'1'/ /lL,. ",', "/ :$ 't .r'r :.] '/'- UNITED REPUBLIC OF TANZANIA rlv ff P f \rPAog4','li IMINISTRY OF HEALTH NATIONAL ONCHOCERCIASIS CONTROL PROGRAMME COUNTRYAIOTF: TANZANIA Proiect Name: TUKUYU CDTI FOCUS PROJECT Approval vear: JULY, 1999 i Launchins year: APRIL,2000 Reportine Period ( From ): MAY,2003 - APRIL, 2004 PROJECTYEAROFTHISREPORT: I 2 3 (4) 5 6 7 8 9 10 Date submitted: SEPTEMBER, 2004 NGDO partner: SIGHT SAVERS INTERNATIONAL (SSD ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) DEADLINE FOR SUBMISSION: TO APOC Management by 31 Januarv for March TCC meeting TO APOC Management by 31 Julv for September TCC meeting AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL @,v (APoc) 2 I JAN. 200s 't ANNUAL PROJE,CT TECHNICAL REPORT TECHNICAL CONSULTATIVE COMMITTEE (TCC) ENDORSEMENT Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the report : COUNTRY: TANZANIA National Coordinator Name: Dr. Grace Sagguti Signature: Date DMO Signature Name: Dr. Ndabwene Sungwa Signature: Date: . This report has been prepared by Name: Dr. Ruhiso M. H. Designation: Project Coordinator Signature: TO Date ll Table of contents Acronyms..... .........v Definitions.... ...... vi FOLLOW UP ON TCC RECOMMENATIONS ...........1 EXECUTIVE SUMMARY: SECTION 1: BACKGROUND INFORMATION ............2_3 ...............4 I.I GENERAL INFORMATION 4 SECTION 2: IMPLEMENTATION OF CDTI............ ...8 2.I TIMELINE OF ACTIVITIES ... ,..9 ...10 2.3 MOBILIZATION, SENSITIZATION AND HEALTH EDUCATION OF AT RJSK COMMUNITES.II 2.4 COMMUNITYINVOLVEMENT ...r....,......... ........ ......12 ' ' ,..-....... .................. .. ...2.5 CAPACITY BUILDING ..;.... . - . ,....13-15 2.6.2 rilhat are the causes of absenteeims? t7 2.6.3 What are the reasons for,rpfusals?. ,.,17 2.6.4 Briefly describe all known and verified serious advcrse events (SAEs) thet .....,.........:................18 2.6.5 Trend of tratment achievement from CDTI Project inception to the current year ........................19 2.7 ORDERING, STORAGE AND DELIVERY OF IVERMECTIN.......... 2.8 to 2.9.1 2.9.2 COMMUNITY SELF-MONITORING AND STAKEHOLDERS MEETING ........ SUPERVTSTON ..........................:........:..::,i.:.,.........,.....:.....:... Provide a flow chart ofsupervision hierrrchy .r......;........-...................,.......... What were the main issues idientified during supervison? .......20 ........21 ........22 .........23 ..,,....23 2.9.3 Was a supervision checklist used? .......... ....................23 2.9.4 What were the outcomes at each level of CDTI implemcntetion supervision? ..............................23 2.9.5 Was feedback given to the person or groups supervised? .23 2.9.6Howwasthcfeedbackusedtoimprovetheoverrllp9rformanceoftheproject? lll SECTION 3: SUPPPORT TO CDTI 3.1 EQUIPMENT 3.2 FINANCIAL CONTRIBUYTIONS OF TIIE PARTINERS AND COMMUNITIES 3.3 OTHER FROMS OF COMMUNITY SUPPORT.............. 3.4 EXPENDITURE PER ACTIYITY ............. SECTION 4: SUSTAINABILITY OF CDTI. 4.4.2 How were the results applied in the project? SECTION 5: STRENGTHIS, WEAKNESSES, CHALLENGES, AND OPPORTUNITIES... SECTION 6: UNIQUE FEATURES OF THE PROJECT/OTHERMATTERS ................. ....24 .24 .......25 ,..25 ..26 4.1 INTERNAL; INDIPENDENT PARTICIPATORY MONITORING; EVALUATION. 4.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable) . 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 (YR3). 4.2.1. Planning at all relevant levels . ' ' t 4.2.2. Funds. 4.2.3 Transport (replacement and maintenence) . 4,2.4 Other resources . 4.2.5 To what extent has the plan been implemented . 4.3 INTEGRATION ............ .....i................:............. ..................27 4.3.1 Ivermectin delivery mechanisms ,......27 4,3.2 Training ..,..,.,..,,,.......27 4.3.3. Joint supervision and monitoring with other programs ............,.,.21 4.3.4 Release offunds for project activities ........,.,,........27 4.3.5 Is CDTI included in the PHC budget? ..,..,....,.........27 4.3.6 Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? ............ ...,..,.............27 4.3.7 Describe others issues considered in the integration of CDTI ..,........27 4.4 OPERATIONAL RESEARCH .....28 4.4.1 Summarize in not more than one halfofa page the operatiinal research undertaken in the project area within the reporting period. ............28-30 ........31 ,..,....32 .....33-34 1V tt Acronyms I. APOC 2. ATO 3. ATrO 4.SSI 5. CSSC 6. CBO 7. CSM 8. NOTF 9. IMA 10. NGDO I l. RMO 12. REMO 13. CHMT 14. CDTI 15. CDD'S 16. CSDI's 17. DOT 18. DMO 19. TOT 20. RHS 2I. IEC 22. DPHC 23. PHC 24. WPHC 25. WHO 26. CBIT 27. UTG 28. UNICEF 29. TCC 30. SHM 3I. CCHP African Programme Onchocerciasis Control Annual Treatment Objective Annual Training Objective Sight Savers Intemational Christian Social Service Commissional Community-Based Organization Communiry Self-Monitoring National Onchocerciasi Task Force. Interchurch Medical Association Non Govemment Development Organization Regional Medical Offl cer Rapid Epidemiological Mapping of Onchocerciasis Council Health management Team Community Directed Treatment with Ivermectin Community Directed Distributors. Community Selected Distributors with Ivermectin District Omchocerciasis Team District Medical Offi cer Training of Trainers Rural Health Staff .,1.. Information Education and Communication Material District primafy Health Care.. i Primary health care j Ward Primary Health Care. World Health Organization Community Based with Ivermectin Treatment. Ultimate Treatment Goal ' .i' United Nations Childen's fund' ' Technical Consultative Committee Stakeholders meeting Council Compreherisive Health Plan' v Definitions (viii) (i) Total populationi the total fopulation living in meso/hyper-endemic communities within the project area (based on REMO and census taking). (ii) Eligible population: calculated as 84%o of the total population in meso/hyper- endemic communities in the project area. (iii) Annual Treatment Objective: (ATO): the estimated number of persons living in meso/hyper-endemic areas that a CDTI firoject 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 expectld to reach the UTG at the end of the 3'd year ofthe project). (v) Therapeutic coverage: number of people treated in a given year over the total population (this should be expressed as a percentage). (vi) Geographical coverage: number of communities treated in a given year over the total number of meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage). (vii) Integration: 