Report of independent monitors of Community Directed Treatment with Ivermectin (CDTI) activities in Tanga, Tanzania, 15-29 September 2002

TANGA - WHO/APOC/CDTI PROJECT REFIS,RT O,F ENI}H,FENE}EI.{T MONITORSi OF CETI ACTIVITIES IIti TANC,A' TAI,I&{NIA 15 - 29 SEPTEMBER 2OO2 .t[ .ry ]J/.{'I f:'t} J{} TIIE NIRECTflR AFRICI+,T,I F,ROG.K4}fi8fr8 C,K ffITCEICC tAEffCI O[T$#[,R Z{I{m: ERC'[,{S[S C$II;TROI" For Aclr..:n fo: [:^ \r, r Fc- iiiformclion Jo, , 2TEAM OF MONITORS DR JOSEPH OKEIBUNOR' Principal Investigator/Social Scientist Department of S ociology/Anthropology University of Nigeria, Nsukka Enugu State, Nigeria JOHN NGANYA Team Member/?roj ect Coordinator Onchocerciasis Control Programme Kilosa CDTI Project . T anzania DR MOSHI RUHISO Team Member/?roj ect Coordinator Onchocerciasis Control Programme Tukuyu CDTI Project Tanzania SEBASTIAN MHAGAMA Team Member/District Coordinator Onchocerciasis Control Programme Mbinga District, T anzania DR SIMON KATENGA Team Member/Ilational Coordinator National Onchocerciasis Control Programme Federal Ministry of Health, Tanzania 3TABLE OF CONTENT TEAM OF MO--L'{TJORS """"'-2 TABLE OF CONTENT .......... 3 LIST OF FIGURES ................ 6 LIST OF ACRONYMS ..........7 4-C-KNOWL-EDGEMENT """ 8 EXECUTM SUMMARY ......................9 TNTROpUCTTON .................12 """"""12 1.2 Tanga Backsround ' ""13% .............141.3 Team Composition - ....................r4t1.4 Terms of Reference METHODOLOGY Studv Desisn Population ..2.2 2.3 The S e and Sampline Procedure RESULTS A. B e D E Ind tors: C-oJnsttaints Community Perception Ouality of implementation of CDTI UNIO.UE FEATURES OF THP PROJECT ABEA .20 .20 .30 .30 .32 .36 prs-Eu s sLoN AND C_9NCLU SrON ...39 RECOMMENDATION .........4I APPENDIX K4Y INFORMAN INTERVIEW: Villaee "A"-Leader GROUP DISCUSSION GUIDE AMONG COMMUNITY MEMBERS .............. IN-DEPTH VIEW OF VILLA ..A'CDD KEY INFORMANT INTERYIEW: Villaee" B" Leaders .' HOUSEHOLD SURVEY FORM (cateeory A villases onlv) IN.DEPTH INTERVIEW OF VILLAGE "B" CDD .46 .46 50 .53 .60 .62 .64 4KERS/ ..,.,,66 wHo A 7l 5LIST OF TABLES Table A1 : Divisions/Wards/Vil1ages and Sub-Villages Covered in Tanga Project Focus 17 Table A2: SUmmary of Instruments and sampling Issues 19 Table 1: Decision-making Process at the village Level(t in Parenthesis) Table 2: Treatment Summary (Yo in Parenthesis) Table 3: Proportion of Villages treated and in which CDDs were changed after the first treatment Table 4: Proportion of villages which received health education, and in which health care personnel supervised CDDs Table 5: Input indicators (Community level) (V, in Parenthesis) Table 6: Distribution of implementation of the components of CDTI and Wards Table 7: Quality of CDD Training in Category "A" villages(t in Parenthesis) 20 23 25 26 27 31 34 6LIST OF FIGURES Fig. l: Community Participation in Decision Making 22 Fig. 2: Treatment Records from CDD Records and Household Survey 24 Fig. 3: Comparison in Treatment Coverage between the Year 2001 and20O2 25 I ,7 4WD APOC CBIT CDD CDTI CHMT DALY DCHP DED DMO DOC FGD IIKI HS TEC IMA NOTF OSD RIIO RMO ROC SSI wHo LIST OF ACRONYMS Four Wheel Drive Vehicle African Programme for Onchocerciasis Control Community Based Ivermectin Treatment Community Directed Distributor Community Directed Treatment with Ivermectin Council Health Management Team Disability Adjusted Life Year District Comprehensive Health Plan District Executive Director District Medical Officer District Onchocerciasis Control Focus Group Discussion Helen Keller International Household Information, Education and Communication Interchurch Medical Assistance National Onchocerciasis Task Force Onchocerciasis Skin Disease Regional Health Officer Regional Medical Offi cer Regional Onchocerciasis Coordinator Sight Savers International World Health Organization 8ACKNOWLEDGEMENT The team would like to extend its sincere gratitude to all those that assisted it during this mission. Of special mention are the following: o The Regional Health Oflicer for Tanga Region, D.A' Mwalyamewile o The Regional Medical Oflicer, Dr. W. Mwengee o District Executive Directors for the three Districts visited o District Medical Officers of the three Districts visited o The Primary Health Care Coordinators of all the rural health facilities visited o Members of Onchocerciasis Control Team for the Districts visited o Coordinators and Members of Onchocerciasis Programme in the Districts visited o The Leaders and members of villages visited o The Community Directed Distributors of the communities visited And more importantly, the team wishes to express its profound thanks to the APOC Director, Dr. A. Sek6t6li, and his team at the APOC management for making this mission a reality. 9EXECUTIVE SUMMARY The Independent Monitoring Team that was constituted by APOC Management and NOTF Tanzania to visit Tanga Region Community Directed Treatment with Ivermectin (CDTI) project, from 15 to 29 September 2002, had Dr Joseph Okeibunor of the O.pu.r1nint of Sociology/Anthropology, University of Nigeria, Nsukka as the Principal Monitor. The other.oritors include Dr S. Katenga, NOCP Tanzania, Dr Moshi Rohiso of Tukuyu CDTI Project, Sebastine Mhagama of Ruvuma CDTI Project and John Nghaya of filoru CDTI project. The team had the members of the CHMT and DOTs of thi d#ferent Districts visited as local guides. The assignment commenced with a briefing of the Regional Medical Team in Tanga on the terms of reference of the Independent Monitors and the areas where their cooperation would be required. The methodology and instruments adopted were the same as those developed in Ouagadougou and finalized in Kabale, Uganda. The objectives were equally left as stated in Kabale, Uganda. Six Category A, and 24 Category B, sub-villages were selected through a simple random sampling procedure. The findings show good low level of the establishment of the CDTI proCess in three Districts, namely Lushoto, Korogwe and Muheza current implementing CDTI The key findings in the Tanga Region CDTI project include high treatment coverage of 82.1 per cent in 2002 treatment, which was an improvement on the 78.2 per cent treatment coverage recorded in 2001. It was observed that the Regional and District political and health policy makers are fully sensitized and willing to ensure the success of ihe programme in their respective areas. According to one of the District Executive Directors interviewed, there is no question of their support because the problem is theirs and APOC is only supporting them to solve their problem. They appreciate the support by APOC. As steps to ensure the success and sustainability of the programme, the Districts were advised by the Regional Government to integrate it into their yearly health plan and make money available for running the programme from other sources including the 'basket fund'. Records show clearly the incorporation of CDTI into the Comprehensive Health Plan of the three Districts as well as budgetary provisions and fund releases for the maintenance of motorcycles by the District Onchocerciasis Team. In Korogwe, the DOCs were posted as staff in the health facilities located in the onchocerciasis endemic areas. At the village levels, some of the villages are well sensitized and are willing to take the drug for a long period. In some of the villages the sub-village chairpersons assist the CDD in census update as well as distribution of Mectizan@. Some took advantage of the CDTI structure to develop vital statistics register for the villages and some village Chairperson maintain a comprehensive record of Mectizan@ distribution in their villages. Each sub-village had two CDDs, one male and one female trained to cover the interest of both males and females in the community ao 10 However, some people who took the drug the previous year declined taking the drug the following year. Thus, even though there was an overall increase in coverage by 3.9 per cent point, a segregation of the data by villages showed a decline in coverage in some villages. The commonly given excuse was that the drugs were brought during the season for iea cultivation. The people preferred the treatment in the harvesting period of June/July when the mild side effects will not interfere with their agricultural work. Unfortunately, the rural health workers and the DOTs insist on the distribution of the drug in February, when the drug arrives from the National levels. The arguments of the health personnel is that the project year ends in March so there was need to finish distribution and make returns before the commencement of a new year. It was also noticed that supervision in the communities was very poor. The rural health workers complained of poor supervisory provisions to cover the numerous CDDs in the widely dispersed area with difficult terrain. In many cases the health facility staff did not supervise CDDs. The only supervision came from the sub-village chairpersons. Worse still, these CDDs are not well educated as the educated ones refuse to perform the function without remuneration. The result of this was poor record keeping by the CDDs. Furthermore, it was observed that the health education in the communities is still too weak. Some people refused treatment because they felt they are healthy. Some of the young persons and women know very little about CDTI, which they may have heard of from their fathers or husbands. IEC materials were practically non-existent at least in the communities. The training of CDDs is poor both in quality and quantity. For a project in the initial year, especially where no organized Mectizan@ distribution programme existed before, two day training for between 30 to 90 CDDs will not achieve the desired goal. The health workers and DOT members were constrained to have such training sessions because of inadequate financial provisions. They were often told that money is only available for one training session. The result of this was reflected in the record keeping of the CDDs who were barely able to read and write. All the same CDTI programme implementation in Tanga region hold some promise for future greater successes and sustainability. To help it reach the enviable heights the following recommendations are being proposed to enhance CDTI implementation in this project area: Continued orientation, training and involvement of the health service personnel implementation levels in the villages on the APOC philosophy and their roles in the CDTI as well as its integration into the PHC system should be intensified. Adequate time should be devoted to the project for proper dialogue with community leaders on the benefit of the Ivermectin treatment, their roles and commitment in the long-term sustenance of the treatment process. They should be made to be aware of their ownership of the programme and right to make the necessary decisions. oo o a ll More personnel from other components of the PHC, media and educational institutions with skills in health education, mobilization, and gender issues should be co-opted in CDTI implementation activities at all levels. Steps should be taken to increase publicity of the CDTI programme as in other disease control programmes. A deliberate attempt must be made to improve the quality of record keeping at all levels of the CDTI implementation in the State. Efforts should be made ensure the supervision of CDDs by health staff It may be necessary to make an arrangement where outreach health workers are trained and they supervise CDDs within their close vicinity while the health staff with motorcycles supervises CDDs in distant places. The District may also create a pool of its means of transport from which the CDTI programme can draw during treatment to ensure effective supervision of the CDDs. More time should be devoted to the training of CDDs and the trainer trainee ratio should be well rationahzed to ensure effective training of CDDs considering their level of enlightenment. t2 INTRODUCTION 1.1 General Background Onchocerciasis, otherwise known as river blindness, is one of the devastating diseases, which continues to affect the health of people in Africa. Its effect on the health and socio- demography of the people is considerable in magnitude is rightly noted. It has been found out that the affected persons suffered from physical discomfort, anxiety, embarrassment, inconvenience, lack ofconfidence and depression. It has been observed that such persons were stigmatrzed, miserable and generally pitiable, and deserving help and sympathy. They were avoided by even close friends and relations, a situation which affected their marital life and general well being. The economic importance of the disease has also been recognized by a number of operation researches on its social and economic impact. For instance, outright blindness associated with the savannah strain of onchocerciasis has been known to cause visual impairment resulting in economic disability of the infected. Concern is also raised about the economic impact of the non-blinding strain of onchocerciasis, which is prevalent in the forest zones. Studies in Uganda, Ethiopia and Nigeria have demonstrated that onchocercal skin disease (OSD) has direct and indirect costs as well as impact on school attendance of children, and the computation of disability-adjusted life years (DALYs). Tanzania is one of the countries in Africa affected with Onchocerciasis and in which feasible vector elimination has not been demonstrated. The burden of Onchocerciasis is high and is a major contributor to the low socioeconomic status of the agrarian population living around the numerous fast-flowing streams and rivers as well as the fertile areas of the country. Mass treatment with Mectizan@ is currently the main control strategy in the country and this is carried in five regions in the country. Vector elimination is however taking in limited foci within Tukuyu region, which is also implementing mass treatment. Other regions implementing mass treatment include Tanga, Mahenge, Kilosa, and Ruvuma In Tanzania, mass treatment with Mectizan@ (ivermectin) commenced 199711998, with introduction of APOC CDTI strategy and with the assistance of various NGDOs, Sight Savers international, Rotary International, Helen Keller International, Interchurch Medical Assistance among others. These agencies are partners with the African Programme for Onchocerciasis Control (APOC), a global health partnership. APOC, which was established in December 1995 with the main objective of setting up an effective and sustainable community directed treatment with ivermectin (CDTI) programme in 19 endemic countries. APOC's strategy is based on the Mectizan@ (ivermectin) donation programme of the Merck Company Inc. Studies have shown that Mectizan@, is well tolerated and effective in reducing micro filarial load, improving ocular lesion, skin lesions and reduction of transmission. The studies further reveal it has anti-helminthic, anti scabetic and anti pediculosis effects, which will increase its acceptability in the endemic communities. \ 13 The CDTI project proposals are based on a partnership between APOC, the National Programmes and several NGDOs. The first grants were awarded in 1997. Each project is funded for a maximum of five years. During this period, it is expected that APOC support will decrease proportionately to that of the other partners and that the cost of treatment per individual will reduce by 90 per cent. In addition, it is expected that the National Onchocerciasis Control Programme (NOCP) will continue to manage their CDTI activities for up to 15 years after APOC, in order to guarantee effective control of Onchocerciasis. APOC's philosophy for CDTI is to ensure that the recipient communities own the programme in order to sustain it The communities themselves determine the activities. They determine where to obtain their Mectizan@, when and how to distribute it. They select their community directed distributors (CDDs); collect information about coverage that helps the determination of programme success. Unlike the community based ivermectin treatment (CBIT), the CDTI is a process building up based solely on the experience of the community members, and consequently, enhancing the decision making and problem solving capacity of the communities. 1,2 Tanga Background Onchocerciasis status of the area Tanga is one of the regions in endemic with onchocerciasis in Tanzania, with a general endemicity of 48 per cent. Helen Keller International has been assisting the State with Ivermectin Distribution Project (IDP) under the APOC supported CDTI programme since 2000 using first the mass distribution method in 2001. Before then an expatriate health superintendent attached to Muheza District Hospital showed personal interest in onchocerciasis as a problem in the area and treated people from Korogwe, Muheza and Lushoto, all in Tanga Region with the 6mg Mectizan@ tablets. With the coming of APOC, in partnership with HKI and the Region, the community directed treatment with ivermectin (CDTI) was introduced in 2000 in the Region. ii Geographical description of the area TangaRegion is located inthe extreme north-east corner of Tar.zania between 4o and6o and below the Equator and 37o - 39o East of the Grenwich Meridian. The region occupies an area of 27,348 Sq. Kms., being 3 per cent of the total area of the entire country. Tanga shares borders with Kenya to the North, Morogoro Region and Coast Region to the South, Kilimanjaro and Arusha Regions to the West. Indian Ocean borders it on the East. Adminstratively, the region is divided into 6 Districts namely, Lushoto, Korogwe, Muheza, Handeni, Pangani and Tanga Municipality. The Region has 37 Divisions, 158 wards, 700 villages and many sub-villages. The dominant climate is warm and wet. I t4 Most areas get annual rainfall of at least 750mm and the main occupation is subsistence agriculture. iii Population composifion of the area Tanga Region has an estimated population of 1,712,217 people in the year 2002 and a population density of 63 persons per Sq. Kms. Of the six Districts, three are hyper/meso endemic with Onchocerciasis. These are Lushoto, Korogwe and Muheza with endemicity levels of 47Yo,32%o and 650Z respectively. The total population at risk in the endemic 'districts is 213249 persons in 22, 42, 55 villages for Muheza, Korogwe and Lushoto respectively. ,v APOC/CDTI activity in the project area With APOC support, CDTI is being implemented to establish sustainable Mectizan@ distribution structures in the three endemic Districts. Currently, all the I 19 endemic villages are under treatment with 147,856 persons treated out of an eligible population of 179,856 persons aged 5 years and above. This gives a treatment coverage rate of 69.3 per cent, according to the treatment records at the project office. The plans for sustainability include to advocacy to the Districts and their respective DEDs to put money for Onchocerciasis control in the plans for the supervision of CDTI by the DOTs. This has started yielding fruits, as two of the three Districts, namely Korogwe and Lushoto have started releasing funds for CDTI supervision. The third, Muheza has completed plans to start giving funds for CDTI supervision. Meanwhile, it has, like other Districts incorporated the programme into the DCHP and also co-opted the DOC as a member of the CHMT. 1.3 Team Composition The independent monitoring team that was constituted by NOTF, Tanzania, on behalf of APOC to visit Tanga CDTI project, from 15th-29ft September 2002, had Dr. Joseph Okeibunor, of the Department of Sociology/Anthropology, University of Nigeria, Nsukka as its Principal Monitor. The other monitors included Mr John Nganya of Kilosa Project; Mr. Sebastian Mhagama, Mbinga District; Dr Simon Katenga, NOCP Tar:.z;ania; and Dr. Moshi Ruhiso, Tukuyu CDTI project. The team also had members of the DHMT and DOT in Muheza, Korogwe and Lushoto Districts as well as community members who acted as local guides. The team also had drivers. 1.4 Terms of Reference The team was constituted with the following terms of reference: l. Succinctly document how ivermectin treatments were undertaken in a sample of )l5 Communities with approved CDTI project in Tanga focus, Nigeria. Assess community involvement in drug collection, decision making on the period and modes of distribution, the selection of distributors, and the willingness of the community to accept and bear these responsibilities designed in the CDTI process. Document community perceptions of CDTI processes especially the issue of ownership, and expectations for Onchocerciasis control, based on these perceptions and expectations determine the degree of satisfaction of the community with the different programme activities and outcomes. Assess the quality of training received by CDDs and health personnel involved in the project. Examine the record books of the CDDs and assess the quality of record keeping and their ability to keep accurate records. The same applies to the health services staffon the project. Determine the number of communities and eligible treated and compare findings with records of the CDDs and the records at the other levels (District, Division Ward - level records.) Determine whether the health personnel participated in ivermectin distribution and assess the degree and quality of supervision by health staff (and the quality and orientation of the health staffto the CDTI) Identify constraints in the distribution and recommend appropriate measures to APOC management to be taken before the next round of treatments. 9 Discuss the prospects of sustainability based on the findings above J 4 5 6 7 8 16 2. METHODOLOGY The methodology used for the selection of the villages and sub-villages was a modified form of the methodology that was developed during the meeting of the nine monitoring team members in Ouagadougou in 1998. In a review of the tools, in a tool development workshop in Kabale, this was further refined to include a few of the things that were not previousiy taken into account. The entire endemic villages were included in the sampling iru*e irrespective of levels of endemicity and closeness to the health facilities in the areas studied. This simplified approach merely selected villages by a simple random sampling approach. 