Report on assessment of CDTI implementation in East Bahr-El-Ghazal and West Equatoria projects in Southern Sudan

IREPORT ON ASSESSMENT OF CDTI IMPLEMENTATION IN EAST BAHR.EL. GHAZAL AND WEST EQUATORIA PROJECTS IN SOUTHERN SUDAN SUMMITTED BY TOM LAKWO {s CHRISPTOPHERF.UZAZA ffitr c "i 2 q 0cI. 2006 Afl(;\-lL)lF. OCTOBER 2OO8 tACKNOWLEDGEMENTS The accomplishment of this mission could not have been possible without the assistance from various people. The team wishes to express first of all thanks to APOC Management for giving us this opportunity to undertake this mission. Our sincere heartfelt gratitude is extended to the Undersecretary MoH-GOSS, Dr. Monywiir Arop Kuol for sparing his valuable time to give historical background of mectizan distribution in Southem Sudan during conflict era and a brief on plan to improve health sector in GOSS. This meeting was possible with the effort of Dr. Abdullahi Ahmed, Head of WHO office, Southern Sudan for which we are grateful. Many thanks to Dr. S. Baba, Director General, PHC, who welcomed us to the MoH-GOSS on arrival and provided insight and guidance on OV programme. We are further indebted to Dr. A. Wurie (WHO office southern Sudan) for his cheerful and fruitful time and also stimulation of discussions and ideas on OV. Our appreciations are extended to the Administrator in WHO office for Southern Sudan in Nairobi, Kenya, for making our travel arrangements and accommodation during this mission. We owe special thanks to Mr. Mohammed, Mr. Eric Manas all of WHO office Juba, southern Sudan and Fasil Chane, NGDO Coordinator who tirelessly ensured that our flight connections with United Nation Humanitarian Air Service and accommodation arrangements were taken care of. Mr. Ali Ngor, Deputy National Onchocerciasis Control Programme Coordinator was also extremely helpful in arranging for our meeting with relevant staff of MoH-GOSS. tn Rumbek current headquarter of SSOTF, the WHO/APOC Technical Advisor (Lazarus Nweke) assisted us in field planning and selection of communities based on their accessibility at the time of visit for which we are quite appreciative. Messrs. Chol Manyiel and David Bido, Project Coordinators for East Barh-el-Ghazal and West Equatoria projects, respectively were extremely commiffed and ensured we reached the selected communities. The contribution of household members, CDDs, supervisors and community leaders in providing information on their experiences of pre-and post-conflict mectizan distribution are highly appreciated. We acknowledged the effort of the interpreters who ensured that we got the right information during our interviews and meetings. The drivers who participated during this mission deserve appreciation since they transported the team around Juba and the various communities in the two projects safely. Many more people contributed to the success of this mission than we can account for individually in this report for which we are collectively grateful APOC CAR CBM CDDs CDTI CHWs DGHS DRC EBG GOSS GPS IDP IMC IRC MDA MoH MSF NGDO NOTF NTDs OV OXFAM PHC SAEs SMoH SPLAA,t SSOTF SSRRC I.JNICEF wHo ACRONYMS African Programme for Onchocerciasis Control Central African Republic Christoffel B linden Mission Community Directed Distributors Community Directed Treatment with Ivermectin Community Health workers Director General of Health Services Democratic Republic of Congo East Balrr-el- Ghazal Government of Southern Sudan Global Positioning System Internally Displaced Persons International Medical Corps International Rescue Committee Mass Drug Administration Ministry of Health Medicins Sans Frontieres Non-Governmental Deve lopmental Organi zation National Onchocerciasis Task Force Neglected Tropical Diseases Onchocerca volvulus Oxford Committee for Famine Relief Primary Health Care Serious adverse events State Ministry of Health Sudanese Peoples Liberation Army/Movement Southern Sudan Onchocerciasis Task Force Southem Sudan Refugee and Rehabilitation Commission United Nation Children's Fund World Health Organization ll TABLE OF'CONTENTS ACKNOWLEDGEMENTS ............. ACRONYMS........... EXECUTIVE SUMMARY ............... 1.0 BACKGROUND INFORMATION I.1 COUNTRY BACKGROI.IND. l. L l Geographic description......... l. 1.2 Onchocerciasis situation in southern Sudan ......... 2.0 BACKGROUND OF PROJECTS.......... 2.1 East Bahr-El-Ghazal project 2. 1. I Geographical location, topogaphy, climate..... 2.1.2 P opulation .......... 2.2 West Equatoria project....... 2.2.1 Geographical location, topography, climate 2.2.2 P opulation, activities, Cultures and language ................ 2.3 The Concept of Community Directed Treatment with Ivermectin (CDTI) 3.0 OBJECTIVE OF THE MISSION AND TERMS OF REFERENCE. 3. l MAIN OBJECTIVE ................... 3.2 TERMS OF REFERENCE......... 4.0 METHODOLOGY ....................... 4.1 Sampling procedure 4.2 Selection of households .............. 4.3 Meetings................. 4.4The meeting with WHO -Southern Sudan and MoH-GOSS officials 4.5 Meeting with State MoH and other partners............... 4.6 Assessment Instruments. 4.7 Interviews with household membe 4.8 Capturing experiences from CDDS through meetings 4.9Data analysis and report writing 4.10 Limitations of the team during assessment of the two projects................ 5.0 FINDINGS AND THEIR IMPLICATIONS FOR TREATMENT COVERAGE AND SUSTAINABILITY ............ 5.1 Post-conflict experiences and present Relief and Rehabilitation efforts 6.0 STRUCTURES FOR CDTI IMPLEMENTATION IN GOSS 6. I Village/community Ievel............. 6.2 County, Payam and Buma levels 6.4 MoH-GOSS level.. 7.0 FACTORS AFFECTING CDTI IMPLEMENTATION 7. I Transport............. 7 .2Maintenance of field vehicles 7.3 Insecurity ............. 8.0 COMMUNITY PARTICIPATION AND INVOLVEMENT ............... 9.0 COMMUNITY TREATMENT COVERAGE 9.1 Geographical coverage .... 9.2 Therapeutic coverage....... 9.3 Absenteeism and refusals. I I I I 2 2 2 J^ J J aJ 4 4 4 4 5 5 5 5 5 6 6 6 6 7 7 7 7 8 8 9 9 0 0 0 0 1 I I I 1 I 1 I I 1 I 1 .......... 1l lll ll IO.O CDD EXPERIENCES IN CDTI IMPLEMENTATION ...................... 12 l0.l Support to CDDs. J 10.2 Training..... J 10.3 Community mobilization and Health Education. I 0. 5 Duration of mecti zan treatment .............. 10.6 Problems encountered by CDDs during CDTI implementation.... 10.7 Suggestions to improve CDTI implementation II.O SUCCESSES IN CDTI IMPLEMENTATION.... I2.O STRENGTHS IN CDTI IMPLEMETATION...... I3.O WEAKNESSES IN CDTI TMPLEMENTATION I4.O CHALLENGES IN CDTI TMPLEMENTATION I5.O DISCUSSION OF KEY FINDINGS I 5. I TREATMENT COVERAGE I5.2 CDDS EXPERIENCES IN CDTI IMPLEMENTATION........ I7.2 MINISTRY OF HEALTH _GOSS...... I7.3 STATE LEVEL AND PROJECT AUTHORITIES Appendix 2 Appendix 3 Appendix 4 Appendix 5 ................ l3 J 3 L3 ..,,.... 14 ........ 14 ........ 14 ........ 14 ........ 15 ........ l5 ........ l5 I7.1 APOC AND OTFIER PARTNERS .. t7 t7 t7 18 2l 22 24 25 26 lt EXECUTIVE SUMMARY Background Onchocerciasis is endemic in Southern Sudan with varying endemicity. The main endemic foci are located in West Equatoria, East and West Bahr-el- Ghazal. CDTI projects in West Equatoria and East Bahr-el- Ghazal were approved by APOC in 2003 but implementation delayed till 2005 and 2006, respectively. Prior to the launching, mectizan distribution had been ongoing in these project areas through support of a consortium of NGDO's. West Equatoria project is now in its 4h year of CDTI implementation while East Bahr-el-Ghazal in the 3'd year. Main objective of the mission To carry out an assessment of CDTI implementation in the two projects of East Bahr -El- Ghazal and West Equatoria in Southern Sudan and make appropriate recommendations to ensure achievement of high treatment coverage and project sustainability. Methodology Nine communities in EBG and five in Western Equatoria projects were randomly selected based on their accessibility at the time of assessment. House hold surveys were conducted in these communities using household survey form designed by WHO/APOC (Monitoring lnstrument, WHO/APOC, 2002). Household members or their representatives were interviewed on some key indicators of CDTI implementation. Meetings were organized with some CDDs in the two project areas. Both key informant interviews with household members and meetings with CDDs were based on designed checklist. Key Findings o Mectizan distribution in the two project areas started way back during southern Sudan conflict by a consortium of NGDOs and humanitarian agencies (CBM, UNICEF, MSF, OXFAM, IMC, IRC Red Cross, World Vision, The Carter Centre). Mass mectizan distribution was not comprehensive and treatment coverage was very low as confirmed by some respondents. o Geographical coverage for 2007 in Western Equatoria project was 100% whereas in EBG this was 77.8Yo. Treatment coverage in Western Equatoria ranges from 32.8ok to75Yo (average 61.6%) and that of EBG from9.6%oto70.3o/o (average 28.9%). o Since the inception of CDTI programme in Western Equatoria annual community treatment has been done uninterrupted. However, in EBG project, there were many communities which did not receive annual treatment due to several reasons. o Although there are few CDDs in the two projects most of them understand their roles and perform them adequately. Contrary, the supervisors at various levels are adequate in number and are also performing their roles effectively. The biggest challenge for the two projects is the demand for incentives by CDDs and provision of adequate facilitation to supervisors. o CDTI implementation in the two projects is progressing fairly well under the circumstances and each of the projects is striving to achieve high geographic and therapeutic coverage. However, they have challenges that may not allow CDTI sustainability in the short term. lll Conclusion CDTI implementation and treatment coverage (Geographical and therapeutic) in Western Equatoria project is good but can still be further improved. In EBG project, treatment coverage ind-other Cnft activities is not good due to flooding, absenteeism associated with " cattle camps" and other weaknesses in the project implementation. There is a functional CDTI iystem in the project areas despite existing challenges. Active and knowledgeable support staffs at lower levels have contributed to CDTI implementation in the two projects. Majority of the communities have adequate knowledge about the disease and have noted the benefits of mectizan even during the conflict era. There are opportunities offered by the existing health and administrative structures that can be used to enhance CDTI implementation and other health care delivery. However, the sustainability of the two projects remains a big challenge. Key Recommendations o APOC and other external partners to provide further support in the areas of transport and other logistics to strengthen CDTI implementation. o MoH-GOSS to facilitate the formation of state Task Forces and streamline leadership at SSOTF and state level so as to have more responsibility in management, coordination and implementation of CDTI activities o State and project authorities to ensure the selection of at least I CDD per 25 to 40 household so as to reduce the work of CDDs and reduce demand for incentives. o To enhance community ownership and participation in the programme, the projects should carry out advocacy through existing administrative structures for the involvement of community in making important decisions in CDTI implementation. o The project of EBG should address peculiar issues affecting CDTI implementation like treatment absenteeism due to cattle camps and flooding. 1V 1.0 BACKGROUND INFORMATION 1.1 COUNTRY BACKGROUND 1.1.1 Geographic description South Sudan lies between latitudes 40 and 100 north and covers an area of 640,000 square kilometers. It lies in the Nile basin and is bordered to the north by Northern Sudan, to the South by Uganda, to east by Kenya and Ethiopia, west by Central African Republic and South east by DRC. It is traversed by the White Nile, the longest river in Africa, originating in Lake Victoria in East Africa and terminating in the Mediteffanean Sea in Egypt. The Nile is a life line for Sudan providing water for drinking, irrigation, hshing and transportation. The 'Sudd' region now designated the largest wetlands in the world holds vast quantities of water thus regulating rainfall patterns and providing constant source of water for the large cattle population in the area. South Sudan lies in the savannah and can be described as semiarid. Its climate has two seasons: hot and humid - April - August, hot and dry - October to march. The population of Southern Sudan is estimated to be 8 million. Women account for 50% of the population but are intellectually, politically and economically marginalized. 1.1.2 Onchocerciasis situation in southern Sudan Onchocerciasis or "river blindness" is one of the major filarial diseases of humans caused by Onchocerco volvulus, and transmitted by the female black fly of the genus Simulium.It is a leading cause of preventable blindness and severe pruritic skin conditions in endemic areas, and thus one of the most important public health and socioeconomic problems faced by rural populations (WHO, 1976).In southern Sudan onchocerciasis is commonly referred to as "Ov" (Onchocerca volvulus). All the ten states of Sudan are endemic for onchocerciasis, with the main endemic foci located in Western Equatoria, Eastern Bahr-el-Ghazal and Western Bahr-el-Ghazal (figure l). In these areas >8Oo of individuals in some villages have palpable nodules and blindness exceeds 12% (Mukhtar et al. 1998). Most OV infection causes only a mild skin reaction, although microfilarial loads in the skin are high. These individuals are important epidemiologically, as they serve as a reservoir for transmission. Skin reactions include pruritic papular rashes that cover wide areas of the body, particularly the lower limbs. A major concern in the West Equatoria zone is the co-existence of Loa loa in specific areas, which can precipitate serious adverse events (SAEs) in those who are given ivermectin Southern Sudan l[T 5: CDTI ry ul trE-ra CDTlfDi.ct $ri fidr E.|.cdt! crorlfuebr rrl rqrcniti.l.fia€l€frE llotakarr !;a<ltr r)rorl Af, lc.r A.Ftllic @ ssor xO, rolc mdnlio oatle l?col tol.d suFr..lcm c.rtr{?scl ! P.olcl cddrtbn dlle (lrCO) I Prolc.t .rDdrl.aon 6rirc (PSC)X - '--- --- --- unou.nc tirpubhc ol Dongo n, atgrrdt{I: ?."id $rerurtm o.dr. (?sc) ody I------]0lm2m Lcgend I s.rV.. -i"l.ftr!' aE .....R Er Iconprro.rtr* lno.ro*o .ii)i Rlato rDcpr&reI Rhiopl, .1 try, Figure 1: Geographical distribution of onchocerciasis in southern Sudan (Source MoH-GOSS/SSOTF) NB Projecs 2 & 3 were assessed. 