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 maximise costs- effectiveness and empower communities to solve more of their health problems. This does not include activities or interventions carried out by community distribution outside of CDTI. Sustainability: 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 mobilised by the community and the govemment and the government. (ix) Community self-monitoring (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 executed in the way intended. It encourages the community to take full responsibility of ivermectin distribution and make appropriate modifications when necessary. vl FOLLOW UP ON TGG RECOMMENDATIONS Using the table below, fill in the recommendations of the last TCC on the project and describe how they have been addressed. TCC session Number of Recommendation in the Report TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT USE ONLY NO N E I EXECUTIVE SUMMARY The Corirmunity Dirbcted Treatment Apprtiabh, fbr'Oirchocerciasis, is becoming more and more popular and interest in it is growing at community level. A multicountry study on additional health care responsibilities of community Directed Distributors (CDDs) has been launched. Eighty five per cent of CDDs of Ivermectiri for On'chocEiciasis Control were seen to be involved in other health and development activities, especially expanded programme of immunization (EPI) activities, but this was seen not have a negative effect on their work as CDD's-Ivermectin treatment coverage was not affected. Communities, CDD's and health workers strongly supported further involvement of CDD's in other health care activities. Many CDD's had been selected for the other activities after becoming a CDD, and often received financial incentives for the other activity, which led too greater motivation. Nearly all CDD's wanted to continue working as a CDD "to help my community" some for self-fulfilment and recognition, although few received or expected any financial reward. i- - Thus additional health and development activities for CDD's were found to not pose a threat to Community Directed Treatment, but to provide opportunities to strengthen sustainability, and it was recommended to further explore this opportunity through intervention studies that address the concept. :' The Community Directed Treatment approach is used to deliver lvermectin to the populations in Onchocerciasis endemic areas following a request by the Board of the African Programme for Onchocerciasis (APOC). Ivemectin is widely and usefully used in Onchocerciasis Control Programmes. However, it not kill adult worms. The fourth year report of Tukuyu CDTI Focus covers the activities and financial matters of the Project for the peiiod May 2003 to Apiil, 2004. the activities conducted during the period under review were integrated retraining of First line Hedlth Facilities Staff and community Directed Distributors (CDD's), community mobilization, pretreatment census, Ivermectin Distribution, Data Collection and reporting writing. A total amount of T.SHs. 12,109,7251: was funded by MOH Tanzania to facilitate all activities done during this year. NGDO partners was contributed a total amount of T.SHs. 12,000,000/: for project activities this year. The Annual Project Review/Planning Meeting took place on 23'd July,2004 at the Landmark Hotel Rungwe District, Mbeya Regional Tanzania. Several critical issue pertinent to Onchocerciasis Control were addressed including integration & sustainability of the Project. A total amount of T.SHs. 2,000,000 was funded by Sight Savers International (SSI) for facilitation. Strong partnership in the programme was witness where the staff from District Council Office, CHMT member, Village Leader was fully participated in community mobilization, supervision during Invermectin distribution and Data collection. Community members have continues to demonstrate willingness to collect Invermectin from the collection points mainly from the Health Facilities nearest to their communities and some contributed money as an incentive for CDD's. DMO's Office Rungwe and Kyela were provided fuel for vehicles and motor cycles whenever necessary. A total of 50 FLHF Staff were retrained, of which 26 (52%) were females, a total of 460 CDD's were trained of which 220 (48%) were Females. A total of 68412 persons out of 93,405 (ATO) persons from 55 villages received Mass Treatment, thus achieving Therapeutic Coverage of 73o/o however the Geographical Coverage of the Project area could not be determine because of lack of Remo Data. In this respect, one CDD treated a total of 148 persons in average of the project level. 2 aa a a During Rain season, a farming community migrate from their homeland to another place where there are a fertile farm and for cattle herding. Also, the young people keep on migrating to look from employment in towns and to the areas or Neighboring Districts/ Regions where there are newly employment. Challenges . Inadequate Incentives to CDD's Solution: More re sensitization done to the community lender for CDD to be Expected from village activities & provide additional support. Inadequate number of women CDD's Solution: Recruit an add ional woman distributor to look after women's interests Increase community awareness meetings. Poor record keeping at the community level Solution: Introduction of CDT[ community'sblf monitoring also for other health interventions such as Vitamin A supplementation and immunization programme Community leadership is key to the implementation of CDTI activities under the leadership of the Village Executive Of{icer Oncho activities are carried out by the CDD's. The facility health workers (FLHF's) is the link between the District and the community in the implementation of the programme activities . J t '_ ,- ,i ,l 'I r'I SECTION { : Background lnfoitmhtlon 1.1. General information Introduction : Tukuyu Focus CDTI project is based in Mbeya Regional located in the ectreme southern highland zone of the United Republic of Tanzania. The project covers three endemic districts namely : Rungwe, Kyela and Ileje ae located and it is boundaring int he southern by Lake Nyasa and Malawi Southern East in Zambia Country. It's an area known as breadbasket of the Nation due to very large amount of cereals produced annually (The big four Region) especially Maize, Irish, Potatoes rice dnd Banana. Infact, it is hot'orie of the poorest regioh of the country and has very good annual rainfall. It is diverse and