Extension CDTI project technical report submitted to Technical Consultative Committee (TCC): January 2010 to December 2010

IORIGINAL : Enslish COUNTRYAIOTF: MALAWI Proiect Name: EXTENSION Approval year:1999 Launching year: 2000 ReportinsPeriod: From: JANUARY,2010...To: DECEMBER, 2010(Month/Year) ( Month/Year) APOCfundinsyear: (circleone) I 2 3 4 5 6 7 8 2 l0 11 12 13 APocProiectimplementationvearreport: (circleone) I 2 3 4 5 6 7 8 9 10 11 12 13 Date submitted: 3-lst Jonuory,2011 Partners: - Ministry of Heolth (MOH) - Africon Progromme for Onchocerciosis Control (APOC) - Mectizon Donotion Progrom (MDP) - Sightsovers - Teo Esloles Associotion (TEA) - 1,514 communilies -'t " : i !i ANNUAL PROJECT TECHNICAL REPORT !i SUBMITTED TO i **"m TECHNICAL coNSULTATIvE coMMITTEE (TCC) h{srmotton ,Nin seA DE ANLINE BOR SUBMISSION: To APOC Management by 31 Januarv for March TCC meeting To APOC Management by 31 Julv for September TCC meeting AFRICANPROGRAMME FOR ONCHOCERCTASTS CONTROL (APOC) RECU LE 3 I JAt{. APOC 20fl / DrR WHO/APOC, 14 September 2009 ANNUAL 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: Countr5i: MAIAWI NOTF Chairman Name: Dr S. Kobuft.zi Signature: -8=-t Date: ......). l..l ., /::t , NGDO Representative Name: Mrs Mercy Mosoo Signature: . g*.-.9.. ..... ... Date: .3rfct /acti.... This report has been prepared by Name : Loston Stflmo Coordlnotor WHO/APOC, 14 September 2fi)9 a I I , )t l" i WHO/APOC, 14 September 2009 a t I a 0 It a Table of contents ACROr{YMS........... ...................... V DEFrNITIONS......... .....................VI FOLLOW UP ON TCC RECOMMENDATIONS .........1 EXECUTM SUMMARY........... ...................2 SECTION 1: BACKGROUND INFORMATION....... ......................3 1.1. GeNpRAr- INFoRMATroN............. .........3 1.1.1 Description of the project (brie/ly). .................. -? 1.1.2. Partnership ...............5 1.2. Popur-auoN............... .......6 SECTION 2: IMPLEMENTATION OF CDTI....... .......7 2.1. Trvpr-iNp oF AcrrvrrrEs ............ .........7 2.2. Aovocncv ..................... l0 2.3. MogrLIzerIoN, SENSITIZATIoN AND HEALTH EDUCATIoN oF AT RISK coMMrxrrres l0 2.4. Cotr,tNacD.ttry INVoLVEMENT......... ..... 11 2.5. Cepecrrv BUTLDTNG.. ...... 13 2.6. TRrarueNTS.............. ..... 16 2.6.1. Treatmentfigures.......... ........... 16 2.6.2 What are the causes of absenteeism?.......... ..................... 18 2.6.3 What are the reasons for refusals?................ ................... 18 2.6.4 Briefly describe all lcnown and verified serious adverse events (SAEs) that....... l8 2.6.5. Trend of treatment achievement from CDTI project inception to the current year 202.7. ORoeRmG, sroRAGE AND DELTvERv oF TvERMECTTN............... ..............21 2.8. CoNaNar-rNury sELF-MoNrroRrNG eNo SrnreHoLDERS MnerrNrc ............22 2.9. SupBRvrsroN............... ......................23 2.9.1. Provide oflow chart of supervision hierarchy. ............ 23 2.9.2. Wat were the main issues identified during supervision? .............................. 23 2.9.3. Was a supervision checHist used? ............. 23 2.9.4. Wat were the outcomes at eoch level of CDTI implementation supervision? 23 2.9.5. Was feedback given to the person or groups supervised?232.9.6. How was the feedback used to improve the overall performance of the project? 24 SECTION 3: SUPPORT TO CDTI ..............24 3.1. EqureueNr .....................24 3.2. FrNeNclRt, coNTRrBtJTroNS oF THE pARTNERS AND coMMrINITIES...... ... .. .. ,..25 3.3. OrHBn FoRMS oF coMMr-rNrry suppoRT............... ................29 3.4. ExppNprruRE pER AcTrvrry .............29 SECTION 4: SUSTAINABILITY OF CDTI....... ..........29 4.1. INreRNel; TNDEeENDENT pARTrcrpAToRy MoNrroRrNc; EvnluerroN.......... ..........29 4.1.1 Has the project ever been evaluated/monitored? Qick any of the following which are applicable) ........ .. ............ 29 4.1.2. What were the recommendations? . .. . . . .. 29 ur WHO/APOC, 14 September 2009 4.1.3. How have they been implemented? ............. ................. 304.2. SusrarNestLITY oF PRoJECTS: ILAN AND sET TARGETS (MANDAToRv AT................ 30 Yn 3) ....... 304.2.1. Planning at all relevant levels.. .................. 304.2.2. Funds....... ............... 30 4.2.3 Transport (replacement and maintenonce) . . ........ 3l4.2.4. Other resources ...... 3l4.2.5. To what extent has the plan been implemented................ .............. 3l4.3. INrecRarroN............ ......314.3.1. Ivermectin delivery mechanism.r............... ................... 3I4.3.2. Training.... ..............314.3.3. Joint supervision and monitoringwith other programs........... ...... 3t4.3.4. Release offundsfor project activities ........314.3.5. Is CDTI included in the PHC budget? .............. ........... 324.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements?............. .................... 324.3.7. Describe others issues considered in the integration of CDTL ..... 33 4.4. OppnerroNAl RESEARCH .....37 4. 4 . L Summarize in not more than one half of q pqge the operational research undertaken in the project area within the reporting period. ........ 374.4.2. How were the results applied in the project?............. .. . . . . ....... 37 SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, AND 0PPORTUNITIES.... ................... 37 SECTION 6: UNIQUE FEATURES oF THE PROJECT/OTHER MATTERS...........38 I a lv WHO/APOC, 14 September 2009 oAcronyms APOC African Programme for Onchocerciasis Control ATO Annual Treatment Objective ATrO Annual Training Objective CBO Community-Based Organization CDD Community-Directed Distributor CDTI Community-DirectedTreatmentwithlvermectin CSM Community Self-Monitoring LGA Local Govemment Area MOH Ministry of Health NGDO Non-GovernmentalDevelopmentOrganization NGO Non-Governmental Organization NOTF National Onchocerciasis Task Force PHC Primary health care REMO Rapid Epidemiological Mapping of Onchocerciasis SAE Severe adverse event SHM Stakeholders meeting TCC Technical Consultative Committee (APOC scientific advisory group) TOT Trainer of trainers UNICEF United Nations Children's Fund UTG Ultimate Treatment Goal WHO World Health Organization CMS Central Medical Stores DEC District Executive Committee DEHO District Environmental Health Officer DHMT District Health Management Team DHO District Health Officer DOC District Oncho Coordinator GVH Group Village Headman HSAs Health Surveillance Assistants TA Traditional Authority TEA Tea Estates Association SWAp Sector Wide Approach WHO/APOC, 14 September 2009 Definitions (i) Total population: the total population living in meso/hyper-endemic communities within the project area (based on REMO and census taking). (ii) Eligible population: calculated as 84%o of the total population in meso/hyper- endemic communities in the project area. (iii) Annual Treatment Objective: (ATO): the estimated number of persons