM): The process by which the community is empowered to oversee and monitor the performance of CDTI (or any community-based health intervention programme), with a view to ensuring that the programme is being execuled in ihe way intended- lt encourages the community to take full responsibility of ivermectin distribution and make appropriate modifications when necessary. ra vi FOLLOW UP ON TCC RECOMMENDATIONS Using the table below, fill in the recommendations of the last TCC on the project anddescribe how they have been addressed. TCC session 35 Number of Recommendati on in the Report TCC RECOMMENDATI oils ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT USE ONLY Report Related 1 Project should update list of Acronyms; The list of acronyms has been updated 2 Complete table 2 by providing UTG figures; The UTG was provided in table 2 3 Provide explanation for high drug balance. We will improve on drug ordering and supply Project Related Ensure that project achieves and maintains 100% geographical coverage and at least 80% therapeutic The project is making progress to maintain adequate geographical and therapeutic coverages. 2 Ensure that refugees that joined Nimba County are treated; The refugees in Nimba County were treated during the 2012 mass drug administration lncrease the number of Health staff involved in CDTI; There is a need to train more health staffs with support from government and partners in order to increase the number of health staffs involved. 4 Effort should be made by the project to ensure that treatment coverage for lvermectin remain high despite the use of CDTI platform for other NTD interventions. Alleffort is been applied to ensure high treatment coverage even with the integrated intervention with other NTDs. Executive Summary Prepare an Executive summary of the report in not more than one page. 1. Background on treatment and population data - Total communities, communities treated, total population, urc, ATo and persons treated. 2. Background on population movements. 3. Training data - CDDS, health workers, Total popuration (community) per cDD trained.4. Challenges and how they were overcome. The North West CDTI Project is located on the North Western part of Liberia. lt is bounded on the north by the Republic of Guinea, on the west by Sierra Leone,Gbarpolu county on the south and on the east by Bong County. The project comprises five counties: namely Bong, Gbarpolu, Lofa NimbaLno uontserrado. Partial data from the five counties indicate out of 1,917,141 targeted population of Bong, Lofa, Gbarpolu, Nimba and Montserrado counties of whicti 1,2040i7 persons were treated with Mectizan representing 58% therapeutic coverage. Treatment data are being expected from Bong, Montserrado and Lofa. Out of 2171targeted communities, 1532 were treated from data received. A total of 3997 CDDs were trained/retrained compared to 3302 CDDs trained in 2011.261 health workers were trained/retrained compared to 3gB health workers trained/retrained in 2011 . 25% communities that reported treatment so far had female cDDs while 11% of health staffs were involved in cDl in 2012 The challenges faced during the implementation of the CDI activities were as follows: ' Late deployment of logistics for training, distribution of Mectizan &Albendazole and supervision ' lnadequate HSAM at community level - Frontline health staff not empowered to engage communities . Some communities are not willing to support their CDDs. 2 SECTION 1: Background information 1.1 General information 1.1.1 Description of the project (briefly) - Geographical location, topography, climate - Population: activities, cultures, language - Communicationsysfems (roads...) - Administration structure - Health system & health care delivery @rovide the number of health posts/centers in the project area if the information is avaitabte). - Number of health staff in project area and number of health staff involved in CDTI activities. The Northwest CDTI project is situated in the northern western part of the country. The CDTI activities in this project consist of five (5) endemic counties which are Bong, Nimba, Lofa, Gbarpolu and Montserrado counties. The climate is tropical and humid all year round, with significant variation between the dry season (October-April) and the wet season (May-October). Most of the roads in the project areas are unpaved, thus causing difficulty in movement in the counties. ln the Northern Counties, palm trees grow wild and the area is fertile for both upland and low land cultivation of rice, the staple food. The vegetation includes the tropical rain forest with many fast running rivers, which covers over 75o/o of the land area. The coastal area is marked by mangroves, dwarf trees, small bushes and various grass types. Most of the population of the communities is normally settled almost homogenous in rural areas and fairly heterogeneous in townships and cities. The structures of the leadership vary according to the types of communities. ln towns and villages, there are chiefs who are elected and guided by council elders who take decision on behalf of the village or town. ln township and cities, there are commissioners who are appointed by the president of the country and city mayors who are elected by the residents of the cities. However, since