Extension annual project technical report submitted to Technical Consultative Committee (TCC): from January 2007 to December 2007

., RESERVED FOR PROJECT LOGO/IIEADIIYG ORIGINAL : English COUNTRYAIOTF MATAWI Proiect Name: EXTENSION Approval year: 1999 Lauuehtuercar: 2000 Reportins Period From: JANUARY, 2OO7...To: DECEMBER, 2007(Month/Year) ( Month/Year) Proiect year of this report: (circle one) 123456789 10 Date submitted: I APRIL, 2008 NGDO partner: SSI/TEA iz For To: x+ ,,, aiH eoP nH3 For lnfrcnnailcn To')ift v 0 ! At,R 200s WHO/APOC, 24 November 2004 AAI H tANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) DEADLINE FOR ST]BMISSION: To APOC Management by 31 Januarv for March TCC meeting To APOC Management by 31 July for September TCC meeting AFRICAN PROGRAMME FOR oNcHocERcIASIS CONTROL (APOC) I I I WHO/APOC, 24 November 2004 , AI{NI-l;t L rIfOJI,C'T TErII3ICAI, RE,PORT .IT,) 'l'l""('HNl( .,\l- {l(}iVSl ll.'fA"} IVF. {-'O1{}ll.l I l"rl: i I ("(lt INI}ORSEMENT lllcasc (oil{it'mr you ha1'e rcad this rcport hy'signing in the i flppropriate space. ()Iili'l(lnllS to sign the report; Cuutttrr-: N() I'l-' e'hnirnian MALAWI Narnr: tlr 5. Kubrrluzi Si.liltlttrrc T I.t-I -.\' '^' "j' \1'l ltr,.\l'(tL J-i l.rur.rrr\-'r Jtrl'{ I )at* N(iiX) Rrpr*senlativc Hixrtr: lYr Frxnk IVIuaf,ulin+ar $rsJr*ture: SS-ffi? r):rre : ,'*n\t-e\ t g. . I'lris r*pofi has beeti prepiued bl,Namc : Lsston $itiruu I)esigrutior: : }ariousrl C'oortliilator r)*r* .. i".i- iI.{ lt.,', ll1 WHO/APOC, 24 November 2004 ,,\, l t, il Table of contents DEFINITIONS VII FOLLOW UP ON TCC RECOMMENDATIONS I SECTION 1: BACKGROUND INFORMATION....... 1.1. GeNrRnl-INFoRMATIoN............. I . 1 . 1 Description of the proj ect (briefly) ..... 1.1.2. Portnership 1.2. Popu1artoN............... SECTION 2: IMPLEMENTATION OF CDTI....... 2.1. TIvEr-tNp oF ACTIVITIES ............ 2.2. Aovocncv 2.3. Mogtl.lznrtoN, SENSITIZATION AND HEALTH EDUCATION OF AT RISK COMMUNITIES 3 J 3 J 6 7 7 9 9 2.9.1. Provide aJlow chart of supervision hierarchy. """""" 20 2.9.2. What were the main issues identified during supervision? .................""""""' 20 2.9.3. Was a supervision checklist used? ........."" 21 2.9.4. What were the outcomes at each level of CDTI implementation supervision? 2l 2.9.5. Was feedback given to the person or groups supervised?. ...... . ....."""""""' 21 2.9.6. How was the feedback used to improve the overall performance of the project? 2I SECTION 3: SUPPORT TO CDTI .......""""22 2.4. 2.5. 2.6. 2) 2 2 2 2.7. 2.8. 2.9. 3.1 3.2 J.J 3.4 Covuuqlry INVoLvEMENT........ ....'. l0 CRpecrrv BUILDING.. ...'.. 11 TRpervpNTS.............. ....' 14 6.1. Treatmentfigures.......... -.---...... 14 6.2 What are the causes of absenteeism?.......... ................. 16 6.3 What are the reasons for refusals?................ -........-..... 16 6.4 Brie/ly describe all lcnown andverified serious adverse events (SAEs) that... 16 6.5. Trend of treatment achievement from CDTI project inception to the current year l8 ORogRtNG, sroRAGE AND DELIVERY oF IVERMECTIN......'....... ..'.'......'... 19 Couvlmrry sELF-MoNIToRING AND STAKEHoLDERS MEruNc -......-....20 SuppRvrsloN............... ................-....-20 EeurpveNr Fmaucte.l coNTRIBUTIoNS oF THE PARTNERS AND coMMLNITIES Ornen FoRMS oF coMMUNITY suPPoRT............. ExppNotruRE PER ACTIVITY 22 23 23 23 SECTION 4: SUSTAINABILITY OF CDTI....... """""'24 4.1. INreRNer-; INDEPENDENT PARTICIPATORY MONITORINC; EvalUaTION........'. ..........24 4.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of thefoltowingwhich are applicable)... . ...... """""' 24 4.1.2. What were the recommendations? ....-....."' 25 4.1.3. How have they been implemented? ............. ....--...."""' 25 4.2. SusrRNasrlrry oF eRoJECTS: ILAN AND sET TARGETS (MANDAToRY AT................25 Yn 3) .......2s lv WHO/APOC, 24 November 2004 4.2.1. ,1 1) 4.2.3 4.2.4. Planning at all relevant \eveLs......... Funds....... Transport (replacement and maintenance) Other resources 25 25 25 25 ........26 ........ 26 ........ 26 4.3. INrecRarroN............ 4.3.1. Ivermectin delivery mechanisms .... 4.3.2. Training.... 4.3.3. Joint supervision and monitoring with other progroms........... ...... 26 4.3.4. Release offundsfor project activities ........ 26 4.3.5. Is CDTI included in the PHC budget? .............. ..-.-...... 26 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. Wat have been the achievements?............. .................... 26 4.3.7. Describe others issues considered in the integration of CDTI. ..... 27 4.4. OprnnrroNAl RESEARCH 4.4.1. Summarize in not more than one half of a poge the operational research undertaken in the project area within the reporting period. .....-.- 27 4.4.2. How were the results applied in the project?............. ...............-.-.- 27 SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, AND OPPORTUNITIES.... ....................27 SECTION 6: UNIQUE FEATURES OF THE PROJECT/OTHER MATTERS...........28 ........,.,.....2] V WHO/APOC, 24 November 2004 Acronyms APOC ATO ATrO CBO CDD CDTI CSM LGA MOH NGDO NGO NOTF PHC REMO SAE SHM TCC TOT UNICEF UTG wHo African Programme for Onchocerciasis Control Annual Treatment Objective Annual Training Objective Community-Based Organization Community-Directed Distributor Community-Directed Treatment with Ivermectin Community Self-Monitoring Local Govemment Area Ministry of Health Non-Govemmental Deve lopment Organization Non-Governmental Organization National Onchocerciasis Task Force Primary health care Rapid Epidemiological Mapping of Onchocerciasis Severe adverse event Stakeholders meeting Technical Consultative Committee (APOC scientific advisory group) Trainer of trainers United