Technical report of CDTI activities in Enugu/Anambra/Ebonyi project: September 1998 - May 1999 submitted to African Programme for Onchocerciasis (APOC) May, 1999

TECHNICAL REPORT OF CDTI ACTIVITIES ENUGU/ANAMBRA/E B ONYI PROJE C T SEPTEMBER 1998 _ MAY 1999 SUBMITTED TO AFRICAN PROGRAMME FOR ONCHOCERCIASIS (APOC) MAY, 1999 IN 2EXECUTIVE SUMMARY The implementation of CDTI in Enugrr/Anambra/Ebonyi States Project commenced in September, 1998, even though APOC money came in January, 1999. Before this date, Global 2000 was the NGDO providing the necessary fund for all the activities. The project has an estimated population of about 7.5 million persons. CDTI implementation started with macro-level advocacy to the states and local govemment areas. The objective was to sufficiently educate and mobilize groups to provide the financial, logistic and human resources for CDTI activities. The project undertook a total of 68 advocacy visits to 32 LGA5 192 trainings were conducted at three levels namely: State, LGA and community. A total of 341 TOTs, 195 DHS, 195 ADHS and 7,025 CDDs, and 184 LOCTs were trained on CDTI. A total of 2,754 villages were mobilized and health educated. Twenty-one [21] Ministry of health staff and one [1] NGDO staffwere involved in the mobilization exercise at LGA level. Treatment has been concluded in only 2,754 villages that collected drug. Active treatment was the case in all the villages and a total of 1,256,840 eligible persons were treated out of a total [census] population of 1,887,514 giving a treatment coverage of 66.59% and cost per treatment of 0.18 US $. From the progress made so far, there are indications that CDTI approach will be successful and sustainable. Finally, the project is being saddled with some immediate attention and these include, provision vehicles, more motorcycles and bicycles. 3 problems which need of new field project .TYPICAL BREEDING SITE FOR BLACKFLY IN NKANU LGA. I ,$t'' Y' \,,t: ,!i- lI { B 't 11/ lff:t ( LGA. ':tu- .&i ABOVE ARRO!{S SHOi,IS DR FRANK RICHARDS DR E.S. MIRI HRH THE TMDITIONAL RULERS OF OZALLA CO}O'IUNITY IN NKANU PROJECT AD}IINISTMTOR FOR EN/AN/EBONYI STATE. SPO ENUGU STATE SPO ANA]'IBM STATE SPO EBONYI STATE SOCT }IE}IBEE.S FOR ENUGU/ANA}IBRA/FBOI{YI STATE. 4'# 3.a ffi .'..,,: ", ,'.i'ffir', i';f'.;,., .,' t,*u*,'Ejiffi,."I"'ffi*'ilffi''ffi !r .;,+;',1";t;:.t=::,i' *,.'.i-,,' . :ji;r+iarjl:....i!,;:;;,i f ,;, ri l: "' ;;.:iri.i:-": o j -, --. :.n:ri.(l-,i l.t -.1 ^.r. ,,....-;t:_.'-.i' " .--'^L. . ; ' ''. .. * '.1. .:: .".n .:,..;+i;{i-,rir:rriili,. . ., :,r,, -,.,:.g .1..;';[,''],'*i;;,ii.,;,' . . ''.t1[ at *#l .rr'iEEL\ tt :llv'-.i.tr- a.' r-E*IFffilf I 8f,7!8ffi ;,:;;:., ',"*,orl'qf.fiffiIffmr fffi t.. ,, t.\ L& =I-E?i* ',,1/_UnE tE il SECTION I BACKGROT]ND INTRODUCTION : Enugu, Anambra and Ebonyi States are among the seven South Eastern States of Nigeria benefiting from the Lions Clubs/Global 2000 River Blindness Programme. The programme started in 1995 with two States, Enugu and Anambra, before Ebonyi State was created later in 1997 . The project area is located between 5"43' and 8'30'N with a combined population of 7.5 million inhabitants [Enugu 2.5 million, Ebonyi 1.8 million and Anambra 3.2 millionl. It has a total of 5l LGAs out of which, 38 are hyper/meso endemic for onchocerciasis, [see map 2]. This giant project received APOC funds in January 1999 and had long commenced operation with three project officers each directing the operations in each state. {i} The total numher of communities in the hyper and meso-endemic districts/LGAs The total number of villages in the hyper and meso-endemic LGAs is 3,553 [Enugu : 1,331, Ebonyi : 1,160 and Anambra : 1,0621. tii) How many villages were receivtng ivermectin before and how many are now included in APOC project? All the 3,553 villages have been receiving Mectizan before the introduction of the Community Directed Treatment with Ivermectin [CDTI] approach, and all are included in APOC project. ,/COMBINED MAP SHOWING EDEMICITY STATUS IN THE THREE STATES. NZ t)7(f, EdF E1 zC f,:C Fl :o 87-S I -6fi? r: = - To ZoZ m ffiffi h _c\ 5{iii} The number of times the communities/villages in the Project orea have received treatment. Any other additional information will be helpful The project commenced in 1995 and all the villages did not start receiving mectizan in the same year. While some villages are currently in their 5tr year, others are either on the 3'd or 4h year of treatment [see map I]. {iv} If you are asing the term communiEt or village, deftne what constitute the communifit or village. This will help the TCC reviewer understand the profile of the project areu A village is a group of houses which forms the smallest unit of Local Government. with this, therefore, a group of villages makes up a community IAdministrative Structures in the Project Area: STATE COMMUNITYCOMMUNITY VILLAGEVILLAGE HOUSEHOI,DS COMMUNITY STRUGTURE IN EN UGU/ANAMBRJA/EBONYI STATES o \ \o VILI.AGE HEALTH ; VILLAGEI neaurnI ^^----.