the 2005 legislatives and presidential election, the election of chiefs and cities mayors has not taken place due to the lack of funding. All city mayors have been appointed by the president. The occupation in the communities varies between urban and rural settings. The rural communities are engaged in farming activities from January to Novemberwhile the inhabitants of the townships and the cities are engaged in commercial activities and other formal employment Population of Northwest CDTI Project, Liberia from Census update by CDDs Counties Population Bong 365605 Gbarpolu 95407 Lofa 219682 Montserrado 534,562 Nimba 701,885 Total 1917141 3 Table 1: Number of health staff involved in CDTI Counties Number of health staff involved in CDTI activities. Total Number of health staff in the entire project area Br Number of health staff involved in GDTI Bz Percentage Bs=Bzl Br *100 Bong 386 57 15% Gbarpolu 85 21 250h Lofa 579 67 12% Montserrado 208 37 1lYo Nimba 998 71 7% Total 2256 253 11% 1.1.2. Partnership - lndicate the partners involved in project implementation at all levels [MoH, Sightsavers, (national/international), communities, local organizations, etc.] - Describe overall working relationship among partners, clearly indicating specific areas of project activities (planning, supervision, advocacy, planning, mobilization, etc)where all partners are involved. - State plans, if any, to mobilize the state/region/districUlcA decision-makers, NGDOs, NGOs, CBOs, to assist in CDTI implementation. Partnership for CDTI was strengthened during the year under review. The program collaborated with Sight savers, wHo Country office, WHo/ApoC, and Liverpool School of Tropical Medicine, MedicalAssistant Program (MAP lnternational and Ministry Education for financial and technical support. Additional resources mobilized from the NTD partners increased the implementation rate through integrated training of cDDs and Health workers, HSAM, transport, supervision and monitoring. ln 2012 the Ministry of Health and Social Welfare had as its theme for the annual health fair "Uniting to Combat NTDs: "Ending the Neglect" with the slogan "reaching the un-reached". The health fair was held at the Bernes ville Estate Football Field, Montserrado County. The event featured public lectures on NTDs of Public health importance in Liberia, drama sketches on Onchocerciasis, parade by health workers and students and exhibition of health services by NationalA|DS Commission, National Malaria Control Program, NTD Programme, Family Heath, NationalTB/ Leprosy Program, National Heath Promotion Program, Nutrition Program and WHO. This is a demonstration of commitment by the government to the fight against NTDs and that has also increased the visibility of the Program of Onchocerciasis and other NTD in Liberia. 4 Tfe NTD Program collaborated with the County Health Services Department, Ministry of Health and Social Welfare to conduct independent monitoring and supervision which incorporated spot check on Mectizan and Albendazote OGtribution in the communities. At the county level, the County Health Team collaborated with international and local NGOs, faith based organizations, concession companies, local radio stations and the affected communities for the implementation of the 201 2 CDI implementation. CDDs were used to sensitize and mobilize communities for the school-based schistosomiasis Program in the endemic counties of Bong, Nimba and Lofa in the North West Project area. Nimba County Health Team forged strong partnership with the Cocopa Rubber Company in the implementation of integrated MDA round for Onchocerciasis and lymphatic filariasis using the CDI approach. The Robber Company provided fuel for supervision of CDDs in their operational area. 5 Population Table 2: Communities and population at risk in the entire project area whether they are treated or not during the reporting period. UTG=calculatedasthemaximumnumberofpeopletobetreatedannuattyinmeso/hyie@ ullimately to be reached when the project has reached full geographic coverage (normalty the project should be expeaed a reach the UTG at tie end of the 3'd year of the project). Was a census for the project done during the reporting period? yes lf No, what is the source of the data in the table above? Source National census Other source, specify: lf you are using the term communily or village, define what constitutes the community or village. This will help understand the profile of the project area. ls there any other information of interest about the population in the project area? If so, include it here. 6 Please add more rows if neces CDT! Districts/ LGAs in the entire project area Total population in the entire project. Area Number of communities/villaqes in Population of Meso- endemic zone in the project area Ar Hyper- endemic zone in the project area Az Total in meso/hyper- endemic zone A3 = [r+ a, Meso- endemic zone in the project area An Hyper- endemic zone in the project area As Tota! in meso/hyper -endemic zone 46= [r+ 4u Ultimate treatment Goal (urG) Bong 365,605 306 269 471 91 650 273,955 365,605 365,605 Gbarpolu 95,407 40 150 190 22649 72,759 95,407 95,407 Lofa 219,682 151 542 693 65904 153,778 219.682 219,682 Montserrado 534,562 169 110 279 138677 395885 534,562 534562 Nimba 701,885 110 428 538 175470 526,415 701,885 701,885 TOTAL 1,917,141 776 1499 2171 494350 1,422.791 1,917,141 1,382,579 lr SECTION 2: lmplementation of CDTI 2.1. Timeline of activities Fill in table 3, timeline of activities for areas treated in current year, indicating when the key activities were implemented by the month they began and the monlithey ended. 