Joint mission to Uganda and Tanzania, 27 May-13 June 2001

\ \t JOINT APOC MISSION TO UGANDAAND TANZANIA 27 NI.ay - 13 June 2001 Dr Uche Amazigo, Acting Chief Sustainable Drug Distribution Unit, WHO/APOC Ms Joyce Msuya-Mpanju, Health Specialist, World Bank Ms Pamela Drameh, NGDO Coordinator Ivermectin DistributionrWHo/HQ The team is grateful to the Governments of Uganda and the Uniled Republic of Tanzaniafor allowing this mission to be undertaken. Sincere thanl<s to the Country Representatives of WHO and the World Bank, Drs Richard Ndyomugtenyi and Simon Katenga, the NOTFs of Uganda and Tanzania and all other APOC partners for their asststance in making this mission possible and successful . ) SECTION A - UGANDA (27 May - 1 June 2001) BACKGROUND Uganda is one of the l9 countries of the African Programme for Onchocerciasis Control (APOC) with the goal of eliminating onchocerciasis as a public health problem through sustainable community directed treatment with ivermectin (Mectizan@). Uganda, with a projected population of 20.4 million (1997) is divided administratively into 45 districts which are further divided into counties, sub-counties, parishes, and villages. The health service infrastructure follows this pattern and the Minimum Health Care Package is delivered through this network. o o '>lt 1DD h,I 5t) lr_lc, mr 1;LJf}AN Arua .Gulu Moroto. l. tJt-f\fl ItIP OF IHE CONG() l . Lira .Sorota Mbale- . Fort Portal -,- KEII.IYA IL- KAMPALA -.. .Jrnla enreouelPortBellMasaka. - ,' .r i.:Mbarara ' f ii ,'1,. i,' i. r 1,. ( ,l /-1 RWATJDA TANZANIIA Geographical access to health has been limited to 49o/o of the population i.e. population living within five kilometres of a health service unit and only 42.7o/o of parishes in the country have any form of health facility (Health Facilities Inventory 2000). The burden of disease attributable to onchocerciasis (skin lesions and blindness) is of significant public health and socio-economic importance in Uganda. Annual treatment with ivermectin has increased significantly over the years to the treatment of over 1 million people in the Year 2000 (see figure below). UTG 2000 1 999 I 99E I 997 r trt,I rN{ Its l-RE{IntEN I CO{l_ 2 I I I PURPOSB OF THE MTSSION A joint WHO/APOC, WHO/HQ, World Bank visit was undertaken to Uganda with the purpose of: (i) Attending an Inter-Agency Meeting to harmonize the implementation of Community Based Health Programmes In less than half a decade, new campaigns on community based health interventions are being launched against major endemic diseases. Among these campaigns are the Global Programme for the Elimination of Lymphatic Filariasis (GELF), Roll Back Malaria (RBM), Tuberculosis (TB) and Schistosomiasis control programmes. All these programmes are increasingly relying on community involvement in the execution of the programmes. The experience of the community directed treatment with ivermectin (CDTI) strategy and the partnership established by APOC provides a model for successful community driven intervention. However, there is the need for standardizationof community directed interventions to ensure that different approaches do not compromise each other at community level. lnrealization of the proven effectiveness of the CDTI, the NOTF Uganda organized an inter-agency meeting of the major health providers in Uganda. (ii) Participating in an NOTF Review Meeting CDTI projects in 8 districts will be nearing their 5th year by z}Oz,when APOC funding is expected to cease. The National Onchocerciasis Task Force (NOTF) Uganda working towards enhancing sustainability indicators convened a meeting to review the programme (iii) Reviewing the draft community Self Monitoring Guide with the NorF Communities are the principal actors in the planning, execution and monitoring of CDTI. To enhance their role in monitoring, a study was conducted in Malawi and Uganda to determine the best ways to initiate community assessment of its perfornance. One of the purpose of this mission was to review a guide for upscaling and facilitating community self monitoring. TNTERAGENCY MEETING Objective of the meeting The objectives of the meeting as presented were: To provide a forum at which programme officers, donors and health providers supporting or financing community based control programmes in Uganda to dialogue on different programme-designed support and sustainable approaches. To sensitize donors and other agencies working in onchocerciasis-affected districts of uganda on the benefits of the community Directed rreatment approach. To harmonize forms of support to community members engaged in disease control programmes and agree on what types of incentives (if any) communities should receive without disrupting the activities and are sustainable. To highlight the importance of using existing community structures, such as kinship and involvement of the entire community in health education and supervision of activities. o a a J o Asenci present althe meetins The agencies represented at the meeting included Ministry of Health (Director General, Director of Health Services and the Commissioner of Clinical services) Affected communities (Community Directed Distributors) Agencies (WHO, Ireland Aid and the World