South West 2 CDTI project annual report : April 2002-March 2003

II I I I I I I JJRESERVED FOR THE PROJECT USE ***"*I"r*:. \v--- t & v) eA+/LL- CnD C.'A G'f 6PSttt 6l-o ,l - 1,,I COUNTRY/l.,lOTF: Comeroon Project: South West II Approval year: 1999 Launching year: 20@ Year being reported: Yeor 3 (2002) Period being reported: Apri! 2@2 - Morch 2OO3 Prepared on: zfh August 2OO3 NGDO partner: Sight Sovers Internotionol BECU 0 I sEP, 2003 APOC/Dffi o.JbslL} ',-,, .\l*L 4e II PROJECT ANNUALREPORT 2 Table of contents LIST OF ACROIYYMS FOLLOW UP ON TCC RECOMMENDATIONS SUMMARY SECTION I : BACKGROUND INFORIVIATION l. l. GTNSRAL TNFoRMATToN l.l.L Description of the project (Very briefly) 1.1.2. Partnership 1.2. Popur-artoNANDHEALTHsysrEM SECTION 2: IMPLEMENTATION OF CDTI 2.I. PSRIoooTACTIVITIES 2.2. ORoERlrrc, SToRAGEANDDELIVERyoFvERMECTIN 2.3. AovocecyexoSsNslrzATIoN 2.4. Mos[zAnoN AND HEALTH EDUCATIoN oF AT RISK coMMLrNrrIES 2.5. COTTNT,TUIUTES INVOLVEMENTINDECISION-MAKING 2.6. CepecllyBUILDING 2.6.1. Training 2.6.2. Equipment and human resources 2.7. TnserrvffiNTs 2.7.1. Treatmentfigures 2.7.2. Trend of treatment achievementfrom CDTI project inception to the current year 2.8. SupsRvrsroN 2.8.1. Supervision o/ health personnel was achieved 2.8.2. Supervision of CDDs and distributionswas achieved2.8.3. Quality of records was ensured2.8.4. The results of supervision were ufilized SECTION 3: SUPPORT TO CDTI 3.I. FngaNcTaT CoNTRIBUTIoNs oF TTIE PARTNERS ANDCoMMUMTIEs3.2. OrrmRponvsoFCoMMUMTy suppoRT 3.3. Cosr pen AcTrvrry SECTION 4: SUSTAINABILITY OF CDTI 4.1. hrrenNer-; TNDErENDENT pARTICIpAToRy MoMToRING; Evaruerroll4.2. ColrytururysELF-MoMToRTNG 4.3. SusrenIABILITy oF pRoJECTS: pLAN AND sET TARGETS4.4. IvrrcnanroN sECTroN 5: DrSCUSsroN, coNCLUsroNs & RECOMMEI\IDATrONS APPENDIX J I Llst of actonyms APOC ATO CBAF CBH CDD CDTI CMO DMO DTS FLHF HIPC HSAM IEC MoH NGDO NGO NOTF OPC REA REMO SSI sw2/swrr TCC UTG wHo African Program for Onchocerciasis Control Annual Treatment Objective Chief of Bureau for Administration and Finance Chief of Bureau Health Community Directed Distributors Community Directed Treatment with Ivermectin Chief Medical Officer District Medical Officer District Temporary Staff First Line Health Facility (health centre) Highly Indebted Poor Country initiative Health Education, Sensitisation, Advocacy and Mobilisation Information Education Communication Ministry of Public Health Non Governmental Development Organisation Non Governmental Organisation National Onchocerciasis Task Force Onchocerciasis Project Co-ordinator Rapid Epidemiological Assessment Rapid Epidemiological mapping of Onchocerciasis Sight Savers International South West Two CDTI Project Technical Consultative Committee Ultimate Treatment Goal World Health Organisation 4 FOLLOW UP O]I TGC RECOHTE]IDATIO]IS The last TCC that dwelled on South West Two Project was TCC 15. Recommendations as such were not made. Instead issues were raised and complementary information requested. The table below details the issues and information provided by the project. Tahle i: Status of the last recommcndations s/N .rsSUES RAISDD AT TCC 75 INNONUITTON PROVIDDD BY T\{E PRo.'tcT 1 Misappropiated funds The funds misappropriated by the then acting DMO of Mamfe Health District, Dr Andoseh Victor had been paid back and placed in the Bank as of tlre 26n September 2OO2. As soon as this happened APOC was informed. 2 Stolen Vehicles The insurance compa.ny had already paid the WHO office in Yaounde for the two vehicles (Southwest 1 and Southwest 2 Project vehicles) that were stolen. WHO has supplied Southwest 2 project with another vehicle as a replacement. 3 SAEs their diagrnsis ard. management In the first year of distribution Dr Bisseck investigated upon the cases of deaths that occurred in the project a.rea. Following a mission by Dr Bisseck to investigate about the cause of the deaths, all the deaths were classified as not due to Mectizan except one of the cases for whom no information was obtained and so no definite statement could be made. In the second year the only case of death reported during the Mectizan@ distribution period was that of an 11 year old boy who had malaria with severe head ache before taking Mectizan@. He was not confirmed as having died from Mectizan@ so we did not see the need to report his case as an SAE. No where in our reports did we ever say the project was suspended due to SAE. SSI suspended treatment of remote communities and did treat these communities after testing individuals. This entailed trekking in the health areas concerned for about fifty days. Only persons without Loa loa were treated since there was no possible means of managrng any SAE if it occurred. 4 Details of iuermectin reeipt and. usage. This was not requested in the previous guidelines for reporting. However by the time this report was written, Mectizan@ had been requested for the Southwest 2 project just once and this was in 2OOl. We received 601,000 tablets of Mectizan@ in September 2000, after distribution 341,908 tablets were left which were to expire in July 2OOl. Haute Sanaga and SWI used these tablets in exchange for SWl tablets, which were to expire in September of 2OO2. For the second distribution we uired 5 254,280 tablets. Given that this exchange could be made there was no need to request for more drugs but a request form was dully filled for tracking of the drugs. Second year's distribution Tablets Available: 341,908 Health district Tablets supplied Tablets used Tablets returned Fontem 110,000 74,397 33,895 Mamfe 91,474 48,3O7 40,145 Akwaya 70,ooo 17,862 40,489 Ekondo Titi 70,000 22,96r 45,951 Mundemba 60,000 26,046 33,342 TotaI 189,573 Since all the district were not distributing at the same time, drugs brought in by one district was eventually transferred to the next district. Thus the number of tablets moving around is greater than those really available. Total of tablets glven to other projects: Haute Sanaga 35,000HKI 46,500 Tablets left in the office of the co-ordinator at the provincial delegation at the end of 2.a round of distribution: 73,297 6 Summary South West Two CDTI activities started in July and September 2OO2 with Ekondo Titi and Fontem Health district respectively taking the lead. As usual activities started with re-trainings at health area and community levels. Provincial and SSI stalfjointly supervised these trainings that all took place at the various district health services. After re-training of the health centre nurses, they on their part re-trained the CDDs. In some areas CDD training took place at the health centre. In other places the training took place in a public place within the village (primary school or chiefs palace). In Akwaya CDDs were all trained at the district health service and not within their communities. Though done at the district this training was carried out by the health area nurses and health area supervisors. It was done this way in Akwaya because of the peculiarities of the health district. Of the four health areas that the district has just two are functional with health centres, one of which has a new chief of post. In the other two, CDTI activities are supervised by teachers and other educated and enthusiastic community people. Effective supervision of these non health personnel during re-training CDDs would have been very difficult for just the staff of three, of the district health service in such a terrain where getting to every village is on foot through forest paths. Also training all CDDs together at a common place helped harmonise the training. After this re-training the CDDs were all given their stock of Mectizan@ tablets. In all, 39 health district stalf, 97 health a-rea nurses and 569 CDDs were trained or re-trained on CDTI. In most health areas as soon as the nurses were trained health