Southeast CDTI project technical report submitted to Technical Consultative Committee (TCC): January 2011 to December 2011

SoutHEASr aDfi PRoiECr, iLIBERIA ilJlI-, Jr\r- L ! TECHNICAL REPORT 2OII I ntds.liberia*mgh@lahgq._c_o_m -- -; ORIGINAL : Enelish ANNUAL PROJECT TECHNICAL REPORT SUBMITTED TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) DEADLINE FOR SUBMISSION: To APOC Management by 31 January for March TCC meeting To APOC Management by 31 July for September TCC rneeting (9/ AFRICAN PROGRAMME FOR ONCHOCERCTASTS CONTROL (APOC) Proiect Name: Southeast CDTI Project COUNTRY/NOTF: Liberia Launchinq vear: 2000Approval yearz 1999 From: January 20ll To: December 20ll onth/Year Month/Year APOC fundins vear: (circle one) 12345 5.7 I 8910 2345 ll 6 t2 l3 789r0APOC Proiect im tion l'car re rt: (circle one ll 12 13 Partners: - Ministry of Health & Social Welfare - Sight Savers International - African Programme for Onchocerciasis Control (APOC) - Mectizan Donation Program (MDP) - 829 communities Date submitted: B ANNUAL PROJECT TECHNICAL REPORT TO TECHNICAL CONSULTATIVE COMMITTEE (TCC) County: Liberia NTD/I{CD Program Director Nam Signature: ... . o*",.J,{i Sightsavers Country Director N ENDORSEMENT Signatu DatF:",,i ,: $4 ! .' :.1-. This report has been p..po.dUby Designatio Signature Date Please confirm you have read this report by signing in the appropriate space. OFFICERS to sign the rePort: lll Table of contents ACRONYMS ........... ...................... v DEFINITIONS......... .....................VI FOLLOW UP ON TCC RECOMMENDATIONS .........1 EXECUTIVE SUMMARY......... .....................2 SECTION l: BACKGROUND INFORMATION........ .....................3 1.1. GpNpnal rNFoRMATIoN............. .........3 1.1.1 Description of the project (briefly)..... .............. 3 1.1.2. Partnership ...............4 1.2. Popur-arroN............... ....... 6 SECTION 2: IMPLEMENTATION OF CDTI........ ........................7 2.1. Trurpr-rNe oF ACTrvrrrES ............ .........7 2.2. Aovocacv .......................9 2.3. MosILIznTIoN, SENSITIZATIoN AND HEALTH EDUCATION OF AT RISK COMMUNITIES . 9 2.4. CovvuNrry rNVoLVEMENT........... ..................... 10 2.5. Capecrrv BUTLDTNG.. ...... 1l 2.6. TnearvpNTs.............. ..... 13 2.6.1. Treatment figut'es .......... ........... 13 2.6.2 What are the causes of absenteeism? .......... . . 1J 2.6.3 What are the reasons for refusals?................ ................... 15 2.6.4 Briefly describe all known andverffied serious adverse events (SAEs) that ....... l5 2.6.5. Trend of treatment achievement from CDTI project inception to the current year l72.7. ORoeRrNc, sroRAGE AND DELIVERv oF IVERMECTIN ........ .. l8 2.8. CovvurNrry sELF-MoNrroRrNG eNo STaTBHoLDERS Meerruc ............ l8 2.9. SuppnvrsroN............... ...................... 19 2 9.1. Provide aflotr chart of superuision hierarchy. ............ 19 2.9.2. Whal v,ere the ntain issues identified dtu'ing supervision? ......... .................... 19 2.9.3. Was a supervision checklist used? ... ... ..... 20 2.9.1. LVhal were the outcontes at each level of CDTI impletnentatiott supervision? 20 2 9.5. W'as.feedback given to the person or groups sttpervised?..... ..........................20 2.9.6 Hotv h,as the feedbackused to intprove the overall per.forntance of the project? 20 SECTION 3: SUPPORT TO CDTI ..............20 3.1. EqureveNr .....................20 3.2. FtNaNcreL coNTRTBUTtoNS oF THE pARTNERS AND coNIivtLrNITIES...........................21 3.3. OIHEn FoRMS oF coMMUNITy suppoRT............... ................26 3.4. ExppNorruRE pER AcTrvrry .............26 SECTION 4: SUSTAINABILITY OF CDTL.'.........,.26 4.1. INTeRNaL; TNDEeENDENT pARTrcrpAToRy N{oNrroRrNc; EveluerroN.......... ..........26 1.1.1 Has the projecl ever been evaluated/monitored? (Tick any of the following which are applicable) ............ 26 4.1.2. lVhat v,ere the recommendations? .............26 4.1.3. Hov,have they been implemented? ...... .... ................28 4.2. SusrarNesrlrry oF eRoJECTS: ILAN AND sET TARGETS (MANDAToRv AT...... ..........29 lll Yn 3) .......29 4.2.1. Planning at all relevant levels... ................. 29 4.2.2. Funds....... .... 29 4.2.3 Transport (replacement and maintenance) ........ 29 4.2.4. Other resources ......29 4.2.5. To what extent has the plan been implemented................ . . . . . 29 4.3. INrpcRarloN .............. ......................29 4.3.1. Ivermectin delivery mechanisms ................ .................. 29 4.3.2. Training.... ..............29 4.3.3. Joint supervision and monitoring with other progroms.... .. . .. ... 29 4.3.4. Release offunds for project activities ........ 294.3.5. Is CDTI included in the PHC budget? .............. . .. . . 29 4.3.6. Describe other health programmes that are using the CDTI structure and how this was achieved. What have been the achievements?............. . ... ... . .. .. . 30 4.3.7. Describe others issues considered in the integration of CDTL ..... 30 4.4. OpenarroNAl RESEARCH .....33 4.4.1. Summarize in not more than one half of a page the operational research undertaken in the project areav,ithin the reportingperiod. ........ 33 4.4.2. How were the results applied in the project?............. .................... 33 SECTION 5: STRENGTHS, WEAKNESSES, CHALLENGES, AND OPPORTUNITIES .....33 SECTION 6: UNIQUE FEATURES OF THE PROJECT/OTHER MATTERS...........33 lv Acronyms APOC African Programme for Onchocerciasis Control ATO Annual Treatment Objective ATrO Annual Training Objective CBO Community-Based Organization CDD Community-Directed Distributor CDTI Community-Directed Treatment with Ivermectin " CSM Community Self-Monitoring LGA Local Government Area . MOH Ministry of Health NGDO Non-Governmental Development Organization 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 LTNICEF United Nations Children's Fund UTG Ultimate Treatment Goal WHO World Health Organization CHT County Health Team OIC Officer -in charge MERLIN Medical emergency relief international CRC Cavalla rubber corporation CHAL Christian Health Association CO County Onchocerciasis supervisor CHDD Community Health department Director CHO County Flealth officer J BPHS Basic Packages of health services NECP National Eye Care Program -' LISGIS