Federal Capital Territory report on year 2 community-directed treatment with ivermectin : September 2000

AFRICAN PROGRAMME FOR ONCHOCE,RCIASIS CONTROL (APoC) Report on Year 2 Community-Directed Treatment with Ivermectin(cDrI) Bwari Gwagwalada Kwali Municipal Kuje Abaji Federal Capital Territory, Nigeria SEPTEMBER 2OOO ta AFRICIANPROGRAMMEFoRONCH0CERCIASISCONTROL(APOC) RePort on Year 2 Community - Directed Treatment with Ivermectin (CDTD MAP OF FCT FEDERAL CAPITAL TERRITORY, NIGERIA ocT.1999 TO SEPT.2000 i IEXECUTIVE SUMMARY: The Federal Capital Territory GCT) lies in the center of Nigeria, just north of the hot humid lowlands of the Niger-Benue Trougtr, but south of the drier areas to the north' It lies just north of the wid-e alluvial plains formed by the confluence of the Jos plateau' extends well into the middle of FCT. Four major rivers flow through the area, all of them flowing roughly from north to south and draining into the river Niger' The rivers often flow swiftly through rocky gorges, providing an ideal habitat for the Simulium fly' The FCT consists of a tmea pUirU rising froln * elevation of 300 in the south- west' to above 2,000 feet at the northeast corner. Rising out of this plain are numerous rocky and inselbergs. The FCT is divided into six administrative areas, comprising Twenty-Eight districts- CDTI is being implemented in areas outside the capital city. clinic based treatment is made available to the urban residents through existing structures within the city capital' There is a good road network leading to the Area Councils Headquarters' However' most to the smaller settlements are at best rudimentary. About 20%o of these roads are not accessible during raining season. 4WD vehicles are quite essential for transportation of equipment, supplies and personnel. Most activities need to be conducted during the dry season. FCT is higtrly endemic of onchocerciasis, and it is in view of this that NocP asked cBM to assist in the control of this disease, which has affected a lot of the farming community members, causing them untold hardship' Mass distribution of Mectizan tablets began in lgg5, after conducting the Rapid Epidemoiological Mapping of Onchocerciasis (REMO) in some communities to provide the insight as to tiior" communities that require urgent treatment' Through the collaborative effort of the government of FCT and CBM, a total of 57,548 persons were treated in 178 communities. Treatment started in these communities through using the Community Based Distributors (CBDs) with the Local Government Onchocerciasis control worker supervising. Since then, the coverage effort was extended to more than 500 communities tirat are presently being treated with Mectizan drugs' FCT is currently in its second year of CDTI implementation and all indication points to the fact that the communities are gradually accepting their roles and responsibilities as it affects ownership of the progrzunme. , 2 oSECTION 1: BACKGROUND INFORMATION : The FCT Oncho control CDTI activities is being implemented in all the six Area Councils. These Area Cogncils include Municipal, Abaji, Kuje, Kwali, Bwari, and Gwagwalada' There are presently 563 communities that are participating in the CDTI programme- Most of these communities are quite small with average population of a community ranging between 350 to 600 persons. 1.2 CDTI The followings are the number of rounds of the Area Councils participating in 1. 2. aJ. 4. 5. 6. Municipal Abaji Kwali Kuje Bwari Gwagwalada Round 6 Round 6 Round 6 Round 6 Round 6 Round 6 Because of gradual expansion to the new communities, not all the communities are in round 6. 3 S/N District ILGA No. of Com m I Villa ges No. of Communit ies /Yillages That selected CDDs No. of Communit ies That collected Drugs No. of Comm that decided on Month(s) of distributio tr. No. of Comm. that decided on the method of Treatmen t No. of Comm with trained CDDs No. of Comm paying CDDs in cash or Kind. I Municipal r29 129 r20 120 120 129 8l 2 Abaji 63 63 73 73 73 63 53 J Kuje ll9 ll9 98 98 98 ll9 67 4 Gwagwalada 75 75 72 72 72 75 45 5 Kwali 83 83 72 72 72 83 55 6 Bwari 90 90 78 78 78 90 60 TOTAL 563 s63 513 513 513 s63 361 SECTION 2: September 2000) TABLE T. THE IMPLEMNTATION OF CDTI (October 1999 to TRAINING OF DIFFERENT LEVELS OF STAFF INVOLVED IN CDTI IMPLEMENTATION 2.1 Trainingobiectives/achievement The year 2000 annual training objectives for FCT is to train l0 SOCT, 3l LOCT, 150 Health workers and 600 CDD;, totaling 791 programme workers. Out of this number, 8 SOCT, 3l LOCT, 600 CDD and 130 Health workers totaling 769 personnel have been trained between January and March 2000, which represent 95%o achievement- 2.2 Developed training material used The material used includes LOCT and CDD guides, flip charts, posters and MIS forms development and produced from APOC funds. The Health education posters were translated into Five diflerent local languages, and the CDDs were asked to make role plays on how they will use them in the communities during the training exercise' 4 2.3 Performanse of the CDD; Although some of the CDDs performed credibly well, most of them did not perform up to expectation this year because of the Poverty Alleviation Programme (PAP) that was introduced by the government to