--i COMMITTEE ,l SECTION 2 The overall strategy for the control of onchocerciasis through chemotherapy revolve around the implementation of community-based sustainable programmes for the distribution of mectizan to all individuals either infected or at the risk of infection. Emphasis is therefore placed on establishing Ivermectin delivery programmes in which the primary responsibility of obtaining the required Mectizan, distributing it to the at-risk population, supervising the activities of the CDDs and keeping relevant records is that of the communities themselves. In addition, the communities are responsible for taking decisions on selection of CDDs, remuneration method of disfribution, month[s] of treatment and remuneration of distributors, [see table 1,2,3 & 41. Training of staff involved in CDTI implementation was conducted at three separate levels. These are: til The state level training for the SOCTs [ii] LGA level fraining for LOCTs and District Health Supervisors [DHS] tiiil Community/Village level training for Community Directed Distributors [CDDs], Village Health Committees [VHCs], Assistant District Health Supervisors [ADHS] and local leaders. In other words, whereas the state and LGA level frainings are for TOTs, the community/village level trainings are for CDDs and Assistant Dishict Health Supervisors [ADHS]. In all the States, 12 SOCTs were trained [i.e. 4 SOCTs per state]. Table 5,6,7 & 8 show training of different levels of staff involved in CDTI implementation. TABLE l: IMPLEMENTATION OF CDTI (SEPTEMBER, {998 - MAY, 1999) IN ENUGU/ANAMBRA/EBONYI STATES' IDP -II'T-IIIII-II-I-III tr * ENUGU 1,141 1,141 1.141 1,471 512 1,141 629 ANAMBRA 632 632 632 642 381 632 379 EBONYI 981 981 981 909 594 981 668 EN/AN/EB. 2,754 2,754 2,754 2,582 1,487 2,754 1,676 I t t I t I I t I I I I I I I I I I I I FIG. 1 IMPLEMENTATION OF CDTI TSEPT. 1998 . FEB. 1999I IN EN'AN'EB. STATES 3,000 2,500 ot! o JJ lr o oz BCDE A,B,C,D,E,F,G, REFER TO TABLI 1.u NO, OF VILLJ WHICH COLLECT] DRUGS c :D o. oF .LAGES WITH TAINED ]DDS LAGEf ;DDS }H , s ANINRI 52 52 52 52 15 52 32 GBO-EZE NORTH 39 39 39 39 12 39 18 AWGU 113 113 113 113 54 113 78 OJI RIVER 43 43 43 43 15 43 18 UDI 142 142 142 142 62 142 84 EZEAGU 112 112 112 112 56 112 51 IGBO.ETITI 99 99 99 99 49 99 43 NSUKKA 87 87 87 87 36 87 29 UDENU 55 55 55 45 31 55 25 NIGNU EAST 171 171 171 171 68 171 101 NKANU WEST 146 146 146 86 71 146 98 UZOUWANI 82 82 82 82 43 82 52 TOTAL 1,141 1,141 1,141 1,071 512 1,141 629 TABLE 2: IMPLEMENTATION oF cDTt (SEPTEMBER, 1998 - MAy, i999) IN ENUGU STATE TII-II rO J LGA TI t T I t t t I T t I I I I I I I I t tla FIG. 2 IMPLEMENTATION OF.CDTI.ISEPT. 199q - MAY 1999I IN ENUGU STATE cl, UI o JJ lL o E, uto E:,2 BCDEF KEY: A,B,C,D,E,F,G, REFER To TABLE 2 TABLE 3: IMPLEMENTATION OF CDTI (SEPTEMBER, 1998 - MAY, 1999) IN ANAMBRA STATE -IIIIIII-III-I-II'II l4 E+ NO. OF VILLAGES WHICH COLLECTED DRUGS NO. OF T'II I A(?tr )F B \GUATA 90 90 90 90 61 90 48 sRUMBA NORTH 90 90 90 90 50 90 50 INEWI NORTH 36 36 36 36 18 36 20 HIALA 35 35 35 35 22 35 33 =KWUSIGO 26 26 26 26 16 26 I DEMILI NORTH 115 115 115 105 85 115 88 ANAMBRA EAST 17 17 17 17 10 17 3 ONITSHA NORTH 14 14 14 14 I 14 5 AYAMELUM 54 54 54 54 24 54 32 ORUMBA SOUTH 85 85 85 85 40 85 45 AWKA SOUTH 70 70 70 70 47 70 47 TOTAL 632 632 632 622 381 632 379 I I t I I T I I I I T I I I t I t I I t FIG. 3 TMPLEMENTATTON OF CDT| IliEpT. 1998 - MAy 1999 tN ANAMBRA STATE o IIJ 3 4ooJ lrg 3oooz CDEF KEY: A,B,C,D,E,F,G, REFER TO TABLE 3 1.e 600 1 0 OJ ) - A1r ) )-)- 63:F' Y \"rtLZ r"--**" I I I I I ffi ffi ' t' W { ffi ffiffi ffi ffi ffi ,,. ffi t:: ::rl :': 't.l ::i I I lffiffi$ TABLE 4: IMPLEMENTATION OF CDTI (SEPTEMBER, 1998 - MAY, 1999) IN EBONYI STATE IIIIT'-IIIIIIII'II f E-F II NO OF VILLAGE:' WHICH DECIDED ON METHOD OF ISHIELU 111 111 111 111 52 111 56 rvo 51 51 51 51 28 51 28 KWO 139 139 139 139 74 139 66 zzt 191 191 191 191 71 191 191 SHAOZARA 96 96 96 96 48 96 25 EZZA NORTH 96 96 96 64 64 96 64 \FIKPO NORTH 102 142 142 89 89 102 77 :ZZA SOUTH )NICHA 81 81 81 76 76 81 79 114 114 114 92 92 114 82 TOTAL 981 981 981 909 594 981 668 I I T I t I I I I I I I T I I I I t t I FIG. 4 |MPLEMENTAT|ON OF CpTt tSEpT. 199S - MAy. 19991 tN EBONYI STATE a IIJ o JJ 5 lt o c;z 900- 800- 700 600 500 400 200 100 0 S1 KEY: A,B,G,D,E,F,G, REFER TABLE 4 Y,6 I l I t I I I t t I I I t I t I I I I I I tl.3 a = j CO(0 I t I I I I I t I I t I I I I I I I t I o IIJz tF ut2z og,g, u.l o. tL o ciz FIG. 5 TRAINING OF THE DIFFERENT LEVELS OF STAFF INVOLVED IN CDfl IMPLEiTENTANON IN EN'AN'EB. STATES 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 ABC KEY: A,B,C,D,E, REFER TO TABLE 5 tl. lo TABLE 6: TRAINING OF THE DIFFERENT LEVELS OF STAFF INVOLVED IN CDTI IMPLEMENTATION IN ENUGU STATE .r IIII'IIIIIIIII'TTII- -L' : E ANINRI 6 11 6 10 247 IGBOEZE NORTH 6 11 6 10 186 AWGU 6 11 6 10 84 OJI RIVER 6 11 6 10 207 UDI 6 11 6 10 473 EZEAGU 6 11 6 10 394 IGBO-ETITI 6 11 6 10 359 NSUKKA 6 11 6 10 192 UDENU 6 11 6 10 151 NKANU EAST 6 o 3 o 342 NKANU WEST 6 I 5 I 189 UZO.UWANI 6 o 4 6 231 rOTAL 72 123 66 110 3,055 LGA :. a li TRAINED iffi D TRAINING OF.THE DIFFERENT LEVELS OF STAFF INVOLVED tN CDT| |MPLEMENTATION fN ENUGU STATE ABCD KEY: A,B,G,D,E, REFER TO TABLE 6 'l-. rL o ruz E, : 2ooo utzzoot H 1s00 u.o oz t I I I I I t I I t t I