variegateed area embracing many climatic zone and gerographical varioation from low to highland montains and rural areas are not so much insulated. People in the rural areas are not general well of and few ae very rich although the region itself is rich agrculturally. Generally the road infrastructure throughout Mbeya's countryside is good however during the long rain season (Nov - June), small section of the Region are at offfrom the rest of the country. It is'uncommbn main road which is good tramatic'road from Mbeya administrative headquarter to the endemic districts and it is easy accessible during the rain season. Tukuyu CDTI Focus project operaties in 55 villages into three districts in Meso and Hyper endemic areas. The project started as a vertical approach under National Institute for medical Research in 1994. Community Directed Treament with Ivermectin launched in April, 2000 when APOC approved the proposal. The project aims at controlling and eventually eliminating Onchocerciasis in the three districts. This is true as the CDTI is being implemented concurrently with Vector Elimination carried out by NIMR, ADMINISTRATION STRUCTURE Administrativelly. two Districts Rungwe & Kyela are implement area. There are 6 Division, l3 Wards and 55 registred vilalges. A small portion of Ileje also is included. The Focus area straddles 4 partliamentary electoral constituents (2 partliamentary from Rungwe District). HEALTH SYSTEM Tukuyu CDTI Focus has 3 Hospital. One is voluntary agency and two owned by the Government , four Health Centres and seventeen (17) are Government Dispensaries Table l: Number of health staffinvolved in CDTI District/LGA Number of health staffinvolved in CDTI activities Total Number of health staff in the entire project area ,1 Number of health staff involved in CDTI ,2 Percentage '3='2l'1'roo RUNGWE 60 26 43% KYELA 24 t6 67% 4I.1. KYELA DISTRICT PROFILE. Kyela district (Fig. l) is one among the eight districts of the Mbeya region. It is located at the extreme south of the region and is about 125 km from the regional headquarters, bordered by Lake Nyasa (Malawi) on the southern part, Ileje district on the western, Rungwe district on the north and Livingstone Mountain ranges on the eastern part. Geographically, the district lies between n 30o - 350 Longitude East and between 90 250 - 930 Latitude south. It is situated at the altitude of 400 -520 meters above sea level and receives an average rainfall of l200mm annually The district has two administrative divisions divided into 14 Wards and 84 registered villages. Four wards containing a total of fourteen (14) villages are under the project area and thus receiving ivermectin annually. It occupies a total area of 1}22 square kilometers (approximately 2.1%o of the area of the whole region). 965 sq. km is a dry land where as 375 sq. kms is occupied by water. The district has a total of 25 health facilities. Out of these, 7 health facilities are under the project area. The District has four main ethnic groups namely the Nyakyusa, Ndali, Kisi and Yao.The Nyakyusa tribe lives on the lowland areas and depends mainly on subsistence farming and pastoralist. Where as the Ndali tribes lives on the highland and are engaged on farming, livestock keeping as well as beekeeping. The later two are living along the like Nyasa are engaged in fishing and pottery 1.2= RUNGWE DISTRICT PROFILE Rungwe district is among the eight districts of Mbeya Region.'The district is bordered by Kyela district on the southern part, ileje and Mbozi districts on the western part, Mporoto volcanic mountains and Livingstone mountain ranges on the northern and eastern parts respectively. Geographically the district is located between 90'05's to 45's and 33o 20'E. From the 1988 census projections the district has an estimated population of 318,019 people with a growth rate of l.4Yo and it is the most densely populated district in the region. The district occupies approximately 22ll sq. divided into four divisions, 30 wards and l4l registered villages. Eight wards (8) comprising of a total of 4l villages aro under the project area and hence their communities aro receiving ivermectin annually. There are 56 health facilities in the district which deliver health services to the inhabitants and people from the neighboring districts. Out of these, 13 health facilities are within the project area and thus serving CDTI activities The district receives adequate rainfall-of mqre than 2l00Mm per annum, one of the highest in Tanzania. It is fairly well distributed over the year, but a clean dry season exist from June to October and the rainy season from November to May, being heaviest in March, April and May On the high attitude hill slopes the weather is slightly cool throirghout the year with annualmean temperature of 60c. The district possesses many iiverS arid streams originating from the northern and western hill slopes that are draining in Lake Nyasa. Most of these rivers and streams have been found to be good breeding sites of onchocerciasis vectors Rungwe District is inhabited by three major q!!r+ig groups namely:- Nyakyusa, Ndali and Safua.tribes. The Nyakyusa tribe comprises about 95%o of the total population and lives in the highland areas. All the tribes depend on agricultural activities for subsistence and trade. The main crops grown for commercipl purpose are rice,..tep, papanq and Irish potatoes. Crops grown for subsistence is cereals, maize etc other activities include l[vestock production, trade tiansportation, Artisan, Mining Industrial production and Harvesting of Forestry products. Tukuyu Focus CDTI Project in the district operates in 41 meso and hyper endemic. 5. :t- 1.1.2 Partnership Ministry of Health, Christian Social Services Commission, Sight Savers International, Districts Council and Communities work together in partnership in implementation CDTI Drug proburement and delivery hai become nrbie effrcient in the past 4 year and has been integrated into National Drug Delivery System. Medical Store Department effectively Receives and delivers Mectizan. Shortage are very rare. AII stakeholders in the partnership have clearly defined rolls and responsibilities. The international NGDO (Sight Savers International) have been particularly instrumental in the provision of interim funds for stake holder meeting and assist in capacity building of project staff. Key activities such as planning, budgeting, distribution and training are included in the District budget. Many of the health personnel are involved in other health activities at the District level. The main constraint is the heavy workload on heath personnel and inadequate number of supervisors. In order to address these constraints other candle of personnel in the PHC system are being incorporated as supervisors. APOC project cover numerous poor communities for which the only accessible medical care was traditional medicine, with CDTI, the sole idea of being treated at an affordable cost, and at home highly impresses these communities which no longer feel abandoned by the public Administration. The CDD's are used to Administer Vaccination against Polio and delivered Vit. A during the National immunization day. There has been commendable progress made towards integrating CDTI into existing health system. Mectizan is delivered through the vehicle in the same way as the other essential drugs supervision is carried out by the health staff. 6
