TRESERVED FOR PROJECT LOGO/HEADING ORIGINAL : English ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) ;,iI AD (n/ Liaf csl; I'Tcc 13 Bi tt c:,I, Loe AHE for Tot e, DEADLINE FO SUBMISSION: To APOC Management by 31 January for March TCC meeting To APOC Management by 31 Julv for September TCC meeting ij tj I: AFRICAN PROGRAMME FOR ONCHOCERCTASTS CONTROL (APOC i ii *1r COUNTRY/NOTF: MALAWI THYOTO/MWANZA Proiect Name: Approval year: 1996 Lauuchinq year: 1997 From: APRIL, 05...To: MARCH,06..(Month/Year) ( Month/Year) Reportins Period: Proiect vear of this report: (circle one) I 234s678910 Date submitted: 14 JULY, 2005 NGDO partner: IEF/wHo/TEA WHO/APOC, 24 November 2004I II I ANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) ENDORSE,MENT Please confirm you have read this report by signing in appropriate space. theii OFFICERS to sign the ort: Country: _MAIAWI NOTF Vice-Chairman Name: Dr S. Kabuluzi. Signature Date NGDO Representative Name: Dr G. Ezepue Signature: . Date This report has been prepared by Name : Laston Sitima for S. Nkwanda Designation : National Coordinator Signature : Date ll WHO/APOC, 24 November 2004 II I ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) DEADLINE FOR SUBMISSION: To APOC Management by 31 January for March TCC meeting To APOC Management by 31 Julv for September TCC meeting AFRICAN PROGRAMME FOR ONCHOCERCTASTS CONTROL (APOC) lll WHO/APOC, 24 November 2004 FOLLOW UP ON TCC RECOMMENDATIONS I EXECUTIVE SUMMARY ...2 SECTION 1: BACKGROUND INFORMATION....... ......................3 1.1. GpNeRal rNFoRMATIoN............. 1.1.1 Description of the project (brieJly). 1.1.2. Portnership 1.2. PopulRuoN....... SECTION 2: IMPLEMENTATION OF CDTI....... .......7 2.t. TIUSIINE OF ACTIVITIES 2.2. AovocRcv 2.3 2.4 MoetI-rzerloN, sENSrrtzATIoN AND HEALTH EDUCATIoN oF AT RISK coMMuNIrtes 10 CovvuNrry INvoLVEMENT........ ...... 11 .....7 ...'.,.,..... 12 J 3 5 6 22 23 23 24 2.5. Cepacrrv BUILDING 2.6. Tnsar\4eNTS.............. ..... 15 2.6.1. Treatmentfigures.......... ........... 16 2.6.2 What are the causes of absenteeism? .......... ................. 17 2.6.3 'tlhat are the reasons for refusals?................ ............... l7 2.6.4 BrieJly describe all known andverified serious adverse events (SAEs) that ... l7 2.6.5. Trend of treatment achievementfrom CDTI project inception to the curuent year l9 2.7. ORDERTNG, sroRAGE AND DELIvERY oF IVERMECTIN ...........20 2.8. CovuuNtry sELF-MoNIToRING eNo STRTpHoLDERS MeeuNc ............21 2.9 SupeRvrsroN ............ .21 2.9.1. Provide a flow chart of supervision hierarchy. ............ 2 I 2.9.2. What were the main issues identified during supervision? .............................. 21 2.9.3. Was a supentision checklist used? ............. 22 2.9.4. What were the outcomes at each level of CDTI implementation supervision? 22 2.9.5. Was feedback given to the person or groups supervised?................................ 222.9.6. How was the feedback used to improve the overall performance of the project? 22 SECTION 3: SUPPORT TO CDTI ..............22 3.1. 3.2. J.J. 3.4. EqureveNr FrNeNclal coNTRTBUTIoNS oF THE pARTNERS AND coMMUNITIES Orupn FoRMS oF coMMUNITy suppoRT.... ExpeNorruRE PER ACTIVITY SECTION 4: SUSTAINABILITY OF CDTI....... ...........25 4.1. INreRNel; TNDEIENDENT eARTICIPAToRY MoNIToRING; Eva1ueuoN....................25 4.1.1 Was Monitoring/evaluation caruied out during the reporting period? (tick any of thefollowingwhich are applicable)............ ...........25 4.1.2. What were the recommendations? ............. 25 4.1.3. How hqve they been implemented? ............. ................. 25 4.2. SusrarNasrt.rry oF IRoJECTS: ILAN AND sET TARGETS (MANDAToRv AT...... ..........26 26Yn 3) lv WHO/APOC, 24 November 2004 4.2.1. Planning at all relevant \eve\s......... 4.2.2. Funds....... 4.2.3 Transport (replacement and maintenonce) . .4.2.4. Other resources 4.2.5. To what extent has the plan been implemented4.3. INrecReuoN............ 4.3. 1. Ivermectin delivery mechanism.s...................... 4.3.2. Training.... 26 Joint supervision and monitoring with other programs Release offunds for project activities Is CDTI included in the PHC budget? ..............4.3.6. Describe other health progrqmmes that are using the CDTI structure and how this was achieved. What have been the achievements?............. .................... 