Bank) NGDOs (Sight Savers International, Global2000 Riverblindness Foundation, Care International, Red Cross, and Uganda Community Based Health Care Association) Ministry of Health Programmes (onchocerciasis, Malaria, TB, Leprosy, Guinea Worm, Family Planning, and EPI) Key issues Community Directed Interventions A large number of health initiative have adopted community based interventions as the modus operandus for the delivery of health care services. Despite the widely used term community- based programmes, it became evident during the course of the meeting that programmes had different approaches and attached different meaning to this. The meeting agreed that there was a difference between community based and community directed initiatives. The level of community involvement in decision making, planning and implementation varied greatly. The meeting agreed that a "community-directed intervention is one that is undertaken at the community level under the direction of the community itself '. ln realization of the proven effectiveness of the Community Directed Intervention (CDI), the meeting recommended "that the Ministry of Health accelerates the implementation of CDI within the context of the Health Sector Strategic Plan". To this effect the meeting further recommended the application of CDI for the prevention and control of other diseases (e.g. Lymphatic Filariasis, Schistosomiasis, etc), to strengthen other health care programme (e.g. Malaria, EpI, Community-based TB care, etc) and consolidating the integrated delivery of outreach Health Care Services (e. g. integrated inter-programme supervision). The process of implementing CDI and the role of oll partners as deJined by this meeting is attached as annex l. Partnership buitding It was widely agreed at this meeting that the achievements of APOC can be attributed to the unique and effective wide-ranging partnerships established in which all partners have clearly defined roles and responsibilities and a shared common goal. Partnership was recognized as a key factor to the success of CDI. Common goals of all partners should include ensuring ownership, accessibility, quality, equity, and building trust. Incentives The meeting deliberated at length on motivation of community based workers and demands for incentives. Incentive was defined as a benefit to anyone performing a task and a condition for the work to be done. Consequently, provision of incentives is not sustainable unless coming from and decided by the community. It was agreed that support systems to the 4 community directed implementers should be addressed during initiation of programmes and discussed with the entire community. The meeting concluded that: "Externally provided financial incentives are often ineffective and may have a negative impact on other community based programmes, and should therefore be discouraged; and Community should collectively decide on the issue of support to implementers of community directed programmes. " The conclusions snd recommendations of this meeting is attached as annex 2 NOTF REVIEW MEETING The NOTF overseas the implementation of CDTI in Uganda, and meets periodically (twice a year) to review activities in the districts. The visiting team participated in this meeting which focused on the following issues: Progress of CDTI activities in 2001; Strategic planing for sustainability of CDTI after external funding ceases; The need for joint advocacy meetings with District Authorities to solicit for CDTI support; Development of additional IEC materials; Review of the draft Community Self Monitoring Guide; Stakeholders'meeting and why they failed in some communities; Involving community based organizations (CBOs) in CDTI; Planned training programme to strengthen the skills and capacity of District Onchocerciasis Coordinators in operational research and report writing; Understanding of kinship and neighbourliness; Assessing the equipment needs for districts embarking on CDTI; and Plan for annual impact assessment studies of ivermectin treatment on community microfilariae load. MEETING WITH REPRESENTATIVE OF WHO (WR)/Ueanda The visiting team had a debriefing session with the WR on the outcome of the inter-agency and the NOTF review meetings. The discussions centred on issues pertaining to sustainability of the programme at district and national levels, broader potential utilization of CDI within communicable disease control programmes, and additional support to the NOTF Secretariat. With regards to sustainability issues, the WR recommended the CDI strategy be broadly used in other health interventions, such as malaria (community distribution of bed nets), IMCI and consequently institutionalise it in the health system. He emphasizedthat in Uganda that this strategy will be used for: - community distribution of anti malarial drugs; and - distribution of insecticide treated bed nets. In response to the need to develop mobilization skills of the District Health Teams, the WR recommended that the programme utilizes UNICEF's leverage in this area and promised to facilitate this process. He further emphasized the need to develop integrated IEC messages 5 The WR agreed to look into the possibility of supporting an