2.0 BACKGROUND OF PROJECTS 2.1 East Bahr-El-Ghazal proiect 2.1.1 Geographical location, topography' climate The East Bahr-el-Ghzal CDTI project is located on the latitude of 6.80961o and longitude of 29.67870o. The project area lies at an altitude of 424m above Sea level. The East Bahr-el-Ghazal CDTI project office is based in the Lake State Ministry of Health and sharing the same block with SSOTF Secretariat. The project is made up of three states, namely Lakes, Warrap and West Equatoria. It is bordered on the North by Unity and Warrap states, on the South by West and Central Equatoria states, on the East by Jonglei and on the West by West Bahr el Ghazal state. The topography of the project area is made up of Sudan savanna and Guinea savannah to the west and flood region to the eastern part. In the western part of East Bahr- El-Ghazal the soil type is a basement complex resting on iron stone plateau. In the western part of East Bahr-el-Ghazal, the soil type is made up of superficial clay. 2 B Dtx&iB r, I t h Ssav v*hM*Poox, Rainfall ranges from 750mm - l200mm. The climate varies from wet monsoon to medium wet monsoon in the west and dry monsoon to long dry monsoon' 2.1.2 Population The project has an estimated population of 1,729,275 at risk and total population of 927,285 for annual treatment with mectizan. This increase in figure was as a result of the returnees from the neighboring countries. 2.2 West Equatoria project 2.2.1 Geographical location, topography, climate The West Equatoria CDTI project is located between latitude 40 to 6.50 and longitude 260 to 310 in the south-western region of south Sudan. The project office is situated in Yambio town in West Equatoria state. The state is bordered on the North by Lake, Warrap and Unity states, on the East by Central and East Equatoria states. South and Western parts share international boundaries with Central African Republic (CAR) and Democratic Republic of Congo (DRC) respectively. The project consists of five counties namely; Tambura, Ezo, Yambio, Maridi and Mundri' The Nile River traverses the Equatoria region dividing it into Eastern and Western Equatoria. The topography of the state is ironstone plateau with complex basement. The project area transects two hydro-topographical zones of the Nile and Congo watershed, which is characterizedby fast-flowing rivers e.g. Yei, Yale, Bahr-Naam, Era, Maridi, Lesi, Sue, Yubu/Ringasi/ Ibba, Bikes, Mbungu and Duma. All rivers drain northeast to the Jur and east to Bahr-el-Jebel, which form a confluence at the White Nile. It is precisely because of climatic and topographic conditions that the disease prevalence rates are so high, as the black fly thrives in such environment. The vegetation of the areas is mainly guinea savannah with woodland derived from rain forests to the south. 2.2.2 P opulation, activities, Cultu res and langu age The estimated total population at risk of being infected of onchocerciasis is 506,848 people. The people who emigrated or internally displaced persons are returning home and ihis affects the overall population of the state. Prior to the war, the majority of the inhabitants of West Equatoria were settled agriculturalists in the communities practicing subsistence farming. Current settlement patterns have been impacted by prolonged conflict. People have been unable to carry out their farming and other occupation as a result of both internal and external conflicts. The population is dispersed with seasonal farmsteads. West Equatoria also accommodates Internally Displaced Persons [tDP] and refugees from DRC and CAR. The languages spoken by the people of West Equatoria are Balanda, Zande, Moru, Baka, and Morukodo. The Zande is the dominant ethnic group. The two CDTI projects were approved by APOC in 2003 and launched in 2004, but there were delays in implementation which only started in 2005 and 2006 in Western Equatoria and EBG, respectively. J 2.3 The Concept of Community Directed Treatment with Ivermectin (CDTI). This is a mass treatment of hyper/meso endemic communities with mectizan. The fundamental of "community directedness" is a community planning and distribution process. Communities decide on how the programme should function, when treatment should occur, and choose the distributors and the distribution method. Programme personnel have roles as facilitators, but must avoid being directive (APOC, 1998). In CDTI implementation the following activities must be comprehensively done: o planning o Training of staff at all levels o Proper village census, record keeping and village register update. o Mobilization and Health Education of communities. o Delivery and distribution of mectizan. o Supervision of activities and mectizan distribution. . Report compilation, submission and providing feedback. o Proper management and coordination of the programme The partners in CDTI implementation in southern Sudan are: o Affected communities o MoH- GOSS o African Programmme for Onchocerciasis Control o NGDO partners 3.0 OBJECTIYE OF THE MISSION AND TERMS OF REFERENCE 3.1 MAIN OBJECTIVE To carry out an assessment of CDTI implementation in the two projects of East Bahr -El- Ghazal and West Equatoria in Southern Sudan and make appropriate recommendations to ensure achievement of high treatment coverage and project sustainability. 3.2 TERMS OF REFERENCE l. Brief the WHO Head of office in Southern Sudan the purpose of the mission. 2. To hold meeting with NOTF to document success stories, challenges and provide technical advice on sustainability of CDTL 3. To document ivermectin treatment coverage in 20 to 30 villages/communities randomly selected from onchocerciasis meso- and hyperendemic areas using household survey form for 2007 and 2008. 4. To document through interviews with members of households, when ivermectin was given in the village/communities and whether treatments have been provided annually (unintemrpted) since inception of project. 5. To hold meeting with some CDDs to document their experiences and to veriff information on duration of treatment gathered from households. 4 4.0 METHODOLOGY 4.1 Sampling procedure The East Bahr-El- Ghazal has five counties, and in order to have uniform coverage of project area four of the five counties were selected. In the four counties, list of u."l.ribl" communities was made and two villages per county were selected randomly. In West Equatoria project five villages were randomly selected from only Yambio County due to time and transport limitations. Table 1: Selected communities/villages in East Barh-el- Ghazal and West Equatoria projects 4.2 Selection of households In most of the communities where the house hold surveys took place, villages exist in such a way that roads or foot paths divide the vitlages in two or more sections and householdswere on both sides. Fiom the centre of the village coordinates were taken using GpS and team members involved in data collection would move in different directions depending on the settlement pattern so as to cover the village adequatelyt Evgry second householJ was sampled, and incase there was no respondent or household had only one person, the next household was selected until 10 households were selected. 4.3 Meetings Series of meetings were held at various levels of interaction, some of which were for courtesy and others as part of procedures for seeking understanding of CDTI implementation in the two projects and status of their sustainability. 4.4 The meeting with WHO -Southern Sudan and MoH-GOSS officials The team reported at WHO office, Southern Sudan on arrival in Juba, and had audience with the Administrator in the absence of Head of office WHO, and explained the mission 5 Proiect County Communities/Villages East Barh-el-Ghazal Mvolo Mvolo Domeri Cuibet Abiriu Keburuwilliam Yirol Shalak Mathir Rumbek Timbar Marborkoch West Equatoria Yambio Yabua Sekure Saura Tibakaikpo Marbordoang Li-Ransua and activities that were planned. Due to very tight travel schedule the Head of WHO, Southern Sudan Dr. Abdullahi Ahmed was de-briefed of the findings when the team completed the mission in the two projects. At the MoH-GOSS, the team had meetings with the Undersecretary, Director NTD control and Acting National Coordinator, Onchocerciasis Control Programme. 