274.3.7. Describe others issues considered in the integration of CDTI. ..... 27 4.4. OpenarroNAL RESEARCH .....2g4'4.1. Summarize in not more than one half of a page the operational research undertaken in the project areq within the reporting period......_......... ....,... 2g4.4.2. How were the results applied in the project?............. .................... 2g SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, ANDOPPORTUNITIES... ....................28 SECTION 6: UNIQUE FEATURES oF THE pRoJECT/orHER MATTERS...........28 4.3.3, 1.3.4. 4.3.5. v WHO/APOC, 24 Novemb er 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 Armual Treatment Objective Annual Training Objective Community-B ased Organization Community-Directed Distributor Community-Directed Treatment with Ivermectin Community Self-Monitoring Local Govemment Area Ministry of Health Non-Governmental Development 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 84%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/tryper endemic areas within the project area, ultimately to be reached when the project has reached full geographic coverage (normally the project should be expected 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. vrl WHOiAPOC, 24 November 2004 FOLLOW UP ON TGG REGOMMENDATIONS Using the table below, fill in the recommendations of the last TCC on the project and describe how they have been addressed. TCC session 22 Note that there were no recommendations to follow up I Number of Recommendation in the Reporl TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROTECT FOR TCC/APOC MGT ASE ONLY WHO/APOC, 24 November 2004 Executive Summary Prepare an Executive summary of the report in not more than one page. The Onchocerciosis Control Progromme in Molowi hos been corrying out lvermeclin distribution since l99l ond I993 in Thyolo ond Mwonzo dislricts respectively under the old slrotegy ( CBTI ). The Community Directed Treotment with lvermectin (CDTI ) wos lounched in 1997 in the some districts with finonciol ossistonce from APOC. APOC's philosophy is sustoinobility of CDTI by ensuring the involvement of the communities themselves in the distribution ond toking the drug for o long time. Thyolo ond Mwonzo districts ore in their eighth yeor of implemenlotion under the CDTI Project. The districts ore under the Post - APOC Sustoinobility phose. The people of the two districts move in certoin seosons of the yeor. The two districts shore on lnlernotionol boundory with Mozombique. During the roiny seoson, the people of lhe two districts 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. ln lhe 2005 distribution yeor, o lotol of 553,132 persons were treoted out of the populotion of 691 ,069 people representing o treotment coveroge of 81 .5%. All the 672 villoges ( inclusive 12 Estotes ) torgeted were lreoted representing o lO0% Geogrophicol coveroge. The Ullimote Treotment Gool wos 573,587 people ond the Annuol Treotment Objective wos 84.5%. The progromme continued to corry out troinings. Troining covered heolth workers directly involved in CDTI oclivities ond the CDDs. During the reporting yeor, o totol of 219 Heolth Workers. Despite thot no CDDs were troined, o totol of 2,014 CDDs were involved during the reporting yeor representing I CDD to o populotion of 343 people. The most notoble chollenge is obsentees ond refusols during mectizon distribution ond drop out of CDDs. To oddress the two chollenges mentioned obove, the NOTF hos developed o reseorch proposol to estoblish the reosons for the obove ond lhen find o woy forword. It should be noted thot during the reporting yeor, lhe Extension project received no funding from APOC however despite no funding from APOC, we ochieved the best treotment coveroge so for. 2 WHO/APOC, 24 November 2004 SEGTION {: Background information 1.1. General information 1.1.1 Description of the project (briefly) Onchocerciosis Control octivities hove been going on in the two districts of Thyolo ond Mwonzo for more thon 5 yeors under the CDTI ond the two districts ore under the Post - APOC Susloinobility