Nations Children's Fund Ultimate Treatment Goal World Health Organization vl WHO/APOC, 24 November 2004 Definitions (i) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking). (ii) Eligible population: calculated as 84o/o of the total population in meso/hyper- endemic communities in the project area. (iii) Annual Treatment Objective: (ATO): the estimated number of persons living in meso/hyper-endemic areas that a CDTI project intends to treat with ivermectin in a given year. (iv) Ultimate Treatment Goal (UTG): calculated as the maximum number of people to be treated annually in meso/hyper endemic areas within the project area, ultimately to be reached when the project has reached full geographic coverage (normally the project should be e*pictld to reach the UTG at the end of the 3'd year ofthe project). (v) Therapeutic coverage: number of people treated in a given year over the total population (this should be expressed as a percentage). (vi) Geographical coverage: number of communities treated in a given year over the total number of meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage). (vii) Integration: delivering additional health interventions (i.e. vitamin A supplements, albendazole for LF, screening for cataract, etc.) through CDTI (using the same systems, training, supervision and personnel) in order to maximise cost- effectiveness and empower communities to solve more of their health problems. This does not include activities or interventions carried out by community distributors outside of CDTI. (viii) Sustainabilitv: CDTI activities in an area are sustainable when they continue to function effectively for the foreseeable future, with high treatment coverage, integrated into the available healthcare service, with strong community ownership, using resources mobilised by the community and the government. (ix) Community self-monitoring (CSM): The process by which the community is empowered to oversee and monitor the performance of CDTI (or any community- based health intervention programme), with a view to ensuring that the programme is being executed in the way intended. It encourages the community to take full responsibility of ivermectin distribution and make appropriate modifications when necessary. vll WHO/APOC, 24 November 2004 FOLLOW UP ON TGG REGOMMENDATIONS Using the table below, filI in the recommendations of the last TCC on the project and describe how they have been addressed. TCC session 25 There were no issues that arose during TCC 25 meeting regarding the extension project 1 Number of Recommendution in the Reporl TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT FOR TCC/APOC MGT USE ONLY WHO/APOC, 24 November 2004 Executive Summary Prepare an Executive summary of the report in not more than 9!!9.page. The Notionol Onchocerciosis Control Progromme hos been corrying out lvermectin Distribution in the Extension project since 2000. This Extension project covers 5 districts of Chikwowo, Blontyre, Pholombe, Mulonje ond Chirodzulu. ln the 2005 distribution yeor, o totol of 880,393 persons were treoted out of the populotion of I ,064,938 people representing o treotment coveroge of 82.7%. All the ,|,514 villoges torgeted were treoted representing o 100% Geogrophicol coveroge. The Ultimote Treotment Gool wos 883,899 people ond Annuol Treotment Objective coveroge rote wos 99.6%. The people of Pholombe, Mulonje ond Chikwowo move in certoin seosons of the yeor. The three districts shore on lnternotionol boundory with Mozombique. During the roiny seoson, the people of Mulonje ond Pholombe move to Mozombique to cultivote. These people hove formlonds in Mozombique where they grow different crops for their livelihood. They stoy there from plonting period till they horvest their produce. People of Chikwowo move to the bonks of Shire River during the dry seoson to grow different crops for their livelihood. ln 2007, the progromme continued to corry out troinings. Troinings covered heolth workers directly involved in CDTI octivities ond the CDDs. During the reporting yeor, o totol of 1,005 Heolth Workers ond 5,820 CDDs were troined. During lhe 2007 distribution period, o totol of 5,820 CDDs were involved during the distribution, representing o rotio of I CDD to o populotion of 124 people. The only chollenge thot the project foced wos lorge rotion of CDD to populotion. This chollenge will be oddressed this yeor (2008) by troining more CDDs. 2 WHO/APOC, 24 November 2004 SEGTION'l: Background information ',.',. General information 1.1.1 Description of the project (briefly) The malawi Extension project started in 2000. This Extension project covers 5 districts of Chikwawa, Blantyre, Phalombe, Mulanje and Chiradzulu. The Extension zone shares the eastern and south western international boundary with Mozambique. On the eastern border with Mozambique lies Phalombe and Mulanje districts. Chikwawa lies in the south western boundary with Mozambique. Blantyre district lies to the North of Chikwawa whilst Chiradzulu lies to the western side of Phalombe. Most of the endemic areas are hilly with difficult terrain. This makes them easily accessible only during the dry season. The numerous small and large rivers emanating from the mountain ranges provide good breeding sites for the blackflies ( Refer to Fig 1 on Page 11 - Map of Southern Region of Malawi ). Phalombe, Mulanje and Chiradzulu are dominated by Lomwe tribe whilst Chikwawa is dominated by Sena and Mang'anja tribes, Blantyre has got mixed tribes and there is no tribe dominating over the other. The district is inhabited by Ngoni, Sena, Yao, Lomwe tribes among others. In all the districts, there are other tribes like Yao, Mang'anja apart