Cross River CDTI annual project technical report submitted to Technical Consultative Committee (TCC): January 2008 to December 2008

t ilti - TRr L S o-)r,. ltrr,^ " $ /fialt /w)9{r,*' os'\t MINISTRY OF HEALTH, CALABAR, IYIGERIA, gTH YEAR TECHNICAL REPORT. ORIGINAL :English TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE _ TCC OF THE AFRICAN PROGRAM FOR ONCHOCRCIASIS CONTROL - APOC OUAGADOUGOU, BURKINA FASO. DEADLINE FOR SUBMISSION: To APOC Management by 31't DEC for MAR TCC meeting AFRICANPROGRAMME FOR oNCHOCERCTASTS CONTROL (APOC) Proiect Name:CROSS RMR NOTF/WHO.APOC CDTI PRJ. COUNTRYA[OTF:NOTF NIGERIA Approval vearz 1997 Launching year: 1.998 From: JAN 2008 To: DEC. 2008 (MonthiYear) ( Month/Yrq) Reportinq Period: Proiect vear of this report: (circleone) I 2 3 4 5 6 7 8 10 Date submitted: 3rd JAN. 2009 NGDO partner:UNICEF WHO/APOC, 24 November 20041 ,I PROGRESS PROJECT TECHNICAL REPORT TO APOC MANAGEMENT ENDORSEMENT Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the report: Country: NIGERIA National Coordinator Name: Dr. Yemi Fayomi Signature Date Zonal Oncho Coordinator Name: Mr. John Eluwa Signature: .. Date NGDO Representative Name: Mr. Saoondo Anom Signature Date This report has been prepared by Name : Mr. Adie, Hilary Adie Designation : Coordinator Signature : ... Date 11 WHO/APOC, 24 November 2004 Table of contents 1.1. GpNeRer- INFoRMATIoN ;;;;,; ; i ;;;;;; ;; ; ;cft"i. ::::::' ::::'! iti !1!!'; 1.1.1 Description of the project (briefly) SECTION 2: IMPLEMENTATION OF CDTI....... .......9 2.1 Ttvpt-me oF ACTIVITIES .... ..............9 ............102.2 Aovocacv. 2.3. MogtLIzertoN, sENSITIZATToN AND HEALTH EDUCATIoN oF AT RISK coMMuNtrrns 11 1.1.2. Partnership......... 1.2. Popu1arroN................ 2.6.1. Treatmentfigures ............ .....Erueur ! Signet non diftni. 2.6.2 What are the causes of absenteeism? .......... ................. 19 2.6.3 What are the reasons for refusals?................ ............... 19 2.6.4 Briefly desuibe all lcnown and verified serious adverse events (SAEs) that ... 20 2.6.5. Trend of treatment achievementfrom CDTI project inception to the curuentyear22 2.7. ORppRING, sroRAGE AND DELIVERY oF IVERMECTIN ............... ..............23 2.8. ColaMlrNltry sELF-MoNIToRING AND STAKEHoLDERS MppuNc ............25 2.9. SuppRvrsroN.... .,.,....27 2.9.1. Provide aflow chart of supervision hierarchy. ............ 27 2.9.2. What were the main issues identified during supervision? .............................. 28 2.9.3. Was a supervision checklist used? ............. 29 2.9.4. What were the outcomes at each level of CDTI implementation supervision? 30 2.9.5. Was feedback given to the person or groups supervised?................................ 302.9.6. How was the feedback used to improve the overall performance of the project? 30 SECTION 3: SUPPORT TO CDTI ..............31 2.4 2.5 2.6 3.1. 3.2. J.J. 3.4. Yn 3)... 4.2.1 4.2.2 Couvr-nqrrY INVoLVEMENT..... Cepa,ctrv BUtLDING.. Tne,q.rveNTs.............. EqurruENr FneNcIeI CONTRIBUTIONS OF THE PARTNERS AND COMMLNITIES Oruen FoRMS oF coMMUNITy suppoRT............. ExppNortuRE PER AcrrvITY t2 ...... t4 ......18 .......... 3 1 ..,.'.,.,.32 ..........32 ..........33 35 35 35 SECTION 4: SUSTAINABILITY OF CDTI....... ..........34 4.1. INrEnNel; TNDEIENDENT IARTICIIAToRY MoNIToRINc; Eva1ulrtoN....................34 1.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable) ...... ... ............ 344.1.2. Wat were the recommendations? ............. 34 4.1.3. How have they been implemented? ............. ................. 34 4.2. SusrarNesrt-rry oF IRoJECTS: ILAN AND sET TARGETS (rreNoeroRy AT................ 35 111 WHO/APOC, 24 November 2004 4.2.3 Transport (replacement and maintenance) . 4.2.4. Other resources 4.2.5. To what extent has the plan been implemented 4.3. INtscRertoN 4.3. 1. Ivermectin delivery mechanism,s...................... 4.3.2. Training.... ............. 36 .,.,.........36 ............. 36 .............36 ............. 36 ............. 37 4.3.3. Joint supervision and monitoring with other programs........... ...... 37 4.3.4. Release of funds for project activities ........ 37 4.3.5. Is CDTI included in the PHC budget? ............ ............. 37 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements?............. .................... 37 4.3.7. Describe others issues considered in the integration of CDTI. ..... 38 4.4. OpeneTroNAL RESEARCH .....38 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. ........ -?8 4.4.2. How were the results applied in the project?............. .................... 38 SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, AND OPPORTUNITIES.... ................... 38 SECTION 6: UNIQUE FEATURES OF THE PROJECT/OTHER MATTERS...........41 lv WHO/APOC, 24 November 2004 , Acronyms APOC ATO AtrO CBO CDD CDTI CSM LGA MOH NGDO NGO NOTF PHC REMO SAE SHM TCC TOT UNICEF UTG wHo African Programme for Onchocerciasis Control Annual Treatment Objective Annual Training Objective Community-Based Organization Community-Directed Distributor Community-Directed Treatment with Ivermectin Community Self-Monitoring Local Govemment Area Ministry of Health Non-Governmental Development Organization Non- Go vernmental Organ ization National Onchocerciasis Task Force Primary health care Rapid Epidemiological Mapping of Onchocerciasis Severe adverse event Stakeholders meeting Technical Consultative Committee (APOC scientific advisory group) Trainer of trainers United Nations Children's Fund Ultimate Treatment Goal World Health Organization v WHO/APOC, 24 November 2004 Definitions (i) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking). (ii) Eligible population: calculated as 84Yo 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 expictld 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 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) 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 government. (ix) Communiw self-monito : 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. vt WHO/APOC, 24 November 2004 FOLLOW UP ON TGG REGOMMENDATIONS Using the table below, fill in the recommendations of the last TCC on the project and describe how they have been addressed. TCC session23 Number of Recommend ation in the Report TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT ASE ONLY 111 Continue training of new and more CDDs both male and female The UNICEF supported activity on involvement of women in CDTI and sensitization for CDDs on guineaworm surveillance prov ided fora for the training of 453 CDDs, 253 of those trained were women. State and LGAs financial contribution should improve -there is renewed commitment by the present Commissioner for health in the pursuance for the release of counterpart funds from Government, the erstwhile commissioner did not believe in CDTI. APOC funds for advocacy were adequately utilized in the mobilization of the LGA councils to support CDTI, at that leveI, LGA councils have approved various sums as monthly imprest for the implementation of CDTI. There is improvement in some LGAs and if this continues, will boost the implementation of CDTI in the areas. The problem lies with the State where no concrete evidence is available for release ofapproved funds by the Governor. There is need to continue the involvement of women -The project is aware of the invaluable contributions of women in health care delivery and with the support of IINICEF identified factors militating against women participation in CDTI, the findings were used for design of countermeasures to improve women participation. There is increased number of women CDDs and number of communities with women as CDDs. (Please add more rows if necessary) I WHO/APOC, 24 November 2004 Executive Summary In 1997, APOC approved the commencement of the Cross River State CDTI project and in 1998 implementation of CDTI commenced in five LGAs. Currently the project is in 930 communities in all 14 onchocerciasis endemic LGAs out of the 18 LGAs in the entire State. The 9th year was aimed at sustaining the distribution of Ivermectin to all endemic communities to ensure 100Yo geographical coverage and at least 80% therapeutic coverage, ensuring that the project continues to provide a good structure to deliver simple