7 Table 3: Timeline of activities for the areas treated in the current year 2012 The MDA round in 2012 was implemented in October and December, due to late deployment of logistics for training and HSAM. The NTD Program commenced the co-implementation of Onchocerciasis and Lymphatic frlariasis in 20'12. ln order to undertake the co- implementation, it needed to conduct Lf baseline studies, integrated training of health workers and CDDS, HSAM on combined treatment of Mectizan and Albendazole. Also Albendazole arived late due to some clearing problem. These challenges will be overcome in the next MDA round if partners disburse funds to the Project in good time. 8 County Mobilization of communities Traininq Census/Update Druq distribution Supervision Starting month Completio n month Startin g month Completio n month Starting month Completion month Starting month Completio n month Startin g month Complet ion month Bong July July August August Sept Sept Oct Dec Oct Dec Gbarpolu July July August August Sept Sept Oct Dec Oct Dec Lofa July July August August Sept Sept Oct Dec Oct Dec Montserrado July July August August Sept Sept Oct Dec Oct Dec Nimba July July August August Sept Sept Oct Dec Oct Dec lt 2.2. Advocacy Stafe the number of policy/decision makers mobitized at each relevant levetduring the current v".?-l_i the reason(s) for undertaking the advocacy and the outcome. Describe difficulties/constraints being faceA and sugge"?ior" on howto improve advocacy Advocacy meetings were held with policy makers from county to community levels by the respective County Health Teams in the project area. ln Gbarpolu County meetings were held with five District Commissioners, five DistrictYouth Leaders, five District women leaders and fourteen town chiefs. ln Bong County advocacy visit was paid to the superintendent, and Development Superintendent. At the District level, eight meetings were planned at every district headquarters involving the district commissioner, paramount chief and other local authorities ln Nimba county, advocacy meetings were held with policy makers onimplementation of Schistosomiasis/STHs, Onchocerciasis, Buruli ulcer, and lymphaticfilariasis. The policy makers included the following; '17 commissioners of the administrative districts 6 statutory superintendents 12 district education officers ln Lofa the Country Heath Team held meetings with nine policy makers, including the Country superintendant, Development Slperintendant and seven political DistrictCommissioners with some strategic community leaders. ln total 14 town chiefs, 18 county officials, 34 district political leaders, .10 youth and women leaders and 12 district education officers were reached in the project area. The advocacy meetings were held with the aim of explaining the roles of the policy makers in CDI as well as to secure their committment fromlo support the MDAProgram through mobilizing of local resources. However to improve advocacy and increase ownership , more logistical support andfunding should be provided to health staff on time to enable thenireach more villages chiefs and representatives of community based organizations including schools, churches and mosques Also cDDs complained of inadequate support from their communities 2.3- Mobilization, sensitization and health education of at risk communitiesProvide information on: - The use of media andlor other local systems to disseminate information - Mobilization and health education of communities including women and minorities Response of target communities/villages Accomplishments Suggest ways to improve mobilization and sensitization of the target communities. During the mass drug administration, various media houses were used disseminate messages on Onchocerciasis, Lymphatic filariasis and other NTDs both national, county and district levels. IEC/BCC materials were distributed various health facilities catchment communities. ln Bong, the County health team conducted mobilization in twenty- nine communities using IEC/BCC materials. General Community health volunteers (gCHVs) and CDDs created awareness on NTDs in their respective communities. Promotional messages on Onchocerciasis, Lymphatic filariasis and were aired on Super Bongese FM radio and radio Gbarnga for 7 days in the month of September 2012. ln Lofa, the County Heath Team conducted mobilization and health education by holding community meetings with chiefs, elders, women group and CBOs. Radio talk shows were held were held at district's community radio stations stressing the importance of Mectizan and Albendazole treatment. Health staff used IEC materials such as fliers and posters to conduct health education in 100 communities. Women and Youth Leaders played active role in mobilisation and Heath education held in some communities. Town criers were also used to mobilize community members. Most communities' leaders and members accepted the program and the drugs distribution was conducted as planned in targeted