from the dominating tribe. In the Southern Region of Malawi, i.e. including the Extension zone, the main rainy season lasts from November through March. Additional light rain usually falls between May and July. The peak farming season begins in July and ends in April. Mulanje is in the highlands, so rains come any time of the year. The climate in Mulanje is favourable for tea plantations thus why the presence of large tea estates. Administratively, Malawi is divided into three regions with twenty-eight districts. The local community is mainly a village set up which follows a common clan ancestry and /or a similar cultural grouping. The village is headed by a traditional chief who may have several assistants or advisors mainly elders of his clan. In some areas several households belonging to one village could be scattered over several kilometres. Several villages can be grouped together under one Group Village Headman (GVH). The highest ranked ruIer is the Traditional Authority commonly called the T.A. whose authority covers a geographic zone in a district. The TA is a very powerful and respected traditional ruler. In the majority of the tribes there is gender equality in the inheritance of headship (chieftaincy). The country's population is currently estimated at more than 12 million with most of it in the Southern Region. On health care system, Malawi underwent decentralization, therefore the regional health offices were abolished. The District Health Officers report directly to the Ministry of Health Headquarters. At district level, there is one district hospital which is headed by a District Health Officer ( DHO ). From the District Hospital, there is either a health centre or a Rural Hospital. Then Health posts follows the Health Centre/Rural Hospital. Communities access medical treatment at each health facility free of charge. There are a total of 49 health facilities and 18 Estate clinics particularly in Mulanje District. Out of atotal number of 814 health workers,595 were involved in CDTI representing 73.1%. There was no 100% health workers involvement because by the end of the year J WHO/APOC, 24 November 2004 (2007) new staff had been employed who have not yet been trained, however, we are planning to train the newly employed staff before the 2008 mectizan distribution. Fig. 1 : Map of Southem Region of Malawi D EEZA {r hNAHGOCH! E 4 HIHGA HEU flvolCH! WHO/APOC, 24 November 2004 f Table l: Number of health staff involved in CDTI (Please add more rows if necessary) District Number of health staff involved in CDTI activities. Total Number of health staff in the entire project area B, Number of health staffinvolved in CDTI Br Percentage Br=Brl Br *100 Blantvre 382 208 54o/o Phalombe 40 t6 40o/o Chiradzulu 92 'il 77Yo Mulanje 239 239 100% Chikwawa 6t 6t l00Yo Total 814 595 73.lYo 1.1.2. Partnership The NOTF Malawi comprises the Ministry of Health ( MOH ) and other partners : the Sight Savers International (SSD, Tea Estates Association of Malawi, the World Health Organization ( WHO ). SSI was taken on board after the winding up of activities of the Intemational Eye Foundation in Malawi. The NOTF partners are involved in various CDTI activities. The SSI Country Representative participates in the planning of CDTI activities, supervision, attending NOTF Meetings. For the past 8 years, the tea estates in Mulanje district have actively carried out treatments on their establishments. Mectizan distribution on the Tea Estates is carried out by volunteers who are trained by the Estate Clinic Health personnel assisted by the District Onchocerciasis Coordinator. 5 WHO/APOC, 24 November 2004 tc.] L 0) -o () o z *N O o Or oi *r C) q) € o o(n(rr d 0.)l-r Cg o C) 'a Lrq C) o (d aoa (.) o -o cd a(.) Lr(.) qi o o (€ L .o t-< C) >t (B C,)t< 0) a o 0) 'a Lr O q< o q) (tr otra o Ia Lro a() (n - q, bo(s t<o >.P ) O (.) cr) o cn o P 0.) rtr(,) c) o0(d lr >\ oo F 0) C) oo U) oLr(!) r-r 0)(! til;(E }r CBo e o C)a v) (D ot< o cn lr c) C'. ,/ G) o -oa'd lJ oFr d C) (g a2 =t)trEv() o-()(s (/)ts9z(,!? .dts (€i .'! (,Ea .{ z(! +i t( z (n(.) +. o lrq)a ao l<o P. 0.) Lr() bI) l-< o oE C)(.) 'a Lr o. c) l-r € (n a o) C) th \o \i !uq) o'L \) q) : q) u B a)\ a) -o \ u B rB$5OLs\ sv\su9 *tA Ss hO' p: BA) :* tB$x $! Sqr \S raU utl ).xrss9 s|\ \q,P-aBr \F P.S -\) la \r\Ea. a_9S\ ": *a: '-\59 sp 's .: rj E' NB. \bo -Y -= ild hB\q) q 4 a)U a) 4 > oL. q) L t \)q E o lr C)a bo li oao! 0) bo ! o Lr o 0) (s 0)Lr 0)L{(d >' 0,) tro c) cl c)L GI Iq) L -q) L q) C) ll cn lr P o (s A.o (d EEO '.=a- '=flt-i62 -H -Eo.xt? e.il .olNEIr cdlF t-l o\ cO cO $(n C\ cn oo \o o\\o t €\ o\6 ?a €a tr e :': = 8e r-(..lq \o c.t c.l o\ c.l tr} oo oo c.) \o f-. tr1 ca oo r o\ t \o cn oo oo € ca € ra o\$\o + il .6)itr -oo .= o.N :> Ei r€ o!1 , <,lE E L'=!6&E.=5;>,,E or 0) -E H E'A -sE +$la) N@ oo =J^NF- r--\oc\ (-.l rn o\NoI o\6N oo cn tt- c.) ca o\ ca oot @ oo oo c.) o\ r- ra F-f- c{ a 'EgE :ed 9crU #si tr) + tr-(.N c.l $ o\ o\ $N ooN ooN cn t+ in I o ON().= (!o) F + il r-N\o N\o o\\o ca .eE E.F *e Co:'l9E Ei-cotr >r c)FFE N oo$ o\ ral caI'r o\N uhq) AT G U)q) t q,) Lq) z c) 'Eg8 *r k ?or6o tr'=gsi o\tr-$ e.lrf.) cn tr)(n ooNcO $NN GIEP .=fc!9.r-?i E.E.E Pcr g'v9-tH AE A tr) @ oo ca \o t-r tr) cn oo ra) o\ $ \o ca oo @ € cn €(a o\ !f,\o 4) q.) ':r()d .= l- q)ia.5 LAECE -c)r r.H.qA!O 0)t< >. (! o o .o o (B 0) H z (B B(! BJi EO ) N (c Lr O Fl Fr t'r SEGTION 2: Implementation of GDTI 2.1. Timeline of activities Fill in table 3, timeline of activities for areas treated in curuent year, indicating when the key activities were implemented by the month they began and the month they ended. 7 WHO/APOC, 24 November 2004 $ ON L() -o () z$ c.l Q \J Or o > oo c/) (,)t tr oO -:. !4q q) uq) q l vl. q) L t ! q) 4 q) E lr(s o >' o)Ltr o o ! 