Primary Health Care interventions to the population, ensuring the release of counterpart funds by Govemment, ensuring practical integration of CDTI and other add on programs into the PHC system, ensuring greater collaboration and participation of local CBOs and NGOs in CDTI implementation in 2008 and ensuring improvement of women participation in CDTI. The project treated a total of 897,649 persons in 915 communities from Jan. 2008 to December 2008 (therapeutic coverage of 80% and geographic coverage of 98 %) . The UTG for 2008 was 919,464,the total population was 1,121,298. Training was held for 224 health workers on technique for community dialogue to change attitude and perception of men so as to improve participation of women in health and development decision making processes. The dialogue process which was supported with funds from LNICEF provided an opportunity for training of 253 female Community Directed Distributors in eight LGAs. A training of CDDs for guineaworm disease surveillance was also conducted in three LGAs for 200 CDDs with support from UNICEF, altogether, 453 CDDs were trained during the year. The major challenges in the CR- CDTI project are: . Ensuring release of approved counterpart funding by Government. . Collaboration with other service providers in delivering other simple PHC services aimed at promoting Health in the communities. o Greater involvement of women in CDTI activities. Various ways have been employed to address these challenges: 2 WHO/APOC, 24 November 2004 Oa a o a a The Local Government councils were approached to ensure their support of CDTI activities, 14 LGA chairmen, Supervisory councilors for Health and PHC directors were mobilizedto ensure adequate budgetary provisions for CDTI activities for the remaining part of the year and in 2009. Some LGAs ( Biase, Yakurr, Obubra, Etung, Yala, Bekwarra, Obanliku) have started monthly payment of imprest to the PHC directors and Oncho. Coordinators to carry out minimal supervision of CDTI ijmplementation. The unit is collaborating with the Sight Savers International, Youthcare, Catholic Diocese of Ogoja, UCTH and Tulsi Chanrai Foundation in provision of eyecare services to the populace. The project is in the process of deliberately convincing the communities on the need to see why it is necessary to increase women participation as CDDs. To achieve 100% geographical coverage, there is continuous collaboration with other service providers who are offering community services in the rugged areas where the health service is absent e.g the forest rangers in the Okwango National Park, the rangers train CDDs and take Mectizan to the communities as well as retrieve Mectizan treatment retirements. Also to ensure adequate therapeutic and geographical coverage, local CBOs have always been approached for support to ensure that basic components of CDTI like Mectizan distribution, Supervision and Mobilization are carried out even in the face of non release of counterpart funds. Early distribution of Mectizan is key and was distributed early to all communities and frontline health workers have been mobilized to ensure that they monitor communities within their catchments to ensure that they treat and retire Mectizan on time. Prepare an Executive summary of the report in not more than one page. J a WHO/APOC, 24 November 2004 SEGTION {: Background information 1.1. General information 1.11 Description of the project STUDY AREA Cross River State is one of the 10 States in South Eastem Nigeria Primary Health Care (PHC) zones. The State is situated within the Cross River Basin between latitude 50 32'North, and 40 27' East. Ebonyi, Abia, and Akwa Ibom States bound the State in the West, in the North by Benue State. The Southern boundary is the Atlantic Ocean and it has international boundary with the Republic of Cameroon in the East. The main occupations of the people are farming, fishing and hunting. The State is situated within the tropical rainforest, one of Africa's most dense forests found on the eastem borders with the Cameroon and the secondary forest and guinea savannah in the westem and northern parts of the State. The climate is tropical, however temperate climate is found in Obudu plateau where altitudes are in the region of 1,500metres above sea level. The topography is mountainous in the Cameroon border; plain fields are found in Yala and Ogoja axis. The population is approximately 3.1 million as projected by the 1991 population census. The State has three main languages, Efik, Ejagham and Bekwarra. One major festival celebrated in the State is the new yam festival, which takes place in the rainy season. There is a good road network, which links the State with other parts of the country. The state can be accessed through land, air and water. There is a two tier administrative structure at this level. A democratically elected Govemor heads the State executive council. The local Government chairmen who are also democratically elected head the local councils. The health system operates at three levels, the primary, secondary and tertiary levels, the primary level which is community based is run by the Local Government administration in conjunction with the State Ministry of Health. The secondary level is managed by the State Ministry of Health and takes care of referrals from the primary level. 4 WHO/APOC, 24 November 2004 The tertiary level is managed by the Federal Government and comprise of the teaching hospital in the university college where special cases are referred to for special care. There are 296health centers and posts in the project area. Table 1: Number of health staff involved in CDTI (Please add more rows if necessary) DistricULGA Number of health staff involved in CDTI activities. Total Number of health staff in the entire project area Br Number of health staffinvolved in CDTI B2 Percentage B.=B,/ B' *100 AKAMKPA 129 89 69Yo AKPABUYO r22 50 4j%o BEKWARRA 7t 55 7704 BIASE 76 65 860/0 BOKI 135 103 760/o ETLING 48 32 67% IKOM 99 44 44Yo OBANLIKU t02 56 55Yo OBUBRA 99 48 48% OBUDU 98 66 67% ODUKPANI 109 76 70% OGOJA 148 48 32% YAKURR 175 76 43Yo YALA 138 121 87v, Total 1549 929 59% 1.1.2 Partnership The partners in the Cross River State CDTI project are 1. The Federal Ministry of Health 2. APOC-WHO 3. State Ministry of Health 4. The LGAs 5. The communities 5 WHO/APOC, 24 November 2004 6. IjNICEF 7. Several other NGOs which include i) South Eastern Nigeria Outreach Eyecare Services (SENOES) ii) Youthcare iii) Ogoja Catholic Diocese Eyecare Services iv) Opthalmology Department University of Calabar v) Cross River National Park vi) Cross River Forestry Commission vii) Tulsi Chanrai foundation viii) Cross River University of Technology (8) The CBOs who are working in partnership include: i) Great Friends Klub of Obudu ii) Pacesetters Klub Exclusive of Calabar iii) Calabar Leo Klub iv) Catholic Nurses Guild v) Beb Rural Health Development Options The State Ministry of Health provides the manpower needs for the implementation of the project, provides counterpart funding for activities and monitors overall implementation strategy and administration. The NGDO (I-INICEF) partner provides part funding, logistics and expert advice for project implementation. The local NGOs and CBOs e.g the Cross River National Park and Forestry Commission are responsible for delivery of Mectizan, training of CDDs in their catchments areas. People from endemic areas residing in Calabar and other major towns in the State are treated with Mectizanin churches by other CBOs like the Catholic Nurses Guild, 6 WHO/APOC, 24 November 2004 Archdiocese of Calabar, the Great Friends of Obudu, The Pacesetters Klub Exclusive of Calabar. A good number of policy makers worship in these churches and are also mobilized during such fora to support CDTI activities. 7 WHO/APOC, 24 November 2004 el FpE rq9 OoovI € * $ \o F-\o^ oo oor- .l €\o o\ oo \o € c.)C\ N oo oo co c.l o\\o .l $ N\o + co o\N ."r $ ca ca € t c- c.l o\ .{ a.l a.) o\ ."I \oO =\o =a o\ .6) -()o .= o.N :> Ei r€ \o ca$ $ oo ot o\$ \o rI t- \o\o c\ co oo o\O s oo 00 r- o\N C-) co co F-$ 00N ca C.l ca € o\ aa O @ c\ \o(\ ooc.t o\ c.) c.l oo o\ ar 6 o\ .I al -.6 . eE; ."r!r &5.=5 >! 