tRESERVED FOR PROJECT LOGO/HEADING ORIGINAL : English ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) T6-\l Ltr, \JT .:( IDEADLINE FOR SUBMISSION: i(* To APOC Management by I Janu for March TCC meeting To APoc Management by 31 July for september TCC meeting I 8 JU|L. ?00s Goc$. For I To, d AFRICAN PROGRAMME FOR ONCHOCERCTASTS CONTROL (APOC) UI{ jl I nfdrmotlon \i\TL ti{' , i COUNTRY/NOTF': MAIAWI Proiect Name: THYOTO/MWANZA Approval year: I996 Launching yearz 1997 Reporting Period: From: APRIL, 04...To: MARCH,05......... ear) ( Month/Year) Projectyearofthisreport: (circleone) I Z 3 4 5 6 7 8 g l0 Date submitted: lL JULY,2005 NGDO partner: IEF/WHO/TEA WHO/APOC, 24 November 2004 t- I I I I I al! tANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) ENDORSEMENT Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the report: Country: _MAtAWl NOTF Chairman Name: Dr H. anJe Si Date: ..8/.q c57 NGDO Representative Name: Dr G. Ezepue... Signature: . Date This report has been prepared by Name : Laston Sitima.... Designation : National Coordinator Signature : .. Date l\ l t\r:i n WHO/APOC, 24 November 2004 , c7- 8-l :tlr) I Table of contents ACROI\-YMS v DEFINITIONS......... ....VI FOLLOW UP ON TCC RECOMMENDATIONS EXECUTIVE SUMMARY........ SECTION 1 : BACKGROUND INFORMATION....... 1.1. GeNnRar- rNFoRMATroN............. 1 .1 .I Desuiption of the project (briefly)... L1.2. Partnership 1.2. PopuLanoN............. SECTION 2: IMPLEMENTATION OF CDTI....... .......6 2.1. Truer-rNB oF ACTIVTTTES .........6 ......... 82.2. Aovocacy 2.3. MoerLzerloN, sENSITIZATIoN AND HEALTH EDUCATIoN oF AT RISK CoMMUNITTns . 8 I ) 3 J aJ 4 5 2.4. CouvruurrYINVoLVEMENT.. 2.5. CepecrryBUrLDrNG.. 2,6. TRrarrrarNTS.............. 2.6.1. Treatmentfigures............ 2.6.2 Wat are the causes of absenteeism? ........... ...... 10 11 ............ t3 ,,,.......,. l3 ............16 .21 .22 .23 .23 2.6.3 Wat are the reasonsfor refusals?.....,.......... ............... t6 2.6.4 Briefly describe all known and verified serious adverse events (SAEs) that ... t 6 2.6.5. Trend of treatment achievementfrom CDTI project inception to the current year l8 2.7. ORoeRntc, sroRAGE AND DELIVERy oF IVERMECTIN ........... 19 2.8. COIT,TTT,TUNITY SELF-MONITORINGAND STAKEHOLDERS MPNTN{C ..,,.,.20 2.9. SupBRvlsroN............... ....20 2.9.1. Provide aflow chart of supervision hierarchy. ............ 20 2.9.2. Wat were the main issues identified during supervisionT ...............,.............. 20 2.9.3. Was a supervision checklist used? ............. 20 2.9.4. What were the outcomes at each level of CDTI implementation supervision? 2l 2.9.5. l(as feedback given to the person or groups supervised?................................ 2l2.9.6. How was the feedback used to improve the overall performance of the project? 2I SECTION 3: SUPPORT TO CDTI ..............21 EqurruENr FrNeNctel coNTRIBUTIoNS oF THE pARTNERS AND coMMLINITIES OrHBn FoRMS oF coMMUNITy suppoRT ............... ExpnNotruRr pER AcTIVITy ............. SECTION 4: SUSTAINABILITY OF CDTI....... ..........24 4.1. INTEnNaI-; TNDEIENDENT pARTICIpAToRy MoNIToRINc; EveluerloN.......... ..........24 4.1 .1 Wqs Monitoring/evaluation carried out during the reporting period? (tick any of thefollowingwhich are applicable)............ ...........24 4.1 .2. What were the recommendations? ............. 24 4.1.3. How have they been implemented?............. .................24 4.2. SusrerNastt-lTy oF IRoJECTS: ILAN AND sET TARGETS (MANDAToRv AT...... ..........24 Yn 3)........ .................24 4.2.1. Planning at all relevant levels... ..... .........., 24 3.1. 3.2. J.J. 3.4. tlt WHO/APOC, 24 November 2004 4.2.2 Funds 4.2.3 Transp ort (replacement and maintenance) 4.2.4. Other resources 4.2.5 To what extent has the plan been implemented 4.3. INrBcRerloN.. .,...'.....,,,... 25 25 25 .... 2s 4.3.1 . 4.3.2. 4.3.3. 4.3.4. 4.3.5. 4.i.6. .......25 Ivermectin delivery mechanisms ............... ................... 25 Training... ...............25 Joint supervision and monitoring with other programs.... ............. 