education within the communities started. This health education went on all through to treatment. Closely following training was the registration update and treatment. This year health education was more intense and involved many more health sta-ff than in the past two years. Treatment was supervised by the district as well as provincial and SSI staff. During these supervisions megaphones were used on vehicles to give heatth education within the communities. Treatment in hyper and meso endemic villages was mostly door-to-door. In hypo endemic villages it was clinic based. This third yeff, out of 183,756 persons registered in all ttre 452 hyper and meso endemic villages a total of 120,500 were treated giving a treatment coverage rate of 65.60/o and a geographical coverage rate of lOOo/o. In hypo endemic villages a total of 7,262 persons were treated. No case of severe side effect was recorded this third year. The few cases of mild and moderate side effects that occurred were treated free of charges. Community participation was good, though most CDDs were males. Community support for CDDs is still a serious issue as the community members still do no not give any support to their cDDs. Though not up to what is in the letter of agreement, government support to this project has started trickling in. This year the Ministry of Public Health provided some equipment to the project area. Plans are underway for CDDs to be motivated financially. Funding is also expected from the Highly Indebted Poor Country Initiative funds. A budget has already been submitted to the Ministry of Public Health in that respect. In April 2003 APOC carried out a mid term sustainability evaluation of theproject. The evaluation revealed that the project is not moving towards 7 sustainability. The areas of concern were planning, leadership, monitoring and supervision, Mectizan@ procurement and distribution, training / HSAM, Financing, transpoft / material resources, human resources and treatment coverage. Recommendations were made and they are in the process of being implemented already. CDTI has contributed in the revolutionising community health interventions in the South West Province. It has set the pace for community involvement in health programmes. 8 I SEGTIOI| { : Baclrground lnformation 1.1. General information 1.1.1. Descripfion of the project (Very briefly) Location The South West Two (SW II) Project Area is made up of three administrative divisions (Ndian, Manyu and Lebialem) of the South West Province of the Republic of Cameroon. It covers five health districts (Mundemba, Ekondo Titi, Fontem, Mamfe and Alsraya) Most of this project area is characterised by dense and luxuriant equatorial forest except for part of Akwaya Health District especially towards the border with Njilnva in the North West Province and the border with the Republic of Nigeria, which has Savannah vegetation. SW tI has a very harsh topography with many rolling hills and valleys. This renders the terrain very rough making accessibility difficult. In most of these valleys run fast flowing streams, providing good breeding grounds for the black fly, simulium. This area has two seasons; the hot dry and the wet rainy seasons. The rainy seasons are usually long (April to mid November) during which the streams get flooded. The road network is very poor with all roads being earth roads. These roads get very slippery and muddy during the rainy season making work in the Iield difficult even with a four-wheel drive vehicle. To get to Akwaya one has to go through the Republic of Nigeria and drive across large streams with no bridges and rough mountainous terrain. The main economic activity in this area is farming. Males are more concerned with cash crops, planting cocoa, coffee, and oil palms. The common food crops include plantains, cocyams, cassava, yarns, groundnuts, maiz'e and a rich variety of fruits and vegetable grown mostly by women. Tablct.7: Shouttng afunhlsbattttc unlb, health dtsffiets and. health areas. Divisioa Subdtvisioa/Dl*rict Hedth Dlstrict Health Arca Ndian Mundemba Isangelle Kombo Itindi Kombo Abedimo Idabato Toko Mundemba Mundemba Lipenja Madie Ngolo Isangelle Kombo Itindi Parnol Kombo Abedirno* Idabato* 9 Ekondo Titi Bamusso Dikome Balue** Ekondo Titi Ekondo Titi Kumbe Balue Bamusso Bafaka Bissoro Bekumu Lobe Bekora Illor Manyu Marnfe Eyumojock Upper Banyang Mamfe Ekok Ogurang Kembong Bachuo-Akagbe Eyumojock Tali Marnfe Afap Kendem Kajifu Akwaya Akwaya Akwa Akwaya Amassi Bazundu Lebialem Aluo Fontem Wabane Fontem Menji Azi Essoh-Attah Bechati Fotang Fonjumetaw Fotabong Bamumbu Tak\ rai Kupe / Muanenguba Nguti Mbetta Njungo *Kombo Abedimo and Idabato are health areas that are really non-functional as the a-reas are found in disputed Bakassi area and occupied only by soldiers. No civilian activity goes on there. **Dikume Balue is under Kumba Healttr District in South West 1 Project Area. SW II is situated between latitude 5" 12'and 6" 30'north and longitude 8" 3O'and 9" 45'east. As mentioned above this project area spans in three administrative divisions, consists of 5 health districts and 40 health areas. The health districts do not strictly follow the administrative units such that a health district or health a.rea can cover more than one division or subdivision. The administrative headquarters of the province is Buea, situated in South West One (SW I) Project Area SW II shares boundaries in the west with Nigeria, in particular Cross River, Taraba and Benue States. In the north it shares boundaries with the North West Province; in the east with the West Province; in the southeast with SW I and is bordered in the south by the Atlantic Ocean. 10 1.1.2. Partnership Partners involved in the implementation of South West II CDTI Project are the Government of Cameroon (Ministry of Public Health [MoH]), African Programme for Onchocerciasis Control (APOC), Sight Savers International (SSI) and the Community. These partners all work in harmony for the smooth running of project activities. Planning is done with the full participation of the MoH, SSI and the community. They together also carry out supervision and mobilisation and monitoring of side effects during Mectizan@ distribution. Advocacy is usually reserved for personnel of MoH and SSI. Plans of action are usually drawn specitring which of these partners does what and at what time. 1.2. Population and health st/stem The surface area covered by SW 2 is approximately 10,610 sq. Km. Registration update this year revealed a total population of 183,756 inhabitants. The table below shows the population change since the onset of the project. Table 7.2: Varlatlon ln ycarlg gntrrulatlon Year of activiEr Totd Populatioa 1"t Yea-r, 2OO0 185,874 2ndYear,2OOl 172,956 3.d Year, 2OO2 183,756 The first year's population is highest; this can be explained by the fact that this first year's population includes population of both hypo and hyper/meso communities. REA was done in the 2nd year and from then onwards hypo endemic communities were excluded from CDTI. Tqble 2: Baslc dati on fupulatlon and. halth sgstem wessthlllp Of these 42 l:ealth a-reas just 40 are involved in Mectizan@ distribution. Of these 40, only 38 carry out CDTI. Ogurang Health Area in Mamfe Health District and Bamusso Health Area in Ekondo Titi Health District do not have CDTI. Ogurang is completely inaccessible (has no motorable roads and there are large streams with no bridges) and has no health centre. The nearest village to the district hospital is over 4 hours of trekking away. In the second year people were all examined for Looloa and only those who were negative were treated, by a health personnel who stayed in the health area for about a month trekking from village to village distributing Mectizan@. He distributes Mectizan@ and at the same