living in meso/hyper-endemic areas that a CDTI project intends to treat with ivermectin in a given year. (iv) Ultimate Treatment Goal (UTG): calculated as the maximum number of people to be treated annually in meso/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 ofthe project). (v) Therapeutic coverage: number of people treated in a given year over the total population (this should be expressed as a percentage) ("i) Geographical coverage: number of communities treated in a given year over the total number of meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage). (vii) Integration: delivering additional health interventions (i.e. vitamin A supplements, albendazole for LF, screening for cataract, etc.) through CDTI (using the same systems, training, supervision and personnel) in order to maximise cost- effectiveness and empower communities to solve more of their health problems. This does not include activities or interventions carried out by community distributors outside of CDTI. (viii) Sustainability: 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 communify ownership, using resources mobilised by the community and the government. (ix) Community self-monitoring (CSM): The process by which the community is empowered to oversee and monitor the performance of CDTI (or any community- based health intervention programme), with a view to ensuring that the programme ' is being executed in the way intended. It encourages the community to take full responsibility of ivermectin distribution and make appropriate modifications when , necessary. vi WHO/APOC, 14 September 2009 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 30 Number of Recommendation in lhe Report TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROTECT FOR TCC/APOC MGT USE ONLY 198 Conduct the planned training of CDDs and others on record keeping, which has implications on the ordering of drugs and monitoring programme performance During this year's planning meetings with the CDDs and health workers, record keeping was stressed to avoid any errors which were encountered during 2009 implementation YCfIT The team should implement CSM and SHM Refer to section 2.8 on CSM. Malawi has stirted implementing CSM in this implementation year whilst SHM have always been implemented The team should be encouraged to document its experiences of co- implementation Refer to section 4.3 on integration WHO/APOC, 14 September 2009 Executive Summary Prepare an Executive summary of the report in not more than one page. The National Onchocerciasis Control Programme has been carrying out Ivermectin Distribution in the Extension project since 2000. The Extension project covers 5 districts of Chikwawa, Blantyre, Phalombe, Mulanje and Chiradzulu. In the 2010 implementation year, a total of 942,356 persons were treated out of the population of 1,148,270 people representing a treatment coverage of 82.lYo. All the 1,514 villages targeted were treated representing a I00% Geographical coverage. The Project's Ultimate Treatment Goal (UTG) and Annual Treatment Objective (ATO) was 964,547 people and Annual Treatment Objective (ATO) coverage rate was 97.7%. The people of Phalombe, Mulanje and Chikwawa move in certain seasons of the year. The three districts share an intemational boundary with Mozambique. During the rainy season, the people of Mulanje and Phalombe who are along the border move to Mozambique to cultivate. These people have farmlands in Mozambique where they grow different crops for their livelihood. They stay there from planting period till they harvest their produce. People of Chikwawa who are near the Shire fuver move to the banks of the river during the dry season to grow different crops for their livelihood. During the reporting year, a total of 2,090 Health Workers and 9,157 CDDs were trained, however, 10,038 CDDs were involved during the mass drug administration representing I CDD to a population of 114 people. The most notable challenge that was experienced during the implementation year was high transport cost of the drug charged by the Central Medical Stores (CMS). This challenge was addressed through the program arranging and transporting the drug to Blantyre DHO Pharmacy where all the CDTI districts were collecting the drugs from. WHO/APOC, 14 September 2009 SEGTION {: Background information 1.1. General information 1.1.1 Description of the project (briefly) The Malawi Extension project covers 5 districts of Chikwawa, Blantyre, Phalombe, Mulanje and Chiradzulu. The Extension zone shares the eastem and south western intemational boundary with Mozambique. On the eastem border with Mozambique lies Phalombe and Mulanje districts. Chikwawa lies in the south westem boundary with Mozambique. Blantyre district lies to the North of Chikwawa whilst Chiradzulu lies to the western side of Phalombe. Most of the endemic areas are hilly with difficult terrain. This makes them easily accessible only during the dry season however during the rainy season, access is with difficulties. The numerous small and large rivers emanating from the mountain ranges provide good breeding sites for the blackflies ( Refer to Fig 1 on Page 4 - Map of Southern Region of Malawi showing CDTI Districts). Phalombe, Mulanje and Chiradzulu are dominated by Lomwe tribe whilst Chikwawa is dominated by Sena and Mang'anja tribes, Blantyre has got mixed tribes and there is no tribe dominating over the other. The district is inhabited by Ngoni, Sena, Yao, Lomwe tribes among others. [n all the districts, there are other tribes like Yao, Mang'anja apart from the dominating tribe. In the Southern Region of Malawi, i.e. including the Extension zone, the main rainy season lasts from November through March. Additional light rain usually falls between May and July. The peak farming season begins in September and ends in April. The climate in Mulanje is favourable for tea plantations thus why the presence of large tea estates. Administratively, Malawi is divided into three regions namely South, Centre and North with twenty-eight districts. The districts vary in population, geographical and socioeconomic factors. The local community is mainly a village set up which follows a corlmon clan ancestry and /or a similar cultural grouping. The village is headed by a Village Headman who may have several assistants or advisors mainly elders of his clan. In some areas, several households belonging to one village could be scattered over several kilometres. Several villages could be grouped together under one Group Village Headman (GVH). The highest ranked ruler is the Traditional Authority commonly called the T.A. whose authority covers a geographic zone in a district encompassing several GVHs. The TA is a very powerful and respected traditional ruler. In the majority of the tribes there is gender equality in the inheritance of headship (chieftaincy). According to the 