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EA rI]U rq a E'.= .ti tr (i) - rI] zD rI] zD o ! tr u) EO L o IE rEI & 14E z rq O rI] H ilI! ta z E] O 14 o E'I tiE d:(h- & 14 ca oF(-) & rrl rooF O o (D c! q D o) o2 o(J o 0) {r' a6EE U r! a rI.]F o.I!a & IJ.] m z Ht- o.Q U) a0trE a)- F v) o Fa o() u0 GI t'r 0) +.q6 EEo' U F U) o o F U) e\J D Eo*ftr d: ch- J ']D -o) a-E s= oor-9a 6)rq6 EE U JD J Er* ',ti tr d: HzD E]z (J I C) t- o) l-l t! B(, zD& F.lH V rl Fr oF o\ d e E( ltl F -lI EEf(, ll .F =olllF( ltlEF o lllE Il I *F E oIL o uI IF = F(, IL o ul - -J ul E -F ; o I!t!F ADVOCACY The following are number of policy/decision makers mobilized at each relevant level during the current year :- a a a o Regional Level 6 District Level 35 Division Lavel l5 Ward Level 20 Village Level 55 Sub-village Level 230 Reason for sensitization - Lack of sensitization and motivation among community leaders - Due to poor attendance of communty meeting - An increase in community awareness on CDTI Phylosophy - To reduce/eliminate Onchocerciasis in all endemic District through the implementation of CDTI strategy at the community level. - For sustaibability of the project - To achieve Therapiutic and Geographical coverage. Difficulties being faced : - Poor attendence of the community meeting - Money demand among the group members Suggestion to improve : - Incentives to communtiy leader are very vital - Allow the community to arrange thenselves when to conduct meeting - Mobilization meeting should be carried out during dry season or soon after harvest. l0 r'! l, - i MOBIL|ZATION, SENSITTZATION & HEATTH EDUCATTON OF ATRTSK ..MMUNITIES , '|, "t' "r' l, l ,'; The IEC plays a vital role in the control of Onchocerciasis. This has been evident through the use a mass media in promoting the CDTI implementation. This strategic plan calls for the availability of IEC materials that are relevant and appropriate to the target audience. The main IEC channel which was used include : Radio, TV, leaflets, posters callenders, and T shirts. Others include local drama groups and health Education in Primary Schools. More innovative ways of delivering IEC will be explored to ensure good coverage of intended audience. a l,l a a The results of mobilization efforts were : Satisfactory because several communities sent there CDD's or their representative to collect their drugs fromthe various helth facilties/collecting points agreed apon. - People over whelminghly appriciate the benefits of Ivermectin. - Number of refusal and absenteesim rate denied. - Good attendance of health education meeting - Number of women attended health education are mereased. Suggestion to improve mobilization and sensitization :- - Increase capacity building among the implementors - Timely release of funds for activities implemantation - More sensitization and mobilizatlion to be done on dry season - Mobilization sessions should be prolonged more than two days ll
B ahQ)0k 00:.o cB l-l L=f-l9-ru E tsejE9 z'a H =Ci oo 3oEcll *- tr o ED q) I cttr \oo\ yOo\ so *.EeO.E cl o E EErt = E€X -;.a-z E ra =t <. iaia an C) tr Ei o() c) €9rEGO oV A.= Q L o! z rq +F tqI6 t06ot{ \o cO \o$ €tr4)o It;fl6 c{\o ss \o (\l Ftr .A h nU q) TB!ta oo o\ \o(a tinN tr o z? >o o'!6Jra0xd: >0)aot aE tro) E(l) otr(J ()! z ta Fq il €tr c) u0 6t troIL c)tr \o \oo\ yOo\ 'EaH ri'7 e 2u() ! o'=-E tr! trtr=tr0) EEET + =l inra tr o -E 6leO) U) :''lq)Y -:EE iEcrE E.I6 0= F\'/ {J + s rain Fl o (a r! zD& Fl frl v j 3 oF cl .9(/) (n O6 EO .ER x'6 a*orrc)€0) L- .o(g: 6 0rc'E cL (€ .; o.r Q r-(t()- HlicA()(!ctfrr Qo(l<(,o o bo! o.= >C)e;^ E E L{E I- _-Er -rv)A!=- oL!U V .- t \ts tr.=vdE E=LPfV ^Gtdx^Ec a_E E.e .e B 8.E e9eHooE: -c-C .) Iii62I q) .SI tr U q) flAEOOEEao'a>E -LOE - (a) rr .X >'=ITrLa f- - T fE -lE_o E\J o(rt 0) 1€Ntr CAPACITY BUILDING Capacity building to enhance efficiency in project management is one of the key areas earmarked. During implementation of project activities this year Project Coordinator and DOT's undergone training on project management which was conducted at CEDHA - Arusha and writing skills workshop which was conducted TANESCO - Morogoro. For project sustainability re- training of CDD's, FLHF Staff from District will continue to be carried out particularly new areas. Training services and material for training will be provided regularly and routinely so as to strengthen the knowledge base and capacity to effectively manage the control of Onchocerciasis. Efforts will be made to ensure quality re-training though utilization of existing policy guidelines. No frequency transferred of trained staff occurs due to consistence of CHMT members. The major constrain in capacity building is inadequate funding to cover training for the staff. il.l., . 13
