Report of independent monitors of CDTI activities in Montserrado county, Liberia 2-21 December 2002

[,Iff]l?"SERR4,t]il COLI NTt - \l;HOiApOCit {}T'I PRO-IECT REPORT OF INDEPENDENT MONITORS OF CDTI ACTIVITIES IN MONTSERRADO COTINTY, LIBERIA 2-2I DE('EI\IBER 2OO2 SUBMITTED TO THE DIRECTOR AFRICAN PROGRAMME ON OI\CHOCERCIASIS CONTROL (APOC) DECE]VIBER 2OO2 ) RECU 2 3 JAN. 200.? APOC/Drn L5 ol 0 lTEAM OF MONITORS The rnonitoring of the Lofa, Bong, Montserrado' Nimba cDTI proJect was carrted out tiom December z to be..nrb", z\,zooz in Montserrado county' the exerclse was .onar.t.O rvith the fuIl participation of the following persons .MrEviniCyrilleThierry,programoftrcerHelenKellerlnternattonal c.,r;;;;",'.-*oil errinj-t:iiilqg:l:Qtmail com' team leader o Mrs Bendu A TulaY . Dr Mei Mei DukulY . Mr Nmah BroPleh . Mr, Larry Gee .AIl tiorn the Ministi-oiH"uttt't and Social Welfare' Liberia .A.lItheabor'epersollstookactivepaftinthethreephasesthatcomposedthisexerclSe rncluding .Preparatoryworkshopaimingatfamiliarizr::.l.:n'.o'swiththeprocessofthe n',onitori,gfJffit'i;o*ii'Z' "tuttgv' activities' tools to be used) o Data collection in the two districts of the Montserrado courtty rvliere cDTI acttr tties are being imPlemented r Data entry, analysis and report writing TABLE OF CONTENT TEAM OF MONITORS TABLE OF CONTENT LIST OF TABLES LIST OF ACRONYN4S ACKNOWLEDGEMENT . EXECUT1VE SLMMARY INTRODUCTION I I Generiil tsacligrountl 1.2 Countl Bachground l.J Team Comllosition " l.J Terms of Ref'erence 2 METHODOLOGY Studr Design,.........." Pollulation The Srrmple antl Sampling Procedure ll II l.\ lr 2.1 ', 1 2.3 l"j RESLTLTS 4 () DISCUSSION AND CONCLUSION 5 O I{ECOMMENDATION -lU il _) -+ 6 1 8 l0 l0 ll il ll lLIST OF TABLES Title of table PNum table Table Al i Drstribution /Clans/towns to be covered in 14 Montserrado CountY Table A'2 Surnmary of instruments and sampling issues Tablel Decrsion-rnaking Process at village level 11 Proportion of villages treated and in which CDDs were clianged after the first treatment Table 4 i""""'-'-""- , t."p.,1i";.f ;ii6g.t iiiuittttiuta rm and in whicli i t;;iil, care perso,ri.l sttptrvised cDDs 23 16 Table2 Table3 - to I Treatment surunary -v 2?. iUur;S lnput indicators I " - - - - - - - -"--- -- - - --' ---------------i'--i Table6 i Distribution of irnplementation of the comPonents o i Cnfl bY Clan TableT Qua[ty of CDD training in category A villages f 21 i28 i- - - -- -. --- ---- - -- -- - ---'--' LIST OF FIGURES Title of figures r PageNum figures Figurel lWlro decides on the penod of treatment l8 nigu,'., Wiro a.aidtJ p; th;-"at oroititib'i6' l9 I --- f- Figure 3 i Figure 4 Wlio selected the CDD -t--- , . - - . - - - - - ' - -lo ' t, Weight of absente .i at cornpared to tt-,. non treated l2t populatrons I ,.--i,.---------------- i Actual coverage, coverage if ab sentees treated il Figure 5 6APOC wHo CDD CDTI CBIT REMO OSD NOTF NOCP CHI) PHC GOL MCH orc NID EPI NGDO DALYS C/DOT FGD CFIAL LIST OF ACRONYMS Africa Programme for Onchocerciasis Control World Health Organization Community Directed Distributor Community Directed Treatment with lvermecttn Community Based Ivermectin Treatment Rapid Assessment Method for Onchocerciztsts Onchocercal Skin Disease National Onchocerciasis Taskforce National Onchocerciasis Control Programme CommunitY Health DePartment Primary Health Care Government of Liberia Maternal and Child Health Offrcer-In-Charge National Immunization DaY Expanded Programme of Immunization Non-gor.rnmental Developmental Organization Disability-adjusted life Year County/District Onchocerciasis Team ' Focus GrouP discussion Christian Health Association of Liberia -ACKNOWLEDGEMENT We would like to extend our profound gratitude to the African Prograu tbr Onchocerciasis (APOC) for commissionrng thJndependent Monitoring Exercise fbr the onchocerciasrs progi# i" r_iu.ria rndeeisuch a worthwh.e rnitiative u'oulcl giv'e us an rnsrght into the ,tr*gti,, and rveaknesses of the program since its rnceptron three vears ago We\vorrldalsoliketotharrktheMonitorsandtheLocalGuidesfortherrdedicatedand sacrificial services," t.fp.".plete the exercise on schedule It was a rewarding and challenging exPerience. Our special thanks go to the loc.al authorities in Montserrado County' especialll' the Superinterrdent. Mr-Jrlius S Parker, for allowing us to visit the targeted r"illages and ro\\,ns and to talk to the people W. *"' uld*'t that without their patience and commitment, rve would not have achieved our objectives' Finallr,,rvethanktheentirestaffoftheonchocerciacisProgramoftheMinistryofHealth and Social welfare for their numerous contributions to make our work easier The charrrl]an of the NOTF. Dr Nathaniel S Bartee, deserves our special commertdatton \\,e hope that the results of the Monitoring Exercise would serve as a basts tbr the ,*irouinr.nt of the ONCHO Program in Liberia EXECUTIVE SUMMARY Havrng realized the magnitude of the fuver blindness disease in tt's country. the Government of Liberia launched an onchocerciasis project in four endemic countres rncluding Montserrado, Bong, Lofa and Nimba in 2000 The project is berng rmplematted by the GOL with the technical and financial assistance of the Christran Healtn Association of Liberia (CHAL), a local NGO representing SSI and is benefitrng tionr tht: financial and logistical assistance from APOC To ensure that the project is moving towards its set objectives, the National Onchocerctacis Task Forie Commissioned with the approval of APOC' decided to conduct art independent participatory monitoring exercise The terms of Reference of the said exercise carried out in Montserrado County are as follows. I Succinctly document how ivermectin treatments were undertaken in a sample of Communities with approved CDTI project in Montserrado County' t-iberia 2 Assess community involvement in drug collection, decision making ort the perrocl and modes of disiribution, the selectron of distributors, and the willingness of tlie community to accept and bear these responsibilities designed in thi: CDTI process i Document community perceptions of CDTI processes especially the issue of ownership, and .