assistant to the National Coordinator under a Special Service Agreement (SSA) to strengthen the NOTF Secretariat CONCLUSIONS AND RECOMMENDATIONS OF THE VISITING TEAM o The mission acknowledged recent changes in the Health Sector Strategic Plan in Uganda which aims at devolving decision making processes to district and lower levels. This new development requires activity rather than disease specific budgeting and therefore allows for integrated activities. However, most districts reported limited budget allocation for health services due to low generation of local revenue associated with poverty and over dependence on donor funds (90% of districts annual budgets). The mission endorsed the recommendation that the NOTF facilitate the District Directors of Health Services (DDHS) and DOCs to advocate at all levels. NOTF Uganda had undertaken annual impact assessment studies between 1992-1996. With the advent of APOC a multi-country impact assessment study is being undertaken with an interval of 5 years resulting in the cessation of the annual country studies. The NOTF has received requests from the communities to be informed about the effect of taking ivermectin annually. The mission encouraged the NOTF to approach APOC and Merck & Co, Inc. for the funding of such studies and suggested the use of the non- invasive DEC patch tests. It is recommended that project reports currently being prepared by the National Coordinator (from monthly reports submitted) be undertaken by DOCs in order to develop capacity at the district level. Recognising the defects of the previously launched stakeholders meetings (SHM) at the sub-district level, the NOTF agreed to reintroduced SHM but at the community level. Based on the lessons leamed from previous SHM and UNICEF's experience, special consideration should be given to community structures and the process of introducing them. The mission commended the NOTF for its initiative to train DOCs on areas of operational research and report writing and promised to look into the possibilities of having the training modules accredited. The mission highly recommends that this be emulated by other countries and programmes as a form of building local capacity. The NOTF agreed to document existing Community Based Organizations (CBOs) in the district including traditional governance structures such as clans and kinships. O a a a a 6 SECTION B. TANZANIA 1 - 13 June 2001 BACKGROUND Tanzania, one of the 19 countries of the African Programme for Onchocerciasis Control(APOC) has a population of 35 million people. It has 20 administrative regions in the mainland and 5 in Zanzibar. The ultimate goal of the National Onchocerciasis Control Programme (NOCp) in Tanzania is to eliminate onchocerciasis as a disease of public and socio-economic problem within a period of l5 -20 years in the 14 onchocerciasis endemic districts.' The most common clinical manifestation of the disease is onchocercal skin problems associated with intense itching. Funding from APOC has been approved for 7 projects (in Ruvuma, Tunduru, Mahenge, Tanga and Kilosa districts) one of which includes vector elimination (in Tukuyu district). The figure below shows ivermectin treatment in Tanzania since 1997. UTG 2000 1 999 1 99E 1997 7 .Tabora ranga. .Wete 14;as66li pernDaDoctoma- zanztbar-.zanzibar DAR ES SALAAM f,A Malia .Sumba'+anga . lrr*ga tstand D T} KENYA .Mbeya IllcAruDA (1f I tlf r.clFJ(;t_l I OO . 2OO krn IOO ZOD rrri Bukoba . ---- ' 'Musoma 'Mrranza t}EM. REP. _]- OF IFIE CUN(;O . ZAMIf !A MALAWI j-l II{]M, Rf P-! oF THE coruGr: | fl_- j ..l-i_i" -,,, RtJtiA I'J Oir', ,, BtiRtil'.it | --.-'/ - Kigorna ,'.'J,:J',,:r ii Arusha. r Ktlirfianjaro" '.. .'r'r ;- , Lindi_l. .Songea Mtwarei'_.) -.' .. .,-* - _ _*--.,'u---'' \/ MOZAMBTQUE ., .ul tl\t.\It_ tRf,\tIttiI coat aa PURPOSB OF THE VTSIT To review with the NOCP and NOTF the progress of onchocerciasis control activities in Tanzania. To visit the Mahenge CDTI project and hold discussions with district officials and community leaders and members. FIELD VISITS The team visited Ulanga and Kilombero districts in Morogoro Region and held discussions with over 40 community members including representatives from the village and district authorities. The major issues discussed were as follows: The need to increase the number of CDDs per hamlet. Treatment records from schools should be harmonized with those of cDDs. Community members stressed the need for ivermectin to be distributed during the dry season (July - September) to improve compliance. One of the perceived benefits of ivermectin as reported by community members was the reduced episodes of epileptic seizures. Findings from the visit to dispensaries in Siginali, Kiberege, and Kisawasawa villages included: All dispensaries (government or mission owned) are involved in the storage of ivermectin and training of CDDs. Census had been undertaken in all villages. The need for further training of rural health workers on their roles and responsibilities in onchocerciasis control activities in particular, their supervisory roles. REVIEW TING OF NOCP Objective of the meeting The main objective of the meeting was to review the progress of the National Onchocerciasis Control Programme (NOCP) in the year 20001200l,particularly the successes and constraints of projects and implementation plans for the following year 200t12002. The list of participants at this meeting is attached as annex 4. Key Issues a The meeting recognized that the programme is not at the point where regions and districts responsible for implementing the programme meet and plan for programme activities on a regular basis. Therefore there is the need for a forum where partners meet formally at the regional and district levels. It was highly recommended that onchocerciasis activities feature in the District Comprehensive Health Plan and budgets to ensure sustainability of the programme. 