0) (6 olr (r') d C)l-r(6 C) Fr € q) c) o CO(rr 0,) o) E F ..ir()l -ol(dt FI o ah Lq) c a o q) o(J r-ooN Q C) o L C) -o o a.()a t-r N o -oo o c c- e.l o z o -oo o ao -E r-OON E o. 0) -o gFr o-oooa(\ F- e.l d L uh bI L E6EE o(, c- N o o L 0) -o 0)q() c/) r-. c.l o .o o Z t-- a. 0) a Op o o o P= 1itr 6t= r* c.l o.()a bo oo 9r-ooOO , a.l tr- >l oo q) c an q) c) U o EE I r- N bo C) N o t.- e.l 0.) EOEE 1ic Gt: r- N (o N d r-- z u! L3 o a.=EE o Q c-O N o bo N >. t-. al >' C) -o () o. C)a EE?tr 6= F-oO c.l o. c.) a >' N o r- ol o LO -o o a.() U) -0) .E .E s= !Eoo = (.)Z o EE (J t--o a.t () o () ! () p. oa N o .o o o) r- (\ >' Lop o o hoiE t- N o) t-- N o F- N d I L u) (:) H (d ca o) -o 0. o N ! cd IJ () '= (d (c cd .v O F] tr Fr 2.2. Advocacy State the number of policy/decision makers mobilized at each relevant level during the current year; the reason(s) for undertaking the advocacy and the outcome. Describe difficulties/constraints being faced and suggestions on how to improve advocacy. During the year, one major advocacy activity was carried out at National level. The Secretary for Health held an advocacy meeting with District Assembly officials. During the meeting, journalists from different media houses both print and electronic including the Television Malawi were invited. Both activities brought awareness to the community since onchocerciasis was featured in local media both print and electronic including Television Malawi. The meeting provided opportunity for many of the participants to understand the issues of Onchocerciasis. As a program the advocacy meeting was successful and we hope to build on the experience to continue to advocate for the participation of other stakeholders. At district level, advocacy was targeted to influential leaders depending on the level. Meetings were held in venues such as churches, village headman headquarters for this purpose. 2.3. Mobilization, sensitization and health education of at risk communities Provide information on: The use of media and/or other local systems to disseminate information Mobilization and health education of communities including women and minorities Response of target communities/villages Accomplishments Suggest ways to improve mobilization and sensitization of the target communities. In addition to the information provided on advocacy, districts took charge of disseminating messages about Onchocerciasis. The Community structures were actively involved in the mobilization of the public. More emphasis was put on the need to participate during ivermectin distribution which was planned to take place within 2 months only. Drama and meetings including onchocerciasis open days were used to disseminate information. These meetings were being conducted by different personnel at different levels such as the community, health center e.t.c. IEC materials such as posters,leaflets were used in sensitization. With the intensive mobilization and Health Education, this has assisted to maintain a higher treatment coverage that has been realized since 2004. For a successful mobitization to be realized, there is a need to involve influential leaders such as village headmen, politicians. 9 WHO/APOC, 24 November 2004 2.4. Gommunityl involvement Table 4: Communities participation in the CDTI (Please add more rows if necessary) During health education meetings, more female members attended the meetings than men. This is also the same in any activity. The participation of female members was more than male members. As of now, no monetary incentives have so far been provided to the CDDs by the community Attrition of CDDs is not a major problem, however, attrition of CDDs comes about due to transfers of CDDs to other areas for employment and marriage Number of communities/villages with community members as supervisors Number of CDDs and the communities involved Number of communities /villages with female CDDs Total no. communities in the entire project area B4 Number with community members as supervisors B. Percentage Bc= Bs/ B. *100 Male CDDs Br Female CDDs Br Total Bs= Br+Bs Number of communities with female CDDs Bro Percentage Bn= Bro/Bd* 100 Blantyre 621 0 0 1,235 2,653 3,888 627 l00o/o Phalombe 62 0 0 149 125 274 58 93.5Yo Uhlradzulu J26 0 0 500 664 I,164 240 13.2 Mulanje 369 0 0 995 1,597 2,592 369 100% Chikwawa 128 0 0 399 248 647 102 79.6% Total t,514 0 0 3,278 5,287 8,565 1,396 92.2Yo 10 WHO/APOC, 24 November 2003 District I ta th 2.5. Gapacity building - Describe the adequacy of available knowledgeable manpower at all levels. Knowledgeable manpower is adequate at all levels. This applies at National, District, Health Centre/Post and at community levels - Where frequent transfers of trained staff occur, state what the project is doing, or intends to do, to remedy the situation. (The most important issue to describe is what measures were taken to ensure adequate CDTI implementation where not enough lcnowledgeable manpower was available or if staff are frequently transferred during the course of the campaign). The situation can be remedied in different ways. First is by training adequate staff in different cadres and secondly by intervening when critical staff are transferred i.e. delay the transfer to identiff replacement before transfer is effected. 11 WHO/APOC, 24 November 2003 ta6 CIa l,o o\ € o\tEd ! o.a + .U ir *o c.l oo oo or) cl $F- : co : co$ N o\vI N a.t o\vl cl F-$\o F-s\o O \o r- -i :_ 00 ca : 00 oo r- ia \o o\ v ta \o q) () o) C) \o q) t- ar) (J L c) z ?!FU oo 00 00^ co r-\o N o\ * r-$\o o\\o o\\o l,o : .U +.: $ riev c.l c.l (\ c.l c.l O r- _i Fr o.l O O aoN N q) q) Q) a \c ia 66 (, c.l O cO coN €r- o ahl- o .