25 Release offunds for project activities ........ 25 Is CDTI included in the PHC budget? .............. ...........26 Describe other health programmes that are using the CDTI structure and how thts was achieved. lVhat have been the achievements? 26 26 27 4.3.7. Describe others issues considered in the integration of CDTI. ..... 26 4.4. OppnerroNAl RESEARCH .....26 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. ........ 26 4.4.2. How were the results applied in the project?............. SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, AI\D OPPORTUNITIES... SECTION 6: UNIQUE FEATURES OF THE PROJECTiOTHER MATTERS........... 26 IV WHO/APOC, 24 November 2004 Acronyms APOC ATO ATrO CBO CDD CDTI CSM LGA MOH NGDO NGO NOTF PHC REMO SAE SHM TCC TOT LNICEF UTG wHo African Programme for Onchocerciasis Control Annual Treatment Objective Annual Training Obj ective Community-B ased Organization Community-Directed Distributor Community-Directed Treatment with Ivermectin Community S elf-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 V WHOiAPOC, 24 November 2004
Definitions (i) Total population: the total population living in mesoftryper-endemic communities within the project area (based on REMO and census taking). Eligible population: calculated as 84o/o of the total population in meso/hyper- endemic communities in the project area. (iiD Annual Treatment Objective: (ATO): the estimated number of persons living in mesoAtyper-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 expected to reach the UTG at the end of the 3'd year of the prqect). (ii) 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 dishibutors outside of CDTI. (v) (viii) Sustainabilitlz: 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 responsibilify of ivermectin distribution and make appropriate modifications when necessary. VI WHO/APOC, 24 November 2004
FOLLOW UP ON TGC 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 (Please add more rows if necessary) 1 Number of Recommendation in the Report TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROJECT 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 lvermectin distribution since l99l ond 1993 in Thyolo ond Mwonzo districts respectively under the old strotegy ( CBTI ). The Community Directed Treotment with lvermectin ( CDTI ) woslounched in 1997 in the some districts with finonciol ossistonce from APOC. ApOC's philosophy is sustoinqbility of CDTI by ensuring the involvement of the communities themselves in the distribution ond toking the drug for o long time. Ihyolo ond Mwonzo districts ore in their seventh yeor of implementotion under the cDTl 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 lnternotionol boundory with Mozombique. During the roiny seoson, thepeople of the 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 the 2004 distribution yeor, o totol of 490,751 persons were treoted out of thepopulotion of 684,524 people representing o treotment coveroge of 71.7%. All the 622 villoges ( inclusive 12 Estotes ) torgeted were treoted representing o IOO% Geogrophicol coveroge. The Ultimote Treotment Gool wos 558,155 people ond the Annuol Treotment Objective wos 86.4%. The progromme continued to corry out troinings. Troining covered heolth workers directly involved in CDTI octivities ond the CDDs. During the reporting yeor, o totol ofl0l Heolth Workers ond l,O0Z CDDs were troined . Despite thot only l,OO7 CDDs were troined, o totol of 2,010 CDDs were involved during the reporting yeor representing I CDD to o populotion of 341 people. The progromme foced o number of chollenges during the reporting yeor. The exoct number of villoges where the treotment is supposed to be conducted continued to be o chollenge to the progromme. Although GIS demorcoted the meso ond hyper endemic oreos ond estimoted the populotion ond number of communities in the extension districts, it wos not until 2004 thot we verified the number of communities ond populotion in these oreos through o census thot wos conducted by the CDDs with ossistonce of the Heolth Workers. The