*p.ciutions for Onchocerciasis control, based on these perceptions and expectations determine the degree of satisfaction of the Lrontntunity with the different program activities and outcomes -l Assess the quality of training received by CDDs and health personnel tnr,'olved tn the project 5 Examine the record books of the CDDs and assess the quality of record l<eepin-e ancl their ability to keep accurate records. The same applies to the health senlces staffon the Project 6 Determine the -number of communities and eligible treated and compare findrngs rvith r.ecords of the CDDs and the records at the other levels (Clan and Totr tt - Ievel records ) 7 Determine whether the health personnel participated in ivertnectirr distrrbutron and assess the degree and quality of supervision by health staff (and the qtralrtr and orientation of the health staffto the CDTI) 8 Iclentify constraints in the distribution and recommend appropriate measures to ApOC management and Liberian NOTF to be taken before the llext round ol treatments 9 Discuss the prospects of sustainability based on the findings above After a careful and thorough monitoring of the oncho activities in N{ontserrado Countr'. the five-menrber team findings and recommendations have been fu[ly noted in the present repofi A total of 28 out of i0 planned villages were visited, 29 CDDs out of,30 expected \\ere rnter\le\\ed. l8 out of l8 FGD were held in 6 different villages' 28 r'illage leaders ;;;;,;;-p*.,i r.r,ere interviewed as rvell as health staffdesignated to supen'rse the CDDs inten,rewed g9 households were visited during the exercise A-lso. pro.lect leaders such as the NocP and NoTF chairman were interviewed so were some top rankttls' adrnrnistrativeandhealthoflicialsofthevisitedCounty The team .bserved that one major of the project has been to make the dru13 avarlable to rhe targeted populations despite thernnny.onrtraints that it has to face including the Ven rnsrable socio-political environment *ithin which it has to be implemented' the lack of Government counterpart funding amongst many others The program has succeeded in building the drug demand u1nong the community which is now overwhelming as the contmunitie, ur. *iifing to take 1.h"e drug and continue to do so as long as it will be nlade ar arlable to them. H9*ever. the team's findings also revealed that there has been very little real shiftrrr-tr tl..ni the tracltrorral opprouJt of health sen'ices delivering to CDTI nlostl\/ due to poor rrarnrng ot'olcs ttrat ,n turn has resulted to poor tr1i11s^of cDDs and poor supenistott of cDDs The hearth staff sti[ prays a too much pervasive rore in decisron making r'^,'here as rhe communitier *,[ still need to be empowered through health edullti.on so as to allow them plav their role and Uy ,o joing ensure that the program is sustarned throughout the years Record f...ping L still ; weak point that will need to be urgentlr zrcldressed in the ,'e.y sho.t term if,. NOff rvill have to advocate so as to ensure that polr*,rnakers u.,uiity provide the necessary counterpart funding expected Ilor, the GOL A plan for sustaining the program is to be developed in the short term Finallt' based on its findings and observations, the team strongly recommends APOC management to keep and if possible .nrrun.. its present financial assistance to the NOTF of Liberia and, that more techni.al usririance be- provided to the NorF of Liberia sir err the unique socio-political situation prevailing in the Country l0 INTRODUCTION I I General Background Onchocerciasis, otherwise known as river blindness, is one of the devastating diseases' which continues to affect the health of people in Africa lts effect on the health and socto- demographv of the people is considerable rn magnitude is rightly noted lt has been tbund our ttlat the affected persons suffered from physical discomfort, anxiety. embarrassnlent rnconr,'enience. lack oi confidence and depression It has been observed that such per:;ons rvere stigmatized, miserable and generally pitiable, and deserving help and- sympathr' They we"re avoided by even clo.se-friends-and relations, a situation which affected therr marital life and g.n.rul well being. The economic importance of the disease has also beert recognized by a number of operation researches on its social and economic impact For rnsta.ce, outright blindness issociated with the savannah strain of onchocerciitsts has been known to cause visual impairment resulting in economic disabilitl' of the rnfected Concern rs also raised about the economic impact of the non-blinding straln ol onchocerciasls, which i, pr.rul.nt in the forest zones studies in Uganda' Ethiopia and Nrgeria have demonstrated that onchocercal skin disease (OSD) has direct and indirect costs as well as ,rpult on school attendance of children' and the cornputation of disabitity-adjusted life years (DALYs) N,lass distribution of Mectizanx (ivermectin) is known to have signiticant impact on morbidity caused by onchocerciasis. thus ,q'FOC, a health partnership' has adopted the conrmunity directej treatment with ivermectin (CDTI) as its main strateg-v- for ensunrls mass distribution of ivermectin in the onchocerciasis endemic communities in the nineteen countries that were not covered under the onchocerciasis control proqralllnle (ocP) The GDTI project proposals based on a partnership between APOC' the Natronal Proqrarlmes and ,.r.rui NGDOs were submitted for APOC support Each approved project is funded i;;;-n-,u*i"',um of five years During this period' it is expected that APOC suppoll will decrease proportionately to that of the other partners and that lhe cost of rrcatment per individual will ieduce Uy eO per c:nl-ln addition' it is expected that the Natrorral O.ch.cerciasis Control Program*. iNOCe) will continue to manage thelr. CDTI activrties fo, up to l5 years afteiepOC, in order to guarantee effective cont'ol of Onchocerciasis APOC's philosophy for CDTI is to ensure that the recipient conlmunities onrr tlte programme in order to sustain it. The communities themselves determine the actir'ttres Thel deterrttitte where to obtain their mectizan@' when and how to distribute rt Ther serect their cornmunity directed distributors (cDDs), coilect information about co'e'age that hetp the determination of programme Success . Unlike the community based ivermec;tin treatmlnt (CBIT), the CD1I is a process building up based solelv on the erperience of the community members, and consequently, enhancing the decision ntaktng and problem solving capacity of the communities II MontserradoCountyissituatedil!3.NonhwesternpartofLiberiaTheEntrreCount\ hosts appro*imately't'J ;illi;;. intauitanis with an esiimated 35000 living withrn Todee and St paul fuver pistricts which ton'uiuit the project area The project area therefore covers two of the three districts ."r;;J;r'rrrJn,t.ttudo county' apart.from Greater Monrovia rr-,. airtri.i, ur. zunn.r divided into clans' towns and communities Based o. the lggg/lggg REMo results, Montr.rrlll coun,y isbelieved to be l00ozo Mesoendemtc Numerous rivers and tributaries rravers;;J;";y The St Paul fuver traverses both St paut and rodee districts. St p.aul niu.i;'[";;;;" be a breeding site for the black tlv #f *,r,',',1tr'Jli "".xff 1:Tr 1,; J[. {,,J,l:rlit,", :,'r, ] 0 0 w it h su p p o rt rr o m AP o c SSI and .HAL These activities covered 5l communitie-s in tt,e year'2000..and included rrarning of cHos. then trainilg { drcr'und cpp rolo*ta by the clistribution of tvlectizan@ to 1t,904 people u.