Liberia Institute of Statistics and Geo Information Services I nnUS Essential Package of Health Services 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. : (ir) 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). (vi) Geographical coverage: number of communities treated in a given year over the total number of meso/hyper-endemic communities as identified by REMO in the project area (this should be expressed as a percentage). (vii) Integration: delivering additional health interventions (i.e. vitamin A supplements, albendazole for LF, screening for cataract, etc.) through CDTI (using the same systems, training, supervision and personnel) in order to maximise cost- effectiveness and empower communities to solve more of their health problems. This does not include activities or interventions carried out by community 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 community ownership. using resources mobilized 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 1 based health intervention programrne), with a view to ensuring that the programme is being executed in the way intended. It encourages the community to take full responsibilityofivermectindistributionandmakeappropriatemodificationswhen necessary. vl FOLLOW UP ON TGG 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 , Number of Recommendation in lhe Report TCC RECOMMENDATIONS ACTIONS TAKEN BY THE PROIECT FOR TCC/APOC MGT ASE ONLY Report Related (D Cross check and correct the following erors: . Calculation of the percentage of communities with members who are CDTI Supervisors (5 I I out of 639:80% and not 69%o); . Calculation of total numbers of CDDs; The total based on the figures given:1749 and not 750. The data was checked and all necessary corrections were made Project related (i) Increase efforts to reduce the number of communities with Iess than 80% therapeutic coverage. especially in Grand Gedeh and Sinoe Counties; Great effort was applied through Health education and awareness in the communities. The numbers of communities rvith less than 80o% therapeutic coverage reduced massively by 18% in 201 I as compared to 37oh in 2010. (ii) Improve the quality of training of CDDs The quality of CDDs training was improved in 201 l. Training was conducted by health facility staff with the supervision of the District Health Officers. County health Team members undertook spot check of CDD training. Pay attention sustainability to issues Sustainability Evaluation was conducted in the project area in 201 I The recommendations from the evaluation are being addressed Executive Summary Prepare an Executive summary of the report in not more than one page. 1. Background on treatment and population data - Total communities, corlmunities treated, total population, UTG, ATO and persons treated. 2 Background on population movements. 3 Trainingdxa - CDDS, health workers, Total population (community) per CDD trained. 4 Challenges and how they were overcome. In 2011, the Southeastern CDTI Project treated 824 communities out of a total 829 taryet communities, putting the geographical coverage at 993% compared to 100% in 2010. 159 communities out of 829 that were treated had <80% therapeutic coverage in2011.During the period under review a total of 415,934 persons were treated out of the target population of 489 , 461 putting the therapeutic covera ge at 84.9Yo compared to 82o/o achieved in 20 1 0. The Project also treated a total of 72,447 lvorian Refugees in four refugee camps in Grand Gedeh County. The refugees crossed into Liberia from endemic communities due to the civil conflict in their country. 183 health workers were trained and retrained out of 1218 health workers in the Project area and 253 ( 21%) out of 121 8 health workers were involved in CDTI activities . 2754 CDDs were trained/retrained out of 4946 CDDs required for the Project and 54o/, of target communities had female CDDs APOC provided 5 motorbikes in 2011 to enhance Mectizan distribution and supervision of CDTI and other health interventions in the Project area. The major challenges faced by the Project during the 2011 treatment round included; l) Limited fund for monitoring and supervision of CDTI activities ll) Lack of computer in the t COS office for reporting lll) Limited Gasoline support for the monitoring and supervision of CDTlactivitiesin2011lV)Unwillingnessonthepartofsomecommunitiestosupporttheir CDDs V) High CDD: population ratio and Vl) Delayed reporting from the Health Facilities 2 SECTION l: Background information 1.1. General information 1.1.1 Description of the project (briefly) - Geographical location, topography, climate - Population: activities, cultures, language - Communication systems (roads...) - Administrationstructure - Health system & health care delivery (provide the number of health posts/centers in the project area if the information is available). - Number of health staff in project area and number of health staff involved in CDTI activities. The South East CDTI Project consists of five counties: Grand Gedeh, Maryland, River Gee, Sinoe and Grand Kru. The project was approved by APOC in2002. The southeastern region is bounded by the Atlantic Ocean to the south, the Republic of Cote d' Ivoire on the east, Rivercess county on the west, and Nimba county on the north. The Region is situated within the Tropical Rain Forest Vegetation Belt of West Africa. Most of the area comprise of forest except a narrow strip along the coast in Sinoe, Grand Kru and Maryland counties where mangrove Vegetation alternate with coastal savannah. There are two seasons: the rainy and the dry season. The rainy season runs from April to October, and the dry season begins in October and ends in April. The average annual rainfall near the coast amounts to 4770 mm, towards the interior, the amount of rainfall decreases to an annual average of 2080 mm. Excessive rainfall comes during the months of June to September. The average number of rainy days during the rainy season is about twenty-two days in a month. Transportation in the South East is mostly by land on unpaved roads and water. Most of the roads in the region are in deplorable condition with very muddy and deep holes filled with wet mud and broken wooden bridges. This situation partially disrupts road access to CDTI target communities in most counties of the Project especially in the rainy season. Most of the people who live in the region engage in farming, fishing and hunting. Their main farm crops are rice, cassava and plantain. There 1218 health staff in the Project areawith2lo/o involved in CDTI. During the period under review, the Project treated 415r934 persons out of atarget population of 489,461 representin g84.9' therapeutic coverage. 