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Advocacy Advocacy visits and letters were made to 1 Governor, 3 Honorable Commissioners, one Secretary to Cross River State Council of Chiefs, 7 Directors in the Ministry of Health, one Permanent Secretary in the Ministry of Health, 1 Director of Finance and Supply, Ministry of Health, 14 Local Government Chairmen of Councils; the advocacy visits to the policy makers at all levels was to gain political will of the government in the provision of counterpart funds for the CDTI project. A memo was written through the Honourable Commissioner for Health early in the year for the release of counterpart funds for the project. The policy makers in the Ministry of Health, Ministry of Local Government and Chieftaincy affairs were written to for them to see the dire need to support the control of onchocerciasis in their domain. It has been seen from experience that advocacy meetings for Local Govemment Chairmen usually fail as the Chairmen claim they have no time to stay all day for an advocacy meeting, the State Oncho team constituted a team that visited all the LGAs for advocacy meetings with LGA policy makers. The meetings were fruitful; LGA Councils of Yakurr, Biase, Obanliku, Bekwarra have started paying monthly imprest for CDTI activities. All twelve LGAs visited also agreed to fund proposals from the LGA oncho teams for activities for the remaining part of the year. Collectively, the LGAs contributed the sum of seven hundred and twenty thousand Naira (l{720,000) as imprest and funds for collection of mectizanand bicycles from the oncho unit in Calabar. At the State level, the Governor approved the sum of two million Naira since March 2008 but the funds have not been released from the State planning commission till date. The problems faced with advocacy is the premium placed by Government on secondary health care, the neglect of health care over the years has made Government to devote most of the funds available in Health into rehabilitation of Hospitals and purchase of equipment thereby neglecting Primary health care programmes. Television and Radio programs were organizedinthe State Broadcasting service to also mobilize policy makers and the general populace on CDTI during the 2008 world sight day and National onchocerciasis day and on other days the project is invited to give health education. 10 WHO/APOC, 24 November 2003 Efforts have been made in the past by the National office to meet with the state policy makers without success, this should not be shoved aside, dialogue with the state policy makers made a lot of difference in the past. State the number ofpolrcy/deasron makers mobrlued at each relevanl level durmg the cutent year, the reason(s) Jor undertaktng lhe advocacy and the outcome. Descnbe dfficulues/constramts bemgfaced and suggesttons on how to tmprove advocacy 2.3. Mobilization, sensitization and health education of at risk communities Community mobilization was done at a comprehensive scale in Akpabuyo and Odukpani LGAs where LINICEF provided funds for special intervention exercise to address the problem of low treatment compliance; mobilization in the remaining twelve LGAs was targeted at problem communities. Generally, LOCTs continued in intensified mobilization and Health Education of endemic communities on the need for them to continue treatment even when the symptoms of the disease may have subsided. Mobilization for Odukpani and Akpabuyo was done through the mass media, rallies, churches and community meetings. -Response of Communities can be measured by treatment coverage and participation even in the face of minimal intervention by the health service. The strength of the Cross River CDTI project lies with the communities; the hope for a sustained treatment for the required number of years lies with the communities, the project has mobilized the communities to the extent that very organized communities have demand driven initiative towards Mectizan now. In the beginning of the year, they plan their Mectizan distribution and demand for the drug from the Health service. At one instance, Akpet central community was willing to provide money for the state to collect Mectizan from Lagos when there was a delay in collection of Mectizan from Lagos. The main problem is with the communities where leadership is weak and organizational structure also weak due to multi cultural and ethnic differences within the community 11 WHO/APOC, 24 November 2004 TOther social organizations like the churches, clubs, age grades etc. are being used to reach out to the people in these areas. The lack of initiative by frontline health facility workers and their dearth in innovative skills have hampered the early realization of a sustained outlook of the Cross River CDTI project. -The project will continue to maintain high treatment coverage both therapeutic and geographic if APOC continues to provide minimal funds for targeted mobilization of problem communities to ensure treatment compliance, however on the final exit of APOC, these activities will be sustained with the network of NGOs and CBOs working with the Cross River CDTI project. Various methods (Radio, TV, town announcers, posters and handbills) will be employed to ensure that all communities are mobilized; funds will still be required to ensure that all the various means are employed to ensure that communities are mobilized. 2.4. Gommunity involvement Communities in the CDTI lease add more rows nece, Number of communities /villages with female CDDs Number of CDDs and the communities involved Number of communities/villages with community members as supervisors Percentage Brr= B',/B.*100Br Female CDDs Total Bq= $r+f,* Bro Number of communities with female CDDs Number with community members as supervisors Bo= BJ B4 *100 Perce ntage B. Male CDDs B7DistricULGA B4 Total no. communities in the entire project area 2427 440 2393 l00Yo 413 AKAMKPA 93 668 30 93100o/o 468 20032 32 AKPABUYO 5td 9 20100Yo 319 946 46 BEKWARRA .t oA t9 59100o/o 172 2332 32 BIASE 34 26572 46 618129 129 100% BOKI 7 249 31729 00v, 308 ETT,]NG 29 93810 8794 100v, 568 242 IKOM 94 r8167 t2l00o/o 155 12 OBANLIKU 67 67 372 9 23100% 361 ll 2424OBUBRA 27 69414 29 443 39 39 l00o/o OBUDU 58 89230 bbl 65 100% 432 ODUKPANI 65 4529 256 25 56 l00Yo 227 OGOJA 56 43350 6100% 336 l4 YAKURR 14 t4 46 221000h 351 lqq63 210 210YALA 435,040 401100'h 5,096 944 930 930Total t2 WHO/APOC, 24 November 2004 I UNICEF supported a research proposal to identify those factors that were preventing active female participation and attendance at meetings and health education sessions, the findings included the following: The culture of marriage where men from one coflrmunity cannot marry from within that community, the mother's community and some other relations that may be determined by tradition has made marriages in some of the LGAs e.g. in Obudu LGA, suitors must be from neighboring communities. Married women are alienated and seen to be foreigners, when issues conceming the communities are discussed, one male adult said - the women are not called out because "it is not an issue that concerns their village, the husband can tell her in the house". Women are not allowed in the playground where major decisions are taken because in the olden days when they were communal clashes, the talking drum called only men out to fight and it was forbidden to allow women to converge with men in the playground. That still holds till now even in the face of reduced communal feuds. In a situation where two communities had a feud, women were not allowed to hear the discussions concerning the feud in the playground because they could easily disclose what was discussed to others especially if it concerned the woman's community where she comes from. It is traditional in most of the communities visited that fines are shared among community members in the village square, if women are involved, sharing will be done with them and a polygamous man will have more than a monogamous man since the former will have his two or three wives in the playground, it is better for men to get the share and they can in turn go home and share among their wives for those who have more than one wife. A community dialogue procedure to initiate involvement of women by