*]11di9Or, cDTl *i*ititt expanded to rnclude St paul District For the year 2001, cDTl-activities were implemented in 1i2 comnlurlrtres and the total number of peoplt^'I:Itiwl"s5qqf.^T:'3bo' activities were launched rrr April 2002 *,ittr tnJ'tr'ai,ii"g "r olcs fo*owed cDD training Distriburion activiti':s r^'ere carried out tr.om May to September. ffi;.'"r, "r the 2002 distribution round rs not 'et 1.2 Countl Background available driv'er t.l Terms of Reference 1.3 Teanr ComPosition The ind-ependent monitoring team-that was constituted by N.TF, Liberia, on behalf of APoC to visit r'roni"i'uao- CDTI n1"iJ9i' fi1 *-"becember 2002' had lVlr Eirttt '.; ; i,,,., * *"'i'Jffi ; J B:;T.F j $;,, ^S: " iI.: iil.'J pi:L : -iil' iiH,, Tlie other monltorl Bropteh, Mr r-ur.y ;;;;;i working *nr, irr. r-iu.iiun rur*""v of Health and Socral welfare in various capacities. the team airo t uo members of the Districts Medical Team as well as community members who ;; .r lo..r guides' Finally' the team had one The team was constituted with the following terms of reference: jsuccinctlydocumenthowivermectintreatmentswereundertakeninasanipleof communities with approved coii'pr"i.ct in Montserrado county' Lrberia .lAssesscommunityinvolvementindrugcolle.ctio.n,decisionmakingontheperrod and modes of distribution, the ,;l;fi of distributoi'' und the willi gn ss of the community to accept una U.ur"i;;t;-r.;;"nsiUiiities designed in the CDTI process l2 J Document community perceptions of CDTI processes especially the issue of ownership, and .*i."iutions for Onchocerciasis control' based on these perceptio;s and expectations determine the degree of satlsfaction of the conrmunity with the different programme activities and outcomes Assess the quality of training received by CDDs and health personnel invglr''ed trr the pro.lect Examrne the record books of the CDDs and assess the quality of record keeptng ancl therr ability to keep accurate records The same applies to the health selvrces staffon the project Determine the number of communities and eligible treated and compare frndrngs with records of the CDDs and the records at the other levels (Clan and Town - level records.) Deterrnine whether the health personnel participated in .iverrnectin distributron ittrd assess the degree and qualiit' of supeivision by health staff (and the tlualrtr and onentatrc.rrt of tlle health staffto the CDTI) ldentifv constraints in the distribution and recommend appropriate measures to APOC management and Liberian NOTF to be taken before the next round of treatments Discuss the prospects of sustainability based on the findings abor,,e. + ) 6 1 9 I 2. METHODOLOGY The methoclology used for the selection of the villages and sub-villages rt'as a modrtlec'l fbrm of the methodology that was developed during the meeting of the nine. nronttortng team members in Ouu-g"uOorgou in 1998 in a re'ie* of the tools' in a tool development workshop in Kabale, ,f,i, *ui further refined to include a few of the things that were not prer rousll' taken into account The entire endemic villages were included rn the sampltnu tiarne lrrespective of levels of endemicity and closeness to the heaith facilrties Ln the areas studied Thrs sirnprlified approach merely selected villages by a simple random sampline approach 2.2 PoPulation The target population for ihe monitoring exercise consisted of four broad groups These include I)HealthPersonnelinvolvedintheCDTIprocessatvariouslevels' 2) Tow'n leaders, 3; Communitl' Directed Distributors (CDDs); 'ned irr the4) Household members in the hyper/meso endemic Districts/clans contarl ilEMO result for Montserrado Countv Irr addrtion. polrct'nlakers in the areas where CDTI rs inlplemented were tntenterved ttr gause thett. plans tor sustainability of CDTI in the future as well as their po[6 dtrecttott i,,tlisp.cial reference to their current support for CDTI 2.1 Study Design For the monitoring conducted in Montserrado county of Liberia in December 2002 a cross-sectional research design was adopted This desrgn was considered the nlost approp.at0 ro generate the nJeded dutu und meet the study lmonitoring) objectir"es T5e data collection .*.r.o. consisted oi u i'iungulation oi qualitatir"e and (luantitatr\e instnl*tents OesigneJ to collect information from different segments of the target popurlation 2.3 'the Sample and Sampling Procedure .\ studv sanrple of thirty to\vl1s was chosen using a simple random sampling procedure The samphng pro..rr *ur ,o begin with stratifling the Districts and clans in thr: countY b' le'els of endemicity Since treatment focus is piioritized based on hyper and meso' the h1'po endemic divisions and wards were excluded from the sampling Montserrado County having only two districts covered by the project' the two were directly included rrr Ir the sa*rpre- The CIansr rn the two Districts were lrsted on preces of paper and three clans uer.erattdonrlvselectedtbreachofthedistrrcttomakeitsrxclansintotal CLAN 1. Parker Comer 2. BillY's town 2 Esatt torr tr J Jah tono Town 3 Vouzotr 4. Fah-nseh 4 Goba town 5. Pleemu 5 Pleemu 6 Mount Coffee t+ se6t'ToWIS l Grattt 2 Wilsor., Cortrer 3 Joues tortn -l Dttdtt tort n lKa lllara to\\ ll ( tttegttt'.1' A turcl B l''i Ilages" Having selected the six clans, three frop each of the. earlier sampled District to be 'rsrred. the J-owns' i" it. chosen ,ili;;, *ere listed Five towns were ratrilonrl' serecred [rom this iisi of io*ns in each cfan Another random sampre of one Towr out of these flu,e chosen-earlier were taken ir r.r.g""y^-l',^:"*" while the remattrtng tbur Torvr]s bec;ame the category "B" Towns for the monitorine exercise' tn each of the str Drsrrrcts TSrs gave a tot;l of si4 categ"w n fo*ns and'*t"n'y-four Categon'B Tou'trs Table.