824 out of 829 communities were treated, representing a geographical coverage of 99.3o/". 183 Health clinic /health center staff and 2754 CDDs were trained in201l compared to 165 health workers and2489 CDDs trained in 2010. 973,920 tablets of Mectizan were distributed in the Project area during the 2011 treatment round lation of South East CDTI Pro Liberia from Census update bv CDDs Counties Population Grand Gedeh 108,415 Grand Kru 62.478 Maryland 137,494 River Gee 71,221 Sinoe 109.853 Total 489,461 Table l: Number of health staff involved in CDTI Counties Number of health staff involved in CDTI activities. Total Number of health staff in the entire project area B, Number of health staff involved in CDTI B. Percentage Br=Brl Br *100 Grand Gedeh 39s 45 fi% Grand Kru 224 67 100/o Marvland 306 50 r6% River Gee 209 57 160 Sinoe 84 34 40% Total 1.2L8 253 21" 1.1.2. Partnership - Indicate the partners involved in project implementation at all levels IMOFI, Sightsavers, (national/international), communities, local organizations, etc.] - Describe overall working relationship among partners, clearly indicating specific areas of project activities (planning, supervision, advocacy, planning, mobilization, etc) where all partners are involved. - State plans, if any, to mobilize the state/region/district/LGA decision-makers, '- NGDOs, NGOs, CBOs, to assist in CDTI implementation. National Level At the national level partnership was maintained with Sightsavers and Christian Association of Liberia (CHAL). Collaboration was improved with other international and local Health partners such as Merlin, Africare, International Rescue Committee and MSF-Belgium. These organizations were invited to attend CDI and CDTI training facilitated by APOC in Liberia in 201 1. WHO/APOC and Sightsavers provided technical assistance and financial support while CHAL supported in facilitating of f health workers training. 4 Also inter-sectoral collaboration with other department of the Ministry of Health and Social Welfare was stepped up during the year. The inclusion of the Neglected Tropical Diseases Program in the National Health and Essential Packages of Health Services has facilitated better collaboration with Community Health Service, Malaria, National Health Promotion Division, Expended Program on Immunization, Planning and Research and Nutrition Division. Project /County Level At the project level, a strong partnership was established with the county health teams in t_ 201L All the county health officers participated in the development of the sustainability plans for their various counties after the sustainability evaluation. They also participated in the . CDTI annual Program review meeting. MSF Belgium provided assistance to Grand Gedeh County Health Team to train CDDs in the Ivorian refugee' camps during the 2011 treatment round. Community Level At the community level, collaboration between community leaders, youth and women groups, local CBOs, community media stations was strengthened to facilitate effective HSAM in the community. 1,2. Population Table 2: Communities and population at risk in the entire project area whether they are treated or not during the reporting period. rcachedfutt geogruphrc cowruge (nonkalb, the pryect sho ld be expected toreachthe UTG at the end oIthe l- yeat oItheprcj.ct). Was a census for the project done during the reporting period? Yes-r/- No If No, what is the source of the data in the table above? * Source: CDD Yes Other source, specify: Year : 20ll lf you are using the telm community or village, define what constitutes the community or village. This will help understand the profile ofthe project axea. Is thele aoy othq information of interest about the population itr the Eoject axea? If so, include it here. 6 (Please add more rows iJ'necessar. CDTI Districts/ LGAs in the entire project area Total population in the entire project. area Number of communities/villages in Population of Meso-endemic zone in the project area A7 Hyper-endemic zone in the project area A2 Total in meso/hyper- endemic zone A3= Ai A2 Meso-endemic zone in the project area At Hyper- endemic zone in the project area A5 Total in meso/hyper- endemic zone A6 = A.7+ [,5 Ultimate treatment Goal (urG) Grand Gedeh 108,415 4B 109 157 15178 93237 108,415 Grand Kru 62,418 32 104 134 15440 47038 62.478 Maryland 137, 494 55 160 215 1 5668 121826 137.494 River Gee 7 1,221 16 99 115 9995 61226 7 t. 221 Sinoe 109,853 53 155 208 21970 87883 109, 853 TOTAL 489,461 204 627 829 78251 4tL2L0 489,461 r! 't ', SEGTION 2: lmplementation of GDTI 2.1. Timeline of activities Fill in table 3, timeline of activities for areas treated in current year, rndicating when the key activities were implemented by the month they began and the month they ended. Table 3: Timeline of activities for the areas treated in the current year 20ll County Mobilization of communities Trainins Census/Update Drus distribution Suner-vision Starting month Completion month Starting month Completion month Starting month Completion month Starting month Completion month Starting month Completion month Grand Gedeh Januarv October July August Januarv April August November July December Grand Kru March Sept July July June July August October March October Maryland January Septernber July July June July August November March November River Gee January September July July June July August November March November Sinoe January Septerrber July July June July August November March November ,l I' I r t, 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 oatcome. Describe dfficulties/constraints being faced and suggestions on how to improve advocacy. Three Advocacy meetings were held with policy makers at national level. The purpose of the meetings was to advocate for the inclusion of