time monitors and manages minor side effects. Bamusso is all maritime. All its villages are hypo endemic for oncho. The whole health area therefore has but clinic based treatment. Since CDTI did Number / % Observation Ar Total nummber of health areas 42 Az Total number of CDTI health areas based on the REMO results 38 No of health arqrs covered by the project in the current year 90.5olo As Total population of CDTI health areas inAz Total Population of CDTI communities/villages in the current year 183,756 1l not take place in the hypo endemic villages it was not possible getting their population figures. Mectizan distribution in such commurrities was just limited to treating people in the health centre. CDDs did not work within the villages as they did in meso and hyper endemic villages, l2 { o P. ? c2 U rn E 3E' rd Ffl o 2,Fl E] Hrn5X -o 2. U ? x{ ooqo-:T- ood* @ -(.,{Ot(D t\)N N) -J\o o\ "|5(4) o\ 5F t){ -I oo(,)5 (r) Jr,o@o 3P-{ =oBI o:'t o s 5 (Jt oo O str zo o -tr 1 o Gtoo N Ot o) {(Jl \o5 o\L'I N)@ o\\o E9-dBE G t.9 .1, o o, o) o) @\o t,L,I o\ (,)o\ \t\o E+$$ ol -(.){ o) .9o{@ N) Jo{5 (Jl @ s{('l) (Jr N) @ e$r ! oEtr o,l!: o o Jo(o(o Ol tJ N)o (, L,T -N o\N tJ\o -o o\o I o) -o O) N\o @ o\ N) 5q- e *E- G 3.9 .9. o @ -(.,{ql o) N)N N){\o o\5 -s (,) o\ 5F N){ { @(,s (, L'T o@o E+$$s \l S.S. G(^, ir' - S t G U) S tr.\ € E. F T. v,E E sla G S l!. Ist E E ct G?)(! u, aa S nS. <a8E -,x G oZiE gE tgl ;<(D .iE ? zo oUI oo (a o g F(D oo a E o oq) 3.t!r o oU q 1. d o 8D oa(D @ ; A community or village is either made up of persons of the s€rme tribe or of heterogeneous origin living together in one agglomeration. The size of a community or village can range from between 6 to 4,876 inhabitants as in Matamani and Mundemba Town respectively in Mundemba health district. In some health areas the population under one CDD is considered to be a communit5r. SEGTIOII 2: lmplementation of GDTI 2.1. Perlod of activities Below is a table that gives a summarJr of what went out in each health district. The more detailed action plans district by district are found in appendix l. These detailed action plans were slightty modified depending on timing following promptness in reporting and requesting of funds for activities. th ? g6 d A' A' B, Fd o (T rrlxo oo H trt *{9' tl trop ly, v, El a qllS6rH iJ tlo aD'o6uJ! A, .: N) r,ooot *g' E.Fl N.J t'J N) F/ tJd =tdor-t (t, t9 * E oa o za-ooTU ;s i. 3.(Droq Ei OJlr r) N) u) E'H N) o UJ N)' tJd 6oit xo N)or ? ot o F.J (f) oo3E EElr9. E AE' N)orFt oxoxtJOero t'J u)oaD N6 er ta I,J |.) !iz tJ6 (t or-t (n P * ll OQ E o E Hrt D ,e N)|/ r.J d 6o E5r le (no(}OE -g, E.i i'J utooOEN6 E. bJ ral a3 ta' o6(r: b, € o E (! o EI E oE ><clts6 sEt N) ral o aD' o6Q! D, .? N) ('o(!ot -g' H. N) N) !iz l.J d doI E3 =BE4 i+E oe oo o t, t,a D (D tJ7 b.J d(' o ? o0H c) N) qJ N) r,OadOEhJ6 rr-t tJr,o(DOEl.J6 rH IJ EIo aD- o6QI bJ ,r o EE EEE3.cE N) ral o aD' o6(f) : !) .: o, o f.) ()) 85hJodrl 8P i5 0t th fJ tlO(D'ocr(}):J b, .? E3 :p Ed =E rl 0a o u, rl r al o z !r B N)o(, ! N.) u) i.) ts7 hJ6 trt6o EP N)or otHo i..) o(r) ooE E(! c E o EI ET !ao =oN)ocr(D r-t N)Eoo'oou)5 D' a? N) r,ooOE r'J 6 F^Et t@ a t') N) !iu58TJ .D E.r-l -(a =DE* *E' o(I a EoI O o ? A]Ho N) u) E i. F.) (, !iz r.J d 6o !ioxoS666 Et. T,J oG) o EE EEEEt oE P. -l 4H J- .+hp !-+ d o o o{ ot ,t 0)H oo o oo ,otop oo o { o o o a{o o op B oo ot -f o) c, o o)bo) op -l' P o. o i-fFt o c, op !' il EF Gi H : ox*I Gq o o GT Ca.!tG}* o tn 7'? qes = Fri"o, ^r_l v iJ 7iUqaH)!L)+H +iv-^-.'rO .'1+--!-\-^a = < :i i.-1.:' -r r+:r,-i. lJ-l=-Ci ' ?- afi o k -t] rn O + - \/ !J -.1i :'5 o ? v1.3. = Y D =; -1= 1.)ii)vtJHXT:D<D^O';',1 2-)idh=Djlr:ial --9'4=-'z+ ^r5 Y O :.A' e 2 f 2: ;.P s :5'922n,Y.H"j a: 0r -' , =.-.uq = d -. a -6 i, t - q n-38; =; -J'<!, =v d?*da42.u-i.i=x' ^4co;'-e*.-j^;:*.d = 2 .j-(rr5 3.: O-,t * 'f---'^rA- .AV+iv^L-UAt--.r+(J_F. ,+J'1 Oi-r r? =c 6'Di.r----^'Z--'-i:r.+=*2 q,: 'rQ)ta\P a'6' I lD oJ :r 9 ts.^FLlnai<3*o =:)'n o n'- o l.-:.': P 5a=a. l.- P.o -u -n==-'ri:*ori2;i- +rJi.J:'^l3 o 5r{oo 7, ,-.la-n)--+3 x : -a 1 =7o 5 ; 4 -.'-\ =''/ + H.l-' A - ^ -J-:aLeFJ-:=f,qtD z = rA,= =. _ 1 AXaYZrnl3;99Pq- TH<ivT5 ro P P +c 6 -cra-5-=lvo o o\Y+trQr =a=l iN='=('<o 5€ii-,:+ ^:-lJr(-}-:Z o *- r* IJ 0e ' -'-.3 o-O'<a.r ) - o odtp.=3aI lir-roorD-NJ o: oz= o - O ^J.-^r-Aa:"pq;5.E ---jrn(n'I',r 5-E'6 osi, o' . ?.] = ?dq o F) !D! o' '-;Al-- 'i.)^^3Qa=a!:^ ^)-iJ-v- ^-- --;Y---5 *o ll -6rDaq=tl_o_A\J-'v-.rJD +i I = 5 !D!+JA\U.hf + = !Y +uq =. r)!-v g---v HJvA+_ TY- =: i 5 il)).trt!jrh:lOaA-r* - a X "' Xg *2Az 9 'n1f^,+!/ U!r- v \(^ 2.2. Ordertng, stolage and delivery/ of ivermectin Mectizan@ ordered/apptied for by - @lease tick the appropriate answer) MOH tr WHO tr UN"ICEF f] Other (please specify) NGDoT( Mectizan@ deliveryed by - Qtlease fich the oppropriate answer) MoH E/ wgo tr rrNrcEF - other(pilase specifu): NGDO! Please described After second year's Mectizan@ distribution the number of tablets left in the project was 106,629 (73,287 at the provincial delegation and 33,342 within the health districts). For year three distribution 21,500 and 96,000 tablets of Mectizan@ were received from Helen Keller International and South West 1 Project respectively. 172,000 tablets were ordered from MDP. This all gave a total of 396,129 tablets received by the project. Table 5.a below gives this summary. We could not get appropriate data on the villages that did not collect drugs from the designated collection points of the health a-reas. However we noted that in many villages the health centre nurses still took drugs to the CDDs. Tablc S.cr.' Soutees of hrcnnec{cn tableB s/n Source of Tablets N". of tablets 1 Left over of year 2 distribution 106,629 2 Helen Keller International (HKI) 21,500 3 South West 1 Project 96,000 4 MDP 172,OOO TOTAL 396,129 Tabla 5.b: Irutentory oJ hrcnncdtn tableb Cr Number of ivermectin tablets requested for the period being reported 396,,129 Cz Number of ivermectin tablets received by the Project 396,129 Cs Number of communities/villages which collected drug from designated point of collection Health District Number of Mec'tizan tablets Requested Received Used Lost Waste Expired AKWAYA 50.000 63,086 61,409 53 69 EKONDO.TITI 65,000 58,342 38,417 74 562 16,789 FONTEM 120,000 107.E90 100.968 36 1,000 MAMFE I16,000 I15,656 113,656 109 l6 oMUNDEMBA 45 129 47 t2t State activities under ivermcctin dclivery that are being canied oat by health carc perconnel in the project area. As far as Mectizan@ delivery is concerned health personnel were involved in the following activities. i) Collection of Mectizan@ from the provincial delegation of public health Buea to the various health districts (by the district medical officer). ii) Collection of Mectizan@ tablets from the health district to the various health centres (done by the health centre nurse). iii) Some health centre nurses carried Mectizan@ to CDDs in some villages. 2.3. Advocacy and Sensitization This year quite a lot of sensitization was done at the various levels. At the provincial level an advocacy workshop was organised by the provincial delegate of public health, during which he invited the governor of the province, all provincial heads of services, senior divisional officers and traditional rulers as well as journalists of the South West Provincial Station of the Cameroon Radio Television and FM Mount Cameroon Radio Station. This was an integrated workshop in which participants were not only sensitised on CDTI but on all other health programmes carried out within the South West Province. Funding for this advocacy workshop was not from the CDTI budget. At the health district level the various district Medical Officers made advocacy visits to the Senior Divisional Oflicers, Divisional Officers, Heads of allied services (agriculture, education, municipalities, etc.), traditional rulers, church leaders, political leaders, heads of social and cultural groups. This intensified advocacy helped increase public awareness of CDTI and the benefits of Mectizan@ within the project area. One of the reasons for the intensified sensitization and health education was to address the high refusal rate and ignorance of the benefits of the drug witnessed during the past years. 