2.1 Study Design For the monitoring conducted in Tanga Focus of Tanzania September 2002, a cross- sectional research design was adopted. This design was considered the most appropriate to generate the needed data and meet the study (monitoring) objectives. The data collection exercise consisted of a triangulation of qualitative and quantitative instruments designed to collect information from different segments of the target population 2.2 Population The target population for the monitoring exercise consisted of four broad groups. These include: 1) Health Personnel involved in the CDTI process at various levels; 2) Village leaders; 3) Community Directed Distributors (CDDs); 4) Household members in the hyper/meso endemic communities contained in the REMO result for Tanga region. In addition, policy makers in the areas where CDTI is implemented were interviewed to guage their plans for sustainability of CDTI in the future as well as their policy direction with special reference to their current support for CDTL 2.3 The Sample and Sampling Procedure A study sample of thirty villages was chosen using a simple random sampling procedure. However, the sampling process began with stratifying the divisions and wards in the District by levels of endemicity. Since treatment focus is prioritized based on hyper and meso, the hypo endemic divisions and wards were excluded from the sampling. Consequently, six hyper/meso endemic wards were chosen through a simple random sampling process (balloting), from three Divisions, one Division each from the three Districts under the Tanga project. The selected Divisions include Soni/Bumbuli for \ t7 Lushoto District; Bungu for Korogwe District and Amani for Muheza District. The chosen wards from the sampled Divisions included Mamba and Mayo for Lushoto; Dindira and Bungu for Korogwe and finally Mlesa and Misalai for Muheza Districts. The villagesr in the selected wards were listed on pieces of paper and six wards were randomly selected by balloting. Category A and B Villages: Having selected the six villages, one from each of the earlier sampled ward to be visited, the sub-villages in the chosen villages were listed Thirty villages were randomly selected from this list. Another random sample of six villages out of these thirty sub- villages chosen earlier were taken as category "A" villages while the remaining twenty four villages became the category "B" sub-villages for the monitoring exercise. Unfortunately these villages could not be classified into hyper or meso because the information was not available. The only information available helped in eliminating the hypo endemic areas from the exercise. Table Al: Focus: DivisionsAilards/Yillages and Sub-Villages Covered in Tanga Project Districts Division Wards "A" Sub-Villages "B'Villaqes l.Lushoto l.Soni and Bumbuli l.Mamba l Mbelei l Mamba 2 Mtindili 3 Bomo 4 Lutindi 2 Mayo 2 Mafelee 5 Mayo'A' 6 Buai 7 Kwekulo 8 Kizanda 2.Korogwe 2.Bung 3 Dindira 3 Milongwe 9 Mtambalae l0 Kweulasi 1l Kwemsala 12 Kwemuohoyo 4 Bungu 4 Bungu Mission 13 Mtunda 14 Kwebanda 15 Kwemadanga 16 Gare 3.Muheza 3.Amani 5Misalai 5 Miselai 17 Mlalo 18 Vungwe 19 Balabalami 20 Kigoma 6 Mlesa 6 Kwamandenga 2l Mlesa 22Ugamba 23 Mtakuja 24 Sangarawe TOTAL 3 6 6 24 I Here villages are the same with communities in Nigeria and elsewhere while the sub-villages are equivalent to villages in communities as used in Nigeria and other places with similar usage for the concepts. \ 18 Households: In each Category "A" sub-village sampled, fifteen households were chosen. To do this, the sub-village was carved into three clusters guided by the village head and local guides. The systematic sampling approach was then applied to select five dwelling units from each cluster. The sampling intervals were determined through a quick estimation of the number of dwelling units in each village-cluster. This differed from one sub- village-cluster to another. In each sampled dwelling unit one household was randomly chosen for the treatment coverage study. Furthermore, to check on the correctness of treatment, one household was randomly chosen, and the dosage for one household member, randomly selected and crosschecked. CDDs and Village Leaders In each Category "A" sub-village sampled, the sub-village leader was purposively selected and interviewed. The sub-village CDD was also purposively sampled and interviewed. In cases where there were two CDDs both of them were interviewed, but where there were more than two CDDs, only two were selected by balloting. Similarly, the sub-village leaders of the Category "B" villages were purposively chosen and interviewed. The sub-village CDDs were also purposively chosen and interviewed where the CDDs were two or less. In some sub-villages with more than two CDDs, two were randomly selected for the Category "B" sub-village CDD interview. Health Personnel and Policy Makers: Various cadres of health personnel involved in CDTI process were purposively selected and interviewed. These included Supervisors, District Onchocerciasis Team (DOT) members and Coordinators. The Coordinators of Primary Health Care and Health Oflicials at the District and Ward levels, involved in the CDTI process were also purposively selected and interviewed. The purpose of these interviews was to examine the orientation to CDTI process and provide information on the records and quality of training they receive and/or give on the CDTI process. Policy makers at these levels of the health systems' operations were also purposively selected and interviewed to give idea of the support of the policy makers for CDTI implementation as well as their plans for the sustainability of the programme. 19 Instruments Eight instruments were used to gather information from both Categories "A" and "B" sub-villages as well as at the District and ward levels. Copies of these instruments are included as appendices to this report. Table A2: Summary of Instruments and Sampling Issues Instrument Category of Sub-villages and Unit Sample Sampling Procedure In-depth interview & Record review with CDD A&B | -2per sub-village Purposive (Simple random, where there are more than2 CDDs) Household coverage survey A 15 households per sub- village Multi-stage (i.e. cluster, systematic and simple random Key informant interview of village leaders A&B I village leader per sub- village Purposive Group discussion A 3 groups per sub-village (i.e. I male and 1 female adult; and 1 female or male youth groups), 6-8 persons in each group Convenience Health personnel interview A I PHC coordinator I Oncho coordinator I DMO per District I LOCT member I health centre staff Purposive Programme manager/Policy maker interview Project, District & National levels 1 Director, Disease Control per District I NOCP Staff 1 Project Coordinator, 1 Supporting NGDO staff Purposive \ lio -oEtr ?z O\ O\ O\N c.l o.l o\\o\oN \o \o \o E() o II tI 0)'=b0trSE -o -o o\o\o\Oci [-- i -Naa .ro.roa o\ o\ -ot- t'- o\#-r\ idC.l IIII Eo -'=o0ii trSE EFfiE s II l- -c !l*!.V(B= o-vEF \o o\^N io-\O o\ oov I I a o\ t--\o $ II r.o o\oO \o o OI) t- <o iri >(J II yO o\ co tttt- II 0) oo !,s6 >E II IIII op bo '= -di)5> \o \o \o6i: 6\ 61\ta)OO ai O\ O\ C)\o\o *N(\ \o \o o\ o\o\Of- ci O\H 0o \-/vv\o dtr)(\ \O \oo\ o\OOOO i roro v) o (n C) o LE: EEE^f 5€EH u) rn.6 EYh oE.3:9Ua E s,pt 5AEa:'5i ^E-:t o EEES# = A €EEE1€€u3-.E.8ts €)E-vP: b E - .r € = o)-Y o o't:># o(Jo. o 3.E8" -- I-doE ! i- i IO;r'uL/ .Z.EEz ;Hb.ESJsE 3,E E #dJzatr(r. o. (\I :o o\o-O^O-!\o ino\:(r) v- V.a Oox6. ,, ll \oll p t-l tr(l)ll9 En E EN9.:vr5L tr!=oBeE oEor-o -c';i!r iDt otrt o)(l)q) ::6gu-oog EE^(1) 0.)^\E! r' ooco)or<E'O i ooE: EE'" ch v)E0)(1){-jb0 bO o>6(ll- ;H.Fi -E ., u) (hq)(l)O trtrtrooooooq< q< qiooo t<Ll<o()o -o -o -o E€Etrtrtr(d(dcd trtrtroootrtrtroooo- o. o.oooLrt<HOrolA t-l Ntlfrl f-l U) U)q) €)L G ti o\ q) (l)I (l) o0 cl o o)q1(u I oL 00 G I o U2 q) q) a () ti oLo c!I ! O3j a riil ?o I I I I I I 2t The decision-making processes on issues of timing and mode of distribution as well as CDD selection were employed to gauge the level of community involvement and ownership of the programme that exist among the communities. Here, decisions that were reported to have been taken in village meetings were taken as indicative of the ownership of the programme. Looking at Table 1, only a total of 29 village leaders in categories A and B villages, were entered in the analysis because one of the sub-village chairpersons traveled out of the community at the time of the survey. No one could deputize for him since the people maintained that sub-village chairpersons have no deputy as they are themselves deputies to the village chairperson. CDDs in categories A and B villages were interviewed. Focus group discussions (FGDs) were also held with people in category "A" villages. The Table shows varied responses on who decided on the mode and timing of distribution as well as selection of CDDs. For instance, only about a third (35.0%) of the village leaders reported that the community in a village meeting took the decision on timing of distribution. Decisions on mode of distribution (90.0%) and selection of CDDs (90.0%) were taken in village meetings. A look at other segments of the village leader interview however revealed that in some villages, the village elders, and village health committee took the decisions. However, in sixty-two per cent (62yo) of the cases health workers took decision on the month of distribution Similarly, 67 per cent of the CDDs from category A sub-villages interviewed that health workers took decision on the month of distribution. And in the FGD it was noted that the decision to distribute in a particular month was taken by the health worker. This, as will be demonstrated from the review of the CDD treatment records is responsible for low treatment coverage in many areas. According to one of the CDDs, in an interview, "people refuse to take the drug because it disturbs theirfarm work", Corroborating this, one-health personnel from Muheza interviewed said that, "they complain that it is the period of farming. The people will appreciate it if it is given to them during the harvest season, which is around June/July". And when asked why they distribute drug during the planting season, the health personnel replied saying that, "that is when the DOC brings the drug. The drug comes in January andwe cannot keep it until June/July because the project year will be over and we need to make returns" From the FGDs, where different segments, namely, adult males and females as well as young males and females were involved, it is observed that all of them indicated that the decision on the timing of distribution was taken by the health personnel in-charge. 22 In measuring the indicators (E-1 and E-2),the responses of the village leaders were used. This is because the village leader information appeared more representative by virtue of its geographical coverage of categories A and B villages, and the three subjects, namely, decision on mode and timing of distribution, as well as the selection of CDDs. The FGDs were limited to category A villages, while the category B village CDD interview did not ensure the collection of information on the timing and mode of distribution. Following from this therefore, it is observed that 35 per cent of the communities indicated that the decision on timing of distribution was taken in village meetings. On the other hand, in 90 per cent of the cases, the decisions on mode and as well as selection of CDDs respectively were taken in the village meeting. Fig. l: Gommunity Participation in Decision ilaking oo ct(E +,e o(, L o o- 1O0o/o 9Oo/o 80o/o 70% 600/0 500h 40% 30% 20Yo 10% Oo/o @Month GMode trCDD Selection Village Leader CDD FGD Sources of lnformation \ o)aq)! C)H () dolr o l- € (h ot) 63q)Lqr o aq) bo CB (.) oLr 0) o. (!) F r-: o) 0.) Bo H EgHRIE9l<9 P9 trq){'o !x CBL t<t€opandc9o -aJ6()g €g HPo>\ a.o 5ath6 obs(l)9l< eo .hC KJ € q.> s3 6)t ,.:3E - ar) cdE o.= €li o)o .< o.r<o dO. \oo\ oj 00 o co ca il €ao t9GE\O o\ iu\-7- >lal r- '- ll -- 0) tr -.1OJ a) 'Err I EE e9P! .sEB Ybor ,Euts(B CB= P arcEktr Oia ;S E >€r-rts y? ..,Y6scBth262 ,taA!E€ & t+( t+< (Hooo li li l-rq)()c) sps (€(€d ooo P.PIi oooa.p.aoooLLL Q.< 0.i F.{ t-r al OOttlooo q) O 4) q) tr e( Fi tr c( a q) 6)Ir - N o c! Fr 6l 9p <,€<Ui ENH EH Ei rCavz 9-l-rl \o&cq \o ^ z \oo\ C.l \oo\O\n o,l \J qO o\oilVv s BE KPr\t i- aF \o ZC rO o\ o\ ao c.l v \oo\ co 96 s \OK s6pti- ?;N(,EE - (,Fa E== HsEr- Oroza yO o\ F$ \oo\ oo=tnv \v o\ oo rn c.) o\ v oO ia6r=t.) i/ o\ :.Dg Hs Orozc \oo\ -S) s -S- -o o\ .t F-9 to= s -NEE o '6rI.] r--@) rhZ() Z dxY iJ =Atrdv O^ E( ot Orozc \o o\ ss3 1O 6\ oo$coi s FO S5 9-;-Ir oO Oroza \o6\\o s$x sm= s €8 t! ,B !gH ==v Hx Oroza s \oo\ -9 -o o\ €8 s E9 s !f,:6F 3 c..riJr rt OGza II oi .o o\OO sNR s_r-rt i- 3o F ?BE rs ;: F/az) O rr.1 =l- OroZO o\$ \o o\ \o s\o @ s F.9 \r =aYO\ a^ iJi I-- Oroza \oo\$ \oo\ o\Ns, rO o\ tr- TYJ s t- iJ s €E 'i - ri 6F caEAEr€Da2J 9.*ti{ t--E c.t o ..oza \oo\q O9 \Oq\FO\ .6 ^o\#o\ s E3, x HH a^ iri \o Oroza -oo\\o ,n9 o\+$g s lrJ o\ i.; slaEE trlo Hi5 <>diEHtdE d d o F,( U) t) () (n Q,)(l) ot2 U)L 4) () CJL o z o) clq) lr3 I I t I 24 Fig.2'. Treatment Records from CDD Records and Household Survey lOOo/o 9Oo/o 8oo/o 70% 60o/o 50o/o 40o/o 30% 20o/o 10o/o Oo/o E Q) oo F o C,)o cooL o TL .,i| $r"' $O- ""- ".;}o' s"* + .o{e Gommunities The Table (2) above presents no definite pattern in the comparison between the results from the sample survey of household treatment and the treatment summary from the CDDs' records. In half the cases the records show lower proportions than the sample survey results as in the case of Mbelei (56%); Mpale (70%) and Misalei (54%).. In the other half, the reverse was the case. The CDD records show higher percentage coverage than the household coverage conducted for the same purpose of ascertaining treatment coverage in the communities. What is impressive here is that the CDDs at least maintain records of treatment though with varying degrees of accuracy. Treatment records were generally poor. It took the monitoring team long hours to fix the records and make meaning conclusions out of them. This was blamed on the literacy level of the CDDs. According to one of the health personnel interviewed, "some CDDs complete the register before distribution. There ls low understanding capacity among them, especially among the /bmale CDDs. The educoted ones refuse to do the work because there is no payment attached to it" Comparing the results of the household survey and the treatment records of the CDDs did not show much except that one had to patiently study the registers and ask the CDDs questions for clarification before aniving at any meaningful conclusions. For instance, in Muheza, CDDs record treatment on rough materials and fail to transfer the same onto the actual treatment register. The use of the term "defaulter" makes is difficult to conclude the number of refusals and absentees. Furthermors, a comparison of the treatment coverage for the current year reveals in three out of the six villages visited there were increases in coverage, where as in the other three there were slight falls in coverage. These are shown in Fig. 3 below. trHH Survey GCCD Rec 25 Fig. 3: Comparison in Treatment Coverage Between the year 2001 and2OO2 o o)(E o oo o E') TE o e o o. 100.00o/o 90.00% 80.00% 70.O0o/o 60.00% 50.00% 4O.OOo/o 30.00o/o 20.OOo/o 10.00% 0.00% 8r2001 32002 Communities Table 3 Proportion of Villages treated and in which CDDs were changed after the first treatment O-3 Proportion and number of at-risk villages treated:30 (100%)O-5 Proportion and number of communities where CDDs were changed by the community after the first treatment : 3 (10.0%) Table 3 simply reveals that all the thirty sub-villages visited had been treated. And in all only three of the sub-villages representing l0 per cent of the sub-villages visited had changed their CDDs since the first distribution. These are found in Bungu ward of Korogwe District and Misalei and Mlesa wards of Muheza District. The reason often given for the change had to do with the CDDs getting married and relocating from the sub-village. Wards Sub-villages (Both A and B) Treated CDD changed MAMBA (Lushoto) 5 5(1 00%) MAYO (Lushoto) 5 5 (100%) DINDERA (Korogwe) 5 5 (100%) BUNGU (Korogwe) 5 5 (100%) | (20.0%) MISALEI (Muheza) 5 5 (r00%) | (20.0%) MLESA (Muheza) 5 s (100%) 1(20.0%) 26 The reasons for retaining the other CDDs according to the village leaders include that the CDDs are doing their work well. All the category 'A' interviewed on the performance of their CDDs attested to the good performance of the CDDs and further justified the reason for not changing CDDs. In describing the performance of the CDDs, they often made statements like, "Drugs are distributed properly and timely" "(CDDs) make sure everyone gats the drug" "They are doing the work with no problem" Some of them also noted that their CDDs take the jobs as theirs "this is my community" " ... help my people with it" " It is service to " Itwill be a source offuture joy" "the people's thrst" communiQ/" These are good for the sustainability and continuity of the programme. It will promote the existence of a pool of experienced CDDs overtime willing to carry on the programme. Table 4 Proportion of villages which received health education, and in which health care nnel su CDDs 0-6 Proportion and number of communities in which the CDD is supervised by the health care (communities scoring 50Yo and above) :4 (66.7%) O-7 Proportion and number of target communities which received health education : 6 (100%) Wards Sub-villages (Both A and B) Received health education (YesA{o) CDD Supervised by health system MAMBA (Lushoto) 5 s (100%) s (100%) 5 s (100%) 2 (400/"1MAYO (Lushoto) DINDERA (Koroqwe) 5 00%)s(l s (100%) BUNGU (Korogwe) 5 s (100%) 2 (40%) MISALEI (Muheza) 5 s (100%) 4 (80%) MLESA Muheza) 5 s (100%) 3 (60%) I Similarly, all the CDDs in this category of sub-villages indicated their willingness to continue with the programme because, in their own words, i 2',7 Table 4 above shows that all the sub-villages in the six villages visited received health education. It has to be noted, however that the data here were collected from the CDDs, who indicated that they have received health education. This is because the analytical guide directed that such information be collected from both categories A and B villages. All the same data from FGDs did not confirmed the results. In many of the cases, when asked if they were given health education the participants in the FGD session keep quiet. But when other questions were posed to find out how many they are expected to take the drug and the benefits of taking the drug for instance they open up and say things like, take ivermectin yearly in order to make the worm sterile", Their main source of information in this case is from Radio Tat:.zania and this is mostly among the adult males. The adult females as well as the youth, both male and female alike know very little in terms of the health education content of the programme and hence could not discuss this aspect of the programme. o>,4L EEEcqr EF9 a* o 16 o\ tr) yO o\OO rat O o O .9E*t?rE; TE E Ei I I I I ()r-Ec) 8 .ELr- 6) -& -o o\OO tr) -o o\ O .o o\OO ra) -o o\OO \,^) soO ra) so (n EO =c)0l) 6)i >a so$ N \oo\Oo rn \o 6\ o rn sOo (n 1Oo\ @ $ \oo\O\o aa EO .9rti c o9 sOo rn -oo\Oo rn \oo\OO ra) soO tr) \o o\oO ra) sOO rn c)b! €l o0E =oAA I I I I I I EEB6!=AA I I 9- 'iai:nF9 \o o\ \n sOO tr) .o o\ O lr) a o\ la) -o o\oO tr) o\ 00 .f, 8aAs€ ==1(/) >\> r la) rn tr) tr) O B <6 FqE az{=Eg oOEr'z<=Eg teti btAO26i-l \-,A- €) REl,/ oz\) r,.lA- HeJN <-E9EEA <sae)f.l € E3 oo al \o 6\OO -v O ca il L0) € (l) o € (o0) '.o' *o\ t< c') ao +a aa .= \J\oooa-aO- -u-o ^'o\ E llVq.g o rrOH O ,;g E .Err a ;EcI .Po'.= E Etr () o -\u)F 9,E S€ ^9 E c ! crro l- (D'5 - tR :.2 t? .^.U I ,; I<* ESo cx3o FA.i cXsugi r;N6.:-v!.:- L*-EgNar o- (a q ll HEAEE-{ 6) l- H5 g E 8.P a if!r-d) -o 6,) o* C) =-tral.r.iVHF! = l- r<.= v E.ir . &tt PE FLrri5.r-.=*cr)P hi hi (, l-€ (D -q;;.97-c'; .E (€ (B j-j:.ts'=B€€.E E } Ev)v)aitr<r:Hoo(uE-()c :-.iu9€!H9€I H.-.- Vccco>tr() = 3 ) t) t A*EEEITXEUE E E 5OX E EI 8I E5 8 g(H (1-< +< (H +r (.r1 (51ooooooo l<lili!t<t<l-(l)oo()o(l)0) -o-o.o.o.o-o-odst4444HHFHFFF )J))))) dt44 EE€€!EEqtrtrtrtrtrq(soO(gCddcd(o sstdF4d .E .E E g.E g.g Lt-litit-til<oooooooo.o.o.o.aoooooooooliHLLtit<L<AA0<OiAOTor th ar)q) q) tr cltr o\ q) €) Q q2 tr o (,) in o) E clF T t in \O r-.tttti-l li l-l - -Gltl -- 29 Table 5 above reveals a good input indicator status for all the Districts and villages visited. In all cases it was observed that CDDs have been trained. The only case where it was reported that CDD was not trained was in Mlesa ward of Muheza. Here, the CDDs could not be reached as were said to have traveled out of the village. They however made their register available for inspection. The interesting thing here is that in each sub- village there are two CDDs, one male and one female working together to distribute the drugs. Apparently, the female CDDs were supposed to protect the interest of the female folks. In terms of registers, all the sub-villages visited had treatment registers. In some like Mayo village in Lushoto District, the village Chairperson maintained a village treatment register which contained the treatment profile of all the sub-villages within the village. Furthermore, it was observed that they all collected the drug from an agreed collection point. However, it is important to note that the interviewers and interviewees often misunderstand this aspect of the instrument. The respondents often respond by saying that no member of the community collected the drug from the collection point, which is often the village dispensary. But when asked the reason for this, they respond by saying that, "...it is only the CDD that is allowed to collect the drug from the village dispensary" None of the villages visited reported cases of late supply of drugs. There were two reasons responsible for the response. One was that the drug came early in the year even though to the discomfort of the people. The second and perhaps more important reason was that the people did not decide on the timing for distribution. The village health workers took the decision in conjunction with their respective District Onchocerciasis Control Coordinators. Surprisingly, the village health workers did not know that the distribution time most depend on the time chosen by the people and not the availability of the drug. According to one village health worker interviewed, "...they complain about the time of the drug, that it disturbs themfrom working in their tea plantation. ...We cannot keep the drug till the harvesting period in June/July, which the people prefer. The drugs come as early as January, and our project year ends in March so we hwe to distribute it before the end of the project year so that we can make our returns". B30 Constraints Management Some Local Governments or Council Health Management Teams demonstrated support for the programme by releasing fund for training, supervision and monitoring activities. These were specifically in Lushoto and Korogwe. The third District still depends on APOC funding with a promise to release fund next year. In this council area as in the other council area supervision is poor. The health staff in the field also has faced logistic constraints due to inadequate motor- cycles and the wide range of areas to be covered by one person. In some the village health worker has to supervise as many as ninety CDDs alone. In one of the areas visited, the health worker noted that she has as many as forty CDDs to supervise. Some of them live far up on the mountains but for the last treatment period she had supervised only three. "Only three of them have submitted their records to me so they are the only ones (out of over thirty) I have supervised. I do not have motor cycle an I cannot climb to the mountains because I am sufferingfrom arthritis" t, Technical A few rural health staffand the CDDs interviewed showed poor knowledge of the APOC philosophy and the right process for the CDTI implementation, particularly in terms of the timing of distribution and decision-making. This may have adverse effect on the quality of CDTI implementation in these areas. Record keeping is still very poor revealing the poor quality of training given to the CDDs, most of whom could barely read and write. C Community Perception Community perception of CDTI programme varied among and within the villages. A few had complains to make about the timing of the distribution, others argued that they do not need the drug since they are not sick of any ailments. On the other hand, however, many welcome the programme and perceive it as theirs. According to an elderly man in Mayo village, "...my people are very hoppy with this programme and they like the drug a lot hence you are able to find them here in spite of the rain. " And at the official level, the various District governments visited understand that the programme is theirs to support and sustain. In an interview with the District Executive \ I 3l Director (DED) for Korogwe District, she noted that they are poised to see that the programme succeeds because the people are really suffering. When asked what supports the District is giving to the programme, she replied with a question, " ...who is supporting who? It is our problem and APOC is the one supporting us to control it andwe very much appreciate the support you people are giving to us. Now we btow about the problem; the Council knows and everyone know what the people in the Bungt area are passing through. Since then we have included it irt our District Comprehensive Health Plan (DCI#) and are making budgetary provisiorts to cover it. Each year since last year we budget 9,412,800 shillingsfor -it. Last year we released 236,000 shillings and this year we have so far released over 300,000 shillings. This is the typical reaction of the administrative and political set-ups in all the Districts visited, except for Muheza, which is yet to release its own funds for Onchocerciasis control activities. It has however incorporated it in their DCHP. Further more, the Ag. DMO noted that as demonstration of their acceptance of the programme as their responsibility, "...the District Onchocerciasis Coordinator (DOC) has been co-opted into the Council Health Management Team (CHMT). This year we invited the Regional Project Coordinator Onchocerciasis to inform us on what should be included in our planfor Onchocerciasis controlfor next year. ...Our aim here is too give the programme effe ctive assi stance " <saq)r-r E >3 *:tsEE ts!d 9or botr :E 0< 4 .i-- - E ' ='E E F e,, -E'' E.E E6.