\l:DISTRICTS/CLANS/TOWNSCOVEREDINMONTSERRADOPROJECT Distrrcts I ST PA\JI 2 TODEE 2C e to\\ ll i Gor rbalt tott tt Ile tori n+ I Mass lol 2 Jithrt'ra i Jalttotto -l Gant I Bahr totttt I Gor,ih tott tr I Grt -l Mo I Gbototr Kolleh zuan h toutl I ce t0\\ ll I rrts toti tt I ii\ to\\ ll I ) 3 Kartoe to\\ n I I Sack IN Blackrc ttlti tt 1 Zore \ el lO\\ ll I re to\\ ll I \c I2 .ILCC I 2l 6 t VOe, Road 6 Zingbor town 6TOTAL r Herc clatts are tlte sattre lrttll collulltllutles r rllugcs lll colllllttllllttcs as ttscd rn Nrgerta a iu Ntgena altd else rrltere lrltrle tlte [o\\ns llre eqtttrillcttt tt' ;; ";f;;; placcs *rlh sttrttlrtr uslge tor tlie cottccpts li Hotrseholcls In e.ach Category "A" Town sampled, fifteen households were chosen To do thrs the Tou rr rvas can,ed into three clusters gurded by the Town leader and local gurdes Ftve du,elhng unrts from each cluster were randomly selected ln each sampled dwelling unrt one household was randomly chosen for the treatment coverage study. Furthermore. to check on tfte correctness of treatment, one household was randomly chosen, and the dosage for one household member, randomly selected and crosschecked ('DI).: tntcl'[rrlln Leqders; In each Category "A" Town sampled, the Town leader was purposively selected and interv,iewed The Town CDD was also purposively sampled and interviewed ln cases where there were two CDDs both of them were interviewed, but where there were more than two CDDs, only two were selected by balloting. Simiiarly, the Town leaders of the Category "B" Towns were purposrvely chosen and interviewed The Town CDDs were also purposively chosen and interviewed wherc the CDDs \\,ere two or less. In some sub-villages with more than two CDDs, two were randomly selt:cted for the Category "B" Town cDD intervierv H attI th l'at' ,rtttttc I urcl PrtIrc'.)' lt4aker.;: Various cadres of health personnel involved in CDTI process were purposively selected and interviewed. These included Supervisors, County/District Onchocerciasis Tearn (C/DOT) members and Coordinators. The Community Health Department (CHD) Director at the County level as well as offrcer in charge (OIC) at the District lev'el inroll,ed in the CDTI process were also purposively selected and interviewed The purpose of these interviews was to examine the orientation to CDTI process and pror rde inforrnation on the records and quality of training they receive and/or giv'e on the CDTI process policy makers at these levels of the health systems' operations were also purposA"ell seleciecl ancl interviewed to give idea of the support of the policy makers for ('DTl rmplententation as well as their plans for the sustainability of the programme l(r Instrumehts Eight instruments were used to gather information from both Categories "A" and "B" sub-villages as well as at the District and ward levels Copies of these instruments are rncluded as appendices to this report Table A2: Summara of Instruments and Sampling lssues lnstrunrent Sampling Procedure I ln-depth interview & Record revrew rvith CDD Household coVerage survey Key intbrmant interview clf vill leaders Group discussion A Proqramme rnanager/Polio' rnaker inten'iew Purposive (Simple random, where there are more than 2 CDDs Multi-stage (r r: cluster. svstentatlc and sim le randorn Purposive Convenience Purposive Purpostr e Category of Towns and Unit Sample A&B | -2per Town l5 households per TownA I Town leader per Town (30 in all) A&B 3 groups per Town (i e I male and I female adult; and I female or male youth groups), 6-8 persons in each group I CHD Director I Oncho coordinator 1 OIC/1 health centre staff Health personnel inten,iew A I Director, Disease Control per District I Supporting NGDO staff Project, District & Natronal levels Lo _c ?Z @&@a.l c..l (.l o .? .O c'l \D \D \D $ a6r u= J)) - 2\J o .t .o .9 N o) -'F :=oo", >-LLr 0) N r- N aa \o N (-.I L aG) 1\O T.5 .a o' s t-- $ \r, (-- ? f- .a O\OO U9O .O \D \2 0) :IJ ,* ==>(, N r*- c.l ?^ t-- r_N(-- (\ aa .a co Nc..l< 5')0)C :,1 'E(Eo) . t--Oa v\O :: q \o$ : .. \o r- t-- @ .O\Dg l3 e' ,t) =c '; 0) -l -lt)L0J-^ !-.-^ 9)PI\ 1P) iL!- UE.?K (J-U+= 0)+ C t-) a - .\ P 'r=Yt) U57-2a aaa 6) e) -.\ ql oo olc O(* o C 9 c)()a a C 9 .Ja .2; a -. 0) :-<?Z aa { (.) oo U C i -o t-l '*-.a ;?1) ;),n I L !- aaa 0 a a.l I : I r, u x o0 0, UD I F a i--J =a 9^ ,nJ'J Ldo) t(.,.) Montserrado monitoring rePort, December 2002 18 CDTI is supposed to be a community initiative with the entire community fully taking active part in all decisions that are taken. An analysis of the table above reveals that while the village leaders tend to think that the period of distribution, the mode of distribution and the selection of CDD were done during town meetings, town people attending FGD thought that all decisions in relation with the above topics were taken by the health worker and imposed on them. Even 5oo/o of the 6 CDDs interviewed in towns A think that the period of distribution was decided by health workers. . THEY DID THEIR OWN THING, DECIDING ON HOW THINGS WERE GOING TO HAPPEN, WHEN THEY WERE GOING TO HAPPEN AND WHO WAS TO DO WHAT" Town chiefs need more education and sensitization in order for them to fully be in control, otherwise, the health worker who has the 'know how' will take advantage on them and have them depending on him. Chiefs tend to think that once they have been involved in the process, the entire community has. This is a serious issue as the gap between what town leaders, CDD think and the FGD is so wide that this shows that if communities were more involved, a lot the problems encountered during CDTI implementation process would have been solved. This can be explained by the fact that village chiefs tend to politicize the answers they were giving while people in FGD spoke out freely Figl: Who deceides on the period of distribution EoE o =ooo o)o coo o(L 100 80 60 40 20 0 trMllage Meeting IVillage Elders trMllage Chief trHealth Worker IMllage Heahh Committee EMllage Committee IOther ..d ..d ;s ""tt "d" ..lt .-F ..b +ts c .e" od Groups interviewed Montserrado monitoring report, December 2002 l9 tsMllage Meeting IMllageElders trVillage Ghief trHealth Worker I Mllage Health Committee EMllage Committee IOther Fig2: Who decides on the mode of distribution? 100 90 880oE70(U360(U ro50 o 840830 (L10 0 Village CDDs FGD leaders interview Groups interviewed Fig3: Who selected the CDD E oEL(!;(U oo o,(E c og o(L 100 90 80 70 60 50 40 30 20 10 0 trVillage Meeting lVillageElders EJVillage Chief tr Heatth Worker I Village Heatth Committee EVillage Commiftee IOther ^""€ i.ots ^"t* ^$"{\9= dP- -C' Groups intervievted I -o o\ c'l\o <r CI I ;O\o9 o\Fr'^= -o 0) -o' /;r-- - ,, <+!rl .:. Y L v.- -r@ 1) .= .A r) Jll L)/-aots 925 EF6) -a)2U !!v .+- (d _O iv6.)rv tt'-+ L'U =>=C-!, >!a o)\r, ada =oc(vLaP>, ,)P,Yioo) LLg(* (+- '+ooo L!L c)0)O) - - - - - ts)) UUV -63€d ooc e9P L!Lcac ^^- LLL AA^ .-o ;cc(! 0-)0)L Yo) -- -o c ..4 0.) d!o)OLAp(C -0) oL _.o ,r) A ed)Es oeeO cf, C ,o 0J ,\ rt, L E0)e C)^ E L -.o i-o *o- -6lCOttl a or o- o) -o a)(t c)L o ,a 'tC o c) ! a 0) 5t) C 0) 0.) o- 0)E t- lj 0) 0) o ! x - in C,) N Ell :r <: -\ z Q r! -l \- Zo. a ^torl clr- * r- -] a..l <t * 6l s tl= :>. * ,: .< oZ (-) r! o] * \5 oZN@ a -l -rl6lx 6) r- a] a r- -f+ + a.l r-- <- Z s : Z ^\ Z ^\ Zo. @ (t lJ.,c a L l) tr.l a t.1 t/i<: rN 4i >\ r\ I 6] * t-- - a-l\c o] + -l * -t * (\l 7.s 'r \) -.:>q. s Z l) 5; 6l(\ .