other chollenge wos how to reoch communities where treotment hos never been corried out. Thyolo/Mwonzo ore in the Post APOC Phose, os such it wos notgetting funding from APOC for troining of the CDDs. Treotment in the oreos where treotment hos never token ploce wos supposed to be conducted by the troined CDDs. This issue wos thoroughly discussed in the NOTF Meeting where it wos resolved thot districts should find money from other sources to troin the CDDs in oll the villoges so thot oll villoges would receive treotment. WHO eventuolly come to the oid of Thyolo/Mwonzo by providing some funds for troining. 2 WHO/APOC, 24 Novembet 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 qnd Mwonzo for more thon 5 yeors under the CDTI ond the two districts ore under the Post - APOC Sustoinobility phose. Thyolo ond Mwonzo lies olmost 100 kilometres 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 therefore 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 feotures os those of Thyolo ( Refer to Fig. I on Poge 4 - Mop of Southern Region of Molowi ). Thyolo district is mostly dominoted 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 proctise motrilineol type of morrioge whereby the mon stoys of the womon's home villoge . Most of the people in the two districts depend on Agriculture ond smoll scole businesses for their livelihood. ln the Southern Region of Molowi, i.e. including Thyolo ond Mwonzq Districts, 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 estotes. Administrotively, Molowi is divided into three regions with twenty-eight districts. The locol community is moinly o villoge set up which follows o common clon oncestry ond /or o similor culturol grouping. The villoge is heoded by o troditionol chief 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 highest 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 estimoted ot l0 million with most of it in the Southern Region. On heolth core system, Molowi is currently undergoing decentrolisotion, therefore the regionol heolth offices were obolished. The District Heolth Officers report direct to the Ministry of Heolth Heodquorters. 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 either 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 treotment of eoch heolth focility free of chorge. Table 1: 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 Bl Number of health staff involved in CDTI B2 Percentage Br=Br/ B' *100 Thyolo 486 486 100 Mwanza 146 132 90.4 Total 632 618 97.8 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 Orgonisotion (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 l0 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. 4 WHO/APOC, 24 November 2004 ra) lif (\l op C) o z $N \J B dH(.) (.) .o o U)(* d C)L{(! oo 'a La G) o CO g oa C) o d v)olr C)I tr $i o o (d ts tr € l-rq) o H C)lro (.n 9Eo(, .q89. EEg E:e EiHO6qr ird o &DE .l 6! o .i-x );E a.=i.i =:0) .tJS vo € O-E ES(-!vO -:: (u6 A9rtk trdQ) =Ev ^oC =ao -i cl 6l 6,_ I g,tAF ;i =q) t aE .2 FdS ia;ft dcl s Eitv o.= . Eo'! 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I *s\l *s 'Is'E IorS IbulHP E' .rs a$ts A.EH !n:9S* Evu \o,s.d boeJr tru= .-\I tr3s esd go.P. ru\x tEF boet Fu^E L{r 1 ^d! :ss H :€ €Iio aSBUEb'Aeas9 A u ". 0-)*N E3$ x *L.Y. <o6SaJ-t\60 6 i* d *= 6d5 0 ild cd rr'S axts sbP 5 I I a aU I .l ? C)o o CB 4 q) oLLc(dA0) a/ * F :6-:tr61 = E,5 o(r) o\ .t r o\!f, inin @\0 ra +d I5 .0)itr -oo .= QN E E.: F AE O ra) \n =f,Nrrl o\F- r+6lia r+ €\o . ..H EL'=e d&8.E6; >.E o oJ - HFi.- ,r05P N= * coNc\ c.l @ r-(r) o\ o\ N a €N o o 6l e o Fr 'EE$ s! H P.; Egsi r-r-\NN co tr)$q o\ I-* NNrr Nov I q) >.: ON8.v d 0,) H + a ll d $ $ \o k1N \o\o .eE ts9 € a_tr o :''i 3€ Xotr >r 0)HE N $(n c-l$ \o o\ tr (r,() a0 € q)q) tr o c) o L c) z e I 'EgE grJ h F; Egsi r ca $ $\ot \r) r,1 $N(a) olr- vNia $ €\o GI FOJ .