sl 6 (J L E z cll +. .Lb.:qv zv -f € {o\ t o, a] F!i r-. t s € o\ o\ L a \o o\ ra = c! -=0 E z clllv s,:qv e \o \o \o al s E \c a) F \o \o cl ( o,o =cdL L z E.'++ \,+.q = \o N + c.l r+ € s N al € \o sco E s U \o N \o att GL 6 z E';* \r' +. a< s R + \o s \o $ N \o F oF \o s Eo .9 s ?3 \o \o F .] El > z & J rr.l V ,I tr q) c) t.l U (a q) 6) tr 0)L c)!- o a0 clL t-{ ral c)I -ol cclFI ra) a o C) ?t) o o ) ) ) ) ) ) ) aL() (o C) F] (!(-) A ) ) ) ) ) ) ) H C) H E a Eo ) ) ) ) ) ) ) I C) oq! "6oit 0) -:4 ij F& gU ) ) ) ) ) ) ) E>,tr =\JEoo; -:6 F.e9\J G).= r! C9Ec =0)lJ.L/Ea ) ) ) ) ) U) n t-t O ) ) ) ) ) ) ) ) ) 00E.Eo).=tro.rlB '6 gtr tsH O co E o) o)o c(E E E6 o) P(L = =(u o - of ro EOE(JO -efr:O>f;8 o u.l U) o c o E o oto c(E =oo =IU' tro c, -e oo (E (E o .9,o .>(! c(E (E (E o o)E 'E;to o.otr EH q) CE L 0) 00 tr tr 6lL q) Fr \OI o.,l ,al6lltl \o rr ri f-1 U -oo\ c- .o o\ c-r- s(r) r- z <,H-\ v5Fnr Fr \.)tr)\o +\o (a) c- €N ia t(a o\ OA lz, Z 9)OoFl oB3zAdAtr o\ \o r+ =f, c.I N c.I N =6\o trltr tro< aEIYda- !-:; Xh1t;, rt r=HFI sf + rala F(J il E.la tJl > z d. l]frl M Fl F o Er oz a c.l U) c)L u0 ltr +) O cgq) li t'( r.t \o N t-- IJ (t G)L(B o() 'a Ha C) B C,)d 0)Lr GI o F< 0)E 0) IHq)q o U) 0) .d 0.) c!3(,) L< ool -o9l ol!xl o-l ul o. =l o;'i 0JEl q ol c,= =l e5tx 6l€ (Hl )< ol H -ol -Ht i: zt? olol -t t6)xl > EI E El8 arl =ol o)ot tr()l -Eol td Elr3lE El d =l czl< 'rl' d 'o) d (_) C) a. G) o rI] ,d >'3 E C) o ad 0 c) ot E =t Exl E El IEl ogl EPI c)oll rdEGl r =l o)>t Q.;t >()t < 'El 3 El eHl (H Ht o ol Lol o) ol 5bt trpl E3l trtrlE =t EZI? C, 0)L CI (_) 0) La o r.H B t)(.) tr o C) o o,€ tro IL C)E Et I -l o)xl E sl col .- 8t Hbt'i o.ll 5 oltrolo C)l 'Eol(d tslE Hetrl d =t 6ZI? ! 0) C) o ()F D \o6\ o 6dE C) bo(d kro0) 6\>voo oF C) (d! C) bI)(dL C) oo (6^ o\o '= o\ a(Ek bo oo (.) dL C) oo cgL(l)I o oC' =vc)o. cl C) F al 6)l skl 6-)l aol -tdl .91 -clol(6l LI s 0)l htl ol cl(6l ol c)lOIdlEIot -qlel o0 trt =tol trl ot ol -l €l ol EI olr!l ,ll an L cl rn 6lq)L 6l Fl I L rt) E th Fi a q) clq) l-3 r-l orl -olcl t-t I og- 'tr85-( JTSEE 3 c ai.3ils€EE€-< d I z J z o *? \a z tl z J z !cE3AD zd co + ro =rr q9o ;,rl IEeEEEOa6 z -8-Y o + co \o c.t 6l ro B. tfs oo Fo ^ 1Oo\ l'. -o6\t'-t- s(a r- Ebs z o o\ \o$ t c.I N c-l N $ a\o :o? E.l } UF F9 ia \o$\o F- €(\ lo t ra o\ 5EH ts -E _ L! E€'F \o$\o F- €N in t (f, o\ 9o!{ &a- -o o o z r!& FB zz @ 63t 6.9 t EEE zEuF s + rf)ra =b> t Ih-F9 \o{\o F-€N ro s ?a o\ >9.,3TE:E.H + c - >-: _ - < aE.Ya E E#E€- t t r,or,o HSt;v F] o zD& Jg.l V rl tr ot- il 2.6.2 What are the causes of absenteeism ? I Young people usually'keep on migriting to Town looking for employement. Farming community migrates to another place where there are fertile farm lands, especially during rain season. People spend a lot of time for field activities (Shamba) by the time they come back, the distribution becomes over. 2.6,3 What are the reasons for refusals ? Fear of side effects eg : severe itching due to microfilaria loading infection a a o o o Inadequate sensitization and mobilization meeting Involvement with alcohol taking. Poor attendance at meetings during mobilization. 2.6.4 Briefly describe all known and verified serious adverse events (SAEs) that occurres during the reporting period and provide (in table 8) the required information when available. In case the project did not have any cases of serious andverse events (SAE) during this reporting period, please tick in the box a o a No SAF, case to renort I 18
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2.7 Ordering, storage and delivery of Ivermectin o Mectizan@ ordered/Applied by: MOH wHo UNICEF NGDO Other: Project Co-ordinators o Mectizan@ delivered by: MOH UNICEF NGDO Other:- MEDICAL STORE DEPARTMENT (MSD) Table 10: Mectizan@ Inventory * The remaining Ivermectin tablets are colleted and kept to the District pharmacist ')r.. DISTRICT NUMBER OF MECTIZAI\I TABLETS Requested Received Used Lost Wast ed Expired RI-INGWE 168,409 168,409 120,0r3 5l 20 NONE KYELA 52,591 52,591 82,105 36 t2 NONE TOTAL 221,000 221,000 202,118 87 32 NONE 2t 2.8 Community self-monitoring and Stakeholders Meeting On 21" July 2004, Integration training was done at the Taliri I Iotel in Kyela Dislrict. all IILI ll: Stafl, DMO's. CHMT members, DOT's, Project Co ordinator, NGDO representatives, DED's and Programnie Manager from MOH were invited. Community self monitoring was one of addressed agenda. r I t Table 11: Cornmunity sclf-monitoring and Stakeholders Meeting 4.3. 4.4. Integration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration The project has promoted integration of other diseases into CDTI in the absence of PHC. Of the 60 Rural Health Staff, 4 District Oncho Co-ordinators are involved in Malaria, TB, AIDS & Leprosy Control Programme Respectively. This structural integration will involved into practical integration with the time. Supervision done together by using one vehicle from District Council and service & Fuel Expenses usually are full filled by District Executive Officer. The project crated immense awareness on CDTI in offrcial communities. This is intensified through community based activities such as football and volley ball competitions Onchocerciasis week activities and formation of Oncho Clubs in Schools. In some communities health committees have been informed. However, as expected in a conflict area, community participation in decision making has not been optimum. Many top govemment offrcials have received training on CDTI and are participating actively in the project. District/ LGA 'l'otal # of comrnunities/villages in the cntire prolect arca No of Communities that carried out self' monitoring (CSM) No ol'Communities that conducted stakeliolders mccting (SHM) RUNGWE '4r 8 20 8KYELN 14 6 TOTAL 55 t4 2tl 22 2.9 Supervlsion 2.9.1 Improper record keeping system at the Sub village and Village level. -Inadequate support of the Community to the CDD's. 2.9.2Diring supervision the check list is always used (Intergrated check list) 2.9.3 Supportive supervision was achieved - Improvement was assured. 2.9.4 Feed back was given during supervision period, self monitoring and evaluation. 2.9.5 Improvement of Project in:- - Proper data collection - Proper record keeping - Competent RHLF Staff. 2.9.6 SUPERVISION FLOW CHART level hegional level level Health Facilities level COMMUNITTE S/CDDs o Planning o Sensitisation and mibilization o Selection of treatment site by community o Invitation of health personnel o Distribution of Mectizan o Monitoring for adverse side effects . Referral of severe side effects o Feedback from health staff. o Mectizan ordering. NOTF R. M o R.P.Co D.M.O DOT RHS 23 26 September 2003 SECTION 3: SUPPORT TO CDTI 3.1 Equipment Table 12: status of equipment * Condition of the equipment (F: Functional, CNFR:Currently non-functional but repairable , WO: Written off). How does the project intend to maintain and replace existing equipment and other materials? - The Project intends to maitain existence of equipment and other material by intergrating with District Matrix where by funds from Basket fund and Councils are usually used for Services and maintanance. - Repalcement of existing equipment it will be difflcult simply because of inadequate budget of District Council. ' i I " Source Type of equipment APOC MOH DISTRICT/ LGA NGDO Others No Condition No Condition No Condition No Condition No Condition l. Vehicle I Functional 2. Motor cycle (s) 2 Functional 2 Functional 3. Computer (s) I Functional 1 Functional 4. Printer (s) I Written off 1 Functional 5. Photocopier (s) 1 Functional 6. FAX Machine (s) 1 Written off 7. Others a) b) c) 24 3.2. Financial contributions of the partners and communities Table I 3: Financial contributions by all partners for the last three years. Contributor Year I ('provide the period') Year 2 ('provide the period') Year 3 ('provide the period') Year 4 TOTAL Budgeted (uS$) TOTAL Released (us$) TOTAL Budgeted (US$) TOTAL Released (us$) TOTAL Budgeted (us$) TOTAL Released (US$) 'l rrte I l{clurrttl Ministry of Health (MOFI) 12,109,725 Local NGDO(s) ( if any) NGDO partner(s) ll.lll l1.lll 14.000 14.000 16.000 16.000 8,000.00 District/LGA 5.500 5.500 7.000 3.000 9.000 4.000 2,000.00 Community 2,000.00 APOC Trust Fund 47.2',10 47.270 41.875 41.875 31.790 31.790 TOTAL 63,881 63,8 8l 62.875 62.875 56.790 51.790 24,109,'.125 Inadequate contribution of District Council is a major problem, but this issue was addressed during Stake holders meeting. Recommendation was achieved :- See Section 6. 3.3 Other forms of Community support:- - Village leaders were fully participated in Community mobilization, supervision during updating census and Mectizan distribution and data collection. - Some contributed food, Transport (Bicycle) and money as an incentive to CDD's. 25 Activity Expenditure ($ US) Source(s) of funding _Dryg!_._!y_.ry from NOTF HQ area to central collection point of community Mobilization and health education of communities ffi;irs of CDDs- lpjn in g o{ h99[tfu19f,f q!all levels Supervisi_lg C_DD_ s and distribution Intemal mon activities Advocacy visits to health and political authorities District Council MOH MOH 1,000 5,540 6.569.72s 2,000 Community IEC materials District Council District Council Summary (reporting) forms for treatment 500 Vehicles/ Motorcycles/ bicycles mqintenance . Office etc Others 500 TOTAL 24,109,725 Total number of persons treated 3.3. Expenditure per activity Table l4: Indicate how much the project spent for each activity listed below during the reporting period Scction 4: sustainability of CDTI 4.1. Internal; independent participatory monitoring Evaluation 4.1.1 Was Monitoring/Evaluation carried out duritrg the reporting period? (tick any of the following which are applicable) 4.2 No Year I Participatclry Independent monitoring DONE Mid lerm Sustainability Evaluation NOT DONE 5 Year Sustainability Evaluation DONE Internal Monitoring by NOTF NOT DONE Other Evaluation by other partners INERGRATION I Cornbined supervision. use of Onchcerciasis Vehicle inlother healthissues. Plan to intergratc Oncho with Eyc care, TB and Leprosy activities, also wcre uscd thc same CDD"s in other Comrnunity health activities as well as Oncho activities to appear in Councils Cornprehensive Health Plan (CCHP). Ivennectin delivery mechanism:- Distributed together with other Drug Kits frorn Disrict Pharmacy to peripheral health facilities. Intergrated training was done by using more than one facilitator in the .lparticipants. i , Soint supervision and monitoring witir other Programmes by using Intergrated check list. Funds released from District Council. YES. CDTI activities is involved in the PFIC budget. CDD's were involved in EPI activities especially during Polio and Measles Vaccination (lrtrational Immunization Dayj. 26 4.2.1 4.2.2 4.2.3 4.2.4 4.2.5 4.2.6 4. 5 Operational research IMPACT ASSESSMENT OF COMMUNITY DIRECTED TREATMENT WITH IVERMECTI (CDTI) FOR ONCHOCERCIASIS CONTROL IN THE TUKUYU FOCUS, , SOUTH WEST TANZANIA ,i ,, , ri r. ,.1(.!, REPORT Field worh Dates : 19th Jatuaryl 2004 to 05th Febru ary,2004 Prepared by : B.Kabula, C.Mweya., K.D/lVlalley and M.H.Ruhiso Submitted to : Dr. B.T.A.Maegga (PI) SUMMARY Mass drug administration (MDA) using Ivermectin (Mectizan) for control of Onchocerciasis in the Tukuyu Focus started in 1994. this exercise is continuing up to the time being albeit with a very initial coverage. Thus the study was done aiming at assign the impact of MDA using Ivermectin for controlling Ochocerciasis in the area. i' I The study was carried out in villages that had relatively high skin snip positive prevalence measured in the population-based on cluster-sampling surveys of 1997, to obtain comparable data. Villages included in the study were Kifunda, Kisegese on the Lufilyo valley, Lumbira, Ngubati section of Lutete and Kapeta on the Kiwira River. Both Entomological transmission indices and parasite prevalence in these communities were used in measuring tangible impact of the MDA. Also a small structured questionnaire was used in assessing the knowledge, altitude and perception towards the disease (Onchocersiasis) and the use of Ivermectin in controlling it. Onchocerciasis clinical signs such as presence nodules & change of skin characteristics were also assessed from every individual who participated in the study. Objectives The main objective of the study was to assess the impact of community directed treament with Invermectin (CDTD for onchocerciasis control in Tukuyu foucs with the specific Objectives of assessing the knowledge, attitude and perception of the community on ocnhocerciasis and the use of Ivermectin towards controlling it, to assessing the current morbidity of Onchocerciasis in the community, mobilizing and sensitizing the community members and their leaders on attaining a critical coverage in the community-based treatment with Ivermectin once per year and monitoring the impact of large-scale treatment on parasite transmission by the vector black files i.e monitoring on longitudinal basis, the entomological transmission indices through time since treatment started. 