I t I I I I t I TZ 123 66 110 FIG. 6 TABLE 7: TRAINING OF THE DIFFERENT LEVELS OF STAFF INVOLVED IN CDTI I IIITTIIIIT"IIIII $ F III \ atE LGA c D 6 10 258AGUATA 6 11 ORUMBA NORTH 6 11 6 10 289 NNEWI NORTH 6 11 6 10 94 10 124 HIALA 6 11 6 iI(VVUSIGO 6 11 6 10 90 10 316 EDEMILI NORTH 6 11 6 ANAMBRA EAST 6 11 6 10 68 DNITSHA NORTH 6 11 6 10 28 AYAMELUM 6 11 6 10 126 CRUMBA SOUTH 6 11 6 10 162 AWKA SOUTH 6 11 6 10 188 {{0 1,743 TOTAL 66 121 66 I I I I I I I I I I I I I I I t I I l'. FIG.7 TRAINING OF THE DIFFERENT LEVELS OF STAFF INVoLVED rN gDTI IMPLEMENTAT|ON tN ANAMBRA SIATE o IJI2 E, IJJzz ooE UJ o. lr. o CJz 1204 1000 7 t.h IN EBONYI STATE EPT. 1998 . MAY { No. oF IHEALTH I ruo. op cENTRE/Posr I coost-*DI'I (AINEU DTI IK n ir7il. ISHIELU 6 11 6 10 242 tvo 6 11 6 10 110 IKWO 6 11 6 10 430 tzzt 6 11 6 10 553 OHAOZARA 6 11 6 10 328 EZZA NORTH 6 11 6 10 MA AFIKPO NORTH 6 11 6 10 124 EZZA SOUTH 6 I 4 10 118 ONICHA 6 11 6 10 177 TOTAL 54 97 52 90 2,222 TABLE 8: TRAINING OF THE DIFFERENT LEVELS OF STAFF INVOLVED !N CDTI IMPLEMENTATION IIIIIIIIIIIIIIIIII tf * II LGA l :. I.- I I I I I I I I T I I I I I I " T rl \ NO. OF PERSONNEL TRAINED JJ, aoloooo .Tt F 6 l{ IBlz lzlo lollr l+I- lmto I.lrl'fl lmlntmlzl{ lnt<tmlrla ls lal-{t>l'n l'7t lal{l>l{ lm TABLE 9: DETAILED BREAKDOWN OF TRAINING ACT|VITIES (SEPT. {998 - MAY {e99} t I I I t I I I I I I I I I I I T t t T ENUGU SOCT 4 4 lOOo/o LOCT/PHC COORDINATOR 142 66 64.7o/o DHS 85 72 84.7% ADHS 85 74 87.1o/o CDDS 2.154 3,055 141.83o/a SUB.TOTAL 2,434 3.271 134.601" ANAMBRA SOCT 4 4 1O0o/o LOCT/PHC COORDINATOR 114 65 57.9o/o DHS 95 66 69.47o/o ADHS 95 66 69.47o/o CDDS 2,296 1,748 76.47o/o SUB.TOTAL 2,594 1,950 75.2% EBONYI SOCT 4 4 lOOo/o LOCT/PHC COORDINATOR 72 52 41.660/o DHS 60 45 72.23Yo ADHS 60 45 75o/o CDDS 2,667 2,222 75o/o SUB-TOTAL 2.963 2,369 82.71o/o EN/AN/EB SOCT 12 12 lOOo/o LOCT 288 184 50o/o DHS 240 183 640/o ADHS 244 185 760/o CDDS 7.1A7 7,025 98.85% $. r? I I I I I I I t t T I I t I I I I I I FIG.9 DETAILED BREAKDOWN OF TRAINING ACTIVITIES tsEPT. 1998 - MAY 1Egl 8, 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 tsTarget IActual tr% Achievement Enugu Anambra Ebonyi En AblEb. PROJECT T, rd alu2 trF J ulz2 oQt IJJG IL o oz TABLE tO: MOBILIZATION AND HEALTH EDUCATION OF TARGET COMMUNITIESI VILLAGES lN ENUGU/ANAMBRA/EBONY| STATES tDp {SEpr. 1998 - MAy. {999} ITIIIIIIIIITIIIII { _* . III $TATE NO. OF VILLAGES MOBILIZED .oF IGET AGES [cH IVED IBOUT ,'rAi.lFE IN\ tt I tt^Arr : EXTEN A ) E ENUGU 1,141 1141 26 7 1 ANAMBRA 632 632 24 7 1 EBONYI 981 981 18 7 1 EN/AN/EB. 2,764 2,754 68 7 1 I t I I I t I I I I I I t I I I I t I I qo M M u N lTl ESfVI LLAG ES-l N ENIALI/EB. STATE$' IDP tl,a, o IIJ NJ6oEe, @ ul(9 JJ 5 oz BCD KEY: A,B,C,D,E, REFER TO TABLE 10 1,500 1 TABLE { 1: MOBILIZATION AND HEALTH EDUCATION OF TARGET COMMUNITIES lN ENUGU STATE TSEPTEMBER {998 - MAy {999} IIIIIIIIIIIIIIIIII ; rL II t NO. OF VILLAGES MOBILIZED 'l v F H.l IMF S I liii:r; t'liJl :rtri, NO. OF ADVOCACY vrsrTs To $TATE OR NO. C MIN. ( HEAL' $TAF INVOL\ IN I MOBILIZATION NO. ( NGDO S INVOU IN F rAFF IED vaI A l E ANINRI 52 52 2 7 1 IGBO-EZE NORTH 39 39 2 7 1 AWGU 113 113 2 7 1 CJI RIVER 43 43 2 7 1 JDI 142 142 3 7 1 :ZEAGU 112 112 3 7 1 GBO.ETITI 99 99 2 7 1 !SUKKA 87 87 2 7 1 JDENU 55 55 2 7 1 IKANU EAST 171 171 2 7 1 IKANU WEST 146 146 2 7 1 JZO.UWANI 82 82 2 7 1 TOTAL 1,141 1,141 26 7 1 MOBILIZATION AND HEALTH EDUCATION OF TARGET COMMUNITIES IN ENUGU STATE BCD KEY: A,B,C,D,E, REFER TABLE 11 FtG. 11 o UINJ o o =Q IU o JJ lI. o oz I I I I I I I I I I I I I I t I I t I I ,f . LL TABLE {2: MOBILIZATION AND HEALTH EDUCATION OF TARGET COMMUNITIES IN ANAMBRA STATE III'IIIIIIIII-III "r)cl * III LGA NO. MIN. HEAI $TA rNvol It\ffi \ Ir/ OF \GE$ rtrEl.r r H :D IMPORT OF EXTE TREAT! rcE )ED NT DIRECTI r.TE IJEA B E {GUATA 90 90 2 7 1 3RUMBA NORTH 90 90 2 7 1 INEWI NORTH 36 36 2 7 1 HIALA 35 35 2 7 1 :KWUSIGO 26 26 2 7 1 DEMILI NORTH 115 115 2 7 1 qNAMBRA EAST 17 17 2 7 1 CNITSHA NORTH 14 14 2 7 1 \YAMELUM 54 54 3 7 1 CRUMBA SOUTH 85 85 2 7 1 AWKA SOUTH TOTAL 70 70 3 7 1 632 632 24 7 1 I .. I I I I I I I I I T t t T I I I I I I FrG. 12 il.J;-t[3ji,.t'g:ii i*, -i]i::.i*i:i$,i]i,,.ili"i i,i$*1,-t-*i.i:iri":#Y."i,,tJS-#$;l; COMMUNITIES IN ANAMBRA STATE C] 500 ul NJ Eg 4oo atuo JJ 300 lro c,z 2AO BCD KEY: A,B,C,D,E, REFEER TO TABLE 12 t-1 s l\ TABLE {3: MoBlLlzATloN AND HEALTH EDUcATtoN oF TARGET COMMUNIflES lN EBONYT STATE {SEPTEMBER 1988 - [rAy 1999] IIIIIIIIIIIII-ITI b o-l r I III LGA V I H. IMI OF TR i r rE iD T NO. OF MIN. OF HEALTH STAFF INVOLVED IN MOBILIZATION NO, OF NGDO STAFF INVOLVED IN MOBILIZATION A trb ISHIELU 111 111 2 7 1 VO 51 51 2 7 1 zzl 191 191 2 7 1 KWO 139 139 2 7 1 CHAOZARA 96 96 2 7 1 =ZZA NORTH 96 96 2 7 1 {FIKPO NORTH 102 102 2 7 1 :ZZA SOUTH 81 81 2 7 1 CNICHA 114 114 2 7 1 TOTAL 981 981 18 7 1 I I T T I I I lI] lTI III Irl Irlrl II Irl ll t I I I T FtG. 13 MOBILIZATION AND HEALTH EDUCAT|ON OF TARGET COMMUNITIES IN EBONYI STATE o ulNJ E o =a IU o JJ 5lr o ciz BCD ir,H *'; ,&,illi,#"i::!"i*, fii*:r--ffii"1ffi: .f"--$ T'r:l$"*i.".H 't jt ', , g.a {i} 8 Project's annual training objective and the percentage of the objecfive