=;- i4 litr HEi€EE€;Cfr f ai o.U o =t o g"E:€ H fOE.EE.: c+jdul .;i (gEze,.B EssEete .I: a(dh8o E"E >-O -E gl< a'-C)'.= aLJ () ii E B€ r trl ciEa= -ts,l>3 *sgH5€tsO O-|-.1 o+iE E<Y O E9E3OE7 a,E - .hEEp-*-SEl6.=; f? I 61;+i cs o 6 6 tr :E EE=EEE EIrr 5 O O.d =E O. 9EPb EE ! 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EE€ Ur-O atsEfl:- Er-/ E .g EgEBE (r) , qY q) H 0) F -lh& o()d9.E E g d 'E(.) a(B<=d() E=(,H o Fuo .qFtrF O= ooiJ-tE: B€ .EtoP =*aiP.. i'v ) G)Eti>?-y P E 5t S rtUHHar,/o-Y(di3 q)h trc qE= sr(J Fcl bo u oao& a0 E .E. B EEtrv E t:ESTFF6e E a 8E a>r O .i-! -ha -o :oG =tr - - a -Tttr u s1 ----v<EH! .E.= tr _EHGEE* EE-I A -9vt\ F 9L./Etr€) ca \ () (l) -o € EoO '60}U =ts€E€ 9FE -6 8tr,.E-E.=:E ..PE =E€ S* * E ,i > EY o o\J (D.=El E () B8E gE€ btsEEuEE:- EE; - -r.E.5g'go 5I#:EE;tf:A oa!= (.> c -6 I -cB6 (g ':i'.=t 5'E LF-J ,.E 9 E ..9 E-9 H =6Fo<85'; E:! e o.l o o(r ! q: () q)#E€r;g*f6 EEE :-E t5E;;g'F. ET2 6 o 5 =s E IE E ESE E s9,,.= 0) o tr > tr!-O =ts€E€ I eEE d5 E !!d-FiXo.=().= > tr ..P89 ) E€ Sx E 'Y t tsW - oU,/ o.=Fl .= tJ B8E gE€ .!:€FubE EeB' - -r.E.igogo=E o .e€ 'E'E.s-'iT scr,EE;EEEe vt\ ot E ,n '- 9t e 0) € !.nE :E'EC) "-o J/LF E6 Hq.).9 > =.. P Eg U E€ Fx+ cI ts.E 5.= E8: E€E€€fiEpE -E bu - -: -. bgP^ ES E;*eE,E t;;au6€.= 5 - a E€€ =ts€E€ I eEE dE B - --ts ^(D .ts(l).= > c ..P89 =E€ Sx Ex > EV - oU/ (l).=Fl .= o BgE gE€ .E!€ E e.bE E E5 - ^r.E.Fgogo s ?- .= E E'E -g' 'E 10 SCE, EEEEEIe =ts€E€ P) eEb dE * -4-F< Xo') .ts(l).= > c ..Ptso =E€ Fx E 'i t EY - O\J tD.=El ,= () B8E gT€ ET€ ,8ubE Esr - -,.E.fsto=E r,. .gE E'E-g'rS 5EE,EE;$Ei5 Ftrbo-oo boo =!ET E.EoOl,tr + ca Table 7: Quality of CDD Training in Category 66A" villages (o/o in Parenthesis) Ward No. of CDDs No. Trained Length of Training No. Trained in a session MAMBA (Lushoto) 5 s (100%) 2 days 92 MAYO (Lushoto) 5 5 (100%) 2 days >30 DINDERA (Koroqwe) 5 s (100%) 2 days 66 BUNGU (Korogwe) 5 s (100%) 2 days 50 MISALEI (Muheza) 5 5 (100%) I days 36 MLESA (Muheza) 4 s (100%) 2 days >30 Tables 6 and 7 take a summary look at the quality of the implementation of CDTI in the project focus. Table 6 looks at the implementation of components of CDTI at the ward levels. Another issue that came up as an area of concern is the success and sustainability of the CDTI process. This is presented on Table 7 above. The Table shows the quality of training both in terns of length of training and the number of CDDs trained in each training session. In all six village and 30 sub-villages visited CDDs reported having been trained. However, with respect to the length of training, it lasted for between one and two days. With regards to the number of CDDs trained in each training session, it was observed that it ranged from more than 30 to 92 persons per session. Ea 36 UNIQUE FEATURES OF THE PROJECT AREA Strengths One of the greatest strength of the Tanga CDTI project area is that there has not been any organized Mectizan@ distribution programme in the area before the introduction of CDTI. Thus unlike areas which had practised CBIT and in which distributors were remunerated by government or international agencies, it will not be so difficult to instill the spirit of community ownership and voluntarism in the community members. There is a good spirit of cooperation among the project, the health systems and the NGDO partner at the Regional and District levels. The Districts have not only included the control of Onchocerciasis in their respective DCHP, some have gone ahead to budget and release funds for supervision of CDTI project, which is integrated into the routine supervisory system of the health systems. Officers in the health units of the Districts other than those scheduled to oversee the control of onchocerciasis control programme supervise the rural health workers on CDTI. In some communities where proper mobilization has taken place there is high consciousness on the programme. Such villages are willing to support the programme and ensure its success. In Kwamandenga sub-village, for instance, villagers contribute one hundred shillings to support the CDDs The training of CDDs at village level, as recommended by APOC has increased the number of CDDs trained at reduced cost to the communities and also created much awareness in the communities. Some of the communities see aspects of the programme as catalyst fortheir own village development. For instance some of the villages have seized the opportunity of developing and maintaining census and treatment registers for CDTI to develop their village census register containing vital statistics of the village population. For this reason some village chairpersons participate actively in both census update and distribution of the drug. Their presence encourage the people in such communities to take the drug. There is also evidence of integration of CDTI programme in PHC at the District level, in terms of sharing logistics and planning of CDTI activities in line with PHC programme in the areas. The presence of monitors/monitoring teams has helped to create further awareness. This awakened the DOT to certain salient areas where they had been weak. According to one of the DOT member "...the presence of monitors has helped to open our eyes very well on what we should do qndwhqt we should not do. We can make our correction". 37 Furthermore, it was observed that prior to the monitoring visit, the Regional Coordinator along with the National Coordinator had in June 2002 invrted the policy makers and political leaders as well as the DMOs to a sensitization workshop. These leaders came out of the forum well sensitized and are now including the control of onchocerciasis in their respective DCFIP and making budgetary provisions and releasing funds to support the programme. In some cases, the Regional Project Coordinator is invited to participate in drawing District health plans to ensure that CDTI is adequately represented before going to the Council. It was also argued in some Districts that, it is now part of their main focus. According to a DOC, when asked about the plan for sustainability, "....for my catchment's area, I am very sure the projectwill continue if APOC stops. Our District has included the programme in the 'Basket fund', so sustainability can be good infuture." And the DMO for the same District (Muheza), argued that, "...the problem in the past is that people did not know . Now, after the seminar the DED and the council htow and wish to support. We have already discussed in the PHC meeting" And on the sustainability of the programme, he said, "...we have already started by incorporating it into our plan. The 'big shots' in the District are qware of it andwill e:want to htow why it is droppedfrom the planfor any year". In another District, the DMO noted that the acceptability of the programme by the District leadership is a very positive thing to be happy with. According to him, "the first thing is approval and acceptance of the programme. The Council recognize the problem and the help from APOC. This is important for sustainability. The money brought in from the Central Goventment come through the Council for running the motorbikes. We have a block grant from Central Government for development. The Local Authority allocated over 300,000 shillings from the block grant for onchocerciasis control ". a Weaknesses One major weakness of the CDTI planning and implementation in Tanga CDTI focus is the nature of the CDDs and the rural health workers. The CDDs are barely able to read and write. The more enlightened members of the communities refuse to perform the functions of CDDs because there is no monetary attachment to it. Unfortunately, the rural health workers are not empowered to ensure effective supervision of the programme ! 38 for proper implementation. The rural health workers who should supervise the CDDs lack adequate means of transport to cover the vast areas and the many CDDs within their area of operation. This is closely related with the decision-making processes. Here, the health personnel make decision on the timing of distribution and in many cases their decision run counter to the period the people think is most congenial for them to take the drugs. The number of CDDs they had to supervise overwhelmed the rural health workers. Most of them complain of inadequate facilities for movement within the diflicult and mountainous areas to effectively cover the CDDs during distribution in the early stages of the programme. Most of them demonstrated lack of motivation and enthusiasm to do the work. Mobilization and health education is still weak in some areas. Health education/IEC materials were lacking. 39 4.0 DISCUSSION AND CONCLUSION Treatment coverage rates are impressively high and above 65 per cent in the communities visited as shown in the household treatment survey. More importantly, the result is the same for both years of treatment, that is, 2001 and 2002, indicating some form of sustainable high treatment coverage rates in the region. It was also noted that both the political leaders and health policy makers are well sensitized to the problem of onchocerciasis in the region. These leaders are currently poised to fight the disease by supporting the programme. Many noted the kind assistance of APOC in this direction and are designing strategies for sustaining the programme in their respective areas. The current spirit in these leaders, the plan to support the programme from the 'basket fund' and other District resources are encouraging pointers to the success of the programme in future. In addition to this, at the different levels in the region, officers charged with the control of onchocerciasis are co-opted member of health planning committees with a view to ensuring proper representation of CDTI in the health plans. Similarly, it was observed that most communities are enthusiastic about the programme. The sub-village leaders are involved in mobilization, census update and distribution of the drugs to community members. However, it was also noted that in some communities, the village leaders were not fully involved in the CDTI process. Here there is lack of suflicient knowledge about CDTI and community responsibility among the leaders. In the words of the health worker in- charge of one of such communities, "the work is left to only the CDDs. It is a CDDs' affair. The sub-village leaders do not show interest and as such the people are not encouraged to take the drugs". It was noted that in villages where the chairpersons show sufficient interest in the programme the people cooperate and take the drug. Conversely in such village where the chairpersons show lukewarm attitude to the programme the people are less cooperative. Furthermore, it was observed that in almost all the villages visited, the rural health workers determine the timing of treatment This adversely affected treatment coverage as the people complained that it coincides with their agricultural calendars. For many it comes at a time when they are cultivating their tea. With the experience of the previous year, when many were weighed down by the effect of the drug, many refused treatment the following year for fear that it will disrupt their farming activities. This accounts for the drop in treatment coverage noticed Mafele, Kwamandenga and Milongwe. It is thus necessary to educate the rural health workers on the importance of abiding by the timing for distribution preferred by members of the communities. 40 There are also the problems of supervision and training. Supervision is very weak as the rural health workers complain that they lack the necessary means of transport to cover too many CDDs during distribution. Supervision of CDTI activities is not yet fully integrated into the health supervisory systems. Training of CDDs is equally weak. On the whole, CDTI implementation in Tanga region appears very strongly rooted at the higher levels with the fulI awareness and involvement of the political leadership as well as health policy makers. At the District and regional levels there exist clear demonstration of both political will and financial support for the programme. The health system at the District level is fully aware and in support of the control of the disease and are making good plans for the sustainability of the program. However, the same cannot be said of the lower levels. Some communities have not been fully involved. Health education is not adequate and CDDs are poorly trained. For the sustainability of the programme at the lower levels more needs to be done in terms of empowering the rural health workers and training the CDDs sufficiently. There is also need for more elaborate sensitization activities at the village levels. o4l 5.0 RECOMMENDATION I To the Project: Training of Health Staff The current training period for the health staff is adequate. However, during the training time should be set out for practical work to ensure good comprehension of what is taught. Training and Supervision of CDDs This should continue within the communities. Initial training should be for at least three days, while retraining activities can be for two days. During the first three-day training, a day should be set aside for demonstration on record keeping, census taking and reporting. The current trainee-trainer ratio should be discouraged. Too many CDDs in one training session will not make for effective training. The ratio of trainer to trainees should not be more than 1:15. More training sessions could be organized to ensure compliance with the acceptable ratio. More funds could be sourced from the Districts and some of the money used for supervision could be put into having effectively trained CDDs. o The involvement of literate members of the communities, such as teachers CDTI implementation at the community level should be explored, to help re-enforce training and record keeping at community level. The villages should be sensitized to convince the literate members of the need to serve their people. a More attention should be paid to the aspects of record keeping and reporting during training, particularly with regards to household treatment and documentation of colour for easy assessment of treatment accuracy. Training and supervision checklists should be made available and used to assist in these activities. Supervision should be emphasized at all levels, especially health staff during and immediately after distribution for the CDDs. Record Keeping and Reporting The quality of record keeping at all levels of CDTI implementation in the State still has room for further improvement. o o o o a ao o Approaching the Health Services and the Community To ensure a proper implementation of the project, precise and concrete steps must be taken to conduct proper orientation of the health personnel and members of the villages. It is recommended that the project intensify the following: Training and orientation of health personnel on the policy and implementation of the APOC philosophy and their roles in CDTI should be encouraged. More health personnel, at all cadre, should be involved and made to understand that more commitment is expected of them with respect to mobilization, health education, training, supervision, monitoring and reporting of CDTI activities. 42 Adequate training on household recording and recording of treated persons immediately after administration of the drug should be emphasized. Continued dialogue should be held with community leaders on the benefits of ivermectin treatment, their roles and commitment in the long-term sustenance of the treatment process should be emphasized. Mobilization should continue to target everybody, including women, youths and as they have been found to lack good knowledge of the CDTI philosophy and process. Supervision of the community by village leaders and health personnel should be directed more to periods during and after distribution. Integration of CDTI into the PHC System The current level of integration of CDTI into PHC in Tanga Region and the Districts is good for this early stage. To District: The Districts must be very active to ensure that the facilitative role of APOC is felt in the first and second years of implementation of CDTI. In this early stage of funding from APOC, the District must ensure that APOC funds are rapidly utilized to train CDDs. If this is not done, there will be great variation of entry of CDTI. Training of CDDs should be budgeted for in the APOC budget, if not already done. Supervision should be enhanced and budgeted for in the District and APOC budgets, if not done already. a o a a a o 43 Ownership The current level of awareness on the ownership of the project should be sustained. The same should be ensured in the case of the villages Mob i li zat i on and sensi ti zati on Mobilization of all relevant players for the success of the programme should be sustained. The CHMT should continue to ensure adequate sensitization of the policy makers for their continued support for CDTL Counterpart funding The current level of counterpart funding should be sustained and even enhanced. Muheza District, which has not yet started releasing its own contribution for support of CDTI should be encouraged to start doing so. Provision of logistics Districts should make proposals to purchase more durable motorcycles and bicycles to enhance supervision and monitoring by health personnel and district health supervisors respectively. P lans for sustainabili ty The current plans for sustainability which has started by defining onchocerciasis as the responsibility of the Council Health Team and its incorporation in the District Comprehensive health plans should be encouraged to continue. Integration into the routine health system The full integration of CDTI in the routine functioning of the health system should be encouraged. To National Onchocerciasis Taskforce Ownership NOTF should ensure project activities are fully decentralized and budget lines should be related to the different Regional and District requirements if not yet done. This will further promote the sense of ownership by the Regions and Districts. o o a o a a a 44 Al ob i li zat i on and se nsi ti zati on a Greater efforts should be put into plans for mobilization of the communities Relevant radio jingles and public address systems should be put in place. o NOTF should make available useful IEC materials for health education a NOTF should source additional funds for the training of CDDs o Counterpart funding NOTF should join efforts with both the Projects and the Regional Medical Office to ensure the release of counterpart funding by both the Regional and District authorities. Provision of logistics NOTF should ensure greater monitoring of the various CDTI projects to ensure that they conform to agreed guidelines and processes. Efforts should be made to get the Districts to provide logistics for the supervision of CDDs during distribution. P lans for sustainability NOTF should start now to develop its plans for the sustainability of CDTI in the Region post-APOC. Integration into the routine health system NOTF should take steps to ensure the full integration of CDTI into the routine health system. The NOTF should make the health policy makers to understand that the control of onchocerciasis should be seen as normal health activity that does not require any specialized structure apart from its being community directed. Thus the training and supervisory requirements should be integrated into the normal health system. To APOC Management Provision of logistics and capital equipments APOC should consider procurement of motorcycles and bicycles for DOTs and DHS respectively to facilitate their supervisory roles in the CDTI process. o o a U 45 Provision of technical assistance The independent monitoring should be encouraged. It creates more awareness for the programme. a 146 6. APPENDD( KEY INFORMAN INTERVIEW: Village "A"Leader This instrumenl is to be admintstered on the village head or a represeruative of the village head. The head can ask arnther person to assist with the tnterviq,v and to even hnve a say during the interview. Do rnt refuse. Most of the questions are structured. Circle appropriale codes. Do not prompt the responses; rather allow the respondent to answer while you circle the appropriate option to the respondent's answer. Listen to the chief and choose annny the items provided. If he says something dffireru selea 'Other' and write the actual response response in the space provided. Village Name: Village Code: Subcounty/LGA District/State:_ Country Month and year of last distribution Please tell us about any programme concerning onchocerciasis treatment in this village? (PROBE THE FOLLOWING ISSUES ARE ADDRESSED) I who brougltt the idea of the onchocerciasis programtne to this village? = when did the person(s) come to talk wilh you about ortchocerciasis? - Did the person(s) meet with you and other vtllage leaders first? = Did they ask for you to arrange a meeting? = whnt did they tell you about communtty responsibility 1. at a village meeting 2. village elders meeting 3. village chief/leader 4. health worker village health committee village committee meeting other 3. What mode of distribution was decided? 1. house-to-house 2. central place (specify) 2. How was the time (month/season) for distribution decided? 5 6 7 4',7 3. both house-to-house and cenual place 4. other (specify)_ 4. How was the mode of distribution decided? 1. at a village meeting 2. village elders meeting 3. village chief/leader 4. health worker 5. village health committee 6. village committee meeting 7. other (speciff) 5. How many persons (CDDs) in this village give out the drug for onchocerciasis? 6. How many male CDDs?_How many female CDDs? 7. How were the persons (CDDs) selected to do the work? at a village meeting village elders meeting village chief/leader Health worker Village health committee Village committee meeting Other (specify 8. Why did you choose these person(s)? (Probe for criteria) 9. Have the CDDs received any training? 1. Yes 2. No 3. Don't know 10. If yes to Q9, when did they receive training? 1 2 J 4 5 6 7 1. 2. aJ. 4. 1. 2. J 4 Before the first distribution During distribution Soon after the first distribution Don't know/Can't remember 11. How well have the CDDs done the work? 1. well 2. fair 3. poor 48 (Explain) t2 13 Have you changed any of your CDDs? 1. yes 2. No 3. Don't know If yes to Q12, why? t4. Have you (the community) received education on the imponance of taking ivermectin/mectizanl Oncho tablet annually for several years? 1. Yes 2. No 3. Don't know/Canflt remember 15. If yes to Q14, ask: When did you receive the education? (circle all that apply) 1. During the first meeting 2. Before the first distribution 3. During distribution 4. Soon after distribution 16. If yes to Q14, what were you told? (Probe for annual treatment for several years benefits community responsibil ity I7 Was there any community decision on how the drug should be collected from a collection point? 1. Yes 2. No 3. Don't know 18. Did any member of the community collect the drug from a collection point? 1. Yes 2. No 3. Don't know 19. If no to Ql8, why? 20. Where is the collection point? 2I. Did you experience late supply of drug during the last distribution? 1. Yes 2. No 3. Don't know Please explain 22a. Did you experience shortage of drugs during the last distribution? a. b. c. 49 1. Yes 2. No 3. Don't know 22b. If yes to Q22a, how was the problem solved? 23a. Was the census of your village undertaken? 1. Yes 2.No 3. Don't know 23b. Does the community have a treatrnent register? 1. Yes2. No 3. Don'tknow 24. It yes to Q23b, where is the register kept? 25. How were you involved in mobilisatton? 26. How were you involved in supervision? 27. Whnt are your suggestions on how the communiry could be more involved in treating its members with ivermectin for several years? 