4.5 Meeting with State MoH and other partners In the Lake State at Rumbek, a meeting was held with the project staff, including WHO/APOC Technical Advisor and NGDO Coordinator, Mr. Fasil Chane Bizuneh' The team de-briefed them on the findings in the East Barh-el-Ghazal project. While in West Equatoria, the Acting Director General of Health and Coordinator for SSRRC were briefed of the mission and planned activities. 4.6 Assessment Instruments i. APOC provided one tool for household survey (Monitoring Instrument- WHO/APOC 2002). ii. Interviews with households members. A guide was developed by the team members. iii. Meetings with the CDDs - a checklist developed by the team members were used' 4.7 Interviews with household members Members of households were interviewed using developed checklist focusing on areas related to CDTI implementation. The key areas of interest were: o Mectizan distribution system in the community. o Decision on CDTI activities in the community. o The number of times ivermectin has been taken in the community o Information source on "OV" and mectizan o Knowledge on the disease and drug 4.8 Capturing experiences from CDDS through meetings Meetings were held with two or more CDDs in the two project areas. This was further supplemented by individual discussions with CDD in every community where household inte-rviews were done. This followed a designed CDD data collection checklist, and this focused on the following areas: o CDTI activities conducted by CDDs. o Support to CDDs. o Training . Community mobilization and health education c Mectizan delivery o Duration of mectizan treatment o Challenges in CDTI implementation o Suggestions for improvement 6 4.9 Data analysis and report writing The team made summaries of responses from the household survey form. Totals for responses in each village was computed and recorded on a summary sheet according to each project. And for household members' interviews, summaries of responses were made depending on the number of respondents interviewed. For the various meetings (NOTF/MoH-GOSS, state, CDDs) views and information during the meetings were recorded. This acted as a basis for some of our recommendations. 4.10 Limitations of the team during assessment of the two projects o Travel distance from where the team settled to communities has been taking between 3- 6 hours. This left very little time for field activities. o A lot of time was spent on travel and connecting to project areas and this was more than the actual field days (Appendix 1). o Poor mechanical condition of the vehicle in West Equatoria project made the team to abandon the randomly selected Ezo County and only concentrated in Yambio county where the distances to communities could be managed by a vehicle in that state. o Lack of stationery (EBG project) to photocopy some of the data collection tools. 5.0 FINDINGS AND THEIR IMPLICATIONS FOR TREATMENT COVERAGE AI\[D SUSTAINABILITY 5.1 Post-conflict experiences and present Relief and Rehabilitation efforts According to key informants at MoH-GOSS and state levels mectizan distribution in Southem Sudan started way back in 1995 spearheaded by health consortium of NGDO's and humanitarian agencies. The Health consortium worked closely with existing community leaders to select Community health workers (CHW's) who volunteered as health service providers, after being trained. It is the same CHWs who distributed mectizan to the community members during the war. During the course of the war and indeed as expected these were challenges of sustainability of mectizan distribution programme in 2000-2003. To keep mectizan distribution on course, NGDO's and humanitarian agencies designed a quick strategy to motivate CHW's and mectizan distributors, like provision of T-shirts, gumboots and bed- nets. In addition the programme in some areas was implemented vertically. At the inception of CDTI strategy with support from APOC in 2004-2005, the disparity of previous vertical implementation of mectizan distribution was not recognized as an important factor. To date, there exist no strong link between MoH-GOSS and the SMoH of Lake and West Equatoria where CDTI project coordinators are located. Project coordinators are strongly linked to individuals in MoH-GOSS and CBM but not SSOTF. In brief the two projects are implementing CDTI vertically and the programme is seen as a vertical programme by APOC. However, there is integration of CDTI into other health activities from county down to communities and this once strengthened will enhance sustainability (refer appendix 4). 7 At present Southern Sudan is in the phase of Relief and rehabilitation under the auspices of SSRRC, and one would wonder whether it is not too ambitious to talk about CDTI sustainability without well established health infrastructure and health care system from MoH-GOSS level to community level. It is therefore worth considering taking CDTI project implementation in Southem Sudan as a "special case" and applying a modified CDTI implementation model for such situation. In this case it is likely to take over 5 years from now (October 2008) to establish self sustainable CDTI programme in Western Equatoria and East Bahr-el-Ghazal projects. 6.0 STRUCTURES FOR CDTI IMPLEMENTATION IN GOSS 6.1 Village/community level There exist traditional leaders in the two project areas. In most villages there are village chiefs or headman who is the lowest placed traditional leader in the society. There also exist payam and paramount chiefs. These are highly respected people with traditional authority to make decision that affect people and provide leadership and guidance at times of need. GOSS has appointed leaders at community level known as "buma chiefs and inspectors. Both traditional chiefs and government leaders work together in matters of mutual interest. CDTI projects in the two areas have not attempted to involve these leaders. In addition, communities are not being involved in making key decisions affecting MDA of mectizan. Consequently, there is lack of community ownership of CDTI programme. From interviews with household members, decision affecting mectizan distribution is being made predominantly by CDDs, supervisors at various levels, health workers and project offices. One of the key decisions made was on house to house mode of distribution. Although this decision was not made by the communities, all the members are happy about it and are satisfied with the delivery of mectizan. This has been compounded by the experiences of the most recent civil war; where everybody claimed to have volunteered in one way or another (including mectizan distribution) and thus expects incentives from the new government authorities and organizations rendering humanitarian services in the country. There is a strong weakness of "dependence syndrome" amongst community members and lack of self esteem. The key implementers of CDTI activities at community level are the CDDs. They are few in number ranging from l-3 per community/village. They carry out their roles adequately. However, their limited numbers make their tasks tiresome. Therefore, they