achieved The project's annual training objective is 7,887 persons. A total of 7,589 persons representing 96.2% of the targeted persons were actually trained. Table 9 shows the detailed breakdown of the haining activities of each of the three states that make up the project. Similarly, the cumulative training targets and percentage achievement is also included in the table. The low level of percentage coverage as compared with the project's annual training objective is as a result of series of industrial dispute between labour and government in respect of minimum wage which in some states lasted for months. The industrial dispute disrupted trainings, especially at the LGA, district and village levels. It is hoped that with the strike action now over, there will be improved coverage of the project's training targets. {ii} Types of materials developed and ased for training heolth staff and CDDs. The project also used the APOC approved CDTI such as: 1. CDD training guide 2. Flip chart 3. CDTI Video tape 4. Informationbrochure In addition, the project in collaboration with NOTF, der,*eloped and used the following materials: training materials 9' [a] Post and Pre-test: These are used to assess the effectiveness of communication of trainers on the course of training, and also an inskument for evaluating the knowledge of the trainees before and after training sessions. tbl Pocket Treatment Guide: This is used as a reference material for LOCTs, DHS, ADHS and CDDs with a view to understanding: ti] What onchocerciasis is tiil Their roles in oncho control [iiil The CDTI concept [iv] The difference between (iii) above and the system formerly in place [vl Community mobilizationstrategies [vi] The new 3mg Mectrzan formulation [vii] Treatment techniques and management of side reactions [c] Samples of measuring stick and village treatment registers. tdl Hand bills in local languages [e] MIS forms tfl Blind walk goggles (to illustrate the challenges to being blind) {iii} The performance of the CDDs, does the pedormance of the CDDs indicate they received and undcrstood important information ubout their roles? At the start of the training, a pre test was administered to assess the level of understanding of the CDDs. After the training, a post test was administered to assess the level of assimilation of the training content. The general observation showed a significant level of improvement. 10 - The CDDs performance on the field was also encouraging, as there were few errors in: I Health Education messages a Dosing t Record keeping I Eligibility criteria i Monitoring and management of side effects t Mectizan inventory control In the light of the above, it is clear that the CDDs received and understood important information about their roles and responsibilities. The CDDs chosen in most communities appreciated the work required of them and were quite zealous in carrying out their tasks. 2.I. MOBILIZATION AND EDUCATION: Successful mobilization and health education are crucial activities, which create awareness of the problem of onchocerciasis at the State, LGA, community and village levels as well as solicit support and patronage of the entire citizens towards effective implementation of the control programme. The ultimate aim is to have a sustained high demand for Mectizan tablets to prevent blindness due to onchocerciasis. Advocacy visits were made to top state and LGA government officials to acquaint them with the problem of onchocerciasis and the need for the government at all levels to support the programme in various til l1 ways. Communities were mobilized with the help of District Health Supervisors and their assistants, the CDDs and members of VHCs. The formal and informal avenues were used to convey appropriate health education messages. Unfortunately, state participation has not been impressive. High level advocacy visit to MOH management (Commissioner, Director General, Director PHC etc.) is required to educate the States on their role in the implementation of CDTI. Some local govemment areas have been quite responsive and most have principally agreed to support the programme and release funds for the project. Provide information on the use of media and/or other local systems to dkseminate information? Information is said to be effectively disseminated when the message relayed or transmitted has been coded [heard, accepted] and the receptor [villager] elicits a positive response. The channels used for disseminating information in the project varied from community to community and village to village. The methods used were: Electronic media: til Radio: Radio jingles, radio discussions/interviews/broadcast were prepared and aired constantly, especially, during the Onchocerciasis Week observed by the project from lzn - 22"d February 1999. Radio stations in all the states and the National radio stations were involved in the mobilization activities. During this period, radio messages were relayed to the public as news inserts or during important programmes. {a} lbl lcl t2 tiil Television: The television was also used, but coverage was limited by lack of electricity in most of the