28. Is there anything you will like to tell/ask us? 50 GROUP DISCUSSION GUIDE AMONG COMMUNITY MEMBERS: VILLAGE A In each category A village, one Male and one Femnle adult group discussion must be conducted. In three of the six category A vilktges, group discussions must be conduaed with male youths_and in the remaining tlree villages, discussions nutst be held with female youths. For monitoring CDTI projects, youths are dfined as individuals between I5 and 24 years. The CDD must arrange for a comfortable place that offirs some privacy and enough places to sit . Each group must consist of 6-8 people. Depending on cuhure, the group discussiotts may need separate meeting place for male and female so that people can speak freely. One of the internal monitors should be the factlitator while a local guide. takes notes (recorder). The group discussion must be tape-recorded. At the end of the session, play back the tape for a few minutes to be sure that the discussion was properly recorded. La.bel the cassette/Notes (Name of the village, the group tdenti$, date). TARGET GROUPS: ADULT MALES; ADULT FEMALES; YOUNG MALES OR FEMALES Please tell us what you know about the onchocerciasis treaunent programme (PLEASE PROBE FOR THE FOLLOWING ISSUES.) 0 the person(s) who brought the idea of the onchocerciasis programme to this village 0 the time when the person(s) came to talk with you about onchocerciasis I whether there was a village meeting at that time Issues that were discussed at the meeting . ownership of the programme . expectation from the programme . responsibility of the communiry 2. Please describe how the community took decision on the time (month/season) and mode of distribution. PLEASE PROBE FOR: Persons involved in decision-making Time of distribution 0Why the time was chosen 0Method of distribution Why the method of distribution was chosen Please describe how the community took decision on the persons responsible for distributing the drugs to communiry members. PLEASE PROBE FOR: 1 I I 0 0 3 4a. 4b. 5l o 0[Persons involved in decision-making o [Who will be responsible for distribution . How the persons were selected . Why the persons were selected o Method of drug collection Has there been any change in the person responsible for drug distribution (CDD) since the beginning of the programme? (PLEASE TELL US WHY) Has there been any change in the programme? o Who brought the change o What was the change What were you told about the need for community treatment with ivermectin? (PROBE FOR ANNUAL TREATMENT FOR SEVERAL YEARS, THE BENEFIT, SOURCE OF INFORMATION, COMMUNITY RESPONSIBILITY AND HEALTH EDUCATION) How is the drug normally brought into the community and distributed to community members? PROBE FOR: point of collection person responsible for bringing it to the community, person responsible for distribution within the community mode of distribution when was the drug swallowed 7. Would you please tell us those who should not be treated with ivermectin (exclusion criteria)? 8. How was dosage determined by the CDDs duing the last distribution? PROBE FOR MEASURING DEVICE 9. What problems have you had with respect to the distribution of the drug? PROBE FOR o timeliness of supply to the community o adequacy of supply o StOrBBe 10. What problems have you had after taking the drugs? 11 How prepared is the community to take control of ivermectin distribution programme? (How does the community intend to sustain the exercise for several years?) 12. What support has the community given to the CDD? PROBE FOR Incentives in cash or in kind 5 6 a a a a a \ 52 : [t*trflLT1i.",. i;o'* 13. Could you please tell us how you would measurethe success of the CDTI programme? 14. How well has the CDD performed? (PROBE FOR ATTITUDE) 15. What suggestions do you have to improve the programme? 53 IN-DEPTH INTERVIEW OF VILLAGE ..A'CDD To be administered only in group "A" villages. Interviw 2 CDDs per village if there are nnre than one CDDs. At end of the interview ask the distributor to let you see his tools: measuring devise, registers, remaining drug if it is the case. Wten a question requires multiple responses, do not forget to put a circle around each applicable response code. Probe where appropiate. Name of Village Distria/State Village code : _Subcouruy /LGA Name of CDD Sex: 1. Female 2. Male Main Occupation Month and year of first CDTI distribution in the village _l_ Month and year of last CDTI distribution in the village _l_ 1, How was the time (month/season) for distribution decided? at a village meeting village elders' meeting village chief/leader health worker village health committee village committee meeting other (specify) 2. What mode of distribution was decided? house-to-house central place (specify) Both house-to-house and central place other (specify)_ 3. How was the mode of distribution decided? at a village meeting village elders' meeting village chief/leader health worker village health committee village committee meeting 1 2 J 4 1. 2. J. 4. 5. 6. 7. I 2 5 4 5 6 7 other (specify) 54 4. How were you selected to do the work? at a village meeting village elders' meeting village chief/leader health worker village health committee village committee meeting other (specify) 5. Has any CDD been changed after the first distribution? 1. Yes 2. No 3. Don't know 6. If YES to Q5, Why was the CDD changed? L 2. J. 4. 5. 6. 7. 7. Have you ever been supervised ? 1. Yes 2. No 3. Don't know 8a. If yes to Q7, who supervised you ? (IF NAME WAS MENTIONED, PLEASE ASK FOR IDENTITY/POSITION/STATUS OF THE PERSON) 1. Health staff 2. Village health committee member 3. NGO panner 4. Community member/chief 5. Other (specify)_ 8b. What did the supervisor do? (CIRCLE ALL THAT APPLY) Checked the ivermectin inventory Checked the records/treatment register Collated the repors Advised on the treatment of absentees other (specify) 9. At what occasions were you supervised? (CIRCLE YES OR NO FOR EACH RESPONSE) 1 2 3 4 5 1. Before distribution 2. During distribution 3. Soon after distribution 1. Yes 1. Yes2. No 1. Yes2. No 2. No 10a. Have you received education on the importance of taking ivermectin tablets annually for several years? 1. Yes 2. No 3. Can't remember 55 10b. If yes, what were you told? 11 Did you provide the community with education on ivermectin treatment? 1. Yes 2. No 12. It yes to Q11, when did you provide the education to the community? (CIRCLE YES OR NO FOR EACH RESPONSE) 1. During the first meeting 1. Yes 2 2. Before the first distribution 1. Yes 2 3. During distribution 1. Yes 2 4. Soon after distribution 1. Yes 2 5. Other (specify) 1. Yes 1. Yes 1. Yes 1. Yes N, N, N, fr{, 2. 2. 2. 2. 1 2 J 4 6 o o o o 13. If yes to Q11, what did you tell the community? (CIRCLE YES OR NO FOR EACH RESPONSE) Taking ivermectin annually for several years Benefits of treatment Community responsibility Side effects Other (specify) 14. Did you receive any training on how to treat community members? 1. Yes 2. No 15. If Yes to Q14, when did you receive raining? 16. Who trained you? (CIRCLE ALL THAT APPLY Health personneli Oncho coordinator NGDO staff (specify Another CDD Other (specify)_ 17. How long did the training last? l" training_ 2nd training_ Last tra ns 18. How many CDDs were trained together (size of the group)? 1't training_ Last training_ No No No No 1 2 J 4 56 19. Where was the venue of the last training? Within the community Outside the community Healthcare facility/hospital Other (specify) 20. Was the venue of training near to your community? 1. Yes 2. No 21. What were you taught during training about onchocerciasis (CIRCLE YES OR NO FOR EACH RESPONSE) Cause Symptoms Socio-economic importance Community mobilisation and education Ivermectin as treatment for a long time Other (specify) 22. What were you taught about the drug? (CIRCLE YES OR NO FOR EACH RESPONSE) 1. Duration of treatment 1. Yes 2. No 2. Coverage of distribution 1. Yes 2. No 3. Dosage determination by measuring height 1. Yes 2. No 4. Expiration of drug after removing container seal 1. Yes 2. No 5. Treatment of absentees and refusals 1. Yes 2. No 6. Side effects (counseling and referral) l. Yes 2. No 7. Exclusion criteria l. Yes 2. No 8. Record keeping 1. Yes 2. No 9. Census 1. Yes 2. No 10. Other (specify)_ 23. What were you taught about reporting? (CIRCLE YES OR NO FOR EACH RESPONSE) 1 2 aJ 4 1 1 1 1 1 1 2 aJ 4 5 6 Yes Yes Yes Yes Yes 2 2 2 2 2 No No No No No 1. 2. J. 4. 5. 6. Number of persons treated 1. Yes Number of refusals 1. Yes Number of absentees 1. Yes Number of excluded persons 1. Yes Number with severe side effects 1. Yes other (specify)_ 2. No 2. No 2. No 2. No 2. No 24. Did any member of the community collect the drug from a collection point during the last distribution? 1. Yes 2. No 3. Don't know 57 25. If "no" to Q24, why? 26. Where is the collection point? 27. Did you experience late supply of drugs during the last distribution? 1. Yes 2. No Please 28. How do you normally determine the quantity of drugs required by the community? Census/registration record Previous treatment records By counting the number of households Other (specify) 29a. Did you experience shortage of drugs during the last distribution? 1. Yes 2. No 29b. It yes, please expla ln 30. How do you determine the number of tables to give to an individual? (CIRCLE YES OR NO FOR EACH RESPONSE) L Take height measurement 1 2. Use weight 1 3. Visual observation 1 4. Age 1 5. Other (specify)_ 31. What do you do about individuals who are absent during normal distribution period? 32. What do you do about individuals who refuse treatment? 33. Which categories of people would you not give the tablets (PLEASE CIRCLE YES OR NO FOR EACH RESPONSE) 1 2 aJ 4 No No No No Y, Y, Y, Y, 2 2 2 2 CS CS es CS l. Individuals below 5 years of agel below 90cm 2. Pregnant women 3. Women who delivered less than one week before distribution 4. Sick individuals 5. Visitors 6. Other (specify)_ l. Yes 1. Yes 1. Yes 1. Yes 1. Yes 2. No 2. No 2. No 2. No 2. No 34. How do you ensure that these categories of people eventually receive 58 treatment? 35a. How long do you normally keep the tablets in the community?- 35b. How many days did you take to complete the last distribution? 36. Where do you normally keep the tablets? 37 . Do you have drugs to take care of minor side effects? 1. Yes 2. No 38. What kind of support do you receive from the community? (CIRCLE ALL THAT APPLY) Transportation for drug collection Incentives (specify) Other (specify) 39. Do you have problems with record keeping? 1. Yes 2. No 40. If yes to Q39, please expla ln 41. Please tell us how you feel about the programme with respect to a) sustaining the programme I 2 J b) community response c) constraints 42. What do you think should be done to improve the programme? 43. Are you willing to continue as a CDD? 1. Yes 2. No Please expla ln PLEASE ASK FOR REGISTER AND MEASURING DEVISE TO PROVIDE FOLLOWING INFORMATION 59 44a. Is measuring device for height present? l. Yes, seen 2. Yes, but not seen (Explain) 3. No, Explain 44b. How do you use it? 45. Is treatment register present? Yes, seen Yes, but not seen (Explain) No, 46.lt Q45 is "Yes, seen" EXAMINE TREATMENT REGISTER AND OBTAIN THE FOLLOWING INFORMATION ON: Total population_ Age composition of people: Below 5 years_ 5 years and above_ Sex composition of the population Male Female Number of persons treated_Male_ Female_ Numberofpersonsunder-5yearswhoreceivedtreatment- Number of refusals Number absent during last treatrnent_ Number with severe side effects_ Number of tables received 10. Number of tablets used I l. Number of tablets left in the drug kit 1 2 J I 2 J 4 5 6 7 8 9 T60 KEY INFORMANT INTERVIEW: Village" B" Leaders This tool is to be administered to the village head or a representative of the village head in all category "B" vilhges. In the case that the village head wants someone else to assist wtth the interview, do not refuse. Put a circle around the appropriate response codes. Do not prompt responses and allow respondent time for answeing the question. Use the option "other" where the response is not listed but remember to specify the response in the space provided. If a village head is not available, iruervievv his assistant or representative. Village Name: State/District Village Code:_subcounty/LGA : Country: Month and year of last distribution I 1. Have people in this community been treated with ivermectin in the past one year? 1. Yes 2. No 3. Don't know IF NO TO Ql END INTERVIEW IF YES TO QI CONTINUE THE INTERVIEW 2. How was the time (month/season) for distribution decided? at a village meeting village elders' meeting village chief/leader health worker Village health committee village committee meeting other (specify)_ 3. What mode of distribution was decided? house-to-house central place (specify) both house-to-house and central place other (specify 4. How was the mode of distribution decided? 1. at a village meeting 2. village elders' meeting village chief/leader health worker Village health committee village committee meeting 1. 2. 3. 4. 5. 6. 7. 1 2 aJ 4 J 4 5 6 7. other (specify) 61 5. How many persons in this village (CDD) give out the drug for onchocerciasis? 7. How were the persons (CDD) selected to do the work? at a village meeting village elders' meeting village chief/leader health worker village health committee village committee meeting other 6. Have the CDDs received any training? 1. Yes 2. No 3. Don't know/ Canft remember 7 . Have you changed any of your CDDs? 1. yes 2. No 3. Don't know 8. If yes, why? 9. Did any member of the community collect the drug from a collection point? 1. Yes 2. No 3. Don't know 10. Did you experience late supply of drug during the last distribution? 1. Yes 2. No 3. Don't know 1 1. Did you experience shortage of drugs during the last disuibution? 1. Yes 2. No 3. Don't know 12. Does the community have a treatment register? 1. Yes 2. No 3. Don't know I 2 3 4. 5. 6. 7. (H o(H >roFb- g E;<ES qO E g - x.; E T ll eE63EgIs E! =EBbE€ 8 ! ol zo F U) IJ] D 0)9t 6.EsX .E H C)C= ij =- d) e =v!^@6 >'d-ctE.-arI i - L' \rEorFo-,Bllllo€ xE'E>z t-q) r! o oF z g. o >r0()trot'oii-61 > a).4 - C) li [ [at -Y (l) -O c 0.) ll rrEs€S'68>z o n 5= * ,=e--LvltdOgao*d-e >:'6 -g - "ij rL < ()-O c! I-FX9SE.E z F(/) r! O oF(r) E] tJ. q.) 3 c -! *tr'= qZ * =E O hP 5+.E.E E € E g€ EE 8* 'Ero(!<i.ir .= >\ Bc.' -€ fr-^B d S o,Ell llA>A€S>Z :(\lltr E b g !,.8 E EE 9€E5 o ra ), > a9 I bo c!-o o >iJltruroI) z F C') r! O- €E;!9q_ HU,E iH?i *^ =;El!U=ll llosSEgs>z q) o0 5IT(AZL !! JJ q- q* g,g.l= o > gts<=6ZEE I c! ^v,n U I oz o ! C) <,)o I -i C) tr c! 0.)E aAs o o 2 Io oo C) o{) = c) z (l) bo € c) o(J o o tr c6 xE ! (I) 60o o) CJ 6) 0) cl) q) .t) o Lo tu bE g =<'E €bbEf,E :6^i>E 9E-q:uE q) -94E g€Es b(l) tJi o. rJrE:9Hc FEI .E ^P#Bp<e6LFa.g trfiEc =; oo E 9pO t'i v(r) ? a- =Oc!A-- -^)ir.:/ of'-()ES()cnF.tE a H cdog)>,EsilE .. C) Y o.lXiro <r0.)()6JaZ b a 69E;8o8 rrl ^ -= d) -=_P!!ld>\'C) > i:!9^r EggH s!Hp6--CF-q-(.* .E'IE s 3 sE 'L^. o =5 g-= E ()"ii o H QoH' #i- I = E g EEa O'-=-i (.) - c):i cor, E,< F =O v(ts tr qlb0 oooE 3(l) tr ,^ o.:-E i gOEV A L 'Iv -Yirii3tr H -9EP:aE F - tsg , l5^<Efi Q ^ Hqr d ogcb:'s-.r^tJ A'i *-c.A q.rSPHe EEAa '!-oE(H = g 9< oH e Bc bE E(tr ga E l'ra dD p= X 9O E} H;tr SrdE N\o o il o(A oE o9lthcr62 d)q) 5H(.)0 .,( c) ,( ,( l( ca\o -ill nnllVE o :C?Ei ll$! r-oS E ll €ro llU]IEE.HII?!FEoq-Arg *o # HE I ; E * m ^[![tr or 'ii .eU .!,4tr * H-il tr gs ooc X llE !r.= oE€E b 9-;-etrtri50 .E o(,) *tf ..d i? ai e ^.9 3 !l rr ?EEg+a E r BE € ; ?? .8ss ES rr tt!2 .Y i <a o.r f E EE.fit 64 IN.DEPTH INTERVIEW OF VILLAGE "8" CDD To be administered only in group "8" villages. Interview 2 CDDs per village if there are more than one CDDs. At the end of the interview ask the distributor to let you see his tools: measuring devise, registers, remntning drug tf available. Wen a question requires multiple responses, do not forget to put a ctrcle around each applicable response code. Probe where approprtate. Name of Village District/State Sex: 1. Female 2. Male 1. Yes 2. No 3. Have you ever been supervised ? 1. Yes 2. No Village code: subcounty/LGA: Name of CDD Main Occupation: 1. How were you selected to do the work? at a village meeting village elders' meeting village chief/leader health worker village health committee village committee meeting other (specify) 2. Has any CDD been changed after the first distribution? Month and Year of last distribution I 3. Don't know/can't remember 3. Don't know 1 2 3 4 5 6 7 4. If yes to Q3, who supervised you ? (IF NAME WAS MENTIONED, PLEASE ASK FOR IDENTITYiPOSITION/STATUS OF THE PERSON) 1. Health staff 2 Village health committee member 3. NGO partner 4. Community member/chief 5. Other (specify)_ 5. Have you received education on the importance of taking ivermectin tablets annually for several years? 1. Yes 2. No 3. Can't remember 6. Did you receive any training on how to treat community members? 1. Yes 2. No 65 9 7. Is measuring device for height present? L. Yes, seen 2. Yes, but not seen (Explain) 3. No, 8. Is treatment register present? 1. Yes, seen 2. Yes, but not seen @xplain) 3. No, (explain) If Q8 is "Yes, seen" EXAMINE TREATMENT REGISTER AND OBTAIN THE FOLLOWING INFORMATION ON: l.Total 2.Age composition of people: Below 5 years_ 5 years and above_ 3. Sex composition of the population: Male_ Female 4 Number of persons treated_ Male Female 5 Number of persons 5 years and above who received treaunent 6 Number of refusals 7 Number absent during last treatrnent_ 8 Number with severe side effects 9 Number of tablets received 10 Number of tables used 11 Number of tablets left in the drug kit_ 12. Update of records 66 QUESTIONNAIRE FOR HEALTH PERSONNEL This questionnaire is administered on any health worker in the area who is directly involved in CDTI programme i.e the health staff nearest to the village. The number of health personnel to be interviewed depends on the situation on the ground. A minimum of 3 health personnel who are supervisors of CDDs should be interviewed within the project area. Afier the iruervisw ask the health personnel for the documents used for CDTI aclivities. LGA/Subcounty State/District Country Name of health personnel_ Sex: 1. Male 2. Female No. of Oncho. Villages Position: No. of CDDs in villages covered_ Qualification: Responsibilities in Oncho control Programme: 1 Oncho Coordinator 2 CDD supervisor 3 other (specify)_ 1. Did you receive any general orientation on CDTI? 1. Yes 2. No 2a. Dld you receive training on how to train CDDs? 1. Yes 2. No 2b.If yes, how long? 2c. List the main topics covered 2d. Were you taught how severe side eff'ects should be managed? 1. Yes 2. No 3.Please tell us what you know about the CDTI programme with respect to 1 . Community responsibility 6',7 2. Involvement of the health system in CDTI 4. Was there an initial meeting with the community where CDTI was introduced? 1. Yes 2. No 5. If yes to Q4, what role did the health staff play in arranging for the first meeting? (CIRLCE ALL THAT APPLY) Facilitated the meeting Met with village leader to arrange for the meeting Other (specify) 6. Who led the facilitating team to the community? health staff government administrative staff (non-health) . NGDO staff . other (speciff) . Nobody 7. Were the communities (where you worked) educated on the importance of treatment with ivermectin tablets? 1. Yes 2. No 3. Don't know 8. If yes to Q7, what were they told? (CIRCLE YES OR NO FOR EACH RESPONSE) 1 2 3 1 2 aJ 4 5 1. Annual treatment for several years 2. Benefits of treatment 3. Community responsibility 4. Others (specify)_ 1. Yes 1. Yes 1. Yes 2 2 2 N N N o o o 9. Were CDDs in the communities (where you worked) trained for the CDTI programme? 1. Yes 2. No 3. Don't know 10a. If yes to Q9, did you participate in the training of CDDs? 1. Yes 2. No 10b. If yes, how long did this training session last? Initial training_ Retraining 1la. Who supervised the CDDs 1. Not supervised 2. Village head 3. Village health committee member 68 4. health personnel 5. Other 11b. If supervised, how many CDDs did you supervise during the last distribution? 12. If not supervised, why? 13. At which occasions did you visit the CDD? (CIRCLE YES OR NO FOR EACH RESPONSE) I 2 3 4 1 2 aJ 4 5 6 Before distribution During distribution Soon after distribution 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No Other (specify ) 14. What functions do you perform during your visit to the CDD? (CIRCLE YES OR NO FOR EACH RESPONSE) 1. Collection of unused drugs after distribution 2. Review of records 3. Management of side effects 4. Supervision of drug disuibution 5. Other (specify)_ 1. Yes 1. Yes 1. Yes 1. Yes 2. No 2. No 2. No 2. No 15. What constraints do you have in supervising the CDD? (CIRCLE YES OR NO FOR EACH RESPONSE) No constraints inadequate/lack of means of transport/fuel Too much work Inadequate/lack of supervision allowance Inaccessibility Other (specify) 16a. Have there been any delays in receiving ivermectin? 1. Yes 2. No 16b. If yes, explain 16c. Have there been any delays in collecting ivermectin by the community? 1. Yes 2. No 17. If yes to Q16c, please 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No explain 69 18. What consuaints have you experienced in getting the drug? (CIRCLE YES OR NO FOR EACH RESPONSE) 1. None 2. Transport problem 3. Inadequate supply 1. Yes 1. Yes 1. Yes 1. Yes 2. 2, 2. 2. No No No No4. Delay in supply 5. Other (specify) 19. How do you estimate the quantity of drug required? Not responsible Number used during last treatment Based on requests from the CDDs Total population (with the formula) Other (specify ) 20. Did you get the drugs when required? 1. Yes 2. No 21. It no to Q20, why? (CIRCLE ALL THAT APPLY) Shortage at state, regional level Means of transport Other (specify) 22. Do you have facility for storage of ivermectin? 1. Yes 2. No 3. Don'tknow 23. Have you experienced loss of tablets due to pilferage? 1. Yes 2. No 3. Don'tknow 24. Were cases of severe side effects reported to you? 1. Yes 2. No 25. RECORDS OF SEVERE SIDE EFFECTS (CHECK AVAILABILITY) : 1. Available 2. Notavailable 26. Whnt other health activtttes do you combine with Oncho Corurol Programme aciivities (PROBE FOR HEALTH ACTIVITY IN THE CDTI COMMUNITIES)? 1 2 3 4 5 1 2 J 70 27 . How do you feel about the CDTI programme? 7l INTERVIEW GUIDE FOR POLICY.MAKERS/ REPRESENTATIVE/PROGRAMME MANAGERS/ COORDINATORS wHo This interview is administered on Co-ordinators, Programme managers, representatives of NGDOs involved in CDTI, Ministry of health policymakers and the WHO representative in the country. It is similar to the interview of health personnel. Documents such as registers should be requested before the formal interview so that information can be extracted for the report 1 SECTION A: PROGRAMME MANAGERS/ ONCHO COORDINATORS Please describe how the CDTI programme is being implemented in your area PROBE FOR The approach used for introducing CDTI to the communities Elements of collaboration between Community, Health system and NGDOs (IDENTIFY SPECTFIC ROLES) General re-orientation of health personnel towards CDTI programme Mobilisation of the communities Training of health staff as trainers Please explain process of receiving ivermectin PROBE FOR : a. Delays in supply . at what level and why? b. Adequacy of the quantity received/shortage c. Storage d. Distribution to communities e. Constraints (storage, transport, etc) f. Pilferage FUNDING: Please probe for a. Delays in endorsement of letters of agreement whv? a b c. d. e. 2. J b. Delays in receiving funds 72 o . at what level and why? c. Delays in disbursement of funds At what level and why? d. Inadequacy of previous budget e Fund administration: delays in submission of financial repofts, disbursement and retirement procedures, delays in feedback from APOC headquarters on financial reports 6 4. Please describe the programme's plans for improving sustainability 5 Which other health activities do the Oncho supervisors combine with their Oncho Control Programme activities? Would you please explain the programmdls record keeping procedures EXAMINE THE FOLLOWING RECORDS Summary sheets: 1. Available 2. Not available 7 EXTRACT INFORMATION ON THE FOLLOWING (relate to the level of operation e.g. state and LGA) Total Population Number of villages in the area_ Number of villages with summary forms_ Number of villages treated_ Number with severe side effects Evidence of report update (check annual returns after distribution) 1. Updated 2. Not updated SECTION B: MOH POLICY MAKERS ( Permanent Secretary/Director Disease Control) 8a. Do you have a national Plan for the control of onchocerciasis ( Probe for the importance attached to onchocerciasis control a. b, c. d. e. f. t5 8b. What kind of support do you provide for Oncho. Control activities (PROBE FOR FINANCIAL INPUT) 9 How do you perceive the CDTI strategy of APOC ( Probe for personal opinion and official policy on CDTI) 10 Is the Oncho Programme integrated into the health system ( Probe for activities which indicate integration and ownership/ Plans for sustainability. SECTION C: WHO COUNTRY REPRESENTATTVE 11.What is your perception about the APOC strategy for ivermectin distribution ( Probe for feasibility of the CDTI approach in solving other health problems) 12. What is the relationship between the WHO office and the National Onchocerciasis Task Force (NOTF) with respect to CDTI implementation. (Probe for issues relating to transfer of funds, support to NOTF and monitoring)