\ oZ N sa -f t-. ,a, =t n <t cl d: >N .\ Z (t lr) 4. -l .\i/ oz\oco a I r- * r--* F- r- q o,) *? oF a q) F q) oZ 6) q,) q) q) 0 Montserrado monitoring report, December 2002 2t Out of a 520 population sample, 324 people got treated representing a therapeutic coverage rate of 62.3% which is still low compared to the "at least 650/o" expected. It is clear that this coverage would have been higher if there were a strategy to treat the people found absent during the treatment. In fact, out of the 196 people not treated, 68 were absent, representing about 35o/o of all that didn't get treated. On the other hand, all the people who were reported absent are willing to get treated which implies that there is a need for the supervisors and CDDs to work out a plan to capture the absentees, especially since most of them are farmers or rubber plantations workers, because, for the sample taken, had these absentees got treated, the coveragerate would have been aroundT5Yo. Also, for those reported absent because of war, there is a need at central level to work out a national plan aiming at treating people in displaced camps. Also, the supervisors need to make sure that, in cases where CDDs are non residents of areas they are supposed to be treating, they actually go there to treat people, otherwise, these people will not get treated. Figure4: w of absentees/not treated 35% 62.3% Population treated 47.3% Population rnt treated other reasons for not taking _F-- the drug 650lr Absentees durirg treatment Fig5: actual coverge, coverage if absentees treated 100 80 60 40 20 0 tr Total population IATO ECoverage ElCoverage if absentees treated 1 ,-- I 1t The table also reveals the poor record keeping from the CDD ln most cases, there was no treatment book When it happened, the information contained was completelv unreliable Theretbre. tliere rs a need to train CDDs wrth tbcus on record keeprng Table 3 Proportion of Villages treated and in which CDDs were changled after the first treatment CLAN Sub-villages (Both A and B) Treated CDD changed Parker Corner ( 4 (80) 2 (s0) Billr 5 4 (80) | (2s) Jah tono J 2 (66 7) 0 (0) Pleeuru 5 s( r 00) r (20) NIount Colfee 5 s( r 00) 0(0) Fenseh _5 s( r 00) r(20) o-3 o-s Froportion and number of at-risk villages treated :25(89 3%) Proportion and number of communities where CDDs were changed bl' the community,after the first treatment : 5(20%) Eren though the geographic coverage expected is 100% of the targeted communities, the proportion of at risk villages treated is good. This shows that a lot of communittes targeted for CDTI are receiving the drug. However, some communities did not receire cornmunities even though they were ready and willing to take the drug " the ('l)l) which wts ussignecl to our town cunte with u stick urul et,en took our n(t,'ttes tlrttvtt. prutmisi'ng to conte huck with the drug. Until now, tve hrn,en't heord o.f him ugitt." The qr-restioti here rv'h;' n66 a number of answers can be thrown in includrng . Lacl</poor supervision by OlCs . Too much towns to be covered by the same CDD Thr:; i:; an issue that needs to be addressed as some of these communities feel that thel' har.'e been abandoned for some unknown reasons On the other hand. the proportion of CDDs changed seems reasonable given the socto- ecor-rontical-politrcal situation of the countr\/ ln fact. some CDDs got lnterested tltrtrkrrtg that tltev had found a job until they reahzed that it wasn't a cash-paying job and decided to quit The supervisors based on their poor performances changed others lr Table 4 Proportion of villages which received health education' and in which health care personnel supervised CDDs Clan Sub-villages(Both A and B) Received education (Yes/I'{o) health CDD SuPervised by health sYstem Parker Corner 5 J 60% J r00% B 5 4 80o/o 4 1009,i,) Jah tono J 2 66 70h 2(100o/o Pleemu 5 5 l00o/o 5 I 00% Nlount Coffee 5 100%5 5 1009'0 Fenseh 5 5 1000h s(l0o% 0-6 Proportion and number of clans in which the cDD is supen'ised by the healttr care (clan scorin g 50% and above) = 24(100o/o) o-7 Proportion and number of ta,get clans which received health educatron = 2{ (100%) Notallthevisitedcommunitiesreceivedhealtheducation.But,allthatgothealth education are those that received supervision by health system This means that, the more Yousupervise,themoreCDDwillprovidehealtheducationtothecommunrtiesanderett the ,rore the\/ will be covering the communities to be treated as shown by tables I and -{ the cra.s rrrar got ail their corn-munities treated are the same that received health educarrorr and superv,ision, in other words, the level of education given to communities and the understanding of the onchocerciasis program conc.epti reflects in the degree of acceptance unO pual.lpuiion rate, also, ,tt. ortput of those implementing the proqranl Is basrcally relative to supervision they receive J N \o (r* (//', @ vs c\ tl L 0) Pc 0)o -c 0) hU \O .\ v ^a O.o u\\-o' o'' - ilr/-r .- L- a.J - O 6) -ico.- -F-onX '=ll co-Y Ecilo lev.Y(J-= - L0){rC^etr I O ..-.?FUL^\+E-GYV ^YF-'0.) --2' .o .- ^) .- v, !o\ q- ! t-ico o.r 6 =='G\rw(-.l >. - E ^a)6--L-O- <-oc,)o.)a\ll =\O C-:,1 >N CN = d -co i'(,rEvo.)>- ll o[!2:;: AdLQi^- o-= -g ll di'= n !-O= d-) L tri-i333.eE; 9 o.> gE9 s'i=U ; i = P Rt 1D* 5(uLLrY.;si!o) o k: -.yV)eu !s!.- PAPe--:P >ss c o) > =aeel--- aaaZCaEd-)0)0)La()F .; .-.-LDa-PeA .L .;.; = .-.- Ycccu<cv l))-)aF ctr-^PtrdE E E Yo? F E V k Y tcr, Y !VaVevtre .* ,+ .+ ,'! ,+ tF .+ oooooco LL!LLLL0.)0)o0)0)q)c) -o -o -o -o ,o -o -o -F > > ts F - -) ) ) ) ) ) - UUUU999 - - -(Edd(€cd(c(g ooooooo LLLI-L-LLoooooooo-o-oooo-aUUUUUVV LI-LLLLLAAAAAAA o l/it F, t lfi rC t-tlrl a,a trF9 o\O o\O O o\ .o o\O \oo- O o\ ,a= 6l< o\ON = o\ c.l o\O O o\ N .o o\o c.l = -o o\ O\o 5:r,- .)