communities. ln Montserrado County, Health Education, Sensitization, Advocacy and Mobilization (HSAM) was conducted before and during the MDA. Two community radio stations; The voices of rural Montserrado & radio shata were used during the HSAM activities in the community. Posters and hand bills were also used in mobilization and health education sessions. ln Nimba County, gCHVs, CDDs and Teachers were trained to carry out extensive mobilizations in their respective communities. Radio talk shows and Onchocerciasis and lymphatic filariasis health promotional messages were conducted on five local FM radio stations (Karn Voice of Peace, Radio Saclepea, Radio Tappita, Radio Kehgayma and Radio Nimba). Town criers, community meetings, brochures and posters were also used for mobilization and health education during the MDA implementation. All the communities/villages were very receptive to the program. To improve HSAM in the Project area, logistical support is required to enable frontline health staffs reach all communities. Adequate plans should be made with Community Radio Managers to allot special time to discuss the role of the community and other stakeholders in the respective counties in the MDA as well as heath education for adherence to treatment by eligible persons in the community. There is need to supply adequate IEC materials to enable frontline health staff to reach communities with appropriate messages during HSAM activities. to at to t0 2.4. Communityinvolvement Table 4: Communities participation in the CDTI County Number of communities/villages with community members as supervisors Number of CDDs and the communities involved Number of communities /villages with female GDDsTotal no. communi ties in the entire project area Ba Number with communit v members as superviso rS Bs Percent age Bo= BJ Ba *1 00 Male CDDs Bz Female CDDs B6 Total Bs= Bz+Be Number ol communit ies with female CDDs Bro Percent age Brr= BrctBf 1 00 Bong 471 162 34% 581 95 673 83 18%Gbarpolu 190 85 45% 315 97 411 66 35%Lofa 693 198 29% 625 95 720 75 11%Montserrado 279 0 0 0 0 0 0 0Nimba 538 194 36%o 883 275 1154 286 53% Total 2171 639 34Yo 2404 s62 2958 510 23% Comment on: - Attendance of female members of the community at health education meetings - ln general, how do you rate the participation of female members of the community meetings when CDTI issues are being discusses (attendance, participation in thediscussion etc). - lncentives provided by communities for the CDDs - Attrition of cDDs. ls attrition a problem for the project? lf yes, how is it addressed? - Other issues The attendance of female members in community meeting is generally high in allCounties. There was active female participationin meeti-ngs when Cbl iJsues werebeing discussed. However only 27Yo of CDDs are female and this calls for moredeliberate effort to encourage community to select more female cDDs. ln Nimba county and to some extent Bong, communities discharged their responsibility in providing support to CDDs in cash and kind. ln oiher areas inGbarpolu, Lofa and Montserrado counties, communities did very litfle in terms ofCDD motivation. CDD attrition is still a problem especialty in Mbntserrado County. This made training budget to continue to be high because-of training many new CDDs. 4t To address the issues of inadequate CDD motivation and high attrition, Health staff should improve community mobilization using appropriate channels such as religious leaders, teachers, CBOs and local health committees to improve community ownership. CDDs attrition will be addressed by advocating to the community to support CDDs and also training more CDDs to reduce their work load. 2.5 Capacity building - Describe the adequacy of available knowledgeable manpower at all levels. - Where frequent transfers of trained staff occur, state what the project is doing, or intends to do, to remedy the situation. (Ihe most impoftant issue to describe is what rneasures were taken to ensure adequate CDTI implementation where not enough knowledgeable manpower was available or if staff is frequently transferred during the course of the campaign). Transfer of trained staff was not an issue. However there is shortage of health staff at peripheral health facility level. The available staff is fully occupied with clinic duties and very few get involved in outreaches. 42 Table 5: Training at the different levels of cDTl implementation District/LGA Number of Districts staff trained /LGAs Number of Health center/post staff trained Num ol Atr o Cg ber of 'traine Pt- |"" i other trainers res (TOTs) i n"r.l i;tati I c,rz= i Crr i Cro+j iCrr Number of CDDs trained ;"/ New i Refr jCziCs Total Cz+ Ca Atr o Cs New Co Refr Ct Tot a! rr8- Ce+ Ct AtrO Crs New Crt Refr Crs Total v't6- Cr++ Crs Bong 8 0 8 8 49 14 35 49 5 1 4 5 698 193 505 698Gbarpolu 5 1 4 5 16 4i12 16 3 2 1 3 400 1250 163 237 400Lofa 6 0 6 6 59 26 33 5q 2 0 2 2 579 671 1250Montserrado 4 0 4 4 29 62 16 13 29 4 1 3 4 500 65 435 500Nimba 6 2 t4 6 18 44 62 3 0 3 3 1149 453 696 1149 TOTAL 29 3 26 29 215 78 i 137 215 17 4 13 17 3997 1453 254 i4i 3ee7 Achievement i 100yo Achievement100% Achievement i 100% Achievement 1O0o/onot available, provide tn" . 