2008 Population and Housing Census, the country's population was estimated to be more than 13 million with most of it in the Southem Region. On health care system, Malawi has a three-tier health care delivery system: primary, secondary and tertiary levels ofcare. The integrated health delivery system at the district level is managed by the District Health Management Team (DHMT). The main function of the DHMT, which is headed by the DHO, is to coordinate the provision of promotive, preventive, curative and rehabilitative services and to ensure that sufficient resources are available, and that they are used effectively and efficiently. WHO/APOC, 14 September 2009 Since Malawi underwent a decentralization process, the regional health offices were abolished and this led to the creation of Health Zones (five Zones; the southern and central regions have 2 zones each while 1 is in the Northern region). T}te Zonal Officer is the in charge of the Health Zone which is comprised of several district hospitals whose in charges are District Health Officers ( DHOs ). At district level, there is one district hospital which is headed by a DHO as earlier indicated. From the District Hospital, there is either a health centre or a Rural Hospital. Then Health posts follow the Health Centre/Rural Hospital. Communities access medical treatment at each public/Government health facility free of charge. Regarding health facilities in the CDTI area, there are a total of 17 health facilities including the district hospital and 18 Estate clinics in Mulanje District, Phalombe district has 2 health facilities, Chikwawa district has 7 health facilities, while in Chiradzulu district, there are 5 health facilities and there are 20 health facilities in Blantyre. In 2010 implementation year, all the 1,906 health workers who are directly or indirectly involved in CDTI area were involved in CDTI representing 100% involvement. The health workers who are involved in CDTI according to Malawi are the Environmental Health Officers, Clinicat Officers, Medical Assistants and Health Surveillance Assistants (HSAs). Fig. I : Map of Southem Region of Malawi showing CDTI Districts 4 Mozambique WHO/APOC, 14 September 2009 7 / \..r'I Table 1: Number of health staff involved in CDTI (Please add more rows if necessory) District Number of health staff involved in CDTI activities. Total Number of health staff in the entire project area B, Number of health staffinvolved in CDTI B, Percentage Br=Bzl Br *100 Blantyre 956 956 100 Phalombe 42 42 100 Mulanje 415 415 100 Chikwawa 94 94 100 Chiradzulu 399 399 100 Total 1,906 1,906 r00 L.1.2. Partnership Both local and international partners are involved in CDTI implementation. The local partners comprises of the Ministry of Health ( MOH ), Sightsavers, Tea Estates Association of Malawi (TEA), the World Health Organization ( WHO ) and the communities. The international partners include the African Program for Onchocerciasis Control (APOC) and Mectizan Donation Program (MDP). The local partners are involved in various CDTI activities such as planning, supervision, advocacy and mobilization, attending NOTF Meetings, funding CDTI activities such as trainings. For the past l0 years, the tea estates in Mulanje district have actively carried out treatments on their establishments. Mectizan distribution on the Tea Estates is carried out by volunteers who are trained by the Estate Clinic Health personnel assisted by the District Onchocerciasis Coordinator (DOC). The estates fund the training of the health workers and the volunteers. APOC provides both financial and technical assistance while MDP donates ivermectin for MDA to all at risk communities. It is planned that other NGDOs would be mobilized to assist in CDTI implementation. WHO/APOC, 14 September 2009 o\ oN Lo -o q) o.() a$ o A.{ o > \o Ebb E'Eo.-E A.-() =os cB'a € +i O{O=orf; sEE. 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Timeline of activities Fill in table 3, timeline of activities for areas treated in curuent year, indicating when the key activities were implemented by the month they began and the month they ended. 7 WHO/APOC, 14 September20}9 o\oo o'l kq) .o og(l) a $ U or{ B A o aht €)e a o +oEE (J k C) ,.otr oo(l) a Lo -o (l) o.(l) a H C)! oooo Ho! (l) o z C) -oo o o .Hs 1i E 6: C) (B GI Lo. op o o.o v) Eo E l- o1 at L a o o.= eEo- U Lop tr 6) z Lo -o Q o.(.)a L 0)so a o -oo o o k C) o o aoEE d= aE r(l) -o C)q(.) a bo () .o () o.()a Hos c.) o. o) a L()p o o. C)a c) GI o 02 01 q)() o o.= EE o Q 0.) c) d z UDCE 1iE cs! a- (l) tr b (d o. Lo bt tr 6lL3 o 9: eE U k C) -o o o.() U) ko -o oq oa L(l) -o oq o Ch q oo aoEE d= o o a oo o (: v4' -€) .EH 6g=N;r oor-()a EE U Iq) o o z 0 dI) H C) -o oq(.) a kq) .o o o o ko E(.) p. a)a b!tE a- (.) k o. I L (r, l-'a 0.)lr >. tr(s o 0.) -o o (O oi o ) z (s B(B Bjl U N cnlr U -:\ v Uaq uq) q \ \)t\ E a)q sq) 5 Lr(t (.) >. 0)trLr)o (.) 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2.2. Advocacy State the number of policy/decision makers mobilized at each relevant level during the current year; the reason(s) for undertaking the advocacy and the outcome. Describe difficulties/constraints being faced and suggestions on how to improve advocacy. During the year, two major advocacy activities were carried out by the National level. The first activity was meetings with District Health Management Teams (DHMTs). The objective of the meetings was to solicit the DHMT's support towards the funding of CDTI activities. The DHMT's were requested to increase financial support to the control of onchocerciasis. The activity managed to solicit support of the DHMT in financial contributions to CDTI activities. The second activity was advocacy to Tea Estates Association (TEA). The main objective of this meeting was to bring awareness to the TEA personnel. The TEA personnel responsible for Public relations was new, therefore, need to meet the officer. Issues of onchocerciasis control and NOTF were discussed. TEA, during the year has been attending NOTF Meetings regularly after the advocacy than before. During Estate Managers meetings, the TEA personnel was able to brief the managers about onchocerciasis and the benefits of their workers being treated with ivermectin. As a program, the activities were successful and hope to build on the experience to continue to advocate for the participation of other stakeholders. At district level, advocacy was targeted to influential leaders depending on the level. Meetings were held at District Assembly headquarters, during District Executive Committee (DEC) meetings, in churches, village headman headquarters for this purpose. The main objective of the meetings was to solicit the leaders' support during the MDA so that their subjects are treated. 