?d, \o \oo\O oo s .,) .o o\O @ .f, \oo\oO N :l !4. >o \o \o a-) \o o\O oo tf, .o o\ t-- \o\o N o\o@ $ o\o3 .o o\ 9e r,y o\ \o co $ o\ t-- \o\o N .o o\ O @ \f, o\ @ $ ci\O :t \oo\ L'\o o\ \eo\ O -o o\ O o\O$ N -o o\ \D .:J o\ON \o O .o o\ o\ N \oo\ \r ol \o \o .:H \o o\ O9 o\ cc sf, \o t-- \o\o(\ \o o\ O? o\OO f _:'{ ==4 a qJ U q) o 4) 0) C) C) o U z q 0) 25 The proportion of trained CDDs in sampled communities is 92.8oh lt is expected that whenever there is an active CDD, he/she should be trained, which means that the trarnins, sessions to come will have to make sure that all active CDDs are trained to ensure accuracy in work being done The table also reveals that25oh of the visited communities experienced late supplv rn N4ectizarr@ delivery, furthermore, 28 60/o experienced shortages in Mectizan@ supplres. thrs is a senous issue as there is a set time for distribution, so a late supplv vn,rll definrtely be unhelpful to the program On the other hand, given that the National Coordinator specrtically sard that the supply being received from MDP has always been enough, shortages of'Mectizan@ can be juftified by the following: o Poor census not taking into consideration all the populations to be covered, . Poor sharing of the Mectizan@ at District level, A]l the above problems can be tackled by regular supervisions by OICs and adecluate sharing of supplies within districts. The table reveals that l8% of the interviewed CDDs lacked measuriug devices There rs no reason tbr a CDD not to have a measuring device This can easily lead to elther uLider dosins or over dosing of the drug, which can be damaging to the program Supen'isors should alwavs make sure that CDDs have adequate measuring devices each time thev visit them As for the measuring device, treatment registers are key instruments to be used by CDDs Urifortunzitely. about 15oh of the visited towns lacked treatment registers Thrs is a serious issue 1lrat should be addressed, as lack of registers will automatically.lead to lack of record k:eeping Finally, the lack of treatment summary at state office (district and County) reveals a lack of close collaboration between OICs and State oftices. All summary forms are given to the implementing NGO with no copy to the state offices. There is a need to re-orientate and/or train OlCs on the absolute necessity to provide regular and accurate sutnman' of activities being carried out in a given district 26 B Copstraints Nlanugenrcnt . Lack of counterpart funding from the county budget to support CDTI related activities o Constant movement of populations running away from fighting areas o Most OICs working to implement CDTI activities are supported by NGO r^,'hrch do not always integrate CDTI in their priorities; . Lack of community initiative to support CDDs . l.ack of transportation means for OICs il T'ecltnical . Lack of adequate training with focus to supervision . Lack of required skitls for record keeping C Community PercePtion Even thOugh communities think that this program is important for their health, thel' hai e the percepiion that it belongs to the government and that theV have a \/ery limitetl role to plar: That rs, in terms of the drug and its effect, they value it " if it is left ri'ith me- lurll take two tablets every night". The populations would like to see the program contrnue providing the drug, "it took out the warms from my stomach, it cleared my skin. I no longer itch myself like I used to, I even wear trousers now.' Some town chief had this to say: "tablet is good. we want more, when I took it, it did well to me" Another hacl thrs to say "we are satisfied with the program, it should continue" "we appreciate treatment with Mectizan@ in our villa,ge and hope that it w'ill be sustained by collaborative efforts, that is: . Provision of drug for necessary duration o SuPPort to CDDs" Frpallt, a to\vn chief said the tbllowing to show his appreciation of the program "\&'e are blessed to be treat with free Mectizan@, we pray that the donors will contirlue ttr provide the drugs. We hope that eventually, river blindness be eliminated liom Liberia We will continue to be committed and supportive to the program arrd our volunteer workers. " About the perception that the program belongs to the goverrunent, a town chief said the fotlowing "the government should provide support for the program by pror"idin-u transportations means to its CDDs and health workers to enable them to go out more often () o or:qoqc!9z,cj9? =.gga.'i;:=i=-E -=-o ;a= E -/:=-'-E.=='2--"'i==ju aJ) -== = 2- (-) >a = - :o * >..= = ? - !E,t;:t,= iEE =: -;q = = oj: = Y, =X R,- -;6a =-_bAo=a.2... I5 .r ?- -rn-. 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B c = .; o? o -.9 302- - *r ? 6 -= C) X.- > -o=3dG j /! 9 = = -.-r = =_ 'i, -- J-J= -4.\a-u LIL-I ., :n - ^ () =lo > "Zi^P,8ql\, :o! :.0d E -<, ,,\ e q o 0=T8E-ut,-E3 Z .rA > r v:i:i=€e=- ; IA-;9L_J >:-,;^da2v =a = + !4.\ -2,J -)ltAIa-Lr-GrJ='J -A-- Slr C EzEE:'- .J -o= ==>odo 2J,2j2?4.2Ei ts =.9 P -- " 2E =)- -a.t-t-/l rLQ^"4---c3d:-;')$L6.iE '== =s *tr,aF H V - IJL',JCA>>.4 N,JOOCL'J. u i 5i3 8 3 F E a o = = ir ^l ^l \l ;,ono-jg]:oi,o--o=?ic86,\ a ...-= o >i Yl, =?= *a=-. 1= -.- - O [j o - =.,-- t-=l?!.: ..1^ L- -.9 L Y-Jr-lLl ,,;.. .- r- ^ U slo :: ; A 3\lU:OO 30i E! =i!2JZ'?--EZdiZ=7s:a9h e ) v r) a Ct;:i,? p *? .)9-:o E c >,3E e'= c = E ?= - (i cJ =; g; a'+"a ; E = .a,Pxa\l d a"-t = i, -.r -il3 ; B: E \ i z o O )o t-,-=2EE€EEE? aE E a i : .: EE 2 L;_-=v)^9J hn! v t c > L =v Q - " >9-'-?.;,J^..,' --v==4, ='r ;E, Xt "Sl 5-iE='-t.3=Sl a ci:(J= 3 51 3=E;u'-=, .'-o2c'!:i) =- 9 ?,'-D? - :--- = () - - ., : or-=.;, l- '-- -,E -') *r/=- \r-9^'' Sl e rr = ') - -Sl. o a ,- ; L '-fl- - - ,,\ aJ L \,1O = -L - a \) qJ .: C v, O -:' (.) :O a) ,-^lz€8a)\ ^2 a-,=OXYi=O-^^==>A- = =:- - Z =-E o I, - =.,-- -d-=='.a8.- '.1,\L;-9LYlLIU/,---^9 :slo :: ; H 3\l(y :O C :O = tr ! ==y9;>,"a=e "ii;3 5 AEE iZ-_ :! to? o >9=o E c >.EE a'33 € 3.,= i= -iESe =€=2:03,3:=9i a?X'Jr\'-\lcj -', = J ,.J'n =il3 ; 3: s ! 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Z )\,1 O = 2L - L () UU a/i !'r c-r on '= ao u'5 '+5 c) oE !.,t E *r= obxo!- :G -IE od creaE> A 0; <<i; * ) q, C 9 - a- o o- $€ 2 -,J = .L ;-o LYe'J;=> .:)_ta)=E>,=-_:) ) )= = it:r{)- o,^A =.='Jn-.= _ay_j-=l=L-LE=! - !<Q '.g 5 ;; = IEiE i:i:5-s . = Q = - : a,i=C ; ,, = - O e = .= ^:= 5--6'=21 r=- .il "- X I ='iE+'J =Z,!l ??o€3az=3,--4\l= 2I 'J E -O q 0 O O (J E '.t'J==-,2,).i7 -:! c:'.o l=55,/; ') t),^ -= .= = =>,:n-4 ?i'--'e-')--2-CJ_9.-'.-:- ,,-c=ci.J+<=2xo=L-=:j;v, l= LiLY='>tA=riFE=:Jl!.?>--n-_''=I- cJ o* = = ! - _J - C o aa- ' - .-.! st;: Tg = = E I - i\l c3 0-oz-E= az- c= = 2Av, o i= cJ ^"n J -I :) :3 -.JL) =J . _= 0!= = >, '>,! = al) c3E r:i "- == ) = >,^h,^z ='- ='- c i ') =_4LJL,.- .,==dd+=43){!J a) ! L r ai J3=!-oP?=-.^!=;-F=$2!> :h+.==F--9Zo- Zi.)7 u) r: :J) J )= = a+ :J)- :..O^^^=;:\l ; i PP = 4=2 - ?; ^el 1g - 5Y 13r';7\! - z\l d o-oz-=7 02. c.D AJ YEZ; .)X:0i _:a '-.aJA - =,Lg?.\J eYe)) -.)JUvotr=oo- -" 2 t ! ? I ? = 3 i E iOE O O= C U =-- ii- = aEE" E E s n=? i:s E;g € =c-j/,=a-,:-a'=t 7 \a16.= Z= '=i I = i= "E-q =!. Ac il r E=$;EEE l;ib a a 0 -'^ ='r, ^ = 30E ) I z t,LJJL-;^ 3* i,EZ!+= E= -.:9: -=a-!=i< = o.o - >.- - q I nicr i'=_b' =2/ ) =-o;i(. 1.--:,.=I- oi-O = = \ = :.. ^=; l:: ..: ,.ar-. -aZil.E;t 3E;Po ==dIE€.= H E. )E =Z 6. J YFY- -:J lri T, arE z,ea= =rc !i)- aYt.J) -^;2;1.\rLlJOi:=l)O, .;0-:)O'J=!i;tr._..i ,j?Es--E -a .eFEEs -9,9! et- .rfE 5 n :t -67"? i:: -z €E .,:--+-0-,:-,i ---L-4^----' -Jv , > > r '1 E = i = c:.1 -. ? ci -,,+ :2 = a = o\t 'J t o =.Y =;sl :5 EEraEl S;* 5 A\l= > + 'J = -O a = O O O O tr' C'JOL J ,-E :Oi 1) -.T ) 'tL U =,LeP;i (i uYFa)J '4.)J(r9 cIaoo- "_):)-to!