=ic{ -!! - .:i i:{ .d = o.:X *o 9'VU-L[r^?l^ u)-i:'l 0) (.) .9E o tssicE; TH -\L AJ H o >' F N cd z rl Fr 3 SEGTION 2: lmplementation of GDTI 2.1. Timeline of activities Fill in table 3, timeline of activities for areas treated in current year, indicating when the key activities were implemented by the month they began and the month they ended. At Notionol level we hod developed o plon os to when to corry out octivities. The toble below summories the timeline of octivities : 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 l5 4 Centrol medicol stores to produce distribution list of Mectizon Moy 15 5 Collection from Centrol Medicol Stores ond distribution of the drug to the districts Moy 30 6 Follow up ( by NOCP Office ) with districts on collection/reception lstweek of June 7 Distribution of the drug to the Heolth Centres by 30 June 8 Review ond plonning meetings with CDDs, HSAs Community Mobilisotion June l-30 I Distribution in the community Mop up octivities July - Sept 30 REPORTS I Collection ond collotion of doto October 30 2 Report to NOTF Secretoriot November l5 6 WHO/APOC, 24 November 2004 $ N kq) -o () z l+ 6l \J { \J B B G) L € oo CBk €(l) N br)Ho o 1 0) cd u)(t B b0 '= lr lr € oo .tr U) (r, a aQ €()dul .i (E !E 0)HLehJ o- 0)= >e 'aa-q 9c e8 0) ' r-< *i FtB5 6, u.9tr 11(o ",E PL a(ll .aa EtHCd Eo6)k !r.!Y 6)E(tr o.v =v)(Jd>, 0) .qlfr rvgE edF o-r 9; -.u SHFL) V') U1q) \) AD a41 oL q) t o \ q) t4 q) E Lr CBo 0.) E)o (.) !.) cB(.) li th(n 0) L C) li € t) o od(fi o 0) ot F c.i t ol -ol(nl FI r- Ao U' L(l) EL u) o EE gE U O 01 +<o ZN oo o Eo -c?tr d= c.tO e.l -.1 d o< d h o L U' E UT fr a =tr =9EE(-) o E() z o o t tr r! oo-E+?tr d E] ca E]F rrla o q) cl c (A ah c)U "QEHI r.l l- Err1itr 6t= lI] z o a0 clL H o: BE EE U il rI] ca rI] o z a)a Pr 9tr d= & 1I]a FOo bo oq) rO iJE s= .oEooEr()e o -=EEQ .E'*1i E 6t= -.1&A o (J lr aa a o o F (, N (! > a I 3 3 2.2. Advocacy A total of 30 policy/decision makers were mobilized at National level. These included the Directors, the Secretary for Health among others. This activity was undertaken to solicit their support in the Oncho Control Program. The mobilization was done at the Ministry headquarters through a meeting called by the Secretary for Health. The program took advantage of the meeting to do the advocacy. During the meeting the problem of Onchocerciasis was presented and the activities being carried were also presented. 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 the participation of other stakeholders. The maior challenge is to mobilize enough funds to conduct the advocacy meetings in an organized manner. 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. 2.3. Mobilization, sensitazation and health education of at risk communities This was thoroughly discussed in the NOTF Meeting before it was resolved that districts will take charge of disseminating the right 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. 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. 8 WHO/APOC, 24 November 2004
cooo C.l k() .o E() z$(\.l o E( s o H B o 3 >t q') cll c! c) U) o oO G U) O F : c) Hb b!tr oocr9ts9q)i5 :u) d.) -! l-lE f;R ?- ^,b Hi r ^99-i.r F q) -FA_L E V -E*iEl!!9^ or EE a cttrao E E E'Fe! aE rEES = EE O EIiIE d'?,.I H E"E e B .io)q.E€ e E9H=9Eqr:,-. eE-Zo er !.tEE?.i oolY---qr ts tr.= =irioL?t- C.) 56,: Etl -c o'I c r.E i€{.) ir 1:'3rE q =5e.f ; E .!.Xr-^itlP oriJL - a o-a d.< u qt o c - vd (.) € € Cdv U) C) cn U)t oU' .l - v bo tH c)s (.) Li U) o t) t/) F O (.) rn oo C)o al A.trbb9, . _-{ thE()(z)AFr bO ii 'tJr -H!=la '5H(!h)X€0)x U)r-i()EE B .9,* oHo sa2 ,; , 61 0-) v-oVA LdH =trc\.rvH9(),.o -C-Y o -(!'F-)AV "Eo!he ar tr := t-..1 -c - I r\ €A-Vrtr X o.o ^vdaH.F *H€9-AHU5E .5Uo'5 si = €'*5 Y? Z: E a:E Ev *€ ;i _ aar()S'vh-E e d F ^-AUUt g'i E:g:'id(/)oH c-iv:r. ?; >.::o 9=-o.3 =-r9-E€€!6:'B c >A : b'* 9 i-i "E E XY ao ^ O -q!: c)::9='.= 9? o iH!:vAvabOdXX>i=(,r V ts.i U.t E8F"€SEU -PwL.\!! E < E iiE < o Orr rrr 8i =9Ed 5eg :E r-B3atra0 zl oo Ii d o u0 6l o) 4) o 6 € !') o\ E.gt € EEfii trEvz a'i t$ NN q) c q) €s =>L=6t !i oZ n.