the community members themselves will take a while to take roots in the communities visited, "this thing you people are asking us to do is very difficult but if you feel that it is women who should decide now, we will do it because Government knows more than we do" (Adult male, Bebuabie community). The counterrneasures designed to improve the process included the following: 13 WHO/APOC, 24 November 2004 Communities accepted to design a new drum language that will call both sexes out to the playground, they equally recognized the need to involve women in decision making especially on health issues since women play a key role as care givers in the home. Women were necessarily to be selected by communities as CDDs. The issue of women participation in health programmes is of great concem, it is a problem that requires attitudinal change from both the male and the female gender and requires time for the right attitude to be built. On the whole, the mobilization can be seen to have yielded dividends, gradually; more women are seen to be involved than when the programme started. Communities have devised various methods of rewarding the CDDs ranging from farming for them to contributing yams for them. The methods for reward have continued to stabihze and are part of the community routine having done that for the past nine yeafs. Communities have imbibed the culture of replacing CDDs with new ones and training them by the old CDDs to ensure continuity, this was seen in Begore recently during a visit to the remote community, the old CDD who recently got recruited into the police force trained six new CDDs before leaving the community for his new assignment. Commenl on - Attendance of female members of lhe communtq' at health educatron meetmgs - In general, ii"' do you rarc rhe partrcryatron of female members of the commuruty meetrngs when CDTI rssues are bemg dscusses (attendance, pdrhcqatton m the dscttssron etc). - Incentoes provtded by communilresfor lhe CDDs - Atlntrcn of CDDs ls dtlntbn a problemfor the proyct2 If yes. how ts i addressed? - Other ssues 2.5. Gapacity building There is adequate manpower in terms of numbers at the State and LGA levels but personnel are not always available for CDTI activities, even when they are available, they lack the skills for independent work at the community level, they are usually engaged in other ventures, they think CDTI should be accorded part time status now, they look at the monetary gains not work. Communities are being mobilized to select more CDDs for training to meet a ratio of 2CDDs:100. t4 WHO/APOC, 24 November 2004 There is an agreement reached with the Local Govemment Service Commission concerning posting of staff involved in CDTI activities. District officers are usually posted from one CDTI area to another CDTI area. Where the health service cannot reach, efforts are been made to involve other service providers in the area, e.g. the forest rangers in the Cross River National Park and Forestry commission in Obaniliku, Boki and Akamkpa LGAs. In some other LGAs, teachers have also been trained to provide support manpower for data processing by the CDDs and CSM implementation. - Descnbe the adequacy ofavailable knowledgeable manpower at all levels - LI/here Jrequent transJers of tramed stafJ occur, state what the prolect s dotng, or mtends to do, to remedy the siluatrcn (fhe most tmportant ssue to descnbe w what measures vere taken to ensure adequate CDTI mplementatton where not enough knowledgeable manpower was available or { stafJ are frequenlly lrdnslerred durmg the course of the campatgn) 15 WHO/APOC, 24 November 2004 NN N I '-) \o \o I I ?o ra$I I \o co c.lN I c.l$ ^) al I N c.l ^) $ c.] Nt € a.t oo an r- ol Nc.) N $ ca O\o 0) o U q) z z F q I I I I I I q GV .6 ,. I II I eh o .i'o'c!frLA Lfr6): -Oo0,L9 6,lt- z I O\o \o I r- r- $ ar or t at al I \o \o co I co co ca co o\ o. 6v q e o\o F- =ararF ca ca o\ c) dL l= i: 3E tr'> z;. 0)I \o al \o(\t I .L .U GV @ 00 \o6tO !x G an o Fl 9e(J0) !, !Y o z @ & Dg J F] Fr E-( () o q) c) vo\ frla ca v a z F lJl z v V r.l z EO p ca a z V D f- rl (, 0 IJr v z v o Da v & v r! +t cooO a.l L 0) -o 0) o zsN (J (J B \o 00 o I ^a \ a) q) 4 \) .t i b0 o\ L\ oU \) \ o\ qt .a o q)\ $' F q) F 4 U\ q) r- t q) \) F O +r U) o () (.)! _c)qi C) (t F #r ol 3l FI 4q) uq) a I I II I I I I I I Table 6: Type of training undertaken Qick the boxes where specific training was carried out during the reporting period) Any other comments Trainees Type of training CDDs Other Community members e.g. Community supervisors Health Workers (frontline health facilities) SOCTs, MOH staff or Other Political Leaders Others(specifu) CBOs Program management How to conduct Health education Management of SAEs CSM SHM Data collection Data analysis Report writing Computer training Strategies for improving women participation in CDTI Identification of guineaworm disease t7 WHO/APOC, 24 November 2003 $OO c.l H(.) -o () o z$ c.l O o H ^1L)lar B € a Ea o o bo q! o q o o bo € o 6 q b0G o oq o o oo -0) o q o6 o o\ a o c d IE ld oil)6 oI o o q G o0 o oo 6\ m o o 2 a o o v, A.l S 6 N UIi I z l- ah L eh q) L cg F] q) L ah uh ri a OEf LEO6)?E .LL9fldG9E'F; q) e€N3 I 6 ^tYF ?z9a;='-d9=or!-=2f '= 9< 3 3i =AE2FE}2>r.Yo!oo-dL I#i =a2z c.l \o co cn N o\ i l,o .It c.l c.l cn r- 00 N No\ o\r- o\ a.l \ot a] NO a.) Ets z€ N o\ $ r- ro rocn o\ \oa.l co co\oc.) co ant \ 6 -E -3 EoE9 J O - .r ::Z o. iY s € o\ o\r- o\ c.l € \vo\ € F- o\ € \o oo o\ o\ F- o\ €r- o\ oo -o 6\ co -o o\ 00 F- .o o\ oor- o\@ F- o -o\ o bo o oo o o.(c o F \o oo o\6 F- \o\o v} co$ \o c.ir- N\o \o^ caN + o\t\o r- o\ € t e.l r-Ci @ od \or-vI @r- \o r- ca c.) o\q o\ co r- o, 00" N co $ .{ * € cn F- F* oo c.t \o n" t- .l r-\o a Z'\a!:o EETE z or! a.l\o \o^ $ ca c.) $ co c.t €^ *r- c.l o,(\ N c.t o\ cn \o t\ot o\ o\ @r-C\ 6\o o\ N oo \o co co oo oo oo o\\oN $ 00 00 co + $ \or-\o 00 ; :oE 6.= ,o.o' -v €N \o N o\ oo co o\ co N 00\o o\ c\ € o\N N o\ + oo oo co r- o\N o @odI r-$ c.)NdI C.l co @^ o\ c.) \o\o c.}$o s oo ot o\ * \o v} r- \o .{ a.l co I o (t o < 9.o 6.=., >F::;i-Es6u .-JrA!! O-oo s6 o\r-o\ o OO N o\\oo\ F-o, oo\ O oo '= bo 9L ^I 9.o' =^ao\ o- o\ co o\o \o $ O N !,r) o\C\ o\N o\ c.l c.l o\ r-\o $No\oo ca) \ot (E= o L tr o0-ooSdo ! F- 6q==o =5>-Z,oO s c.t tt o\r-\o $cn o\co \oNcO \o$ c.lco o\ c.] o\ a.l $ o\ Ec:E 6.U ja-a' FU a.lo\ o(r)(D O) CO r.r) @ (o ro sf o N (os NCO o)N o)N so, F-(o $N!:E U Q O * = =o xE @ * riE a i G -EE=E;IH=:6> 9IrooE (o o, N(f) al 0Jl bol(€ t ch 0,) oU -o o o E.tlY J j F Fo Y fY) z co o E. cof d) o fo =co o =(L\lfo o (L Y V o f c0 (L )< E.t BV I.JJ d] I,IJa 6 =otrl (, zfF I.JJ l) -t ;v o\ I Therapeutic coverage rate (%) communities within the project area Formula for computing and seoqraohical coverages Number of treated x 100 Total population living in meso/hyper-endemic Geographicalcoverage rate : Number of communities/villages treated x 100(%) Total number of meso/hyper-endemic communities as identified by REMO in the project area ATO coverage rate (%) Number of pqople treated x 100 Annual Treatment Obj ective %UTG achieved Number of people tre Total number of people to be treated in meso/hyper-endemic areas within the project area (UTG) ATO = The estimated number of people living in meso/hyper-endemic areas that a CDTI projecl intends to trcat t)ith ivermectin in a given year. UTG = The naximam number of people to be treated in mcso/hyper-endemic areas wilhin the projecl area, ultimdely to be reached when the project has reachedfull geographical coverage (normally the project should be expected to reach lhe UTG al the end of the 3'd year of the project). 2.6.2 What are the causes of absenteeism? The main cause of absenteeism is wrong timing of treatment period, in some communities visited during the recent monitoring, some CDDs decide on when they treat the people not the community deciding when they want treatment, that has caused absenteeism. Wrong census update is also one of the factors responsible for absenteeism, in Yala, Ogoja, Yakun and Bekwarra LGAs movement of young people to western Nigeria to work in cocoa farms after enumeration cause high absenteeism during treatment period. The high non indigent nature of the communities in the southern senatorial district causes unstable populations and this has caused absenteeism also. These have been stemmed through mobilization of communities for correct enumeration and excluding people who are not present in the communities there is positive change hence the reduced number of absenteeism for 2008. 