Onchocerciasis and other Neglected Tropical Diseases in the Ten Years National Health Plan and the Essential Packages of Health Services ( EPHS) (2012 -2021) and as a division within the Ministry of Health and Social Welfare. The advocacy lead to the inclusion of NTDs in the National Health Plan and the EPHS. Advocacy meetings were also held at the project level with county health teams, superintendents, development superintendents, district commissioner, paramount Chiefs and town chiefs. In Sinoe County two advocacy meetings were held with 22 policy makers including County and District commissioners. In Grand Gedeh County three advocacy meetings were held with 40 policy makers including county authorities, representatives of health partners and the Ivorian refugee leadership. One of the outcome of the advocacy was the inclusion of onchocerciasis and other NTDs as one of the priority diseases in the operational plans and budgets of the five counties in the Project area. A five years sustainability plan was also developed by each of the county within the project area. During this planning meeting, counties authorities participated in the development of the sustainability plans. 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. There was increased community awareness through the local radio stations in the five counties. In Grand Gedeh, Sinoe, Grand Kru, Maryland and River Gee counties sensitization meetings were held for 150 Opinion leaders, town elders, women and youth leaders, teachers. religious leaders and leaders of the Ivorian Refugee communities on the control and prevention of Onchocerciasis and the roles and responsibilities of the community in CDTI. In most health facilities there are designated staffs who supervise the Community Directed Distributors (CDDs) as well as conduct awareness in the catchment communities. CDTI posters and brochures were distributed to all health facilities and communities. The Iocal radio stations in each county aired oncho jingles and discussion programs on the Mectizan distribution and the role of the community. The local radio stations in the project area that were involved in the airing ofjingles, talk shows and phone in programs and the schedule of activities included ; Voice of Sasstown in Grand Kru County played jingles twice a week from August to September 30th 20tr . Voice of Sinoe in Sinoe County August- September 30th 201 I . Smile FM in Grand Gedeh County; August to October l5th 201 I o Kanweaken community Radio in River Gee County August - September 30'h 2011 . Radio Harper 94.I FM in Maryland County August -september 15th 201 1 ounty 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 Bo= BJ B, *IOO Male CDDs B7 Female CDDs B" Total Bo= Br*Bn Number of communities with female CDDs B,n Percentage Brr: Bt,,/Br* 100 Grand Gedeh 157 87 55% 257 77 334 52 33% Grand Kru 134 102 76% 334 249 583 134 1.00% Maryland 215 126 59% 450 415 865 14',7 68% River Gee 115 t5 63% 351 194 545 95 83% Sinoe 208 t3l 63% 296 80 376 66 32% Total 829 519 63% 1688 1015 2703 464 56% 2.4. Gommunity involvement Table 4: Communities participation in the CDTI 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 Attendance of female members of the community has increased in the treatment round based on conscious effort made by health workers to reach them. Women compared to their male folks in mo' parts of the Project area women have greater responsibility for performing both the domestic chores o,,d farm work to sustain their families, such that when health talks are scheduled, fewer females are usually available to participate in discussions. This calls for the need to give health education from house to . house to reach rnore women. Most communties have not lived up to their responsibility when it comes to CDDs motivation. However.'- Some communities provided cash incentives to CDDs during the distribution while other communities in Sinoe County, CDDs were assisted with labor to make their farms, some others gave CDDs rice and other food items at the end of treatment.. The percentage of Female CDDs was high in Grand Kru and River Gee Attrition is a serious problem for the project because some of the young CDDs leave the community on a regular basis to seek employment in the cities , while in some other areas young people occupy themselves in gold mines rather than spend time helping with drug distribution . Health workers are addressing this issue by engaging the women and youths groups. 10 2.5. Gapacity building - Describe the adequacy of available knowledgeable manpower at all levels. - Where frequent transfers of trained staff occur, state what the project is doing, or intends to do, to remedy the situation. (The most important issue to describe is what measures were taken to ensure adequate CDTI implementation where not enough knowledgeable manpower wqs available or if staff is frequently transferred during the course of the campaign). i tn 201 I a total of 109 community fbcal persons were trained in 109 frontline health facilities in the project area to assist the Officer in charge of the health facilities who are overloaded i with clinic work to facilitate CDTI in the community The transferred staffs were limited in 2011 as the various Medical Institutions graduated more qualified staffs who took assignment in the rural areas. The transfer of staff did not pose a problem to the CDTI program during the period under review. 11 Table 5: Training at the different levels of CDTI irrplementation 'Nev', 'ReJr' Udelatl nol avdilable, provde lhe correspondrng tolal only counhnS. t2 District/LGA Number of Districts/LGAs staff trained Number of Health center/post staff trained Number of other trainers of trainees ( TOTs) Number of CDDs trained ATrO C, Ct Rnrt' a Total Cr= Cz+ Cr .