27 METHODOLOGY The Study Area The Tukuyu Focus CDTI Project in is the only CDTI Project in Mbeya Region (Tanzania) and covers Kyela, Ileje and Rungwe districts. Geographically, the Kyela district lies at an altitude between 400-520 meters above see level and receives an average rainfall of 1200 mm annually. The district occupies area of about 1,322 square kilometers of which about 965 square kilometers is dry and 375 square kilometers are covered by water. The district is hilly with a lot of fast running revers/strams, which provide a good breeding ground for the simulium fly that transmits Onchocerciasis. The district has two administrative divisions divided into fourteen wards and 84 registered villages. Four wards containing a total of fourteen villages are included in the project area and receive Mectizan annually. The district has a total of 25 health facilities of which seven health facilities are in the Tukuyu Focus CDTI project. Most of the gerographicla features of Rungwe district are located in a high altitude and many rivers originating from the nor them and western hill slopes draining into lake Malawi (Nyasa). Most of these rivers have been found to provide good breeding sites for the vector of onchocerciasis. The district occupies anarea of about Z,2llsquare kilometers and is divided into four divisions, forty wards, and 141 villages. Eight wards containing forty-one villages are registered in the Tukuyu focus project and, therefore, receive Mectizan annually. There are fifty health facilities in the district of which thirteen are in the project area and thus participating in CDTI activities. The work was done in five selected villages of the Tukuyu Focus. The indicator tillages selected for the impact assessment area, were as far as p[possible, those nearestto S.damnosum productive breeding sites, they are normally called "first line villages". These were Kifunda, Kisegese and Lutete (in Rungwe), Lumbira (Ludewa district) and Kapeta (Ileje district). All these villages (except Kifunda) are bordering Kyela district therefore have geographical and weather condition similar to that of Kyela district rather than the districts they belong. Data collection Community mobilization and sensitiiation was conducted from district, ward and village levels; where by the leaders and some implementers from respective levels were first sensitized so as to make a clear way to the target communities. The target community was then contacted to obtain oral informed consent for them to participate in the study. All people in target village who had the age of 15 years and above, who have been taking Mectizan annually and who were able to participate in the study were probed using a small structured questionnaire on their awareness about onchocerciasis, its.symptoms, treatmentr, benefits of treatment, and their. willingness to take the drug annually for several years. ,, l:, Through this the knowledge, attitude and perception of the communities on the disease and its control was assessed. Random sampling was used in selecting individuals to participate in the study, where the first 100 people were included in each village depending on the population. The dispensaries/health centers used by the.,cpmpgnity.wgre.also visited to get the data in regard to the disease in the aimed localities 28 i.' rt I. 1-t All participating people were clinically examined for the onchocerciasis skin lesion, nodules and cases of skin itching where all findings were recorded. This followed by parasitoligical work, where at least two skin biopsy specimens was taken from the buttocks. The biopsy specimens were examined in physiological saline under low power of the microscope for the presence of Onchocerca volvulus miciofilariae after 30 minutes of incubation. Negative samples were re- exarhindd dfter iricdtjation for 24 hours in irhysioldgical saline. In oider to indicate the magnitude of the parasite infection among the population, the parasitological indices such as prevalence was considered. Prevalence of infection provides a measure of the regression of the reservoir of infection (Hougard, J., et al 2001 and Roberts, J.M.D., et al 1967). Entomological transmission indices such as Crude Annual Transmission Potential (ATP before and after mass treatment with invermectin was used to directly evaluate mass treatment. Crude ATP is defined as the estimated number of Onchocercal L3 larvae which would have been transmitted to a iubject at a catching site per'year. This crude ATP includes all the onchocercal species. But it is an indicator of human exposure to infectious simulium bites and therefore directly measures ongoing transmission. Crude ATP then was essentially used as good measure of transmission rather than the (Animal biting rates) ABR which is the estimation of number of simulium bites a subject at a catching point would receive per year but this index is presumably not affected by ivermectin treatment however is a good indicator of human exposure to simulium files bifes. Results " I Sample Composition: Of 438 people participated in the study, 220 were males and 218 females. The ration of males of females was 0.502:0.489. The age ranged from 16 to 99 years and of mean age was 40 years. Of these 94 were from Kifunda, 131 from Kisegese,35 from Lumbira, 110 from Kapeta and 68 from Lutete as shown in table l. Level of Literacy: Of all people participated in the study 300 know how to read and write as273 had primary School Education, 1 I had Secondary School Education, only 2 affended college, t had attended adult education and 134 had no formal education. Some of them recorded to have been to school but unable to read and write or they had never been to school but they can read and write. Of 138 who don't know how to read and write, 80 were females and 50 were males, among who 44 were from Kisegese, 33 Kapeta, 26Lutete,25 Kifunda and l0 from Lumbira village. 421 (96.1%) ot these people were farmers, few fishermen and students. Knowledge about Onchocerciasis A good number of the people involved in the study failed to metion Onchocerciasis as one of the five major health problem in their area, only 37 (9.5%) mentioned the disease as one of the health problems. 260 (59.4%) of all people knows what Onchocerciasis is, and almost 50% of these don't know the signs of the disease though they claimed to know the disease. Community Drug Distributors (CDDs) seemed to have contributed a lot to the knowledge about the disease to the community. 214 (48.92%) people swallow Mectizan without knowing what it does to them. This is because only 224 (51.1%) people seems to have been educated about Onchocerciasis and the use of Mectizan to control it. 119 people got the knowledge form CDDs, 44 from District Onchocerciasis Team Members, 30 from Village Health Workers (VHWs) and 2 from NIMR Tukuyu Staff. 