Year 1, report on Community directed treatment with ivermectin (CDTI) Borno State Nigeria: June 1999 to May 2000

IAFRICAN PROGRAM FOR ONCHOCERCIASIS CONTROL (APoc) YEAR l REPORT ON COMMT]NITY DIRECTED TREATMENT WITHTVERMECTIN(cDrr) ^r- L- I I'JI Acuv^r Tc: .J -{ Lc '' : I 1., . :-L"..,' ' :-i _l r cl(8r /) lP ,/.f. rx For hformotton To, -'P.. JUNE, 1999 TO MAY, 2000. IBORNO STATE Year 1 Annual Technical Reports on CDTI Implementation in Borno State 1. BACKGROUND INFOR]VIATION Borno State ofNigeria is located at the northeastern part of the country where the State shares International Border with the Republics of Niger and Chad in the north and Cameroon in the east. It shares borders with Adamawa State in the Southeast, Gombe in the South and Yobe State in the West. The total land mass area of the State is 69,436.sq. km. The State has two notable vegetational zones with the grassland savanna in the southern half and Sahel - dessert zone in the northern half. Onchocerciasis is endemic in the southern half, which is endowed with seasonal and perennial fast flowing rivers; suitable for the agricultural activities and breeding sites for black fly. (SIMILLIM DAMNOSUM), the Vector for river blindness. The northern half is notable for water scarcity stunted Srasses and sparse trees. The State has two season, the dry and wet seasons. The raining season begins in late May and ends in early October when the dry season commences until mid May. The average rainfall in the State is 760mm. The wettest period is around August, September and the driest months being January, February and March with humidity as lows as l2Yo. The total population of Borno State is 2,596,589 (projected from the 1991 National Population Census results), with over 80% of the people living in the rural communities. The State is divided into 27 t ocal Government areas (LGAs) and ten of these LGAs are Onchocerciasis endemic (5 Hyper and 5 Meso endemic). The endemic LGAs have a total population of 507 ,205 people who are invariably at the risk of infection. Before the commencement of Community Directed Treatment with Mectizan (CDTI) about a year ago, all but two endemic LGAs were already at different rounds of Mectizan treatment based on Community-based Ivermectin Treatment (CBIT) approach. With CBIT the Program was responsible for the selection of Community Distributors (CBDs) and delivery of Mectizan drug to the beneficiaries without any community inputs. The aspect of program ownership and sustainability by the "Community" and Governments was not very much emphasized. Refer to graph I for the Pre-APOC (1993 - 1998) treatment results. ,) Commudtics torctudcd tr APIOC Trertnent Round Mcso Endcmlc Communlties Comnrtics under Trcetncnt bcfore AP(rc s/N LGA Hypor Endemlc Communltier 90 490 901 Bru 482 82822 HAWUL 350 50SHANI 503 53 4534 KWAYA KUSAR 53 38 4385 BAYO 38 J7566 666 DAMBOA 10 60607 GWOZA J67 48678 CHIBOK I120 0 509 DIKWA 377 80l0 ASKIRA UBA 77 14403 523 626TOTAL 300 I IJ The project started receiving APOC's financial support from June, 1999 but Logistic support was received about 3 months earlier (with the release of I Hilux Motor vehicle to the Project). However, full implementation of CDTI commenced with the inflow of funds from apOC and the supporting International Non-Governmental Organization (NGDO), Helen Keller International (HKI). HKI started operations in Nigeria and indeed the support of Borno CDTI Project in June, 7999; the inputs of HKI are in the areas of Technical, Managerial, Logistics and Financial Assistance. Please refer to table I for the total number of communities in the hyper and Meso endemic LGAs that have received Mectizan treatment in the reporting period. See table below for the treatment rounds of various endemic LGAs. SAI LGA Treatment Round I DIKWA 1 2 GWOZA I 3 ASKIRA UBA J 4 CHIBOK 3 5 Bru 4 6 HAWUL 4 7 KWAYA-KUSAR 4 8 BAYO 4 9 DAMBOA 3 l0 SHAM J The treatment round of individual endemic LGA is the same as the treatment round for communities. All communities in the same LGA are covered with Mectizan treatment during the respective Mectizan distribution cycle. Therefore, the treatment round of every LGA is synonymous with the treatment cycle of its endemic communities. The Term Community refers to a group of people living together under the leadership of a recognized traditional leader & sharing many things in common. The communities are not of the sime population but are often within the range of 250 to 5,000 people. Exceptional cases are abound. 