= (J o o z ta +Fle lt n 6l oF 0\o\ \o 6l tr 9-6tAEAO r\ o\\o r- s cq AU q, al 2 \o F-- a N o\ E? >o oa b.o ..L >q --oo6 tro Eq) oE9* Z') o il* tqlq le g u0 6t o q) la farrz'i e 2b = e't ==co 2EEa le ?oaiEi H -!6r:EEgE -ts-9 $sf a.l \o o F N d ' o Fi r'\ a'1 qj Q !0 .S U't > o\ q)\ S q) V1 Bq) S t-r aQ o o (!a o Lda ah o O +t orl dlFI +. tr o E o a: o .E *. .E 3 E E o o 1N 2.5. GapaciQr building - Describe the adequacy of available knowledgeable manpower at all levels. - Where frequent transfers of trained staff occur, state what the project is doing, or intends to do, to remedy the situation. (The most tmportant issue to describe is what measures wet"e taken to ensure adequate CDTI implementation where not enough knowledgeable manpower was available or if staff arefrequently transferued 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. 11 WHO/APOC, 24 November 2003 q) E 6lL ar, n Q Lq) z Q + Q S.i i'tG I (-) ca oF r-F-\o o r*r-\o o c.l aO o ao ca F-oo o r-Oo \o r-@ o o e) o s F(J r+ r-- $ o ra o q)Lo .a'o'clfiLX r. Fro: oErrY r- GloLr tr z o -= + * ".j Sur i.tu O o o o o o o !,) q) C) s QF o o dLo)e IE H3 tr':-' Z,E 6)(J Ei'l+F-d U .L A< 3 = \o o \o r) * O t o o 6 o\ o q,) 0) 9 1O ()F o\ o !| GI q2 U) rl Fl €r ;cr 0) z B.'i*F-d ,LP$ i^ *u O O O o o c o 0) q) q,) o \o QL O O o o F CO N (! z ,-] F Fr c.loON () -o E() z * c..t (J o H o+ o.l bo .: q a "o\ o L { s\ B i 6n o a_ LL o a, e -a E B o \ : = :. U;q) c)q) ,S L q) L o q) v1 q) s o cl C) tr 0.) a. F aOqr o cn C) (.) C)li _0) +.1 C) d bo dlrF .ii1 q.l I5l(gI FI o Table 6: Type of training undertaken (Tick the boxes where specific training was carried out during the reporting period) During the reporting year, NOTF in coordination with APOC organized a training on data management. 2 participants came from each of the 2 districts. It was a week long training. 2.6. Treatments 2.6.1. Treatment figures If the project is not achieving 100% geographical coverage and a minimum of 650/o therapeutic coverage or the coverage rate is fluctuating, state the reasons and the plans being made to remedy this. Trainees Type of taining CDDs Other Community members e.g Community supervisors Health Workers (frontline health facilities) MOH staff or Other Political Leaders Others(specify) Program management \r How to conduct Health education "/ J Management of SAEs CSM ./ ./ SHM Data collection ./ "/ "/ Data analysis "/ "/ Report writing ./ J Drug distribution ./ "/ 13 WHO/APOC, 24 November 2003 $o Nko -o () zsN Ci o H o *< B $ { Gs\ ql EO It !i q) ,a ltt) ti c) u I E q .s EU tl EU { ers € Uo '! '\t q) a \t) E u \) sl I F\\ oF doHd o c) 'a lra o tr E a(, C)Lr(d o E C) tro I tio a.x o0 o tr Eo d ^r C)VILot #Hl o.) xl ! -ol e9l ardl '=(1)t t+i=l Iot o- 51 o()l L Et3ol tr ot a -.ol -'trlE 5t EZI? (€ C) H Po C) 'a (dH(l) HC)CUd €€o 'aA LV C) rYl €a =.o! v>(t)?t- u) .;i()! 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E z Eq) () o(€ rFt F \o^\ o dH c) b0 cd^L:^'C)^\ o -t- o (nL (.) bo(nlro o o N^ (n H oo o o li 0) 00 cO li -o oo o- o o. cdtr 0) F a 0.) bI Li G) oo do p(glrbI 0)bI () 0)o tr(.) b{ a o li € d Eo tJ< : fi€ s;4 g< e-c'a E E€EEET z gci o6g o o #?Ea2z bs -otrco a-o zd tf\o oo od cn o\t'-q o\ cos oo od+ b ." _3:b H oI E -o;-c 6 tr E['€E \o N r= ao N o d ao or o ith\o o !O5bood E9ootoF o\ ot-- \ cOF- \ t-. o a- 969!- '!D dE69 = o_!z F* o\("I @ ca tr)d} N cO c- o\s -Es,d o,=3tr- E C,.:49.o' Fv rn o\ .+ (a) o\ .t od\o .9 .'3E qE = o P(E1€ _?.g o-: o E = o; -o L6F- $ o.l oi tr- t c.l{ oo (n o o0 U)o € tr) oO ll i o\ .9 qrEbO o- !s !vo 5o> 6ori OO E.9 -- 3 E gofltr tr= ii fE>!z6 o c-.r 3 d x0) =(oYO \oN N tr-\o :od o .= =EEj (D-o' -ao o.r 3 6 =o)Ycg!o c.l N tr-\o !EE * fl ".= tr rLE+ c I i. - E E-E'B-E v2O .r3 (o Xo)+E N N(--\o o a t-.,1 o F (! N cd B z, -l 3 Fr ?\o t4 BU \D .S oL q)\ o \ q)q q) $-j4 U) li cn (n (.) li o Fl o l-i U) € p a Iq a o tr d(.) li3 c-l orl -ol CBIFI tl .+oo c\ kiD -o () o z t a.l O O{{ \J B la) $!oIqr I st) E .lt E- t- sqr !o\ \ ut Itt) lt ',rl!i U '5 \ q) s u{ \tq) _! E! t)a S\ q) tr s { el B :. '$s \.9 tl G't\ EqJ .is .ts\is'3bdp €l !\l =.StftelY'uhrS: ss s_EE9 sX .\tu tssrSr!