2.3. Mobilization, sensitization and health education of at risk communities Provide information on: - The use of media and/or other local systems to disseminate information - Mobilization and health education of communities including women and minorities - Response of target communities/villages - Accomplishments - Suggest ways to improve mobilization and sensitization of the target communities. In addition to the information provided on advocacy, districts took charge of disseminating messages about Onchocerciasis. The Community structures were actively involved in the mobilization of the public. More emphasis was put on the need to participate during the 2010 MDA which included mectizan and albendazole. Drama performances, town criers and meetings were used to disseminate information. These meetings were being conducted by different personnel at different levels such as 10 WHO/APOC, 14 September 2009 the community, health center, outreach clinics e.t.c. IEC materials such as posters, leaflets were used in sensitization. Health education sessions were also carried out in Out Patient Departments (OPDs) of health facilities. It should also be pointed out that during mobilization of communities on the need of conducting Community Self Monitoring (CSIYI), communities were sensitized about the year's MDA and the need that everyone in the communities be treated. Intensive mobilization, sensitization and Health Education has assisted to maintain a treatment coverage of more than 807o since 2005. For a successful mobilization to be realized there is a need to involve influential leaders such as village headmen, politicians. Different structures and opportunities such as funeral gathering, political gathering could also be used to bring awareness to the communities on the need for treatment. 2.4. Gommunity involvement Table 4: Communities participation in the CDTI (Please add more rows if necessary) Please, note that the health system in Malawi does not have community supervisors, however, there is a cadre of Health Surveillance Assistants (HSAs-Government employees) who provide supervisory role at community level. Comment on: - Attendance of female members of the community at health education meetings - In general, how do you rate the participation of female members of the community meetings when CDTI issues are being discusses (attendance, participation in the discussion etc). - Incentives provided by communities for the CDDs - Attrition of CDDs. Is attrition a problem for the project? If yes, how is it addressed? - Other issues ll District Number of communities/villages with community members as supervisors Number of CDDs and the communities involved Number of communities /villages with female CDDs Total no. communities in the entire project area B, Number with community members as supervisors B. Percentage Be= BJ B. *100 Male CDDs B, Female CDDs B. Total Bo= Br*Bo Number of communities with female CDDs B," Percentage Brr= B'JB,*100 Blantyre 627 0 0 1,536 2,779 4,315 618 98.6 Phalombe 62 0 0 208 192 400 59 95.2 Mulanje 369 0 0 956 2,030 2,986 369 100 Chikwawa 128 0 0 424 313 737 lll 86.7 Chiradzulu 328 0 0 672 928 1,600 328 100 Total 1,514 0 0 3,796 6,242 10,038 1.485 98.1 WHO/APOC, 14 September 2009 During health education meetings, more female members attended the meetings than males. This is also the same in most of the activities. This is so because some male members go out to work or business. However, during discussions, male members participate more than females. This is so because of cultural background where females are not supposed to talk much in the presence of males. As of now, no monetary incentives have so far been provided to the CDDs by the community, but in kind incentives are given to the CDDs. Sometimes CDDs are offered bicycles by community members to collect drugs from either a health facility or a health worker. However, the CDDs get incentives from other health related programmes such as growth monitoring, HBC, net re-treatment campaign and child health days campaigns and these keep them motivated on health issues generally. Attrition of CDDs is not a major problem, however, in a few cases attrition of CDDs comes about due to transfers of CDDs to other areas for employment and marriage. Replacement of CDDs is done once attrition has occurred. t2 WHO/APOC, 14 September 2009 2.5, Gapacity building - Describe the adequacy of available knowledgeable manpower at all levels. Knowledgeable manpower is adequate at all levels except the National level where there is only the National Coordinator. At district level, there are more newly employed supervisors( TOTs) being deployed at that level. At community level, the Ministry is continuing to employ Health Surveillance Assistants (HSAs) to meet the target of I HSA to serve a population of 1,000 people. The increase in number of HSAs would enhance superuision of CDDs since the HSAs are based at community level and they are the supervisors of the CDDs. - Where frequent transfers of trained staff occur, state what the project is doing, or intends to do, to remedy the situation. (The most important issue to describe is what measures were taken to ensure adequate CDTI implementation where not enough l*towledgeable manpower was available or if staff are frequently transferred during the course of the campaign). Usually the transfers that occur in the Ministry of Health are replacement transfers and the programme has no control over them. When a member of staff has been transferred, a replacement is done. Usually, the DHOs are the most frequently transferred cadre at district level while the other cadre can take more than ten years before being transferred. In case when the replacement is coming from the non-oncho area, the district makes arrangement to orient the staff in CDTI. This applies at all levels; district, health centre and community (HSAs) levels. 13 WHO/APOC, 24 November 2003 o6lL ah H nU L oE z o -= +F"j (rl c.t $ o\ q c.l t.* r- o\o F-ia o\ r- t- o\ s_:d \.,) a.l co O co N 00 c.i o cl\o c.t ??l GI = € o (u o () s E.j N t-\o r* (\ =rar- ?! co $ oo o\ c.t *\o t.- O\o ?o F-(a o\ ah C) .