all complain of too much work, walking long distances and working without incentives. The CDDs strongly feel they should be paid or given incentives for their work. They seem not to understand that they are voluntary workers, rather they take their work like any other job. 8 6.2 County, Payam and Buma levels Leadership of CDTI implementation at these levels is provided for by the county, payam and buma supervisors. Initially, county and payam supervisors were meant to be health workers. However, because of lack of adequate health manpower and infrastructure in Southern Sudan, a few county and payam supervisors are health workers formally employed by the SMoH. This was confirmed by the NGDO coordinator who stated that in all the 5 projects, 3 out of the 5 project coordinators and 15 out of the 33 payam supervisors are formally employed by the MoH. The health workers who are supervisors demand allowances for CDTI work because they are not paid promptly by the government' Those who are not health workers have very little commitment and morale since they receive little facilitation and are not given incentives. Consequently, drop out of supervisors at these levels are equally high. These projects have very few experienced county and payam supervisors. Lack of adequate transport in form of motorcycles and bicycles compounds the situation at this level. A county is very big administrative unit that is comparable to a district in some other countries. To supervise such a large area, the supervisor should have adequate means of transport and be facilitated. 6.3 State level There is a fully functional health service system under the jurisdiction of the Minister and Director General of Health Service. However, the DGHS appears to have inadequate qualified and experienced health staff, consequently he is overwhelmed by responsibilities. In West Equatoria project, CDTI project coordinator is formally employed under PHC Division oi SMgH; while in the EBG project the project coordinator is not formally employed and thus paid top-up allowance from APOC. In both projects there are no "o-rnitt"", or Task Force for CDTI implementation and coordination, therefore, the project coordinators single handedly manage, coordinate and implement all CDTI activities. 6.4 MoII-GOSS level There is SSOTF that was recognized by APOC as the official partner in charge of onchocerciasis control in southern Sudan in 2001. Their role is to steer CDTI implementation at lower levels through the provision of policy, guidelines, coordination and resor."e mobilization. This Task Force is supported by a Technical Advisor for CDTI hired by WHO/APOC and now based in Rumbek town of the Lake State. SSOTF established a coordination centre in Rumbek town to coordinate CDTI implementation in the projects of EBG and Western Equatoria. It was observed that MoH-GOSS seems to have a weak control and coordinating mechanism over individual CDTI projects. For sustainability of CDTI projects in GOSS in the near future this trend should be reversed (Appendix 4). 9 7.0 FACTORS AFFECTING CDTI IMPLEMENTATION 7.I Transport There is a very poor road network in the project areas which cover large areas. Even the situation of the roads is appalling with many pot holes, small valley like ridges and in the Lake state, the floods form lakes in low lying areas thereby blocking roads and at times sweeping away small bridges. This transport and flood situation makes villages inaccessible. At the time of the visit of assessment team five payams in Rumbek East county of East Bahr-el-Ghazal project had not received mectizan, yet medicine was dispatched to the county in June 2008, 3 months earlier. To access villages sampled the vehicle could literally pass through bushes and footpaths in flat areas. This transport scenario is well known and documented by the MoH-GoSS Qrlational vision 2020 Plan, 2008). One of the quotations on page 5 of this document states: "In rural areas of southern Sudan infrastructure is virtually non-existent, there are no paved roads outside the towns of Jubo, lV'au and Malakal. Access to other state is still by air. All roads are gravel and bridges are either brokcn or in bad state of repair" T.2Maintenance of field vehicles The assessment team observed that none of the two projects has a vehicle in a good mechanical condition. The vehicle for East Bahr-el-Ghazal project was gtounded in a garage while that of Western Equatoria has very old worn out tyres. The team had to risk traveling with the vehicle for three consecutive field trips without a spare tyre. Lack of fund for maintenance of vehicles and motorcycles was the complaints of the project field workers wherever we went in the two projects. T.3Insecurity Although the conflict between 1972 and 2005 ended with the signing of Comprehensive Peace Agreement between Southern Sudan SPLAA,I and Khartoum Govemment in January 2005, tribal conflicts and cattle rustling continue to be a source of insecurity in Southern Sudan including the two project areas. The situation has been made worse by the possession of illegal guns in the hands of many ordinary people. The GOSS is implementing a disarmament campaign so as to get rid of illegal fire arms in communities but it is faced with many challenges and this is likely to take some time. The CDTI assessment team encountered this insecurity when on a visit to Yirol from Rumbek in the Lake state, East Bahr-el-Ghazal project. A gun fight occurred in the out skirts of Yirol town for about one hour which left one person dead. The team was held up in Yirol hospital and when the baffle ended one warring faction set a road block on the only road leaving the town to Rumbek. The situation was saved by the Yirol Hospital Health officer who talked with the SPLA officer in charge, who allowed us to leave. l0 8.0 COMMUNITY PARTICIPATION AND INVOLYEMENT According to information from household interviews the main mode of mectizan by CDDs is from house to house. However, some community members residing near health facilities got treated from these health facilities. The decision to adopt this distribution system in the two projects was not made by community members, but communities are very happy with this mode of mectizan distribution. Other key decisions related to mectizan at community level were also made by health workers, supervisors and CDDs. There is need to involve communities particularly in making key decisions affecting the programme at community level to enhance community ownership and participation. During the southern Sudan conflict mectizan distribution was ongoing on a small scale as confirmed by many respondents who informed the assessment team that they had taken medicine for >5years. However, there was no systematic programme to ensure successful annual treatments in most communities. With the support of APOC and CBM, since 2005 unintemrpted annual mectizan distribution programme has been in place to date. Health education and information dissemination about OV disease and mectizan is adequate at higher and even community levels. This has been due to a combination of key players notably CDDs, buma/payam supervisors, church leaders and health workers. A few indigenous chiefs and NGDO's staff have also been involved but not significantly. A lot is still required to address the issue of community ownership of the programme through existing traditional and government leaders at payam, buma and community levels. Advocacy and community leaders' empowerment are crucial to achieve this objective (Appendices,2,3). 