2.6.3 What are the reasons for refusals? Misconceptions about Mectizan treatment and fear of severe adverse reactions have been the reasons advanced for refusals, there are still persons with weird views about 19 WHO/APOC, 24 November 2004 Mectizan, though they are few, they are still being mobilized to take up treatment. There are 337 refusals so far in 2008. There were 1 07 I refusals in 2007 , 2365 for 2006 as against 8121 in 2005 and 10713 persons in2004. 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 information when available. The project started treatment 13 years ago, at this period of the project life, SAEs are not common again since there is no expansion to any new area. In case the project did not have any cases of serious adverse events (SAE) during this reporting period, please tick in the box. No SAE case to reported {< 20 WHO/APOC, 24 November 2004 $ cl Lo .o 0.) o z +cl (-) { - > N q) \\) o'\q) Lq)q tF 4q q) Qq) (r.- q q) L t q)q q) 5 o (.)a bo a(") L 0) bo L{ oLL oo Cd ah rl] a U) o 0.) C)thL. C) a o fro U1 +r o U) 0,) U)(t O #; 0)t -ot(nt FI o o99 395 <.= E L "- oo o)dr9 60a 6 ==9E9 -X o.=llloo o'3 =Ygq0 (J A. qO-(HX a9 ^ 6.= (Dq)E q&3d (*;()- o.2ECq) tr tr=(BoO(,)A = .K,N!99k (*'- oZi-c,C a)'=== O H-EE € - I 9p.E sEEtg o o. a --:.q) -.: \olfo)9L ^^*l-]oo6 = (.) .NtgE;d>; +i c)o0cG.- =bo?o Xoa (.) oo * 1a +N () -o C) o z +N O \J l.J NN o ol-r (,) cn bo o(t q) U) o (h U) C)o 0)o (r) *r(c o >. o qr () c.) Cd o -od (t (d op >t o o oo lr(.) o bo O(!() L< ,oH ch(.) C) q) F U) o C) q) () F D L q) () en q)L U) q) ah N o\ q) L 6l I() o) L 3p o) 6) cl9 q) U) ctq) t NJ S. A)\ !qr9E e.= P;: :'i . o$J r0) A+.oc)oq) LEA c) q) l- C) f ) ! OCBL0) HHIoEl HLt6 orl ool -cxe .ol c)!bo 9b Gr5 o) cHE €ctrc)e)El-H -cd 9)qa \o e.i o,l()ld. FlFI o\ \o o\ co oo o\r-r- o\ c.l oo o\s oo o\ an o\ -oo\$ o\ o\ oo € o\ o\ o\ ca o\ 6\\o o\ \o r- o\0)ooO E,:F ()X - >L.ro U r-r- o\ o\ c.)o\ so\ @@ o\ coo\ \oo\ .oo\r- o\oo &o-F UX< 3-I \o +co r- €r- o\F- Nr- r- F-F- € o\ @o'Eo O 6^3ES ooEOF (\ o\ \o o\\o ol @ N t\o N * @ oor- F- .+ \o \o o o\t\o o\\o Or- s o\N a.tr- .f, o\ ro^ aa c.lr- F- +\o c- ca co co c.l\o oo @ o\$ .o^ F- o\ @ o a- c5g!@dEE95 0!z C.l$ € @ o\$ o\ $ F- \o o Ooo(-- r- O r- oa N co a- \o an a.l @ o\\oq F-t oo t aa6\o oo NO^ € o\ € $ $ o\ o\ ?o d O.= l=o ::o i99' Fv ) c.l oor- aa o\ a.) .:.r6 = :io -i r FE5_.c ? o at d llE :o *r- ca o\$ o\ \o r- r-+ r- $ c.lr- a- + oo $ al o\ $$ N o\ o\o a.) o\ c.l$\o o F- o\ oo odO O^ o\ r-d$ --i' $ c.l$ \o o\ o^ @ o\N N d q o F- o, o\ o\ o\00 o, F- o\ (-- 00 s o\ o\ o\o\ \oo\ No\ Oo ^ooUF.: F Oa\4'>- -o r- o\ o\o\ o\ € o\ F- o\ tr-o, \o€ $o\ o, o,o, \oo' clo\oo o.i: -!go-o__a>o\ o- co o\ oo oo oo co o\ N o\ € o\ o\;.- 6 v =vtrDooi;7 O.Y E t o\\o tr-F- $ co t-- t-- oo N oo c.l o, o\ r- c.l 00 o\ o, $ co o\ s c.t o\ a.l a.) o\ cao\ cao' c.lo, cao, a.)o, a.to\\:od o.= 4a.o' -v s c.t o\ s c.) o\ a.l c.l o\ O ca o\ o c.t o\ o\ O c.t o, a.t o, o\ () oo () oO 6 >_16!> 9 U e r'E - t:: !3aoE3 E tof g(trdc; oo o\ r- cat oo o\ o\ coOoN s C.l o(\ \ooO(\ c-o N co a.lrrl r- o\ o\ € o\ o\ o, o\ o\ OOoN O(\ a.l c.l 2.7. Ordering, Mectizan@ ordered/ MOH tr storage and delivery of ivermectin applied for by - (please underline the appropriate answer) WHOtr UNICEf,E** NGDO Other (please specify): Mectizan@ delivered by - (please tick the appropriate answer) MOH E** WHO tr UNICEF tr NGDO tr Other (please specify): Please describe how Mectizan@ is ordered and how it gets to the communities NOCP orders the total drug requirement for the whole country; LfNICEF facilitates clearing of the drugs from the ports and storage in the central stores in Lagos. The State Ministry of Health authorities collect the State consignment from Lagos and the drugs are stored in the Onchocerciasis control unit stores in Calabar. The LGA councils sponsor the collection of the drugs from the central store in Calabar. At the LGA level, the drugs are stored in the LGA central drug store. The drugs are distributed to the health districts in the LGAs. The communities around the districts come to the District headquaters to collect the drugs for the end users. 23 WHO/APOC, 24 November 2004 n Table 10A: Mectizan@ Inventory 2007 (Please add more rows d necessary) StateiDistricULGA Number of Mectizano tabtets * * * I Number in stock RequTsted Received Used Used/Person treated Lost Wasted Expired Remaining AKAMKPA 280.000 280.000 280.000 212.316 84,245 78 2 0 67.606 AKPABUYO 96.000 96.000 96.000 92.734 38.773 42 t9 0 3.224 BEKWARRA l 60.000 160.000 I 60.000 147.279 56,4s6 43 t4 0 12.678 BIASE 180.000 r 80.000 I 80.000 177.002 67.237 78 3 0 2.920 BOKI 320.000 320.000 320.000 319.723 150,124 98 7 0 179 ETLING 200.000 200.000 200.000 153.726 58,827 74 7 0 46.200 IKOM 180.000 180.000 1 80.000 157.220 78,576 63 41 0 22,717 OBANLIKU 130.000 130.000 130.000 94.962 37,006 39 23 0 34.999 OBUBRA I 20.000 120.000 120.000 93.729 39,993 JJ 27 0 26,238 OBUDU 160.000 r 60.000 r 60.000 86.200 32,897 27 28 0 73,773 ODUKPANI 121.046 121.046 121.046 121.046 43,566 39 66 0 0 OGOJA 200.000 200.000 200.000 181.262 73,156 78 5 0 18,660 YAKURR 120.000 120.000 120.000 86.072 31,662 45 43 0 33.883 YALA 280.000 280.000 280,000 263.938 104,236 29 32 0 16.033 TOTAL 2,547,046 2,547,046 2,547,046 2,187,170 897,649 766 317 0 359, I l0 - How are the remaining ivermectin tablets collected and where are they kept? All remaining tablets are collected from the communities by the Local Government oncho. Coordinators, the drugs are stored in the Local Government Drugs store if the expiry dates are still within safe limits or retumed to the State Oncho unit if the drugs will expire soon. - List and briefly describe the activities under ivermectin delivery that are being carried out by health care personnel in the project area. Health personnel collect Mectizan from the State onchocerciasis control unit and ensure that the drugs get to all centers agreed by community members, community members are intimated on the availability of the drugs and requested to send a representative to collect the drugs. Inventory of the drugs collected and usage is kept by the health personnel. Training of CDDs on dosing, f,rlling of data forms and community self monitoring are all done by the health personnel. 24 WHO/APOC, 24 November 2004 Any other comments 2.8. Gommunity self-monitoring and Stakeholders Meeting 280 communities were involved in community self monitoring and stakeholders meetings in all 14 LGAs in2007 with support from UNICEF. Table 11 Community self-monitoring and Stakeholders Meeting (Add rows if needed) Describe how the results of the community self- monitoring and stakeholders meetings have affected project implementation or how they would be utilized during the next treatment cycle. Community self monitoring is still one concept that should be an end process activity after each distribution every year, FLHFs are yet to imbibe this, so this was implemented only where health staff were reminded to do same to solve very crucial problems that were identified. The reports have not yet been received from the LGAs, during the advocacy visits, CSN{/SHM were two activities that the LGA chairmen agreed to support for the remaining part ofthe year. However, lessons from the past have shown that communities have designed various methods of ensuring that everybody gets treatment every year through the CSIWSHM mechanisms e.g, 25 WHO/APOC, 24 November 2004 DistricV LGA Total # of communities/villages in the entire project area No of Communities that carried out self monitoring (CSN[) No of Communities that conducted stakeholders meetins (SHIvt) Af(AMKPA AKPABUYO BEKWARRA 93 32 2) 23 19 t1 7 t7 4 BIASE 46 I I BOKI 129 4 2 ETLING 29 7 I IKOM 94 t9 2 OBANLIKU 67 2 I ODUKPANI o5 7 3 OBUBRA 24 5 I OBUDU 39 13 4 OGOJA 50 16 7 YAKURR t4 6 2 YALA 210 9 0 TOTAL 930 137 52 + in Edomi community, Yakurr LGA, community members have resolved that since onchocerciasis is a community disease and requires everybody to be treated before the disease