TANGA - WHO/APOC/CDTI PROJECT REFIS,RT O,F ENI}H,FENE}EI.{T MONITORSi OF CETI ACTIVITIES IIti TANC,A' TAI,I&{NIA 15 - 29 SEPTEMBER 2OO2 .t[ .ry ]J/.{'I f:'t} J{} TIIE NIRECTflR AFRICI+,T,I F,ROG.K4}fi8fr8 C,K ffITCEICC tAEffCI O[T$#[,R Z{I{m: ERC'[,{S[S C$II;TROI" For Aclr..:n fo: [:^ \r, r Fc- iiiformclion Jo, , 2TEAM OF MONITORS DR JOSEPH OKEIBUNOR' Principal Investigator/Social Scientist Department of S ociology/Anthropology University of Nigeria, Nsukka Enugu State, Nigeria JOHN NGANYA Team Member/?roj ect Coordinator Onchocerciasis Control Programme Kilosa CDTI Project . T anzania DR MOSHI RUHISO Team Member/?roj ect Coordinator Onchocerciasis Control Programme Tukuyu CDTI Project Tanzania SEBASTIAN MHAGAMA Team Member/District Coordinator Onchocerciasis Control Programme Mbinga District, T anzania DR SIMON KATENGA Team Member/Ilational Coordinator National Onchocerciasis Control Programme Federal Ministry of Health, Tanzania 3TABLE OF CONTENT TEAM OF MO--L'{TJORS """"'-2 TABLE OF CONTENT .......... 3 LIST OF FIGURES ................ 6 LIST OF ACRONYMS ..........7 4-C-KNOWL-EDGEMENT """ 8 EXECUTM SUMMARY ......................9 TNTROpUCTTON .................12 """"""12 1.2 Tanga Backsround ' ""13% .............141.3 Team Composition - ....................r4t1.4 Terms of Reference METHODOLOGY Studv Desisn Population ..2.2 2.3 The S e and Sampline Procedure RESULTS A. B e D E Ind tors: C-oJnsttaints Community Perception Ouality of implementation of CDTI UNIO.UE FEATURES OF THP PROJECT ABEA .20 .20 .30 .30 .32 .36 prs-Eu s sLoN AND C_9NCLU SrON ...39 RECOMMENDATION .........4I APPENDIX K4Y INFORMAN INTERVIEW: Villaee "A"-Leader GROUP DISCUSSION GUIDE AMONG COMMUNITY MEMBERS .............. IN-DEPTH VIEW OF VILLA ..A'CDD KEY INFORMANT INTERYIEW: Villaee" B" Leaders .' HOUSEHOLD SURVEY FORM (cateeory A villases onlv) IN.DEPTH INTERVIEW OF VILLAGE "B" CDD .46 .46 50 .53 .60 .62 .64 4KERS/ ..,.,,66 wHo A 7l 5LIST OF TABLES Table A1 : Divisions/Wards/Vil1ages and Sub-Villages Covered in Tanga Project Focus 17 Table A2: SUmmary of Instruments and sampling Issues 19 Table 1: Decision-making Process at the village Level(t in Parenthesis) Table 2: Treatment Summary (Yo in Parenthesis) Table 3: Proportion of Villages treated and in which CDDs were changed after the first treatment Table 4: Proportion of villages which received health education, and in which health care personnel supervised CDDs Table 5: Input indicators (Community level) (V, in Parenthesis) Table 6: Distribution of implementation of the components of CDTI and Wards Table 7: Quality of CDD Training in Category "A" villages(t in Parenthesis) 20 23 25 26 27 31 34 6LIST OF FIGURES Fig. l: Community Participation in Decision Making 22 Fig. 2: Treatment Records from CDD Records and Household Survey 24 Fig. 3: Comparison in Treatment Coverage between the Year 2001 and20O2 25 I ,7 4WD APOC CBIT CDD CDTI CHMT DALY DCHP DED DMO DOC FGD IIKI HS TEC IMA NOTF OSD RIIO RMO ROC SSI wHo LIST OF ACRONYMS Four Wheel Drive Vehicle African Programme for Onchocerciasis Control Community Based Ivermectin Treatment Community Directed Distributor Community Directed Treatment with Ivermectin Council Health Management Team Disability Adjusted Life Year District Comprehensive Health Plan District Executive Director District Medical Officer District Onchocerciasis Control Focus Group Discussion Helen Keller International Household Information, Education and Communication Interchurch Medical Assistance National Onchocerciasis Task Force Onchocerciasis Skin Disease Regional Health Officer Regional Medical Offi cer Regional Onchocerciasis Coordinator Sight Savers International World Health Organization 8ACKNOWLEDGEMENT The team would like to extend its sincere gratitude to all those that assisted it during this mission. Of special mention are the following: o The Regional Health Oflicer for Tanga Region, D.A' Mwalyamewile o The Regional Medical Oflicer, Dr. W. Mwengee o District Executive Directors for the three Districts visited o District Medical Officers of the three Districts visited o The Primary Health Care Coordinators of all the rural health facilities visited o Members of Onchocerciasis Control Team for the Districts visited o Coordinators and Members of Onchocerciasis Programme in the Districts visited o The Leaders and members of villages visited o The Community Directed Distributors of the communities visited And more importantly, the team wishes to express its profound thanks to the APOC Director, Dr. A. Sek6t6li, and his team at the APOC management for making this mission a reality. 9EXECUTIVE SUMMARY The Independent Monitoring Team that was constituted by APOC Management and NOTF Tanzania to visit Tanga Region Community Directed Treatment with Ivermectin (CDTI) project, from 15 to 29 September 2002, had Dr Joseph Okeibunor of the O.pu.r1nint of Sociology/Anthropology, University of Nigeria, Nsukka as the Principal Monitor. The other.oritors include Dr S. Katenga, NOCP Tanzania, Dr Moshi Rohiso of Tukuyu CDTI Project, Sebastine Mhagama of Ruvuma CDTI Project and John Nghaya of filoru CDTI project. The team had the members of the CHMT and DOTs of thi d#ferent Districts visited as local guides. The assignment commenced with a briefing of the Regional Medical Team in Tanga on the terms of reference of the Independent Monitors and the areas where their cooperation would be required. The methodology and instruments adopted were the same as those developed in Ouagadougou and finalized in Kabale, Uganda. The objectives were equally left as stated in Kabale, Uganda. Six Category A, and 24 Category B, sub-villages were selected through a simple random sampling procedure. The findings show good low level of the establishment of the CDTI proCess in three Districts, namely Lushoto, Korogwe and Muheza current implementing CDTI The key findings in the Tanga Region CDTI project include high treatment coverage of 82.1 per cent in 2002 treatment, which was an improvement on the 78.2 per cent treatment coverage recorded in 2001. It was observed that the Regional and District political and health policy makers are fully sensitized and willing to ensure the success of ihe programme in their respective areas. According to one of the District Executive Directors interviewed, there is no question of their support because the problem is theirs and APOC is only supporting them to solve their problem. They appreciate the support by APOC. As steps to ensure the success and sustainability of the programme, the Districts were advised by the Regional Government to integrate it into their yearly health plan and make money available for running the programme from other sources including the 'basket fund'. Records show clearly the incorporation of CDTI into the Comprehensive Health Plan of the three Districts as well as budgetary provisions and fund releases for the maintenance of motorcycles by the District Onchocerciasis Team. In Korogwe, the DOCs were posted as staff in the health facilities located in the onchocerciasis endemic areas. At the village levels, some of the villages are well sensitized and are willing to take the drug for a long period. In some of the villages the sub-village chairpersons assist the CDD in census update as well as distribution of Mectizan@. Some took advantage of the CDTI structure to develop vital statistics register for the villages and some village Chairperson maintain a comprehensive record of Mectizan@ distribution in their villages. Each sub-village had two CDDs, one male and one female trained to cover the interest of both males and females in the community ao 10 However, some people who took the drug the previous year declined taking the drug the following year. Thus, even though there was an overall increase in coverage by 3.9 per cent point, a segregation of the data by villages showed a decline in coverage in some villages. The commonly given excuse was that the drugs were brought during the season for iea cultivation. The people preferred the treatment in the harvesting period of June/July when the mild side effects will not interfere with their agricultural work. Unfortunately, the rural health workers and the DOTs insist on the distribution of the drug in February, when the drug arrives from the National levels. The arguments of the health personnel is that the project year ends in March so there was need to finish distribution and make returns before the commencement of a new year. It was also noticed that supervision in the communities was very poor. The rural health workers complained of poor supervisory provisions to cover the numerous CDDs in the widely dispersed area with difficult terrain. In many cases the health facility staff did not supervise CDDs. The only supervision came from the sub-village chairpersons. Worse still, these CDDs are not well educated as the educated ones refuse to perform the function without remuneration. The result of this was poor record keeping by the CDDs. Furthermore, it was observed that the health education in the communities is still too weak. Some people refused treatment because they felt they are healthy. Some of the young persons and women know very little about CDTI, which they may have heard of from their fathers or husbands. IEC materials were practically non-existent at least in the communities. The training of CDDs is poor both in quality and quantity. For a project in the initial year, especially where no organized Mectizan@ distribution programme existed before, two day training for between 30 to 90 CDDs will not achieve the desired goal. The health workers and DOT members were constrained to have such training sessions because of inadequate financial provisions. They were often told that money is only available for one training session. The result of this was reflected in the record keeping of the CDDs who were barely able to read and write. All the same CDTI programme implementation in Tanga region hold some promise for future greater successes and sustainability. To help it reach the enviable heights the following recommendations are being proposed to enhance CDTI implementation in this project area: Continued orientation, training and involvement of the health service personnel implementation levels in the villages on the APOC philosophy and their roles in the CDTI as well as its integration into the PHC system should be intensified. Adequate time should be devoted to the project for proper dialogue with community leaders on the benefit of the Ivermectin treatment, their roles and commitment in the long-term sustenance of the treatment process. They should be made to be aware of their ownership of the programme and right to make the necessary decisions. oo o a ll More personnel from other components of the PHC, media and educational institutions with skills in health education, mobilization, and gender issues should be co-opted in CDTI implementation activities at all levels. Steps should be taken to increase publicity of the CDTI programme as in other disease control programmes. A deliberate attempt must be made to improve the quality of record keeping at all levels of the CDTI implementation in the State. Efforts should be made ensure the supervision of CDDs by health staff It may be necessary to make an arrangement where outreach health workers are trained and they supervise CDDs within their close vicinity while the health staff with motorcycles supervises CDDs in distant places. The District may also create a pool of its means of transport from which the CDTI programme can draw during treatment to ensure effective supervision of the CDDs. More time should be devoted to the training of CDDs and the trainer trainee ratio should be well rationahzed to ensure effective training of CDDs considering their level of enlightenment. t2 INTRODUCTION 1.1 General Background Onchocerciasis, otherwise known as river blindness, is one of the devastating diseases, which continues to affect the health of people in Africa. Its effect on the health and socio- demography of the people is considerable in magnitude is rightly noted. It has been found out that the affected persons suffered from physical discomfort, anxiety, embarrassment, inconvenience, lack ofconfidence and depression. It has been observed that such persons were stigmatrzed, miserable and generally pitiable, and deserving help and sympathy. They were avoided by even close friends and relations, a situation which affected their marital life and general well being. The economic importance of the disease has also been recognized by a number of operation researches on its social and economic impact. For instance, outright blindness associated with the savannah strain of onchocerciasis has been known to cause visual impairment resulting in economic disability of the infected. Concern is also raised about the economic impact of the non-blinding strain of onchocerciasis, which is prevalent in the forest zones. Studies in Uganda, Ethiopia and Nigeria have demonstrated that onchocercal skin disease (OSD) has direct and indirect costs as well as impact on school attendance of children, and the computation of disability-adjusted life years (DALYs). Tanzania is one of the countries in Africa affected with Onchocerciasis and in which feasible vector elimination has not been demonstrated. The burden of Onchocerciasis is high and is a major contributor to the low socioeconomic status of the agrarian population living around the numerous fast-flowing streams and rivers as well as the fertile areas of the country. Mass treatment with Mectizan@ is currently the main control strategy in the country and this is carried in five regions in the country. Vector elimination is however taking in limited foci within Tukuyu region, which is also implementing mass treatment. Other regions implementing mass treatment include Tanga, Mahenge, Kilosa, and Ruvuma In Tanzania, mass treatment with Mectizan@ (ivermectin) commenced 199711998, with introduction of APOC CDTI strategy and with the assistance of various NGDOs, Sight Savers international, Rotary International, Helen Keller International, Interchurch Medical Assistance among others. These agencies are partners with the African Programme for Onchocerciasis Control (APOC), a global health partnership. APOC, which was established in December 1995 with the main objective of setting up an effective and sustainable community directed treatment with ivermectin (CDTI) programme in 19 endemic countries. APOC's strategy is based on the Mectizan@ (ivermectin) donation programme of the Merck Company Inc. Studies have shown that Mectizan@, is well tolerated and effective in reducing micro filarial load, improving ocular lesion, skin lesions and reduction of transmission. The studies further reveal it has anti-helminthic, anti scabetic and anti pediculosis effects, which will increase its acceptability in the endemic communities. \ 13 The CDTI project proposals are based on a partnership between APOC, the National Programmes and several NGDOs. The first grants were awarded in 1997. Each project is funded for a maximum of five years. During this period, it is expected that APOC support will decrease proportionately to that of the other partners and that the cost of treatment per individual will reduce by 90 per cent. In addition, it is expected that the National Onchocerciasis Control Programme (NOCP) will continue to manage their CDTI activities for up to 15 years after APOC, in order to guarantee effective control of Onchocerciasis. APOC's philosophy for CDTI is to ensure that the recipient communities own the programme in order to sustain it The communities themselves determine the activities. They determine where to obtain their Mectizan@, when and how to distribute it. They select their community directed distributors (CDDs); collect information about coverage that helps the determination of programme success. Unlike the community based ivermectin treatment (CBIT), the CDTI is a process building up based solely on the experience of the community members, and consequently, enhancing the decision making and problem solving capacity of the communities. 1,2 Tanga Background Onchocerciasis status of the area Tanga is one of the regions in endemic with onchocerciasis in Tanzania, with a general endemicity of 48 per cent. Helen Keller International has been assisting the State with Ivermectin Distribution Project (IDP) under the APOC supported CDTI programme since 2000 using first the mass distribution method in 2001. Before then an expatriate health superintendent attached to Muheza District Hospital showed personal interest in onchocerciasis as a problem in the area and treated people from Korogwe, Muheza and Lushoto, all in Tanga Region with the 6mg Mectizan@ tablets. With the coming of APOC, in partnership with HKI and the Region, the community directed treatment with ivermectin (CDTI) was introduced in 2000 in the Region. ii Geographical description of the area TangaRegion is located inthe extreme north-east corner of Tar.zania between 4o and6o and below the Equator and 37o - 39o East of the Grenwich Meridian. The region occupies an area of 27,348 Sq. Kms., being 3 per cent of the total area of the entire country. Tanga shares borders with Kenya to the North, Morogoro Region and Coast Region to the South, Kilimanjaro and Arusha Regions to the West. Indian Ocean borders it on the East. Adminstratively, the region is divided into 6 Districts namely, Lushoto, Korogwe, Muheza, Handeni, Pangani and Tanga Municipality. The Region has 37 Divisions, 158 wards, 700 villages and many sub-villages. The dominant climate is warm and wet. I t4 Most areas get annual rainfall of at least 750mm and the main occupation is subsistence agriculture. iii Population composifion of the area Tanga Region has an estimated population of 1,712,217 people in the year 2002 and a population density of 63 persons per Sq. Kms. Of the six Districts, three are hyper/meso endemic with Onchocerciasis. These are Lushoto, Korogwe and Muheza with endemicity levels of 47Yo,32%o and 650Z respectively. The total population at risk in the endemic 'districts is 213249 persons in 22, 42, 55 villages for Muheza, Korogwe and Lushoto respectively. ,v APOC/CDTI activity in the project area With APOC support, CDTI is being implemented to establish sustainable Mectizan@ distribution structures in the three endemic Districts. Currently, all the I 19 endemic villages are under treatment with 147,856 persons treated out of an eligible population of 179,856 persons aged 5 years and above. This gives a treatment coverage rate of 69.3 per cent, according to the treatment records at the project office. The plans for sustainability include to advocacy to the Districts and their respective DEDs to put money for Onchocerciasis control in the plans for the supervision of CDTI by the DOTs. This has started yielding fruits, as two of the three Districts, namely Korogwe and Lushoto have started releasing funds for CDTI supervision. The third, Muheza has completed plans to start giving funds for CDTI supervision. Meanwhile, it has, like other Districts incorporated the programme into the DCHP and also co-opted the DOC as a member of the CHMT. 1.3 Team Composition The independent monitoring team that was constituted by NOTF, Tanzania, on behalf of APOC to visit Tanga CDTI project, from 15th-29ft September 2002, had Dr. Joseph Okeibunor, of the Department of Sociology/Anthropology, University of Nigeria, Nsukka as its Principal Monitor. The other monitors included Mr John Nganya of Kilosa Project; Mr. Sebastian Mhagama, Mbinga District; Dr Simon Katenga, NOCP Tar:.z;ania; and Dr. Moshi Ruhiso, Tukuyu CDTI project. The team also had members of the DHMT and DOT in Muheza, Korogwe and Lushoto Districts as well as community members who acted as local guides. The team also had drivers. 1.4 Terms of Reference The team was constituted with the following terms of reference: l. Succinctly document how ivermectin treatments were undertaken in a sample of )l5 Communities with approved CDTI project in Tanga focus, Nigeria. Assess community involvement in drug collection, decision making on the period and modes of distribution, the selection of distributors, and the willingness of the community to accept and bear these responsibilities designed in the CDTI process. Document community perceptions of CDTI processes especially the issue of ownership, and expectations for Onchocerciasis control, based on these perceptions and expectations determine the degree of satisfaction of the community with the different programme activities and outcomes. Assess the quality of training received by CDDs and health personnel involved in the project. Examine the record books of the CDDs and assess the quality of record keeping and their ability to keep accurate records. The same applies to the health services staffon the project. Determine the number of communities and eligible treated and compare findings with records of the CDDs and the records at the other levels (District, Division Ward - level records.) Determine whether the health personnel participated in ivermectin distribution and assess the degree and quality of supervision by health staff (and the quality and orientation of the health staffto the CDTI) Identify constraints in the distribution and recommend appropriate measures to APOC management to be taken before the next round of treatments. 9 Discuss the prospects of sustainability based on the findings above J 4 5 6 7 8 16 2. METHODOLOGY The methodology used for the selection of the villages and sub-villages was a modified form of the methodology that was developed during the meeting of the nine monitoring team members in Ouagadougou in 1998. In a review of the tools, in a tool development workshop in Kabale, this was further refined to include a few of the things that were not previousiy taken into account. The entire endemic villages were included in the sampling iru*e irrespective of levels of endemicity and closeness to the health facilities in the areas studied. This simplified approach merely selected villages by a simple random sampling approach. 