9.0 COMMUNITY TREATMENT COVERAGE 9.1 Geographical coverage In East Barh-el-Ghazal during 2007 fieatment two of the sampled communities missed treatment thus giving coverage of 77.8o/o. Whereas in West Equatoria, all communities received ivermectin in2007 giving coverage of 100% for communities treated. 9.2 Therapeutic coverage The treatment coverage for 2007 in East Bahr-el- Ghazal range from 9.60/o to 70.3Yo, with a mean coverage of 28.9% for nine communities sampled. And in 2008, although treatment is still ongoing, coverage at the time of assessment was from loh to 66.70/o with mean coverage of 37.7% (Tables 4 and 5). In West Equatoria, treatment coverage for 2007 ranged from32.8ohto75Yo with a mean coverage of 6l.6yo, and for 2008, the coverage range from 45Yoto 68.9Yo, with mean coverage of 58.6%o (Tables 6 and 7). 9.3 Absenteeism and refusals A total of 4 communities reported refusals and were, Mvolo (2.7%), Marbodouang (1.3%), Abiriu (2J%) and Timbar (1.2%). With regards to absentees, seven communities reported absenteeism ranging from 6(8.0%) in Mvolo to 30 (37%) in Timbar (Table 2). ll Village Population sampled Refusal Absent Number % Number % Mvolo 75 2 2.7 6 8.0 Domeri 58 0 0.0 4 6.9 Marbordouang 78 I 1.3 l0 12.8 *Mathir 75 *Shalak 79 Abiriu 94 2 2.1 2I 22.3 Keburuwilliam 81 0 0.0 7 8.6 Marborkoch 87 0 0.0 9 10.3 Timbar 81 I 1.2 30 37.0 Total 708 6 0.8 87 12.3 Table 2: Refusal and absentees by communities in East Bahr-el- Ghazal projectr 2fi)8 * No treatsnent yet Table 3 shows a total of one refusal and 33 absentees giving a0.3o/o refusal rate and 10.3% absentee rate, respectively. Table 3: Refusals and absentees by communities in West Equatoria project 1O.O CDD EXPERIENCES IN CDTI IMPLEMENTATION A total of five meetings with CDDs were held in the two projects, three in East Bahr-el- Ghazal and two in Western Equatoria. Most CDDs understand their roles and they have been performing well in the two projects. According to information gathered during the meeting the common activities carried out by CDDs are: o Distribution of mectizanto community members o Mobilization and health education to community members o Referring cases of side effects to health facility o Keeping records of ivermectin treatment o Reporting to Payam and Buma supervisors. o Registration of communities. Village Population sampled Refusal Absent No % No % Yabua 94 0 0.0 6 6.4 Li-Rangu 60 I 1.7 4 6.7 Saura 58 0 0.0 6 10.3 Sakure 6l 0 0.0 0 0.0 Tibakaikpo 47 0 0.0 t7 36.2 Total 320 1 0.3 33 10.3 t2 10.1 Support to CDDs A number of CDDs confessed that that they receive no support from the communities. Most of the communities' referred them to the "Ov" programme that deployed them to take care of their needs. However, as far as supervision is concern, in few incidences they are helped by County/ Payam supervisors including some community leaders. 10.2 Training Most CDDs admitted to have been trained at least once before each treatment cycle, and the training usually takes between 1-4 days. The content of this training covered Ov disease, cause, transmission, symptoms, side effects and control, including mectizan distribution. 10.3 Community mobilization and Health Education This was noted to be done predominantly by CDDs but once in a while the payam and buma supervisors assist. 10.4 Delivery of mectizan Mectizan is always sent to the health facilities and in areas where this is lacking mectizan is sent to county. The payam supervisors then collect the drug from these outlets. The CDDs collect mectizan from the nearest heatth facility or Payam supervisors. In a few circumstances, buma supervisors deliver mectizan to the communities. 10.5 Duration of mectizan treatment It was noted that this does not target the treatment of everybody eligible rather it is the time when CDDs are willing to volunteer. In this case a CDD takes between 2 weeks to 6 months to complete. But where a CDD targets everybody who is eligible, treatment takes between 2- 6 months, with a majority completing between 2-3 months. 10.6 Problems encountered by CDDs during CDTI implementation o Inaccessibility of certain households due to flooding especially the East Bahr-el- Ghazal project o lnsecurity in some project areas. o No support or incentives given to CDDs. o Side effects of mectizan treatment. o Heavy work load attributed to few numbers of CDDs in the village. 10.7 Suggestions to improve CDTI implementation o To provide incentives to both supervisors and CDDs since the war is over. o Provision of mosquito nets, T-shirts, raincoats, gumboots and blankets to those who did not get o Provision of drugs for side effects. 13 I1.() SUCCESSES IN CDTI IMPLEMENTATION o Successful inception of mectizan distribution from house to house by CDDs on voluntary basis, which was not the case before. o Involvement and participation of many partners in CDTI implementation. o High mectizan treatment coverage in Western Equatoria. o Established efficient mectizan delivery system amidst great transport and communication challenges. 12.0 STRENGTHS IN CDTI IMPLEMETATION o Village treatment registers in all communities. o Availability of supervisors who are formally employed by MoH and in some cases volunteers at county, payam and buma levels. o Communities are aware of the disease and the benefits of mectizan. o Existence of health and administrative structures that can support CDTI implementation. 13.0 WEAKNESSES IN CDTI IMPLEMENTATION o Delays in release of funds by APOC. o Few CDDs per community. . High CDDs drop out which is extreme in EBG project. o Input and involvement of MoH is still low. o Community ownership and involvement is not satisfactory. o Most political and traditional leaders at state and lower levels are not actively participating in the programme. 14.0 CHALLENGES IN CDTI IMPLEMENTATION o Overlapping of projects across states due to inaccessibility of these areas. This makes coordination and support to these projects not feasible by the concerned states. o Floods, particularly in EBG projects make some villages inaccessible, thus affecting treatment coverage. o Insecurity due to tribal conflicts and cattle rustling. . Poor transport and communication in project areas. o Lack of adequate health infrastructure and human resource to implement CDTI activities. o High demand for incentives. o Cattle camps affecting coverage due to absenteeism of community members. t4 15.0 DISCUSSION OF KEY FINDINGS I5.1 TREATMENT COVERAGE The geographical coverage in East Bahr-el-Ghazal was not 100% in 2007. This might have been attributed to the floods which always renders communities inaccessible resulting into poor mectizan distribution. And the good therapeutic coverage observed in West Equatoria project could have been associated with the high endemicity of the disease and the CDDs might have worked hard to ensure every one is treated. In such situation awareness and information levels about the disease and mectizan is always good. Comparatively, in East Bahr-el-Ghazal, the poor coverage could have been attributed to the fact that CDDs have worked for a short period coupled with the yearly changes of CDDs. The situation in this project is even worse because the project coordinator has not worked for long and replaced some one who left because of dissatisfaction and poor condition of service. This has been the same with supervisors who regularly leave the programme because they are volunteers. Some CDDs who leave the programme in protest de-campaign CDTI