2.4. tobilization and health education o,f at risk communities - Within the risk communities health education was given by the heatth centre nurses to social and religious groups, chiefs and their traditional councils and during antenatal and child welfare clinic sessions. Also town criers were used for making announcements within the villages. Trained social mobilisers were also used. In most villages these social mobilisers as 17,7t9396,129 391,974 352,675 248 776Total t7 well as health sta-ff that carried out mobilisation and health education consisted of both males and females. - Community response to mobilisation in most villages was poor; attendance to health education sessions was equaly poor. It is for this reason that a new stratery; to meet people in their socio-cultural and religious groupings had to be adopted. If good health education is to be maintained this stratery of meeting the community people should be maintained. 2.5. Gommunities involyement in decision-making Tdblc 6.a: Communltg paftlcfpdon ln t'he CDTI Tdble 6.b: (I4fonna;tlon ollecied.ttom q, runtdom sanple of 30 ulllages/communltfles) On Table 6b above instead of collecting information randomly from 3O villages the health personnel collected information from all the villages in their health districts. No information came from Mamfe health district. In most cases it was discovered that female CDDs did a better job than their male colleagues. They were more meticulous in their job. The participation of female community members in decision making was very little. The males always had the upper hand. Females could not oppose or say anything contrary to what the males said. There was however no significant difference Health Districts No of villages which selected GDDs No of villages paying GDDs in cash or kind No of CDDs No of villages with female CDDe Total D1 o/o D2=Dll B3 100 Total D3 oh D4=D3/ 83'100 Male CDDs D5 Female CDDs D6 Total D7= D5+D6 Total D8 Yo D9=D8/ 83.100 AKWAYA 79 100% t2 15.2% 113 t4 127 11 13.9% EKONDO. TITI 36 l00Yo 0 0% 37 7 44 7 19.4% FONTEM ll3 97.4% 0 0% 118 6 124 6 s.2% MAMFE 135 l0OYo 0 0% t72 9 I 8 I 6 4.0% MUNDEMBA 88 98.9% 0 0% 83 15 98 l5 16.9% Total 451 96yo t2 2.6Yo 523 5l 574 45 9.6Yo Health Districts N'of villages in which women took part in decission makinq No of villages with community members as supervisors l\o of supenisors (Ilealth stefr & communitSr memberc) No ofCDDg who abandoned their word during the reporting period Total o/o Total o/o Total o/o AKWAYA 38 48.1o/o 18 22.8o/o 2L 1 O.8o/o EKONDO- TITI o Oo/o o Oo/o o 1 2.60/o FONTEM 79 68.7o/o 0 Oo/o 15 5 4.OVo MAMFE MUNDEMBA 4 4.5o/o 0 Oo/o 6 5 5.Lo/o Total t2L 26.9o/o 18 3.8o/o 42 L2 2.lo/o l8 I in convenience of time and mode of distribution amongst male and female CDDs. t9 l0 P htlgo'hoFr-€ ilF{H II+9.€F.='E :loqE *rat6g s3G}E G} I G F. sI(!I r+ It Ro e, o E H € G : G TC} aC}{. o T \o(,t s e) o (D o Fl o c, 7r-g o-o d F' o, (D' Frl o +(D rn7fo Eo. o Fl F{p, c) -*o to U U' rt(t v, N)o 5 s s 5 5 41 4 -o zo o U ta rt a rlA D rt D @o o o s$ o o o O Bq (, \o \o { @ @ { El -rYo'EE t.) s o o (D (D @o N) N)o N)N 6 oo ^PEEtr r.t -o zo o oD Da (!=,OH(D :g o v, U' E =B o B$ o\(, (.)N (4) tJo sq \o{ @ t,l.J u) \o N)(, E ..r1- o'Etr '.oo\ o (D (D (D o ^PE I.J\orl -o zoo o o -t F.l oFl U' rt E (D EL t-J N) SFg€ No No Bq 5 00 o\ o\ N)(Jr ,, ?dEE \o UJ -o 6\ o (D @ (D o\ N) ^DEJ55 zo o o U UIA Et E oa l+) -l (,){ s3s.= t'J 5 N)5 \oo Bq L'I o\\o \o @ oo N5 u)\o N){ l!, :L=+xEE f, *tG €{ .G:l .'-\ a-G a s o o s s _G\!o a-o G oo\\G \l o: : 0a 6 o:s qsir€3 BF T! EE: Eil$f$E5 Om r- X oh. L)*1 igt *EE "E'gH€ [5 ci H o;i 5'E 6 6'P-qq;996' .-rg il5. g$Hrq ,j srESa' : BEg I B:cF€ sB'€ES9Hq gfi d g*< E Sts4BE B a*il33 5'ts E'o9 A H.F F * "Eg I r;eH} : a;H* ?EHBTaD:rD(D-HvXB :iD Q.9 siI 1*PP9E*dg r F'g f, H3[il i!.F H a1 Es3 gg ;=[H?(! ^E E.\/ H. U = s&g.-{qq (D tr[FH rr$E gFF$ V +i-.(, -lo'5< jpo! E 6'8 8 3 fi =il.+c.1.5 (.Dc+F O.trts9s5u.tHi{.+PPx o d-Ee 35't3[il< o +=15.+-!f o 5!D -ooBidp<$5 gia: 3[€ Eilo I Fdq'nC DEga'g. so H 6'h O@ * i$H IIto -oO +)H o)E'! P. tr- .+!? 5,+ EIi35 0.: ?!@-€* ,r6ofu'En E BI E E$f.A O o)<"5+o gch n. 3E r€ - O i3* Hg qg 0Qx@O sE qa sgEH Ef; 3B ieE'iB P5E H 5'o --.H PH.it ,f E.o 0q No T For training of community distributors the health centre nurses have been making use of the training manual as a guide. Also they used the training hand-outs, posters, flip charts, fliers and brochures provided them by the project during their own training. Measuring sticks were prepared during training / re-training of CDDs. CDDs were all asked to bring a stick, obtained locally from their environment. Painting the colours of the Cameroon National flag (green, red and yellow), then blue was done jointly with green, red, yellow and blue standing for one, two, three and four tablets respectively. Each year new health stalf are transferred from other places to this project area and vice versa. Also some retire and are replaced by new ones. New ones are also being recruited. This makes it imperative for tratning / retraining to be conducted yearly prior to onset of activities. Also most of our health centres are staffed but with nurse aids who need to be refreshed fairly often. A similar situation exists with CDDs. New ones come on board each year. This time some even abandoned the job midway into the year's activities leaving the health centre nurse helpless. The case of Mundemba can be cited where the health centre chief of post had to ask for and train new CDDs midway into the programme with no extra funds for this supplementary activity. In a few places such as Mamfe, Ekondo Titi and Akuraya CDDs resigned and the nurses had to do Mectizan@ distribution themselves. Most of the CDDs did a good job. What they complained of most was the fact that cost recovery has been suppressed leaving them with no source of motivation. It should be noted that little or no motivation came from the communities for the CDDs. Just like mentioned above, the training objective of health district personnel was greatly exceeded because in some remote districts like Mamfe, Mundemba and Akwaya health a.rea sub-supervisors were trained to work along side health centre chiefs of post. 2.6.2. Equipment and human resources Table 8: Slt,rlltlls of qulpment T Health Distict Source Vehicles (motorcycles & cars) Computers Prrinters Fax machines Functio nal Non- functio nal Functi onol Non- functi onal Functi onal Non- functio nal Functi onal Non- functio nal Akwaya APOC 0 0 MOH 3 1 1 0 NGDOs 1 0 Ekondo Titi APOC 4 0 0 0 MOH 1 1 1 0 NGDOs 2 0 0 0 2t APOC Fontem The various health facilities that have these equipment have funds to run their activities and these equipment would be maintained like other equipment possessed by the health structure. However there is no laid down plan yet for replacement of these items (especially vehicles) when the present ones get out of use. 2.7. Treatments 2.7.1. Tneatmentfigures 0007 1 1 0MOH 1 0NGDOs 5 0 0 0 0 0APOC o 0MOH 2 3 1Mamfe NGDOs 5 0 1 0 APOC 3 0 0 0 0 0 MOH 4 0 1 0 1 0Mundemba NGDOs 2 1 0 0 0 0 22 Ho D 7rttr o.(D d E) ?A At (D' Ffl o o rfl ,fo o. o Fl 7f{ o) ct 9raG *Egt 5(rl N @(o J (l)(, IA(.r) (rJo) \t(o : s E *d!t o.o r l! .6=0Q- aE.E g.z{r" q E q E oo(! a s(,tN @(o J o)(,l J(r) (l)o) \,1(o 3F> a93E9q.E Ed1- 5 OtN @@ J(r)(, Io) o)O) {@ aE*z.9 Ets q oo s d s d s Ioo s Joo s d s gr; $r 6F o -(.,{ C'I o, NN i\){(o o)5 -5 G) o) s -sJN{ I -{@I (.l) _(rto@o B[g*Ee :c o E oE JoI(.) 