phose. Thyolo ond Mwonzo lies olmost ,l00 kilomelres oport on the southeost ond southwestern borders with Mozombique in the Southern Region of Molowi. Thyolo is o more densely populoted district thon Mwonzo ond is very hilly ond with difficult terroin. Accessibility is lherefore good during the dry seoson.The numerous riverine systems moke it fovouroble for the breeding of Onchocerciosis vectors. Blockfly. However, the Neno port of Mwonzo hos similor topogrophicol ond climotic feolures os those of Thyolo ( Refer to Fig. 1 on Poge 4 - Mop of Southern Region of Molowi ). Thyolo district is mostly dominoled by Lomwe people. These constitute o high percentoge thon ony other tribe in the district. Mwonzo is dominoted by the Ngoni people. People in these two districts proclise motrilineol type of morrioge whereby the mon stoys of the womon's home villoge . Most of the people in the two dislricts depend on Agriculture ond smoll scole businesses for their livelihood. ln the Southern Region of Molowi, i.e. including Thyolo ond Mwonzo Dislricts, the moin roiny seoson losts from November through Morch.Additionol light roin usuolly folls between Moy ond July. The peok forming seoson begins in July ond ends in April. Thyolo is in the highlonds, so roins come ony time of the yeor. The climote in Thyolo is fovouroble for teo plontotions thus why the presence of lorge teo estoles. Administrotively, Molowi is divided into three regions with tweniy-eighl districts. The locol community is moinly o villoge set up which follows o common clon oncestry ond /or a similor culturol grouping. The villoge is heoded by o trodiiionol chlef who moy hove severol ossistonts or odvisors moinly elders of his clon. ln some oreos severol households belonging to one villoge could be scottered over severol kilometres. Severol villoges con be grouped together under one Group Villoge Heodmon (GVH). The highesi ronked ruler is the Troditionol Authority commonly colled the T.A. whose outhority covers o geogrophic zone in o district. The TA is o very powerful ond respected troditionol ruler. ln the mojority of the tribes there is gender equolity in the inheritonce of heodship (chieftoincy). The country's populotion is currently eslimoted ot lO million with most of ii in the Southern Region. On heolth core system, Molowl is currently undergoing decentrolisotion, therefore the regionol heolth offices were obolished. The District Heolih Officers report direct to the Minislry of Heolth Heodquorlers. At district level, we hove one district hospitol which is heoded by o District Heolth Officer (DHO ). From the District Hospitol, we hove got the eilher o heolth centre or o Rurol Hospitol. J WHO/APOC, 24 November 2004 Then Heolth posts follow the Heolth Centre/Rurol Hospitol. Communities occess medicol lreotment of eoch heolth focility free of chorge. Out of o totol number of 699 heolth workers, 635 were involved in CDTI represenling 9l%. Fig. I : Map of Southem Region of Malawi E EEZA + hTtAHGOCHI Mozambi zambique E 4 H!HGA HEU h'lBA CHI WHO/APOC, 24 November 2004 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 Br Number of health staff involved in CDTI B? Percentage Br=Brl Br *100 Thyolo 494 486 98.4% Mwanza 205 ls0 73% Total 699 636 9t% 1.1.2. Partnership The NOTF Molowi comprises the Ministry of Heolth ( MOH ) ond other portners : the lnternotionol Eye Foundotion, Teo Estotes Associotion of Molowi, the World Heolth Orgonizotion ( WHO ). The NOTF portners ore involved in vorious CDTI octivities. The IEF Country Director porticipotes in the plonning of CDTI octivities, supervision, ottending NOTF Meetings. For the post 10 yeors the teo estotes in Thyolo district hove octively corried out treotments on their estoblishments. Mectizon distribution on the Teo Estotes is corried out by volunteers who ore troined by the Estote Clinic Heolth personnel ossisted by the District Onchocerciosis Coordinotor. 5 WHO/APOC, 24 November 2004 \t ct L() 0) z vN (J {o Ti eq)oEl 0)(,) EE -!J! >..=*() 6l'- *-9! o? != 5q)(.,) ot E cl a0=6}i -v.* .i-y>dE. L5E irE bD9 --11# E3i.i Qo6) L -,= l-i -X rE0 = oE a. qEE F.b9- - -- 9-B ts.E a =H'= 9Etr inc; ---EL -: AiclgS .T'T E --v.' >HE L?":nOLO6)a 9E uD .g a; rc aoa = cjs kE E!o.