activities, as was revealed in Li-Rangu village in West Equatoria project. One of the leading causes of poor treatment compliance especially in East Bahr-el- Ghazal are absentees who for most of the time of the year are away from homes in "cattle camps" It was observed that family members fully occupied in grazing cattle are usually more than one per household and in some cases ranging to 60%o of members of household. This deserves serious attention if the project of EBG is to achieve high treatment coverage. To interrupt transmission and achieve the public health benefits of mectizan, treatment should take the shortest possible period. However, it has been observed that in the two projects less than 5% of the villages' complete treatment within one month. On average the majority of communities' complete treatment within l-3 months. There are extremes where treatment is completed in 6 months. This could be attributed to large size of the communities and the few CDDs involved in CDTI activities. Despite the above challenges, community awareness on the disease is very high due to high endemicity of the disease, but also coupled with extensive health education done by CDDs, supervisors at all levels based at a few governmentA{Go health facilities in the project areas. 15.2 CDDS EXPERIENCES IN CDTI IMPLEMENTATION In the CDDs' meetings some of the challenges revealed included walking long distances during mectizandistribution. This is attributed to the size of the communities/villages that are rather big and homesteads are separated by a reasonable distance thus compelling them to reach all the household members within the village. The issue of incentives was highly raised in every meeting. This expectation has been for all the CDDs met yet it is against the principle of CDTI implementation and at the same time impossible for GOSS to provide adequate incentive or to compensate for their work given their current challenge of re-building the country. During one of the meetings a CDD said: 15 "I did voluntorism during the war because I started mectizan distribution in 2000. During the war voluntarism was possible because of hardship we were experiencing but at the present time voluntarism should be no more because the war ended. During that time my village had more than 6 CDDs but now we are only two" (CDD, Rumbek East County, Cuei-cok village) Training duration for CDDs is exceptionally high compared to other countries. It was learnt that CDDS train for 3 or more days; this is attributed to the fact that every year there are new CDDs that come on board when previous CDDs have abandoned work. This long duration is a discouragement to volunteers and is costly for the project and not sustainable. The duration of treatment has been observed to be too long for the two projects. A CDD who volunteers for all this time must definitely demand incentive. In the same scenario, the supervisors fail to do adequate supervision of MDA since it is not easy to supervise treatment in all these areas during all this time. It could have been better if the days were few to minimize the cost of MDA. Moreover, in this case onchocerciasis transmission is unlikely to be intemrpted due to the long period of treatment. Another related issue of concern is dosage determination. Although the CDDs reported to be using height as a tool for dosage determination, there is a weakness in this area that needs to be addressed. There was evidence for use of dosage pole in West Equatoria project but this was not the case in East Bahr-el-Ghazal In one of the meetings in Cuei-Cok village CDDs demonstrated how dose determination could be done by mere physical appearance of a person. In a few incidences, wrong doses were given by CDDs to household members, as viewed from the household survey forms and some respondents interviewed duration this assessment. In another scenario in the Western Equatoria project, it was observed that breastfeeding women were not being treated, and as a consequent, some women had spent three years without undergoing mass treatment with ivermectin. 16.0 Conclusion CDTI implementation and treatment coverage (Geographical and therapeutic) in Western Equatoria project is good but can still be further improved. In EBG project, treatment coverage and other CDTI activities is not good due to flooding, absenteeism associated with " cattle camps" and other weaknesses in the project implementation. There is a functional CDTI system in the project areas despite existing challenges. Active and knowledgeable support staffs at lower levels have contributed to CDTI implementation in the two projects. Majority of the communities have adequate knowledge about the disease and have noted the benefits of mectizan even during the conflict era. There are opportunities offered by the existing health and administrative structures that can be used to enhance CDTI implementation and other health care delivery. However, the sustainability of the two projects remains a big challenge. t6 17.0 RECOMMENDATIONS 17.1 APOC AND OTHER PARTNERS l. Timely release of funds and logistics to projects to ensure CDTI activities are implemented as planned. 2. All Payam and buma Supervisors be facilitated with bicycles to ease transport. However, the users should be asked to maintain them. 3. Each project coordinator and county supervisor should at least have one sound and well maintained vehicle (aWD) and motorcycle, respectively. 17.2 MINISTRY OF HEALTH 4OSS l. Strengthen the SSOTF and streamline its leadership so as to have more responsibility in management and coordination of CDTI projects. 2. Enhance community ownership of CDTI programme through high level advocacy and formation of state "Ov control Task Forces" with full responsibility of steering all CDTI activities. 3. Ov control through CDTI strategy should be integrated into the existing health care delivery system in southern Sudan to ensure sustainability of the programme. 4. CDTI project coordinators, county supervisors and payam supervisors should be formally employed by the MoH-GOSS or other health sector to enhance commitment to CDTI work. 5. The MoH-GOSS top management should guide the SSOTF and the proposed state Task Forces in their roles related to CDTI implementation. 17.3 STATE LEVEL AND PROJECT AUTHORITIES 1. To reduce workload of CDDs and decrease on demand for incentives, communities need to select at least I CDD per 25-40 households. 2. Flood prone areas like the Lake state to carry out mectizan delivery and MDA starting at the beginning of dry season to solve the problem of inaccessibility. 3. To solve the issue of high CDD drop out, communities, chiefs and community leaders to be involved in making key decisions on CDTI implementation. 4. Arrangements be made to take mectizan to people in "cattle camps" since these absentees contribute significantly towards low treatment coverage. 5. To interrupt Ov transmission and to reduce demand for incentives by CDDs and buma supervisors, each viltage to be advised to complete MDA within one month. 6. Targeted training of CDDs should put special emphasis on dosage determination using calibrated stick, taking community census/update and exclusion criteria especially children under 5 years and breastfeeding mothers not taking mectizan. 7. Records management at project and county levels needs strengthening. 