8 a ao o a a a Furthermore, the reporting system for onchocerciasis activities should be decentralized through the existing health channels with copies to the NoCp Secretariat. NOCP workplans and budgets should be developed in a decentralized manner while focusing on activities to empower communities. Efforts must be made to ensure that districts with projects (in particular those in their 3'd to 4th year) start budgeting and disbursing funds for onchocerciasis activities to sustain the programme when external funding ceases. The meeting recognized that there is a need to review the existing community-based health programmes and where possible harmonize the use of human and financial resources. It noted the need for the national health policy to address the issue of payment of incentives in donor assisted programmes. The rate of refusals and/or absentees was determined to be the main cause of low treatment coverage in a number of communities. The low coverage was assumed to be caused by non-adherence to the period of distribution agreed with the communities and fear of side effects. Operational research offers an opportunity to address this issue. There is an urgent need to strengthen supervision of programme activities at all levels in a coordinated manner including guidelines and checklists. To promote cross fertilisation of experiences, efforts should be made for DOCs and Project Coordinators to visit projects outside their districts. This could be done through planned monitoring and supervisory activities. The meeting recommended that the staff hired in the WHO country office for APOC projects undertake regular field visits to assist district accountants and participate in the financial monitoring of APOC funded projects. MEETING Key Issues o a o a The meeting was informed that a letter had been sent to the Vice President inviting him to be the guest of honour at the 200 Millionth Mectizan@ treatment worldwide to be held in Kilosa, Morogoro Region. The Chair of the NOTF emphasized the need to ensure all logistics and protocol are in place for the event well in advance and further suggested that representatives from Kilosa participate in the planning meetings for this event. To address the problem of customs clearance of insecticide for the Vector Elimination Project in Tukuyu, the NOTF will liaise with the Ministry of Agriculture and Tropical Pesticide Research Institute (TPRI) in clearing insecticides from customs while ensuring that national environmental regulations are met. Dr Maegga, the vector elimination project coordinator was approved to be a formal member of the NOTF. In line with the ongoing Government Expenditure Review, the Chair emphasized the need to undertake an inventory of all programme equipment and formulate a Memorandum of Understanding of how the assets and equipment will be disposed at cessation of APOC . He endorsed the recommendation for an audit of the projects, promised to make available the services of internal auditors from the MOH and proposed the use of external auditors from the Ministry of Finance. The NOTF supported the NGDOs plans to form a formal coalition of NGDOs supporting Mectizan@ distribution in T anzania. 9 o NOTF' MEBTING WITH REPRESENTATIVE OF WHO (WR)/Tanzania In a debriefing session with the WR and his team, the mission was informed that the APOC project was one of the "largest portfolio" under the auspices of the WHO office inTanzania. The WR strongly commended the APOC support staff in his office for being very pro-active in follow ups with the Government and other partners and for their significant input in the financial management process of the projects. The WR offered his office's support to help the Government (at all levels) to start planning for the sustainability of the programme and reiterated the significance of undertaking such an exercise at an earliest time. He further noted his satisfaction with the programme and promised his continued support to onchocerciasis control activities inTanzania. CONCLUSIONS AND RECOMMENDATIOS a The mission agreed with all recommendations made at the NOCP and NOTF meetings 10 aANNEX T Community-Directed Intervention A community-directed intervention is a health intervention that is undertaken at the community level under the direction of the community itself. Possible intervention(s) and the concept of Community-Direction are introduced by the health services and its partners in a participatory manner, highlighting community ownership from the onset. From then on, the community takes