$qrs\SS U\ESa\t\+ tr qJ b3s\ SE =.S!sr!i .s's {q.SP Srt\ ='r!ult\S 2aJ 2.6.2 What are the causes of absenteeism? a. Poor coordination with Estates during distribution b. Chronic illness - the person could be registered during the census update however due to chronic illness the person is hospitalized during the treatment c. Unplanned emigration - the person could be registered during the census update however, it could be found out that the person has emigrated to Mozambique or other districts during the treatment d. Deaths could also contribute to absenteeism 2.6.3 What are the reasons for refusals? Religion - there are some religious sects which do not allow their followers to take drugs In adequate health education - the people are not fully aware of the benefits for taking ivermectin Sometimes people are afraid of the side effects if the side effects are over emphasized during health education 2.6.4 Briefly describe all known and verified serious adverse events (SAEs) that occurred during the reporting period and provide (in table 8) the required information when available. In case the project did not have any cases of serious adverse events (SAE) during this reporting period, please tick in the box. No SAE case to report t6 WHO/APOC, 24 November 2004 1 .+ oN L(.)p E() o z +(\.t O o H *IJ rrr B r- o) EEE8E 5 <.E E o - boog.E BEE.S ctoia q o.= ,EEE o().9 laHO9Ell boio \J O. O a a(1)* eY(HY o: 9l F^ AE Eq)-q tr&?d =d(H;o-o.9'q 6() E trI=(,@oq a €q! e o o vaEu' ua!-E-E f,'5 a H.EqI tr GIE . 9 ip.E EfiEEg tr o Etr a ok(l()qq(!q o:* ,1 a tl c) .Nt 99- o> x O qi o o0cd.i =60>5 xo U) O C) b0 4a o v B q._ \q) L q 1\ r-l V1 qj Uq) S ? o a)L o \ q) V1 N A) u o 'E q) a. bo L o 0) L{ o b0 3i E q) L<t< oo o Cd t) rq o (n tr 0.) q) 0.)a!o d a lr C) U)(H (n C) ct cdU #1 ol -ol(nt FI !to N H(.)p 0) o zs c..t O s H B @ -q) Eo .-9s - - .9 c!() o) a0 CBLq) o()() i1) = 4lJ' .ibbH\:oY!\El- '-.EE :l!\9StrL 6.)2$roUSeg.s: 6=G!.q.q)lrL -u63do()StEEN.e o>E !!! cl oJ =ota .-J €LlVE-l(l)(Jl(.)ol .E'il IEo. I .oole'E IaclHc)llaolh€lu!l .vt -qltst oAltE.,l IIcEEEI 9 e)frl ItrEl cl0-el Ea$l oJq)()l .- .-lAt_51 : -x ! An \laE H: !^Lc! 5 ..SJ \JiU €tEb ij q)rJc-eltr ti rr-9trorLH€HdG 0) c,) \d:E 6i ot1 ';0.)l u) =l dHeFl tr o bI) H Es*r ></ -o (_) o\ c{s ,.,,1(r) r-(.) \\o$ 9 t-- TN -t tr-\o n\o @ o d q o Or a rr i tri trl td o ^bo!-r Ear Oo\ <>v 'o o c! q N <f .Q fr1 ol tr-(.) r-6s q r-(a) =qtr-\o -q oo o ll * QE] ri o\ o!o =bood a- -o oo -.C oF q la) 9rn ao oo oi .t ( F-$ 09 oo cr) @ t-- .t \ola) \ r- ri 't, ,o od .o6!4o =ozE a o\ o\ c.I oo F- .t o\ r.) @ $ oo o.lN oo Nq @ r.) ol (.) 1.}N r.) N r-\o c-N co c.l ,rI c.)N ca \.) tr- o\$ rd _E.,do= =tr!E E.SI < E4'FU t-- o\d C.l$ oo 00 ,rI cn co <f, t-- caq N$$ c-\oq ra)\f, oo \os N oo Or-$ |r)t-\o^ o\ r-r$ (.) la) 00\o(n L6;-i .r d -oy - h sEEEoio. .os€= Ea ' d. 3e ,o @ .t o\ (a) \o o\ cfl N c.llr) r-(oO co co(.) co ca$\.) r- ca (n(.)(.| s\o cti \o\otn NNq r-r-(.) $N ra) +@\o () bo cd to 0) tr O ll * f-l l-l t{ o9Sai oo\ o O q .t oq (n n\o\o nr- ra) \a) v EoQ !s-F.:ili *3954.i Oor.l q $ oe la) s v n tr-lr) ,.r1 \o \o H AOo E 3_b E 9PU E E:J O =E>F>Oa \o\o r-r-N N$ c-t @ ca$ o\F- cn \o t @ ca .t Nr-\o I-l -Et)d o.=2E3 e cg.A i .Q .o'*Eo \o\o O\o\o \o \o \o\o vv \ov Nr-\o bo 63 =a!: ^. b i; +r oE >,': =.= tr< =IrlO=Yl qaF tr U 9.OF EtrEO oo v v \o\o \ov \o\o O\o\o NF-\o & t! tr- o\ o\ @ o\ o\ o\o\ OOON N N N O N vO N OON 2,7. Ordering, storage and delivery of ivermectin Mectizan@ ordered/applied for by - Qtlease tick the appropriate answer) MOH A/ wHotr UNICEil NGDC Other (please speciff): Mectizan@ delivered by - @lease tick the appropriate answer) MOH tr WHOE UNICETE NGDC 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 ability 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 Surveillance 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 to. The districts collect the remaining tablets from the Health Centres. When the district has collected all the remaining tablets in the district, it deliver 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 1,448,812 1,448,812 1 , I 83,448 0 3,178 0 262,186 Mwanza 535,943 535,943 336,922 0 765 0 198,25 TOTAL 1,994,755 1,994,755 1,520,370 0 3,943 0 460,442 l9 WHO/APOC, 24 November 2004 List and briefly describe the activities under ivermectin delivery that are being carried out by health czue personnel in the project area. The Health Care personnel carry out the following activities under Mectizan delivery :1. Collection of the drug from the collection point 2. Mobilization of communities 3. Reporting on the drug usage and persons treated 4. Supervision of Mectizan distribution 5. Census update 6. Collection of remaining Ivermectin tablets from the CDDs after treatment Any other comments 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 1 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. 