-trcso=!==cre!? .- o. rra -t_ QOGIOA0S 6J- E €Y.-:o:E 83.35 ;a-H FEEdvgrtE E.= HE €&;E oj:ET :!EE6)JJ 'E;=cE6) 9i'-.0= € #H: ait-qroXn OrOE +r?r = .EE;i 6rEUHgY >\ .E^1=!-Hv '= =*-E :R gH ';YEH E-cEo Tiut IE ?Etts=cBbolr 9'9S() -*= -c7o>; r!'ua ss E; '=+kH 66c = ?,i<l.Hv 5E?s-E r:.i $- O o I I I I n a() I I I I e 0.) C) (d o (!4.. ooLLl$ia()d> I I I Io z\l >t Ia, o c\. .E o bO -6) '5o L6 F3 od Pc) bo -c l-r li ES()(!tr'o EF OqrG)o 'd c.rEe orI +1 A k() .os 3.22E0)+o5 CB frzBs ct oq) o'\\q) q) : q) q)\ q) o \) ru Fi'=rs\ $t\r\G uS -s ,\ -S s) %O' 9S Bq) s{ t(J U< L\qJ \J$q, ()$Rsi Q't:tEsp iNB l-( N3p\ IFst s\ !r\P\(.p\:r ": .d! \s '-L59\EU. $E\ N$Bq) :bo <\ d} ildstl\B\q) q q) I\) q q) L a t q)q <i o H() b0 ti oaotr C) bo ! l-r o € o (d O (.) Ld x C) r< c.) o B ct c) (.) q) L c)lr () 0) .54 th li (! o (d oq ! (! ar) C) O c.ir o.ll -ol ,(dl FI ' E o IIg 6 -3c or aN a F \o I I I I I I I E.(-) c.) -" C)oL 8 L() 6 (J F:Ec = f,9 c.t$ ca cOs \o(n $ r- €uI ?ar-ia + lt E .o) -oo .= Nt F.c9\ E F As \o c\ N c.l(r) ca\o oo co\o o\\o o\\o -, Gl . oE EL'=-6&E.=r: >.!oO-E E E'FN= \oNN oo @ \oq f- o\ r-6 \o €N o .9E9UP= E Fiso tr'=gsi ooo\cAcO c.l N (tt (\l6 ra t I q) !io ON?et c! c) F + il + .f, \o ra)N \o\o .eE E.F(J= =-,69E EL- cEC)t= rB N +(r} oi .t ra ?a U) c) a0 at)q) I L 0) z 'Egs *! kqis otX: 2 \n cO + t-\o ?a t 9.)o9= .-LrY!.i _SEEd I o.:E *o P' _v9-EF qE A \o c\ N c.ltr} ca\o oo @\o o\\o o\\o Qh I 'i{)GlELc)'0'E , =ic -6)*.E-;.9Aeo {r, .= A o o >) F (€ N Cd =z tI 3 o3 * SEGTION 2: lmplementation 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. At National level we had developed a plan as to when to carry out activities. This plan is followed every year. The table below summaries the timeline of activities as planned by the NOTF : ACTIVITY PERIOD I Ordering to MDP Lotest l5 December 2 Reception of the drug from MDP April 30 3 lnformotion ( orrivol of the drug ) to districts from NOCP Office Moy 15 4 Notionol Office to produce distribution list of Mectizon Moy 15 5 Collection from Notionol Office ond distribution of the drug to the districts Moy 30 6 Follow up ( by NOCP Office ) with districts on collection/receplion l'f week of June 7 Dislribution of the drug to the Heolth Centres by 30 June 8 Review ond plonning meetings with CDDs, HSAs; Community Mobilisotion June I-30 I Distribulion in the community Mop up octivities July - Sept 30 REPORTS I Collection ond collotion of doto Oclober 30 2 Report to NOTF Secretoriol November l5 7 WHO/APOC, 24 November 2004 s N (.)p C) z$C\ (-) o o. o.=E:HE o(J \oo N oLd bo o 00 o a0EE 6: q) oo bo o 00 o o fr U) bd l-l "l o o,= 5EU L C) -o C) o. 0)a o a0CE o) a c) cll q U) t) q) U o (Je E=EE oI 0) 0) 6I)EE 1itr Cd d ut L Er o EF I Cd z boEE a- d z rG) .Y .;<iiEE5Nr =q)a EFo-I C) 0) u0EE a- d cd q) L .a F CB N (B 2 F] E-,, 3 oo rh G) oQ u 4 Iq) q: \ q) LU *x! ! q) F; S) 5 Lr 63 C) >\ (.) liLr O (.) o CdoL{ ar)d 0)tr(d O tr € th o o(t +i o o C) F #r d-)l -ol(BI FI 9 WHO/APOC, 24 November 2004 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, 2 major advocacy activities were carried out at National level. The first activity was a press briefing presided by the NOTF Chairman. The press briefing involved journalists from different media houses both print and electronic including the Television Malawi. The second activity was a press conference by the Minister of Health. As was with the press briefing, the press conference involved journalists from different media houses both print and electronic including the Television Malawi. 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 target to influential leaders depending on the level. Meetings were held in churches for this purpose. 2.3. Mobilization, sensitization and health education of at risk 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 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 T-Shirts were used in sensitization. With the intensive mobilization and Health Education, this has assisted to have a higher treatment coverage than the previous year. For a successful mobilization to be realized, there is a need to involve influential leaders such as village headmen, politicians. 