=),^=_: l-t (--691" .=2 = '4 i 6 =: =. =- , ) .c =7= nE .EQ ? 'o! .€' ==s=q),:'.,-1'-"1*.===-at = 5o!a'; =E i-aI r . L "-(,E = g = ci:l r E- ? I s gi A > E i ,rl 3 5Ef €EI€ E E ats 5 r 939i J -,7= _J/ T,) -.-O ) tl U p:11)ai afe)r :3o: a;+f.)JU9 o='J',JE = q -a c: Y .tzN-Oi = ,i ii,i= == = rt? :aza E =E ._, ==3=v)-':-.,= i-- I = 5 9! R'c =+ A-aI = .^-' "!'q=i Aci'\0 = <:i - (J= !? =:) tr O ,Sl E E=-a; nnElsr-=q\l o o >L )=.O'a = o O C (J i ,,, t ,J OI)r r QU i'E E.:! r-G V=c) N 1l Table 7; Quality of CDD Training in Category "A" villages('/, in Parenthesis) Clans No. of CDDs No. Trained Length of Training No. Trained in a session Parker Corner _5 s ( r00%) J 30 Billv 5 4(80%) J 25 Jah tono 2 2(100%) 3 30 Pleemu 5 s(100%) 3 30 Mount Coffee 5 s(100%) 3 30 Fenseh 5 s(lo0%) 3 30 Eren though the duration and ratio per session seems reasonable' the question rests'*lth the content of the training. There is a need to adapt the training content to the real need of the trainees Also, it ii vital that these training sessions be closell' supervised and fotlowecl up by on -the-job training' l() The compogrents here above can be grouped into five categories Categoryl '[rorntng o/ hettlth workers, lrilntng of CDD':, Srtpenl.srrtn o/ ('DDs The tralnrng of health workers has not been consistent, as a result of ttrrs. the trarnrttg and supen,rsion of CDDs were done in a very approximate manner The trarningirefresher course rs being done irrespective of the level of knowledge of CDTI principles New and old trainees are all grouped and undergo the same training. The r,'ery few OlCs exrstlng and wrlling to supervise go out without really knowing what to look at since there rs no supervision checklist that would have enabled them to improve on CDDs' performances Category2 Tt'eatmenl orr,,ror1,, Rec(rd keeping and repctrling, slorage and 'sc)/t:11 o/ clt'trg Thrs section looks at CDDs performances While treatment accuracv and storage and sat'ety of drug score good grades, record keeping and reporting is still a weakness l\'lost of the time. CDDs give theiight doses and keep the drug in good places, theY still need to be taught the rmportance of good record keeping and adequate reportlnq 'l'hrs ts an on_ooinle process ihut.un be addressed in the corning training sessions, now'that there is tittL to ue taught olt treatment accuracy and other related topics Nso, there ts a need to improve on th; actual treatment registers so that they include all the necessary data and. more lmportant, that a summary sheet be attached to it instead of the actual fl]'in-c paper which is presently being given to CDDs at the end of the treatment perlod This sttmmarr shcet could be done in AouUte so that one be removed and sent to the supen'isor r^,hile tht' second wrll remain within the register so as to keep track of annual results Catesorr3 At,ailabili0t and adeqttacy of treatmenl This is a component that does not need a lot to be added to the existin,q The drug rs orderetj I adequate quantities However. it will be necessary to ensure. throttqh rnore regular alcl eilecti, e supen'ision that the drug is adequatell' redistrrtruted to the cornnrunitres rn need so as to avoid frustrations Categorry 4 (.'tttttttttrttrl).' ntobi ltzctlion and educaliott N{ost targetecl communities were mobilized to receive the treatment Hower"er, thele ls a leed to ensu;e that communities receiv'e the appropriate educational messages relatrng to contnrunit\ responsibilit),touards the program, the necessity for the commttnltY to take oriner.ship of the program and the reason to ensuring its continuity after.the erternal funding ceases Catesorv5. Irtegration into PHC Fr"n1 th. *unty level all the way down to the community level, it is absolutell' essential that ernphasis be put in makin-q people understand that the program will not sutr,'ir e unless iris fulli, integrated into the PHC This is r,ery important especiallv qiven to socr- political en'u'ironment prevailing in the country E UNIQTIE FEATURES OF THE PROJECT AREA Strengtlts r1 created gab between the CDDs and the a Given the prevailing socio-political environment in the entlre proJect area makes it so that it is a permanent challenge to have the program running I{ad the people implementing it (OICs, CDDs and the NGO) not been committed to haye'it achieve its objectives, had they not shown a lot of enthusiasrn. the pro1ect would have collapsed before it reaches its third year Community acceptance towards the project is another demonstration that rt they were iully mobilized much progress would have been achieved Weukrtesses a a The absence of community inrttattve community a The lack of counterpart funding from the government to help support the proJect There is absolutely no plan for sustaining the program0 4.0 DISCUSSION AND CONCLUSION Three years after its launching, it is encouraging to see that the onchocerciasis control program has succeeded in making the drug available to most of the affected communrtres desprte the numerous daily challenges it has been facing As the benefits of the treatment are easrlv noticeable, the program has succeeded in building the community dernand of the druq Durrng the present monitoring exercise, all the visited communrtles were r,3adv and willing to take the drug and bontinue to do so throughout the years Hou,ever, there rs still work to be done as far as sustainability is concerned. The NOTF has to lobbv tou,ards a stronger national commitment. It has to ensure that the Government which has already has a very good appreciation of the CDTI approach and has shown good signs bv rncluding the oncho control program into its national budget tbr the year 2002-3003 actually steps in by going beyond good intentions The program needs to be made tnore rrsrble so that all the communitres and other stakeholders become more a\\are of the oncho problem in Liberia. The capacity of all internal implementers has to be burlt bl providing with the opportunity to attending workshops where they would learn froni other countrres' experiences Liberia has to be consrdered a 'special case' and nrore tlnancial and technical assistance should be provided to enable the prograrn achteve its obl ectiv'e t+ 5.0 RECOMMENDATION I To the Project: General recommendation: Given that the project document was prepared based on sometimes-anecdotat information, it is necessary that it be revised so as to ensure that it reflects the scientific evidence existing on the field. Also, this document should be made available.to all the stakeholders involved in the project implementation. This documint should clearly