communities and villages. Print Media: Newspapers and magazines were used for mobilization. Local Systems: These are the traditional methods applicable to different communities and villages and relate to varied traditions. The local methods include: {i} Town criers: These are persons chosen by the community for the purpose of moving around the villages or market squares with metal or wooden gongs or drums disseminating information to the people. The village or community through their common purse usually compensates them. They move around the markets during the day, but around the villages at dawn or at night. {ii} Churches: The main religion of the inhabitants of the project area is Christianity. There are churches in all the towns and are built through communal contribution. They are usually centrally located and important messages disseminated through the churches reach every household. {iii} Schools: Health Education messages are provided through schools during health lessons or drama. Education is one of the valuable assets recognized in the project area. {i"} Village/Community Heads/Ezes - The head of the village or community, convenes meetings of his cabinet chiefs or other members of the community at regular intervals. Health Education messages are being passed at these meetings. t3 {"} ViIIage SociaUGroup Meetings:- The project team used social meetings such as Youth Development Associations to disseminate Health Education messages. Tables 10,11,12,13, show mobilization and Health education target communities/villages in the project area. {ii} Are you satistied with the results of the mobilization efforts? The use of media and other local system of disseminating information were very effective and gave satisfactory results from the target villages. The effectiveness is reflected by the increased commitment of the community leaders and distributors and the high degree of involvement of the communities and their willingness to commit available local resources to the distribution process [see pix I, II, III]. {iii} Did target commanities/villages respondfavourably? The target villages are responding very well to the CDTI approach as a result of mobilization, all the villages have: t Selected one or more CDDs in each village o Paid CDDs transport fare to collect Mectizan from the district centres i Made cash or in-kind compensations to CDDs t Plans to conduct mop-up treatment for absentees t Formed Village Health Committees Some villages also developed workplans for fraining and Mectizan distribution. {iv} Suggest ways to improve mobilizotion of target communifies. t4 Ways to Improve Mobilization of Target Communities include: {a} Increased logistic support (particularly motorcycles) for LGA staff participating in CDTI implementation. {b} Provision of bicycles for health cenfre staff involved in the CDTI implementation to enable them cover the villages more effectively. {c} Use of mobile public address system for better outreach of the population. PIX I CROSS SECTION OF PARTICIPANTS IN AN ORIENTATION MEETING ON CDTI FOR WOMEN LEADERS FROM FIVE COMMLINITIES OF OMCHA LGA OF EBONYI STATE ORGANI ZEDBY ONICHA WOMEN DEVELOPKMENT AS SOCIATION. lLr,4 +-- F ilr\ ; Ii li )l II II)IX 2 A CROSS ST'C'I'ION OI,'I'N I('I'ICII'N N'I'S IN A I;I ]NI) RAISING CLIRIiMONY I;OIi StJI'l'}OR'l'OIr CITI IN \ OLO COMMtJNII'Y, L.ZITAGiJ I-'(i /\ fr,ffi , [}-' *m 4q,?_ PIX 3 COMMUMTY AND OPIMON LEADERS PRESIDING IN A FUND RAISING CEREMONY FOR SUPPORT OF CDTI IN OLO COMMUNITY ' I'I 'III lh,3 I ['rt llll 15 SECTION 3: ACHIEvEMENTS: The project total [census] population is 1,887,514 persons. The number of persons treated is 1,256,840. This gives a treatment coverage rate of 66.59%. Out of the total population, 1,475,629 persons were eligible. Based on that the coverage rate (eligible) is 85.2o/o. {irr} Describe brietly whether the proportion of village/community members who were absent during fieatment is higher than upected The proportion of absentees and refusals is lower than expected in all the project areas. This situation is athibuted to the aggressive mobilization of the communities, perceived benefits of ivermectin and the high demand for it in all the endemic villages. In addition, the ability of the communities to recognize problems with distribution methods and modifu the methods accordingly contributed to low absenteeism recorded so far. {"} State the most common reasonsfor absenteekm For those lhat are absent during treatment, the most common reason given by them is "farming activity" which keeps them away from the community during distribution period. {"i} Suggest what actions need to be taken by the project to reach absentees and detaulters during the nut treatment and if any constraints might prevent their inclusion There is need for the villages to adjust the distribution period in line with their tradition to avoid clashing with the farming season. Where this is not I6 possible, alrangement should be made to treat absentees/defaulters in the farm settlements. There are also some people who refuse the d.ogs for some reasons. For this group of persons, continuous education and mobllization is suggested. TABLE {4: ACHIEVEMENTS [SEPTEMBER {998'MAY 1999 IN ENUGU/ANAMBRA/EBONYI STATES' IDP IIIIIIII-IIIIIIII'-I d\i I ENUGU 1141 545,242 0.16 2 3,055 1,141 629 ANAMBRA 632 345,622 0.23 NIL 1,612 632 379 EBONYI 981 365,976 0.17 NIL 2,222 981 668 TOTAL 2,7il 1,256,840 0.