13 Table 6: Type of training undertaken (Tick the boxes where specific training was carried out during the reporling period) - Any other comments 2.6 Treatments 2.6.1 . Treatment figures - lf the project is nof achieving 100% geographical coverage and a minimum of 65% therapeutic coverage or the coverage rate is fluctuating, sfate the reasons and the plans being made to remedy this. The Project achieved 80% therapeutic coverage in 2010 and 2011 . ln 2012 it achieved above 80% therapeutic coverage in two counties, Gbarpolu and Nimba were full data has been reported, and there is every indication that the Lofa, Bong and Montserrado will record similar coverage when the remaining treatment data have been received and processed. 100% Geographical coverage was not achieved Trainees Type of training CDDs Other Communit y members e.g. Communit v supervisor S Health Workers (frontline health facilities) MOH staff or Other Political Leaders Others(speci tu) Program manaqement How to conduct Health education Management of SAEs CSM SHM Data collection Data analysis Report writinq Others (specify) Partnership l4 in previous years, but the geographicar coverage survey and Gps mapping conducted in 2012 provided comprehensive list of communities includin! where treatment had not taken place. The Geographical coverage data was usedduring the MDA planning and follow-up exercises to endure that all communities were treated in 2012 ,t5 Table 7. Treatment and SAEs by district/LGA in all areas at risk in 2012 County CommunitiesA/illaqes Population Numbe rof person s who refuse d the treatm ent Numb er of absen tees Numbe rof COMMU nities with < 80% therape utic covera ge Nu mbe rof SAE S Number of serious adverse events (SAEs) referred to the health posUhosp ital Total# of comm unities/ village s in the meso/ hyper- endem ic areas Dr Annual Treatm ent Objecti VE Dz Number of commu nities/vill ages treated D3 Geograp hical coverage ("/") D+= Ds/ D1*100 Total populatio n of the meso/hyp er- endemic areas Ds Annual Treatmen t Objective Ds Number of persons treated Dz Thera peutic COVET age ("/") Da= Dzl Ds*10 0 Bong** 471 471 379 80% 365,605 365,605 287567 78.7o/o 2881 4928 102 245 0 Gbarpolu 190 190 185 97o/o 95,407 95,407 80676 84.6% 618 1791 62 655 0 Lofa** 693 693 430 620/o 219,682 219,682 170473 77.6% 1817 5580 175 404 0 Montserra do *** 279 279 0 534,562 534,562 0 0 0 0 0 0 Nimba 538 538 538 100o/o 701,885 701,885 581 659 g2.go/o 5934 1 6683 192 102 0 TOTAL 2171 2171 1532 71% 1,917,14 1 1,917 ,14 1 1120375 58% 11250 28982 531 140 6 0 ** Partial data from Lofa and Bong counties *** Montserrado has not yet reported. Formula for computinq therapeutic and qeoqraphical coveraqes ATO coverage rate (%) = Number of people treated x 100 Annual Treatment Objective 46 rl aa % UTG achieved = Number of oeoole treated x 1OO Totat number of peopte to be treated in mesgt lq:r_:nd-e119 areas within the project area (UTG)ATo ---.lhe estimated number of people tiving in nesinypiiiii"iil-"-n"" tn"t , cDfr ptoject intends to treat wrah ivermectintn a gtven year. urc = The maximum numbef of Plople-to.be treated.in meso/hyper-endemic.afeas within the project arca, uttimately to bercached when the prciect has reached tutl geognpnicat covii{e inii}afi the proie"t "nii['ii ip-iiliio reach the rJTc atthe end of the ta yeat ot the project), 47 2.6.2 What are the causes of absenteeism? Absentees were persons not aware of the treatment dates in the community. 2.6.3 What are the reasons for refusals? Refusals were those still afraid of adverse events 2.6.4 Briefly describe all known and verified serious adverse events (SAEs)that Occurred during the reporting period and provide (in table 8)the required lnformation when available. No SAE case to report l8 Table 8: cases of serious adverse events (sAEs) that occurred during the reporting period in 2012 Date 1"t ,Syrnploms symptoms appeared Date of dismissal from health facility Results of tests (thick blood smear) Extenuating or complicatin g circumstanc ES * Sera/ number oi@i 19 Alcohol involve ment or not 2.6,5, Trend of treatm€nt achievement from CDTI project inception to the current year faulqg: Treatments and coverage bv calendar vear for the entire project aroa 2005 - 2012 Please indicate the UTG for the proiect area: 843823 (use this figure as the denominator in all UTG coverage calculations.) YEA R CommunitiesA/illaqes Population Total# of communities /villages in the meso/hyper- endemic areas Er Annual Treatmen t Objective Ez Number of commu nities/vil lages treated Eg Geogra phical covera ge (%) Ea= Ee/ E1*100 ATO coverag e (%) Es= Esl Ez*100 Total population of the meso/hyp er- endemic areas Eo Annual Treatment Objective Ez Number of persons treated E6 Therape utic coverag e (%) Es= Es/ Es*100 ATO coverag e (%) Eto= Ea/ E7"100 UTG Covera ge ("/") 2000 2001 2002 2003 2004 2005 2598 2598 294 11% 2308932 1, 500,806 678,178 29Yo 45% 61o/o 2006 2598 2598 1463 56% 1,333116 866,525 905.449 68% 104Yo 81Yo 2007 2680 2680 1875 70Yo 2,260867 1, 478,692 1. 486.041 66Yo 100% 79% 2008 1687 1687 539 32% 20.1% 2, 571,669 1. 