2 fl (YIIAI s/N DlstrtcUl.GA #of CommticJ Vltrrgcs #of Comrns/Vil hgcs which sclec'ted CDIh #of Comrnflil tagcs whlch Collectcd Drrg #of ComrnJVlIIegcs thrt dccldod on thc mctlrod of Distrlbudon #of comrnJVlllege s whlch dccidcd on tlrc months of Trcetncnt #of ComrnJville gcs wtth tnlned CDI>s #of Comms/Vllhg cs peylng CDDslnCrsh orkind- I Bru 90 90 90 90 90 90 2. HAWUL 82 80 80 80 80 80 J SHANI 52 50 50 50 50 50 4 KWAYA_ K 53 53 53 53 53 53 5 BAYO 38 38 38 38 38 38 6 DAMBOA 75 75 75 75 75 75 7 GWOZA 60 60 60 60 60 60 8 ASKIRA UBA 80 80 80 80 80 80 9 CHIBOK 48 48 48 48 48 48 l0 DIKWA 50 50 50 50 50 50 TOTAL 626 626 626 626 626 626 KI,TUKT I ISECTION tr 4. COMMUNITYMOBILIZATION: Corn*unity Mobilirutio*r*puigrs were undertaken by a team comprised of the State Onchocerciasis Control (SOCT;) members, Local Government Onchocerciasis Control Team Members (LOCTs) and HKI freld Staff. A total of 626 communities in the ten endemic LGAs were reached and mobilized for Mectizan treatment within the period under review. The strategies implored were face-to-face contact for highJevel advocacy and use of town criers to mibilize th. gen".ul public. The target groups were the community leaders and their subjects, religious leaders, iommunity development associations and notable influential individuals inthe communities. The campaigns were enhanced by the availability of I.E.C. Materials, which were sufficient for all the endemic communities. Community Mobilization campaigns produced the desired results by enhancing Mectizan uptake andcommunity supports for CDTI implementation in the State. Community members bicame more informed about the transmission of this dreadful disease and the treatment by way of mass treatment with Mectizan. Community Mobilization using the appropriate Information, Education and Communication tools will be an ongoing process throughout the initial five-years of CDTI implementation. This will continually sensitize the Mectizan beneficiaries and implementers of their roles and responsibilities for the program sustainability. This aspect was emphasized during the training/retraining of various levels of CDTI personnel. F No ofNGDO st fiinvolvcd in Mobilization No. ofMOH Stefrinvolved in mobilizrtion No. of Advocrcy Vlsftto Strtc or Rcy'onrl Ilircctors of HcrItOt No. of Comrnlts/Vlllegcr which rccelved HE ebout Importrncc ofErtcnded Treet sa{ DISTRIC'T/LGA No. of Comm-/Vtll rgcs Mobilized 23)501 DIKWA 50 22 J60 602 GWOZA 23280 80J ASKIRA UBA 2aJ248 484 CHIBOK 23290 905 Bru 2J)82 826. HAWUL ) 2)53KWAYA-KU 537 J 2238BAYO 388 2 2775DAMBOA 759 3 225010 SHANI 50 30 122626TOTAL 626 5 SAI DISTRICT/LGA No of Trainfrrg Undertrken No. ofTOT Trrined No. of IXstrlc-torLGA StefiTreincd ln CDTI No of llcdth Ccntrcs/Post Strfr Treincd tn CDTI No of CDIX Tnforcd I Bru I 4 4 None 114 2 HAWUL 1 J 3 162 3 SHANI I 4 4 .C 72 4 KWAYA KUSAR I 4 4 at 49 5 BAYO 1 4 4 a< 30 6 DAMBOA 1 4 4 a< to7 7 GWOZA I 4 4 (a 143 8. CHIBOK I 3 5 aa 75 9 DIKWA 1 3 3 aa 82 10 ASKIRA UBA I J 3 <a 104 TOTAL 1 36 36 93E Training/Retraining of CDTI personnel were carried out during the last one year before the comme;cement olMectizan distribution in the State. A total of 938 CDTI health workers were traine d,9 atthe State level, 36 at the LGA and District levels and 938 at the Community level i.e. the Community Directed Distributors (CDDs)' Training materials used during the training sessions includes the APOC field guide, approved Informartion, Education and Cimmunication (I.E.C.) materials developed by NOCP and made available by ApOC and Helen Keller International. Others Include the CDD guides, Information Brochure & Management Information System (lntrS) forms for the practical sessions. a) The Annual Training Objective for Year 1 was 1019 but a total of 983 CDTI personnel were eithe; trained or re-trained with and the Breakdown provided is as follo*s: 9 (SOCTs) retrained, 36 (LOCTs) trained/Re-trained and 938 CDDs trained/re-trained. b) Materials utilized during traininglre-training were the Training Manuals, Information Brochure for CDDs u.rd Co*-.rnity Members, Flip Charts and MIS Forms for the practical sessions. c) The need for increase in the number of trainers has been acknowledged. Training materials were initially in short supply because of constraints in cash flow. Most training sessions were conducted close to the endemic communities and at the nearest health-facilities where CDDs could come for their Mectizan drug. The collection points also served as referral c€nter for cases of adverse reactions. 