=66l t-rrr h, L r.<6): io oq)L9 Lc! o)L z .I =\o N = = CI U E.= +F-d q e .+ oo oo co c.l t \o \o o\ aoN o\ c.) c.l \o $ o\ @r- c) q) (,) a \c a6q) cd tro- -rEE> zE q) I (J t c.l \o o co s o\ o\Nr- = ori +F-(5 ,L \,! ,vv c.l N O o\ a.t -: o\ co c.l \o s t : o c.l t o\ cl ra6 ail o\ tr c( eh tt) F] Seo0) a!t o Lrq) z U c.l O c.) \o tc\ ia = q) 0 a)rb (B ca C) -o o cd H () '= (6 (d B cd }( (J 3 N (d L O F] tr Fr () 0) c) () vo\ \o Nr- co oN () -o () o z$ al o H o N bO \ p aB o B o M -E o * o t o\ * .a s o t\ ,* : z; -:. !q 4 (.) q) 4l \ q) r. E q)q 9q) s o (€ o 0.) F Uqr (/) o o 0)L _c)H E o CE bo (t frF .Ar()l -ol(El FI \o Trainees Type of training CDDs Other Community members e.g Community supervisors Health Workers (frontline health facilities) MOH staff or Other Political Leaders Others(specifu) Program management x How to conduct Health education x x x x Management ofSAEs CSM SHM x x x x Data collection x x x X Data analysis x x x Report writing x x x x Others (speci&) x x x x Table 6: Type of training undertaken (Iick the boxes where specific training was caruied out during the reporting period) During the reporting year, NOTF in coordination with APOC conducted training on Data Management in July, 2007. This training drew participants from all the CDTI districts. The training was conducted in August, 2007. DHOs, DEHOs and DOCs and District HMIS coordinators were participants from the districts. In addition to this training, NOTF in coordination with APOC conducted training on Financial Management in August, 2007. The training was attended by District Accountants, District Oncho Coordinators and Accounting personnel from the Ministry of Health Headquarters. During the same reporting period, NOTF Secretariat conducted training on resource mobilization. The training was conducted in May,2007. The training was attended by DOCs, DHOs and other district Environmental Health Officers. This training was a follow up after the National Coordinator attended training on resource mobilization in Ouagadougou, Burkina Faso in September,2006. This training was funded by the Ministry of Health. l3 WHO/APOC, 24 November 2003 2.6. Treatments 2.6.1. Treatment figures If the project is not achieving 100% geographical coverage and a minimum of 65%o therapeutic coverage or the coverage rate is fluctuating, state the reasons and the plans being made to remedy this. t4 WHO/APOC, 24 November 2004 + c.l H() -o o o z$ c.l o o. F ra) q) s\ x Q\B ss L oos a, !O \(,E uJCrv$ -\EEd'S ESq) ':i 9',s \ r*s =ts ='3.8t Br't .s -I '-v h.=B EES6 E's rr $ S .= >\ F'taF-il6E* et: O <!EJ. T}c)\o-s sFisA SF;SUI .S'Ssur\.! .E'$i P H\E\X \s qrr: \'= {(ght- ol tsli1a'ol !wL" al -l 9sSU .z xl: E s35 Tl !s;LE xle F s!6 gt FstEts o.rl 6-.9 Y rE EtS E.TE BJ U S€ST EIE $ Eirl = *tYE -Bl c ^s'.s S = trl ru i\ uE =l E Iis .isx E.U $ ES \ 'rO-S !r\i ,, } u\il *E-*:*s-v RSs\.:';\ i.a *rE : s{E i S! .e N'i g _c sda.s H iSsv rh SJi rV l\!\='F rrrtSD s9 ! rO l\S:o\ \aS -lxl EI ol (d1()l L]I o) al o() al(H o Lrop z C) L 0) bI)(! L 0) o oF cd oL(n Poo U L(g^()L0)(E- 9€o(,) '='a- La<r -1() rr'l =&tA =-o9 v - Ia(.) ts .= c)tr-O atr(! FA :c) ()P otr )EAt F 6) ol =E -l tstr vl O0) '-l o rl Hl <.rdj) ;t .-o- tal tr + !l EA alc.Y, ol 6);i blt rE sl b -l Atr >l>r -\l -cb0 [il > .= el Lh -lL)tul-l L .E El " ^lLtd Xl o,) -vlAJ9I Fo- oltrO rl 5o. Plc 'fri trl cd -tIb =l oF ZI? tl o (d! 0) bo ,(n L C) oo ,r/^qo .I ro o\ -.C o\,v6.v (s bo c) x C) C)k 0) o oo +r o l< C) -o z o (g C) oo L c) oo o 0)a Lo F al olhll(6lLIol BI ol EI ol -(lOI(!tLl$()l oll 'oltrldl ol al al(dtLl 6-)l -el*J .El EI EI ol :l €l ,al 3l EI ol II.I -o vaOia,'Ig a E a; E EEH€EH3;z HE e o O rrle-4 Ea AO o O o bE EO zd c.l co c.I .f, c.)+v} +I + @q c.) \o co o\ \o aiq (Ho Lc^-o .3 9.EE EEE},3E2* E! F-coc.l $o\ F- F-q m \o ooq c.l r-\o c.) \o o\ o d q o O. o\ o 'Eo o(! =o9e F o\ a.) oo o\q oo 5\ co o\\ @ o\N oo \N@ c6gpadEb9 = o-!z \o c.) o\ \o co t odN N b N o\co c.) +ol ci oo a.) o\ co O oo € :()E 6.2 ::oT EtrFU \o c.t o\ \o co c.) o\N 3\ .o oo N co $ ol ci 00 o\ o\ oo c.t € € c, .=.r6E E9 = o P(,5-E io o=Otr E " E€ .9OF € @ co \ot'-O.|r) co * * ,d co o\ $ \o ao o 6 co o\$\o Ch C) o0(c a() oO ll * o\ .9o:s !eo bo< ue O -o o\ E.9 .- 3 E S.Htr c= o =tr>*AO o tr- c{\o c.l\o toN o\\o ca) ooN $ EoE 6.U < gP'F q.l c-c.l\o N\o :oN \c) cn oo N $ \Oq6--rdk o= - o er-^= It tr'- h,, - - 1A !-=^d = o-\ ar E E.S' TE o>-o c-C\\o ol\o EN o\\o co co N $ r/) o ! q IJ () d o () -o (! N (€ O C) '= (n z l4 O F] 3 Fr u 44 Uq) q UL q) L N \) F{ q) 5 ,y a ! (6 t)(€ C)tr oJ o Lr a >' -o a rrl a (d 0) dolrF r-t orl .ol(dt FI 2. J 2.6.2 What are the causes of absenteeism? Chronic illness - the person could be registered during the census update however due to chronic illness the person is hospitalized during the treatment Unplanned emigration - the person could be registered during the census update however, it could be found out that the person has emigrated to Mozambique or other districts during the treatment Deaths also contributed to absenteeism 2.6.3 What are the reasons for refusals? Religion - there are some religious sects which do not allow their followers to take drugs Sometimes people are afraid of the side effects if the side effects are over emphasized during health education 2.6.4 Briefly describe all known and verified serious adverse events (SAEs) that occurred during the reporting period and provide (in table 8) the required information when available. In case the project did not have any cases of serious adverse events (SAE) during this reporting period, please tick in the box. No SAE case to report 2 t6 WHO/APOC, 24 November 2004 1 1 $OO o.l C) .o o zs c.l (-) o o. o r- \ q) kr o' L a) R LqJ4 !qq a)u q o\ q) L o tR q)q 9q) 5 o l-roo bo tr oq 0)H 0) o0 t< !ot<tr oo o d a trl a c/) C) o oatr 0) (s cr) l<(.) a (+< o a C) cn(! 