29 Of those who knows Onchocerciasis only l5l(58.1%) knows that Black files do transmit the disease, some 8 knows that mosquito do transmit it with the rest knowing nothing on Onchocerciasis transmission. On controlling the disease 217 (50%) people mentioned swallowing Mectizan annually as way of controlling the disease 18 (4%) people mentioned insecticide application in rivers as way of controlling he disease. At least a310970.7Yo of all people know how many times they are required to swallow Mectizan ayear. Of people 173 (37.5%) got reactions after taking Mectizan. The reaction includes swelling the whole body and some parts of the body (58 people), itching (56 people) and reactions such as fever, vomiting, headaches and malaise uncounted to 59 people. Of those who got reaction only 9l (52.6%) people goes to the dispensaries/hospital for treatment while the rest just waits for recovery without treatment. Basides the reactions they got 428 (97.7%)people are able to continue taking drugs for some more years as long as they are alive. Clinical and Parasitological Examination Of all people examined, 30 (6.8%) had nodules located in several parts of the body. Also 48 (11.0%) had Onchocerciasis skin lesions where as itching was reportedto92 people (21%). 434 people had their skin snip taken at the left and right buttock and examined, with some reason skin snips were not taken from four people. Of all samples taken there were no positive samples for microfilaria indicating the current prevalence of Onchocorciasis in the communities to be zero. Discussion It might be difficult to link epidemiological and entomological data in these sites, recent entomological data of 2004 suggests that transmission is still going on while epidemiological data show that there is no microfilaria in the human reservoir. There maybe several explanations for this. Possibly presence of non human onchocercal species i.e onchocerca oocheng obtained by the simulium animals bites. Delays in the distribution of Invermectin in some sites may contribute to the re-emergence of micorifilaria in some human infected populations. Possibly a need to recheck the coverage of Ivermectin treatment.. However a slight transmission interruption is possibly due to the year 2001 Temephos larviciding trial in some sites. The impact of large scale larvicide application on disease transmission that carried out 2003 will clearly be shown in2004 entomological data. 30 Section 5: STRENGTHS, WEAKNESSES CHALLENGES & RECOMMENDATION Challenges l. Timely release of APOC Funds 2.' Increase number of women CDD's 3. Strengthen CDTI Partnership 4. More involvement of PHC Staffin CDTI 5. Improve Advocacy/trealth education at District and community level 6. Increase community awareness meetings. Strengths 1. CDTI has been integrated into local health system 2. Ivermectin supplies flowing smoothly through the system 3. people overwhelmingly appreciate the benefits of Ivermectin 4. Local resources are gradually being offered for programme support Weaknesses/Constraints l. Poor timing of Ivermectin Distribution 2. Inconsistent release of Funds from WHO/APOC for Project 3. Lack of Transparence from District Council partner regarding CCHP budget 4. Inadequate multisectoral collaboration. Recommendation 1. The implementation of REMO has been slow in some project (eg. Tukuyu CDTI Focus) and should be accelerated. 2. NOTF should create regional task forces or similar bodies whenever needed . 3. Development and linkage with women's advocacy group. 4. Motivation of community based workers. Lessons Learnt l. Government leadership and Co ordinator is the key to success of the Programme. 2. Supportive supervision and regular monitoring is a necessity to field intended results. 3. Intergration of Project activities into CCHP increases programme ownership at District level. 4. Focused training and guidelines improves performance community and FLHL Staff. 31 SECTION 6: unique features of the project/other matters RECOMMENDATIONS OF TUKUYU CDTI PROJECT ANNUAL REVIEW MEETING HELD AT LANDMARK HOTEL, TUKUYU, ON 23RD JULY 2OO4 1. MECTIZAN SHOULD BE DISTRIBUTED TO COMMUNITIES AN INTEGRATED APPROACH I.E. USING OTHER TRANSPORT AVAILABLE IN DISTRACT COUNCILS FOR ESSENTIAL DRUGS AND OTHER SUPPLIES TO HEALTH FACILITIES. 2. DISTRICT ONCHO PROJECT COORDINATORS SHOULD BE CO-OPTED INTO THE COUNCILS' HEALTH MANAGEMENT TEAMS ESPECIALLY DURING PREPARATION OF COMPREHENSTVE COUNCIL HEALTH PLANS AND TO DURING PLANING FOR THE ANNUAL COMMUNITY TREATMENT ANY OTHER TIME. 3. PROJECT REPORTS SHOULD BE PREPARED, SUBMITTED AND DISCUSSED QUARTERLY BY ALL NECESSARY LEVELS IN THE DISTRICT _ CHMT, DED, FULL COLINCIL, ETC. THE DISTzuCT EXECUTIVE DIRECTOR SHOULD BE GTVEN A COPY DIRECTLY. CHMT SHOULD REPORT ON ONCHO ACTIVITIES TO HEADS OF DEPARTMENT MEETING. 4. THE PROJECT SHOULD ENHANCE THE DISTRIBUTION AND USE OF I.E.C. MATERIALS FOR COMMLINITY SENSITISATION, IN COLLABORATION WITH OTHER PROGRAMMES WHERE POSSIBLE. 5. THERE IS NEED.TO REDUCE TIP GAP BETWEEN ITHE PROJECT AND THE DISTzuCT COI-NCIL LEADERSHIP ), BY' ST&ENGTHENING EXISTING COMMI.INICATION. COMMTINITY HEAI-TH EUND.qTJOUI-D BE UTILVED FOR SUPPORTING ONCHOCERCIASIS ACTTVITIES AT : COI\4IvII.NITY, LEVEL. TFIE PROCES S OF ESTABLISHING.THE FTIND IN ALI'COMMUNITIES SHOULD BE SPEEDED UP. 6. THE PROJECT SHOULD INCREASE INVOLVEMENT OF THE PRIVATE SECTOR (BOTH THE PROFIT AND NOT.FOR-PROFIT ORGANIZATIONS) 7 8. THE RECOMMENDATION BY THE EVALUATION TEAM OF HAVING THE PROJECT COORDINATOR ,AT REGIONAL LEVEL AND DISTRICT COORDINATORS WAS SUPPORTED BY THE PARTICIPANTS. HOWEVER, IT WAS RECOMI\4ENDED THATI, THERE SHOULD BE APPROPRIATE DISCUSSION BETWEEN THE REGION AND THE DISTRICTS BEFOREHAND. 32 r':'"jt..: .... | { ... ,1 9. THE REGION AND ALL THREE DISTRICTS SHOULD FI.IND AND SUPPORT TI{E IMPLEMENTATION OF THE PROJECT ACTTVITIES AS PER THE 3-YEAR SUSTAINABILITY PLANS WHICH WERE SUBMITTED TO MINISTRY OF HEALTH AND APOC IN 2004. 10. DISTRICTS SHOULD PRIOzuTIZE ONCHO ACTIVITIES IN THE CURRENT CCHP AND IF NECESSARY, SEEK TO REALLOCATE FUNDS IN CASE SUPPORT FROM "OTHER FIINDS" IS NOT RECETVED OR SOME OTHER IMPORTANT ACTIVITIES WERE OVERLOOKED. 1 1. THERE IS NEED TO QUANTIFY, CONTzuBUTION IN KIND E.G MAINTENANCE, ETC., AS WELL STAKEHOLDERS COST AND DOCUMENT DISTRICT FUEL, STATIONERY, VEHICLE AS THAT OF OTHER DISTRICT 12. IT IS SUGGESTED THAT TFM NAME OF THE PROJECT SHOULD BE CHANGED FROM "TUKUYU FOCUS CDTI PROJECT" TO "MBEYA CDTI PROJECT" TO REFLECT THE NEW ORGANIZATIONAL/LEADERSHIP STRUCTURE OF THE PROJECT. 13. ILEJE CCHP SHOULD HAVE A BUDGET FOR ONCHO ACTIVITIES, APART FROM SOLICITING FUNDS FROM OTHER PARTNERS, EVEN THOUGH IT HAS ONLY ONE VILLAGE AFFECTED (KAPETA). 14. THE PROJECT SHOULD HAVE EXISTING STRATEGIES IN PREPARATION BE FORE THE END OF DONOR SUPPORT. JJ