\TrO Cs Nev : nt, Cr ', C, Total Cr: Ce+ Ct ATrO C. Nel' Cro Refr Crr Total C,:-- Cro+ Crr ATrO Crr Nett C,, Refr Ctt Total Crr= Crr+ Crs Grand Gedeh 5 4 1 5 25 9 16 25 I 0 1 I 400 61 i 267 328 Grand Kru 5 5 0 5 60 19 36 55 I 0 I I 650 186 405 59L Maryland 6 6 6 58 1.7 34 51 I 0 I I r 000 192 692 884 River Gee 6 6 6 6 t9 13 6 1,9 1 0 I I 650 400 160 560 Sinoe l0 8 2 10 33 17 16 33 2 I I 2 400 90 301 391 TOTAL 32 29 9 32 195 75 108 183 5 L 5 5 3100 929 182s 2754 1007o Achievement 93.8o/" Achievement 1007" Achievement 88.8% Achievement larl Make sure thal lhere ts no 't r' Table 6: Type of training undertaken (Tick the boxes where specific training was carried out during the reporting period) - Any other comments 2.6. Treatments 2.6.1. Treatment figures - If the project is trot achieving 100% geographical coverage and a minimum of 65% therapeutic coveroge or the coverage rate isJluctuating, state the reasons und the plotts being macle to remedy this. In this Project area, Therapeutic and geographical coverage have been consistent since 2008. In 2010 the Proj ect achieved 84.9% therapeutic and 99 .3Yo geographical coverage. Number of target communities has been fairly stable, but in 2011 the number of target communities increased from 639 in2010 to 829 in 2011. Maryland and Sinoe accounted for additional communities. The reason given for the huge increases in number of communities was that a particular CDD produced one treatment report. irrespective of how many communities they treated. Most of the communities have been receiving treatment except that they were reporting under bigger towns and villages. Trainees Type of trainins CDDs Other Community members e.g Community supervisors Health Workers (frontline health facilities) MOH staff or Other Political Leaders Others(soecifi?) Program management How to conduct Health education Management of SAEs CSM SHM Data collection Data analysis Report writing Others (speciff) Partnership 13 Table 7: Treatment and SAEs by district/LGA in all areas at risk (Please add more rows if necessary) District ILGA Communities/Villages Population Number of persons rvho refused the treatment Number of absente CS Number of communiti es with < 80% therapeutic coverage Numb er of SAEs Number of serious adverse events (SAEs) referred to the health postrtrospital Total # of communit res/ villages rn the meso/hyp endemrc areas Dr Annual Treatment Objective Dz Number of communiti es/vrl Iages treated D: Geographical coverage (%) Dr: Dr/ Dr*100 Total population of the meso/hyper- endemic areas Ds Annual Treatment Objective Dr Number of persons treated D7 Therape utic coverag (%) De: Dt/ Ds* 100 Grand Gedeh 157 157 157 100% 108,415 108,415 90770 83.7% 576 2512 57 158 0 Grand Kru 134 134 t34 100% 62.478 62,478 53160 85.1% 262 805 J 134 0 Maryland 215 215 215 100% 137.494 137,494 1t9587 87.0% 514 1307 50 264 0 River Gee 115 115 115 100% I 1,221 7 l, 221 5868 1 82/% 389 l0l6 43 174 0 Sinoe 208 208 203 970 109, 853 109, 853 93736 8s.3% 7t0 1401 6 109 0 TOTAL 829 829 824 99.3% 489,461 489,461 41.5,934 84.9% 2451 704L 159 839 0 Fomula for computins theopeulic and qeoeraphical cove.aees ATO coverage rate = Numb.r ofpeople trealed x 100(Y.) Annual Treatmenr Objective o/" UTG achi€ved = Number ofpeogle treaied x I00 Total number ofpeople to be treated in meso/hrTer-endemic areas within the project area (UTG) ATO = The estimaled nunb.r of people living in neso/hlpeFerulenic orc6 thot a CDTI pruJect i^t.nds to t.eat vith ieemectin L. a gttq leE .qeted to r@.h fi. aTc at tt .nd ojthc 1r rat o/h. ptoj.ct). rl ra l4 't rt 2.6.2 What are the causes of absenteeism? The main cause of absenteeism was due to inadequate health education to the community on the time and schedule of the drug distribution.. 2.6.3 What are the reasons for refusals? . Few persons are still apprehensive ofadverse reactions despite health education provided by ' CDDs and health workers. Fear is the main cause of refusals, but the numbers of refusals are getting smaller and smaller compared to previous years. 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. The project did not have any case of serious adverse events (SAE) during this reporting period,. No SAE case to report ! 15 tr Table 8: Cases of serious adverse events (SAEs) that occurred during the reporting period (Please add more rows if necessary) t6 s/l{+ Age Sex Village of origin Date Mectizan was taken Date l'' symptom S appeared Syrnptoms Health status before taking Mectizan Date of admission health facility ln Date of dismissal flom health faciliry Results of tests (thick blood smear) Outcome of prognosis Extenuating or complicating circumstances Alcohol involveme nt or not * Serial number of the patient tl rt tt ,t 2,6,5, Trend of treatment achievement from CDTI project inception to the current year Table 9: Treatments and coverage b), calendar year for the entire project area. (PleaseJill in the required data) Please indicate the UTG for the project area: 843823 (use this figure as the denominator in all UTG coverage calculations.) YEAR Communities/Villages Population Total # of com mun itres/v illag es in the meso/hyper- endemic areas El Annual Treatment Objective E, Number of communitre s/vi I lages treated Er Geographi cal coverage (%) Er= Er/Er*100 ATO coverage (%) Es: Er/ Er*100 Total population of the meso/hyper- endemic areas E6 Annual Treatment Objective Et Number of persons treated Es Therapeutic coverage (%) Eg= Es/ E5*100 ATO coverage (%) Ero= Eal Er*100 UTG Coverage (%) 1999 2000 200 I 2002 2003 2004 2005 2006 597 597 597 100% 100% 465,496 302,572 303,007 65o/o 100% 77% 2007 597 567 567 100% 100% 465,496 302,572 303,007 65o/o 100o/o 77.60/o 2008 909 909 718 79% 79% 380,975 328,194 310,972 82o/o 94.8o/o 79.5% 2009 598 598 s98 100% 100Y" 301347 253131 243248 8t% 96Yo 81% 2010 639 639 639 100% 100% 335,428 281,7 59 274,726 82% 97Yo 970/, 20tt 829 829 824 99.3'h 99.3"h 489467 489461. 41.5934 84.90 84.9"/" 84.9"/" t7 2.7. Ordering, storage and delivery of ivermectin Mectizan@ ordered/applied for by - (please tick the appropriate answer) UNICEF tr Mectizan@ delivered by - (ltlease tick the ctppropriate answer) Other (plEASElpec-ify): - MoH tr wHo aj-l Other (please specify): NGDO tr UNICEF E NGDO tr - How are the remaining ivermectin tablets collected and where are they kept? Remaining Mectizan tablets are received at health facility serving as collection points from CDDs. The storage of un-used drugs is at the store room of the health facility. The counties Onchocerciasis Supervisor then collects the balance from the health facilities and take to county drug depot. - List and briefly describe the activities under ivermectin delivery that are being carried out by health care personnel in the project area. At the completion of community census by the CDDs, the county requests the Mectizan through the NOTF secretariat based on population. The drugs collected from the National drug service are supplied to the county pharmacist who stores them at the County drug depot. District health officers request for drugs from the County pharmacist through the oncho supervisor. The officer in charge at the health facility is supplied Mectizan for its catchment communities based on request made to the DHO. - Any other comments The Mectizan is being ordered by the NOTF based on the target population of the various counties, districts and communities. 