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E9()o F \$ ncl ct)\o c{ n o\ oq lr)\o t-r- 9 N@ \ N oo E] .oO.dLg)()E4- a6 o. c.l o\ co^$ c.) @ $ o\ co oo^ c.lON oo h ao o\r-\$o\o o\N coN F* N o^ +r- co o\ c1 6 oo t-l tso d o.= aEo < 9P'F\J o\ @q o\ \o N c.)\o c.l O^ +\o \o o\ oo \o \ c.l\o F- coq oo c-t- \o c'l o\ o\ o\ €^ oo @ : .'K - 59E^= A.E o ho . 'iaa E Ofioc=a- -6 Nr- c'I \otf, r- ri- \o (-- r-$ -i r-r- t--O co r- N o\ 00 o\ r-q € co o\ @OO @ oo coq t\o -i C)bo(u o E oO ll * f.l ld rd o _b0!, E.;F oo\ <. >v -o o q \o c.l 9 c.) 9\o\o t-+ oo o O EOY+ s_ = FE 58&tOotrl cl ao oq to q \o\o r-c.l o E] ac)O:E B- o =:Yotr E=;; =c>Lz3- r- N $ Nc.) + * + t ri =od ().= Itro 4.(')9' FU oo c.lt \o ta6\o \o oo * * t $ bod =a;;.rd!?,,5 ev d; o=r ()= t:: oaq?aaF- tr u 9! EO o O oo c.) \o \o oo\o \o 00 s + * |r) $ & trl OoO c.l N N ON a.) o(\ $ o c..l N \oo N F- CI @ cl 2.7. Ordering, storage and delivery of ivermectin Mectizan@ ordered/applied for by - (please tick the appropriate answer) MOH 5]/ WHO tr UNICEF E Other (please specify) Mectizan@ delivered by - (please tick the appropriate answer) MOH N/ WHO f] UNICEF tr NGDO tr NGDO N Other (please specify): Please describe how Mectizan@ is ordered and how it gets to the communities - Mectizan tablets are ordered by the NOTF Secretariat from Merck. Estimation of total tablets requirement is done basing on the total population and how many tablets are remaining from the previous distribution, the difference is the request that goes to Merck. After the mectizan has been received at the National Office, it is taken to Blantyre DHO Pharmacy where all the districts make their orders from. The order should be within their allocation based on the population the district is to treat during that particular year. When their allocation is approved, the districts collect the drugs from Blantyre Pharmacy. From the district, Mectizan is delivered to health facilities which are closer to the communities. Health Surveillance Assistants who are direct superisors of the CDDs collect Mectizan from the Health Facilities and the CDDs collect the mectizan from these Health Surveillance Assistants who are based in the communities . Other CDDs who are close to the Health facilities collect Mectizan directly from the Health facility. Table 1 Mectizan@ Inventory (Please add more rows if necessary) - How are the remaining ivermectin tablets collected and where are they kept? After distribution, the CDDs deliver the remaining tablets to the Health Surveillance Assistants who in turn delivers it to the Health Centres they report . The districts collect the remaining tablets from the Health Centres. When the district has collected all the remaining tablets in the district, it delivers the tablets to Blantyre DHO pharmacy which is serving as a regional pharmacy for safe keeping. District I{.,-f"" "f tUectizano tabletsRequested Received Used Lost Wasted Expired Blantyre 1,266,042 1,266,042 1,042,632 0 2,410 0 221,000 Phalombe 113,341 113,341 78,341 0 410 0 34,500 Chiradzulu 395,242 395,242 342,703 0 539 0 52,000 Mulanje 860,949 860,949 853,167 2,163 0 0 5,619 Chikwawa 310,718 310,718 230,70',7 830 0 0 79,181 TOTAL 2,946,292 2,946,292 2,547,550 2,993 3,359 0 392,300 t9 WHO/APOC, 24 November 2004 - List and briefly describe the activities under ivermectin delivery that are being carried out by health care personnel in the project area. The Health Care personnel carry out the following activities under Mectizan delivery : Collection of the drug from the collection point Mobilization of communities Reporting on the drug usage and persons treated Supervision of Mectizan distribution Census update Collection of remaining Ivermectin tablets from the CDDs after treatment - Any other comments 2.8. GommuniQl self-monitoring and Stakeholders Meeting Has any training (of trainers) for community self-monitoring been done in the project area? If so, When? Table 11: Community self-monitoring and Stakeholders Meeting (Add rows if needed) Describe how the results of the community self- monitoring and stakeholders meetings have affected project implementation or how they would be utilized during the next treatment cycle. 2.9. Supervision 2.9.1 . Provide a flow chart of supervision hierarchy. National Level + District + Health Centre + CDD 2.9.2. What were the main issues identified during supervision? The main issues that were identified during the supervision are: 1. Failure by some Health Workers to calculate for CDTI related data e.g. Therapeutic and Geographical coverage. 2. Inaccurate recording by some CDDs in the recording notebooks. 3. Some mectizan stock records were not updated by the CDDs 4. Inadequate supervision from the District to CDD levels 5. Lack of commitment by some CDDs and Health workers l. l. 2. 3. 4. 6. District Total # of communities/villages in the entire project area No of Communities that carried out self monitorins (CSIO No of Communities that conducted stakeholders meeting (SHIvt) Blantyre Phalombe Chiradzulu 1?7 62 328 0 0 0 627 62 328 Mulanie 369 0 369 Chikwawa r28 0 t28 TOTAL 1,514 0 1,514 20 WHO/APOC, 24 November 2004 2.9.3. 2.9.4. 2.9.5. 