=6 9E t'r r. fro: Ianoq)+.9 oL z o -= +Fv.i C\ oo cll d: a<v o1 : c.l O t- o\ () o OJ =v o O .I -U c.l o o € ol 6) -E dL 8E!s 3E E --- zE q) I E.t +F'u" \oo\ c.l $ 00 o\ o\ cr) €6 oo t'b o € o\ o s * \: oo o *s!. q Po \oa6 oco ov oo ooc.l r- €t\- o) (u o) (J v Eu' a- @ ! o\ FU \o o\ ao r) t o€ o\ o\ co 66 E 0) GL cl o ar) o L ar) n L c) z Eil+F-d F- N s * rr ps r- N $ $ rr o q) o I \oo\ *u O O o O FL r-. c'l $ $ r- g) O e (l)E >r d ca C) -o I(B -q Or o (o z d (B B -v O Nt L O Fl F Fr o\O N L0)r -o (.) c)a s (J oA + -:\ q 4 a)Qq) L1 1 r. q) t* o t B q) a q) ea (B (l) o a tr F a(J q-i o at) o (.) q)lr _(!)qi '(, o d oo (d LrF .iir()l -ol(Bt FI .i A J Trainees Type of trainine CDDs Other Community members e.g. community suDervisors Health Workers (frontline health facilities) MOH staffldistrict staff Political Leaders Others- monitors Program management :F * How to conduct Health education :& ,|< *< Management ofSAEs CSM :F * >F SHM * Data collection * * rf * Data analysis ,F :F * * Report writine ,k ,F ,k * Data validation ,F Supervision * Table 6: Type of training undertaken Qick the boxes where specific trainingwos carried out during the reporting period) During the reporting year, NOTF secretariat organized an orientation workshop of District team members on APOC Philosophy and CDTI Concept. The training was organized following the Workshop held in Kampala, Uganda in July, 2010. This workshop drew participants from all the CDTI districts and the partners such as Tea Estates Association. District Health Officers (DHOs), Deputy DHOs, District Environmental'Health Officers (DEHOs) and District Onchocerciasis Coordinators (DOCs) were district participants to the workshop. NOTF secretariat also organized an orientation meeting on Technical Annual Report writing. This meeting was organized against the background that APOC had introduced a new revised Technical Reporting format; therefore, for the districts to ably use this new format, there was a need for the orientation meeting. The meeting was attended by DEHOs, DOCs and Assistants DOCs. During the same reporting period, NOTF Secretariat organized an MDA Supervision feedback meeting. After the NOTF Secretariat supervised the MDA, it organized a feedback meeting with the district teams to share experiences and charter a way forward. The meeting was attended by DEHOs, DOCs and the Assistants DOCs. All the four planned NOTF Meetings were conducted in the year. The November,2}l} NOTF Meeting was used as a forum for reporting of the 2010 activities including the treatment results. The NOTF Meetings were attended by DHOs, DEHOs and DOCs and partners such as SSI, WHO, TEA. l5 WHO/APOC, 14 September 2009 NOTF Secretariat also organized refresher training for the district accountants handling APOC Trust funds. Some CDTI districts had assigned new accountants to be handling ApOa Trust funds, therefore, a need for this training. NOTF Secretariat organized a TOT Training for all the TOTs in the district of Blantyre on APOC Philosophy and CDTI concept. This training was targeted for Blantyre becausi there were many new TOTs deployed to the district. A total of 20 TOT underwent this training. 2.6. Treatments 2.6.1. Treatment figures - If the project is not achieving 100% geographical coverage and a minimum of 65%o therapeutic coverage or the coverage rate is fluctuating, state the reasons and the plans being made to remedy this. 16 WHO/APOC, 14 September 2009 t-- o\ o a.l Lo -oa q) p. C)a !+ o o< s E $s\ E!o $(s=(u\FP\E 5E'A'.u:3E.HS5€E,qA .s g sN.? 9 rs,s €* 6 2 !sE 4 .= a= = 5' t .sl.-g a.=q>_ !E E ESo t- cE s€ .E b .o !sE f2 - :s) 6 6 EStr co E 1SE 3 E F:S3 :E * Sio E + s$'==E orE 5'€i(l) Ol = A SF -o -l E 6 SUF XIP H i$B[ f;lE r $sR4 Yl o ii Qs qJa= ;r! ; IESafi 4F I Bg SEFpl ;l E :l g. rl g ;ls :E!, $HgEItBgHeEsifl ;l * :lE ;lf ?lE $iE$J fl 5 #l; €lE #l; Er i El ilE zt1 lti zt1 : E E .el ps EEl 'l -s -sHl EEg €l e *s$bd s F IsiEI E A IIE EI $ B' g E SIE EI H i i" E Es.$ El *s as :s g sssEI E F. . 5 A{,8ol -q o F trri 6rr.t F o < S \SS :egE EEigiEgZ 9€ o6 g o' O O .oL oE bl4! p{Zori o o o :.8 s.g ., XE?AR' E Es E 5zE'rE" €(\ o c.l Nco al6 EtEnei36 (\ o\ € c.l € \o$ \o\O^ a o\ ?a : e- r E "i EJ 6I O Ecq>4= ;e-Es q o\ \o$o\ N<-cn al o\(-) \ q h a)Q va: oL q) r. o t q) ri a) S J1 rn L d U1(€(l) L.(d G, tr o F.l o li v) ,.o U)r! O €i GI tro E (d ot<t o (d g o Or 3. aJoo =O 6^ rr iO!\o rr-_-E 9a dooo\ -qo,i \q @ v? oo c! c.l oo a.l oo oj € cl € a 21 €q59Eor* a2 &E \o\("I @ co a.t o\r- ..i co c.l c.l c"I a.l\o co @\o^ @ oo oo o\ o' \oiA rr? ol =o\ =9 .Z E 8..E" c<F 6 co @+ c.) F- caol cn c.) o @ dr- co \o co o\ c.l o\\o^ c.l c.l f-tuit\o o\ aq;i .r cd: 6e - *6 -tY-o='oo c6-c{'a C ' a 39 o Nt n"s $ oo\o v) o\ ca o o\ \O^ $$ r-ov'I F-. \o \o !f, t- al €t V)ob(d U) o) E, =-cbo =o.!q': fl *r! 6X :A60t- rr xo^ rl \o o o\ o \oo\O -o o\o .o o\ o s o E.9 -^ (] c h0s,t _ .O5cdE^' =E>!AO o F- al\o c.l\o o\\o c.t @ C.l @(\ =in tr EoO Eo d o.=EEE d ,r Q-o' FU t-N\o N\o o'\o co oo N € N c.t t ia \OA6atdq o=:1 0 -.= E re+ E'I )o - E E-gAEE'; tr g t--c.l\o a.l\o o\co € c.l @ c.l cn =in (.) L 6 t-.1 oLx tr ad ca op tr cd 0. o (u z (B & (.) N E(nlr O rl F oF 2.6.2 What are the causes of absenteeism? 1. Unplanned emigration - the person was registered during the census update however, it was found out that the person has emigrated to other districts during the treatment period. People migrating to urban areas particularly districts such as Chiradzulu, Blantyre which are close to the town looking for employment. Sometimes people migrate to other areas within or outside the districts for summer farming. 2. Laying off of workers particularly in tea estates-the workers registered during census update. However it was found that the workers were laid off during distribution. 2.6.3 What are the reasons for refusals? Religion and cultural beliefs are the main reasons contributing to refusals. There are some religious sects which do not allow their followers to take drugs. 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. Parasitologist trained? With assistance from APOC, there are 3 laboratory technicians who were trained on Cytotaxonomy. The training was conducted in Malawi for fwo months. This team will be dealing with larva and pupa stages of the black fly. In addition to the 3 laboratory technicians, there are 3 participants who were trained in Togo for three weeks. This team will be dealing with adult black flies. Existence of microscope? There are two microscopes which were purchased by APOC. 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 l8 WHO/APOC, 14 September 2009 fl o\o c.l ko -o C;) q C;)a t (J op. > o\ q) B s. q) o' r-q) *a B L A)q .t6 !-. q 4q) U h: v\ q)\ ,xI q) F5 q) q-U o Lr() O. bo Loa(.)! (.) n bo h ol<L ooo Cd U) I! 'tL v) c) 9q)(.) +.RaD o .:ia-6= !=t(g c) a() o.9 'El. oq)oa(H ,rlo6) v) 0)()tr 94q) U? 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No\ @ + c.l o € + o\ h ro 00 c.i ci oo c.) o\ c-\ d \o o\N NF- c.t{F- 00 co o\dI o € oo @q r- o\ € \o \(\ o\ \o c.I a.ltf, o\ !o d o.a =Co iE E.gT E </ 9 -o' o\ @n o\ \o cat c.i co\o c.l o- ot\o \o o\ od \o \ C\\o r- coq € t--r- \o c.) o\ o\ o\ oo- co € oo r- r-: o\ coq o\ c.t o\ r-t .r1 s\o o\ Lq ^.r(€,oyE^E S X or ho . )+ 9! o Nr- c.I \o$F- $o\o \o r- F-s F-r- c-O c.i o\t,- o\Nq oo o\ F-q oo co o\ \ooo- 00 -i oo co o\{\o -i a.l 00 c'l c.l o\ r- o\ oo r- c'l oo$ C)ho(B q C) oO U !E- il i? 95 uo o9l q \o c.l 9 co 9\o\o F-$ o OO Oo O oo oo to=o.oo= 6- €^il;' *3 gE,-rg Oor.l c.l c.l oe c.t q \o\o t-a.l o oo o o !Oo.E 3_ E 5 Sg 5 Et ! '7Od r- a.l .+ c.l cO $ t s .f, !+ * \f =o(d o.