2.1 Study Design For the monitoring conducted in Tanga Focus of Tanzania September 2002, a cross- sectional research design was adopted. This design was considered the most appropriate to generate the needed data and meet the study (monitoring) objectives. The data collection exercise consisted of a triangulation of qualitative and quantitative instruments designed to collect information from different segments of the target population 2.2 Population The target population for the monitoring exercise consisted of four broad groups. These include: 1) Health Personnel involved in the CDTI process at various levels; 2) Village leaders; 3) Community Directed Distributors (CDDs); 4) Household members in the hyper/meso endemic communities contained in the REMO result for Tanga region. In addition, policy makers in the areas where CDTI is implemented were interviewed to guage their plans for sustainability of CDTI in the future as well as their policy direction with special reference to their current support for CDTL 2.3 The Sample and Sampling Procedure A study sample of thirty villages was chosen using a simple random sampling procedure. However, the sampling process began with stratifying the divisions and wards in the District by levels of endemicity. Since treatment focus is prioritized based on hyper and meso, the hypo endemic divisions and wards were excluded from the sampling. Consequently, six hyper/meso endemic wards were chosen through a simple random sampling process (balloting), from three Divisions, one Division each from the three Districts under the Tanga project. The selected Divisions include Soni/Bumbuli for \ t7 Lushoto District; Bungu for Korogwe District and Amani for Muheza District. The chosen wards from the sampled Divisions included Mamba and Mayo for Lushoto; Dindira and Bungu for Korogwe and finally Mlesa and Misalai for Muheza Districts. The villagesr in the selected wards were listed on pieces of paper and six wards were randomly selected by balloting. Category A and B Villages: Having selected the six villages, one from each of the earlier sampled ward to be visited, the sub-villages in the chosen villages were listed Thirty villages were randomly selected from this list. Another random sample of six villages out of these thirty sub- villages chosen earlier were taken as category "A" villages while the remaining twenty four villages became the category "B" sub-villages for the monitoring exercise. Unfortunately these villages could not be classified into hyper or meso because the information was not available. The only information available helped in eliminating the hypo endemic areas from the exercise. Table Al: Focus: DivisionsAilards/Yillages and Sub-Villages Covered in Tanga Project Districts Division Wards "A" Sub-Villages "B'Villaqes l.Lushoto l.Soni and Bumbuli l.Mamba l Mbelei l Mamba 2 Mtindili 3 Bomo 4 Lutindi 2 Mayo 2 Mafelee 5 Mayo'A' 6 Buai 7 Kwekulo 8 Kizanda 2.Korogwe 2.Bung 3 Dindira 3 Milongwe 9 Mtambalae l0 Kweulasi 1l Kwemsala 12 Kwemuohoyo 4 Bungu 4 Bungu Mission 13 Mtunda 14 Kwebanda 15 Kwemadanga 16 Gare 3.Muheza 3.Amani 5Misalai 5 Miselai 17 Mlalo 18 Vungwe 19 Balabalami 20 Kigoma 6 Mlesa 6 Kwamandenga 2l Mlesa 22Ugamba 23 Mtakuja 24 Sangarawe TOTAL 3 6 6 24 I Here villages are the same with communities in Nigeria and elsewhere while the sub-villages are equivalent to villages in communities as used in Nigeria and other places with similar usage for the concepts. \ 18 Households: In each Category "A" sub-village sampled, fifteen households were chosen. To do this, the sub-village was carved into three clusters guided by the village head and local guides. The systematic sampling approach was then applied to select five dwelling units from each cluster. The sampling intervals were determined through a quick estimation of the number of dwelling units in each village-cluster. This differed from one sub- village-cluster to another. In each sampled dwelling unit one household was randomly chosen for the treatment coverage study. Furthermore, to check on the correctness of treatment, one household was randomly chosen, and the dosage for one household member, randomly selected and crosschecked. CDDs and Village Leaders In each Category "A" sub-village sampled, the sub-village leader was purposively selected and interviewed. The sub-village CDD was also purposively sampled and interviewed. In cases where there were two CDDs both of them were interviewed, but where there were more than two CDDs, only two were selected by balloting. Similarly, the sub-village leaders of the Category "B" villages were purposively chosen and interviewed. The sub-village CDDs were also purposively chosen and interviewed where the CDDs were two or less. In some sub-villages with more than two CDDs, two were randomly selected for the Category "B" sub-village CDD interview. Health Personnel and Policy Makers: Various cadres of health personnel involved in CDTI process were purposively selected and interviewed. These included Supervisors, District Onchocerciasis Team (DOT) members and Coordinators. The Coordinators of Primary Health Care and Health Oflicials at the District and Ward levels, involved in the CDTI process were also purposively selected and interviewed. The purpose of these interviews was to examine the orientation to CDTI process and provide information on the records and quality of training they receive and/or give on the CDTI process. Policy makers at these levels of the health systems' operations were also purposively selected and interviewed to give idea of the support of the policy makers for CDTI implementation as well as their plans for the sustainability of the programme. 19 Instruments Eight instruments were used to gather information from both Categories "A" and "B" sub-villages as well as at the District and ward levels. Copies of these instruments are included as appendices to this report. Table A2: Summary of Instruments and Sampling Issues Instrument Category of Sub-villages and Unit Sample Sampling Procedure In-depth interview & Record review with CDD A&B | -2per sub-village Purposive (Simple random, where there are more than2 CDDs) Household coverage survey A 15 households per sub- village Multi-stage (i.e. cluster, systematic and simple random Key informant interview of village leaders A&B I village leader per sub- village Purposive Group discussion A 3 groups per sub-village (i.e. I male and 1 female adult; and 1 female or male youth groups), 6-8 persons in each group Convenience Health personnel interview A I PHC coordinator I Oncho coordinator I DMO per District I LOCT member I health centre staff Purposive Programme manager/Policy maker interview Project, District & National levels 1 Director, Disease Control per District I NOCP Staff 1 Project Coordinator, 1 Supporting NGDO staff Purposive \ lio -oEtr ?z O\ O\ O\N c.l o.l o\\o\oN \o \o \o E() o II tI 0)'=b0trSE -o -o o\o\o\Oci [-- i -Naa .ro.roa o\ o\ -ot- t'- o\#-r\ idC.l IIII Eo -'=o0ii trSE EFfiE s II l- -c !l*!.V(B= o-vEF \o o\^N io-\O o\ oov I I a o\ t--\o $ II r.o o\oO \o o OI) t- <o iri >(J II yO o\ co tttt- II 0) oo !,s6 >E II IIII op bo '= -di)5> \o \o \o6i: 6\ 61\ta)OO ai O\ O\ C)\o\o *N(\ \o \o o\ o\o\Of- ci O\H 0o \-/vv\o dtr)(\ \O \oo\ o\OOOO i roro v) o (n C) o LE: EEE^f 5€EH u) rn.6 EYh oE.3:9Ua E s,pt 5AEa:'5i ^E-:t o EEES# = A €EEE1€€u3-.E.8ts €)E-vP: b E - .r € = o)-Y o o't:># o(Jo. o 3.E8" -- I-doE ! i- i IO;r'uL/ .Z.EEz ;Hb.ESJsE 3,E E #dJzatr(r. o. (\I :o o\o-O^O-!\o ino\:(r) v- V.a Oox6. ,, ll \oll p t-l tr(l)ll9 En E EN9.:vr5L tr!=oBeE oEor-o -c';i!r iDt otrt o)(l)q) ::6gu-oog EE^(1) 0.)^\E! r' ooco)or<E'O i ooE: EE'" ch v)E0)(1){-jb0 bO o>6(ll- ;H.Fi -E ., u) (hq)(l)O trtrtrooooooq< q< qiooo t<Ll<o()o -o -o -o E€Etrtrtr(d(dcd trtrtroootrtrtroooo- o. o.oooLrt<HOrolA t-l Ntlfrl f-l U) U)q) €)L G ti o\ q) (l)I (l) o0 cl o o)q1(u I oL 00 G I o U2 q) q) a () ti oLo c!I ! O3j a riil ?o I I I I I I 2t The decision-making processes on issues of timing and mode of distribution as well as CDD selection were employed to gauge the level of community involvement and ownership of the programme that exist among the communities. Here, decisions that were reported to have been taken in village meetings were taken as indicative of the ownership of the programme. Looking at Table 1, only a total of 29 village leaders in categories A and B villages, were entered in the analysis because one of the sub-village chairpersons traveled out of the community at the time of the survey. No one could deputize for him since the people maintained that sub-village chairpersons have no deputy as they are themselves deputies to the village chairperson. CDDs in categories A and B villages were interviewed. Focus group discussions (FGDs) were also held with people in category "A" villages. The Table shows varied responses on who decided on the mode and timing of distribution as well as selection of CDDs. For instance, only about a third (35.0%) of the village leaders reported that the community in a village meeting took the decision on timing of distribution. Decisions on mode of distribution (90.0%) and selection of CDDs (90.0%) were taken in village meetings. A look at other segments of the village leader interview however revealed that in some villages, the village elders, and village health committee took the decisions. However, in sixty-two per cent (62yo) of the cases health workers took decision on the month of distribution Similarly, 67 per cent of the CDDs from category A sub-villages interviewed that health workers took decision on the month of distribution. And in the FGD it was noted that the decision to distribute in a particular month was taken by the health worker. This, as will be demonstrated from the review of the CDD treatment records is responsible for low treatment coverage in many areas. According to one of the CDDs, in an interview, "people refuse to take the drug because it disturbs theirfarm work", Corroborating this, one-health personnel from Muheza interviewed said that, "they complain that it is the period of farming. The people will appreciate it if it is given to them during the harvest season, which is around June/July". And when asked why they distribute drug during the planting season, the health personnel replied saying that, "that is when the DOC brings the drug. The drug comes in January andwe cannot keep it until June/July because the project year will be over and we need to make returns" From the FGDs, where different segments, namely, adult males and females as well as young males and females were involved, it is observed that all of them indicated that the decision on the timing of distribution was taken by the health personnel in-charge. 22 In measuring the indicators (E-1 and E-2),the responses of the village leaders were used. This is because the village leader information appeared more representative by virtue of its geographical coverage of categories A and B villages, and the three subjects, namely, decision on mode and timing of distribution, as well as the selection of CDDs. The FGDs were limited to category A villages, while the category B village CDD interview did not ensure the collection of information on the timing and mode of distribution. Following from this therefore, it is observed that 35 per cent of the communities indicated that the decision on timing of distribution was taken in village meetings. On the other hand, in 90 per cent of the cases, the decisions on mode and as well as selection of CDDs respectively were taken in the village meeting. Fig. l: Gommunity Participation in Decision ilaking oo ct(E +,e o(, L o o- 1O0o/o 9Oo/o 80o/o 70% 600/0 500h 40% 30% 20Yo 10% Oo/o @Month GMode trCDD Selection Village Leader CDD FGD Sources of lnformation \ o)aq)! C)H () dolr o l- € (h ot) 63q)Lqr o aq) bo CB (.) oLr 0) o. (!) F r-: o) 0.) Bo H EgHRIE9l<9 P9 trq){'o !x CBL t<t€opandc9o -aJ6()g €g HPo>\ a.o 5ath6 obs(l)9l< eo .hC KJ € q.> s3 6)t ,.:3E - ar) cdE o.= €li o)o .< o.r<o dO. \oo\ oj 00 o co ca il €ao t9GE\O o\ iu\-7- >lal r- '- ll -- 0) tr -.1OJ a) 'Err I EE e9P! .sEB Ybor ,Euts(B CB= P arcEktr Oia ;S E >€r-rts y? ..,Y6scBth262 ,taA!E€ & t+( t+< (Hooo li li l-rq)()c) sps (€(€d ooo P.PIi oooa.p.aoooLLL Q.< 0.i F.{ t-r al OOttlooo q) O 4) q) tr e( Fi tr c( a q) 6)Ir - N o c! Fr 6l 9p <,€<Ui ENH EH Ei rCavz 9-l-rl \o&cq \o ^ z \oo\ C.l \oo\O\n o,l \J qO o\oilVv s BE KPr\t i- aF \o ZC rO o\ o\ ao c.l v \oo\ co 96 s \OK s6pti- ?;N(,EE - (,Fa E== HsEr- Oroza yO o\ F$ \oo\ oo=tnv \v o\ oo rn c.) o\ v oO ia6r=t.) i/ o\ :.Dg Hs Orozc \oo\ -S) s -S- -o o\ .t F-9 to= s -NEE o '6rI.] r--@) rhZ() Z dxY iJ =Atrdv O^ E( ot Orozc \o o\ ss3 1O 6\ oo$coi s FO S5 9-;-Ir oO Oroza \o6\\o s$x sm= s €8 t! ,B !gH ==v Hx Oroza s \oo\ -9 -o o\ €8 s E9 s !f,:6F 3 c..riJr rt OGza II oi .o o\OO sNR s_r-rt i- 3o F ?BE rs ;: F/az) O rr.1 =l- OroZO o\$ \o o\ \o s\o @ s F.9 \r =aYO\ a^ iJi I-- Oroza \oo\$ \oo\ o\Ns, rO o\ tr- TYJ s t- iJ s €E 'i - ri 6F caEAEr€Da2J 9.*ti{ t--E c.t o ..oza \oo\q O9 \Oq\FO\ .6 ^o\#o\ s E3, x HH a^ iri \o Oroza -oo\\o ,n9 o\+$g s lrJ o\ i.; slaEE trlo Hi5 <>diEHtdE d d o F,( U) t) () (n Q,)(l) ot2 U)L 4) () CJL o z o) clq) lr3 I I t I 24 Fig.2'. Treatment Records from CDD Records and Household Survey lOOo/o 9Oo/o 8oo/o 70% 60o/o 50o/o 40o/o 30% 20o/o 10o/o Oo/o E Q) oo F o C,)o cooL o TL .,i| $r"' $O- ""- ".;}o' s"* + .o{e Gommunities The Table (2) above presents no definite pattern in the comparison between the results from the sample survey of household treatment and the treatment summary from the CDDs' records. In half the cases the records show lower proportions than the sample survey results as in the case of Mbelei (56%); Mpale (70%) and Misalei (54%).. In the other half, the reverse was the case. The CDD records show higher percentage coverage than the household coverage conducted for the same purpose of ascertaining treatment coverage in the communities. What is impressive here is that the CDDs at least maintain records of treatment though with varying degrees of accuracy. Treatment records were generally poor. It took the monitoring team long hours to fix the records and make meaning conclusions out of them. This was blamed on the literacy level of the CDDs. According to one of the health personnel interviewed, "some CDDs complete the register before distribution. There ls low understanding capacity among them, especially among the /bmale CDDs. The educoted ones refuse to do the work because there is no payment attached to it" Comparing the results of the household survey and the treatment records of the CDDs did not show much except that one had to patiently study the registers and ask the CDDs questions for clarification before aniving at any meaningful conclusions. For instance, in Muheza, CDDs record treatment on rough materials and fail to transfer the same onto the actual treatment register. The use of the term "defaulter" makes is difficult to conclude the number of refusals and absentees. Furthermors, a comparison of the treatment coverage for the current year reveals in three out of the six villages visited there were increases in coverage, where as in the other three there were slight falls in coverage. These are shown in Fig. 3 below. trHH Survey GCCD Rec 25 Fig. 3: Comparison in Treatment Coverage Between the year 2001 and2OO2 o o)(E o oo o E') TE o e o o. 100.00o/o 90.00% 80.00% 70.O0o/o 60.00% 50.00% 4O.OOo/o 30.00o/o 20.OOo/o 10.00% 0.00% 8r2001 32002 Communities Table 3 Proportion of Villages treated and in which CDDs were changed after the first treatment O-3 Proportion and number of at-risk villages treated:30 (100%)O-5 Proportion and number of communities where CDDs were changed by the community after the first treatment : 3 (10.0%) Table 3 simply reveals that all the thirty sub-villages visited had been treated. And in all only three of the sub-villages representing l0 per cent of the sub-villages visited had changed their CDDs since the first distribution. These are found in Bungu ward of Korogwe District and Misalei and Mlesa wards of Muheza District. The reason often given for the change had to do with the CDDs getting married and relocating from the sub-village. Wards Sub-villages (Both A and B) Treated CDD changed MAMBA (Lushoto) 5 5(1 00%) MAYO (Lushoto) 5 5 (100%) DINDERA (Korogwe) 5 5 (100%) BUNGU (Korogwe) 5 5 (100%) | (20.0%) MISALEI (Muheza) 5 5 (r00%) | (20.0%) MLESA (Muheza) 5 s (100%) 1(20.0%) 26 The reasons for retaining the other CDDs according to the village leaders include that the CDDs are doing their work well. All the category 'A' interviewed on the performance of their CDDs attested to the good performance of the CDDs and further justified the reason for not changing CDDs. In describing the performance of the CDDs, they often made statements like, "Drugs are distributed properly and timely" "(CDDs) make sure everyone gats the drug" "They are doing the work with no problem" Some of them also noted that their CDDs take the jobs as theirs "this is my community" " ... help my people with it" " It is service to " Itwill be a source offuture joy" "the people's thrst" communiQ/" These are good for the sustainability and continuity of the programme. It will promote the existence of a pool of experienced CDDs overtime willing to carry on the programme. Table 4 Proportion of villages which received health education, and in which health care nnel su CDDs 0-6 Proportion and number of communities in which the CDD is supervised by the health care (communities scoring 50Yo and above) :4 (66.7%) O-7 Proportion and number of target communities which received health education : 6 (100%) Wards Sub-villages (Both A and B) Received health education (YesA{o) CDD Supervised by health system MAMBA (Lushoto) 5 s (100%) s (100%) 5 s (100%) 2 (400/"1MAYO (Lushoto) DINDERA (Koroqwe) 5 00%)s(l s (100%) BUNGU (Korogwe) 5 s (100%) 2 (40%) MISALEI (Muheza) 5 s (100%) 4 (80%) MLESA Muheza) 5 s (100%) 3 (60%) I Similarly, all the CDDs in this category of sub-villages indicated their willingness to continue with the programme because, in their own words, i 2',7 Table 4 above shows that all the sub-villages in the six villages visited received health education. It has to be noted, however that the data here were collected from the CDDs, who indicated that they have received health education. This is because the analytical guide directed that such information be collected from both categories A and B villages. All the same data from FGDs did not confirmed the results. In many of the cases, when asked if they were given health education the participants in the FGD session keep quiet. But when other questions were posed to find out how many they are expected to take the drug and the benefits of taking the drug for instance they open up and say things like, take ivermectin yearly in order to make the worm sterile", Their main source of information in this case is from Radio Tat:.zania and this is mostly among the adult males. The adult females as well as the youth, both male and female alike know very little in terms of the health education content of the programme and hence could not discuss this aspect of the programme. o>,4L EEEcqr EF9 a* o 16 o\ tr) yO o\OO rat O o O .9E*t?rE; TE E Ei I I I I ()r-Ec) 8 .ELr- 6) -& -o o\OO tr) -o o\ O .o o\OO ra) -o o\OO \,^) soO ra) so (n EO =c)0l) 6)i >a so$ N \oo\Oo rn \o 6\ o rn sOo (n 1Oo\ @ $ \oo\O\o aa EO .9rti c o9 sOo rn -oo\Oo rn \oo\OO ra) soO tr) \o o\oO ra) sOO rn c)b! €l o0E =oAA I I I I I I EEB6!=AA I I 9- 'iai:nF9 \o o\ \n sOO tr) .o o\ O lr) a o\ la) -o o\oO tr) o\ 00 .f, 8aAs€ ==1(/) >\> r la) rn tr) tr) O B <6 FqE az{=Eg oOEr'z<=Eg teti btAO26i-l \-,A- €) REl,/ oz\) r,.lA- HeJN <-E9EEA <sae)f.l € E3 oo al \o 6\OO -v O ca il L0) € (l) o € (o0) '.o' *o\ t< c') ao +a aa .= \J\oooa-aO- -u-o ^'o\ E llVq.g o rrOH O ,;g E .Err a ;EcI .Po'.= E Etr () o -\u)F 9,E S€ ^9 E c ! crro l- (D'5 - tR :.2 t? .^.U I ,; I<* ESo cx3o FA.i cXsugi r;N6.:-v!.:- L*-EgNar o- (a q ll HEAEE-{ 6) l- H5 g E 8.P a if!r-d) -o 6,) o* C) =-tral.r.iVHF! = l- r<.= v E.ir . &tt PE FLrri5.r-.=*cr)P hi hi (, l-€ (D -q;;.97-c'; .E (€ (B j-j:.ts'=B€€.E E } Ev)v)aitr<r:Hoo(uE-()c :-.iu9€!H9€I H.-.- Vccco>tr() = 3 ) t) t A*EEEITXEUE E E 5OX E EI 8I E5 8 g(H (1-< +< (H +r (.r1 (51ooooooo l<lili!t<t<l-(l)oo()o(l)0) -o-o.o.o.o-o-odst4444HHFHFFF )J))))) dt44 EE€€!EEqtrtrtrtrtrq(soO(gCddcd(o sstdF4d .E .E E g.E g.g Lt-litit-til<oooooooo.o.o.o.aoooooooooliHLLtit<L<AA0<OiAOTor th ar)q) q) tr cltr o\ q) €) Q q2 tr o (,) in o) E clF T t in \O r-.tttti-l li l-l - -Gltl -- 29 Table 5 above reveals a good input indicator status for all the Districts and villages visited. In all cases it was observed that CDDs have been trained. The only case where it was reported that CDD was not trained was in Mlesa ward of Muheza. Here, the CDDs could not be reached as were said to have traveled out of the village. They however made their register available for inspection. The interesting thing here is that in each sub- village there are two CDDs, one male and one female working together to distribute the drugs. Apparently, the female CDDs were supposed to protect the interest of the female folks. In terms of registers, all the sub-villages visited had treatment registers. In some like Mayo village in Lushoto District, the village Chairperson maintained a village treatment register which contained the treatment profile of all the sub-villages within the village. Furthermore, it was observed that they all collected the drug from an agreed collection point. However, it is important to note that the interviewers and interviewees often misunderstand this aspect of the instrument. The respondents often respond by saying that no member of the community collected the drug from the collection point, which is often the village dispensary. But when asked the reason for this, they respond by saying that, "...it is only the CDD that is allowed to collect the drug from the village dispensary" None of the villages visited reported cases of late supply of drugs. There were two reasons responsible for the response. One was that the drug came early in the year even though to the discomfort of the people. The second and perhaps more important reason was that the people did not decide on the timing for distribution. The village health workers took the decision in conjunction with their respective District Onchocerciasis Control Coordinators. Surprisingly, the village health workers did not know that the distribution time most depend on the time chosen by the people and not the availability of the drug. According to one village health worker interviewed, "...they complain about the time of the drug, that it disturbs themfrom working in their tea plantation. ...We cannot keep the drug till the harvesting period in June/July, which the people prefer. The drugs come as early as January, and our project year ends in March so we hwe to distribute it before the end of the project year so that we can make our returns". B30 Constraints Management Some Local Governments or Council Health Management Teams demonstrated support for the programme by releasing fund for training, supervision and monitoring activities. These were specifically in Lushoto and Korogwe. The third District still depends on APOC funding with a promise to release fund next year. In this council area as in the other council area supervision is poor. The health staff in the field also has faced logistic constraints due to inadequate motor- cycles and the wide range of areas to be covered by one person. In some the village health worker has to supervise as many as ninety CDDs alone. In one of the areas visited, the health worker noted that she has as many as forty CDDs to supervise. Some of them live far up on the mountains but for the last treatment period she had supervised only three. "Only three of them have submitted their records to me so they are the only ones (out of over thirty) I have supervised. I do not have motor cycle an I cannot climb to the mountains because I am sufferingfrom arthritis" t, Technical A few rural health staffand the CDDs interviewed showed poor knowledge of the APOC philosophy and the right process for the CDTI implementation, particularly in terms of the timing of distribution and decision-making. This may have adverse effect on the quality of CDTI implementation in these areas. Record keeping is still very poor revealing the poor quality of training given to the CDDs, most of whom could barely read and write. C Community Perception Community perception of CDTI programme varied among and within the villages. A few had complains to make about the timing of the distribution, others argued that they do not need the drug since they are not sick of any ailments. On the other hand, however, many welcome the programme and perceive it as theirs. According to an elderly man in Mayo village, "...my people are very hoppy with this programme and they like the drug a lot hence you are able to find them here in spite of the rain. " And at the official level, the various District governments visited understand that the programme is theirs to support and sustain. In an interview with the District Executive \ I 3l Director (DED) for Korogwe District, she noted that they are poised to see that the programme succeeds because the people are really suffering. When asked what supports the District is giving to the programme, she replied with a question, " ...who is supporting who? It is our problem and APOC is the one supporting us to control it andwe very much appreciate the support you people are giving to us. Now we btow about the problem; the Council knows and everyone know what the people in the Bungt area are passing through. Since then we have included it irt our District Comprehensive Health Plan (DCI#) and are making budgetary provisiorts to cover it. Each year since last year we budget 9,412,800 shillingsfor -it. Last year we released 236,000 shillings and this year we have so far released over 300,000 shillings. This is the typical reaction of the administrative and political set-ups in all the Districts visited, except for Muheza, which is yet to release its own funds for Onchocerciasis control activities. It has however incorporated it in their DCHP. Further more, the Ag. 