5 -s o]\) 5 -@ o,A N @ -o) @ G) j '(rt(oN NN -@ oN 3E> sEBEd1- NP(,too N\ o) J 5oL o) Cr) .GJo G){ -o 5 o) N coL(o C'T a tE z ."899. C') s,lo s (rlJ(, s oNb s {I @ s o9(, s o)Jo s Fltr.l a Ella- c6A^ < x gu# E N -5(o(,t o) -sI(rl Io5(o(o \Ns -5 o)oo -o)@@N H-a*s; -s(., @ J -(o t\)(, -sG' -CJA G){ -Ctt (rl]\) -(o o)@o F aa,6-EJ(!El(! EUEBp; o o o o o o EEgu*r$ ttr i o p rlt FG} : o T G} oIg 6ia. F. G .G B oC} 1o u(s\I o F HG}td o T ah b 't C}tI G .;! ot :a! oI. o P. j ot A' ,tr! ^9roFii/6 o o @Ft S) oa(D 0, o lt -l12o lc'sti : lH' :6 tT5lo!4l\ trlE El*glq tslE 6'tB =l lo.lx lolo o(D o@B A) '-c, It :/C) E) o o CDr-tq) 0a(D H D' .D ll 1t2Q lE' El3 +lF -lHBlo olT:gt8 EIE e, 13 3:lEtT lg. vt lOi13 !D l=0o l8D(D0Q U)l(D -. l(aEl+ 5 tradt9altao lo.Flx rJ l- E15tg o.g 3 5' o,H @ 0, .l o oo sdvoJ oao H o) o il >tz5lC5l!1 P.IH =13oi lFio, lEta lo3toi1 lC, eh- HE stg <lxot lolo + 9)+(D H r_t(D A,+ (D + oop eFl o lt @5 s o+)3 o o c, o(D v)Fq) -o o\,tr D, o I IN) UJ oo lxrJ, Lo{ lur(Jtlo o\ lo X il - lt.l Jo LoS lLrt5lO -lO X oo ll 9\o s 5t5L^ IL,T NJ IN) X O I o -o6\ UI .5(])(,(a ol@o15 X @(4){(,l o\ o\Ur O. 1Oo\ '!c \ia ts&ll lliJdtr\l sS H}, EE $; *l $il$ ig $$f EFTH B $$ $ E T$ EE tsS Ii r$ sE FS$ s Es $I AR E.E*.>Ea[II E E$ [ 3$s $+ e,l. E' E $$ $E -€.t B5 e^8. IenilL'qB (lAF{. -=.85. EIs:. s. Iis$E}EG t!F { cs. a F E - 8.\E'E o0 ad E = R. H El. 6' hr P LIf o G} : oIC}lo o S n o o ilIa G nC}! d G o G} !t E lo teIH IGII Itr talrr h E Noos Noo(, oo (.r) I NooN oo N I ]\)oo I o 0) I Nooo o!l s(rlN 5(rl @ (,o@ : s H =H!! a.o D tth6>oc-aEQ 8 Zg;'E E-q 5 !, GI oo 5(,N sol@ (,o@ 3H> EEBEd1- 5(, N) 5 Ol(rl 5 @(r) aE*z9 EqB q -Q Ioo s (o so o) s (o frt s AA EE: A H#Et8g Ioo s @ so(.r) s <) srt J s iJt (ts^? >FSg '-ri"# o J @ _(l){(, o) J{ Ju(o(, o) J @ -(,@{s EE$+Eg ! otttr o,+ of J J -(Ot(, J I !\)sN J N -o@ I @ gE> EgBE riE- I N -o(,oo (, -(rlo@(rl o @ irro(,l a tE z{rBg 9. o\(,r o\ s (.) 'm s (,) S N) 1.Oo\ 'JEE ezHe- o6J^< .' EsE TE (D+. JoP(o s 5(o s (,1{ s llas^ ? >!lSC '.rf e-d o N)5 I If project is not achieaing 7OO% geographical coaerage and. o tninirnum of 65% therapetttic coaerage rqte or coaerage rate is fluctttating stqte reclsorls and plan^s being made to remedg this. During the first year of this project (in 2000), all villages were involved in CDTI activities. No REA was done yet. It was in the beginning of year two that REA was done. Following REA results villages that were hypo-endemic for onchocerciasis were eliminated from CDTI, hence the drop in number of villages from 508 to 458. This number of villages further dropped during the third year. This time reason for the drop was the fusion of quarters of villages. i.e. in some places quarters were considered as villages. These were all fused and only villages were counted. During the first year treatment coverage was 37.2oh. Due to side effects, refusals were higher in the second year leading to a drop in treatment coverage (31.8%). In the third year mobilisation, health education, suppression of cost recovery, return to door-to-door mode of treatment and better management of side effects were responsible for the increased treatment coverage rute (65.6%o). Increased mobilisation and better ma.nagement of side effects will be maintained and hopefully this would increase the treatment coverage rate further. 25 Ho l! o q (D I() zo Eoo o I r oa(! ot @ lcl oto @ o 5 q {o ta !J o otrE Fl !! JZ E+iEts+ $[g? gE EEF: Fq3 +f s lt - Ho t! zAE *EEt It sqEO0='tE!la EEE s..9 EL-EOEIEz6;* E_ E'tiT d= B€ O s il FU oE E t! oE Fi 6 TD R(! c ,lz iE EBEox Fl G t Tc (D{6 de(! il i +a(D E (D6 ! Et l, o u ll (Dt! o c(D :n l0 Htrx G h. ::.It .E oq E o : o T oIl il T oI. € a Tt la $ T s oI ? : CI o l(o IO lolo t:II lIIrlo t$Id E IG lgD TI n o :(s o E € i(! a 9.tz E6gtrQo EH9^9ts+dE6 H5A- 5gFt i+olr P.o q9OB E-Eoao5tr rDxa.5 <Ldp0E=.q3 oFttrHrJ6 O 't+ e8 Hs <ooptrd s?oo P$ ,-a (D PO- 9bE{ P6 a. -' .+05cCD ,-, -5p(h -|'aFh5s ,i* 8e ..+ Fl z'R(D rg rdE -+ Ft -.D)a ,+ A) oit oo -t P @o N) o\ Generally the main cause of absenteeism was travelling for diverse reasons (farming, funerals and business). This time drugs will be left in the communities for a longer period to take care of those that travel during the distribution period. 2.8. Supenrision 2.8,1. Supervision of health personnel Supervision of health personnel was done at different levels, depending on activity being carried out. Health district staff were supervised by the provincial and NGDO staff during training / retratning of health area nurses and health area sub-supervisors. Most of these trainings were carried out at the various district health services following their pre-prepa-red plans of action. Another health district activity that was supervised by the province and NGDO was the appraisal meetings that held after the distribution exercise. During distribution of Mectizarr@ the provincial and NGDO staff also did spot checks in some health areas and even villages to see how CDDs were supervised by their nurses and to see how side effects were monitored and managed. These spot checks took place in Mamfe, Mundemba, Ekondo Titi and Fontem health districts. During these spot checks the supervisorsjoined the health area staJf in giving health education to the villages visited and this helped a lot in increasing uptake of the drug. In Mamfe health district for instance the supervision team happened to be in Bachuo Akagbe health area during the National Youth Day Celebrations (l ttt, February 2003). The whole population that came out for the Youth Day celebrations at the ceremonial grounds was addressed and educated on the ongoing CDTI. A very interesting question and answer session followed. Another level of activities carried out by health personnel was the trainings of CDDs and community members. Most of these trainings were carried out at the leading health centres of the health areas. Here the health area nurses were routinely supervised by the health district staff. Occasionally the project co-ordinator at the provincial level made spot checks to problem health centres to witness the trainings and reinforce the training team. Supervisions by health districts were greatly handicapped by the lack of means of transport. Apart from Fontem, no other health district has a vehicle that can be used for supervision. Supervisions carried out by the health district \f,rere generally integrated, though during Mectizarr@ distribution more emphases were laid on CDTI. NGDO supervisions and spot checks were not integrated as NGDO sta-ff are generally not involved in other health programmes. 2.8.2. Superuision of CDDs and distributions Community CDTI activities (those carried out by CDDs within their villages)just like those carried out at the level of the heatth areaand health district were carried out according to pre-made plans of action. After training / 27 retraining of CDDs they carried out registration updates in their different villages. This was then followed by Mectizan@ distribution. Apart from the case of Ekondo Titi Health District where treatment went on for over 5 months, in most villages Mectizan@ distribution generally lasted tor 7 to 14 days. During this period the health centre nurses visited each village daily to supervise CDDs as well as monitor and treat any side effects. During these daily supervisions the nurses took along with them drugs for treatment of minor side effects which they treated on the spot. This year's distribution was door-to-door in most of the villages, as was the wish of the community members. No case of severe side effect was recorded within the whole project area. 2.t.3, How quality of records was ensured During training / retraining of health centre nurses and CDDs recording and reporting was greatly stressed upon. Practical sessions on these were even included in the training programmes. Recordings in the registers (registration / registration update and Mectiz,arr@ distribution) done by the CDDs, were routinely supervised by the health area nurses and occasionally by the district staff. At the end of the exercise the CDDs together with the health centre nurses filled the individual community/village treatment forms. These were then crosschecked during the health a.rea appraisal meetings. Also during supervision and spot checks from higher levels, recording and reporting was one of the points dwelled on. 2.8.4. How the results of supervision were utilized During supervision issues found were dealt with on the spot; weaknesses were pointed out and mistakes corrected. Merits were also given for good performances and strong points. Supervision findings were usually listed out in the trip report, and resolutions made. These then served as action points for improvement of implementation of field activities. 