387.625 62.9% 54% 2009 1 686 1686 519 3'.1% 30.8% 809469 679954 648543 53.4o/" 84% 95% 2010 1,327 1,327 1,304 98% 98% 1,423,463 1,195,709 1.163.604 81.7% 97% fr 2o tt l1 at 97o/o 2011 1973 1973 1801 91o/" 910/^ 1, 740,475 1 ,917,141 1, 740,475 1,423,477 81.8% 81.8% 81.8%*2012 2171 2171 1532 71% 71o/o 1,917,141 1120375 58Yo 58% 58% *The actual2012 treatment coverage will be determined after complete data is received 2.7. Ordering, storage and detivery of ivermectin Mectizan@ ordered/app.ried for by:-@q-s_g t!c! the appropriate answer)MoH [-l wHo 'l--lNtcEF '' ti NGD. nother hl"rt"-tpe-cify): L----f'rr\'Er- L-l Mectizan@ delivered by - (p/eas e tick lhe appropriate answer)MoH tr wHo ["Il Uucep n NGDO tr l!: Mectizan@ lnve County Nuntber of Mectizan%-bl-ets- ln stock from previous year 2011 Requeste d Received Total in stock plus received Used Lost Wasted Expired Remainin g Bong 0 1 , 160,000 1, 160,000 1, 160,000 76561 0 2867 0 0 391 523Gbarpolu 20453 193,500 183,500 203,953 1 71 686 278 0 2000 29989Lofa 0 1, 399,000 1, 399,000 1 398000 504488 156 0 6000 887356Montserra do 45796 721500 721500 767296 0 0 945 0 0 0 Nimba 195817 1 , 910,000 1 , 910,000 2005817 1,896,479 0 15,000 93,394 TOTAL 262066 5.273.000 5,273,000 5, 535,066 3,339,262 4,246 0 23,000 1,402,262 24 -- - How are the remaining ivermectin tablets collected and where are they kept? After the distribution, the remaining ivermectin tablets are taken to the health facilities and kept in the health facilities drug store - List and briefly describe the activities under ivermectin delivery that are being carried out by health care personnel in the project area. Mectizan and Albendazole request was made to WHOiAFRO through WHO country office and cleared at the port of entry by WHOLiberia. The drugs are stored.at National Drug store (NDS). The County Health Team makes requisition lo the Ministry of Health through the county Pharmacist. The requisitions is reviewed and approved by the National coordinaior and approval send to NDS for collection ofdrugs with a letter signed by the NTD Manager. Drugs collected from NDS are taken to the couniy drug depot for onward distribution to health facilities. The CDDS collect Mectizan drugs from the health facilities serving as collection'poinls bdild on upOates of enumeralion or census ofthe target population. - Any other comments 22 2.8. community serf-monitoring and stakehorders Meeting Has any training (of trainers) for community self-monitoring been done in the projectarea? lf so, When? ble '!_!-: Community self-monitorinq and Stakeholders Meeti DistricU LGA Total # of communities/villages in the entire project area No of Communities that carried out self monitorinq (CSM) No of Communities that conducted stakeholders meeting (sHM) Bong Gbarpolu Lofa 471 190 693 Nit Nit Nit Nit Nit Nit Montserrado 279 Nit Nit Nimba 538 Nit Nit TOTAL 2171 Nit Nit Describe how the results of the community self- monitoring and stakeholders meetings have affected project implementation or how they would be utilized duringthe next treatment cycle. 2.9. Supervision 2.9.1. Provide a flow chart of supervision hierarchy.Central Level a a Distridt Level l-tJ'ComMity Level 2-9-2. what were the main issues identified during supervision?Some communities did not have community's registeL. some cDDs were putting more than two househords on one page of the community register. Protocols, Fliers, and IEC materials were not seen at some facilities and communities especially in Foya District. Errors were indentifled in recording and dosage for Albendazore 23 Was a supervision check-list used? Supervisory checklist was used at national, County and district levels2.9.3. What were the outcomes at each level of CDTI imptementation supervision? ' Communities where treatment had not started were encouraged to commence treatment. . communities were supplied with additionalcommunity registers o cDDs were coached on census taking using community register. ' Meetings were held with some town chiefs district Commissioners to mobilize for mob-up treatment in some communities 2.9.4- was feedback given to the person or groups supervised? Feedback was given at all levels 2.9'5. How was the feedback used to improve the overalt performance of the project? The actions required from feedback were implemented in a timely manner SECTION 3: Support to CDTI 3.1. Equipment Table 12: Status of equipment Source Type of equipment APOC MOH DISTRICT/ LGA NGDO Others No. Condi tion v Condition )" Condition )" Condition )" Condition 1. Vehicle 1 WO 2. Motor cvcle(s) 5 F 3.Motor cvcle(s) Bicycles 168 F Generator Portable METS 3. Compute(s) Laptops 2 F 4. Printer(s) Cannon 1 F Desk Top Computer GX 280 1 F 5. Photocopier (s) 6. Fax Machine(s) 7. Others ,L4 *Condition repairable, How does materials? of the equipment (F=Functionai, CNFR=Currently non-functional butWO=Written off). the project intend to maintain and replace existing equipment and other This will addressed by providing it in the budget 3.2. Financial contributions of the partners and communities - Fill tables 13a, 13b and 13c - lf there are problems with release of counterpart funds, how were they addressed? The issue of non release of counter fund was addressed through advocacy and thepolicy makers now fully support onchocerciasis and other NTDs. 25 Table 13a : Financial contributions for the last three continued r previous to Calendar YEAR bei GOVERNMENT contribution OTHER partners' disbursement Amounts disbursed at the following levels Nation al Gounty District TotalBUDGET LINE l. Mobi lization, advocacy, se-n sitization et health education 1.1. Mobilization 1.2. Sensitization 1.3. Advocacy 1.4. Health education Suh-total I 1,600.00 2,800.00 2,700.00 675.00 7,77i.00ll. Training 2.1. Training/retraining of CDds 2.2. T raining/retraining of Health workers $11_b7!9t7! tt lll. Superuision, monitoring, Evaluation 4,776.00 1,500.00 6,276.00 5,600.00 6,155.00 11,75b.0 _ 3.1. Supervision 3.2. Monitoring 3..3. Evaluation Sub-total lll 9,006.00 z,zsti.o6 0 1 1,266.0 0lV. lvermectin distribution and management of severe adverse events 4. 