10 WHO/APOC, 24 November 2003 2,4. Gommunity involvement Table 4: Communities participation in the CDTI (Please add more rows if necessary) During health education meetings, more female members attend the meetings than men. This is also the same in any activity. The participation of female members is more than male members. As of now, no incentives have so far been provided to the CDDs by the community istrict 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 B, Number with community members as supervisors B{ Percentage Be= BJ B, *1OO Male CDDs Br Female CDDs Br Total B"= B,*B. Number of communities with female CDDs B,n Percentage Brr= B,,/Br*100 Thyolo 404 0 0 703 713 t,416 404 l00Yo Mwanza 256 0 0 289 309 598 256 100% Total 660 0 992 1,022 2.014 660 100% 11 WHO/APOC, 24 November 2004 0 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 meqsures were taken to ensure adequate CDTI implementation where not enough knowledgeable 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 identify replacement before transfer is effected. t2 WHOiAPOC, 24 November 2003 0) cl ah U o L oE z .(J U ts.i =v *. q o o o 0) C) 0) () v Q O O at) rrq) .=6 c(l t-<rrh rF o) .oE r- !s()l.r z r:(J = .U U =v +. q O O ra to s r,o () c) o I \o U q) :'i i.j !i: oq) .oP tr ':- zr, 0)(.) .t E.'t+F-u' U+.o< z o\ N o\ : o\ (.ll o\ N s 0) q) 0,) q) \6 U o o\ N o\ .I (l o ah (, F]$a9q) u) !Y q) z E,ldOri+F-d Ss *o O O O (.) O I o h F- N Cd z Fl 3 F,( co c.l L(,)p c) o z$ c.l o o B aa 60 oo -a o\ o L B $ a bO Bp s o t o\ qi a B o Gt\ ,a\q .. -! ; qq q)() q) q- 4l o\ q) L t B a)q a) ea o 0) E() a E F Qqr o t/) C) 0) ok tr C) (B bo HF ..iir ,l -ol(Bt 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 Program management :|< How to conduct Health education :t * it Management of SAEs CSM SHM Data collection ,k :k :|< ,lc Data analysis * :|< Report writing ,& r|< Others (specifi,) Table 6: Type of training undertaken (Tick the boxes where specific training was carried out during the reporting period) During the reportingyear, NOTF in coordination with APOC conducted a training on CDTIimplementers. This training drew participants from all the CDTI districts, partners such asIEF, Tea Association. The training was conducted in June, 2005. DHos, rjprro, and DoCs were participants from the districts. 2.6. Treatments 2.6.1. Treatment figures If the project is not achieving loo% geographical coverage and a minimum of 65yotherapeutic coverage or the "ouetugelute is fluctuating, siate the reasons and the plansbeing made to remedy this. t4 WHO/APOC, 24 Novemb er 2003 * ON L C)p () o z tf, N o q) bo G p F c a. 0o qJ bO t) q a *i Qq) S' q a)s .rii s <tql t)s t! U a F tr-! cJ-'s .ll\!\ Su SE is' $$ B=' uh^ E*yi PT .U s'{>\ s9 Fr,:t srss93I os eN$f$U b{\36rEi s:Es s9 .s'$ d\st AJ: :ai rl\=' rB utIio\s ra F (n c)Ld o 0) 'd* a.d o1EB .= bo .;E (,s(EU9!(dt ox o.E!i os i\ Es pE .- G' ES cd l\ ^,0)svl L.: Il o-r sXIs EEl as9l ork Ul o.PLI OE 5t 8..:7l u t5t6tol Ls:tsi 9I ER()IC(s' st - -trl (nh -t hEzl;: 0o sll u tr q) b qJs ()s o.li HT rft S HlDS o\\ (.) C) 0)5 0) E d oLF C) cCL C)bo 0s o o F (n()Ld Io C) 'a cgko*hE 9POFo.='a^ LV 6) .'l id, A =-o9 U - Ia(,): L .= c)trE5 iAtr(€ F6 =6) .i()P o'E )tr ol tr6) ol =! -l Etr yl oo '-lob El.eo- bttr = el ! ^ trlCol 6 (l)l (.) ool o olf .r o -1tr sl6xl : =l o. x -l L>l >rul .- \l - I6)l -^ uil = c)FIH gI9 FEl t '=l o i9l .l El - I 6Jt =tr o) -l - El aotE =tH ool .= Hl : ool H ol x 0) ,*l = el = (* ol ir- ol E o rlo rl= LC)lo- olc o -ol _ -ol - -otrl(B trl(n trHt!-t! =lb =lb =zl? zl? z(! Lr € rr1 il (.) (gL 0) oo 0) oo -c o\o-v cOL 00 0) IJ C) c0L C) bo Lo oo()^ '.5 .ro dv a.(d o F ! di€ sI s g( o='6.a<iLh-Pa3-:Jolt-;O 5H€EHg;Z 9H o ' '.9 o' o O rrl €?2a2z O !9 E9a9zd O\o co t (\ o\ \o oor- : o!va+C ! c ^- o -o;.c d trCL>@= = q -,7 u =L \o co c.i \oq N r- o\ ri o d o o oi ll . aa-\ o!o ,h0o6 =oooEOF -o o\(\ oo -o o\ oo -o o\ v'l € o-- a6gJOdEb9 5 q! z NO s^ @ N+ cor- .f, co c.l c.t ..i\o :oE 6.2 ,9-o' F9 \ooc\ NN \o \O^ $$ a.l c.l @ \o\o .9 .'8 E " [H5-.c I o o:otr E - q€ = Etr9O F c.l N(\ @ oo\o o\\o -lo\\o th() bod an o oU ll * .rA-o6\ cd -UE- s!!€6 b0a uo o\oo o\ o o\oo a E.9 .