2,8. Gommunity self-monitoring and Stakeholders Meeting Has any training (of trainers) for community self-monitoring been done in the project area? If so, When? No comment here? a- : Mectizan@ Inven County Number of Mectizant tablets In stock from previous year 2010 Requested Received Used Lost Wasted Expired Remaining Grand Gedeh 53 539 120000 120000 136684 177 0 500 34339 Grand Kru 5778 1 55000 I 55000 I 59640 90 0 0 194',70 Maryland ts01 57 320000 320000 323150 468 1 500 60423 River Gee 2361 I I 1500 I r 1500 125262 33',l 0 0 6488 Sinoe 243606 320000 320000 229184 t) 0 1 500 66093 TOTAL 45604L 1026500 1026500 973920 1.1,45 0 3s00 186813 18 Table I l: Community self-monitoring and Stakeholders Meetin 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. Community Self Monitoring was not conducted last year. The activities will be implemented in March 2012. 2.9, Supervision 2.9.1. Provide a flow chart of supervision hierarchy. Central Level . NOTF . NOCP County Level . County Health Officer (CHO) . Community Health Department Director (CHDD) o County Onchocerciasis Supervisor (COS) District Level r District Health Officers . Officer in Charge of Health Facilities Community Level . Community leaders /town chief . Developmentcommittees o CDDs 2.9.2. What were the main issues identified during supervision? In 2011, training of health workers and Community Directed Distributors was conducted in all counties with support from WHO/APOC and Sightsavers. The training of CDDs was decentralized in most of the communities. The health workers were able to move closer to communities that were closer together to conduct the training instead of bringing all the : u l l District/ LGA Total # of communities/villages in the entire project area No of Communities that carried out self monitorins (CSM) No of Communities that conducted stakeholders meetins (SHIVD Grand Gedeh Grand Kru Maryland 157 134 z1s Nil Nit Nil Nil Nil Nil River Gee 115 Nil Nil Sinoe 208 Nil Nil TOTAL 829 t9 CDDs at the health facility. During the supervision it was noticed that almost all of the health facilities received funding from the county to conduct their training. 2.9.3. Was a supervision checklist used? A supervisory checklist was used by NOTF 2.9.4. What were the outcomes at each level of CDTI implementation supervision? . NOTF spot check was able to assess quality of CDDs training and the lapses were corrected o Supervision of health workers training helped to re-enforce important information o County level supervision helped to identiff communities with inadequate drug supply arrangements made to replenish their stock. . Health facilities with inadequate supplies were replenished during county level supervision of health facilities 2.9.5. Was feedback given to the person or groups supervised? Feedback was given at community, health and facility and county health team depending on the level of supervision. 2.9.5. How was the feedback used to improve the overall performance of the project? The feedback provided to the health staff, community leaders and CDDs was used to correct identified weakness SECTION 3: Support to CDTI 3.{. Equipment Table 12: Status of equipment Source Type of equipnrent APOC MOH DISTRICT/ LGA NGDO Others No Condrtron No Condition No Condrtron No Condrtron No Condrtlon l. Vehicle 2 wo 2. Motor cycle(s) 5 F 3.Motor cycle(s) Generator Portable METS 3. Computer(s) Laptops 4. Printer(s) Cannon Desk Top Computer GX 280 5. Photocopier (s) 6. Fax Machine(s) 20 7. Bicycles 1s5 F a) b) c) *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 inclusion of CDTI activities the Ten Years National Health Plan and Essential Package for Health Services under the Neglected Tropical Diseases Program by the Ministry of Health and Social Welfare is a great step towards sustainability. Onchocerciasis and other NTDs will now have approved budget lines in MOH and County annual plans. 3.2. Financial contributions of the partners and communities - Fill tables l3a,73b and l3c - If there are problems with release of counterpart funds, how were they addressed? When there are problems, the NOTF chairperson who is also the chief medical officer at the MOH will be briefed and there follow-up with Finance and administration division . The Ministry advocate to the county authorities to support Onchoceriasis control and other health care interventions 21 Table 13a: Financial contributions by all partners for the last three years (continued) Two (2) years previous to Calendar YEAR being reported (2011) GOVERNMENT ;ontribution OTH ER partners' disbursement Budgeted Amounts disbursed at the following levels % disburs ed Sightsaver s Local NGDO S Commu nities oth ers APOC Trust Fund BUDGET LINE National Reqional District Total l. Mobilization, advocacy, sensitization et health education 1.1. Mobilization 1.2. S,ensitization _1 .3._Advocacy 1-4. Health education Sub-total I 250 284 98 4,200 4832 200 150 " 75 425 200 150 75 425 734 2,919.75 3,OO3.OO 6656.75 2,155100 2,100.00 3,163.00 5263 ll. Training 2.1 . Training/retraining _of CDDs 2.2. f raininglretraining of Health workers Sub-total ll ll l. S u pervision, m onitori n g, Eval u ati o n 1400 2750 41 50 900 2,100.00 3000 3000 7,000.00 4950.25 11950.25 7,575100 5,660.00 s660 3.1 . Supervision 3.2. Monitoring 3.3. Evaluation Sub-total lll 900 2,180 00 3080 600 1,600.00 2200 2200 7,629.00 1,000.00 8629 4,121.60 122.25 4243.85 lV. lvermectin distribution and management of severe adverse events 4.1 lvermectin drstribution 4.2. Management of Severe adverse events Sub-total lV 1,500.00 1 500 V. Additional