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? CDDs failing to record properly in the recording book 2.9,3. Was a supervision checklist used? DistricU LGA T otal # of communities/villages in the entire project area No of Communities that carried out self monitorins (CSM) No of Communities that conducted stakeholders meeting (SIIM) Thyolo 404 256 0 0 0 0Mwanza TOTAL 660 0 0 Yes 20 WHO/APOC, 24 Novembet 2004 2.9.4 What were the outcomes at each level of CDTI implementation supervision? The supervision managed to correct some issues identified immediately thereby improving the implementation of CDTL 2.9.5. Was feedback given to the person or groups supervised? Feedback was given after the supervision. 2.9.6. How was the feedback used to improve the overall performance of the project? It assisted to identify 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 there has been an improvement in the 2004 treatment coverage. The treatment coverage this year has been the best so far. 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 ofQ. Note that the MOH at district level did not specifically allocate any capital equipment to the Onchocerciasis Control Programme. Since there is integration of services, the programme uses either motorcycles/vehicles from other programmes. 2l WHO/APOC, 24 November 2004 Source Type of equipment APOC MOH DISTzuCT/ LGA NGDO Others No. Condrtion No. Con ditio n No. Conditron No. Conditron No. Condition l. Vehicle 2. Motor cycle(s) 4 2-F 2- CNFR 3. Computer(s) 2 4. Printer(s) 2 5. Photocopier (s) 1 CNFR 6. Fax Machine(s) 1 CNFR 7. Others a) b) c) 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. With integration of services in the ministry at different levels, the Ministry uses Other Recurrent Transaction ( ORT ) funds for maintenance of equipment and other materials. Funds for ORT 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. 3.2. 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? lndirectly 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. Contributor Year I ('provide the penod') Year 2 ('provide the period') Year 3 ('provide the period') TOTAL Cash Budgeted (US$) TOTAL Cash Released (US$) TOTAL Cash Budgeted (US$) TOTAL Cash Released rus$) TOTAI Cash Budgeted rus$) TOTAL Cash Released (us$) MOH (Central * Provincial/State) MOH (District/LGA) Local NGDO(s) ( if any) NGDO partner(s) Others a) b) Communities In kind In kind In kind APOC Trust Fund 29,500 26,000 TOTAL 22 WHO/APOC, 24 November 2004 tr t, 3.3. Other forms of communityl 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 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 Table 14: Indicate how much the project spent for each activity listed below during the reporting period Any comments or explanations? a ActiviW Expenditure ($ us; Source(s) of funding Drug delivery from NOTF HQ area to central collection point of e_o_r_ngryni!y M9!i!!zatr_on q1q health education of communities f14!4ingof CDDs Idti"e of !q-l[r sta,ff at all,level_s CDDs and distribution L{_e11el T g1i lg1tqg o f. CD TI .aqtiyitr_qs_ $-d_vocqgy visits to health and political authorities IEC materials (rep_q4iqg) &rys &r trg-a!q1g!t Vehicles/ Motorcycles/ bicycles mai!tenance 9f,g-. Equip_m_ent (e.g compute5, p5rpJqrs g!c) Others 160 518 s,qso 660 1,349 2,464 MOH MOH wHo MOH MOH APOC 68 I4o t76 3,470 MOH MOH MOH MOH TOTAL 14,991 Total number of persons treated 490,751 23 WHO/APOC, 24 November 2004 aSEGTION 4: Sustainabilityr 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) It was done especially during Ivermectin distribution period. Year 1 Participatory Independent monitoring Mid Term Sustainability Evaluation 5 year Sustainability Evaluation Intemal 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. In 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?