- 3 5 SH =c>!z6o N3 6 vo?s \o(\ Nr-\o :o d o-a E:Oj93' or3 d xq)+3 \o a.l a.l F-\o \oqO--r6q o= - o via^= * E'; F.e : E E 9o! E-a Es [jgL ^- ts =o>-o or3 Cd Xc)Yo \o c.t Nr-\o o L q o F (B N d Fl H Fr trr Bqq q)(.) q) 4 o\ q)\o ts q) %Bq) U }1 ah Lr (d an(i o)lr(B (d o t< u) € >. -o ch rI] a (B 0) (d(.) l<F rr.l ,l -oldlFI 2.6.2 What are the causes of absenteeism? a. Poor coordination with Estates during distribution b. Chronic illness - the person could be registered during the census update however due to chronic illness the person is hospitalized during the treatment c. 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 d. Deaths could also contribute to absenteeism 2.6.3 1. What are the reasons for refusals? Religion - there are some religious sects which do not allow their followers to take drugs In adequate health education - the people are not fully aware of the benefits for taking ivermectin Sometimes people are afraid of the side effects if the side effects are over emphasized during health education 2 J 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 t6 WHO/APOC, 24 November 2004 $ N L 0) -o 0.) z$N O o. o t-r q) q) \r o' Lq) "a I\ q +t 94q a)U s) q: L q) L t v q) F5vq) 5 o lr()a bI) ii a C)H C) b0 t< (.) liL. oo o CB a, r! a (n q) o 0,)(n k a,) !(B (/) o t< C) c/) +i o U)(.) lr)(t C) #r 6)l -oldlFI () E0es-,lE 5 <.E E z -- bo c)qrc 9 GOi, tr o-!a 7'r;EC lL,l o o z o o.= EAo-9qn =?o6. z Ofl;i qD ^ .! v'r' a= EC).c trd9d z ,*SE-o.2 -c 6() tr tr=9LE'-(!OOOoE&e z ;6>vo-c{-' vts!- A H.EE z (6 €-E9p€ E E€.5 BiH-8E> z o. a z tr!;:() -ts bo=o ^^*l-lao(l z =()N* ots: AS E z o 0)oocd.J =oo?o z x 0)a z (,) bo z IC a z
a$Oo c.l k 0) -o 0) o z s c.l o. o o\ 0) bo cllrq) () 3p 6l L d E o () 6) U) c)L a0 uh q)t) NN6^ \o\o ll q)fr G q,) 6) La c) L 3 q) q) r) ahEa .= ij or iI H.EE8 q) B< AJ AJ{ s *= *. q)6S!s I o.jEU OG Bi?c) cJtrc)q) 0) l- J-l -o , (lr t^k I.l cBr) 0) EHIo#l&El o)t tr(dloolE5l obo o (.) rOtroq)EttrE clr,c)PLtrrc)t-tr E.sc)H 3 o.t ui sl vi *l 6l Ft () bo P Es - ></Jo O o\ N$ ,r? n t--lr) \\o .f, 9 t-.n nt'-\o n\o oo ,.r..! $ oo o )ao oi ,_i rd ti o _bo s, scF oo\ <. >v o c.l o\ q N$ v1 (n c.l F. r \\o$ 9 F-(n nr-\o n\o oo rn +a ll r td Id li o\ o!o ,boo(€ *b ootoF q ra) 9\.) c.) oo c.i+ v.l r--$ oq oo ca oo r-+ \o(r) \ r- v? oo rd ,o od .o6!4- z? 'O o. o\ o\c'I oo r-+ o\ ( oo $ aNN € Nq oo\aN la) rn c.l tri N r-\o r-. ol cO c-.1t/.I coN cA rn t-- o\ -+ N co ca\o\n FT =oE E.U 5 E.:, F \./ (-. q $N$ oo oo(n cn cn$ r-. c.)q N$s r-\oq lr)$ oo\o \o$ N oo r-+ \r) tr-\o^ o\ t-r$ ta)lrl od\o t C.JN@\i\o\o L@ e kii _ E AEq.X o }., . .os€='EEr 6 ^tO. o; o- rE oo$ o\ (n \o o\ c"i NN ra) r-(n cn cn tar \o cOq ca .+(n r- ca tr) rlr) $\o c"I \o\o ta1 C\ c..lq r-r-t +N(r) + €\o o\\o o\\o q o oo(B q 0:) O ll +ti'ti ri o 9 SaF oo\< e-o q $ oq lal n\o\o nr-tr) ,r? \o \q \o\o O so=o-ao=(€ - !g - ll i' S3 9u;"i Oo!-l q + oq rrl n\o\o n r--tn ,.r? \o \q \o\o ri qo b E 9pd 'tr E= ii =E>L206 \o\o r-t-.N N$ cO oo co$ o\ t-r co \o $ oo cn$ NF-\o NF-\o t! :oE 6.> -Eo!:otgg \o\o \o\o \o\o \o\o \o\o \o\o \o\o Nr-\o c..l t--\o bo .r6q>-oo> 9 Kk + o= >:: o=t4baF E - EE EO oo \o\o \o\o \o\o \o\o \o\o \o\o O\o\o Nr-\o c..l r-.\o t-- o\ o\ oo o\ o\ o\ o\ o\ o o c.l oo at NOO c.l co N $oo e.l O N \oOON 2.7. Ordering, storage and delivery of ivermectin Mectizan@ ordered/applied for by - (please tick the appropriate answer) MOH Nl,/ WHO tr UNICEF N Other (please speciff) Mectizan@ delivered by - Qtlease tick the appropriate answer) MOH N/ wHo tr UNICEF tr NGDO N NGDO tr 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 and they should demonstrate their abilify to distribute. When their allocation is approved, the drugs are sent to the districts. From the district, Mectizan is delivered to health facilities which are closer to the communities. Health Surweillance Assistants who are direct supervisors 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 10: 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 Number of Mectizant tablets Requested Received Used Lost Wasted Expired Remaining Thyolo 1,064,686 1,064,686 1,062,342 0 94 0 2,250 Mwanza 478,256 478,256 33 5,883 0 1,382 0 l40,ggl TOTAL 1,542,942 1,542,942 1,398,225 0 1,476 0 143,241 20 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 2.8. Gommunity self-monitoring and Stakeholders Meeting Has any training (of trainers) for community self-monitoring been done in the project area? If so, When? Table I 1: 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, Superwision 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. Few mectizan tablets collected by CDDs 5. Inadequate supervision from the District to CDD levels 6. Some CDDs were having problems in dose determination using the stick 1. 