2.9.6. Was a supervision checklist used? The checklist was used during the supervision What were the outcomes at each level of CDTI implementation supervision? The superuision managed to correct some issues identified immediately thereby improving the implementation of CDTI. For example CDDs were taught on how to do correct recording in the notebooks Was feedback given to the person or groups supervised? Feedback was given after the supervision. How was the feedback used to improve the overall performance of the project? Feedback assisted to identiff the existing gaps in the performance of the CDTI program and thereafter came up with remedial measures such as conducting on the job training of old CDDs and local training of new CDDs to replace the drop outs . This has also assisted because the program has maintained high therapeutic coverage. 2t WHO/APOC, 24 November 2004 SEGTION 3: Support to GDTI 3.{. Equipment Table 12 Status of equipment (Please add more rows if necessary) *Condition of the equipment (F:Functional, CNFR:Currently non-functional but repairable, WO:Written ofO. How does the project intend to maintain and replace existing equipment and other materials? The project maintains and replaces existing equipment and other materials in different ways. The project uses government resources and other donor funds which have been pooled together in what is known as Sector Wide Approach (SWAP). SWAP funds are not meant for a specific purpose, but rather the funds are used for different purposes, therefore the project's equipment is not excluded when maintaining or replacing equipment of other programs. This is applicable at all levels i.e. at Headquarters and district levels. Source Type of equipment APOC MOH DISTRICT NGDO Others No Conditron No. Condrtion No Condition No. Condrtion No Conditron 1. Vehicle 1 wo 2. Motor cycle(s) 15 14F, I CNFR 33 F 3. Computer(s) 10 8F, I CNFR ,l wo 13 F 4. Printer(s) 1l F 5. Photocopier (s) 1 F 4 F 6. Fax Machine(s) I CNFR J F 7. Others a)Video Camera I F b)Power generator 2 F c)Cash safe I F d)Panasonic TV 1 F e)Sony VCR 1 stolen flFilling cabinets 2 F J F g)LCD 1 F h. Shelves 3 F i. Binding machine 1 F 22 WHO/APOC, 24 November 2004 Contributor Year 2005 ('provide the period') Year 2006 ('provide the period') Year 2007 ('prowde the penod') TOTAL Cash Budgeted (us$) TOTAL Cash Approve d (us$) TOTAL Cash Budgeted (us$) TOTAL Cash Approve d (us$) TOTAL Cash Budgeted (us$) TOTAL Cash Approve d (us$) MOH (Central ) 10,376 10,376 24,350 29,045.7 MOH (District) 152.279 t28,792.85 516,207 5l0.l4l 581.244 573,270 Local NGDO(s) ( if any) NGDO partner(s) Others a) b) Communities In kind In kind In kind In kind In kind In kind APOC Trust Fund 186,969 83,289 186.969 ? 190, I 84 41,346 TOTAL 9.2, Financial contributions of the partners and communities Table 13: Financial contributions by all partners for the last three years - If there are problems with release of counterpart funds, how were they addressed? So far there have not been any problems in the release of counterpart funding. All the funds requests made to the basket fund (SWAP) are honoured. In 2006, the NGDO partner released USD82 for both projects, however some of their contributions are not always in cash but in kind. Additional comments 3.3. Other forms of community support Describe (indicate forms of in-kind contributions of communities if any) Identification of a suitable CDD Collection of drugs Community awareness during census, distribution periods Mobilisation of other community members Distribution of drugs 3,4. Expenditure per activity Indicate in table 14, the amount expended during the reporting period for each activity listed. Write the amount expended in US dollars using the current United Nations exchange rate to local currency. Indicate exchange rate used here-I USD: MKl40 23 WHO/APOC, 24 November 2004 Activify Expenditure ($ us) Source(s) of funding Drug delivery from NOTF HQ area to central collection point of community Mobilization and health education of communities CDDs Jra!$qg of health staff at all levels Supgrvf riqgCD_ps gnd distribution "Intgrnal _mogltq{lg qf CDTI activities A.dy_o_gacy visits to &ultt, and political authoritig!_ _ IEC materials S forms for treatment Vehicles/ \Aolqry y.91. sl 4 9 1c !.e s_ p?lntgryqc 9 Office e. g. lggpgte_rt.pg{grs etc) CENTRAL LEVEL IEC Advocacy Supervision NOTF Meetings Telephone bills Vehicle maintenance 8,477.18 4,847.85 23;,694.32 rc,azziz 4,297.29 r,017 t,45t 4 1,591 6,734.85 :,0:o.g+ 5,695.70 6,457 3,368.50 5,659.60 1,514.29 3,435.71 MOH MOH M_OH, APOC MOH, APOC Mon MOH uon MOH MOH MOH Mon MOH TOTAL 91,908.85 Total number of persons treated 880,393 Table 14: Indicate how much the project spent for each activity listed below during the reporting period Note that central level expenses were catering for both Thyolo/lVlwanza and Extension projects SEGTION 4: Sustainability of GDTI 4.1. lnternal; independent participatory monitoring; Evaluation 4.1.1 Was Monitoring/evaluation carried out during the reporting period? (tick any of the following which are applicable) Year I Participatory Independent monitoring Mid Term Sustainability Evaluation 5 year Sustainability Evaluation Internal Monitoring by NOTF 24 WHO/APOC, 24 November 2004 Other Evaluation by other partners 4.1.2. What were the recommendations? Reduction of CDD to population ratio 4.1.3. How have they been implemented? The recommendation will be implemented this year with training of additional CDDs 4.2. Sustainability of proiects: plan and set targets (mandatory at Yr 3) Was the project evaluated during the reporting No Was a sustainability plan written? Yes When was the sustainability plan submitted? What arrangements have been made to sustain CDTI after APOC funding ceases in terms of: 4.2.1. Planning at all relevant levels The planning at all levels follows the planning cycle. The community participates in providing information to the Health Centres, District Hospital. The Government financial year starts from July to June. Before July, government ministries, departments and programs are requested to submit their plans and budgets for the year, During the planning cycle, all plans are drawn up including activities of Onchocerciasis Control Programme. At the district level, their plans and budgets are consolidated in one document known as the DIP which is submitted to Ministry headquarters. 