state the role of each of the stakeholder. Also, there is a need for the project leaders to work out a strategy aiming at treatitlg the displaced in camps as these people constitute a big portion of he targeted poulations. Trainins of Health Staff As these people are key players in CDTI implementation process, it is essenttal that there trarning be set as high piioiity. Therefore, considering their fair performances nou'. it is highly recommendeJthat their training be strengthened in terms of quality 'There should be an assessment on what is expected from health worker based on which the training content will be defined. Finally, ihere is a need to provide for additional training davs of training for the OlCs joining the program for the first time instead of having to undergo the same training Tr?ipine and Supervision of CDDs There is a need toffigth.n C-oo training with great emphasis on basic operational principles of the progru* CDDs must be trained in simple language with emphasis put on practical e*eriisei during the training sessions. Training content will have to ansuel the tbllorv in-e questions . progrant: What does a CDD need to know about the prograni Partners. role of partners . Onchocerciasis What does a CDD need to know about Onchocerciasis rts causes, symptoms and consequences if not treated o Mectizan@ What does a CDD have to tell the people about the treatment u'rth Mecttzan benefits, duration of treament . Census Why,should a CDD do an exhaustive census of his population' How does a CDD do the census? o Treatment and record keeping: WhO is to be treated with Mectizan' How many tablets does a CDD give to the people to be treated? Why does the CDD have to keep track of all the i nformations he/she col lects') r5 How and where does a CDD keep hrs/her records? Once the trarning over, there is a need to ensure that frequent and effective supen'isron r,'isits are paid to CDDs This should be done by o Providing OICs with sufficient resources to effectively carry out supervisions to CDDs o Developing a simplified checklist to gurde OlCs during supervision visits Record keepin and reoortins There rs an urgent need to imptove on the record keeping aspect of the prolect The follcvvrng measures should urgently be implemented: n lnrprove on the census and treatment registers that need to be combined illto one census/treatment register The same register should also have a summary sheet attached to it The inside cover of the register can be used as a reminder to CDDs . Thi: community census/treatment summary sheet should be filled out in trvt-l coples. olte that is sent to the OIC, one that will remain attached to the register . lt has to be made clear to both OlCs and DHO that summary sheets need to get to both the supporting NGO and County health authorities. These sumnlary sheets need to be sent along with narrative report of the area covered. o Regular feed-back has to be provided to people implementing the program. Anoroac ins the Ilealth S ices and the Communitv As the project intends to strqngthen to approach the communitY or the existrng hierarchical structures This the health and social structures in place. all atternpts health services must be done in full respect of the will ensure full participation of all the partners and at the same tillle ensure sustainability of the program Itttegi'cttiot o/ CDTI utto the PHC Systent It should be.copsidered a priority progranr and integrated at all levels ]t is nou'a publrc health concerl that peeds to be given serious attention like any other progranl as tnalarta. and diarrhea To District: (hrtrcr.ship The conrinLrrrity,should begin to appreciate the progratn and be totalh'inr"olied both rn planning and irnplementation stages in order to sustain it 1v4 oh I i zal i on and sen s i I i zctl i orr Local authoritres should be involved as mobilizes and develop and dissemrnate appropriate messages through local media such as "talking drums, town criers, Contnrentoratt\e ONC'HO Dav should be declared to demonstrate the itnportancr: of the d rsease t6 ('otrnlerpart finding Appropriate allocation should be made to facilitate the work of the program Varrous stakeholders in the district should be encouraged to provide minimum fund1 towards the proj ect Prot,r si ctrt r\f I ogi str cs Adequate logistics such as vehicles, stationery, motorbikes should be provided by, all stakeholders to ensure effective implementation of project activities P I ut t.s fbr .\t t.\'tcu t?obt I t 0,, A three-year sustainable plan that would contain every shades of community involvemenr should be developed. Itttegt'otrrtt tnto the rortttne health s.y;slent The proJect should be rnade visible in all facet of the health sysrem Thal rs rhe cotnmunitl, should be fully aware of the existence of the project either at the conrmunrty and facility levels. To National Onchocerciasis Taskforce (\lrer.shyt The program should be regarded as a national program Decision and polrcl rlakers should be committed and accept the program as any other health program such as Malaria, TB/Leprosy and Environmental Health. Budgetary appropriation shoulcl be made to enhance the work of the program. N'ktb r I i za fi ot t cncl seny li zcr| r orr The Taskforce should use all available media (prrnt and electronic, towrr crier) and develop appropriate message for dissemination to the target population (- o t t t? t e rpat' t ./imdi n g Appropriirt.e budgetary allocation should not only be made but be disbursed to rhe proqram NOTF should continue to advocate to ensure the disbursement of the fiinds I ) t'r.n't.s i ot t r t/ I rtg sti c'.s The taskforce should ensure that adequate logistics are provided by adr,'ocatins tbr appropriate funding in the national budget. P I u t.s .f o r s r r.:' t u r nab t I i ty The NOTF should develop a three year plan involving all stakeholders and rarsets to be achieved as rvell commitment of various partners t7 Inregratrort trttct lhe routine health systent NOTF should advocate that the program be incorporated into the overall health s)'sten) at all ler, els To APOC Management Prrt,tsrr,trr oJ logrsttcs and capilal equipmenls .\s the projecr presently operates exclusively on APOC funding and in order to keep growrng the present ntticeable results, the team encourages APOC .to increase rts financial supporr to the NOTF.pf Liberia to facilitate the work being done to get the Mectizan@ to the suffering communities of Liberia' Prot,r si ctn rl' technical assislance The team strongly recommends APOC management to allow that enhanced technical assistanoe be providld to the NOTF of Liberia given the unique socio-political enr,'ironment in which it has to operate'