= =tro n::oEl) 0)a'*r:o €N$ \o ao @\o \o @ $ $ $ r) $ + .f, * $ =qti g IE * o= >.:: o=.!?4aF tr 9 9! EO oo o € ci \o \o €\o \o 00 $ s $ $ $ $ $ & tr.l o C.l o c..l c.lo c.l coo c.l '+ c.l O ol \oooN c-O N @oo a.l o\oo ct oo.l -U) dI v .l +.s - -<) -clI o u0 clLq) a II(,3) =- EEl' .ibE- *os9\E\ESE\q) :uEljs9l5r= :.i06=cnFq.eXL -v63do €)dlE\t&.2 _o+I GloH(Da € HE ael()9l9c)1 .='i IECt .gele.E Ia.El roll-(Dl arLiltrt€tuxlQYIH;Iodt!- oi, I s -l GttrEl I991 eE-Ul E (D()I .- lilE H 'ol a.eEbgE E: 9Aqr6t5grY !.d Llrr (5 iJVb vE'HStrC)tl9F6)LrlleFr tE Gt ' 6t C, .-ln-EG '.. E o.i or1 ';C)l an =l cttl sFl er l Mectizan@ delivered by - Qtlease tick the appropriote answer) MOH N-- wHO tr UNICEF E 2.7. Ordering, storage and delivery of ivermectin Mectizan@ ordered/applied for by - Qtlease tick the appropriate answer) MOH N-'- wHotr T]NICEF tr NGDO tr Other (please specify): NGDO E Other (please speciff): 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 were remaining from the previous distribution, the difference is the request that goes to Merck. - After the mectizan has been received at the National level by the National Central Medical Stores (CMs)-Government institution responsible for purchase and delivery of medical supplies, this year, the drugs were transported to Blanf,yre DHO Pharmacy where all the districts made their orders from. The orders should be within their allocation based on the population the district is to treat during that particular year. When their allocation is approved, the districts collect the drugs from Blantyre DHO Pharmacy. - From the district, Mectizan is delivered to health facilities which are closer to the communities. Health Surveillance Assistants (HSAs) who are direct supervisors of the CDDs collect Mectizan from the Health Facilities and the CDDs collect the mectizan from these HSAs 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) Note that even though there was a balance of 20,556 tablets, all these remaining tablets were collected and delivered to the non-oncho area where there was shortage ofdrugs - 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 deliver them to the Health Centres they report to. The districts collect the remaining tablets from the Health Centres. When the district has collected all District Number of Mectizan' tablets In stock from previous vear Requested Received Used Lost Wasted Expired Remaining Blantyre t0,932 964,500 964,500 959,310 0 2,374 0 2,816 Phalombe 3,162 90,000 90,000 89,550 0 450 0 0 Mulanje 727 875,260 875,260 865,946 0 2,699 0 6,615 Chikwawa 2,714 246,912 246,912 246,255 0 657 0 0 Chiradzulu 3,021 368,080 368,080 360,760 0 2,089 0 5,231 TOTAL 20,556 2,544,752 2,544.752 2,521.E21 0 8,269 0 14.662 2l WHO/APOC, 14 September 2009 the remaining tablets in the district, the tablets are kept at district pharmacy for safe keeping to be used during the following distribution year. - List and briefly describe the activities under ivermectin delivery that are being carried out by health care personnel in the project area. The Health Care personnel carry out the following activities under Mectizan delivery : 1. Ordering and collection of the drug from the health centres for the CDDs whom they superuise 2. Advocacy and mobilization of communities on the year's MDA 3. Reporting on the drug usage and persons treated 4. Supervision of Mectizan distribution 5. Consolidation of data collected by CDDs during census update 2.8. Gommunity self-monitoring and Stakeholders Meeting Has any training (of trainers) for community self-monitoring been done in the project area? Yes.Malawi started to implement the CSM strategy in 2010. If so, When? The first level of training was National Team training the district teams who would in turn train the community monitors. The broad objective of this training was to impart knowledge and skills on how to implement CSM. The training was conducted in July, 20f0. A total of 24 participants attended the training, 3 participants from each of the 8 CDTI district. The selected monitors were trained on how to conduct CSM. The three district team members were responsible for training the monitors. Each session was lasting for two days and number of sessions in each district depended on number of villages involved and number of monitors selected. Trainings of monitors were conducted during the months of August-September, 2010. 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. District Total # of communities/villages in the entire project area No of Communities that carried out self monitoring (CSnO No of Communities that conducted stakeholders meetins (SHIID Blantyre 627 56 627 Phalombe 62 l0 62 Mulanje 369 74 369 Chikwawa r28 39 t28 Chiradzulu 328 98 328 TOTAL 1,514 277 1,514 22 WHO/APOC, 14 September 2009 Through SHM and CSM, communities were able to take their own decisions in the project implementation such as on how to ensure that absentees are treated in the next treatment cycle. Communities were able to discuss on how to improve on the treatment coverage. During such fora, communities were able to select a CDD to replace the CDD in cases where monitors reported of the number of CDDs that would not continue in the next treatment cycle or had dropped out. 2.9. Supervision 2.9.1. Provide a flow chart of supervision hierarchy. National Level + District + Health Centre + CDD At National level, the Director of Preventive Health Services (DPHS), National Oncho. Coordinator were involved in the supervision. At District level, the DHO, Environmental Health Staff including the DOC and Assistant DOC were involved in the supervision while the MAs and Environmental Health staff were involved in supervision at the health centre level. HSAs supervised the CDDs at community level, however, each level was free to by-pass the level next to it to supervise the other level. 2.9.2. What were the main issues identified during supervision? The main issues that were identified during the superwision are: 1. No proper recording in the registers by some CDDs. For example some CDDs were recording Absentee for those people who had transferred out of the village 2. Inadequate or no supervision from the District to health facility level 3. Some CDDs had not started the MDA at the time of the supervision two weeks after geffing the drugs 2.9.3. Was a supervision checklist used? The checklist was used during the superuision 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 CDTI. For example CDDs were taught on how to record properly for the people who had transferred out of the village. 2.9.5. Was feedback given to the person or groups supervised? Feedback was given to the CDDs, HSAs and the district soon after the supervision. During the reporting year, the secretariat organized an MDA feedback meeting where all the CDTI districts were invited. The objective of the meeting was to give feedback and share experiences for proper supervision of the MDA. 23 WHO/APOC, 14 September 2009 2.9.6. How was the feedback used to improve the overall performance of the project? Feedback identified solutions to the identified gaps. This had assisted the district and HSAs so that objective superuision is conducted as a result it improved the performance of the project such as in recording and reporting by the CDDs. 