4.2.2. Funds The activities of Onchocerciasis Control Programme are integrated into the District Implementation Plan ( DIP ). This ensures that the activities of the Onchocerciasis Control programme are funded from the district Other Recurrent Transaction (ORT) under SWAP. ORT funds under SWAP come in a basket form for different health related activities. Onchocerciasis activities are expected to get an allocation and when planned activities are ready for implementation. At National level, each year each program including onchocerciasis, submits its annual budget for inclusion in the Ministry annual budget. When the budgets have been approved by the parliament, funds are spent through what is known as ORT under SWAP in the ministry. 4.2.3 Transport(replacementandmaintenance) The activities of Onchocerciasis Control Program are integrated into the District Implementation Plan ( DIP ). This ensures that the activities of the program are getting funds from the district ORT. 25 WHO/APOC, 24 November 2004 Transport at district level is managed in a pool , each program is given preference according to the work plan on that particular day. Maintenance is carried when due. At National level, each program manages its own transport, however, when the vehicle is due for service, it is treated as any other government vehicle. The MOH pays for it. 4,2.4. Other resources Through integration with other programs in the District Implementation Plan ( DrP ). 4.3. lntegration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration: 4.3.1. Ivermectin deliverymechanisms Mectizan is taken as any other drug. When the DHO is dispatching other drugs to the Health Facilities in the peripheral, Mectizan is included in the transportation. 4.3.2. Training There is a plan to develop an integrated training package which will allow health workers to be developed incrementally. 4.3.3. Joint supervision and monitoring with other programs Using an integrated checklist which includes Onchocerciasis activities 4.3.4. Release of funds for project activities All districts in Malawi develop a DIP for sourcing funding from the Central level. In the DIP all health related activities are included. Each activity is budgeted for. When the plans have been approved, funding is made available to the districts on monthly basis. When district has been funded in a particular month, the DHMT sits down and plan for activities to be funded and carried out during that month depending on the level of funding during that month. Therefore, since onchocerciasis control is one of the prograrnmes included in the DIP, funds are released to the activities for onchocerciasis control. 4.3.5 Is CDTI included in the PHC budget? Yes 4.3.6 Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? Malaria control program is using CDTI structure especially during the net retreatment week. The program uses the CDDs that are used for ivermectin distribution for this purpose 26 WHO/APOC, 24 November 2004 4.3.7. Describe others issues considered in the integration of CDTI. Other issues considered in the integration of CDTI is the implementation of other NTD such as Schistosomiasis, STH, LF including trachoma using the CDTI structures. 4.4. Operational research 4.4.1. Summarize in not more than one half of a page the operational research undertaken in the project area within the reporting period. No Operational Research was undertaken during the reportingyear. However, a research was conducted in 2006 and no feedback meetings have been held till to date because the funds which were meant for this activity have not been released from APOC. 4.4.2. How were the results applied in the project? SEGTION 5: Strengths, weaknesses, challenges, and opportunities List the and weaknesses of CDTI - List the challenges and indicate how they were addressed. The only challenge that the project faced was large CDD to population ratio. This challenge will be addressed this year by training more CDDs Strengths 1. Integration of CDTI activities into the normal government operations 2. Ability of the govemment to co-fund CDTI activities at central and district levels Challenges 1. Dropping out of CDDs 2. Employment of new HSAs who will require training Opportunities 1. Availability of HSAs at community level 2. Availability of SWAP funds 3. Availability of NGDO partner Weaknesses Transferring of experienced staff particularly HSAs 27 WHO/APOC, 24 November 2004 L a SECTION 6: Unique features of the proiecUother matters The most notoble unique feoture is the presence of o codre of Heolth Workers known os Heolth Surveillonce Assistonts. These Heolth workers ore bosed in the community. They supervise the CDDs octivities in the communities. The HSAs corry out ony heolth reloted octivity in the communities they ore bosed. These ore government employees. Another unique feoture of the project is Estote Distribution. Thyolo ond Mulonje District hove got estotes. To ensure thot estote workers ore protected from onchocerciosis since they ore olwoys out in the teo fields, distribution wos introduced on the teo estotes. The estote heolth workers conduct the distribution. ln 2006, the estote distribution period wos hormonised the with community distribution period. Estote distribution ond community distribution ore toking ploce of the some period. 28 WHO/APOC, 24 November 2004 .f I I