8. Mechanisms to use and maintain capital equipment like vehicles, motorcycles etc be put in place to ensure longevity and efficiency of transport in the project areas. I7 18.0 References APOC (I998).Community Directed Treatment with lvermectin (CDTI).A Practical Guide for trainers of Community Directed Distributors. APOC, Ouagadougou Mukhtar, M.M., Kheir, M.M., Baraka, o.z. and Homeida, M.M. (1998). The burden of Onchocerca volvulus in Sudan. Ann. Trop. Med. Parasrr. 92 (Suppl.) 1,129-l3l WHO (1976). Epidemiology of onchocerciasis. Report of a WHO Expert Committee, World Health Organ Tech. Report Series,l-94 MoH-GOSS (2008). Revised National VISION2020 plan for prevention of avoidable blindness in South Sudan -2005-2010. 18 q \o$ \ F- ?o o AI GILq) oI s \o ca c.;s c.ico q o O q oo .+ c- \o\o nt\o s I a o c.t O O O o F- in N o ca ca tr) ro N \o s 6l AIq)L er s q) a o.l c.l ca t \o cl oo co l'- oo 6 € (f)(a G 6 (?)(a l-l ri t-r riiltrz s rt) ,- 6l o) ra o.lN co + \o o.l oo co r- 6 \on €co r-\oN o dtE8o. 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I Fl c!l< (!a 0)L) .\z CCa ooJI d .\4(g et- F] F F z a C-l co !+ (.l s/N ACTIVITIES AM PM Sat.2019 Traveled from Entebbe to Nairobi Arrived Nairobi Kenya Sun. 21l9 On transit in Nairobi On transit in Nairobi Mon.2219 On transit in Nairobi due to delay in ticket booking On transit in Nairobi due to delay in ticket booking Tue2319 Traveled from Nairobi to Juba Arrived in Juba. Met WHO Administrator, MoH -GOSS officials Wed.2419 Traveled to Rumbek EBG project Field planning and selection of communities Thur.2519 Traveled to field EBG Mvolo and Domeri communities Fri.2619 Traveled to field Marborduang community Sat.2719 Traveled to field EBG Mathir and Shalak communities Sun.28/9 Data compilation/analysis Data compilation /analysis Mon.29/9 Field activities in Abiriu and Keburuwilliam communities Tue. 30/9 In field, Timbar community Maborkoch community Wed. 1/10 Meeting with EBG project staff, NGDO coordinator, WHO/APOC Technical Advisor. Data compilation/analysi s Thur.2/10 Traveled Juba from Rumbek to Planning for Western Equatoria proiect trip Fri. 3/10 Traveled from Juba to Yambio in Western Equatoria. Meeting with Ag. Director General SMoH and Coordinator SSRRC. Field planning with project coordinator. Sat.4/10 Field trip to Ezo county aborted. Field activities in Yabua community in Yambio county. Sun. 5/10 Saura community Li-Rangu community Mon 6/10 Field travel Activities in Sakure and Tibakaikpo communities Tue.7ll0 Traveled from Yambio to Juba Arrived in Juba Wed.8/10 Meeting with Director, NTD Meeting with Undersecretary MoH- GOSS and WHO Head of office S/Sudan Thur.9/10 Travel from Juba to Nairobi Arrive Nairobi Fri. l0/10 Travel Nairobi to Entebbe (air) and to Kampala by road Appendix 1: TIME TABLE FOR TIIE ASSESSMENT OF TWO CDTI PROJECTS IN SOUTHERN SUDAN (20rH SEPTEMBER TO lorH OCTOBER 2008). 2l Appendix 2: SUMMARY OF KEY INFORMAI{T INTERVIEWS IN HOUSEHOLDS IN EAST BAHR.EL.GHAZAL PROJECT. l. Mvolo village Distribution system: House to house in combination with health facility Decision on CDTI activities: Supervisor and health workers. Number of times ivermectin taken: l-10 times Information source about Ov: CDDs, church, chiefs, health workers Knowledge about disease and drug: Satisfactory 2. Domeri village Distribution system: House to house in combination with health facility Decision on CDTI activities: Don't know, CDDs, buma supervisors. Number of times ivermectin swallowed: 5-10 times Information source about Ov: church, health workers, CDDs, county supervisors Knowledge about disease and drug: Satisfactory 3. Marbordouang village Distribution system: House to house. Decision on CDTI activities: predominantly CDDs. Number of times ivermectin swallowed: 0 to 5 times. Information source about Ov: CDDs. Knowledge about disease and drug: Satisfactory 4. Mathir village Distribution system: house to house Decision on CDTI activities:NGO, health worker Number of times ivermectin swallowed: 0-2 times. Information source about Ov: CDDs. Knowledge about disease and drug: Satisfactory 5. Shalak village Distribution system: house to house Decision on CDTI activities: CDDs Number of times ivermectin swallowed: 0-5 times. Information source about Ov: CDDs. Knowledge about disease and drug: Satisfactory 6. Abiriu village Distribution system: house to house and health facility Decision on CDTI activities: CDDs and health workers Number of times ivermectin swallowed: l-4 times. Information source about Ov: CDDs. Knowledge about disease and drug: Satisfactory 22 7. Keburuwilliam village Distribution system: house to house Decision on CDTI activities: supervisors Number of times ivermectin swallowed: l-4 times. lnformation source about Ov: CDDs, Oxfam Knowledge about disease and drug: Satisfactory 8. Marborkoch village Distribution system: house to house Decision on CDTI activities: NGO, health worker Number of times ivermectin swallowed: 0-6 times lnformation source about Ov: CDDs Knowledge about disease and drug: Satisfactory 9. Timbar village Distribution system: house to house Decision on CDTI activities: NGO, health worker Number of times ivermectin swallowed: once Information source about Ov: CDDs. Knowledge about disease and drug: Satisfactory 23 Appendix 3: SUMMARY OF KEY INFORMANT INTERYIEWS IN HOUSEHOLDS IN WEST EQUATORIA PROJECT 1. Yabua village Distribution system: House to house in combination with community centre. Decision on CDTI activities: don't know, health workers, CDDs. Number of times ivermectin taken: 3-10 times Information source about Ov: CDDs, church, chiefs, community health workers Knowledge about disease and drug: Very satisfactory 2. Li-Rangu village Distribution system: House to house. Decision on CDTI activities: CDDs, buma supervisors. Number of times ivermectin swallowed: 1-8 times Information source about Ov: church, CDDs Knowledge about disease and drug: Satisfactory 3. Saura village Distribution system: House to house, community centres. Decision on CDTI activities: Don't know, project office, health workers. Numberof times ivermectin swallowed:2to 14 times. Information source about Ov: CDDs, church, headman, village chief, h/workers Knowledge about disease and drug: Satisfactory 4. Sakure village Distribution system: house to house Decision on CDTI activities: CDDs Number of times ivermectin swallowed: 4-8 times. Information source about Ov: CDDs and health workers. Knowledge about disease and drug: Satisfactory 5. Tibakaikpo village Distribution system: house to house and central place Decision on CDTI activities: CDDs and payam supervisors. Number of times ivermectin swallowed: l-6 times. Information source about Ov: CDDs, supervisors. Knowledge about disease and drug: Satisfactory 24 Appendix 4: ORGANOGRAM FOR CDTI AND HEALTII/ADMINISTRATIVE CHANNELS IN SOUTHERN SUDAN * SSOTF headquarters at present in Rumbek, Lake State, not MoH-GOSS in Juba. 25 t b i Appendix 5: GUIDELINE FOR INTERVIEWS WITH HOUSEHOLD MEMBERS Name of project: Name of House hold member: (Optional) .... Age:.. Sex:.. a) How is ivermectin distribution done in this community? (Mode of distribution, period?) b) Who makes decision on how to distribute ivermectin in this village? c) Since inception of this programme have you always received ivermectin in this village annually? Yes ( ) No ( ) If yes, how many times? If No, can you remember when you did not receive mectizan that time? c) Are you happy about the way ivermectin distribution is done in this village? Yes ( ) No( ) If No, explain... d) How do you obtain information and knowledge about mectizan distribution programme? e) What is this medicine for and why do you take it annually? 26