1 . lvermectin distribution 4.2. Management of Severe adverse events 7,000.00 0 9,039.00 Sub-total lV e,o3e.ool I ] i7,oo.oolV. Additional expenses I I 5.1.Salaries I| 5.2: Equipment 5.3 Top up lncentives 5.4 Geographical Coordinate Suryey Sub-totalV 14,400 7,039.00 14,400.00 14,400 7,039.0 0 14,400. 00 27,429. 57 27,429:. 57 212,520. 00 212:s20. 00 1,395 30,521.5 0 31,907 GRAND TOTAL 21,439.00 21,439. 00 27,429. 57 212,520. 00 18,1 19.0 0 69,693.0 0 Table Financial contributions ll. Training for the last three continued s to Calendar yEAR GOVERNMENT contributio;Amountsais@ levels Region National al District TotalBUDGET LINEl. Mobilization, advocacy, g e n_g i t! 4g li 9 n et- ! e.a t th e d u c ati o n 1.1. Mobilization 1 .2..Sensitizetion . 1.3. Advocacy 1.4. Health education Sub-total I 50 .366 240 0 637 681.00 2,919.7 5 3,005.0 0 6605.75 '2,261.6 1 ,g19.3 4080.90 2. 1 . T rainino/retraining of CDDs 27 10,000. 16,230 2.2. 1 raining/retraining of Health workers Sub-total ll t t t. Su pervi sion, mon itori ng, Evaluation 00 7,375 0 0 17375.0 0 11 ,127 .5 27,359.00 _ 3.1. Supervision 3.2. Monitoring 3.3. Evaluation Sub-total lll 1612.30 296.80 2000 3909.1 25,347.00lV. lvermectin distribution and management of severe adverse 9ve4fs " 4._1 _. _lve" .r!'necti n. d i stri butio n 4.2. Management of Severe " adverse events Sub-total lV 1000 1000 4058 !. Ad"dltignal .expenses 3000 1062 4062 9240.00 130,090 130,090. 00 6,69-d 18,510 25,200 GRAND TOTAL 15,000.00 86,044.00 28 Table 13c: Financial contributions ers for the last three continued rs previous to Calendar yEAR Amounts disbursed at the foilowing levels Region Mtional a! District TotalBUDGET LINEl. Mobilization, advocacy, 1.1. M_obilization - 1-.2,-Sensitiftion 1.3. Advocacy 1.4. Health education 750.00 750.00 1 198 1295.25' 2192.75 4,6g6.00 8857.00 8857.00 117d2.5 r sass.s.o 0 1.1,72i:5 3.1 . _Su.perv_ision 3-2. Monitoring 3.3. Evaluation Sub-total lll 1594.00 1s94.00 10,939.q 1,599.75 tz,ila.bslV. lvermectin distribution aN management of severe adverse events 4.1. lvermectin distribution 4.2. Management of Severe adverse events Sub-total lV V. Additional expenses 29 GOVERN MENT contribution Sub-total I 5.1. Salaries 5.2. Equipment 5.3. Vehicles Maintenance 5.4. Top up lncentives 5.5 Community Evaluation Assessment 5.6 Communication Strategic Planning Workshop Sub-totalV 687,600.0 0 3,845.4 691,445.4 0 3400 1997 10,733.9 7804 1 6983 12,970. 52,987.9 3.3. Other forms of community aupport - Describe (indicate forms of in-kind contributions of communities if any) Community support to CDOs were in the following forms 3.4. Expendlture per activity - lndicate in table 13, the amount expended during the reporting period for each activity listed. Write the amount expended in USdollars using the cunent United Nations exchange rate to local currency. lndictate eichange rate used here_l USD = 70LD - Any comments or explanations? SECTION 4: Sustainability of CDT| 4-1. lnternal; independent participatory monitoring; Evatuation GRAND TOTAL 30 al aa 4.1.1 Has the project ever been evaluated/monitored? (Tick any of the following which are applicable) Year 1 Participatory lndependent monitoring Mid Term Sustainability Evaluation .5 year Sustainability Evaluation lnternal Monitoring by NOTF Other Evaluation by other partners 4.1.2. What were the recommendations? 4.1.3. How have they been implemented? 4-2- sustainability of projects: plan and set targets (mandatory at Yr 3) Wastheprojectevaluatedduringthereportingperiod?- Was a sustainability plan written?. When was the sustainability plan submitted? What arrangements have been made to sustain CDTI after APOC funding ceases in terms of: 4.2.1. Planning at allrelevant levels Planning was done at all levels. At National.level Operational plan for NTD was integrated in Health services Division plan for 2012.The county level, Health Teams developed integrated operational plan for 20'12 incliding plan/budget for Onchocerciasis and other NTDs. 4.2.2. Funds At national level funds were disbursed for implementation of integrated activities for Onchocerciasis and other NTD. ln 2012 MOH & SWfunds disbursement was the highest ever for field activities. 31 4,2.3 Transport Vehicles provided by government and other donors were used to implement CDI program. 4.2,3. Other resources Also additional funding was secured from partners to support co-implementation with other NTD. 4,2.4. To what extent has the plan been implemented The plan was well implemented, however the program is lacking support to fully institute community self monitoring and HSAIV to reach all target communities in the project area 4.3. lntegratlon outline the extent of integration of cDTl into the pHc struclure and the plans for complete integration: Onchocerciasis is now part of the National health plan and the Essential packages of health services (EpHS) and budget in the country. cDDs have been incorporated in the framework for community health services. More effort is required to improve budlet at all levels. ' 4,3.1. lvermectin delivery mechanisms lvermectin delivery is done through the supply chain system of the Ministry of Health and Social Welfare from the Natjonal Drug Service to the County Depot. 