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P Eg U E€ Fx+ cI ts.E 5.= E8: E€E€€fiEpE -E bu - -: -. bgP^ ES E;*eE,E t;;au6€.= 5 - a E€€ =ts€E€ I eEE dE B - --ts ^(D .ts(l).= > c ..P89 =E€ Sx Ex > EV - oU/ (l).=Fl .= o BgE gE€ .E!€ E e.bE E E5 - ^r.E.Fgogo s ?- .= E E'E -g' 'E 10 SCE, EEEEEIe =ts€E€ P) eEb dE * -4-F< Xo') .ts(l).= > c ..Ptso =E€ Fx E 'i t EY - O\J tD.=El ,= () B8E gT€ ET€ ,8ubE Esr - -,.E.fsto=E r,. .gE E'E-g'rS 5EE,EE;$Ei5 Ftrbo-oo boo =!ET E.EoOl,tr + ca Table 7: Quality of CDD Training in Category 66A" villages (o/o in Parenthesis) Ward No. of CDDs No. Trained Length of Training No. Trained in a session MAMBA (Lushoto) 5 s (100%) 2 days 92 MAYO (Lushoto) 5 5 (100%) 2 days >30 DINDERA (Koroqwe) 5 s (100%) 2 days 66 BUNGU (Korogwe) 5 s (100%) 2 days 50 MISALEI (Muheza) 5 5 (100%) I days 36 MLESA (Muheza) 4 s (100%) 2 days >30 Tables 6 and 7 take a summary look at the quality of the implementation of CDTI in the project focus. Table 6 looks at the implementation of components of CDTI at the ward levels. Another issue that came up as an area of concern is the success and sustainability of the CDTI process. This is presented on Table 7 above. The Table shows the quality of training both in terns of length of training and the number of CDDs trained in each training session. In all six village and 30 sub-villages visited CDDs reported having been trained. However, with respect to the length of training, it lasted for between one and two days. With regards to the number of CDDs trained in each training session, it was observed that it ranged from more than 30 to 92 persons per session. Ea 36 UNIQUE FEATURES OF THE PROJECT AREA Strengths One of the greatest strength of the Tanga CDTI project area is that there has not been any organized Mectizan@ distribution programme in the area before the introduction of CDTI. Thus unlike areas which had practised CBIT and in which distributors were remunerated by government or international agencies, it will not be so difficult to instill the spirit of community ownership and voluntarism in the community members. There is a good spirit of cooperation among the project, the health systems and the NGDO partner at the Regional and District levels. The Districts have not only included the control of Onchocerciasis in their respective DCHP, some have gone ahead to budget and release funds for supervision of CDTI project, which is integrated into the routine supervisory system of the health systems. Officers in the health units of the Districts other than those scheduled to oversee the control of onchocerciasis control programme supervise the rural health workers on CDTI. In some communities where proper mobilization has taken place there is high consciousness on the programme. Such villages are willing to support the programme and ensure its success. In Kwamandenga sub-village, for instance, villagers contribute one hundred shillings to support the CDDs The training of CDDs at village level, as recommended by APOC has increased the number of CDDs trained at reduced cost to the communities and also created much awareness in the communities. Some of the communities see aspects of the programme as catalyst fortheir own village development. For instance some of the villages have seized the opportunity of developing and maintaining census and treatment registers for CDTI to develop their village census register containing vital statistics of the village population. For this reason some village chairpersons participate actively in both census update and distribution of the drug. Their presence encourage the people in such communities to take the drug. There is also evidence of integration of CDTI programme in PHC at the District level, in terms of sharing logistics and planning of CDTI activities in line with PHC programme in the areas. The presence of monitors/monitoring teams has helped to create further awareness. This awakened the DOT to certain salient areas where they had been weak. According to one of the DOT member "...the presence of monitors has helped to open our eyes very well on what we should do qndwhqt we should not do. We can make our correction". 37 Furthermore, it was observed that prior to the monitoring visit, the Regional Coordinator along with the National Coordinator had in June 2002 invrted the policy makers and political leaders as well as the DMOs to a sensitization workshop. These leaders came out of the forum well sensitized and are now including the control of onchocerciasis in their respective DCFIP and making budgetary provisions and releasing funds to support the programme. In some cases, the Regional Project Coordinator is invited to participate in drawing District health plans to ensure that CDTI is adequately represented before going to the Council. It was also argued in some Districts that, it is now part of their main focus. According to a DOC, when asked about the plan for sustainability, "....for my catchment's area, I am very sure the projectwill continue if APOC stops. Our District has included the programme in the 'Basket fund', so sustainability can be good infuture." And the DMO for the same District (Muheza), argued that, "...the problem in the past is that people did not know . Now, after the seminar the DED and the council htow and wish to support. We have already discussed in the PHC meeting" And on the sustainability of the programme, he said, "...we have already started by incorporating it into our plan. The 'big shots' in the District are qware of it andwill e:want to htow why it is droppedfrom the planfor any year". In another District, the DMO noted that the acceptability of the programme by the District leadership is a very positive thing to be happy with. According to him, "the first thing is approval and acceptance of the programme. The Council recognize the problem and the help from APOC. This is important for sustainability. The money brought in from the Central Goventment come through the Council for running the motorbikes. We have a block grant from Central Government for development. The Local Authority allocated over 300,000 shillings from the block grant for onchocerciasis control ". a Weaknesses One major weakness of the CDTI planning and implementation in Tanga CDTI focus is the nature of the CDDs and the rural health workers. The CDDs are barely able to read and write. The more enlightened members of the communities refuse to perform the functions of CDDs because there is no monetary attachment to it. Unfortunately, the rural health workers are not empowered to ensure effective supervision of the programme ! 38 for proper implementation. The rural health workers who should supervise the CDDs lack adequate means of transport to cover the vast areas and the many CDDs within their area of operation. This is closely related with the decision-making processes. Here, the health personnel make decision on the timing of distribution and in many cases their decision run counter to the period the people think is most congenial for them to take the drugs. The number of CDDs they had to supervise overwhelmed the rural health workers. Most of them complain of inadequate facilities for movement within the diflicult and mountainous areas to effectively cover the CDDs during distribution in the early stages of the programme. Most of them demonstrated lack of motivation and enthusiasm to do the work. Mobilization and health education is still weak in some areas. Health education/IEC materials were lacking. 39 4.0 DISCUSSION AND CONCLUSION Treatment coverage rates are impressively high and above 65 per cent in the communities visited as shown in the household treatment survey. More importantly, the result is the same for both years of treatment, that is, 2001 and 2002, indicating some form of sustainable high treatment coverage rates in the region. It was also noted that both the political leaders and health policy makers are well sensitized to the problem of onchocerciasis in the region. These leaders are currently poised to fight the disease by supporting the programme. Many noted the kind assistance of APOC in this direction and are designing strategies for sustaining the programme in their respective areas. The current spirit in these leaders, the plan to support the programme from the 'basket fund' and other District resources are encouraging pointers to the success of the programme in future. In addition to this, at the different levels in the region, officers charged with the control of onchocerciasis are co-opted member of health planning committees with a view to ensuring proper representation of CDTI in the health plans. Similarly, it was observed that most communities are enthusiastic about the programme. The sub-village leaders are involved in mobilization, census update and distribution of the drugs to community members. However, it was also noted that in some communities, the village leaders were not fully involved in the CDTI process. Here there is lack of suflicient knowledge about CDTI and community responsibility among the leaders. In the words of the health worker in- charge of one of such communities, "the work is left to only the CDDs. It is a CDDs' affair. The sub-village leaders do not show interest and as such the people are not encouraged to take the drugs". It was noted that in villages where the chairpersons show sufficient interest in the programme the people cooperate and take the drug. Conversely in such village where the chairpersons show lukewarm attitude to the programme the people are less cooperative. Furthermore, it was observed that in almost all the villages visited, the rural health workers determine the timing of treatment This adversely affected treatment coverage as the people complained that it coincides with their agricultural calendars. For many it comes at a time when they are cultivating their tea. With the experience of the previous year, when many were weighed down by the effect of the drug, many refused treatment the following year for fear that it will disrupt their farming activities. This accounts for the drop in treatment coverage noticed Mafele, Kwamandenga and Milongwe. It is thus necessary to educate the rural health workers on the importance of abiding by the timing for distribution preferred by members of the communities. 40 There are also the problems of supervision and training. Supervision is very weak as the rural health workers complain that they lack the necessary means of transport to cover too many CDDs during distribution. Supervision of CDTI activities is not yet fully integrated into the health supervisory systems. Training of CDDs is equally weak. On the whole, CDTI implementation in Tanga region appears very strongly rooted at the higher levels with the fulI awareness and involvement of the political leadership as well as health policy makers. At the District and regional levels there exist clear demonstration of both political will and financial support for the programme. The health system at the District level is fully aware and in support of the control of the disease and are making good plans for the sustainability of the program. However, the same cannot be said of the lower levels. Some communities have not been fully involved. Health education is not adequate and CDDs are poorly trained. For the sustainability of the programme at the lower levels more needs to be done in terms of empowering the rural health workers and training the CDDs sufficiently. There is also need for more elaborate sensitization activities at the village levels. o4l 5.0 RECOMMENDATION I To the Project: Training of Health Staff The current training period for the health staff is adequate. However, during the training time should be set out for practical work to ensure good comprehension of what is taught. Training and Supervision of CDDs This should continue within the communities. Initial training should be for at least three days, while retraining activities can be for two days. During the first three-day training, a day should be set aside for demonstration on record keeping, census taking and reporting. The current trainee-trainer ratio should be discouraged. Too many CDDs in one training session will not make for effective training. The ratio of trainer to trainees should not be more than 1:15. More training sessions could be organized to ensure compliance with the acceptable ratio. More funds could be sourced from the Districts and some of the money used for supervision could be put into having effectively trained CDDs. o The involvement of literate members of the communities, such as teachers CDTI implementation at the community level should be explored, to help re-enforce training and record keeping at community level. The villages should be sensitized to convince the literate members of the need to serve their people. a More attention should be paid to the aspects of record keeping and reporting during training, particularly with regards to household treatment and documentation of colour for easy assessment of treatment accuracy. Training and supervision checklists should be made available and used to assist in these activities. Supervision should be emphasized at all levels, especially health staff during and immediately after distribution for the CDDs. Record Keeping and Reporting The quality of record keeping at all levels of CDTI implementation in the State still has room for further improvement. o o o o a ao o Approaching the Health Services and the Community To ensure a proper implementation of the project, precise and concrete steps must be taken to conduct proper orientation of the health personnel and members of the villages. It is recommended that the project intensify the following: Training and orientation of health personnel on the policy and implementation of the APOC philosophy and their roles in CDTI should be encouraged. More health personnel, at all cadre, should be involved and made to understand that more commitment is expected of them with respect to mobilization, health education, training, supervision, monitoring and reporting of CDTI activities. 42 Adequate training on household recording and recording of treated persons immediately after administration of the drug should be emphasized. Continued dialogue should be held with community leaders on the benefits of ivermectin treatment, their roles and commitment in the long-term sustenance of the treatment process should be emphasized. Mobilization should continue to target everybody, including women, youths and as they have been found to lack good knowledge of the CDTI philosophy and process. Supervision of the community by village leaders and health personnel should be directed more to periods during and after distribution. Integration of CDTI into the PHC System The current level of integration of CDTI into PHC in Tanga Region and the Districts is good for this early stage. To District: The Districts must be very active to ensure that the facilitative role of APOC is felt in the first and second years of implementation of CDTI. In this early stage of funding from APOC, the District must ensure that APOC funds are rapidly utilized to train CDDs. If this is not done, there will be great variation of entry of CDTI. Training of CDDs should be budgeted for in the APOC budget, if not already done. Supervision should be enhanced and budgeted for in the District and APOC budgets, if not done already. a o a a a o 43 Ownership The current level of awareness on the ownership of the project should be sustained. The same should be ensured in the case of the villages Mob i li zat i on and sensi ti zati on Mobilization of all relevant players for the success of the programme should be sustained. The CHMT should continue to ensure adequate sensitization of the policy makers for their continued support for CDTL Counterpart funding The current level of counterpart funding should be sustained and even enhanced. Muheza District, which has not yet started releasing its own contribution for support of CDTI should be encouraged to start doing so. Provision of logistics Districts should make proposals to purchase more durable motorcycles and bicycles to enhance supervision and monitoring by health personnel and district health supervisors respectively. P lans for sustainabili ty The current plans for sustainability which has started by defining onchocerciasis as the responsibility of the Council Health Team and its incorporation in the District Comprehensive health plans should be encouraged to continue. Integration into the routine health system The full integration of CDTI in the routine functioning of the health system should be encouraged. To National Onchocerciasis Taskforce Ownership NOTF should ensure project activities are fully decentralized and budget lines should be related to the different Regional and District requirements if not yet done. This will further promote the sense of ownership by the Regions and Districts. o o a o a a a 44 Al ob i li zat i on and se nsi ti zati on a Greater efforts should be put into plans for mobilization of the communities Relevant radio jingles and public address systems should be put in place. o NOTF should make available useful IEC materials for health education a NOTF should source additional funds for the training of CDDs o Counterpart funding NOTF should join efforts with both the Projects and the Regional Medical Office to ensure the release of counterpart funding by both the Regional and District authorities. Provision of logistics NOTF should ensure greater monitoring of the various CDTI projects to ensure that they conform to agreed guidelines and processes. Efforts should be made to get the Districts to provide logistics for the supervision of CDDs during distribution. P lans for sustainability NOTF should start now to develop its plans for the sustainability of CDTI in the Region post-APOC. Integration into the routine health system NOTF should take steps to ensure the full integration of CDTI into the routine health system. The NOTF should make the health policy makers to understand that the control of onchocerciasis should be seen as normal health activity that does not require any specialized structure apart from its being community directed. Thus the training and supervisory requirements should be integrated into the normal health system. To APOC Management Provision of logistics and capital equipments APOC should consider procurement of motorcycles and bicycles for DOTs and DHS respectively to facilitate their supervisory roles in the CDTI process. o o a U 45 Provision of technical assistance The independent monitoring should be encouraged. It creates more awareness for the programme. a 146 6. APPENDD( KEY INFORMAN INTERVIEW: Village "A"Leader This instrumenl is to be admintstered on the village head or a represeruative of the village head. The head can ask arnther person to assist with the tnterviq,v and to even hnve a say during the interview. Do rnt refuse. Most of the questions are structured. Circle appropriale codes. Do not prompt the responses; rather allow the respondent to answer while you circle the appropriate option to the respondent's answer. Listen to the chief and choose annny the items provided. If he says something dffireru selea 'Other' and write the actual response response in the space provided. Village Name: Village Code: Subcounty/LGA District/State:_ Country Month and year of last distribution Please tell us about any programme concerning onchocerciasis treatment in this village? (PROBE THE FOLLOWING ISSUES ARE ADDRESSED) I who brougltt the idea of the onchocerciasis programtne to this village? = when did the person(s) come to talk wilh you about ortchocerciasis? - Did the person(s) meet with you and other vtllage leaders first? = Did they ask for you to arrange a meeting? = whnt did they tell you about communtty responsibility 1. at a village meeting 2. village elders meeting 3. village chief/leader 4. health worker village health committee village committee meeting other 3. What mode of distribution was decided? 1. house-to-house 2. central place (specify) 2. How was the time (month/season) for distribution decided? 5 6 7 4',7 3. both house-to-house and cenual place 4. other (specify)_ 4. How was the mode of distribution decided? 1. at a village meeting 2. village elders meeting 3. village chief/leader 4. health worker 5. village health committee 6. village committee meeting 7. other (speciff) 5. How many persons (CDDs) in this village give out the drug for onchocerciasis? 6. How many male CDDs?_How many female CDDs? 7. How were the persons (CDDs) selected to do the work? at a village meeting village elders meeting village chief/leader Health worker Village health committee Village committee meeting Other (specify 8. Why did you choose these person(s)? (Probe for criteria) 9. Have the CDDs received any training? 1. Yes 2. No 3. Don't know 10. If yes to Q9, when did they receive training? 1 2 J 4 5 6 7 1. 2. aJ. 4. 1. 2. J 4 Before the first distribution During distribution Soon after the first distribution Don't know/Can't remember 11. How well have the CDDs done the work? 1. well 2. fair 3. poor 48 (Explain) t2 13 Have you changed any of your CDDs? 1. yes 2. No 3. Don't know If yes to Q12, why? t4. Have you (the community) received education on the imponance of taking ivermectin/mectizanl Oncho tablet annually for several years? 1. Yes 2. No 3. Don't know/Canflt remember 15. If yes to Q14, ask: When did you receive the education? (circle all that apply) 1. During the first meeting 2. Before the first distribution 3. During distribution 4. Soon after distribution 16. If yes to Q14, what were you told? (Probe for annual treatment for several years benefits community responsibil ity I7 Was there any community decision on how the drug should be collected from a collection point? 1. Yes 2. No 3. Don't know 18. Did any member of the community collect the drug from a collection point? 1. Yes 2. No 3. Don't know 19. If no to Ql8, why? 20. Where is the collection point? 2I. Did you experience late supply of drug during the last distribution? 1. Yes 2. No 3. Don't know Please explain 22a. Did you experience shortage of drugs during the last distribution? a. b. c. 49 1. Yes 2. No 3. Don't know 22b. If yes to Q22a, how was the problem solved? 23a. Was the census of your village undertaken? 1. Yes 2.No 3. Don't know 23b. Does the community have a treatrnent register? 1. Yes2. No 3. Don'tknow 24. It yes to Q23b, where is the register kept? 25. How were you involved in mobilisatton? 26. How were you involved in supervision? 27. Whnt are your suggestions on how the communiry could be more involved in treating its members with ivermectin for several years? 28. Is there anything you will like to tell/ask us? 50 GROUP DISCUSSION GUIDE AMONG COMMUNITY MEMBERS: VILLAGE A In each category A village, one Male and one Femnle adult group discussion must be conducted. In three of the six category A vilktges, group discussions must be conduaed with male youths_and in the remaining tlree villages, discussions nutst be held with female youths. For monitoring CDTI projects, youths are dfined as individuals between I5 and 24 years. The CDD must arrange for a comfortable place that offirs some privacy and enough places to sit . Each group must consist of 6-8 people. Depending on cuhure, the group discussiotts may need separate meeting place for male and female so that people can speak freely. One of the internal monitors should be the factlitator while a local guide. takes notes (recorder). The group discussion must be tape-recorded. At the end of the session, play back the tape for a few minutes to be sure that the discussion was properly recorded. La.bel the cassette/Notes (Name of the village, the group tdenti$, date). TARGET GROUPS: ADULT MALES; ADULT FEMALES; YOUNG MALES OR FEMALES Please tell us what you know about the onchocerciasis treaunent programme (PLEASE PROBE FOR THE FOLLOWING ISSUES.) 