{ I 2 6,889 2,754 1,676 TABLE {5: ACHIEVEMENT [SEPTEMBER 1998 - MAY {999] IN ENUGU STATE IDP I.TIEIIIIII'IIIIII'I O,., 1o ANINRI 52 43.908 0.16 NIL 247 52 32 GBO.EZE NORTH 39 23,999 0.30 NIL 186 39 18 AWGU 113 53,828 0.13 NIL 84 113 78 OJI RIVER 43 41,202 ai7 NIL 207 43 18 UDI 142 58,735 ai2 NIL 473 142 84 EZEAGU 112 65,1 87 0.12 NIL 394 112 51 IGBO.ETITI 99 49,879 0.14 NIL 359 99 43 NSUKKA 87 40,122 0.'t8 NIL 192 87 29 UDENI 55 27,665 0.26 NIL 151 55 25 IKANU EAST 171 50,013 0.14 NIL 342 171 101 IKANU WEST 146 37,28A 0.19 NIL 189 146 98 UZO.UWANI 82 53,440 0.13 2 231 82 52 TOTAL 1,141 545,247 0.16 2 3.055 1,141 629 LGA NO, OF VILLAGES IFttrlvvuyg IN CASH OR KIND NUMBER OF VILLAGES WHERE CDD IS A HEALTH WORKER .': A F AGUATA 90 49235 0.14 NIL 228 90 48 ORUMBA NORTH 90 48,012 0.15 NIL 264 90 50 NNEWI NORTH 36 13,422 0.49 NIL 94 36 2A IHIALA 35 24,823 0.28 NIL 144 35 33 EKWUSIGO 26 18,248 0.39 NIL 90 26 8 IDEMILI NORTH 115 47,963 0.15 NIL 278 115 88 ANAMBRA EAST 17 11j82 0.64 NIL 46 17 3 ONITSHA NORTH 14 14,386 0.49 NIL 28 14 5 AYAMELUM 54 31,795 0.22 NIL 126 54 32 ORUMBA SOUTH 85 51.360 0.14 NIL 162 85 45 AWKA SOUTH 70 35,1 91 0.20 NIL 170 70 47 TOTAL 632 345,617 0.23 NIL 1,590 632 379 TABLE {6: ACHIEVEMENT [SEPTEMBER {998 - MAY 19991 IN ANAMBRA STATE IDP I-IIIIIII-IIII-IIIII I (O STATE v PA' OF \GES i CDD$ ASH TABLE 17: ACHIEVEMENTS [SEPTEMBER {998 - MAY 1999 IN EBONYI STATE IDP TTIIIIIIIIIIIIIIIIII { (o I STATE I ROF ITORS ISED NO, OF EA IES WITH AKY vts l E$ zzt 191 52,925 0.13 NIL 553 191 191 SHIELU 111 36,251 0.20 NIL 242 111 56 VO 51 3,102 2.29 NIL 110 51 28 KWO 139 39,461 0.18 NIL 430 139 66 )HAOZARA 96 35.182 0.2 NIL 328 96 25 EZZA NORTH 96 55,357 0.13 N!L 14A 96 64 AFIKPO NORTH 102 50,335 0.14 NIL 124 102 77 EZZA SOUTH 81 41.751 0.17 NIL 118 81 79 )NICHA 114 51,612 0.14 NIL 177 114 82 TOTAL 981 365.976 0.17 NIL 2,222 981 668 t; I I t I I I I I t I I I I I I I I I t' ACHIEVEMENT TSEPT. '98. MAY'99I COST PER P.ERSON TREATED Anambra STATE 16, 5 TABLE {8: TREATMENT [SEPTEMBER 1998 TO MAy 19991 IN ENUGU/ANAMBRA/EBONYI STATES IDP .IIIIIIIIIIIIIIIII \o \o II 1,141 437,579 EBONYI 1,997 ,514 1,475,629 STATE il vI TF ,. (,F .AGES iATED AL iusl \TION P( A ENUGU 791,745 599,756 545,242 68.86% ANAMBRA 632 522,967 345,622 66.1o/o 981 572,902 439,295 365,976 63.98% EN/AN/EB, 2,754 1.256 gen 66.59% I I I I I I I I I I I t I t I I I t t I FtG. 18 TREATqTENT tSEpT. 1998 - MAy 1999I tN EN/AN,EB. STATE$'IDP cI ulF ul E,F @z oQu UI o. lI. o ciz 2,000,000 1,800,000 1,600,000 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 KEY: A,B,C,D,E, REFER TO TABLE 18 16 , .l- TABLE ,l9: TREATMENT [SEPTEMBER 1998 TO MAY 19991 IN ENUGU STATE IDP I I I I I I .. I I I T I I I I I - -.I qO ie =tiD I lc POF }TAL wusl LATION EL POP II AGE E ANINRI 52 62,921 46,360 43,908 69.784/o GBO-EZE NORTH 39 35,542 26,335 23,988 67.494/o AWGU 113 75,060 56,679 53,828 71 .71% OJI RIVER 43 60,473 44,051 41,202 68.13% UDI 142 79,182 63,101 58,735 74.180/o EZEAGU 112 95,287 73,287 65,187 68.410/o IGBO.ETITI 99 7A,438 56,534 49,874 70.81% NSUKKA 87 60,690 47,022 40,122 66.11% UDENU 50 42,334 31 ,7 51 27,665 65.35% NKANU EAST 171 73,548 54,426 50,013 68.00% NKANU WEST 146 53,865 40,054 37,280 69.21% UZO-UWANI 82 82,405 60,156 53,440 64.85% TOTAL 687 539,593 413,369 376,844 69.840/o A I t I I I t I I I I I I I I I I I I I I E 4oooook tuuF o2 a 300000 G, UI o- ILo g 200000 100000 te . g FtG. 19 TEFATMENT ISEPT. 1eq.8 - MAY 1e99I rN ENUGU STATE IDP ABCDE KEY: A,B,C,D,E, REFER TO TABLE 19 TABLE 20: TREATMENT [SEPTEMBER {998 TO FEBRUARY 19991 IN ANAMBR^A STATE IDP IIII-III'II-I'IIIIIT ,c .O AGUATA 90 78,776 52,983 49,235 62.50/o CRUMBA NORTH 90 62,785 50,563 48,012 76.47o/o NNEWI NORLTH 36 28,512 28,395 13,422 47.07% IHIALA 35 31,621 28,447 24,823 78.5% EKWUSIGO 26 24,889 22,786 18,248 73.32% IDEMILI NORTH 115 79,949 61,529 47,963 59.99% ANAMBRA EAST 17 14,844 12,863 11,182 75.33o/a ONITSHA NORTH 14 21,165 18,198 14,386 67.97% AYAMELUM 54 51,680 48,738 31,795 61.52% ORUMBA SOUTH 85 78,250 73,805 51,360 65.64% AWKA SOUTH 70 50,496 39,271 35.1 96 69.7Ao/o TOTAL 632 522,967 437,578 345,622 66.09% I VI TI .oF AGES ATED r r II t I I I I I I I I I I t I T I I I FrG.20 TREATMENT ISEPT. 1998 - lt[AY 1999I lN ANAMBRA STATE IDP o UIF ul e,F rnz o utE ule IL o oz BCD KEY: A,B,C,D,E, REFER TO TABLE 20 16, rr 400000 300000 TABLE 21: TREATMENT ISEPTEMBER 1998 TO MAY 19991 IN EBONYI STATE IDP I'IIIIIIIII-I'IIIIIT { ae tzzt 191 76,411 61,011 52,925 69.26% ISHIELU 111 52,624 37,009 36,251 68.89% tvo 51 6,028 5,147 3,102 51.460/o IKWO 139 68,036 53,786 39,461 58,00% OHAOZARA 96 52,51A 37 ,A13 35,182 67.000/o EZZA NORTH 96 93,984 69,895 55,357 58.90% AFIKPO NORTH 102 80,665 61,836 50,335 62.400/o EZZA SOUTH 81 69,852 49,917 41,751 59.77% ONICHA 114 72,692 62,681 51,612 71.00% rOTAL 981 572,802 438,295 365,976 63.98% STATE V T r. oF AGES iATED . rr.,.l..!OTAL.l.'r,', ,'l'ailr:..;ii.,;:.X0f '':':'''..;,,,.,..,:: POPULATION I I I I I I I I I I I I T I I I t t I I l'. FlG.21 TREATTIdENT-ISIEPT. 