4.3.2. Training Training is integrated with other NTD programs. Effort to have training unit at MOH to include Onchocerciasis and other NTD in training curiculum for frontline health workers and community distributors is in process. 4.3.3, Joint Eupervision and monitoring wlth other programs At the national level, Onchocerciasis and other NTD have been incorporated in the Health services division monitoring and supervision at part of the Essential Package of Health Services. At project level , counties use integrated checklist for supportive sufervision of healthcare activities in EPHS. 4,3.4. Release of funds for projeci actlvl es Funding for the program are released by the government of Liberia through the Pool system and the office of Financial Management at the lVinistry of Health and Social Wetfare at 32 Ia <, aa 4.3.5. ls CDTI included In the pHC budget? The,cD-Tl and other Neglected Tropical Diseases have been included in the Ten Years National Health plan and Essential package forHealth Service and have been included the into the national budget. 4.3.6. Descrlbe other heallh programmes that are using the CDTI structure and how thls was achieved. what have been theachievements? ' Filltables 14 and 15 and provide describe other programmes that are using the cDTlstructure and how this was achieved. What have been the achievements? ' For each intervention listed in table 15, explain what were the roles played by the cDDs (census, mobilization, distribution, data collection, storage, collection ofdrugs, referralofSAES, et;...)? . Explain what are the combinations of interventions co_implemented? . How were the interventions implemented? (at the same time?) 4.3,7. Descrlbe others issues considared ln the integration of CDTI. The CDI concept has been adopted by the NTD Programs for LF and Onchocerciasis elimination. The community Heatth servicesDivision oJthe ministry of health is favorabte to cDt Secause its ,r*nf;;"" piC;ir;tesv. ii"iJ i" iipi"ririir't) il'r [raooration wilrcommunity Health Services Division in strengthening of community heatih itructure" roi'"tr""1ue ioiil" ;;ild. -- 4.3.7. Descrlbe others issues considered in the lntegration ofCDT|. other issues considered in the integration ln the integration o-f ttre coit wi*r lympnatic Fitariasis, training of health workers, cDDs andsupervision were done together. Funds were also intedrated. Table 14: Cojmplementaflon Type of control Type of intervention Roles played by CDDs (explain in bullet points) Number of districts Number of communities Number of GDDs involved Number of persons tarqeted Number of persons reachedTarget ed Reache d fargete d Reach ed Mal es Fem ales Total Males Femal es Total Mal es Fema !es Total uncnocerctast s control .lvermectin distribution Conduct census, provide health 29 25 1892 1532 630 718 562 63128 0 63071 8 70082 0 1,331,539 508 447 6173 05 1,125,7 52 ymphatic lariasis o Distribution of Praziquant el o Distribution of Mebendaz ole . Distribution of LLINs NB: the interuentions /lsfed in the table are just few examples 34 Table 15: other programmes using cDl structu re (tick as appropriate) Type of control Type ofintervention lnvolvement of communities in lmplementation o lvermectin distribution Malaria control r Distribution of LLINs . Home management of malaria NB: the interuentions /isfed in the table are just few examples 35 collecti on of commo dities Onchocerciasis control 4.4. Operational research 4.4.1. Summarize in not more than one half of a page the operational research undertaken in the project area within the reporting period. Knowledge Attitude and Practice (KAP) survey was conducted in Nimba County as part of National formative research to commence integrated NTD Program in the country. 4.4.2. How were the results applied in the project? The result of the KAP will feed into the development of national NTD communication and plan and development of IEC materials SECTION 5: Strengths, weaknesses, challenges, and opportunities Strengths Experienced NTD focal persons at county level Weakness lnadequate logistics for frontline health staff lnadequate of health staff in engaging communities Challenges CDDs demand for incentives Opportunities Availability of CBOs and private sector organizations Viable community structures in some counties e.g. Nimba lntegration with other health programs SECTION 6: Unique features of the projecUother matters Parts of the Project area are within Monrovia and other big urban areas in Liberia as well as the gold mining areas where the population is in constant movement. This project requires innovative strategies to address community participation, CDD selection and retention and population updates. To implement CDI in the highly populated urban areas, deliberate effort must be needed to engage religious organizations, schools and other community based organizations to elicit their participation in the program 36