expenses 5.1 . Salaries 5.2. Equipment 5.3. Vehicles Maintenance 5.4 Top up lncentives 87,240.00 6,500 00 87240 4690 1 500 87,240.0 0 4,690.00 1,500.00 2,775t00 18,1 92.00 22 tt 5.5 Stationeries 5.6 Communrcation Strategic Planning Workshop 2,500 1,000.00 1,000.00 Table 13b: Financial contributions bv artners for the last three ears (continued Two (2) years previous to Calendar YEAR being reported (2010) Amounts disbursed at the following levels National Regional District Total l. Mobilization, advocacy, sensitization et health education _ 1.1. Mobilization -1.2. Sensitization 1.3. Advocacy 1.4. Health education Sub-total I 2,155.00 2,100.00 2,807.O0 7,062.00 ll. Training 2.1 . Training/retraining of CDDs 2.2. f raininglretraining of Health workers Sub-total ll lll. Superuision, monitorinq, Evaluation 1 1 ,150.00 7,254.90 18,404.90 3 1. Supervision 3.2. Monitoring 3 3. Evaluation Sub-total lll 7982.00 5000 1 2982.00 7,695.00 7,695.00 lV. lvermectin distribution and management of severe adverse eyents 4 1. lvermectin drstributron 4.2. Management of Severe adverse events Sub-total lV 23 V. Additional expenses 5.1 . Salaries 5.2. Equipment 5.3. Vehicles Maintenance 5.4. Others Sub-total V 332,400.00 3,845.4 1,900.00 1,900.00 GRAND TOTAL Table 13c: Financial contributions lV. lvermectin distribution and management of severe adverse eyents 4.1. lvermectin distribution rs for the last three Calendar YEAR being reported (specify the year) 2009 OTHER partners' disbursement Amounts disbursed at the following levels Regiona National I District Total l. Mobilization, advocacy, sensitization et health education '1 .1 . Mobilization 1.2. Sensitization 1.3 Advocacy 1.4. Health education Sub-total I 1,591.75 1,591.75 1,591.75 1,591.75 6,367 4,500.00 2,000.00 6,500.00 ll. Training 2.1. Training/retrainrng of CDDs 2.2 Traininglretraining of Health workers Sub-total ll ll l. S u perui si on, m on ito ri nq, Eval u atio n 6,610.00 5,550.00 4,550.00 23,210.00 _3.1 . Supervision 3.2. Monitoring 3.3. Evaluation Sub-total lll 24 1363.45.00 V. Additional expenses 5.1. Salarles --5.2- Equipment 5.3 Mano River Union Conference Sub-total V 170,723.66 25 3.3. Other forms of community support - Describe (indicate forms of in-kind contributions of communities if any) Community support to CDDs were in the following forms CDDs supports by communities are still low in all the counties. However, some communities motivate their CDDs by giving cups of rice and other food stuffs. In some communities they assist the CDDs with labor to brush their farm lands . 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. Indictate exchange rate used here_l USD = 70LD - Any comments or explanations? SEGTION 4: Sustainability of GDTI 4.1. lnternall independent participatory monitoring; Evaluation 4.1.1 Has the project ever been evaluated/monitored? (Tick any of the following which are applicable) x Year 1 Participatory Independent monitoring x_ Mid Term Sustainability Evaluation 5 year Sustainability Evaluation Internal Monitoring by NOTF Other Evaluation by other partners 4.1.2. What were the recommendations? Recommandations at the County level Recommandation Implementation Monitoring and Supervision : Intensify monitoring and supervision of FLHF using supervisory checklist Priority: HIGH Indicators ofsuccessz Supervisory checklists indicating action available, supervisory schedule/reports LVho to take action: COS, CHO, CHDD D e adline fo r co mp let io n : 31 October 201 I 26 Training and HSAM: . Produce adequate number of diverse training and educational materials . Train OIC and other members of Health facility and community supervisors to raise awareness at the community levels . Use diverse community institutional resources for awareness raising and mobilisation (radio, schools, churches) Priority: HIGH Indicators of success: 65% Community members are aware of their responsibilities within CDTI, 65% of Communities support CDDs ll/ho to take action: COS Deodline for co mpletio nz 3l May 2012 Finance: . Prepare annual plan with budget o Budget line for CDTI in county budget Priority: HIGH Indicators ofsuccess: Written annual budget is available, Who to take action: COS De adl ine for compl e t i o n: 3l May 2012 Transport: . Provide a supervisory motorcycle to enable movement at different times in addition to joint supervision Priority: HIGH Indicators of success: Availability of vehicle for CDTi Who to take action: CHO D e adline for c ompl e t ion'. 31 Dec 201 i Coverage: Document Mectizan supply to communities Document Mectizan usage in all communities Priority: HIGH Indicators of success: Summary of treatment records available, inventory of supplies and usage available Who to take action: COS D e adl ine fo r c ontp I e ti o n: 3l May 2012 Recommendation Implementation MONITORING/SUPERVISION Monitor community activities and supervise all CDDs Priority: HIGH Indicutors ofsuccess: Supervisory checklist available in health facilities lYho to take actiott: OIC Deadl ine for co mp I etio tt : 30 October 201I Coverage Retain copies of summary treatment records at the health facility Priority: HIGH Indicotors of success: Records of summary sheets in the health facilities ll4to to take actiort: OIC D ea dl ine for co mp I eti o n : 30 October 2011 27 ! RECOMMENDATIONS IMPLEMENTATION Leadership: Community leaders should be sufficiently mobilized and empowered to take full responsibility for the CDTI project in their communities. Priority: HIGH Indicators of Success: Aware of their responsibilities. Communities take decisions on and monitor CDTI activities at their level Who to Take Action: OIC Deadline for completion: 31 October 201 1 Monitoring: The FLHF should be empowered to monitor and supervise CDTI activities in their area Priority: HIGH Indicator of Success: The FLHF staffs gets fully involved in the CDTI activities in the communities. Who to Take Action: OIC Deadline for completion: October 201I HSAM: OIC should use innovative and creative approaches to increase awareness and level of information, education and communication of CDI to the communities. Use of radio, news media, churches, schools Priority: HIGH Indicator of success: Enacting sanctions against defaulters and community by-laws in relation