can be controlled, community members must show a card from a CDD showing that such a member has received Mectizan for the current treatment round before being allowed to go to farm. Monitors are stationed on the farm roads to enforce this. In Busi communities, the week of peace, aweek set aside for rest after harvest has been agreed upon as treatment period for the Busi communities to ensure good coverage. CDD incentives have also been tackled during stakeholders meetings, communities have devised various ways of ensuring that treatment is given to the people every year, CDDs have been rewarded by employment opportunities in the Local Government Councils, as Representatives of wards and councilors for their communities and as civil defense corps. Communities have used fora created by stakeholders meetings to indict primary health workers who are not doing their jobs, since community self monitoring has indicators for monitoring health workers too and this has made health workers to wake up to their responsibilities. Stakeholders meetings have provided fora for communities to discuss on health and development activities generally, in Assiga, the stakeholders forum was used to discuss on the completion of their bridge project after all about Mectizan had been exhausted in the agenda for the day. The meetings have fostered unity amongst communities, providing a forum for ution of conflicts and making it possible for two communities that were not sitting together talk to each other 26 WHO/APOC,24 2004 2.9 Supervision 2.9.1. Provide a flow chart of supervision hierarchy. SUPERVISION IN CR-CDTI PROJECT NGDO UNICEF NOCP NOTF Zonal Onchocerciasis Control Team (ZPM, consultants, & stafJ) State Onchocerciasis Control Team (State Coordinator, SOCT, Dir. PHC, PHC Coordinator) Local Government Onchocerciasis Control Team (LOCTs Leader, LOCT, PHC Coord, Heahh Supemisor, District Supenisor) Community-Directed Treatment with Ivermectin (Community Leader(s) Village Health Committee, Communitv memhers. CDDs) 27 WHO/APOC, 24 November 2004 Akamkpa, Oban district had problems too because of laxity on the side of the health worker supervising that area, this was reported to the LGA council for necessary action. supervisory visits also were primarily targeted at very hard to reach areas to ensure mectizan was given to all the communities that needed the drugs. Routine supervi visits are duties of the LOCTs at this stage of the project life and the LOCTs in a majori of the LGAs carried out routine monitoring to ensure adequate therapeutic and geo coverage. The last major supervisory visit identified the following: The issues identified during that monitoring were of interest to the Primary Health Department in General, the supervisory checklist used had indicators on Immuniza coverage, vaccine storage, reproductive health, HIV/AIDS, primary eyecare, drugs supply, diarrhoael diseases, food and nutrition, environmental sanitation. The report of the monitoring exercise has been shared with the Director of Primary 2.9.2. What were the main issues identified during supervision? During the period under review, supervision was carried out in eight LGAs, SOCTs out spot checks to ensure that all communities were treated adequately with ensure that there was mectizan in all the communities. Results revealed that Ekajuk and Mbube East in Ogoja were not well covered with Mectizan, the exercise the team to distribute 82,500 tablets to 42 communities to improve therapeutic care and program managers of the various programs monitored. For CDTI, the following indicators were monitored in the field: INTEGRATION: In 100 oh of the health centers / posts visited, there was a roster showing schedule visits by health facility staff, only 63Yo of the staff comply to the schedule, in facilities, some of the staff were not present. Health staff present had knowledge of onchocerciasis and their role as primary in the onchocerciasis control program. and to ties in In home health workers 28 WHO/APOC,24 2004 MECTIZAN DELIVERY: Mectizan was in all communities visited, the monitoring provided opportunity to deliver Mectizan to communities that were not given Mectizan to quickly treat for the year. INCENTIVES TO CDDS: Some CDDs get material incentives ranging from money to food stuff, others are rewarded in kind- appreciation by the community elders but the CDDs are willing to continue to help their communities. RECORD KEEPING: There is an improvement in record keeping over last year, the training offered by the special country initiative for CDDs and the data management training for LOCTs provided opportunity for personnel in CDTI to be trained especially on the new reporting forms. TRAINING: All CDDs interviewed knew the key elements of CDTI implementation, dosing criteria and compilation of reporting forms, however, some CDDs still have problems with the new reporting forms. SUSTAINABILITY: The key strength of the Cross River Project is the communities who have expressed their willingness to continue to ensure the success of the project and add on simple health interventions that will improve their health. LOGISTICS: Some LOCTs have been allocated motorcycles from other PHC programs, the latest batch of motorcycles supplied by APOC were given in 2000, most of the motorcycles have broken down and this has hampered the smooth implementation of CDTI. 2.9.3. Was a supervision checklist used? Yes, an integrated PHC supervisory checklist that was developed by the unit was used and trip authorizations also contained other salient issues that were not reflected in the checklist but came up and was pertinent to be checked. 29 WHO/APOC, 24 November 2004 2.9.4. What were the outcomes at each level of CDTI implementation supervision? COMMUNITY LEVEL: The communities are the strength of the project and are providing personnel for distribution and motivating them. HEALTH FACILITY LEVEL: The performance of the health facility staff is still a far cry from the expected, at health facilities; staff does not take their job seriously. Record keeping still needs improvement and more training and regular motivation to ensure adequate im CDTI. Some health personnel are still demanding for incentives before doing the communities where they are residing. DISTRICT AND LGA LEVEL: The health personnel at this level are committed to their duties, they have been portfolios of duties in Primary Health Care apart from CDTI, given some minimal and logistics, they can ensure smooth implementation of CDTI. 2.9.5. Was feedback given to the person or groups supervised? There is a normal routine during monitoring in the State where a monitoring team a member of the LOCT in each of the LGAs visited to ensure that he got first hand as respondents were giving their answers during questioning. 2.9.6. How was the feedback used to improve the overall performance of of the other project? in the of in The LOCT members were in the monitoring team and saw for themselves the gaps field; the lapses that needed immediate attention were addressed. 30 WHO/APOC,24 2004 SEGTION 3: Support to GDTI 3.