28 SEGTIOII 3: Support to GDTI 3.{. Financlal contributions of the partnens and communlties The table bellow shows the financial contributions of each of the project partners. The main funding partners are APOC and Sight Savers International. These two partners provide direct financial support. The Ministry of Public Health also funds this project but its contribution is difficult to assess. It does not provide direct financial contribution. Its contributions are mainly personnel, infrastructure and "running credits' which are funds for running of all health activities. Last year the Ministry purchased a lap top computer and desk jet printer. CDDs'motivation for the year we are reporting on is to be provided for by funds from the Ministry of Health. At the end of yea.r one activities the project had under spent and over 30 million francs CFA were left in the account. This amount was rolled over into the next year. As a result the amount of funds spent during year 2 exceeded the amount of funds APOC released during that year. In year 2 (2OO1) and year 3 (2OO2l Sight Savers International budgeted additional funds for support of the project. Additional support funds for 2OOl were under spent. This was as a result of the fact that district temporar5r staff on whom part of this money was to be spent were recruited after the year's CDTI activities. So funds meant for paying them were not used. Sta-ff cost borne by SSI for its stalf are also not shown on this table. 29 {o o, l, oo -{ eo -Tt E5 o. oo 3 3c 6'o o6' J.o @L o. o- 6' =q) (tt Lt c,o z o0 o E' 0,f o a @ oo o, =oo th o, = c< o=: J-(/l a o I(D o,) oo = crc oa N(.,(,l 'oglo N(r) -(ri o) Ctl@ crco.{ a(ootsd o. (D q, c--or- =.EB\< =.gH oo 8a1<i6sad N= Eg 8; -! o 9 5 Lo -{ooo 5 Lo _!ooo 3g d (oo\oo (o -o{oo d. @ fr e- o,(,l Or B o(.,o 5 -@ 5o -o N N -o,{o\lLo(o oB =l11 o)!{ o- -{ oN -\t @N TD c.o. -.1 -E & CL o A' fu r'.t E> aE. ON Bq8*3;oo,34qB 6B9G oI 5(., "(.,(., .@I CDo G) -cooo -oooo _o(r,(r) _os o)o (D 3a'd 8. d @ a e N -(., N !.,(.,o (o _o)(r) o) J.)o o,\l N J\) oN o,(,l @ _{ o,(,l _{ Ctr@N o* ^{'n o :/. o. (o J\'5@(o (oNs(O(o g c cL{ ."E & CL I I> 18*p* l' or I c-> 3E !,N €g 5:N oo8<oo' =oor= !P nrNg 9.5N No 'or o -5 Ot J$ o) o) -(oAo -(,l(os _5 --l(,lo $E. d I d. @ fl E N .CD @ -oo @(,r -- o _(,l('l(I, o, -(rio@ _o)o(o(O (D. C) iD-' = 'Tl o !L o- HB G F.\) TI trIllta. F R o oI$ t&B sC}d. o Th B(s p HR! arr G}I o il b .t CT i G i ob G} G} d il G lc G n il tr)o If problems are being encountered in getting counterryrtfundingwhat plans are being made to address the situation Government funding is being advocated for from the Ministry of Public Health and the HIPC initiative. Requests are being made for a budget line to be created at the district and provincial levels for onchocerciasis control activities. This has started yielding fruit as last yetr the Ministry of Public Health purchased some equipment for the project. !.2. Other forms o,f communlQr support Describe (indicateforms of in-kind contributions of communities if any)a Generally there is little or no community support of this programme. Very few villages provided food to the CDDs while carrying out their activities. It has been very difficult to make the community understand and actually take the project as theirs. Despite the amount of sensitisation carried out all through it has still not been possible making the community members providing substantial support to the programme. We hope with sustained sensitisation this will be achieved gradually. 3.3. Go6t per activityl - Indicate the cost o/the activities below in US dollms using the curuent United Nations exchange rate to local currency Tablc 73: thoutlrtg prcteci expendldtre per c,L4foltg ltstcd o Comments Much was not spent on Mectizan@ delivery to the community. What went on this year was as follows; drugs were collected from WHO Yaounde premises after being signed out by the NoTF. These drugs were then taken to SSI country oflice in Yaounde from where they were transferred to the provincial Activity Ertimatcdcort($US1 AFOC ssr Drug delivery from NOTF HQ to central collection pgi4l of tle communit5r 100 Mobilisation and health education of communities and IEC materials L,742 1,833 Training of CDDs 2,262 Training of health staff at all levels 8,233 3,384 Supervising of CDDs and distribution - treating hard to reach communities (Lm loa testing and Mectizan distribution) 6,256 5,707 8,212 Internal of CDTI activities tt,526 13,091 visits to health and authorities Total 27,?p,f, 35,137 Crtand Totd 62,3,46 3l delegation of health in Buea. At the provincial delegation the drugs were kept by the provincial co-ordinator. The DMOs then collected consignments for their various districts when they came for a routine (not CDTI) meeting at the delegation. Supplementary quantities were supplied the districts by the provincial co-ordinator during supervision visits. Supplies from the province to the communities were not paid for as such. Supplies were always linked to an activity that was sponsored already. Advocacy visits to health and political authorities was budgeted for under mobilisation and health education, and expenditure was made as such. SEGTIOI{ 4: Sustalnabltlty of GDTI 4.11. lnternal; independent partlcipatoryr monitoring; Evaluation If there has been an operational research carried out within the project area, please describe how the results have been applied This project has never benefited from an operational research but internal evaluations are carried out each year. Highlight the recommendations of the most recent internol or independent participatory monitoring or evaluation of project sustainabilily and describe the extent to which they have been implemented. The project however had a mid term sustainability evaluation this year. The recommendations made as well as their level of implementation so far are as follows: Tablc 14: Shorlag Recommendrtionr of thc mid-tcrm surtelaebility cvaluatlon rnd thcir lcvcl of implcmcntetlon Recommendetioa Lcvel of lmplcmentatlon Plannina The Province should draw the attention of all CDTI partners (communities; NGDOs; APOC and MOH), to their roles based on the proposal document and lessons learned to date in the implementation of CDTI. All health districts should have comprehensive work plans showing that CDTI is integrated into the ottrer health programs of the district Census taking and distribution of Mectizan by CDDs should be undertaken during the same period. Immediate action should be taken by project to improve the participation of communit5r leadership in assisting.lCDDs to mobilise and educate members. This has been done already. Already done (April 2003) To be addressed from when year four activities commence. However a few CDDs use this method in their villages Leadership District Health Management Tearns should immediately retrain health area