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 off). How does the project intend to maintain and replace existing equipment and other materials? The project maintains and replaces existing equipment and other materials in different ways. The project uses government resources and other donor funds which have been pooled together in what is known as Sector Wide Approach (SWAp). However, the equipment and other materials are centrally maintained. Source Type of equipment APOC MOH DISTRICT NGDO Others No Condition No Condition No. Conditi on No Conditron No Condition l. Vehicle I wo 0 2. Motor cycle(s) 22 l6- F 5- CNFR l-wo 84 71-Fl3- CNFR 0 3. Computer(s) l0 3-F 6 -CNFR, l- wo 3l 29-F CNFR 0 4. Printer(s) 25 21-F 4- CNFR 0 5. Photocopier (s) I F 5 F 0 6. Fax Machine(s) 1 CNFR 4 F 0 7. Others a)Video Camera 1 F 2 F 0 b)Power generator 2 F 4 F 0 c)Cash safe 1 F 0 d)Panasonic TV I F 0 e)Sony VCR 1 F 2 F 0 0Filline cabinets 2 F J F 0 S)LCD I F 0 h) Shelves aJ F 0 i) Bindine machine I F 0 i) bicycles 160 F 991 F 0 k) Microscopes 2 F 24 WHO/APOC, 14 September 2009 Every year, each program is requested to submit its budget. The budget includes activities in the field and procurement. So each program indicates its requirements in terms of capital equipment. The equipment is purchased after the approval of the national budget. 3.2. Financial contributions of the partners and communities - Fill tables l3a, l3b and 13c - If there are problems with release of counterpart funds, how were they addressed? 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Other forms of communityr support Describe (indicate forms of in-kind contributions of communities if any) - Identification of a suitable CDD - Collection of drugs - Communlty awareness during distribution periods - Mobilisation of other community members - Distribution of drugs - Giving CDD a bicycle to use in collection of drugs 3.4. Expenditure per activity - Indicate in table 13, 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 Refer to the tables SECTION 4: Sustainability of CDTI 4.1. lnternal; independent participatory monitoring; Evaluation 4.1.1 Has the project ever been evaluated/monitored? (Tick any of the following which are applicable) Year I Participatory Independent monitoring Mid Term Sustainability Evaluation \ 5 year Sustainability Evaluation Internal Monitoring by NOTF Other Evaluation by other partners ' 4.1.2, What were the recommendations? Internal Monitoring by NOTF 1. HSAs/Supervisors to ensure that shortfalls noted in the registers are corrected on spot2. The district to hold meetings with HSAs at their reporting Health Facilities to share the gaps noted so that they are dealt with soon External Evaluations 1. Procurement and storage of mectizan should be integrated in the district drug procument and storage system 2. Advocacy and sensitization of district leadership towards funding CDTI activities 3. The need for capacity building of HSAs and CDDs to improve reporting coverage levels 29 WHO/APOC, 14 September 2009 4. Ensure complete integration of health activities of sharing transport 5. Report of CDTI activities to go through the DHO 6. Order of mectizan should be based on the previous year's figures to avoid delay in drug availability at community level 4.1.3. How have they been implemented? Internal Monitoring by NOTF' Soon after the monitoring, NOTF Secretariat organized a feedback meeting with the district teams. The districts were urged to implement all the recommendations put forward. The districts were requested to organize meetings with the health workers directly involved in CDTI to correct the errors noted during the monitoring. External Evaluations All the above recommendations were implemented for example districts are able to fund CDTI activities, transport at district level is shared i.e. the DOC is able to use transport from Expanded Program on lmmunisation (EPI) when the oncho motor bicycle is being serviced 4.2. Sustainability of proiects: plan and set targets (mandatory at Yr 3) Was the project evaluated during the reporting period? NA Was a sustainability plan written? NA When was the sustainability plan submitted? NA What arrangements have been made to sustain CDTI after APOC funding ceases in terms of: 4.2.1. Planning at all relevant levels The planning at all levels follows the planning cycle. The Government financial year starts from July to June. Before July, government ministries, departments and programs are requested to submit their plans and budgets for the year. During the planning cycle, all plans are drawn up including activities of Onchocerciasis Control Programme. At the district level, their plans and budgets are consolidated in one document known as the District ' Implementation Plan (DIP) which is submitted to Ministry headquarters. 4.2.2. Funds At District level, the activities of Onchocerciasis Control Programme are integrated into the District Implementation Plan ( DIP ). This ensures that the activities of the Onchocerciasis Control programme are funded from the district Other Recurrent Transaction (ORT) under SWAp. ORT funds under SWAp come in a basket form for different health related activities. Onchocerciasis activities are funded when planned activities are ready for implementation. At National level, each year, each program including onchocerciasis, submits its annual budget for inclusion in the Ministry headquarters annual budget. When the budgets have 30 WHO/APOC, 14 September 2009 been approved by the parliament, funds are spent through what is known as ORT under SWAP in the Ministry. 4.2.3 Transport(replacementandmaintenance) Transport at district level is managed in a pool , each program is given preference according to the work plan on that particular day. Maintenance is carried when due. At National level, each program manages its own transport, however, when the vehicle is due for service, it is treated as any other govemment vehicle. The MOH pays for the maintenance. 4.2.4. Other resources Cunently, the Oncho Offices are housed in Government buildings; therefore, no office space payment is made. When APOC funding ceases, office occupancy will not be affected. 4.3. lntegration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration: 4.3.1. Ivermectin deliverymechanisms Ivermectin delivery mechanism is already integrated in the PHC structure. Mectizan is taken as any other drug. At National level, the drugs are delivered to the Central Medical Stores (Government institution responsible for drug requisition and delivery to peripheral). The drugs are then transferred to the Central Medical Stores (South) where the districts collect from. When the DHO is dispatching and delivering other drugs to the Health Facilities in the peripheral, Mectizan is transported and delivered at the same time. 4.3.2. Training In the CDTI Districts, during the ten weeks training of HSAs, they are taught different topics and CDTI is amongst the topics they are trained on. During Environmental Health Meetings, CDTI is discussed along with other Environmental Health issues. 