to CDTI project in the communities. Who to take Action: OIC Deadline for Completion: May 2012 FINANCE: Communities should be informed using the different communication approaches of the fact that the CDDs are not paid and that the community should support them. Priority: HIGH Indicator of Success: 65% communities support their CDDs. Who to take Action: Community leaders/ FLHF staff Deadline for Completion: 31May 2012 HUMAN RESOURCES: Communities should be encouraged to select more CDDs in order to keep to the recommended ratio of 1:20 households or 1 CDD per 250 people. Priority: HIGH Indicator of Success: there is 1 CDD to 20 Households or 250 persons. Who to take Action: OIC Deadline for Completion: 31May 2012 COVERAGE: OIC to encourage CDDs to retain treatment registers in the community leaders house. Priority: HIGH Indicator ofSuccess: Community treatment record in the community Who to take Action: OIC, CDD Deadline for Completion: 3l October 201 1 Recommendations at Community Level 4.1.3. How have they been implemented? A plan has been developed to follow-up with the implementation of the recommendations of the sustainability evaluation. There will be a review in June 2012. 28 4.2. Sustainability of projects: plan and set targets (mandatory at Yr 3) Was the project evaluated during the reporting period?_yes Was a sustainability plan written? yes_ When was the sustainability plan submitted? Not yet 4.2.1. Planning at all relevant levels '- At the national, plan hai been integrated with other Neglected Tropical Diseases. The ten years national health plan and the essential package of health services has prioritized CDTI at all level. 4.2.2. Funds The program will be supported through the government and co-implementation with other NTDs will secure resources from partners 4.2.3 Transport Vehicles provided by other partner for NTDs will be used to implement CDTI program 4.2.4. Other resources Resources for implementation will be mobilized through the govemment annual budget and partners for NTDs 4.2.5. To what extent has the plan been implemented ' The NTDs master plan and the National Health Plan including the Essential Package of health Services will be used to address the implementation process of the integrated NTDs program 4.3. lntegration Outline the extent of integration of CDTI into the PHC structure and the plans for complete integration: 4.3.1. Ivermectin delivery mechanisms Ivermectin delivery is done through the supply chain system of the Ministry of Health and Social Welfare from the National Drug Service to the County Depot. 4.3.2. Training! An integrated NTDs training will be carried out 4.3.3. Joint supervision and monitoring with other programs Supervision will be integrated with NTDs and Community Health Services Department based on the implementation strategy of the Essential Package of Health Service 4.3.4. Release of funds for project activities Funding for the program will be release by the goverrunent of Liberia through the Pool system and the office of Financial Management at the Ministry of Health and Social Welfare 4.3.5. Is CDTI included in the PHC budgetz The CDTI and other Neglected Tropical Diseases have been included into the Ten Years National Health Plan and Essential Package for Health Service and has been included the into the national budget. 29 4.3.6. 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? 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 ...)? o Explain what are the combinations of interventions co-implemented? o How were the interventions implemented? (at the same time?) 4.3.7. Describe others issues considered in the integration of CDTI. " The CDTI concept has be adopted by the NDTs program and community Health Services Division. 30 a' I lr Table 14 : Co-implementation Type of control Type of intervention Roles played by CDDs (explain in bullet points) Number of districts Number of communities Number of persons targeted Number of persons reached Fema les nchocerciasis o lvermectin distribution Health education. istribute drugs and Lymphatic filariasis o Distribution of albendazole Schistosomiasi S o Distribution of praziq ua nte I o Distribution of mebendazole Health education and ministration of mebendazole. Malaria control o Distribution of LLI Ns o Home management of malaria Malnutrition o Vitamin A supplementati on Mobilizer, vaccinator and registrar 97 5tt NB: the interventions listed in the table are just.few examples 31 arl. Number of CDDs Table 15: Other programmes using CDI structure (tick as appropriate) Type of control Type of intervention Involvement of communities in Planning SHI}1 Implementation Monitoring CSM Reporting Provision of resources activities period mode selection of implementer s collection of commodit ies storage of commodit ies distribu tion supervrs ion In kind financi al Onchocerciasis control o lvermectin distribution Lymphatic filariasis a Distribution of albendazole Schistosomiasis o Distribution of praziquantel STH o Distribution of mebendazole Malaria control o Distribution of LLINs Malaria control o Home management of malaria Malnutrition o Vitamin A supplementation Trachoma a Cataracts a Others (specifo) a a a a a o NB: the interventions listed in the table are just few examples t,ra- 32 'aa ,,, l. 4.4. Operationa! 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 have been conducted in the project area 4.4.2. How were the results apptied in the project? No operational Research has taken place since the program began - t SEGTION 5: Strengths, weaknesses, challenges, and opportunities Strengths o Inclusion of CDTI into the EPHS o Integration with other health programs r CDDs willing to continue CDTI implementation Weakness a . Lack of motivation of CDDs by community members . Inadequate maintenance of logistics o Inadequate HSAM in the community . Inadequate IEC materials for distribution in the community Challenges . Prevision of incentive by other programs . Bad roads condition especially during the rainy season Opportunities . Inclusion of CDTI into the EPHS o Integration with other health programs : . CDDs willing to continue CDTI implementation - . Involvement of CDDs in other health programs tt sEGTloN 6: unique features of the proiect/other matters JJ