1998 - MAy 19e9t tN EBOrlyt STATE o 400000 uJ I,'J E,F ozo 300000U' E, u,L l& o c,z 200000 KEY: A,B,C,D,E, REFER TO TABLE 21 16, 13 t7 SECTION 4 STRENGTHS AND WEAKNESSES OF CDTI IMPLEMENTATION: {i} How did CDDs chosen by the communifies perform their tasks? From the progress made so far, there are indications that the CDTI approach is bound to be more successful and sustainable than any other distribution strategy applied before. Indications of this success can be seen in the way CDDs carried out their tasks in these areas during the period under review: a) Record keeping - Less number of errors are now being recorded than before. b) Correct dosing - It is obvious that even with the change from 6mg to 3 mg tablets, CDDs have adjusted to the new dosing. c) Exclusion criteria - From our experienoe, CDDs in the project have demonstrated clear understanding of who qualifies to be treated or not. d) Monitoring and management of side effects - A majority of CDDs have also demonstrated competence in this regard. e) Health Education Most CDDs gave correct Health Education messages to the people. {ii} Willingness or not of communifies to participate in CDTI process - to collect the drug and to take charge of distribution and its supervision. There is increased willingness and involvement of the communities/villages to commit available local resources to the CDTI process. The communities happily plan and collect their drugs. The increase in the number of CDDs l8 has reduced the area and population covered by one person. The use of more CDDs definitely accelerates the time of distribution and coverage is enhanced. However, there are complaints about increased burden of compensation on the entire community as a result of increase in the number of CDDs involved in the process. However, there is already growing rivalry and leadership problem among the multiple CDDs now being used per village. In terms of Mectizan management, CDTI strategy provides for appropriate and accurate Mectizan inventory down to the household level and the communities feel more sense of fulfillment as they now participate more actively in the planning and execution of the distribution process. They now determine the quantity of their own drugs and collect them by themselves. They also determine the method of distribution. However, there is increased distortion of data, because they now have to pass through multiple hands for verification. There were no difficulties in sending reports/records back to the ivermectin collection points since the points are closer to the CDDs. The communities are happy to take custody of their drugs, but the safety of the Medicine cannot be assured in times of community clashes. Although supervision is done by the health staff, the village health committees assist in this component since the CDTI approach provides participatory opportunity to all segments involved in programme implementation. Monitoring of village registers are ulmong the tasks performed by the VHCs. t9 {iii} Describe the level of involvement of the regionaUstate and district/LGA governments in the activifies including involvement of Sectors outside health in facilitafing distribution If any level of government provided funds [actual cashJ and/or materiak towards Implementafion of CDTI. It is important to state so and how much. Mobilization of states, LGAs and benefiting villages for acceptance, ownership and involvement in onchocerciasis control has been an integral part of the project's routine activities and has yielded useful fruits. The States, LGAs and villages have contributed a total of N816,170. Details of the breakdown are in table 23. The states and Local Governments apart from approving and releasing fund for CDTI activities, also release their personnel whom they pay salaries and other benefits. Similarly, benefiting communities nominate their indigenes as CDDs and also provide fund for their transportation and stipend for distribution activities. Also, other community-based NGDOs like the Sudan United Mission [St]M] of the Netherlands and local radio stations at state level support CDTI in training, community mobilization and monitoring of dishibution activities. {i"} What do yoa consider the major achievements of the project {1} Treatment: The project treated 1,256,840 persons within the period under review. {ii} Training: During the period 184 LOCTs, 185 DHS, 185 ADHS were frained. In the silme period, 7,025 CDDs and 341 TOTs were also hained to lay a shong foundation for CDTI take offin the project. {iii} Mobilization: 2,754 villages were mobilized during the period covered by this report. ! Qesfion.' lf any level of government provided funds [actual cash! and or malerials towads implementation of CDT| it is importantto shfe so and how much. LEVEL OF FINANCIAL INVOLVEIIJIENT OF STATES, LGAS, BEilEFtilNc VTLLAGES AND OTHERS tsEpr. 