_December, 2003 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 will follow 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 Onchoceciasis Control Programme. 24 WHOiAPOC, 24 November 2004 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(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. Transport is managed in a pool , preferance is given to a program that contribute the vehicle. Planning and maintenance is carried when due and resources permitting. 4.2,4, Other resources Through integration with other programs 4.2.5. To what extent has the plan been implemented 4.3. !ntegration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration: 4.3.1, Ivermectin delivery mechanisms Mectizan is to be taken as any other drug. When the DHO is ordering drugs from Central Medical Stores, he/she will be including Mectizan in the order When the DHO is despatching other drugs to the Health Facilities in the peripheral, Mectizan is included in the transportation. 4.3.2 Training Currently not possible. However, 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. a 25 WHO/APOC, 24 November 2004 rrl I 4.3.5. Is CDTI included in the PHC budgetr 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 is the use of resources like motorcycles. The District supervisor is free to use any motor cycle for supervising onchocerciasis control activities. The TB District Coordinator can use the TB Programme motorcycle to supervise CDTI activities 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 4.4.2. How were the results applied in the project? SEGTION 5: Strengths, weaknesses, challenges, and opportunities The progromme foced o number of chollenges during the reporting yeor. The exoct number of villoges where the treotment is supposed to be conducted continued to be o chollenge to the progromme. Although GIS demorcoted the meso ond hyper endemic oreos ond estimoted the populotion ond number of communities in the extension districts, it wos not until 2004 thot we verified the number of communities ond populotion in these oreos through o census thot wos conducted by the CDDs with ossistonce of the Heolth Workers. The other chollenge wos how to reoch communities where treotment hos never been corried out, Thyolo/Mwonzo ore in the Post APOC Phose os such it wos not getting funding from APOC for troining of the CDDs. Treotment in the oreos where treotment hos never token ploce wos supposed to be conducted by the troined CDDs. This issue wos thoroughly discussed in the NOTF Meeting where it wos resolved thot districts should find money from other sources to troin the CDDs in oll the villoges so thot oll villoges would receive treotment. WHO eventuolly come to the oid of Thyolo/Mwonzo by providing some funds for troining. ln oddition to WHO providing funding, the Heoth Workers Supervisors ond the community leoders working hond in hond to support both the HSAs ond the CDDs to complete the distribution on time ond reoch out to oll the villoges. a 26 WHO/APOC, 24 November 2004 .lP' t SEGTION 6: matters Unique features of the proiecUother The most notable unique feature is the presence of a cadre of Health Workers known as Health Surveillance Assistants. These Health workers are based in the community. They supervise the CDDs activities in the communities. The HSAs carry out any health related activity in the communities they are based. These are govefirment employees. In the current reporting period they provided supervision and support to the CDDs. In areas where the CDDs were weak the HSAs provided leadership in mobilization of the communities. Their combned effort with the CDDs provided the remarkable treatment results obtained in this report. a b a t 27 WHO/APOC, 24 November 2004