4 5materials HKI to those the State. ACHIEVEMENTS: T't " fotto*it g achievements have been recorded within one Year of CDTI implementation in the State. Formation of well-trained and motivated CDTI personnel at various levels (State, LGA and Community) of the program. A total of 626 Communities were reached with health education campaigns on the disease Onchocerciasis and the current approach for its control through mass annual treatment with Mectizan. iii) A total of 1,164,018 (3mg) Mectizan tablets were used for treatment of 413,203 people in 626 endemic communities. The treatment coverage is ir) Formation of CDTI program management structure at all the three levels of implementation. See annex I for Year 1 treatment Note: Calculated based on cqsh advancement by APOC and D ii) 5 BALANCEQUAI\[TITY ISSUED QUANTITY PRODUCED ITEMSAI 100019,00020,000Household Cards1 4165841,0002 Community Register 1000 1500 1000 1500 2,000 3,000 J Community Summary Treatment Form Big Small 100010002,0004 Treatment Form 100010002,0005 Adverse Reaction Form 5005001,000LGA Mectizan T r eatment Form6 10001,000State Mect izan T r eatment F orm7 15005002,000Mectizan Inventory Form8 10399612,0009 Posters 99010102,000Information Brochurel0 80 106186HKI Training Manualll No. of Ilisttlbudons supcrkcd by hc.lth wor}crr No. of Trertcd Communldeslv ilhEes ndtlr ![lnmrrJ forms. Cost pcr Pcnon trcrted No of CommJVllhgc s whlch CDIIs is e heelth worlrcr No of Terget Communltics /Villagcs Trceted No. of cliglblc pcnrons Trert d s{ Distrtc'l/LGA 4 90us$o.18 None90 39,838I Bru 4 8246,390 (<HAWUL 822 50<a 329,304503 SHANI 4 53aa aa53 17,3474 KWAYA_ K 4 38<a <a38 29,3045 BAYO J 75aa75 58,6426 DAMBOA 60<a 173,944 aa7 GWOZA 60 80J49,595 aa8 ASKIRA UBA 80 45aa aa J25,6139 CHIBOK 45 1 50aa50 43,22710 DIKWA 1-4 626(a626 413,204TOTAL HKr). 6 SUGGESTIONSWEAKNESSESSTRENGTHS The number of trainers will increase in the next treatment cycle. Alternative training centers will be sought for where the available healft facilities do not have the required environment for leanring. Lower the particiPants: Trainer ratio to maximize the benefits of the training sessions and P'ractical demonstrations. InsutEcient number of trainers available Per training session Some primary health care facilities are non- frrnctional and lack conducive environment for effective learning Participants to trainer ratio is higtr, not conducive for leaming during P,ractic€l demonstrations in the field. CDTI Implementation Team members of various levels in the State have been appropriately trained Training/re-training sessions were conducted at Primary Health Care facilities close to the catchment communities. An average of 30 - 35participants Per trainer/session. Training materials available were fairly sufficient for the TRAINING: With the availabilitY additional logistics supports from APOC, HKI and MOIL frequent contact with the communities will be achieved More I.E,C. materials will be available with zubsequent financial instalknents to the project. Early preparation and planning will guarantee more time for communitY mobilization/sensitization. ofIn ability to maintain frequent contact with the communities to further drum in tlre concePt of CDTI. Insufficient quantitY of I.E.C. materials. Ditrculty in reaching some communities due to poor terrain All endemic communities deserving IIUtsS treatment with Mectizan were reached with the aPProPriate Information, Education & Communication (EC) materials. Most stakeholders like the traditional &, religious leaders, community based organizations etc were reached. Traditional methods of communications like face to face contact, town criers were used. HEALTH EDUCATION/]VIOB ILIZATION Advocacy requked to impression the MOH officials about the pros and cons of frequent staffchanges. llave more PHC statr assigned to the program. Encourage Government employees in the Prognm to adopt and cherish the principle of teamwork Some of the program staff are changed when their services are most needed by the program. Some staff appears not to be trainable to undertake assigrred responsibilities. Some saff are not used to teamwork and find it difficulty to shift paradigm. Most of the program staff are either Government employees from the PHC department or community based volunteer workers. INGDO ([IKI) staffare verY few. Government emPloYees have career ProsPects andjob security which are motivating factors. Community volunteers have the apreciation of their members being demonstrated in cash or kind STAITING: Not all communities show similar level of participation Some do not provide any form of incentives to their CDDs. Some advocate for Endemic communities are I increasingly getting committed to the progranr Setect their CDDs Decide on the Period of Mectizan distribution Provide incentives (in cash COMMUNITY PARTICIPATION 6 - Sustained advocacY visis required - Discourage the idea of user fees as accountability is usually the stumbling block. - That those who can not afford may miss or be denied of aor kind) to their CDDS. Ensure the securitY of