0 the person(s) who brought the idea of the onchocerciasis programme to this village 0 the time when the person(s) came to talk with you about onchocerciasis I whether there was a village meeting at that time Issues that were discussed at the meeting . ownership of the programme . expectation from the programme . responsibility of the communiry 2. Please describe how the community took decision on the time (month/season) and mode of distribution. PLEASE PROBE FOR: Persons involved in decision-making Time of distribution 0Why the time was chosen 0Method of distribution Why the method of distribution was chosen Please describe how the community took decision on the persons responsible for distributing the drugs to communiry members. PLEASE PROBE FOR: 1 I I 0 0 3 4a. 4b. 5l o 0[Persons involved in decision-making o [Who will be responsible for distribution . How the persons were selected . Why the persons were selected o Method of drug collection Has there been any change in the person responsible for drug distribution (CDD) since the beginning of the programme? (PLEASE TELL US WHY) Has there been any change in the programme? o Who brought the change o What was the change What were you told about the need for community treatment with ivermectin? (PROBE FOR ANNUAL TREATMENT FOR SEVERAL YEARS, THE BENEFIT, SOURCE OF INFORMATION, COMMUNITY RESPONSIBILITY AND HEALTH EDUCATION) How is the drug normally brought into the community and distributed to community members? PROBE FOR: point of collection person responsible for bringing it to the community, person responsible for distribution within the community mode of distribution when was the drug swallowed 7. Would you please tell us those who should not be treated with ivermectin (exclusion criteria)? 8. How was dosage determined by the CDDs duing the last distribution? PROBE FOR MEASURING DEVICE 9. What problems have you had with respect to the distribution of the drug? PROBE FOR o timeliness of supply to the community o adequacy of supply o StOrBBe 10. What problems have you had after taking the drugs? 11 How prepared is the community to take control of ivermectin distribution programme? (How does the community intend to sustain the exercise for several years?) 12. What support has the community given to the CDD? PROBE FOR Incentives in cash or in kind 5 6 a a a a a \ 52 : [t*trflLT1i.",. i;o'* 13. Could you please tell us how you would measurethe success of the CDTI programme? 14. How well has the CDD performed? (PROBE FOR ATTITUDE) 15. What suggestions do you have to improve the programme? 53 IN-DEPTH INTERVIEW OF VILLAGE ..A'CDD To be administered only in group "A" villages. Interviw 2 CDDs per village if there are nnre than one CDDs. At end of the interview ask the distributor to let you see his tools: measuring devise, registers, remaining drug if it is the case. Wten a question requires multiple responses, do not forget to put a circle around each applicable response code. Probe where appropiate. Name of Village Distria/State Village code : _Subcouruy /LGA Name of CDD Sex: 1. Female 2. Male Main Occupation Month and year of first CDTI distribution in the village _l_ Month and year of last CDTI distribution in the village _l_ 1, How was the time (month/season) for distribution decided? at a village meeting village elders' meeting village chief/leader health worker village health committee village committee meeting other (specify) 2. What mode of distribution was decided? house-to-house central place (specify) Both house-to-house and central place other (specify)_ 3. How was the mode of distribution decided? at a village meeting village elders' meeting village chief/leader health worker village health committee village committee meeting 1 2 J 4 1. 2. J. 4. 5. 6. 7. I 2 5 4 5 6 7 other (specify) 54 4. How were you selected to do the work? at a village meeting village elders' meeting village chief/leader health worker village health committee village committee meeting other (specify) 5. Has any CDD been changed after the first distribution? 1. Yes 2. No 3. Don't know 6. If YES to Q5, Why was the CDD changed? L 2. J. 4. 5. 6. 7. 7. Have you ever been supervised ? 1. Yes 2. No 3. Don't know 8a. If yes to Q7, who supervised you ? (IF NAME WAS MENTIONED, PLEASE ASK FOR IDENTITY/POSITION/STATUS OF THE PERSON) 1. Health staff 2. Village health committee member 3. NGO panner 4. Community member/chief 5. Other (specify)_ 8b. What did the supervisor do? (CIRCLE ALL THAT APPLY) Checked the ivermectin inventory Checked the records/treatment register Collated the repors Advised on the treatment of absentees other (specify) 9. At what occasions were you supervised? (CIRCLE YES OR NO FOR EACH RESPONSE) 1 2 3 4 5 1. Before distribution 2. During distribution 3. Soon after distribution 1. Yes 1. Yes2. No 1. Yes2. No 2. No 10a. Have you received education on the importance of taking ivermectin tablets annually for several years? 1. Yes 2. No 3. Can't remember 55 10b. If yes, what were you told? 11 Did you provide the community with education on ivermectin treatment? 1. Yes 2. No 12. It yes to Q11, when did you provide the education to the community? (CIRCLE YES OR NO FOR EACH RESPONSE) 1. During the first meeting 1. Yes 2 2. Before the first distribution 1. Yes 2 3. During distribution 1. Yes 2 4. Soon after distribution 1. Yes 2 5. Other (specify) 1. Yes 1. Yes 1. Yes 1. Yes N, N, N, fr{, 2. 2. 2. 2. 1 2 J 4 6 o o o o 13. If yes to Q11, what did you tell the community? (CIRCLE YES OR NO FOR EACH RESPONSE) Taking ivermectin annually for several years Benefits of treatment Community responsibility Side effects Other (specify) 14. Did you receive any training on how to treat community members? 1. Yes 2. No 15. If Yes to Q14, when did you receive raining? 16. Who trained you? (CIRCLE ALL THAT APPLY Health personneli Oncho coordinator NGDO staff (specify Another CDD Other (specify)_ 17. How long did the training last? l" training_ 2nd training_ Last tra ns 18. How many CDDs were trained together (size of the group)? 1't training_ Last training_ No No No No 1 2 J 4 56 19. Where was the venue of the last training? Within the community Outside the community Healthcare facility/hospital Other (specify) 20. Was the venue of training near to your community? 1. Yes 2. No 21. What were you taught during training about onchocerciasis (CIRCLE YES OR NO FOR EACH RESPONSE) Cause Symptoms Socio-economic importance Community mobilisation and education Ivermectin as treatment for a long time Other (specify) 22. What were you taught about the drug? (CIRCLE YES OR NO FOR EACH RESPONSE) 1. Duration of treatment 1. Yes 2. No 2. Coverage of distribution 1. Yes 2. No 3. Dosage determination by measuring height 1. Yes 2. No 4. Expiration of drug after removing container seal 1. Yes 2. No 5. Treatment of absentees and refusals 1. Yes 2. No 6. Side effects (counseling and referral) l. Yes 2. No 7. Exclusion criteria l. Yes 2. No 8. Record keeping 1. Yes 2. No 9. Census 1. Yes 2. No 10. Other (specify)_ 23. What were you taught about reporting? (CIRCLE YES OR NO FOR EACH RESPONSE) 1 2 aJ 4 1 1 1 1 1 1 2 aJ 4 5 6 Yes Yes Yes Yes Yes 2 2 2 2 2 No No No No No 1. 2. J. 4. 5. 6. Number of persons treated 1. Yes Number of refusals 1. Yes Number of absentees 1. Yes Number of excluded persons 1. Yes Number with severe side effects 1. Yes other (specify)_ 2. No 2. No 2. No 2. No 2. No 24. Did any member of the community collect the drug from a collection point during the last distribution? 1. Yes 2. No 3. Don't know 57 25. If "no" to Q24, why? 26. Where is the collection point? 27. Did you experience late supply of drugs during the last distribution? 1. Yes 2. No Please 28. How do you normally determine the quantity of drugs required by the community? Census/registration record Previous treatment records By counting the number of households Other (specify) 29a. Did you experience shortage of drugs during the last distribution? 1. Yes 2. No 29b. It yes, please expla ln 30. How do you determine the number of tables to give to an individual? (CIRCLE YES OR NO FOR EACH RESPONSE) L Take height measurement 1 2. Use weight 1 3. Visual observation 1 4. Age 1 5. Other (specify)_ 31. What do you do about individuals who are absent during normal distribution period? 32. What do you do about individuals who refuse treatment? 33. Which categories of people would you not give the tablets (PLEASE CIRCLE YES OR NO FOR EACH RESPONSE) 1 2 aJ 4 No No No No Y, Y, Y, Y, 2 2 2 2 CS CS es CS l. Individuals below 5 years of agel below 90cm 2. Pregnant women 3. Women who delivered less than one week before distribution 4. Sick individuals 5. Visitors 6. Other (specify)_ l. Yes 1. Yes 1. Yes 1. Yes 1. Yes 2. No 2. No 2. No 2. No 2. No 34. How do you ensure that these categories of people eventually receive 58 treatment? 35a. How long do you normally keep the tablets in the community?- 35b. How many days did you take to complete the last distribution? 36. Where do you normally keep the tablets? 37 . Do you have drugs to take care of minor side effects? 1. Yes 2. No 38. What kind of support do you receive from the community? (CIRCLE ALL THAT APPLY) Transportation for drug collection Incentives (specify) Other (specify) 39. Do you have problems with record keeping? 1. Yes 2. No 40. If yes to Q39, please expla ln 41. Please tell us how you feel about the programme with respect to a) sustaining the programme I 2 J b) community response c) constraints 42. What do you think should be done to improve the programme? 43. Are you willing to continue as a CDD? 1. Yes 2. No Please expla ln PLEASE ASK FOR REGISTER AND MEASURING DEVISE TO PROVIDE FOLLOWING INFORMATION 59 44a. Is measuring device for height present? l. Yes, seen 2. Yes, but not seen (Explain) 3. No, Explain 44b. How do you use it? 45. Is treatment register present? Yes, seen Yes, but not seen (Explain) No, 46.lt Q45 is "Yes, seen" EXAMINE TREATMENT REGISTER AND OBTAIN THE FOLLOWING INFORMATION ON: Total population_ Age composition of people: Below 5 years_ 5 years and above_ Sex composition of the population Male Female Number of persons treated_Male_ Female_ Numberofpersonsunder-5yearswhoreceivedtreatment- Number of refusals Number absent during last treatrnent_ Number with severe side effects_ Number of tables received 10. Number of tablets used I l. Number of tablets left in the drug kit 1 2 J I 2 J 4 5 6 7 8 9 T60 KEY INFORMANT INTERVIEW: Village" B" Leaders This tool is to be administered to the village head or a representative of the village head in all category "B" vilhges. In the case that the village head wants someone else to assist wtth the interview, do not refuse. Put a circle around the appropriate response codes. Do not prompt responses and allow respondent time for answeing the question. Use the option "other" where the response is not listed but remember to specify the response in the space provided. If a village head is not available, iruervievv his assistant or representative. Village Name: State/District Village Code:_subcounty/LGA : Country: Month and year of last distribution I 1. Have people in this community been treated with ivermectin in the past one year? 1. Yes 2. No 3. Don't know IF NO TO Ql END INTERVIEW IF YES TO QI CONTINUE THE INTERVIEW 2. How was the time (month/season) for distribution decided? at a village meeting village elders' meeting village chief/leader health worker Village health committee village committee meeting other (specify)_ 3. What mode of distribution was decided? house-to-house central place (specify) both house-to-house and central place other (specify 4. How was the mode of distribution decided? 1. at a village meeting 2. village elders' meeting village chief/leader health worker Village health committee village committee meeting 1. 2. 3. 4. 5. 6. 7. 1 2 aJ 4 J 4 5 6 7. other (specify) 61 5. How many persons in this village (CDD) give out the drug for onchocerciasis? 7. How were the persons (CDD) selected to do the work? at a village meeting village elders' meeting village chief/leader health worker village health committee village committee meeting other 6. Have the CDDs received any training? 1. Yes 2. No 3. Don't know/ Canft remember 7 . Have you changed any of your CDDs? 1. yes 2. No 3. Don't know 8. If yes, why? 9. Did any member of the community collect the drug from a collection point? 1. Yes 2. No 3. Don't know 10. Did you experience late supply of drug during the last distribution? 1. Yes 2. No 3. Don't know 1 1. Did you experience shortage of drugs during the last disuibution? 1. Yes 2. No 3. Don't know 12. Does the community have a treatment register? 1. Yes 2. No 3. Don't know I 2 3 4. 5. 6. 7. (H o(H >roFb- g E;<ES qO E g - x.; E T ll eE63EgIs E! =EBbE€ 8 ! ol zo F U) IJ] D 0)9t 6.EsX .E H C)C= ij =- d) e =v!^@6 >'d-ctE.-arI i - L' \rEorFo-,Bllllo€ xE'E>z t-q) r! o oF z g. o >r0()trot'oii-61 > a).4 - C) li [ [at -Y (l) -O c 0.) ll rrEs€S'68>z o n 5= * ,=e--LvltdOgao*d-e >:'6 -g - "ij rL < ()-O c! I-FX9SE.E z F(/) r! O oF(r) E] tJ. q.) 3 c -! *tr'= qZ * =E O hP 5+.E.E E € E g€ EE 8* 'Ero(!<i.ir .= >\ Bc.' -€ fr-^B d S o,Ell llA>A€S>Z :(\lltr E b g !,.8 E EE 9€E5 o ra ), > a9 I bo c!-o o >iJltruroI) z F C') r! O- €E;!9q_ HU,E iH?i *^ =;El!U=ll llosSEgs>z q) o0 5IT(AZL !! JJ q- q* g,g.l= o > gts<=6ZEE I c! ^v,n U I oz o ! C) <,)o I -i C) tr c! 0.)E aAs o o 2 Io oo C) o{) = c) z (l) bo € c) o(J o o tr c6 xE ! (I) 60o o) CJ 6) 0) cl) q) .t) o Lo tu bE g =<'E €bbEf,E :6^i>E 9E-q:uE q) -94E g€Es b(l) tJi o. rJrE:9Hc FEI .E ^P#Bp<e6LFa.g trfiEc =; oo E 9pO t'i v(r) ? a- =Oc!A-- -^)ir.:/ of'-()ES()cnF.tE a H cdog)>,EsilE .. C) Y o.lXiro <r0.)()6JaZ b a 69E;8o8 rrl ^ -= d) -=_P!!ld>\'C) > i:!9^r EggH s!Hp6--CF-q-(.* .E'IE s 3 sE 'L^. o =5 g-= E ()"ii o H QoH' #i- I = E g EEa O'-=-i (.) - c):i cor, E,< F =O v(ts tr qlb0 oooE 3(l) tr ,^ o.:-E i gOEV A L 'Iv -Yirii3tr H -9EP:aE F - tsg , l5^<Efi Q ^ Hqr d ogcb:'s-.r^tJ A'i *-c.A q.rSPHe EEAa '!-oE(H = g 9< oH e Bc bE E(tr ga E l'ra dD p= X 9O E} H;tr SrdE N\o o il o(A oE o9lthcr62 d)q) 5H(.)0 .,( c) ,( ,( l( ca\o -ill nnllVE o :C?Ei ll$! r-oS E ll €ro llU]IEE.HII?!FEoq-Arg *o # HE I ; E * m ^[![tr or 'ii .eU .!,4tr * H-il tr gs ooc X llE !r.= oE€E b 9-;-etrtri50 .E o(,) *tf ..d i? ai e ^.9 3 !l rr ?EEg+a E r BE € ; ?? .8ss ES rr tt!2 .Y i <a o.r f E EE.fit 64 IN.DEPTH INTERVIEW OF VILLAGE "8" CDD To be administered only in group "8" villages. Interview 2 CDDs per village if there are more than one CDDs. At the end of the interview ask the distributor to let you see his tools: measuring devise, registers, remntning drug tf available. Wen a question requires multiple responses, do not forget to put a ctrcle around each applicable response code. Probe where approprtate. Name of Village District/State Sex: 1. Female 2. Male 1. Yes 2. No 3. Have you ever been supervised ? 1. Yes 2. No Village code: subcounty/LGA: Name of CDD Main Occupation: 1. How were you selected to do the work? at a village meeting village elders' meeting village chief/leader health worker village health committee village committee meeting other (specify) 2. Has any CDD been changed after the first distribution? Month and Year of last distribution I 3. Don't know/can't remember 3. Don't know 1 2 3 4 5 6 7 4. If yes to Q3, who supervised you ? (IF NAME WAS MENTIONED, PLEASE ASK FOR IDENTITYiPOSITION/STATUS OF THE PERSON) 1. Health staff 2 Village health committee member 3. NGO partner 4. Community member/chief 5. Other (specify)_ 5. Have you received education on the importance of taking ivermectin tablets annually for several years? 1. Yes 2. No 3. Can't remember 6. Did you receive any training on how to treat community members? 1. Yes 2. No 65 9 7. Is measuring device for height present? L. Yes, seen 2. Yes, but not seen (Explain) 3. No, 8. Is treatment register present? 1. Yes, seen 2. Yes, but not seen @xplain) 3. No, (explain) If Q8 is "Yes, seen" EXAMINE TREATMENT REGISTER AND OBTAIN THE FOLLOWING INFORMATION ON: l.Total 2.Age composition of people: Below 5 years_ 5 years and above_ 3. Sex composition of the population: Male_ Female 4 Number of persons treated_ Male Female 5 Number of persons 5 years and above who received treaunent 6 Number of refusals 7 Number absent during last treatrnent_ 8 Number with severe side effects 9 Number of tablets received 10 Number of tables used 11 Number of tablets left in the drug kit_ 12. Update of records 66 QUESTIONNAIRE FOR HEALTH PERSONNEL This questionnaire is administered on any health worker in the area who is directly involved in CDTI programme i.e the health staff nearest to the village. The number of health personnel to be interviewed depends on the situation on the ground. A minimum of 3 health personnel who are supervisors of CDDs should be interviewed within the project area. Afier the iruervisw ask the health personnel for the documents used for CDTI aclivities. LGA/Subcounty State/District Country Name of health personnel_ Sex: 1. Male 2. Female No. of Oncho. Villages Position: No. of CDDs in villages covered_ Qualification: Responsibilities in Oncho control Programme: 1 Oncho Coordinator 2 CDD supervisor 3 other (specify)_ 1. Did you receive any general orientation on CDTI? 1. Yes 2. No 2a. Dld you receive training on how to train CDDs? 1. Yes 2. No 2b.If yes, how long? 2c. List the main topics covered 2d. Were you taught how severe side eff'ects should be managed? 1. Yes 2. No 3.Please tell us what you know about the CDTI programme with respect to 1 . Community responsibility 6',7 2. Involvement of the health system in CDTI 4. Was there an initial meeting with the community where CDTI was introduced? 1. Yes 2. No 5. If yes to Q4, what role did the health staff play in arranging for the first meeting? (CIRLCE ALL THAT APPLY) Facilitated the meeting Met with village leader to arrange for the meeting Other (specify) 6. Who led the facilitating team to the community? health staff government administrative staff (non-health) . NGDO staff . other (speciff) . Nobody 7. Were the communities (where you worked) educated on the importance of treatment with ivermectin tablets? 1. Yes 2. No 3. Don't know 8. If yes to Q7, what were they told? (CIRCLE YES OR NO FOR EACH RESPONSE) 1 2 3 1 2 aJ 4 5 1. Annual treatment for several years 2. Benefits of treatment 3. Community responsibility 4. Others (specify)_ 1. Yes 1. Yes 1. Yes 2 2 2 N N N o o o 9. Were CDDs in the communities (where you worked) trained for the CDTI programme? 1. Yes 2. No 3. Don't know 10a. If yes to Q9, did you participate in the training of CDDs? 1. Yes 2. No 10b. If yes, how long did this training session last? Initial training_ Retraining 1la. Who supervised the CDDs 1. Not supervised 2. Village head 3. Village health committee member 68 4. health personnel 5. Other 11b. If supervised, how many CDDs did you supervise during the last distribution? 12. If not supervised, why? 13. At which occasions did you visit the CDD? (CIRCLE YES OR NO FOR EACH RESPONSE) I 2 3 4 1 2 aJ 4 5 6 Before distribution During distribution Soon after distribution 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No Other (specify ) 14. What functions do you perform during your visit to the CDD? (CIRCLE YES OR NO FOR EACH RESPONSE) 1. Collection of unused drugs after distribution 2. Review of records 3. Management of side effects 4. Supervision of drug disuibution 5. Other (specify)_ 1. Yes 1. Yes 1. Yes 1. Yes 2. No 2. No 2. No 2. No 15. What constraints do you have in supervising the CDD? (CIRCLE YES OR NO FOR EACH RESPONSE) No constraints inadequate/lack of means of transport/fuel Too much work Inadequate/lack of supervision allowance Inaccessibility Other (specify) 16a. Have there been any delays in receiving ivermectin? 1. Yes 2. No 16b. If yes, explain 16c. Have there been any delays in collecting ivermectin by the community? 1. Yes 2. No 17. If yes to Q16c, please 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No explain 69 18. What consuaints have you experienced in getting the drug? (CIRCLE YES OR NO FOR EACH RESPONSE) 1. None 2. Transport problem 3. Inadequate supply 1. Yes 1. Yes 1. Yes 1. Yes 2. 2, 2. 2. No No No No4. Delay in supply 5. Other (specify) 19. How do you estimate the quantity of drug required? Not responsible Number used during last treatment Based on requests from the CDDs Total population (with the formula) Other (specify ) 20. Did you get the drugs when required? 1. Yes 2. No 21. It no to Q20, why? (CIRCLE ALL THAT APPLY) Shortage at state, regional level Means of transport Other (specify) 22. Do you have facility for storage of ivermectin? 1. Yes 2. No 3. Don'tknow 23. Have you experienced loss of tablets due to pilferage? 1. Yes 2. No 3. Don'tknow 24. Were cases of severe side effects reported to you? 1. Yes 2. No 25. RECORDS OF SEVERE SIDE EFFECTS (CHECK AVAILABILITY) : 1. Available 2. Notavailable 26. Whnt other health activtttes do you combine with Oncho Corurol Programme aciivities (PROBE FOR HEALTH ACTIVITY IN THE CDTI COMMUNITIES)? 1 2 3 4 5 1 2 J 70 27 . How do you feel about the CDTI programme? 7l INTERVIEW GUIDE FOR POLICY.MAKERS/ REPRESENTATIVE/PROGRAMME MANAGERS/ COORDINATORS wHo This interview is administered on Co-ordinators, Programme managers, representatives of NGDOs involved in CDTI, Ministry of health policymakers and the WHO representative in the country. It is similar to the interview of health personnel. Documents such as registers should be requested before the formal interview so that information can be extracted for the report 1 SECTION A: PROGRAMME MANAGERS/ ONCHO COORDINATORS Please describe how the CDTI programme is being implemented in your area PROBE FOR The approach used for introducing CDTI to the communities Elements of collaboration between Community, Health system and NGDOs (IDENTIFY SPECTFIC ROLES) General re-orientation of health personnel towards CDTI programme Mobilisation of the communities Training of health staff as trainers Please explain process of receiving ivermectin PROBE FOR : a. Delays in supply . at what level and why? b. Adequacy of the quantity received/shortage c. Storage d. Distribution to communities e. Constraints (storage, transport, etc) f. Pilferage FUNDING: Please probe for a. Delays in endorsement of letters of agreement whv? a b c. d. e. 2. J b. Delays in receiving funds 72 o . at what level and why? c. Delays in disbursement of funds At what level and why? d. Inadequacy of previous budget e Fund administration: delays in submission of financial repofts, disbursement and retirement procedures, delays in feedback from APOC headquarters on financial reports 6 4. Please describe the programme's plans for improving sustainability 5 Which other health activities do the Oncho supervisors combine with their Oncho Control Programme activities? Would you please explain the programmdls record keeping procedures EXAMINE THE FOLLOWING RECORDS Summary sheets: 1. Available 2. Not available 7 EXTRACT INFORMATION ON THE FOLLOWING (relate to the level of operation e.g. state and LGA) Total Population Number of villages in the area_ Number of villages with summary forms_ Number of villages treated_ Number with severe side effects Evidence of report update (check annual returns after distribution) 1. Updated 2. Not updated SECTION B: MOH POLICY MAKERS ( Permanent Secretary/Director Disease Control) 8a. Do you have a national Plan for the control of onchocerciasis ( Probe for the importance attached to onchocerciasis control a. b, c. d. e. f. t5 8b. What kind of support do you provide for Oncho. Control activities (PROBE FOR FINANCIAL INPUT) 9 How do you perceive the CDTI strategy of APOC ( Probe for personal opinion and official policy on CDTI) 10 Is the Oncho Programme integrated into the health system ( Probe for activities which indicate integration and ownership/ Plans for sustainability. SECTION C: WHO COUNTRY REPRESENTATTVE 11.What is your perception about the APOC strategy for ivermectin distribution ( Probe for feasibility of the CDTI approach in solving other health problems) 12. What is the relationship between the WHO office and the National Onchocerciasis Task Force (NOTF) with respect to CDTI implementation. (Probe for issues relating to transfer of funds, support to NOTF and monitoring)