cater for the unemployed school leavers. These CDDs who were unemployed before now, saw the new payment by the government as a betterjob that takes into consideration their welfare than being CDDs. They have often complained of poor community response to their plight when it comes to compensating them in either cash or kind. This issue too is relative as one can hardly get the true information from them. This ugly situation brought about a lot of delays in retrieving data from the communities. Most of the communities had poor treatment coverage this year despite the increased number of communities for initial treatment. The project could not attain its set Annual Treatment Objective (ATO). This is a real issue for concern especially as it has to do with sustainability of the prograrnme in the communities. The project plans to have its appraisal workshop before the next treatment exercise and issues bothering on the attitude of the CDDs will be tackled. Another issue of concern is the way other programmes implement their activities in communities with monetary rewards, leaving only the CDTI programme as community self sustaining. A perfect example is the National Programme on Immunization (NPI), where by community guides are paid handsome amount of money upon completion of the three days exercise, In the presence of CDDs from such communities watching, and wondering why the disparity in the rule of the game of community participation and compensation. 2.4 Improving the qualitv of trainins. The quality of training has improved with the continuous participation of the LOCT who have started training the CDDs with courage. The success of training is being hindered by the high turnover rate of CDDs in the project every year. This is mainly due to the relative young ages of these secondary School leavers who depart for further studies or take up job appointments were they can earn living wages to support their families. 5 TRAINING OF DIFFERENT LEVELS OF STAFF INVOLVED IN CDTI IMPLEMENTATION TABLE 2. MOBILIZATION, AND EDUCATION OF TARGET COMMUNITIES' 2.2.1 The use of media: The media houses have gone more commercial in their ventures, requiring the project to make annual budgetary irovisions for such services. During the period undgr review, the services of the media- ho.,.", was utilized on selective basis, during training and other Mectizan distribution o ccasions. The media house (Radio) personnel were also of great help to the project because of the part they played i" "*rrring that the oncho health education posters were translated into Five local languages. 2.2.2 Result of mobilization efforl Health education activities was given a lot of emphasis in FCT this current period, with the objective of ensuring that community members are awuye of the continuous roles and ,".po*ibilities in the iniplementation olCDTI. The SOCT, LOCT and the officials of the Ministry have been involved in such exercises' 6 s/N District /LGA No of training undertaken No of TOT trained No of LGA stafi trained in CDTI No of Health centres stafl trained on CDTI No of CDDs treincd. I Municipal S(lfor FVworker 2 each for LOCT / cDD) r2(socr/Lo CT) 5 26 ll4 2 Abaji aa 5 5 l6 89 5 Kuje aa 5 5 29 t2l 4 Gwagwalada aa 5 aa 5 2l 86 5 Kwali aa 5 5 20 92 6 Bwari aa 6 6 l8 98 TOTAL TOTAL 38 31 130 600 The issue of great concern to the project currently is the response of the communities to CDD welfare or support, which has not been encouraging in most of the treatment communities. The resultant effect was that most of the CDDs refused putting in their best to cover most of the areas, leading to a not too impressive result despite the additional communities for treatment in the year 2000. The best effort that the teams from both the State and the Local government have done, was to encourage communities to support the CDDs. This problem has to be given allot of emphasis before and during the next disribution period so that sustainability will be achieved. 2.2.3 Response of the communities Most of the communities have appreciated the need to take Mectizan yearly, and in the process have even asked the LOCT and CDDs for their doses, even when it is not yet time for distribution. This demand however has to be complemented by the zeal and enthusiasm of the CDDs who distributes the drugs to them. The community members actually recognize the various contribution of the CDDs to the prograrnme, but the issue of ,upp"ort is still a big problenq as they often complain of poverty and the suspicion that gwernment pay them some allowances that are not made known to them. They also wonder why some programmes such as the National Programme on Immunization (NPI) do pay some compensation to the village workers on immunization days. 2.2.4 Sugeestions to imorove mobilization' In FCT the mobilization effort has to be shifted more to the area of CDD support and community ownership of the prografirme. The proximity of these communities to the center of government, which is the Nigerian Headquarter, has complicated matters by raising the expectation of the local communities on the need to enjoy free services for almost all health care progrzmlmes. There is the urgent need to identify and involve Community Based Organizations (CBOs) to help in the education and mobilization process so that communities can rise up to their ."rpo*ibilities and devoid of much expectation from the govemment. APOC management and the Federal Ministry of Health shoud ensure that all prgrammes to the community takes the same pattern as the CDTI, with community owning the programme from the onset. This reduces conflict in the implementation methods. CDTI requires taking time to be with the communities in order to make impact. The high number of communities that deserve attention in this project will therefore transform into much longer time period for the mobilization exercise which will affect other activities in the implementation Process. 