Mectizan in their custody and assist in awareness campaigs. adoption of user - fees to supportthe CDDs. treament, thereby affecting the prognrn. LGA PARTICIPATION Have established Onchocerciasis Control unit in the PHC departrnent. Assigned some PHC staffto the program with the appropriate office space available. Some LGAs make financial contributions to the program. Support their staff involved in the program. Some LGAs do not make satisfactory counter - Part financial contribution to the program. ln adequate support to their staff involved in the program as been noticed in manyLGAs. Occasional misuse of external logistics support to the program. More advocacy visits to the LGA officials by the SOCTs and the zupporting NGDOs. Discourage the misuse of available logistic suports by pooling them in a safe place after each cycle of Mectizan distribution. LOGISTICS - Pooling of Logistics from MOH, APOC &, HKI fOT effective utilization in the field lnsufEcient Logistics support More motorcycles and Bicycles needed for effective coverage. Additional logistics inputs anticipated from APOC & HKI will address the problem. Pooling of vehicles for repairs after active field activity in readiness for the next treatment cycle. SUSTAINABILITY Greater involvement of community organiztions based e.g. Commiuees Based Bamako Initiative CommunitY(CBBI) will ensure sustainability. Sustained communitY involvement in the program especially in CDDs selection and incentives supports in cash or kind Most communities Ptck their drugs from the collection points. Some conllicting roles of Ithe community based I organizations especially I where user fee is emphasized could affect Mectizan update. Reduce the present CDDs attention rate due to poor incentives. Occasional frequent trips to drug pick up poirts due to strike actions by PHC worters. Sustained awareness campaigrlrequired. Adequate time and attention be given for interactions with the relevant health personnel in+harge of dmg distribution and collections. 8 CDDS PERFORMANCE OF TASKS: Community Directed Distributors in the past one year have shown high degree of interest and commitment to the program by executing their functions diligently. These include among others: Community Awareness Campaigns, collection and distribution of Mectizan drug, return of treatment data to their next senior CDTI personnel, drug management and referral of adverse reactions cases to the appropriate health facilities for further affention. However, the level of commitment is proportionate to personal conviction/perception about the debilitating effects of the disease, literacy level of the CDDs and community remuneration. WILLINGNESS OF COMMUNITMS TO PARTICIPATE IN CDTI Most communities supported the program in the last year; through selection and supports of their CDDs. Satisfactory contributions were made toward drug collection 9 7 l0 ll at the designated pick up points. They also indicated the appropriate periods for Mectizan treatment. In^ communities where community based health committees exist; the committees are saddled with the responsibility of mobilizing resourc'es from members to support the CDTI program. They have been found to be quite effective and also command the respect of ttreir community members' However, the level of willingness and participation vary greatly from appreciable to liftle/no involvement' INVOLYEMENT OF NOCP , N0CP relentlessly supported the Project by getting involved in Advocacy Visits to the State Ministries of Health and training activities. CDTI activities *"." t"q,.rently monitored and the implementers advised accordingly' NOCP scrutinized financial returns to APOC being sent through the World Health organizations (wHo) Lagos and at the same time facilitate the inflow of funds and materials from APOC. NOCP also ensured hitch free flow of Mectizan drug to the Project and ultimately to the beneficiaries. There is always a feed back of information to t'he project on the ievel of perfoilnance and the timeliness of program execution' THE STATE MINISTRY OF HEALTH: preciable supports to the program by: i) Creating (inchocerciasis Control Unit in the Department of Disease Control. ii providing offrce space for Onchocerciasis Control Program. iii) Assigne,Isome stiff(State Co-ordinator and SOCTs) to the program' ivi Make a vehicle orruilubl" for the program and occasionally support field activities. CONTRIBUTIONS OF THE STATE GOVERNMENT The Borno St"t" Co us ways for the success of CDTI in the State. Some of the contributions include: a) Allocation of I motor vehicle (Peugeot Station Wagon) and 2 motorcycles to beef up the logistics status of the project. b) provilon of office accommodation for the