4.3.3. Joint supervision and monitoring with other programs During MDA, supervision of CDTI is integrated with other programs. For example, during supervision of MDA of ivermectin, MDA of albendazole is also supervised at the same time 4.3.4. Release of funds for project activities All districts in Malawi develop a District Implementation Plan (DIP) for sourcing funding from the Central level. In the DIP all health related activities are included and 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 prografirmes included in the DIP, funds are released to the activities for onchocerciasis control. 31 WHO/APOC, 14 September 2009 4.3.5. Is CDTI included in the PHC budget? Yes 3.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements? o Fill tables 14 and l5 and provide describe other programmes that are using the CDTI structure and how this was achieved. What have been the achievements? 1. Malaria control program is using CDTI structure especially during the net retreatment week. The program uses the CDDs that are used . for ivermectin distribution for this purpose. 2. LF is another health program that is using CDTI structure. CDDs are used for distribution of albendazol in addition to the mectizan they . have been distributing over the years. 3. Nutrition department also uses the CDDs during the child health week where the CDDs are involved in distribution of Vit A and prazinquantel 4. Environmental Health Department uses the CDDs in Water and Hygiene. The CDDs distribute 17o stock solution to the households especially during the rainy season 5. In schistosomiasis, CDDs are involved in community sensitization, identification and referral of patients 6. CDDs are involved in weighing children in Expanded Program of Immunisation (EPI) The following could be the notable achievements: 1. Co-implementation with albendazole increased mectizan uptake by the communities 2. CDD retention was high because through involving them in other health related interventions, they are motivated and encouraged to work as CDDs 3. Through CDD involvement in other health interventions, more people were served with a particular health services compared if the health workers would have been used 4. CDDs are able to reach out to hard to reach areas by the health care personnel o For each intervention listed in table 15, explain what were the roles played by the . CDDs (census, mobilization, distribution, data collection, storage, collection of drugs, referral of SAEs, etc ...)? See Table 14 for the roles o Explain what are the combinations of interventions co-implemented? MDA of mectizan and albendazole were co-implemented. 32 WHO/APOC, 14 September 2009 o How were the interventions implemented? (at the same time?) Ivermectin and albendazole were distributed at the same time. While the CDD is giving out mectizan, he/she is giving out albendazole to the client at the same time. The other interuentions were implemented at different times 4.3.7. Describe others issues considered in the integration of CDTI. Another issue considered in the integration of CDTI is the implementation of other NTD such as eye infection, STH using the CDTI structures. Challenges with co-implementation : In the process of co-implementation, the following challenges were experienced: 1. Delayed commencement of MDA of mectizan. With co-implementation, delay in delivery of commodities from the supplier was experienced. For example, there was delay in delivery of albendazole from GSK, thereby delaying the MDA for mectizan. 2. Other health personnel have negative attitude towards co-implementation resulting in diffi culties in implementation 33 WHO/APOC, 14 September 2009 o\ o ..l Los o o. 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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 reporting year, however, the programme also submitted to APOC a protocol on ITN availability baseline survey. The purpose of the baseline survey was to establish number of ITNs before the CDDs would be used in net distribution so that impact would be measured after say five years. No feedback has been received for both protocols. 4.4.2. How were the results applied in the project? NA SEGTION 5: Strengths, weaknesses, challenges, and opportunities - List the strengths and weaknesses of CDTI implementation process. Strengths l. Integration of CDTI activities into the health system 2. Ability of the govemment to co-fund CDTI activities at central and district levels 3. Unintemrpted MDA since 1997 4. High therapeutic coverage of more than 80oZ 5. Communityparticipation 6. Inclusion of CDTI activities in the District Implementation Plan (DIP) Weaknesses 1. I CDD serving apopulation of more than 100 people 2. Data management Opportunities 1. Availability of HSAs at community level 2. Availability of SWAp funds 3. Availability of NGDO partner 4. Co-implementation Threats/Challenges 1. Employment of new HSAs who would require training 2. Transfer of staff 3. Seasonal movement of people within and out of the districts 37 WHO/APOC, l4 September 2009 - List the challenges and indicate how they were addressed. The most notable challenge that was experienced during the implementation year was high transport cost of the drug charged by the Central Medical Stores (CMS). Even though CMS is a Govemment department, it collects revenue through drug handling and transport. The funds generated are used to buy drugs. The cost which CMS was charging to transport mectizan to the CDTI areas was high. This challenge was addressed through the program ananging and transporting the drug to Blantyre DHO Pharmacy where all the CDTI districts were collecting the drugs from. The only cost that was incurred was for the driver's allowance and fuel. SEGTION 6: Unique features of the proiect/other matters One of the unique features of the project is the role of private sector and corporate social responsibility. The estates train the health workers and fund the MDA activities. To ensure that estate workers are protected from onchocerciasis since they are always out in the tea fields, distribution was introduced on the tea estates. The estate health workers conduct the distribution. Estate distribution and community distribution is conducted at the same period. One of the other issues worthy knowing was the launch of Community Self Monitoring (CSM). Malawi started to implement the CSM in this year's implementation year. 38 WHO/APOC, 14 September 2009