charge of the process, usually through a series of community meetings combined with implementation by selected community members. The community, the health services and other partners have the following specific roles in Community-Directed Interventions: Role of Community: Community members collectively discuss the health problem from their own perspective, as well as possible interventions taking into account relevant community knowledge and additional information provided to them community members collectively design the approach to implementing the intervention in the community and identify the resources, Community members collectively plan how, when, where and by who to implement the intervention, what support to provide to the implementers and how to monitor the process Community Directed Implementers execute the intervention Community members collectively discuss the results of the monitoring and adjust the implementation strategy accordingly Role of Health Services/Partners: Identify community leadership structure and cultural composition, and take this into account in all interaction with the community. Introduce to the community the concept of CDI and technical aspects of the intervention Provide and facilitate capacity building and technical support as required ' Provide and support supervision on the basis ofprocedures and criteria that are agreed upon with the community and with community-directed implementers In this process, it is essential that all partners are committed to the empowernent process, that they don't try to dominate but rather contribute according to their roles and responsibilities, and that they share a common objective a a t a 11 a a ANNEX 2 CONCLUSIONS & RECOMMENDATIONS OF THE INTER-AGENCY MEETING ENTEBBE (28-29 May 2001) ln realization of the proven effectiveness of the Community Directed Interventions (CDI), the meeting recommends that the Ministry of Health accelerates the implementation of CDI within the context of the Health Sector Strategic Plan (HSSP). In particular, the meeting recommends the use of the CDI for the following purposes:- l. Application of CDI for the prevention and control of other diseases of Public Health significance e.g. Lymphatic Filariasis, Schistosomiasis etc. 2. Strengthening other PHC programmes, e.g. re-vitalisation of EPI, Malaria, IMCI, Community-based TB care etc. 3. Consolidating the integrated delivery of outreach Health Care Services using the existing additional pool of human resources of the CDTI program, OTHER RECOMMENDATIONS 4. The Ministry of Health should work towards standardization of the process of implementation of community-directed interventions to ensure that different approaches do not compromise each other at the community level. 5. Community should collectively decide on the issue of support to implementers of Community Directed programmes. 6. Externally provided financial incentives are often ineffective and may have a negative impact on other community based programmes, and should therefore be discouraged 7. The health sector should collaborate with other sectors to ensure uniformity in the communify level development activities, including the issue of incentives 8. Integrated, inter-programme supervision in community based health care programmes should be encouraged 9. The community should be encouraged to conduct routine self-monitoring of its performance using appropriate indicators 10. Available information from research should be disseminated and used at all relevant levels, and further operational research is needed on the issues of sustainability, facilitation/motivation of CDDs, political commitment to Community Directed Interventions and the impact of CDI on the Health System. t2 ITINERARY Uganda ANNEX 3 Arrival in Entebbe Inter-Agency Meeting NOTF Meeting (in Entebbe) NOTF Meeting Kampala Debriefing Meeting with WR Departure from Uganda Arrival in Dar-Es-S alaam Departure to Morogoro Region - Ifakara Division Visit to Idunda village in Ulanga District Visit to dispensaries in Siginali, Kisawasawa, Kiberege villages in Kilomboro District Arrival in Morogoro City Public Holiday (Report writing) NOCP Meeting NOTF Meeting Return to Dar-Es-S alaam Report writing Departure from Dar-Es-Salaam 27 May - 28-29 May - 30 May - 3l May - 1 June - Tanzania I June - 2 June - 3 June - 4June- 5 June- 6 - 7 June- 8 June - 9 June - 10-13 June - 13 ANNEX 4 NOCP REVIEW MEETING - 6-7 June 2001 Participants Regional Medical Officers Region Administrative Secretary National Onchocerciasis Control Programme Secretariat Clinical Officers District Planning Offi cers Helen Keller International Sight Savers International Christian Social Services Commission District Onchocerciasis Coordinators District Medical Offi cers Project Coordinators for CDTI Projects National Institute of Medical Research/Tukuyu WHO Tanzania/APOC/HQ World Bank/HQ NOTF MEETING - 8June 2001 Participants Director Preventive Services, MOH NOCP Secretariat Regional Medical Offi cers District Medical Offi cers wHo National Institute of Medical Research (NIMR) Sight Savers International Inter-Church Medical Association Christian Social Services Commission Chairman of the Christian Medical Association Tanzania I4