7 SAI District /LGA No of Communities Mobilized No. of Target Comm that received Health Education about the importance of extended treatment No of Advocacy Visits to State or Regional Directors of Health No of MOH staff involved in Mobilizati on. No of NGDO Staff involved in Mobilizati on. I Municipal 129 r20 4 8 2 2 Abaji 63 73 4 8 2 3 Kuje l19 98 4 8 2 4 Gwagwalada 75 1) 4 8 2 5 Kwali 83 72 4 8 2 6 Bwari 90 78 4 8 2 TOTAL s63 513 24 8 ) TABLE 3. MOBILIZATION, AND EDUCATION OF TARGET COMMUNITIES * The same MOH and NGDO staff involved in the mobiliation activities traveled to project LGAs and the level of attention given to these communities mobilized differ due to time constraints. SECTION 3: (See table 4) ACHIEVEMENTS 3.1.1 Treatment coveraqe ratez A total of 196,783 persons representing 837o were treated during the period under review. Total (censusl population: A total of 236,228 persons were registered in the endemic communities of FCT. 3.2 3.3 Elisible population: A total of 2l1,538 were eligible for treatment. 8 3.4 AbsenteedRefusals A total of 14,755 eligible persons were not treated. This number is on the high side and a source of concern. Our preliminary investigation so far is that some CDDs were complacent and not keen on treating the entire community member as they *.." 1.."d to doing. The reasons discovered was that the Poverty Alleviation Programme has offered them more lucrative job to do. 4.5 Some of the reasons for and soelt out bv some of the communities include: l) Lack of seriousness on the part of the CDDs, for not putting in their best during distribution exercise. Z) Farming activities has taken some family members to some farms that are quite far away from their original communities. The olans we have for reducing the number of absentees and refusals durin? the round of For the project to have appreciable reduction in the number of absentees and refusals after the distribution exercise, the following measures shall be taken in the next treatment round:- 1) Discussing with the community members on how to get this group of people treated during distribution or after. 2) Increase the time for mobilization and education of the commturities and also discuss the issue of CDD suPPort. 3.6 9 t , I \TABLE 4 TREATMENT RESULTS IN FCT AREA COUNCILS (October 1999 to September 2000) * We have not been able to calculate the cost per dose because of the fact that the budgetary allocation for FCT for year 1 spilled over to year 2. The financial authority can better advice the project on how to calculate the cost per dose please- SAI District /LGA No. of Target Comm I Villages No. of Eligibte people treated Cmt per person treated. No. of Comm/Villa ges in which CDDs are health workers No. of Distribution s supervised by health workers No. of treated Comm/V illages with summar y forms I Municipal 129 59,352 * None 1 129 2 Abaji 63 27,758 * I 63 ) Kuje ll9 38,366 * I l19 4 Gwagwalada 75 28,591 * I 75 5 Kwali 83 27,','176 * I 83 6 Bwari 90 29,695 * I 90 TOTAL 563 211,538 :} None 6 563 l0 SECTION 4: 4.1 STRENGTHS/WEAKNESSES/SUGGESTIONS. LGA particiapation. o Strength: The LGA Executive are gradually appreciating the need to support the CDTI programme in the various LGAs, because of the free treatment services with Mectizan that is given to the people. o Weakness: Some LGA5 claim to have other projects that require attention, and so are over relying too much on the MOH. o Suggestion: If it will be possible, we think that a Memorandum of understanding should be written indicating commitment of the partners and only those that fulfil their yearly obligation should have the prograrnme implemented. This however will be a hard decision to abide by, since we cannot afford to leave any LGA untreated, but can probe for more commitment on their parts. Training: Strength: The project has completely decentrahzed its training activities to centers that are close to the CDDs. This has eliminated distant travels to be trained. Thanks to the CDTI that encourages community participation and decision making processes- weakness: Inadequate competent trainers in the LGAs to carry out the training prograrnme. Suggestion: The LOCT and the other health workers trained need to be encouraged to be able to assume more responsibilities of training CDDs using local languages that they are familiar with. Staffins: Strength: The MOH has dedicated and committed staff, who are ever ready to work *.