sta-ff and empower Usually action plans are prepared during appraisal 32 them to prepare and implement their own action plans according to the needs of the communities in their catchment areas. Communit5r leadership should be urgenfly be visited and empowered about their roles and responsibilities in CDTI. They should understand the communities have the powers to select CDDs and change those not performing well. Communities should decide the timing and method of distribution. meetings of the preceding year. They are done at each level. Fourth year training will pay particular attention to this. Monitorino and sp erui,ston There should be an element of quality assurance in place as a mechanism for assessing tlle skills and quality of performance of the Districts level stalf following training activity. All transmission of reports should be paid for with funds from the goverrrment partner and the communit5l. Integrated superwision check list should be established and utilized in atl health districts Mectizan@ requests and supply should be based on FLHF and community requests, which in turn should be based of census records. The project should devolve tlre pa5rment of the DTS to the govemment partner to ensure efficiency and sustainability of the process. From the fourth year of prograrn implementation, health area sta-ff should be trained to carry out supervision of CDTI in an integrated manner. DMOs should routinely send letters of commendation to chief of posts and communities. To sustain the interest of CDDs, project should sensitise communities to provide adequate support to their CDDs Still to be done Mectizan@ requests are usually based of census figures which emanate from data from FLHF. DTS are not permanent staff, neither are they government employed. They only senre as back up for the deficiency in health stafl in our healt]r facilities. Dwolving their payment to the government will be dilfrcult as they are not government employed. Also the ministry of health has started employing addition personnel. When this exercise is over there may be no need to have DTS within the project. Being done already. Needs to be intensified Medizan@ hocurement and Di,stribution It is recommended that the NOCP should ensure that the procurement, storage and timely delivery of Mectizan@ tablets be done within the existing health systenqs from the national level to the entire project Arangements have been made (July 2OO3)with the Drug prograrnme in Buea so that Mectizan@ is procured JJ areas. Secondly, a standardised method of Mectizan@ requirements estimation should be stricfly followed. The duration of distribution should be extended in all communities. Mectizan should be left with CDDs for about two weeks after the community distribution in order to allow enough time for absentees to receive treatment. This recommendation will improve treatment coverage. and delivered like other essential drugs in the province. This will take effect as from the next round if Mectizan@ distribution. From year four of Mectizan@ distribution this will be done. Tlainirw and HSAM HSAM should be intensffied at district level. The district management teams should empower tJre FLHF to identi$z training needs Health education, sensitization, mobilization and communication messages should provide communities with specific information to deal with identified problems. In ttre fourth vear proiect manaeement should tarqet traininq of chiefs of post. The educational background of the chiefs of post should be considered in planning targeted retraining sessions. To strengthen HSAM, community and social mobilisation officers and health educators should be co-opted to assist tJ:e project and improve the effectiveness of HSAM on the benefits of long-term compliance and ownership of CDTI. The practice of intensified health education strould continue and strengthened. Health education, sensitization and mobilization materials should be made available in sufficient quantity to support the work of chief of posts and CDDs in mobilizing communities. This will be particularly considered during this oncoming fourth year of activities. Social mobilisation agents were used during the third year and this is probably one of the contributing factors to improved treatment coverage. Financinq The evaluators are concerned t]'at the Government has not fulfillsd her obligations as highlighted in the project proposal and the endorsed letters of agreement for the project implementation. It is recommended ttrat government take action to comply with the obligation to ensure sustainabilit5r of CDTI whose success is of great importance to the people of Carneroon. Government funding of CDTI activities should increase. A budget line for CDTI should be created at this level Though still small government's direct financial contribution to this project has started coming. Advocating for increased financial support from the government needs to be intensified. 34 NOTF should urgenfly sensitise the national, provincial and district governments to immediately assume their appropriate responsibilities. Governments should cover the costs of Mect2an@ procurement and delivery to health areas, supervision, advocacy and transmission of reports to districts. Immediate changes a-re necessary in order for communities to appreciate the tasks of CDD as their own responsibilities. The Provincial delegate and NGDO partner should as a matter of priority organizn the health personnel at districts and health area levels and embark upon immediate sensitization of the leaders and communities on the responsibilities as the lead partner in CDTI. This is very crucial for sustainability of long-term treatment. The present complicated financial management of APOC funds should be simplified as follows: . The project should have its primary Bank Account in the town where the project is located or the nearest convenient location where funds can be withdrawn easily. The Delegation team (MOH) should take full control of the day-to-day management of APOC funds, while the facilitating NGDO is expected to provide the needed technical support and financial control. The NGDO should remain a mandatory signatory to all cheques. a a The present Finance Oflicer being paid with APOC funds under technical assistance should relocate to the project office in Buea and work under the direction of the Provincial Delegation (MOH). This arrangement should continue until the delegation is in the position to absorb the Finance Officer. This is usually done during training and re-training sessions that go on yearly. It will be reinforced this year. An account for the project has already been opened at BICEC bank Buea. The account at Standard Chartered Bank in Yaounde is in the process of being closed. The APOC finance oflicer has already assumed duty at the provincial delegation of health Buea. 35 Tlansport and othq Materiol Resources To ensure sustainability of CDTI, government and APOC should ensure replacement of transport before APOC support ends. Log books should be used routinely in all districts and they should contain routine maintenance schedule in order to extend the life span of the vehicles. Necessar5r health education materials should be made available in all districts in adequate quantities From the fourth year of implementation, district funds should be used to support travel costs of chief of posts for the collection of Mectizan from the districts. This needs to be done and reinforced. Adequate IEC materials will be made available but time next year's CDTI activities take off. This will be advocated for as from the oncoming fourth year. Human Resources Provincial, District and Health Area staff should be trained on community sensitization and mobilization. And this includes utilization of IEC materials. This is