{. Equipment Table 12: Status of equipment (Pleose add more rows if necessary) *Condition of the equipment (F=Functional, CNFR:Cunently non-functional but repairable, WO:Written off). The State Government purchased project vehicles for Ministries and projects in 2008, the onchocerciasis control programme did not benefit from the scheme since APOC had just provided a brand new Toyota Hilux for the project, if this trend continues, we are optimistic that Government may replace the vehicles when they get old. Government is encouraging all staff to be computer literate by providing opportunities for the purchase of cheap computers, this availability will greatly enhance the processing of reports and lessen the burden on the provision of new computers, there is hope that with the change in the leadership of the Ministry of health, the unit may have counterpart funds for 2009 and will be able to maintain the equipment donated. How does the project intend to maintain and replace existing equipment and other materials? Govemment provides minimal funds for the maintenance of logistics, we are optimistic that with the present trend of events, outright replacement of the logistics may be possible in future. Source Type of equipment APOC MOH DISTRICT/ LGA NGDO Others No Condltlon No Condrtion No Condition No Condition No. Condrtron 1. Vehicle 2 IF I CNFR 2. Motor cycle(s) r9 11 F, 6CNFR, 2WO 3. Computer(s) 4 2F 2CNFR 4. Printer(s) 4 3WO IF 1 1F 5. Photocopier (s) 2 2F 6. Fax Machine(s) I IF 7. Others a) Generator 2 ICNFR 1F b)Television I IF c)outboard engines 2 2F 31 WHO/APOC, 24 November 2004 ( + l + + + * 3.2. Financial contributions of the partners and communities : Financial contributions all for the last three 1$ = N126.50 - If there are problems with release of counterpart funds, how were they Counterpart funds for 2008 were apploved by the Govemor but release of the problem till date, to be truthful, the outgone Commissioner did not believe in C not his priority to provide funds for the project, the approval that was got from the has been represented by the present Commissioner to the State planning for release of the counterpart funds, we are still awaiting the outcome. Neither release was made for 2007. Additional comments The project is aware of the need for counterpart funding and has used both the and direct consultation to ensure that Govemment is aware of her responsibility in and to ensure that they are aware that tackling neglected diseases generally is a very addressing poverty and realizing the millennial development goals. 3.3. Other forms of community support - Describe (indicate forms of in-kind contributions of communities if any) way of ? lsa so it was nor Year 9 (Ja t 2008 TO Jun. 008) Year 8 (JULY 2006 TO JUNE 2007) Year 7 (JULY 2005 TO JUNE 2006) I TOTAL Released (US$) TOTAL Released (US$) TOTAL Budgeted (US$) TOTAL Released (us$) TOTAL Budgeter (us$) TOTAL Budgeted (us$)Contributor 553.36 20.000 6.71923.715.41 877.47s 23.715.41Ministry of Health (MOH) Local NGDO(s) ( if any) 103 t7 7.23112.260.86 9.106.72NGDO partner(s) District/LGA Others.' 2.426.87a) Sight Savers In'tl 305.67b)Cross River National Park c)Youth Care t42.29t.069.76 142.290d)Great Friends of Obudu 4;743.001.868.00 4.743.00Communities 3.000 3.0003.850.00 1 5.1 50.98 15.150.987.704.00APOC Trust Fund 16,95057,293.15 29,696.35 s33r731,419.41 10,397.77TOTAL 32 WHO/APOC,24 2004 Communities have organized age grades or youth groups to cultivate or weed farms belonging to CDDs as a form of incentive to encourage him to work for the community. There are reports where CDDs are given one extra cup of palm wine as appreciation for his work and the CDD appreciates the gesture. Various reward systems that are common in the communities abound. Communities in Yakurr (Assiga communities) have actually given land to CDDs to cultivate cassava as a form of incentive to motivate them to work. There are also a good number of communities who are giving yams to their CDDs after harvest. Other communities have excluded CDDs from communal work and levies. 3.4. Expenditure per activity Indicate in table 14, the amount expended during the reporting period for each activity listed. Write the amount expended in US dollars using the current United Nations exchange rate to local currency. Indicate exchange rate used here_N126.50 :1USD Table 14: Indicate how much the project spent for each activity listed below during the Source(s) of funding Expenditure ($ us)Activiff 500 GOVT Drug delivery from NOTF HQ area to central collection point of community UNICEF/GOVT7,231Mobilization and health education of communities 1442 LINICEF/GOVTTrainins of CDDs 3577 UNICEF/GOVTTraining of health staff at all levels r200 LTNICEF/GOVTSupervisine CDDs and distribution Internal monitoring of CDTI activities J 000) APOCAdvocacy visits to health and political authorities IEC materials Summary (reporting) forms for treatment Vehicles/ Motorcycles/ bicycles maintenance Office Equipment (e.g computers, printers etc) Others 16,950TOTAL 897,649Total number of persons treated Any comments or explanations? JJ WHO/APOC, 24 November 2004 SEGTION 4: Sustainability of GDTI 4.1. lnternall independent participatory monitoring; Evaluation 4.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable) DONE IN YR 2000 Year I Participatory Independent monitoring DONE IN YR 2002 Mid Term Sustainability Evaluation DONE IN YR 2003_5 year Sustainability Evaluation LAST DONE IN YR 2005 Intemal Monitoring by NOTF DONE IN YR 2005 Other Evaluation by other partners 4.1.2. What were the recommendations? o That the implementation of CDTI which made reasonable progress in 2003 and2004 became badly stalled in 2005 due to a dramatic reduction in funds released for the operations of the CDTI project by local partners, State, Local Govemment and NGDO partner (LTNICEF). o That report keeping and data generated at all levels was poor. o That there was extensive turn over of staff and officials in the CDTI project. 4.1.3. How have they been implemented? o The report of the evaluation made the State Government to approve the sum of Three million Naira for activities at the LGAs, this funds have not been released till date, the project has resorted to other service providers to "piggy back" on them to ensure that activities are carried out, The Cross River University of Technology provided a forum for monitoring, the Great Friends of Obudu provided the funds for some offrce stationery. o Report keeping has improved on at all levels with training of personnel on data management during the special country initiative and data training for LOCTs. 34 WHO/APOC, 24 November 2004 o The staffs that are in the project now are stable; there has been training of new staff to replace the ones that left. 4.2. Sustainability of projects: plan and set targets (mandatory at Yr 3) Was the project evaluated during the reporting period? NO Was a sustainability plan written?_YEs , IN 2003_ When was the sustainability plan submitted? _2003_ What arrangements have been made to sustain CDTI after APOC funding ceases in terms of? 4.2.1. Planning at all relevant levels There is joint planning for all PHC prograrnmes and an integrated monitoring checklist comprising of key indicators for PHC programs is in use in the project now. This is aimed at reducing cost of monitoring and ensuring that there is sustainability in terms of monitoring and supervision of PHC activities since any programme with funds to be in the field can monitor all aspects of PHC with the integrated checklist. Joint planning on utilization of vehicles, motorcycles and other resources has been discussed in recent PHC fora in the State to encourage sustained and reduced running cost in PHC programmes. 4.2.2. Funds Resources have been got either directly or indirectly from local NGOs and CBOs, A list showing areas of collaboration where Local NGOs and CBOs can help indirectly without providing physical funds have been made and circulated, trainings and supervision in the National Park and Cross River Forestry Commission operational area are done by the forest rangers, the Cross River broadcasting corporation are willing to air jingles at subsidized rates to mobilize the populace. 35 WHO/APOC, 24 November 2004 There are budget line items specifically for CDTI activities at the LGA and State levels though that has not been implemented since 2005 and there is need to mobilize the in coming policy makers to sustain it. 4.2.3 Transport(replacementandmaintenance) APOC has given the project a new vehicle in the current year. Outright replacement of the logistics will be difficult because there are no concrete plans on ground to replace the existing ones by Govemment. 4.2.4. Other resources Local CBOs have been mobilized to provide or fund some activities for the project, the Great Friends Klub of Obudu produced community mectizan retirement forms for the LGAs of Obudu and Obanliku. Training and the pilot implementation of awareness creation on HIV/AIDs control using the CDTI structures was solely funded by a local NGO, the Great Friends of Obudu. 4.2.5. To what extent has the plan been implemented The implementation of the plans are on track, there are few adjustment resulting from shortfall of funds but other sources have been used to augment funds and the project is achieving and hopes to continue achieving integration, add on of new simple health initiatives and above all ensure at least 650/otherapeutic coverage and 100% geographical coverage for Mectizan treatment. 