*ai"g to planned schedule. They have worked wilh the Area Councils to put together a Team of LOCT in all the Area Councils for the sake of CDTI implementation. Weakness: They are not all skillful in dealing with all field difficulties. Suggestion: There is the need to organize skill acquisition training for the staffto deal effectively with field situations. t q a a o a a a a ll aHealth Ed and Mobilizat Strength: More health education materials in local languages have been produced- The turn Lut of people to be treated is quite encouraging. Their involvement and participation is also commendable due to the increase in awareness. Weakness: The numerous numbers of communities requiring treatment in the state has greatly increased the work load of the SOCT and LOCT who do not have the opportunities of making return visits to communities for further discussion after their first visit. a a Suggestion: The health workers already trained need to be encouraged to play greater roles in ensuring that treatment communities are adequately mobilized and educated before, during and after distribution activities. a a Mectizan Distribu tion: Strength: Dosing with Mectizan has been higtly accepted by the communities who turn out en-masse to be treated during distribution activities. Weakness: Poor coverage in some communities due to the complacent attitude of the CDDs who have refused to put in their best during the just concluded distribution activities. Suggestion: A mop up prograrnme for treating absentees and refusals needs to be worked out in near future to dose those that were not treated during the last treatment exercise. Community leaders need to be educated of the needs to support CDDs during distribution. a a a a Record Keeping: Strensth: NOCP MIS simplified forms have been printed for use during the subsequent exerc$es. Weakness: Most CDDs are still aided by their immediate supervisors in the final compilation of the community treatment data. Suggestion: The LOCT should effectively monitor and correct the CDDs in the area of record keeping during distribution activities- 12 aa Monitoring and Sunervision: Strength: Monitoring and supervision schedule are usually arranged during the planning stage . Weakness: Some of the prograrnme workers still require more supervision and monitoring skills to become more efficient. Suggestion: Programme workers should be thought supervisory skills to make them more efficient in the job. Data ar!atysis: Strength: The State, LGAs and Communities were involved in analyzing treatment data after every treatment to measure success or failure. Weakness: LGAS and communities do not adequately commit their time to the final compilation of treatment data without necessarily depending on the SOCT. Suggestion: The LGAs and communities should view this programme as theirs and not that of the Ministry of Health. They need to assume the role of prompt data compilation without over depending on the SOCT Programme Plannin p and Evaluation: Strength: The project has developed a planned schedule of activities for implementation. Weakness: Inability to conduct appraisal workshops at the LGA level for CDDs, community leaders and the executive personnel to discuss issues of concern in the last distribution exercise and what strategies to embark on to correct future anomalies. Suggestion: Appraisal workshop at the LGA level should be planned to interact with the CDDs and community leaders yearly. The LGA should be encouraged to organize and host such meetings. Strength: Since the introduction of CDTI in the State, emphasis has been shifted completely to community ownership of the progftlrnme from the onset. All activities are planned with that in mind. t a a o o a I l3 Sustainability: a o a Weakness: Accepting to own the programme completely by the communities is still far Ao1n U"i"g realized. So1n" community members are complaining that they are poor and so cannot continue to support the CDDs for a long period of time. Suggestion: The communities should be educated more on this issue of ownership as the programme reaches the second year of implementation' a a/ 1.2 CDDs performance of task Most CDDs that became the beneficiaries of the federal goverrlment poverty alleviation Programme did not perform up to expectation. This accounted for the low treatment coverage in some communities. Most of them however performed well in their respective communities. 4.3 lYillingness of communities to participate in CDTI' The community members, since the inception of the Mectizan distribution programme in FCT have demonstrated the willingness to support and participate in activities. Though they have indicated their willingness to support, but actualizing such commitment has been very difficult in alrnost half of the communities that are being treated in FCT. 4.4 Involvement of the NocP The NOCp has been supportive of the programme in FCT. They have participated in the prograrnme review, training and in supervision activities' 4.5 The Federal Capital Territorv Ministrv of Health' The Ministry of Health have been working hard towards implementing CDTI in the territory. The SOCT members have worked through the existing Area councils to get to the communities. There is indeed every sense of commitment on the part of the FCT- 4.6 FCT fundins. During the period under review, the FCT govemment has been able contribute the sum of N: 3,000,000.00 to the progralnme. a l4