an essential ingredient to irnprove treatment coverage. Appropriate and suflicient number of training and HSAM materials should be made available to health areas before the next distribution to enhance the efforts of chief of posts, and sustain communit5r interest in taking Mectizan that seem to have been achieved only during the last distribution The ratio of CDDs per population should be reviewed and ratilied before the next treatment. Communities should be encouraged to select as many CDDs as possible so that one CDD will treat a m€udmum of 5O people and their work reduced to 2- ! !qys. CDDs should also work in pairs. Community sensitization is usually an important component of the yearly re- trainings that take place at the onset of CDTI activities. This will continue to be done yearly. The communities will be asked to select more CDDs so as to reduce their workload Coueraqe Coverage has been generally low since the project inception, although the third year has seen improvement over the first two years. The level of coverage should be raised and maintained to ensure maximum benefit to the eligible population. Therapeutic coverage rate should increase to at least 657o in all communities of t] e health district. Geographic coverage should increase to 1007o in all the health districts The duration of distribution in communities is of concern and should immediately be reviewed upwards to the range of 4 weeks, to reflect APOC CDTI guidelines and the wishes of the communities. Therapeutic coverage has improved considerably during this third year. This needs to be maintained. Geographical coverage is at IO0P/o and needs to be maintained too. 36 4.2. GommuniQr self-monitoring Tablc 75: Up scallng Communltg self-monttortrtg Describe how the results of the community self monitoring and stakeholders meeting have affected project implementation or how they would be utilized during the next treatment cycle. Apart from in Fontem health district community self monitoring and stake holders meetings were carried out in no other place. Even in Fontem where it was done, it was more like an activity imposed on the community. They still need to understand the importance of self monitoring. Results of this activity have therefore not affected project implementation significantly. Before onset of year four activities the health district and health area staff will have to be refreshed in the whole activity. 4.3. Sustainabtlity of proiects: plan and set targets South West Two Project is at the end of its third yetr. APOC funding is still expected for two more yea.rs. Nevertheless the following sustainability plans have been made for the project;i) Fltndirry: Government funding during the post APOC funding period will be from government "running credits" of the different health facilities. So far some funding from the government for CDTI activities was made available last yetr from special disbursements of the Ministry of Public Health, used for the purchase of a computer and printer. Plans are also underway for extra funds to be mobilised from the Highly Indebted Poor Country (HIPC) Initiative. Budgets for HIPC initiative funding have already been submitted to the Ministry of Public Health for year 4 activities.ii) Tfar*port: No plans have been made yet for replacement of existing means of transport yet. However maintenance and repairs will be done with funds provided by the goveflrment for running of the health facilities.iii) Otlrcr Sources of Funding: Funding from SSI will still be avaitable but would not replace APOC funds. Most of the financial support will have to come from the Ministry of Public Health and the community.iu) Sustainabilitu Plan: South West Two Project had a sustainability evaluation in April this year. At the end of the evaluation Health District Totd # of communities/villages in the meso/hyper-endemic areas No of Communities that carried out self monitoring No of Communities that conducted stakeholders meeting Akwaya 79 0 0 Ekondto Titi 36 0 0 Fontem 116 135 ll6 37 Mamfe 0 0 Mundemba 89 0 0 TOTAL 455 116 37 37 sustainability plans were drawn up by each of the five health districts. Copies of the sustainability plans are attached to this report. The plans are still to be implemented in their entirety when year four activities effectively take off later this year. 4.4 lntegration Outline the extent of integration of CDTI into the PHC structure and the plansfor complete integration So far CDTI is being integrated in the minimum package of health care activities at all levels. This integration is however not complete yet as some health sta-ff still find it difficult integrating CDTI activities with other community health activities they carry out. At the provincial and district levels supervisions are fully integrated. Although trainings are not fully integrated yet, during CDTI trainings information on other health programmes was occasionally passed on to the trainees. Fully integrating trainings may confuse the trainees, considering the level of health staff we have in our health facilities. Also this may pose a problem as different health programmes have different focal persons with different plans of action. Describe other health programmes that are using the CDTT structure and how thiswas achieved. lthat hove been the achievements. Other health programmes like measles and polio immunization campaigns make use of both human (CDDs) and material resources (vehicles) put in place by CDTI but the programmes are not community directed. Instead they are health intervention programmes. So far the achievements of these other progra.mmes have been good. \ 38 SEGTIOII 5: Discussion, Gonclusions & recommendations Discuss the strengths andweaknesses of CDTI implementation process. South West Two CDTI Project has just rounded up its third yetr activities. Compared to the preceding two years this year's performance has been good. Activities were better carried out and treatment coverage rate has increased considerably. Merits should go to this programme as it has brought to light the fact that the community could be made to take interest and take care of issues concerning their health. It is a leading project as far as community activities are concerned. Through this project interaction of health personnel and the community has been greatly increased. This has greatly facilitated implementation of other community health programmes. CDDs who are the main CDTI field actors are now used not only for CDTI but for other community health programmes like the oNational Immunization Days against poliomyelitis" and "Measles elimination programme'. Thanks to the CDTI project transport facilities have greatly improved in the project area. Apart from making available a four wheel drive vehicle at the provincial level, every health area with a motor-able road has at least a motorcycle to boast of. These vehicles are not only used for CDTI but for all health programmes within the province. CDTI has rekindled the spirit of project planning and budgeting which had almost died out since the withdrawal of GTZ support to health activities in the province. More and more people are becoming aware of the importance of treatment with MectLan@ as they notice improvement in poor vision, improvement if skin infections and elimination of intestinal worms and lice. As weaknesses, this project has never been able to fully function within the limits of its planned period. Some communities still do not see the importance of their full involvement in matters that should, according to them concern only health care professionals. This is probably one of the reasons why their involvement in CDTI activities is lower than expected. CDTI activities are very involving and have a lot of paper work. 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