4.3. lntegration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration: 4.3.1. Ivermectindeliverymechanisms Plans have been made with the PHC directors of all the 14 LGAs on the need to seize the opportunity of collection of supplies for routine immunization in the first part of every 36 WHO/APOC, 24 November 2004 year to collect their Mectizan, so Mectizan drug requirements for the following year are got by December, for proper requisition. 4.3.2. Training There is integration in training. That opportunity has not been provided during the reporting period. In2007, some trainings undertaken were done using fora provided by Sight Savers Eyecare Program or the HIV/AIDS awareness training by the Great Friends of Obudu. SOCTs also attended various joint training sessions organized by the Primary Health Care and Disease control Department. 4.3.3. Joint supervision and monitoring with other programs There is in place an integrated monitoring checklist which is being used for monitoring in PHC. This checklist contains supervisory indices for all components of PHC. This is to help joint supervision at the State, LGA and Community levels. 4.3.4. Release of funds for project activities The funds for onchocerciasis control have not been released since 2005. 4.3.5. Is CDTI included in the PHC budget? The current strategic frame work for Cross River State has Onchocerciasis as a component in the PHCiDC department and provisions have been made for 2006 to 2018 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? Over 1,200 Cataract surgeries have been conducted by the Tulsi Chanrai Foundation and Sight Savers international eyecare services. Community members were mobilized and screened by CDDs. The Project has used CDTI structures for distribution of Vitamin A to under 5s and post partum mothers in 18 LGAs. In the LGA level, LOCTs are key persons for data entry during NIDs because of the rigorous data training they 37 WHO/APOC, 24 November 2004 t 4.3.7. have gone through in CDTI, in the communities; the CDDs are used for other health projects like local guides during NIDs. Describe others issues considered in the integration of CDTI. The CDTI structure in Cross River State has integrated the following, vitamin A supplementation, Primary eyecare services, and currently awareness creation for HIV/AIDS IN 3 LGAs. A pilot on usage of the CDTI approach to enshrine a model PHC structure like the one in South Sudan is also considered, here, the community is responsible for the choice of the community health worker, payment of the fees of the community health worker in a college of health technology, after the training, the health worker retums to the community to offer basic health services to community members. Communities will be encouraged to assist CDDs achieve more training to be of greater help to them. 4.4. Operational research 4.4.1.1.1. Summarize in not more than one half of a page the operational research undertaken in the project area within the reporting period. No operational research was conducted during the period. 4.4.2. How were the results applied in the project? No report during the period. SEGTION 5: Strengths, weaknesses, challenges, and opportunities STRENGHTS Adequate knowledge of strengths and weaknesses of the communities implementingo CDTI in the State Clear evidence of the advantages of Mectizan especially in the forest area where skina conditions have greatly improved. 38 WHO/APOC, 24 November 2004 Utilization of opportunities provided by other organizations to implement CDTI activities to effectively save funds. Commitment of local CBOs and other orgarization in collaborating with the Onchocerciasis control unit. Working with organizations that have projects with high impact on community members have increased acceptance of the CDTI strategy by community members e.g the skills acquisition training for youths by the community services Department of Cross River University of Technology, Calabar, free screening eyecare services by Sight savers and Tulsi Chanrai. Good working relationship between the project and the NGDO partner IINICEF. WEAKNESSES o a o a a o t a o a Prioritization of curative or secondary health care over Primary Health care in Cross River State. Poor attitude, lack of initiative and laxity on the part of the frontline health facility workers who are key to CDTI implementati0on at the grassroots. Inability of PHC structures to support CDTI activities due to inadequate manpower and absence of health facilities in some remote areas of Akamkpa and Obanliku LGAs. Inadequate community participation due to Leadership and Communal clashes and distortion in population leading to poor planning especially in the southern senatorial district LGAs. Inadequate community participation due to weak community structures in the heterogeneous area ofthe southern senatorial area ofthe state. Non release of approved funds from Government has stalled the plans for implementation of activities during the period. D a 39 WHO/APOC, 24 November 2004 I CHALLENGES AND HOW THEY WERE ADDRESSED a Prioritization of secondary healthcare over Primary health care was debated in several for a with policy makers collectively by primary healthcare programme managers during advocacy visits to policy makers. We have made several reports to the National Onchocerciasis control programme and Unicef for assistance towards stemming this trend. Laxity and poor attitude of frontline health facility staff have been slightly stemmed by the introduction of mandatory quarterly reporting system introduced by Unicef to necessarily demand work and report from primary health care departments in the LGAs. To achieve 100% geographical coverage, other service providers who are offering community services in the rugged areas where the health service is absent have continued to be used in the delivery of Mectizan, training of CDDs and retirement of drugs. To ensure adequate therapeutic and geographical coverage, local CBOs were still approached for support to ensure that the basic components of CDTI like Mectizan distribution, Supervision and Mobilization are carried out in face of poor funding from Government. The southern senatorial area where stranger elements abound were given special intervention activities especially in Akpabuyo and Odukpani LGAs to as a necessity shore up the low indices in community participation in this area. Efforts were made to improve participation by using other organizational units like the churches to mobilize the populace. LGA councils were mobilized during the APOC supported advocacy visits to ensure that the LGA chairmen were met personally since they usually send representatives to centrally organized meetings. Onchocerciasis control was provided for in the supplementary budgets of Obudu, Yala, Obanliku, 40 WHO/APOC, 24 November 2004 a o o a o a a Ia Bekwarra, Ogoja, Etung, Yakurr and Obubra LGAs. Other LGAs will still be approached again for support. Akamkpa LGA chairman will specially be targeted because he gave no audience during the advocacy visit; he directed the team to his personal assistant and said the o visit was not important. The supervisory councilor for health was not seen too. List the strengths and weaknesses of CDTI implementation process List the challenges and indicate how they were addressed. SECTION 6: Unique features of the proiect/other matters The strength of the Cross River CDTI project lies with the communities who are supportive and are willing to go the extra mile to ensure that they receive their treatment every year. The clear evidence of the benefits of Mectizan drug in the communities has elicited positive attitude towards CDTI and other programmes initiated by the CDTI personnel. This has won the confidence of the community members. The continuous networking of local community based organizations has been of tremendous help in the face of non release of counterpart funds by Govemment. Identification and utilization of the services of other organizations offering community services have saved funds. D 4l WHO/APOC, 24 November 2004