1998 - MAy {999} IIIIIIIII-IIIIIIII \) I (n \ -a II N110,000 Nl96,000 N837,650 20 - {i"} All communities also provided notebooks for their CDDs and took care of transportation for collection of Mectizantablets. {v} Increased awareness about Oncho and its treatment was achieved. {vi} Increased level of participation of host villages in CDTI. {vii} Decentralization of the issuance of Mectizan tablets from LGA headquarters to the district. {"} The constraints and the challenges for the nut treatment cycle. {a} Villages have added responsibilities by involving more than one CDD and the brnden of compensation is increased. {b} V/ith more than one CDD, there is the tendency for contention for leadership among the CDDs, resulting in negative consequences for the work. {c} ::,::"" changes in government leadership, requiring more advocacy vrsrts. {vi} Clearly state what types of help you need from: [aJ the government [b] APOC Management [cJ other parties to be ahle to improve the CDTI process netct year. A From State Government: {i} Non-diversion of project vehicles and equipment should be strictly enforced. {ii} States should demonstrate commitment to CDTI by releasing counterpart funds on time. {iii} Advocacy visits to the LGAs are required. {i"} State Government should solicit for support from electronic and print media for enlightenment on Oncho activities. 2l {"} They should restrict frequent and disruptive transfers of Oncho personnel at LGA level. B From Local Government Area {i} Exclusive use of project motorcycles should be enforced. {ii} LGAs should be committed to CDTI by timely release of budgeted funds. {iii} Advocacy visits to haditional rulers should be embarked upon. C. From APOC Management: {i} APOC management should release its counterpart funds on time to the project. {ii} Release of project annual funds in two installments will be appreciated. {iii} Three new vehicles will be required to run the project. This is because the vehicles earlier provided by Lions Club International are too old and therefore, breakdowr very frequently. {i"} 120 ADHS will require a bicycle each for effective supervision in their respective districts. {"} For effective supervision, motorcycles will be needed in 5l LGAs covered by the CDTI project. D. Other Parties: {i} Advocacy visits by the Federal Government to the States will be necessary. 22 {ii} Compensation for CDDs by the communities is a major concern. We therefore, expect District and Village Health Committees to play a major role in this respect. Appendix 1 ORGANIZATIONAL SETUP Organizational Structure of Community-Directed Treatment witlr lvermectin Procurement of Mectizan Policy formulatlon Fornrulation of National Plan Of Action, Monitoring, Supervision and Evaltration Steerin g Committe Non-Govern nrental organization (Country Representative - Global 2000) (Asst. National Director, Mectizan Manager) Collection of Mectizan from Lagos Supervision of State Prolect Officers and SOCTs Monitoring and Evaluation of lvermectin Distribution Advocacv arrrl MoIrilization of Policv Makr:rs State Onchocerciasis Control Team (Stafe Coordinator, SOCT, Director PHC, PHC Coordinator) Collection of Drug from NGDO Training of SOCTs, & Operation Research Supervision of SOCTs and LOCTs Monitoring & Evaluation of ivermectin Distribution Advocacy and Mobilization of Policy Makers, and Private Sector Local Government Onchocerciasis Control Team (LOCTs Leader, LOCT, PHC Coord., Health supervisor, District Supervisor) Colleoiron of Drug frorn tlre State Advocacy and t'/obilization of LGA Policy Makers Training of CDDs, & Mobilization of endemic Communities Monitorinq & Evaluation of ivermectin Distribution (Comnrunity Cont rn u rr ity-D i rr-,c tc cl Troatm ent with lvorm ccti rr Leader(s) Vil iage H ealtlr C onrrn ittee, Com nr u rr ity tnenr be rs, C DDs) Collcction of l'.4ectrziln fronr [-GA i-]i:adquarlr:rs L.,tl rrn(i(.lt I n iJr Stri ltLr tron Su pen,rsion or Oontrnu n rty Disirrbution Activitrcs Managemcni r)[,Arjvr,:r':;c Rcaction and rc[c-,rretl Funds for translrort anrj clrstribution activities to CDDI; NOCP NGDO Appendix 2a MAGRO FLOW-CHART FOR SUPERVISION AND MONITORING OF CDTI AGTIVITIES IN STATE PROJEGT GLOBAL 2OOO GRBP QUARTERLY MONITORING ZONE, STATE, LGAs, AND COMMUNITIES NOCP I GRBP OF I Ii STATE ON CONTROL I I + FICE, ENUGU CHOGERCIASIS TEAM (SOGTS) i : I i LOCAL GOVERNMENT ONCHO. CONTROL TEAMS (LoCTs) PROJECT OFFICE MONITORING AND SUPERVISION OF STATE, LGAs AND COMMUNITIES ROUTINE MONITORING AND SUPERVISION OF LGAs AND SPOT CHECK ON COMMUNITIES VHCs AND COMMUNITY LEADERS AND GDDS .i Appendix I : : -FINANGIAL FLOW-CHART OF APOC FUNDS lN E N U G U/ANAM BRA/EBONYI STATES NOCP HEADQUARTERS \!t NOTF AGCOU NT SIGNATORIES : -WR - NGDO CHAIRMAN - NATIONAL ONCHO COORDINATOR GRBP OFFICE ENUGU PROJ EGT ACCOUNT SIGNATORIES: - PROJECT ADMINISTRATOR - ZONAL COORDINATOR NOCP - STATE ONCHO COORDINATOR ENUGUiANAMBRfuEBONYI STATE ONCHOCERCIASIS GONTROL UNIT EN UGU/ANAM BRA/EBONYI PROJ ECT SITES ACCOUNT SIGNATORIES: - DIRECTORS OF PHC/DC . STATE PROJECT OFFICER ENUGU, ANAMBRA & EBONYI Appendix 4 < t J .t f z 7t-- wF COMBINED MAP SHOWINC TREATMENT ROUNDS IN THE THREE SIATES. E] zc nC El EE C z H [[I ul+\Ni=3=dSAtv IL ./ Z- -2:LU\JU