2. 3. 4. 5. 6. District Total # of communitiesivillages in the entire project area No of Communities that carried out self monitorinq (CSM) No of Communities that conducted stakeholders meetins (SHM) Thyolo Mwanza 416 256 0 0 0 0 TOTAL 2t WHO/APOC, 24 November 2004 2.9.3. Was supervision checklist used ? The checklist was used during the supervision. 2'9'4. What were the outcomes at each level of CDTI implementation supervised The supervision managed to correct some issues identified immediately therebyimproving the implementation of CDTI. For example HSAs were taught on howto correctly calculate for Therapeutic and Geographical coverage. 2'9'5' Was feed-back-given to the supervised, and how was the feedback used in improving the overall performance of the project Feedback was given after the supervision.It assisted to identify the existing gaps in the performance of the CDTI program and thereafiei came up with remedial measures such as conducting on the job training of old cDDs andlocal training of new CDDs to reprace the drop outs . This has also assisted because there Las been an improvement in the 2005treatment coverage. The treatment coverage this year has been the best so far. SEGTION 3: Support to CDTI 3.{. Equipment Table l2: status of equipment (please add more rows if necessary) *Condition of the WO=Written off) equipment (F=Functional, CNFR=Currently non-functional but repairable, The project maintains and replaces existing equipment and other materials in differentways' The project uses government resources. with integration of services in theministry at different levels, the Ministry uses other Recurient Transaction ( oRT )funds for maintenance of equipment and other materials. Funds for oRT are not meant 22 WHO/APOC, 24 Novemb er 2004 Source Type of equipment APOC MOH DISTRICT/ LGA NGDO Others No. Condltron No. Conditlon No Condition No. Condition No. Condition l. Vehicle 2 F 2. Motor cycle(s) 8 6-F 2- CNFR 2 F 3.C s J 4. S J 5 s I CNFR 6. Fax s I CNFR 2 F 7. Others a b) _qI 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. 3.2. Financial contributions of the partners and communities Table 13: Financial contributions by all partners for the last three years Indirectly the Ministry of Health is spending in areas of personnel time and the expenditure of the NGDO partner is in the areas of personnel time and others which cannot be quantified. During the reporting year, the Government has been spending for Quarterly NOTF Meetings. District participants were coming to the meetings using MOH funds. These catered for fuel and perdiems. 3.3. Other forms of community support - Describe (indicate forms of in-kind contributions of communities if any) 1. Identification of a suitable CDD 2. Collection of drugs 3. Community awareness during census, distribution periods 4. Mobilisation of other community members 5. Distribution of drugs Contributor Year | ('provide the oeriod') Year 2 ('provide the period') Year3 ('provide the oeriod') TOTAL Cash Budgeted (US$) TOTAL Cash Released (US$) TOTAL Cash Budgeted (US$) TOTAL Cash Released (us$) TOTAL Cash Budgeted (us$) TOTAL Cash Released (US$) MOH (Central + Provincial+ District) 86,241 Local NGDO(s) ( if any) NGDO partner(s) Others a) b) Communities In Kind In Kind In Kind APOC Trust Fund TOTAL 86,241 23 WHO/APOC, 24 November 2004 3.4. Expenditure per activity Indicate in table 14, the amount expended during the reporting period for each activity listed. Write the amount expended in US dollars using the current United Nations exchangeratetolocalcurrency'Indictateexchangerateusedhere- 24 WHO/APOC, 24 November 2004 Activity Expenditure ($ us) Source(s) of funding Salaries Offige_Equip,-qfrl er! lyppti.q _ Fuel & Lubricants &S HSAM CDD Motivation Office Running cost Vehicle/motorcycle maintenance 16,900 3,000 j,szs t4,2zs rr,iir In kind 3,241 28,218 MOH ]4QH MOH APOC & MOH APOC & MOH MOH & APOC MOH TOTAL 86,241 Total number of persons treated 563,132 Table 14: Indicate how much the project spent for each activity listed below during the reporting period Indirectly the Ministry of Health is spending in areas of personnel time and some of the expenditures cannot be quantified e.g. reporting forms for treatment In the previous year, we received no money from APOC however despite no funding from APOC, Therapeutic coverage was higher than the previous years 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 Other Evaluation by other partners 4.1.2. What were the recommendations? For the districts with signs with poor coverage, it was emphasized that the DHO take keen interest and get involved in the activities. During NOTF Meetings, poor Therapeutic coverage of some districts were being rejected and told to reach out to all the absentees. 25 WHO/APOC, 24 November 2004 a aIn addition when funds were not coming on time, DHOs were asked to finance the activities using ORT funds on loan to be reimbursed by MOH Headquarters. 4.1.3. How have they been implemented? They were implemented as suggested and the districts performed satisfactorily. 4,2. Sustainability of projects: plan and set targets (mandatory at Yr 3) Was the project evaluated during the reporting period? No Was a sustainability plan written?_Yes When was the sustainability plan submitted? 7 Februa rY, 2005 What arrangements have been made to sustain CDTI after APOC funding ceases in terms oft 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. During the cycle, all plans are drawn up including activities of Onchocerciasis Control Programme. 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 ORT. ORT funds come in a basket form for different health related activities. Onchocerciasis activities are expected to get an allocation and when planned activities are now ready for implementation. 4.2.3 Transport (replacement and maintenance) 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. Transport is managed in a pool, each program is given preference according to the work plan on that particular day. Maintenance is carried when due and resources permitting. a 26 WHO/APOC, 24 November 2004 a 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. Ivermectindeliverymechanisms Mectizan is to be 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 develop 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 programmes 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? 4.3.7. Describe others issues considered in the integration of CDTI. Other issues considered in the integration of CDTI are the use of resources like motorcycles. The District supervisor is free to use any motorcycle for supervising onchocerciasis control activities. The TB District Coordinator can use the TB Programme motorcycle to supervise CDTI activities a I 27 WHO/APOC, 24 Novemb er 2004 I I (4.4, Operational research 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 reporting year 4.4.2. How were the results applied in the project? SEGTION 5: Strengths, weaknesses, challenges, and opportunities List the strengths and weaknesses of CDTI implementation process List the challenges and indicate how they were addressed The most notoble chollenge is obsentees ond refusols during mectizon distribution ond drop out of CDDs. To oddress the two chollenges mentioned obove, the NOTF is plonning to develop o reseorch proposol to estoblish the reosons for obove ond then find o woy forword. 4.4.1 SEGTION 6: matters Unique features of the proiect/other a 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. ln the current reporting period they provided supervision ond support to the CDDs. ln oreos where the CDDs were weok the HSAs provided leodership in mobilizotion of the communities. Their combined effort with the CDDs provided the remorkoble treotment results obtoined in this report 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. Their distribution is usuolly from Jonuory to April of eoch yeor toking into considerotion thot this is their peok seoson for the workers. However plons ore there to hormonise the distribution period with the com munity distribution. a 28 WHO/APOC, 24 November 2004 )I )