Onchocerciasis control program. "i Secondment of additional staff to the program to address the problem of inadequate number of senior level trainers in the State' d) Advocacy visits to the LGAs by the MOH oflicials to enhance program supports by I from the LGA PolicY makers. e) Financial contributions of One Hundred and Fifty Thousand Naira (N150,000'00) as part payment of the counter part contributions for Year I, CDTI implementation in the State. The Local Government Areas: 1'ne LCe. nive shown appreciable supports for the progrirm. a) The LGAs have &eated Onchocerciasis Control Units in the PHC Departments to plan and co-ordinate CDTI activities' b) hour pHC stof p". endemic LGA have been assigned to the Onchocerciasis Control unit to supe.vise the activities of Community Directed Distributors (CDDs)' The LOCTs relate very well with the SOCTs for effective execution of CDTI activities. c) Most LGAs make periodic allocation of motorcycles to the Onchocerciasis Control unitofthePHCdepartmentwhenevertheneedarises. 8 I t d) Some LGAs have made financial contributions to strengthen CDTI activities including payment of LOCTs allowances and office supplies of the Onchocerciasis Control unit. The Districts: M*t dirt"rtgnder the leadership of their paramount traditional leaders have embraced the program. The paramount leaderJoften arrange for meetings with the community leaders to soticit their supports and assurance for the CDTI activities. The responses of the community leaders to this call have been encouraging thereby enhancing Mectizan uptake the community level. External Involvement: @ationintheprojecthaveacknowledgedwithprofoundappreciation the enormous contributions of APOC and other partners like the HKI both in cash and in kind to the program. Supports from APOC include financial contribution of Forty Thousand US Dollars (fou. Milli;; Naira), Ten (10) motorcycles, 1 computer, 1 printer to mention but a few. HKI has expended the sum of Sixty-two thousand nine hundred and seventy-five US Dollars ($62,975.00) within the period under review. This is in addition to Managerial, Technical and Logistics Supports rendered to the project. HKI'5 contributions are courtesy of the Nippon Foundation, that is funding the Onchocerciasis Control activities of this organiz-ation in Nigeria. Chewon Nigeria Ltd', also supported HK['s presence in the country and indeed Onchocerciasis Control Program with cash donation. Other organizations too numerous to mention have supported the CDTI activities in the State. These include Religious and Community Development Associations. The invaluable contributions of Merik & Co. for the donation of the needed quantity of Mectizan drug to be distributed free to the deserving communities . SECTION 5 5. Maior Achievements of the Proiect: a) Re-engineering of the Management structure for the various levels of CDTI implementation in the State. b) Uigh level advocacy to sensitize the policy makers to accept the principle of partnership as the ultimate for the Onchocerciasis Control Program. c) Re-orientition of the general public and indeed the endemic communities about the prevalence of this dreadful disease and the management approach through the CDTI. d) iligh number of PHC stafftrained or re-orientated towards CDTI both at the State and LGA levels. e) High number of volunteers at the community level that could be mobilized for other health related programs. 0 Steady flow of the Mectizan drug to the deserving communities through their CDDs.g) Increased Mectizan treatment figure after one year of CDTI implementation in the State.h) Improved logistics suppo(s to the prograrn See Annex II 9 n a a Constraints and Challenses: forcommunitymobi1izationtoimprovetheirlevelofprogram appreciation and suPPorts. b) Steady and greater commitment from the policy makers required. "i In adequate-financial support to the Local Government Onchocerciasis Control Team members. d) Inadequate logistics support at the various levels of program implementation' Assistance required from a) Government: o Renovation of the onchocerciasis control unit in the sMoH. o Fulfil the pledge for counter-part financial contributions to the program' APOC Management: o Timely release of financial installments and approved materials o Provision of resource materials to the project' b) t0 I :! :E3lis6!ili! a I !-p3i=iE; E'& ts d i-!: E i" F rI F s :li! Er"i! Lg I r 8: F x s $ s * F tr e s R ts ig:l 8 E tr r 8 !r,:a! g i3 *I r €& E 2zBl 3{a TEEi:32\g -! !E fr l= -l E ! "€: !Ei! 3 r * F .l o Ee :iE!f E' Y E E C) E!i! e F F e .l .E a o !!?: sr s g!EFg oH z I d leF h ] I Fl .1 o o eI o o EO o I P c a I No o e s E ? 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